# Presentation: 712253

## Focus Area 21: Oral HealthProgress Review

- Focus Area 21: Oral HealthProgress Review

- March 17, 2004

**Notes:**
-Welcome to our progress review.  

## Estimated new cases of oral/pharyngeal cancers in U.S. will affect 28,000 + persons in 2004

Profound disparities exist in disease levels and receipt of care 

100+ million Americans lack dental insurance

- Profound disparities exist in disease levels and receipt of care
**100+ million**** **Americans lack dental insurance

- The Burden of Oral Disease

**Notes:**
1.  Incidence CA: The 5-year survival rate in whites is 56% and only 34% in blacks.
2. Disparities: Over half of children age 5-9 have at least one cavity or filling, dental caries in children is 5 times more common than asthma.
3. insurance: Children living in poverty have more severe and untreated decay and Americans w/out dental insurance are more likely to have unmet dental needs compared to those with insurance

## Reduction in decay among U.S. teens in the 1990s (NHANES 1988-94 to 1999-2000) saved more than 30 million teeth from decay and almost $3 billion in treatment costs 

- Progress:

## Oral Health Objectives

- Cannot assess (limited data)

- Getting worse

- 21-16 Oral and craniofacial State-based
-            surveillance system

- 21-7 Annual exams for oral and
-          pharyngeal cancers

*  **Children 2-4 years*
*  **Children 6-8 years*
*  **Adolescents 15 years*

- 21-1 Dental caries experience

*  **Children 2-4 years*
*  **Children 6-8 years*
*  **Adolescents 15 years*
*  **Adults 35-44 years*

- 21-2 Untreated dental decay

- 21-3 No permanent tooth loss

- 21-4 Complete loss

- 21-5 Periodontal diseases

- 21-6 Early detection of oral and
-          pharyngeal cancers

- 21-8   Dental sealants

- 21-9   Community water fluoridation

- 21-12 Dental services of for low-income
-            children

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

- 21-14 Health centers with oral
-            health service components

*   **Children 8 years*
*   **Adolescents 14 years*

- 21-10 Use of oral health care system

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

- 21-15 Referral for cleft lip or palate

- 21-17 Tribal, State & local programs

**Notes:**
-The focus area of Oral Health has 17 objectives

## Oral Health Objectives

-            surveillance system

- 21-7 Annual exams for oral and
-          pharyngeal cancers

- Improving

- Cannot assess (limited data)

- Getting worse

*  **Children 2-4 years*
*  **Children 6-8 years*
*  **Adolescents 15 years*

- 21-1 Dental caries experience

*  **Children 2-4 years*
*  **Children 6-8 years*
*  **Adolescents 15 years*
*  **Adults 35-44 years*

- 21-2 Untreated dental decay

- 21-3 No permanent tooth loss

- 21-4 Complete loss

- 21-5 Periodontal diseases

- 21-6 Early detection of oral and
-          pharyngeal cancers

- 21-8   Dental sealants

- 21-9   Community water fluoridation

- 21-12 Dental services of for low-income
-            children

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

- 21-14 Health centers with oral
-            health service components

*   **Children 8 years*
*   **Adolescents 14 years*

- 21-10 Use of oral health care system

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

- 21-15 Referral for cleft lip or palate

- 21-17 Tribal, State & local programs

**Notes:**
-Trends indicate improvement for some objectives; for example the proportion of children aged 6-15 with dental caries experience and with untreated decay. 
-Also, a greater proportion of adults aged 35-44 years are keeping all of their teeth and have lower levels of destructive periodontal disease.
-A greater proportion of children are getting dental sealants
-A greater percentage of Americans are served by fluoridated water systems  
-More low income children are getting preventive dental services, and
-More community based health centers have an oral health component

## Oral Health Objectives

*  **Children 6-8 years*
*  **Adolescents 15 years*

- 21-1 Dental caries experience

- Improving

- Cannot assess (limited data)

*  **Children 2-4 years*
*  **Children 6-8 years*
*  **Adolescents 15 years*
*  **Adults 35-44 years*

- 21-2 Untreated dental decay

- 21-3 No permanent tooth loss

- 21-4 Complete loss

- 21-5 Periodontal diseases

- 21-6 Early detection of oral and
-          pharyngeal cancers

- 21-7 Annual exams for oral and
-          pharyngeal cancers

- 21-8   Dental sealants

- 21-9   Community water fluoridation

- 21-12 Dental services of for low-income
-            children

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

- 21-14 Health centers with oral
-            health service components

*   **Children 8 years*
*   **Adolescents 14 years*

- 21-10 Use of oral health care system

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

- 21-15 Referral for cleft lip or palate

- 21-16 Oral and craniofacial State-based
-            surveillance system

- Getting worse

- 21-17 Tribal, State & local programs

**Notes:**
-Where are things getting worse?  The proportion of children aged 2-4 who have experienced dental caries and the percentage who have untreated decay has increased slightly.
-Also the use of the oral health care system has decreased slightly

## Oral Health Objectives

-          pharyngeal cancers

- Improving

- Getting worse

- Cannot assess (limited data)

*  **Children 2-4 years*
*  **Children 6-8 years*
*  **Adolescents 15 years*

- 21-1 Dental caries experience

*  **Children 2-4 years*
*  **Children 6-8 years*
*  **Adolescents 15 years*
*  **Adults 35-44 years*

- 21-2 Untreated dental decay

- 21-3 No permanent tooth loss

- 21-4 Complete loss

- 21-5 Periodontal diseases

- 21-8   Dental sealants

- 21-9   Community water fluoridation

- 21-12 Dental services of for low-income
-            children

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

- 21-14 Health centers with oral
-            health service components

*   **Children 8 years*
*   **Adolescents 14 years*

- 21-10 Use of oral health care system

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

- 21-15 Referral for cleft lip or palate

- 21-16 Oral and craniofacial State-based
-            surveillance system

- 21-17 Tribal, State & local programs

- 21-6 Early detection of oral and
-          pharyngeal cancers

**Notes:**
-In summary, for most of the objectives for which we have data, trends are moving in the right direction.   Other objectives will be assessed at the Mid Course Review.

## Highlighted Objectives

**21-3      No permanent tooth loss in adults**
**21-6      Early detection of oral and pharyngeal cancers**
**21-8      Sealants**
**21-10    Use of oral health care system**
**21-12    Dental services of for low-income children**
**21-14    Health centers with oral health services**

**Notes:**
-We selected 7 objectives to highlight at this review. Our presentation will focus on reducing disparities. We have chosen objectives for children, for adults, and objectives involving the health care system and its utilization

## Highlighted Objectives

**21-3      No permanent tooth loss in adults**
**21-6      Early detection of oral and pharyngeal cancers**
**21-8      Sealants**
**21-10    Use of oral health care system**
**21-12    Dental services of for low-income children**
**21-14    Health centers with oral health services**
**5-15      Dental visits among persons with diabetes**

**Notes:**
-We are highlighting one related objective- Diabetes and dental visits. This is related to STEPs for a healthier USA.
-I would like to mention that when we talk about dental caries, sealants, tooth loss, we need to be cautious with our interpretations. The Baseline data base (NHANES3) for these objectives had 6 years of data. The recent data base we are using to measure our progress since baseline is smaller, it has less than two years of data. Therefore, estimates are imprecise and unstable. We can speak more confidently at Mid Course Review when we have added two more years of data.   

## Adolescents 12-18 Years Who Ever Had Caries in Permanent Teeth, 1988-94

**Obj. 21-1c**

**Total**

- Black

- Mexican
- American

- White

- Male

- Female

- Percent

- 2010 Target

- 1988-94

- Note:  Target is for adolescents 15 years old.  Black and white exclude persons of Hispanic origin. Persons of Mexican-American origin may be any race.
- Source: National Health and Nutrition Examination Survey, NCHS, CDC.

## Adolescents 12-18 Years Who Ever Had Caries in Permanent Teeth, 1988-94 and 1999-2000

**Obj. 21-1c**

- Note:  Target is for adolescents 15 years old.  Black and white exclude persons of Hispanic origin. Persons of Mexican-American origin may be any race.
- Source: National Health and Nutrition Examination Survey, NCHS, CDC.

**Total**

- Black

- Mexican
- American

- White

- Male

- Female

- Percent

- 2010 Target

- 1988-94

- 1999-2000

## Children 2-4 Years Who Have Ever Had Caries in Primary Teeth, 1988-94

**Obj. 21-1a**

- Note: Black and white exclude persons of Hispanic origin. Persons of Mexican-American origin may be any race.
- Source: National Health and Nutrition Examination Survey, NCHS, CDC.

**Total**

- Black

- Mexican
- American

- White

- Male

- Female

- Percent

- 2010 Target

- 1988-94

## Children 2-4 Years Who Have Ever Had Caries in Primary Teeth, 1988-94 and 1999-2000

**Obj. 21-1a**

- Note: Black and white exclude persons of Hispanic origin. Persons of Mexican-American origin may be any race.
- Source: National Health and Nutrition Examination Survey, NCHS, CDC.

**Total**

- Black

- Mexican
- American

- White

- Male

- Female

- 2010 Target

- 1988-94

- 1999-2000

- Percent

## Early Childhood Caries (ECC) in American Indian/Alaska Native Children 0-4 Years  

- Note: from Niendorff & Jones, JPHD 2000: 60: 245. Data are for IHS service areas.
- Source: 1991 Patient Survey, IHS.

*Early Childhood Caries* (ECC) in American Indian/Alaska Native Children 0-4 Years

**1991**

**Notes:**
Early Childhood Caries is a very serious, rapidly destructive presentation of dental decay that involves multiple teeth, including anterior teeth.  Left untreated, this decay can destroy the entire dentition.  Treatment often involves general anesthesia in the operating room, incurring both risk to patient and high economic cost.
Although the US Preventive Services Task Force on preventive clinical services has found the evidence to support a periodic health exam for the early detection of oral cancer to be inconclusive, the Task Force on Community Preventive Services has recently recommended that (1) more widespread use of effective strategies to reduce tobacco use and excessive alcohol consumption and (2) periodic oral exams of people at high risk should be undertaken. Moreover, this same Task Force has also recommended implementing other considerations discussed in the 1998 MMWR: Preventing and Controlling Oral and Pharyngeal Cancer.

Reference source: The Guide to Community Preventive Services, Interventions to Prevent Dental caries, Oral and Pharyngeal Cancers, and Sports-Related Craniofacial Injuries, systematic reviews of evidence, recommendations from the Task Force on Community Preventive Services, and expert commentary. In Supplement to American Journal of Preventive Medicine July 2002.

## Early Childhood Caries (ECC) in American Indian/Alaska Native Children 0-4 Years  

*Early Childhood Caries* (ECC) in American Indian/Alaska Native Children 0-4 Years

- Note: from Niendorff & Jones, JPHD 2000: 60: 245. and Kaste et al., JPHD 1999; 59: 199.
- Source: 1991 Patient Survey, IHS; National Health and Nutrition Examination Survey, NCHS, CDC.

**1991**

- Less than 2% of all U.S. children 1-2 years in 1988-94 had ECC

**Notes:**
Native American children have significantly more "baby bottle tooth decay" or "early childhood dental caries" than the general U.S. population of children.  The prevalence of this disease in the general U.S. population is about 2%, compared to 24% among children examined by IHS dentists.  The epidemic of early childhood decay in Native American children is the one greatest oral health disparity among Native Americans.

## Dental Sealants

**Notes:**
A dental sealant (also called a pit and fissure sealant) is a plastic, professionally-applied material that is put on the chewing surfaces of back teeth to prevent cavities. Sealants provide a physical barrier so that cavity-causing bacteria cannot invade the pits and fissures on the chewing surfaces of teeth.
Dental sealants effectively protect the pits and fissures on the biting surfaces of teeth, the surfaces most prone to dental decay.
Sealants do not protect the smooth surfaces of teeth.

## Dental Sealants: 1988-94

- Note: Targets are for children 8 years and 14 years.  Black and white exclude persons of Hispanic origin. Persons of Mexican-American origin may be any race.
- Source: National Health and Nutrition Examination Survey, NCHS, CDC.

- Total

- Percent

- 2010
- Targets

**6-11 Years**

**12-18 Years**

- Black

- Mexican
- American

- White

- Total

- Black

- Mexican
- American

- White

**Obj. 21-8**

- 1988-94

- 1988-94

**Notes:**
-For dental sealants at baseline (1988-94) both younger and older children were well under the target of 50% prevalence and there were disparities by race/ethnic group.
- Fewer Black and Mexican American children had sealants than white children.

## Dental Sealants: 1988-94 and 1999-2000

- Total

- 2010
- Targets

**6-11 Years**

**12-18 Years**

- Black

- Mexican
- American

- White

- Total

- Black

- Mexican
- American

- White

**Obj. 21-8**

- 1999-2000

- 1999-2000

- 1988-94

- 1988-94

- Note: Targets are for children 8 years and 14 years.  Black and white exclude persons of Hispanic origin. Persons of Mexican-American origin may be any race.
- Source: National Health and Nutrition Examination Survey, NCHS, CDC.

- Percent

**Notes:**
There is some good news. By 1999-2000, there has been an increase in sealants for all groups.
-The biggest increase has been for blacks and Mexican American and also for children in the older age group
-This is one objective in which there is some reduction in disparities, although they still remain. 
- It was mentioned earlier in this presentation that caries in permanent teeth is moving in the right direction. 
-One reason is that the increase in sealants has contributed to a decrease in caries in permanent teeth. 

## No Permanent Tooth Loss in Adults

**Obj. 21-3**

**Total**

- Black

- Mexican
- American

- White

- Male

- Female

- 1988-94

- 2010 Target

- Note:  Black and white exclude persons of Hispanic origin. Persons of Mexican-American origin may be any race.
- Source: National Health and Nutrition Examination Survey, NCHS, CDC.

- Percent

*No* Permanent Tooth Loss in Adults
- 35-44 Years: 1988-94

**Notes:**
-At baseline, about 30% of adults had no permanent tooth loss due to disease, yet fewer blacks (12%) reported no tooth loss. 
-This was a large disparity. 

## No Permanent Tooth Loss in Adults

**Obj. 21-3**

- Note:  Black and white exclude persons of Hispanic origin. Persons of Mexican-American origin may be any race.
- Source: National Health and Nutrition Examination Survey, NCHS, CDC.

*No* Permanent Tooth Loss in Adults
- 35-44 Years: 1988-94 and 1999-2000

- 2010 Target

**Total**

- Black

- Mexican
- American

- White

- Male

- Female

- 1988-94

- 1999-2000

- Percent

**Notes:**
-All groups have moved toward the target of keeping more of their teeth, Blacks have made a bigger jump so this disparity has been reduced somewhat.    
-Males have reached the 2010 target of 42% keeping all permanent teeth. 
-This may be due to the fact that males use dental services less frequently than females and therefore did not visit a dentist to have a tooth extracted. 
-Data are not shown here, but even though more adults in this age group are keeping their teeth, one–third of them have untreated decay in the teeth they are keeping.

## Early Detection of Oral and Pharyngeal Cancers: 1990-95

- 1990-95

- 2010 Target

- Note: Data are for Stage 1 (localized) tumors, excluding Kaposi Sarcoma tumors.   Black and white exclude persons of Hispanic origin. Persons of Hispanic origin may be any race.
- Source: Surveillance, Epidemiology, and End Results Program, NIH, NCI.

- Percent

**Total**

- Black

- Hispanic

- White

- Male

- Female

## Early Detection of Oral and Pharyngeal Cancers: 1990-95 and 1996-2000

**Obj. 21-6**

- 1990-95

- 1996-2000

- 2010 Target

- Note: Data are for Stage 1 (localized) tumors, excluding Kaposi Sarcoma tumors.   Black and white exclude persons of Hispanic origin. Persons of Hispanic origin may be any race.
- Source: Surveillance, Epidemiology, and End Results Program, NIH, NCI.

- Percent

**Total**

- Black

- Hispanic

- White

- Male

- Female

**Notes:**
Although the US Preventive Services Task Force on preventive clinical services has found the evidence to support a periodic health exam for the early detection of oral cancer to be inconclusive, the Task Force on Community Preventive Services has recently recommended that (1) more widespread use of effective strategies to reduce tobacco use and excessive alcohol consumption and (2) periodic oral exams of people at high risk should be undertaken. Moreover, this same Task Force has also recommended implementing other considerations discussed in the 1998 MMWR: Preventing and Controlling Oral and Pharyngeal Cancer.

Reference source: The Guide to Community Preventive Services, Interventions to Prevent Dental caries, Oral and Pharyngeal Cancers, and Sports-Related Craniofacial Injuries, systematic reviews of evidence, recommendations from the Task Force on Community Preventive Services, and expert commentary. In Supplement to American Journal of Preventive Medicine July 2002.

## Receipt of Preventive Services by Low Income Children

**1996**

**Obj. 21-12**

- Note:  Data are for children under 19 years.  Low income is less than 200% of poverty level.  Preventive services include examinations, cleaning, x-rays, fluoride treatments and sealant applications.
- Source: Medical Expenditure Panel Survey, AHRQ.

**Notes:**
-20% of low income children received a preventive dental service in 1996. Preventive services are defined
as a check-up. X-ray, fluoride treatment, cleaning or sealant application. 

## Receipt of Preventive Services by Low Income Children

- 2010 Target = 57%

**1996**

**2000**

**Obj. 21-12**

- Note:  Data are for children under 19 years.  Low income is less than 200% of poverty level.  Preventive services include examinations, cleaning, x-rays, fluoride treatments and sealant applications.
- Source: Medical Expenditure Panel Survey, AHRQ.

**Notes:**
-This has increased to 31% in 4 years, making some progress towards the target that 57% of low income children should preventive services.
-This increase from  is likely due to positive changes from 1996 to 2000 in the dental Medicaid program for children. 
Still, 2/3 of low income children are not receiving these services.

## Annual Dental Visits: 1996

**Obj. 21-10**

- Note:  Data are for ages 2 years and over, age adjusted to the 2000 standard population.  Black and white exclude persons of Hispanic origin. Persons of Hispanic origin may be any race.
- Source: Medical Expenditure Panel Survey, AHRQ.

- 2010 Target

- 1996

- Race/ethnicity

- Percent

**Total**

- White

- Black

- Hispanic

**Notes:**
-At baseline in 1996, all groups were below the target of 56%. 
-56% of persons ages 2 and over should have an annual dental visit. 
-There were large disparities by race/ethnicity in annual dental visits, with blacks and Hispanics behind whites

## Annual Dental Visits: 1996

**Obj. 21-10**

- 1996

- Race/ethnicity

- Disability status

- Percent

- 2010 Target

- Note:  Data are for ages 2 years and over, age adjusted to the 2000 standard population.  Black and white exclude persons of Hispanic origin. Persons of Hispanic origin may be any race.
- Source: Medical Expenditure Panel Survey, AHRQ.

**Total**

- White

- Black

- With

- Without

**Notes:**
-In addition, at baseline in 1996,  fewer persons with disabilities had dental visits than those without disabilities. 

## Annual Dental Visits: 1996 and 2000

**Obj. 21-10**

**Total**

- White

- Black

- Hispanic

- 1996

- 2000

- With

- Without

- Percent

- 2010 Target

- Note:  Data are for ages 2 years and over, age adjusted to the 2000 standard population.  Black and white exclude persons of Hispanic origin. Persons of Hispanic origin may be any race.
- Source: Medical Expenditure Panel Survey, AHRQ.

- Race/ethnicity

- Disability status

**Notes:**
-From 1996 to 2000, annual dental visits dropped for nearly all groups. 
- Disparities have persisted among race ethnic groups.
-The greatest drop was observed among those with a disability.

Disability defined: IADL, ADL, Work/school limitations (5+ yrs), Cognitive limitations (18+yrs).

## Slide 28

## Community Health Centers with Onsite Dental Services 

**Obj. 21-14**

- Source: Bureau of Primary Health Care, HRSA.

- 1997

- 1998

- 1999

- 2000

- 2001

- 2002

- Number

- Dental Services at Center

- Health Centers

**Notes:**
-The proportion of community based health centers with a dental component has increased from 1997 to 2002.
-These centers serve groups that traditionally have limited access to dental services; minorities, persons with low income and persons living in rural areas. 

## Community Health Centers with Onsite Dental Services 

- Number

**Obj. 21-14**

- Percent

- 2010 Target

- Source: Bureau of Primary Health Care, HRSA.

- 1997

- 1998

- 1999

- 2000

- 2001

- 2002

- Dental Services at Center

- Health Centers

**Notes:**
-The proportion of community based health centers with a dental component has increased from 1997 to 2002.
-These centers serve groups that traditionally have limited access to dental services; minorities, persons with low income and persons living in rural areas. 

## Annual Dental Visits for Personswith Diabetes: 2002

**Obj. 5-15**

- Note:  Data are for ages 2 years and over, age adjusted to the 2000 standard population.  Black and white exclude persons of Hispanic origin. Persons of Hispanic origin may be any race.
- Source: National Health Interview Survey, NCHS, CDC.

- Annual Dental Visits for Personswith Diabetes: 2002

**Total**

- Black

- Hispanic

- White

- Rural

- Urban

- Persons with
- diabetes

- Race/ethnicity

- 100-199

- >200

- <100

- Poverty level (%)

- Percent

- 2010 Target

- Urbanicity

**Notes:**
 -Persons with diabetes are more likely to get periodontal disease and periodontal disease makes glycemic control more difficult. 
-Persons with diabetes should have annual dental visits. 
-The biggest disparity here is by income. 

## Annual Dental Visits for Personswith and without Diabetes: 2002

**Obj. 5-15**

- Note:  Data are for ages 2 years and over, age adjusted to the 2000 standard population.  Black and white exclude persons of Hispanic origin. Persons of Hispanic origin may be any race.
- Source: National Health Interview Survey, NCHS, CDC.

- Annual Dental Visits for Personswith and without Diabetes: 2002

**Total**

- Black

- Hispanic

- White

- Rural

- Urban

- Persons with
- diabetes

- Race/ethnicity

- Urbanicity

- 100-199

- >200

- <100

- Persons without
- diabetes

- Percent

- 2010 Target

- Poverty level (%)

**Notes:**
 -Persons with diabetes are more likely to get periodontal disease and periodontal disease makes glycemic control more difficult. 
-Persons with diabetes should have annual dental visits. 
-The biggest disparity here is by income. 

## Annual Dental Visits for Personswith and without Diabetes: 1997-2002

**Obj. 5-15**

- Note:  Data are for ages 2 years and over, age adjusted to the 2000 standard population.
- Source: National Health Interview Survey, NCHS, CDC.

- Annual Dental Visits for Personswith and without Diabetes: 1997-2002

- 2010 Target

**Persons with diabetes**

- Percent

**Persons without diabetes**

**Notes:**
-The last slide shows that dental visits among persons with diabetes have remained stable since baseline (see legend).

## http://www.cdc.gov/nchs/hphome.htm

**Progress review data and slides**
**can be found on the web at:**

**http://www.cdc.gov/nchs/hphome.htm**

## 12 IHS Service Areas

**Notes:**
Additional data germane to objective 21-8.  The placement of dental sealants throughout the Indian Health Service has increased dramatically in recent years.  Total number of sealants placed in 2003 approached 1⁄4 million.  This is a 74% increase in annual production over the last five years.
In 2004, IHS will likely exceed 1/4 million sealants placed.  The prevalence of IHS patients age 8 with dental sealants exceeds 60%.  This estimate exceeds the HP2010 target for dental sealants, which postulates a 50% prevalence.