+

Principles in Dental Public Health

© AAPHD
+ Course Objectives
 Identify and describe the principles of public health as it relates to oral
health and the dental professional.

 Describe the public health and dental public health achievements in

the US.

 Describe the oral health status and needs of the US population,

including various age groups, underserved, and minority populations.

 Describe the dental disease trends among various US populations.

 Identify and explain determinants associated with heath care access

and utilization of dental care services.

 Recognize the roles of public, private, professional and voluntary

organizations in promoting oral health, and the delivery of dental health
care services.

 Describe and differentiate different oral health workforce models.

© AAPHD 2
 Introduction to Dental Public Health

© AAPHD 3
+ Learning Objectives
 Define Public Health and Dental Public Health

 Describe three core functions of public health

 Describe the ten essential public health services

 Identify the difference between the roles of a private dental

practitioner and a dental public health specialist

 List and describe the roles of major federal agencies involved

in oral health and dental public health

 Identify the roles of other professional

organizations
promoting oral health

© AAPHD 4
+ Mission of Public Health

“Improve the health of the public and achieve equity in health status.”

https://www.apha.org/about-apha/our-mission

© AAPHD 5
 + Definition

 *Public Health: Public health is the science of protecting

and improving the health of people and their communities
(CDC, n.d.).
 **Dental Public Health*: that part of dentistry providing
leadership and expertise in population-based dentistry, oral
health surveillance, policy development, community-based
disease prevention and health promotion, and the maintenance
of the dental safety net.

• *https://www.cdcfoundation.org/what-public-health
• ** https://www.ada.org/~/media/ADA/Member%20Center/FIles/dph_educational_module.pdf

© AAPHD 6
+ Dental Public Health (DPH)
One of nine dental specialties recognized by the American Dental
Association (ADA)
 Recognized a specialty in 1950
 Sponsoring organization is the American Association
of Public Health Dentistry (AAPHD)
 Separate and distinct from any recognized dental specialty
 Contributes to new knowledge, research, education, services that
directly benefits different aspects of clinical patient care
 Unique knowledge and skills (Masters in Public Health and
residency) that generally takes two years of education beyond the
pre-doctoral dental curriculum

© AAPHD 7
+ Core Competencies in Dental Public Health (DPH)

Journal of Public Health Dentistry 76 (2016) S18–S28

© AAPHD 8
+ Public Health

 Theconcept of Public Health that emerged in the

beginning of the 20th century had three core
public health functions:
 Assessment : assess and notice that there is a problem
 Policy Development
 Assurance : re-evaluate

http://publichealthne.org/phan-sections/public-health-education-
section/marketing/core-functions-of-public-health/

© AAPHD 9
+ Assessment

 Monitor health status to identify community health

problems
 Diagnose and investigate health problems and
health hazards in the community
http://ocw.uci.edu/opencourses/09f/89300/core_functions.pdf

© AAPHD 10
+
Example of
Assessment:

The Case for Water

Fluoridation
How community water fluoridation was adopted
in the US?

© AAPHD 11
+ The Case for Water Fluoridation

 Assessment:
 1901 – Dr. McKay – investigates “Colorado Brown stain”
 1909 – Dr. Robertson observes similar symptoms
 Belief something in water caused stains
 1930 – Churchill identifies Fluoride in water supplies
 1930s to 40s - identifies Caries lower in cities with more fluoride in
their community water supplies at concentrations > 1.0ppm
 Subsequent long term studies – found that caries reduced in 50 to 70% of
children from fluoridated communities.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4841a1.htm

© AAPHD 12
+ Policy Development
 According to the Institute of Medicine, policy development is an essential
public health function.

 Policy development is included in three of the 10 Essential Public

Health Services.

 Public health professionals play an important role in policy development by

conducting policy-relevant research, communicating findings in a manner that
facilitates action, developing partnerships, and encouraging the efficient use of
resources through the promotion of policies based on science—such as the
promotion of evidence-based, health interventions.

https://www.cdc.gov/policy/analysis/process/definition.html

© AAPHD 13
+ Example for Policy Development: The
Case for Water Fluoridation

 Policy Development:
• 1950 – US Public Health Services issued a policy statement to
American Dental Association, supporting community water
fluoridation
• 1951- Reaffirmed “ community water fluoridation ” - Official
policy of public health service in testimony before senate

McLure FJ. Water Fluoridation – The search and the victory. Bethesda (MD):US Dept
of Education and Welfare, NIH, NIDR: 1970. Chapter 14: 247-9

© AAPHD 14
+ Assurance

https://www.cdc.gov/healthlit
e
racy/training/page1299.html

© AAPHD 15
+ Example of Assurance: The Case for
Water Fluoridation
 Assurance:
 Effectiveness of water fluoridation and policy statement from
US Public Health Service promoted rapid adoption of water
fluoridation
 Professional scientific organizations endorsed water
fluoridation
 Additional modalities for delivery fluoride such as tooth
pastes, gels, rinses, tablets and drops were developed

McLure FJ. Water Fluoridation – the search and the victory. Bethesda (MD):US Dept of
Education and Welfare, NIH, NIDR: 1970. Chapter 14: 247-9
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4841a1.htm

© AAPHD 16
The Ten Essential
Public Health
Services

© AAPHD 17
+ How can DMD/DDS/RDH use 3 core PH
functions compared to a DPH specialist?

Private Practice Public Health

(DMS/DDS/RDH) (DPH Specialist)
Individual Patient Community as Patient

Exam Survey

Diagnosis/Assessment Analysis

Treatment Plan Program Planning

Treatment Program Implementation

Fee/payment Budget/Financing

Recall/pt. evaluation Program Evaluation

© AAPHD 18
+
Dental Public Health
Infrastructure in the US

© AAPHD
+ Dental Public Health Infrastructure
 The dental public health (DPH) infrastructure is the foundation upon which
public dental programs and activities are assessed, planned, executed, and
evaluated.

 Federal, state, and local or county governments have the potential to make a
significant impact on a community’s oral health

 US Department of Health and Human Services (HHS) is the primary federal

agency that administers public health programs in the US
 it oversees agenceis that may be invovled in PH programs, including DPH
programs

Allukian M J, Adekugbe O. The Practice and Infrastructure of Dental Public

Health in the United States. Dent Clin N Am 2008, 52: 259-280

© AAPHD 20
+ HHS Organization Chart The Executive Secretariat
Secretary
---------------------- Office of Intergovernmental and
External Affairs

Office of Health Reform

Deputy
Secretary
-----------------------
Chief of Staff
Office of the Assistant Secretary
for Administration (ASA) Administration for Children and Centers for Medicare and Center for Faith-based and
Families (ACF) Medicaid Services (CMS) Neighborhood Partnerships
(CFBNP)

Administration for Community Food and Drug

Program Support
Center (PSC) Living (ACL) Administration (FDA) *
Office of Civil Rights (OCR)

Health Resources and

Office of the Assistant Agency for Health Care Services Administration
Secretary for Financial Research and Quality (AHRQ)* Departmental Appeals Board
(HRSA) *
Resources (ASFR) (DAB)

Agency for Toxic Substances and

Office of the Assistant Disease Registry (ATSDR)* Indian Health Services (IHS) *
Secretary for Health (OASH) * Office of the General
Counsel(OGC)

Centers for Disease Control National Institute of Health

Office of the Assistant and Prevention (CDC) * (NIH) * Office of Global Affairs
Secretary for Legislation (ASL) (OGA) *

Office of the Assistant Office of Inspector General

Secretary for Planning and (OIG)
Evaluation (ASPE) Substance Abuse & Mental
Health Services Administration
(SAMHSA) *
Office of the Assistant Office of Medicare Hearing
Secretary for Preparedness and and Appeals (OMHA)
Response (ASPR) *

Office of the Assistant

* Designates a component of U.S. Public Health Services
Office of National Coordinator for
Secretary for Public Affairs Health Information Technology
(ASPA) (ONC)

http://www.hhs.gov/about/orgchart/

© AAPHD 21
+
HHS
 Office of Surgeon General
 Surgeon General - nation’ s chief health educator, appointed
by the President and confirmed by the Senate, and reports to
the Secretary of Health and Human Services.

 In 2000, the first ever Surgeon General’s Report on Oral

Health describing the magnitude of oral diseases in the
United States population and the actions necessary to address
them was released

Allukian M J, Adekugbe O. The Practice and Infrastructure of Dental

Public Health in the United States. Dent Clin N Am 2008, 52: 259-280

© AAPHD 22
+ HHS
 Healthy People 2020
 Healthy People - health objectives for the nation. Current one is Health People
2020 to be achieved over the second decade of this century
 Oral health Goal
“Prevent and control oral health diseases, conditions, and injuries, and
improve access to preventive services and dental care”
 Oral health objectives (OH 1 to 17)
 OH1 to 6 - Oral health in children, adolescents and adults
 (dental caries, untreated tooth decay, tooth loss)
 OH7 to 11- Access Preventive Services
 (school based centers, service utilization, FQHCs with oral health)
 OH 12 to 14 - Oral health interventions
 (sealants, community water fluoridation)
 OH 15 to 16 – Monitoring and surveillance systems
 (systems recording and referring cleft lip and palate,
oral and craniofacial systems)
 OH 17 - Public health infrastructure
 (health agencies with a DPH professional directing programs)

https://www.healthypeople.gov/2020/topics-objectives/topic/oral-health/objectives

© AAPHD 23
+ HHS
Healthy People 2020
“Increase the proportion of children, adolescents, and adults
who used the oral health care system in the past year.”

 HP2020 Baseline is 2007: 44.5% of persons aged 2 years and over

had a dental visit in the past 12 months (age adjusted).

 HP2020 Target: 49.0% (age adjusted), or 10 percent improvement

http://www.healthypeople.gov/2020/LHI/oralHealth.aspx?tab=data

© AAPHD 24
© AAPHD
+
HHSUnitedServices
States Public Health
(USPHS)
Indian Health Services

 Uniformed service of  Primary care provider

more
than 6,000 health professionals advocate for Alaskan Native
and
who serve in the HHS and other and American Indians
federal agencies
 https://www.hrsa.gov/sites/default/file
s/oralhealth/hhsinitiative.pdf
 The Surgeon General heads this
uniformed commissioned corps

 In 2007 approximately 390 dental

offices

Allukian M J, Adekugbe O. The Practice and Infrastructure of Dental

Public Eealth in the United States. Dent Clin N Am 2008, 52: 259-280

© AAPHD 26
+ HHS
 National Institute for Dental and Craniofacial Research
(NIDCR) – one of the 24 institutes under National Institutes of
Health (NIH)
 Mission: To improve oral, dental and craniofacial health through
research, research training, and the dissemination of health
information.
 Performing and supporting basic, translational, and clinical research;
 Conducting and funding research training and career development programs
to ensure an adequate number of talented, well-prepared, and diverse
investigators;
 Coordinating and assisting relevant research and research-related
activities among all sectors of the research community;
 Promoting the timely transfer of knowledge gained from research and its
implications for health to the public, health professionals, researchers, and
policy-makers.

http://www.nidcr.nih.gov/AboutUs/MissionandStrategicPlan/MissionStatement/

© AAPHD 27
+ HHS
 Centers for Disease Control and Prevention: Division of Oral
Health
 Works to improve the oral health of the nation and
reduce inequalities in oral health by:
 Helping states improve their oral health programs.
 Extending the use of proven strategies to prevent oral disease by—
 Encouraging the effective use of fluoride products
and
community water fluoridation.
 Promoting greater use of school-based dental
sealant
programs.

 Enhancing
Contributingefforts totomonitor oral diseases,
the scientific such as dental regarding
knowledge-base caries oral
and periodontal
health infections.
and disease.
 Guiding infection control in dentistry.

Allukian M J, Adekugbe O. The Practice and Infrastructure of Dental Public

Health in the United States. Dent Clin N Am 2008, 52: 259-280

© AAPHD 28
+ HHS
 Health
Resources and Services Administration
(HRSA)
 Federal agency for improving access to health care services
for people who are uninsured, isolated or medically
vulnerable.
 HRSA grantees provide health care to uninsured people,
people living with HIV/AIDS, and pregnant women, mothers
and children
 Goal I: Improve Access to Quality Care
and Services.
 Goal II: Strengthen the Health Workforce.
 Goal III: Build Healthy Communities.
 Goal IV: Improve Health Equity.

© AAPHD 29
+
 Centers for Medicare & Medicaid
HHS
Services (CMS)
 The CMS is an agency within the HHS responsible for
administration of several key federal health care programs
- in addition to Medicare (the federal health insurance program for
seniors) and Medicaid (the federal needs- based program), CMS
oversees the Children ’ s Health Insurance Program (CHIP), and
the Health Insurance Portability and Accountability Act
(HIPAA), among other services

© AAPHD 30
+
HHS
 U.S Food and Drug Administration (FDA)
 Protect the public health by assuring that foods are safe, wholesome,
sanitary and properly labeled; ensuring that human and veterinary drugs,
and vaccines and other biological products and medical devices intended
for human use are safe and effective.
 Protect public from electronic product radiation
 Assure cosmetics and dietary supplements are safe
and properly labeled
 Regulate tobacco products
 Advance the public health by helping to speed product
development

© AAPHD 31
+ Professional Organizations
Supporting Dental Public Health
 Advocate and promote optimal oral health
care for all
 American Association of Public Health Dentistry
 American Board of Dental Public Health
 American Public Health Association, Oral Health
Section
 Association of State and Territorial Dental Directors
 American Association of Community Dental
Programs
 American Dental Education Association
 American Dental Association
 American Academy of Pediatric Dentistry

© AAPHD 32
+ American Association of Public
Health Dentistry (AAPHD)
 Founded 1937

 Sponsor of the American Board of Dental Public Health,

 Publishes the Journal of Public Health Dentistry, and is

 Co-sponsor of the yearly National Oral Health Conference

 AAPHD is committed to:

 “ Promotion of effective efforts in disease prevention,
health
promotion and service delivery.”
 “Education of the public, health professionals and decision-makers
regarding the importance of oral health to total well-being”, and
 “ Expansion of the knowledge base of dental public health
and
fostering competency in its practice”.

© AAPHD 33
+ American Board of Dental Public
Health
 National examining and certifying agency for the
specialty of dental public health
 Functions
 creation of standards for the practice of dental
public health;
 grant and issue dental public health certificates to dentists
who have successfully completed the prescribed training and
experience requisite for the practice of dental public health;
and
 ensure continuing competency of diplomats in public
health dentistry

© AAPHD 34
+ American Public Health
Association
 Founded in 1872 – largest public health organization in
the world

 Publishes the American Journal of Public Health.

 Oral Health Section is one of many sections of APHA

 Provides DPH members a forum to obtain support from non-
DPH members/leaders and decision makers
 Some public health issues that OH section investigates and promotes
 Community water fluoridation
 Access to dental care for vulnerable groups
 Reducing racial and ethnic oral health disparities
 Domestic violence screening

© AAPHD 35
+ Association of State and Territorial
Dental Directors
 Non-profit organization representing the directors and staff
of state public health agency programs for oral health
 Promote the leadership capacity of state dental programs
and the impact that their collective oral disease prevention
and health promotion activities have on the nation's oral
health
 establishes national dental public health policies,

 assists in development and implementation

programs of
diseases; and policies for the prevention of oral
 developing position papers and policy statements;
 provides information on oral health to health officials and
policy makers, and conducts conferences for the dental public
health community

© AAPHD 36
+ American Association of
Community Dental Programs

 Voluntary membership organization - Supports effort of

those with an interest in serving the oral health needs at the
community level
 Guides local public health agencies through the steps for developing,
integrating, expanding, or enhancing community oral health
programs

 Members include local dental directors and staff of city,

county, and community-based health programs

© AAPHD 37
 American Dental
+ Association Education

 National organization representing academic dentistry - voice of dental

education.

 ADEA members - 19,000 students, faculty, staff, and administrators

from all of the U.S. and Canadian dental schools, many allied and
advanced dental education programs, and numerous corporations
working in oral health education

 ADEA has a section on community and preventive dentistry and

behavioral sciences.
 explores issues related to community and preventive
dentistry as apply to dental and dental hygiene
they
education, research and practice

 The ADEA publishes the Journal of Dental Education

© AAPHD 38
+ American Dental Association
 Founded in 1859, the American Dental Association (ADA) is the
oldest and largest national dental society in the world - over
157,000 ADA members

 “ professional association of dentists committed to the public’s oral

health, ethics, science and professional advancement; leading a
unified profession through initiatives in advocacy, education,
research and the development of standards”
 Works to advance the dental profession on the national, state and
local level

http://www.ada.org/6876.aspx
http://www.ada.org/sections/profess
ionalResources/pdfs/dph_education
al_module.pdf
© AAPHD 39
+ American Academy of
Pediatric Dentistry
 Membership organization representing the
specialty of pediatric dentistry
 Mission of the AAPD is to advocate policies, guidelines
and programs that promote optimal oral health and oral
health care for children.
 Serves and represents its membership in the areas of
professional development and governmental and
legislative activities.
 http://www.aapd.org/assets/1/7/P_OralHealthCar
eProg1.PDF
© AAPHD 40
+ Lecture 2
Population-Based Public Health
Strategies

41

© AAPHD 41
+ Learning Objectives

 Define the approaches used by Public Health to improve

the health of the community
 Describe importance of various public health
the
achievements, including dental public health
achievements in the last century
 Describe the population level impact of community level
water fluoridation

© AAPHD 42
+ Public Health Practice
 Focuses on the health of groups, community, or
the
nation.
 Population-focused care is defined as interventions aimed at
disease prevention and health promotion that shape a
community ’ s overall health profile (DHHS, 1994a)
 Key feature of public practice is the
health
acknowledgment that health is greater than the
biological determinants of individual health;
 It also embraces a host of behavioral, social, economic, and
environmental factors (including biological determinants of
individuals) that affect the health of a community.
Porsche DJ. Public & community health nursing practice : a population-based approach 2004. Available at
http://www.sagepub.com/upm-data/3989_Chapter_1.pdf

© AAPHD 43
+ 20th Century Public Health
Achievements U.S. 1900-1999

 Vaccination  Healthier Mothers and Babies

 Motor Vehicle Safety  Family Planning
 Safer Workplaces  Community Water Fluoridation
 Control of Infectious Disease  Recognition of Tobacco Use as
a Health Hazard
 Decline in Deaths from CVD
and Stroke
 Safer and Healthier Foods

http://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm

© AAPHD 44
+ Vaccinations
 Polio vaccinations
 First outbreak in US in
described
1843
 1951-1954, an average of
16,316
paralytic polio cases and 1879 deaths

 Polio vaccines introduced in US 1955

 Following the introduction of vaccine,

polio cases declined sharply to less than
1000 cases in 1962 and remained below
100 cases after that year

http://www.cdc.gov/vaccines/pubs/pinkbook/polio.html

© AAPHD 45
+ Vaccinations
ONLY 82 %
receive
vaccination i n
2011

Only 69%
received
DTP, polio, MMR, and
vaccinatio DTP, polio, Hib vaccines
n MMR, and Hib + hepatitis B vaccine, and
vaccines the varicella vaccine

© AAPHD 46
+ Vaccinations
 Community or Herd immunity
 Critical portion of a community is immunized against a contagious disease,
most members of the community are protected against that disease because
there is little opportunity for an outbreak.

The National Institute of Allergy and Infectious Diseases (NIAID)

http://www.vaccines.gov/basics/protection/index.html

© AAPHD 47
+

What happens when 18% of a

community is not vaccinated??

© AAPHD
+ Vaccinations

 Community or Herd immunity

 18% not immunized could increase the risk of outbreaks

The National Institute of Allergy and Infectious Diseases (NIAID)

http://www.vaccines.gov/basics/protection/index.html

© AAPHD 49
+ Measles outbreak in the US
 https://www.msn.com/en-us/health/health-news/us- measles-outbr
eak-is-largest-since-disease-was-declared-
eliminated-in-2000/ar-BBWfDhz?ocid=spartanntp

 681 measles cases across 22 states this year, according to CNN's

analysis of data from state and local health departments.

 Most cases in the United States have emerged in communities with

low rates of vaccination against the virus, according to public
health officials.

 Nationally, the United States has high measles vaccination coverage.

The CDC says 91.5% of US children aged 19 months to 35 months
received at least one dose of the measles, mumps and rubella vaccine
in 2017, the most recent year available.

© AAPHD
+ History of Measles in the US
 1912-Measles became a nationally notifiable disease
(healthcare providers required to report cases)

 In the 1st decade of reporting there were 6000 deaths

 1950s-researchers isolated the virus from a patient’s blood

 1960s-the isolated virus was transformed into a vaccine

 Before the introduction of the vaccine, 3 to 4 million people

contracted the disease each year nationally
 963 reported cases in 1994
 508 reported cases in 1996
 86 cases in 2000 an measles considered eradicated (no
continuous transmission for 12 months)

 Vaccine benefits far outweigh the risks

© AAPHD
+ Whooping cough
 In 2012, the United States had the highest number of whooping
cough cases in more than 50 years with 48,277 reported cases
and 20 deaths.

 Most of the deaths occurred among infants, according to the

U.S. Centers for Disease Control and Prevention.

 In Georgia, there were 318 cases in 2012, which included no deaths.

Since then, there have been three whooping cough- related deaths
(two in 2013 and one in 2016) in Georgia, and all of the deaths
involved babies.
 https://medicalxpress.com/news/2018-09-whooping-comeback.html

© AAPHD 52
+ Whooping cough (cont’d)
 Rise in cases is due to decreased effectiveness of vaccines
after administration.

 The older vaccine for whooping cough was phased out in the late
1990s due to a high risk of serious but temporary side effects such as
pain and swelling at the site of injection and serious complications
such as febrile convulsions & loss of consciousness.

 The newer pertussis vaccine, while safer and with fewer side effects
than the older version, is not as effective.
 https://medicalxpress.com/news/2018-09-whooping-comeback.html

© AAPHD
+ Motor Vehicle Safety
 1960 unintentional injuries caused 93,803 deaths
–
41% related to motor vehicle crashes
 1966- Highway Safety Act and Motor Vehicle Safety
Act
 Vehicles were built with new safety features
 head rests, energy-absorbing steering
wheels, shatter-resistant windshields, and safety belts
 Roads were improved – use of breakaway
signs, improved illuminations
 1970 – evidence decrease in deaths due to motor vehicle
crashes.

© AAPHD 54
+ Motor Vehicle Safety
Motor-vehicle related death rates per 100,000 population and per 100 million
vehicle miles traveled (VMT), by year – Unites States, 1966-1997

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4818a1.html

© AAPHD 55
© AAPHD
+ Safer Workplaces
 Beginning of this century – workers faced high health
and safety risk in their workplaces

© AAPHD 57
+ Safer Workplaces – Example Mining
related deaths
50% decrease in coal mining fatality rates Following the 1977 Federal Mine Safety and Health
occurred from 1966-1970 to 1971- Act, a 33% decrease in fatalities occurred in metal
1975 following passage of the 1969 and nonmetallic minerals mining (1976-1980
Federal Coal Mine Health and Safety Act compared with 1981-1985)

MMWR July 11, 1999 / 48(22);461-469

© AAPHD 58
+ Safer Workplaces – Dental office
 Universal precautions
 Infection control
 Mercury and amalgam safety
 Radiation safety: lead apron, stand
outside the room

 Ergonomics

 Agency responsible to oversee workplace

safety: Occupational Safety and Health
Administration (OSHA)

© AAPHD 59
+ Control of Infectious Disease
 The 19th century shift in
 population from country to city
 industrialization and immigration
 overcrowding in poor housing served by inadequate or nonexistent
public water supplies and waste-disposal systems.
 These conditions resulted in repeated outbreaks of cholera,
dysentery, TB, typhoid fever, influenza, yellow fever, and malaria

 Discovery of microorganisms as the cause of diseases – resulted

in improvements in sanitation, hygiene, discovery of antibiotics,
vaccination programs etc
 Tuberculosis
 Typhoid Fever
 Diphtheria
 Cholera
 HIV/AIDS

© AAPHD 60
+ Control of Infectious Diseases
 Typhoid fever in US
 Dramatic declines in incidence and mortality - after widespread
implementation of municipal water and sewage treatment systems
 1920: 33.8 new cases per 100,000 population; 1930, 20 new cases, and 1960
less than 1 new case
 Rare disease, with approximately
300 clinical cases reported per
year

http://www.cdc.gov/healthywater/observances/dww-graph.html

© AAPHD 61
Control of Infectious Diseases

HAART= highly active

anti-retroviral therapy

https://www.drugabuse.gov/publications/drugfacts/drug-use-viral-infections-hiv-hepatitis

© AAPHD 62
+ Safer and Healthier Foods
 Early 20th century – contaminated food, milk, water caused
foodborne infections
 1906 – Pure food and drug act
 Food Safety:
 Identification of handwashing, sanitation, refrigeration, pasteurization, and
pesticide application as methods to minimize foodborne infections (TB,
Typhoid fever, Cholera)
 Healthier animal care, feeding and processing – improved food
supply
 Nutrition:
 Food fortification programs decreased nutritional deficiency diseases like
goiter, rickets
 Pellagra elimination in 1940s – improved diet, enrichment of flour with
niacin

© AAPHD 63
+ Safer and Healthier Foods
Number of reported pellagra deaths, by sex of decedent and year – US, 1920-1960

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4840a1.html

© AAPHD 64
+ Decline in Deaths from CVD and
Stroke
 1920s-30s: heart disease and stroke leading cause of death – together
40% of all deaths
 Since 1950- death rates from cardiovascular disease (CVD) declined 60%
 During 1970s-80s – public health interventions to reduce CVD have
benefitted from a “high risk” approach (target high risk people for CVD), and
“population-wide” approach (lower risk for the entire community)
 National programs targeted health providers, patients and public
 National High Blood Pressure Education Program:1972
 National Cholesterol Education Program: 1985
 Reduction due to
 Decline cigarette smoking
 Decrease in mean blood pressure and cholesterol levels
 Changes in diet
 Improvements in medical care and availability of medications

© AAPHD 65
+ Decline
Stroke
in Deaths from CVD and

https://newsarchive.heart.org/progress-against-heart-disease-stroke-reflected-in-latest-statistics/

© AAPHD 66
+ Family Planning
 In 1900, 6 to 9 /1000 women died in childbirth, and one in five
children died during the first 5 years of life.
 Distributing information and counseling patients about
contraception and contraceptive devices was under
illegal federal and state laws

 1912 – Modern Birth control movement began

 Hallmark of family planning – the ability to achieve desired birth

spacing and family size - leading to decreased fertility rates
 Traditional methods of fertility control
 Modern contraception and reproductive health systems
 1972 - Publicly supported family planning services through Medicaid
funding prevented 1.3million unintended pregnancies annually

© AAPHD 67
+ Family Planning

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4847a1.html

© AAPHD 68
+ Healthy Mothers and Healthy
Babies

https://
http://time.com/5090112/infant-mortality-rate-usa/ www.cdc.gov/reproductivehealth/materna
linfanthealth/pregnancy-mortality-surveillance-
system.htm

© AAPHD 69
+ Healthy Mothers and Healthy
Babies
 Infant mortality - Beginning of 20th  Maternal Mortality – Beginning of
century – 100 infants/1000 live births 20th century, for every 1000 live birth
died before age 1 6 to 9 women died of pregnancy
complications
 Improved sewage, refuse disposal,
 Maternal mortality highest
safe drinking water – key role in
between 1900 to 1930 – due to
infant mortality
Poor obstetric education and
 Decline fertility rate – longer delivery practices
spacing of children, small family,  1930s to 40s – White House
better nutritional status Conference Review
 Milk pasteurization – controlled committees
milk-borne diseases  Home births shift to
hospital
 Antibiotics, safe blood
births
transfusions, electrolyte
 Improved institutional
replacements
guidelines
 Vaccinations  Antibiotics, asepsis,
management of
hypertension

© AAPHD 70
+ Tobacco Use
 First decades of 20th century-lung cancer rare
 Per capita cigarette consumption increased from 54 cigarettes in
1900 to 4345 cigarettes in 1963
 Increased smoking lead to more lung cancer cases

 1964 – advisory committee to US Surgeon general

identified – tobacco use as a serious health hazard
 Various public health efforts followed suit
 Health hazards of tobacco established – scientific evidence
 Disseminating this evidence to public;
 surveillance and evaluation of prevention and cessation
programs;
 campaigns by advocates for nonsmokers' rights;
 restrictions on cigarette advertising;
 policy changes (i.e., enforcement of minors' access laws, legislation
restricting smoking in public places, and increased taxation);
 improvements in treatment and prevention programs;

© AAPHD 71
Decline in cigarette smoking

© AAPHD
+ e-cigarettes

https://www.cdc.gov/tobacco/infographics/youth/index.htm

© AAPHD 73
+
Community Water Fluoridation

© AAPHD
+ History
Colorado Springs,
Colorado

 1901 Dr. F. McKay

investigates “Colorado
Brown Stain” (teeth stain)
 1909 – Dr Robertson
observed brown stained
teeth of children drinking
from a locally dug well
 Hypothesis that
something in the water
causes the stain
 1930 Alcoa chemist H.V
Churchill identifies
fluoride by
spectrophotometry -- up to
14 ppm
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4841a1.html

© AAPHD 75
+ History
• 1931 - Dentist H.Trendley Dean appointed to begin the Dental Hygiene
Unit of the newly established National Institute of Health to
investigate
• 1934 - Severity of dental fluorosis categorized as “Dean’s Index”
Compares fluorosis data from 26 states to tooth decay data – identifies
Caries lower in cities with more fluoride in their community water supplies
at concentrations > 1.0ppm
• 1941 - “21 Cities Study” - documented dental caries experience in different
communities dropped sharply as F concentration rose toward 1.0 ppm,
then leveled off
• 1945 – Four pair city study – over 15 years, reduced caries in 50 -70%
children in communities with fluoridated water
• 1950 – US Public Health Services issued a policy statement to American
Dental Association, supporting community water fluoridation
• 1951- Reaffirmed “community water fluoridation” - Official policy of
public health service in testimony before senate

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4841a1.html McLure FJ.

Water Fluoridation – the search and the victory. Bethesda (MD):US Dept of Education
and Welfare, NIH, NIDR: 1970. Chapter 14: 247-9

© AAPHD 76
+ What Is Community Water
Fluoridation?

 The adjustment of the level of fluoride in the water supply

 Current (recommended level of fluoride: 0.7 parts
per
million (ppm) or 0.7 mg/Liter of water (revised in 2015)
 Previous recommended level of fluoride in water: 0.7 to
1.2 ppm or 0.7 to 1.2 mgs/Liter of Water
 Most water supplies contain trace amounts of fluoride.
 Water systems are considered naturally fluoridated when the natural
level of fluoride is greater than 0.7 parts per million (ppm).

http://wayback.archive-it.org/3926/20140108162323/http:/www.hhs.gov/news/press/2011pres/01/20110107a.html

© AAPHD 77
+ Facts about Fluoride
 Fluorine [F] is a member of the halogen family
–
naturally occurring
 The most electronegative of all elements, F -2
 Is extremely reactive
 Occurs in minerals, e.g. fluorspar (CaF2),
(Na 3AlF6), fluorosilicates (Na2SiF6)
cryolite
 Also found in mica, hornblende, pegmatites
(coarse
granite)
 Ranks 17th abundance in earth’s crust (0.06-0.09%)
 Present in sea water (1.2 – 1.4 ppm)
 Occurs in biological mineralized tissue, e.g. bones and
teeth as fluoridated hydroxyapatite

© AAPHD 78
© AAPHD
+ 3 Mechanisms of Fluoride
Action
1. Topical interaction with the enamel
 Remineralization with more acid-resistant apatite - Conversion of
hydroxyapatite into calciumfluoroapatite which reduces the solubility of tooth
enamel in acid and makes it more resistant to tooth decay – topical effect

2. Interaction with the bacteria

 Fluoride inhibits glycolysis, inhibits dextran formation for dental
plaque adherence, and direct effect on bacteria

3. Developmental interaction with enamel

 Reduction in enamel solubility

© AAPHD 80
Calciumfluoroapatit
e crystals – reduced
solubility

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.html

© AAPHD 81
+ Benefits of Fluoridation

© AAPHD 82
https://www.cdc.gov/nchs/products/databriefs/db307.htm

© AAPHD 83
+ Benefits of Fluoridation
 It does not require costly services of health
care
professionals to deliver
 There are no daily –dosage schedules to remember
 No bad taste
 Widespread community water fluoridation prevents cavities
even in neighboring communities that are not fluoridated –
Halo effect or the diffused effect – eating food beverages
processed from fluoride water

© AAPHD 84
+ In United States (2010)

 Total US population – 308, 745, 538

 U.S. Population on Public Water Supply Systems
- 276,607,387
 Total U.S. Population on Fluoridated Drinking
Water
Systems -204,283,554
 Percentage of U.S. Population receiving
Fluoridated Water -66.2%

http://www.cdc.gov/fluoridation/statistics/2010stats.html

© AAPHD 85
+ Dental Fluorosis
 Seriesof conditions occurring in those teeth that have
been exposed to excessive sources of fluoride ingested
during enamel formation

 Older children and adults are not at risk for dental

fluorosis

Mild -Photo by Elke Babiuk Severe-Source of photo unknown

© AAPHD 86
+ Antifluoridation

© AAPHD