Abstracts of Papers and Posters

Vol. 50, No. 3, Spring 1990 207

1989 A A P H D A N N U A L M E E T I N G

Abstracts of Papers and Posters

Opening Scientific Session k Symposium: Ethical Issues in Contemporary Dentistry

CORBIN S, USPHS, Centers for Disease Control; HOROWITZ H, USPHS Ret.; Private Consultant; MUMMA R, Executive Director, American Association of Dental Schools; SADDORIS J, Past President, ADA; Private Prac- titioner; BIDDINGTON WR, President, American College of Dentists; Dean, W W School of Dentistry; SAVAGE T, Presi- dent, Rockhurst College.

Standards of ethical conduct have been increasingly dominating political, scientific, and social institutions in this country in recent years. While frequently sensationalized evidence of questionable ethical behaviors by individuals in leadership positions is presented regularly in the media, little insight is offered as to what practical steps society, institutions, and professions can take to help ensure ethical behaviors.

Dentistry has formalized itsethical positioninthe "American Dental Association Principles of Ethics and Code of Profes- sional Conduct." Still, the very nature of ethical decision making is rarely a simple black or white matter. A panel of senior dental leaders will present personal perspectives on ethical decision making in dentistry. They will address specific areas ofdentalresearch, education, administration,and practice in which they have accumulated significant experiences and opinions relative to professional ethics.

It is anticipated that, as a result of the presentations, a con- sensus paradigm for ethical decision making in dentistry will emerge. Reaction to the presentations will be provided by a nondental professional educator with a broadly based background and experiences in ethical decision making.

Scientific Sessions 11: Symposium: Tobacco Intervention at the Clinical, Com-

munity and Organizational Level: What Works?

National Cancer Institute COMMIT and ASSIST programs:Tobacco use intervention in the 1990s. PECHACEK TF, Smoking, Tobacco and Cancer Program, National Cancer Institute, NIH, Bethesda, MD.

The tobacco industry is shifting its market strategies to main- tain profits in an increasingly hostile public environment. Pro- health forces must do likewise. In recent years, the National Cancer Institute supported over 50 major studies to scientifically determine which tobacco use intervention services are most effective. Based on findings, large scale community intervention projects have been organized for the 1990s. The Com- munity Intervention Trial for Smoking Cessation (COMMIT) was initiated in 1986 to establish a nationwide cooperative intervention program in 22 US communities. It involves 2 million people in the testing of smoking cessation strategies delivered through existing community organizations and social institutions. The second project is called the America Stop Smoking Intervention Study (ASSIST). It is being organized now and will go into states and large metropolitan areas beginning in 1994. It will involve 50 million people. Other interven-

tionactivities aredevelopingas an outgrowth of theexperiences gained with these projects.

"I don'VI won't: smokeless tobacco education for schoolchildren grades K3." BRUERD B, KINNEY MB, BACK- INGER CL, Health Policy Consultant, 1095 Kathy Way S, Salem, OR

Centers for Disease Control, Dental Disease Prevention Ac- tivity,designed ateaching unit forgradesK3.Theteachingunit is named "l Don't/I Won't" and is a series of seven activities designed to prevent young children from using smokeless tobacco. Older students (grades 5-7) were trained in each community to teach the younger students. This is a variation of peer teaching called "cross-age" teaching. Three state sites and three Indian Health Service sites were selected to participate in a pilot test of the teaching unit. Within each of the six sites, one school was randomly assigned to the intervention and one school to the control group. A total of 1,324 children participated in the pilot test. The evaluation design was a randomized untreated control group with pretest and posttest. The results of the outcome evaluation demonstrated significant, although modest, increases in knowledge, attitudes, and behavior. This presentation will describe the intervention and evaluation design, report both the outcome and formative evaluation results, and present recommendations for future implementation of the teaching unit.

Oral health organizational opportunity and commitment. MECKLENBURG RE, Consultant in Health Policy and Ad- ministration, Potomac, MD.

One year ago, the Association sponsored a special meeting to learn about tobacco industry stratagems and to identify means by which dentistry can counteract their marketing of products that lead to addiction, needless illness, and premature loss of life. In late October, another panel addressed issues of ethics and equity in the development of tobacco intervention strategies. This panel focuses on practical considerations of tobacco intervention strategies in relation to oral health service provider involvement.

This paper reports on the several events that have occurred within the past year to helpensure that theoral health team and dental organizations in the United States are directly, a p propriately, and routinely influencing the public to avoid and discontinue the use of tobacco. The National Cancer Institute decision to include the dental profession at several levels in its initiatives has produced several benefits. Smoking issues are often expanded to include all tobacco products. Emphasis on clinical intervention seMces continues, but the professional role in professional and community affairs and by personal example in daily living has been recognized for their importance. NCI publications now increasingly refer to "health professionals," rather than physicians only. Progress in or- ganizing support for oral health team intervention services, developing education programs that increase knowledge and skills, developing recommended dental organization tobacco- related policies, and strategic planning will be described.

208 Journal of Public Health Dentistry

Scientific Session 111: Symposium: Can People with AIDS Get the Dental Care

They Need?

The dental profession has come under attack for denying people with AIDS the dental care they seek. Newspaper headlines claim that dentists are refusing to treat those who are HIV-infected ("Dentists Shun AIDS Patients") and that, as a result, dentists are being sued for breach of antidiscrimination laws ("AIDS Bias Suit Against Dentists"). Messages like these give the profession a negative public image and give the public a poor model for reacting to people with AIDS.

Is the media's portrayal of dentistry's response to the AIDS epidemic accurate or misleading? Several recently completed studies have examined whether dentists deny care, drawing on the perspectiveof community dentists, public health providers, people with AIDS/HIV, and the general public. The results of these studies will be presented in this session. The issue is complex and subject to change as the HIV-infected population needing dental caregrows. Evidenceaboutthecunt situation can help us develop appropriate policy responses. Time will be allowed for discussion and input from the audience.

AIDS and dentistry: an interpretive portrait of a profession's response to a crisis. CORBIN s, DDS, MPH,* US Centers for Disease Control.

This presentation will reflect upon dentistrfs struggle to identify its appropriate role in the AIDS epidemic during the 1980s. The actions, policies, and options of governmental and private organizations will be reviewed relative to their con- tribution toward resolving the most pressing needs of AIDS patients, dental providers, and the public. The ways in which AIDS may affect dentistry in the future will be considered.

Public perception as an influence on access to care AIDS and dentistry. GERBERT B, PhD,* MAGUIRE B, SUMSER J, PhD, and SPITZER S, PhD, University of California, San Francisco.

Most dentists (up to 85%) are worried that patients may leave their practice if it becomes known that they are treating people with AIDS. To explore whether dental patients might seek another dentist under such circumstances, we interviewed by telephone 1,825 dental patients in the summer of 1988. Thirty- three percent of respondents said they would change dentists if their dentist or hygienist were treating someone with AIDS. This finding was consistent across sex, ages, racial groups, and areas with different prevalence rate of AIDS. More patients would switch dentists than would change physicians, possibly because patients believe that blood is more frequently associated with dental work. Implications: Would all patients who say they would changeprovidersactuallydoso?If patients would really leave the practices of dentists who treat people with AIDS, how can dentists be convinced to act professionally and continue to treat people with AIDS?

Are the headlines accurate: how frequently do dentists refuse to care for people with AIDS? SUMSER J, PhD,* GER- BERT B, PhD, MAGUIRE B, CHAMBERLAIN K, GREENBLATT R, MD, McMASTER J, MSW, University of California, San Francisco.

To explore whether people with AIDS are frequently denied dental care, we conducted three studies. In November 1988 telephone interviews with 754 gay men in San Francisco

revealed that only 1.5 percent reported being denied dental care. A second study in March 1989 showed that 11 percent of 535 people with AIDS who attend an outpatient AIDS clinic at the University of California, San Franasco repolted they had been denied care by dentists. A more indepth look at the issue was provided by focus groups made up of gay men and of men who used intravenous drugs and gay men in Seattle and Los Angeles in June 1989. Most participants in these groups believed that people with HIV disease were having difficulty obtaining dental care. They ascribed these difficulties to HIV status, riskgroup membership, and lackof financial resources. Implications: These data indicate that if only a small portion of persons with AIDS are having difficulty obtaining care it can result in a widespread impression that dentists as a group are refusing to treat persons with AIDS. Will this impression result in a reluctance of persons with HIV to seek needed dental care or to conceal their HIV status when seeking routine care?

Why are some dentists willing to treat people with AIDS? MAGUIRE B,* GERBERT B, PhD, SUMSER J, PhD, UNvm- sity of California, San Francisco.

To examine the correlates of reluctance to provide oral health care for people with AIDS and HIV disease, we analyzed responses to a mailed questionnaire from a representative random sample of US dentists conducted in February 1989 (n=233, response rate=75%). The dependent measure used was a reliable (alpha in this sample=.81), eight-item, reluctance-to-treat scale developed and validated in previous work. The relationship of this variable to demographic characteristics, previous AIDS-related experience, and scales measuring perceived risk of HIV infection, infedion control practices, and skill in per- forming oral soft-tissue examinations were examined using hierarchical multiple regression, with the results shown in the table.

Step Beta StepR2 P

Demographic .03 .01 Age .16 .02 Sex .09 .16 Practice size -.05 .42

HIV experience .07 c.01 # of AIDS cases -.11 20 # of HIV+ cases .20 .02

Scales .20 <.01 Perceived risk .44 <.01

Oral examination skills -.03 58 Infection control practices -.14 .02

We conclude that dentists' reluctance to treat people with HIV disease seems largely driven by perceived risk of infection. This may be compounded by inadequate infection control practices. Programs that target the problem of access to dental care for people with HIV disease need to address psychosocial issues such as perceived risk, as well as technical ones such as methods of infection control.

Dental health care resources for HIV-infected persons: the role of the public and nonprofit private sectors. HARDWICK

Vol. 50, No. 3, Spring 1990 209

K, DDS, MPH,* GERBERT B, PhD, SUMSER J, PhD, MAGUIRE 8, BSc, SCHNEIDER D, DDS, MPH. Health Resources and Services Adminishation, US Public Health Service; University of California, San Francisco.

One hundred and twenty-three public or non rofit private

oral health care services to people infected with HIV in the 25 cities with the highest prevalence of AIDS. Administrators of these facilities were asked to respond to a written questionnaire exploringtheir capacityto providethenecessarydental services to this special population. We will report on the number of HIV-infected patients served, the types of care rendered, whether patients had to wait for care, referral patterns to and from the facility, and other information pertaining to the administration and function of these facilities.

facilities (including dental schools) were identifi J as providing

Contributed Papers I: Preventiofiducation Programs

1. Sealant policy and utilization in state dental programs: characteristics associated with sealant usage in Vennont. GERLACH RW,* SENNING JH, Vermont Department of Health, Burlington, VT.

Several factors are reported to contribute to limited utilization of dental sealants, including restrictions associated with sealant coverage by dental insurers. The paper reports the impact of sealant coverage on utilization in a state-financed dental program in Vermont. Dental claims filed during October 1988-March 1989 for Vermont's 'Tooth Fairy'' program for children were analyzed for characteristics associated with sealant utilization. Sealants made up 6 percent of all services provided under "Tooth Fairy," with 8.4 percent of treated children receiving at least one sealant. Children received an average 2.8 teeth. Utilization of sealants exceeded amalgams by 1 .5:1, with preference demonstrated for sealing first permanent molars. Age distribution of sealant cases is reported to be consistent with expected eruption sequences. Despite relatively unrestricted coverage, less than one-third of all participating dentists provided sealant services to "Tooth Fairy" patients during the study period. In Vermont, improved access to sealant services may be achieved through expansion of the provider base and support for sealant placement on second permanent molars of children at risk for dental caries.

2. Preventing caries in the Caribbean with limited resources. MEHLISCH DF, DDS, DrPH*, SIU School of Dental Medicine, Alton, IL.

Overwhelming national medical problems in contrast to national dental needs, orientation toward "treatment" rather than "prevention," limited funding for dental health programs and lack of expertise in dental health may prevent many developing countries from mounting programs to prevent dental caries. Nevertheless, school-based NaF tablet demonstration programs are possible in the Caribbean by utilizing the expertise of volunteer public health dentists, indigenous dental personnel, and without extensive financial support. Such demonstration projects are useful to generate baseline epidemiologic data, prepare accurate estimates of costs and cost effectiveness, assess acceptance levels, and facilitate transfer of "ownership" from foreigners to nationals. In addition, a highly visible demonstration p r o w may generate considerable political support for expansion to a national scale.

The results of an NaFtablet program in Haiti after two years of a fiveyear demonstration p r o w PROJEX DENTS GAIES

(Project Happy Teeth) in parochial and public schools are reported. Described are the extensive planning required by the volunteer PH dentist, the sources of the limited funds, and the difficulties encountered to first secure a letter of understanding with the Ministry of Public Health, and then diredly involve Haitian DPH personnel in the project during the second year. The successful outcomes are shared with encouragement for replication in other developing countries in the Caribbean ar- chipelago.

3. Provider compliance with recommended dietary fluoride supplement protocol. LEVY SM,* MUCHOW G, College of Dentistry, University of Iowa, Iowa City, IA.

Proper water fluoride (F) assay is essential if dietary F supplements are to be used appropriately for caries prevention by children without optimally fluoridated water. Little is known about the communications that occur between parents and providers both prior and subsequent to water F assay. The p q s e of this paper is to report on dentist/physician/parent interaction and their outcomes concerning dietary F s u p plementation.Two hundred sixty-seven parents were surveyed three to four months after water F assay. Ninety-one percent reported that a health care professional had recommended water Fassay. Among these, 75 percent reported initial consult- ation with a dentist, 21 percent with a physician, and 5 percent other. Eight percent reported contacts with second health care provider. Patients in the study were aged 0-11, with mean and median age of three. Types of parent/provider contacts after water F assay were: regular appointment (a%), telephone (41%), special contact in person (8%), and main (8%). Assess- ment of children's sources of drinking water showed that 63 percent received water outside the home (day care, 38%; school, 30%), yet only 20 percent of the providers asked about these other sources. Seventy-three percent of children received an F supplement prescription and 14 percent of them received it prior to the assay results. When considering only primary source of drinking water, 32 percent of the child patients and 43 percent of their siblings received an incorrect supplement even after the assay results were known. Considering multiple sources, 42 percent of identified child patients' prescriptions were incorrect. Numerous errors in supplement protocol were identified. Providers must be encouraged to consider multiple patient water sources and further individualize F dosage recommendations to balance caries prevention and dental fluorosis. Supported by the American Fund for Dental Health.

4.Public knowledgeand attributeeabout community water fluoddation. ISMAN, R, DDS, MPH,* California Department of Health Services.

There is relatively little information in the recent social science literature that describes current public opinion about community water fluoridation. Because of increasing public concern over the quality of drinking water, and because of demographic changes in the population that include increasing proportions of minorities and the elderly, it is important for proponents of fluoridation to be aware of the changes in the public's knowledge and attributes about fluoridation. This paper will describe a recent public opinion survey on fluoridation in several demographically distinct communities in California. The survey methodology included oversampling certain population groups for which very little prior information was available on attributes toward fluoridation. The paper will describe how the survey findings are being used to target


educational efforts aimed at fluoridating these communities.

5. From a disastrous community water fluoridation program to a leader. LEO JN, PE,* Chief Evaluation & Technical Assistance, Indian Health Service.

In 1959, the US Congress passed Public Law 86-121 wherein the Indian Health Service (IHS) was given the authority and opportunity to improve the environmental health conditions for groups of Native Americans and Alaska Natives. While the major emphasis of this bill was to provide sanitary water and waste disposal to the home, it also provided for the installation of community water fluoridation equipment. While the IHS provided fluoridation equipment between 1959 and 1978, there was little if any fluoridating being done. That is not to say that attempts have a viable program were not addressed between 1959 and 1978. However, all efforts met with littleor no success. In addressing the issue again in 1978, it was imperative that a systematic approach be taken to identify why the program had been unsuccessful and to provide solutions. This presentation will detail a step-by-step process of how an unsuccessful community water fluoridation program, where only 8 of 325 fluoridated systems, or 2 percent, were providing optimally fluoridated water at a point in timeto the present where wenow have +520 of +700 fluoridated systems, or +70 percent, providing optimally fluoridated water. Inventory, funding, policy, design, installation, training, and probably most important, reporting and accountability will be addressed.

6. AIDS train-the-trainer preventionleducation program for dental professionals: a pilot demonstration. FINE JI,* McCARTHY PK, Dental Health Bureau, Alameda County Health Care Services Agency, Oakland, CA.

In Alameda County, California, which has the fourth highest prevalence of HIV infection in the state, dental public health officials had growing concerns about occupational exposure and cross-contamination, implementation of universal precau- tions, and assurance of access to dental care for patients with or at risk of HIV infection. In addition, the recognition of the potential for the dental community to play a significant preventive role through the early detection of oral manifestations or riskbehavior led to thedevelopmentofacomprehensiveeduca- tional intervention for dentists, dental hygienists, and dental assistants. Since the success of the intervention was dependent on addressing the knowledge, attitudes, and practices in the local dental community, a train-the-trainer model of education dissemination, which had been successfully implemented with other health care providers, was developed to emphasize inter- active learning strategies and produce an educational stand alone capability in the community.

Three hundred dentists, hygienists, and dental assistants attended a twoday expert educational program, “AIDS and HIV Infection in the Dental Setting.’’ Fifty of the attendees expressed interest in becoming trainers, and eight were selected to attend a twoday training covering instructional strategies and infection control assessment. These trainers subsequently conducted four eight-hour courses reaching 108 dental prac- titioners and performed infection control reviews in 20 dental offices.

Preliminary analyses show significant improvement in will- ingness to treat HIV-infected persons. Comparison of knowledge, attitudes, and practices between attendees of the expert training and those trained by the trainers will be reported, as will recommendations for general applicability.

7. Infection control practices and beliefs of Minnesota dental hygienists and dental assistants. HASTREITER RJ,* JACKSON MH, DANILA RN, HECKERT KA, Minnesota Department of Health, Minneapolis, MN.

In late 1988, an infection control mail survey of a random sample of Minnesota dental assistants and hygienists was conducted. Response rates were 60 percent (426/599) for assistants and 71 percent (381/632) for hygienists. The survey found that 87 percent of assistants and 98 percent of hygienists always wore gloves, 42 percent of assistants and 64 percent of hygienists always wore a mask, 49 percent of assistants and 54 percent of hygienists always wore nonstreet clothes uniforms, and 48 percent of assistants and 47 percent of hygienists always used protective eyewear. Dental office injuries and mucosal splashes of blood were higher than previously reported by dentists. In the past year, 33 percent of assistants and 13 percent of hygienists experienced needlesticks; 72 percent of assistants and 71 percent of hygienists incurred instrument wounds; and 45 percent of assistants and 51 percent of hygienists had blood splashes to the eyes, nose, or mouth. Seventy-two percent of assistants and 65 percent of hygienists reported that staff m a p needles with an unprotected hand. Only 5 percent of assistants and 9 percent of hygienists believed that the private practice dental office was the best place to treat HIV-infected persons. Forty-three percent of assistants and 47 percent of hygienists indicated that they were willing to provide care for HIV-infected persons, but 77 percent of both groups said staff were uncomfortablein doing so. Whereas28 percent of assistants and 32 percent of hygienists felt that dental offices had a legal responsibility to treat HIV-infected persons, 56 percent of assistants and 61 percent of hygienists said it was their ethical responsibility to provide care. Eleven percent of assistants and 19 percent of hygienists said that staff had refused to care for HIV-infected persons. This survey indicates that positive changes in infection control practices and access to care for HIV-infected persons is occurring, that additional improvement is indicated, and that there is considerable dissonance between some of the beliefs and the practices of assistants and hygienists.

8. Infection control practices of Mississippi dentists. SIL- BERMAN SL,* TRUBMAN A, ALEXANDER WN, University of Mississippi School of Dentistry, Jackson, MS.

There has been inconsistent and inappropriate use of infection control practices in the dental office. In addition, there is a great deal of concern about providing treatment to patients with AIDS. The recent ADA Survey of Dental Practice added significantly to the literature; however, the sample contained responses from less that 2 percent of Mississippi dentists. To establish baseline levels of attitudes, knowledge, and practices regarding infection control practices and AIDS, and dental practice, a pretested 38-item questionnaire was sent to all registered dentists (1,018). The response rates was 52.2 percent (531), with 504 usable questionnaires. The majority of dentists (66.4%) have taken the hepatitis B vaccine and another 14.0 percent say they plan to take it. Most practicing dentists do not determine the patient’s history with recreational drugs (76.6%), IV drug use (865%), HIV antibody (64.6%), or AIDS (54.2%). Most dentists believe that barrier protection is effective in con- trolling the transmission of AIDS, hepatitis, and herpes (>85%). Actions toward this belief are mixed, as 78 percent use gloves, 52.2 percent use masks, and 76.7 percent use protective eyewear with all patients. The majority of dentists are willing to treat

Vol. 50, No. 3, Spring 1990 21 1

patients with herpes (79.5%), or hepatitis (75.1%), but not with AIDS (33.9%). In fact, only 6.8 percent of dentists believe that AIDS patients ought to be treated in private practice. The majority (85.4%) view hospital clinics and public health facilities as the place for treatment. These data, as well as additional information retrieved from this questionnaire, will be presented and discussed.

9. Alameda County geriatric dental care program case study in community organization. FINE JI, PRATT DF,* Den- tal Health Bureau, Alameda County Health Care Services Agency, Oakland, CA.

The Alameda County Geriatric Dental Care Program was created to provide dental care to the residents of skilled nursing facilities (SNFs) regardless of their ability to pay for services, utilizing volunteer dental providers. Working together with the Alameda County Dental Society, the Dental Health Bureau launched a campaign to educate the community regarding the need for elderly dental care, obtain sponsors and raise funds for portable dental equipment. The first phase of activity climaxed with a benefit held in September 1987 at the Oakland Museum, cosponsored by numerous local politicians, community organizations, threedental societies, Proctor & Gamble, California Dental Association, community leaders, and others.

An eight-part continuing education series on "Elderly Dental Care" was provided during the summer of 1988, resulting in a 58-minute videotape produced for SNF staff education. Sixteen dentists and one dental hygienist volunteered to participate in the pilot year. Utilizing state grant funds for program development and coordination in 1 9 W 9 and the commitment of over 1,100 volunteer hours, examinations and treatment were provided to residents of threeSNFs, working with each facility's advisory dentist. An educational module was developed and in-services are provided for SNF daily health care workers. Revenue from treatment is recycled into operations and an aggressive campaign of fundraising from corporations and foundations is underwaytoensurefutureviability. Revenue for the first 12 months of treatment is projected at $25,000 to $30,000. A steering committee meets quarterly to provide guidance and strategy. The program's success to date ex- emplifies the partnership among the health department, local dental community, elderly organization, and private corporate sponsors. Details of community organization and garnering of volunteer support and services are described.

Contributed Papers 11: Geriatric DentistryEpidemiology

10. Monitoring long-term care regulations: a cooperative statewide project. ENTWISTLE BA,* NEAGREES J, BERKEY D, University of Colorado School of Dentistry and Colorado Department of Health.

HCFA recently issued new requirements for dental care in nursing homes that receive federal funds. Legislative actions in some states already mandate this responsibility, but monitoring is sporadic and difficult. In 1984, a survey in Colorado docu- mented variable compliance for using an advisory dentist, providing annual in-service training, and following writtenoral hygiene policies. Dental care was perceived as a low priority by nursing home personnel. In 1987, the state survey team evaluated 11,115 patients alld 179 facilities on six oral/dental parameters; 22 percent of the patients were rated as having poor oral care. In 1988, only one parameter was used in the 110 facilities surveyed. Mid-year 1988, the health department

dropped all monitoring of dental regulations, demonstrating their perception of oral health as a low priority. The Statewide Steering Committee for Oral Care for the Elderly initiated a formal objection to this action, leading to a joint dental school and health department project to design a meaningful monitoring system. This project generated (1) protocols for interpreta- tion and monitoring of dental regulations; and (2) training packets and workshops for surveyors, advisory dental personnel, facility administrators, nursing personnel, direct care staff, and ombudsmen. Effectiveness of these efforts will be reviewed annually to establish incentives and feedback mechanisms for nursing home staff, ultimately improving the oral health of patients in long-term care facilities.

11. California geriatric dental health promotion project: attitudes of the elderly toward dental services. FAINE RC,* ISMAN RE, California Department of Health Services.

The California Geriatric Dental Health Promotion Project is attempting to increase the level of knowledge about oral disease prevention for the well elderly in senior centers and congregate meal sites. Dental health education materials developed by the project will be provided by volunteer dental professionals. Part of the program will involve the training and updating of oral health assessment skills of public health nurses employed by local health departments to screen the elderly at senior centers. Screening data on the elderly will be collected by public health nurses in oral lesions, edentulous rates, dental treatment patterns, and enrollment in dental insurance plans. Approximately 600 seniors were screened in six target sites in California for this project. A separate questionnaire was administered to the elderly on the value of dental services to the individual, economic status of the group, utilization profiles, and what "barriers," if any, prevent senior citizens from seeking dental care. Over 700 seniors responded to this survey in all target countries.

12 Development of geriatric oral health promotion survey instruments. BARDUHN MS,* FURMAN L, SZPUNAR S, KINNEY MB, State University of New York, NY, US Centers for Disease Control, GA.

Despite recently compiled data on the oral health of American adults, there are limited data on a number of salient oral health issues of the elderly. The present study was conducted at the US Centers for Disease Control's Dental Disease Prevention Activity through the Gerontological Society of American's Postdoctoral Fellowships in Applied Gerontology Programs. Instrumentation to measure the dental health knowledge, attitudes, preventive practices, oral functional status, dental activities of daily living, perceived intergenera- tional dental health influence, and intended voting behavior on dental health issues, such as community water fluoridation, of the largest segment of the older population, the noninstitution- alized (or community-living) elderly was developed and is now available for use in public health dental programs.

Following a review of existing literature from the fields of gerontology, dental public health, behavioral psychology, and geriatric dentistry, small focus groups of elderly were convened at several sites throughout the country to identify mapr dental health concerns and issues through a nominal group process format. Data gathered from these groups were employed to develop both a 94-item self-administered survey and a 12-item telephone survey instrument. An 11-member panel of reviewers from the fields of dental public health, gerontology, and geriatric dentistry and a five-member panel of consultants


in epidemiology, health promotion, and research design from the staff at the US Centers for Disease Control assisted with content validation of the instruments.

This report presents the methodology used to develop and revise these survey instruments, along witha review of relevant literature. Increasing recognition of the need for comparable data on the dental health of the elderly has led to the develop ment of instruments that can be used to establish such a data base.

13. Five-year tooth loss and edentulism among the elderly. HAND JS,* KOHOUT FJ, University of Iowa, Iowa City, LA.

Little is known about the incidence of tooth loss in any subpopulation. This study presents self-reported tooth loss data from baseline and five-year followup interviews conducted during a longitudinal epidemiologic study of the entire elderly population of two Iowa counties. Sixty-two percent of this population were dentate at baseline.

Of the 1,542 dentate people for whom baseline and five-year followup data were available, 36.6 percent reported they lost at least one tooth, and those who lost some teeth reported an average of 3.3 teeth lost. Two and nine-tenths percent of this dentate population became completely edentulous and an additional 2.7 percent becameedentulous in one arch only. Seven- ty-five percent of those who became completely edentulous were dentate in only one arch at baseline.

Men were more likely than women to report losing at least one tooth, but there was no sex difference in the incidence of complete edentulism. Edentulism incidence was associated positively with age and negatively with education. the prevalence of edentulism was virtually the same at followup as it was at baseline, due mainly to a higher death rate among the edentulous subpopulation.

14. Gains in elders’ dental care use not shared by minority elders. JONES J, FEDELE D,’ BOLDEN A, VAMC, Bedford, MA and Harvard School of Dental Medicine.

The percent of older Americans who used dental services within the past year increased dramatically over the past 30 years, from 16 percent in 1957-59 to 42 percent in 1986. This growth, however, has not been evenly distributed across racial/ethnic lines. In 1957-59,17 percent of whites and 9 percent of nonwhites had seen a dentist in the last year. By 1986, these percentages increased to 44 percent of whites, 21 percent of blacks, and 28 percent of Hispanics.

If we define “users” of dental care as persons who use services within two years, in 1986 25 percent of black and 36 percent of Hispanic elders were users compared with49 percent of white elders. This represents essentially no change in users among black elders between 1986 and 1975 (when 28 percent were users), contrasted with an ll-point increaseamong whites during this same period. Similarly, if “nonusers”are defined as persons not using services in over five years, in 1986 only 34 percent of whites, 38 percent of Hispanics, yet 50 percent of blacks were nonusers. This represents no change for black elders since 1975, versus a decline of 12 percent for whites.

Our presentation will review NCHS data, examine 30-year trends in dental care use by minority elders, identify factors contributing to between-race discrepancies, and suggest strategies for improving minority elders’ dental care use in the decades ahead.

15. Perceived competency/relevancy of skills associated with treating gemdontic patients. BERKEY DB,* MANN JM, CALL RL, University of Colorado School of Dentistry and Hebrew University, Israel.

Determining and providing the appropriate primary, won- dary, and tertiary dental care for geriatric patients who have altered physiology, take multiple drugs, and make errors in comprehension and compliance can be especially difficult. In 1987, Colorado dentists were asked to complete a questionnaire addressing55 district dental skillsthat might be necessary when treating a 75-year-old female patient. For each question, the dentist was asked to address two issues: their competency regarding the procedure, and the relevance of the competency. Both were evaluated on a six-point scale with the 1 representing low and 6 high. A random sample of 598 Colorado dentist6 was selected, with a total response rate of 475 percent. The mean age of the nondental specialist respondents was 44.4 years. Recognizing that prevention is generally the best solution to preserving oral health, it is interesting to note the following comparatively low mean scores and low relative competency and relevancy ranking for several preventive dentistryaiented skills: diet analysis (c x=3.30, r x=3.71; c rank 49, r rank 48, r rank 501, prescribing artificial saliva (c ~ 4 . 4 2 , r x=4.19; c rank 48, r rank 47), assessing patient functional status (c xd.74, r x=3.84; c rank 47, r rank 491, and preventing and containing root caries (c x=4.70, r xA.13, crank 35, r rank 27). A more definitive effort to motivate and train dental professionals in the prevention of dental diseases affecting the elderly seems warranted.

16. Medication use and xerostomia of homebound elders in Boston. MONOPOLI M,* CRUM P, MARCUS P, KASTE L, ALLUKIAN ML, DOUGLASS C, Veterans Administration, Bedford, MA, Veterans Administration, Sepulveda, CA, and Harvard University, Boston, MA.

Homebound elders use numerous prescription and nonprescription medications with potential adverse side effects. The most common oral side effed is xerostomia. This study assessed the medication usage, self reported compliance, and clinical level of xerostomia of homebound elders in Boston. A list of homebound people over age 65 was provided by the Boston Visiting Nurse Association and four neighborhood health centers. One hundred seven randomly selected people were interviewed in their homes. A tongue blade drawn against the buccal mucosa and graded on a four-point scale was used to assess mouth moisture. Homebound elders consumed an average of 4.07 (SD4.72) prescription and 1.46 (SD=1.54) nonprescription medications. Sixty-five percent took one or more medications with xerostomia reported as a potential side effect. Fourteen percent wereassessed to exhibit xerostomia. Diuretics were the most frequently used medication with xerostomic potential. The total number of prescribed medications was moderately correlated with the number of potential xerostomic medications consumed (Spearman corr=.60). Clinical mouth moisture was weakly associated with total number of potential xerostomic medications (Spearman corr=.19) and with total number of antihypertensives (Spearman corr=-25). We conclude that homebound elders use a significant number of prescription and nonprescription medications that may produce xerostomia. However, use of potential xerostomic medications alone was not strongly associated with clinical manifestation of xerostomia. This study was supported in part by the Medical Foundation, Inc.

Vol. 50, No. 3, Spring 1990 213

17. Sdace-spedfic caries patterns from a national survey in schoolchildren: implications for sealant use. SWANGO P,' BRUNELLE J8 EODPP, NIDR, NIH, Bethesda, MD.

The 198687 NIDR National Survey of Oral Health in School- children provided dental caries examinations from more than 40,000 subjects representing the entire population of US schoolchildren in grades K-12. These data were used to compute age-specific caries attack rates for each tooth surface in the permanent dentition. Despite a general decline in caries prevalence during the past two decades, caries remains a problem in pit and fissure surfaces of molars. About 10 percent of first molars and 15 to 20 percent of second molars are affected by occlusal caries within two years after eruption (by age 8 and 14, respectively). By age 17, about 60 percent of first molars and 40 percent of second molars have occlusal canes or restorations. In contrast, the proportion of mesial or distal surfaces attacked is only 6 to 12 percent in first molars and less than 3 percent in second molars at the same age. These findings underscore the need for placement of fissure sealants as won as possible after eruption of molars. They also show that the likelihood of sealed occlusal surfaces being involved later as part of multisurface restorations for mesial or distal caries is relatively low. Com- parison of these findings with data from two earlier national surveys show that occlusal caries in molars at age 17 is about 10 to 25 percent lower than reported in the NIDR survey of 1979-80, and 20 to 40 percent lower than in the WANES I survey of 1971-74.

18. Periodontal attachment loss in 14- to 17-year-old US children. BHAT M,* Epidemiology Branch, National Institute of Dental Research, Bethesda, MD.

A national survey of oral health in US schoolchildren was conducted during 1986-87. Periodontal attachment loss was measured in millimeters, using the NIDR probe, on buccal and mesial sites of 28 permanent teeth. This report represents the findings of 11,111 surveyed children, aged 14 to 17 years, who represent an estimated 13,295,404 US schoolchildren in this age group. The national estimates for prevalence of attachment loss, assessed by the presence of attachment loss of 2 mm or more, on either the buccal or mesial sites was 21.7 percent and showed a tendency to increase with age. Prevalence of attachment loss was 23.6 percent for males and 19.8 percent for females. The slightly higher prevalence of attachment loss was 16.4 percent for whites and 40.6 percent for nonwhites, with whites showing less than half the prevalence recorded for nonwhites at all ages. The national estimate for mean attachment loss was 0.33 mm, and varied little with age. The mean attachment loss was 0.26 mm for buccal sites and 0.40 mm for mesial sites, and these figures also varied with age. Mean attachment loss was 0.35 mm for all males, 0.31 mm for all females, 0.30 mm for whites and 0.45 mm for nonwhites. A detailed analysis of these findings will be presented.

Contributed Papers III: Oral Epidemiology

19. Strategies for improving the oral health of Native Americans. COLLINS RJ, DMD, MPH,' Dental Services Branch, Indian Health Service.

Surveys have demonstrated that American Indians suffer from a large backlog of oral disease. The prevalence of oral diseases, such as dental canes and periodontal disease, are much higherthanin thegeneralpopulationoftheUnitedStates. The Indian Health Service (IHS) provides dental services to

American Indian and Alaskan Native people in a variety of settings, such as hospital8 health centers, mobile dental units and at hundreds of field locations using portable equipment. An increasing proportion of dental programs serving Indian people am operated by Indian tribes or corporations.

This presentation will describe the establishment and monitoring of objectives for an oral health program, as well as some of the methods used by the IHS to make maximum use of the resources available. The concept of Community-Oriented Primary Care (COPC) is used as a model for the planning and delivery of health services in the IHS. The presenter will describe the use of epidemiologic services information to provide a rationale for program development and operation.

20. Computerized support for dental public health practice the IHS experience. NIENDORFF W,DDS,MPH,* WHITTH, DDS, Indian Health Service, Dental Services Branch, Albu- querque, NM.

The use of computers in dental practice is rapidly increasing. Commercial software currently available for dental practice does not supply the range of information needed to manage a communitywiented public health program. This paper discusses the planning and development of software to serve the practice of dental public health in offices operated by the Indian Health Service (IHS).

Dental practice in the IHS entails the use of health information from various sources. With recent advances in computer technology, the IHS has begun to integrate its existing data bases it uses for resource management and patient manage ment. The automation of patient records is being designed to support care delivery, program planning and evaluation, and research.

The dental portion of the patient record integrates workload data as well as basic epidemiologic measures for monitoring needs. Existing applications and those under development will be discussed.

21. Oral health patterns and research opportunities in Na- tive American communities. BOTHWELL ED, DDS, MPH, PHD,* Indian Health Service, Dental Services Branch, Albu- querque, NM.

The Indian Health Service Dental Program (IHSDP) is responsible for the provision of oral health treatment and preventive services for Native American groups across the USA. Consistent with the principles of "Community-Oriented Primary Care," the IHSDP has been attempting to scientifically describe the oral health problems in Native American communities both in terms of oral health status and the contributing mial/behavioral variables. Through a series of oral health-related surveys and studies, the IHSDP has identified unique oral health problems including (1) baby bottle tooth decay prevalence in excess of 50 percent for preschoolers in many communities, (2) high prevalence of severe early onset periodontal disease in some Native American groups, (3) very high smooth surface caries experience in several Native American groups, (4) smokeless tobacco use rates in excess of 30 percent for school-aged boys and girls in several communities.

The purpose of this presentation is to present some of these findings in the context of unique opportunities for further scientific description of these conditions and their prevention and treatment through collaborative research efforts with interested dentalresearch institutionsand the 1HSDP.These opportunities


are facilitated by the assessments of oral health behavior and outcome. Furthermore, new funding sources have earmarked support for Native American health improvement projects.

22. An oral health survey of Head Start children in Alaska. JONES DB,* SCHLIFE CM, RDH, MPH, WHITT HM, Indian Health Services, Alaska Area Native Health Service, Anchorage, AK.

The Rural Alaska Community Action Program (Rural CAP) administers a Head Start program for 975 children in 32 communities located throughout Alaska. The budget for the Rural CAP program has been chronically underfunded. The Indian Health Service (IHS) has been looked on as the primary provider of dental services for children in most Head Start centers since these programs were predominantly Alaska Na- tive children. In rural Alaska, the IHS and Alaska Regional HealthCorporationdentistsprovidecaretoHead Start children on an itinerant basis. Factors such as inclement weather, cost of air transportation, limited funding, and a shortage of dental providers have created a situation in which many children are not receiving the dental care they require. The IHS has developed an Automated Oral Health Survey System to assess oral health status.

A computer-generated treatment needs and cost assessment model also have been developed. This paper will present the results of the oral health survey, the treatment needs, and cost analysis. Rural CAP will use the treatment needs information to advocate for more funds to treat these children. The results of an analysis of the correlation of several demographic, economic, and behavioral variables with the oral health status of these children will also be presented.

23. Canes experience in children on one Native American reservation. KASTE L,* MARIANOS D, PHIPPS K, Harvard School of Dental Medicine, Boston, Indian Health Service, Whiteriver, AZ, and Oregon Health Sciences University, School of Dentistry, Portland, OR

Native American children have been reported at high risk for baby bottle tooth decay (BBTD). The purpose of this study was to assess the caries experience for children in a reservation preschool program and their dental care utilization, versus their caries presentation approximately ten years later. Chart audits of the dental examinations made in preschool year 1977-78, medical record reviews, and dental examinations with brief questionnaire for the corresponding 98 childrp in 1988, were conducted. BBTD was defined as two or more carious maxillary incisors, or caries specifically on buccal or lingual surfaces in maxillary incisors. The population was 50 percent female, the mean age at the examination was 15 years (SM8.6). The chart audit yielded mean defs of 18.9 (SM17.0), BBTD prevalence of 68 percent for definition 1 and 37 percent for definition 2. The mean number of dental visits was 10.9 (SW5); ds appears to be the best predictor for DS (r=.45). BBTD does not seem to have extensive prediction for future caries experience in this population with low dental care utilization and high caries prevalence.

24. Oralhealthhabitsamongteenagers in Helsinki,Beijing, Hanoi, and Hochiminh City. AINAMO J,* AINAMO A, KAG LIO P, Department of Periodontology, University of Helsinki, Helsinki, Finland.

During a WHO consultationship in 1987 in Vietnam and China, a questionnaire study was conducted to clarify the oral health habits of 14- and 15-year-old schoolchildren. In Hanoi,

Hochiminh City, and Beijing, groups of 200 children (100 boys and 100 girls) filed out the questionnaire at school. In 1988, the questionnaire was answered by 200 schoolchildren of the same age in Helsinki. Of the Finnish children, 90 percent had seen a dentist during the last 12 months as compared to 10 percent of the children in Beijiig and Hanoi. In Hanoi, 52 percent had never visited a dentist. The Beijing children were the ones that most often visited a dentist because of toothache or to have fillings or extractions. Toothpaste was not available in Vietnam. In Beijing all children brushed with toothpaste but only 23 percent used fluoride toothpaste. In Beijing and Vietnam, the primary reason to brush the teeth was "to feel clean." In Hel- sinki, 89 percent used fluoride dentifrice at least once daily and the primary reason to brush the teeth was "to avoid cavities." In all cities, bleeding from the gums had been observed by >50 percent of the children.

25. Trends in oral disease: the Kentucky experience. LEWIS GP,* WILLIAMS JN, FOWLER R, YANDELL B, MOORE D, University of Kentucky and University of Louisville Colleges of Dentistry, State of Kentucky, and Kentucky Dental As- sociation.

Various Kentucky institutions and agencies cooperated in a statewide survey of oral health in 1987. The survey consisted of two components: a household interview of adults aged l8years or older, and a screening examination of household members. The purpose of the survey was to gather baseline information on dental disease prevalence, treatment needs, attitudes, and behaviors. This paper will report highlights of the clinical protocol, survey methodology, and selected findings. Two pretests were conducted to assess the response of households to the clinical screening. The in-home appointment method yielded a very low response rate. Urban areas demonstrated lower response rates than rural areas. The final protocol consisted of screenings, conducted in county health departments with subjects being paid to participate. Interviews were completed for 1,319 households representing 3,809 persons. A total of 392 households consisting of 906 adults and children were screened statewide. Selected oral disease findings include: prevalence of TMJ muscle pain/tenderness, d percent; active ortho treatment, 2.5 percent; 7 5 percent, edentulous; 59.6 percent >= 1 decayed coronal surface; 9 percent >= 1 decayed root decay; 13 percent, no clinical decay. CPITN findings: calculus (68%) and bleeding (785%) on one or more surfaces. The results indicate low levels of TMJ symptoms and moderate levels of caries and perio conditions in the sample population.

26. Use of students' oral health information data base at high school. TAKADA K, YASUDA Y, HIRASE E, SAKAMOTO M, SAKUDA M,* Osaka University Faculty of Dentistry, Centerfor School Health, MukogawaGakuin High School, Japan.

The current report describes a personal computer-assisted data base available both for administration and promotion of oral health conditions for high school students. Oral health examinations have been performed annually since 1976 at a private high school that has a population of about 3,900 students. The raw data were recorded by dentists, school nurses, and students and processed for subsequent use. A data base of oral and general health conditions of these students (1976-86) has been constructed and prevalences of carious teeth were evaluated both on cross-sectional and longitudinal bases. In- cidences of carious teeth for the first and second molars ranged

Vol. 50, No. 3, Spring 1990 215

from 7 to 9 percent for grade 12in 1975, and gradually decreased to 3 percent in 1986. Caries incidences of the samegroup of teeth for grade 9 were 8 percent and 5 percent in 1976 and 1986, respectively. Longitudinally, the molars revealed peak caries incidences at grades 9 and 10. After grade 11, the proportion of treated molar teeth increased significantly. These results suggest the significance of oral health care during the adolescent period. The proposed data base system facilitates understanding students' oral health conditions in a comprehensive way and promotes the extension of their own knowledge on oral health through their participation in the examination program.

Contributed Papers IV: Health Services

27. Dental training of health personnel in rural areas of Peru: results and problems. MAUTSCH W,* Unidad Depart- mental de Salud Cusco, Peru.

In the regions of Cusco and Apurimac, there are only 28 dentists working in the Public Dental Health Services. They have to meet the demand for emergency dental care of more than a million people. Nearly all of them work in urban or suburban hospitals or health centers; only two of them work in rural health centers. Out of 106 districts of the Department of Cusco, only 15 districts have one or more dentists in Public Dental Health Services.

To avoid people having to resort to the services of persons promising to relieve the pain but who mostly lack any formal training and who have only inadequate equipment at their disposal, the Regional Health Departments of Cusco and Apurimac, in cooperation with the German Agency for Techni- cal Cooperation (GTZ), have established a dental training and supervision system for auxiliary health personnel.

The author will present the training program he has estab- lishedduring thelast twoand one-half years,discusstheresults, and focus on problems that have been emerging while the training program has been carried out.

28. Attitudes and enrollment of Army families in dental insurance. CHISICK M,* US A m y Health Care Studies and Clinical Investigation Activity, Ft. Sam Houston, TX.

In August 1987, the Army initiated a dental insurance plan for soldiers' families. No study explored their attitudes toward this plan. This study measured attitudes and enrollment of families at one Army post. In March 1988, parents of 905 children in grades P-6 (96 percent of eligibles), representing 654 families, completed a self-administered questionnaire. Results show that 57 percent of families considered the plan a loss of benefits; 66 percent felt coverage was inadequate. Overall, 66 percent of families enrolled. Of families who thought coverage adequate, 89 percent enrolled versus 51 percent of those who thought coverage inadequate. Queues (40%) and limited services (37%) at military clinics were primary reasons cited for joining. Major reasons for not enrolling included: inadequate range of services covered by the plan (36%), highcost of off-post dental care (18%), and preference for military clinics (16%). Parents who thought their children needed dental care were slightly more likely to enroll in the plan (66%) than those who did not (62%). Enrollees (73%) were willing to pay more for expanded coverage than nonenrollees (52%). Quality and range of services appeared to heavily influence enrollment in the dental insurance plan. Expansion of benefits should enhance enrollment and satisfaction among Army families.

29. Collecting utilization data on VA dental longitudinal paltidpants. MCGUIRE SM,* DOUGLASS CW, BROWN LJ, CHAUNCEY H, Harvard School of Dental Medicine, Boston MA.

The NIDR, VA, and Harvard School of Dental Medicine are planning a major new study to determine the longitudinal relationships among (1) oral health status, (2) professional determined need-for-treatment, and (3) the utilizationof dental care. This pilot study tested the feasibility of retrospectively collecting valid and reliable dental care utilization data on participants in the VA Dental Longitudinal Study (DLS). Oral health status and a variety of socioeconomic information have already been collected over the past 20 years. The 1%8-71 DLS baseline oral health status data were divided into four disease severity categories, from little or no disease to high levels of dental caries and/or periodontal disease. Ten participants per category were randomly chosen from 1,221 original participants. An in-office visit was used to collect the data, ADA code, charge, and cost to patient (charge minus insurance coverage) for each service rendered.

Complete dental utilization records for an 11-year span wen? obtained for 76 percent (28 of the 37) of the DLS participants sampled. An example of analysis includes findings that show fixed prosthodontics accounts for 26 percent of all charges, but only 3 percent of counts of all services. A regression analysis showed that cost per service increases with increasing education level. We conclude from this pilot study that a full scale retrospective study of the dental care utilization of DLS participants is feasible.

This project was funded by NIDR, Grant 5T32 DEO 715144.

30. Dental licensure in the common market: implications for US. FREED JR,* BLOCK LE, University of California-Los Angeles, School of Dentistry, University of Minnesota, School of Public Health.

Recently in the United States, there has been an increasing interest in lessening restrictions on the ability of dentists to move their practices from state to state, a suggestion that has been met with resistance by state licensing boards. While debate continues, dramatic changes are occurring in licensing of dentists in Europe so that by theend of 1992 there will be fewer legal restrictions on a dentist moving from France to the United Kingdom than from New York to California. The process leading to this change started in 1957 when the Treaty of Rome, which formed the European Economic Community (EEC), was ratified. The treaty called for the free movement of persons, services, and capital among the member nations (which now number 121, and was based on the philosophy that restrictions on freedom inhibit and distort competitive markets so that efficient producers are not rewarded. This philosophy is the same as that underlying many of the approaches suggested in the United States to control health care costs by promoting competition. This paper will examine licensure of dentists in the European countries prior to the EEC, the transitional periods leading to the free movement of dentists after 1992, and the implications of the Europeanexperience for licensureof dentists in the United States.

31. Dental public policy implications of Eyeglasses 11. BLOCK LE,* School of Public Health, University of Min- nesota.

In a controversial and precedent-setting action, the Federal Trade Commission has issued a trade regulation rule, "Eyeglas-

21 6 Journal of Public Health Dentistry

ses 11"- series of rules that prohibit various state restrictions on optometrists' practices. Among the prohibited state restrictions are rules that would prohibit limitations on the number of offices an optometrist may own, prohibitions on optometrists' use of trade names and prohibitions on nonoptometrists from owning optometric practices and employing optometrists. This action by the FTC sets up a conflict between the Preemption and State Action doctrines and thus pits the federal government against state governments: if Eyeglasses I1 is upheld on appeal, it would override current state laws prohibiting such practices. Optometry is being used as a bellwether for the other professions for the FTC. If the FTC wins this legal battle, it could then attempt to implement similar prohibitions on states that prohibit similar forms of practices of dentistry, the very ones recommended by the FTC's San Francisco Regional Office in its 1981 final report of its investigation of the dental industry. Now for the first time, the results of their investigation can be made public. The differences between optometry and dentistry may not be enough to keep the FTC from next attempting to override state dental practice acts. This paper will analyze "Eyeglasses 11" and the FTc's justification for its promulgation, present the F K s constitutional tension created by FTC's action, and sum- marize theFTC'sinvestigationof thedental industryasit relates to prohibition or restrictions of forms of dental practice.

32. Factors influencing professional satisfaction among male and female dentists. PIERCE KL,* POWELL BJ, DURANT RH, Departments of Community Dentistry, Oral Diagnosis and Patient Services, Pediatrics, Medical College of Georgia, Augusta, GA.

Professional satisfaction among dentists has been a topic of research interest in recent years. The purpose of this study was to compare the level of professional satisfaction among male and female dental graduates from the Medical College of Geor- gia, and to determine if any gender differences existed in factors influencing professional satisfaction among dentists. A 161- item questionnaire was used to survey a random sample of 276 male and 71 female dentists. Th? overall response rate was 65.4 percent UV=227). Maleand femaledentists did not differ in their overall professional satisfaction with dentistry. Female dentists were significantly more satisfied than male dentists in nine of 20 areas of dental practice and in ten other areas related to practicing dentistry and managing their dental practices.

When factors influencing overall professional satisfaction were investigated using multiple regression analysis, 58.8 percent of the variation in t he dentists' professional satisfaction was explained by the following six variables: dentists' level of satisfaction with their chances for professionalgrowth (355%), satisfaction with their present job position (11.2%), dentists' level of satisfaction with their income (5.7%)' satisfaction with the patients' acceptance of their treatment plan (3.4%), respect received from patients (1.5%), and satisfaction with their mar- riage and other interpersonal relationships (1.3%). Gender did not account for a significant amount of variation in overall professional satisfaction. These results have implications on dental education. Those factors that tend to promote p b satisfaction need to be addressed both in dental school and in continuing education courses.

33. Survey of state/local health departments regarding of dental services. EASLEY MW,. ENTWISTLE BA, University

of Detroit and University of Colorado. Fifty-one state health departments (SHDs) and 1% local

health departments (LHDs) were surveyed regarding dental services to 11 special population groups. Of 40 SHDs responding, <20 percent provide clinical services to HIV/AIDS/HBV patients, while <40 percent provide such services to other groups; 30 percent provide prevention programs and <40 percent provide educational programs. Of97 LHDs responding, 40 percent provide clinical services to HIV/AIDS/HBV patients, while <60 percent provide such semices to other groups; 41 percent provide prevention programs and <45 percent provide educational programs. SHDs finance clinical services with state funds (So%), federal grants (53%), third party reimbursements (43%), and user fees (23%). LHDs finance clinical services with local taxes (79%), user fees (51%), third party reimbursements (49%),and stategrants (29%).Twenty-ninepernt of SHDs and 56 percent of LHDs provide translators; 49 percent of SHDs and 49 percent of LHDs use non-English educational materials. Thirty-two percent of SHDs and 28 percent of LHDs indicate state practice acts impede care for special populations. Data suggest that in SHDs and LHDs the 11 special population groups experience uneven access to services, HIV/AIDS/HBV patients are less likely than most other groups to receive services, and there is a continuing need to address access at the highest policy levels.

34. Prediction of overall dental practice quality using only radiology items. HUNT RJ,* FANN SJ, KANTOR ML, MOR- RIS AL, University of Iowa, University of Connecticut, and University of N o d Carolina.

The DEMCAD dental office quality assessment instrument was developed to collect measures of structure and process in dental practices to assess practice quality. This previously validated instrument takes about six hours to complete. Sub- sequent analysis was undertaken to determine whether an abbreviated office assessment based on the evaluation of radiology items alone was sufficiently sensitive, specific, and practical to be used as a screening instrument for identifying dental offices with very low evaluation scores. Data for this analysis were obtained from 300 general dental practices evaluated in the field testing of the DEMCAD instrument.

Stepwise regression analyses showed that the nine radiology structure items assessed predicted very poorlytheoverall structure evaluation scores. However, other stepwise regression analyses showed that each of four of 13 radiologypmess items (periodontal diagnoses recorded, interdental bone shown on x-rays, caries diagnoses recorded, and current x-rays mounted) were significant predictors (P<.OOl) of overall process quality and produced a combined R2 of 0.58. Discriminate function analysis using these four radiology variables predicted the 10 percent of the dental practices with the lowest overall process score with 87 percent sensitivity and 93 percent specificity. Two of these items (periodontal diagnosis and caries diagnosis), when combined with two other nonradiology process sub- scores (treatment plan development and all data recorded), predicted the 10 percent lowest process scores with 97 percent sensitivity and 90 percent specificity. This analysis showed that anabbreviated dental practice process quality assessment could be practical and easy to apply as a screening test, yet produce a high level of sensitivity and specificity.

Vol. 50, No. 3, Spring 1990 217

Contributed Posters I: Oral Epidemiology

35. Trends in dentist manpower in Iowa. FELDS HM,* JAKOBSEN JR, LOGAN NS, University of Iowa College of Dentistry.

During the years 1973 to 1988, the Iowa dental relicensure form was used to collect self-reported data on demographics, professionaleducation, typeof practice, work location,and time worked. A practicing dentist was defined as one who had an office location within the state, had patient appointments 30 weeks or more per year, and delivered dental services to the public as a primary activity. The number of actively practicing dentists has gradually increased until 1988. There were 1,209 practicing dentists in Iowa in 1973,1,207 in 1978,1,296 in 1982, 1,327 in 1986, and 1,305 in 1988. The proportion of female dentists is currently 4.3 percent (3%-ADA, 1986). Eighty percent of the dentists are University of Iowa graduates. Seventy- six percent of the dentists indicated that they were in a solo type practice and 14 percent indicated that they practiced a dental specialty. The median age of Iowa dentists has gradually decreased from a high of 29 in 1978 to a low of 41 in 1986. In 1988, the median age was 43 (&ADA, 1986). The median number of weeks worked per year has ranged from 46 in 1973 to 48 in 1988 (47-ADA, 1986). In 1973, the dentist worked 38 hours providing patient care per week, 37 in 1984, and 36 hours in 1988, (33-ADA, 1986). There has been a gradual increase in the total number of actively practicing dentists until 1986. The small reduction in 1988mayindicate that the numberof dentists in Iowa has peaked. This has been projected (AADS) to happen in 19% for all US dentists. The declining median age of Iowa dentists appears to have reversed due in part to fewer new graduates entering practice as more pursue additional training.

36. Antimicrobial effects of processing radiographic films. BACHMAN C,* WHITE JM, GOODIS HE, Department of Dental Public Health and Hygiene, Department of Restora- tive Dentistry, University of California, San Francisco, CA.

Radiographic equipment and the surrounding environment are areas of contamination and crosscontamination. Sampling these areas in a clinical setting confirms that radiographic processing rooms are not sterile. The purpose of this investigation was to determine effects of radiographic processing on five types of microorganisms. Intentional contamination of film packets placed in an automatic radiographic processor was done to show the effects of the processing on the microorganisms. Intraoral films were contaminated with known concentrations of B. subtilis, E. coli, s. aureus, s. mutans, and s. marcescens. Two films were contaminated with 0.1 ml of bac- terial solution with concentrations between 108 and 10" or- ganisms/ml. Unprocessed control films were swabbed with either bacteria or sterile nutrient broth, and the samples in- cubated immediately. Test films were run in series through the processor to simulate clinical usage. Films, solutions, and surfaces showed significant contamination when compared to negative controls (Pc.05). The degree of contamination was not affected by the number of cycles. Film and fixer have significantly fewer colonies than developer and water. Bacteria on radiographic film survive processing. Solutions became contaminated by microorganisms. While processing procedures significantly reduce the number of bacteria on films, the potential for contamination and crosscontamination remains.

37. Income, dental health and dental health habits in Nor- wegian adults. LERVIKT,. HOLMBAKKEN N, HAUGEJOR- DEN 0, Public Dental Services, County of Telemark, Skien, Norway, and Department of Community Dentistry, Univer- sity of Bergen, Bergen, Norway.

Most dental services for the adult population in Norway are paid entirely by the patients themselves. Annual examination free of charge for the individual user has been suggested to raise the percentage of adults seeking regular dental care. The present study was undertaken to measure the effect of an offer of freedental examination in any dental office on theattendance rate of 300 randomly selected Norwegian adults born in 1930 and 1945. In addition, different characteristics of the participants' dental health and habits were registered in a clinical and radiographic examination combined with a self-administered questionnaire. Net income was extracted from offi- cial tax protocols. Sixty-five percent accepted the offer of a free dental examination. No difference in net income was found between those who responded and those who did not. In- dividuals with higher income had on average more teeth (Pc.05). Regularity of dental care was similar in low- and medium/high-income groups and $5 percent visited a dentist regularly. Main reason for visit was recall by the dentist. It is concluded that in a population like this, an offer of free dental examination is unlikely to increase regular dental attendance significantly.

38. Association between use of removable dentures and some background factors. AINAMO A,* TERVONEN T, NIEMINEN P, Institute of Dentistry, University of Helsinki, Institute of Dentistry, and Department of Biostatistics, University of Oulu, Finland.

Random samples aged 25,35,50, and 65 years were examined with respect to their dental conditions. A questionnaire was used to chart social factors, availability of dental services, a p preciation of natural teeth, and opinions and experiences of dental care received. Logistic regression analysis was used to test which variables best described and discriminated subjects with full dentures from those with natural teeth with or without removable dentureb). Female sex, high age, low education, high appreciation of natural teeth, and low annual income were found to be significantly associated with theuseof fulldentures. The selected model correctly classified 79 percent of the subjects with full dentures (sensitivity, 85.3%; specificity, 77.5%). The probability of having any removable denture was found to be significantly associated with female sex, high age, low education, and opinions such as dental care is too expensive, ashamed of not going earlier to the dentist, it is not the dentist's business to take care of my teeth. The fina1 fitted model correctly classified 78 percent of the subjects with any kind of denture (sensitivity 82.3%, specificity 75.4%).

39. Second molarcaries experience: implications for sealant programs. KUTHY RA,* BRANCH LG, SIEGAL MD, Ohio State University, Boston University, Ohio Department of Health.

Dental caries, particularly in the pit and fissure surfaces, remains a prevalent disease among children. School-based dental sealant programs area viablemethod to substantially reduce the caries experience of children. During the 1987-88 school year, 4,879 Ohio schoolchildren participated in an assessment of dental health. Grades chosen for this particular assessment included6,7,8,and 11.Thisstudyinvestigated somepredispos-


ing and enabling factors for those children with occlusal caries experience without proximal involvement on the second permanent molars. Among 1,913 children the influence of gender, grade, race, locale, fluoridation status of the community, percentage of children participating in free and reduced lunch programs, method of payment for dental care, and utilization of dental services was examined using an ordinary least squares, multiple regression model.

The percentage of children with at least one erupted second molar, but no occlusal caries experience, ranged from 93.0 percent of those children in sixth grade to 59.0 percent for children in 11 th grade. Conversely, 0.8 percent of the sixth grade children and 9.8 percent of those in l l th grade had occlusal caries experiences on all erupted second permanent molars. Only 3.5 percent of the l l th grade students had proximal caries experiences on one or more second molars.

The regression model indicated that 12.1 percent of occlusal caries experience in second molars is explained by the selected variables. When grade level is deleted from the regression model, only 2.9 percent of occlusal caries experience is explained by the remaining variables. These data suggest that factors other than demographic variables must be studied before planners can successfully target children for dental sealant programs.

Funded, in part, by the Ohio Department of Health and the Robert Wood Johnson Foundation.

40. 1988 Oral health survey of Navajo schoolchildren. GREEN LD,* MCFADYEN J, Tsaile IHS Clinic, Tsaile, AZ.

During the spring of 1988, a cross-sectionaloral health survey of 2,046 Navap schoolchildren was conducted by calibrated dental examiners from the Navap Area Indian Health Service Dental Program. Students were randomly selected from grades 1, 3, 6, 9 and 12 at reservation and adjacent schools and examined for caries experience, periodontal condition, and tobacco product usage.The examination data was entered into a data base via a direct data entry system using laptop portable computers operated by dental assistants. Caries rates overall were found to be slightly below the national average found by the 1979-80 NIDR survey (DMFS of 1.88 versus a national average of 2.02). The mean CPITN score for the Navajo schoolchildren was found to be 1.60. Nine percent of the children surveyed admitted to regular use of smokeless tobacco. Results from the Navajo Area Oral Health Survey are currently being used in the implementation of program strategies for the prevention of oral health problems on the reservation.

41. Assessing dental education outcomes: a concern for public health dentistry. FIELDS WT,* University of Ten- nessee College of Dentistry.

Given our primary goal of improving the oral health of the public, public health dentistry has a legitimate interest not only in the number and distribution of dentists, but also in the skills they bring to bear on the problem. With the notable exception of water fluoridation, no function of public health dentistry has as much potential for influencing the dental health of the public as molding the dental curriculum.

Historically, curricular revision has been sluggish, frag- mented, and reactive; however, recent actions indicate a national trend toward more thorough and ongoing assessment of educational outcomes, representingan uncommon opportunity to influence curricula in a planned and timely manner. Skills in the scientific method and expertise in program planning and

evaluation techniques prepare us to provide leadership in es- tablishing the data base, assessing curricular outcomes, and revising the dental curriculum to reflect the changing needs of society. The opportunity for impact is unprecedented and we must accept the challenge! This poster describes the superstruc- ture of an educational outcomes assessment program built on Andres Steinmetz's Discrepancy Evaluation Model, focusing on the interrelationship of context, input, process, and product (educational outcomes). Standards, data sources, and data collection instruments will be addressed.

4 2 Comparisons of patient and professional evaluations of dental practices. C U L L JJ,* MORRIS A, University of Con- necticut, University of North Carolina.

This research seeks to investigate the relationships between patient and professional evaluations of dental practices using data obtained during field testing of the DEMCAD office assessment instrument in 300 general dental practices. The DEMCAD instrument contains 248 items aggregated into 19 components related to the structure, process, and outcome dimensions of dental practice. Our previous analyses demonstrated comparatively high correlations (r=0.40-0.79) among structure, pmess, and outcome dimension scores relative to other reports in the health care evaluation literature. However, the correlations between patient satisfaction (one of the components of outcome) and the structure and process dimension scores were found to be substantially lower (rd.09 and 0.18, respectively).

The present study sought to further the investigation by examining relationships among the scores obtained 'for the various components of structure and process and the overall practice ratings supplied by more than 2,200 patients. Results showed that aggregate scores for five of the 12 components comprising the structure and process dimensions were correlated with patient ratings at a level greater than r4.10-those being personnel, data collection, diagnosis, treatment, and patient management. However, when patient ratings were regressed on those five component scores, patient management was the only variable that was significant at the .05 level. Therefore, results of analyses conducted to date suggest that ratings obtained from patients and professional evaluators via the DEMCAD instrument on dental practice attributes should be viewed as complementary, not as substitutes.

43. Dental studentdattitudes toward chemical dependency and related issues. SANDOVAL VA,* HENDRICSON WD, DALE RA, WOOD RC, University of Texas Health Science Center at San Antonio Dental School.

It is conservatively estimated that 10 percent of the US population suffers from chemical dependency, including alcoholism. The implications of this widespread illness include not only the possibility that dentists will become dependent or will be used as sources of drugs, but also that an increasing number of dental patients will be in the active or recovering phases of this disease. Dentists' attitudes toward these issues can therefore influence their management of affected patients and colleagues. This study utilized 12 items from the Substance Abuse Attitude Survey (Chappel, 1985) to evaluate dental students' attitudes toward some issues relevant to chemicals and chemical dependency. Students in all four classes were surveyed (N=366). Data analysis was accomplished byKruska1- Wallis one-way ANOVA at a significance level of .01. Followup testing between groups was obtained by Student-Newman- Kuels procedure. Significant differences between freshman and

Vol. 50, No. 3, Spring 1990 219

senior classes included responses to statementscontending that alcoholism is associated with a weak will, that well-groomed people probably don't use illegal drugs, that drug abuse is a treatable illness, and that addicted doctors should not be allowed to resume practice. Results favor the prospect that positive influences are imparted to students as their education progresses.

Contributed Posters 11: PreventioniEducation Programs

44. Development of a geriatric oral health assessment index. DOLAN TA,* ATCHISON KA, University of Florida, College of Dentistry and UCLA School of Dentistry.

Oral health status and dental treatment outcomes are con- ventionally measured in terms of clinical indices with little attention to theeffectsoforaldiseasesonan individual'squality of life and daily functioning. The Geriatric Oral Health Assess- ment Index (GOHAI) includes self-assessed oral health status items designed to measure the physical, emotional, and social impacts of oral diseases. Individuals are asked how often they were affected by a particular condition or situation during the past three months, with graded responses ranging from "always" to "never." The GOHAI, as well as batteries assessing general, mental, social and physical health were self-administered to 87 community-dwelling elders with mean age of 76 years. This pilot study provides preliminary data on the reliability, validity, and ease of administration of the index. Responses to the original 36 GOHAI items were analyzed, and items were systematically dropped based on predetermined criteria. The 14 retained items showed a high level of internal consistency and homogeneity (Cronbach's alpha=.87). The indexcontains items regarding the following oral health dimensions: oral function (mastication, swallowing, speech), psychosocial well-being, and oral pain and discomfort. Index scores were derived by summation of responses. There were no significant differences in mean scores of dentateand edentulous respondents. With further development, a self-assessed oral health index is a potentially valuable component of the complete geriatric assessment.

45. Prediction of an outcome of the expected fluoride plebiscite in a Canadian city. DOSHI s,* Gleenwood Public School, Winsor, Ontario, Canada.

Research indicates an inverse relationship between fluoride and tooth decay rates and a direct relationship between socioeconomic status and support for the fluoridation. A recent report of the Newfoundland Department of Health (1987) indicates the tooth decay rates in the school population of St. John's are high. The purpose of this study was to predict the outcome of a fluoride plebiscite expected to take place in November of 1989 in the nonfluoridated city of St. John's, Canada. A population sample of 105 voters was questioned during the November 1988 federal election. The population was distributed between two locations in the city: downtown low socioeconomic area, and suburban affluent area. The instrument was used as a questionnaire specially designed for this study to assess the sociodemographic characteristics of the voters and their s u p port for fluoridation.

The response rate to the questionnaire was 95%. Results indicate that, overall, 63 percent of the voters supported fluoridating the water supply. There was equal support for fluoridation between males and females (67 percent vs 65%). There wasgreater support from thoseunder 30yearsof agethan

those over 30 years of age (80 percent vs 63%). There was greater support for fluoridation from those with elementary school education (63%) and university education (75%), and least s u p port from those with high school education (75%). The chi- square test shows no significant difference in the support for fluoridation between the downtown low socioeconomic area and thesuburbanaffluent areaof thecity(P>.05). Based onthese findings, it is concluded that in this nonfluoridated city of Canada, between 65 percent and 85 percent of the voters will support fluoridation in a plebiscite that is expected to take place in November of 1989 (Pc0.05).

46. Sealants adoption by dentists despite lack of coverage by a national health insurance system. GAGNON PF,* AL- BERT G, DUFOUR L, Universitb Lava1 and Universitb de MontlSal, Canada.

Pit and fissure sealants adoption by the dental profession has been reported as slow by several authors. In the province of Quebec, a comprehensive national health insurance program covers dental treatments for children up to age 15.The program, however, does not reimburse for dental sealants. The purpose of this study was to measure sealants usage in private practice and evaluate the influence of noncoverage on sealants adoption by dentists.

A survey questionnaire was sent to a sampleof 1,409 dentists practicing in the province of Quebec. Seven hundred fourteen completed questionnaires were returned, a response rateof 50.7 percent. After adjustment for ineligible respondents and exclusion of dentists who did not treat children, 72.5 percent reported using sealants at least sometimes. An additional 13.4 percent admitted an earlier attempt to use sealants, but had stopped since then. Recent graduates (less that ten years) had a better rate (82.2%) than their older colleagues (61.1%). Ninety and two-tenths percent of female dentists reported sealants usage, compared to 68.1 percent for males. The reasons most often cited for not using sealants were lack of coverage (58.4%), dentists' preference to place an occlusal filling (43.8%), and patients' unwillingness to pay for procedure (43.8%).

These results indicate that despite recurrent complaints regarding exclusion of sealants by the provincial health insurance program, Quebec's dentists have adopted this preventive measure and their level of sealants usage is comparable to their North American colleagues.

47. Pit and fissure caries prevention on the Navajo reservation: a report. SUTHERLAND JN, DDS,* US Public Health Service, Navajo Area Indian Health Service, Shiprock, NM.

Previous Indian Health Service Oral Health Status Survey findings (1983) indicated that the caries experience of Native American schoolchildren, aged 5-17, was almost 2 5 times that of the national level (National Caries Prevalence Survey 1979- 1980). IHS oral objectives for 1990 include covering occlusal molar surfaces with protective sealants in at least 75 percent of nine-year-old Native American schoolchildren. The Shiprock Service Unit under the direction of Navap Area Dental Program has dedicated a significant portion of its program to school- based pit and fissurecaries prevention.Theclinical sealant team consists of a dentist and two dental assistants and operates throughout the school year, providing care for 27 schools with a total enrollment of 9,284 (1987). During a period of three years, there have been an average of over 12,200 sealants placed each year, with over 70 percent of them molar teeth. It is estimated that by the 1989 term school year, 8085 percent of nine-year-old


schoolchildren were treated by the sealant program. An oral health survey conducted throughout the Navajo a m (1987) revealed a dramatic decline in pit and fissure decay in the 5- to 17-year-old age group, including the Shiprock Service Unit.

48. Oral health care for institutionalized elderly: a training program for nurses and nurses' aides. BRANGAN P,* GLOVER S, Old Dominion University, Norfolk, VA.

Currently, all nurses' aides employed in long-term care facilities within Virginia must graduate from a geriatric nurses' aides training program. While oral health care is included in the curricula, the content is minimal. Considering the poor oral conditions of institutionalized elderly, routine oral care is not being performed. A recent state survey of long-term care facilities indicated that oral health in-service education and marking dentures are their two strongest needs. Consequently, a program to provide preventive oral hygiene care for long- term care facility residents was initiated.

Considering the dental needs of the elderly and the minimal training of nurses' aides in providing oral care, a statewide prevention program was developed. Nursing home in-service coordinators were trained to teach oral disease identification and disease control techniques to nurses' aides. In-service coordinators were chosen because they are responsible for the training of nurses' aides. Each in-service coordinator was provided with an oral health module including objectives, lecture outline, teaching aids, learning activities, and evaluation items to facilitate the delivery of their in-service programs. This presentation will discuss the training program including the benefits and issues involved in coordinating the project. Preliminary results indicate that the program is an effective model for training nurses' aides.

49. A model dental health promotion project for "home- 1ess"children.FERNANDEZ JB,* COLCHAMIROEK,MOSS SJ, Department of Pediatric Dentistry, New York, NY.

The National Institute of Dental Research reports that 50 percent of children under the age of 12 have no cavities. But among children who live in shelters or other temporary hous- ing, only 25 to 30 percent are caries-free, leaving the vast majority with unmet dental needs.The goal of thisdental health promotion project was to create an environment in which "homeless" children could become part of the "cavity-free generation" by learning to develop good oral hygiene habits and receiving preventive dental care/treatment. This project, which commenced in July 1988 and is ongoing, concentrates on the use of two techniques proven effective to prevent dental caries: (1) brushing twice daily with a fluoride toothpaste, and (2) the application of sealants to children's teeth. As a result of this project, we have seen considerable improvement in the children's dental health as evidenced by debris index scores that improved in over 65 percent of these children. We have also begun an onsite sealant program at one of the shelters using portable dental equipment. In six weeks, we were able to seal 501 teeth on 102 children.

50. Child-to-child dental health education in Nairobi, Kenya. STEPHEN S, RDH, BS*, GATHUA P, BDS, Depart- ment of Public Health, San Francisco, CA, and University of Nairobi

The teaching method known as "child-to-child," where older children teach younger ones, was researched for effectiveness in the promotion of dental health among rural school-aged

children in Nairobi, Kenya. The oral health status and knowledge of dental health of 212 children in grades 2 and 6 were tested before and after instruction of dental health con- cepts. Results demonstrated mean plaque reductions of 20 percent for second graders and 25 percent for sixth graders and a mean decrease in gingival bleeding of 40 percent for both second and sixth graders. The mean increase in dental knowledge was 22 percent for sixth grade students. The con- clusion was drawn that this method of instruction is successful in carrying out dental health education, particularly in settings with a shortage of personnel or where multiple languages are spoken among children.

51. Practical program evaluation: Knowledge and "skills" assessments relating to BBTD. BERLING S, DMD*, USPHS, Navajo Area Indian Health Service, Shiprock, NM.

A prevalence of baby bottle tooth decay (BBTD) in Native American children appears to be substantially higher than in other populations. 1985 clinical survey data collected in Head Start centers across the Indiana Health Service revealed a 72 percent prevalence rate on the Navajo reservation. S i e this is a behavior moderated disease entity, educational programs involving Head Start personnel, volunteer community coun- selors, mass media knowledge, and skills transfer to parents and potential parents of children aged 0 to 4. In 1988-89, a knowledge and "skills" survey tool was developed to measure the effectiveness of these programs. The survey tool used an interview format to assess knowledge of the disease, weaning patterns, and also incorporated a skillsassessment to determine if behavior changes were actually occurring. The tool was pilot tested and results obtained in early 1989. The results of the survey tool will be presented along with results of a followup clinical survey of actual disease rates in the same centers as were surveyed in 1985.

52. A multidisciplinary, multiagency approach to baby bottle tooth prevention. HUGHES KF, BILLER RN, CAR- NAHAN BW, CHEN M, JOHNSON DJ, RACE PO, Ohio Department of Health, Columbus, OH, Case Western Reserve University, Cleveland, OH, and Ohio State University, Columbus, OH.

A three-year demonstration project was initiated in October, 1987, to reduce the incidence of baby bottle tooth decay (BBTD) among children aged 12 to 24 months served by Ohio Women, Infants, and Children Supplemental Food Program (WIC), and Maternal and Child Health (MCH) programs. Twelve demonstration sites representative of Ohio WIC and MCH population were selected. Oral screenings were conducted by dental hygienists to determine a baseline prevalence of the disease in this target group. Parents and health professional staff of the WIC and MCH clinics were interviewed to assess their levels of awareness and perceptions concerning BBTD. One month following a clinic visit, telephone interviewing was conducted to determine parent recall of counseling regarding BBTD prevention. Data from these four assessments were used to design an education module to be used by health professional staff in the demonstration sites. The module consisted of educational materials and a protocol for their use. Unique features of this project include the collaborative efforts of the Dental, WIC, and MCH programs of the state health department, Case Western Reserve, and Ohio State Universities. Detail regarding the educational module and the multidisciplinary, multiagency approach to their implementation will be discussed.

Vol. 50, No. 3, Spring 1990 221

53. Survey of state school-based fluoride mouthrinse pmgrams. KAY S, RDH, MSPA, EMPEY G, DMD, MPH*, Seattle-King County Department of Public Health, Seattle, WA.

The Seattle-King County Department of Public Health offers a school-based fluoride mouthrinse program to elementary schools in nonfluoridated areas of King County. After using the pump-jug method for many years, the program switched to using exclusively a unit dose cup product in 1987. Problems with spoilage, storage, and wastage resulted when the transi- tion occurred. To address the problem, the authors surveyed 44 states and five Canadian provinces to determine products they use and comments regarding their success or failure.

This paper discusses the results of that survey, including information about the choiceof specific fluoride productsbased on a set of parameters. The value of the survey lies in the experiences of programs as they report success and failure using different systems. Choices based on number of students served, financial limitations, size of staff, and satisfaction with different products will be discussed.

54. Urinary fluoride levels inchildren: fluoridesupplemen- tation based on body weight. MACINTYRE MI.,,* DDS, MPH, Preventive Dentistry Coordinator, Dhahran,The Kingdom of Saudi Arabia.

Urinary fluoride levels inchildren. As increased fluorides (F) utilization has decreased in the level of caries, the potential for fluorosis has increased. Conditions affecting F intake have changed since the 1940s and 1950s when most F intake studies were performed. This has led to recent studies on F levels in urine and ingestion of F from dentifrice. It is also true that there are many locations in the world where the monthly maximum average daily air temperature differs significantly from the yearly average used by most authorities to adjust F drinking water levels. Variations in diets, in the F levels of drinking waters, and a general increase in sources of fluoride intake make an accurate estimate of F intake a necessity before prescribing an F supplement. F urinalysis is sufficient for this purpose. On data for over 500 children, 15 percent had excessive(>l.S ppm), 20 percent optimal, and 65 percent deficient (<5 ppm) F urinary levels. These data are categorized by age, time of day, and the average daily air temperature for the samples, as well as other variables.

Conclusions: The relation between maximum air temperature and F excretion continues to be significant despite the recent increase in alternate sources of F. A large percentage of children had deficient fluoride intake and a significant percentage had an excessive fluoride intake. In almost all instances, F dentifrice was the source of excessive intake.

Fluoride supplementation is based on body weight. The dental and medical organizations with minor exceptions are unanimous in their standards for F supplementation. The standards are based on age (birth or six weeks to age 2, age 2-3, and age 3 or older) and the level of fluoride in the drinking water. In cases where the fluorideintakeisconsidered deficient, the supplementation is given as a tablet or liquid. The amount of supplement is not controlled by the amount of water consumed, as in fluoridation, nor by weight, as in prescription of medications. The standard weight tables for children indicate that the weight of any two children the same age may vary significantly and that children whose ages differ by as much as one year may weigh the same. Therefore, it would seem logical to prescribe F supplements by weight rather than age, as is the

case with most supplements in which there is an amount that is considered excessive. A table of F supplementation based on weight is presented with alternatives provided based on the amount of F in the tablet or liquid being used. Other issues in F- supplementation are discussed.

55. From restoration to prevention-new goals h West Germany's oral health care system; the experience of the first year. NIPPERT RP,* Institute of Medical Sociology, Univer- sity of Miinster, Federal Republic of Germany.

The oral health care system of West Germany traditionally has been oriented toward dental care delivery covering nearly all costs for restorative and prosthetic treatment, but excluding prevention. This regulation has resulted in comparatively high expenditures for dental care, which in 1985 approached 136 US dollars per capita per year. Since the beginning of 1989, new legislation has been put into effect, with the aim of curbing the costs and shifting the emphasis in oral health care from restora- tiveand prosthetic to more preventive services.The poster gives a description of the system of late, the main changes that have been introduced, and presents the evidence of the first-year experience with the new regulations using the data from the national sick funds.

56. Patient characteristics and utilization patterns in a dental school clinic. CUNNINGHAM MA,* KNIGHT CA, GAETH GJ, University of Iowa, Iowa City, IA.

Previous health services research has identified a relationship between patients' demographic characteristics and dental utilization patterns. This information, when applied to a dental clinic setting, can be used to plan and evaluate a dental marketing strategy. An analysis of demographic data (i.e., age, sex, geographic distribution, and referral source) was conducted using the clinic's computerized patient record system for new patients admitted to the University of Iowa College of Dentistry during a one-year period (N=2,988). An additional one-page questionnaire was administered at the patient's first visit to collect data on time since last dental visit, level of education, and occupation.

The results of this analysis indicated that 44 percent of these new patients had visited a dentist within the past year; 30 percent, one to three years; and 21% reported over three years since their last dental visit. Referrals from family members, friends, or self made up the majority of referral sources (86%). This finding confirms the importance of word+f-mouth as an effective marketing strategy. The 65+ age group was found to be underrepresented among the new patients in comparison to state census data (10% versus 14%, respectively). A targeted marketing strategy such as senior center presentations or screenings could be used to attract more senior citizens to the dental clinic. It is interesting to note that over 50 percent of the patients reported their occupation as retired, student, un- employed, or homemaker. Dental school clinics should consider consumers in these occupational categories to be a primary target market because of their flexible time schedules. This presentation will provide a model of other dental clinics to use in planning and evaluating marketing strategies.

57. Presentation of HIV treatment facility Data. AMES RK, DDS, MPH,* LASCH AH, DDS, MSPH, HRS Broward Coun- ty Public Health Unit, Ft. Lauderdale, FL, and HRS Palm Beach County Public Health Unit, FL.

As thenumber of HIV positive patients continues to increase,


the demand and need for dental services by this population continues to grow. This presentation describes costs and dental treatment services provided in facilities designed solely for the treatment of HIV positive patients and operated by two neigh- boring South Florida counties. The number of patients and services, the types of dental services provided, and the cost of these services are presented. Services are provided to all income levels by private dentists and dental assistants under contract with the health departments. The services are provided in specially designed AIDS-dedicated health department facilities, where medical and social management of the patient is readily available and coordinated to provide comprehensive health services to this specific population group not available elsewhere in the community. Service priorities have been established by, and the program is operated in accordance with, specially developed procedures manuals. This project has demonstrated that given adequate funding, a partnership between the public and privatedental sectors can provide needed dental treatment services in a clean, caring environment that is conducive to patient comfort and helps to meet the demands of this underserved group.

58. Consumer information and prices and demand for dental services. KWON IW, PhD, KIM JH, PhD,' SAFRANSKI SR, PhD, Rider College, NJ, and St. Louis University, MO.

Economic theory of advertising provides us with two con- flicting arguments in the areas of prices and demand for goods and services. The Chicago model argues that the advertising

THE UNIVERSITY OF MICHIGAN FINANCIAL SUPPORT FOR DOCTORAL TRAINING IN ORAL EPIIDEMIOLOGY

Applications are invited for the doctoral program in oral epidemiology at the University of Michigan School of Public Health. Successful applicants receive full tuition and stipend, in accordance with NIH rates, for 3 years. Both dentists and dental hygienists who are US citizens, nationals, or permanent residents may apply. Applicants should have MPH or equivalent degree and be able to demonstrate superior scholastic ability. A personal interview is recommended where possible.

The program consists of advanced course work in biosta tistics, computer management, epidemiology, and research design, followed by a research disserta- tion in any area of the epidemiology of oral conditions. Graduates receive the Doctor of Public Health degree from the University of Michigan. For further infor- maiton and application materials, contad: Dr. Brian A. Burt, Program in Dental Public Health, School of Public Health, University of Michigan, AM Arbor, MI 48109-2029. Tel.: (313) 764-5477, FAX (313) 763-5455, or contact Dr. Burt via CONFER. Equal Opportunity/Af- firmative Action employer.

provides consumers with alternative choices, thereby making the elasticity of demand, in respect to price, greater than other- wise (consumer information model). Demand will grow as the price is kept lower, according to this theory. The Harvard model, on the other hand, insists that advertising creates product differentiation in the market, thereby making consumers less sensitive to the price (market power model). Fur- thermore, a heavy advertising by a single firm effectively deters market penetration by others firms that do not have large advertising budgets. In the long run, according to this theory, the price tends to be higher and the consumer's choice may become restricted.

This paper attempted to investigate whether dentists' choice of advertising for their business has either the consumer information effect (lowering price) or has the market power effect (higher price) by using the economic theory of advertising. The 1982 Dental Survey conducted by the American Dental Associa- tion was used as a data source. Multivariate regression models along with discriminate models are employed to test the hypotheses. A preliminary result indicates that although statistically insignificant, the prices of oral exam and extraction are slightly higher for dentists who practiced advertising than those who did not. The number of office visits between these two groups, however, are not noticeably different. Although there arenonoticeabledifferencesof priceand volumebetweenthese two groups, this study uncovered that statistically significant differences of the Andersenian behavioral attributes exist between these two groups.

THE UNIVERSITY OF MICHIGAN RESIDENCY IN

DENTAL PUBLIC HEALTH

The Program in Dental Public Health, School of Public Health, in cooperation with Delta Dental Fund of Michigan, is cosponsoring a l-year Dental Public Health Residency, to begin in September of each year. The residency is accredited by the American Dental Association; residents who already have a l-year MPH degree will thus complete their educational requirements for specialist certification by the American Board of Public Health. The resident will spend half of his or her time on practical experience with the Michigan Department of Health. Residents will also have the opportunity to gain teaching experience and to take courses at the University of Michigan. The residency experience is based on guidelines established by the American Board of Dnetal Public Health. Applicants must have already completed an MPH or equivalent degree. Financial support includes stipend, tuition, and travel. Applicants must apply to and be accepted by the School of Public Health. Further details and enrollment forms are available from Dr. Brian A. Burt, Program in Dental Public Health, School of Public Health, University of Michigan, Ann Arbor, MI 48109-2029. Tel.: (313) 764-5477, FAX (313) 763- 5455, or contact Dr. Burt via CONFER. Equal Oppor- tunity / Affirmative Action employer.

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Abstracts of Papers and Posters