PROJECT HEAD START AND DENTAL CARE-

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1 This paper includes some information on the extent of Head Start projects and the nature of dental care programs. It refers to various administrative mechanisms which have been used to establish programs, and to instances where multiple funding sources have been used to initiate short-range and long-range programs. Some examples involving innovation in the origin of programs and personnel involved are given, together with roles currently played by health professionals. PROJECT HEAD START AND DENTAL CARE- ONE SUMMER OF EXPERIENCE George M. Gillespie, D.D.S., M.P.H., F.A.P.H.A. It CAN'T believe that,' said Alice. 'Can't you?' the queen said. 'Try again; draw a long breath, and shut your eyes.' Alice laughed. 'There's no use trying,' she said: "One can't believe impossible things.'" Perhaps this quotation from "Through the Looking Glass" in many ways sums up some of the thoughts that may have occurred to people involved in Operation Head Start during the course of the past summer. The definition of the word "impossible" is open to liberal interpretation but, if you were to reflect upon some of the programs in your particular areas, perhaps you might consider that even if the impossible has not been achieved, possibly something that you considered unlikely a few years ago has been accomplished or has now become a distinct reality for the future. Project Head Start has not produced a revolution in the provision of actual dental service. There has been no dramatic discovery of a new way to provide dental services; there has been no discovery of a new treatment method or a new preventive or therapeutic measure. The basic delivery of dental care or dental treatment services is probably the same as it has been for the last hundred or so years. However, Head Start as a program is a result of legislation and as such should have some impact on some sector of the community. I would like to assess the impact that this particular program has had upon the provision of dental care services to a specific group. Impact on Dental Care for a Specific Group The first item of interest is the fact that during the summer of 1966, 575,000 children in families considered to be within the poverty group (that is, from families whose over-all. income for a family of four is under $3,000 in urban communities and $2,100 in rural communities) have at least been exposed to a dental examination either by a dentist 90 VOL. 58. NO. 1. A.J.P.H.

2 PROJECT HEAD START AND DENTAL CARE or a dental hygienist. Approximately 600 year-round and follow-through programs have enrolled 193,000 children. When we consider these figures, and the figures quoted of visits to dentists in general by children from families within these income brackets, it will be seen that in the past two years Project Head Start alone has introduced a number of persons, equivalent to approximately 5 per cent of the United States population under five years old, to at least one visit to the dentist. More important, it has thrown a decided emphasis and impetus upon dental treatment for the preschool child to such an extent that it is hoped that these children will begin schooling with at least the elimination of extensive dental caries and with completed restorations. The requirement that children enrolled in Project Head Start have a dental examination-a requirement that has been in existence for the past two years -has probably had its greatest impact upon bringing to local communities the extent and nature of dental disease in the preschool population. The common identification that 85 per cent of children enrolled in Head Start programs suffer from dental diseases, as compared with the 8, 10, or 12 per cent who suffer from various medical problems, has caused one frequently to hear the cry of "Our problems are dental problems." Thus, whereas those of us in public health may well have wanted to adopt a righteous attitude and to have said, "I could have told you so," the mere fact that such examinations have been conducted, and that such projects have originated at the local level with local nonprofessional groups organizing and taking an interest in the procedures involved in arranging for a dental examination, has more than ever brought home to communities-at-large the extent and nature of dental problems. Coincident with the knowledge of the extent of dental disease in preschool children, community organizers have begun to learn about dentistry. It is amazing to travel around the country and to discover at first-hand the ability with which nonprofessional persons have learned to tackle the problems that relate to the provision of dental care. An example is a recent discussion between two Head Start program coordinators on the relative DMF rates in their two communities in the light of the presence and absence of fluoridation. In fact, so great has been this ability of nonprofessionals to come to grips with dental problems that an observer wonders whether perhaps this program has not done more in the field of dental health education than many programs before it. The need to provide dental services has introduced many community people to the dental profession. Sometimes this introduction has been of a somewhat unfortunate nature, since neither the community organizer nor the dentist has been accustomed to contact with one another, except perhaps in a true dentistpatient relationship. However, in most instances both parties have learned an approach that has caused the gradual development of programs to stem from the initial contact. In many instances the very knowledge of the local community organizers, and this apparently has happened mainly in small communities, has led to the swift and efficient establishment of a local program using local dental services for Head Start children. Impact on Dental Profession What has been the impact upon the profession? The first realization has been the fact that there is now a definite emphasis placed on children and preschool children and the necessity to remedy their dental defects. The fact that funds are available, specifically for dental care and specifically for the preschool group, has caused many a practitioner to realize that, rather than a somewhat nebulous JANUARY,

3 program, Project Head Start has a significant role to play in the future dental health of children. The second effect upon the dental practitioner would appear to be that for the first time a community group, possibly representative of his own community associates, has approached him with a request for some indication of the costs of his services to a particular segment of the population in that community. Such a request has been in many instances a surprise to local practitioners who, in all fairness, have never been requested to provide cost estimates on treatment plans on more than an individual basis. Such requests have at times led to somewhat inadequate estimates, somewhat inflated estimates, confusion, and at times hesitancy or nonparticipation for fear that assessments might result in inadequate fees for the dental profession. Perhaps this apparent need highlights some of the failures of those versed in public health or public health technics to communicate some guidelines for cost estimates to the average practitioner prior to the innovation of such programs. This experience certainly outlines a need for inclusion of such a subject area in the dental school undergraduate curriculum. Another effect upon the profession and the private practitioner has been the sudden realization that within his own administrative mechanisms - such as the Dental Service Corporation-there already exists an organization which could effectively administer such federal programs while still maintaining a true relationship with the profession and with all the principles of ethics for which the profession is noted. The warnings of many persons who advocated the early establishment of Dental Service Corporations and their implementation would now appear to be justified. The states that have active service corporations have found that it is a relatively simple matter to arrange a contract with the local community action agency in order to 92 provide dental services through such a corporation. Perhaps those states that have not activated their corporations are now beginning to see that they may be missing out already on one very worthwhile mechanism for providing dental services. Impact on Public Health Personnel There has also been an impact upon the professionals in public health. Whereas many years ago the Public Health Service and those in public health were directly concerned with the provision of direct service, in recent years the emphasis on direct service has not been apparent. With the exception of the Coast Guard and programs conducted by the Division of Indian Health, Head Start is perhaps the first federal program in the field of dentistry that has specifically delineated service for a target group in the United States civilian population and has actively encouraged public health personnel to insure that direct service, including the provision of care, be provided. To this end the Division of Dental Health of the United States Public Health Service, as consultants and technical assistants to the Office of Economic Opportunity for Project Head Start, has been attempting to insure that this purpose and this emphasis are carried out in practice. Innovations What then are some of the innovations that have occurred during this past summer? As outlined earlier, any innovations that may have occurred with this program mainly concern administration in the provision of dental care. The first innovation would appear to be the fact that for the first time a community can organize a dental program at the local level. Nonprofessionals have been given the authority to plan, it is hoped in conjunction with professional personnel, a program involving the pro- VOL. 58, NO. 1. A.J.P.H.

4 PROJECT HEAD START AND DENTAL CARE vision of dental care for a specific community and to seek funds to back up this program. This form of administration has led to the introduction of different approaches and additional resources in communities in which no dental care facilities were available. These changes have resulted in some instances in the provision and construction of facilities, and ill making available care services which otherwise would not have been available in that particular area. For example, the dental trailer programs initiated in Missouri and North Carolina are truly creations of the Office of Economic Opportunity program. Health agencies and city health departments have played a prominent role in the provision and administration of dental care for Head Start children. The responsibility that has been taken on by the health departments of such cities as Detroit, New York, Washington, D. C., and Houston has shown how the health department as an administrator can either provide direct service to children or delegate the provision of service through the private office, either directly or through the Dental Service Corporation. There have been instances where such funds allocated for children in Head Start have been combined or are proposed to be combined with funds available for health through the Elementary and Secondary Education Act, Title I, such as in programs in Minneapolis and Cleveland. There have been instances in which multiple sources of funding have been used. One notes, for instance, the dental clinic established in Austin, Tex., which combined the use of dental formula grants for dental equipment, the provision of a site by the local city council and health department, the provision of operating funds and the purchase of a building through the local community action agency. Additional local resources have been used for provision of dental care. For instance, in certain areas of the country dental care to preschool children has been provided through the use of dental schools (as in Loyola, New Orleans, and St. Louis) and in dental offices in areas where such treatment was not provided before on such a scale. Another innovation in the provision of dental care concerns the role of the armed forces. It is extremely interesting that the United States Navy has accepted the responsibility for providing a preventive dentistry program for dependents' children who would otherwise fall into the Head Start bracket. This program, together with some proposed projects involving dependent parents and children, has indicated that the armed forces might be prepared to play a significant role in the over-all emphasis on the dental health of the preschool child. Dental programs conducted through the Division of Indian Health are currently using the creation of Project Head Start to place emphasis on this preschool age group. Finally, innovation has occurred in the use of nonprofessional personnel to assist in dental programs. Time and again one has heard of interesting approaches by which volunteers, aides, and neighborhood workers have been used to assist parents in taking children to the dental office or to the dental clinic. One has heard interesting reports of how aides have been used to chaperone and amuse children and provide dental health education messages for groups of children waiting for the dentist. Problems Certainly there have been problems. and these have fallen into two main categories: Communications Inadequate communications within Office of Economic Opportunity offices and departments. and between local administrators and local professionals, has led to inadequate JANUARY

5 dental programs and delays (sometimes involving the release of funds). It also has been difficult to completely inform local dental professionals of the program content in the limited period of time available. Disillusionment -The dental profession in some instances has been disillusioned by the previous programs involving mere screening without treatment. Consequently, this past summer many were reluctant to continue to participate because they did not realize that the current emphasis is on treatment. Similarly, local OEO officials are often disillusioned because the dental component of a program costs money but provides no treatment. Conclusion It is fair to say that Project Head Start even in its short existence has exposed a segment of the population to dental care services-a 1.3-million segment-that probably would not otherwise have received such exposure. The summer of experience has shown that it has introduced innumerable laymen to dental professionals, dental problems, and the processes for insuring the provision of dental care. It has also provided needed dental treatment services to many children who would otherwise be suffering now from dental neglect. In certain places it seems that some "impossible" things have happened. Dr. Gillespie is former chief, Public Care Unit, Dental Care Branch, Division of Dental Health, Public Health Service, Bethesda, Md This paper was presented before the Dental Health Section of the American Public Health Association at the Ninety-Fourth Annual Meeting in San Francisco, Calif., November 1, Pest Control Technology A correspondence course in pest control technology is being offered by the Department of Entomology and the Division of Conferences and Continuation Services of Purdue University, Lafayette, Ind. The course consists of 19 lessons. Upon completion of a final examination, a certificate is awarded by the university. Total cost is $58.75, which includes textbook fee. Further information from the Business Office, University Extension Administration, Memorial Center, Room 110, Purdue University, Lafayette, Ind VOL. 58, NO. 1. A.J.P.H.