Dental Public Health The State of Georgia did an exemplary job of building a strong program for ensuring the good dental health of its citizens between 1859 and 1959. With the help of Georgia Dental Association members, state health officials established a program that ranked among the nation’s top 10 states in public health dentistry when the association celebrated its centennial. Yet they all knew full well that maintaining the leadership position they had establish would require them to overcome a wide range of challenges in the decades that lay ahead. The first and greatest of those challenges involved the fluoridation of water supplies. The ADA and the U.S. Public Health Service had endorsed the fluoridation of public water supplies in 1950. The GDA and the State Board of Health had even adopted resolutions approving fluoridation in municipalities where voters okayed the measure, local dental and medical professions had given their approval, and the community had the resources to meet and maintain the standards mandated by the Georgia Department of Public Health. But selling the benefits of fluoride to a skeptical public at the height of the Cold War turned out to be far more complicated than publishing and doling out copies of irrefutable study results. Despite ample evidence that adding fluoride to water supplies would dramatically improve the dental health of the state’s population, local and state officials resisted the idea for many different reasons, as did large blocs of voters. At the government
level, no agency wanted to have to come up with the funding to pay for such an effort. On top of that, many Georgia citizens didn’t see the necessity in spending any time and effort on something that generations of their families had done without for their whole lives. A few even feared that fluoridating water supplies was a communist plot to destroy America – starting with its teeth. So even though proponent hoped the state would one day require communities to fluoridate their water supplies, the effort mired at the local level for many years to come. Although fluoridation proponents never lost an election prior to 1961, the effort had to be repeated over and over in communities all over the state. Many referendums proved extremely tough and extraordinarily close, too. For example, Thomaston approved fluoridation by a vote of 851-805 in a referendum held on Nov. 1, 1960. In an effort to hold down the profluoridation vote, opponents of the measure had scheduled the referendum for the Tuesday before the November 8, 1960 General Election “While a matter of scientific fact should not be submitted to a referendum in the view of the Georgia Dental Association and the Georgia Department of Public Health, it is a tribute to the pro-fluoridation groups in Thomaston that the referendum was successful,” the Journal of the Georgia Dental Association reported.
The outcome of subsequent referendums in Conyers and Milledgeville proved far less competitive. The Conyers vote marked the culmination of an 18-month profluoridation effort by the Rockdale County Jaycees and resulted in a three-to-one triumph for the measure. Voters in Milledgeville approved fluoridation by a similar margin. The GDA and state public health officials kept churning out information to support the positions of fluoridation proponents elsewhere in the state, too. The Journal reported the results of a study showing that Children in Waycross benefited from the fluoridation of the local water system, even the wells that supplied the system had higher-thannormal natural fluoride concentrations. Another article focused on an Atlanta pediatrician who proclaimed that fluoridation would benefit the health of the state’s children more than drinking milk. The Journal even included a somewhat technical story about the “Effect of Modifying Sub-Optimal Fluoride Concentration” in public water supplies. These and previous efforts to educate the public about the benefits of fluoridation had paid great dividends By 1962, 85 Georgia communities had fluoridated water supplies, although Atlanta wasn’t among them. Donalsonville and many more had joined the number by 1964. The slow pace of the progress and more rapid progress in other states soon prompted a great deal of impatience. Journal editor Paul F. Brown wrote in 1965 that “very positive, progressive action be taken here in Georgia to accomplish widespread fluoridation.” He added: “we urge the department to issue immediately a directive to all water systems with fluoride deficient water supplies to add fluoride to bring the content up to the optimum.” The GDA Legislative Committee expressed association sentiments even more emphatically in 1966, when it passed a
resolution calling on the legislature to form a joint Senate-House committee to study the possibility of a statewide fluoridation requirement. Still, that goal remained several years down the road, as did the resolution of another major public health dentistry issue. For more than a decade, the Council on Public Health had vigorously recommended that the Georgia Department of Public Health (DPH) give greater financial support to Dental Public Health Services. Moreover, the DPH dental division lacked influence in crafting the state’s overall health program, which prompted the GDA legislative committee to call for legislation mandating a statewide dental health program and the funding to operate it. When Dr. John E. Chrietzberg retired in 1967 after 14 years as DPH dental director, the division had three regional consultants, one special projects director, and one hygienist consultant. At the local and county levels, 13 full-time dentists worked in clinics throughout the state, with seven full-time local public health dentists. Another 13 full-time dentists practiced in state institutions. Chrietzberg praised local private practicing dentists who volunteered their time to staff local clinics: “Without their time and support, Georgia would be in poor shape when it came to providing clinical services. These dentists are the backbone of out dental clinic and public health program.” In addition to his role in expanding dental health services through local clinics and helping to champion fluoridation of public water systems, Chrietzberg played an instrumental role in establishing the residency program in dental public health in the state health department and bringing the program to dental students at Emory University. “In was my good fortune to be able to help recruit and appoint this highly qualified and experienced man,” Dr. T.F. Sellers, director emeritus of the state health department said
when Chrietzberg retired. “During Dr. Chrietzberg’s tenure, great progress has been made, not only in dental health education but also in bringing health services through local levels to the children of our state.” “All phases of dental health have generally advanced during his 14 years of service,” he added. “We shall miss him and his services very much.” To Chrietzberg as dental division director, the DPH chose Dr. William T. Johnson. The Arkansas native had lived and worked in Georgia since 1958 and previously served as president of the Georgia Pubic Health Association, regional director with the DPH, director of the Dental Division of the Fulton County Health Department, and professor at the Emory University dental school. Johnson continued to build on the foundation that Chrietzberg established. Within three years, he even managed to land the “big fish” that had long eluded his predecessor and other proponents of fluoridation. On November 5, 1968, the voters of Atlanta and Fulton County approved the addition of fluoride to their water supplies. Buoyed by the success, the state board of health again began pressing the state legislature to require the fluoridation of all water supplies that served 5,000 or more people. Their first attempt to pass the legislation fell nine votes short in the state house. Most of the opposition came from counties that had no fluoridated water systems and saw no reason to require communities to incur the expense of creating them. “It should be just a matter of time before the legislators realize that this is not sponsored for the benefit of dentists, but is a measure that should be passed for the good of the health of the people of Georgia,” GDA president Dr. Marvin M. Sugarman wrote in the Spring 1970 issue of the Journal of the GDA. “It is my belief that the next legislature
should have no problem passing a mandatory fluoridation measure.” It actually took another three years to overcome resistance from fluoridation opponents. But the Georgia legislature of 1973 finally did what its predecessors would not and passed a law to require fluoridation of all public water systems in the state. GDA member and then-representative Dr. John Savage had sponsored the bill, which then governor and future President Jimmy Carter signed into law. (The desk on which Carter signed the measure into law now resides at the GDA office in Atlanta.) Implementing the provisions of the law presented another set of hurdles. The legislature failed to appropriate funds for fluoridation in its next two budgets, and supporters had to obtain funds through state grants. Georgia’s Environmental Protection Division administered these funds, which totaled $400,000 in 1974. These funds enabled 40 public water systems that served 557,000 people to fluoridate their water. The following year, grants totaling $250,000 enabled 40 more systems serving 133,000 people to fluoridate water systems. The overall state of Dental Public Health in Georgia did not fare as well as the decade wore on, however. In 1978, the DPH abolished the division of dentistry in favor of a Georgia Dental Services Advisory Committee that relied on part-time consultation by volunteer district dentists. After utilizing that approach until 1980, the state contracted Dr. John P. Daniels to head up Georgia’s dental public health programs, but that arrangement lasted only until the following year. State health officials reestablished the position of state dental director in 1981, and selected Dr. E. Joseph Alderman to reinvigorate Georgia’s dental public health efforts. Alderman earned his D.D.S. degree from the Creighton University School of Dentistry, his master’s degree in public health
at the University of Michigan, and his residency certificate from the Jefferson County Health Department in Birmingham, AL. He then went into private practice in Denver, Colorado, until becoming a local Head Start dental consultant. Dr. Alderman also became a diplomate of Dental Public Health in 1978. As he settled in at the controls of the Peach State’s dental public health efforts, which now fell under the auspices of the Georgia Department of Human Resources, more and more communities took advantage of available grand money to fluoridate their water systems. In 1984, Alderman reported that 270 water systems throughout the state were fluoridating their water. Yet Alderman knew that much more work lay ahead if Georgia’s dental public health programs were to accomplish their ultimate goal of achieving “optimum oral health for each citizen in Georgia.” He also understood that dentists could play an important role in promoting overall health among their patients. He and GDA Council on Dental Health Chairperson Dr. Anne Hanse demonstrated this conviction in a column about the dentist’s role inn detecting high blood pressure, which appeared in the March 1984 issue of the GDA Journal. Every few years, though, Alderman also found himself in the midst of another legislative battle over funding. In 1991, the Department of Human resources suggested the elimination of all state support for oral health and all support for fluoridation. In response, the GDA House of Delegates passed Resolution 91-25 Support of Dental Public Health Care Program. GDA members and other oral health advocates then helped Alderman pressure legislators into rejecting the idea. Two years later, the EPD and the DNR took their turn at suggesting legislator’s nix the fluoridation program because of budget constraints. Significant input from
fluoridation’s supporters again derailed the effort, however. The DNR’s decision to continue the state fluoridation program also helped the state avoid a major embarrassment. In 1994, the Centers for Disease Control (CDC) awarded Georgia a National Fluoridation Program Award for outstanding achievement in water fluoridation growth. That year also witnessed the release of the Fluoridation Census that the CDC’s Division of Oral Health had conducted in 1992. The study placed Georgia 10th in the nation with 92.1 of its public water systems having fluoridation. Another challenge arose in 1997, when Governor Zell Miller sought to cut the state’s budget by privatizing many state programs. Although many oral health proponents feared privatizing the fluoridation program would lead to its ruin, Alderman accepted the challenge. He spearheaded the effort to establish Georgia Rural Water Association, and soon made Georgia’s privatized fluoridation program a model for others to follow. Dental public health in Georgia got another big boost in 1998, when the Georgia Legislature established the PeachCare program to improve health services to the children of low income families. With funding for dental care available through this program, another proposal to eliminate public health dentistry from the state budget surfaced in 1999. Once again, however, the division and its allies – including the GDA – succeeded in saving the program, which by then served serve the more than 124,000 Georgia children. “Each time we faced the possibility that Georgia’s dental public health program would go unfunded, the GDA took a leadership role in making sure that legislators understood the adverse effects such a decision would have on the health of the state’s citizens,” Alderman said. “Everyone involved with dental public health in Georgia has always placed great value
on the good relationship we have with the GDA.” The arrival of the new millennium brought new responsibilities to Georgia’s dental public health infrastructure. The state’s public health lab took over testing of all fluoridated water systems throughout the state in 2000. Public health dentists and dental hygienists also participated in a variety of community oral health education and prevention initiatives in partnership with private dentists and other health care groups. These endeavors included Georgia Spit Tobacco Education Program activities; community dental sealant, dental screening, early childhood caries, and baby bottle tooth decay education programs; and the Prevent Abuse and Neglect through Dental Awareness (P.A.N.D.A.) program. Georgia’s dental public health program reached approximately 17,570 children with just these programs in 2000. In addition, the U.S. Department of Health and Human Services gave Georgia dental health proponents a new set of goals to which to aspire when it released its Healthy People 2010 guidelines that year. The guidelines established national health objectives and served as the basis for the development of Georgia’s subsequent dental public health plans. Dental Public Health achieved its next major milestone in 2001, when the Division of Public Health established the Georgia Oral Health Prevention Program. The statewide school-based program targeted preschool and elementary school children who were eligible for the free and reduced meal program, who lacked dental insurance, and had no access to a dentist. The program used mobile dental trailers to reach eligible children in seven of Georgia’s 19 health districts. Each trailer contained two chair operatories equipped to perform basic dental services. The trailers operated out of Rome, Clayton, LaGrange,
Macon, Dublin, Valdosta, and Augusta (where two trailers were stationed) By then, Alderman’s contributions to these and other achievements had earned widespread recognition for Georgia’s dental public health program and the work he had done in building it. After becoming the state’s dental health director in 1981, he had served as president of the Georgia Public Health Association in 1981, the Southern Health Association in 1987–1988, American Association of Public Health Dentistry (AAPHD) in 1990, the Association of State and Territorial Dental Directors from 1992–1994, the American Board of Dental Public Health in 1995–1996, and the Georgia Partnership for School Health in 1997–1998. Thanks largely to his leadership, Georgia ranked ninth in the nation in the percentage of water systems fluoridated in 2002. At that time, 92.1 percent of the state residents who relied on public water system enjoyed the benefits of fluoridation. In comparison, the CDC estimated that only 62 percent of the overall U.S. population who relied on public water system enjoyed the same benefits. With these and many other achievements to his credit, and with plenty of budget battles behind him, Alderman finally decided to seek new challenges and retired from the DHR on May 31, 2003. As word got around, praise rolled in from dentistry’s leaders in all parts of the state. “The GDA has enjoyed Dr. Alderman’s unwavering support,” then GDA president Dr. Douglas Giorgio Jr. said at the time. “Both Georgia’s children and organized dentistry have benefited greatly from his experience and guidance.” “Joe Alderman has been a spokesperson for dental public health for 30 years,” Elaine Rutti Cain of the Georgia Rural Water Association wrote at the time. “His message has never been selfish or self serving. It has often
been unpopular and, at times, I feared it would mean the end of his public health career. But that never stopped him.” State officials took until August 2003 to name Dr. Thomas E. Duval as Alderman’s successor. Duval had served as Dental Director of District 5, Unit 2 Division of Public Health from 1998 – 2003. He earned his DDS degree at the Howard University College of Dentistry in 1978 and received post doctoral training at the Johns Hopkins School of Public Health. He also had experience as a staff dentist at the Central State Prison in Macon and as dental director for the Middle Georgia Correctional Complex. Duval quickly set out to determine the oral health status of Georgia citizens more accurately than ever before. Under his leadership, the state would go evaluate the situation more thoroughly and comprehensively than ever before. “We can’t develop strong policy for the future of dentistry without accurate data on the state’s oral health status, Duval said. “To keep improving the quality of oral health in Georgia, we also need more information and analysis on the adult population and the special needs population.” Studies conducted by the DHR during his term as dental director revealed that, although Georgia’s dental public health programs compared favorably to those of other states, much work remained to be done. The most recent report issued by the department, Status of Oral Health in Georgia 2007, revealed that poor oral health remained a significant public health problem among Georgia residents. The percentages of third grade children with caries experience, untreated dental decay, and dental sealants remain below Healthy People 2010 Objectives. The percentage of Head Start children ages 2-5 with caries experience and untreated dental decay failed to meet the standards as well. In fact, the Healthy People 2010 Objectives met by
Georgia were those for adults in the category of dental visits and tooth loss. However, lower income groups failed to meet the adult objectives as well. Dentists per 1,000 Georgians also remain below the national average, and some Georgia counties still do not have a dentist that accepts Medicaid or PeachCare. To address the below-average percentage of dentists in the state, Duval placed a special emphasis on working with the MCG School of Dentistry to provide additional training opportunities to dental students. The division also took steps to ensure that students gained a proper appreciation for the importance of dental public health. “Working together, we are able to provide public health opportunities for senior dental students at clinics across the state,” Duval said. “MCG dental students represent the next generation of our profession, and we need to instill in them the importance of dental public health in Georgia.” “Public Health must also continue working with the GDA, the Medical College of Georgia School of Dentistry, and all other public health advocates to continuously and accurately assess the quality of dental care that the people of our state receive,” Duval said. Duval said. For that reason, Duval cultivated stronger relationships with leaders in education, organized dentistry, and other proponents of public health while serving as state dental director. For example, the department increased its efforts to partner with the GDA on Give Kids a Smile Events and other special observances by allowing members to use the state’s Mobile Dental fleet and staff members on such occasions. He oversaw further expansion of the Mobile Dental Program as well. During his watch, the state added four trailers to its fleet, giving it a total of 11. The state also added a dental services van to its lineup.
Georgia’s statewide Mobile Dental Program is the envy of many states,” Duval said. Thanks to this program and others, Georgia succeeded in providing dental public health care to a record number of Georgia children in 2007. During that fiscal year, a total of 191,475 children received dental prevention, education, and treatment services provided by Georgia’s Dental Public Health Programs. The prevention portion of those services focused primarily on fluoridated water, school-linked fluoride supplement programs for high-risk children, and dental sealants. As of December 2007, 95.8 percent of Georgia’s population using public water systems received fluoridated water. The state also provided fluoride mouth rinse or topical fluoride treatments to more than 9,000 school age children who lacked an adequate source of fluorides, such as children in rural areas who get drinking water from privately owned wells. More than 8,000 additional children received sealants during the course of the year. This form of treatment involves placing a plastic coating on the chewing surfaces of permanent molar teeth to seal out food and bacteria that cause tooth decay. The department also continued to expand its dental education efforts in 2007, as Public Health dental hygienists taught nearly 65,000 school children the importance of proper brushing, flossing, and good nutrition for good dental health. Screenings and referrals remained an important part of the department’s overall oral health strategy too. By identifying common problems such as dental decay, gum disease, and malocclusion early, dental public health professionals saw to it that thousands of youngsters received prompt treatment that eliminated pain, prevented infections, and headed off progressive oral diseases. In all, more than 60,000 school children underwent screenings and were subsequently referred for treatment as a result of public health dental programs.
Of this total, dental public health personnel provided more than 47,000 diagnostic, preventive, and basic dental treatment visits to eligible children during 2007. Children eligible Free and Reduced Meal Program who needed emergency dental services because of pain, infection, or rapidly deteriorating condition got first priority. The basic treatment services they received included examinations, cleanings, dental sealants, silver (amalgam) and tooth colored (composite) fillings, stainless steel crowns, minor nerve treatments, and extractions. Payment for dental treatment services is based on a sliding fee scale based upon ability to pay, although many health departments have a minimal administrative fee. Duval believes that continued emphasis on public education and preventive care will continue to improve the overall dental health picture in Georgia. He and other experts predict that the use of fluoride varnish will play a major part in this effort in the years to come. Fluoride varnish and prevention programs designed especially for young children in Head Start and other preschool programs are now being implemented statewide by public health to reduce dental caries. “Public health in Georgia has taken the lead in educating dentists about the importance of fluoride varnish in preventing caries in the younger population,” Duval said. “The birth-to5 age group is the only part of the population in which caries is not in decline.” “Fluoride varnish has been approved by the American Dental Association as a safe and effective way to prevent dental caries in young children,” said Dr. Stuart Brown, Director of the Division of Public Health. “With this treatment, we have a great opportunity to prevent childhood tooth decay and promote both the oral and overall health of a child.” With fluoride varnish treatment and education programs established and many other successes to his credit, Duval announced
that he would step down as state dental director in the final months of 1997. The DHR selected Dr. Elizabeth Lense as his successor. She inherited a dental public health program that remained among the nation’s finest, yet had many more opportunities to make positive contributions to the health of Georgia citizens. To continue improving the state of oral health, the DHR’s dental division will remain committed to: • Developing, supporting, and promoting effective efforts in disease prevention and service delivery. • Educating the public, health professionals and decision-makers about the importance of oral health to total well-being. • Expanding the knowledge base of dental public health and fostering competency in its practice. To guide its efforts in these areas, the division will soon have a new set of national guidelines to which to aspire as well. The federal government has already begun work on its Healthy People 2020 guidelines, which will call on Georgia’s dental public health community to achieve even higher standards of excellence. In addition, Lense and her colleagues will have to continue coping with the uncertainty that has surrounded the PeachCare and Medicaid components of the dental public health equation since three Care Management Organizations (CMOs) took over administration of the programs at the beginning of 2007. The CMOs instituted 14 cost control measures in the first seven months after taking over the programs. These included closing dental networks, changing age and frequency limitations, altering prior approval requirements, substantially reducing fees, and unilaterally terminating more than 100
primarily large Medicaid providers from existing networks. These and other CMO actions generated so many complaints from health care providers and others that state leaders had to take action. Near the end of the 2008 session, both houses of the legislature, the offices of the governor and lieutenant governor, the GDA, the Medical Association of Georgia, and the hospital association teamed up to draft House Bill 1234, the Medicaid Management Organization Act. The groundbreaking legislation passed in the final hours of the 2008 legislative session and was signed into law by Governor Sonny Perdue on May 13, 2008. The law placed CMOs under the auspices of the state insurance commissioner’s office, included provisions that addressed verification of patient eligibility, prohibited recoupment when providers followed established eligibility verification guidelines, required CMOs to maintain a web site for claims payment (complete with information on the dental provider network), and allowed dentists to challenge closed provider panels in shortage areas. The GDA and dental public health proponents also scored another victory on behalf of their PeachCare and Medicaid patients during the session. The GDA succeeded in convincing the legislature to include dentists in the list of providers who would receive a 2.5 percent increase in reimbursement rates for dental services provided under the programs. Yet with more such uncertainties likely to arise in the future, longtime oral health advocates agree that it will become even more essential for organized dentistry to have a strong voice in the development, implementation, and operation of effect dental public health programs during the GDA’s next 150 years.
“We must ensure that we have dental representation wherever strategies for public health are developed,” Duval said. “We have to make sure the dental health interests of everyone in Georgia are considered by anyone with the authority to make changes in dental public health programs and the dental care elements of Medicaid and PeachCare.” “The oral health of future generations of Georgians will depend on organized dentistry’s continuing support for sound dental public health programs in the state,” Alderman said. “The voice of organized dentistry must always be heard loud and clear when it comes to determining to best ways to provide these services in the state of Georgia.”