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Task Force on Community Preventive Services. The Guide to Community Preventive Services. Atlanta (GA): Centers for Disease Control and Prevention; 1999-.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of The Guide to Community Preventive Services

The Guide to Community Preventive Services.

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Wishes for the Future

, DDS, MPH and , PhD.

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Published: 2002.

We are delighted that the Guide to Community Preventive Services Task Force (the Task Force) identified oral health as one of its first set of topics for the development of systematic reviews and recommendations. This document serves as an important companion to the 2000 Surgeon General's Report on Oral Health 1 and the Healthy People 2010 2 national oral health objectives. Dentistry has for too long practiced the hand-me-down tradition of knowledge dissemination, as in "I'll recommend (or teach) this procedure because it works in my hands." Thus, it is an important achievement that "evidence-based dentistry" and the use of systematic reviews are rapidly becoming part of the culture of dental research and policy development. For example, at a recent International Association for Dental Research annual meeting, several systematic reviews were presented and critiqued at a well-attended symposium; systematic reviews were presented elsewhere in the program; systematic reviews were required at a recent NIH Consensus Development Conference on the diagnosis and management of dental caries throughout life 3 ; at least two new dental journals are devoted to this topic (Evidence-Based Dentistry and Journal of Evidence-based Dental Practice); and there is increasing dental participation in the Cochrane Collaboration, an international group that conducts very thorough systematic reviews of randomized clinical trials pertaining to health care. There are probably many other examples.

The Task Force carved out for itself a very challenging task. The five interventions selected for evaluation target different populations and age groups, different diseases and conditions with different associated risk factors and determinants, and deliver different outcomes. These interventions also vary considerably in their phase of development, with community water fluoridation beginning in 1945 and dental sealant trials in the early 1970s, to relatively recent attempts at population-based oral cancer and injury prevention interventions. In viewing the findings of the Task Force as an overall package of community preventive services to improve oral health, we found ourselves wishing that more information had been available to the Task Force to assist them in the process and outcome of their work. We will present our vision for the future of oral health community preventive services in the form of four wishes and indicate how the current version of this process might be viewed at a time when more information is available.

Wish 1. There are many preventive methods that have been tested by high quality studies, alone and in combination, in many different community settings, populations, and circumstances.

Public health research and practice optimally proceeds on a continuum, generally from observational to efficacy to effectiveness to cost-effectiveness studies, to more general implementation, marketing and promotion, and continued evaluation and improvement. It is not surprising that there are more evidence and favorable recommendations for the longer-term programs (community water fluoridation and school-based and school-linked sealant programs) and less evidence for newer programs. It is curious why the newer oral cancer intervention was selected for inclusion in this process at this time. Since the effectiveness of various types of oral cancer screening on an individual basis has yet to be determined, evaluating their effectiveness on a population-based approach seems premature. At the other end of the spectrum, the Task Force did not consider multicomponent interventions. Often there are multiple interventions or exposures operating simultaneously, especially with regard to caries prevention, such as sealant programs in fluoridated communities. Since caries is a multifactorial disease, prevention is likely to require more than one component. Interventions that deliver an educational message or require behavioral change (such as tobacco cessation) are often improved if the message comes from a variety of sources. More research is needed to test the available preventive modalities, alone and in combination.

It is noteworthy that the Task Force considered study designs other than randomized clinical trials (RCT). Some systematic reviews limit their inclusion criteria to RCTs. This study design is indeed our "gold" standard in clinical, patient-oriented research. However, this type of design is exceedingly difficult, and sometimes not possible nor appropriate for evaluating a community-based intervention. Community water fluoridation is a classic example. Antifluoridationists are always quick to point out that there has never been an RCT to test the effectiveness of community water fluoridation. It is difficult to imagine a scenario where it would be possible to randomize study participants to live in a fluoridated or nonfluoridated community for several years. If the inclusion criteria had been limited to RCTs, then this effective public health measure would not have been recommended.

In any given study, the selection of the population greatly influences the results. Factors such as the prevalence and incidence of the disease being prevented, and the full host of biologic, social, environmental, and contextual factors influence the degree of effectiveness of an intervention. The results may not be generalizable to all types of communities, or even similar communities where the intervention is not being done as part of a study or demonstration program with specific attention to participants, monitoring of adherence to regimens, and incentives for participants. This report places little emphasis on cultural issues and barriers, disparities in access to care, or environmental factors such as school system support in their interpretation of the studies or their recommendations. Future research needs to consider these factors.

Wish 2. The public, policymakers, and health professions understand the nature of medical (and dental) uncertainty as they wait for science to provide answers.

The report appropriately cautions readers "insufficient evidence should not be confused with evidence of ineffectiveness." Unfortunately, many readers will make such an assumption. It is easy to do given the common use of the term and the relative inattention to the distinction in the oral health report itself, which is limited to a single sentence toward the end. Thus, professional audiences, policymakers, and laypersons who do not fully understand this nuance may misinterpret the recommendations. Since three of the five oral health preventive community interventions reviewed were deemed to have insufficient evidence, the correct interpretation is critical. An intervention may be deemed to have "insufficient evidence" because of lack of available studies (as is the case for promotion of state- and community-based sealant programs), because the research yields conflicting findings, or because the effect sizes are small. An alternative approach might have been to consider different categories of "insufficient" evidence that could give the reader more information about the level of insufficiency. As indicated by Soller and Lee, 4 we may also need to educate the public (policymakers and the profession) about the concept of medical (and dental) uncertainty. If our first wish comes true, in the future we will have sufficient evidence to choose the optimal interventions.

Wish 3. Oral health is a well-accepted component of overall health, and the medical/dental/public health research and literature are viewed together.

We hope that this oral health report will not be used as a stand-alone document, but will be viewed in conjunction with the overall Guide to Community Preventive Services. 5 Oral health interventions should be placed in the broader scope of other communitylevel interventions. For example, since another task force addressed tobacco use, large-scale communitybased approaches aimed at reducing the initiation of tobacco use and tobacco cessation programs were not included in the oral health report, even though tobacco use is a major risk factor for oral and pharyngeal cancers. One would also hope that readers are aware of the effectiveness of policies and laws in other public health areas (like drinking and driving, seatbelt and helmet use) before accepting the conclusions of the Task Force regarding the lack of evidence for such approaches in the specific area of sports-related craniofacial injuries. Confining the analysis to the top of the body and ignoring the literature on the effectiveness of laws, policies, and protection equipment to prevent injuries to the rest of the body may be doing the public a disservice. After all, oral health is part of total health.

Wish 4. Lots of resources are available for community-based research.

The Task Force has done a splendid job identifying areas where more research is needed. Taking this a step further, it behooves us to ask what it will take to actually answer the questions posed. Community-based research is difficult, time-consuming, and expensive. Although small changes in behavior or disease outcome may be very meaningful when magnified on a population perspective, to demonstrate such changes requires very large sample sizes, which would require lots of resources, if such studies were even feasible. We may need new approaches for measuring macro-level changes and perhaps different methodologic and statistical strategies for determining whether interventions are effective in the broadest sense.

In the past, there have been few sources of funding for community-based research. In recent years, the Centers for Disease Control and Prevention's Prevention Research Centers 6 have provided some funding for community-based research. The National Institute of Dental and Craniofacial Research's plan to eliminate craniofacial, oral, and dental health disparities 7 includes substantial new funding in this area, with an emphasis on academic-community partnerships. Unfortunately, the dental public health infrastructure in the United States is not well equipped to provide financial or human resources. Many state and local health departments do not have dental directors 1 and there are few board certified public health dentists. 8 There is a decreasing number of specialists in preventive medicine. 9 Partnerships and collaborations are critical to make the best use of limited resources.

What next? We hope not just wishful thinking. The Task Force appropriately raised more questions than they answered. We need to learn from our colleagues in medicine, public health, nursing, psychology, anthropology, economics, and other disciplines, as well as the new emerging discipline of population health. This discipline expands our traditional view of health focused primarily on biological and behavioral components to include the interconnectedness of many factors and the important influence of our environment and public policies. Individuals and communities enjoy life in its glorious multitude-with multiple exposures, coexisting risk and protective factors, behaviors, comorbidities, and diseases - and in situations continuously changing over time. The challenge is to develop and implement the most effective clinical and communitybased preventive approaches to achieve optimal health over a lifetime. We hope our wishes will come true.

References

1.
U.S. Department of Health and Human Services. Oral Health in America: A report of the Surgeon General, Rockville, , MD: . Department of Health and Human ServicesNational Institute of Dental and Craniofacial Research, National Institutes of Health, 2000. [PMC free article: PMC384376] [PubMed: 10811624]
2.
U.S. Department of Health and Human Services. Healthy People 2010. Available at: www​.health.gov/healthypeople. Accessed on March 15, 2002.
3.
National Institutes of Health. Consensus Development Conference on Diagnosis and Management of Dental Caries throughout Life. J Dental Educ. 2001;65:940–1168.
4.
Soller M, Lee PR. A new look at preventive care guidelines. Am J Prev Med. 1999;17:315–16. [PubMed: 10606201]
5.
Task Force on Community Preventive Services. Introducing the Guide to Community Preventive Services: Methods, first recommendations and expert commentary. Am J Prev Med. 2000;18(suppl 1):1–140.
6.
Centers for Disease Control and Prevention: Prevention Research Centers. Available at: www​.cdc.gov/prc/index.htm. Accessed March 15, 2002.
7.
National Institute of Dental and Craniofacial Research. Plan to eliminate craniofacial, oral and dental health disparities. Available at: www​.nidcr.nih.gov/research​/healthdisp/hdplan.pdf. Accessed March 15, 2002.
8.
Weintraub JA, Lotzkar S. The dental public health specialty boards: process and outcomes. J Public Health Dent. 2000;60:–.
9.
Lane DS. A threat to the public health workforce: evidence from trends in preventive medicine certification training. Am J Prev Med. 2000;18:87–96. [PubMed: 10808988]

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