Linkages with General Health

Glavind L, Lund B, Lee H. The relationship between
periodontal state and diabetes duration, insulin
dosage and retinal changes. J Periodontol 1968
Nov;39(6):341-7.

Glick M, Garfunkel AA. Common oral findings in two
different diseases-leukemia and AIDS. Part 1.
Compendium 1992 Jun:13(6):432,434,436 passim.
Glick M, Muzyka BC, Lurie D. Salkin LM. Oral mani-
festations associated with HIV-related disease as
markers for immune suppression and AIDS. Oral
Surg Oral Med Oral Path01 1994a Apr:77(4):344-9.
Glick M, Muzyka BC, Salkin LM. Lurie D. Necrotizing
ulcerative periodontitis: a marker for immune deteri-
oration and a predictor for the diagnosis of AIDS. J
Periodontol 1994b May;65(5):393-7.
Gonzalez M. Banderas JA, Baez A, Belmont R. Salivary
lead and cadmium in a young population residing in
Mexico City Toxic01 Lett 1997 Sep 19;93(1):55-64.
Goteiner D, Sonis ST, Fasciano R. Cavernous sinus
thrombosis and brain abscess initiated and main-
tained by periodontally involved teeth. J Oral Med
1982;37:80-3.

Goteiner D, Vogel R, Deasy M, Goteiner C. Periodontal
and caries experience in children with insulin-
dependent diabetes mellitus. J Am Dent Assoc 1986
Aug;113(2):277-9.

Grau 14J, Buggle E Ziegler C, Schwarz W, Meuser J,
Tasman AJ, Buhler A, Benesch C, Becher H, Hacke
W. Association between acute cerebrovascular
ischemia and chronic and recurrent infection. Stroke
1997 Sep;28(9):1724-9.

Greenberg MS. HIV-associated lesions. Dermatol Clin
1996 Apr;14(2):319-26.

Greenspan D, Greenspan JS. HIV-related oral disease.
Lancet 1996 Sep;348(9029):729-33.

Greenspan D, Greenspan JS, Conant M, Petersen V,
Silverman S Jr, De Souza Y. Oral "hairy" leukoplakia
in male homosexuals: evidence of association with
both papillomavirus and a herpes-group virus.
Lancet 1984 Ott 13;2(8407):831-4.

Greenspan D, Greenspan JS, Hearst NG, Pan LZ,
Conant MA, Abrams DI, Hollander H. Levy JA.
Relation of oral hairy leukoplakia to infection with
the human immunodeficiency virus and the risk of
developing AIDS. J Infect Dis 1987 Mar;155(3):
475-81.

Greenspan D, Greenspan JS, Souza YG, Levy JA, Ungar
AM. Oral hairy leukoplakia in an HIV-negative renal
transplant recipient. J Oral Path01 Med 1989
Jan;18( 1):32-4.

Greenspan JS. In: Fauci AS, Isselbacher KJ, Braunwald
E, Wilson JD, Martin JB, Kasper DI. editors.
Harrisons principles of internal medicine. 14th ed.
New York: McGraw-Hill; 1998.
Greenspan JS, Greenspan D. Lennette ET, Abrams DI,
Conant MA, Petersen VH. Oral viral leukoplakia-a
new AIDS-associated condition. Adv Exp Med Biol
1985:187:123-8.

126        ORAL HEALTH IN AMERIC.4: A REPORT OF THE SURGEON GENERAL

Grossi SG, Genco RJ. Periodontal disease and diabetes
mellitus: a two-way relationship. Ann Periodontol
1998 Jul;3( 1):51-61.

Grossi SG, Zambon JJ, Ho AW, Koch G, Dunford RG,
Machtei EE, Norderyd OM, Genco RJ. Assessment of
risk for periodontal disease. I. Risk indicators for
attachment loss. J Periodontol 1994 Mar;65(3):
260-7.

Grossi SG, Skrepcinski FB, DeCaro T, Zambon JJ,
Cummins D, Genco RJ. Response to periodontal
therapy in diabetics and smokers. J Periodontol 1996
Oct;67(10 Suppl):1094-102.

Grossi SG, Skrepcinski FB, DeCaro T, Robertson DC,
Ho AW, Dunford RG, Genco RJ. Treatment of peri-
odontal disease in diabetes reduces glycated hemo-
globin. J Periodontol 1997 Aug;68(8):713-9.
Grossi SG, Donahue R, Quattrin T, Trevisan M, Ho A,
Genco RJ. Periodontal disease increases the risk for
insulin resistance. J Dent Res 1999;78(IADR abstract
no. 3486).

Guven Y, Satman I, Dinccag N, Alptekin S. Salivary per-
oxidase activity in whole saliva of patients with
insulin-dependent (type-l) diabetes mellitus. J Clin
Periodontol 1996 Sep;23(9):879-81.
Haeckel R. Factors influencing the saliva/plasma ratio of
drugs. In: Malamud D, Tabak L, editors. Saliva as a
diagnostic fluid. Ann NY Acad Sci 1993;694: 128-42.
Hallgren R, Lundquist G. Elevated serum levels of pan-
creatic polypeptide are related to impaired glucose
handling in  inflammatory   states.  Stand J
Gastroenterol 1983 May;18(4):561-4.
Harrison R, Bowen WH. Periodontal health, dental
caries, and metabolic control in insulin-dependent
diabetic children and adolescents. Pediatr Dent 1987
Dec;9(4):283-6.

Hayes C, Sparrow D, Cohen M, Vokonos PS, Garcia RI.
The association between alveolar bone loss and pul-
monary function: the VA Dental Longitudinal Study.
Ann Periodontol 1998 Ju1;3(1):257-61.
Heimdahl A, Gahrton G, Groth G-C, et al. Selective
decontamination of the alimentary tract microbial
flora in patients treated with bone marrow trans-
plantation. Stand J Infect Dis 1984;16(1):51-60.
Heimdahl A, Mattson T, Dahllbf E Lonnquist B,
Ringden 0. The oral cavity as a port of entry for early
infections in patients treated with bone marrow
transplantation. Oral Surg Oral Med Path01 1989;68:
71 l-6.

Herzberg MC, Meyer MW. Effects of oral flora on
platelets: possible consequences in cardiovascular
disease. J Periodontol 1996 Oct;67(10 Suppl):
1138-42.

Herzberg MC, Meyer MW Dental plaque, platelets, and
cardiovascular diseases. Ann Periodontol 1998
Ju1;3( 1):151-60.

Herzberg MC, Brintzenhofe KL, Clawson CC.
Aggregation of human platelets and adhesion of
Streptococcus sanguis.  Infect   Immun   1983
Mar;39(3):1457-69.


Herzberg MC. MacFarlane GD, Liu P Erickson PR. The
platelet as an inflammatory cell in periodontal dis-
eases: interactions with Porphyromonas gingivalis. In:
Genco R, Hamada S, Lehner T, McGhee J,
Mergenhagen S, editors. Molecular pathogenesis of
periodontal disease. Washington: American Society
for Microbiology; 1994. p. 247-55.
Hildebolt CE Pilgram TK, Dotson M, Yokoyama-
Crothers N, Muckerman J, Hauser J, Cohen 5,
Kardaris E, Vannier MW, Hanes P, Shrout MK.
Civitelli R. Attachment loss with postmenopausal
age and smoking. J Periodontal Res 1997
Oct;32(7):619-25.

Hillier SL, Martius J, Krohn MJ, Kiviat N, Holmes KK,
Eschenbach DA. A case-control study of chorioam-
nionic infection and histologic chorioamnionitis in
prematurity N Engl J Med 1988 Oct;319(15):972-8.
Hillier SL, Nugent RP, Eschenbach DA, Krohn MA,
Gibbs RS, Martin DH, Catch MF, Edelman R,
Pastorek JG Znd, Rao AV, et al. Association between
bacterial vaginosis and preterm delivery of a low-
birth-weight infant. The vaginal infections and pre-
maturity study group. N Engl J Med 1995
Dec;333(26):1737-42.

Hirai T, lshijima T, Hashikawa Y, Yajima T. Osteoporosis
and reduction of residual ridge in edentulous
patients. J Prosthet Dent 1993 Jan;69( 1):49-56.
Holmes K, Sparling PE Mardh P, Lemon SM, Stamm W,
Piot P Wasserheit J, editors. Sexually transmitted dis-
eases. 3rd ed. New York: McGraw-Hill: 1999.
Hotamisligil GS, Shargill NS, Spiegelman BM. Adipose
expression of tumor necrosis factor-alpha: direct role
in obesity-linked insulin resistance. Science 1993
Jan;259(5091):87-91.

Hove KA, Stallard RE. Diabetes and the periodontal
patient. J Periodontol 1970 Dec;41(12):713-8.
Hugoson A, Thorstensson H, Falk H, Kuylenstierna J.
Periodontal conditions in insulin-dependent diabet-
ics. J Clin Periodontol 1989 Apr;16(4):215-23.
Humphries 5, Devlin H, Worthington H. A radiograph-
ic investigation into bone resorption of mandibular
alveolar bone in elderly edentulous adults. J Dent
1989 Apr;17(2):94-6.

Institute of Medicine (IOM), Committee to Study the
Prevention of Low Birth Weight, Division of Health.
Promotion and disease progression. Preventing low
birth weight. Washington: National Academy Press;
1985.

Itin P, Rufli T, Rudlinger R, Cathomas G, Huser B,
Podvinec M, Gudat E Oral hairy leukoplakia in a
HIV-negative renal transplant patient: a marker for
immunosuppression? Dermatologica 1988;177(2):
126-8.

Itin PH, Lautenschlager 5, Fluckiger R, et al. Oral man-
ifestations in HIV-infected patients: diagnosis and
management. J Am Acad Dermatol 1993:29:749-60.
Jeffcoat MK. Osteoporosis: a possible modifying factor
in oral bone loss. Ann Periodontol 1998;3:312-21.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

Linkages with General Health

Jeffcoat MK, Lewis CE, Reddy MS, Wang CY, Reford M.
Post-menopausal bone loss and its relationships to
oral bone loss. Periodontology 2000. (in press).
Joselow MM, Ruiz R, Goldwater LJ. Absorption and
excretion of mercury in man. XIV Salivary excretion
of mercury and its relationship to blood and urine
mercury Arch Environ Health 1968 Jul;17(1):39-43.
Joshi N, O'Bryan T, Appelbaum PC. Pleuropulmonary
infections caused by Eikenella corrodens. Rev Infect
Dis 1991 Nov-Dec;13(6):1207-12.
Joshipura KJ, Rimm EB, Douglass CW, Trichopoulos D,
Asherio A, Willett WC. Poor oral health and coro-
nary heart disease. J Dent Res 1996 Sep;75(9):
  1631-6.

Joshipura KJ, Ascherio A, Rimm E, Douglass CW,
Willett WC. The relation between tooth loss and
incidence of ischemic stroke. Circulation 1999;
99:1121.

Kaye D. Infective endocarditis. In: Fauci AS, Isselbacher
KJ, Braunwald E, Wilson JD, Martin JB, Kasper DL,
editors. Harrison's principles of internal medicine.
13th ed. New York: McGraw-Hill; 1994. p. 520-6.
King GN, Healy CM, Glover MT, Kwan JT, Williams
DM, Leigh IM, Thornhill MH. Prevalence and risk
factors associated with leukoplakia, hairy leuko-
plakia, erythematous candidiasis, and gingival
hyperplasia in renal transplant recipients. Oral Surg
Oral Med Oral Path01 1994 Dec;78(6):718-26.
Kjellman 0, Hem&son CO, Berghagen N, Andersson
B. Oral conditions in 105 subjects with insulin-treat-
ed diabetes mellitus. Sven Tandlak Tidskr 1970
Feb;63(2):99-110.

Klein A. Bruser B, Bast M, Rachlis A. Progress of HIV
infection and changes in the lipid membrane struc-
ture of CD4+ cells. AIDS 1992 Mar;6(3):332-3.
Klein RS, Harris CA, Small CB, Moll B, Lesser M,
Friedland GH. Oral candidiasis in high-risk patients
as the initial manifestation of the acquired immun-
odeficiency syndrome. N Engl Med J 1984 Aug
9;311(6):354-8.

Kline MW. Oral manifestations of pediatric human
immunodeficiency virus infection: a review of the lit-
erature. Pediatrics 1996 Mar;97(3):380-8.

Koelle DM, Huang ML, Chandran B, Vieira J, Piepkom
M, Corey L. Frequent detection of Kaposi's sarcoma-
associated herpesvirus (human herpesvirus 8) DNA
in saliva of human immunodeficiency virus-infected
men: clinical and immunologic correlates. J Infect
Dis 1997;176(1):94-102.

Krall EA, Dawson-Hughes B, Papas A, Garcia RI. Tooth
loss and skeletal bone density in healthy post-
menopausal women. Osteoporos Int 1994 Mar;4(2):
104-9.

Krall EA, Garcia RI, Dawson-Hughes B. Increased risk
of tooth loss is related to bone loss at the whole body
hip, and spine. Calcif Tissue Int 1996 Dec;59(6):
433-7.

127


Linkages with General Health

Kribbs PJ. Comparison of mandibular bone in normal  Malamud D, Tabak L, editors. Saliva as a diagnostic
and osteoporotic women. J Prosthet Dent 1990 Feb;    fluid. Ann NY Acad Sci 1993;694:128-42.
63(2):218-22.                   Mandel ID. The diagnostic uses of saliva. J Oral Pathol
Kribbs PJ, Chesnut CH 3rd. Osteoporosis and dental    Med 1990;19:119-25.
osteopenia in the elderly. Gerodontology 1984   Manouchehr-Pour M, Bissada NE Periodontal disease in
Summer;3(2):101-6.                 juvenile and adult diabetic patients: a review of the
Kribbs PJ, Smith DE, Chesnut CH 3rd. Oral findings in    literature. J Am Dent Assoc 1983 Nov;107(5):
osteoporosis. Part II: Relationship between residual     766-70.
ridge and alveolar bone resorption in generalized  Martin0 R, Subira M, Manteiga R, Bade11 I, Argiles B,
skeletal osteopenia. J Prosthet Dent 1983 Nov;50(5):    Sureda A, Brunet S. Viridans streptococcal bac-
719-24.                       teremia and viridans streptococcal shock syndrome
Kribbs PJ, Chesnut CH 3rd, Ott SM. Kilcoyne RE    in neutropenic patients: comparison between chil-
Relationships between mandibular and skeletal bone    dren and adults receiving chemotherapy or undergo-
in an osteoporotic population. J Prosthet Dent 1989    ing bone marrow transplantation. Clin Infec Dis
Dec;62(6):703-7.                       1995;20:476-7.
Kribbs PJ, Chesnut CH 3rd, Ott SM, Kilcoyne RF   Mattila KJ, Nieminen MS, Valtonen W, Rasi VP,
Relationships between mandibular and skeletal bone    Kesaniemi YA, Syrjala SL, Jungell PS, Isoluoma M,
in a population of normal women. J Prosthet Dent    Hietaniemi K, Jokinen MJ. Association between den-
1990 Jan:63( 1):86-9.                  tal health and acute myocardial infarction. BMJ 1989
Kroes I, Lepp PW, Relman DA. Bacterial diversity with-    Mar 25;298(6676):779-81.
in the human subgingival crevice. Proc Nat1 Acad Sci   Mattila KJ, Valtonen W, Nieminen M, Huttunen JK.
USA 1999 Dee 7:96(25):14547-52.            Dental infection and the risk of new coronary events:
Lacassin E Hoen B, Leport C, Selton-Suty C, Delahaye E    prospective study of patients with documented coro-
Goulet V, Etienne J, Briancon S. Procedures associat-    nary artery disease. Clin Infect Dis 1995 Mar;20(3):
ed with infective endocarditis in adults, A case con-     588-92.
trol study Em Heart J 1995 Dec;16(12):1968-74.    Mattila KJ, Asikainen S, Wolf J, Jousimies-Somer H,
Lafferty WE, Hughes JP Handsfield HH. Sexually trans-    Valtonen v\! Nieminen M. Age, dental infections,
mitted diseases in men who have sex with men.    and coronary heart disease. J Dent Res 2000;79:
Acquisition of gonorrhea and nongonococcal ure-     756-60.
thritis by fellatio and implications for STD/HIV pre-   McCormick MC. The contribution of low birth weight
vention. Sex Transm Dis 1997 May;24(5):272-8.      to infant mortality and childhood morbidity. N Engl
Leggott PL. Oral manifestations in pediatric HIV infec-    J Med 1985 Jan;312(2):82-90.
tion. In: Greenspan JS, Greenspan D. editors. Oral  Mealey BL. Periodontal implications: medically com-
manifestations  of HIV infection.  Chicago:    promised patients. Ann Periodontol 1996;1:256-321.
Quintessence; 1995. p. 234-9.            Meyer DH, Sreenivasan PK, Fives-Taylor PM. Evidence
Lifson AR, Hilton JE Westenhouse JL. Canchola AJ,    for invasion of a human oral cell line by
Samuel MC, Katz MH. Buchbinder SP Hess01 NA,    Actinobacillus actinamyceterncomitans. Infect Immun
Osmond DH, Shiboski S, et al. Time from HIV sero-     1991; 59:2719-26.
conversion to oral candidiasis or hairy leukoplakia   Miller IS, Manwell MA, Newbold D, Reding ME,
among homosexual and bisexual men enrolled in    Rasheed A, Blodgett J, Komman KS. The relationship
three prospective cohorts. AIDS 1994 Jan;8( 1):73-9.    between reduction in periodontal inflammation and
Loe H. Periodontal disease-the sixth complication of    diabetes control: a report of 9 cases. J Periodontol
diabetes mellitus. Diabetes Care 1993 Jan;lG(l):     1992 Oct;63(10):843-8.
  329-34.                      Mohajery M. Brooks SL. Oral radiographs in the detec-
Lorenz KA, Weiss PJ. Capnocytophagal pneumonia in a    tion of early signs of osteoporosis. Oral Surg Oral
healthy man. West J Med 1994 Jan;160(1):79-80.     Med Oral Path01 1992 Jan;73( 1):112-7.
Lucas RM, Howell LP Wall BA. Nifedipine-induced gin-   Montaner JS, Le TN, Le N, Craib KJ, Schechter MT.
gival hyperplasia. A histochemical and ultrastructur-    Application of the World Health Organization sys-
al study. J Periodontol 1985 Apr;56(4):211-5.         tem for HIV infection in a cohort of homosexual men
Lucas VS, Roberts GJ, Beighton D. Oral health of chil-    in developing a prognostically meaningful staging
dren undergoing allogenic bone marrow transplanta-    system. AIDS 1992 Ju1;6(7):719-24.
tion. Bone Marrow Transpl 1998;22:801-8.       Morfeldt-Manson L, Julander 1, Nilsson B. Dermatitis of
Mackenzie RS, Millard HD. Interrelated effects of dia-    the face, yellow toe nail changes, hairy leukoplakia
betes. arteriosclerosis and calculus on alveolar bone    and oral candidiasis are clinical indicators of pro-
loss. J Am Dent Assoc 1963;66: 191-8.          gression to AIDS/opportunistic infection in patients
Malamud D. Oral diagnostic testing for detecting    with HIV infection. Stand J Infect Dis
human immunodeficiency virus-l antibodies: a tech-    1989;21(5):497-505.
nology whose time has come. Am J Med 1997;  Morris JF Sewell DL. Necrotizing pneumonia caused by
102(4L4):9-14.                     mixed infection with Actinobacillus actinomycetem-

128         ORtL HFALTH IN AXlERICrl: A REPORT OF THE SURGEON GENERAL


comitans and Actinomyces israelii: case report and
review. Clin Infect Dis 1994 Mar;18(3):450-2.
Morrison HI, Ellison LE Taylor GM! Periodontal disease
and risk of fatal coronary heart and cerebrovascular
diseases. J Cardiovasc Risk 1999;6:7-11.
Morton AA, Williams RW, Watts TL. Initial study of
periodontal status in non-insulin-dependent diabet-
ics in Mauritius. J Dent 1995 Dec;23(6):343-5.
Moulsdale MT, Eykyn SJ, Phillips I. Infective endo-
carditis. 1970-1979. A study of culture-positive cases
in St. Thomas' Hospital. Q J Med 1980;49(195):315-
28.

Murrah VA. Diabetes mellitus and associated oral man-
ifestations: a  review. J Oral Path01 1985
Apr;14(4):271-81.

Murray CG, Herson J, Daly TE, Zimmerman S.
Radiation necrosis of the mandible: a IO-year study.
Part I. Factors influencing the onset of necrosis. Int J
Radiat Oncol Biol Phys 1980a;6:543-8.
Murray CG, Herson J, Daly TE, Zimmerman S.
Radiation necrosis of the mandible: a IO-year study.
Part II. Dental factors; onset, duration and manage-
ment of necrosis. Int J Radiat Oncol Biol Phys
1980b;6:549-53.

National Institute of Arthritis, Musculoskeletal and
Skin Diseases. Available from: http://wwwnih.gov/
niams/healthinfo/opbkgr.htm [ 20001,
National Institute of Diabetes and Digestive and Kidney
Diseases (NIDDK). Diabetes statistics. Bethesda
(MD): National Institutes of Health; 1999 Mar. NIH
Pub. no. 99-3892.

National Institutes of Health (NIH). Consensus
Development Conference on Oral Complication of
Cancer Therapy, Diagnosis, Prevention and Treat-
ment. NIH monograph no. 9. Bethesda (MD):
National Institutes of Health; 1990.
Nelson RG, Shlossman M, Budding LM, Pettitt DJ, Saad
ME Genco RJ, Knowler WC. Periodontal disease and
NIDDM in Pima Indians. Diabetes Care 1990
Aug;13(8):836-40.

Njoroge T, Genco RJ, Sojar HT, Hamada N, Genco CA.
A role for fimbriae in Porphyromonas gingivalis inva-
sion of oral epithelial cells. Infect Immun 1997 May;
65(5):1980-4.

Novaes Junior AB, Pereira AL, de Moraes N, Novaes AB.
Manifestations of insulin-dependent diabetes melli-
tus in the periodontium of young Brazilian patients.
J Periodontol 1991 Feb;62(2):116-22.

Novaes Junior AB, Gutierrez FG, Novaes AB.
Periodontal disease progression in type II non-
insulin-dependent  diabetes mellitus patients
(NIDDM). Part I-Probing pocket depth and clinical
attachment. Braz Dent J 1996;7(2):65-73.

O'Farrell BJ, Rajan E, Albloushi SS, Courtney MG,
Fielding J, Shattock AG. The reliability of saliva as a
sample for the detection of hepatitis A immunoglob-
ulins under various sampling conditions, Clin Diagn
Virol 1997:7(3):153-7.

Linkages with General Health

Offenbacher S, Katz V, Fertik G, Collins J, Boyd D,
Maynor G, McKaig R, Beck J. Periodontal infection
as a possible risk factor for preterm low birth weight.
J Periodontol 1996 Oct;67(10 Suppl):1103-13.
Offenbacher S, Jared HL, O'Reilly PG, Wells SR, Salvi
GE, Lawrence HP, Socransky SS, Beck JD. Potential
pathogenic mechanisms of periodontitis associated
pregnancy complications. Ann Periodontol 1998
Jul;3(1):233-50.

Oliver RC, Tervonen T. Periodontitis and tooth loss:
comparing diabetics with the general population. J
Am Dent Assoc 1993 Dec;124(12):71-6.
Oliver RC, Tervonen T. Diabetes-a risk factor for peri-
odontitis in adults? J Periodontol 1994 May;65(5
Suppl):530-8.

Ortman LF, Hausmann E, Dunford RG. Skeletal
osteopenia and residual ridge resorption. J Prosthet
Dent 1989 Mar;61(3):321-5.
Ostrow DG, DiFranceisco W. Why some gay men
choose condoms and others switch to "safer" sex. Int
Conf AIDS 1996;11:260.

Padian N, Glass S. Transmission of HIV possibly associ-
ated with exposure of mucous membrane to contam-
inated blood. MMWR Morb Mortal Wkly Rep
1997;46:620-3.

Payne B, Zachs NR, Reinhardt RA, et al. The association
between estrogen status and alveolar bone density
changes in post menopausal women with a history of
periodontitis. J Periodontol 1997;6:24-31.
Peterson DE. Research advances in mucositis. Curr
Opin Oncol 1999;11:261-6.

Peterson DE, Minah GE, Overholser CD, et al.
Microbiology of acute periodontal infection in
myelosuppressed cancer patients. J Clin Oncol 1987;
5:1461-8.

Phelan JA. Oral manifestations of human immunodefi-
ciency virus infection. Med Clin North Am 1997
Mar;81(2):511-31.

Pinson M, Hoffman WH, Garnick JJ, Litaker MS.
Periodontal disease and type 1 diabetes mellitus in
children and adolescents. J Clin Periodontol 1995
Feb;22(2):118-23.

Pizzo PA, Meyers J, Freifeld AG, Walsh T. Infections in
the cancer patient. In: DeVita VT, Hellman 5,
Rosenberg SA, editors. Cancer: principles and prac-
tice of oncology. 4th ed. Philadelphia: J.B. Lippincott
Co.; 1993. p. 2292-337.

Pope M, Frankel S, Steinman R, Elmore D, Ho D, Marx
l? Cutaneous dendritic cells promote replication of
immunodeficiency viruses. Adv Exp Med Biol 1997;
417:395-9.

Ramos-Gomez FJ, Hilton JE Canchola AJ, Greenspan D,
Greenspan JS, Maldonado YA. Risk factors for HIV-
related oral-facial soft-tissue manifestations in chil-
dren. Pediatr Dent 1996 Mar-Apr; 18(2):12I-6.
Redfield RR, Wright DC, Tramont EC. The Walter Reed
staging classification for HTLV-III/LAV infection. N
Engl J Med 1986 Jan;314(2):131-2.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

129


Linkages with General Health

Reilly TG, Poxon V, Sanders DS, Elliot TS, Walt RF!
Comparison of serum, salivary, and rapid whole
blood diagnostic tests for Helicobncter pylori and
their validation against endoscopy based tests. Gut
1997:40(4):454-B.

Richards AL, Rerrault JG, Garingal LT, Manaloto CR,
Sie A, Graham R. Ramos RM, Leonardo JB, Hyams
KC. A non-invasive assessment of hepatitis B virus
carrier status using saliva samples. Southeast Asian J
Trop Med Public Health 1996;27( 1):80-4.

Ringelberg ML, Dixon DO, Francis 110, Plummer RW
Comparison of gingival health and gingival crevicu-
lar fluid flow in children with and without diabetes.
J Dent Res 1977 Feb;56(2):108-11.

Rylander H, Ramberg P, Blohme G, Lindhe J. Prevalence
of periodontal disease in young diabetics. J Clin
Periodontol 1987 Jan;l4( 1):38-43.
Saah AJ, Munoz A, Kuo V, Fox R, Kaslow RA, Phair JP,
Rinaldo CR Jr, Detels R, Polk BE Predictors of the
risk of development of acquired immunodeficiency
syndrome within 24 months among gay men
seropositive for human immunodeficiency virus type
1: a report from the Multicenter AIDS Cohort Study.
Am J Epidemiol 1992;135:1147-55.
Saal CJ, Mason JC, Cheuk SI, Hill MK. Brain abscess
from chronic odontogenic cause: report of case. J Am
Dent Assoc 1988;117:453-5.

Riviere GR. Weisz KS. Adams DF. Thomas DD.
Pathogen-related oral spirochetes from dental plaque
are invasive. Infect Immun 1991 Oct;59(10):
3377-80.

Rocke LK, Loprinzi CL, Lee JK, et al. A randomized
clinical trial of two different durations of oral
cryotherapy for prevention of 5-fluorouracil-related
stomatitis. Cancer 1993; 7212234-8.

Rogers MF, White CR, Sanders R. Lack of transmission
of HIV from infected children to their household
contacts. Pediatrics 1990;85:210-4.

Rolston KVI, Bodey GF! Infections in patients with can-
cer. In: Holland Jc Frei E, Bast RC, Kufe DW, Morton
DL, Weichselbaum RR, editors. Cancer medicine.
3rd ed. Philadelphia: Lea & Febiger: 1993. p. 2416-
41.

Saglie FR, Marfany A, Camargo I? Intragingival occur-
rence of Actinobacillus actinotiycetemcomitans and
Bacteroides gingivalis in active destructive periodon-
tal lesions. J Periodontol 1988 Apr;59(4):259-65.
Salvi GE, Lawrence HP, Offenbacher S, Beck JD.
Influence of risk factors on the pathogenesis of peri-
odontitis. Periodontoi 2000 1997 Jun;14:173-201.
Sammalkorpi K. Glucose intolerance in acute infec-
tions. J Intern Med 1989 Jan;225(1):15-9.
Sande MA. Transmission of AIDS. The case against
casual contagion. N Engl J Med 1986;314:380-2.
Sandler HC, Stahl SS. Prevalence of periodontal disease
in a hospitalized population. J Dent Res 1960 May-
Jun;39(3):439-49.

ORAL HE-iLTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

Romero R. Baumann P, Gomez R, Salafia C, Rittenhouse
L, Barberio D, Behnke E, Cotton DB, Mitchell MD.
The relationship between spontaneous rupture of
membranes, labor. and microbial invasion of the
amniotic cavity and amniotic fluid concentrations of
prostaglandins and thromboxane B2 in term preg-
nancy. Am J Obstet Gynecol 1993 Jun;168(6 Pt
1):165-l-64: discussion 1664-8.

Rothenberg RR, Scarlett Ml, delRio C, Reznik D,
Daniels C. Oral transmission of HIV AIDS 1998;12:
2095105.

Roy R, Burghoff R, Steffens DL. Detection of STR,
DlS80, and gender alleles from body fluids collected
on isocode (TM) foam collectors and paper-based
devices. Crime Lab Digest 1997;24( 1):4-9.

Royce RA, Luckmann RS, Fusaro RE, Winkelstein W Jr.
The natural history of HIV-1 infection: staging clas-
sifications of disease. AIDS 1991 Apr;5(4):355-64.
Ruescher TJ, Sodeifi A, Scrivan SJ, Kaban LB, Sonis ST.
The impact on alpha-hemolytic streptococcal infec-
tion in patients undergoing autologous bone marrow
transplantation for hematologic malignancies.
Cancer 1998;82:2275-81.

Sandros J, Papapanou PN, Dahlen G. Porphyromonas
gingivalis invades oral epithelial cells in vitro. J
Periodont Res 1993 May;28(3):219-26.
Sandros J, Papapanou PN, Nannmark U, Dahlen G.
Porphyromonas gingivalis invades pocket epithelium
in vitro. J Periodont Res 1994 Jan:29(1):62-9.
Scannapieco FA. Position paper of the American
`Academy of Periodontology: periodontal disease as a
potential risk factor for systemic diseases. J
Periodontol 1998 Ju1;69(7):841-50,
Scannapieco FA. Role of oral bacteria in respiratory
infection. J Peridontol 1999;70:793-802.
Scannapieco FA, Mylotte JM. Relationships between
periodontal disease and bacterial pneumonia. J
Periodontol 1996 Oct;67(10 Suppl):1114-22.
Scannapieco FA, Papandonatos GD, Dunford RG.
Associations between oral conditions and respiratory
disease in a national sample survey population. Ann
Periodontol 1998 Jul;3(1):251-6.
Schmidt MI, Duncan BB, Sharrett AR, Lindberg G,
Savage PJ, Offenbacher S, Azambuja MI, Tracy RP,
Heiss G. Markers of inflammation and prediction of
diabetes mellitus in adults (Atherosclerosis Risk in
Communities study): a cohort study. Lancet 1999
May 15;353: 1649-52.

Ruprecht RM, Baba TW, Liska Y Ray NB, Martin LN,
Murphey-Corb M, Rizvi TA, Bernacky BJ, Keeling
ME, McClure HM, Andersen J. Oral transmission of
primate lentiviruses. J Infect Dis 1999 May;179
(Suppl 3):S408-12.

Schubert MM, Epstein JB, Peterson DE. Oral complica-
tions of cancer therapy. In: Yagelia JA, Neidle EA,
Dowd FJ, editors. Pharmacology and therapeutics in
dentistry. St. Louis: Mosby-Year Book Inc.; 1998. p.
644-55.

Schubert MM, Peterson DE, Lloid M. Oral complica-
tions. In: Thomas E, Blume KG, Forman SJ, editors.

130


Hematopoietic cell transplantation. 2nd ed. Malden
(MA): Blackwell Science, Inc.; 1999. p. 751-63.
Schwartz SK, Kellogg TA, Kohn RP et al. Temporal
trends in human immunodeficiency virus seropreva-
lence and sexual behavior at the San Francisco
municipal sexually transmitted disease clinic, 1989-
1992. Am J Epidemiol 1995;142:314-22.
Scully C, Epstein JB. Oral health care for the cancer
patient. Eur J Cancer B Oral Oncol 1996 Sep;32B(5):
281-92.

Seage GR 3rd, Gatsonis C, Weissman JS, Haas JS,
Craven DE, Makadon H, Goldberg J, Coltin K, Lewin
KS, Epstein AM, et al., The Boston AIDS Survival
Score (BASS): a multidimensional AIDS severity
instrument. Am J Public Health 1997 Apr:87(4):567-
73.

Semenciw R, Morrison H, Mao Y, Johansen H, Davies
JW, Wigle D. Major risk factors for cardiovascular
disease mortality in adults: results from the Nutrition
Canada Survey. Int J Epidemiol 1988; 17:3 17-24.
Seppala B, Ainamo J. A site-by-site follow-up study on
the effect of controlled versus poorly controlled
insulin-dependent diabetes mellitus. J Clin
Periodontol 1994 Mar;21(3):161-5.
Seppala B, Seppala M, Ainamo J. A longitudinal study
on insulin-dependent diabetes mellitus and peri-
odontal disease. J Clin Periodontol 1993 Mar;20(3):
161-5.

Shapiro S, McCormick MC, Starfield BH, Krischer JP
Bross D. Relevance of correlates of infant deaths for
significant morbidity at 1 year of age. Am J Obstet
Gynecol 1980 Feb 1;136(3):363-73.
Shinzato T, Saito A. A mechanism of pathogenicity of
"Streptococcus miller-i group" in pulmonary infection:
synergy with an anaerobe. J Med Microbial 1994
Feb;40(2):118-23.

Shlossman M, Knowler WC, Pettitt DJ, Genco RJ. Type
2 diabetes mellitus and periodontal disease. J Am
Dent Assoc 1990 Oct;l21(4):532-6.
Silver JG, Martin AW, McBride BC. Experimental tran-
sient bacteraemias in human subjects with varying
degrees of plaque accumulation and gingival inflam-
mation. J Clin Periodontol 1977 May;4(2):92-9.
Smith GT, Greenbaum CJ, Johnson BD. Persson GR.
Short-term responses to periodontal therapy in
insulin-dependent diabetic patients. J Periodontol
1996 Aug;67(8):794-802.

Sonis ST. Oral mucositis as a biological process: a new
hypothesis for the development of chemotherapy
induced stomatotoxicity. Oral Oncol 1998;34:39-43.
Sonis ST, Van Vugt AG, Brien JP Muska AD, Bt-uskin
AM, Rose A, Haley JD. Transforming growth factor-
beta 3 mediated modulation of cell cycling and atten-
uation of 5-fluorouracil-induced oral mucositis. Oral
Oncol 1997 Jan;33( 1):47-54.

Sparrelid E, Hagglund H, Remberger M, Ringden 0,
Lonnquist B, Ljungman P Andersson J. Bacteraemia
during the aplastic phase after allogenic bone mar-
row transplantation is associated with early death

Linkages with General Health

from invasive fungal infection. Bone Marrow Transpl
1998;22:795-800.

Sreebny LM, Schwartz SS. A reference guide to drugs
and dry mouth. 2nd ed. Gerodontology 1997;14:
33-47.

Sriskandan S, Soto A, Evans TJ, Cohen J. Viridans strep-
tococccal bacteraemia: a clinical study. QJM 1995;88:
415-20.

Stahl-Hennig C, Steinman RM, Tenner-Racz K, Pope M,
Stolte N,  Matz-Rensing K, Grobschupff G,
Raschdorff B, Hunsmann G, Racz I? Rapid infection
of oral mucosal-associated lymphoid tissue with
simian immunodeficiency virus. Science 1999 Aug
20;285(5431):1261-5.

Strom BL, Abrutyn E, Berlin JA, et al. Dental and cardiac
risk factors for infective endocxditis. Arch Intern
Med 1998 Nov 15;129(10):761-9.
Svenson KL, Lundquist G, Wide L, Hallgren R.
Impaired glucose handling in active rheumatoid
arthritis: relationship to the secretion of insulin and
counter-regulatory hormones. Metabolism 1987
Oct;36( 10):940-3.

Sznajder N, Carraro JJ, Rugna S, Sereday M. Periodontal
findings in diabetic and nondiabetic patients. J
Periodontol 1978 Sep;49(9):445-8.
Szpunar SM, Ismail AI, Eklund SA. Diabetes and peri-
odontal disease: analyses of NHANES I and
HHANES. J Dent Res 1989;68(51):164-438 (abstract
1605).

Taylor GW, Burt BA, Becker MP, Genco RJ, Shlossman
M, Knowler WC, Pettitt DJ. Severe periodontitis and
risk for poor glycemic control in patients with non-
insulin-dependent diabetes mellitus. J Periodontol
1996 Oct;67(10 Suppl):1085-93.
Taylor GW, Burt BA, Becker MP, Genco RJ, Shlossman
M, Knowler WC, Pettitt DJ. Non-insulin dependent
diabetes mellitus and alveolar bone loss progression
over 2 years. J Periodontol 1998a Jan;69(1):76-83.
Taylor GW, Burt BA, Becker MP, Genco RJ, Shlossman
M. Glycemic control and alveolar bone loss progres-
sion in type 2 diabetes. Ann Periodontol 1998b
Jul;3( 1):30-9.

Tervonen T, Karjalainen K. Periodontal disease related
to diabetic status. A pilot study of the response to
periodontal therapy in type 1 diabetes. J Clin
Periodontol 1997 Jul;24(7):505-10.
Tervonen T, Knuuttila M. Relation of diabetes control to
periodontal pocketing and alveolar bone level. Oral
Surg Oral Med Oral Path01 1986 Apr;61(4):346-9.
Thorstensson H, Hugoson A. Periodontal disease expe-
rience in adult long-duration insulin-dependent dia-
betics. J Clin Periodontol 1993 May;20(5):352-8.
Tindall B, Car-r A, Cooper DA. Primary HIV infection:
clinical, immunologic, and serologic aspects. In:
Sande MA, Volberding PA, editors. The medical man-
agement of AIDS. Philadelphia: W.B. Saunders; 1995.
p. 105-29.

ORAL HEALTH IN AMERICA: `4 REPORT OF THE SURGEON GENERAL

131


Linkages with General Health

U.S. Department of Health and Human Services (USD-
HHS), Center for Research for Mothers and
Children. Public Health Service/National Institutes
of Health Progress Report. Washington: U.S.
Department of Health and Human Services; 1984.
U.S. Preventive Services Task Force. Guide to clinical
preventive services. 2nd ed. Washington: US GPO;
  1996.

van Schie RC, Wilson ME. Saliva: a convenient source
of DNA for analysis of bi-allelic polymorphisms of
Fcg receptor IIA (CD32) and Fcg receptor IIIB
(CD16). J lmmunol Methods 1997;208:91-101.
von Wowern N. Dual-photon absorptiometry of
mandibles: in vitro test of a new method. Stand J
Dent Res 1985 Apr;93(2):169-77.
von Wowem N. Bone mineral content of mandibles:
normal reference values-rate of age-related bone
loss. Calcif Tissue Int 1988 Oct;43(4):193-8.
von Wowem N, Klausen B, Kollerup G. Osteoporosis: a
risk factor in periodontal disease. J Periodontol 1994
Dec;65(12):1134-8.

Wactawski-Wende J, Grossi SG, Trevisan M, Genco RJ,
Tezal M, Dunford RG, Ho AW, Hausmann E,
Hreshchyshyn MM. The role of osteopenia in oral
bone loss and periodontal disease. J Periodontol
1996;67(10 Suppl):1076-84.
Wallace JI, Bloch D, Whitmore R, et al. Fellatio is a sig-
nificant risk activity for acquiring AIDS in New York
City streetwalking sex workers. Int Conf AIDS
1996;11:381.

Ward JW, Duchin JS. The epidemiology of HIV and
AIDS in the United States. AIDS Clin Rev 1997;45.
Weinberg A, Belton CM, Park Y, Lamont kJ. Role of
Porpllyromonas gingivalis fimbriae invasion of gingi-
val epithelial cells. Infect Immun 1997 Jan;65(1):
313-6.

Weinstein L, Schlesinger JJ. Pathoanatomic, pathophys-
iologic and clinical correlations in endocarditis (sec-
ond of two parts). New Engl J Med 1974;291:832-6,
  1122-6.

Westfelt E, Rylander H, Blohme G, Jonasson P, Lindhe J.
The effect of periodontal therapy in diabetics.
Results after 5 years. J Clin Periodontol 1996 Feb;
23(2):92-100.

Wilkes JD. Prevention and treatment of oral mucositis
following cancer chemotherapy. Semin Oncol
1998;25:538-51.

Williams ME, Quesenberry PJ. Hematopoietic growth
factors. Hematol Path01 1992;6(3):105-24.
Williams RC Jr, Mahan CJ. Periodontal disease and dia-
betes in young adults. JAMA 1960 Feb 20;172:776-8.

Wilson JT. Clinical correlates of drugs in saliva. Ann NY
Acad Sci 1993 Sep 30;694:48-61.

Wilton JM, Griffiths GS, Curtis MA, Maiden MFJ, Gillet
IR, Wilson DT, Steme JA, Johnson NW. Detection of
high-risk groups and individuals for periodontal dis-
eases. Systemic predisposition and markers of gener-
al health. J Clin Periodontol 1988 Ju1;15(6):339-46.
Winkler JR, Robertson PB. Periodontal disease associat-
ed with HIV infection. Oral Surg Oral Med Oral
Path01 1992 Feb;73(2):145-50.

Winkler JR, Grassi M, Murray PA. Clinical description
and etiology of HIV-associated periodontal diseases.
In: Robertson PB, Greenspan JS, editors. Perspectives
on oral manifestations of AIDS: Piagnosis and man-
agement of HIV-associated infections. Littleton
(MA): PSG Publishing; 1988.

Wolf J. Dental and periodontal conditions in diabetes
mellitus. A clinical and radiographic study. Proc Finn
Dent Sot 1977;73 (4-6 Suppl):l-56.

Wu T, Trevisan M, Genco RJ, Dom JP, Falkner KL,
Sempos CT. Periodontal disease and risk of cere-
brovascular disease: a prospective study of a repre-
sentative sample of U.S. adults. Am J Epidemiol
1999;149:(11)290, Suppl S Jun 1.

Wu TJ? Trevisan M, Genco RJ, Dorn JP, Falkner KL,
Sempos CT. Examination of the relation between
periodontal health status and cardiovascular risk fac-
tors: serum total and high density lipoprotein, cho-
lesterol, C-reactive protein, and plasma fibrinogen.
Am J Epidemiol 2000;151:273-82.

Yavuzyilmaz E, Yumak 0, Akdoganli T, Yamalik N, Ozer
N, Ersoy F, Yenijay I. The alterations of whole saliva
constituents in patients with diabetes mellitus. Aust
Dent J 1996 Jun;41(3):193-7.

Yuan A, Yang PC, Lee LN, Chang DB, Kuo SH, Luh KT.
Actinobacillus actinomycetemcomitans pneumonia
with chest wall involvement and rib destruction.
Chest 1992 May;101(5):1450-2.

Zakrzewska JM, Aly Z, Speight PM. Oral hairy leuko-
plakia in a HIV-negative asthmatic patient on sys-
temic steroids. J Oral Path01 Med 1995 Jul;24(6):
282-4.

Zijlstra EE, Swart GR, Godfroy FJ, Degener JE.
Pericarditis, pneumonia and brain abscess due to a
combined  Actinomyces-Actinobacillus   actino-
mycetemcomitans infection. J Infect 1992 Jul;25(1):
83-7.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


Effects on Well-being
and Quality of Life

Fifty years ago the World Health Organization
(WHO) defined health as the "complete state of
physical, mental, and social well-being and not mere-
ly the absence of infirmity" (WHO 1948). In its defi-
nition the WHO acknowledged that an individual
who is technically "cured" of disease may not neces-
sarily be "well" and went on to indicate three dimen-
sions of well-being. Physical well-being assumes the
ability to function normally in activities such as
bathing, dressing, eating, and moving around. Mental
well-being implies that cognitive faculties are intact
and that there is no burden of fear, anxiety, stress,
depression, or other negative emotions. Social well-
being relates to ones ability to participate in society,
fulfilling roles as family member, friend, worker, or
citizen or in other ways engaging in interactions with
others.

The WHO declaration resonated with ongoing
developments in the social sciences as theoreticians
recognized the need for multiple indicators in assess-
ing health and treatment outcomes (Bergner et al.
1981, Fries et al. 1982, Hunt et al. 1985, Meenan et
al. 1980). These efforts led to definitions of "health-
related quality of life" (Guyatt et al. 1993) as well as
explanatory models. The model proposed by Wilson
and Cleary (1995), for example, posits five dimen-
sions by which to measure treatment outcomes: bio-
logical and physiological variables, symptom status,
functional status, general health perceptions, and
overall quality of life. These factors are not inde-
pendent but may be reciprocally connected. For
example, a diabetic patient with symptoms of depres-
sion may experience a rise in serum glucose as a
result of less vigilant glucose monitoring; the depres-
sion may then lead to a deterioration in physical and
social activities. Most importantly, measures of bio-
logical and physiological factors are often inconsis-
tent with patients' own reports of symptoms, ability
to function, general health perceptions, and overall

quality of life. In the wake of these developments in
general medicine, researchers began to elaborate
multidimensional models of "oral-health-related"
quality of life.

The efforts to understand these relationships are
particularly relevant given the aging of the popula-
tion. As Gift and Atchison (1995) stated, measuring
health-related quality of life allows assessment of
"the trade-off between how long and how well peo-
ple live." Diseases and disorders that result in dental
and craniofacial defects can thwart that goal, disturb-
ing self-image, self-esteem, and well-being. Oral-
facial pain and loss of sensorimotor functions limit
food choices and the pleasures of eating, restrict
social contact, and inhibit intimacy

Oral complications of many systemic diseases
also compromise the quality of life. Problems with
speaking, chewing, taste, smell, and swallowing are
common in neurodegenerative conditions such as
Parkinson's disease; oral complications of AIDS
include pain, dry mouth, mucosal infections, and
Kaposi's sarcoma; cancer therapy can result in painful
ulcers, mucositis, and rampant dental caries; and
periodontal disease is a complication of diabetes and
osteoporosis. Prescription and nonprescription drugs
often have the side effect of dry mouth.

The ability to measure the quality of life has the
practical value of guiding policymakers, health serv-
ice researchers, epidemiologists, program evaluators,
and clinicians interested in the effects of interven-
tions. The measures can also provide useful informa-
tion to patients and family members, third-party pay-
ers, and employers. For example, measures of the
ability to perform activities of daily living may inch-
cate areas where the patient is able and competent, as
well as areas where further therapy may be helpful.

This chapter reviews oral-health-related quality
of life findings along functional, psychosocial, and
economic dimensions, taking into consideration the

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          133


Effects on Well-being and Quality of Life

influence of cultural and spiritual values. The results
of studies in which investigators asked adults how
they value their oral health and whether they are sat-
isfied with their oral health care are included. The
study of the association between oral health and
quality of life is a relatively new but rapidly growing
field. A variety of questionnaires have been designed
to assess oral-health-related quality of life, and the
chapter concludes with a discussion of their use in
surveys and analytic studies, and their potential
importance in outcome research.

THE CULTURAL CONTEXT

The determination of the health-related quality of life
of an individual is implicitly made against a cultural
background that includes a set of values, standards,
customs, and traditions associated with a particular
society.

  Decisions about whether to seek care from a den-
tist, a physician, or other care provider may be influ-
enced by cultural or ethnic perspectives and under-
standing (Aday and Forthofer 1992, Andersen and
Davidson 1997, Davidson and Andersen 1997,
Diehnelt et al. 1990, Kiyak 1993, Lee and Kiyak
1992). Different population groups differ in the way
they think about health, and in how they define a
health problem, determine its seriousness, and
decide whether to seek care. In one cultural setting a
painful tooth may be enough to motivate care seek-
ing. In another, bleeding, swelling, or fever may be
necessary before care is sought. Similarly, decisions
about whether to comply with a suggested treatment
regimen, whether to engage in self-care, and whether
to return for a follow-up appointment are also cul-
turally influenced.

The anthropology and ethnography literature is
rich in references to the ways in which different cul-
tures at different times and places have regarded the
human body (Hufford 1992, Kleinman 1979).
Cultural beliefs regarding the body, health, and dis-
ease are often embedded in religious or spiritual
traditions, which in turn may govern how diseases
and disorders are regarded and treated. A brief des-
cription of Western and non-Western perspectives
follows.

Cultural Models

In the medical model typical of Western society the
body is partitioned into organs and systems, each
with identifiable functions. The body is seen as func-
tioning well unless disease disrupts it. Diseases in
themselves are understood to be invariable across

cultures. The medical model has traditionally
dichotomized body and mind/soul/spirit-science
and magic. Such a perspective sees the body as rela-
tively objective and value-free, immune to nonso-
matic influences.

That perspective began to change with the pio-
neering work of Hans Selye in the 1930s on the
importance of stress in health and disease (McEwen
1999). Research in the intervening half century has
confirmed the reciprocal connections of the nervous,
endocrine, and immune systems, not only in relation
to stress, but also in terms of the effects of emotions
and cognitive processes on health status.

The model that has emergkd as a new paradigm
in the study of health and disease incorporates bio-
logical with psychological and social factors. This
biopsychosocial model is defining agendas for
research in such fields as behavioral medicine and
psychoneuroimmunology Social and psychological
factors are routinely incorporated into health assess-
ments, the better to describe the quality of life. Other
societies hold views of the body strikingly different
from the medical model. In some cultures, individu-
als and their care providers conceive of the body as
the union of soul and soma. Illness may occur as a
result of a "failure in harmony" or "an imbalance of
forces." Schools of medicine in China, India, and
other non-western societies incorporate such princi-
ples into their teaching and practice (Hufford 1992).

Combining Perspectives

All Americans hold culturally influenced perspec-
tives on healing and illness (Henderson et al. 1997),
some of which come from more traditional beliefs.
Some people accept pain as an inevitable part of ill-
ness, a necessary evil, or even punishment for past
iniquities or shortcomings and may shun pain-reliev-
ing drugs (Zborowski 1952). Many pragmatically
combine cultural, folk, complementary, and altema-
tive healing practices with participation in conven-
tional care delivery systems. A recent survey indi-
cates that over 50 percent of Americans sought non-
traditional therapies for a number of ailments
(Eisenberg et al. 1998).

Traditional beliefs are often comforting and satis-
fying to individuals (Selikowitz 1994). Certainly,
Western culture and science have not always
improved the quality of people's lives (Harris et al.
1993). Dietary changes to refined foods have been
associated with dental caries (Godson and Williams
1996, Navia 1994), obesity, and other deleterious
health changes (Selikowitz 1994). The marketing of
tobacco products has added to the burden of cancer

134

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


and heart and lung problems worldwide. Migrations
from traditional community rural life to urban cen-
ters have been associated with family disruption and
Iiolence, drug abuse, sexually transmitted diseases.
and hypertension in developing countries.
On the other hand, Western science may inform
some cultural groups that certain traditional child-
rearing practices can be detrimental to oral health
(Kolasa 1978, Scheper-Hughes 1990). Early child-
hood caries is a form of tooth decay with complex
etiologies. Researchers studying high rates of infant
caries among some cultural groups are exploring the
extent to which traditional means of soothing crying
babies or handling bedtime routines play a role, as
xvell as investigating prenatal nutrition and transmis-
sion of infection from caregiver to child (Febres et al.
1997, Kelly and Bruerd 1987, Ripa 1988, Tinanoff
and O'Sullivan 1997).

People who hold different cultural perspectives
may distance themselves from Western, scientific
worldviews (Lee et al. 1993), a behavior that must be
addressed in any program of health promotion and
disease prevention. Health professionals who under-
stand indigenous or local healing practices and con-
cepts are better able to motivate patients and thereby
enable them to integrate elements from various heal-
ing systems (Kleinman 1979).

America is undergoing major demographic
changes, with the expectation that at some point
before 2050 the white population will no longer
represent the majority (Henderson et al. 1997). As
these changes occur, cultural elements that now
reflect minority groups may become more accepted
and dominant. However, cultural values are neither
static nor omnipotent in shaping people's lives.
Furthermore, individuals within a culture manifest
their cultural identity in different ways. Therefore,
both the direction of these changes and their effects
may be hard to predict.

ORAL-HEALTH-RELATED QUALITY OF
LIFE DIMENSIONS
Multiple factors act and interact in determining
one's quality of life, as Wilson and Cleary (1995) and
others have observed. Thus the idea of assessing
quality of life along multiple "dimensions" implies a
departure from a simple linear scale with excellent
quality of life at one end and greatly diminished
quality of life at the other. The following sections
explore several dimensions, beginning with effects
along functional and psychosocial dimensions and
concluding with a discussion of economic effects on
quality of life.

Effects on Well-being and Quality of Life

Functional Dimensions

Investigators have reported on the effects of dental
and craniofacial diseases on the ability to eat and
enjoy the full range of dietary choices. The impact of
less-than-optimal oral health also has been studied in
relation to sleep problems, primarily in relation to
oral-facial pain.

Eating

Both dental and systemic diseases can profoundly
affect appetite and the ability to eat, and hence can
compromise overall health and well-being. Because
chronic illness and medications increase in aging
populations, these effects may be particularly evident
among the frail elderly (Ship et al. 1996).
Undernutrition was observed in 50 percent of geri-
atric residents in a U.S. long-term care facility; in
many cases, it was linked to eating and swallowing
problems (Keller 1993).

Less severe oral disorders have more subtle
effects on functions relating to eating, although the
high prevalence of those disorders elevates their rela-
tive importance among health problems. For exam-
ple, data from the National Health and Nutrition
Examination Survey III indicate that 33.1 percent of
people aged 65 and older have no teeth (Marcus et al.
1996). Furthermore, clinical studies indicate that the
masticator-y efficiency of replacement teeth is at least
30 to 40 percent lower than that of natural teeth
(Idowu et al. 1986). Consistent with these findings,
surveys of elderly populations in the United States
indicate that self-reported chewing problems affect
significant proportions of people. For example, in
California 1 percent of Medicare enrollees were
unable to swallow comfortably, whereas 37 percent of
senior center residents reported trouble biting or
chewing foods (Table 6.1).

A number of studies have indicated that having
missing teeth is linked to a qualitatively poorer diet.
For example, in studies of U.S. veterans (Chauncey et
al. 1984), Canadians (Brodeur et al. 1993), and Finns
(Ranta et al. 1987), people with impaired dentitions
preferred soft, easily chewed foods that were lower in
fiber and had lower nutrient density than foods eaten
by people with intact dentitions. Quality of life clear-
ly suffers when individuals are forced to limit food
choices and the foods chosen do not provide optimal
nutrition. For example, they would be hard put to
comply with the healthful diet recommendation of
"five-a-day" helpings of fiber-rich fruits and vegeta-
bles. In the elderly, edentulousness and poor oral
health may contribute to significant weight loss,

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

135


Effects on IYell-being and Quality of Life

TABLE 6.1

Prevalence of self-reported eating dysfunction in surveys of elderly Americans

Dysfunction Attributed to Oral Condition(s)   Percentage of Population Group Reporting Dysfunction
                     Elderly Persons in Californiaa
                    Senior Center Residents     Medicare Enrollees
Had trouble biting or chewing              37              13
Limited the kinds of foods eaten              23               10
Unable to swallow comfortably               10                 1
                     Elderly Persons in Floridab
Mouth sometimes dry                         39
Noticed an unpleasant taste in mouth                  23
Unable to chew hard things                        19
Experienced change in sense of taste                   9
Difficulty tasting some foods                       6
Noticed change in sense of smell                      5
                   Elderly Persons in North Carolina<
                      African Americans         Whites
Difficulty chewing any foods               18               6
Felt sense of taste had worsened              13               3
Uncomfortable eating foods                13               6
Had to avoid eating some foods              10               4
Felt digestion had worsened                8               <l
Had to interrupt meals                    6               <l

an = 1,842 elderly persons (Atchison and Dolan 1990).
b n = 390 dentate persons aged 65 and older living in retirement communities (Gilbert et al. 1993).
[n = 440 persons aged 70 and older in five North Carolina counties (Hunt et al. 1995).

which may affect overall health (Blaum et al. 1995,
Ritchie et al. 2000, Sullivan et al. 1993).

Clinical research has demonstrated a general
reduction in chewing function as the number of
missing teeth increases, even when dentures are
worn (Carlsson 1984, Feldman et al. 1980, Helkimo
et al. 1978). However, clinical studies in Scandinavia
have observed relatively good chewing performance
when no more than 12 teeth are missing and the
remaining 20 teeth are distributed fairly equally,
providing good contact between the upper and the
lower jaw (Agerberg and Carlsson 1975). This find-
ing has led some researchers to advocate the concept
of a "shortened dental arch" as a treatment goal for
older adults, that is, retention of at least 20 well-dis-
tributed teeth (Kayser 1981). A consistent finding
from research into treatment of tooth loss is that
removable dentures produce only partial improve-
ment in chewing performance (Garrett et al. 1996,
van der Bilt et al. 1994, Witter et al. 1989). Dentures
anchored by implants result in significantly better
chewing performance than conventional, removable
dentures (Geertman et al. 1996).

Self-reported measures of eating ability, satisfac-
tion with eating, and avoidance of foods are widely

used to evaluate the effects of
tooth loss and replacement. These
measures capture aspects of eating
that are not necessarily reflected in
the clinical measures of chewing
performance with specific foods
(Demers et al. 1996). Such studies
of self-reported chewing ability
confirm  several  relationships
already noted, including the find-
ings that chewing ability declines
as the extent of tooth loss increas-
es and that removable dentures do
not fully compensate for the
reduction (Hildebrandt et al. 1997,
Leake 1990, Slade et al. 1996,
Wayler et al. 1984). In a study of
male veterans with varying levels
of tooth loss, Wayler et al. (1982)
reported that levels of taste, smell,
texture, perceived ease of chewing,
and frequency of ingestion were
adversely affected only among
people with severely compromised
dentitions. However, in some stud-
ies of prosthodontic treatment,
self-reported chewing ability im-
proved following treatment, even

in the absence of signilicant change in clinical meas-
ures of chewing performance (van der Bilt et al. 1994).
Impaired eating due to conditions other than
tooth loss has been evaluated less frequently. In a
study of dental patients with intact dentitions, Ernest
(1993) correlated reduced salivary flow with
decreased intake of 18 of 22 nutrients. Locker and
Slade (1988) found that 6 percent of the Canadians
surveyed who reported symptoms of temporo-
mandibular disorders also reported problems with
eating, talking, or swallowing. These conditions are
often associated with limited mouth opening and
severe pain, which may be constant or present when-
ever jaw movements are made. The constant dry
mouth of patients with Sjiigren's syndrome, a disease
in which the salivary glands are progressively
destroyed, is a major source of discomfort that affects
speaking, chewing, and swallowing.

As part of a Performance Status Scale study of
oral and pharyngeal cancer patients, List et al. (1990)
reported that only one third of patients achieved a
perfect score on a measure of normalcy of diet and
only 60 percent on a measurement of eating in pub-
lic. Communication skills also suffered; only 55 per-
cent scored perfectly on understandability of speech.

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


Sleeping                     recovery by an enemy could be used magically to
Sleep problems associated with oral conditions   inflict harm on the tooth owner. Remnants of that
appear to be most closely related to chronic pain,  belief persist in the ritual of the tooth fairy, who res-
either directly or indirectly in cases where pain and  cues the hidden baby tooth and leaves a reward. The
insomnia are exacerbated by depression. In a survey  potency of teeth is well recorded in the metaphors of
of elderly Floridians, Gilbert et al. (1993) found that  language. As Ziolkowski (1976) observed, "if some-
3 percent of the `population reported trouble sleeping  thing sets our teeth on edge or if someone casts an
because of pain or discomfort from dental problems,  insult in our teeth, we can gnash our teeth in anger,
whereas in a Canadian study Locker and Grushka  show our teeth belligerently, grit our teeth resolutely,
(1987) reported that 14.2 percent of those with acute   take the bit in our teeth, arm ourselves to the teeth,
or chronic oral-facial pain (or 5.5 percent of the total  and fight tooth and nail in the teeth of great danger
population) experienced sleep disturbance related to  and, with luck, escape by the skin of our teeth."
pain. Goulet et al. (1995) assessed sleep problems    The perception of healthy teeth contrasts sharply
not specifically attributed to pain among adults in  with that of diseased teeth. The sixteenth-century
Quebec. The prevalence of sleep problems was 13  French surgeon Ambroise Par6 remarked that
percent for persons with no temporomandibular  "toothache was the greatest and most eternal of all
(jaw) pain. The proportion with sleep disturbance   pains . . . the fiery torture of the damned in hell"
among persons with jaw pain increased with the  (Kunzle 1989); and a preacher of that time saw the
severity of the pain, rising from 20 percent for those  root of original sin in a rotting tooth, as quoted in
with mild pain, to 32 percent for moderate pain, and   Kunzle (1989): "We unfortunate humans: We all
59 percent for severe pain.              have toothache and suffer ever and always from the
                        teeth with which Adam bit the forbidden apple." In
                        the nineteenth century, Sir James Frazer reported that

Psychosocial Dimensions            African tribal kings could not be crowned if they
The social and psychological dimensions of well-  were symbolically emasculated by having a broken
being and quality of life are deeply intertwined in  tooth, a theme Freud echoed in declaring that dreams
everyday life and so are considered together here.  of pulling teeth were symbols of castration
Findings are reported for those oral conditions where   (Ziolkowski 1976).

the most research has been conducted: dental dis-     The link between diseased teeth and weakness,
eases (primarily those that affect appearance or  impotence, and even moral turpitude and sin has
involve extensive tooth loss), pain conditions, cran-  been analyzed by scholars exploring the vast legacy
iofacial deformities (primarily clefting syndromes),   of dental themes in art and literature. These authors
and oral and pharyngeal cancers. Psychological dis-  offer .a variety of political, social, psychological, and
tress associated with oral health problems has been  economic interpretations of diseased versus healthy
measured through individual questions (e.g., items  teeth, attesting to the seriousness with which human-
assessing worry) and through standardized psycho-  ity has invested dental pain and tooth loss.
logical instruments such as the Beck Depression    Cultures have sanctioned a variety of alterations
Inventory (Beck 1967) or the Symptom Checklist 90  to teeth by shaping and filing, embedding with jew-
(SCL-90) (Derogatis 1983). Overall, the results point  els, bleaching, capping, or providing orthodontic
to a poorer quality of life and a tendency to avoid  treatments to improve occlusion and aesthetics.

social contact as a result of concerns over facial  These procedures have been variously designed to
appearance. Persistent pain has similar isolating and  enhance the status, power, and attractiveness of the
depressing effects.                 owner. Cultures have also dictated specific practices
                       to indicate social position, such as the former

Cultural Significance of Teeth

Japanese custom of dyeing a married woman's teeth
black to denote her marital status.

Cultural beliefs and customs are a major influence on    Decisions about aesthetic surgery (Kaw 19931,
the psychosocial effects of dental disease on individ-   the definition of what constitutes a severe malocclu-
uals In a historical essay on the art of pulling teeth,  sion, and the need for dental aesthetics (Cons et al.
Kunzle (1989) noted that "the tooth has always been  1986) and surgical intervention (Strauss 1985)
accorded a special, even magical, role among all peo-  depend on social norms. Recently, researchers have
ples and at all times, and has stood for power, and its  begun to examine the perceived attractiveness of the
loss for loss of power." The practice of hiding or  human smile in terms of tooth length, shape, and
burying a lost tooth was based on the fear that its  color, lip line and plumpness, and tooth exposure

Effects on Well-being and Quality of Life

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          137


Effects on \X7ell-being and Quality of Life

(Dunn et al. 1996). Although there are no reliable
studies to document the proportion of people who
would seek treatment for perceived defects, the
growth of practitioner groups and dental supply
companies that specialize in aesthetic dentistry
attests to a substantial increase in cosmetic dental
treatments. Follow-up studies of patients who have
undergone tooth bleaching indicate high levels of sat-
isfaction with the extent and stability of the color
change (Haywood et al. 1994).

Dental Problems and Social Function

Given the importance of the mouth and teeth in ver-
bal and nonverbal communication, diseases that dis-
rupt their functions are likely to damage self-image
and alter the ability to sustain and build social rela-
tionships. The social functions of individuals encom-
pass a variety of roles, from the most intimate in dat-
ing and mating behaviors, to other interpersonal con-
tacts, to participation in social or community activi-
ties. Dental diseases and disorders can interfere with
these social roles at any or all levels (Patrick and
Bergner 1990). Whether because of social embarrass-
ment or functional problems, people with oral condi-
tions may avoid conversation or laughing, smiling, or
other nonverbal expressions that show their mouth
and teeth.

Two surveys of different segments of the adult
population in Ontario, Canada, addressed the issue
of self-consciousness or embarrassment related to
oral health problems. Both inquired into the frequen-
cy of such problems in the prior year. Among persons
over 18 years old in North York, Ontario, 7 percent
reported limiting conversation with others because of
oral problems in the prior year, 15 percent reported
that they had avoided laughing or smiling because of
oral problems, and 19 percent reported being embar-
rassed at least sometimes by the appearance or health
of their teeth or mouth (Locker and Miller 1994).
Among persons 50 years of age and older throughout
the province, 24 percent reported being self-con-
scious about their appearance at least occasionally
because of problems with their teeth, mouth, or den-
tures, 22 percent reported feeling uncomfortable at
least occasionally, and 13 percent reported that they
avoided smiling (Locker and Slade 1993).

Recently, investigators have begun to develop
quantitative tools to assess patterns of facial anima-
tion, including normal facial expressions, in order to
assess functional impairment in these movements
(Trotman et al. 1998)-and ultimately to address
implications for quality of life. The effects of facial

expressions, particularly smiling, on social relation-
ships warrant further research.

The more subtle aspects of social function may
also be affected by relatively common oral conditions
such as tooth loss. In a study of elderly people with
tooth loss in the United Kingdom, 30 percent report-
ed difficulty chewing. Although only 5 percent had
changed their diet, 9 percent felt uncomfortable
chewing in front of others, and 13 percent reported
embarrassment during social interactions (Smith and
Sheiham 1979). Bergendal (1989) acknowledged
tooth loss in adults to be a serious life event with a
more difficult period of readjustment than retire-
ment. In a study by Fiske et al. (1998), 25 percent of
people without teeth reported that they had avoided
close relationships because of fear of rejection when
their toothlessness was discovered. The authors
reported that reactions to tooth loss by the elderly
include lowered self-confidence and altered self-
image, bereavement, dislike of appearance, and the
perception of being more advanced in age. A nation-
al study surveying 3,000 homes in Great Britain
regarding the effect of oral health on the quality of
life was performed in 1997-98. Seventy percent of
respondents reported that their oral health affected
their quality of life-either positively or negatively.
Older people in higher socioeconomic groups, espe-
cially those who had seen a dentist within the last
year, were more likely to report an enhancing effect
(McGrath and Bedi 1998). In a study of older
Californians, people who viewed themselves as more
attractive than other people their age were more like-
ly to have a greater number of natural teeth. They
were also more likely to report less emotional anxiety,
to rate their health as excellent or very good, and to
be less likely to wear full or partial removable den-
tures (Matthias et al. 1993).

Less severe oral conditions may also have
adverse effects on social function. Table 6.2 summa-
rizes self-reported levels of impact on personal con-
tact and social integration from surveys of numerous
population groups  within the United States.
Generally, the prevalence of adverse effects ranges
from 1 to 10 percent, although 20 percent of senior
center residents in California reported feeling
uncomfortable when eating with others. Avoidance
of smiling or conversation tended to be more fre-
quent than limitation of social interaction. However,
the largest amount of variation appeared to be among
population subgroups, even within studies. For
example, within the Boston area, Veterans Affairs
ambulatory care patients in the Veterans Health
Study had substantially higher prevalence rates of

138         ORAL HEALTH IN AMERICA: .4 REPORT OF THE SURGEON GENERAL


Effects on Well-being and Quality of Life

t~L.Cr5e effects than community-dwelling, healthy
nlcn enrolled in the Normative Aging Study
The effects on people's perceived ability to per-
iL,rrll their usual social roles appear to be more subtle
T.mfe o.2). Depending on the phrasing of questions
.,nd the population subgroup surveyed, the preva-
l(ttcc of limitation in social roles varied from 0 to 5
\lerccnt, although as many as 10 percent of Veterans
\ff.ttrs patients reported that their daily activities
:\cre affected because of oral conditions.
There are very few studies of the effects of dental
trc;ttment on specific forms of social function. One
.tudy of handicapped adults in the United Kingdom
dud. ho\vever, report large improvements in five
.ispccts of social functioning following provision of

general dental care, including prosthodontic care
(Fiske et al. 1990).

Impacts of Oral-Facial Pain

Acute pain from dental caries can usually be treated
effectively or, as in the case of recurrent aphthous
ulcers (canker sores), will resolve over time. Chronic
pain in the oral-facial region presents a different situ-
ation in that the cause may not be removable and
treatment focuses on pain management. Researchers
have compared  chronic oral-facial pain to other
types of pain in terms of severity and emotional
impact. In a study of adult enrollees of a large health
maintenance organization, Von Korff et al. (1988)

r.\BLE 6.2
Reported impacts of oral conditions on social function among U.S. population groups

SOCMI function Dimension(s) Assessed

Intimacy
Perceived effect of mouth on:
Sex appeal
Kissing
Romantrc relationships
Personal contact/social integration
Avoid conversation
Personal contact/social integration
Reported impacts due to oral conditions:
Limiting contact with people
Feeling uncomfortable eating with others
Personal contact/social integration
Avoid laughing or smiling
Avoid conversation
Social roles
Limit activities

Personal contact/social integration
Avoidance of conversation
Social interaction affected
Social roles
Daily activities affected

Personal contact/social integration
Avoided smiling
Unable to enjoy people's company
Avoided going out with others
Less tolerant of others
Social roles
Difficulty doing jobs
Unable to work

%aurr and Hunt 1993.        dGilbertetal.1993.
' Gooch et al. 1989.           eKressin 1997.
' Atchlron and Dolan 1990.       `Hunt et al.1995.

       Percentage of Population Group Reporting Effect

          Elderly Persons in North Carolinaa
  Good Effect            Bad Effect            No Effect
     75                 21                 S
    78                18                 4
     81                17                3
         Persons Aqed 18 to 61 in Five U.S. Site+
                       4

            Elderly Persons in Califomiar
Senior Center Residents                     Medicare Enrollees
    10                                  1
    20                                  4

             Elderly Persons in Floridad
                      6
                      3

                      S
          Selected Populations in Boston Areae
Normative Aqinq Study      Veterans Health Study      Women's Health Project
     2                 10                 7
     1                 9                 7

     1                 10                10
           Elderly Persons in North Carolinar
African Americans                           Whites
    10                               3
     S                                  1
     3                                  0
    3                                 0

     1                                  0
     3                                  0

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          139


compared pain in the temporomandibular region to
back pain, headache, chest pain, and abdominal pain
on a number of dimensions. The usual intensity of
temporomandibular disorder (TMD) pain (4.3 on a
lo-point scale) was similar to that of chest pain (4.3)
and back pain (4.7); abdominal pain and headache
were rated as more intense (5.1 and 5.9, respective-
ly). TMD pain and back pain were more persistent
than other pains, with 28 percent of persons with
TMD pain (and 29 percent of those with back pain)
reporting pain on more than half of the days in the
prior 6 months. The daily duration of pain was also
relatively high for TMD pain, with 27 percent report-
ing pain for 9 or more hours per day; this proportion
was roughly the same as for headache and back pain.
In this setting, persons with TMD pain sought care
for their pain at about the same rate as persons with
other pain, with about one quarter having sought
care in the past 6 months and about 60 percent hav-
ing sought care at some time in the past.

Locker and Grushka (1987) reported that more
than 70 percent of persons with-all types of acute and
chronic pain worried about their dental health. Using
scales of the Symptom Checklist 90 (SCL-90), age-
and sex-standardized to the population under study,
persons in the general population who reported TMD
pain had substantially higher levels of anxiety and
depression than those without a current pain condi-
tion (Von Korff et al. 1988). In the same study, items
from the XL-90 were used to assign an algorithm for
diagnosis of depression. The percentage of persons
with TMD who met the criteria for a possible diag-
nosis of major depression was 11 percent, compared
with 2 percent among those without a current pain
condition and 3 to 5 percent in the general popula-
tion. Recent studies suggest that depression in TMD
patients follows the onset of symptoms and reflects
uncertainty about the cause(s) and the lack of effec-
tive treatments.

Social Responses to Facial Appearance

Just as cultural considerations color an individual's
response to dental disease and tooth loss, so, too,
does culture play a major role in the psychosocial
impact of craniofacial deformities. More than any
other body part, the face bears the stamp of individ-
ual identity, a fact neurobiology confirms in identify-
ing an area of the brain that is dedicated to the recog-
nition of faces.

  In ancient Greece the face was seen as the mortal
reflection of the gods, and those faces deemed most
beautiful were also judged to be morally superior.
Although cultures differ in the details, there appear

to be some invariant factors in the judgment of facial
beauty and deformity (Stafford et al. 19891, and they
are learned early in life. One U.S. study concluded
that perceptions of what does and does not constitute
an attractive face are established by age 7 (Cross and
Cross 1971).

Aristotle also thought that the face, because of its
position in the uppermost part of the body, pointed to
the highest, most spiritual parts of the cosmos.
Something of this mystical belief is preserved in lin-
guistic traditions that regard what is "higher" and
"ascending" as nobler than what is "lower" and
"descending," whether in reference to body parts,
human feelings, or classes and castes in society

But if facial beauty is the mask of truth, moral
superiority, nobility, and the soul, what of the oppo-
site? Faces judged ugly or disharmonious, or those
marred or scarred by birth defects or injury, have
been associated with defects in character, intelli-
gence, and morals. There is a long tradition of read-
ing character on the basis of facial and head shapes
according to one or another school of "physiog-
nomics." Some schools likened human faces to ani-
mal species, such as cats, monkeys, or horses,
endowing the human with the traits of the animal in
question. Others constructed facial geometries that
purported to show which races were nobler, which
closer to animal ancestors. During the nineteenth
century, Cesare Lombroso, an Italian physician and
criminologist, developed a measuring scheme linking
certain facial types to criminality (Magli 1989).

Given such a tradition, it is not surprising that
people continue to "judge a book by its cover." A
large body of research indicates that attractiveness
has an important effect on psychological develop-
ment and social relationships (Berscheid 1980).
Noteworthy among early social psychological studies
was the demonstration that physical attractiveness
plays a key role in social expectations (Clifford and
Walster 1973). Schoolteachers who were asked to
evaluate the educational potential of students from
school records and facial photographs judged attrac-
tive students to have higher educational potential
and social ability than unattractive students. This
finding has been replicated in a variety of school set-
tings and grade levels.

The process of attributing positive characteristics
to physically attractive persons is called the "beauty
is good hypothesis." The positive impact of attractive
appearance has been demonstrated to influence a
wide range of social activities, from legal proceedings
(Sigall and Ostrove 1975) to psychotherapeutic prog-
nosis. This body of research indicates that appear-
ance affects social expectations not only in educa-

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


tional performance, but also in vocational, marital,
legal, and health care endeavors. However, the con-
cept may not apply to all personal attributes. Bennett
and Stanton (1993) found that appearance may have
little effect on perceptions of intelligence or honesty.
Discrimination and stigmatization have histori-
cally characterized social responses to deformities.
People whose appearance is significantly different
from what society considers "normal" continue to be
stigmatized. Examples in literature abound, in fable
and myth, novels, movies, and plays (e.g., Beauty and
the Beast, The Elephant Man, The Hunchback of Notre
Dame, The Phantom of the Opera, and Scarface).
Goffman (1963) provided a theory of stigmatization
useful in understanding social responses to human
differences and health conditions (Ablon 1981).
Persons seen as deviant experience social devaluation
associated with prejudices about the causes and con-
sequences of congenital and acquired deformities
(Macgregor 1974).

Ethnographic studies of facial deformities
demonstrate marked variation in how birth defects
are explained and treated (Cheng 1990, Meyerson
1990, Scheper-Hughes 1990, Toliver-Weddington
1990). Many cultures have regarded birth defects and
the appearance of multiple births as ill omens, with
the infants fated to be abandoned or killed. Even
today, when it is understood that birth defects may
result from an inherited genetic disorder, decisions
about what that means and what if anything should
be done about it are affected by religious or spiritual
beliefs (Strauss 1988).

Progress in dentistry, medicine, and surgery has
raised expectations that deformed or injured persons
can be treated to enhance their appearance. Although
critics have objected to the high value that U.S. soci-
ety places on attractiveness and youthful appearance,
and on how this emphasis influences opportunity,
advocates of remediation counter that social values
are hard to change and that individuals must adapt to
a society's norms and stereotypes. Corrective surgery
does produce positive assessments from others
(Berscheid and Gangestad 1982). People in postoper-
ative photographs following reconstructive and plas-
tic surgery were seen as kinder, more sexually appeal-
ing, more likely to be better marriage partners, and
more employable and successful than the same indi-
viduals in preoperative views.

Effects on I!Tell-being and Quality of Life

Cleft Lip/Palate and Malocclusion
Persons with cleft lip/palate have a variety of prob-
lems related to appearance, eating, and speech.
Studies of self-concept (Broder and Strauss 1989,
Kapp-Simon 1986), psychosocial development
(Richman and Eliason 1982, Richman et al. 1988),
and social perception by peers (Schneiderman and
Harding 1984, Tobiasen 1987), parents and teachers
(Mitchell et al. 1984, Schneiderman and Auer 1984),
and the public (Middleton et al. 1986) highlight the
psychosocial problems  of children with cleft
lip/palate (Broder and Richman 1987).
These problems often continue into adolescence,
with appearance and speech remaining problematic
(Richman et al. 1985), even when the individual has
had comprehensive care (Strauss et al. 1988). Studies
show an association between cleft lip/palate and the
increased reporting of conduct problems at home
(Tobiasen and Hiebert 1984) and of behavioral and
learning problems at school (Tobiasen et al. 1987).
Although children with cleft lip/palate have not been
shown to suffer from a negative self-concept (Kapp
1979, Richman 1983) or psychological disorders,
they often become socially inhibited and self-con-
scious (Richman and Eliason 1982).
Adolescent girls with cleft lip/palate have higher
rates of social adjustment problems, particularly
related to appearance (Leonard et al. 1991). Using
psychological projection methods, one study
(Pillemer and Cook 1989) also concluded that chil-
dren with facial deformities may have inhibited per-
sonality styles as well as reduced expectations for
succ&s in social interactions. Kapp-Simon (1986)
found that social relationships negatively influence
overall self-esteem and that adjustment of adoles-
cents is associated with the degree of inhibition
(Kapp-Simon et al. 1992).

Many of the earliest studies of the consequences
of oral disease examined the impact of developmen-
tal disorders such as facial clefts and malocclusion on
personal contact and social integration. There are few
outcome studies that demonstrate how social, mari-
tal, and occupational status may be affected in adults
with facial deformities or cleft lip/palate. In studies
dating from the 197Os, persons with cleft lip/palate
achieved greater educational levels than did their
fathers, but did not exceed their fathers' occupation-
al status (McWilliams and Paradise 1973). Persons
with cleft lip/palate were less upwardly mobile than
their siblings and achieved lower adult incomes
(Peter et al. 1975). Although persons with cleft

ORAL HEALTH 1N AMERICA: A REPORT OF THE SURGEON GENERAL

141


Effects on IYell-being and Quality of Life

lip/palate had higher occupational desires, they had
lower income expectations than did controls; adults
felt socially inept and had a tendency to shy away
from group activities (Van Demark and Van Demark
1970). Subtle forms of discrimination and stigmati-
zation were experienced among adults with cleft
lip/palate (McWilliams 1970).

Studies of marital status have indicated that per-
sons with cleft lip/palate are less likely than nonaf-
fected peers to date (Peter et al. 1975) or marry
(McWilliams and Paradise 1973), and that when they
marry, they marry later (Heller et al. 1981, Peter and
Chinsky 1974). Persons with cleft lip/palate were
also more likely to remain childless or have fewer
children (Peter and Chinsky 1974).

The evidence concerning anatomical misalign-
ments of the jaws (e.g., overbite, open bite, crossbite)
is less consistent, with some early studies showing no
clear relationship between the malocclusion and job
opportunities or social discrimination (Shaw et al.
1980a). However, people with severe malocclusions
are likely to be teased and to have difficulty
interacting socially. These problems improve
following orthodontic and orthognathic treatment
(Cunningham et al. 1996, Helm et al. 1985, Shaw et
al. 1980b).

Oral and Phatyngeal Cancers

Surgical treatment for oral and pharyngeal cancers
can result in functional impairment as well as per-
manent disfigurement. Problems may include the
loss of part of the tongue, loss of taste, loss of chew-
ing ability, difficulty in speaking, and pain.
Furthermore, in addition to concerns about their
function and their future, oral and pharyngeal cancer
patients must cope with an altered appearance. In a
study of patients who were disease-free from 6
months to 8 years following surgical tumor removal,
Gamba et al. (1992) reported that those with more
pronounced disfigurement had greater changes in
self-image, a worsened relationship with their part-
ner, reduced sexuality, and increased social isolation.
A study by Bjordal and Kaasa (1995) also noted that
30 percent of oral and pharyngeal cancer patients
were still experiencing psychological distress 7 to 11
years after treatment. Depression, too, is frequent in
cancer patients. Patients with oral and pharyngeal
cancers are at an even greater risk for depression than
other cancer patients, due to surgeries that alter their
appearance (Gritz et al. 1999). Because oral and pha-
ryngeal cancers are also frequently associated with
chronic alcohol and tobacco use, depression may be
related to withdrawal from these substances or to

preexisting psychopathology. Persistent pain, as
noted earlier, may also be a contributing factor to
depression.

Gritz et al. (1999) conducted a prospective
analysis of changes in quality of life over time with
the aim of identifying which factors might be predic-
tive of future improvements or declines. Participants
were 186 oral and pharyngeal cancer patients, all
smokers or recent former smokers, diagnosed with
primary carcinomas of the oral cavity, pharynx, or
larynx. The patients were tested at baseline, at 1
month after radiation and/or surgery, and 1 year later
(for a subset of 105 patients available for follow-up).
Measures used included the Kamofsky Performance
Scale, which uses expert judgments of functional per-
formance scored from 0 to 100; the Cancer
Rehabilitation Evaluation System Short Form, in
which patients rate their quality of life along physi-
cal, psychosocial, marital, sexual, and medical inter-
action scales; the previously mentioned Performance
Status Scale for Head and Neck Cancer Patients
(which includes scales for eating and speaking); and
the Profile of Mood States, in which patients rate
their feelings over the previous week, yielding analy-
ses that enable scaling along six mood states: tension-
anxiety, depression-dejection, anger-hostility, confu-
sion-bewilderment, and vigor-activity. Results indi-
cated that in spite of functional improvement on
some scales over time, there was continued dysfunc-
tion in speech and eating. Patients also reported
declines in marital and sexual functioning, as well as
an increase in alcohol use. Interestingly, the best pre-
dicror of quality of life 1 year after treatment was the
scores obtained after initial smoking cessation advice
was given, while the patients were undergoing treat-
ment and in recovery Other predictors were treat-
ment type (quality of life was generally poorer for
radiation patients) and score on the vigor subscale of
the Profile of Mood States. The investigators con-
cluded that medical follow-up must integrate tailored
psychological and behavioral interventions to
achieve better quality of life for oral and pharyngeal
cancer patients.

Indirect Economic Costs

The financial impact of oral disease on quality of life
is easiest to quantify in terms of direct per capita
costs of oral disease and treatment as well as the costs
of publicly supported dental care programs. The
Health Care Financing Administration includes these
costs in its annual total health care expenditure
reports. These expenditures are presented in Chapter
9, and the related data on utilization of care are given

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


Effects on Well-being and Quality of Life

in Chapter 4. Estimating the indirect costs associated
\vith oral health conditions and treatments, such as
disability days or lost productivity, is more difficult.
Several methodologies are used to estimate these
costs. although relatively few studies have actually
estimated the indirect costs associated with mortality
or lost productivity due to dental conditions or treat-
ments (Reisine and Locker 1995).

The annual National Health Interview Survey
routinely collects data on disability days associated
with selected conditions. As shown in Table 6.3,
there were 3.7 days of restricted activity per 100
employed persons 18 years and older reported in the
United States in 1996 associated with an acute dental
condition, as defined by a dental symptom or treat-
ment visit. Restricted activity days were most preva-
lent among adults aged 18 to 24 years, women,
blacks, and individuals with annual incomes of less
than $10,000. Compared to the 624.0 restricted
activity days per 100 persons per year for all acute
conditions, the 3.7 restricted activity days for dental
conditions represent a relatively small loss on an
individual basis. They do, however, add up to a siz-
able number of days lost from work or school every
year for the population as a whole.

In addition, Table 6.3 presents the number of bed
days and work-loss days per 100 employed persons
aged 18 and older. Also, for youths 5 to I7 years of
age, 3.1 days of school were lost per year.

An important aspect of identifying the specific
health-related quality of life burden of oral disease
will be to acquire more data on how the overall
health-related quality of life of persons with oral dis-
ease differs from that of healthy persons, those with
other diseases and activity limitations, and those with
co-morbid oral and general health problems. The
CDCS "Healthy Days" measures and population

data-used by all states since 1993 on the Behavioral
Risk Factor Surveillance System (BRFSS) and recent-
ly added to the National Health and Nutrition
Examination Survey (NHANES)-offer the potential
of examining quality of life outcomes in relation to
oral health and other disease measures used in these
surveys (Gift 1996). These productivity-related
measures ask about the number of recent days when
physical health was not good, mental health was not
good, and activities were limited. These measures
were found to be valid in use with general popula-
tions and among older persons and adults with dis-
abilities (Moriarty and Zack 1999). Related measures
on activity limitations and recent days of pain,
depression, anxiety, sleeplessness: and vitality are
also asked by about half of all BRFSS states and-
when used with oral disease measures-could help
to identify the impact of oral disease prevention pro-
grams at the state and local levels.

In the 1996 National Health Interview Survey,
the percentage of all acute conditions that are med-
ically attended for all ages is 67.9 percent. "Medically
attended" is defined as having contacted a physician
(or other provider) or having a condition that causes
a person to cut back on activities for at least half a
day. For acute dental conditions, 59.6 percent are
medically attended for all ages (NCHS 1996).

The most dramatic oral diseases by virtue of their
high mortality rates are oral and pharyngeal cancers.
The Centers for Disease Control and Prevention esti-
mated in 1988 that 16.2 years of life were lost per
person dying of cancer of the oral cavity and pharynx
(CDC 1991). This exceeds the average for all cancer
sites, which was 15.4 years lost.

Researchers are beginning to assess costs associ-
ated with chronic craniofacial conditions such as
periodontal diseases, pain syndromes, and congeni-

TABLE 6.3
Disability days due to all acute conditions and acute dental conditions,
United States, 1996

Acute Dental Conditions
Total Days   Days per
(in thousands)   100 Persons

1,611      3.V
2,442      1.9b
4,602      1.7b
9,705      3.7b

tal anomalies. These estimates
may also include the costs to care-
givers who take time off from
work to attend to these needs or
to take children to the dentist.
Recent estimates put the lifetime
costs of multiple surgeries and the
other medical, dental, and rehabil-
itation therapies typical of the
team approach to the habilitation
of individuals with cleft lip or
palate at a minimum of $101,000
(Waitzman et al. 1996). Overall
costs of chronic pain conditions
in America are estimated to be
$79 billion (Bonica 1990). Given
the prevalence of headaches and

               All Acute Conditions
            Total Days   Days per
           (in thousands)   100 Persons
School-loss daysa        152,305     296.9
Work-loss days        358,377      284.0
Bed daysd          717,868      271.7
Restricted activityd      1,648,932      624.0

a Youths 5 to 17 years of age.
b Figure does not meet NCHS standard of reliability or precision.
r Currently employed persons 18 years and older.
d Persons of all ages.
Source: NCHS 1996.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          143


Effects on LVell-being and @alit)- of Life

temporomandibular disorders, the amount repre-
senting chronic oral-facial pain would certainly be
in the billions.

RATINGS OF ORAL HEALTH
Researchers use two ways to assess how individuals
rate their oral health: global ratings and satisfaction
ratings. Global ratings employ a ranking scale, with
excellent health at one end and poor health at the
other. Satisfaction ratings are more akin to oral-
health-related quality of life measures insofar as they
ask individuals how satisfied (or dissatisfied) they are
with their oral health status in relation to symptoms,
physical function. appearance, social function, and
psychological status.

Global Ratings

The dental survey conducted in connection with the
International Collaborative Survey II (ICS II) asked
younger (35 to 44 years) and older adults (65 to 74
years) of various ethnic groups at three sites in the
United States to rate their oral health from 1 (excel-
lent) to 6 (poor). The vast majority of younger and
older white adults rated their oral health as good to
excellent (82 and 80 percent, respectively, in
Baltimore, and 71 and 68 percent, respectively, in San
Antonio). In contrast, American Indians, Hispanics,
and African Americans were more likely to rate their
oral health as fair or poor. More detailed analysis
found a significant relationship between oral health
ratings and perceived general health, dentate status,
importance of oral health, income, oral pain, symp-
toms, and dental visits (Chen et al. 1997).

  Studies in the United States (Bloom et al. 1992,
Chen et al. 1997, Gift et al. 1997, Matthias et al.
1995) have related global ratings of oral health to
demographic, clinical, and psychosocial factors. A
special supplement on oral health in the National
Health Interview Survey in 1989 asked participants
to rate their oral health as excellent, very good, good,
fair, or poor (Bloom et al. 1992). The majority of peo-
ple (67 percent) rated their oral health as excellent or
very good, 23 percent rated it good, and only 10 per-
cent rated it fair or poor. Men, younger people, and
more frequent users of dental services tended to rate
their oral health better than women, older adults, and
less frequent users. African Americans, Hispanics,
and American Indians were less likely to rate their
oral health positively than were whites in similar geo-
graphic locations (Atchison and Gift 1997).

A study of Medicare participants in California
(Matthias et al. 1995) also found that when asked to

rate oral health as excellent, very good, good, fair, or
poor, most people rated it as good or above (74 per-
cent). Interestingly, the relationship between self-
rated global oral health and clinical measures used to
rate the severity of dental caries or periodontal dis-
ease was weak. The finding of such inconsistency has
been confirmed in other studies (Gooch et al. 1989,
Reisine and Bailit 1980, Rosenberg et al. 1988) and
was noted by Wilson and Cleary (1995). The most
important correlates of self-rated oral health were
worry about teeth and appearance, race, education,
general health status, and depression scores.

Satisfaction Ratings

According to Jokovic and Locker (1997), "expres-
sions of satisfaction and dissatisfaction are important
oral health status indicators since they synthesize
objective health states, subjective responses, and cul-
turally based values and expectations." ICS I repre-
sented an early effort at assessing satisfaction with
dental status (Amlijot and WHO 1985). Specifically,
it looked at satisfaction with teeth and gingiva among
adults and adolescents in metropolitan and non-
metropolitan areas in 10 countries. With the excep-
tion of Japanese participants, satisfaction with teeth
and gingiva among adolescents was fairly high, but
the percentage of adults satisfied with teeth among
participants from all countries was relatively low. A
decade later, ICS II (Chen et al. 1997) again assessed
whether younger and older adults were satisfied with
the way their teeth looked. American Indians were
the least satisfied with the appearance of their teeth.
Other community surveys of satisfaction (Barenthin
1977, Gilbert et al. 1994, Jokovic and Locker 1997,
Murtomaa and Laine 1985, Rosenoer and Sheiham
1995, Van Waas et al. 1994) show that most people
are satisfied with the performance and appearance of
their teeth.

ORAL-HEALTH-RELATED QUALITY OF
LIFE MEASURES
Much of the research on oral health and quality of life
focuses on the negative impact of craniofacial dis-
eases and disorders, diverting attention from the pos-
itive effects of good oral health. Although it could be
argued that the benefits are self-evident, few studies
have investigated how people value oral health.
Strauss and Hunt (1993) found that older adults in
North Carolina felt that the presence of teeth
enhanced their appearance, ability to eat, and enjoy-
ment of food, and that teeth also had a positive effect
on comfort, confidence, speech, enjoyment, and

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


longevity More generally, a large multisite study in
the United States found that most adults across eth-
nic groups believe in the seriousness of oral disease
and the importance of oral health for general health
(Davidson et al. 1996, Nakazono et al. 1997).

During the last decade, researchers have identi-
fied and described specific effects of oral disease on
quality of life, and there are now at least 11 ques-
tionnaires designed to measure oral-health-related
quality of life (Slade et al. 1998). These range from
the three-item Rand Dental Health Index (pain,
worry, conversation) to the 49-item Oral Health
Impact Profile, which includes items relating to func-
tion, pain, physical disability, psychological disabili-
ty, social disability, and handicap.

Other researchers have used generic quality of
life questionnaires (Reisine and Weber 1989) or ana-
lyzed oral health survey data, statistically summariz-
ing clinical measures with self-reported symptoms,
perceptions, and behaviors to create scales of oral-
health-related quality of life (Gift et al. 1997, Gilbert
et al. 1997). An essential requirement for these
analyses is the establishment of theoretical models
that describe and distinguish among quality of life
dimensions.

Although the questionnaires have been used in
population studies, there is increased emphasis on
the need to incorporate concepts of quality of life
into outcome research, using the questionnaires in
longitudinal or intervention studies to examine
changes in quality of life following provision of den-
tal care. Individual items from the questionnaires
can be used in describing the impact of oral health
status on specific functions. For example, the ques-
tions concerning eating dysfunction presented in
Table 6.1 are derived from such questionnaires.
Multidimensional indicators also can be used to pro-
duce quantitative scores that indicate the severity of
the impact caused by oral health problems. Because
there are seldom any reference values or population
norms to indicate thresholds at which such scores
represent "abnormal" or "severe" impacts on quality
of life, the results are more valuable for analytic
studies examining trends and associations than for
describing impacts of oral health within populations.

Surveys in the United States and elsewhere have
used multidimensional questionnaires and have
revealed consistent correlations between reduced
quality of life and poorer clinical oral status and
reduced access to dental care. Table 6.4 provides an
overview of these studies, their populations, and
descriptions of the assessment tools used. In the
studies using varied tools, there are consistent rela-
tionships between quality of life and standard epi-

Effects on Well-being and Quality of Life

demiological indices of missing teeth, decayed teeth,
and periodontal disease-conditions that are linked
to a lack of dental care. In several studies, infrequent
dental visits and problem-motivated dental visits
were found to be independently associated with
reduced quality of life in multivariate models (Gilbert
et al. 1997, Slade and Spencer 1994a). Lower socio-
economic status was an additional explanatory factor
in five studies (Atchison and Dolan 1990, Gilbert et
al. 1997, Gooch et al. 1989, Leao and Sheiham 1995,
Locker and Slade 1994).

  All of the studies in Table 6.4 used cross-section-
al designs to analyze associations with quality of life;
it is thus not possible to infer a causal link between
quality of life and the facto& under study.
Information about change in quality of life from
those questionnaires is available from only two
population-based longitudinal studies. In one, a
study of elderly Floridians, small and statistically
nonsignificant changes in the Geriatric Oral Health
Assessment Index were observed following an oral
health promotion program (Dolan 1997). In the sec-
ond, a 2-year longitudinal study of elderly South
Australians, change in quality of life was measured
using the Oral Health Impact Profile. The study did
not find that regular dental attendees had consistent-
ly better patterns of change than episodic dental
attendees (Slade and Spencer 199413).

In contrast, some information from experimental
studies of carefully selected clinical samples indicates
effects of specific dental treatments on quality of life.
Using the Sickness Impact Profile in a U.S. study of
30 patients treated for TMDs, Reisine et al. (1989)
found significant improvements for rest/sleep, home
tasks, work, and leisure following treatment. A ran-
domized clinical trial of 63 Canadians treated for
TMDs compared changes in quality of life, measured
using visual analog scales. The investigators found
equivalent improvements in quality of life, which
mirrored improvements in pain ratings, in all three
treatment groups (Dao et al. 1994). A German study
by Schliephake et al. (1996) reported improvements
in quality of life, measured using a 22-item scale,
among 85 patients following tumor removal and
reconstructive surgery.

Two multidimensional scales have been specifi-
cally designed to assess global disability (e.g., disabil-
ity days, pain interference with daily activities) relat-
ed to recurrent or chronic pain. Both the Graded
Chronic Pain Scale (Von Korff et al. 1992) and the
Multidimensional Pain Inventory (Kerns et al. 1985)
have been used to assess disability related to TMDs,
as well as back pain and headache. Although TMD
patients are generally found to have lower mean levels

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          145


Effects on Mirll-being and Quality of Life

of disability than patients with other types of pain
using these scales, both scales can discriminate the
full range of disability in TMDs. For example, the
Graded Chronic Pain Scale is an ordinal scale that
assigns persons with pain to hierarchical grades indi-
cating low-intensity, nondisabling pain (grade 1);
high-intensity, nondisabling pain (grade II); high-
disability, moderately limiting pain (grade III); and
high-disability, severely limiting pain (grade IV). In
a sample of HMO patients with TMDs, 41 percent
were grade I, 43 percent grade II, 1 I percent grade III,
and 5 percent grade IV (Von Korff et al. 1992). That
is, about 16 percent of patients seeking care for
TMDs were moderately or severely limited by their
pain.

Advances in public health and biomedical research in
HEIGHTENED EXPECTATIONS

The new field of science aimed at formulating con-
the late twentieth century have transformed our lives
remarkably, adding years to the life span, providing
cures for many diseases and disorders, and promising
a new era of genetic medicine and bioengineering.

cepts and methods for determining health-related
quality of life is a reflection of these advances. People
living in societies that enjoy the benefits of this
progress are responding with heightened expecta-
tions: They want to live long and live well, free of
infirmity, impairment, disability, and handicap; they
want an optimal quality of life and well-being. In
terms of oral health, new social norms and cultural
values now dictate that teeth should be retained over
the lifetime, and oral pain and dysfunction forever
banished. Quality of life measures applied to oral
health outcomes will be used to further those goals.

FINDINGS

Examination of efforts to characterize the functional

health.
   o
and social implications of oral and craniofacial dis-

   Oral health is related to well-being and qual-
eases reveals the following findings:

ity of life as measured along functional, psychosocial,
and economic dimensions. Diet, nutrition, sleep,
psychological status, social interaction, school, and
work are affected by impaired oral and craniofacial

TABLE 6.4
Studies of multidimensional quality of life measures

Gooch et al. 1989

Atchison and Dolan
1990

Hunt et al. 1995

Kresrin et al. 1996

Gift et al. 1997

Gilbert et al. 1997

Locker and Miller
1994

Locker and Slade
1994
Slade and Spencer
1994b

Leao and Sheiham
1995

Coates et al. 1996

Population Studied
USinsured adults aged
18-61 years
California Medicare
recipients aged 65+
N.C.elderly aged 70+

Male veterans aged 47+

USaged 18+

Floridians aged 45+

Canadians aged 18+

Canadians aged SO+

Australians aged 60+

Brazilians aged 35-44

Australian dental patients

Numbers of
Individuals

902 female
756 male
1,000 female
755 male

440

1,242 male

760 female
555 male

491 female
383 male

299 female
244 male

168 female
144 male

660 female
557 male

303 female
359 male

635 (+795
previously
surveyed)

  Assessment Tool        Description of AssessmentTool
Rand Dental Health index   Three dental questions written to represent
          factors contributing to adverse effects of dental disease
Geriatric Oral Health     A series of 12 questions measuring patient-reported
Assessment Index (GOHAI)   oral functional problems
Oral Health Impact Profile   A comprehensive measure of self-reported
(OHIP)          dysfunction consisting of 49 questions
Oral Health-related Quality   A brief global assessment of the impact of oral conditions
Of Life (OHQOL)      consisting of three items
1981 Health Resources and  Multidimensional concept using data from a large
Services Administration study  national sample
Oral Disadvantage Assessment Eight self-reported measures of avoidance in daily
              activities due to decrements in oral health
Subjective Oral Health     Five oral health status indicators based on WHO's
Status Indicators      International Classification of Impairments,
           Disabilities and Handicaps
Oral Health Impact Profile   A comprehensive measure of self-reported
(OHIP)         dysfunction consisting of 49 questions
Oral Health Impact Profile   A comprehensive measure of self-reported
(OHIP)         dysfunction consisting of 49 questions
Dental Impact on Daily    Thirty-six questions that assess the oral health impacts
Living (DIDL)       on daily living
Oral Health Impact Profile   A comprehensive measure of self-reported
(OHIP)         dysfunction consisting of 49 questions

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


   0  Cultural values influence oral and craniofa-
cial health and well-being and can play an important
role in care utilization practices and in perpetuating
acceptable oral health and facial norms.
   .  Oral and craniofacial diseases and their treat-
ment place a burden on society in the form of lost
days and years of productive work. Acute dental con-
ditions contribute to a range of problems for
employed adults, including restricted activity, bed
days, and work loss, and school loss for children. In
addition, conditions such as oral and pharyngeal can-
cers contribute to premature death and can be meas-
ured by years of life lost.

  o Oral and craniofacial diseases and condi-
tions contribute to compromised ability to bite, chew,
and swallow foods; limitations in food selection; and
poor nutrition. These conditions include tooth loss,
diminished salivary functions, oral-facial pain condi-
tions such as temporomandibular disorders, alter-
ations in taste, and functional limitations of prosthet-
ic replacements.
   o  Oral-facial pain, as a symptom of untreated
dental and oral problems and as a condition in and of
itself, is a major source of diminished quality of life.
It is associated with sleep deprivation, depression,
and multiple adverse psychosocial outcomes.
   o  Self-reported impacts of oral conditions on
social function include limitations in verbal and non-
verbal communication, social interaction, and inti-
macy. Individuals with facial disfigurements due to
craniofacial diseases and conditions and their treat-
ments may experience loss of self-image' and self-
esteem, anxiety, depression, and social stigma; these
in turn may limit educational, career, and marital
opportunities and affect other social relations.
   o  Reduced oral-health-related quality of life is
associated with poor clinical status and reduced
access to care.

REFERENCES

Ablon J. Stigmatized health conditions. Sot Sci Med
[Med Anthropoll 1981 Jan;15B(1):5-9.
Aday LA, Forthofer RN. A profile of black and Hispanic
subgroups' access to dental care: findings from the
National Health Interview Survey J Public Health
Dent 1992;52(4):210-5.

Agerberg G, Carlsson GE. Symptoms of functional dis-
turbances of the masticatory system. A comparison
of frequencies in a population sample and in a group
of patients. Acta Odontol Stand 1975;33(4): 183-90.
Andersen RM, Davidson PL. Ethnicity, aging and oral
health outcomes: a conceptual framework. Adv Dent
Res 1997 May;11(2):203-9.

Effects on Well-being and Quality of Life

Amlijot HA, World Health Organization (WHO), edi-
tors. Oral health care systems: an international col-
laborative study London: Quintessence; 1985.
Atchison KA, Dolan TA. Development of the Geriatric
Oral Health Assessment Index. J Dent Educ 1990
Nov;54( 11):680-7.

Atchison KA, Gift HC. Perceived oral health in a diverse
sample. Adv Dent Res 1997 May;11(2):272-80.
Barenthin I. Dental health status and dental satisfaction.
Int J Epidemiol 1977 Mar;6(1):73-9.
Beck AT. Depression: clinical, experimental, and theo-
retical aspects. New York: Hoeber; 1967.
Bennett ME, Stanton ML. Psychotherapy for persons
with craniofacial deformities: can we treat without
theory? Cleft Palate Craniofac J 1993 Ju1;30(4):
406- 10.

Bergendal B. The relative importanc; of tooth loss and
denture wearing in Swedish adults. Community
Dent Health 1989;6: 103-l 1.

Bergner M, Bobbitt RA, .Carter WB, Gilson BS. The
Sickness Impact Profile: development and final revi-
sion of a health status measure. Med Care 1981
Aug;19(8):787-805.

Berscheid E. Overview of the psychological effects of
physical attractiveness. In: Lucker GW, Ribbens KA,
McNamara JA, editors. Psychological aspects of
facial form. Proceedings of a sponsored symposium
honoring Professor Robert E. Moyers; 1980 Feb and
Mar; Ann Arbor: Center for Human Growth and
Development, The University of Michigan; 1980,
1981. Craniofacial growth series; monograph no. 11.
p. l-23.

Berscheid E, Gangestad S. The social psychological
implications of facial physical attractiveness. Clin
Plast Surg 1982 Ju1;9(3):289-96.
Bjordal K, Kaasa S. Psychological distress in head and
neck cancer patients 7-11 years after curative treat-
ment. Br J Cancer 1995 Mar;71(3):592-7.
Blaum CS, Fries BE, Fiatorone MA. Factors associated
with low body mass index and weight loss in nursing
home residents. J Gerontol Med Sci 1995;50:Ml
62-8.

Bloom B, Gift HC, Jack SS. Dental services and oral
health. Vital Health Stat 10 1992 Dec;(183):1-95.
Bonica JJ. General considerations of chronic pain. In:
Bonica JJ, Loeser JD, Chapman CR, Fordyce WF,
editors. The management of pain. Vol. 1.
Philadelphia: Lea and Febiger; 1990. p. 180-96.
Broder HL, Richman LC. An examination of mental
health services offered by cleft/craniofacial teams.
Cleft Palate J 1987 Apr;24(2):158-62.
Broder HL, Strauss RI? Self-concept of early primary
school age children with visible or invisible defects.
Cleft Palate J 1989 Apr;26(2):114-7.
Brodeur JM, Lam-in D, Vallee R, Lachapelle D. Nutrient
intake and gastrointestinal disorders related to mas-
ticatory performance in the edentulous elderly. J
Prosthet Dent 1993 Nov;70(5):468-73.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

147


Effects on Well-being and Quality of Life

Carlsson GE. Masticatory efficiency: the effect of age,
the loss of teeth and prosthetic rehabilitation. Int
Dent J 1984 Jun;34(2):93-7.
Centers for Disease Control (CDC). Cigarette smoking
among adults-United States, 1988. JAMA 1991 Dee
11;266(22):3113-4.

Chauncey HH, Muench ME, Kapur KK, Wayler AH.
The effect of the loss of teeth on diet and nutrition.
Int Dent J 1984;34(2):98-104.
Chen M, Andersen RM, Barmes DE, Leclercq MH, Lyttle
CS. Comparing oral health care systems-a second
international collaborative study. Geneva: World
Health Organization; 1997.

Cheng LR. Asian-American cultural perspectives on
birth defects: focus on cleft palate. Cleft Palate J 1990
Ju1;27(3):294-300.

Clifford M, Walster E. The effect of physical attractive-
ness on teacher expectations. Sot Educ 1973;46:
248-58.

Coates E, Slade GD, Goss AN, Gorkic E. Oral condi-
tions and their social impact among HIV dental
patients. Aust Dent J 1996 Feb;41(1):33-6.
Cons NC, Jenny J, Kohout FJ. DAI: the dental aesthetic
index. Iowa City: University of Iowa College of
Dentistry; 1986.

Cross JE Cross J. Age, sex, race and the perception of
facial beauty Dev Psycho1 1971;5:433-9.
Cunningham SJ, Crean SJ, Hunt NP, Harris M.
Preparation, perceptions, and problems: a long-term
follow-up study of orthognathic surgery Int J Adult
Orthodon Ortognath Surg 1996;l l( 1):41-7.
Dao TT, Lavigne GJ, Charbonneau A, Feine JS, Lund JP
The efficacy of oral splints in the .treatment of
myofascial pain of the jaw muscles: a controlled clin-
ical trial. Pain 1994 Jan;56(1):85-94.
Davidson PL, Andersen RM. Determinants of dental
care utilization for diverse ethnic and age groups.
Adv Dent Res 1997 May;11(2):254-62.
Davidson PL, Andersen RM, Marcus M, Atchison KA,
Reifel N, Nakazono T, Rana H. Indicators of oral
health in diverse ethnic and age groups: findings
from the International Collaborative Study of Oral
Health Outcomes (ICS-II) USA research locations. J
Med Syst 1996 Oct;20(5):295-316.
Demers M, Bourdages J, Brodeur JM, Benigeri M.
Indicators of masticatory performance among elder-
ly complete denture wearers. J Prosthet Dent 1996
Feb;75(2):188-93.

Derogatis LR. Symptom Checklist-90. Administration,
scoring and procedures manual for the revised ver-
sion. Baltimore: Clinical Psychometric Research;
  1983.

Diehnelt D, Kiyak HA, Beach BH. Predictors of oral
health behaviors among elderly Japanese-Americans.
Spec Care Dentist 1990;10:112-8.
Dolan T. The sensitivity of the Geriatric Oral Health
Assessment Index to dental care. J Dent Educ
1997;61(1):37-46.

Dunn WJ, Murchison DE Broome JC. Esthetics:
patients' perceptions of dental attractiveness. J
Prosthodont 1996 Sep;5(3):166-71.
Eisenberg DM, Davis RB, Ettner SL, Appei S, Wilkey S,
Van Rompay M, Kessler RC. Trends in alternative
medicine use in the United States, 1990-1997: results
of a follow-up national survey JAMA 1998 Nov
11;280(18):1569-75.

Ernest SL. Dietary intake, food preferences, simulated
salivary flow rate, and masticatory ability in older
adults with complete dentitions. Spec Care Dentist
1993 May-Jun;13(3):102-6.

Febres C, Echeverri EA, Keene HJ. Parental awareness,
habits, and social factors and their relationship to
baby bottle tooth decay Pediatr Dent 1997 Jan-
Feb;19(1):22-7.

Feldman RS, Kapur KK, Alman JE, Chauncey HH.
Aging and mastication: changes in performance and
in the swallowing threshold with natural dentition. J
Am Geriatr Sot 1980 Mar;28(3):97-103.
Fiske J, Gelbier S, Watson RM. The benefit of dental
care to an elderly population assessed using a socio-
dental measure of oral handicap. Br Dent J
1990;168(4):153-6.

Fiske J, Davis DM, Frances C, Gelbier S. The emotional
effects of tooth loss in edentulous people. Brit Dent J
1998;184(2):90-3.

Fries JE Spitz PW, Young DY. The dimensions of health
outcomes: the health assessment questionnaire, dis-
ability and pain scales. J Rheumatol 1982 Sep-
Oct;9(5):789-93.

Gamba A, Roman0 M, Gross0 IM, Tamburini M, Cantu
G, Molinari R, Ventafridda V Psychosocial adjust-
ment of patients surgically treated for head and neck
cancer. Head Neck 1992 May Jun;14(3):218-23,
Garrett NR, Kapur KK, Perez I? Effects of improve-
ments of poorly fitting dentures and new dentures
on patient satisfaction. J Prosthet Dent 1996
Oct;76(4):403-13.

Geertman ME, Boerrigter EM, Van? Hof MA, Van Waas
MA, van Oort RF: Boering G, Kalk W Two-center
clinical trial of implant-retained mandibular over-
dentures versus complete dentures-chewing ability
Community Dent Oral Epidemiol 1996 Feb;24(1):
79-84.

Gift HC. Quality of life-an outcome of oral health
care? Public Health Dent 1996;56(2):67-8.
Gift HC, Atchison KA. Oral health, health, and health-
related quality of life. Med Care 1995 Nov;33(11
Suppl):NS57-77.

Gift HC, Atchison KA, Dayton CM. Conceptualizing
oral health and oral health-related quality of life.
Sot Sci Med 1997 Mar;44(5):601-8.
Gilbert GH, Heft MW, Duncan RF! Oral signs, symp-
toms, and behaviors in older Floridians. J Public
Health Dent 1993 Summer;53(3):151-7.
Gilbert GH, Heft MW, Duncan RP, Ringelberg ML.
Perceived need for dental care in dentate older
adults. Int Dent J 1994 Apr;44(2): 145-52.

148

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


Gilbert GH, Duncan RP, Heft MW, Dolan TA, Vogel
WB. Oral disadvantage among dentate adults.
Community Dent Oral Epidemiol 1997 Aug;25(4):
301-13.

Godson JH, Williams SA. Oral health and health related
behaviours among three-year-old children born to
first and second generation Pakistani mothers in
Bradford, UK. Community Dent Health 1996
Mar;l3( 1):27-33.

Goffman E. Stigma: notes on the management of
spoiled identity. Englewood Cliffs (NJ): Prentice-
Hall; 1963. p. 2-3.

Gooch BF; Dolan TA, Bourque LB. Correlates of self-
reported dental health status upon enrollment in the
Rand Health Insurance Experiment. J Dent Educ
1989 Nov;53( 11):629-37.

Goulet JP, Lavigne GJ, Lund JP Jaw pain prevalence
among French-speaking Canadians and related
symptoms of temporomandibular disorders. J Dent
Res 1995 Nov;74( 11):1738-44.
Gritz ER, Carmack CL, de Moor C, Coscarelli A,
Schacherer CW, Meyers EG, Abemayor E. First year
after head and neck cancer: quality of life. J Clin
Oncol 1999;17(1):352-60.

Guyatt AH, Feeny DH, Patrick DL. Measuring health-
related quality of life. Ann Intern Med 1993 Apr
15;118(8):622-9.

Harris EC Woods MA, Robinson QC. Dental health
patterns in an urban Midsouth population: race, sex
and age changes. Quintessence Int 1993 Jan;24(1):
45-52.

Haywood VB, Leonard RH, Nelson CF, Brunson WD.
Effectiveness, side effects and long-term status of
nightguard vital bleaching. J Am Dent Assoc 1994
Sep;l25(9):1219-26.

Helkimo E, Carlsson GE, Helkimo M. Chewing effi-
ciency and state of dentition. A methodologic study.
Acta Odontol Stand 1978;36(1):33-41.
Heller A, Tidmarsh W, Pless IB. The psychosocial func-
tioning of young adults born with cleft lip or palate.
A follow-up study Clin Pediatr 1981;20:459-65.
Helm S, Kreiborg S, Solow B. Psychosocial implications
of malocclusion: a 15-year follow-up study in 30-
year-old Danes. Am J Orthod 1985 Feb;85(2): 110-8.
Henderson GE, et al., editors. The social medicine
reader. Durham (NC): Duke University Press; 1997.
p. 6-11.

Hildebrandt GH, Dominguez BL, Schork MA, Loesche
WJ. Functional units, chewing, swallowing, and food
avoidance among the elderly, J Prosthet Dent 1997
Jun;77(6):588-95.

Hufford DJ. Folk medicine in contemporary America.
In: Kirkland J, et al., editors. Herbal and magical
medicine. Durham: Duke University Press; 1992. p.
14-31.

Hunt RJ, Slade GD, Strauss RF! Differences between
racial groups in the impact of oral disorders among
older adults in North Carolina. J Public Health Dent
1995 Fall;55(4):205-9.

Effects on Well-being and Quality of Life

Hunt SM, McEwen J, McKenna SP Measuring health
status: a new tool for clinicians and epidemiologists.
J R Co11 Gen Pratt 1985 Apr;35(273):185-8.
Idowu AT, Graser GN, Handelman SL. The effect of age
and dentition status on masticatory function in older
adults. Spec Care Dentist 1986 Mar-Apr;6(2):80-3.
Jokovic A, Locker D. Dissatisfaction with oral health
status in an older adult population. J Public Health
Dent 1997 Winter;57( 1):40-7.
Kapp K. Self-concept of the cleft lip and/or palate child.
Cleft Palate J 1979 Apr;l6(2):171-6.
Kapp-Simon K. Self-concept of primary-school-age chil-
dren with cleft lip, cleft palate, or both. Cleft Palate J
1986 Jan;23(1):24-7.

Kapp-Simon KA, Simon DJ, Kristovich S. Self-percep-
tion, social skills, adjustment, and inhibition in
young adolescents with craniofacial anomalies. Cleft
Palate Craniofac J 1992 Jul;29(4):352-6.
Kaw E. Medicalization of racial features: Asian-
American women and cosmetic surgery. Med
Anthropol Q 1993;7(1):74-89.
Kayser AE Shortened dental arches and oral function. J
Oral Rehabil 1981 Sep;8(5):457-62.
Keller HH. Malnutrition in institutionalized elderly:
how and why? J Am Geriatr Sot 1993 Nov;41(11):
1212-8.

Kelly M, Bruerd B. The prevalence of baby bottle tooth
decay among two Native American populations. J
Public Health Dent 1987 Spring;47(2):94-7.
Kerns RD, Turk DC, Rudy TE. The West Haven-Yale
Multidimensional Pain Inventory (WHYMPI). Pain
1985 Dec;23(4):345-56.

Kiyak HA. Age and culture: influences on oral health
behavior. Int Dent J 1993 Feb;43(1):9-16.
Kleinman A. Sickness as cultural semantics: issues for
ati anthropological medicine and psychiatry In:
Ahmed P, Coelho G, editors. Toward a new definition
of health: psychosocial dimensions. New York:
Plenum; 1979. p. 53-65.

Kolasa K. I won't cook turnip greens if you won't cook
kielbasa: food behavior or Polonia and its health
implications. In: Bauwens E, editor. The anthropolo-
gy of health. St. Louis: Mosby; 1978. p. 130.
Kressin NR. Oral health-related quality of life measure
(OHQOL). In: Slade GD, editor. Measuring oral
health and quality of life. Chapel Hill: University of
North Carolina, School of Dental Ecology; 1997.
Kressin N, Spiro A 3rd, Bosse R, Garcia R, Kazis L.
Assessing oral health-related quality of life: findings
from the normative aging study. Med Care 1996
May;34(5):416-27.

Kunzle D. The art of pulling teeth in the seventeenth
and nineteenth centuries: from public martyrdom to
private nightmare and political struggle? Part 3. In:
Feher M, with Nadaff R, Razi N, editors. Cambridge
(MA): distributed by MIT Press; 1989. p. 28-89.
Leake JL. An index of chewing ability. J Public Health
Dent 1990 Summer;50(4):262-7.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

149


Effects on \Vell-being and Quality of Life

Leao A, Sheiham A. Relation between clinical dental sta-
tus and subjective impacts on daily living. J Dent Res
1995 Jul;74(7):1408-13.

Lee J, Kiyak HA. Oral disease beliefs, behaviors, and
health status of Korean-Americans. J Public Health
Dent 1992 Spring;52(3):131-6.
Lee KL, Schwarz E, Mak KY. Improving oral health
through understanding the meaning of health and
disease in a Chinese culture. Int Dent J 1993
Feb;43( 1):2-B.

Leonard BJ, Brust JD, Abrahams G, Sielaff B. Self-con-
cept of children and adolescents with cleft lip and/or
palate. Cleft Palate Craniofac J 1991 Oct;28(4):347-
53.

List MA, Ritter-Sterr C, Lansky SB. A performance sta-
tus scale for head and neck cancer patients. Cancer
1990;66:564-9.

Locker D, Grushka M. The impact of dental and facial
pain. J Dent Res 1987 Sep;66(9):1414-7.
Locker D, Miller Y. Subjectively reported oral health sta-
tus in an adult population. Community Dent Oral
Epidemiol 1994 Dec;22(6):425-30.
Locker D, Slade G. Prevalence of symptoms associated
with temporomandibular disorders in a Canadian
population. Community Dent Oral Epidemiol 1988
Oct;16(5):310-3.

Locker D, Slade G. Oral health and the quality of life
among older adults: the Oral Health Impact Profile. J
Can Dent Assoc 1993 Oct;59(10):830-3,837-8,844.
Locker D, Slade G. Association between clinical and
subjective indicators of oral health status in an older
adult population. Gerodontology 1994 Dec;ll(Z):
108-14.

Macgregor FC. Transformation and identity, the face
and plastic surgery. New York: Quadrangle/New York
Times; 1974. p. 119.

Magli I? The face and the soul. In: Feher M, with Nadaff
R, Razi N, editors, Fragments for a history of the
human body. Part 2. Cambridge (MA): distributed by
MIT Press; 1989. p. 87-127.
Marcus SE, Drury TE Brown LJ, Zion GR. Tooth reten-
tion and tooth loss in the permanent dentition of
adults: United States, 1988-1991. J Dent Res 1996
Feb;75(Spec No):684-95.

Matthias RE, Atchison KA, Schweitzer SO, Lubben JE,
Mayer-Oakes A, De Jong E Comparisons between
dentist ratings and self-ratings of dental appearance
in an elderly population. Spec Care Dentist 1993
Mar-Apr;l3(2):53-60.

Matthias RE, Atchison KA, Lubben JE, De Jong E
Schweitzer SO. Factors affecting self-ratings of oral
health. J Public Health Dent 1995;55(4):197-204.
McEwen B. Stress and the brain. In: Conlan R, editor.
States of mind. New York: John Wiley; 1999. p. Bl-
  102.

McGrath C, Bedi R. A study of the impact of oral health
on the quality of life of older people in the UK-find-
ings from a national survey. Gerodontology
1998;15(2):93-8.

McWilliams BJ. Psychosocial development and modifi-
cation. Washington: American Speech and Hearing
Association; 1970. ASHA Reports No. 5.
McWilliams BJ, Paradise LI? Educational, occupational,
and marital status of cleft palate adults. Cleft Palate J
1973 Jul;10:223-9.

Meenan RF, Gertman PM, Mason JH. Measuring health
status in arthritis. The arthritis impact measurement
scales. Arthritis Rheum 1980 Feb;23(2):146-52.
Meyerson MD. Cultural considerations in the treatment
of Latinos with craniofacial malformations. Cleft
Palate J 1990 Jul;27(3):279-88.
Middleton GE Lass NJ, Starr P Pannbacker M. Survey of
public awareness and knowledge of cleft palate. Cleft
Palate J 1986 Jan;23(1):58-62. .
Mitchell CK, Lott R, Pannbacker M. Perceptions about
cleft palate held by school personnel: suggestions for
in-service training development. Cleft Palate J 1984
Oct;21(4):308-12.

Moriarty D, Zack M. Validation of the Centers for
Disease Control and Prevention's Healthy Days
measures [abstract]. Qua1 Life Res 1999;8(7):617.
Murtomaa H, Laine I? Differentiating dental satisfaction
in Finns by means of discriminant analyses.
Community Dent Oral Epidemiol 1985 Feb;13(1):7-
  10.

Nakazono TT, Davidson PL, Andersen RM. Oral health
beliefs in diverse populations. Adv Dent Res 1997
May;11(2):235-44.

National Center for Health Statistics (NCHS). Current
estimates from the National Health Interview Survey,
1996. Series 10, no. 200. Hyattsville (MD): Public
Health Service; 1996.

Navia JM. Carbohydrates and dental health. Am J Clin
Nutr 1994 Mar;59(Suppl3):719S-27s.
Patrick DL, Bergner M. Measurement of oral health sta-
tus in the 1990s. Annu Rev Public Health
1990;11:165-83.

Peter JP, Chinsky RR. Sociological aspects of cleft palate
adults: I. Marriage. Cleft Palate J 1974 Jul;11(0):295-
309.

Peter JP Chinsky RR, Fisher MJ. Sociological aspects of
cleft palate adults: III. Vocational and economic
aspects. Cleft Palate J 1975 Apr;12:193-9.
Pillemer FG, Cook KV The psychosocial adjustment of
pediatric craniofacial patients after surgery Cleft
Palate J 1989 Jul;26(3):201-7, Discussion 207-S.
Ranta K, Tuominen R, Paunio I. Perceived oral health
status and ability to chew among an adult Finnish
population. Gerodontics 1987 Jun;3(3):136-9.
Reisine ST, Bailit HL. Clinical oral health status and
adult perceptions of oral health. Sot Sci Med [Med
Psycho1 Med Social] 1980 Dec;14A(6):597-605.
Reisine S, Locker D. Social, psychological and econom-
ic impact of oral conditions and treatments. In:
Cohen LK, Gift HC, editors. Disease prevention and
oral health promotion: socio-dental sciences in
action. Copenhagen: Munksgaard; 1995. p. 33-72.

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