#  V. RISK AND PROTECTIVE FACTORS AFFECTING ORAL DISEASES

The most common oral diseases and conditions can be prevented. Safe and
effective measures are available to reduce the incidence of oral
disease, reduce disparities, and increase quality of life.

## 

##  a. Community Water Fluoridation

Community water fluoridation is the process of adjusting the natural
fluoride concentration of a community's water supply to a level that is
best for the prevention of dental caries. In the United States,
community water fluoridation has been the basis for the primary
prevention of dental caries for 60 years and has been recognized as one
of 10 great achievements in public health of the 20th century \[CDC
1999\]. It is an ideal public health method because it is effective,
eminently safe, inexpensive, requires no behavior change by individuals,
and does not depend on access or availability of professional services.
Water fluoridation is equally effective in preventing dental caries
among different socioeconomic, racial, and ethnic groups. Fluoridation
helps to lower the cost of dental care and helps residents retain their
teeth throughout life \[USDHHS 2000a\].

Recognizing the importance of community water fluoridation, *Healthy
People 2010* Objective 21-9 is to "Increase the proportion of the U.S.
population served by community water systems with optimally fluoridated
water to 75 percent." In the United States during 2002, approximately
170 million persons (67 percent of the population served by public water
systems) received optimally fluoridated water \[CDC 2004\].

Not only does community water fluoridation effectively prevent dental
caries, it is one of very few public health prevention measures that
offers significant cost savings to almost all communities \[Griffin et
al. 2001\]. It has been estimated that about every \$1 invested in
community water fluoridation saves approximately \$38 in averted costs.
The cost per person of instituting and maintaining a water fluoridation
program in a community decreases with increasing population size.

![](media/image1.wmf){width="0.375in" height="0.37222222222222223in"}

## b. Topical Fluorides and Fluoride Supplements

Because frequent exposure to small amounts of fluoride each day will
best reduce the risk of dental caries in all age groups, all people
should drink water with an optimal fluoride concentration and brush
their teeth twice daily with fluoride toothpaste \[CDC 2001\]. For
communities that do not receive fluoridated water and persons at high
risk of dental caries, additional fluoride measures might be needed.
Community measures include fluoride mouth rinse or tablet programs,
which typically are conducted in schools. Individual measures include
professionally applied topical fluoride gels or varnish for persons at
high risk of caries.

## ![](media/image1.wmf){width="0.375in" height="0.37222222222222223in"}  {#section-1 .unnumbered}

## c. Dental Sealants

Since the early 1970s, the incidence of childhood dental caries on
smooth tooth surfaces (those without pits and fissures) has declined
markedly because of widespread exposure to fluorides. Most decay among
school age children now occurs on tooth surfaces with pits and fissures,
particularly the molar teeth.

Pit-and-fissure dental sealants---plastic coatings bonded to susceptible
tooth surfaces---have been approved for use for many years and have been
recommended by professional health associations and public health
agencies. First permanent molars erupt into the mouth at about age 6
years. Placing sealants on these teeth shortly after their eruption
protects them from the development of caries in areas of the teeth where
food and bacteria are retained. If sealants were applied routinely to
susceptible tooth surfaces in conjunction with the appropriate use of
fluoride, most tooth decay in children could be prevented \[USDHHS
2000b\].

Second permanent molars erupt into the mouth at about age 12 to 13
years.

Pit-and-fissure surfaces of these teeth are as susceptible to dental
caries as the first permanent molars of younger children. Therefore,
young teenagers need to receive dental sealants shortly after the
eruption of their second permanent molars.

The *Healthy People 2010* target for dental sealants on molars is 50
percent for

8-year-olds and 14-year-olds. The most recent estimates of the
proportion of children aged 8 years with dental sealants on one or more
molars are presented in Table VII. Within each age group, African
Americans and Mexican Americans are less likely than non-Hispanic whites
to have sealants. The prevalence of sealants also varies by the
education level of the head of household.

![](media/image1.wmf){width="0.375in" height="0.37222222222222223in"}

##  

**Table VII. Percentage of Children in United States and \<STATE\> with
Dental Sealants on Molar Teeth, by Age and Selected Characteristics**

+-------------------------+-------------+-----------+---------+------+
| > **Children, Selected  | **Dental    |           |         |      |
| > Ages,\                | Sealants on |           |         |      |
| > 1999--2000 (unless    | Molars**    |           |         |      |
| > otherwise             |             |           |         |      |
| > indicated)**          |             |           |         |      |
+-------------------------+-------------+-----------+---------+------+
|                         | **21-8a.\   |           | **      |      |
|                         | Aged 8      |           | 21-8b.\ |      |
|                         | years**     |           | Aged 14 |      |
|                         |             |           | years** |      |
+-------------------------+-------------+-----------+---------+------+
|                         | **United    | **\       | **%     | **\< |
|                         | States,     | <STATE\>, | United  | STAT |
|                         | (8-yea      | 3^rd^     | Sta     | E\>* |
|                         | r-olds)\*** | graders** | tes\*** | *^d^ |
|                         |             | ^d^       |         |      |
|                         | **(%)**     |           | **(%)** | **(  |
|                         |             | **(%)**   |         | %)** |
+-------------------------+-------------+-----------+---------+------+
| > ***Healthy People     | 50          |           | 50      |      |
| > 2010* Target**        |             |           |         |      |
+-------------------------+-------------+-----------+---------+------+
| > **TOTAL**             | 28          |           | 14      |      |
+-------------------------+-------------+-----------+---------+------+
| **Race or ethnicity**   |             |           |         |      |
+-------------------------+-------------+-----------+---------+------+
| > American Indian or    | 63 ^a^      |           | 46 ^a^  |      |
| > Alaska Native         |             |           |         |      |
+-------------------------+-------------+-----------+---------+------+
| > Asian or Pacific      | DSU         |           | DSU     |      |
| > Islander              |             |           |         |      |
+-------------------------+-------------+-----------+---------+------+
| > Asian                 | DNC         |           | DNC     |      |
+-------------------------+-------------+-----------+---------+------+
| > Native Hawaiian or\   | 20 ^b^      |           | \-\--   |      |
| > other Pacific         |             |           |         |      |
| > Islander              |             |           |         |      |
+-------------------------+-------------+-----------+---------+------+
| > Black or African      | 11 ^c^      |           | 5 ^c^   |      |
| > American              |             |           |         |      |
+-------------------------+-------------+-----------+---------+------+
| > White                 | 26 ^c^      |           | 19 ^c^  |      |
+-------------------------+-------------+-----------+---------+------+
| > Hispanic or Latino    | DSU         |           | DSU     |      |
+-------------------------+-------------+-----------+---------+------+
| > Mexican American      | 10 ^c^      |           | DSU     |      |
+-------------------------+-------------+-----------+---------+------+
| > Not Hispanic or       | 25 ^c^      |           | DNA     |      |
| > Latino                |             |           |         |      |
+-------------------------+-------------+-----------+---------+------+
| > Black or African      | 23          |           | 14      |      |
| > American, not         |             |           |         |      |
| > Hispanic or Latino    |             |           |         |      |
+-------------------------+-------------+-----------+---------+------+
| > White, not Hispanic   | 35          |           | 16      |      |
| > or Latino             |             |           |         |      |
+-------------------------+-------------+-----------+---------+------+
| **Sex**                 |             |           |         |      |
+-------------------------+-------------+-----------+---------+------+
| > Female                | 31          |           | 12      |      |
+-------------------------+-------------+-----------+---------+------+
| > Male                  | 25          |           | 17      |      |
+-------------------------+-------------+-----------+---------+------+
| **Education Level**     |             |           |         |      |
| (head of household)     |             |           |         |      |
+-------------------------+-------------+-----------+---------+------+
| > Less than high school | 17 ^c^      |           | 4 ^c^   |      |
+-------------------------+-------------+-----------+---------+------+
| > High school graduate  | 12 ^c^      |           | 6 ^c^   |      |
+-------------------------+-------------+-----------+---------+------+
| > At least some college | 35 ^c^      |           | 28 ^c^  |      |
+-------------------------+-------------+-----------+---------+------+
| **Disability Status**   |             |           |         |      |
+-------------------------+-------------+-----------+---------+------+
| > Persons with          | DNA         |           | DNA     |      |
| > disabilities          |             |           |         |      |
+-------------------------+-------------+-----------+---------+------+
| > Persons without       | DNA         |           | DNA     |      |
| > disabilities          |             |           |         |      |
+-------------------------+-------------+-----------+---------+------+
| **Select Populations**  |             |           |         |      |
+-------------------------+-------------+-----------+---------+------+
| > 3rd grade students    | 26 ^c^      |           | NA      |      |
+-------------------------+-------------+-----------+---------+------+

Table VII Sources:

*Healthy People 2010, Progress Review, 2000*. U.S. Department of Health
and Human Services.

Available at
[[www.cdc.gov/nchs/ppt/hpdata2010/focusareas/fa21.xls]{.underline}](http://www.cdc.gov/nchs/ppt/hpdata2010/focusareas/fa21.xls).

\<These data will be updated in 2006.\>

\-\-- = Data not available

DNA = Data not analyzed

DNC = Data not collected

DSU = Data are statistically unreliable or do not meet criteria for
confidentiality

NA = Not applicable

\*National data are from NHANES 1999--2000 unless otherwise indicated.

^a^ Data are for IHS service areas, 1999.

^b^ Data are for Hawaii, 1999.

^c^ Data are from NHANES III, 1988--1994.

## ^d^ \<State Data Source(s)\> 

## d. Preventive Visits

Maintaining good oral health takes repeated efforts on the part of the
individual, caregivers, and health care providers. Daily oral hygiene
routines and healthy lifestyle behaviors play an important role in
preventing oral diseases. Regular preventive dental care can reduce the
development of disease and facilitate early diagnosis and treatment. One
measure of preventive care that is being tracked, as shown in Table
VIII, is the percentage of adults who had their teeth cleaned in the
past year. Having one\'s teeth cleaned by a dentist or dental hygienist
is indicative of preventive behaviors.

## ![](media/image1.wmf){width="0.375in" height="0.37222222222222223in"}

##  

**Table VIII. Percentage of Adults Aged 18 Years or Older Who Had Their
Teeth**

**Cleaned Within the Past Year, 2002**

+---------------------------+---------------------+-------------------+
|                           | **Median % United   | **\<STATE\>^a^**  |
|                           | States (%)**        |                   |
|                           |                     | **Status (%)**    |
+---------------------------+---------------------+-------------------+
| **Total**                 | 69                  |                   |
+---------------------------+---------------------+-------------------+
| **Age**                   |                     |                   |
+---------------------------+---------------------+-------------------+
| 18 -- 24 years            | 70                  |                   |
+---------------------------+---------------------+-------------------+
| 25 -- 34 years            | 66                  |                   |
+---------------------------+---------------------+-------------------+
| 35 -- 44 years            | 69                  |                   |
+---------------------------+---------------------+-------------------+
| 45 -- 54 years            | 71                  |                   |
+---------------------------+---------------------+-------------------+
| 55 -- 64 years            | 73                  |                   |
+---------------------------+---------------------+-------------------+
| 65 + years                | 72                  |                   |
+---------------------------+---------------------+-------------------+
| **Race**                  |                     |                   |
+---------------------------+---------------------+-------------------+
| White                     | 72                  |                   |
+---------------------------+---------------------+-------------------+
| Black                     | 62                  |                   |
+---------------------------+---------------------+-------------------+
| Hispanic                  | 65                  |                   |
+---------------------------+---------------------+-------------------+
| Other                     | 64                  |                   |
+---------------------------+---------------------+-------------------+
| Multiracial               | 56                  |                   |
+---------------------------+---------------------+-------------------+
| **Sex**                   |                     |                   |
+---------------------------+---------------------+-------------------+
| Male                      | 67                  |                   |
+---------------------------+---------------------+-------------------+
| Female                    | 72                  |                   |
+---------------------------+---------------------+-------------------+
| **Education Level**       |                     |                   |
+---------------------------+---------------------+-------------------+
| Less than high school     | 47                  |                   |
+---------------------------+---------------------+-------------------+
| High school or G.E.D.     | 65                  |                   |
+---------------------------+---------------------+-------------------+
| Some post high school     | 72                  |                   |
+---------------------------+---------------------+-------------------+
| College graduate          | 79                  |                   |
+---------------------------+---------------------+-------------------+
| **Income**                |                     |                   |
+---------------------------+---------------------+-------------------+
| Less than \$15,000        | 49                  |                   |
+---------------------------+---------------------+-------------------+
| \$15,000 -- 24,999        | 56                  |                   |
+---------------------------+---------------------+-------------------+
| \$25,000 -- 34,999        | 65                  |                   |
+---------------------------+---------------------+-------------------+
| \$35,000 -- 49,999        | 72                  |                   |
+---------------------------+---------------------+-------------------+
| \$50,000+                 | 81                  |                   |
+---------------------------+---------------------+-------------------+

Table VIII Sources:

Division of Adult and Community Health, National Center for Chronic
Disease Prevention and Health Promotion, Centers for Disease Control and
Prevention, *Behavioral Risk Factor Surveillance System Online
Prevalence Data,* 1995--2004.

Available at [www.cdc.gov/brfss](http://www.cdc.gov/brfss).

^a^ \<State Data Source(s)\>

> e\. Screening for Oral Cancer

Oral cancer detection is accomplished by a thorough examination of the
head and neck; an examination of the mouth including the tongue, the
entire oral and pharyngeal mucosal tissues, and the lips; and palpation
of the lymph nodes. Although the sensitivity and specificity of the oral
cancer examination have not been established in clinical studies, most
experts consider early detection and treatment of precancerous lesions
and diagnosis of oral cancer at localized stages to be the major
approaches for secondary prevention of these cancers \[Silverman 1998;
Johnson 1999; CDC 1998\]. If suspicious tissues are detected during an
examination, definitive diagnostic tests, such as biopsies, are needed
to make a firm diagnosis.

Oral cancer is more common after the age of 60 years. Known risk factors
include use of tobacco products and alcohol. The risk of oral cancer is
increased 6 to 28 times in current smokers. Alcohol consumption is an
independent risk factor and, when combined with the use of tobacco
products, accounts for most cases of oral cancer in the United States
and elsewhere \[USDHHS 2004a\]. Individuals should also be advised to
avoid other potential carcinogens, such as exposure to sunlight (a risk
factor for lip cancer) without protection (use of lip sunscreen and hats
is recommended).

Recognizing the need for dental and medical providers to examine adults
for oral and pharyngeal cancer, *Healthy People* *2010* Objective 21-7
is to increase the proportion of adults who, in the past 12 months,
report having had an examination to detect oral and pharyngeal cancers.
Nationally, relatively few adults aged 40 years and older (13%) reported
receiving an examination for oral and pharyngeal cancer, although the
proportion varied by race/ethnicity (TABLE IX).

![](media/image1.wmf){width="0.375in" height="0.37222222222222223in"}

##  

**Table IX. Proportion^a^ of Adults in the United States and \<STATE\>
Who Were Examined for Oral and Pharyngeal Cancer in the Preceding 12
Months**

+---------------------------------------+-----------------+-----------+
| **Adults Aged 40 Years and Older**    | **Oral and      |           |
|                                       | Pharyngeal      |           |
|                                       | Cancer\         |           |
|                                       | Examination in  |           |
|                                       | Past 12         |           |
|                                       | Months**        |           |
+=======================================+=================+===========+
|                                       | **United        | **\<STA   |
|                                       | States**        | TE\>^c^** |
|                                       |                 |           |
|                                       | **(1998)**      | **(%)**   |
|                                       |                 |           |
|                                       | **(%)**         |           |
+---------------------------------------+-----------------+-----------+
| ***Healthy People 2010* Target**      | 20              | 20        |
+---------------------------------------+-----------------+-----------+
| **TOTAL**                             | 13              |           |
+---------------------------------------+-----------------+-----------+
| **Race or ethnicity**                 |                 |           |
+---------------------------------------+-----------------+-----------+
| > American Indian or Alaska Native    | DSU^b^          |           |
+---------------------------------------+-----------------+-----------+
| > Asian or Pacific Islander           | 12 ^b^          |           |
+---------------------------------------+-----------------+-----------+
| > Asian                               | 12 ^b^          |           |
+---------------------------------------+-----------------+-----------+
| > Native Hawaiian and other Pacific   | DSU^b^          |           |
| > Islander                            |                 |           |
+---------------------------------------+-----------------+-----------+
| > Black or African American only      | 7 ^b^           |           |
+---------------------------------------+-----------------+-----------+
| > White only                          | 14 ^b^          |           |
+---------------------------------------+-----------------+-----------+
| > 2 or more races                     | DNC             |           |
+---------------------------------------+-----------------+-----------+
| > American Indian or Alaska Native;   | DNC             |           |
| > White                               |                 |           |
+---------------------------------------+-----------------+-----------+
| > Black or African American; White    | DNC             |           |
+---------------------------------------+-----------------+-----------+
| > Hispanic or Latino                  | 6               |           |
+---------------------------------------+-----------------+-----------+
| > Not Hispanic or Latino              | 14              |           |
+---------------------------------------+-----------------+-----------+
| > Black or African American, not      | 6 ^b^           |           |
| > Hispanic or Latino                  |                 |           |
+---------------------------------------+-----------------+-----------+
| > White, not Hispanic or Latino       | 15 ^b^          |           |
+---------------------------------------+-----------------+-----------+
| **Sex**                               |                 |           |
+---------------------------------------+-----------------+-----------+
| > Female                              | 14              |           |
+---------------------------------------+-----------------+-----------+
| > Male                                | 12 ^b^          |           |
+---------------------------------------+-----------------+-----------+
| **Education Level**                   |                 |           |
+---------------------------------------+-----------------+-----------+
| > Less than high school               | 5               |           |
+---------------------------------------+-----------------+-----------+
| > High school graduate                | 10              |           |
+---------------------------------------+-----------------+-----------+
| > At least some college               | 19              |           |
+---------------------------------------+-----------------+-----------+

Table IX Sources:

H*ealthy People 2010, Progress Review, 2000.* U.S. Department of Health
and Human Services.

Available at
[[www.cdc.gov/nchs/ppt/hpdata2010/focusareas/fa21.xls]{.underline}](http://www.cdc.gov/nchs/ppt/hpdata2010/focusareas/fa21.xls).

\<These data will be updated in 2006.\>

DNC = Data not collected

DSU = Data are statistically unreliable or do not meet criteria for
confidentiality

**^a^** Age adjusted to the year 2000 standard population.

^b^Persons reported only one race or reported more than one race and
identified one race as best representing their race.

## ^c^ \<State data source\>

##  

##  f. Tobacco Control 

Tobacco use has a devastating effect on the health and well-being of the
public. More than 400,000 Americans die each year as a direct result of
cigarette smoking, making it the nation's leading preventable cause of
premature mortality, and smoking causes over \$150 billion in annual
health-related economic losses \[CDC 2002\]. The effects of tobacco use
on the public's oral health are also alarming. The use of any form of
tobacco --- including cigarettes, cigars, pipes, and smokeless tobacco
--- has been established as a major cause of oral and pharyngeal cancer
\[USDHHS 2004a\]. The evidence is sufficient to consider smoking a
causal factor for adult periodontitis \[USDHHS 2004a\]; one-half of the
cases of periodontal disease in this country may be attributable to
cigarette smoking \[Tomar & Asma 2000\]. Tobacco use substantially
worsens the prognosis of periodontal therapy and dental implants,
impairs oral wound healing, and increases the risk of a wide range of
oral soft tissue changes \[Christen et al. 1991; AAP 1999\].

Comprehensive tobacco control would have a large impact on oral health
status. The goal of comprehensive tobacco control programs is to reduce
disease, disability, and death related to tobacco use by

-   Preventing the initiation of tobacco use among young people.

-   Promoting quitting among young people and adults.

-   Eliminating nonsmokers' exposure to secondhand tobacco smoke.

-   Identifying and eliminating the disparities related to tobacco use
    and its effects among different population groups.

![](media/image1.wmf){width="0.375in" height="0.37222222222222223in"}

National and state data on Behavioral Risk Factor Surveillance System
(BRFSS):

[[http://apps.nccd.cdc.gov/brfss/page.asp?cat=TU&yr=2004&state=US#TU]{.underline}](http://apps.nccd.cdc.gov/brfss/page.asp?cat=TU&yr=2004&state=US#TU)

National data on National Youth Tobacco Survey:

[[http://www.cdc.gov/tobacco/research_data/youth/mmwr_5412_intro.htm]{.underline}](http://www.cdc.gov/tobacco/research_data/youth/mmwr_5412_intro.htm)

National and state data on Youth Risk Behavioral Surveillance System:

[[http://apps.nccd.cdc.gov/yrbss/]{.underline}](http://apps.nccd.cdc.gov/yrbss/)
and
[http://apps.nccd.cdc.gov/yrbss/CategoryQuestions.asp?Cat=2&desc=Tobacco%20Use](http://apps.nccd.cdc.gov/yrbss/CategoryQuestions.asp?Cat=2&desc=Tobacco Use)

Other national sources include the National Health Interview Survey
(NHIS): <http://www.cdc.gov/nchs/nhis.htm>,

and the National Health and Nutrition Examination Survey (NHANES):
[http://www.cdc.gov/nchs/nhanes.htm]{.underline}.

The dental office provides an excellent venue for providing tobacco
intervention services. More than one-half of adult smokers see a dentist
each year \[Tomar et al. 1996\]. Dental patients are particularly
receptive to health messages at periodic check-up visits, and oral
effects of tobacco use provide visible evidence and a strong motivation
for tobacco users to quit. Because dentists and dental hygienists can be
effective in treating tobacco use and dependence, the identification,
documentation, and treatment of every tobacco user they see needs to
become a routine practice in every dental office and clinic \[Fiore et
al. 2000\]. However, national data from the early 1990s indicated that
just 24 percent of smokers who had seen a dentist in the past year
reported that their dentist advised them to quit, and only 18 percent of
smokeless tobacco users reported that their dentist *ever* advised them
to quit.

Cigarette smoking among adults 18 years older is described in Table X.
Data from the Youth Risk Behavior Surveillance System on students who
smoked or used other tobacco products are shown in Table XI.

![](media/image1.wmf){width="0.375in" height="0.37222222222222223in"}

## 

## Table X. Cigarette Smoking Among Adults Aged 18 Years and Older

+-----------------------------+------------------+--------------------+
| ***Healthy People 2010*     | **United         | **\<STATE\>        |
| Target: *12%***             | States**^a^      | Status** ^b^       |
|                             |                  |                    |
|                             | **(%)**          | **(%)**            |
+-----------------------------+------------------+--------------------+
| **Total**                   | 24               |                    |
+-----------------------------+------------------+--------------------+
| **Race or Ethnicity**       |                  |                    |
+-----------------------------+------------------+--------------------+
| > American Indian or Alaska | 35               |                    |
| > Native                    |                  |                    |
+-----------------------------+------------------+--------------------+
| > Asian or Pacific Islander | 13               |                    |
+-----------------------------+------------------+--------------------+
| Asian                       | 13               |                    |
+-----------------------------+------------------+--------------------+
| > Native Hawaiian and other | 17               |                    |
| >                           |                  |                    |
| > Pacific Islander          |                  |                    |
+-----------------------------+------------------+--------------------+
| > Black or African American | 25               |                    |
+-----------------------------+------------------+--------------------+
| > White                     | 25               |                    |
+-----------------------------+------------------+--------------------+
| Hispanic or Latino          | 19               |                    |
+-----------------------------+------------------+--------------------+
| Not Hispanic or Latino      | 25               |                    |
+-----------------------------+------------------+--------------------+
| Black or African American   | 25               |                    |
+-----------------------------+------------------+--------------------+
| > White                     | 25               |                    |
+-----------------------------+------------------+--------------------+
| **Sex**                     |                  |                    |
+-----------------------------+------------------+--------------------+
| Female                      | 22               |                    |
+-----------------------------+------------------+--------------------+
| Male                        | 26               |                    |
+-----------------------------+------------------+--------------------+

Table X Sources:

H*ealthy People 2010*, 2^nd^ Ed. U.S. Department of Health and Human
Services, November 2000.

\<These data will be updated in 2006.\>

^a^ Age-adjusted to the Year 2000 standard population.

^b^ \<State Data Source(s)\>

**Table XI. Percentage of Students in High School (Aged 12--21 years)
who Smoked Cigarettes or who Used Chewing Tobacco or Snuff One or More
of the Past 30 Days**

+-----------+------------+------------------+------------+-------------+
|           | **Ci       | **Cigarettes**   | **Chew**   | **Chew**    |
|           | garettes** |                  |            |             |
|           |            | **\<STATE\>**    | **United   | **\<STATE\> |
|           | **United   |                  | States     | ^a^**       |
|           | States     | **(%)**          | (%)**      |             |
|           | (%)**      |                  |            | **(%)**     |
+-----------+------------+------------------+------------+-------------+
| **Total** | 22         |                  | 7          |             |
+-----------+------------+------------------+------------+-------------+
| **Race**  |            |                  |            |             |
+-----------+------------+------------------+------------+-------------+
| White     | 25         |                  | 8          |             |
+-----------+------------+------------------+------------+-------------+
| Black     | 15         |                  | 3          |             |
+-----------+------------+------------------+------------+-------------+
| Hispanic  | 18         |                  | 5          |             |
+-----------+------------+------------------+------------+-------------+
| Other     | 18         |                  | 10         |             |
+-----------+------------+------------------+------------+-------------+
| **Sex**   |            |                  |            |             |
+-----------+------------+------------------+------------+-------------+
| Female    | 22         |                  | 2          |             |
+-----------+------------+------------------+------------+-------------+
| Male      | 22         |                  | 11         |             |
+-----------+------------+------------------+------------+-------------+

Table XI Sources:

Division of Adolescent and School Health, National Center for Chronic
Disease Prevention and Health Promotion, Centers for Disease Control and
Prevention, [Youth Risk Behavior Surveillance System
Online]{.underline}, Available at
[http://apps.nccd.cdc.gov/yrbss/SelQuestyear.asp?cat=2&desc=Tobacco%20Use&loc=XX]{.underline}.

^a^\<State Data Source(s)\>

> g\. Oral Health Education

Oral health education for the community is a process that informs,
motivates, and helps people to adopt and maintain beneficial health
practices and lifestyles; advocates environmental changes as needed to
facilitate this goal; and conducts professional training and research to
the same end \[Kressin & DeSouza 2003\]. Although health information or
knowledge alone does not necessarily lead to desirable health behaviors,
knowledge may help empower people and communities to take action to
protect their health.

![](media/image1.wmf){width="0.375in" height="0.37222222222222223in"}

##