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2 TRENDS IN PUBLIC HEALTH DENTISTRY IN LAT Victor Lopez Carnara, C.D., M.P.H. N AMERICA Dental problems are beginning to be considered a matter of importance among the general aspects in public health in most of our countries in Latin America. More than 200 million people, speaking Spanish, Por- tuguese or French in twenty different countries, are facing similar health problems and are trying to solve them in simi?ar ways but having considerably different economical means to do so. Resources are being used in trying to attack the bigger mortality problems, such as malaria, gastro intestinal diseases or respiratory diseases. This approach is the reason why, until now, some of our countries were not able to con- sider dentistry among their health programs, or they just considered it in a very sl ight manner. Lately there has been a strong tendency of the governments of the Latin American countries to organize divisions or sections of dentistry within the institutions dedicated to public health, although not yet a l l of them have done it. Probably the recommendation of the project "A1 1 iance for Progress"' to the governments, for the preparation of national health plans for this decade, will help them regarding the decision of having a section dedicated entirely to the special problems of public health dentistry. They will help them also in planning for utilization of the dental resources for the next ten years, considering them as an integrated and inseparable part of the national health plans menti~ned.~ The situation in this field is actually difficult, because dental needs are, by far, much bigger than the dental resources in all Latin America. However, the future of pub1 ic health dentistry in most of our twenty countries has to be seen in an optimistic way. We will try to comment briefly on what we think could be, in the immediate future, the general development of pub1 ic health dentistry in Latin America. DENTAL MANPOWER There are very few Latin American countries that at the present mo- ment do not have at least one dentist with a Pub1 ic Health degree. Most of them are occupying advisory positions, but the tendency is toward administrative positions at the national level in every country.

TRENDS IN PUBLIC HEALTH DENTISTRY IN LATIN AMERICA

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TRENDS I N PUBLIC HEALTH DENTISTRY I N LAT

V i c t o r Lopez Carnara, C.D., M.P.H.

N AMERICA

Denta l problems a r e beg inn ing t o be cons idered a m a t t e r o f importance among t h e genera l aspec ts i n p u b l i c h e a l t h i n most o f ou r c o u n t r i e s i n L a t i n America. More t h a n 200 m i l l i o n peop le , s p e a k i n g Spanish, Por - tuguese o r F rench i n t w e n t y d i f f e r e n t c o u n t r i e s , a r e f a c i n g s i m i l a r h e a l t h problems and a r e t r y i n g t o s o l v e them i n s i m i ? a r ways b u t hav ing c o n s i d e r a b l y d i f f e r e n t economica l means t o do so. Resources a r e be ing used i n t r y i n g t o a t t a c k t h e b i g g e r m o r t a l i t y problems, such as malar ia , g a s t r o i n t e s t i n a l d i s e a s e s o r r e s p i r a t o r y d iseases . T h i s approach i s t h e reason why, u n t i l now, some o f o u r c o u n t r i e s were n o t a b l e t o con- s i d e r d e n t i s t r y among t h e i r h e a l t h programs, o r t hey j u s t c o n s i d e r e d i t i n a ve ry s l i g h t manner.

L a t e l y t h e r e has been a s t r o n g tendency o f t h e governments o f t h e L a t i n American c o u n t r i e s t o o rgan ize d i v i s i o n s o r s e c t i o n s of d e n t i s t r y w i t h i n t h e i n s t i t u t i o n s d e d i c a t e d t o p u b l i c h e a l t h , a l t h o u g h n o t y e t a l l o f them have done it. Probab ly t h e recommendation o f t h e p r o j e c t " A 1 1 i a n c e f o r P r o g r e s s " ' t o t h e governments, f o r t h e p r e p a r a t i o n o f n a t i o n a l h e a l t h p l a n s f o r t h i s decade, w i l l h e l p them r e g a r d i n g t h e d e c i s i o n o f hav ing a s e c t i o n ded ica ted e n t i r e l y t o t h e s p e c i a l problems o f p u b l i c h e a l t h d e n t i s t r y . They w i l l h e l p them a l s o i n p l a n n i n g f o r u t i l i z a t i o n o f t h e d e n t a l resources f o r t h e n e x t t e n years, c o n s i d e r i n g them as an i n t e g r a t e d and inseparab le p a r t o f t h e n a t i o n a l h e a l t h p lans m e n t i ~ n e d . ~

The s i t u a t i o n i n t h i s f i e l d i s a c t u a l l y d i f f i c u l t , because d e n t a l needs are , by f a r , much b i g g e r than t h e d e n t a l resources i n a l l L a t i n America. However, t h e f u t u r e o f pub1 i c h e a l t h d e n t i s t r y i n most of o u r twenty c o u n t r i e s has t o be seen i n an o p t i m i s t i c way.

We w i l l t r y t o comment b r i e f l y on what we t h i n k c o u l d be, i n t h e immediate f u t u r e , t h e genera l development o f pub1 i c h e a l t h d e n t i s t r y i n L a t i n America.

DENTAL MANPOWER

There a r e ve ry few L a t i n American c o u n t r i e s t h a t a t t h e p r e s e n t mo- ment do n o t have a t l e a s t one d e n t i s t w i t h a Pub1 i c Hea l th degree. Most o f them a r e o c c u p y i n g a d v i s o r y p o s i t i o n s , b u t t h e tendency i s toward a d m i n i s t r a t i v e p o s i t i o n s a t t h e n a t i o n a l l e v e l i n every coun t ry .

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The d e n t i s t - p o p u l a t i o n r a t i o v a r i e s w i d e l y , f r o m one d e n t i s t f o r every 1,500 persons i n U r ~ g u a y ~ ' ~ t o 1:36,000 i n H a i t i . 1 4 D e n t i s t s tend t o c o n c e n t r a t e more i n b i g towns. Many c o u n t r i e s have f r o m 40 t o 50 per c e n t o f t h e i r d e n t i s t s i n t h e i r c a p i t a l c i t i e s , where t h e r e i s a p - p r o x i m a t e l y 10 per c e n t o f t h e t o t a l p o p u l a t i o n ; i n c o n t r a s t t h e r e a r e some areas hav ing more than 100,000 p o p u l a t i o n and no p r o f e s s i o n a l pe r - sonne l t o t a k e c a r e o f t h e i r d e n t a l needs . I ' T h i s s i t u a t i o n m i g h t be due t o t h e poor economic c o n d i t i o n s o f t h e peop le l i v i n g i n t h e a reas and t h e accompanying u n d e r - u t i l i z a t i o n o f d e n t a l s e r v i c e s t h a t f o r c e s t h e d e n t i s t s t o seek o t h e r p laces where they can l i v e and be p a i d f o r t h e i r s e r v i c e s i n a b e t t e r way. There a r e s t i l l some c o u n t r i e s where more than 40 p e r c e n t o f t h e p o p u l a t i o n l i v e i n a reas where t h e r e a r e no d e n t i s t s . l l Even i n b i g c i t i e s h a v i n g a r a t i o o f one d e n t i s t f o r every 1,200 persons, t h e t r e a t m e n t rece ived takes c a r e o f app rox ima te l y o n l y one t h i r d o f t h e i r needs.5 T h i s s i t u a t i o n means t h a t even t h e b e s t r a t i o o f d e n t i s t s pe r p o p u l a t i o n i s n o t adequate. I t i s observed t h a t s e r v i c e s a r e p r e f e r a b l e f o r a d u l t s , o b v i o u s l y because t h e y a r e more " d e n t a l l y - c o n s c i o u s " t h a n c h i l d r e n .

I n genera l t h e s i t u a t i o n seems t o remain " s t a t u s quo." P r o d u c t i v i t y o f schoo ls o f d e n t i s t r y i s growing a t t h e same r a t e as t h e general POPU-

l a t i o n , t h u s m a i n t a i n i n g t h e same r a t i o o f d e n t i s t s p e r p o p u l a t i o n i n t h e g r e a t m a j o r i t y o f c o u n t r i e s i n t h e reg ion .

The use o f t h e den ta l p r o s t h e t i s t i s ve ry genera l i zed , and t h e number i s f a i r l y adequate f o r t h e a c t u a l demand f o r work done f o r d e n t i s t s . The r e s t o f t h e a u x i l i a r y personne l a re p r a c t i c a l l y begging t o f u n c t i o n i n a few c o u n t r i e s . 1 0 - 1 3 - 1 8 - 2 1 - 2 3 - 2 5 The t r e n d i s t o u t i l i z e them more and more every t ime, bu t , a t p r e s e n t t hey a r e employed o n l y i n govern- mental se rv i ces . Such personne l c o n s i s t s ma in l y o f a u x i l i a r i e s of den- t a l hygiene (sometimes c a l l e d d e n t a l h y g i e n i s t s ) and d e n t a l a s s i s t a n t s . The re i s no o t h e r k i n d o f a u x i l i a r y p e r s o n n e l i n d e n t i s t r y i n L a t i n America.

A t t h e i n t e r n a t i o n a l l e v e l , t h e r e i s o n l y one p u b l i c h e a l t h d e n t i s t work ing w i t h t h e World H e a l t h Organ iza t i on i n t h e Region o f t h e Americas as a whole.8 He a c t s as a c o n s u l t a n t t o t h e governments t h a t ask f o r adv i ce on d e n t i s t r y w i t h i n t h e i r m i n i s t r i e s o f h e a l t h . There have been some o c c a s i o n s i n wh ich s h o r t - t e r m c o n s u l t a n t s have been employed t o g i v e adv i ce i n t h e f i e l d s o f den ta l p u b l i c hea l th , and/or i n the o rgan i - z a t i o n o f t h e c u r r i c u l u m o f d e n t a l s c h o o l s o f some c o u n t r i e s . 2 2 I t seems t h a t i n a s h o r t t ime t h e r e w i l l be den ta l c o n s u l t a n t s work ing w i t h t h e Wor ld H e a l t h O r g a n i z a t i o n -- Pan American S a n i t a r y Bureau a t t h e zone l e v e l s ( c o v e r i n g f rom one t o s i x L a t i n American c o u n t r i e s ) o r i n s p e c i f i c c o u n t r i e s a t n a t i o n a l l e v e l s . 8 T h i s s i t u a t i o n undoubtedly w i l l improve p u b l i c h e a l t h d e n t i s t r y i n L a t i n America because ( I ) i t w i l l b r i n g as an immediate consequence the t rend t o make un i fo rm the u t i l i z a - t i o n o f den ta l resources i n a l l t he c o u n t r i e s (up t o where i t i s p o s s i b l e

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o r adv i sab le ) and (2) hav ing i n t e r n a t i o n a l adv isers , t o c o o r d i n a t e and make p l a n s f o r t h e b e t t e r use o f w i 1 be a v a i l a b l e from t h e p r o j e c t s o f programs o f b o r p h i l a n t h r o p i c a id .

EDUCAT1 ON

i t w i l l be p o s s i b l e t h e resources t h a t l a t e r a l , u n i l a t e r a l

L a t i n Amer i can p u b l i c h e a l t h d e n t i s t s a r e t r a i n e d m a i n l y a t t h e School o f Pub1 i c H e a l t h o f Sao Pau lo , B r a z i l . The re a r e some o t h e r schoo ls o f p u b l i c h e a l t h , such as those i n A rgen t ina , Colombia, Mexico, P u e r t o R i c o and C h i l e , t h a t a r e a l s o o f f e r i n g p u b l i c h e a l t h t r a i n i n g t o d e n t i s t s . 5

I n r e g a r d t o t h e s u b j e c t o f t h e t r a i n i n g o f d e n t i s t s , t h e r e a r e around 75 d e n t a l s c h o o l s i n L a t i n America: j u s t one c o u n t r y does n o t have a d e n t a l schoo l . T h e i r p r i n c i p a l problems seem t o be t h e s e l e c - t i o n o f s tuden ts , o r g a n i z a t i o n o f t h e c u r r i c u l u m , t r a i n i n g o f t eachers and methods f o r t e a c h i n g . P r o d u c t i v i t y o f some s c h o o l s i s v e r y low ( 4 t o 5 ) pe r yea r , a b o u t 80 p e r c e n t o f t h e i r s t u d e n t s b e g i n n i n g t h e d e n t a l course b u t n o t f i n i s h i n g it.5 The p r o p o r t i o n o f female s tuden ts i s h i g h i n a l m o s t a l l s c h o o l s , r e a c h i n g i n some o f them 40 p e r c e n t o r more. For s e v e r a l reasons , t h e p r o p o r t i o n o f f ema le d e n t i s t s n o t work ing i n d e n t i s t r y i s a l s o h igh .

The o b j e c t i v e s o f schoo ls o f d e n t i s t r y a r e n o t u n i f o r m i n t h e coun- t r i e s o f t h e r e g i o n s , so t h e c u r r i c u l u m canno t be u n i f o r m e i t h e r . I n t r y i n g t o d e v e l o p recommendat ions t o s-olve t h i s p a r t i c u l a r p rob lem, t h e Wor ld H e a l t h O r g a n i z a t i o n , i n c o o p e r a t i o n w i t h t h e Government o f Colombia, t h e W. K. K e l l o g g Foundat ion and t h e L a t i n American Associa- t i o n o f Schools o f D e n t i s t r y , i s o r g a n i z i n g t h r e e " L a t i n American Sem- i n a r s on t e a c h i n g o f D e n t i s t r y . " 1 7 The f i r s t o f them t o o k p l a c e i n Bogota j u s t a few days ago, f r o m O c t o b e r 14 t o 19. R e p r e s e n t a t i v e s o f a l l t h e d e n t a l schoo ls i n L a t i n America a r e go ing t o a t t e n d a t l e a s t one o f t h e s e m e e t i n g s , and a l l t h e s c h o o l s a r e g o i n g t o r e c e i v e t h e r e s o l u t i o n s t a k e n i n each o f t h e semina rs .17 E v e r y L a t i n Amer ican d e n t a l schoo l shou ld be m o t i v a t e d t o be a member o f t h e L a t i n American A s s o c i a t i o n o f Schoo ls o f D e n t i s t r y and t o f o l l o w t h e recommendations g i v e n i n o r d e r t o c l a r i f y t h e g o a l s o f d e n t i s t r y i n t h e i r c o u n t r i e s .

I n r e l a t i o n t o t h e t r a i n i n g o f t eachers , t h e W. K. K e l l o g g Founda- t i o n 2 6 i s p l a y i n g a ve ry i m p o r t a n t r o l e i n g i v i n g f e l l o w s h i p s t o p ro - f e s s o r s o f d i f f e r e n t s u b j e c t s , r e i n f o r c i n g , i n t h i s way, t h e q u a l i t y o f d e n t a l e d u c a t i o n . Many L a t i n American s c h o o l s have p r o f e s s o r s on an exchange b a s i s and obse rva t i on programs f o r teachers o f o t h e r schools. The L a t i n American A s s o c i a t i o n o f Schoo ls o f D e n t i s t r y , i n c o o p e r a t i o n w i t h Wor ld H e a l t h O r g a n i z a t i o n and W. K. K e l l o g g Founda t ion , has o r -

17 gan ized a cou rse on d e n t a l e d u c a t i o n f o r L a t i n American p r o f e s s o r s : i t w i l l t a k e p l a c e a l s o i n Bogota , Co lombia , i m m e d i a t e l y a f t e r t h e

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c e l e b r a t i o n o f t h e Seminar on T e a c h i n g o f D e n t i s t r y . I t i s i n t e n d e d 17 t o i n v i t e a t l e a s t one r e p r e s e n t a t i v e o f every L a t i n American coun t ry .

I t shou ld be h i g h l y recommended t h a t a course o f t h i s t y p e be organ ized, i f n o t a t e v e r y d e n t a l s c h o o l , a t l e a s t i n e v e r y c o u n t r y i n o r d e r t o make i t a v a i l a b l e f o r most o f t h e teachers . I t i s a v e r y s h o r t cou rse (one week 's d u r a t i o n ) , so t h i s t i m e f a c t o r c o u l d f a c i l i t a t e i t s o r - g a n i z a t i o n i n many o f t h e c o u n t r i e s o f t h e reg ion .

A s i n g l e , v e r y i m p o r t a n t a c t i v i t y t h a t w i l l be i n f l u e n t i a l i n t h e deve lopment o f p u b l i c h e a l t h minded d e n t i s t s i n o u r c o u n t r i e s i s t h e c r e a t i o n o f d e p a r t m e n t s o f s o c i a l d e n t i s t r y i n s c h o o l s . 2 The School o f D e n t i s t r y o f t h e U n i v e r s i t y o f An t ioqu ia , aga in i n c o o p e r a t i o n w i t h t h e Wor ld H e a l t h O r g a n i z a t i o n and t h e W. K . K e l l o g g F o u n d a t i o n , has c r e a t e d a Depar tment o f P r e v e n t i v e and S o c i a l D e n t i s t r y i n M e d e l l i n , C o l ~ m b i a . ~ It i s hoped t h a t t h i s department w i l l a c t as a demonst ra t ion and t r a i n i n g c e n t e r f o r t h e c r e a t i o n o f s i m i l a r d e p a r t m e n t s i n o t h e r L a t i n American Schools.

Ano the r v e r y i m p o r t a n t a s p e c t f o r t h e improvement o f p u b l i c h e a l t h d e n t i s t r y i n t h e r e g i o n i s t h e o r g a n i z a t i o n o f r u r a l , o r s o c i a l s e r v i c e p e r i o d f o r s t u d e n t s f i n i s h i n g t h e l a s t y e a r o f d e n t a l schoo l .12 Some governments demand, as a r e q u i s i t e f o r a t t a i n m e n t o f t h e d e n t a l degree, t h e f u l f i l l m e n t o f a c e r t a i n p e r i o d o f t i m e w o r k i n g i n r u r a l a reas o r i n a reas where t h e d e n t i s t - p o p u l a t i o n r a t i o i s l o w e r t h a n i n t h e r e s t o f t h e c o u n t r y .

12 The advantages expec ted f rom t h e r u r a l yea r a re :

A more complete p r a c t i c a l educat ion o f t he s tuden t B e t t e r knowledge o f d e n t a l needs i n t h e coun t ry Fac i 1 i t a t i o n of d e n t a l s e r v i c e s f o r some s e c t o r s o f t he

p o p u l a t i o n t h a t do n o t have enough economic resources t o go t o p r i v a t e d e n t i s t s

A t ta inmen t o f a b e t t e r d i s t r i b u t i o n o f d e n t i s t s i n the coun t ry .

I n some c o u n t r i e s t h e c o m p u l s o r y r u r a l y e a r f o r d e n t a l s t u d e n t s means d u p l i c a t i o n o f t h e number o f d e n t i s t s work ing i n t h e p u b l i c h e a l t h se rv i ces .

A few c o u n t r i e s a r e engaged i n t h e i n - s e r v i c e t r a i n i n g o f d e n t i s t s w o r k i n g i n l o c a l p rograms. D i f f e r e n t s e m i n a r s o r s h o r t c o u r s e s a r e o r g a n i z e d i n o r d e r t o g i v e them some up - to -da te knowledge, e s p e c i a l l y i n rega rd t o p r e v e n t i v e measures and a d m i n i s t r a t i o n o f d e n t a l programs a t l o c a l l e v e l s . They a r e i n t e n d e d t o be f o l l o w e d by o t h e r semina rs as a c o n t i n u i n g e d u c a t i o n a l program.

T r a i n i n g o f a u x i l i a r y p e r s o n n e l i s s t i l l b e g i n n i n g i n some o f o u r c o u n t r i e s . io -12-18-21-23-25 Courses f o r d e n t a l a s s i s t a n t s have been

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T r a i n i n g o f a u x i l i a r y p e r s o n n e l i s s t i l l b e g i n n i n g i n some o f o u r c o u n t r i e s . 10-12-18-21-23-35 Courses f o r d e n t a l a s s i s t a n t s have been g i v e n i n s e v e r a l p l a c e s and s e v e r a l t i m e s , b u t , maybe s i n c e d e n t a l s t u d e n t s a r e n o t t a u g h t t o use them e f f e c t i v e l y , t h e y u s u a l l y d o n o t h e l p t h e d e n t i s t i n t h e a p p r o p r i a t e way.

A new t y p e o f a u x i l i a r y pe rsonne l , t h e a u x i l i a r y o f d e n t a l hyg iene, i s now i n use i n some o f t h e L a t i n Amer i can c o u n t r i e s . 1 5 They a r e t r a i n e d i n c o u r s e s o f f r o m one t o t h r e e months’ d u r a t i o n and a r e ex - pec ted t o work m a i n l y i n programs o f t o p i c a l a p p l i c a t i o n o f f l u o r i d e s . They a r e a l s o i n charge o f some o t h e r a c t i v i t i e s , such as h e a l t h educa- t i o n o f t h e p u b l i c -- p r e f e r a b l y c h i l d r e n and mo the rs -- management o f r e c o r d s and, i n some i n s t a n c e s , a c t a l s o as d e n t a l a s s i s t a n t s . By now t h i s t y p e o f p e r s o n n e l i s w o r k i n g o n l y i n p u b i i c h e a l t h p rograms suppor ted by governments, b u t t h e t i m e w i l l come when d e n t a l h y g i e n i s t s w i l l be w o r k i n g i n t h e p r i v a t e o f f i c e o f t h e d e n t i s t , a l s o h e l p i n g him i n o t h e r a c t i v i t i e s as i n o t h e r coun t r i es .24

I t i s expec ted t h a t i n t h i s decade t h e i n t e r n a t i o n a l agenc ies w i l l h e l p t h e L a t i n Amer ican c o u n t r i e s i n t h e s u p p o r t and o r g a n i z a t i o n o f t r a i n i n g courses, b o t h f o r p r o f e s s i o n a l and a u x i l i a r y personne l work ing i n h e a l t h s e r v i c e s .

PREVENTIVE MEASURES

I n t h e p r e s e n t c i r c u m s t a n c e s , w i t h t h e knowledge t h a t d e n t a l needs a r e never g o i n g t o be s o l v e d o r d i m i n i s h e d i n a s i g n i f i c a n t p r o p o r t i o n t h r o u g h t h e use o f p r e s e n t manpower r e s o u r c e s , t h e mass p r e v e n t i v e measures a r e t h e b e s t approaches t o t h e problem.

I t i s r e c o g n i z e d t h a t i n a l l L a t i n Amer i can c o u n t r i e s t h e f i r s t d e n t a l p u b l i c h e a l t h p rob lem i s d e n t a l c a r i e s . I t s p r e v a l e n c e v a r i e s not o n l y f r o m c o u n t r y t o c o u n t r y b u t f r o m p l a c e t o p l a c e , b e i n g f rom 2.4 t o 4.3 DMF a t 7 y e a r s o f age and f r o m 5 . 8 t o 12. I DMF a t 12 y e a r s o f age i n p l a c e s t h a t do n o t have t h e p r o t e c t i o n o f f l u o r i d e s . l 0 - I 3 - l 4 18-21-23-25 The i n c i d e n c e o f d e n t a l c a r i e s a l s o v a r i e s f r o m 0.5 t o 1.6 DMF p e r c h i l d and p e r y e a r .

The p r o b l e m t h a t seems t o f o l l o w d e n t a l c a r i e s i n i m p o r t a n c e i s t h a t o f p e r i o d o n t a l d i s e a s e s . There a r e no d a t a i n r e g a r d t o t h e s e p rob lems , because, u n t i l now, t h e r e i s no one i n d e x used u n i f o r m l y i n t h e s t u d y o f t h i s g roup o f d i s e a s e s i n L a t i n America. Anyway, i t i s r e c o g n i z e d i n mos t o f o u r c o u n t r i e s as t h e second p r o b l e m i n i m - p o r t a n c e i n d e n t a l pub1 i c h e a l t h .

I n t h e p r e v e n t i o n o f t h e c a r i e s problem, t h e most e f f e c t i v e measure i s w a t e r f l u o r i d a t i o n . U n f o r t u n a t e l y t h e r e a r e v e r y few c o u n t r i e s u s i n g i t i n a c o n s i s t e n t way. The m o s t advanced c o u n t r i e s i n t h i s a s p e c t a r e w i t h 39 f l u o r i d a t i o n p r o j e c t s , and C h i l e , w i t h 23 i n o p e r a t i o n now and a n o t h e r 29 p lanned f o r n e x t year . ” More than s i x o f t h e t w e n t y c o u n t r i e s a r e n o t u s i n g f l u o r i d a t i o n , and many o f

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them have j u s t one demonst ra t ion p r o j e c t .

B a r r i e r s t o f l u o r i d a t i o n a r e m a i n l y economic. A l t h o u g h t h e r e has been no o r g a n i z e d o p p o s i t i o n t o f l ~ o r i d a t i o n , ~ g r e a t p r o g r e s s has n o t been made, because wa te r q u a l i t y and q u a n t i t y a r e s t i l l b a s i c problems i n o u r r e g i o n . B e s i d e s , t h e c o s t o f i m p o r t i n g s a l t s and e q u i p m e n t makes i n i t i a t i o n and o p e r a t i o n more d i f f i c u l t .

Even k n o w i n g t h a t w a t e r f l u o r i d a t i o n i s o r w i l l be a v a i l a b l e t o o n l y a sma l l segment o f o u r p o p u l a t i o n i n L a t i n America, t h e b e n e f i t s o f t h e measure o u g h t t o be g i v e n t o t h o s e who a r e i n a p o s i t i o n t o have it. Most o f t h e e f f o r t s o f p u b l i c h e a l t h d e n t i s t s i n L a t i n America a r e b e i n g employed i n t h i s p a r t i c u l a r a rea . Programs o f t o p i c a l f l u - o r i d e s a r e n o t v e r y p o p u l a r a t t h e p r e s e n t moment, because t h e r e i s a l a c k o f a u x i l i a r y pe rsonne l t o c a r r y them o u t . As soon as t h e aux- i l i a r y personnel i s t r a i n e d , these programs w i l l become t h e bas i c preven- t i v e measure f o r d e n t a l c a r i e s i f , by t h a t t i m e , t h e r e i s n o t a new form o f a d m i n i s t r a t i o n , o r a new k i n d o f p r e v e n t i v e procedure.

R e s t r i c t i o n on t h e i n t a k e o f c a r b o h y d r a t e s i s promoted by h e a l t h e d u c a t o r s and a u x i l i a r i e s o f d e n t a l h y g i e n e . What i s g e n e r a l l y ex - pec ted f rom t h e p romot ion o f t h i s s u b j e c t , i s t h a t t h e p u b l i c , i n gen- e r a l , w i l l know t h e d i r e c t r e l a t i o n between sugar and d e n t a l c a r i e s . Recommendations a r e made i n t h e sense o f r e s t r i c t i n g t h e consumpt ion o f s u g a r i n f r e q u e n c y and amount. I n some c o u n t r i e s , m a t e r i a l s i n t h e fo rm o f f l i p - c h a r t s and f i l m s t r i p s a r e used i n e lemen ta ry s c h o o l s and m o t h e r ' s c l u b s .

I n rega rd t o p e r i o d o n t a l d i seases , t h e o n l y p r e v e n t i v e measure used 16 i n a l m o s t a l l o f o u r c o u n t r i e s i s t h e p r o m o t i o n o f t o o t h b r u s h i n g ,

e s p e c i a l l y i n programs o f d e n t a l h e a l t h e d u c a t i o n i n schoo ls .

Cons ide r ing t h a t t h e two a forement ioned problems t a k e a l l t h e e f f o r t s made i n t h e a p p l i c a t i o n and p r o m o t i o n o f p r e v e n t i v e measures, t h e r e i s no chance t o a p p l y any o t h e r i n t r y i n g t o s o l v e any one o f t h e r e s t o f t h e problems o f d e n t i s t r y i n p u b l i c h e a l t h i n L a t i n America.

PROGRAMS OF TREATMENT

We have seen t h a t d e n t a l manpower, p r o f e s s i o n a l o r a u x i l i a r y , i s ex t reme ly inadequate t o t a k e c a r e o f t h e d e n t a l needs o f o u r p o p u l a t i o n i n L a t i n America. On t h e o t h e r hand, p r e v e n t i v e measures a r e n o t h e l p i n g ve ry much i n reduc ing t h e d e n t a l h e a l t h problems. It has been necessary, t h e r e f o r e , t o o r g a n i z e t h e programs o f t r e a t m e n t i n a way t o o b t a i n more reasonab le b e n e f i t s f o r t h o s e s e c t o r s o f t h e community where t h e e f f o r t s a r e more needed and a r e a l s o more p r o d u c t i v e . I n g e n e r a l , t h e t h o u g h t o f t h e L a t i n Amer ican pub1 i c h e a l t h d e n t i s t i s t o l i m i t t h e s e r v i c e s rendered t o t h e p o p u l a t i o n i n o r d e r t o g i v e a t t e n t i o n t o more i m p o r t a n t demands o f b i g g e r g roups .20 The more accep ted p o l i c y

8

r e g a r d i n g d e n t a l t r e a t m e n t p rog rams i n mos t o f o u r c o u n t r i e s i s t o have c e r t a i n p r i o r i t i e s i n t h e t y p e o f s e r v i c e s g i v e n and t h e k i n d o f p o p u l a t i o n g roups t r e a t e d . These p r i o r i t i e s , v a r y i n g l i t t l e f rom c o u n t r y t o coun t ry , a re :

Emergencies i n any k i n d o f p o p u l a t i o n group E x t r a c t i o n s f o r school boys and pregnant women F i l l i n g s i n permanent t e e t h o f school c h i l d r e n .

I n v i e w o f t h e v e r y 1 i m i t e d r e s o u r c e s , i t has been n e c e s s a r y t o r e s t r i c t t h e s e r v i c e s t o t h o s e m e n t i o n e d above. Some p rog rams a r e a b l e t o g i v e a t t e n t i o n o n l y t o t h e f i r s t o f t h e p r i o r i t i e s , some can be extended more and more; b u t ve ry few a r e a b l e t o g i v e f u l l a t t e n t i o n t o a l l t h e l i s t e d p r i o r i t i e s .

The f o l l o w i n g d i s t r i b u t i o n o f t i m e i n t h e programs o f d e n t a l t r e a t - ment has been suggested:’

70% f o r o p e r a t i v e work i n school c h i l d r e n 15% f o r e x t r a c t i o n s i n pregnant women 10% f o r emergency s e r v i c e s i n any k i n d o f p a t i e n t 5% f o r h e a l t h educat ion programs and p ro fess iona l r e l a t i o n s .

A t t h e p r e s e n t moment t h e i dea o f f o l l o w i n g t h e p r i o r i t i e s ment ioned i s n o t y e t f u l l y a c c e p t e d by d e n t a l c l i n i c i a n s b u t i s g a i n i n g such acceptance. Complete u n d e r s t a n d i n g seems t o be j u s t a m a t t e r o f t ime.

The o t h e r b i g problem f a c i n g t h e a d m i n i s t r a t o r o f programs o f d e n t a l t r e a t m e n t i n L a t i n Amer ica i s t h a t o f p r o d u c t i v i t y . A v i c i o u s c i r c l e appears when s a l a r i e s a r e low and equipment and s u p p l i e s a r e d e f i c i e n t . The h e a l t h a d m i n i s t r a t o r r e f u s e s t o improve them when p r o d u c t i v i t y i s l o w and, v i c e v e r s a , d e n t i s t s r e f u s e t o i n c r e a s e p r o d u c t i v i t y o r s i m p l y c a n n o t d o so when t h e y a r e u n d e r p a i d o r do n o t have adequa te means t o work e f f i c i e n t l y . T h i s p rob lem has t o be s o l v e d i n d i v i d u a l l y f o r each case.

I n r e g a r d t o p rog rams o f t r e a t m e n t , t h e more g e n e r a l i d e a seems t o be t h e o r g a n i z a t i o n o f p i l o t h e a l t h c e n t e r s t o s t u d y t h e a p p l i c a - t i o n s o f l o c a l programs and t o s e r v e as d e m o n s t r a t i o n c e n t e r s f o r t h e o r g a n i z a t i o n o f programs i n o t h e r h e a l t h u n i t s .

D i f f e r e n t t y p e s o f o r g a n i z a t i o n have been recommended f o r gove rn - 19 mental p u b l i c h e a l t h programs, such as group f i n a n c i n g o f d e n t a l care ,

prepayment and postpayment, b u t t hey have r e s u l t e d i n be ing i ncompa t ib le w i t h c i v i l s e r v i c e r e g u l a t i o n s . However, t h e s e k i n d s o f p l a n s a r e v e r y e f f e c t i v e i n s e r v i c e s f o r s o c i a l o r i n d u s t r i a l i n s t i t u t i o n s and t h e i r use i s g r a d u a l l y g row ing i n L a t i n America.

HEALTH EDUCATION

Much o f t h e e f f o r t s o f t h e d e n t a l p r o f e s s i o n i n t h e m a j o r i t y o f

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o u r L a t i n Amer i can c o u n t r i e s have been used i n t h e f i e l d o f h e a l t h e d u c a t i o n o f t h e p u b l i c . D e n t i s t s a r e concerned abou t t h e impor tance o f h e a l t h e d u c a t i o n b e i n g a b a s i c a c t i v i t y i n t h e p r a c t i c e o f p u b l i c h e a l t h , such as p r e v e n t i o n and t r e a t m e n t .

The r e s u l t s o f h e a l t h e d u c a t i o n programs have n o t been s a t i s f a c t o r y i n many ins tances , maybe because t h e o b j e c t i v e s have n o t been r e a l i s t i c o r p r a c t i c a l . The genera l i dea i s t o educate t h e pub1 i c t o seek d e n t a l s e r v i c e s , w i t h o u t knowing i f t h e group r e c e i v i n g t h e impact o f d e n t a l e d u c a t i o n i s a b l e t o pay f o r t h e s e r v i c e s o f f e r e d o r i s w i l l i n g t o change i t s a t t i t u d e s o r p r e f e r e n c e s so r a p i d l y and go t o t h e d e n t i s t i n s t e a d o f b u y i n g c i g a r e t t e s .

What t h e p u b l i c h e a l t h d e n t i s t s want i n o u r r e g i o n i s t h a t h e a l t h e d u c a t i o n be a p p l i e d i n a way t o o b t a i n p r a c t i c a l r e s u l t s and t h a t t h e a c t i v i t y be c a r r i e d o u t by t h e a u x i l i a r y p e r s o n n e l -- e i t h e r t h e h e a l t h e d u c a t o r o r t h e a u x i l i a r y on d e n t a l h y g i e n e -- and n o t by t h e d e n t i s t . 1 5 I n t h i s way, t h e d e n t a l c l i n i c i a n c o u l d d e d i c a t e h i s t i m e t o t h a t a c t i v i t y wh ich he i s t h e o n l y one capab le o f pe r fo rm ing . The j o b o f t h e d e n t i s t i n t h i s f i e l d c o u l d be t o g i v e i n f o r m a t i o n t o t h e pe rsonne l who a r e g o i n g t o p u t h e a l t h e d u c a t i o n i n t o p r a c t i c e d i r e c t l y w i t h t h e pub1 i c .

RESEARCH

I n t h e f i e l d o f p u b l i c h e a l t h d e n t i s t r y , research i s p l a y i n g a ve ry i m p o r t a n t r o l e i n o u r c o u n t r i e s . Den ta l needs a r e b e t t e r known eve ry t i m e t h e e p i d e m i o l o g i c a l i n v e s t i g a t i o n s o f d e n t a l d i s e a s e s a r e more extended. New p r e v e n t i v e measures a r e be ing s t u d i e d i n t h e l a b o r a t o r i e s o f d e n t a l s c h o o l s . The most f a s c i n a t i n g , b u t a l s o most d i f f i c u l t t o ge t , i s t h e v a c c i n e f o r d e n t a l c a r i e s . New ways o f a d m i n i s t r a t i o n o f f l u o r i d e s t o schoo l c h i l d r e n a r e s t u d i e d . F l u o r i d e t a b l e t s a r e g i v e n t o t h e s t u d e n t s and r e s u l t s a r e b e i n g measured.23 Maybe t h e measure w i l l n o t be as e f f i c i e n t as f l u o r i d a t i o n , b u t i f i t p r e v e n t s d e n t a l c a r i e s i n an a c c e p t a b l e p r o p o r t i o n , i t c o u l d be an a l t e r n a t i v e when f l u o r i d a t i o n c a n n o t be a t t a i n e d .

The use o f f l u o r i d a t i o n would be more extended i n t h e L a t i n American c o u n t r i e s i f f l u o r s p a r ( c a l c i u m f l u o r i d e ) c o u l d be p roved e f f i c i e n t f rom t h e a d m i n i s t r a t i v e p o i n t o f v iew . W i t h f l u o r s p a r much e a s i e r t o g e t i n o u r c o u n t r i e s t h a n i s any o t h e r f l u o r i d e compound, i t would be much cheaper t o o p e r a t e . The e s t i m a t e d c o s t wou ld be a round one t h i r d o f t h a t o f sod ium s i l i c o f l u o r i d e .

Another a l t e r n a t i v e method t o wa te r f l u o r i d a t i o n i n o u r r e g i o n c o u l d be t h e use o f f l u o r i d a t e d t a b l e s a l t , T h i s v e h i c l e i s a l r e a d y i n use f o r t h e a d m i n i s t r a t i o n o f i o d i n e i n t h e f i g h t a g a i n s t g o i t r e . S a l t f l u o r i d a t i o n i s n o t y e t b e i n g s t u d i e d i n any o f o u r c o u n t r i e s , b u t i t c e r t a i n l y i s i n t h e m i n d s o f many o f o u r p u b l i c h e a l t h d e n t i s t s .

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N o t o n l y l a b o r a t o r y o r e p i d e m i o l o g i c a l r e s e a r c h i s c a r r i e d o u t i n t h e r e g i o n . A d m i n i s t r a t i v e r e s e a r c h has a l r e a d y begun, o r i s a b o u t t o begin, i n many o f t h e c o u n t r i e s . The p i l o t h e a l t h c e n t e r s ment ioned b e f o r e a r e s e r v i n g t h i s purpose. New c l i n i c a l methods o r a d m i n i s t r a t i v e p rocedures a r e b e i n g p roved t h e r e , and, when e f f e c t i v e , t h e y a r e r e c - ommended f o r use i n t h e o p e r a t i o n o f t h e programs o f t h e d e n t a l se rv i ces .

A l though research i s a b a s i c a c t i v i t y i n any f i e l d o f p u b l i c h e a l t h , f o r t h e moment we have t o depend on t h e i n v e s t i g a t i o n done i n o t h e r c o u n t r i e s t h a t have s u f f i c i e n t means t o do it. Our l i m i t e d b u d g e t f o r d e n t a l pub1 i c h e a l t h does n o t a l l o w o u r c o u n t r i e s t o go f a r i n i n t h e f i e l d o f r e s e a r c h .

SUMMARY AND CONCLUSIONS

G e n e r a l l y speak ing , t h e t r e n d s i n p u b l i c h e a l t h d e n t i s t r y i n L a t i n Amer i ca a r e , i n t h e f i r s t p l a c e , t o w a r d d i m i n i s h i n g d e n t a l needs by t h e e x t e n s i v e use o f e v e r y p o s s i b l e p r e v e n t i v e measure. The p r o b l e m i n t h i s a s p e c t i s t o make e a s i e r t h e a p p l i c a t i o n o f t h e s e measures. I n t h e second p l a c e , t h e r e i s t h e i d e a o f mak ing b e t t e r use o f and, a t t h e same t i m e , i n c r e a s i n g t h e d e n t a l resources . The second o b j e c - t i v e i s be ing approached by t r y i n g t o augment the p r o d u c t i v i t y o f schoo ls ?f d e n t i s t r y , c r e a t i n g and u s i n g e x t e n s i v e l y d i f f e r e n t types o f aux i 1 i a r y ge rsonne l , i m p r o v i n g d e n t a l h e a l t h programs t h r o u g h t h e e s t a b l i shment o f p r i o r i t i e s i n t h e s e r v i c e s g i v e n and t h e p o p u l a t i o n s e l e c t e d , groups mak ing r u r a l s e r v i c e by d e n t a l s t u d e n t s compulsory and t r y i n g t o d i s - t r i b u t e i n a b e t t e r way t h e d e n t a l manpower a v a i l a b l e i n t h e d i f f e r e n t c o u n t r i e s .

I n o r d e r t o imp lemen t a l l t h e s e i d e a s and be c l o s e r t o t h e f i n a l o b j e c t i v e o f d e n t a l p u b l i c h e a l t h , t h e L a t i n Amer ican d e n t i s t works on t h e f i r s t s t e p wh ich i s t o have a s p e c i a l d i v i s i o n o r s e c t i o n w i t h i n t h e m i n i s t r i e s o f h e a l t h .

I t i s hoped t h a t t h e d i v i s i o n s o f p u b l i c h e a l t h d e n t i s t r y w i l l b e a b l e t o i n t e g r a t e t h e i r a c t i v i t i e s o f p r o m o t i o n , p r o t e c t i o n and r e - c o v e r i n g o f h e a l t h w i t h t h e n a t i o n a l h e a l t h p l a n s o f o u r L a t i n American c o u n t r i e s .

We w i l l n o t be a l o n e i n t h e achievement o f o u r o b j e c t i v e s . A s s i s t - ance f rom d i f f e r e n t agenc ies and i n d i f f e r e n t forms w i l l be a v a i l a b l e .

The Pan American H e a l t h O r g a n i z a t i o n , r e g i o n a l b ranch o f t h e World H e a l t h O r g a n i z a t i o n , w i l l c o o p e r a t e w i t h governments t o u t i l i z e t h e i r p r e s e n t r e s o u r c e s i n t h e b e s t p o s s i b l e way. i t s s p e c i f i c a r e a s o f work w i l l be:8

Ass is tance i n t h e development o f t r a i n i n g i n d e n t a l p u b l i c

Ass is tance i n t h e development o f t r a i n i n g i n d e n t i s t r y h e a l t h

Ass is tance i n the development o f t r a i n i n g o f a u x i l i a r y per- sonnel and f o r t he opera t i on o f demonst ra t ion p r o j e c t s us ing them

Ass is tance t o n a t i o n a l departments o f h e a l t h i n s t reng th - en ing t h e i r den ta l programs.

The O r g a n i z a t i o n o f Amer ican S t a t e s has a v e r y a c t i v e program o f f e l l o w s h i p s i n wh ich , o f cou rse , t h e f i e l d o f d e n t i s t r y i s i nc luded . The " A c t o f Bogota" and t h e program " A l l i ance f o r Progress" have among t h e i r o b j e c t i v e s t h e i n t e g r a t i o n o f a l l h e a l t h a c t i v i t i e s f o r t h e i m - provement o f s o c i a l and economic deve lopment o f L a t i n Amer ican coun- t r i e s . ' W. K. K e l l o g g F o u n d a t i o n has been a s s i s t i n g , and i t i s ex- pec ted t h a t i t w i l l c o n t i n u e do ing so i n t h e s t r e n g t h e n i n g o f t each ing i n d e n t a l schools.26 The p o i n t I V program o f t h e U n i t e d Sta tesGovern- ment, t h r o u g h t h e A i d t o I n t e r n a t i o n a l Development, a l s o has an ac- t i v e program o f f e l l o w s h i p s and g i v e s a s s i s t a n c e i n some s p e c i a l p ro - j e c t s . The N a t i o n a l I n s t i t u t e s o f H e a l t h w i t h t h e i r i n t e r n a t i o n a l p rograms w i l l , no doubt , i n f l u e n c e i n t h e improvement o f d e n t a l r e - search .

I n t h e f i e l d o f o r g a n i z a t i o n o f t h e p r o f e s s i o n , t h e d e n t a l assoc ia - t i o n s a t t h e n a t i o n a l l e v e l s a r e w o r k i n g v e r y ha rd t o have b e t t e r i n - t e r n a t i o n a l p r o f e s s i o n a l r e l a t i o n s . A ve ry good example has been t h e s p e c i a l emphas is t h a t t h e Amer i can D e n t a l A s s o c i a t i o n has g i v e n a t t h i s annual sess ion t o t h e improvement o f r e l a t i o n s w i t h L a t i n American co l l eagues .6 The F e d e r a t i o n D e n t a i r e I n t e r n a t i o n a l e i s p l a y i n g a ve ry i m p o r t a n t r o l e i n t h e o r g a n i z a t i o n o f t h e d e n t a l p r o f e s s i o n th roughout t h e world. I t i s hoped t h a t i n t h e p resen t decade i t w i l l be adequately represented i n L a t i n America.

I am s u r e t h a t we, t h e L a t i n American d e n t i s t s , a r e g o i n g t o make e v e r y p o s s i b l e e f f o r t t o h e l p i n t h e c o r r e c t u t i l i z a t i o n o f o u r own resources and t h e i n t e r n a t i o n a l ass i s tance . T h i s s h a l l be done i n t h e most e f f e c t i v e manner, because i t i s t h e o n l y way t o o b t a i n f o r o u r p e o p l e t h e b e s t p o s s i b l e s t a t e o f h e a l t h , a v e r y i m p o r t a n t f a c t o r i n t h e achievement o f t he u l t i m a t e goal o f humanity: happiness.

I t h i n k t h a t we c o u l d say, w i t h o u t f e a r o f b e i n g wrong, t h a t t h i s w i l l be t h e g r e a t decade o f p u b l i c h e a l t h d e n t i s t r y i n L a t i n America.

REFERENCES

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F a c u l t a d d e O d o n t o l o g i a , U n i v e r s i d a d d e A n t i o q u i a . A c u e r d o e n t r e e l G o b i e r n o d e l a R e p u b l i c a d e C o l o m b i a , L a O r g a n i z a c i o n P a m a m e r i - c a n a d e l a S a l u d y l a F u n d a c i o n W . K . K e l l o g g p a r a l a o r g a n i z a c i o n d e u n d e p a r t a m e n t o d e O d o n t o l o g i a p r e v e n t i v a y s o c i a l e n l a F a c u l t a d d e O d o n t o l o g i a d e l a U n i v e r s i d a d d e A n t i o q u i a . M e d e l l i n , C o l o m b i a , 1 9 6 1 .

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O f i c i n a S a n i t a r i a P a n a m e r i c a n a . D e n t a l p u b l i c h e a l t h i n L a t i n A m e r - i c a . (Summary r e p o r t ) . Doc . O f i c i a l e s , HHP-1765-56 /AMRO-72 , W a s h i n g - t o n , O . C . , O i c i e m b r e , 1 9 5 6 .

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O r g a n i z a c i o n M u n d i a l d e l a S a l u d . L a s p a r o d o n t o p a t i a s . O r g . m u n d . S a l u d S e r . I n f . T e c n . , 1 9 6 1 , 2 0 7 .

O r g a n i z a c i o n P a n a m e r i c a n a d e l a S a l u d - P r i m e r s e m i n a r 1 0 L a t i n o A m e r i c a n 0 s o b r e l a e n s e n a n z a d e l a o d o n t o l o g i a . O M S l O S P N o t i c i e r o s N o s . 2 y 3, a b r i l - j u l i o , 1 9 6 2 .

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P e l t o n , W a l t e r , J . G r o u p f i n a n c i n g o f d e n t a l c a r e - w h a t i t m e a n s . J . D i s t . C o l u m b i a D e n t . S o c . 3 5 : 2 - 7 , J u n e 1 9 6 0 .

P r i m e r C o n g r e s o d e l a F e d e r a c i n O d o n t o l o g ! r a d e C e n t r o A m e r i c a y Panama. S e r v i c i o s d e n t a l e s p a r a e s c o l a r e s . k ~ c o m e n d a c i o n e s g e n e - r a l e s . B o l . O f . S a n . P a n . X L I v : 8 5 - 6 , No. 1, e n r r o 1 9 5 8 .

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S e b e l i u s , C a r l L . T h e d e n t a l h e a l t h p r o g r a m o f t h e W o r l d H e a l t h O r g a n i z a t i o n . B u l . A m . Ass . Pub. H e a t t h D e n t . , 1 7 : 9 - 1 1 N o v . 1 9 5 7 .

23. V i e g a s , A l f r e d 0 R . C o m u n i c a c i o n p e r s o n a l S a o P a u l o , B r a z i l 1 9 6 2 .

13

24. W a t e r m a n , G e o r g e E. T h e e f f e c t i v e u t i l i z a t i o n o f a u x i l i a r y d e n t a l p e r s o n n e l . M u ! . Med. , 122:405-7 J u n e 1956.

25. W i l l i a m s A . , D o n a l d o . C o m u n i c a c i o n p e r s o n a l . Panama, Panama.

2 6 . W . K. K e l l o g g F o u n d a t i o n . D e n t a l c a r e - i n c r e a s i n g l y I m p o r t a n t i n h e a l t h s e r v i c e s . W. K. K e l l o g g Found . Rep. f o r 1957, 53-66

D r . C a m a r a i s D e n t a l C o n s u l t a n t , M i n i s t r y o f H e a l t h a n d A s s i s t a n c e , M e x i c o C i t y , M e x i c o .

TRAINING OF WBLIC HEALTH DENTISTS

IN LATIN AMERICA

A l f redo Reis Viegas, D.D.S., M.P.H.

There are two types o f courses f o r t h e t r a i n i n g o f d e n t i s t s i n pub- l i c h e a l t h i n L a t i n America. The f i r s t i s a genera l course i n p u b l i c h e a l t h educa t ion and does n o t i n c l u d e a s e c t i o n s p e c i f i c a l l y designed f o r d e n t i s t r y o r , i f d e n t i s t r y i s i nc luded , i t i s i n a v e r y genera l manner. The second course, w h i l e s u p p l y i n g a genera l background i n p u b l i c h e a l t h , o f f e r s , a t t h e same t ime, a s p e c i f i c d e n t a l t r a i n i n g .

I n t h e cou rses o f t h e f i r s t type, p u b l i c h e a l t h d e n t i s t s a c q u i r e o n l y a genera l e d u c a t i o n i n p u b l i c h e a l t h , w h i l e i n t h e second, they r e c e i v e bas i c p u b l i c h e a l t h t r a i n i n g and a s p e c i f i c educa t ion i n den- t a l h e a l t h t r a i n i n g . As a consequence, t h e f i r s t group i s t r a i n e d u n i l a t e r a l l y and t h e second b i l a t e r a l l y . I n t h e l a t t e r group, i n ad- d i t i o n t o t h e s p e c i f i c p u b l i c h e a l t h t r a i n i n g , t h e d e n t i s t has an op- p o r t u n i t y t o a c q u i r e c a p a c i t y f o r i n t e r p r e t i n g t h e d e n t a l problems: w i t h e x a c t i t u d e f rom t h e genera l p u b l i c h e a l t h t r a i n i n g , he r e c e i v e d t h e necessary b a s i s f o r i n t e g r a t i n g t h e d e n t a l program i n t o t h e t o t a l program o f pub1 i c hea l th .

We a r e go ing t o d i s c u s s t h e second type, s p e c i f i c a l l y t h e program o f t h e Faculdade de H i g i e n e e Saude P u b l i c a da U n i v e r s i d a d e o f Sao Paulo, B r a z i l . T h i s course was e s t a b l i s h e d on t h e b a s i s of analyses, obse rva t i ons and suggest ions presented t o us i n a r e p o r t by t h e Denta l Consul tant o f t h e Pan American Heal th Organizat ion, Mar io W. Chaves,' q 2

a f t e r a s tudy o f t h e p u b l i c d e n t a l h e a l t h problem i n L a t i n America.