I32 Journal of Public Health Dentistry

Guest Editorial The Greatest Good for the Greatest Number

James M. Dunning, DDS, MPH, SD Professor Emeritus Department of Dental Care Administration Harvard School of Dental Medicine 188 Longwood Avenue Boston, MA 021 15

The bimodal nature of our society, with increasing gaps between the well-to-do segment and the even larger low-income segment, complicates the problem of access to health care. Delivery patterns applicable to the private sector of the health profession in years gone by are proving inadequate to US society as a whole today. Access to care for the low-income segment, never great in terms of comprehensive dental care, has decreased to the extent that all but the most obvious emergency care is excluded, except in a small number of public programs. Cost-efficient measures require low-cost de- livery systems, particularly in public programs. If these systems cooperate with the private sector, they can improve access to both sectors.

Halberstam, writing for the Institute of Medicine (National Academy of Sciences) has pointed out the antithetical ethical approaches of the physician (or den- tist) and the legislator (1). The physician's ethic is "the greatest good for the individual that he or she is charged with taking care of," while the legislator's ethic is "the greatest good for the greatest number of peo- ple." This is where cost efficiency comes in.

A fine example of cost efficiency has recently been found in the state of New Mexico dental sealant pro- gram, observed in action this year. It is one of the largest in the United States and has been described in general terms in other pgblications (2,3). Certain fea- tures of the current administration of this program il- lustrate its efficiency. It serves approximately 17,000 children in New Mexico elementary and middle schools at a cost of $3.27 per tooth sealed, including indirect costs. It also refers children, through their parents, to private or public dental facilities for restorative care. This increases comprehensive care beyond the level achieved by current educational and advertising techniques.

A prominent feature of this sealant program is the use of auxiliaries: teams consisting of a dental hygienist and a dental assistant. Both are trained in a special course on sealants and given a carefully written proto- col to follow. These teams operate on school premises under a supervisory system worked out in cooperation with the state Board of Dentistry. When a dentist is on the premises, he or she can supervise several teams of auxiliaries, usually about three. In this situation, the hygienists screen the children as well as apply sealants to the teeth they select. Where a dentist is not available

at the time of sealant application, the teams can operate independently, as in small schools in rural areas, pro- vided a dentist has preceded them and screened all cases to receive sealants. This frees the state dentists to do restorative dentistry in properly equipped facilities for children who are found to need such care. At the sealant sites, an even flow of eligible children (with parental consent) is directed to the hygienists by school staff (Calderone JJ, personal communication, 1988).

Several arrangements encourage quick, high-quality work on school premises. Equipment is simple: hand instruments for use with cotton rolls and absorbent shields; portable suction equipment operated by spe- cially trained assistants; portable chairs, air compres- sors, and autoclaves; and, finally, the use of rubber gloves in line with current standards for infection con- trol. Gloves are changed between patients and thus save hand washing. This cuts down the time per case and permits the use of schoolrooms without running water. Rubber dam use was tried experimentally, but doubled the operating time per case and was found unnecessary.

Prevention of occlusal caries has been documented by the New Mexico Health and Environment Depart- ment. Occlusal lesions in first permanent molars have been reduced from 34.99 percent to 6.12 percent over four years (3).

The cost of $3.27 per tooth sealed is borne by the state Public Health Division; costs in private practice are nec- essarily higher, ranging from $12 to $18 per tooth (4). Report forms to parents explain conditions that may have prevented sealing of certain teeth and indicate whether the child should go to the dentist for routine examination or "immediately for emergency evalua- tion."

In this way, New Mexico brings "the greatest good to the greatest number."

References 1. Halberstam MJ. Professionalism and health care. In: Institute of

Medicine, Ethics of health care. Washington, DC: National Acadc- my of Sciences, 1974:248.

2. Calderone JJ, Mueller LM. The cost of sealant application in a state dental disease prevention program. J Public Health Dent

3. Calderone JJ, Davis JM. The New Mexico sealant program: a pro-

4. Wilson B. National and regional dental fee survey. Dent Manage

1983;43(3):249-54.

gress report. J Public Health Dent 1987;47(3):145-9.

1988;28(2):28-33.