Out in the public

Practicing in public health can mean working in many different locations. It can mean treating the elderly or school children, working with ethnic or special-needs populations, or going into the inner city or rural areas. Wherever people have dental needs, dental hygienists seem to be able to work around obstacles. School-based delivery of care is often overlooked, but has tremendous impact on children`s dental health.

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Public health dentistry for children surfaces in some unusual locations.

Cathleen Terhune Alty, RDH

Practicing in public health can mean working in many different locations. It can mean treating the elderly or school children, working with ethnic or special-needs populations, or going into the inner city or rural areas. Wherever people have dental needs, dental hygienists seem to be able to work around obstacles. School-based delivery of care is often overlooked, but has tremendous impact on children`s dental health.

The sweet smell of success is always in the air in Hershey, Pa., home of the famous Hershey Kisses. What you may not know is that purchases of the company`s chocolate help fund the Milton Hershey School, a private residential school that has three dental care clinics on the grounds. The school was started by Milton and Katherine Hershey in the early 1900s with an endowment from the Hershey chocolate fortune. Today, Milton Hershey School enrolls boys and girls K-12 from families of limited income and of diverse backgrounds.

Rachel Walker, RDH, has worked full-time in the school`s dental department for the past 13 years. "We offer full preventive care in the on-site clinics," she said. "All of the students` needs are taken care of through the Hershey endowment: clothing, meals, housing, medical care, and dental care. We receive no county or state funding."

Dr. Peter Caso is the director of dental services at the school, handling both administrative and operative duties. Other dentists are hired on a part-time basis to handle any increased operative load, and two orthodontists are contracted to work one day per week.

Walker said each hygienist in the three clinics schedule their own appointments. Children are seen every six months for preventive care. The children live in 70 ranch-type homes with 10 to 15 children in each home. A couple serves as house parents, overseeing the home care of the students. They are encouraged to function as a family as much as possible within the home.

Walker said, "We also have a lot of collaboration between the child`s parents, teachers, and the dental clinic." She said that some classroom teaching is done by the hygienists, and they provide information to the teachers about dental health as well.

She points out, "These children are not the `have nots.` They are all cared for."

A big difference in hygiene practice in a school setting is that you are involved in the children`s social life. "For example," said Walker, "we may chaperone a school dance. We can sit with them and have lunch on a daily basis. We can also attend the children`s sport activities such as wrestling matches. I can take a couple of hours out of my evening and see all of my patients!"

Another difference is that the school requires a substantially higher level of continuing education credits than required by Pennsylvania dental law.

Walker said that when children graduate and leave the school, it`s hard on everyone because they have gotten so close. She loves her job. "It`s an ideal situation," she said. "We have modern equipment, a lovely setting, and summers off."

Not all students of residential schools are offered on-site dental care, and most have to pay for dental services. For example, the Scotland School in Chambersburg, Pa., is a school for U.S. Veterans` children. An operator at the school said if children need dental work they have to send the children home to get it. "We don`t have any dentists who volunteer to see these children, and the dentists in town insist on cash only!"

Even the famous Boys Town in Omaha, Neb., doesn`t have on-site dental care or volunteer dentists from town. Dental insurance is offered to all students, and they go into town for their dental care. One of the Boys Town operators commented, "Dentists go overseas and volunteer their time and dental skills. Why won`t they help here occasionally for no financial reward?"

On the reservation

Sometimes the hygienists have to travel to the school clinic to help the children who reside there. Lynnette Engeswick, RDH, is an instructor at the department of dental hygiene at Minnesota State University in Mankato. Twenty-three dental hygiene students travel to three different Indian reservations in Minnesota to volunteer at the reservation`s Indian Health Clinics.

"I was a student here in the 1970s, and we went to the White Earth Indian Reservation in northern Minnesota to volunteer with 16 other hygiene students," Engeswick said. "Twenty-eight years ago, we did tons of sealants, prophys, and fluorides for four full days."

Today, student teams live in nearby resort complexes when it`s off-season for tourists, but they still work very hard providing care to an underserved population. Each one of the three clinics offers distinctive conditions among patients.

Engeswick explained, "At the Red Lake Reservation, access to dental hygiene care is poor. It is located in northernmost Minnesota and there are few, if any, jobs. Poverty is very intense. We see rampant caries in children from nursing-bottle syndrome and rampant decay in adults with bulging pulps. This is a Third World level of dentistry, because we can only deal with the urgent care issues. The one dentist who is in this facility is performing lots of extractions and pulpectomies.

"At the Leech Lake Reservation we go into the Bug-O-Nay-Ke-Shing Tribal School, which has its own dental clinic. All the children receive exams and are screened for sealants. Then hygienists come in as teams of two for four days and do nothing but seal teeth. Believe me, they get really good at it! We figured that we do 412 sealants in four days, working four to five hours a day.

"At the White Earth Reservation, there is not much dental disease because the years of preventive care have helped the population to be healthy. Public health dentistry really does work!"

Patient education is critical at all three facilities. Because of the cultural differences, the students learn the best ways to approach their Native American patients. "We front-load it just a bit so the students are prepared. You don`t want to insult or be too bold," said Engeswick. "We want them to know we are interested in their care, not in lecturing them. Our values and motivations are different. Most of our patients want to put other`s needs first, because they realize that others need our care more than they do."

After the students complete their "externship," they participate in a debriefing and sharing time to help understand and digest what they have learned.

"We are so gifted," Engeswick said. "We can heal with our hands. But some hygienists say, `If we get paid for it, we do it.` This is missionary work." Engeswick said the dental hygiene program is actively recruiting students from the Native Americans they serve, but have yet to recruit even one Native American in the program.

Costs of student transportation and lodging are covered by grants from the Grotto Foundation of St. Paul, tribal councils, and the Indian Health Service. The University pays for three faculty members from the dental hygiene school to chaperone. Engeswick said there is not much money for public health available, and many of the tribes support the cost of their care.

Cathleen Terhune Alty, RDH, is a frequent contributor to RDH. She resides in Clarkston, Michigan, and can be contacted at alltees@juno.com.

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Rachel Walker, right, works at the Milton Hershey Memorial Hall Elementary School.

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