, To Lizzie and Sue
and to the memory of Dr. Keith Heller, a dear friend and
dedicated colleague
,11830 Westline Industrial Drive
St. Louis, Missouri 63146
DENTISTRY, DENTAL PRACTICE, AND 0-7216-0515-X
THE COMMUNITY
Copyright © 2005, 1999, 1992, 1983, 1969, 1964 by Elsevier Inc.
All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system,
without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s
Health Sciences Rights Department in Philadelphia, PA, USA: phone: (+1) 215 238 7869, fax: (+1) 215
238 2239, e-mail: . You may also complete your request on-line via the
Elsevier Science homepage (http://www.elsevier.com), by selecting ‘Customer Support’ and then
‘Obtaining Permissions’.
NOTICE
Dentistry is an ever-changing field. Standard safety precautions must be followed, but as new research
and clinical experience broaden our knowledge, changes in treatment and drug therapy become nec-
essary or appropriate. Readers are advised to check the product information currently provided by the
manufacturer of each drug to be administered to verify the recommended dose, the method and
duration of administration, and the contradictions. It is the responsibility of the treating physican,
relying on experience and knowledge of the patient, to determine dosages and the best treatment for
the patient. Neither the publisher nor the editor assumes any responsibility for any injury and/or
damage to persons or property.
International Standard Book Number
0-7216-0515-X
Publishing Director: Linda Duncan
Executive Editor: Penny Rudolph
Developmental Editors: Courtney Sprehe and Jaime Pendill
Publishing Services Manager: Deborah Vogel
Senior Project Manager: Mary Drone
Senior Designer: Kathi Gosche
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
, PREFACE TO THE SIXTH EDITION
Change is the only true constant in our uncertain world, and this sixth edition comes into a world
that is very different from that which greeted the fifth edition in 1999. The budget surpluses of that
time have plunged to become record deficits, and as a nation we are ambivalent about a war that may
bring democracy to a troubled land or may drag us into a morass. Most of all, our national mindset
is dominated by the horrors and heroism of September 11, 2001. And what has unpredictable social
change got to do with dentistry? The answer is a great deal, for the dental world, like any other insti-
tution, is part of the overall pattern. If the world is an ecosystem, then changes in population,
income, employment, inflation, and just about everything else will affect dentistry to some extent.
The purpose of this book is to present dentistry and dental practice against the backdrop of social
events: economic, technological, and demographic trends, as well as the distribution of the oral dis-
eases that dental professionals treat and prevent. The pace of change in these areas can be bewilder-
ing, and substantial rewriting of many parts of this book has thus been required. Since the 1999
edition came out, we have seen our health system, based on something called managed care, become
less and less workable. Dentistry in Medicaid is barely visible, “access” has emerged as a major health
issue, and the corporate burden of providing health care for employees is threatening our national
economy. Dentistry cannot be a bystander as these issues continue to demand public attention.
Rather, dentistry needs to understand them as best we can and take its place at the table as a leader in
setting health care policy.
Our guiding principle in this sixth edition is that we lay out the facts on all matters discussed and
interpret them as we see them. We express our opinions, taking care to distinguish opinion from fact,
and leave the reader to develop his or her own views. We subscribe to the view that health is a major
contributor to a higher quality of life rather than an end in itself. We have no doubt that good oral
health significantly improves the quality of life and that the constant improvement of the public’s
oral health is a worthy goal.
The lineage of this book can be traced from the landmark work of Pelton and Wisan’s Dentistry in
Public Health, first published in 1949, up to our fifth edition in 1999. We carry on the tradition in
this sixth edition, which has 30 chapters in five parts, more than ever before. That growth reflects the
expansion of the issues with which dentistry is involved. The first part looks at the dental professions
and the public they serve and deals with ethics, the public-private partnership, public health prac-
tice, and health promotion. Part II deals with the structure and financing of dental practice, types of
personnel in the dental workforce, infection control and mercury safety, and a new chapter on access
to dental care. The chapter on reading the literature is now joined by a new chapter on evidence-
based dentistry. Part III is the nitty-gritty of oral epidemiology, from research designs and survey
methods to the various indexes used to measure oral disease, and Part IV looks at the distribution of
these diseases in the population and the various risk factors associated with them. In conclusion,
Part V deals with the prevention of oral diseases and conditions.
In matters of style, we favor liberal referencing. This gives readers a chance to pursue further the
issues that interest them, and the references give the basis for our interpretation of the more con-
tentious issues. We list more references with potentially contentious issues than with the more
straightforward ones. Although most references reflect current work, we have retained a lot of older
ones to illustrate how issues have developed over time and to show the richness of the dental litera-
ture. We should never forget our roots. As would be expected, a growing number of references are to
sites on the Internet, although we all have mixed feelings about the growing dominance of the
Internet as a source of basic information. On the one hand, it makes information more immediately
available than ever: if knowledge is power, we are all more powerful. On the other hand, Internet
material can be startlingly temporary. Even during the production of this edition, a number of
vii
and to the memory of Dr. Keith Heller, a dear friend and
dedicated colleague
,11830 Westline Industrial Drive
St. Louis, Missouri 63146
DENTISTRY, DENTAL PRACTICE, AND 0-7216-0515-X
THE COMMUNITY
Copyright © 2005, 1999, 1992, 1983, 1969, 1964 by Elsevier Inc.
All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system,
without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s
Health Sciences Rights Department in Philadelphia, PA, USA: phone: (+1) 215 238 7869, fax: (+1) 215
238 2239, e-mail: . You may also complete your request on-line via the
Elsevier Science homepage (http://www.elsevier.com), by selecting ‘Customer Support’ and then
‘Obtaining Permissions’.
NOTICE
Dentistry is an ever-changing field. Standard safety precautions must be followed, but as new research
and clinical experience broaden our knowledge, changes in treatment and drug therapy become nec-
essary or appropriate. Readers are advised to check the product information currently provided by the
manufacturer of each drug to be administered to verify the recommended dose, the method and
duration of administration, and the contradictions. It is the responsibility of the treating physican,
relying on experience and knowledge of the patient, to determine dosages and the best treatment for
the patient. Neither the publisher nor the editor assumes any responsibility for any injury and/or
damage to persons or property.
International Standard Book Number
0-7216-0515-X
Publishing Director: Linda Duncan
Executive Editor: Penny Rudolph
Developmental Editors: Courtney Sprehe and Jaime Pendill
Publishing Services Manager: Deborah Vogel
Senior Project Manager: Mary Drone
Senior Designer: Kathi Gosche
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
, PREFACE TO THE SIXTH EDITION
Change is the only true constant in our uncertain world, and this sixth edition comes into a world
that is very different from that which greeted the fifth edition in 1999. The budget surpluses of that
time have plunged to become record deficits, and as a nation we are ambivalent about a war that may
bring democracy to a troubled land or may drag us into a morass. Most of all, our national mindset
is dominated by the horrors and heroism of September 11, 2001. And what has unpredictable social
change got to do with dentistry? The answer is a great deal, for the dental world, like any other insti-
tution, is part of the overall pattern. If the world is an ecosystem, then changes in population,
income, employment, inflation, and just about everything else will affect dentistry to some extent.
The purpose of this book is to present dentistry and dental practice against the backdrop of social
events: economic, technological, and demographic trends, as well as the distribution of the oral dis-
eases that dental professionals treat and prevent. The pace of change in these areas can be bewilder-
ing, and substantial rewriting of many parts of this book has thus been required. Since the 1999
edition came out, we have seen our health system, based on something called managed care, become
less and less workable. Dentistry in Medicaid is barely visible, “access” has emerged as a major health
issue, and the corporate burden of providing health care for employees is threatening our national
economy. Dentistry cannot be a bystander as these issues continue to demand public attention.
Rather, dentistry needs to understand them as best we can and take its place at the table as a leader in
setting health care policy.
Our guiding principle in this sixth edition is that we lay out the facts on all matters discussed and
interpret them as we see them. We express our opinions, taking care to distinguish opinion from fact,
and leave the reader to develop his or her own views. We subscribe to the view that health is a major
contributor to a higher quality of life rather than an end in itself. We have no doubt that good oral
health significantly improves the quality of life and that the constant improvement of the public’s
oral health is a worthy goal.
The lineage of this book can be traced from the landmark work of Pelton and Wisan’s Dentistry in
Public Health, first published in 1949, up to our fifth edition in 1999. We carry on the tradition in
this sixth edition, which has 30 chapters in five parts, more than ever before. That growth reflects the
expansion of the issues with which dentistry is involved. The first part looks at the dental professions
and the public they serve and deals with ethics, the public-private partnership, public health prac-
tice, and health promotion. Part II deals with the structure and financing of dental practice, types of
personnel in the dental workforce, infection control and mercury safety, and a new chapter on access
to dental care. The chapter on reading the literature is now joined by a new chapter on evidence-
based dentistry. Part III is the nitty-gritty of oral epidemiology, from research designs and survey
methods to the various indexes used to measure oral disease, and Part IV looks at the distribution of
these diseases in the population and the various risk factors associated with them. In conclusion,
Part V deals with the prevention of oral diseases and conditions.
In matters of style, we favor liberal referencing. This gives readers a chance to pursue further the
issues that interest them, and the references give the basis for our interpretation of the more con-
tentious issues. We list more references with potentially contentious issues than with the more
straightforward ones. Although most references reflect current work, we have retained a lot of older
ones to illustrate how issues have developed over time and to show the richness of the dental litera-
ture. We should never forget our roots. As would be expected, a growing number of references are to
sites on the Internet, although we all have mixed feelings about the growing dominance of the
Internet as a source of basic information. On the one hand, it makes information more immediately
available than ever: if knowledge is power, we are all more powerful. On the other hand, Internet
material can be startlingly temporary. Even during the production of this edition, a number of
vii
