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152        ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


I~!~tZlmrIl,l~B tU

How Is Oral Health Promoted
and Maintained and How Are
Oral Diseases Prevented?

Safe and effective disease prevention measures for the common dental diseases exist and allow
individuals, health care providers, and the community each to play a role, one that is enhanced by
active partnerships among these groups. Unfortunately, not everyone has access to these measures.
For example, some 40 percent of the U.S. population resides in communities that do not have
optimal fluoride levels in their water supply

Chapter 7 reviews the evidence for current prevention measures. Community water
fluoridation remains an ideal public health measure, which benefits individuals of all ages and all
socioeconomic strata. Other methods to deliver fluoride are reviewed, as is the use of dental
sealants in caries prevention. The prevention of periodontal diseases and conditions such as oral
and pharyngeal cancers and craniofacial injuries is at an early stage. Surveys of the knowledge and
practices of the public and care providers reveal opportunities for enhanced education.

Attaining and maintaining oral health require a commitment to self-care and professional care.
Chapter 8 highlights both individual responsibilities and emerging roles for health care providers.
With greater understanding of the pathophysiology of oral diseases, providers can incorporate new
preventive, diagnostic, and treatment strategies. These include developing risk assessment
approaches for individual patients and adopting new strategies for the control of infections. Care
providers are well positioned to instruct patients on tobacco cessation, appropriate dietary
practices during pregnancy, and other healthful behaviors.

The professional provision of oral health care in America involves contributions from the
dental, medical, and public health components. These are reviewed in Chapter 9, which focuses
primarily on the dental component. A number of factors limit the capacity to improve the
nation's oral health. Public assistance programs as currently designed are not meeting the oral
health needs of eligible populations. A troubling lack of diversity exists in the oral health
workforce, along with continued shortfalls in the number of men and women attracted to
positions in oral health education and research. Correcting these limitations would contribute to
increased access to care for underserved populations, enhanced preparation of future practitioners,
and an expanded ability to pursue the many research questions generated in this report.

ORAL HE.4LTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

153


Community and Other Approaches
to Promote Oral Health and Prevent
Oral Disease

The remarkable improvements in oral health over the
past half century reflect the strong science base for
prevention of oral diseases that has been developed
and applied in the community, in clinical practice,
and in the home. This chapter presents the evidence
for key preventive measures for those oral conditions
that pose the greatest burden to U.S. society. Because
the emphasis given to each condition discussed here
reflects the extent of the evidence for the associated
preventive measures, the chapter is heavily weighted
toward the prevention and control of dental caries,
for which multiple effective preventive modalities
have been developed.

The dental profession has long championed dis-
ease prevention and health promotion approaches to
oral health. The initial observations in the 1930s that
people living in communities served by naturally
fluoridated water had lower dental caries inspired the
trailblazing clinical prevention studies of the 1940s
and 1950s. Researchers compared whole cities agree-
ing to fluoridate their water supplies to control cities
whose drinking water contained only trace amounts
of fluoride. Five years into the studies, follow-up
with schoolchildren who had been examined at base-
line revealed dramatic reductions in dental caries in
the children drinking fluoridated water, as compared
to controls. The overwhelming success of the studies
led to a widespread adoption of community water
fluoridation in the United States as a high-benefit,
low-cost preventive method that benefited old and
young, rich and poor alike. It also provided momen-
tum for health practitioners, researchers, industry,
and public health directors to consider other kinds of
community-wide, provider-based, and individual
strategies aimed at improving oral and general
health.

Most common oral diseases can be prevented
through a combination of community, professional,
and individual strategies. The strategies selected here

include disease prevention and health promotion
interventions directed toward the public, practition-
ers, and policymakers to create a healthy environ-
ment, reduce risk factors, inform target groups, and
improve knowledge and behaviors. They were select-
ed on the basis of the significance of the health prob-
lem they were designed to prevent, whether in terms
of prevalence, incidence, severity, cost, or impact on
quality of life (see Chapters 4 and 6). Table 7.1 sum-
marizes the strategies for the primary prevention of
caries, periodontal diseases, oral and pharyngeal can-
cers, inherited disorders, and trauma, distinguishing
among those that can be implemented community-
wide, through health professionals, or through the
exercise of individual responsibility. Some strategies
can be applied at multiple levels. Box 7.1 provides
a glossary of terms related to community health
programs.

This chapter also includes a discussion of knowl-
edge and practices of the public and health care
providers regarding the three oral conditions about
which we have the most knowledge. The purpose of
this discussion is not to outline specific health pro-
motion strategies to enhance knowledge and prac-
tices but to indicate the opportunities and needs for
both broad-based and targeted health promotion pro-
grams and activities.

WEIGHING THE EVIDENCE THAT
INTERVENTIONS WORK
Researchers, policymakers, and practitioners make
judgments about whether a health intervention
works based on estimates of its efficacy or effective-
ness. Estimates of an interventions efficacy are best
based on randomized controlled trials, which may be
conducted under ideal circumstances. Evidence for
whether an intervention works when applied in the
community at large is referred to as its effectiveness

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          155


Comn~unity and Other Approaches to Promote Oral Health and Prevent Oral Disease

(O'Mullane 1976). The distinction between efficacy    The current trend in health care and public
and effectiveness is often blurred in dental public   health is to base recommendations on evidence
health programs because the studies and their set-  derived from systematic reviews of the literature and
tings can be very similar. Nevertheless, the major dif-  an assessment of the quality of evidence. The U.S.
ference between the two lies in the degree of control   Preventive Services Task Force (1996) and the
exerted over factors that can affect results.   Canadian Task Force on the Periodic Health Exam-
Effectiveness studies more accurately reflect results   ination (Ismail and Lewis 1993, Lewis and Ismail
that may be expected from the implementation of  1995) are examples of groups that have used system-
interventions.                   atic reviews to establish the evidence of efficacy or

TABLE 7.1

Community, provider, and individual strategies for primary prevention of key oral diseases and conditions

Community Strategies                Professional Strategies             Individual Strategies

Dental caries
Community-wide health promotion       Counseling to follow measures to reduce risk of    Being informed about strategies to prevent disease
intervention9                   disease

Fluoride use                    Fluoride use                    Fluoride use
Community water fluoridation          Prescriptions for fluorides (supplements or rinses)    Dentifrice
School-based dietary fluoride tablets       Gels and other high-fluoride topicals         Mouthrinse, over the counter
School-based fluoride mouthrinse        Topical remineralization solutions
                    Fluoride-containing restorative materials

School-based and school-linked sealant programs



School-linked screening and referral

Periodontal diseases
Community-wide health promotion
intervention9

School-based personal hygiene,reinforcement
of personal oral hygiene habits in Headstart or
primary school classrooms


School-linked screening and referral
Oral and pharyngeal cancers
Community-wide health promotion
intervention9



Cancer screening programs (such as health fairs)


Inherited disorders
Early detection programs

Trauma
Community-wide health promotion
intervention9

Mouth protector fittings for entire team

Provision of sealants
Prescriptions for antimicrobial agents


Individualized recall schedule


Counseling to follow measures to reduce risk of
disease
Control of plaque bacteria by mechanical means
(prophylaxis or scaling)
Chemical plaque control
Chemotherapeutic agents

Monitoring and early detection of disease


Professional education and patient counseling on
risk factors



Routine soft-tissue oral examination for early
detection of precancerous lesions


Interdisciplinary early detection programs


Professional education and patient counseling on
risk factors

Fabrication of mouth protectors

Asking about sealants
Use of antimicrobial agents


Self-initiated use of dental services


Being informed about strategies to prevent disease


Oral hygiene measures
Toothbrushing and flossing
Toothbrushing with dentifrices
Plaque control

Self-initiated use of dental services


Being informed about strategies to prevent disease
Avoidance of tobacco use
Reduction of alcohol use
Use of sunscreen and lip protector

Self-initiated use of dental services
Request for cancer screening





Being informed about strategies to prevent trauma


Use of mouth protectors and helmets

Yommunity-wide health promotion interventions (education,political,regulatory,and organizational) are directed toward the public,practitioners,and policymakers
to create a healthy environment,reduce risk factors, inform target groups, and improve knowledge and behaviors.

3 `: ,-,          ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


~c~mn~unity and Other Approaches to Promote Oral Health and Prevent Oral Disease

BO;Y 7.1

Glossary: The Nature of Community Health Programs

Community health programs are defined as health promotion and disease prevention activities that address health problems in populations.
Community health programs often provide a level of organization and resources beyond those available to an individuaLThe programs thus com-
plement personal care and professional services. Many programs target populations with limited access to pmfessional services or limited resources
to pay for services.Govemment agencies,religious organizations,charities,schools,foundations,and other private and publicgmups may spearhead
such programs, tapping into the expertise, enthusiasm, and knowledge of community values of staff and volunteers. Some programs are sponsored
by national, state, and local dental societies and their members.

Five terms related to community health programs- community, health promotion, health literacy, health education,and disease prevention-have
been further articulated by experts in the field.

Community. According to Last (1995), a community is"a group of individuals organized into a unit, or manifesting some unifying trait or common
interest."The unit can be a town, a geographic area, the state, nation, or body politic (Last 1995J.The unit may also be a selected subgroup, such as
disadvantaged children living in a large city or women urged to have mammograms according to specified schedules.

In designing and implementing community programs, planners must take into consideration that no two communities are identical. In a classic
expression of this concept, McGavran (1979) wrote that a community is"an entity different from every other community as an individual is different
from his neighbor:different in its physical makeup, its geographic and demographic limitation, different in its social structure, its power structure, its
governmental and legal structure, different in mental and emotional patterns, in its ethnic groups, its mores, its religious and nutritional patterns,
and different in its educational procedure, its institutions, and its community organization."On the other hand, communities may have similar risk
factors for poor oral health,allowing common solutions to similar problems.Lessons learned in one community may be applicable to those with sim-
ilar characteristics.

In recent years, investigators have begun to examine characteristics of communities, noting that some communities provide an environment that
contributes to the overall health and well-being ofthe members,whereas othersappearto be detrimental.All communities,however,have both pos-
itive and negative influences on health and well-being-the challenge is to minimize the negative factors and maximize the positive in each com-
munity. Healthy communities have been characterized as having a degree of openness and cooperation -neighbors helping neighbors. Healthy
communities also are ones in which there are less extreme separations of individuals by social class (Wilkinson 19%).

Health Promotion. Health promotion is"any planned combination of education, political, regulatory, and organizational supports for action and
conditions of living conducive to the health of individuals, groups, or communities"(Green and Kreuter 1999). Examples of broad-based health pro-
motion activities include programs encouraging people of all ages to stop using tobacco, regulations requiring the use of mouthguards in contact
sports, laws to prohibit tobacco sales to minors,and labels that indicate the amount of sugar in a product.

Health literacy. Health literacy is"the capachy of individuals to obtain, interpret,and understand basic health information and services and the
competence to use such information and services in ways which enhance health" (Joint Commission on National Health Education Standards 1995).
Health literacy is correlated with general literacy, and both vary by educational achievement, socioeconomic status, race, and ethnicity. This is an
important concern in a society that is becoming more diverse in terms of language, religion, culture, race, and ethnic@. Programs intending to serve,
immigrants, for example, must attend to ensuring that information, programs, and systems are accessible, understandable, and culturally sensitive,
particularly if the target audience for health information and services does not speak English,if there are unique cultural and religious beliefs at vari-
ance with those of the dominant culture, or if living arrangements are such that individuals lack access to sources of health information and care.

Health Education. Health education is an important part of health promotion. It is defined as"any planned combination of learning experiences
designed to predispose, enable, and reinforce voluntary behavior conducive to health in individuals, groups, or communities" (Green and Kreuter
1999). Examples include the multiple campaigns to prevent tobacco use among youth. An example at the statewide level is Arizona's promotion of
the use of dental sealants with an educational campaign that says"Sealants Are in the Groove."

Disease Prevention, The term prevention embodies the goal of promoting and preserving health and minimizing suffering and distress.
Community health programs generally focus on eitherprimory prevention- removing or reducing risks or providing protection from disease before
it occurs-or secondufy prevention- screening and early detection and intervention to arrest the progress of disease after it occurs. Tertiary pre-
vention-rehabilitating and restoring structure and function-is provided in some community-based programs,such as clinical dental care organ-
ized and delivered under conditions determined by the community.

ORAL HEALTH IN AMERIC4: A REPORT OF THE SURGEON GENERAL

157


Community and Other Approaches to Promote Oral Health and Prevent Oral Disease

effectiveness of clinical preventive services for the
purpose of making recommendations. Similar
reviews of the evidence of effectiveness for commu-
nity preventive services are currently under way by
the Task Force on Community Preventive Services
(2000). These reports provide clear statements about
the evidence and recommendations for or against a
given strategy.

regarding self- or provider care further reflects the
subjective value placed on the outcome of care.
Therefore, it is not possible to make general state-
ments about the superiority of any given approach.

PREVENTION AND CONTROL OF
DENTAL CARIES

The discussion in this chapter is more illustrative
than comprehensive. Readers are encouraged to seek
specific guidance from the reports of the U.S.
Preventive Services Task Force where available.
Furthermore, because of the interest in community
preventive services, "expert opinion" about the mer-
its of community interventions is included, even
though the work of the Task Force on Community
Preventive Services has not been completed. Expert
opinion is formed by less systematic reviews of the
literature or addresses interventions to be applied in
settings other than those previously studied.

In particular, suggestions are offered for several
interventions intended to reduce oral disease and
promote oral health that reflect the opinion of
experts who contributed to this report. Until findings
from additional research are available, expert opinion
remains the best guidance for community interven-
tions where only efficacy studies have been done or
where they were applied to populations with differ-
ent attributes or risk factors than those of current
interest. Also, expert opinion has been used where
there is an interest in criteria that were not consid-
ered in previous efficacy studies, such as cost-effec-
tiveness and practicality,

  Readers interested in more detailed information
about interventions in areas such as control of tobac-
co use or motor vehicle safety are directed to the
upcoming report of the Task Force on Community
Preventive Services (2000).

Although many caries prevention strategies, notably
community water fluoridation and use of a fluoride-
containing dentifrice, benefit adults and children
alike, most of our understanding of the effectiveness
of these strategies comes from the study of children,
during a life stage when caries incidence is high.
Caries prevention programs have been designed and
evaluated for children and have used a variety of flu-
oride and dental sealant strategies applied separately
and together. Because these strategies are comple-
mentary, their use in combination has the potential of
virtually eliminating dental caries in all children.
However, dental caries is a problem for all ages.
Although direct evidence of caries preventive strate-
gies in adults is limited, the evidence that does exist
is consistent with expected effects based on experi-
ence with children. The Centers for Disease Control
and Prevention (CDC) recently convened an expert
work group to develop recommendations for modal-
ities to prevent and control dental caries based on a
review of publications selected by the work group
and other experts. The resulting recommendations
are summarized in Table 7.2, where they are organ-
ized according to quality of evidence, strength of rec-
ommendation, and target population in accordance
with criteria adapted from the U.S. Preventive
Services Task Force (CDC in press).

Fluoride

Interventions included in this chapter (and high-
lighted in Table 7.1) are those that have been shown
to be effective in certain settings, but which can be
applied in other settings. The anticipated benefits
may be difficult to determine. In general, the per
capita cost of an intervention is lower for communi-
ty interventions and is usually a function of the num-
ber of people reached for a given level of profession-
al effort. Effectiveness, however, is often a function
of the risk characteristics of a given individual in the
group receiving the intervention. Such risk factors
are often easier to target by individual practitioners
than by community programs. In the absence of con-
temporary data, the promotion of strategies deemed
to be more cost-effective than others relies on the
opinion of experts. Individual decision making

Fluoride reduces the incidence of dental caries and
slows or reverses the progression of existing lesions
(i.e., helps prevent cavities). Today, ail Americans are
exposed to fluoride to some degree, and there is little
doubt that widespread use of fluoride has been a
major factor in the overall decline in recent decades
in the prevalence and severity of dental caries in the
United States and other economically developed
countries (Bratthall et al. 1996).

  Fluoride is the ionic form of the element fluo-
rine, the thirteenth most abundant element in the
crust of the Earth. Because of its high affinity for cal-
cium, fluoride is mainly associated with calcified tis-
sues (i.e., bones and teeth). The ability of fluoride to
inhibit, and even reverse, the initiation and progres-
sion of dental caries is well known. Fluoride's mech-

158         ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


Community and Other Approaches to Promote Oral Health and Prevent Oral Disease

.,n,sms of action include incorporation of fluoride
,nto enamel preeruptively, inhibition of demineral-
lI;ltIon. enhancement of remineralization, and inhi-
t,ltlon of bacterial activity in dental plaque.

.-\ variety of theories regarding fluoride's mecha-
nlsms of action account for the range of fluoride
products available (Burt and Eklund 1999, Stookey
.ind Beiswanger 1995). The initial theory of action
\\-a~ based on the belief that incorporation of fluoride
Into the hydroxyapatite of developing tooth enamel
in the preeruptive phase reduced the mineral's solu-
\,ility. thereby increasing enamel resistance. Because
of the length of time the tooth is at risk of caries dur-
ins the posteruptive phase. however, the topical
effects of fluoride are considered to predominate
(Clarkson et al. 1996). These effects are based on flu-
oride`s role in the aqueous phase around the tooth,
both in saliva and in dental biofilm (plaque).
Fluoride in plaque contributes to the remineraliza-
tion of demineralized enamel when bound fluoride is
released during an acid challenge, resulting in a more

acid-resistant enamel surface structure. Fluoride also
has been shown to inhibit the process of glycolysis by
which fermentable carbohydrates are metabolized by
cariogenic bacteria to produce acid. All these effects
occur after the tooth erupts, while it is functioning in
the mouth, enabling fluoride to prevent caries over a
lifetime in both children and adults.

The first use of fluoride for caries prevention was
in 1945 in the United States and Canada, when the
fluoride concentration was adjusted in the drinking
water supplying four communities (Arnold et al.
1962, Ast and Fitzgerald 1962, Blayney and Hill
1967, Hutton et al. 1956). This public health
approach followed a long period of epidemiologic
studies of the effects of naturally occurring fluoride
in drinking water (Burt and Eklund 1999).

The success of the community water fluoridation
trials in reducing dental caries led to the develop-
ment of other important fluoride-containing prod-
ucts, such as dietary supplements and, most notably,
fluoride-containing dentifrices, in the early 1960s.
      Fluoride-containing gels, solu-

T:4BLE 7.2

Quality of evidence, strength of recommendation, and target population of recom-
mendation for each modality to prevent and control dental caries

            Quality of    Strength of
                Evidence    Recommendation     Target
Modality"           (grade)      (code)      Populationb
Community water fluoridation      11-l         A         All areas
School water fluoridation        II-3         L     Rural, nonfluoridated areas
Fluoridated dentifrices          I          A       All persons
Fluoride mouthrinses           I          A       High rizkc
Fluoride supplements
Pregnant women            I           E           None
Children aged <6 years         II-3         C       High risk
Children aged 6 to 16 years       I          A       High risk
Persons aged >16 years       N.A.         C       High risk
Fluoride gels               I          A        High risk
Fluoride varnishes            I          A        High risk
Dental sealants              I          A       High riskd
Notes: Criteria for quality of evidence and strength of recommendation designations are adapted from USPSTF as
Table 5.3.

N.A. = no published studies of effectiveness of fluoride supplements in controlling dental caries among persons
aged > 16 years.
a Assume that the modalities are used as directed in terms of dosage and age of user.
%e quality of evidence for targeting some modalities to persons at high risk is grade Ill, representing the opinion of
respected experts, and is based on considerations of cost-effectiveness that were not included in the studies establishing
efficacy or effectiveness.
[Groups believed to be at high risk for caries are members of families of low socioeconomic status (SES) or with low levels
of parental education; those seeking dental tare on an irregular basis; and persons without dental insurance or access to
dental service. Individual factors contributing to increased risk are currently active dental caries;a history of high caries
experience in older siblings or caregivers; exposed root surfaces; high levels of infection with cariogenic bacteria; impaired
ability to maintain oral hygiene;reduced salivary flow due to medications,radiation treatment,or disease;and the wear-
mg of orthodontic appliances or prostheses.
dAssessment of risk is based on both patient and tooth-specific factors.
Source: Modified from CDC in press,and ASTDD 1995.

tions, pastes, and varnishes were
also developed for topical use,
either applied by professionals or
self-applied at home or in other
settings. All of these products were
tested for safety and effectiveness
in reducing caries.  Products
designed for professional use gen-
erally have higher concentrations
and are used at less frequent inter-
vals than those designed for self-
application.

  Controlled clinical trials from
the 1940s through the 1970s doc-
umented the benefits of profes-
sionally applied fluoride in reduc-
ing dental caries, and several
excellent reviews are available
(Horowitz and Ismail 1996,
Johnston 1994, Ripa 1990,
Stookey and Beiswanger 1995).
Professional application of fluoride
is inherently more expensive than
self-applied methods, so the use of
such an approach for groups and
individuals at low risk of dental
caries is unlikely to be cost-effec-
tive. For patients at high risk of
dental caries, however, profession-
ally applied fluoride is still consid-
ered cost-effective. It is not clear
whether fluoride varnishes and

ORAL HEALTH IN AMERICA: ,4 REPORT OF THE SURGEON GENERAL          159


Comtnunit)~ and Other ;\pproaches to Promote Oral Health and Prevent Oral Disease

gels would be most efficiently used in clinical pro-
grams targeting groups at high risk of dental caries or
whether they should be reserved for individual high-
risk patients.

The U.S. Preventive Services Task Force (Greene
et al. 1989, USPSTF 1996) and the Canadian Task
Force on Periodic Health Examination (Lewis and
Ismail 1995) affirm that there is strong evidence to
support the major methods for providing fluoride to
prevent dental caries.

The safety of fluoride is well documented and
has been reviewed comprehensively by several scien-
tific and public health organizations (Institute of
Medicine (IOM) 1997, National Research Council
(NRC) 1993, Newbrun 1996, U.S. Department of
Health and Human Services (USDHHS) 1991, World
Health Organization (WHO) 1984). When used
appropriately, fluoride has been demonstrated to be
both safe and effective in preventing and controlling
dental caries. The IOM (1997) classified fluoride as a
micronutrient, citing it, along with calcium, phos-
phorus, magnesium, and vitamin D, as an important
constituent in maintaining health.

Water fluoridation is the controlled addition of a flu-
oride compound to a public water supply to achieve
a concentration optimal for dental caries prevention.
In the 1940s Dean et al. (1941) concluded that 1
ppm (part per million) fluoride was the optimal con-
centration for climates similar to that of the Chicago
area; this concentration would significantly reduce
the prevalence of dental caries with an acceptably
low prevalence of enamel fluorosis. Current U.S.
Public Health Service (USPHS) recommendations for
fluoride use include an optimally adjusted concen-
tration of fluoride in drinking water ranging from 0.7
to 1.2 ppm, depending on themean maximum daily
air temperature of the area (Galagan and Vermillion
1957, USDHEW 1962). A lower fluoride concentra-
tion is recommended for communities in warmer cli-
mates than cooler climates, because it is assumed that
persons living in warmer climates drink more tap
water.

Effectiveness

Appropriate use of fluoride products can mini-
mize the potential for enamel fluorosis, a broad term
applied to certain visually detectable changes in the
opacity of tooth enamel associated with areas of flu-
oride-related developmental hypomineralization.
There are also many developmental changes in
enamel that are not fluoride-related (Fejerskov et al.
1990). Most enamel fluorosis seen today is of the
mildest form, which affects neither aesthetics nor
dental function. Cosmetically objectionable enamel
fluorosis can occur when young children ingest
higher than optimal amounts of fluoride, from any
source, while tooth enamel is forming (up to age 6).
Its occurrence appears to be most strongly associated
with the total cumulative fluoride intake during the
period of enamel development, but the condition's
severity depends on the dose, duration. and timing
of fluoride intake. Specific recommendations have
been made to control fluoride intake by children
during the years of tooth development (USDHHS
1991).

Numerous studies in naturally fluoridated areas pre-
ceded the field trials. There are no randomized,
double-blind, controlled trials of water fluoridation
because its community-wide nature does not permit
randomization of people to study and control groups.
Similar results have been derived from numerous
well-conducted field studies by various investigators
on thousands of subjects in different parts of the
world. Conducting a study in which individuals are
randomized to receive or not receive fluoridated
water is unnecessary and is not feasible.

Fluoridation of Drinking Water

For more than half a century, community water fluor-
idation has been the cornerstone of caries prevention
in the United States; indeed, CDC has recognized
water fluoridation as one of the great public health
achievements of the twentieth century (CDC 1999).
All water contains at least trace amounts of fluoride.

In 1945, Grand Rapids, Michigan, became the
first city in the United States to fluoridate its water
supply; the oral health of its schoolchildren was peri-
odically compared with that of schoolchildren in the
control city, Muskegon, Michigan. Dramatic declines
in dental caries among children in Grand Rapids and
three other cities conducting studies shortly there-
after led to fluoridation in many other cities. In an
extensive review of 95 studies conducted between
1945 and 1978, Murray et al. (1991) reported the
modal caries reduction following water fluoridation
to be between 40 and 50 percent for primary teeth
and 50 and 60 percent for permanent teeth. Newbrun
(1989) reported on more than 60 studies conducted
during the 1970s and early 1980s limiting his review
to those with concurrent control groups because of
the continuing decline in dental caries in both fluor-
idated and nonfluoridated areas. Comparisons of flu-
oride-deficient and fluoridated communities in the
United States, Australia, Britain, Canada, Ireland, and
New Zealand have consistently demonstrated the

ORAL HFALTH IN AhlERICA: A REPORT OF THE SURGEON GENERAL


iontinued effectiveness of water fluoridation. Caries
reductions ranged between 15 and 40 percent in
fluoridated, as compared with fluoride-deficient,
communities (USDHHS 1991).

Fluoridation also benefits middle-aged and older
adults. Benefits to adults include reductions in both
coronal and root caries. These benefits are important
because older people typically experience gingival
recession, which results in exposed root surfaces,
ivhich are susceptible to caries. In addition, tooth
retention in older U.S. cohorts has increased in recent
decades, so that the number of teeth at risk for caries
in older age groups is also increasing. Finally, many
medications used to treat chronic diseases common
in aging have the side effect of diminished salivary
flow, depriving teeth of the many protective factors in
saliva.

  Other evidence of the benefits of fluoridation
comes from studies of populations where fluorida-
tion has ceased. Examples in the United States,
Germany and Scotland have shown that when fluor-
idation is withdrawn and there are few other fluoride
exposures, the prevalence of caries increases. In Wick,
Scotland, which began water fluoridation in 1969 but
stopped it in 1979, the caries prevalence in 5- to 6-
year-olds with limited exposure to other sources of
fluoride increased by 27 percent between 1979 and
1984. This was despite a national decline in caries
and increased availability of fluoride-containing den-
tifrices (Kugel and Fischer 1997, Seppa et al. 1998,
Stephen et al. 1987).

Costs and Cost-effectiveness

The increase in other fluoride exposures since water
fluoridation was first introduced in 1945-particu-
larly from fluoride-containing dentifrices, mouth-
rinses, and foods and beverages processed using
fluoridated water-has led to smaller differences in
the prevalence of dental caries between people in
fluoridated and those in nonfluoridated communities
than in the past. Most public health experts believe
that water fluoridation continues to be a highly cost-
effective strategy, even in areas where the overall
caries level has declined and the cost of implement-
ing water fluoridation has increased (Burt 1989, CDC
1999).

Compared to the cost of restorative treatment,
water fluoridation actually provides cost savings, a
rare characteristic for community-based disease pre-
vention strategies (Garcia 1989). The mean annual
per capita cost of fluoridation ranges from $0.68 for
systems serving populations greater than 50,000
(large systems) and $0.98 for systems serving

between 10,000 and 50,000 (medium systems), to
$3.00 for systems serving less than 10,000 (small sys-
tems) (reported in 1999 dollars) (Ringelberg et al.
1992). In 1992, approximately 60 percent of the U.S.
population receiving fluoridated water was served by
large systems, 31 percent by medium systems, and 9
percent by small systems (USDHHS 1993).

Access to Optimally Fluoridated Water in the
United States

The most recent national data on the extent of com-
munity water fluoridation reflect the status of fluori-
dation in 1992 (see Figure 7.1 and Table 7.3). About
145 million people, or 62 percent of the population
served by public water supplies, con&me water with
optimal fluoride levels. Of the 50 largest cities in the
United States, 43 are fluoridated (Table 7.4).
Residents of the seven unfluoridated cities in the
group are among the almost 100 million persons
in the United States who lack this method of caries
prevention.

Although many states and large cities had been
quick to implement fluoridation programs in the
1950s and 1960s the trend then began to level off. In
the absence of legislative mandates in most states and
categorical federal funding, fluoridation decisions are
left to the states, and frequently to local governments
and city councils. Thus expansion of fluoridation in
the United States is not simple and requires decisions
at many levels. The national health promotion and
disease prevention objectives in Healthy People 2010
(USDHHS 2000) call for increasing the percentage of
Americans on public water supplies drinking fluori-
dated water from 62 to 75 percent-a 21 percent
improvement (see Figure 7.1). This would mean
adding 30 million people served by well over 1,000
community water systems to those who currently
have access to fluoridated public water systems
(USDHHS 1993).

Summary: Community Water Fluoridation
Epidemiological studies carried out during the last
five decades provide strong evidence supporting the
effectiveness of water fluoridation in preventing
coronal and root caries in children and adults.
Further support of effectiveness comes from studies
that indicate that caries experience increases in com-
munities that no longer fluoridate the water supply
(and where there are few other exposures to fluo-
rides). Given the modest cost of less than 1 dollar per
person per year to fluoridate water systems serving
most people, community water fluoridation is rec-
ommended as a very effective and cost-effective

~c~inmunit~ and Other- .Approaches to Promote Oral Health and Prevent Oral Disease

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          161


Community and Other ,\pproaches to Promote Oral Health and Pre\rent Oral Disease

FIGURE 7.1

Percentage of U.S. population by state served by fluoridated public water supply, 1992

Source: USOHHS1993.

HealthyPeople2010Goalof75Percent
0 Goalnotattained
m Goalattainedorexceeded

TABLE 7.3

Population served by fluoride-adjusted and naturally
fluoridated water, United States, 1992

Type of Fluoridation
Adjusted
Natural
Both

Source:USDHHS1993.

Population

134.6 million
10.0 million
144.6 million

Number of   Number of
Systems    Communities

10,567     8,572
3,784     1,924
14,351     10,496

method of preventing coronal and root caries in chil-
dren and adults. Moreover, water fluoridation bene-
fits all residents served by community water supplies
regardless of socioeconomic status. Few barriers to
its implementation exist, with the important excep-
tion of the political opposition that the measure often
engenders and certain technical difficulties and costs
involved in fluoridating very small water systems.

        the children were present for
        only portions of the day and
            year.
           Although  the strategy
         shares some of the advantages
         of community water fluorida-
        tion-serving rich and poor
         alike and requiring no action
         on the part of the children
         (other than drinking the
          water)-a number of disadvan-
        tages were evident from the
           outset. These included the lim-
        itation: inherent in beginning
        exposure to fluoride only when
         children were of school age
         and then providing only inter-
         mittent exposure. Also, the
         possibility that the exposure
           would not confer benefits after
           the children left school was a
            concern. Practical considera-
tions included the cost of operations, personnel,
logistical difficulties, and mandatory water testing
(CDC 1995). Moreover, the intervening decades have
seen increased school consolidations, increased cov-
erage of schools by community-wide water systems,
declining numbers of children who could benefit
from such programs, and a continuing general
decline in dental caries in children. Another concern
is that schools increasingly enroll preschoolers into
daycare programs for which school water fluorida-
tion at higher levels than for community water sys-
tems is not appropriate. Only four intervention stud-
ies evaluating the effectiveness of school water fluor-
idation have been published.

School Water Fluoridation

During the 1960s 1970s and 1980s programs were
initiated to bring the benefits of fluoride in drinking
water to children living in homes supplied by well
water and whose schools had independent water sup-
plies. The idea was to adjust the fluoride content of
the water supplies of the schools these children
attended, especially consolidated rural schools, to
levels higher than those that would be used for com-
munity water fluoridation, taking into account that

Summary: School Water Fluoridation

Given the limitations of the evidence for effec-
tiveness, as well as the difficulties of implementation
and operation, school water fluoridation has limited
application. Decisions to initiate or continue school
fluoridation programs should be based on an
assessment of present caries risk in the target
school(s), alternative preventive modalities that may
be available, and periodic evaluation of program
effectiveness.

Dietary Fluoride Supplements
Dietary fluoride supplements are available as tablets
that are swallowed or chewed, drops that are swal-
lowed, and lozenges that dissolve slowly in the

162        ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


- - ~C~nlmunit\' and Other tipproaches to Promote Oral Health and Prevent Oral Disease

r,,~,L,t]l. They can provide topical
tnL1 s\.stcmic fluoride for children
;,, (hc absence of optimally fluori-
,i.,tcd drinking water. In the
~~,,,[ed States. supplements are
.,,-,,,l&lc by prescription only, to
I,~, Lrsed once a day beginning at 6
months and ending at age 16.
.\ccL,rding to a 1986 National
~jL.;~lth Intenliew Survey (NHIS),
.I,+ly more than 16 percent of
Ltllldrcn younger than 2 years used
IlllL)rlde dietary supplements
t sCJurjnh et al. 1994).
The fluoride supplement
tiCjsage schedule in use in the
[`nitcd States was last revised by
lhc .\merican Dental Association
(,.\DX) in 1994 (Table 7.5) (ADA
14%). This schedule, based on
the level of fluoride in the com-
munity water supply and on the
age of the child, has also been
endorsed by the American Acad-
cmy of Pediatric Dentistry and the
..\merican Academy of Pediatrics.
Fluoride supplements should
not be prescribed for individuals
living in optimally fluoridated
communities.

Effectiveness of Home Use

The current fluoride supplement
dosage schedule does not recom-
mend prescribing fluoride for
infants younger than 6 months. A
double-blind study of fluoride sup-
plements conducted to ascertain
the effects of fluoride administered
to the mother during the last 6
months of pregnancy followed by
5 years of supplements to the child
after birth found no additional
benefits from prenatal fluoride use
(Leverett et al. 1997). In a ran-
domized, double-blind, controlled
trial in which supplements were
administered from birth, Hennon
et al. (1967) had found statistical-
ly significant 4-year reductions in
caries in primary and permanent
teeth of 65 and 41 percent, respec-
tively. Beyond this study, which
was conducted when other sources

TABLE 7.4
Water fluoridation status of top 50 U.S. cities

               Population Estimate    Size Rank     Fluoride/
                   (7/l/96)        1996     No Fluoridea

New York, New York            7,380,906         1        F
Los Angeles, California           3,553,638         2        F
Chicago, Illinois              2,721,547         3        F
Houston, Texas               1,744,058          4        F
Philadelphia, Pennsylvania          1,478,002         5        F
San Diego, Californiaa            1,171,121          6        NF
Phoenix,Arizona             1,159,014         7        F
San Antonio,kxas             1,067,816         a        NF
Dallas,Texas               1,053,292         9        F
Detroit, Michigan             1,000,272         10        F
San Jose, California              838,744         11   o     NF
Indianapolis, Indiana             746,737         12        F
San Francisco, California            735,315         13        F
Jacksonville, Florida              679,792         14       F-nat
Baltimore, Maryland             675,401         15        F
Columbus,Ohio               657,053         16        F
El Paso,Texas                599,865         17       F-nat
Memphis,Tennessee             596,725         18        F
Milwaukee,Wisconsin            590,503         19        F
Boston,Massachusetts            558,394         20        F
Washington, D.C.              543,213         21        F
Austin,Texas                541,278         22        F
Seattle, Washington              524,704         23        F
Nashville-Davidson (remainder),Tennessee    511,263         24        F
Cleveland, Ohio               498,246         25        F
Denver,Coiorado               497,840         26        F
Portland,Oregon              480,824         27        NF
Fort Worth,Texas              479,716         28        F
New Orleans, Louisiana            476,625         29        F
Oklahoma City,Oklahoma           469,852         30        F
Tucson, Arizonab              449,002         31        NF
Charlotte,North Carolina            441,297         32        F
Kansas City, Missouri             441,259         33        F
Virginia Beach,Virginia            430,385         34        F
Honolulu, Hawaii               423,475         35        NF
tong Beach, California             421,904         36        F
Albuquerque, New Mexico           419,681         37        F
Atlanta, Georgia               401,907         38        F
Fresno,California               396,011         39       NF
Tulsa,Oklahoma              378,491         40        F
Las Vegas, Nevada              376,906         41        F
Sacramento,California            376,243         42        F
Oakland, California               367,230         43        F
Miami, Florida               365,127         44        F
Omaha, Nebraska              364,253         45        F
Minneapolis, Minnesota            358,785         46        F
St. Louis, Missouri              351,565         47        F
Pittsburgh, Pennsylvania           350,363         48        F
Cincinnati,Ohio               345,818        49        F
Colorado Springs, Colorado           345,127         50        F

a F = fluoride, NF = no fluoride, and F-nat = natural, nonadjusted fluoride in the water supply.
Woted but not yet started.
Source:bReeves,CDC Division of Oral Health,personal communication, April 18.2000.

ORAL HEALTH IN AMERICA: ,4 REPORT OF THE SURGEON GENERAL         163


Community and Other Approaches to Promote Oral Health and Prevent Oral Disease

of fluoride were not as widespread as today, there
are no well-designed clinical trials of home-based
administration of postnatal supplements. As Murray
and Naylor (1996) noted, many studies are difficult
to interpret, either because of small size, short exper-
imental period, or inadequate reporting. The studies
are further complicated by problems in self-selection
bias, in choosing comparable control groups, and in
compliance to the daily regimen.

Notwithstanding the paucity of true randomized
controlled clinical trials to demonstrate efficacy of
supplement use in children, at least 60 studies have
reported on the effectiveness of fluoride tablets or
drops in home- or school-based programs (Driscoll
1974, Murray and Naylor 1996, Stephen 1993).
However, none used the current prescribing sched-
ule. Altogether, the evidence for using fluoride sup-
plements to prevent and control dental caries is
mixed. Although many studies have reported that the
use of fluoride supplements by infants and children
before their permanent teeth erupt reduces caries in
permanent teeth, many other studies have reported
that it does not (CDC in press). For children aged 6
to 16 who take supplements after most teeth have
erupted, the evidence is much clearer that fluoride
reduces caries experience (DePaola and Lax 1968,
Driscoll et al. 1978, Stephen and Campbell 1978).

Most of the supplements taken at home are
prescribed by physicians and dentists in private
practice, with physicians prescribing the larger share.
Two difficulties are associated with home use. First,
the provider may prescribe incorrectly; second,
compliance with home-based tablet programs can be
very poor. More public and professional education is
needed to overcome the difficulties inherent in
following recommended regimens for home use of
fluoride supplements, which require motivation
and adherence on the part of children, parents, and
prescribers.

Effectiveness of School-based Programs

Most community fluoride supplement programs are
school-based. Each school day, participating students
receive a tablet, which they chew under supervision,
swishing the resultant solution between the teeth for
30 seconds before swallowing.

Supplement programs in schools have been
shown to be effective in preventing caries in perma-
nent teeth when administration is tightly controlled
and children are instructed to let the tablet dissolve
slowly, to ensure as much topical fluoride exposure
as possible. Under these conditions, randomized con-
trolled trials in the United States reported caries

reductions of 20 to 28 percent over periods of 3 to 6
years (DePaola and Lax 1968, Driscoll et al. 1978). In
a randomized, double-blind, 3-year study of Scottish
schoolchildren who were 5.5 years of age at the start
of the study, a much higher percentage reduction in
caries in permanent teeth was observed (Stephen and
Campbell 1978). In this study, teachers were specifi-
cally requested to encourage children each school
day to let the sodium fluoride tablet dissolve slowly.
These children were from lower socioeconomic
groups and may not have had access to fluoride-con-
taining dentifrices and other sources of fluoride, fac-
tors that most likely put them at high risk for caries.

Costs of School-based Programs

The costs of a school-based tablet program are low
because equipment is not necessary, the procedure
does not take long, and an entire classroom of chil-
dren can participate at once. A 1988 survey of five
programs ranging from 7 to 49 schools and 657 to
10,751 children found an average direct cost of
approximately $2.53 per child per school year
(Garcia 1989). The costs ranged from $0.81 to $5.40,
depending on whether paid personnel or volunteers
supervised the procedure. The economic benefits of a
fluoride supplement program were assessed in ran-
domized controlled clinical trials in Manchester,
England, and results showed overall health and cost
benefits for the experimental group (O'Rourke et al.
1988).

Summary: Dietary Fluoride Supplements

For children not exposed to optimal fluoride concen-
tration in their water supply, the evidence from stud-
ies conducted prior to the 1980s supporting the
effectiveness of home use of daily dietary fluoride
supplements in preventing dental caries in school-
aged children is weak. However, the evidence of the
effectiveness of school-based fluoride supplement
programs is strong. Such programs require highly

TABLE 7.5

Dietary fluoride supplement dosage schedule
          Fluoride Dosage (milligrams per day)
            at Fluoride in Water Concentration of
Age of Child       CO.3 ppm  0.3 to 0.6 ppm   >0.6 ppm

Birth to 6 months
6 months to 3 years
3 to 6
years years
6 to 16 years
years

Source: ADA 1995.

None      None
0.25      None
0.50      0.25
1.00      0.50

None
None
None
None

164         ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


,,,otivated teachers and students, a requirement that
jtkflv has limited their widespread adoption. Experts
recommend that school-based dietary fluoride sup-
plement programs are likely to be effective in provid-
tng topical fluoride protection for children at high
risk for dental caries in settings where supervising
personnel are highly motivated (CDC in press,
Clarkson 1992, Ismail 1994, WHO 1994). Under
these conditions, such programs may also be cost-
effective.

Fluoride Mouthrinses

Several different formulations of fluoride mouth-
rinses are available, differing in the amount of fluo-
ride and suggested frequency of use. Rinses with low
fluoride concentrations (0.05 percent neutral sodium
fluoride or 0.1 percent stannous fluoride) are
designed for daily use and are available over-the-
counter. Higher-concentration rinses (0.2 percent
sodium fluoride) are designed for weekly use and are
available only by prescription or in public programs.

School-based Programs

Fluoride mouthrinses were developed in the 1960s as
a public health measure for use primarily in schools.
They were conceived as a way of avoiding the high
costs associated with professional applications of gels
and other topical fluoride products in school settings
and the poor acceptance by children of brush-on flu-
oride pastes.

For children in the first grade and up, the proce-
dure consists of vigorously rinsing with 10 milliliters
(ml) of solution for 60 seconds. After the rinsing, the
fluoride solution is expectorated into a cup, a napkin
is inserted to absorb the solution, and both are dis-
posed. Kindergarten children rinse with only 5 ml of
solution,

Effectiveness

School-based fluoride mouthrinse programs have
been evaluated extensively during the past three
decades and have been the subject of numerous
reviews (Adair 1998, Birkland and Tore11 1978,
Bohannan et al. 1985, Petersson 1993, Ripa 1991,
Stamm et al. 1984, Tore11 and Ericsson 1974). Of the
many studies during the 1970s and 1980s 13 satis-
fied the strict criteria of randomized controlled clini-
cal trials. Caries reductions ranging from 20 to 50
percent were observed, firmly establishing their effi-
cacy. No recent controlled trials have been done.
After the efficacy of fluoride mouthrinses was estab-
lished, a 17-site national school-based demonstration

program showed that a protocol involving weekly
rinsing with 0.2 percent sodium fluoride was emi-
nently practical. Most studies done after efficacy was
established used a before-and-after design with no
concurrent comparison group. This design might over-
estimate the caries reduction effects. On the whole,
however, the programs appear to have been effective.

A survey conducted in 1984 found fluoride
mouthrinsing programs in 48 states, with 3.2 million
children participating (Bednarsh and Connolly
1984). A later study by CDC reported that 3.25 mil-
lion schoolchildren were participating in mouthrins-
ing programs at 11,683 sites in 1988 (Burt 1989),
although there are reports that some states have
recently curtailed use of these programs (R. Kuthy,
personal communication, 2000).

Cost-effectiveness

The cost of the procedure in 1988 ranged between
$0.52 and $1.78 per child per school year, depending
on whether paid or volunteer adult supervisors were
used (Garcia 1989). An extensive study during the
late 1970s when downward trends of caries rates
were noted, questioned the cost-effectiveness of rinse
programs (Klein et al. 1985). Fluoride mouthrinses
may be more cost-effective when targeted to school-
children with high caries activity (Bawden et al.
1980, Leverett 1989, Tore11 and Ericsson 1965).

Summary: School-based Fluoride Mouthrinse
Programs

Sufficient evidence exists from studies conducted
before 1985 to support the effectiveness of 0.2 per-
cent sodium fluoride mouthrinses in preventing
coronal caries in school populations. There is evi-
dence that with a declining prevalence of dental
caries, the cost-effectiveness of these procedures is
reduced. Experts recommend that school-based rins-
ing once a week with 0.2 percent sodium fluoride is
likely to be effective if used in schools and class-
rooms where students are at high risk for caries and
if applied consistently over time (CDC in press).
Fluoride mouthrinse programs are not recommended
for preschool children in the United States, and pro-
grams for kindergarten children should use only 5 ml
of solution.

Fluoride Varnishes

Fluoride varnishes have not been approved for use in
the United States with an anticaries indication.
However, the U.S. public health community has
begun to investigate the use of fluoride varnishes,

-

Community and Other Approaches to Promote Oral Health and Prevent Oral Disease

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          165


Community and Other Approaches to Promote Oral Health and Prevent Oral Disease

which became available in this country in 1994. The
varnishes are viscous, resinous lacquers painted onto
teeth. Because the varnish adheres to enamel surfaces
for up to 12 hours or more, fluoride retention in the
mouth is greater than with solutions or gels.
Varnishes have been used in Europe for 30 years.

  No data are available on the use of varnishes in
children under 3 years, and, although the results
were positive, only two randomized clinical trials
have been conducted abroad using preschoolers
(Holm 1979, Peyron et al. 1992). Many fluoride rins-
ing programs in Finland have been replaced with flu-
oride varnish application programs (Seppa 1991,
Sundberg et al. 1996). Studies conducted in Canada
(Clark et al. 1987) and Europe (de Bruyn and Arends
1987, Helfenstein and Steiner 1994, Twetman et al.
1996) have found that fluoride varnish is efficacious
in preventing dental caries. Applied semiannually,
this modality is as effective as professionally applied
fluoride gel (Seppa et al. 1995). Some researchers
advocate application of fluoride varnish up to 4 times
per year to achieve maximum effect, but the evidence
of benefits from more than two applications per year
remains inconclusive (Mandel 1994, Seppa 1991,
Seppa and Tolonen 1990). Other studies have shown
that three applications in 1 week, once a year, may be
more effective than the more conventional biannual
regimen (Petersson et al. 1991, Skold et al. 1994).
European studies have shown that fluoride varnishes
prevent decalcification (a very early stage of dental
caries) beneath orthodontic bands (Aclriaens et al.
1990) and slow the progression of existing enamel
lesions (Peyron et al. 1992). Findings on cost-effec-
tiveness are mixed (Kirkegaard et al. 1986, Koch et
al. 1979, Seppa and Pollanen 1987, Vehmanen 1993).

fissure surfaces of teeth. The material hardens within
60 seconds or so into a thin, hard, protective coating.
Sealants were introduced in the late 1960s and
received the American Dental Association Seal of
Approval in 1976 (ADA 1976). Most of the dozen
products approved by the ADA do not contain a ther-
apeutic agent, but work by providing a physical bar-
rier that prevents microorganisms and food particles
from collecting in the pits and fissures (ADA 1997).
First-generation sealants used ultraviolet light to
harden or "cure" the material; improved second- and
third-generation sealants cure by chemical or visible
light activation, respectively.

Sealant placement requires meticulous attention
to technique, but they can be successfully provided
in "field" settings using portable dental equipment.
To be most effective, sealants should be placed on
teeth soon after they erupt, but they can be applied
across a wide age range. Not only does the risk for
caries continue across the life span, but an individ-
ual's risk can increase for any number of reasons.
Sealants are particularly helpful for persons with
medical conditions associated with higher caries
rates, children who have experienced extensive caries
in their primary teeth, and children who already have
incipient caries in a permanent molar tooth.

Effkacy

Dental Sealants

The pits and fissures that characterize the biting sur-
faces of posterior teeth provide a haven for food
debris and decay-causing bacteria. Not surprisingly,
these sites are often the first and most frequent to be
affected by decay in children and adolescents. The
width of most pits and fissures is narrower than a sin-
gle toothbrush bristle, making cleaning of their deep-
est recesses almost impossible. According to national
estimates, as much as 90 percent of all dental caries
in schoolchildren occurs in pits and fissures (Kaste et
al. 1996). The teeth at highest risk by far are perma-
nent first and second molars.

Initial clinical trials using a random half-mouth
design and first- or second-generation sealant materi-
als established their efficacy. Several comprehensive
reviews and a meta-analysis of the amount of caries
prevented testify to the utility of these materials
(Llodra et al. 1993, Ripa 1993, Weintraub 1989).
Llodra et al. (1993) used a systematic process to
select and review studies of one-time sealant place-
ment on permanent teeth in subjects unexposed to
other preventive measures. Pooled results from 17
studies meeting their selection criteria found that
second-generation sealants reduced caries over 70
percent.

Enamel bonding, a technology introduced in the
mid-1950s led to the development of sealants. These
are clear or opaque plastic resinous materials
designed for professional application to the pit-and-

These early trials firmly established retention as
essential to preventing caries; a sealant is virtually
100 percent effective if it is fully retained on the tooth
(NIH 1984). Mertz-Fairhurst (1984) reported 92 to
96 percent retention rates in second-generation
sealants after 1 year, with 67 to 82 percent retention
after 5 years. A review of studies of long-term reten-
tion of second-generation sealants showed 41 to 57
percent intact after 10 years (Ripa 1993). The
longest-running study of a one-time application of a
first-generation sealant indicated a reduction in pit-
and-fissure caries by 52 percent after 15 years

166         ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


;irnonsen 1991). Retention results for third-genera-
ILon sealants are similar to those for second-genera-
l,ol~ systems (Ripa 1993).

flfcctiveness

.\dnunistrators of school-linked sealant programs
Collins et al. 1985, Sterritt and Frew 1988) and of
,chool-based programs with either fixed clinics
, Ismail et al. 1989, Messer et al. 1997, Whyte et al.
1987) or portable equipment (Bravo et al. 1996,
C,ilderone and Davis 1987, Calderone and Mueller
1083. Hardison 1983, Kumar et al. 1997, Morgan et
Lll. 1998) have reported on their experiences with
tlrcse programs. These studies, using second-genera-
tion sealants, have shown effectiveness results com-
parable to those of clinical trials, regardless of the
physical delivery site or personnel used for sealant
application. Complete retention after approximately
I vear varied from 83 to 94 percent (Calderone and
1Iueller 1983, Hardison 1983, Ismail et al. 1989,
Stcrritt and Frew 1988, Whyte et al. 1987).
A Consensus Development Conference spon-
sored by the National Institutes of Health concluded
that "an extensive body of knowledge has firmly
established the scientific basis for the use of sealants"
(NlH 1984). The panel urged the development of
educational materials to enhance public and profes-
sional acceptance as well as third-party reimburse-
ment. Consensus on the value of sealants is reflected
by the inclusion of sealant objectives in Healthy
People 2000 and Healthy People 2010 (see Table
7.6). In addition, sealant placement is supported in
federally funded programs for women and children,
and sealants are covered services in all state Medicaid
programs. A Workshop on Guidelines for Sealant Use
has made recommendations for sealant use in both
community and individual care programs (ASTDD
1995).

Community Dental Sealant Programs

Several community-based public health initiatives
have arisen to promote sealant use among private
practitioners and through community-based pro-
grams. These activities include reaching dentists
through continuing education courses (Bader et al.
1987, Callanen et al. 1986, Siegal et al. 1996); direct-
ing large-scale promotional activities to consumers,
community leaders, and third-party payers (Siegal et
al. 1997a); and providing sealants directly to children
in school programs.

Community programs that provide sealants
directly to schoolchildren generally target vulnerable
populations less likely to receive private dental care,

--

(:L~nrmunit\~ and Other Approaches to Promote Oral Health and Prevent Oral Disease

such as children eligible for free or reduced-cost
lunch programs. School-based programs are usually
conducted entirely on site. School-linked programs
conduct some portion of the program in schools,
such as patient selection and parental permission,
but generally provide the sealants at an off-site pri-
vate practice or clinic. Nationally, 88 community-
based sealant placement programs were in operation
in the 1992-93 school year. These programs served
children in 1,636 schools (Siegal et al. 1997b).

Combining Sealants with a Fluoride Program
Dramatic evidence of the impact of a combined fluo-
ride and sealant program is provided,by a program in
Guam (Sterritt et al. 1990). For many years the chil-
dren on this island had experienced dental caries
rates more than double those of their U.S. mainland
counterparts. In 1984 a school-linked pit-and-fissure
sealant program was added to an existing school-
based fluoride mouthrinse program. More than
15,000 children participated annually in the sealant
program. After 8 years of fluoride mouthrinsing
(from 1976 to 1984), mean decayed, missing, and
filled surface (DMFS) scores declined by 1.79 sur-
faces per child. Only 7 percent of that decline was
due to prevention of caries on surfaces that can ben-
efit from sealants. With the addition of the sealant
program to mouthrinsing, overall DMFS scores
decreased an additional 2.34 surfaces per child in
only 2 years. Most of this decline took place on pit-
and-fissure surfaces. For the lo-year period a reduc-
tion of 4.13 DMFS per child was seen-a decline
from 7.06 DMFS per child at baseline to 2.93 DMFS
in 1986. At the end of the 10 years, participating chil-
dren on Guam had caries rates close to those of main-
land schoolchildren.

The National Preventive Dentistry Demonstra-
tion Program, a large project conducted in 10 U.S.
cities between 1976 and 1981 to compare the costs
and effectiveness of combinations of caries preven-
tion procedures, found that the inclusion of sealants
was critical to the cost-effectiveness of prevention
strategies (Disney et al. 1989, Klein et al. 1985). In
another combined program, Morgan et al. (1998)
found that a 3-year sealant program and a fluoride
mouthrinse program for secondary schoolchildren
incurred a low cost for each tooth surface saved from
caries. The incremental cost-effectiveness ratios com-
paring the intervention to the control group varied
from a cost of $35.60 per tooth surface spared to a net
savings of $7.00, depending on the assumptions used
in the analysis.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

167


Sealing Incipient Caries

Heller et al. (1995) evaluated the effect of sealants
placed as part of a school-based program on perma-
nent first molar teeth after 5 years. Sealants were
applied to both sound teeth and those with incipient
carious lesions (where the fissure is stained but not
yet cavitated). For the initially incipient carious sur-
faces, the 5-year decay rate was 10.8 percent
for sealed surfaces and 5 1.8 percent for unsealed sur-
faces. Initially sound surfaces had a decay rate of 8.1
percent for sealed surfaces and 12.5 percent for
unsealed surfaces. Initially sound tooth surfaces were
unlikely to become decayed in 5 years and did not
benefit greatly from the application of sealants. The
study showed potential efficiencies in targeting teeth
with incipient caries for sealants.

Cost-effectiveness of Sealant Programs

Studies suggest that sealants are an efficient use of
resources when used in populations with higher-
than-average disease incidence rates and when selec-
tion methods limit sealants to teeth at highest risk of
disease. Weintraub et al. (1993) demonstrated cost
savings or improving cost-effectiveness with time in
a sealant study at a children's dental clinic for low-
income families. A strategy of identifying children
with prior molar restorations (an indicator of high
risk) and sealing the remaining molars showed cost
savings within 4 to 6 years.

Summary: Dental Sealant Programs
Studies carried out during the last 20 years provide
strong evidence to support the effectiveness of

TABLE 7.6
Baseline data for Healthy People 2010 objective 21-8a &b: increase the proportion
of children who have received dental sealants on their molar teeth

                   Percentaoe of Children Who Have Received Sealantsa
                       Aaed 8 Years      Aaed 14Years
2010 target                      50           50
Total, 1988-94 baseline                  23            15

Race and ethnicity
American Indian or Alaska Native (1999)b          37           26
Asian or Pacific Islander                  DSU          OSU
Asian                        DNC          DNC
Native Hawaiian and other Pacific Islander        DNC          DNC
Black or African American                  11            5
White                          26          19
Hispanic or Latin0                    DSU          DSU
Mexican American                    10            7
Nat Hispanic or Latin0                  25          DNA
Black or African American                 11            5
White                          29            18
E%                         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 disabilities               DNC          DNC

Selected opulations
Third-gra ! e students                    26           NA

a DNA = data have not been analyzed. DNC = data are not collected. DSU = data are statistically unreliable. NA = not
applicable.
bData are for IHS service areas.
Data rources:National Health and Nutrition Examination Survey (NHANES), NCHS,CDC;Dral Health Survey of Native
Americans, 1999, IHS.
Source: USDHHS 2000.

sealants in preventing the develop-
ment of caries in tooth pits and fis-
sures. Economic analyses suggest
that community sealant programs
are cost-effective and may even
provide cost savings when used in
high-risk populations. Experts rec-
ommend that programs should be
limited to high-risk children and
high-risk teeth.

PREVENTION AND
CONTROL OF
PERIODONTAL
DISEASES

Periodontal diseases, caused by
specific bacteria in dental plaque,
affect most adults at some point in
their lives. The mildest and most
common form of periodontal dis-
ease is gingivitis. Over time, peri-
odontitis, the more severe form of
periodontal disease, can lead to the
destruction of the soft tissue and
bone that anchor the teeth into the
jaw. Lacking support, teeth can
loosen and be lost.

  Periodontal diseases can be
prevented and controlled through
an array of mechanical and chemi-
cal means (Ismail and Lewis 1993,
AAP 1996). Conscientious oral
hygiene and professional oral
cleanings to reduce plaque can
reverse gingivitis (Lee et al. 1965).

768         ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


blethods for personal oral hygiene include tooth-  proper methods of oral hygiene, no community
brushing and flossing, which may be augmented by  methods, other than programs designed to discour-
over-the-counter and prescription mouthrinses with  age tobacco use, are available for preventing gingivi-
antimicrobial action.              tis or periodontitis in the general population.

Community Programs to Prevent
Gingivitis

\`v?th the confirmation of specific bacteria in dental
plaque as the cause of gingivitis, public health offi-
cials began to seek ways to educate the public about
plaque control in community settings, primarily in
schools. These efforts have had equivocal results.
.I\lthough knowledge and attitudes were enhanced in
demonstration programs, improvements in plaque
levels and gingivitis were short-lived in clinical trials
(Horowitz et al. 1980).

Prevention of Periodontitis
Tobacco use is a major risk factor for the develop-
ment and progression of periodontal diseases, and
proven strategies aimed at reducing tobacco use
should aid in the prevention of periodontitis. The
following section on oral and pharyngeal cancers
includes a discussion of such intervention strategies.
Until recently, most interest in controlling tobacco
use reflected concerns about oral cancers. As appre-
ciation of the role of tobacco in the progression of
periodontal diseases and tooth loss increases, atten-
tion to these oral health effects may increase atten-
tion to tobacco cessation in primary oral health care.
Periodontitis can also be a complication of poorly
controlled diabetes. (See Chapters 3 and 5 for a dis-
cussion of other periodontal risk factors; Chapter 5
discusses the connection between periodontal dis-
ease and diabetes.)

PREVENTION AND CONTROL OF
ORAL AND PHARYNGEAL CANCERS
The term oral and pharyngeal cancers refers to a
diverse group of tumors affecting the oral cavity and
pharynx, the majority of which are squamous cell
carcinomas. Usually included are cancers of the lips,
tongue, pharynx, and oral cavity. These malignan-
cies are among the most debilitating and disfiguring
of all cancers. More than 30,00O*new cases of oral
and pharyngeal cancers are diagnosed each year, and
more than 8,000 people die annually from these dis-
eases. The overall 5year survival rate (52 percent)
has not changed in the past four decades (Murphy et
al. 1995, Silverman 1998).

Some efforts have been directed at alerting dental
practitioners to the need to educate patients about
diseases affecting the periodontal tissues (Bader et al.
1990. Brown and Spencer 1989). These efforts have
met with some success, but they tend to reach
only those people who already use dental services.
Currently, there are no broad community-based inter-
vention programs that address periodontal diseases.

Summary

Gingivitis can be controlled with available methods,
and its control is the principal way to prevent peri-
odontitis. However, the currently available methods
are individually or professionally based and require
conscientious oral hygiene practices and regular den-
tal visits. Although some schools instruct children in

Primary risk factors for oral cancers in the
United States are the use of tobacco and alcohol
products and, for lip cancer, exposure to sun.
Tobacco and alcohol independently increase the risk
of oral and pharyngeal cancers and also act synergis-
tically, so that persons who use both are at much
higher risk than those who use only one. Other risk
factors include insufficient fruits and vegetables in
the diet, failure to use ultraviolet protection, and
infection with certain viruses (Winn et al. 1998).
In 1996 CDC convened the National Oral
Cancer Strategic Planning Conference to develop
strategies for preventing and controlling oral and
pharyngeal cancers in the United States. The confer-
ence, which was co-sponsored by the National
Institute of Dental and Craniofacial Research and the
ADA, included over 125 experts in oral and pharyn-
geal cancer prevention and control, treatment, and
research (CDC 1998). These experts developed rec-
ommendations concerning public advocacy, collabo-
ration, and coalition building; public education; pro-
fessional education and practice; and data collection,
evaluation, and research. An ongoing multidiscipli-
nary subgroup from that conference, the Oral Cancer
Working Group, met in 1997 and again in 1999 to
share information on progress made and to discuss
steps to implement a national plan. This group's work
will augment existing interventions directed at the
reduction of tobacco use, for which several commu-
nity-based interventions have already been shown to
be effective. The group is also developing several
statewide models for the prevention and early detec-
tion of oral and pharyngeal cancers.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

169


Many recommendations from the 1996 Strategic
Planning Conference relate to the inclusion of pri-
mary prevention (i.e., reducing risk factors) and early
detection. These include a recommendation that
because people at high risk for oral cancers are more
likely to visit a physician than a dentist, and because
physicians may be less likely than dentists to perform
an oral cancer examination on such patients, all pri-
mary care providers should assume more responsibil-
ity for counseling patients about behaviors that put
them at risk for developing these cancers; should per-
form oral cancer examinations on all patients who
are at high risk for developing the disease because of
tobacco use or excessive alcohol consumption; and
should refer patients to the appropriate specialist for
management of suspicious oral lesions (CDC 1994c,
Elwood and Gallagher 1985, Lynch and Prout 1986,
Prout et al. 1990, Yellowitz and Goodman 1995).
Further research is needed to better define screening
parameters. Comprehensive education of medical
and dental practitioners in diagnosing and promptly
managing early lesions was recommended to facili-
tate the multidisciplinary collaboration needed to
detect oral cancers in their earliest stages.
Furthermore, because of the public's lack of knowl-
edge about the risk factors for oral cancers and
because these diseases can often be detected in the
early stages. it is also recommended that programs to
raise the public's awareness of oral cancers (including
their risk factors, signs, and symptoms) be increased.

Community-based Interventions

Community-based interventions for oral and pharyn-
geal cancer prevention have depended on tobacco
control programs.

School-based Prevention Programs

On average, more than 3,000 children and teenagers
become regular smokers each day (USDHHS 1994).
Prevention efforts aimed at young people are
extremely important because nearly all initiation of
tobacco use in the United States occurs by age 18.
Moreover, the finding that the earlier that smoking
begins the more likely it is to lead to heavy use in
adulthood makes preventing tobacco use among
school-age youth all the more critical (CDC 1994a).

Programs identifying the social influences that
foster tobacco use in schoolchildren and teaching
skills to resist such influences have yielded consis-
tent and significant results. Reductions or delays in
adolescent smoking have been documented, ranging

from 25 to 60 percent and persisting from 1 to 4 years
(CDC 1994b). The interventions were based on a
CDC review of published research, including the
conclusions of the National Cancer Institute's (NCI)
Expert Advisory Panel on School-based Smoking
Prevention Programs and findings from the 1994
Surgeon Generals report, Preventing Tobacco Use
Among Young People (CDC 1994b). The Guidelinesfor
School Health Programs to Prevent Tobacco Use and
Addiction cites seven recommendations (CDC
1994a,b):

1. Develop and enforce a school policy on
tobacco use.

  2. Provide instruction about the short- and
long-term negative phys;ologic and social conse-
quences of tobacco use, social influences on tobacco
use, peer norms regarding tobacco use, and refusal
skills.

3. Provide tobacco-use-prevention education
in kindergarten through 12th grade; this instruction
should be especially intensive in junior high or mid-
dle school and reinforced in high school.

4.  Provide program-specific training for teachers.
5. Involve parents or families in support of

school-based programs to prevent tobacco use.

6. Support cessation efforts among students
and all school staff who use tobacco.

7. Assess the tobacco-use-prevention program
at regular intervals.

A major part of most successful interventions has
been the decrease of illegal sales to minors. This
strategy has been accomplished by increasing mer-
chant education and enforcement of laws prohibiting
tobacco sales to minors under 18 and increasing the
cost of cigarettes (CDC 1994a,b, Lewit et al. 1997,
Lynch and Bonnie 1994). All 50 states and the
District of Columbia have laws prohibiting the sale of
tobacco, including smokeless (spit) tobacco, to
minors.

In recent years, attempts to prevent and reduce
the use of spit tobacco have increased. These infor-
mational and educational efforts have largely target-
ed baseball clubs, Little League baseball teams, and 4-
H Club members. A major new initiative, the
National Spit Tobacco Education Program, has been
launched by Oral Health America, with support from
NIH and CDC and funding largely from the Robert
Wood Johnson Foundation in collaboration with the
Major League Baseball Players Association, to help
break the link between spit tobacco and Major
League Baseball.

170        ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


Other Program Models

The majority of community programs designed to
prevent or reduce the use of tobacco products have
focused on cigarette smoking. Initially, NC1 funded
randomized trials of interventions to prevent smok-
ing in adolescents and promote cessation in adults.
The value of multiple interventions delivered
through multiple channels was confirmed in NCIS
Community Intervention Trial for Smoking
Cessation (COMMIT 1995a,b).

Findings from more than 100 intervention trials
continue to provide important information about
how to reach smokers and potential smokers. A
major conclusion from these studies is that large-
scale reductions in smoking prevalence are unlikely
when interventions focus on the individual, but that
interventions can be effective when community-
based. Further, researchers found a statistically sig-
nificant difference in the proportion of light-to-mod-
erate (but not heavy) smokers who quit in the inter-
vention communities compared with control com-
munities (COMMIT 1995a,b, Klausner 1997, NC1
1995).

Findings from COMMIT and other studies in the
United States and abroad led to planning for ASSIST
(American Stop Smoking Intervention Study for
Cancer Prevention). In 1990, California adopted the
ASSIST model, and early success in the California
Statewide Tobacco Control Program clearly showed
an impact on per capita cigarette consumption in that
state compared with consumption in the United
States as a whole (Manley et al. 1997a.b, Shopland
1993). The ASSIST model uses surveillance systems
that allow for time-series analysis designs comparing
intervention and control communities, Media-led
tobacco control campaigns, as well as efforts to
increase state excise taxes on cigarettes and thereby
discourage teenagers from smoking, are included in
the model.

There are now dedicated tobacco-control coali-
tions in all 50 states, and the Agency for Healthcare
Research and Quality (formerly Agency for
Healthcare Policy and Research) has developed clini-
cal practice guidelines on smoking cessation to aid
health professionals in interventions with patients
(Fiore 1997).

Although the major focus in reducing the risk for
oral and pharyngeal cancers has been on tobacco ces-
sation programs, reduction in alcohol use is clearly
indicated. Currently, alcoholic beverages carry the
Surgeon Generals warning label stating that pregnant
women should not drink because of the risk of birth
defects and admonishing that alcohol impairs the

ability to drive and operate machinery and may cause
other health problems, Many communities have pro-
grams that stress responsible drinking by adults relat-
ed to the use of motor vehicles and completely dis-
courage drinking among young drivers. Community
approaches have also been developed to discourage
drinking among young people. Targets are youth and
adults who are at risk for alcohol-related problems,
such as college students who may need to develop
skills to avoid binge drinking, or women attending
women's clinics who might not know the risk of fetal
alcohol syndrome. Because alcohol use, like tobacco
use, usually begins in adolescence, development and
testing of community- and school-based programs
that provide youth with the skills'to avoid alcohol
use are warranted.

Early Diagnosis of Oral and Pharyngeal
Cancers

Primary care providers can counsel patients about
lifestyle behaviors that increase the risk for oral can-
cers. Dental as well as medical personnel have pro-
vided successful tobacco control programs in their
offices (see Chapter 8). Generally, Americans are ill-
informed about the risk factors as well as the signs
and symptoms of oral cancers (Horowitz and
Nourjah 1996, Horowitz et al. 1995). The mass
media have paid little attention to the topic, and
health education textbooks are nearly devoid of dis-
cussion (Canto et al. I998b, Chung et al. 2000, Gold
and Horowitz 1993, Horowitz et al. 1998). The scant
attention that has been paid to oral cancers has
focused on the role of spit tobacco.

At present, the principal test for oral and pha-
tyngeal cancers is a comprehensive clinical examina-
tion that includes a visual/tactile examination of the
mouth, full protrusion of the tongue with the aid of
a gauze wipe, and palpation of the tongue, floor of
the mouth, and lymph nodes in the neck. The U.S.
Preventive Services Task Force concluded that there
was insufficient evidence to recommend for or
against routine screening for oral cancers, but noted
that clinicians should remain vigilant for signs and
symptoms of oral cancers and premalignancy in peo-
ple who use tobacco or regularly use alcohol (USPSTF
1996). The Canadian Task Force on Periodic Health
Examination (1997) states that although there is
insufficient evidence to include or exclude screening
for oral cancers from the periodic health examination
for the general public, those at high risk (smokers
and heavy drinkers) over 60 warrant an annual oral
cancer exam by a physician or dentist (Lewis and

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          171


Contmunit~ and Other ;\pproachts to Promote Oral Health and Prevent Oral Disease

Ismail 1995). The American Cancer Society recom-
mends annual examinations for individuals 40 and
older and for individuals who are exposed to known
risks. Nevertheless, a 1992 national survey showed
that only 15 percent of U.S. adults reported ever hav-
ing had an oral cancer examination (Horowitz and
Nourjah 1996).

molecular events involved in developing cancer
might provide the tools needed to design novel pre-
ventive, diagnostic, prognostic, and therapeutic regi-
mens to combat oral cancers. Acquiring greater
knowledge of the biology, immunology, and patholo-
gy of the oral mucosa may also help reduce the mor-
bidity and mortality from these cancers.

There are large gaps in knowledge of the efficacy
of oral cancer examinations and the effectiveness and
cost-effectiveness of community approaches to early
detection of oral cancers. Methodologies and settings
differ across studies. Moreover, these studies do not
provide definitive evidence supporting the oral can-
cer exam, and there have been no controlled clinical
trials for defining the effectiveness of screening pro-
grams. Further research is thus needed.

PREVENTION AND CONTROL OF
CRANIOFACIAL BIRTH DEFECTS

Summary

Although no school- or community-based interven-
tions specifically designed for the prevention or early
detection of oral and pharyngeal cancers are now in
place, scientists representing the agencies in the
newly formed oral cancer consortium have begun to
develop statewide model protocols, beginning with
the state of Maryland. In the meantime, any program
that aims at eliminating tobacco use will reduce the
primary risk factor for oral and pharyngeal cancers,
along with other tobacco-related diseases. The evi-
dence on the effectiveness of school-based programs
to prevent tobacco use and addiction among children
and adolescents provides strong support for their use
as part of the school health education curriculum.
Further, other community-based interventions such
as COMMIT and ASSIST are recommended because
they have demonstrated effectiveness in getting light-
to-moderate smokers to quit. After reviewing the evi-
dence, an expert panel convened by AHCPR (now
the Agency for Healthcare Research and Quality) rec-
ommended that all primary care clinicians be trained
to provide smoking cessation activities (see Chapter
8). In addition, providers should perform oral cancer
examinations on high-risk persons regularly. The rec-
ommendation to use all of these interventions to pre-
vent or cease tobacco use in communities is based on
expert opinion.

The causes of craniofacial birth defects are often
complex and multifactorial-the result of gene-envi-
ronment interactions occurring'from the time of con-
ception to birth. Even when a mutation in a single
gene has been discovered as the cause of a particular
syndrome, there can be considerable variation in sus-
ceptibility, with some infants showing little or no sign
of a problem and others experiencing multiple organ
defects.

The work to complete the mapping and sequenc-
ing of the human genome will undoubtedly shed
light on the hundreds of genes involved in craniofa-
cial development and provide details on when and
how they function in development. This knowledge
may in turn lead to gene therapies that restore or
"rescue" the function of a defective gene and thus
prevent the anomaly.

Craniofacial defects also may occur because the
susceptible embryo or fetus was exposed to an envi-
ronmental teratogen, a diminished oxygen supply, or
a deficit in an essential nutrient. Chapter 5 reports an
association between low-birth-weight, premature
babies who may show other subtle craniofacial
anomalies and mothers with chronic oral infectious
disease. In addition, diets poor in folic acid increase
the risk of spina bifida and possibly clefting syn-
dromes. Clinical trials using vitamin supplementa-
tion with varying levels of folic acid are under devel-
opment to determine if they can lower the risk of
clefts in high-risk pregnancies. Outcomes of clinical
trials of nutrient supplementation in pregnancy may
lead to new nutritional guidelines and the develop-
ment of enriched food products, which can form the
basis for community-wide health promotion and dis-
ease prevention programs.

  Oral cancers occur in sites that lend themselves
to early detection by most primary health care
providers and, to a lesser extent, by self-examination.
Heightened awareness in the genera1 population
could help with early detection and could stimulate
dialogue between patients and their primary health
care providers about behaviors that may increase
their risk. Recent advances in understanding the

Given the array of variables affecting prenatal
growth and development, the key to public health
programs aimed at preventing birth defects lies pri-
marily in health promotion and education cam-
paigns. Individuals need to be made aware of known
risk and protective factors in pregnancy Such pro-
grams should emphasize the importance of good
nutrition, avoidance of tobacco and alcohol use, and

172         ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


prenatal care. Education includes knowledge about
tl,c teratogenic effects of prescription drugs, such as
the antiepileptic drug phenytoin and the retinoic acid
drugs used to treat cystic acne.

Summary

.\s information from developmental biology genetics,
.ind epidemiologic and clinical studies accrues, den-
tal care providers are better positioned to provide
counseling. The public is best served by health pro-
motion and disease prevention campaigns that com-
municate findings about risk and protective factors in
pregnancy.

PREVENTION AND CONTROL OF
INTENTIONAL AND UNINTENTIONAL
INJURY

Intentional and unintentional injuries are related to
behaviors and are thus amenable to prevention. As
studies of motor vehicle and sports injuries have de-
monstrated, injuries are frequently due to a sequence
of predictable events, and a public health approach
can be successful in injury prevention and control.
The interventions that have proved to be most
effective in controlling injuries have been passive;
that is, they do not require the individual to partici-
pate. Examples include the use of environmental
controls such as vehicle and roadway design, speed
limits, passenger restraints, and airbags to prevent
injuries from motor vehicle collisions (Karlson 1992,
Smith and Falk 1987). Passive measures such as
these are more easily implemented at the state or fed-
eral level. However, many preventive measures for
oral-facial injuries have been directed at the individ-
ual and professional health service levels, rather than
at the population at large (see Table 7.7).

Craniofacial Injuries

The principal causes of craniofacial injuries are
motor vehicle collisions, falls, assaults, and sporting
activities. Except in relation to sports, injuries to the
craniofacial region have received little attention.
These injuries are hardly insignificant, however, and
efforts to prevent them are gaining acceptance. For
example, to increase public awareness of the impor-
tance of facial protection, the inaugural National
Facial Protection Month was celebrated in April
2000. This national campaign, providing information
to the media and the public, was sponsored by the
American Association of Oral and Maxillofacial
Surgeons (AAOMS 2000).

Motor vehicle collisions are the leading cause of
death during the first three decades of life in the
United States and the leading cause of death from
injury over most of the life span (Baker et al. 1992).
Data from multiple sources indicate that craniofacial
injuries account for a substantial subset of these
injuries annually (USDOT 1998). Even though it is
likely that passive measures enacted to reduce fatali-
ties have reduced nonfatal craniofacial injuries, no
supporting data exist.

Various sources report the number of motorcy-
cle- and pedal-cycle-related craniofacial injuries.
Data from the National Electronic Injury Surveillance
System indicate that head injuries account for 50 per-
cent of all pedal-cycle-related injuries; of those, bicy-
cle-related events accounted for 19 percent of all
facial injuries within the study period (McDonald
1994). In similar studies, tricycle-related incidents
were found to be responsible for up to 61 percent of
injuries to the head, face, or mouth (CDC 1987,
USCPSC 1986). Motorcycle injuries are a major
source of fatal and nonfatal head trauma in the
United States (Rivara et al. 1988).
Helmet use reduces head and facial injuries
among bicyclists (Acton et al. 1995, Grimard et al.
1995, Rivara et al. 1997) and motorcyclists (Bachulis
et al. 1988, Johnson et al. 1995, Lee et al. 1995) by
up to 50 percent. Health promotion efforts have
increased acceptance at the community level for hel-
met use by bicyclists; however, helmet use regula-
tions vary by state (Sacks et al. 1996) and with the
public whim (Sosin et al. 1990). Over a dozen states
currently have bicycle helmet laws, and half of the
states have motorcycle helmet laws (NCHS 1992).
Many authors  have described craniofacial
injuries related to sports. Information is usually
obtained from community or regional surveys of
injuries or mouthguard use and effectiveness.
Craniofacial injuries sustained during sporting activ-
ities are a major source of nonfatal injury and dis-
ability (Baker et al. 1992), possibly accounting for up
to one third of all sports injuries (Cathcart 1982,
Meadow et al. 1984). The increasing participation of
women in competitive sports means that young
women should be alerted to the risks and advised of
the need for additional protective gear as appropriate.
The most comprehensive data on the effectiveness of
protective equipment have been collected by agen-
cies such as the National Alliance of Football Rules
Committee,  the National Collegiate Athletic
Association, and the U.S. Consumer Product Safety
Commission. Data on craniofacial injuries from par-
ticipation in football before and after the enactment
of mandatory mouthguard regulations indicate a

ii~nlmunity and Other Approaches to Promote Oral Health and Prevent Oral Disease

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          173


TABLE 7.7

Community-based interventions for the prevention and control of craniofacial injuries

          Restraints and Airbags              Helmets

Mouthguards

Guidelines for use

Public policies

Utilization rates

Type of evidence for
effectiveness and PHS
ratings

Evidence for
effectiveness

Combination of manual lap and
automatic shoulder restraints plus
airbag;emphasis on passive
systems to overcome
noncompliance

Restraints: Mandatory use
required by law in 48 states
Airbags: All late model vehicles
required to have driver-side
airbags,and future models to add
passenger-side airbags;National
Traffic and Motor Vehicle Safety
Act legislates policies

Restraints:Compliance with
seatbelt laws ranges from 29 to 74
percent (Reinfurt et al. 1991);
current use may be as high as 67
percent (NCHS 1992)
Airbags: Utilization may become
an issue if on-off switch is
implemented

* Hospital and trauma registry

studies (Sutyak et al.
1997, Orsay et al. 1990)

* Modeling from insurance
studies (Sorenson 1993)

* Case-control study (Marine

et al. 1994)

Restraints: Use reduces facial
injuries by 30 percent (Orsay et al.
1990)
Airbags: Projected facial injury
harm reduction of up to 90
percent for airbag added to
restraint (Sorenson 1993); report
of facial injuries may increase with
airbags due to a decrease in
fatalities and more severe injuries
(Blacksin 1993)

Cyclists, both motorized and nonmotorized,
wear approved protective helmets,
preferably with a full face mask for
motorcyclists

* 13 states have bicycle helmet laws;
25 have motorcycle helmet laws
* Post-law bicycle helmet use rates increase
by up to 50 percent among children
(National Center for Injury Prevention and
Control 1995)

. States with helmet use laws have higher

Football: Wear helmet with face mask and
use mouthguard
Hockey: Wear helmet with face mask and
use mouthguard because face shields do not
prevent injury to lower face
Football: Requirement since 1962 for
mandatory mouthguard use in football
accompanied by significant decline in inci-
dence of oral-facial injuries
Hockey: Mand$ory requirement for full
facial protection in Canada has reduced facial
injuries among youth (Rampton et al. 1997)

rates of helmet use

Bicycle: Approximately half of bicyclists    Football: 72 percent of children wear head-
own a helmet,and half of those consistently   gear and mouthguards
wear it (Sacks et al. 1996); 62 percent of    Baseball/softball: 35 percent of children
motorcyclists and 17.6 percent of bicyclists   wear headgear; 7 percent consistently wear
wear helmets (NCHS 1992)         mouthguards

* Hospital and trauma registry studies
(Bachulis et al.1988, Johnson et al.1995)
* National survey (Sacks et al. 1996)
* Case-control study (Thompson et al.
1996)

Motorcycle: A twofold decrease in
incidence of maxillofacial trauma in
helmeted versus nonhelmeted motorcyclists
(Bachuiis et al. 1988); nonhelmeted 3 times
more likely to have facial fractures than
those with helmets (Johnson et al. 1995)
Bicycle: Helmet wearers have a 65 percent
reduction in upper- and mid-face injuries
(Thompson et al. 1996); head injuries
decreased 67 percent in children
concomitant with rate of helmet use
increase of 35 percent following educational
campaign (Rivara et al. 1994); helmets with
face protection decrease facial injuries by a
factor of 3 (Vaughan 1977); helmet wearing
alone is not sufficient to prevent serious
injury and fatality (Rivara et al. 1997)

Soccer: 4 percent of children wear headgear;
7 percent of children wear mouthguards
(Nowjack-Raymer and Gift 1996)
Basketball:4 percent of respondents report-
ed wearing mouthguards (Maestrello-
deMoya and Primosch 1989)

. Hospital and trauma registry studies
* Questionnaire (baseball and basketball)
* Before and after NFA rule in 1962
* Descriptive survey (Maestrello-deMoya

and Primosch 1989)

Football: Face mask reduces oral-facial
injury by 50 percent;addition of a mouth-
guard reduces risk to less than 1 percent
(AAHPER 1960)
Hockey: Full-face protection reduced chance
of upper facial injury; half visor same as no
face protection (Rampton et al. 1997)
Baseball and basketball: 60 times more
likely to sustain oral injury without mouth-
guard (McNutt et al. 1989);30 percent
reduced risk of oral-facial injury for those
wearing mouthguards (Powers et al. 1984)

174

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


Restraints and Airbags

Helmets

Mouthguards

I            airbag
costs and effectiveness  Airbags and restraints: U.S. costs
          are calculated for all injuries or
         fatalities,not craniofacial injuries:
          Australian report estimated
         savings of 108 million (Australian)
         dollars per year due to facial injury
           reduction (Sorenson 1993)

Risks

Restraints:
* Improper car seat design and
use for infants
Airbags:

* No injuries have been documented
secondary to the helmet itself; helmets do
not decrease risk of injury to lower face,
mandible,and mouth

* Concern regarding higher risk
for death in children and small

women

* Case report of facial
desquamation from ruptured

Bicycle: Hospital treatment costs for
bicyclists estimated at 51 billion annually-
includes mortality and morbidity (Sacks
et al. 1996)

Recommendations
(abstracted from CDC
1987,USOHHS 2000)

. Extend safety belt laws to all 50   . Helmets should meet recommended

states            industry manufacturing standards
* Increase airbag efficacy and    * Implement national mandatory helmet
safety research for craniofacial    requirement law for motorcyclists in all
injuries                 states

* Implement national mandatory helmet
requirement law for child bicyclists in all
states-strongly recommend helmet use
for adult bicyclists

* Combine helmet use with education and

`  health promotion and environmental
controls (e.g., separation of cyclists and
motor vehicles, features to make cyclist
more visible)

* State and local health departments should
engage in health promotion for helmet
use, develop and work for legislation for
mandatory helmet use, and evaluate
programs

Costs are high because mouthguards should be
fabricated for each individual by a health
professional

Hockey: Oirect costs:3 million (Canadian)
dollars annually (Rampton et al. 1997)

* Extend mandatory mouthguard use for all
team sports sponsored by organizations,
agencies, and institutions
. Utilize health promotion and education of
trainers, athletes, and parents to increase use
of protective sporting equipment

J

significant decline in craniofacial injuries (Sane
1988). Further, the U.S. Consumer Product Safety
Commission's review of National Electronic Injury
Surveillance System data showed that mouth in-
juries were more frequent in baseball than in any
other sport monitored (USCPSC 1981). These com-
bined reports were instrumental in implementing
policies for protective equipment use in these two
sports. (See Box 7.2, Sports Injuries and Oral-Facial
Trauma.)

Research on elderly and disabled individuals has
led to the development of safety measures to prevent

unintentional injuries from falls in the home. These
include installing adequate lighting and handrails,
using nonskid materials on floors and in bathrooms,
and positioning furniture to reduce the risk of trip-
ping. Wider distribution and adoption of such safety
measures should lower the risk of oral and craniofa-
cial injuries due to falls for the general population as
well, not only in the home but also in the workplace
and other settings.

ORAL HE4LTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

175