IV\. THE BURDEN OF ORAL DISEASES

## a. Prevalence of Disease and Unmet Needs

###  *i. Children*

Nationally, dental caries (tooth decay) is four times more common than
childhood asthma and seven times more common than hay fever. Dental
caries is a disease in which acids produced by bacteria on the teeth
lead to loss of minerals from the enamel and dentin, the hard substances
of teeth. Unchecked, dental caries can result in loss of tooth
structure, inadequate tooth function, unsightly appearance, pain,
infection, and tooth loss.

The prevalence of decay in children is measured by assessing caries
experience (if they have ever had decay and now have fillings),
untreated decay (active unfilled cavities), and urgent care (reported
pain or a significant dental infection that requires immediate care).

Caries experience and untreated decay are monitored by \<STATE\> as
consistent with the National Oral Health Surveillance System (NOHSS),
which allows comparisons with other states and with the nation. For
comparisons between \<STATE\>, the nation, and the *Healthy People 2010*
targets, see Figure I.

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

![](media/image2.wmf){width="5.739583333333333in"
height="3.5083333333333333in"}

Source: *Healthy People 2010*, 2nd edition. U.S. Dept of Health and
Human Services, November 2000.

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

\<State Data Source(s). State rates are examples only.\>

Dental caries is not uniformly distributed in the United States or in
\<STATE\>. Some groups are more likely to experience the disease and are
less likely to receive treatment. The most recent data for 3rd grade
children in \<STATE\> and the nation, for selected demographic groups,
are summarized in Table II.

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

**Table II. Dental Caries Experience, Untreated Dental Decay, and Urgent
Need for Dental Care Among 6 to 8-year-old Children in the United States
and Third Graders in \<STATE\>, by Selected Demographic
Characteristics**

+-------------+---------+---------+---------+---------+-------------+
|             | *       |         | **Un    |         | **Urgent    |
|             | *Caries |         | treated |         | Need for    |
|             | Exper   |         | Decay** |         | Care**      |
|             | ience** |         |         |         |             |
+-------------+---------+---------+---------+---------+-------------+
|             | *       | **      | *       | **      | **\<S       |
|             | *United | \<STATE | *United | \<STATE | TATE\>**^f^ |
|             | Stat    | \>**^f^ | Stat    | \>**^f^ |             |
|             | es^a^** |         | es^a^** |         | **(%)**     |
|             |         | **(%)** |         | **(%)** |             |
|             | **(%)** |         | **(%)** |         |             |
+-------------+---------+---------+---------+---------+-------------+
| **TOTAL**   | 50      |         | 26      |         |             |
+-------------+---------+---------+---------+---------+-------------+
| **Race or   |         |         |         |         |             |
| Ethnicity** |         |         |         |         |             |
+-------------+---------+---------+---------+---------+-------------+
| > American  | 91^b^   |         | 72^b^   |         |             |
| > Indian or |         |         |         |         |             |
| > Alaska    |         |         |         |         |             |
| > Native    |         |         |         |         |             |
+-------------+---------+---------+---------+---------+-------------+
| > Asian or  | DSU     |         | DSU     |         |             |
| > Pacific   |         |         |         |         |             |
| > Islander  |         |         |         |         |             |
+-------------+---------+---------+---------+---------+-------------+
| > Asian     | 90^c^   |         | 71^c^   |         |             |
+-------------+---------+---------+---------+---------+-------------+
| > Native    | 79^d^   |         | 39^d^   |         |             |
| > Hawaiian  |         |         |         |         |             |
| > or other  |         |         |         |         |             |
| > Pacific   |         |         |         |         |             |
| > Islander  |         |         |         |         |             |
+-------------+---------+---------+---------+---------+-------------+
| > Black or  |         |         | 36^e^   |         |             |
| > African   |         |         |         |         |             |
| > American  |         |         |         |         |             |
+-------------+---------+---------+---------+---------+-------------+
| > White     |         |         | 26^e^   |         |             |
+-------------+---------+---------+---------+---------+-------------+
| > Hispanic  | DSU     |         | DSU     |         |             |
| > or Latino |         |         |         |         |             |
+-------------+---------+---------+---------+---------+-------------+
| > Mexican   | 69      |         | 42      |         |             |
| > American  |         |         |         |         |             |
+-------------+---------+---------+---------+---------+-------------+
| > Not       | 49^e^   |         | 26^e^   |         |             |
| > Hispanic  |         |         |         |         |             |
| > or Latino |         |         |         |         |             |
+-------------+---------+---------+---------+---------+-------------+
| > Black or  | 56^e^   |         | 39 ^e^  |         |             |
| > African   |         |         |         |         |             |
| > American, |         |         |         |         |             |
| > not       |         |         |         |         |             |
| > Hispanic  |         |         |         |         |             |
| > or Latino |         |         |         |         |             |
+-------------+---------+---------+---------+---------+-------------+
| > White,    | 46 ^e^  |         | 21 ^e^  |         |             |
| > not       |         |         |         |         |             |
| > Hispanic  |         |         |         |         |             |
| > or Latino |         |         |         |         |             |
+-------------+---------+---------+---------+---------+-------------+
| **Sex**     |         |         |         |         |             |
+-------------+---------+---------+---------+---------+-------------+
| > Female    | 49 ^e^  |         | 24 ^e^  |         |             |
+-------------+---------+---------+---------+---------+-------------+
| > Male      | 50 ^e^  |         | 28 ^e^  |         |             |
+-------------+---------+---------+---------+---------+-------------+

+------------------------------------------------------+---+------+-------+
| **Education Level (Head of household)**              |   |      |       |
+------------------------------------------------------+---+------+-------+
| > Less than high school                              |   | 6    | 44^e^ |
|                                                      |   | 5^e^ |       |
+------------------------------------------------------+---+------+-------+
| > High school graduate                               |   | 5    | 30^e^ |
|                                                      |   | 2^e^ |       |
+------------------------------------------------------+---+------+-------+
| > At least some college                              |   | 4    | 25^e^ |
|                                                      |   | 3^e^ |       |
+------------------------------------------------------+---+------+-------+
| **Children Eligible for Free or Reduced Lunch        |   |      |       |
| Program**                                            |   |      |       |
+------------------------------------------------------+---+------+-------+
| > Yes                                                |   |      |       |
+------------------------------------------------------+---+------+-------+
| > No                                                 |   |      |       |
+------------------------------------------------------+---+------+-------+
| **Disability Status**                                |   |      |       |
+------------------------------------------------------+---+------+-------+
| > Persons with disabilities                          | D |      | DNA   |
|                                                      | N |      |       |
|                                                      | A |      |       |
+------------------------------------------------------+---+------+-------+
| > Persons without disabilities                       | D |      | DNA   |
|                                                      | N |      |       |
|                                                      | A |      |       |
+------------------------------------------------------+---+------+-------+
| **Select Populations**                               |   |      |       |
+------------------------------------------------------+---+------+-------+
| > 3rd grade students                                 |   | 6    | 33^e^ |
|                                                      |   | 0^e^ |       |
+------------------------------------------------------+---+------+-------+

Table II Sources:

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

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

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

DNA = Data not analyzed

DNC = Data not collected

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

^a^ All national data are for children aged 6--8 years old, 1999--2000,
unless otherwise noted.

^b^ Data are for Indian Health Service areas, 1999.

^c^ Data are for California, 1993--1994.

^d^ Data are for Hawaii, 1999.

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

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

*ii. Adults*

Dental Caries / Tooth Loss / Periodontal (Gum) Diseases / Oral Cancer

People are susceptible to dental caries throughout their lifetime. Like
children and adolescents, adults can experience new decay on the crown
(enamel covered) portion of the tooth. But adults can also develop
caries on the root surfaces of teeth as those surfaces become exposed to
bacteria and carbohydrates as a result of gum recession. In the most
recent national examination survey, 85 percent of U.S. adults had at
least one tooth with decay or a filling on the crown. Root surface
caries affects 50 percent of adults aged 75 years or older \[USDHHS
2000a\].

Not only do adults experience dental caries, but a substantial
proportion of that disease is untreated at any point in time. The
prevalence of untreated dental decay in \<STATE\> and the United States
for adults aged 35--44 years or 65--74 years, by selected demographic
groups, is summarized in Table III.

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

**Table III. Proportion of Adults\* with Untreated Dental Caries, by
Selected Age Groups and Demographic Characteristics**

+---------------------+----------+-----------+-----------+-----------+
|                     | **Age    |           | **Age     |           |
|                     | 35--44   |           | 65--74    |           |
|                     | Years**  |           | Years**   |           |
+---------------------+----------+-----------+-----------+-----------+
|                     | **United | **\<STA   | **United  | **\<STA   |
|                     | Sta      | TE\>**^f^ | States**  | TE\>**^f^ |
|                     | tes**^a^ |           |           |           |
|                     |          | **(%)**   | **(%)**   | **(%)**   |
|                     | **(%)**  |           |           |           |
+---------------------+----------+-----------+-----------+-----------+
| ***Healthy People   | 15       | 15        | []{.mark} | []{.mark} |
| 2010* Target**      |          |           |           |           |
+---------------------+----------+-----------+-----------+-----------+
| **TOTAL**           | 26       |           | 19        |           |
+---------------------+----------+-----------+-----------+-----------+
| **Race or           |          |           |           |           |
| Ethnicity**         |          |           |           |           |
+---------------------+----------+-----------+-----------+-----------+
| > American Indian   | 68^b^    |           |           |           |
| > or Alaska Native  |          |           |           |           |
+---------------------+----------+-----------+-----------+-----------+
| > Asian or Pacific  | DSU      |           |           |           |
| > Islander          |          |           |           |           |
+---------------------+----------+-----------+-----------+-----------+
| > Asian             | DNC      |           |           |           |
+---------------------+----------+-----------+-----------+-----------+
| > Native Hawaiian   | DNC      |           |           |           |
| > and               |          |           |           |           |
| >                   |          |           |           |           |
| > other Pacific     |          |           |           |           |
| > Islander          |          |           |           |           |
+---------------------+----------+-----------+-----------+-----------+
| > Black or African  | 46^d^    |           |           |           |
| > American          |          |           |           |           |
+---------------------+----------+-----------+-----------+-----------+
| > White             | 24^d^    |           |           |           |
+---------------------+----------+-----------+-----------+-----------+
| > Hispanic or       | DSU      |           |           |           |
| > Latino            |          |           |           |           |
+---------------------+----------+-----------+-----------+-----------+
| > Mexican American  | 34^c^    |           | 34^c^     |           |
+---------------------+----------+-----------+-----------+-----------+
| > Not Hispanic or   | DNA      |           |           |           |
| > Latino            |          |           |           |           |
+---------------------+----------+-----------+-----------+-----------+
| > Black or African  | 47^d^    |           | 27        |           |
| > American          |          |           |           |           |
+---------------------+----------+-----------+-----------+-----------+
| > White             | 23^d^    |           | 18^e^     |           |
+---------------------+----------+-----------+-----------+-----------+
| **Sex**             |          |           |           |           |
+---------------------+----------+-----------+-----------+-----------+
| > Female            | 25^d^    |           | 14^e^     |           |
+---------------------+----------+-----------+-----------+-----------+
| > Male              | 29^d^    |           | 24        |           |
+---------------------+----------+-----------+-----------+-----------+
| **Education Level** |          |           |           |           |
+---------------------+----------+-----------+-----------+-----------+
| > Less than high    | 51^d^    |           |           |           |
| > school            |          |           |           |           |
+---------------------+----------+-----------+-----------+-----------+
| > High school       | 34^d^    |           |           |           |
| > graduate          |          |           |           |           |
+---------------------+----------+-----------+-----------+-----------+
| > At least some     | 16^d^    |           |           |           |
| > college           |          |           |           |           |
+---------------------+----------+-----------+-----------+-----------+
| **Disability        |          |           |           |           |
| Status**            |          |           |           |           |
+---------------------+----------+-----------+-----------+-----------+
| > Persons with      | DNA      |           |           |           |
| > disabilities      |          |           |           |           |
+---------------------+----------+-----------+-----------+-----------+
| > Persons without   | DNA      |           |           |           |
| > disabilities      |          |           |           |           |
+---------------------+----------+-----------+-----------+-----------+

Table III Sources:

[Aged 35--54 years]{.underline}

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

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

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

[*A*ged 65--74 years]{.underline}

*Health, United States, 2004.* Table 80, p. 267.Available at
[www.cdc.gov/nchs/data/hus/hus04.pdf](http://www.cdc.gov/nchs/data/hus/hus04.pdf).

DNA = Data not analyzed

DNC = Data not collected

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

^a^ National data are for 1999--2000 unless otherwise indicated.

\* Excludes edentulous adults (persons without natural teeth).

^b^ Data are for areas served by Indian Health Service, 1999.

^c^ National data are for Mexican Americans.

^d^ Data from NHANES III, 1988--1994.

^e^ Data are statistically unreliable.

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

Dental Caries / Tooth Loss / Periodontal (Gum) Diseases / Oral Cancer

A full dentition is defined as having 28 natural teeth, exclusive of
third molars (the wisdom teeth) and teeth removed for orthodontic
treatment or as a result of trauma. Most persons can keep their teeth
for life with adequate personal, professional, and population-based
preventive practices. As teeth are lost, a person's ability to chew and
speak decreases and interference with social functioning can occur. The
most common reasons for tooth loss in adults are tooth decay and
periodontal (gum) disease. Tooth loss also 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, not all groups have benefited to the same extent. Women tend
to have more tooth loss than men of the same age group. African
Americans are more likely than whites to have tooth loss. The percentage
of African Americans who have lost one or more permanent teeth is more
than three times as great as for whites. Among all predisposing and
enabling factors, low educational level often has been found to have the
strongest and most consistent association with tooth loss.

Data for \<STATE\> and the United States on the percentage of adults who
have had no teeth extracted because of disease and the percentage who
have lost all of their permanent teeth are presented in Table IV.

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

**Table IV. Proportion of Adults Aged 35--44 Years Who have Lost No
Teeth and Proportion of Adults Aged 65--74 Years Who have Lost All
Natural Teeth, by Selected Demographic Characteristics**

+----------------------------+---------+---------+----------+---------+
|                            | **Aged  |         | **Aged   |         |
|                            | 35--44  |         | 65--74   |         |
|                            | Years** |         | Years**  |         |
|                            |         |         |          |         |
|                            | **No    |         | **Lost   |         |
|                            | Tooth   |         | All      |         |
|                            | Extrac  |         | Natural  |         |
|                            | tions** |         | Teeth**  |         |
+----------------------------+---------+---------+----------+---------+
|                            | *       | **      | **United | **      |
|                            | *United | \<STATE | Sta      | \<STATE |
|                            | Stat    | \>**^e^ | tes**^b^ | \>**^e^ |
|                            | es**^a^ |         |          |         |
|                            |         | **(%)** | **(%)**  | **(%)** |
|                            | **(%)** |         |          |         |
+----------------------------+---------+---------+----------+---------+
| ***Healthy People 2010*    | 42      | 42      | 20       | 20      |
| Target**                   |         |         |          |         |
+----------------------------+---------+---------+----------+---------+
| **TOTAL**                  | 39      |         | 25       |         |
+----------------------------+---------+---------+----------+---------+
| **Race or Ethnicity**      |         |         |          |         |
+----------------------------+---------+---------+----------+---------+
| > American Indian or       | 23^c^   |         | 25^c^    |         |
| > Alaska Native            |         |         |          |         |
+----------------------------+---------+---------+----------+---------+
| > Asian or Pacific         | DSU     |         | DNA      |         |
| > Islander                 |         |         |          |         |
+----------------------------+---------+---------+----------+---------+
| > Asian                    | DNC     |         | DSU      |         |
+----------------------------+---------+---------+----------+---------+
| > Native Hawaiian and      | DNC     |         | DSU      |         |
| > other Pacific Islander   |         |         |          |         |
+----------------------------+---------+---------+----------+---------+
| > Black or African         | 12^d^   |         | 34       |         |
| > American                 |         |         |          |         |
+----------------------------+---------+---------+----------+---------+
| > White                    | 34^d^   |         | 23       |         |
+----------------------------+---------+---------+----------+---------+
| > 2 or more races\*        |         |         | DSU      |         |
+----------------------------+---------+---------+----------+---------+
| > American Indian or       |         |         | DSU      |         |
| > Alaska Native; White\*   |         |         |          |         |
+----------------------------+---------+---------+----------+---------+
| > Black or African         |         |         | DSU      |         |
| > American; White\*        |         |         |          |         |
+----------------------------+---------+---------+----------+---------+
| > Hispanic or Latino       | DSU     |         | 20       |         |
+----------------------------+---------+---------+----------+---------+
| > Mexican American\*       | 38      |         |          |         |
+----------------------------+---------+---------+----------+---------+
| > Not Hispanic or Latino   | DNA     |         | 24       |         |
+----------------------------+---------+---------+----------+---------+
| > Black or African         | 30      |         | 34       |         |
| > American, not Hispanic   |         |         |          |         |
+----------------------------+---------+---------+----------+---------+
| > White                    | 43      |         | 23       |         |
+----------------------------+---------+---------+----------+---------+
| **Sex**                    |         |         |          |         |
+----------------------------+---------+---------+----------+---------+
| > Female                   | 36      |         | 24       |         |
+----------------------------+---------+---------+----------+---------+
| > Male                     | 42      |         | 24       |         |
+----------------------------+---------+---------+----------+---------+
| **Education Level**        |         |         |          |         |
+----------------------------+---------+---------+----------+---------+
| > Less than high school    | 15^d^   |         | 43       |         |
+----------------------------+---------+---------+----------+---------+
| > High school graduate     | 21^d^   |         | 23       |         |
+----------------------------+---------+---------+----------+---------+
| > At least some college    | 41^d^   |         | 13       |         |
+----------------------------+---------+---------+----------+---------+
| **Disability Status**      |         |         |          |         |
+----------------------------+---------+---------+----------+---------+
| > Persons with             | DNA     |         | 34       |         |
| > disabilities             |         |         |          |         |
+----------------------------+---------+---------+----------+---------+
| > Persons without          | DNA     |         | 20       |         |
| > disabilities             |         |         |          |         |
+----------------------------+---------+---------+----------+---------+

Table IV Sources:

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

Available at
[www.cdc.gov/nchs/ppt/hpdata2010/focusareas/fa21.xls](http://www.cdc.gov/nchs/ppt/hpdata2010/focusareas/fa21.xls).
Accessed July 26, 2005.

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

DNA = Data not analyzed

DNC = Data not collected

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

^a^ National data are for 1999--2000 unless otherwise indicated.

^b^ National data are for 2002 unless otherwise indicated.

^c^ Data are for Indian Health Service areas, 1999.

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

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

> Dental Caries / Tooth Loss / Periodontal (Gum) Diseases / Oral Cancer

Gingivitis is characterized by localized inflammation, swelling, and
bleeding gums without a loss of the bone that supports the teeth.
Gingivitis is usually reversible with good oral hygiene. Daily removal
of dental plaque from the teeth is extremely important to prevent
gingivitis, which can progress to destructive periodontal disease.

Periodontitis (destructive periodontal disease) is characterized by the
loss of the tissue and bone that support the teeth. It places a person
at risk of eventual tooth loss unless appropriate treatment is provided.
Among adults, periodontitis is a leading cause of bleeding, pain,
infection, loose teeth, and tooth loss \[Burt & Eklund 1999\].

The prevalence of gingivitis and destructive periodontitis in \<STATE\>
and the United States is summarized in Table V. Nationally, the
prevalence of gingivitis is highest among American Indians and Alaska
Natives, Mexican Americans, and adults with less than a high school
education. 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. The major method available to prevent destructive
periodontitis, therefore, is to prevent the precursor condition of
gingivitis and its progression to periodontitis.

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

**Table V. Proportion of Adults aged 35--44 Years with Gingivitis or
Adults Aged 35--44 Years with Destructive Periodontal Disease, by
Selected Demographic Characteristics**

+-----------------------+-----------+-----------+--------+-----------+
|                       | **Aged    |           | **Aged |           |
|                       | 35--44    |           | 35--44 |           |
|                       | years**   |           | Y      |           |
|                       |           |           | ears** |           |
|                       | **Gin     |           |        |           |
|                       | givitis** |           | *      |           |
|                       |           |           | *Destr |           |
|                       |           |           | uctive |           |
|                       |           |           | Perio  |           |
|                       |           |           | dontal |           |
|                       |           |           | Disea  |           |
|                       |           |           | se\*** |           |
+-----------------------+-----------+-----------+--------+-----------+
|                       | **United  | **\<STA   | **     | **\<STA   |
|                       | St        | TE\>^e^** | United | TE\>^e^** |
|                       | ates^a^** |           | State  |           |
|                       |           | **(%)**   | s^b^** | **(%)**   |
|                       | **(%)**   |           |        |           |
|                       |           |           | *      |           |
|                       |           |           | *(%)** |           |
+-----------------------+-----------+-----------+--------+-----------+
| ***Healthy People     | 41        | 41        | 14     | []{.mark} |
| 2010* Target**        |           |           |        |           |
+-----------------------+-----------+-----------+--------+-----------+
| **TOTAL**             | 48        |           | 20     |           |
+-----------------------+-----------+-----------+--------+-----------+
| **Race or Ethnicity** |           |           |        |           |
+-----------------------+-----------+-----------+--------+-----------+
| American Indian or    | 96^c^     |           | 59^c^  |           |
| Alaska Native         |           |           |        |           |
+-----------------------+-----------+-----------+--------+-----------+
| Asian or Pacific      | DSU       |           | DSU    |           |
| Islander              |           |           |        |           |
+-----------------------+-----------+-----------+--------+-----------+
| > Asian               | DNC       |           | DNC    |           |
+-----------------------+-----------+-----------+--------+-----------+
| > Native Hawaiian and | DNC       |           | DNC    |           |
| > other Pacific       |           |           |        |           |
| > Islander            |           |           |        |           |
+-----------------------+-----------+-----------+--------+-----------+
| Black or African      | 51        |           | 33^d^  |           |
| American              |           |           |        |           |
+-----------------------+-----------+-----------+--------+-----------+
| White                 | 47        |           | 20^d^  |           |
+-----------------------+-----------+-----------+--------+-----------+
| Hispanic or Latino    | DSU       |           | DSU    |           |
+-----------------------+-----------+-----------+--------+-----------+
| Mexican American      | 61        |           | 16     |           |
+-----------------------+-----------+-----------+--------+-----------+
| Not Hispanic or       | DNA       |           | DNA    |           |
| Latino                |           |           |        |           |
+-----------------------+-----------+-----------+--------+-----------+
| > Black or African    | 51        |           | 24     |           |
| > American            |           |           |        |           |
+-----------------------+-----------+-----------+--------+-----------+
| > White               | 45        |           | 17     |           |
+-----------------------+-----------+-----------+--------+-----------+
| **Sex**               |           |           |        |           |
+-----------------------+-----------+-----------+--------+-----------+
| Female                | 45        |           | 14     |           |
+-----------------------+-----------+-----------+--------+-----------+
| Male                  | 52        |           | 26     |           |
+-----------------------+-----------+-----------+--------+-----------+
| **Education Level**   |           |           |        |           |
+-----------------------+-----------+-----------+--------+-----------+
| Less than high school | 60        |           | 35^d^  |           |
+-----------------------+-----------+-----------+--------+-----------+
| High school graduate  | 52        |           | 28^d^  |           |
+-----------------------+-----------+-----------+--------+-----------+
| At least some college | 42        |           | 15^d^  |           |
+-----------------------+-----------+-----------+--------+-----------+
| **Disability Status** |           |           |        |           |
+-----------------------+-----------+-----------+--------+-----------+
| Persons with          | DNA       |           | DNA    |           |
| disabilities          |           |           |        |           |
+-----------------------+-----------+-----------+--------+-----------+
| Persons without       | DNA       |           | DNA    |           |
| disabilities          |           |           |        |           |
+-----------------------+-----------+-----------+--------+-----------+

Table V Sources:

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

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

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

DNA = Data not analyzed

DNC = Data not collected

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

\* Defined as 1 or more teeth with 4 mm or more loss of periodontal
attachment.

^a^ National data are from NHANES III, 1988--1994 unless otherwise
indicated.

^b^ National data are from 1999--2000 unless otherwise indicated.

^c^ Data are for Indian Health Service areas, 1999.

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

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

Dental Caries / Tooth Loss / Periodontal (Gum) Diseases / Oral Cancer

Cancer of the oral cavity or pharynx (oral cancer) is the fourth most
common cancer in African American men and the seventh most common cancer
in white men in the United States \[Ries et al. 2004\]. An estimated
28,000 new cases of oral cancer and 7,200 deaths from these cancers
occurred in the United States in 2004. The 2001 age-adjusted (to the
2000 U.S. population) incidence rate of oral cancer in the United States
was 10.4 per 100,000 persons. Nearly 90 percent of cases of oral cancer
in the United States occur among persons aged 45 years and older. The
age-adjusted incidence was more than twice as high among men (15.0) than
among women (6.6), as was the mortality rate (4.1 vs. 1.6).

Survival rates for oral cancer have not improved substantially over the
past 25 years. More than 40 percent of persons diagnosed with oral
cancer die within five years of diagnosis \[Ries et al. 2004\], although
survival varies widely by stage of disease when diagnosed. The 5-year
relative survival rate for persons with oral cancer diagnosed at a
localized stage is 81 percent. In contrast, the 5-year survival rate is
only 51 percent once the cancer has spread to regional lymph nodes at
the time of diagnosis and is just 29 percent for persons with distant
metastasis.

Some groups experience a disproportionate burden of oral cancer. In
\<STATE\> and nationally, African Americans are more likely than whites
to develop oral cancer and much more likely to die from it. Cigarette
smoking and alcohol are the major known risk factors for oral cancer in
the United States, accounting for more than 75 percent of these cancers
\[Blot et al. 1988\]. The use of tobacco, including smokeless tobacco
\[USDHHS 1986; IARC 2005\] and cigars \[Shanks & Burns 1998\] also
increases the risk of oral cancer. Dietary factors, particularly low
consumption of fruit, and some types of viral infections also have been
implicated as risk factors for oral cancer \[McLaughlin et al. 1998; De
Stefani et al. 1999; Levi 1999; Morse et al. 2000; Phelan 2003; Herrero
2003\]. Radiation from sun exposure is a risk factor for lip cancer
\[Silverman et al. 1998\].

The incidence rates of cancers of the oral cavity and pharynx for
\<STATE\> and the United States is shown in Figure II. The oral cancer
death rate by sex and race/Hispanic Origin for \<STATE\> and the United
States is shown in Figure III.

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

![](media/image3.wmf){width="4.6875in" height="2.7604166666666665in"}

![](media/image4.wmf){width="5.247916666666667in"
height="3.4069444444444446in"}

Based on available evidence that oral cancer diagnosed at an early stage
has a better prognosis, several *Healthy People 2010* objectives
specifically address early detection of oral cancer: Objective 21-6 is
to "Increase the proportion of oral and pharyngeal cancers detected at
the earliest stage," and Objective 21-7 is to "Increase the proportion
of adults who, in the past 12 months, report having had an examination
to detect oral and pharyngeal cancer" \[USDHHS 2000b\]. Data for
\<STATE\> and the United States on the proportion of oral cancer cases
detected at the earliest stage (stage I, localized) are presented in
Table VI.

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

**Table VI. Proportion of Oral Cancer Cases Detected at the Earliest
Stage, by Selected Demographic Characteristics**

+-----------------------------------------+--------------+-------------+
|                                         | **United     | **          |
|                                         | States\***   | \<STATE\>** |
|                                         |              |             |
|                                         | **(%)**      | **(%)**^c^  |
+-----------------------------------------+--------------+-------------+
| ***Healthy People 2010* Target**        | 50^a^        | 50          |
+-----------------------------------------+--------------+-------------+
| **TOTAL**                               | 35           |             |
+-----------------------------------------+--------------+-------------+
| **Race or Ethnicity**                   |              |             |
+-----------------------------------------+--------------+-------------+
| > American Indian or Alaska Native      | 24           |             |
+-----------------------------------------+--------------+-------------+
| > Asian or Pacific Islander             | 29           |             |
+-----------------------------------------+--------------+-------------+
| > Asian                                 | DNA          |             |
+-----------------------------------------+--------------+-------------+
| > Native Hawaiian or Other Pacific      | DNA          |             |
| > Islander                              |              |             |
+-----------------------------------------+--------------+-------------+
| > Black or African American             | 21           |             |
+-----------------------------------------+--------------+-------------+
| > White                                 | 38           |             |
+-----------------------------------------+--------------+-------------+
| > Hispanic or Latino                    | 36           |             |
+-----------------------------------------+--------------+-------------+
| > Not Hispanic or Latino                | 34^b^        |             |
+-----------------------------------------+--------------+-------------+
| > Black or African American             | DNA          |             |
+-----------------------------------------+--------------+-------------+
| > White                                 | DNA          |             |
+-----------------------------------------+--------------+-------------+
| **Sex**                                 |              |             |
+-----------------------------------------+--------------+-------------+
| > Female                                | 40           |             |
+-----------------------------------------+--------------+-------------+
| > Male                                  | 33           |             |
+-----------------------------------------+--------------+-------------+
| **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          |             |
+-----------------------------------------+--------------+-------------+

Table VI Sources:

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

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

DNA = Data not analyzed

\*National data are for 1996--2000.

^a^*Healthy People 2010*, 2nd ed. U.S. Department of Health and Human
Services, November 2000.

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

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

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

## b. Disparities

###  *i. Racial and Ethnic Groups*

Although gains in oral health status have been achieved for the
population as a whole, they have not been evenly distributed across
subpopulations. Non-Hispanic blacks, Hispanics, and American Indians and
Alaska Natives generally have the poorest oral health of any of the
racial and ethnic groups in the U.S. population. As reported above,
these groups tend to be more likely than non-Hispanic whites to
experience dental caries in some age groups, are less likely to have
received treatment for it, and have more extensive tooth loss. African
American adults in each age group are more likely than other
racial/ethnic groups to have gum disease. Compared with white Americans,
African Americans are more likely to develop oral or pharyngeal cancer,
are less likely to have it diagnosed at early stages, and experience a
worse 5-year survival rate.

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

### 

###  *ii. Women's Health*

Most oral diseases and conditions are complex and are the product of
interactions between genetic, socioeconomic, behavioral, environmental,
and general health influences. Multiple factors may act synergistically
to place some women at higher risk of oral diseases. For example, the
comparative longevity of women, compromised physical status over time,
and the combined effects of multiple chronic conditions and side effects
from multiple medications used to treat them can result in increased
risk of oral disease \[Redford 1993\].

Many women live in poverty, are not insured, and are the sole head of
their household. For these women, obtaining needed oral health care may
be difficult. In addition, gender-role expectations of women may affect
their interaction with dental care providers and could affect treatment
recommendations as well.

Many, but not all, statistical indicators show women to have better oral
health status than do men \[Redford 1993; USDHHS 2000a\]. Women are less
likely than men at each age group to have severe periodontal disease.
Both African American and white women have a substantially lower
incidence rate of oral and pharyngeal cancers than do African American
and white men, respectively. However, a higher proportion of women than
men have oral-facial pain, including pain from oral sores, jaw joints,
face/cheek, and burning mouth syndrome.

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

*iii. People with Disabilities*

The oral health problems of individuals with disabilities are complex.
These

problems may be due to underlying congenital anomalies as well as to an

inability to receive the personal and professional health care needed to
maintain

oral health. More than 54 million persons are defined as disabled under
the

Americans with Disabilities Act, including almost 1 million children
under 6 years

of age and 4.5 million children between 6 and 16 years of age.

No national studies have been conducted to determine the prevalence of
oral and craniofacial diseases among the various populations with
disabilities. Several smaller-scale studies show that the population
with intellectual disability or other develop-mental disabilities has
significantly higher rates of poor oral hygiene and needs for
periodontal disease treatment than the general population, due, in part,
to limitations in individual understanding of and physical ability to
perform personal prevention practices or to obtain needed services.
Caries rates among people with disabilities vary widely among people
with disabilities but overall their caries rates are higher than those
of people without disabilities \[USDHHS 2000a\].

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

### 

###  *iv. Socioeconomic Disparities*

People living in low-income families bear a disproportionate burden from
oral diseases and conditions. For example, despite progress in reducing
dental caries in the United States, children and adolescents in families
living below the poverty level experience more dental decay than do
children who are economically better off. Furthermore, the caries seen
in individuals of all ages from poor families is more likely to be
untreated than caries in those living above the poverty level.
Nationally, 50 percent of poor children aged 2 to 11 years have one or
more untreated decayed primary teeth, compared with 31 percent of
nonpoor children \[USDHHS 2000a\]. Poor adolescents aged 12 to 17 years
in each racial/ethnic group have a higher percentage of untreated decay
in the permanent teeth than does the corresponding nonpoor adolescent
group. The pattern is similar in adults, with the proportion of
untreated decayed teeth being higher among the poor than the nonpoor. At
every age, a higher proportion of those at the lowest income level than
at the higher income levels have periodontitis. Adults with some college
(15%) have 2 to 2.5 times less destructive periodontal disease than do
adults with high school (28%) or with less than high school (35%) levels
of education \[USDHHS 2000b\]. Overall, a higher percentage of Americans
living below the poverty level are edentulous (have lost all their
natural teeth) than are those living above \[USDHHS 2000a\]. Among
persons aged 65 years and older, 39 percent of persons with less than a
high school education were edentulous in 1997, compared with 13 percent
of persons with at least some college \[USDHHS 2000b\]. People living in
rural areas also have a higher disease burden because of difficulties in
accessing preventive and treatment services.

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

## 

## 

## c. Societal Impact of Oral Disease

###  *i. Social Impact*

Oral health is related to well-being and quality of life as measured
along functional, psychosocial, and economic dimensions. Diet,
nutrition, sleep, psychological status, social interaction, school, and
work are affected by impaired oral and craniofacial health. Oral and
craniofacial diseases and conditions contribute to compromised ability
to bite, chew, and swallow foods; limitations in food selection; and
poor nutrition. These conditions include tooth loss, diminished salivary
functions, oral-facial pain conditions such as temporomandibular
disorders, alterations in taste, and functional limitations of
prosthetic replacements. Oral-facial pain, as a symptom of untreated
dental and oral problems and as a condition in and of itself, is a major
source of diminished quality of life. It is associated with sleep
deprivation, depression, and multiple adverse psychosocial outcomes.

More than any other body part, the face bears the stamp of individual
identity. Attractiveness has an important effect on psychological
development and social relationships. Considering the importance of the
mouth and teeth in verbal and nonverbal communication, diseases that
disrupt their functions are likely to damage self-image and alter the
ability to sustain and build social relationships. The social functions
of individuals encompass a variety of roles, from intimate interpersonal
contacts to participation in social or community activities, including
employment. Dental diseases and disorders can interfere with these
social roles at any or all levels. Perhaps due to social embarrassment
or functional problems, people with oral conditions may avoid
conversation or laughing, smiling, or other nonverbal expressions that
show their mouth and teeth.

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

###  *ii. Economic Impact*

Direct Costs of Oral Diseases / Indirect Costs of Oral Diseases

Expenditures for dental services in the United States in 2003 were
\$74.3 billion, 4.4 percent of the total spent on health care that year
\[Centers for Medicare & Medicaid Services 2004\].

A large proportion of dental care is paid out-of-pocket by patients.
Nationally in 2003, 44 percent of dental care was paid out-of-pocket, 49
percent was paid by private dental insurance, and 7 percent was paid by
federal or state government sources. In comparison, 10 percent of
physician and clinical services were paid out-of pocket,

50 percent were covered by private medical insurance, and 33 percent
were paid by government sources (Centers for Medicare & Medicaid
Services, 2005. See
<http://www.cms.hhs.gov/statistics/nhe/definitions-sources-methods/>).

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

\[Note: If your state has collected DFS and retention data regarding
sealants, you may be able to use software (SEALS) to analyze
cost-effectiveness. This is being developed by CDC. For more
information, please contact the CDC Division of Oral Health at
oralhealth@cdc.gov.\]

Direct Costs of Oral Diseases / Indirect Costs of Oral Diseases

Oral and craniofacial diseases and their treatment place a burden on
society in the form of lost days and years of productive work. In 1996,
the most recent year for which national data are available, U.S.
schoolchildren missed 1.6 million days of school as a result of acute
dental conditions, which is more than 3 days for every 100 students.
Acute dental conditions also were responsible for more than 2.4 million
days of work loss and contributed to a range of problems for employed
adults, including restricted activity and bed days \[DHHS 1999\]. In
addition, conditions such as oral and pharyngeal cancers contribute to
premature death and can be measured by years of life lost.

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

### 

### 

### *iii. Oral Disease and Other Health Conditions*

Oral health and general health are integral to each other. Many systemic
diseases and conditions including diabetes, HIV, and nutritional
deficiencies, have oral signs and symptoms, and these manifestations may
be the initial sign of clinical disease and therefore may serve to
inform health care providers and individuals of the need for further
assessment. The oral cavity is a portal of entry as well as the site of
disease for bacterial and viral infections that affect general health
status. Recent research suggests that inflammation associated with
periodontitis may increase the risk of heart disease and stroke,
premature births in some women, difficulty in controlling blood sugar in
persons with diabetes, and respiratory infection in susceptible
individuals \[Dasanayake 1998; Offenbacher et al. 2001; Davenport et al.
1998; Beck et al. 1998; Scannapieco et al. 2003; Taylor 2001\]. More
research is needed in these areas.

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