# ![](media/image1.wmf){width="2.3986111111111112in" height="2.2930555555555556in"} {#section .Chapter-#}

# 21 {#section-1 .Chapter-#}

# Oral Health

Co-Lead Agencies: Centers for Disease Control and Prevention\
Health Resources and Services Administration\
Indian Health Service\
National Institutes of Health

### Contents {#contents .Heading-Special}

[Goal Page 21-3](#goal)

[Overview Page 21-3](#overview)

[Issues Page 21-3](#issues)

[Trends Page 21-6](#trends)

[Disparities Page 21-7](#disparities)

[Opportunities Page 21-7](#opportunities)

[Interim Progress Toward Year 2000 Objectives Page
21-8](#interim-progress-toward-year-2000-objectives)

[Healthy People 2010---Summary of Objectives Page
21-10](#healthy-people-2010summary-of-objectives)

[Healthy People 2010 Objectives Page
21-11](#healthy-people-2010-objectives)

[Related Objectives From Other Focus Areas Page
21-36](#related-objectives-from-other-focus-areas)

[Terminology Page 21-39](#terminology)

[References Page 21-40](#references)

## Goal

Prevent and control oral and craniofacial diseases,\
conditions, and injuries and improve access to related\
services.

## Overview

Oral health is an essential and integral component of health throughout
life. No one can be truly healthy unless he or she is free from the
burden of oral and craniofacial diseases and conditions.[^1] Millions of
people in the United States experience dental caries, periodontal
diseases, and cleft lip and cleft palate, resulting in needless pain and
suffering; difficulty in speaking, chewing, and swallowing; increased
costs of care; loss of self-esteem; decreased economic productivity
through lost work and school days; and, in extreme cases, death.[^2]
Further, oral and pharyngeal cancers, which primarily affect adults over
age 55 years, result in significant illnesses and disfigurement
associated with treatment, substantial cost, and more than 8,000 deaths
annually.[^3]

Poor oral health and untreated oral diseases and conditions can have a
significant impact on quality of life. Millions of people in the United
States are at high risk for oral health problems because of underlying
medical or handicapping conditions, ranging from very rare genetic
diseases to more common chronic diseases such as arthritis and
diabetes.[^4] Oral and facial pain affects a substantial proportion of
the general population.Error: Reference source not found**^,^** [^5]

### Issues

Dental caries is the single most common chronic disease of childhood,
occurring five to eight times as frequently as asthma, the second most
common chronic disease in children.Error: Reference source not found
Despite the reduction in cases of caries in recent years, more than half
of all children have caries by the second grade, and, by the time
students finish high school, about 80 percent have caries.[^6] Unless
arrested early, caries is irreversible.

Early childhood caries (ECC) affects the primary teeth of infants and
young children aged 1 to 6 years.[^7] The exact cause of ECC is unknown,
but factors such as large family size, nutritional status of the mother
and the infant, and the transfer of infectious organisms from caregiver
to infant are under study.[^8]**^,^** [^9] Infant feeding practices in
which children are put to bed with formula or other sweetened drinks or
sweetened pacifiers, especially if a child falls asleep while feeding,
have been associated with ECC.[^10] Some professional associations
recommend that a child should first visit a dentist at age 1 year.[^11]

Since the early 1970s, the cases of dental caries in permanent teeth
have declined dramatically among school-aged children.Error: Reference
source not found This decline is the result of various preventive
regimens such as community water fluoridation and increased use of
toothpastes and rinses that contain fluoride. Dental caries, however,
remains a significant problem in some populations, particularly certain
racial and ethnic groups and poor children.[^12] National data indicate
that 80 percent of dental caries in the permanent teeth found in
children is concentrated in 25 percent of the child and adolescent
population.[^13] Increased use of dental sealants, toothbrushing with
fluoridated toothpaste, community water fluoridation, and sound dietary
practices are needed to reduce tooth
decay.![](media/image2.wmf){width="4.501388888888889in"
height="5.361111111111111in"}

Data from the third National Health and Nutrition Examination Survey
(NHANES III) indicated that 30 percent of all adults had untreated
dental decay; 85 percent had ever experienced dental caries. More than
37 percent of dentate persons aged 65 years or older in the United
States had at least one decayed or filled root surface.[^14] If current
trends continue, the baby boomer generation will lose fewer teeth as
they age but will have more teeth that are at risk for dental caries
throughout life.

Oral and pharyngeal cancers comprise a diversity of malignant tumors
that affect the oral cavity and pharynx; virtually all of these tumors
are squamous cell carcinomas. Some 31,000 new cases of oral and
pharyngeal cancers were expected to be diagnosed in 1999, and
approximately 8,100 persons were expected to die from the disease.Error:
Reference source not found Oral and pharyngeal cancers occur more
frequently than leukemia, Hodgkin's disease, and cancers of the brain,
cervix, ovary, liver, pancreas, bone, thyroid gland, testes, and
stomach. Oral and pharyngeal cancers are the 7th most common cancers
found among white males (4th most common among black men) and the 14th
most common among U.S. women. The 5-year survival rate for oral and
pharyngeal cancers is only 53 percent,[^15] and most of these cancers
are diagnosed at late stages.[^16] Only 13 percent of U.S. adults aged
40 years or older reported having had an oral cancer examination in the
past year,[^17] which is the recommended interval.[^18]

Cleft lip and cleft palate are among the more common birth defects in
the United States. These congenital defects occur in about 1 per 1,000
live births.[^19]**^,^** [^20] States should have an effective,
efficient mechanism in place for identifying, recording, and referring
for treatment infants with these conditions. Primary prevention of these
craniofacial anomalies involves minimizing exposure to known causes of
malformations and, where indicated, providing genetic counseling.

Oral diseases and conditions may have a significant impact on general
health; some poor general health conditions also may affect oral health
status. Chemotherapy for cancer may cause inflammation and infection of
oral mucous tissues. Head and neck radiotherapy and medications taken
for many chronic conditions can affect the salivary glands, resulting in
decreases in or loss of salivary flow, which, in turn, contribute to the
ability to chew and speak and to dental decay.Error: Reference source
not found Studies point to associations between periodontal diseases and
low birth weight and premature births,[^21]**^,^** [^22]**^,^** [^23] as
well as between periodontitis and heart disease and stroke.[^24]**^,^**
[^25]**^,^** [^26] The initiation and progression of periodontal
infections are affected by systemic factors and habits,[^27] including
tobacco use, uncontrolled diabetes, stress, and genetic factors.

For patients with special risks, invasive dental procedures may result
in infective endocarditis;[^28] infections of artificial knee, hip, and
shoulder joints; and complications associated with organ and bone marrow
transplantation. Oral complications associated with human
immunodeficiency virus (HIV) infection also can have a significant
impact on overall health, resulting in loss of appetite, painful mouth
sores, weight loss, hospitalization, and potentially life-threatening
fungal infections.Error: Reference source not found

Many persons in the United States do not receive essential dental
services.[^29] Through increased access to appropriate and timely care,
individuals can enjoy improved oral health. Barriers to care include
cost; lack of dental insurance, public programs, or providers from
underserved racial and ethnic groups; and fear of dental visits.
Additionally, some people with limited oral health literacy may not be
able to find or understand information and services.

To promote oral health and prevent oral diseases, oral health literacy
among all groups is necessary. In addition, oral health
services---preventive and restorative---should be available, accessible,
and acceptable to all persons in the United States. In areas where
different languages, culture, and health care beliefs would otherwise be
barriers to care, a cadre of clinically and culturally competent
providers must be available to provide care.

Of the 16,926 undergraduate dental students enrolled in U.S. dental
schools in 1996--97, fewer than 1,000 were African American, and fewer
than 1,000 were Hispanic.[^30] Native Americans continue to constitute
less than 1 percent of the total undergraduate dental enrollment.Error:
Reference source not found Strategic measures are needed to increase the
number of individuals from certain racial and ethnic groups who seek
careers in dentistry and public health, now and in the future. With the
current health disparities and projected demographic changes in the U.S.
population, such measures are needed for all aspects of oral health:
education, research, health promotion, and clinical services within the
private and public sectors.

One subject of oral health interest, daily brushing with a
fluoride-containing toothpaste, is not addressed because data for
tracking progress will not be available during the first half of the
decade (2000-2005).

### Trends

Cases of dental caries in the permanent teeth of school-aged children
have been declining in the United States since the early 1970s.Error:
Reference source not found The proportion of untreated dental caries in
permanent dentition of school-aged children also has been declining
overall but has increased in the primary dentition among children aged 6
to 8 years.[^31]**^,^** [^32] Fewer adults are having teeth extracted
because of dental decay or periodontal disease, and the percentage of
persons who have lost all of their natural teeth has been declining
steadily.Error: Reference source not found

The percentage of school-aged children with dental sealants has risen in
recent years as the public and private sectors increasingly use the
procedure, dental insurance pays for dental sealants, and parents
request sealants for their children.Error: Reference source not found No
increase, however, has occurred among children in low-income
populations.

Community water fluoridation grew rapidly from its inception in 1945
until about 1980; since then, the proportion of the U.S. population
living in communities with fluoridated water supplies has remained at 60
to 62 percent.[^33] About 100 million persons still lack the benefits of
community water fluoridation.

Over the past 20 years, deaths from oral and pharyngeal cancers have
declined by about 25 percent, and new cases have declined by 10 percent,
but the 5-year survival rate has remained unchanged. African American
men, however, have experienced increases in both death rates and new
case rates.Error: Reference source not found

Spending for dental services in the United States has risen steadily but
has remained fairly constant as a proportion of personal health care
spending---about 5 percent in 1997.Error: Reference source not found
Dental insurance coverage has not increased. Only 44 percent of persons
in the United States have some form of private dental insurance (most
with limited coverage and with high copayments), 9 percent have public
dental insurance (Medicaid and Children's Health Insurance Program), 2
percent have other dental insurance, and 45 percent have no dental
insurance.[^34]

### Disparities

As with general health, oral health status tends to vary in the United
States on the basis of sociodemographic factors. For example, the level
of untreated dental caries among African American children aged 6 to 8
years (36 percent) and Hispanic children (43 percent) is greater than
for white children (26 percent);Error: Reference source not found as few
as 3 percent of poor children have dental sealants compared to the
national average (23 percent).Error: Reference source not found Further,
the 5-year survival rate is lower for oral and pharyngeal cancers among
African Americans than whites (34 percent versus 56 percent);Error:
Reference source not found adults with less than a high school education
(5 percent) and those with a high school education (10 percent) were
less likely than those with some college (19 percent) to have had an
oral cancer examination in the past year;Error: Reference source not
found adults with some college (15 percent) have 2 to 2.5 times less
destructive periodontal disease than those with high school (28 percent)
and with less than high school (35 percent) levels of education.Error:
Reference source not found Among persons aged 65 years and older, 39
percent of persons with less than a high school education were
edentulous (had lost all their natural teeth) in 1997, compared with 13
percent of persons with at least some college.[^35]

Promotion of oral health requires self-care and professional care as
well as population-based initiatives. Several national surveys show that
the proportion of the U.S. population that annually makes at least one
dental visit and the average number of visits made vary significantly by
age, race, dental status, level of education, and family incomeError:
Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,^** [^36] For example,
the Medical Expenditure Panel Survey in 1996Error: Reference source not
found indicated that about 44 percent of the total population over age 2
visited a dentist in the past year; 50 percent of non-Hispanic whites,
30 percent of Hispanics, and 27 percent of non-Hispanic blacks had a
visit while 55 percent of those with some college and only 24 percent of
those with less than a high school education had a past-year visit.
Approximately twice as many adults with teeth had a dental visit
compared to adults without teeth.Error: Reference source not found

### Opportunities

An increased focus on oral health by Federal, State, and professional
organizations that occurred at the end of the 1990s should help achieve
improvements in oral health and quality of life for individuals and
communities. If initiatives, partnerships, and collaborations flourish
in this environment of heightened interest, then oral health literacy
will increase, access to preventive and restorative services for persons
in need will improve, surveillance of oral diseases or conditions will
be enhanced, and appropriate research will explore new ways to improve
oral health for everyone in the United States.

Recent legislation in three States requires the widespread
implementation of water fluoridation, which should lead to more
communities with optimally fluoridated water. By the end of the 20th
century, dental caries was limited in many children to pit and fissure
tooth surfaces, for which dental sealants are ideal. Opportunities to
encourage the dental profession to adopt and implement this preventive
technology and for dental insurance companies to pay for sealants must
be promoted. Every opportunity must be taken to educate the public about
the value of sealants for children shortly after their permanent molars
erupt. Opportunities must be expanded to target certain preventive
procedures to poor, largely inner-city and rural children in
school-based or school-linked programs.

Reducing deaths from oral and pharyngeal cancers and improving the early
detection of both types of cancer require immediate attention. Efforts
must be made to continue the momentum begun in the 1990s that focused on
reducing the number of new cases of oral and pharyngeal cancers and
improving survival.[^37]**^,^** [^38] Specifically, dental personnel
need to provide comprehensive oral cancer examinations on a routine
basis for persons aged 40 years and older or who are otherwise at high
risk. Dental personnel also need to provide counseling to patients to
stop tobacco use and limit alcohol use, both of which are associated
with oral and pharyngeal cancers.

The 21st century may provide the opportunity to reduce the burden of
birth defects, such as cleft lip and cleft palate. As local and State
surveillance systems of developmental anomalies are created or expanded,
opportunities should be explored to integrate cleft lip and cleft palate
into those systems. If studies confirm the beneficial effects of folic
acid in preventing cleft lip and cleft palate, then programs
incorporating the use of folic acid should be implemented and monitored.

In general, access to primary preventive and early intervention services
must be improved, and barriers to the dental care system should be
removed. Many persons of all ages are receiving professional services in
the oral health care system, but more emphasis must be placed on
vulnerable populations who need professional care.

## Interim Progress Toward Year 2000 Objectives

More than half the 17 Healthy People 2000 oral health objectives show
progress, and 1 was met. One objective has moved away from the target,
and two have shown mixed results. Data since baseline are not available
for four of the objectives. The objective of reducing deaths from oral
and pharyngeal cancers was met. Dental decay has declined in persons
aged 15 years nearly to its target, although less progress has occurred
in children aged 6 to 8 years. Similar trends are apparent in those two
age groups for untreated dental decay. Elderly persons show improvement
in edentulousness, but the number of persons aged 35 to 44 years who had
never lost a tooth from caries or periodontal disease fails to show
improvement. An increased proportion of children are receiving dental
sealants, but further improvement is needed. Little change has occurred
in the proportion of the U.S. population served by fluoridated water
systems.

Note: Unless otherwise noted, data are from the Centers for Disease
Control and\
Prevention, National Center for Health Statistics, *Healthy People 2000
Review, 1998--99.*

## Healthy People 2010---Summary of Objectives

### Oral Health {#oral-health-1 .Heading-Special-Sub}

**Goal:** Prevent and control oral and craniofacial diseases,
conditions, and injuries and improve access to related services.

  ------------ --------------------------------------------------------------
  **Number**   **Objective Short Title**

  21-1         Dental caries experience

  21-2         Untreated dental decay

  21-3         No permanent tooth loss

  21-4         Complete tooth loss

  21-5         Periodontal diseases

  21-6         Early detection of oral and pharyngeal cancers

  21-7         Annual examinations for oral and pharyngeal cancers

  21-8         Dental sealants

  21-9         Community water fluoridation

  21-10        Use of oral health care system

  21-11        Use of oral health care system by residents in long-term care
               facilities

  21-12        Dental services for low-income children

  21-13        School-based health centers with oral health component

  21-14        Health centers with oral health service components

  21-15        Referral for cleft lip or palate

  21-16        Oral and craniofacial State-based surveillance system

  21-17        Tribal, State, and local dental programs
  ------------ --------------------------------------------------------------

## Healthy People 2010 Objectives

21-1. Reduce the proportion of children and adolescents who have dental
caries experience in their primary or\
permanent teeth.

**21-1a.** Reduce the proportion of young children with dental caries
experience\
in their primary teeth.

**Target:** 11 percent.

**Baseline:** 18 percent of children aged 2 to 4 years had dental caries
experience in 1988--94.

**Target setting method:** Better than the best.

**Data sources:** National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS; Oral Health Survey of Native Americans, 1999, IHS;
California Oral Health Needs Assessment of Children, Dental Health
Foundation, 1993--94.

Throughout childhood and adolescence, many opportunities exist for the
primary prevention of dental decay. The earliest opportunity to prevent
dental decay occurs during prenatal counseling about diet, oral hygiene
practices, appropriate uses of fluorides, and the transmission of
bacteria from parents to children. Early childhood caries, sometimes
referred to as baby bottle tooth decay or nursing caries, can be a
devastating condition, often requiring thousands of dollars and a
hospital visit with general anesthesia for treatment.Error: Reference
source not found**^,\ Error:\ Reference\ source\ not\ found^** The pain,
psychological trauma, health risks, and costs associated with
restoration of these carious teeth for children affected by ECC can be
substantial.Error: Reference source not found Dental care for pregnant
females, counseling, reinforcement of health promoting behaviors with
caregivers of children, and intervention by dental and other
professionals to improve parenting practices (use of fluorides, use of
professional services, and diet) provide the best available means of
preventing this serious oral disease.

The average number of decayed and filled teeth among 2- to 4-year-olds
has remained unchanged over the past 25 years.Error: Reference source
not found Children whose parents or caregivers have less than a high
school education or whose parents and caregivers are Hispanic, American
Indians, or Alaska Natives appear to be at markedly increased risk for
developing ECC.Error: Reference source not found

**21-1b.** Reduce the proportion of children with dental caries
experience in their primary and permanent teeth.

**Target:** 42 percent.

**Baseline:** 52 percent of children aged 6 to 8 years had dental caries
experience in 1988--94.

**Target setting method:** Better than the best.

**Data sources:** National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS; Oral Health Survey of Native Americans, 1999, IHS;
California Oral Health Needs Assessment of Children, 1993--94, Dental
Health Foundation;\
Hawai'i Children's Oral Health Assessment, 1999, State of Hawaii
Department of Health.

Children aged 6 to 8 years are at an important stage of dental
development. They still have the majority of their primary teeth, and
their permanent first molars and incisors are erupting into their
mouths. Maintaining optimal oral health for these children is important
for their current functional oral health and for their long-term health.
Between the time the first permanent molars erupt into the mouth and
before vulnerable pits and fissures are infected, children should be
assessed for their need for dental sealants.

**21-1c.** Reduce the proportion of adolescents with dental caries
experience\
in their permanent teeth.

**Target:** 51 percent.

**Baseline:** 61 percent of adolescents aged 15 years had dental caries
experience in 1988--94.

**Target setting method:** Better than the best.

**Data sources:** National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS; Oral Health Survey of Native Americans, 1999, IHS;
California Oral Health Assessment of Children, 1993--94, Dental Health
Foundation.

Caries experience is cumulative, thus higher among adolescents than
among young children. Effective personal preventive measures---for
example, tooth brushing with fluoride toothpastes---need to be applied
throughout adolescence, as children become more independent in their
oral hygiene and dietary habits. Regular dental visits provide an
opportunity to assess oral hygiene and dietary practices and to place
sealants on vulnerable permanent teeth that erupt during this life stage
(including second permanent molars at around age 12 years).

Note: The table below may continue to the following page.

+--------------------------------+------------+------------+-----------+
| **Children and Adolescents,\   | **Dental   |            |           |
| Selected Ages, 1988--94        | Caries     |            |           |
| (unless noted)**               | Ex         |            |           |
|                                | perience** |            |           |
+================================+============+============+===========+
|                                | **21-1a.\  | **21-1b.\  | **21-1c.\ |
|                                | Aged 2 to  | Aged 6 to  | Aged 15   |
|                                | 4 Years**  | 8 Years**  | Years**   |
+--------------------------------+------------+------------+-----------+
|                                | Percent    |            |           |
+--------------------------------+------------+------------+-----------+
| > **TOTAL**                    | 18         | 52         | 61        |
+--------------------------------+------------+------------+-----------+
| **Race and ethnicity**         |            |            |           |
+--------------------------------+------------+------------+-----------+
| > American Indian or Alaska    | 76\*       | 90\*       | 89\*      |
| > Native                       | (1999)     | (1999)     | (1999)    |
+--------------------------------+------------+------------+-----------+
| > Asian or Pacific Islander    | DSU        | DSU        | DSU       |
+--------------------------------+------------+------------+-----------+
| > Asian                        | 34^†^\     | 90^†^\     | DSU^†^\   |
|                                | (1993--94) | (1993--94) | (         |
|                                |            |            | 1993--94) |
+--------------------------------+------------+------------+-----------+
| > Native Hawaiian and other\   | DNC        | 79^‡^      | DNC       |
| > Pacific Islander             |            | (1999)     |           |
+--------------------------------+------------+------------+-----------+
| > Black or African American    | 24         | 50         | 70        |
+--------------------------------+------------+------------+-----------+
| > White                        | 15         | 51         | 60        |
+--------------------------------+------------+------------+-----------+
|                                |            |            |           |
+--------------------------------+------------+------------+-----------+
| > Hispanic or Latino           | DSU        | DSU        | DSU       |
+--------------------------------+------------+------------+-----------+
| > Mexican American             | 27         | 68         | 57        |
+--------------------------------+------------+------------+-----------+
| > Not Hispanic or Latino       | 17         | 49         | 62        |
+--------------------------------+------------+------------+-----------+
| > Black or African American    | 24         | 49         | 69        |
+--------------------------------+------------+------------+-----------+
| > White                        | 13         | 49         | 61        |
+--------------------------------+------------+------------+-----------+
| **Gender**                     |            |            |           |
+--------------------------------+------------+------------+-----------+
| > Female                       | 19         | 54         | 63        |
+--------------------------------+------------+------------+-----------+
| > Male                         | 18         | 50         | 60        |
+--------------------------------+------------+------------+-----------+
| **Education level** (head of   |            |            |           |
| household)                     |            |            |           |
+--------------------------------+------------+------------+-----------+
| > Less than high school        | 29         | 65         | 59        |
+--------------------------------+------------+------------+-----------+
| > High school graduate         | 18         | 52         | 63        |
+--------------------------------+------------+------------+-----------+
| > At least some college        | 12         | 43         | 61        |
+--------------------------------+------------+------------+-----------+
| **Disability status**          |            |            |           |
+--------------------------------+------------+------------+-----------+
| > Persons with disabilities    | DNC        | DNC        | DNC       |
+--------------------------------+------------+------------+-----------+
| > Persons without disabilities | DNC        | DNC        | DNC       |
+--------------------------------+------------+------------+-----------+
| **Select populations**         |            |            |           |
+--------------------------------+------------+------------+-----------+
| > 3rd grade students           | NA         | 60         | NA        |
+--------------------------------+------------+------------+-----------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable. NA = Not applicable.

\*Data are for IHS service areas.

^†^Data are for California.

^‡^Data are for Hawaii.

Note: The table above may have continued from the previous page.

21-2. Reduce the proportion of children, adolescents, and adults with
untreated dental decay.

**21-2a.** Reduce the proportion of young children with untreated dental
decay\
in their primary teeth.

**Target:** 9 percent.

**Baseline:** 16 percent of children aged 2 to 4 years had untreated
dental decay\
in 1988--94.

**Target setting method:** Better than the best.

**Data sources:** National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS; Oral Health Survey of Native Americans, 1999, IHS;
California Oral Health Needs Assessment of Children, 1993--94, Dental
Health Foundation.

Primary teeth should be retained until they come out naturally and are
replaced by the permanent teeth. Healthy retained primary teeth enhance
self-image; decayed or missing primary teeth may cause a child to be
self-conscious and reluctant to smile. Children need to eat nutritious
foods to develop normally. The pain and infection of rampant dental
disease compromise their ability to eat well. Moreover, early tooth loss
caused by dental decay can result in impaired speech development,
failure to thrive, absence from and inability to concentrate in school,
and reduced self-esteem.

Children aged 2 to 4 years are least likely to have been seen by a
dentist, whereas a much larger proportion have been taken to a health
provider for medical care or counseling.[^39] Thus these latter
providers should be trained to examine and identify major oral diseases
of toddlers and refer those with problems for necessary care.

**21-2b.** Reduce the proportion of children with untreated dental decay
in primary and permanent teeth.

**Target:** 21 percent.

**Baseline:** 29 percent of children aged 6 to 8 years had untreated
dental decay\
in 1988--94.

**Target setting method:** Better than the best.

**Data sources:** National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS; Oral Health Survey of Native Americans, 1999, IHS;
California Oral Health Needs Assessment of Children, 1993--94, Dental
Health Foundation;\
Hawai'i Children's Oral Health Assessment, 1999, State of Hawaii
Department of Health.

To avoid pain and discomfort, decayed primary teeth need to be restored,
particularly molars in children aged 6 to 8 years. Retention of primary
molars until they fall out normally (age 10 to 12 years) allows adequate
dental arch space for the eruption of succeeding permanent premolars and
avoids the tipping forward of first permanent molars, possibly creating
serious orthodontic problems. Carious permanent teeth should be repaired
promptly so that fillings may be kept small and as much natural tooth as
possible conserved. Often, fillings have to be replaced several times
during life; each time, additional tooth structure has to be removed,
weakening the tooth. Preventing the initial cavity by appropriate use of
fluorides and sealants is preferable to restoring the tooth after
disease has occurred.

**21-2c.** Reduce the proportion of adolescents with untreated dental
decay in their permanent teeth.

**Target:** 15 percent.

**Baseline:** 20 percent of adolescents aged 15 years had untreated
dental decay in 1988--94.

**Target setting method:** Better than the best.

**Data sources:** National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS; Oral Health Survey of Native Americans, 1999, IHS;
California Oral Health Needs Assessment of Children, 1993--94, Dental
Health Foundation.

By age 15 years, all permanent teeth other than third molars have
erupted, and vulnerable chewing surfaces of permanent second molars have
been exposed to cariogenic factors for 2 or 3 years. Further, by this
age, approximately 75 percent of adolescents have experienced dental
decay.Error: Reference source not found

**21-2d.** Reduce the proportion of adults with untreated dental decay.

**Target:** 15 percent.

**Baseline:** 27 percent of adults aged 35 to 44 years had untreated
dental decay\
in 1998--94.

**Target setting method:** Better than the best.

**Data sources:** National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS; Oral Health Survey of Native Americans, 1999, IHS.

Approximately 30 percent of adults have untreated dental decay.Error:
Reference source not found Untreated dental decay can lead to extensive
dental treatment and can be quite costly. If decay is left unheeded, an
individual can experience pain, abscess, and extraction of the tooth.

Among adults aged 35 to 44 years, twice as many blacks or African
Americans (46 percent) as whites (23 percent) have tooth decay. More
than three times as many persons with less than a high school education
(51 percent) have untreated dental decay than adults with some college
education (16 percent).Error: Reference source not found Dental decay is
just as preventable in adults as it is in children. Access to community
water fluoridation benefits adults as well as children. Access to other
preventive interventions is critical, as well as access to dental
treatment to restore the tooth.

+-----------------------------+---------+---------+---------+---------+
| **Children, Adolescents,    | **Un    |         |         |         |
| and Adults, Selected Ages,\ | treated |         |         |         |
| 1988--94 (unless noted)**   | Dental  |         |         |         |
|                             | Decay** |         |         |         |
+=============================+=========+=========+=========+=========+
|                             | **      | **      | **      | **      |
|                             | 21-2a.\ | 21-2b.\ | 21-2c.\ | 21-2d.\ |
|                             | Aged\   | Aged\   | Aged\   | Aged\   |
|                             | 2 to 4  | 6 to 8  | 15      | 35 to   |
|                             | Years** | Years** | Years** | 44      |
|                             |         |         |         | Years** |
+-----------------------------+---------+---------+---------+---------+
|                             | Percent |         |         |         |
+-----------------------------+---------+---------+---------+---------+
| ######## TOTAL              | 16      | 29      | 20      | 27      |
+-----------------------------+---------+---------+---------+---------+
| **Race and ethnicity**      |         |         |         |         |
+-----------------------------+---------+---------+---------+---------+
| > American Indian or        | 67\*    | 69\*    | 67\*    | 67\*    |
| > Alaska\                   | (1999)  | (1999)  | (1999)  | (1999)  |
| > Native                    |         |         |         |         |
+-----------------------------+---------+---------+---------+---------+
| > Asian or Pacific Islander | DSU     | DSU     | DSU     | DSU     |
+-----------------------------+---------+---------+---------+---------+
| > Asian^†^                  | 30^†^   | 71^†^   | DSU^†^  | DNC     |
|                             |         | (19     | (19     |         |
|                             | (19     | 93--94) | 93--94) |         |
|                             | 93--94) |         |         |         |
+-----------------------------+---------+---------+---------+---------+
| > Native Hawaiian and       | DNC     | 39^‡^\  | DNC     | DNC     |
| > other\                    |         | (1999)  |         |         |
| > Pacific Islander          |         |         |         |         |
+-----------------------------+---------+---------+---------+---------+
| > Black or African American | 22      | 36      | 29      | 46      |
+-----------------------------+---------+---------+---------+---------+
| > White                     | 11      | 26      | 19      | 24      |
+-----------------------------+---------+---------+---------+---------+
|                             |         |         |         |         |
+-----------------------------+---------+---------+---------+---------+
| > Hispanic or Latino        | DSU     | DSU     | DSU     | DSU     |
+-----------------------------+---------+---------+---------+---------+
| > Mexican American          | 24      | 43      | 27      | 34      |
+-----------------------------+---------+---------+---------+---------+
| > Not Hispanic or Latino    | 14      | 26      | 19      | DNA     |
+-----------------------------+---------+---------+---------+---------+
| > Black or African American | 22      | 35      | 28      | 47      |
+-----------------------------+---------+---------+---------+---------+
| > White                     | 11      | 22      | 18      | 23      |
+-----------------------------+---------+---------+---------+---------+
| **Gender**                  |         |         |         |         |
+-----------------------------+---------+---------+---------+---------+
| > Female                    | 16      | 32      | 22      | 25      |
+-----------------------------+---------+---------+---------+---------+
| > Male                      | 16      | 25      | 17      | 29      |
+-----------------------------+---------+---------+---------+---------+
| **Education level** (head   |         |         |         |         |
| of household)               |         |         |         |         |
+-----------------------------+---------+---------+---------+---------+
| > Less than high school     | 26      | 44      | 29      | 51      |
+-----------------------------+---------+---------+---------+---------+
| > High school graduate      | 16      | 30      | 18      | 34      |
+-----------------------------+---------+---------+---------+---------+
| > At least some college     | 9       | 25      | 15      | 16      |
+-----------------------------+---------+---------+---------+---------+
| **Disability status**       |         |         |         |         |
+-----------------------------+---------+---------+---------+---------+
| > Persons with disabilities | DNC     | DNC     | DNC     | DNA     |
+-----------------------------+---------+---------+---------+---------+
| > Persons without           | DNC     | DNC     | DNC     | DNA     |
| > disabilities              |         |         |         |         |
+-----------------------------+---------+---------+---------+---------+
| **Select populations**      |         |         |         |         |
+-----------------------------+---------+---------+---------+---------+
| > 3rd grade students        | NA      | 33      | NA      | NA      |
+-----------------------------+---------+---------+---------+---------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable. NA = Not applicable.

\*Data are for IHS service areas.

^†^Data are for California.

^‡^Data are for Hawaii.

21-3. Increase the proportion of adults who have never had\
a permanent tooth extracted because of dental caries\
or periodontal disease.

**Target:** 42 percent.

**Baseline:** 31 percent of adults aged 35 to 44 years had never had a
permanent tooth extracted because of dental caries or periodontal
disease in 1988--94.

**Target setting method:** Better than the best.

**Data sources:** National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS; Oral Health Survey of Native Americans, 1999, IHS.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Persons Aged 35 to 44 Years, 1988--94**      | **No Tooth\         |
|                                                | Extractions**       |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 31                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 23\* (1999)         |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 12                  |
+------------------------------------------------+---------------------+
| > White                                        | 34                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | DSU                 |
+------------------------------------------------+---------------------+
| > Mexican American                             | 36                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | DNA                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 12                  |
+------------------------------------------------+---------------------+
| > White                                        | 36                  |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 32                  |
+------------------------------------------------+---------------------+
| > Male                                         | 30                  |
+------------------------------------------------+---------------------+
| **Education level**                            |                     |
+------------------------------------------------+---------------------+
| > Less than high school                        | 15                  |
+------------------------------------------------+---------------------+
| > High school graduate                         | 21                  |
+------------------------------------------------+---------------------+
| > At least some college                        | 41                  |
+------------------------------------------------+---------------------+
| **Disability status**                          |                     |
+------------------------------------------------+---------------------+
| > Persons with disabilities                    | DNA                 |
+------------------------------------------------+---------------------+
| > Persons without disabilities                 | DNA                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*Data are for IHS service areas.

Note: The table above may have continued from the previous page.

A full dentition is defined as having 28 natural teeth, exclusive of
third molars and teeth removed for orthodontic treatment or as a result
of trauma. Most persons can keep their teeth for life with optimal
personal, professional, and population-based preventive practices. Early
tooth loss has been shown to be a predictor of eventual edentulism.[^40]
As teeth are lost, a person's ability to chew and speak decreases. A
loss of or a withdrawal from social functioning can occur. Tooth loss
can result from infection, unintentional injury, and head and neck
cancer treatment. In addition, certain orthodontic and prosthetic
services sometimes require the removal of teeth.

Despite an overall trend toward a reduction in tooth loss in the U.S.
population,Error: Reference source not found older data indicate 25
percent of American Indians or Alaska Natives aged 35 to 44 years have
fewer than 20 natural teeth;Error: Reference source not found among all
persons aged 55 years and older, nearly 75 percent have fewer than 20
natural teeth. Females tend to have more teeth extracted than males of
the same age group. African Americans are more likely than whites to
have teeth extracted.Error: Reference source not found The percentage of
whites who have never had a permanent tooth extracted is more than three
times as great as for African Americans. Among all predisposing and
enabling variables, low educational level often has been found to have
the strongest and most consistent association with tooth loss.[^41]

21-4. Reduce the proportion of older adults who have had\
all their natural teeth extracted.

**Target:** 20 percent.

**Baseline:** 26 percent of adults aged 65 to 74 years had lost all
their natural teeth in 1997.

**Target setting method:** Better than the best.

**Data sources:** National Health Interview Survey (NHIS), CDC, NCHS;
Oral Health Survey of Native Americans, 1999, IHS.

+------------------------------------------------+---------------------+
| **Adults Aged 65 to 74 Years, 1997\            | **Lost All Natural  |
| (unless noted)**                               | Teeth**             |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 26                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 30\* (1999)         |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DSU                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 30                  |
+------------------------------------------------+---------------------+
| > White                                        | 25                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 24                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 26                  |
+------------------------------------------------+---------------------+
| > Black or African American                    | 30                  |
+------------------------------------------------+---------------------+
| > White                                        | 26                  |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 27                  |
+------------------------------------------------+---------------------+
| > Male                                         | 24                  |
+------------------------------------------------+---------------------+
| **Education level**                            |                     |
+------------------------------------------------+---------------------+
| > Less than high school                        | 39                  |
+------------------------------------------------+---------------------+
| > High school graduate                         | 26                  |
+------------------------------------------------+---------------------+
| > At least some college                        | 13                  |
+------------------------------------------------+---------------------+
| **Disability status**                          |                     |
+------------------------------------------------+---------------------+
| > Persons with disabilities                    | 34                  |
+------------------------------------------------+---------------------+
| > Persons without disabilities                 | 22                  |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*Data are for IHS service areas.

Despite a steady decline in the rate of complete tooth loss over the
past several decades, 26 percent of persons aged 65 to 74 years had lost
all of their natural teeth. The rate of complete tooth loss among
African Americans is 30 percent whereas that for Hispanics is 24
percent. Among all persons aged 65 years and older, 30 percent had lost
all of their natural teeth.Error: Reference source not found Low-income
adults aged 65 years and older experience a higher rate of edentulism
(48 percent in 1993).Error: Reference source not found Also,
State-specific variations range from 13 to 47 percent in the
self-reported prevalence of complete tooth loss.[^42]

Among elderly persons, loss of all natural teeth can contribute to
psychological, social, and physical impairment.Error: Reference source
not found Even when missing teeth are replaced with well-constructed
dentures, there may be limitations in speech, chewing ability, taste
perception, and quality of life. Most tooth loss is the result of dental
caries and periodontal disease. The level of edentulism reflects not
only the cases of caries and periodontal disease but also the
availability and use of appropriate professional services and community
preventive services. Tooth loss can be prevented through education,
early diagnosis, and regular dental care. Children and adults (and the
health care professionals who serve them) must recognize the signs and
symptoms of oral and systemic diseases and know the oral and general
health care practices necessary to prevent them.

21-5. Reduce periodontal disease.

Target and baseline:

+---------+-------------------------+----------------+----------------+
| Ob      | Reduction in            | 1988--94\      | 2010\          |
| jective | Periodontal\            | Baseline       | Target         |
|         | Disease in Adults Aged  |                |                |
|         | 35 to 44 Years          |                |                |
+---------+-------------------------+----------------+----------------+
|         |                         | #              |                |
|         |                         | ###### Percent |                |
+---------+-------------------------+----------------+----------------+
| **2     | Gingivitis              | 48             | 41             |
| 1-5a.** |                         |                |                |
+---------+-------------------------+----------------+----------------+
| **2     | Destructive             | 22             | 14             |
| 1-5b.** | periodontal\            |                |                |
|         | disease                 |                |                |
+---------+-------------------------+----------------+----------------+

**Target setting method:** Better than the best.

**Data sources:** National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS; Oral Health Survey of Native Americans, 1999, IHS.

Note: The table below may continue to the following page.

+--------------------------------+-----------------+------------------+
| **Adults Aged 35 to 44 Years,\ | **21-5a.\       | **21-5b.\        |
| 1988--94 (unless noted)**      | Gingivitis**    | Destructive\     |
|                                |                 | Periodontal\     |
|                                |                 | Disease**        |
+================================+=================+==================+
|                                | Percent         |                  |
+--------------------------------+-----------------+------------------+
| > **TOTAL**                    | 48              | 22               |
+--------------------------------+-----------------+------------------+
| **Race and ethnicity**         |                 |                  |
+--------------------------------+-----------------+------------------+
| > American Indian or Alaska    | 98\* (1999)     | 54\* (1999)      |
| > Native                       |                 |                  |
+--------------------------------+-----------------+------------------+
| > Asian or Pacific Islander    | DSU             | DSU              |
+--------------------------------+-----------------+------------------+
| > Asian                        | DNC             | DNC              |
+--------------------------------+-----------------+------------------+
| > Native Hawaiian and other\   | DNC             | DNC              |
| > Pacific Islander             |                 |                  |
+--------------------------------+-----------------+------------------+
| > Black or African American    | 51              | 33               |
+--------------------------------+-----------------+------------------+
| > White                        | 47              | 20               |
+--------------------------------+-----------------+------------------+
|                                |                 |                  |
+--------------------------------+-----------------+------------------+
| > Hispanic or Latino           | DSU             | DSU              |
+--------------------------------+-----------------+------------------+
| > Mexican American             | 64              | 24               |
+--------------------------------+-----------------+------------------+
| > Not Hispanic or Latino       | DNA             | DNA              |
+--------------------------------+-----------------+------------------+
| > Black or African American    | 51              | 33               |
+--------------------------------+-----------------+------------------+
| > White                        | 45              | 20               |
+--------------------------------+-----------------+------------------+
| ###### Gender                  |                 |                  |
+--------------------------------+-----------------+------------------+
| > Female                       | 45              | 15               |
+--------------------------------+-----------------+------------------+
| > Male                         | 52              | 29               |
+--------------------------------+-----------------+------------------+
| **Education level**            |                 |                  |
+--------------------------------+-----------------+------------------+
| > Less than high school        | 60              | 35               |
+--------------------------------+-----------------+------------------+
| > High school graduate         | 52              | 28               |
+--------------------------------+-----------------+------------------+
| > At least some college        | 42              | 15               |
+--------------------------------+-----------------+------------------+
| **Disability status**          |                 |                  |
+--------------------------------+-----------------+------------------+
| > Persons with disabilities    | DNA             | DNA              |
+--------------------------------+-----------------+------------------+
| > Persons without disabilities | DNA             | DNA              |
+--------------------------------+-----------------+------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*Data are for IHS service areas.

Note: The table above may have continued from the previous page.

Gingivitis is characterized by localized inflammation, swelling, and
bleeding gum tissues without a loss of connective tissue or bone
support. Gingivitis usually is reversible with proper daily oral hygiene
and serves as a crude measure of a person's self-care practices.[^43]
Removal of dental plaque from the teeth on a daily basis is extremely
important to prevent gingivitis, which can progress to destructive
periodontal disease. Most plaque removal can be achieved by
conscientious tooth brushing. The use of dental floss helps to remove
dental plaque from tooth surfaces that touch one another.

Most young adults have some gingivitis. Cases of gingivitis are high
among Hispanics, American Indians, Alaska Natives, and adults with low
incomes.Error: Reference source not found Cases of gingivitis likely
will remain a substantial problem and may increase as tooth loss from
dental caries declines or as a result of the use of some systemic
medications. Although not all cases of gingivitis progress to
periodontal disease, all periodontal disease starts as gingivitis.[^44]
The major method available to prevent destructive periodontitis,
therefore, is to prevent the precursor condition of gingivitis.

Periodontal disease is manifested by the loss of the connective tissue
and bone that support the teeth.[^45] It places a person at risk of
eventual tooth loss unless appropriate treatment occurs.Error: Reference
source not found The presence of one or more sites with 4 mm or greater
loss of tooth attachment to surrounding periodontal tissues has been
used to measure the cases of destructive periodontal disease.Error:
Reference source not found This measure has allowed the monitoring of
changes in periodontal disease over time and distinguishes the status of
select populations from one another. Other measurements under
development may serve as indicators of periodontal disease in the
future. Among adults, destructive periodontal disease may be associated
with an increased risk of some systemic disease and is a leading cause
of bleeding, pain, infection, tooth mobility, and tooth loss.Error:
Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found^**

Tobacco use, especially cigarette smoking, is a significant risk factor
for periodontal disease,Error: Reference source not found accounting for
up to half of all cases of periodontitis.[^46] Home-care oral hygiene
practices, such as daily tooth brushing and flossing, reduce bacterial
plaque on teeth and gingiva and help maintain periodontal health. The
number of cases of periodontal disease in persons with poor oral hygiene
is more than 20 times that for persons who have good oral care
practices.Error: Reference source not found Recent research has
suggested that bacteria associated with periodontal disease are
associated with an increased risk of heart disease and stroke, premature
births in some females, and respiratory infection in susceptible
individuals.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found^**

The cases and severity of destructive periodontal disease are measured
by loss of tissue attachment to the tooth and gingival pocket depth.
These measures increase with age and vary by socioeconomic status. The
number of cases of periodontal disease is higher than the national
average among American Indians and Alaska Natives, adults with less than
a high school education, and migrant workers.Error: Reference source not
found Unless preventive measures are taken, the problem of destructive
periodontal disease will grow as the aging U.S. population retains more
teeth later in life. More effective intervention across the entire adult
age spectrum will be essential.

21-6. Increase the proportion of oral and pharyngeal cancers\
detected at the earliest stage.

**Target:** 50 percent.

**Baseline:** 35 percent of oral and pharyngeal cancers (stage I,
localized) were detected in 1990--95.

**Target setting method:** Better than the best.

**Data source:** Surveillance, Epidemiology, and End Results (SEER),
NIH, NCI.

+------------------------------------------------+---------------------+
| **Persons With Oral and Pharyngeal\            | **Detected at\      |
| Cancers, 1990--95**                            | Earliest Stage**    |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 35                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 20                  |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DNA                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNA                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNA                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 21                  |
+------------------------------------------------+---------------------+
| > White                                        | 38                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 36                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 34                  |
+------------------------------------------------+---------------------+
| > Black or African American                    | DNA                 |
+------------------------------------------------+---------------------+
| > White                                        | DNA                 |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 39                  |
+------------------------------------------------+---------------------+
| > Male                                         | 34                  |
+------------------------------------------------+---------------------+
| **Education level**                            |                     |
+------------------------------------------------+---------------------+
| > Less than high school                        | DNA                 |
+------------------------------------------------+---------------------+
| > High school graduate                         | DNA                 |
+------------------------------------------------+---------------------+
| > At least some college                        | DNA                 |
+------------------------------------------------+---------------------+
| **Disability status**                          |                     |
+------------------------------------------------+---------------------+
| > Persons with disabilities                    | DNA                 |
+------------------------------------------------+---------------------+
| > Persons without disabilities                 | DNA                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

For many years, the proportion of oral and pharyngeal cancer lesions
diagnosed at stage I has remained low at about 35 percent.Error:
Reference source not found Increasing the proportion of lesions detected
at the earliest stage of diagnosis improves the 5-year survival rate and
is one strategy to reduce illness and deaths.

For example, the 5-year survival rate for early stage cancer is 81
percent but is only 22 percent among persons diagnosed with advanced
stage cancer. Further, only 19 percent of African Americans with oral
and pharyngeal cancers are diagnosed at the local stage (with 34 percent
5-year survival), compared to 38 percent of whites (with 56 percent
5-year survival).Error: Reference source not found

A higher proportion of oral and pharyngeal cancer lesions diagnosed at
stage I and a lower number of deaths from oral and pharyngeal cancers
would indicate that strategies to increase appropriate detection with
comprehensive oral and pharyngeal cancer examinations and referral have
been successful. Other outcome measures indicating success include a
reduction in new cases of oral and pharyngeal cancers, reduced death
rates, and an increase in 5-year survival rates.

21-7. Increase the proportion of adults who, in the past 12 months,
report having had an examination to detect oral and pharyngeal cancers.

**Target:** 20 percent.

**Baseline:** 13 percent of adults aged 40 years and older reported
having had an oral and pharyngeal cancer examination in 1998 (age
adjusted to the year 2000 standard population).

**Target setting method:** Better than the best.

**Data source:** National Health Interview Survey (NHIS), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Adults Aged 40 Years and Older, 1998**       | **Oral and\         |
|                                                | Pharyngeal\         |
|                                                | Cancer\             |
|                                                | Examination in Past |
|                                                | 12 Months**         |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 13                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | 12                  |
+------------------------------------------------+---------------------+
| > Asian                                        | 12                  |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 7                   |
+------------------------------------------------+---------------------+
| > White                                        | 14                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 6                   |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 14                  |
+------------------------------------------------+---------------------+
| > Black or African American                    | 7                   |
+------------------------------------------------+---------------------+
| > White                                        | 15                  |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 14                  |
+------------------------------------------------+---------------------+
| > Male                                         | 13                  |
+------------------------------------------------+---------------------+
| **Education level**                            |                     |
+------------------------------------------------+---------------------+
| > Less than high school                        | 5                   |
+------------------------------------------------+---------------------+
| > High school graduate                         | 10                  |
+------------------------------------------------+---------------------+
| > At least some college                        | 19                  |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Data age adjusted to the year 2000 standard population.

Note: The table above may have continued from the previous page.

Oral cancer detection is accomplished by a thorough extra-oral
examination of the head and neck and an intra-oral examination including
the tongue and the entire oral and pharyngeal mucosal tissues, lips, and
intra- and extra-oral palpation of the lymph nodes. Although the
sensitivity and specificity of the oral cancer examination have not been
established in clinical studies, evidence clearly supports a better
prognosis with early detection and treatment of oral cancer.Error:
Reference source not found If suspicious tissues are detected during
examination, definitive diagnostic tests are needed, such as biopsies,
to make a firm diagnosis.

The occurrence of oral and pharyngeal cancers varies by race and
ethnicity. For example, blacks and whites have 12.5 and 10.0 new cases
per 100,000 per year, respectively; Hispanics and American Indians and
Alaska Natives have only 6.5 and 8.8 new cases per year,
respectively.Error: Reference source not found

Regular oral cancer examinations afford an opportunity for practitioners
to discuss with patients primary prevention of these lesions---that is,
avoiding known risk factors, such as the 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 90 percent of
all oral cancers.[^47] Individuals also should be advised to avoid other
potential carcinogens, such as exposure to sunlight (risk factor for lip
cancer) without protection (use of lip sunscreen and hats recommended).
(See Focus Area 3. Cancer.)

Because more adults seek care from physicians than from dentists,
medical personnel must be educated on the importance of routinely doing
oral cancer detection examinations of patients at high risk, and they
also must be trained in the proper procedures for these
examinations.[^48]

21-8. Increase the proportion of children who have received\
dental sealants on their molar teeth.

Target and baseline:

+----------+----------------------------+--------------+-------------+
| O        | Increase in Children       | 1988--94\    | 2010\       |
| bjective | Receiving Dental Sealants  | Baseline     | Target      |
|          | on Their Molar Teeth       |              |             |
+----------+----------------------------+--------------+-------------+
|          |                            | ###          |             |
|          |                            | #### Percent |             |
+----------+----------------------------+--------------+-------------+
| **       | Children aged 8 years      | 23           | 50          |
| 21-8a.** |                            |              |             |
+----------+----------------------------+--------------+-------------+
| **       | Adolescents aged 14 years  | 15           | 50          |
| 21-8b.** |                            |              |             |
+----------+----------------------------+--------------+-------------+

**Target setting method:** Better than the best.

**Data sources:** National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS; Oral Health Survey of Native Americans, 1999, IHS;
Hawai'i\
Children's Oral Health Assessment, 1999, State of Hawaii Department of
Health.

Note: The table below may continue to the following page.

+-------------------------------+------------------+------------------+
| **Children, Selected Ages,\   | **Dental         |                  |
| 1988--94 (unless noted)**     | Sealants on      |                  |
|                               | Molars**         |                  |
+===============================+==================+==================+
|                               | **21-8a.\        | **21-8b.\        |
|                               | Aged 8 Years**   | Aged 14 Years**  |
+-------------------------------+------------------+------------------+
|                               | Percent          |                  |
+-------------------------------+------------------+------------------+
| > **TOTAL**                   | 23               | 15               |
+-------------------------------+------------------+------------------+
| **Race and ethnicity**        |                  |                  |
+-------------------------------+------------------+------------------+
| > American Indian or Alaska   | 55\* (1999)      | 42\* (1999)      |
| > Native                      |                  |                  |
+-------------------------------+------------------+------------------+
| > Asian or Pacific Islander   | DSU              | DSU              |
+-------------------------------+------------------+------------------+
| > Asian                       | DNC              | DNC              |
+-------------------------------+------------------+------------------+
| > Native Hawaiian and other\  | 20^†^ (1999)     | DNC              |
| > Pacific Islander            |                  |                  |
+-------------------------------+------------------+------------------+
| > Black or African American   | 11               | 5                |
+-------------------------------+------------------+------------------+
| > White                       | 26               | 19               |
+-------------------------------+------------------+------------------+
|                               |                  |                  |
+-------------------------------+------------------+------------------+
| > Hispanic or Latino          | DSU              | DSU              |
+-------------------------------+------------------+------------------+
| > Mexican American            | 10               | 7                |
+-------------------------------+------------------+------------------+
| > Not Hispanic or Latino      | 25               | DNA              |
+-------------------------------+------------------+------------------+
| > Black or African American   | 11               | 5                |
+-------------------------------+------------------+------------------+
| > White                       | 29               | 18               |
+-------------------------------+------------------+------------------+
| **Gender**                    |                  |                  |
+-------------------------------+------------------+------------------+
| > Female                      | 24               | 14               |
+-------------------------------+------------------+------------------+
| > Male                        | 22               | 16               |
+-------------------------------+------------------+------------------+
| **Education level** (head of  |                  |                  |
| household)                    |                  |                  |
+-------------------------------+------------------+------------------+
| > Less than high school       | 17               | 4                |
+-------------------------------+------------------+------------------+
| > High school graduate        | 12               | 6                |
+-------------------------------+------------------+------------------+
| > At least some college       | 35               | 28               |
+-------------------------------+------------------+------------------+
| **Disability status**         |                  |                  |
+-------------------------------+------------------+------------------+
| > Persons with disabilities   | DNC              | DNC              |
+-------------------------------+------------------+------------------+
| > Persons without             | DNC              | DNC              |
| > disabilities                |                  |                  |
+-------------------------------+------------------+------------------+
| **Select populations**        |                  |                  |
+-------------------------------+------------------+------------------+
| > 3rd grade students          | 26               | NA               |
+-------------------------------+------------------+------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable. NA = Not applicable.

\*Data are for IHS service areas.

^†^Data are for Hawaii.

Note: The table above may have continued from the previous page.

Since the early 1970s, childhood dental caries in smooth tooth surfaces
(those without pits and fissures) has declined markedly because of
widespread exposure to fluorides. By 1986--87, approximately 90 percent
of the decay in children's teeth occurred in tooth surfaces with pits
and fissures, and almost two-thirds were found in the chewing surfaces
alone.Error: Reference source not found

Pit-and-fissure sealants---plastic coatings applied 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.[^49]

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 teens need to receive dental sealants shortly after the
eruption of their second permanent molars.

21-9. Increase the proportion of the U.S. population served by community
water systems with optimally fluoridated water.

**Target:** 75 percent.

**Baseline:** 62 percent of the U.S. population was served by community
water\
systems with optimally fluoridated water in 1992.

**Target setting method:** 21 percent improvement.

**Data source:** CDC Fluoridation Census, CDC, NCCDPHP.

> **Data for population groups currently are not collected.**

Community water fluoridation is the procedure of adjusting the natural
fluoride concentration of a community's water supply to a level that is
best for the prevention of dental decay. In the United States, community
water fluoridation has been the basis for the primary prevention of
dental decay for nearly 55 years and has been recognized as 1 of 10
great achievements in public health of the 20th century.[^50] It is an
ideal public health method because it is effective, eminently safe,
inexpensive, requires no cooperative effort or direct action, and does
not depend on access or availability of professional services. It is
equitable because the entire population benefits regardless of financial
resources.Error: Reference source not found

Water fluoridation reduces or eliminates disparities in preventing
dental caries among different socioeconomic, racial, and ethnic groups.
Fluoridation helps to lower the cost of dental care and dental insurance
and helps residents retain their teeth throughout life. Of the Nation's
50 largest cities, only 7 do not benefit from community water
fluoridation.Error: Reference source not found The consumption of
fluoridated water provides both systemic fluoride exposure to developing
teeth and frequent topical exposure to erupted teeth, promoting
remineralization of early caries among persons of all ages.

Operators of municipal water plants need to maintain targeted
concentrations of fluoride in water in fluoridated communities. Ongoing
education for water plant personnel must continue with appropriate
surveillance by State and local health officials.

21-10. Increase the proportion of children and adults who use\
the oral health care system each year.

**Target:** 56 percent.

**Baseline:** 44 percent of persons aged 2 years and older in 1996
visited a dentist during the previous year.

**Target setting method:** Better than the best.

**Data source:** Medical Expenditure Panel Survey (MEPS), AHRQ.

Note: The table below may continue to the following page.

+-----------------------------------------------+----------------------+
| **Persons Aged 2 Years and Older, 1996**      | **Dental Visit in\   |
|                                               | Previous Year**      |
+===============================================+======================+
|                                               | Percent              |
+-----------------------------------------------+----------------------+
| > **TOTAL**                                   | 44                   |
+-----------------------------------------------+----------------------+
| **Race and ethnicity**                        |                      |
+-----------------------------------------------+----------------------+
| > American Indian or Alaska Native            | 34                   |
+-----------------------------------------------+----------------------+
| > Asian or Pacific Islander                   | 42                   |
+-----------------------------------------------+----------------------+
| > Asian                                       | DSU                  |
+-----------------------------------------------+----------------------+
| > Native Hawaiian and other Pacific Islander  | DSU                  |
+-----------------------------------------------+----------------------+
| > Black or African American                   | 27                   |
+-----------------------------------------------+----------------------+
| > White                                       | 47                   |
+-----------------------------------------------+----------------------+
|                                               |                      |
+-----------------------------------------------+----------------------+
| > Hispanic or Latino                          | 30                   |
+-----------------------------------------------+----------------------+
| > Not Hispanic or Latino                      | DNC                  |
+-----------------------------------------------+----------------------+
| > Black or African American                   | 27                   |
+-----------------------------------------------+----------------------+
| > White                                       | 50                   |
+-----------------------------------------------+----------------------+
| **Gender**                                    |                      |
+-----------------------------------------------+----------------------+
| > Female                                      | 47                   |
+-----------------------------------------------+----------------------+
| > Male                                        | 41                   |
+-----------------------------------------------+----------------------+
| **Education level** (aged 25 years and older) |                      |
+-----------------------------------------------+----------------------+
| > Less than high school                       | 24                   |
+-----------------------------------------------+----------------------+
| > High school graduate                        | 40                   |
+-----------------------------------------------+----------------------+
| > At least some college                       | 55                   |
+-----------------------------------------------+----------------------+
| ###### Disability status                      |                      |
+-----------------------------------------------+----------------------+
| > Persons with disabilities                   | 40                   |
+-----------------------------------------------+----------------------+
| > Persons without disabilities                | 45                   |
+-----------------------------------------------+----------------------+
| **Select populations**                        |                      |
+-----------------------------------------------+----------------------+
| > Children aged 2 to 17 years                 | 48                   |
+-----------------------------------------------+----------------------+
| > Children at first school experience\        | 48                   |
| > (aged 5 years)                              |                      |
+-----------------------------------------------+----------------------+
| > 3rd grade students                          | DNC                  |
+-----------------------------------------------+----------------------+
| > Children, adolescents, and young adults     | 20                   |
| > aged 2 to 19 years; \<200 percent of        |                      |
| > poverty level                               |                      |
+-----------------------------------------------+----------------------+
| > Adults aged 18 years and older              | 43                   |
+-----------------------------------------------+----------------------+
| > Adults aged 65 years and older              | 41                   |
+-----------------------------------------------+----------------------+
| > Dentate adults aged 18 years and older      | DNC                  |
+-----------------------------------------------+----------------------+
| > Edentate adults aged 18 years and older     | DNC                  |
+-----------------------------------------------+----------------------+
| > Adults aged 18 years and older with         | DNC                  |
| > disabilities                                |                      |
+-----------------------------------------------+----------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

Although appropriate home oral health care and population-based
prevention are essential, professional care also is necessary to
maintain optimal oral and craniofacial health. Oral health care is an
important, but often neglected, component of total health care. Regular
dental visits provide an opportunity for the early diagnosis,
prevention, and treatment of oral and craniofacial diseases and
conditions for persons of all ages, as well as for the assessment of
self-care practices. Experts recommend that children as young as age 1
year be examined for evidence of developing ECC.Error: Reference source
not found Further, parents should be advised to avoid feeding practices
that may lead to ECC, and parents should be counseled about the
appropriate use of fluoride and other preventive measures. Necessary
tooth restorative care must be provided to avoid pain, abscesses, and
the need for tooth extractions. Sealants should be placed shortly after
the permanent molars erupt.

Adults who do not receive regular professional care can develop oral
diseases that eventually require complex restorative treatment and may
lead to tooth loss, systemic health problems, and even death in rare
cases. As gums recede in adults, the root surfaces of teeth become
susceptible to dental caries. As the U.S. population ages, root caries
may become a significant dental problem for adults and, particularly,
for seniors; one in every five persons will be aged 65 years or older by
the year 2010. Adults susceptible to root caries should visit their
dentists regularly for evaluation and treatment, if necessary.

Persons who have lost all their natural teeth are less likely to seek
periodic dental care than those with teeth,Error: Reference source not
found which, in turn, decreases the likelihood of early detection of
oral cancer in those without teeth. Edentulism occurs most frequently
among older adults who also have the greatest risk of developing oral
cancer.

Persons with no natural teeth who lack regular dental care may develop
soft tissue lesions from medications, systemic conditions, and exposure
to tobacco, as well as from prosthetic appliances that are not fully
functional or are not maintained properly. As they grow older, persons
with and without teeth are at increased risk of oral and pharyngeal
cancers, as well as autoimmune disorders and other chronic disabling
conditions that have oral manifestations. People without teeth may be
unaware that they are still at risk for oral diseases. Consequently,
they may have long intervals between professional examinations.
Coordination of care between physicians and dentists is essential for
optimal general health and oral health.

21-11. Increase the proportion of long-term care residents who use the
oral health care system each year.

**Target:** 25 percent.

**Baseline:** 19 percent of all nursing home residents received dental
services in 1997.

**Target setting method:** 32 percent improvement. (Better than the best
will be used when data are available.)

**Data source:** National Nursing Home Survey, CDC, NCHS.

> **Data for population groups currently are not analyzed.**

To improve the oral health of the Nation's elderly persons and persons
with disabilities who reside in long-term care facilities, every
resident needs to have access to oral health assessment and treatment.
Federal regulations require nursing facilities certified under Medicare
or Medicaid or both to ensure that each resident attains and maintains
the highest practicable physical, psychosocial, and mental well-being.

For many nursing home residents, substantial anecdotal evidence suggests
that neither dental assessments nor subsequent treatments are being
provided effectively. Nursing home staff members and State surveyors who
assess long-term care facilities for certification should receive
appropriate training to enable them to recognize residents' needs
correctly and to ensure that necessary oral health services are
available.

Residents of institutions face several barriers to obtaining needed
dental services. Often, residents have multiple chronic diseases, take
medications that affect their oral health, or have diseases or
disabilities that make brushing and flossing their teeth difficult or
impossible.[^51] A decline in physical and oral health, use of one or
more of the many medications that cause dry mouth (xerostomia), and
inadequate access to dental care increase the risks of oral diseases
such as yeast infections (candidiasis), caries on the crowns and roots
of teeth, gingivitis, oral mucosal lesions, and periodontal disease.

21-12. Increase the proportion of low-income children and\
adolescents who received any preventive dental service during the past
year.

**Target:** 57 percent.

**Baseline:** 20 percent of children and adolescents under age 19 years
at or\
below 200 percent of the Federal poverty level received any preventive
dental service in 1996.

**Target setting method:** Better than the best.

**Data source:** Medical Expenditure Panel Survey (MEPS), AHRQ.

+------------------------------------------------+---------------------+
| **Children Under Age 19 Years at or\           | **Preventive Dental |
| Below 200 Percent of the Federal Poverty       | Visit in Past 12    |
| Level, 1996**                                  | Months**            |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 20                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 13                  |
+------------------------------------------------+---------------------+
| > White                                        | 25                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 16                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | DNA                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DNA                 |
+------------------------------------------------+---------------------+
| > White                                        | DNA                 |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 21                  |
+------------------------------------------------+---------------------+
| > Male                                         | 19                  |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Public policymakers have long recognized the need for programs to
facilitate access to dental services for children from low-income
households. Coverage for pediatric dental services has been required
under Medicaid for more than two decades and is allowed, although not
required, under the new State Children's Health Insurance Program, also
known as SCHIP.[^52]

Despite the potential for improved oral health status, only about 20
percent of Medicaid children were reported to have received any
preventive dental services in 1993.Error: Reference source not found
Current research also indicates that children from low-income households
have higher caries rates and more unmet dental treatment needs than
their higher income counterparts.Error: Reference source not found

21-13. (Developmental) Increase the proportion of school-based health
centers with an oral health component.

**Potential data source:** School Health Policies and Programs Study
(SHPPS), CDC, NCCDPHP.

In some rural areas and urban neighborhoods, where health and social
problems are concentrated and few residents have health insurance or the
personal means to pay for private health care, most children do not
receive timely preventive procedures.Error: Reference source not found
The burden of untreated caries falls heaviest on children from
low-income families.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^** Moreover,
disparities in oral health status and the use of dental services persist
among certain ethnic and racial groups.Error: Reference source not found

Increasingly, schools are being viewed as an effective way to improve
access to health and social support services for vulnerable populations.
Parents give permission for health center staff members to oversee the
provision of health education and preventive and treatment services.
School-affiliated strategies mobilize existing community resources to
create referral networks for students and provide services in the school
when appropriate, based on community needs, resources, standards, and
requirements.[^53] Few school-based health centers include an oral
health component. School-based oral health services could enable the
targeting of preventive services such as fluoride mouth rinses or
tablets and dental sealants to underserved, low-income children.
Services also could include screening, referral, and case management to
ensure the timely receipt of treatment services from community
practitioners. School-based health centers should have oral health
services and educational materials that are culturally and
linguistically appropriate.

Multiple models for school-based health centers are in place. They
typically are funded from a mix of sources, both public and private.
School-based health centers have been increasing in numbers nationwide.
The number of school-based health centers nationally was estimated to be
1,157 in 1997--98; the proportion with a dental component, however, is
thought to be low.[^54]

21-14. Increase the proportion of local health departments and
community-based health centers, including community, migrant, and
homeless health centers, that have an oral health component.

**Target:** 75 percent.

**Baseline:** 34 percent of local jurisdictions and health centers had
oral health components in 1997.

**Target setting method:** 19 percent improvement.

**Data source:** HRSA, Bureau of Primary Health Care (BPHC).

Although dentists donate more services than do physicians to individuals
who cannot afford care,[^55] persons who cannot afford routine dental
care and who are not covered either by public programs or by private
dental insurance often do not receive basic dental services. Access to
care for children and adults continues to be a problem for many,
particularly for economically disadvantaged populations.Error: Reference
source not found

To eliminate disparities in the provision of health care, more
opportunities for preventive and restorative dental services must be
provided in areas where need is demonstrated. Some local health
departments promote community-based preventive services and provide
dental services to children and to some adults; most local health
departments lack a dental component.[^56] Other sources of health care
are community, migrant, or homeless health centers, which are located in
approximately 700 areas where a need has been documented. By the late
1990s, nearly 60 percent of community-based health centers had a dental
component.[^57] These centers, which strive to ensure that health
education programs and oral health staff members are culturally
competent and linguistically appropriate, extend dental care to groups
that traditionally have limited access to dental services.

The need is great among many populations in the United States. These
centers serve primarily certain racial and ethnic populations, who are
more likely than whites to live or work in medically and dentally
underserved areas. Rural and low-income urban select population
communities are more likely to have a shortage of health care providers.
More health care providers from certain racial and ethnic groups are
needed because they are more likely than white health care providers to
treat Medicaid or uninsured patients.Error: Reference source not
found**^,^** [^58]**^,^** [^59]**^,^** [^60]**^,^** [^61]

21-15. Increase the number of States and the District of Columbia that
have a system for recording and referring infants and children with
cleft lips, cleft palates, and other craniofacial anomalies to
craniofacial anomaly rehabilitative teams.

**Target:** All States and the District of Columbia.

**Baseline:** 23 States and the District of Columbia had systems for
recording and referring children with craniofacial anomalies in 1997.

**Target setting method:** Total coverage.

**Data source:** Survey of State Dental Directors, Illinois State Health
Department.

States should have an effective mechanism in place for identifying,
recording, and referring for treatment infants with cleft lips or cleft
palates or both. Cleft lip and cleft palate are reported in about 1 of
1,000 live births, and isolated cleft palate is reported in about 0.5 of
1,000 live births, making these three conditions among the most common
birth defects.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^**

Physicians and nurses in hospital nurseries are usually the first to
examine newborns and are responsible for noting any congenital anomalies
and describing them on the neonatal medical records. Therefore, hospital
personnel must understand the definitions of congenital defects and
abnormalities of the lips and palate, properly examine newborns, and
correctly record any malformations.

Proper diagnosis is important because newborns with cleft lip or cleft
palate should be referred immediately to an interdisciplinary core
craniofacial team to assess these infants and to counsel the parents
prior to discharge. Sending infants home without comprehensive
instructions for their parents or caregivers can seriously compromise
the health of the infants. Therefore, children need to be enrolled in a
system that provides for continuity of care.[^62] Surgical repair of the
lips often is performed soon after birth, repair of the palate usually
should be performed before age 18 months.[^63] Appropriate intervention
will minimize the extent to which physical and psychosocial trauma
adversely affect child development.

21-16. Increase the number of States and the District of Columbia that
have an oral and craniofacial health surveillance\
system.

**Target:** All States and the District of Columbia.

**Baseline:** No States or the District of Columbia had oral and
craniofacial health surveillance systems in 1999.

**Target setting method:** Total coverage.

**Data source:** Association of State and Territorial Dental Directors.

State and local dental programs have been hampered severely in carrying
out their programmatic activities to improve health because of a lack of
State-specific oral health data.Error: Reference source not found The
existence of surveillance systems within States to assess oral health
needs is essential for determining trends in oral diseases, implementing
and evaluating interventions, and identifying where resources are
required to improve oral health status. Surveillance systems are not
just data collection systems, but involve at least (1) a timely
communication of findings to responsible parties and to the public and
(2) the use of data to initiate and evaluate public health measures to
prevent and control diseases and conditions.[^64] An oral health
surveillance system for a State should contain, at a minimum, a core set
of measures that describe the status of important oral health conditions
to serve as benchmarks for assessing progress in achieving good oral
health.

21-17. (Developmental) Increase the number of Tribal, State\
(including the District of Columbia), and local health\
agencies that serve jurisdictions of 250,000 or more\
persons that have in place an effective public dental health program
directed by a dental professional with public health training.

**Potential data sources:** Association of State and Territorial Dental
Directors; IHS.

The ability to improve the health and quality of life for communities
and individuals relies on population-based preventive programs and the
public and private capacity to provide needed care. The capability to
provide services depends on an adequate infrastructure at the Tribal,
State, and local health department level. This infrastructure is
seriously compromised; for example, in 1999 only 29 States had full-time
State dental directors, 14 States had part-time directors, and 8 States
had no director. Dental professionals in leadership positions who have
public health training are needed in Tribal, State, and local health
departments to implement necessary oral health programs. A survey found
that two-thirds of 243 local health departments serving nearly 80
million persons in the United States in 1995 reported having a dental
program, of which 62 percent were directed by dentists and 22 percent by
dental hygienists; the other 16 percent were directed by nondental
personnel. The level of public health training of these persons was not
assessed.Error: Reference source not found

## Related Objectives From Other Focus Areas

1\. Access to Quality Health Services

1-1. Persons with health insurance

1-2. Health insurance coverage for clinical preventive services

1-3. Counseling about health behaviors

1-4. Source of ongoing care

1-7. Core competencies in health provider training

1-8. Racial and ethnic representation in health professions

1-15. Long-term care services

2\. Arthritis, Osteopororsis, and Chronic Back Conditions

2-2. Activity limitations due to arthritis

2-3. Personal care limitations

2-7. Seeing a health care provider

2-8. Arthritis education

3\. Cancer

3-1. Overall cancer deaths

3-6. Oropharyngeal cancer deaths

3-9. Sun exposure and skin cancer

3-10. Provider counseling about cancer prevention

3-14. Statewide cancer registries

3-15. Cancer survival

5\. Diabetes

5-1. Diabetes education

5-2. New cases of diabetes

5-3. Overall cases of diagnosed diabetes

5-4. Diagnosis of diabetes

5-15. Annual dental examinations

6\. Disability and Secondary Conditions

6-13. Surveillance and health promotion programs

7\. Educational and Community-Based Programs

7-1. High school completion

7-2. School health education

7-3. Health-risk behavior information for college and university
students

7-4. School nurse-to-student ratio

7-5. Worksite health promotion programs

7-6. Participation in employer-sponsored health promotion activities

7-7. Patient and family education

7-10. Community health promotion programs

7-11. Culturally appropriate and linguistically competent community
health\
promotion programs

7-12. Older adult participation in community health promotion activities

8\. Environmental Health

8-5. Safe drinking water

11\. Health Communication

11-1. Households with Internet access

11-2. Health literacy

11-3. Research and evaluation of communication programs

11-4. Quality of Internet health information sources

11-6. Satisfaction with health care providers' communication skills

12\. Heart Disease and Stroke

12-1. Coronary heart disease (CHD) deaths

14\. Immunization and Infectious Diseases

14-3. Hepatitis B in adults and high-risk groups

14-9. Hepatitis C

14-10. Identification of persons with chronic hepatitis C

14-28. Hepatitis B vaccination among high-risk groups

15\. Injury and Violence Prevention

15-1. Nonfatal head injuries

15-17. Nonfatal motor vehicle injuries

15-19. Safety belts

15-20. Child restraints

15-21. Motorcycle helmet use

15-23. Bicycle helmet use

15-24. Bicycle helmet laws

15-31. Injury protection in school sports

16\. Maternal, Infant, and Child Health

16-6. Prenatal care

16-8. Very low birth weight infants born at level III hospitals

16-10. Low birth weight and very low birth weight

16-11. Preterm births

16-16. Optimum folic acid levels

16-19. Breastfeeding

16-23. Service systems for children with special health care needs

17\. Medical Product Safety

17-3. Provider review of medications taken by patients

17-4. Receipt of useful information about prescriptions from pharmacies

17-5. Receipt of oral counseling about medications from prescribers and\
dispensers

18\. Mental Health and Mental Disorders

18-5. Eating disorder relapses

19\. Nutrition and Overweight

19-1. Healthy weight in adults

19-2. Obesity in adults

19-3. Overweight or obesity in children and adolescents

19-5. Fruit intake

19-6. Vegetable intake

19-11. Calcium intake

19-15. Meals and snacks at school

19-16. Worksite promotion of nutrition education and weight management

20\. Occupational Safety and Health

20-2. Work-related injuries

20-3. Overexertion or repetitive motion

20-10. Needlestick injuries

22\. Physical Activity and Fitness

22-4. Muscular strength and endurance

22-5. Flexibility

23\. Public Health Infrastructure

23-1. Public health employee access to the Internet

23-2. Public access to information and surveillance data

23-3. Use of geocoding in health data systems

23-4. Data for all population groups

23-6. National tracking of Healthy People 2010 objectives

23-7. Timely release of data on objectives

23-8. Competencies for public health workers

23-9. Training in essential public health services

23-10. Continuing education and training by public health agencies

23-11. Performance standards for essential public health services

23-12. Health improvement plans

23.13. Access to public health laboratory services

23-14. Access to epidemiology services

23-16. Data on public health expenditures

23-17. Population-based prevention research

25\. Sexually Transmitted Diseases

25-5. Human papillomavirus infection

26\. Substance Abuse

26-12. Average annual alcohol consumption

27\. Tobacco Use

27-1. Adult tobacco use

27-2. Adolescent tobacco use

27-3. Initiation of tobacco use

27-4. Age at first tobacco use

27-5. Smoking cessation by adults

27-7. Smoking cessation by adolescents

27-8. Insurance coverage of cessation treatment

27-11. Smoke-free and tobacco-free schools

27-12. Worksite smoking policies

27-14. Enforcement of illegal tobacco sales to minors laws

27-15. Retail license suspension for sales to minors

27-18. Tobacco control programs

27-19. Preemptive tobacco control laws

27-20. Tobacco product regulation

27-21. Tobacco tax

## Terminology

(A listing of abbreviations and acronyms used in this publication
appears in Appendix H.)

**Candidiasis (oral):** Yeast or fungal infection that occurs in the
oral cavity or pharynx or both.

**Cleft lip or palate:** A congenital opening or fissure occurring in
the lip or palate.

**Congenital anomaly:** An unusual condition existing at, and usually
before, birth.

**Craniofacial:** Pertaining to the head and face.

**Dental caries (dental decay or cavities):** An infectious disease that
results in de-\
mineralization and ultimately cavitation of the tooth surface if not
controlled or remineralized. Dental cavities may be either treated
(filled) or untreated (unfilled).

**Caries experience:** The sum of filled and unfilled cavities, along
with any missing teeth resulting from decay.

> **Early childhood caries (ECC):** Dental decay of the primary teeth of
> infants and young children (aged 1 to 5 years) often characterized by
> rapid destruction.
>
> **Root caries:** Dental decay that occurs on the root portion of a
> tooth. (In younger persons, root surfaces are usually covered by gum
> \[gingival\] tissue.)

**Dentate:** A condition characterized by having one or more natural
teeth.

**Edentulism/edentulous:** A condition characterized by not having any
natural teeth.

**Endocarditis:** Inflammation of the lining of the heart.

**Fluoride:** A compound of the element fluorine. Fluorine, the 13th
most abundant element in nature, is used in a variety of ways to reduce
dental decay.

**Gingivitis:** An inflammatory condition of the gum tissue, which can
appear reddened and swollen and frequently bleeds easily.

**Oral cavity:** Mouth.

**Oral health literacy:** Based on the definition of health
literacy,[^65] the degree to which individuals have the capacity to
obtain, process, and understand basic oral and craniofacial health
information and services needed to make appropriate health decisions.

**Periodontal disease:** A cluster of diseases caused by bacterial
infections and resulting in inflammatory responses and chronic
destruction of the soft tissues and bone that support the teeth.
Periodontal disease is a broad term encompassing several diseases of the
gums and tissues supporting the teeth.

**Pharynx:** Throat.

**Sealants:** Plastic coatings applied to the surfaces of teeth with
developmental pits and grooves (primarily chewing surfaces) to protect
the tooth surfaces from collecting food, debris, and bacteria that
promote the development of dental decay.

**Soft tissue lesion:** An abnormality of the soft tissues of the oral
cavity or pharynx.

**Squamous cell carcinoma:** A type of cancer that occurs in tissues
that line major organs.

**Xerostomia:** A condition in which the mouth is dry because of a lack
of saliva.

## References

[^1]: U.S. Department of Health and Human Services (HHS). *Oral Health
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