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15. Describe the oral health workforce in public health, including qualifications, formal public health training requirements, and roles.

The oral health workforce in public health departments was sparse, and consisted of more than just dentists. In many departments without an oral health professional, the public health nursing staff or others provided dental public health services. If a dentist did work for the department they were doing direct clinical services, perhaps with some public health activities. Three of the five counties surveyed indicated they employed dental staff. Qualifications: Dentists working in public health at any level are only required to have a valid State DDS or DMD license.

Formal Public Health Training: There were no dentists working in the case study sites with an MPH or board certification in dental public health. This type of training was considered important by administrators, but a dentist with these qualifications was so rare they cannot require it. In addition, most dentists working in a public dental clinic were providing indigent care, rarely doing “public health” activities.

Roles: The role of dentists in public health departments was not well defined. Most departments only employed dentists if they were serving as a safety net provider. Very few dental public health activities were found. Administrators in the departments could not articulate a role for dentists in leadership positions within the departments, for lack of precedent and funding for such activities.

Each department surveyed was asked to indicate the roles of their dentists and to rank the importance of these roles. Dentist’s roles varied across departments; all provided health education, screening, assessment of oral health status and needs, and analysis of

determinants of identified need and these were all ranked of highest importance as a role for dentists in the department.

On average, roles in direct patient care, assessment and policy development all ranked 3.5 in importance on a scale of 1-4. Roles in assurance ranked 3.25 in importance on average. Direct patient care roles were performed most often (76%), followed closely by

assessment (75%), policy development (67%) and assurance (61%).

Table 10. Dentist Roles in California Public Health Departments

DDS Roles in California: Role (Level) DDS Role in % of Counties Average (scale 1-4) Health Education 100% 4.00 Screening 100% 4.00 Importance

Assess oral health status and needs 100% 4.00 Analyze determinants of identified oral health

needs 100% 4.00

Case Management 67% 4.00

Counseling and Advocacy for Patients 67% 4.00 Provide leadership to address oral health 67% 4.00

Link people to oral health services 67% 4.00

Support services w/primary and secondary

prevention 67% 4.00

Medical Treatments 67% 3.50

Disease Investigation 67% 3.50

Inform, educate public regarding oral health

problems 67% 3.50

Promote and enforce laws and regulations 67% 3.50 Assess fluoridation status of water systems 67% 3.00

Develop plans & policies 67% 3.00

Evaluate effectiveness, accessibility and quality 67% 2.50

Outreach 67% 1.50

Implement oral health surveillancec system 33% 3.00 Conduct research and support demonstration

projects 33% 2.00

16a. Do State and local health departments encounter difficulty recruiting or retaining oral health workers?

Yes. The high cost of providing dental care prevented many departments from providing any dental services. Those that did had an easier time hiring staff dentists than a dental director, as it was extremely hard to find a dentist with public health training.

16b. If so, why?

Wages in the private sector were so out of proportion to what public health departments could pay that very few dentists consider applying for the position. Those that do tended to choose it for lifestyle reasons, they didn’t have to bother with owning a practice, have a set schedule etc.

16c.How does it impact hiring, roles, services?

Counties employing dentists said there was great need to expand services, but no funding to do so. Most dental services were paid by Medicaid reimbursement and grants; there were simply not enough resources there to expand services. Many who needed but could

services. Hiring a workforce might be problematic if services were expanded, but the service delivery was fundamentally restricted by a lack of funding.

17a. What are the most pressing continuing education training needs for oral health staff?

A variety of topics were listed across agencies, however none came out as more or less important.

Table 11. Percent of Departments Reporting Continuing Education Needs for Dentists, by Content Area

Percent of

Topic Departments

CPR 33% Current Trends in Dentistry 33%

Dental Law 33% Dentistry with HIV Population 33%

HIPAA 33% Infection Control 33%

Minor Surgical Procedures 33% Pediatric Dentistry 33% Population-focused dentistry 33%

17b. Are there sufficient training opportunities?

Yes, for all topics listed except population-focused dentistry.

17c. Are there adequate resources to support training opportunities?

Most departments had a training budget funded by Federal, State and local grants. All departments supported the dentists in attaining the continuing education required for licensure. Funding for tuition reimbursement and other additional benefits were more likely to be found in counties in good fiscal shape.

18. How many (%) oral health staff are expected to retire in the next five years?

Among the three counties employing dentists, three retirements were predicted in the next five years, or 35% of the dentist workforce across those counties. The range at the county level was from 0% to 40% of the workforce.