Violence

The family is the single most frequent locus of vio-
lence in Western society Domestic violence includes
child abuse, spousal and elder abuse, and abuse of
the disabled. Child abuse is of particular concern to
the oral health community because 65 percent of
cases  involve head and oral-facial trauma
(Mathewson 1993, Needleman 1986) and dentists
are required to report suspected cases of child abuse.
fn the young child, head injury is the most common
cause of death. Psychological trauma from abuse can
result in sleep disturbances, eating disorders, devel-
opmental growth failure in young children, and nerv-
ous habits such as lip and fingernail biting and
thumb sucking. Effects may also include chronic
underachievement in school and poor peer relation-
ships (Mathewson 1993). In abusive families, physi-
cal neglect is commonplace, with inadequate provi-
sion of basic needs, including medical and oral health
care (Mathewson 1993).

SELECTED CHRONIC AND DISABLING
CONDITIONS

Oral, dental, or craniofacial signs and symptoms play
a critical role in autoimmune disorders such as
SjGgren's syndrome and in a number of chronic and
disabling pain conditions.

Sjiigren's Syndrome

Sjogren's syndrome is one of several autoimmune dis-
orders in which the body's own cells and tissues are
mistakenly targeted for destruction by the immune
system. Like other autoimmune conditions, Sjogren's
syndrome is more prevalent among women. The ratio
of females to males affected is 9:1, with symptoms
usually developing in middle age. There are an esti-
mated 1 to 2 million individuals in the United States
with Sjogren's syndrome (Talal 1992).

The disease occurs in two forms. Primary
Sjogren's involves the salivary and lacrimal (tear)
glands. In secondary Sjogren's the glandular involve-
ment is accompanied by the development of a con-
nective tissue or collagen disease, most often
rheumatoid arthritis, lupus erythematosis, scleroder-
ma, or biliary cirrhosis.

The glandular involvement causes a marked
reduction in fluid secretion, resulting in xerostomia
and xerophthalmia (dry eyes). The constant oral dry-
ness causes difficulty in speaking, chewing, and swal-
lowing; the dry eyes often itch and feel gritty. There

Diseases and Disorders

is no cure for Sjogren's, and patients often carry eye-
drops and water bottles or saliva substitutes in an
attempt to provide symptomatic relief. Clinically, the
reduction in salivary flow changes the bacterial flora,
which, in addition to the reduction in salivary pro-
tective components, increases the risk of caries and
candidiasis (Daniels and Fox 1992). Recent studies
have indicated that there is a reduction in masticato-
r-y function (Dusek et al. 1996) and an increased
prevalence of periodontal disease (Najera et al.
1997). In advanced stages the salivary glands may
swell because of obstruction and infection or lym-
phatic infiltration, In both forms of the disease, other
systems may eventually become* affected. Nasal,
laryngeal. and vaginal dryness may occur, as well as
abnormalities in internal organs (Oxholm and
Asmussen 1996).

Diagnosis is difficult in the early stages, and
women often report that it took many years and con-
sultations with many specialists before they received
the correct diagnosis. Diagnosis involves demonstra-
tion of specific antibodies in the blood characteristic
of an autoimmune disorder, a labial (minor) salivary
gland biopsy, and a series of eye tests to measure flow
rate and tissue characteristics. Confirmatory tests
include an evaluation of salivary flow and chemistry.
Patients with Sjogren's syndrome are at some risk
of developing diseases such as non-Hodgkin's lym-
phoma; clinical data indicate that such lymphomas
develop in 5 percent of patients with Sjogren's syn-
drome (Moutsopoulos et al. 1978).
Histological examination shows that immune
cells infiltrate the glands and cluster around the
secretory elements, resulting in a breakdown of the
normal structure of the gland. The mechanisms by
which this occurs involve immune-cell-mediated
inflammation and stimulation of the salivary gland
cells themselves to produce tissue-destructive mole-
cules such as cytokines. Another hypothesis is that a
viral infection of the glands may trigger the immune
response that leads to autoimmunity, whereas genet-
ic or regulatory alterations might lead to abnormali-
ties in apoptosis (Fox and Speight 1996).
  In addition to saliva substitutes and artificial
tears, some medications, such as pilocarpine and
cevimeline, are prescribed to increase salivary flow
from the residual healthy gland tissue, again provid-
ing symptomatic relief only The problems that
develop in the other organ systems are also treated
symptomatically At advanced stages, steroids are
employed intermittently to alleviate problems.

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

51


Diseases and Disorders

Acute and Chronic Oral-Facial Pain

Since the nineteenth century when two dentists,
Horace Wells and Frederick Morton. demonstrated
the analgesic powers of nitrous oxide and ether, oral
health investigators have been recognized leaders in
the field of pain management worldwide. Their
analyses of the cells, pathways, and molecules
involved in the transmission and modulation of pain
have given rise to a growing variety of medications,
often combined with other approaches, that can con-
trol acute and chronic pain. Pain researchers today
stress that chronic pain can become a disease in itself,
causing long-term detrimental changes in the nerv-
ous system. These changes may affect resistance to
other diseases as well as effectively destroy quality of
life. Most people have experienced acute pain involv-
ing teeth and the oral tissues at one time or another.

Atypical Facial Pain

Atypical facial pain is characterized by a continuous
dull ache on one or both sides, most frequently in the
region of the maxilla (the upper jaw). The pain tends
to be episodic and is aggravated by fatigue, worry, or
emotional upset. It is often accompanied by pain
elsewhere in the body and depression. Once a dental
cause can be ruled out, pain resolution depends on
the successful use of antidepressants, psychotherapy,
or both (Tyldesley and Field 1995).

Tic Douloureux

The oral-facial region is also subject to pain that can
be paroxysmal or continuous along a distinct nerve
distribution. The most frequently encountered of
these oral facial neuralgias is tic douloureux, or
trigeminal neuralgia, a disease of unknown etiology
affecting one, two, or all three branches of the
trigeminal nerve. The pain is highly intense and of a
stabbing nature, and lasts for a few seconds. This
transient attack may be repeated every few minutes
or several hours. There may be no precipitating fac-
tor, or it may occur in response to a gentle touch or a
breeze wafting across the face-a condition experts
call allodynia, the feeling of pain in response to a nor-
mally nonpainful stimulus. On other occasions, there
may be a specific trigger zone. Although spontaneous
remission for weeks or months may occur, it is rarely
permanent. Given the unknown, unpredictable
nature of tic douloureux, it is not surprising that fear
of pain comes to dominate these patients' lives, as
they avoid doing anything that might trigger an
attack.

Trigeminal neuralgia generally occurs in later
life, but also occurs in younger individuals affected

by multiple sclerosis, where it is assumed to be asso-
ciated with lesions (multiple sclerosis "plaques") in
the brain stem. Medical treatment depends largely on
the use of a drug that has become a virtual specific,
the antiepileptic drug carbamazepine. For those
patients with no consequential adverse effects, it can
control the disease. An alternative for chronic suffer-
ers is the surgical removal of a small vein or artery
that may be exerting pressure on the nerve root or
the selective destruction of the nerve fibers them-
selves using chemical or electrical methods. In many
cases, these procedures can produce complete relief
from pain (Tyldesley and Field, 1995).

Temporomandibular Disorders

Various etiological factors, including trauma, can
give rise to pain and dysfunction in the temporo-
mandibular joint and surrounding muscles, condi-
tions collectively called temporomandibular disor-
ders (TMDs). The pain may be localized or radiate to
the teeth, head, ears, neck, and shoulders. Abnormal
grating, clicking, or crackling sounds, known as
crepitus, in the joint often accompany localized pain.
Pain is also found in response to clinical palpation of
the affected structures. TMDs are common, occur-
ring in as many as 10 million Americans. Although
surveys indicate that both sexes are affected, the
majority of individuals seeking treatment are women
of childbearing age, a phenomenon. suggesting that
hormonal influences should be investigated.

  Several factors can contribute to the onset or
exacerbation of TMD symptoms. These factors
include certain developmental anomalies; injury to
the jaw from accidents or abuse; oral habits that
greatly stress the joint and musculature, such as
tooth grinding (bruxism); jaw manifestations of sys-
temic diseases such as fibromyalgia and arthritic dis-
eases; and some irreversible treatments for initial
signs and symptoms.

The multiplicity of factors that may cause or con-
tribute to TMDs has unfortunately led to a multiplic-
ity of treatments. Most of these treatments have not
been tested in randomized controlled clinical trials.
During the 1970s and 1980s many individuals
underwent surgery, which proved unsuccessful in
many cases.

Leading investigators have proposed standard-
ized research diagnostic criteria to clarify the kinds of
pathology that can give rise to TMDs and to classify
the most common forms of TMDs. Such criteria
could be used in designing clinical trials and could
ultimately lead to better diagnostics. treatments, and
prevention. The criteria use two dimensions or axes:

52        ORAL HEliLTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


Diseases and Disorders

axis I delineates various forms of joint or muscle
pathology; axis II explores pain-related disability and
psvchologic 1 t t
         a s a us. The approach requires detailed
clinical examinations and patient histories (Dworkin
,md LeResche 1992).

A MIRROR, A MODEL, AND A BETTER
UNDERSTANDING OF DISEASES AND
DISORDERS

Studying the diseases and disorders that affect cran-
iofacial tissues can provide scientists with models of
systemic pathology Because some craniofacial tis-
sues, such as bones, mucosa, muscles, joints, and
nerve endings, have counterparts in other parts of the
body and these tissues are often more accessible to
research  analysis  than deeper-lying tissues,
researchers studying craniofacial tissues can gain
valuable insights into how cancer develops, the role
of inflammation in infection and pain, the effects of
diet and smoking, the consequences of depressed
immunity, and the changes that can arise from a
mutated gene.

Other craniofacial tissues-teeth, gingiva,
tongue, salivary glands, and the organs of taste and
smell-are unique to the craniofacial complex. Study
of the diseases affecting these tissues has revealed a
wealth of information about their special nature as
well as the molecules and mechanisms that normally
operate for the protection, maintenance, and repair of
all the oral, dental, and craniofacial tissues. When
factors perturb these nurturing elements, the oral
health scale can tip toward disease. When those fac-
tors stem from systemic diseases or disorders, the
mouth can sometimes mirror the body's ill health.
Similarly underscoring the connection between oral
and general health are studies suggesting that poor
dental health, mainly due to chronic dental infec-
tions, may heighten the risk for both cardiovascular
disease and stroke independently of factors such as
social class and established cardiovascular risk fac-
tors (Grau et al. 1997). The interplay between cran-
iofacial and systemic health and disease has become
a lively focus of interest and research, as discussed in
Chapter 5.

Current research on developmental disorders
and diseases affecting the craniofacial complex is
facilitating and complementing the intense effort of
the Human Genome Project to map and sequence all
100,000 genes. This goal should be accomplished
early in the twenty-first century and should begin to
yield information on the genetic program that gov-
erns morphogenesis, organ development, and disease
etiology and pathogenesis, with the potential for

ORAL HE.4LTH IN AMERICr\

interventions that can correct errors in the program.
The continued sequencing of the genomes of micro-
bial pathogens involved in oral diseases also should
lead to new diagnostic and preventive approaches.

FINDINGS

   o  Microbial infections, including those caused
by bacteria, viruses, and fungi, are the primary cause
of the most prevalent oral diseases. Examples include
dental caries, periodontal diseases, herpes labialis,
and candidiasis.

   o  The etiology and pathogenesis of diseases
and disorders affecting the craniofacial structures are
multifactorial and complex, involving an interplay
among genetic, environmental, and behavioral
factors.

   o  Many inherited and congenital conditions
affect the craniofacial complex, often resulting in dis-
figurement and impairments that may involve many
body organs and systems and affect millions of chil-
dren worldwide.

   o  Tobacco use, excessive alcohol use, and inappro-
priate dietary practices contribute to many diseases
and disorders. In particular, tobacco use is a risk fac-
tor for oral cavity and pharyngeal cancers, periodon-
tal diseases, candidiasis, and dental caries, among
other diseases.

   o  Some chronic diseases, such as Sjogren's syn-
drome, present with primary oral symptoms.
   o  Oral-facial pain conditions are common and
often have complex etiologies.

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Diseases and Disorders

ORAL HEALTH IN AMERICA: .4 REPORT OF THE SURGEON GENERAL           59


The range of oral, dental, and craniofacial diseases
and conditions that take a toll on the U.S. population
is extensive. This chapter provides highlights of dis-
eases and conditions affecting the U.S. population
using available national and state data to describe the
burden of disease in the United States. To capture the
dimensions and extent of these diseases and condi-
tions, the data are presented where possible by demo-
graphic measures such as racefethnicity, sex, age,
education, and economic status. Statistics and trends
are presented for each of the six categories of oral dis-
eases and disorders whose etiology and pathogenesis
are described in Chapter 3: dental and periodontal
infections, oral and pharyngeal cancers, mucosal
infections and conditions, developmental disorders,
intentional and unintentional injuries, and chronic
and disabling conditions. Included are conditions as
common as dental caries and periodontal diseases as
well as relatively rare clefting syndromes. Also men-
tioned are conditions that are more common in cer-
tain demographic subpopulations-for example,
Sjiigren's syndrome and temporomandibular disor-
ders, which are more common in women, and
injuries, which are more common in men. (See Box
4.1 for a glossary of terms used in this chapter.)

There is no single measure of oral health or the
burden of oral diseases and conditions, just as there
is no single measure of overall health or overall dis-
ease. As a result, this chapter assembles clinical and
epidemiologic measures for specific conditions
affecting the craniofacial structures. Note too that the
chapter presents an incomplete picture. State-specif-
ic data on oral diseases are extremely limited. There
is a paucity of national data on rare conditions as well
as on the health of selected populations and
their subgroups. Some characteristics and unique
needs of these populations are highlighted, and a
number of questions raised. More extensive analyses
of the differences among racial/ethnic, sex, and

income groups are warranted. The relationship of
oral health to the use of dental services is described.
However, the effects of health care visits and of spe-
cific services rendered need further study.

Most of the data in the figures and tables pre-
sented in this chapter are derived from large, nation-
ally representative surveys of the U.S. civilian, nonin-
stitutionalized population. These include complex
sample surveys, such as the National Health and
Nutrition Examination Survey (NHANES), which
use a sample of individuals selected with known
probability to estimate the prevalence of particular
characteristics and conditions in the nation as a
whole. The multipurpose NHANES provides data on
the frequency of the most common oral diseases and
conditions. The most recent survey, NHANES III,
was conducted by the National Center for Health
Statistics (NCHS) of the Centers for Disease Control
between 1988 and 1994. Trained interviewers gath-
ered demographic, health, and related data from eli-
gible households. Selected persons in these house-
holds were invited to a mobile examination center,
where they underwent multiple health assessments,
including an oral examination by a trained dentist
(NCHS 1996). Related surveys such as the National
Health Interview Survey (NHIS) also use complex
survey sampling and household interviews to obtain
health information about the U.S. population (Kovar
1989). The NHIS conducted in 1989 included data
on oral-facial pain conditions; several of these sur-
veys have captured data on dental visits. The most
extensive dental utilization survey that provides
demographic and socioeconomic data and data on
reasons for not visiting a dentist was conducted in
1989.

Surveys conducted by the National Institute of
Dental and Craniofacial Research of a probability
sample of U.S. schoolchildren in 1979-80 and 1986-
87 (Snowden and Miller-Chisholm 1992) used

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           61


The Magnitude of the Problem

BOX 4.1
Glossary

Complex sample survey. A survey of individuals selected with
known probability to estimate the prevalence and/or extent of
particular characteristics and conditions.
dfs. The count (number) of decayed (untreated) or filled primary
tooth surfaces per person.

dft. The count (number) of decayed (untreated) or filled primary
teeth per person.
DMFS.The count (number) of decayed (untreated), misiing (due
to caries), or filled permanent tooth surfaces per person.
DMFT.The count (number) of decayed,missing (due to caries),' 0;
filled permanent teeth per person.
Epidemiology.The study of the distribution and determinants of
disease frequency in human populations.
Incidence. The number of cases of a disease, or condition, that
occurs during a specified period of time.
Incidence rate. The number of cases of a disease, or condition,
that occurs during a specified period of time, per specified unit of
population.

Loss of periodontal attachment.' The distance from the
cementoenamel junction to the bottom of the gingival sulcus.
Mortality rate. The number of deaths during a stated period of
time divided by the total number of persons in the population.
Prevalence. The number of existing cases of a disease, or condi-
tion, at a designated point in time.

Prevalence rate. The number of existing cases of a disease, or
condition, at a designated point in time, per the number of per-
sons in the population.

Relative survival rate. Survival rates for persons with a partic-
ular disease or condition corrected for the expected occurrence of
death in persons in the age group.

Survival rate. The number of persons surviving over a specified
time period divided by the number of persons alive at the start of
the time period.

`In theThird National Health and Nutrition Examination Survey,the M (miss-
ing) component of the DMFl (S) index reflects teeth (or tooth surfaces) miss-
ing because of dental caries or periodontal disease. Teeth missing because of
trauma, orthodontic treatment or other non-disease-related reasons were
not scored.
*Periodontal disease status is assessed by measuring the distance from the
gingivai margin (FGM) to depth of the gingival sulcus, or pocket depth, and
the distance from thegingival margibto the cementoenamel junction (FGM-
CEl).A third measure,loss of attachment,is determined by calculating the dif-
ference between pocket depth and the FGM-CU distance. Loss of attachment
is important because it serves as a measure of how much support from the
tissues surrounding the tooth has been lost.

similar oral examination procedures as in NHANES.
Because school attendance is high in the United
States, these surveys are considered representative of
noninstitutionalized children throughout the United
States and are used in this chapter.
Record-based surveys are another approach to
obtaining health data for the nation as a whole or for
selected broad areas. Mortality statistics are obtained
by determining the number of deaths in the United
States and dividing that figure by the total U.S. pop-
ulation as determined from U.S. Census data (Kovar
1989). Cancer statistics are derived from population-
based cancer registries in selected large geographic
areas of the United States usirig reports of cancer
occurrences from hospitals, doctors, and laborato-
ries. This data system, maintained by the National
Cancer Institute,  is called the Surveillance,
Epidemiology, and End Results program (Ries et al.
1999). Birth certificate registries in geographic areas
and surveys of health care facilities provide valuable
information from record-based systems about other
aspects of oral and craniofacial health such as birth
defects (Schulman et al. 1993). The Centers for
Disease Control and Prevention's Behavioral Risk and
State Surveillance System provides essential state
data on edentulousness (Tomar 1997). In selected
cases, survey findings other than from national prob-
ability surveys are used. State-specific data are pro-
vided for those conditions for which there are data
from most states--that is, cancer mortality statistics
and self-reports of edentulism.

Economic status is derived from annual income
data. Unless otherwise stated, "poor" is defined in
this chapter as an annual income below the U.S.
poverty level. For both national and other surveys,
the race and ethnicity terms used in this report are
consistent with the terms used in the supporting
documentation as referenced in the text and cited in
the reference list. Available national data for most
conditions are limited primarily to Hispanic, non-
Hispanic black, and non-Hispanic white populations,
due to the sampling design of the national surveys.
The NHANES III oversampled Mexican Americans,
so the data from that survey are available for this sub-
population of Hispanics.

62

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


The Magnitude of the Problem

WHO HAS WHAT DISEASES AND
CONDITIONS?

Dental Caries, Periodontal Diseases, and
Tooth Loss

Dental Caries

Dental caries is one of the most common childhood
diseases. In this section, decayed refers to teeth with
caries that have not been treated. The term filled
refers to treated caries. Dental caries refers to both
decayed and filled teeth. Among 5- to 17-year-olds,
dental caries is more than 5 times as common as a
reported history of asthma and 7 times as common as
hay fever (Figure 4.1). Prevalence increases with age.
The majority (51.6 percent) of children aged 5 to 9
years had at least one carious lesion or filling in the
coronal portion of either a primary or a permanent
tooth. This proportion increased to 77.9 percent for
17-year-olds and 84.7 percent for adults 18 or older.
Additionally, 49.7 percent of people 75 years or older
had root caries affecting at least one tooth (NCHS
1996, NHANES III).

Despite progress in reducing dental caries, indi-
viduals in families living below the poverty level
experience more dental decay than those who are
economically better off. Furthermore, the caries seen
in these individuals is more likely to be untreated
than caries in those living above the poverty level
(Figure 4.2); more than one third (36.8 percent) of
poor children aged 2 to 9 have one or more untreat-
ed decayed primary teeth, compared to 17.3 percent
of nonpoor children.

In addition to poverty level, the proportion of
teeth affected by dental caries also varies by age and
race/ethnicity. Poor Mexican American children aged

FIGURE 4.1

Dental caries is one of the most common diseases among
S-to 17-year-olds

Caries I]\ 58.6

0    10   20    30   40   so   60    70
Percentage of children and adolescents aged 5 to17

Note: Data include decayed or filled primary and/or decayed,Rlled, or mlsring
permanent teeth. Asthma, chronic bronchitis, and hay fever based on report of
household respondent about thesampled S- to 17-year-olds.
Source: NCHS 1996.

2 to 9 have the highest number of primary teeth
affected by dental caries (a mean of 2.4 decayed or
filled teeth) compared to poor non-Hispanic blacks
(mean 1.5) and non-Hispanic whites (mean 1.9).
Among the nonpoor, Mexican American 2- to g-year-
olds have the highest number of affected teeth (mean
1.8)) followed by non-Hispanic blacks (1.3) and non-
Hispanic whites (1 .O).

There are also differences by race/ethnicity and
poverty level in the proportion of untreated decayed
teeth for all age groups. Poor Mexican American chil-
dren aged 2 to 9 have the highest proportion of
untreated decayed teeth (70.5 percent), followed by
poor non-Hispanic black children C67.4 percent)
(Figure 4.3). Nonpoor children have lower propor-

FIGURE 4.2
A higher percentage of poor people than nonpoor have at least
one untreated decayed tooth
  so

* Poor

teeth only) and permanent teeth) teeth only)
        Age

iource: NCHS 1996.

FIGURE 4.3
Poor children aged 2 to 9 in each racial/ethnic group have a
higher percentage of untreated decayed primary teeth than
nonpoor children

    80
c
&    70
01x4
cs 6o
55 50
55 w 40
XC
rts
00) 3o
i; 20
w-
x    10
2
     0
   Non-Hispanic black Mexican American Non-Hispanic white

       * Poor children  W Nonpoor children

Source: NCHS 1996.

ORAL HEALTH IN AMERICA: A REPORT OF THE WRGEON GENERAL          63


The Magnitude of the Problem

tions of untreated decayed teeth, although the group
with the lowest proportion (non-Hispanic whites)
still has an average of 37.3 percent of decayed teeth
untreated.

Poor adolescents aged 12 to 17 in each raciaueth-
nit group have a higher percentage of untreated
decayed permanent teeth than the corresponding
nonpoor adolescent group (Figure 4.4). Poor
Mexican American (47.2 percent) and poor non-
Hispanic black adolescents (43.6 percent) have more
than twice the proportion of untreated decayed teeth
than poor non-Hispanic white adolescents (20.7 per-
cent). For nonpoor adolescents the proportion of
untreated decayed permanent teeth is highest in non-
Hispanic black adolescents (41.7 percent)-a pro-
portion only slightly lower than for this group's poor
counterparts (43.6 percent). The mean number of
permanent teeth affected by dental caries (decayed or
filled) for this age group is similar among Mexican
Americans (2.7), non-Hispanic whites (2.5), and
non-Hispanic blacks (2.3). As income level increases,
the percentage of adolescents with decayed teeth
decreases and the proportion of decayed teeth that
have been filled increases (Vargas et al. 1998).
Adult populations (aged 18 and older) show a
similar pattern, with the proportion of untreated
decayed teeth higher among the poor than the non-
poor (Figure 4.5). Regardless of poverty level status,
adult non-Hispanic blacks and Mexican Americans
have higher proportions of untreated decayed teeth
than their non-Hispanic white counterparts.

FIGURE 4.4

Poor children aged 12 to 17 in each racial/ethnic group have a
higher percentage of untreated decayed permanent teeth than
nonpoor children

Non-Hispanic black  Mexican American `Non-Hispanic white

  W Poor children   H Nonpoor children

Source: NCHS 1996.

Improvements have been noted over the past 25
to 30 years with regard to dental caries. Among most
age groups, the average number of teeth per person
affected by dental caries has decreased, and the aver-
age number of teeth per person that show no signs of
infection, as well as the proportion of the population
that is caries-free, has increased.
Since 1971-74, major increases have been noted
in the percentage of children and adolescents aged 5
to 17 who have never experienced dental caries in
their permanent teeth. Younger adults have experi-
enced a decline in dental caries during this time
period, as measured by the average number of teeth
without decay or fillings (Figure 4.6). These trends
are not found among those 55 to 74 years of age.
                         I

1

FIGURE 4.5
Poor adults aged 18 and older have a higher percentage of
untreated decayed teeth than nonpoor adults
   50

   45
5
5 40
=E
r c 35
sg
F z 30
f=
25 15
`s t -
g#E 20
s `, 15
5s
E It! 10
    5

    0

      * Poor adults

Source: NCHS 1996.

O Nonpoor adults

FIGURE 4.6
Since 1971-74, the average number of permanent teeth without
decay or fillings has increased among 18- to 54-year-olds

                                7
       1971-74        1988-94
          Survey year
Sources: NCHS 1975,1996.

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


The Magnitude of the Problem

The number of untreated decayed teeth per per-
son across all age groups has also declined.

periodontal Diseases

The presence of periodontal disease is measured clin-
ically in several ways, one of which is by calculating
the loss of periodontal attachment. Figure 4.7 shows
that most adults 25 years and older have at least 2
mm or more loss of attachment. The disease is more
serious as the amount of attachment loss and number
of tooth sites affected increase. More severe disease
can be defined as having 4 mm or more loss of attach-
ment in at least one site. The percentage of adults
with 6 mm or more loss of attachment at one or more
sites increases at older age groups, with 19.0 percent
of 55- to 64-year-olds and 23.4 percent of 65 to 74-

year-olds having this amount of loss or more. Figure
4.8 displays these data in a different format and shows
that a small but increasing percentage of the popula-
tion at each older age group has severe disease.

At all ages, men are more likely than women to
have at least one tooth site with a 6 mm or more loss
of attachment (Figure 4.9). In addition to age and
sex, the prevalence of periodontal loss of attachment
also varies by racial/ethnic group (Figure 4.10). A
higher percentage of non-Hispanic black persons at
each age group have at least one tooth site with 6 mm
or more of periodontal attachment loss as compared
to other groups. Within each racial/ethnic group, the
highest percentage affected is found among individu-
als 70 years and older. At every age, a higher propor-
tion of those at the lowest socioeconomic status

FIGURE 4.7

The proportion of adults with at least one site with loss of periodontal attachment of 2 mm or more,
4 mm or more, and 6 mm or more increases with age

           94.5    95.7
     89.8 v
86.4              i
                     3

2   80                               ,1
      -                                               Loss of attachment
3                  14.9
t                         $4.6        .% 2 mm or more
`s   60        60.5
      -          1                 50.2    :54.9              m 4 mm or more
L                                           m             * 6 mm or more
s               .
z   40 -  37.3                  38.0

2!
81       "
         ?            22.1
   20-  ;      .12.0
        $3.0

0    - 0.2
        I       1       ,       I              ,
  18-24    25-34    35-44   45-54    55-64    65-74    75+
              Age group

Sources: Adapted from NCHS 1996,Burt and Eklund 1999

FIGURE 4.8

Although older adults have more periodontal attachment loss
than younger adults, severe loss is seen among a small
percentage of individuals at every age

Age

+ la-44
- 45-M
- 65+

         3    5    7    9    11
     Loss of periodontal attachment (mm)
Sources: Adapted from NCHS 1996, Burt and Eklund 1999.

FIGURE 4.9
Males are more likely than females to have at least one tooth
site with 6 mm or more of periodontal loss of attachment

  40
f 35
g 30
B 25
E 20
g 1s
#j 10
   5
   0

            Age vw
           O Female   * Male
SourcesAdapted from NCHS 1996,Burtand Eklund 1999.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           65


The Magnitude of the Problem

(SES) level have at least one site with attachment loss
of 6 mm or more, compared to those at higher SES
levels (Figure 4.11) (Burt and Eklund 1999).'

Gingivitis as measured by gingival bleeding, a
sign of inflammation, is more evident among
Mexican Americans (63.6 percent) than among non-
Hispanic blacks (55.7 percent) and non-Hispanic
whites (48.6 percent) (Albandar et al. 1999).
Early-onset periodontitis, a severe, rapidly pro-
gressive disease occurring in individuals under age

FIGURE -t.lO

Non-Hispanic blacks are more likely than other groups to have
at least one tooth site with 6 mm or more of periodontal loss
of attachment

  50                      47.1
  45

a8  40
H  35
E  30
5  25

5  20
5  15
=
   10

   5

   0

     30-49   SO-69     70+
            Age group
Race/ethnicity
W Non-Hispanic black    Mexican American  PI Non-Hispanic white
Source: NCHS 1996.

35, has been reported to be 4 times more common in
males than in females (Lee and Brown 1991); among
13- to 17-year-olds, it has been found to be highest
among African Americans (10.0 percent), as com-
pared with Hispanics (5.0 percent) and whites (1.3
percent) (Albandar et al. 1997).

Tooth Loss and Edentulism

Although teeth are lost for a number of reasons,
including trauma,  orthodontic treatment, and
removal of third molars (wisdom teeth), most teeth
are lost because of periodontal disease or dental
caries (Phipps and Stevens 1995, Neissen and
Weyant 1989). By age 17, mom than 7.3 percent of
U.S. children have lost at least one permanent tooth
because of caries; by age 50, Americans have lost an
average of 12.1 teeth, including the third molars.

Men and women are nearly equally likely to be
edentulous. Overall, a higher percentage of individu-
als living below the poverty level are edentulous than
are those living above (Figure 4.12). Individuals with
incomes equal to or above twice the poverty level
have a rate of edentulism of 6.9 percent. This rate is
less than half the rate for those with incomes below
twice the poverty level (14.3 percent).

Although the overall rate of edentulism for adults
18 and older is approximately 10 percent (9.7 per-
cent), the rate increases with age, so that about a third
(33.1 percent) of those 65 and older are edentulous.
Comparisons across raceIethnicity for the population
18 years and older indicate that the edentulous rate

FIGURE 4.11

The percentage of adults with at least one tooth site with 6 mm or more of periodontal attachment loss is
greater among persons of low socioeconomic status at all ages

    40                                       37.8      36.2

Y    35
e   30
x                            25.8                      25.5
t   25
ii   20
E    15
E
81    10
    5
    0
        18-24     25-34     35-44     45-54     55-64     65-74      75+

                      Age group
Socioeconomicstatus
tow   B Middle  * High

Sources: Adapted from NCHS 1996,Burt and Eklund 1999.

`In this section, income levels are defined as low (less than 185 percent of the U.S. poverty level or below), middle (185.1 percent
to 350 percent of the poverty level), and /rig/l (350.1 percent of the poverty level or higher).

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


for non-Hispanic whites is 10.9 percent; for non-
Hispanic blacks, it is 8.0 percent; and for Mexican
,\mericans, 2.4 percent. Non-Hispanic whites, both
poor and nonpoor, have the highest rates of eden-
tufism compared to non-Hispanic blacks and
\tesican Americans. Of the three population groups,
\lexican Americans are the least likely to lose all of
their teeth, and the proportion of Mexican Americans
\vho are edentulous varies only slightly by economic
status. A lower proportion of U.S. adults have lost all
their natural teeth now than was the case two
decades ago (Figure 4.13). The decline is most pro-
nounced at older ages.

Edentulism is one of a few conditions for which
state-specific data exist. These data reveal a wide
variation in the percentages of the population aged
65 and older who have no teeth, from a low of 13.9
percent in Hawaii to a high of 47.9 percent in West
Virginia; this is more than a threefold difference
(Table 4.1) (Tomar 1997). Reasons for these differ-
ences are unknown at this time.

Oral and Pharyngeal Cancers and
Precancerous Lesions

Oral and Pharyngeal Cancers
Every year, about 1.2 million people develop cancer
in the United States (based on 2000 estimates). Sites

FIGURE 4.12

Complete tooth loss varies by race/ethnic@ and poverty status:
a higher percentage of poor and nonpoor non-Hispanic white
adults (18 and older) have no teeth compared with non-Hispanic
blacks and Mexican Americans

   Non-Hispanic black  Mexican American  Non-Hispanic white
        * Poor adults   II Nonpoor adults

Source: NCHS 1996.

The Magnitude of the Problem

in the oral cavity and pharynx (throat) account for
about 30,200 cases, or 2.4 percent of all cancers, and
about 7,800 Americans die from these cancers each
year (ACS 1999). The life of each person with these
cancers is shortened by an average of 16.5 years. The
median age at diagnosis of oral and pharyngeal can-
cer is 64, and the rate of occurrence increases with
age. More than 95 percent of oral cancers occur in
individuals aged 35 and older (Ries et al. 1999).

The overall 5-year survival rate for people with
oral and pharyngeal cancers is 52 percent, which is
worse than that for-among others-cancers of the
prostate, corpus and uterus, breast, bladder, larynx,
cervix, colon, and rectum in both blacks and whites
(Ries et al. 1999). People with oral cancers detected
at an early stage have a 5-year survival rate of 81.3
percent; however, only 35 percent of individuals with
oral and pharyngeal cancers are diagnosed at an early
stage. The 5-year survival rate drops to 21.6 percent

FIGURE 4.13

The percentage of people without any teeth has declined among
adults over the past 20 years

28.6

12& is.2

Age

+65-74
+55-64
+35-54
* 18-34

2.0 .c           0.4     /
1971-74       1988-94
   Survey years

Sources: NCHS1975,1996.

TABLE 4.1

Five states with highest and lowest percentages of
edentulous persons aged 65 and older

States with Highest Percentage
      Percentage
State      Edentulous
West Virginia     47.9
Kentucky      44.0
Louisiana      43.0
Arkansas      39.2
Maine        37.8

Source: Tomar 1997.

States with Lowest Percentage
      Percentage
State      Edentolous

Hawaii       13.9
California      16.2
Oregon       16.5
Arizona       18.5
Wisconsin      19.4

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           67


among people diagnosed with advanced-stage can-
cers (Ries et al. 1999). Compared to patients with
other types of cancer, oral and pharyngeal cancer
patients who survive have the highest rate of devel-
opment of new cancers in the mouth or in other parts
of the body (Winn and Blot 1985).

Incidence rates for oral and pharyngeal cancers
are higher for black individuals than for whites: 12.5
cases versus 10.0, respectively, per 100,000 people
each year. In the United States, Asians and Pacific

Islanders (7.9 per lOO,OOO), American Indians and
Alaska Natives (6.4 per lOO,OOO), and Hispanics (5.8
per 100,000) have lower incidence rates than whites
and blacks (Wingo et al. 1999).

Figure 4.14 provides incidence rates for selected
racial/ethnic groups by sex. Males have higher inci-
dence rates than females; specifically, they are 2.6
times more likely to develop oral and pharyngeal
cancers than women (Ries et al. 1999). The incidence
rates of oral and pharyngeal cancers for black males

FIGCRE -4.1-t
Males have higher incidence rates of oral and pharyngeal cancers than females

Z Female
H Male

are 39.6 percent higher than for
white males (20.8 versus 14.9,
respectively, per 100,000 males
per year). Rates for black and
white females are the same (6.0
per 100,000 females per year)
(Ries et al. 1999). Oral and pha-
ryngeal cancers are the seventh
most common cancer among
white males and the fourth most
frequently diagnosed cancer
among black males (Figure 4.15)
(Wing0 et al. 1999).

Black

White

   Asian and
Pacific Islander
American Indian
and Alaska Native

Hispanica

0      5      10     15     20     25
        Rate per 100,000

Nate: Age adjusted to the 1970 U.S.standard.
1 Data are unavailable for Hispanic females.
Sources: Adapted from Wingo et al. 1999;SEER Program, 1990-96, Ries et al. 1999.

As for many other cancer
sites, the overall 5-year survival
rate for oral and pharyngeal can-
cers is lower for blacks than for
whites: 34 versus 56 percent

FIGURE -t.15

Cancers of the oral cavity and pharynx are the seventh most common cancers in white males
and the fourth most common in black males

   Prostate gland

  Lung & bronchus

    Colon/rectum

  Urinary bladder

    tymphomas

  Melanoma of skin

Oral cavity & pharynx

      Leukemia

   Kidney/renal

      Pancreas


           0    50    100    150    200    250

   Prostate gland

  Lung&bronchus

    Colon/recrum

Oral cavity&pharynx

      Stomach

  Urinary bladder

   Lymphomas

      Pancreas

   Kidney/renal

    Esophagus

           0    50    100    150    200   250

White males

Note: Age adjusted to the 1970 U.S.standard.
Sources: Adapted from Wingo et al. 1999; SEER Program, 1990-96, Ries et al. 1999.

Incidence rate per lW,OOO

Black males

a;        ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


(Ries et al. 1999) (Figure 4.16). However, only 19
percent of blacks with oral and pharyngeal cancers
are diagnosed when the cancer is at the local, and
more easily treatable, stage, compared to 38 percent
for whites (Figure 4.17). At every stage of diagnosis,
the survival rate for blacks is lower than for whites
(Figure 4.18).

The occurrence of cancers in specific sites with-
in the oral cavity and pharynx varies by sex and
race/ethnicity A relatively rare subtype of pharyngeal
cancer, nasopharyngeal cancer, occurs more often in
,American males and females of Chinese descent than
among other raciauethnic groups (Miller et al. 1996).
Blacks are twice as likely as whites to develop cancers
of the pharynx: 6.0 and 2.9 per 100,000 per year,
respectively (Ries et al. 1999). Individuals with can-

FIGURE 4.16
Five-year relative survival rates for selected cancers for
whites and blacks

       0 16 2d io 4 5b ti 70 io io 100
         Five-year relative survival rates
         H White patients  W Black patients
Note: NOS = not otherwise specified.
Source: Korary 1996.

cers of the pharynx generally have a worse survival
rate than those with cancers in oral cavity sites: 5-
year pharyngeal cancer survival rates range from 53.3
to 29.5 percent, depending on the subsite, whereas
oral cavity cancer survival rates range from 94.3 to
48.3 percent. The incidence of lip cancer, a highly
treatable cancer, is more common in whites than
among blacks (1.2 per 100,000 persons per year
compared to 0.1).

Overall, the incidence rate for oral cavity and
pharyngeal cancers is decreasing, with an estimated
annual percentage decrease of 0.5 percent per year
between 1973 and 1996. There are wide variations in
the incidence of site-specific cancers. The largest
                               .

FIGURE 4.17
Blacks are less likely to be diagnosed with a localized oral or
phatyngeal cancer than whites
60

I White patients

          Stage at diagnosis
Source: Adapted from SEER Program, 1989-95, Ries et al. 1999.

FIGURE 4.18
At every stage of diagnosis, the S-year relative survival rates
for blacks with oral and pharyngeal cancers are lower than
for whites

   90

80

* White patients

Stage at diagnosis

Source: Adapted from SEER Program, 1989-95, Ries et al. 1999.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           69


The Magnitude of the Problem

annual declines in incidence were noted for lip can-
cer (-3.4 percent per year between 1973 and 1996)
(Ries et al. 1999). In contrast, the incidence of
tongue cancer, the most common form of oral and
phar)-ngeal cancer, may be increasing among young
men (Day et al. 1994).

Although overall mortality rates for oral and pha-
ryngeal cancers declined by 1.6 percent per year
between 1973 and 1996, the 5-year survival rate for
individuals with oral and pharyngeal cancers has
shown no improvement for the past 25 years (Ries
et al. 1999).

Mortality statistics by state allow for analysis of
deaths due to oral cavity and pharyngeal cancers.
Table 4.2 highlights the wide variation in mortality
found in the country The highest rate is in the
District of Columbia-6.7 per 100,000 population;
this is nearly 5 times the lowest rate, 1.4 in Utah.
Again, reasons for this variation need to be studied
(Ries et al. 1999).

Tobacco-related Lesions

Tobacco use has been estimated to account for over
90 percent of cancers of the oral cavity and pharynx
(Peto et al. 1995) and thus represents the greatest
single preventable risk factor for oral cancer. Both
smoking and spit (smokeless) tobacco (moist snuff
and chewing tobacco) are associated with a number of
other oral conditions, including oral mucosal lesions,
that may progress to oral cancer (Silverman 1998).

One type of tobacco-related lesion.is seen in peo-
ple who use spit tobacco. A national survey of U.S.
schoolchildren in 1985-86 showed that 6.1 percent of
males and 0.1 percent of females used spit tobacco.
The survey also showed that 34.9 percent of current
snuff users aged 12 to 17 and 19.6 percent of current
adolescent chewing tobacco users had a spit tobacco
lesion (Figure 4.19) (Tomar et al. 1997). The preva-

TABLE 4.2
Five states with highest and lowest oral and pharyngeal
cancer mortality rates

  States with Highest Rates      States with Lowest Rates
       Mortality Rate per       Mortality Kate per
State      100,000 Population State    100,000 Population
District of Columbia     6.7     Minnesota     2.0
Delaware         4.0    Wyoming      2.0
South Carolina       3.9     Colorado      2.0
Louisiana         3.5     North Dakota    1.8
Florida           3.4     Utah         1.4

Note: Ages adjusted to the 1970 standard population.
Source: Ries et al. 1999.

lence of tobacco-related lesions increased with
increasing duration and frequency of spit tobacco use.

In some American Indian tribes, both adolescent
males and females commonly use spit tobacco and
have an especially high frequency of spit tobacco
lesions. On a Sioux reservation, 37.0 percent of stu-
dents in grades 7 through 12 used spit tobacco. Spit
tobacco lesions occurred in over one third of those
tobacco-using adolescents (CDC 1988). In another
study of Navajo adolescents, three fourths of male
adolescents (75.4 percent) and one half of female
adolescents (49.0 percent) used spit tobacco. Of
Navajo adolescents who used spit tobacco, 25.5 per-
cent had spit tobacco lesions-29.6 percent of males
and 17.0 percent of females (Wolfe and Carlos 1987).

Selected Mucosal Infections and Diseases

Oral Herpes Simplex Virus Infections

The prevalence of recurrent herpes lesions is estimat-
ed to be between 15 and 40 percent (Scully 1989).
The proportion of the U.S. population with herpes
simplex virus type 1 (HSV-1) antibodies is 68.2 per-
cent (as evidenced by positive antibody titer). The
proportion reporting a history of herpes lesions in the
past 12 months is 17.7 percent. The presence of anti-
bodies and occurrence of herpes lesions vary by age
(Figure 4.20). The frequency of recurrence also varies
greatly, ranging from once to several times per year.

Infection with the oral herpes simplex virus has
been related to socioeconomic factors, with 75 to 90
percent of individuals from lower socioeconomic

FIGURE 4.19

Tobacco-related oral lesions are more common in 12-to 17-
year-olds who currently use spit tobacco

35 -I

c 30-
.,0
f 25-
.=
B
s 20-
&
g 15-
aI
g lo-
5
2  5-


  O--

L

m Current user

Snuff user      Chewing tobacco user

Source: Adapted from Tomar et al. 1997.

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


populations developing antibodies by the end of the
first decade of life (Whitley 1993a,b). In comparison,
30 to 40 percent of individuals from middle and
upper socioeconomic groups evidence antibodies by
the middle of the second decade of life.

The prevalence of one or more herpes labialis
lesions within the past 12 months is 8.4 percent for
non-Hispanic blacks. 16.2 percent for Mexican
Americans, and 19.7 percent for non-Hispanic whites
(NHANES III).

Recurrent Aphthous Ulcers
Various epidemiologic studies of recurrent aphthous
ulcers have indicated that the prevalence in the gen-

eral population can vary from 5 to 25 percent (Axe11
et al. 1976, Embil et al. 1975, Ferguson et al. 1984,
Ship 1972, Ship et al. 1967). In NHANES III, 17.2
percent of persons reported having a recurrent aphthous
ulcer within the past 12 months, and occurrences were
most common among young adults (18 to 24 years
old) (Figure 4.21). In selected population groups, the
prevalence of recurrent aphthous ulcers can be as
high as 50 to 60 percent (Miller and Ship 1977, Ship
et al. 1961, 1977).

Other Mucosal Lesions

Other mucosal conditions contribute to the burden
of oral diseases. The following are among the most

FIGURE 4.20

Herpes simplex type 1 virus infection is widespread, and oral herpes lesions
(cold sores/fever blisters) are common

  100

   90
   80
a
5 70
Q,
f 60
5 50
z 8 40
% 30

88.9

Age
* 8-11
* 12-17
O l&24
O 25-44
:$45-64
  >65

0 Orul candidiasis (commonly
called thrush) is a particular prob-
lem for individuals with impaired
immune function. A prevalence of
9.4 percent has been reported in
renal transplant patients (King et
al. 1994); Samaranayake (1992)
reports prevalences between 43
and 93 percent among HIV-infect-
ed patients. It is estimated that 3.6
percent of full denture wearers
have candidiasis.

   20

   10

   0     Positive antibody to HSV-la
2 Data not available for the 8- to 1 l-year-old age group.
Source: NCHS 1996.

Had oral herpes lesion
in past 12 months

FIGURE 4.21

A substantial percentage of the population, particularly
among young adults, has experienced recurrent aphthous
lesions (canker sores) in the past 12 months

26.9

         o Denture stomatins, a condi-
       tion in which the mucosa under-
       neath a denture becomes inflamed
      and sometimes painful, affects 25.6
      percent of people aged 18 and older
        who have two full dentures.
      Additionally, 32.2 percent of those
       with one full denture are affected,
26.7 percent of those with one or more partial den-
tures, and 0.87 percent of those who do not have full
or partial dentures.
   0  Oral human papillomavirus infections, oral
and genital papillomas (or condyloma acuminata,
also called venereal warts), are especially common
among HIV-positive patients. Human papilloma-
viruses may be associated with some oral leukopla-
kias with a high risk for malignant transformation
(Palefsky et al. 1995).

Age group

Source: Adapted from NCHS 1996

The Magnitude of the Problem

common:

Developmental Disorders

Numerous developmental disorders affect the oral,
dental, and craniofacial complex. These include con-
genitally missing teeth [all or specific tooth types);
congenital problems involving tooth enamel, pulp, or
dentin; and craniofacial birth defects or syndromes.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           71


The Magnitude of the Problem

Cleft lip and palate are the most common congenital
anomalies and may occur as isolated defects or as part
of other syndromes. Other craniofacial defects and
syndromes that have been the focus of recent genet-
ics research include ectodermal dsyplasia, Treacher
Collins syndrome, Apert's syndrome, and Waarden-
burg syndrome. Craniofacial defects and syndromes
have many serious consequences including unusual
facial features; severe functional problems; and the
need for extensive surgical, medical, and rehabilita-
tive interventions and prosthetic devices.

Cleft Lip/Palate

Oral clefts are one of the most common classes of
congenital malformations in the United States, with
prevalence rates in the general population of 1.2 per
1,000 births for cleft lip with or without cleft palate
and 0.56 per 1,000 births for cleft palate alone
(Schulman et al. 1993). These conditions affect facial
appearance throughout life.

The rate of oral clefts for whites is more than 3
times that for blacks (1.7 versus 0.5 per 1,000 live
births) (Figure 4.22). Oral clefts are more common
among North American Indians (3.7 per 1,000 births)
(Lowry et al. 1989). Cleft palate occurs more fre-
quently in females, whereas cleft lip or cleft lip/palate

-

FIGURE 4.22

Cleft lip and cleft palate are among the most common
congenitai malformations, and prevalence varies by race

Hydrocephalus

Trisomy 21

Microcephalus

Obstruction kidney/ureter

Cleft lip & palate

Pyloric stenosis

0.0 0.5  1.0  1.5  2.0  2.5  3.0 3.5 4.0
Prevalence perl,OOOlivebirths

Source: Schulman et al. 1993.

* Whites     * Blacks

is more common in males (Burman 1985, Fraser and
Calnan 1961, Habib 1978, Owens et al. 1985).

Malocclusions

Malocclusions can occur due to congenital or
acquired misalignments (crowding) of the teeth or
jaws. In a national study of individuals between 8
and 50 years old, 25 percent were found to have no
crowding of the incisors (front teeth), whereas 11
percent were found to have severe crowding
(Bnmelle et al. 1996). About 9 percent had a posteri-
or crossbite, where there is poor contact of the back
upper and lower chewing surfaces. This crossbite was
most common in non-Hispanic \nlhites. Severe over-
jet-where the upper front teeth project far for-
ward-was found in approximately 8 percent of this
population, with a similar percentage demonstrating
a severe overbite-where the front top and bottom
teeth greatly overlap when the mouth is closed. Less
than 5 percent of non-Hispanic whites had an open
bite, an inability to bring the upper and lower front
teeth together.

Injury

Injuries to the head, face, and teeth are very com-
mon. They can range in severity from the very mild
to those that cause death. Although injuries have a
major impact on oral health, data on the number and
severity of head and face injuries in the United States
are very limited.2 Most of our knowledge about the
number of injuries that occurs comes from more
severe injuries that involve a visit to the emergency
room.

In 1993 and 1994, there were 20 million visits
per year to emergency departments for craniofacial
injuries. Less serious injuries can be treated on an
outpatient basis. More than 5.9 million injuries in
1991 were treated by dentists in private offices (Gift
and Bhat 1993). Overall, 25 percent of all persons
aged 6 to 50 have had an injury that resulted in dam-
age to one or more anterior teeth (Kaste et al. 1996a).
An estimated 2.9 million emergency room visits for
all age groups related to tooth or mouth injuries
between 1997 and 1998. Twenty-five percent of these
injuries were seen in children under the age of 4
(NCHS 1997b).

The leading causes of head and face injuries that
result in emergency room visits include falls, assaults,

IThis section reporrs national data that should provide some estimation of the scope of craniofacial injuries in the population.
However, the findings may not be directly comparable because they are from different sources at different times, and because
those at risk for each type of injury are not quantified in most cases.

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


sports injuries, and motor vehicle collisions (De Wet
1981, Pinkham and Kohn 1991, Sane 1988). In the
yational Health Care Survey of emergency rooms,
,lssaults and falls each accounted for 31 percent of
visits related to head and face injury. Other studies
have reported that up to 19 percent of head and face
Injuries are sports-related (McDonald 1994), and 5
percent of head and 19 percent of face injuries result
from riding bicycles and tricycles (U.S. Consumer
Product Safety Commission 1987).
There are differences in rates of emergency room
visits for head and face injuries among demographic
groups. Males had higher rates than females, except
among older adults. The rates of injury were higher
for younger and older adults than for those in the
middle years.

Chronic and Disabling Conditions

Oral-Facial Pain

Oral-facial pain can greatly reduce quality of life.
These types of pain may be due to tooth-related
infections, mucosal sores, and irritations, and may
include burning sensations, pain in the jaw joint
area, and aching pain across the face or cheek. Over
39 million people, or 22 percent of adults 18 years of
age and older in the civilian U.S. population, experi-
enced at least one of five types of oral-facial pain dur-
ing a recent 6-month period (Lipton et al. 1993).
Based on the results of a national study of the preva-
lence and distribution of oral-facial pain, it is esti-
mated that during a 6-month period, 1 American
adult in 8 (12.2 percent) suffers from toothache, 1 in
12 (8.4 percent) from painful oral sores, 1 in 19 (5.3
percent) from jaw joint pain, and 1 in 71 (1.4 per-
cent) from face or cheek pain (Lipton et al. 1993).
The prevalence of toothache and pain due to oral
sores decreases with age, whereas the prevalence of
burning mouth pain increases with age. Women are
twice as likely as men to report two specific types of
oral-facial pain: jaw joint pain and face/cheek pain
(Figure 4.23). Non-Hispanic blacks and Hispanics
were slightly more likely to report toothache than
non-Hispanic whites (Lipton et al. 1993). Adults liv-
ing in poverty were more likely to report toothaches
than adults living above the poverty level (Vargas et
al. 2000).

Temporomandibular Disorders
Symptoms of temporomandibular disorders (TMDs)
vary but may include severe pain in the jaw muscu-
lature, severe pain or difficulty when opening the

The Magnitude of the Problem

mouth and chewing, headaches, and ear pain. Based
upon assessments of pain in or around the jaw joint,
these disorders are estimated to affect 10 million
Americans (Lipton et al. 1993).

Data from the few available population-based
epidemiologic studies indicate that the prevalence of
self-reported pain symptoms and clinical signs of
TMD pain is between 5 and 15 percent, with peak
prevalence in young and middle-aged adults (20 to
40 years of age) (Von Korff 1995).

i\lthough physical signs associated with TMDs
have been shown to occur with nearly equal fre-
quency among men and women, clinical studies have
found that women in the third and fourth decades of
life were much more likely than men pf the same age
to have sought care for reported facial pain in the tem-
poromandibular region (Carlsson and LeResche 1995).

Sjiigren's Syndrome
Sjogren's syndrome, an autoimmune disorder that
causes xerostomia (dry mouth), difficulty in swal-
lowing, and xerophthalmia (dry eyes), is estimated to
affect 1 to 2 million people in the United States (Talal
1992). The diagnosis is most often made in women
in middle age. One estimate of the average annual
incidence rate for Sjogren's syndrome, based on the
Olmsted County, Minnesota, medical database, is
about 3 to 5 cases per 100,000 population; this may
be low, however (Pillemer et al. 1995). As with most
other autoimmune conditions (e.g., rheumatoid
arthritis, systemic lupus erythematosis), Sjogren's
syndrome affects more women than men. The
femalelto-male ratio depends on the study, but may
be as high as 9:l (Fox 1996).

FIGURE 4.23

Toothache is the most common source of oral-facial pain

  14
P
g  12
,"
8  10

;  8
L
;  6
P  4
f  2

  0

I     Toothache Oral sores Jaw joint Face/cheek  Burning

Pain category

          * Female   m Male
Note: Data are for persons aged 18 and older looking back over the past 6 months.
Sources: Adapted from NCHS 1989, Lipton et al.1993.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           73


The &lagnitude of the Problem

WHAT IS THE BURDEN OF DISEASE IN
SELECTED POPULATIONS?
CHALLENGES AND OPPORTUNITIES
The national data provide a broad-brush picture of
America's oral health. For selected populations, how-
ever, oral health and disease status has a different
profile. By 2050 about 50 percent of the U.S. popula-
tion is expected to be Asian, non-Hispanic black,
Hispanic,  and American Indian (Council of
Economic Advisers 1998). Currently available data
for these groups present a picture of disease that is
generally poorer than that for non-Hispanic whites.
These subgroups present a unique cluster of health,
socioeconomic, and cultural issues. At the same time,
data for the subgroups within each of these categories
are lacking. In addition to raciauethnic groups, other
groups such as individuals with disabilities, the
homeless, incarcerated individuals, and migrant
workers have unique needs and challenges. Cutting
across all subgroups are gender-specific health issues.
For improvements to be made in America's overall
health, a better understanding of the full dimension
of the problems faced by these populations and

development of specific solutions are
part of the chapter examines each
greater depth.

needed. This
subgroup in

Racial and Ethnic Minorities

Although there have been gains in oral health status
for the population as a whole, they have not been
evenly distributed across subpopulations. Non-
Hispanic blacks, Hispanics, and American Indians
and Alaska Natives generally have the poorest oral
health of any of the racial and ethnic groups in the
U.S. population. Other health statistics, such as life
expectancy and infant mortality, indicate that the
general health of these groups is varied and also poor
compared to other population groups (Council of
Economic Advisers 1998). To address the elimination
of these disparities in health-and also in housing,
education, and other indicators of social and eco-
nomic well-being-the administration has launched
"The President's Initiative on Race: One America in
the 2lst Century" Recommendations for improving
the oral and general health status of racial and ethnic
minorities are also a prominent feature of Healthy
People 2010, the goal-setting health agenda devel-
oped for the decade by the USDHHS (2000).

African Americans
Numerous studies over the decades have compared
the health status of blacks and whites in American

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

society, but relatively little systematic attention has
been focused on the oral health of blacks. Although
the overall oral health status of Americans has been
improving, many oral diseases and conditions among
blacks remain a serious problem--despite the fact
that for almost three decades these disparities have
been highlighted and recommendations made for
addressing health issues including research, educa-
tion, human resources, and delivery systems
(National Dental Association 1972). These recom-
mendations still represent opportunities for improve-
ment in the oral health status of African Americans.
Baseline data for the Healthy People 2010 objec-
tives establish that, for children aged 2 to 4 years,
24.0 percent of non-Hispanic `blacks have experi-
enced dental caries in their primary teeth, compared
to 15.0 percent for their non-Hispanic white coun-
terparts. For children aged 6 to 8, there were no dif-
ferences among the' races; but for 15year-olds, a
higher percentage of non-Hispanic blacks were
affected than of whites. In addition the percentage of
people of all ages who had untreated caries was sub-
stantially higher for blacks than for whites-about
twice as many Higher levels of gingivitis and peri-
odontal loss of attachment were also seen in non-
Hispanic blacks as compared to non-Hispanic whites.
A greater percentage of non-Hispanic blacks 18
years and older have missing teeth when compared to
non-Hispanic whites. Relative to non-Hispanic
whites, however, non-Hispanic blacks aged 18 and
older are less likely to have lost all their teeth (eden-
tulism) regardless of whether they are poor.
African American males have the highest inci-
dence rate of oral cavity and pharyngeal cancers in
the United States compared with women and other
racial/ethnic groups (Wingo et al. 1999). The distr-i-
bution of oral cancer cases reveals that blacks also
have a higher proportion of pharyngeal cancer than
oral cavity cancer compared to whites. Also, the 5-
year relative survival rate (1989-95) for oral cancer
was much lower among blacks than whites: 34 ver-
sus 56 percent (American Cancer Society (ACS)
1999). This latter finding may be related to the fact
that a high percentage of these cancers are diagnosed
in later stages of disease in blacks as compared to
whites (ACS 1999).

On the other hand, for several conditions,
African Americans have a lower disease burden than
do whites. The incidence rate for cleft lip and cleft
palate in African Americans is 0.54 per 1,000, about
a third the rate for whites (1.70 per 1,000). Also the
prevalence of having one or more herpes labialis
lesion within the past 12 months is 50 percent less


than that for Mexican Americans and non-Hispanic
whites.

Hispanics

Disparities in oral and general health status between
Hispanic and non-Hispanic populations in the
United States have been long recognized. Yet the
health profile of Hispanics is incomplete due to insuf-
ficient sampling of subgroups in national surveys,
inconsistent or inadequate assessment of ethnicity, or
ambiguities in reporting of ethnic identity (Hahn
1992). Recent efforts to improve data collection,
identify subgroups, and provide more baseline data
for Hispanics have addressed the situation somewhat,
but much work remains to ensure accurate data for
health planning and research (Delgado and Estrada
1993).

Among preschool Hispanic children early child-
hood caries is a particular concern. Two reports have
documented early childhood caries among 12.9 per-
cent of Hispanic children examined in San Antonio
and 37 percent of predominantly Hispanic children
in San Francisco (Garcia-Godoy et al. 1994, Ramos-
Gomez 1999). Most recently, national survey data
suggest that a higher proportion of Mexican
American children ages 12 to 23 months may experi-
ence dental caries than other racdethnicity groups
(Kaste et al. 1996b).

Preliminary data from NHANES III indicate that
young Mexican American children aged 2 to 4 are
more likely to have experienced dental caries in their
primary teeth, have on average more decayed and
filled tooth surfaces, and have more untreated disease
than either non-Hispanic white or non-Hispanic
black children (Kaste et al. 199613). Mexican
American children aged 2 to 5 years-especially
those from lower-income households-were more
likely than their African American and non-Hispanic
white counterparts to have one or more decayed
primary teeth (Vargas et al. 1998).

Dental caries continues to affect large numbers of
school-age children and youth, as only 30 percent of
Mexican Americans, 32 percent of non-Hispanic
whites, and 41 percent of non-Hispanic blacks 12 to
17 years of age were free of caries in their permanent
teeth (USDHHS 1996). However, most of the dental
caries in the permanent teeth of non-Hispanic white
children aged 12 to 17 had been treated or filled (87
percent), compared to 63 percent for Mexican
Americans and 60 percent for non-Hispanic blacks.

The only large-scale survey that permits compar-
ison among Hispanic subgroups is the Hispanic
Health and Nutrition Examination Survey (HHANES
1982-84). After controlling for age, sex, income, and

-

The Magnitude of the Problem

education, HHANES results show that Cuban
American and Puerto Rican adults had about twice as
many missing teeth as Mexican Americans. Puerto
Ricans and Cuban Americans also had on average
more filled teeth than Mexican Americans. Puerto
Rican children and adults under 45 years old had
more gingivitis than Cuban Americans and Mexican
Americans; the highest prevalence of periodontal dis-
ease was reported among Puerto Ricans compared to
the two other Hispanic groups (Ismail and Szpunar
1990).

A national survey found that employed Hispanic
adults were twice as likely to have untreated dental
caries as non-Hispanic whites. In this study, gingivi-
tis and periodontal problems (attachment loss and
pockets) were also among the more common prob-
lems among the Hispanic adults studied (Watson and
Brown 1995).

Analysis of a more recent survey (NHANES III)
that sampled Mexican Americans is particularly
revealing. After adjusting for age, sex, educational
attainment, and annual family income, Mexican
American adults are similar to their white non-
Hispanic counterparts on most oral health indicators.
However, among Mexican Americans, individuals in
families with less than $20,000 annual income were
1.6 times less likely to have an intact dentition, 3.1
times more likely to have any untreated decay on the
crowns of their teeth, and 4.2 times more likely to
have severely decayed teeth (very large cavities or
only the roots of teeth remaining) than non-Hispanic
whites (Garcia and Drury 1999). Also, Mexican
Americans were less likely to be edentulous regard-
less of poverty status than either non-Hispanic
whites or non-Hispanic blacks (Drury et al. 1999).

These findings confirm the importance of con-
trolling for sociodemographic factors in reporting on
oral health status as well as the need to assess other
factors related to health status. As a group, Hispanics
have lower median incomes, higher poverty rates,
more unemployment, and less education than non-
Hispanic whites (Ramirez 1999). However, sociode-
mographic factors are just one aspect of the questions
raised when attempting to understand differences in
oral health. The effect of financial barriers and nonfi-
nancial factors such as language, culture, dietary pat-
terns, and behaviors on access, care seeking, and
health outcomes must also be examined. Variations
in conditions such as diabetes also may contribute to
differences in oral health.

It is estimated that Hispanics will surpass African
Americans as the country's largest minority group by
2020 (U.S. Bureau of the Census 2000). Aggregate
statistics obscure substantial variations within

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           7s