Oral Health Tutorial

Toolkit for Dental Health Professionals Evidence-Based Dental Public Health

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Oral Health Tutorial for Dental Public Health Professionals

Patient Information Purpose: Provides instruction for public How to Use Tutorial health dental practitioners thatThis focuses on This project has been funded in whole or in part with Federalfinding funds from the National Library of Medicine, National Institutesrelevant of Health, and evaluating information Department of Health and Human Services, under Contract No. N01-LM-6-3505 under the Houston Academy of Medicine-Texas Medical

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How to use this tutorial:  You can navigate to any module topic in any order you choose. The 4 modules are color-coded, so that you always know which module you are viewing. You can navigate to any module by clicking one of the four tabs at the top of each page. To navigate sequentially from one page to the next or to go back, just click the grey arrow buttons at the bottom of each page.  If you would like to return to the home page, simply click this

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Toolkit for Dental Public Health Professionals

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Objectives  Define public health dentistry  Identify professional resources to help you stay informed of developments in public health dentistry

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Definition Dental public health is the science and art of preventing and controlling dental diseases and promoting dental health through organized community efforts. It is that form of dental practice that serves the community as a patient rather than the individual. A merican Association of Public Health Dentistry

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Major Associations and Organizations

 American Association for Community Dental Pro

 American Association of Public Health Dentistry Competency Statements for Dental Public Healt  American Dental Hygienists’ Association  

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Major Associations and Organizations (cont.)  American Dental Association  Hispanic Dental Association

   American Public Health Association: Oral Health

 Centers for Disease Control: Division of Oral He  

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Major Associations and Organizations (cont.)  

International Association for Disability and Oral  National Dental Association

 National Maternal and Child Oral Health Resour  Public Health Foundation

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Major Associations and Organizations (cont.)  Texas Dental Association  Texas Dental Hygienists’ Association  Texas Dental Assistants Association

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Education and Training Accreditation Standards:

 American Dental Association: Accreditation Sta

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Education and Training Residency and Fellowship Programs:

 American Association of Public Health Dentistry  Association of Schools of Public Health

 National Institute of Dental and Craniofacial Re

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Education and Training

(cont.)

Continuing Education Programs:  American Public Health Association  TRAIN National Note: many schools of public health also offer continuing education programs, including Harvard (Center for Continuing Professional Education, www.hsph.harvard.edu/ccpe/); University of North Carolina (School of Public Health Office of Continuing Education, http://www.sph.unc.edu/oce); University of Albany (Center for Public Health Continuing Education, http://www.albany.edu/sph/coned/); and Johns Hopkins University (http://www.jhsph.edu/academics/continuing_ed/). A list of Schools of Public Health is available on the website of the Association of Schools of Public Health (ASPH) at http://www.asph.org/.

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Meetings and Conferences  American Association for Community Dental Programs The annual symposium is held as a pre-conference session to the National Oral Health Conference.  American Public Health Association The APHA Annual Meeting & Exposition is the oldest and largest gathering of public health professionals in the world.  National Oral Health Conference The National Oral Health Conference is sponsored by the Association of State and Territorial Dental Directors, the American Association of Public Health Dentistry, the Health Resources and Services Administration, and the Centers for Disease Control and Prevention.

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Legislation and Policy  American Academy of Pediatric Dentistry The mission of the AAPD is to advocate policies, guidelines and programs that promote optimal oral health and oral health care for children.  Center for Health Policy A project of the School of Nursing at Columbia University, the Center is working with the Centers for Disease Control and Prevention (CDC), to document, analyze, and disseminate public health legal principles relating to improved oral health through community water fluoridation, identifying the legal boundaries and considerations that pervade debates about community water fluoridation and thus furthering CDC’s goal of raising the proportion of the population with access to fluoridated water.

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Legislation and Policy 

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(cont.)

Healthy People 2010 Objectives for Oral Health The overall goal of the Healthy People 2010 oral health objectives is to prevent and control oral and craniofacial diseases, conditions, and injuries and improve access to related services. National Center for Fluoridation NCF was created to provide information within that network of scientists, educators, public officials, organizational representatives, and media concerned about the availability of reliable, timely, and scientifically-based information about community water fluoridation. National Conference of State Legislatures: State Childrens’ Health Insurance Program (SCHIP) Dental Care for Kids The National Conference of State Legislatures is a bipartisan organization that serves the legislators and staffs of the nation's 50 states, its commonwealths and territories.  NCSL provides research, technical assistance and opportunities for policymakers to exchange ideas on the most pressing state issues.

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Public Health Dentistry Journals Open Access Journals

 Journal of Contemporary Dental Practice Provides a peer-reviewed forum for professionals to contribute new findings to the literature.  Bio Med Central Peer-reviewed, scientific articles available in all areas of medical research.

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Public Health Dentistry Journals (cont.) Open Access Journals

 Directory of Open Access Journals(DOAJ) Categorized, searchable links to 3700 fulltext scientific and scholarly journals in all subjects and languages.  Free Medical Journals Full text medical journals categorized by specialty or alphabetized by title; variety of languages.

 

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Public Health Dentistry Journals (cont.)

 Journal of Public Health Dentistry Original research, methods and review articles relevant to the advancement of public health dentistry.  Community Dental Health Scientific articles concerned with disease prevention, health service planning and health promotion.  Community Dentistry and Oral Epidemiology Behavioral sciences literature related to dentistry,

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Public Health Dentistry Journals (cont.)  Journal of the American Dental Association Reliable, peer-reviewed source of information on dentistry and dental science.  Journal of Dental Hygiene Published by the American Dental Hygienists’ Association to provide refereed, original research articles concerned with the practice and education of dental hygiene.

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Public Health Dentistry Journals (cont.)  Journal of Dentistry for Children Publishes topics related to the clinical care of children; provides information on the physical, psychological and emotional conditions of children related to and affecting their dental health.  Pediatric Dentistry Includes scientific articles, case reports and abstracts of current pediatric dental

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Public Health Journals  American Journal of Public Health Publishes work that advances the field of public health research, policy, practice and education.  Public Health Reports Publishes articles in three main areas: public health practice, research, and viewpoints/commentaries with topics such as tobacco control, teenage violence, occupational disease and injury and many others.  Journal of Epidemiology and Community Health International journal that that contains all aspects of epidemiology related to the study and improvement of communities.

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Public Health Journals

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 American Journal of Epidemiology For professionals who use epidemiological data. Publishes empirical research findings, methodological developments in the field of epidemiological research, and opinion pieces.  Critical Public Health Peer-reviewed, critical analyses of theory and practice for researchers and practitioners working in public health, health promotion and related fields.

 

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E-Books  National Library of Medicine (NLM) Bookshelf Largest collection of biomedical textbooks that can be searched directly from NLM.  FreeBooks4Doctors Freely available biomedical textbooks categorized by specialty or alphabetized by title; variety of languages.  

 

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Reports and Other Publications  Healthy People 2010 Oral Health Toolkit Toolkit designed to help states, territories, tribes, and communities develop programs that will in turn help eliminate oral health disparities and achieve the nation's Healthy People 2010 oral health objectives.  Journal articles written by CDC staff  National Call to Promote Oral Health Released by Department of Health and Human Services in 2003 to improve oral health and prevent disease for all Americans.  Oral Health in America: A Report of the Surgeon General (pdf) In May 2000, Surgeon General David Satcher released this report on oral health in America.

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 Literature and Guidelines  ASTDD Guidelines for State & Territorial Oral Health Programs Provide guidance to health agency officials and public health administrators in the development and operation of oral health programs at the state level.  Guidelines and Recommendations from the CDC Guidelines and recommendations for community prevention programs, fluoride, infection control, oral cancer, and water fluoridation.  National Guideline Clearinghouse The National Guideline Clearinghouse includes practice guidelines for dental and oral care.

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 Grants and Funding Opportunities

 National Institute of Dental and Craniofacial Researc

 The American Dental Association Foundation (ADAF)

 The Agency for Healthcare Research and Quality (AH

 Health Resources and Services Administration (HRSA

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 Professional Communication: Electronic Lists  Community Oral Health Programs Hosted by the National Maternal and Child Health Resource Center (http://www.mchoralhealth.org) that discusses the operation of local oral health programs.  KidsOralHealth State and federal oral health policies and programs hosted and maintained by the National Maternal and Child Health Resource Center (http://www.mchoralhealth.org).  American Association of Public Health Dentistry Discusses topics related to dental public health.

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 Professional Communication: Newsletters

 National Institute of Dental and Craniofacial Research (NIDC

 American Association for Community Dental Programs (AAC

 Association of State and Territorial Dental Directors (ASTDD)

 American Academy of Pediatrics (AAP): Children's Oral Healt

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Evidence-Based Dental Public Health

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Objectives Define evidence-based dental public health Learn a strategy for effective retrieval of evidence-based research Be able to critique and synthesize scientific literature and apply it to public health dental practice Identify evidence-based resources on the Web

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What is Evidence-Based Dental Practice? “ An approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient’s oral and medical condition and history with the dentist’s clinical expertise and the patient’s treatment needs and preferences.” - American Dental Association For additional information about evidence-based dentistry, refer to the American Dental Association

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Why Practice Evidence-Based Dentistry?  Helps filter the immense amount of information that emerges in the literature  Effective method of keeping up with the most current research  Provides information on how similar cases have been treated

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The 5 A’s of Evidence-Based Dentistry Assess

the patient Ask clinical questions (Use PICO model) Acquire the best evidence Appraise the evidence Apply evidence to patient care

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PICO Model:

The well-built question for evidence–based research

P= Population or problem or patient What are the characteristics of the patient or population? What is the condition or disease?

I= Intervention or exposure What do you want to do with/for the patient or population?

C= Comparison What is the alternative to the intervention?

O= Outcome

Evidence Based Dentistry for Effective Practice, 2003.

What are the relevant outcomes?

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Searching the Literature: PubMed 

PubMed is a search engine for MEDLINE created by the U.S. National Library of Medicine (NLM).

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PubMed is a free, easy-to-use database that is accessible by any computer with Internet service

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Includes over 17 million citations from MEDLINE and other life science journals for biomedical articles back to the 1950s.

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Citations are indexed, or coded, with the NLM's controlled vocabulary, called Medical Subject Headings or MeSH®

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Contains bibliographic citations and author abstracts from more than 5,000 biomedical journals published in the United States and 80 other countries. PubMed includes links to full text articles and other related resources. PubMed also includes citations to newer articles that are not yet "PubMed Tutorial", this Web-based program will show fully indexed.

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The PubMed Search 

Medical Subject Headings (MeSH) The papers in PubMed are indexed by a subject specialist who reads the paper and notes all the search terms that apply to that paper, cataloguing them as Medical Subject Headings (MeSH). The terms come from a standardized list of vocabulary and definitions. Click on the MeSH database link on PubMed's home page: ( http://www.nlm.nih.gov/mesh/meshhome.html), where a quick tutorial will take you step by step through using the search. MeSH can be more useful than performing a general search because it allows you to capture the synonyms associated with your topic across multiple fields. Once you've set up a MeSH search that pulls the papers you are looking for, save the search and get weekly alerts for any new citations.

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Text words Include the words the author uses in the title or abstract. “Mouthguard" as a text word would retrieve articles that use the word “mouthguard" but would not necessarily retrieve other relevant articles that use the words “mouth protection" or “mouth pieces, protective." Text words are useful when there is no good match to a subject heading and as an addition to your MeSH searches. Text words can also help you find citations that have

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Study Types  Systematic Reviews- "A type of scientific study that tries to answer a special question by finding, appraising and summarizing all published, and, if possible, unpublished work on a topic, according to predetermined criteria."  Randomized Controlled Trial (RCT)- "An experiment where eligible patients are randomly allocated into groups to receive (experimental group) or not receive (control group) one or more interventions that are being compared.“  Cohort Study- “Makes observations about the association between a particular exposure or risk factor and the development of a disease or condition.”  Case-Control Study- “Involves identifying patients who have had a particular outcome (cases), and control patients who do Evidence-Based Decision Making : A not have that outcome, and then establishing whether there Translational Guide for Dental had been a specified exposure or not.” Professionals, 2009

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Hierarchical Levels of Evidence Table Rank

Evidence Level

Study Type

1

Systematic review & randomized controlled trials

Review of randomized controlled trials, Experimental + control, Randomization

2

Cohort Studies

Experimental + control, no randomization

3

Case-Control Studies

Experimental + control, retrospective

4

Case Reports

5

Narrative review, editorial

Experimental only, prospective

N/A

Epidemiology, Animal studies, In vitro studies

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Hierarchical Levels of Evidence A well done study assigned a Level 1 rank is considered the most rigorous and least susceptible to bias, while a study ranked Level 5 is considered the least rigorous and is more susceptible to bias.

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Try to find a systematic review to answer your question. If one is not available, you can choose other types of studies lower on the hierarchical pyramid of evidence.

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Evidence-Based The Centre for Evidence-Based Medicine, provides useful Tools information and downloads for critical appraisal of medical evidence: Example critical appraisal sheets- Step-by-step guidelines for critical appraisal Calculators- Designed to calculate statistical data related to evidence-based dentistry CATmaker- Download a wizard that guides you through a critical appraisal, then calculates appropriate evidence-based medicine values Explanations & Examples- Learn how to apply statistical applications and terms to evidence-based dentistry To access the detailed critical appraisal section from the Centre for EvidenceBased Medicine: www.cebm.net/critical_appraisal.asp

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Guide to Reading Research The University of Southern California Health Science Center Articles developed this four question guide to help researchers critically analyze content in articles:

What is the purpose of the study? Does the purpose of the study relate to an important problem? How was the purpose investigated? Was the question studied in a credible and rigorous manner? What are the findings and conclusions? Do the findings and conclusions relate the data to the purpose?  Are the findings of this study applicable to my practice?

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Further Study: Overviews of EvidenceBased Practice  Evidentista  Academic Center for Evidence-Based Practice, UTHSCSA School of Nursing

 Agency for Healthcare Research and Quality (A  Centre for Evidence Based Medicine

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Sample Clinical Question Are school-based fluoride varnish programs effective in preventing approximal caries? P= Children I= School-based fluoride varnish programs C= Implied O= Reduce incidence of approximal caries

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MeSH Search Terms In the sample clinical question, the “key concepts” or PICO parts must be identified with their MeSH terms: Key Concept

MeSH Term

P

Children

All Child 0-18 years (limit)

I

School-based programs Fluoride Implied varnish

School health services Topical Implied fluoride

Reduced incidence of approximal caries

Dental caries

C O

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Practice Case Study #1 Sam is a 49-year old man with moderate periodontitis, who was recently diagnosed with type 2 diabetes mellitus. Sam’s glycosylated hemoglobin is 12%, which places him in the category of poorly controlled diabetes. Sam is worried that his diabetes will increase his chance of losing his teeth. He wants to know the impact diabetes now has on his oral health. Evidence-Based Decision Making : A Translational Guide for Dental Professionals, 2009

Write down an answerable question, then put it

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Clinical Question: Case Study #1

What impact will Type 2 diabetes mellitus have on the oral health, specifically tooth loss, of a 49-year old man with moderate periodontitis? P= 49-year old man with moderate periodontitis? I= Type 2 diabetes mellitus C= Implied O= Tooth Loss

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Case Study #1: MeSH Search Terms In the practice case study, the “key concepts” or PICO parts must be identified with their MeSH terms: Key Concept

MeSH Term

P

49-year old man with moderate periodontitis

Middle Aged: 45-64 years (limit) Periodontitis

I

Type 2 Diabetes Mellitus

Diabetes Mellitus, Type 2

C

Implied

Implied

O

Tooth Loss

Tooth Loss

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Practice Case Study #2 A partnership between your community dental clinic and the dental school is establishing an oral cancer screening program as part of an outreach initiative. To justify the new program, you must find research that supports the objective to increase patients’ chance of early oral cancer detection. Write down an answerable question, then put it in the PICO format.

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Clinical Question: Case Study #2 Do community oral cancer screening programs increase a patient’s chance of early oral cancer detection?

P= Adults I= Community oral cancer screenings C= No screenings O= Increase a patient’s chance of early oral cancer detection

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Case Study #2: MeSH Search Terms In the practice case study, the “key concepts” or PICO parts must be identified with their MeSH terms: Key Concept

MeSH Term

P

Adult

Adult: 19-44 years (limit)

I

Community

Community Health Services

Cancer Screening

C

Implied

Early Detection of Cancer Implied

O

Early Detection Oral Cancer

Already Stated Mouth Neoplasms

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Databases

 American Dental Association’s Directory of System Links to systematic review abstracts available on PubMed  The Cochrane Database of Systematic Reviews Full-text of systematic reviews prepared by the Cochrane Collaboration

 Cochrane Central Register of Controlled Trials (CEN Contains over 300,000 bibliographic references to controlled trials that have been identified by the distinguished contributors to the Cochrane Collaboration

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(cont.)

 DARE( Database of Abstracts of Reviews of Effects) Contains 15,000 abstracts of systematic reviews that focus on the effects of interventions used in health and social care.  PubMed/MEDLINE Principal biomedical database that contains bibliographic citations and author abstracts from over 4,900 medical journals (250 journals are specific to the field of Dentistry)  PubMed Clinical Queries Provides specialized PubMed searches for clinicians

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Examples of EvidenceBased Journals  Evidence-Based Dentistry Publishes quarterly, some FREE, full-text available online. Publishes articles on the latest developments in oral health.  Journal of Evidence-Based Dental Practice FREE Table of Contents and Abstracts available online. Publishes original articles and review articles about clinical procedures and their outcomes.

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Additional Tutorials on EvidenceBased Practice  UNC-Chapel Hill Evidence-Based Dentistr

 Boston University, Alumni Medical Library  University of Illinois at Chicago

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References Clarkson, Jan, Harrison, Jayne E., Ismail, Amid I., Needleman, Ian & Worthington, Helen. (2003). Evidence Based Dentistry for Effective Practice. New York, New York: Martin Dunitz, an imprint of the Taylor & Francis Group. Forrest, Jane L, Miller, Syrene A., Overman, Pamela R. & Newman, Michael G. ( 2009). Evidence-Based Decision Making: A Translational Guide for Dental Professionals. Philadelphia, PA: Lippencott Williams & Wilkins, a Wolters Kluwer business.

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Oral Health Data Tools and Statistics

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Objectives  Develop a basic understanding of the types of statistics and data sets that are available related to oral health  Identify oral health related web resources with data sources and statistics for use at the local, state, national and international levels

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What are health statistics?  The most common statistics reported are: -vital (birth, death, marriage, divorce rates) -morbidity (incidence of oral cancer in a population) -mortality (the number of people who die of oral cancer compared with the total number of people)  Other common statistical data are health care costs and demographic distribution of disease based on geographic, ethnic, and gender variables

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Oral Health Statistics and Data: National Level  CDC Division of Oral Health  U.S. Department of health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics- fast stats A to Z, Oral and Dental Health

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Oral Health Statistics and Data: State/Local Level  Bexar County Health Collaborative 2006 Oral Health Assessment Data

 National Center for Chronic Disease Preve

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General Health Statistics and Data: International Level

 World Health Organization (WHO) Statisti

 Pan American Health Organization (PAHO

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General Health Statistics and Data: National Level  CDC- Data and Statistics  CDC’s National Center for Chronic Disease Prevention and Health Promotion Behavioral Risk Factor Surveillance System (BRFSS)

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General Health Statistics and Data: National Level

 Division of Health Promotion Statistics at the N An interactive database system that contains the most recent monitoring data for tracking Healthy People 2010.

 US Census Bureau- American Fact Finder

 United States Department of Health and Huma

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General Statistics and Data: State Level  Cancer Registry         

CHARTing Health Information for Texas Community Health Status Indicators (CHSI) Border County Health Workforce Profiles: Texas FedStats.gov Kaiser State Health Facts Texas Department of State Health Services Texas Research Links Texas Vital Statistics U.S. Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics- fast stats A to Z, Texas

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To Learn More…

 Data Detective: Finding the Gems of Hea Slide presentation from a course on public health data developed by the University of Connecticut Health Center.  Finding and Using Health Stats A self-study course developed by the National Library of Medicine.

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Patient Information: Oral Health Resources

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Objectives  Be able to identify and evaluate quality online patient/consumer oral health information  Be introduced to quality online resources for patient/consumer oral health information

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Evaluating Online Consumer Health Resources 5 basic criteria for website evaluation:  Accuracy  Authority  Bias  Currency  Coverage.

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How accurate is the information?  Are the facts accurate?

 Are the sources of the information clearly stated? Is the author drawing conclusions and generalizations based on his/her experience or personal opinion and are they appropriate?  Is the information consistent with other sources?  Is the information well written, well

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Who maintains the website? Who is the author?  Can you identify the author/s or sponsoring organization? Is there an “About Us” section?  Are credentials given for contributors to the site? Is the person/s qualified to provide the information?  Is there a way to contact the author(s)?  Good sources of health information include: sites maintained by a government agency, nonprofit organization or educational group

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Is bias evident in the content?  Are there advertisements on the site? Who paid for the site?  Are there endorsements on the site? Are they hidden or obvious?  Do the ads or endorsements represent a conflict of interest?

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How current is the information on the site?  Is the information revised and updated regularly?  If dates are given, are they for when the information was first written, first included on the site or last revised?  Do links to other sites work? If more than a few links are “dead”, it could mean the site is not maintained regularly.

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What is the coverage and scope of the site?  What topics are covered and how in-depth are they discussed?

 Who is the intended audience? A health professional or a consumer?  How does this information compare with other sources (including published print sources) on the same topic? Is a better source available?  Is there content on the website or just a collection of links to other sites?  What is the purpose of the site? Be cautious of sites trying to sell you a product or service.

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Government Consumer Health Resources  Medline Plus Created by the National Library of Medicine, a directory to the most reliable sources of information about oral health on the internet. There are interactive tutorials, games and videos, links to major organizations, a directory of dentists, and a medicalencyclopedia/dictionary. A Spanish version can be found by clicking the español button at the top. Links:  MedlinePlus.gov-Mouth and Teeth  MedlinePlus.gov- Dental Health  MedlinePlus.gov- Child Dental Health  Medline Plus.gov- Oral Cancer

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Government Consumer Health Resources (cont.)  National Institutes of Health-Oral Health

 National Institute of Dental and Craniofacial Researc Locate information on a broad range of topics and order free publications about oral health.  womenshealth.gov- Oral Health The National Women's Health Information Center (NWHIC) is a reliable and current information resource on women’s health

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Government Consumer Health Resources(cont.)

 Cancer.gov- Head and Neck Accurate, up-to-date, comprehensive information from the US government's principal agency for cancer research, The National Institutes of Health.

 Healthfinder.gov Coordinated by the Office of Disease Prevention and Health Promotion (O and its health information referral service, the National Health Information Center. This is the US government’s gateway to reliable health information resources from over 1,500 healthrelated organizations.

 Toolkit EvidenceStatistics Patient Info Based Non-Governmental Consumer Health Resources

 Academy of General Dentistry (AGD), For the Pub Subscribe to a free oral health newsletter, ask a dental question, find articles about oral health or find an AGD member dentist.

 American Cancer Society- Oral Cavity and Oroph Includes reliable information about oral cancer risk factors, prevention, treatment, and more.

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Non-Governmental Consumer Health Resources (cont.)  American Academy of Pediatric Dentistry Browse and print Parent Education Brochures.

 American Academy of Periodontology Association of dental professionals that specialize in diseases affecting the gums. Find a periodontist and information about gum diseases, treatment, cosmetic dentistry and implants.

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Non-Governmental Consumer Health Resources (cont.)

 American Dental Association Information on oral health, cosmetic dentistry, restorative procedures, and has games and animations for children. A glossary of dental terms, a directory of dentists and a section in Spanish add useful information.  American Dental Hygienist’ Association Find oral health information, including tips on brushing & flossing, games & cool links for kids and printable Fact Sheets in English & Spanish.

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Non-Governmental Consumer Health Resources (cont.)  Familydoctor.org Clear and concise information about common medical concerns and conditions. Features a medical dictionary, health calculators, Healthy Living Guides, a Smart Patient Guide, Health Tools section and a Health Tip of the Day.  Mayo Clinic.com Easy-to-understand health and medical information. The site has a number of healthy living guides and helpful resources such as Health Tools, Treatment Decision Guides, blogs and pod casts, and an Ask a Specialist feature.

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Non-Governmental Consumer Health Resources (cont.)  NOAH: New York Online Access to Health Bi-lingual in Spanish and English, NOAH provides links to high quality consumer health information that is accurate, up-to-date, relevant and unbiased. Arranged both alphabetically and by body region, it includes a search feature to guide you to a specific topic.

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References National Libraries of Medicine. (2006). MedlinePlus Guide to Healthy Web Surfing. Retrieved 2-01-2009, from Website: http://www.nlm.nih.gov/medlineplus/healthywebsurfing.html