ficlrtnlenf. Prompt treatment of early carious lesions
permits the preservation of tooth structure through
,onsen'ative approaches. A lo-year study reported
that caries did not progress under a dental sealant
pfaced over cavitated lesions where the lesions were
no more than halfway through the dentin (Mertz-
Fnirhurst et al. 1998).

Materials that can bond to enamel and to dentin
continue to be refined and improved. Glass ionomer
cements have contributed to materials that can bond
to enamel and dentin, release fluoride, and increase
rcnrineralization in adjacent teeth (Mount and Hume
1998, Qvist et al. 1997). These cements, together
ivith polymeric resin composites and hybrids of these
tlvo materials, are now available for tooth restoration
\vith other materials. Based on the available materials
and emerging techniques, such as air abrasion and
laser ablation (Featherstone et al. 1998, Kantorowitz
et al. 1998), restoration procedures are more conser-
vative than ever before (Mount and Hume 1997).
A proposed categorization of carious lesions for
the purpose of conservative management places
lesions into three categories: lesions where no treat-
ment is advised, lesions where preventive care is
advised, and lesions where restorative treatment is
advised (Pitts and Longbottom  1995). This
approach, using caries as an infectious disease para-
digm, resulted in a marked reduction of operative
procedures in Danish schoolchildren (Thylstrup et
al. 1995) and has been proposed as a means to pre-
serve tooth structure and maximize appropriate care
in the CTnited States (Ismail 1997).
New imaging and laser technologies are emerg-
mg as tools for early diagnosis and prompt treatment
of dental caries. For example, quantitative light-
induced fluorescence is showing promise (de Josselin
de Jong et al. 1996) for dental caries diagnosis. Two
different methods, the quantitative infrared laser flu-
orescence method and electrical conductance meas-
urements, are currently commercially available. At
present, these methods are being used to augment
conventional diagnostic tools but are not yet part of
routine practice, However, they could potentially be
used for close monitoring of the lesions and for
patient motivation (Angmar-Mansson et al. 1996).
Laser treatments for soft tissue surgery have been
used in dentistry in recent years. Currently, in vitro
studies are under way for the application of lasers for
hard tissues, specifically to prevent dental caries by
altering tooth mineral and inhibiting progression of
artificial caries-like lesions (Featherstone et al. 1998,
Kantorowitz et al. 1998).

Despite the best efforts of the individual and
health care provider, caries may progress. Advances

in materials science over the last two decades have
fortunately led to major improvements in dental
restorative materials, resulting in a wide range of aes-
thetically pleasing, longer-lasting restorations that
can be placed with less trauma. Traditional materials
such as amalgam fillings and gold crowns are now
augmented by aesthetic materials, including bonded
composite resins, porcelain fused to metal crowns,
and facings.

When teeth have been lost, the options for reha-
bilitation include a range of prosthetic devices.
Removable full and partial dentures and fixed bridges
provide aesthetic and serviceable restorations for
many patients. Still another option is the use of den-
tal implants. These are used not only in patients who
have lost teeth due to caries and periodontal diseases,
but also to restore form and function in patients
treated for trauma, craniofacial cancers, hereditary
tooth defects, and other abnormalities.

The evidence base for the survival of the
endosseous dental implants, an implant that is placed
directly into a tooth socket, is extensive and has been
recently reviewed (Cochran 1996, Fritz 1996). The
predictability of endosseous dental implants in fully
and partially edentulous patients has been clearly
demonstrated in longitudinal studies (Albrektsson
1988, Albrektsson et al. 1988, Buser et al. 1991,
Spiekermann et al. 1995). Many implant designs and
surfaces have shown high success rates (often
exceeding 95 percent in good-quality bone and 85
percent in poorer-quality bone, such as the posterior
maxilla) (Buser et al. 1988, Cochran 1996, Fritz
1996).

  Rehabilitation of lost tooth structure or even the
whole tooth itself may be revolutionized in the next
century, based on discoveries of the natural repair
and regeneration mechanisms the body uses. The
new sciences of biomimetics and tissue engineering
combine engineering principles and materials sci-
ence with rapidly growing knowledge of the progen-
itor cells and molecules that give rise to specific tis-
sues such as skin, bone, teeth, and cartilage. Already
it is possible to generate new cartilage and bone of a
prescribed shape to replace tissue lost from injury or
disease (Reddi 1995). Eventually, it may be possible
to use a patient's own oral cells and cell products to
generate new tooth enamel, dentin, and cementum
for the natural repair of carious lesions.

Periodontal Diseases

Periodontal diseases are caused by microbial infec-
tions, and are plaque-related complex diseases like
dental caries, presenting as several clinical variants

Personal and Provider `approaches to Oral Health

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          201


(see Chapter 3). The mildest form is gingivitis, char-
acterized by inflammation of the gingiva with a
marked loss of gingival collagenous material (Page
and Schroeder 1976, Schroeder et al. 1973). In a
more advanced disease, periodontitis, there is
involvement of the soft tissue and bone that support
the teeth. If untreated. periodontitis may progress
and result in abscesses, mobile teeth, and tooth loss.
Periodontitis also may be associated with certain sys-
temic diseases and conditions (see Chapter 5).

Gram-negative anaerobic bacteria in plaque are
implicated as causative agents in periodontitis.
However, host immune system factors, specifically, a
chronic inflammatory response, are now considered
to be the primary determinants of disease progression
and outcome (Page 1998). The disease process is
very similar across the different types of periodontal
disease and involves interactions between infectious
agents and their virulence factors and host defense
mechanisms, operating within a context of environ-
mental, acquired, and genetic risk factors specific to
a given individual. F' tgure 8.5 illustrates the patho-
genesis of these diseases (Page and Beck 1997).

Risk Assessment. Sufficient knowledge of demograph-
ic and systemic risk factors and indicators has been
acquired to guide clinical decisions in the manage-
ment of periodontal diseases (Genco 1996, 2000,
Page and Beck 1997, Papapanou 1998). Table 8.7
provides an overview of the strength of the associa-
tions of local and systemic factors with destructive
periodontal diseases (Genco 1996, 2000). Table 8.8
presents the odds ratios derived from studies that
investigated the likelihood of developing periodontal
disease given a specific risk factor, indicator, or mark-
er/predictor (Jeffcoat et al. 1997, Page and Beck
1997). The presence of pathogenic bacteria, poor oral
hygiene, tobacco smoking, diabetes mellitus, and
preexisting periodontal disease are some of the fac-
tors that contribute to the likelihood of disease pres-
ence, progression, and treatment outcomes.

A systematic identification of risk factors, indica-
tors, and predictors has been proposed as the first
step in diagnosing and managing periodontal dis-
eases (Genco 1996, Page and Beck 1997, Papapanou
1998). Clinicians can weigh the known risks for indi-
vidual patients and devise treatment plans appropri-

FIGURE 8.5

A new paradigm for the pathobiology of periodontitis

Microbial
challenge

TfzxTTl     Host

inflammaton

Cytokiner & o
prostanoids

Matrix *
metallo-
nrnthawc

Connective
tissue
and bone
metabolism

     Clinical
    signs of
* disease and

Source: Page and Kornman 1997. The pathogenesis of human periodontitis:an introduction. Periodontology 1997; 14:9-l l.Copyright 1997 byPeriodonfoloqy2OOO
Reprinted by permwon of Munksgaard International Publishers Ltd.,Copenhagen, Denmark (2000).

-02          ORAL HEALTH IN AMERIC.4: A REPORT OF THE SURGEON GENERAL


r

T,\BLE 8.7

The strength of association of local and systemic factors with destructive periodontal disease

Factor

Case Report     Case-Control
Studies       Studies

Cross-sectional
Studies

Longitudinal
Studies

intervention Studies

Specific bacteria
P ginqivdis
B. fonyrhus
p intermedia

Yes
Yes
Yes

Yes
Yes
Yes

Yes
Yes
Yes

Yes
Yes
Yes

Yes
Yes
Yes

Sex
Male

Age
Diabetes mellitus
Type 2

Type 1
Smoking
Osteoporosis
Stress, distress, coping

Yes

Yes

Yes

Yes

NR

Yes

Yes

NR

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

   NR
No (to 7th decade)

   Yes

   NR

   Yes

   NR

   NR

     NR

     NR

Yes (treatment reduces
glycosylated hemoglobin)
     NR
Yes (smokers heal poorly)
     NR

    NR

Polymorphonuclear disorders
Genetic factors (IL-1 polymorphisms)
Dietary calcium
Preexisting periodontal disease

Yes

NR

NR

Yes

Yes

Yes

Yes

Yes

NR

NR

Yes

Yes

Yes (case series)
  NR

   NR

  Yes

NR

NR

NR

Yes

Note: NR = not reported,or not relevant.
Source: Genco 2ooO. Copyright 1996 byJourno/ offeriodonrology. Reprinted by permission of the lourno/ofPeriodonto/ogy (2000).

TABLE 8.8
Risk of periodontal disease
          Strength of Association With  Odds Ratio
Demographic characteristics
Age, 35.44years       alveolar bone loss        2.60
Age, 65-74 years       alveolar bone loss       24.08

Risk factors
Smoking, light      periodontal disease       2.05
              alveolar bone loss        1.48
Smoking, heavy      periodontal disease       4.7s
               alveolar bone loss        7.28

Bacterial risk factors
Poor oral hygiene     periodontal disease       20.52
P qiflqivolis        periodontal disease       3.60
A. actinomyceremcomi   periodontal disease       2.50

Clinical measurement
Bleeding on probing"    progression of periodontitis    2.7

"Meta-analysis (Armltage 1996).
Sources: Jeffcoat et al. 1997, Page and Beck 1997.

ate to their risk category. These same factors and the
outcomes of treatment can also be used to assess
prognosis upon completion of therapy. Studies are
under way to determine the feasibility and validity of
assessing a complex of risk factors to predict states of

periodontal health and disease (Genco 1996, 2000,
Genco et al. 1999, Papapanou 1998).

Most recently, putative genetic markers for sus-
ceptibility for oral disease have been studied. In par-
ticular, a specific genotype of the polymorphic IL-1
gene cluster has been shown to be associated with
severe periodontitis in nonsmokers (Kornman et al.
1997). IL-1p is of interest because the proinflamma-
tory cytokines are key regulators of the host immune
response to microbial infection and extracellular
matrix catabolism and bone resorption. Functionally,
this polymorphism is associated with high levels of
IL-1 production, and high levels of IL-1 have been
associated with progressive periodontal breakdown
(Cavanaugh et al. 1998).

A consensus has been reached by a specialty
organization that all patients in general and specialty
care should be screened for periodontal disease (AAP
1996). The recommended approach is to apply the
Periodontal Screening and Recording examination
(PSR). Related screening tests include the Com-
munity Periodontal Index of Treatment Needs
(CPITN) (Ainamo et al. 1982) and the Basic
Periodontal Examination.

Diagnosis. The strengths and weaknesses of the range
of tests and methods used to diagnose periodontal

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

-n:
cv-


Personal and Provider Xpproaches to Oral Health

diseases are presented in Table 8.9. Most diagnostic
tests for periodontal diseases rely on a physical
examination to note any swelling, redness, gingival
bleeding, or tooth mobility. Periodontal probing,
radiographs, and microbiologic and histological
examinations of biopsied tissue provide important
additional information. These tests indicate the
presence, extent, and severity of gingival and
periodontal tissue destruction; they do not indicate
the cause of disease or whether it is quiescent or
actively progressing.

Gingival inflammation may be assessed using a
variety of methods, including bleeding on probing
and the use of indices such as the gingival index (Lee
and Silness 1963) to grade redness and bleeding. In
adult periodontitis, the absence of inflammation is
associated with a lack of disease progression, but the
presence of inflammation does not indicate inevi-
table progression to destruction (Armitage 1996,
Halazonetis et al. 1989, Okamoto et al. 1988). Longi-
tudinal studies have also been conducted in patients
who participate in maintenance programs. The

absence of gingival bleeding, especially at recall vis-
its, has been shown to be a valid indicator of gingival
health in these patients (Lang et al. 1986).

Measurement of probing depths (also termed
pocket depths) is an integral part of the periodontal
examination. Longitudinal studies have shown that
shallow probing depths and minimal loss of attach-
ment are associated with lack of disease progression.
The mere presence of a pocket does not herald pro-
gressive periodontitis at that site. Although teeth
with moderate to deep probing depths are at higher
risk for additional destruction, a single examination
cannot determine the fate of,the tooth with certainty
(Armitage 1996, Haffajee et al. 1983, Halazonetis et
al. 1989, Okamoto et al. 1988).

Radiographs are used to obtain a visual image of
the bony support around a tooth or dental implant.
They are an essential tool in planning complex pros-
thetic reconstructions, as well as a necessary diag-
nostic aid in assessing periodontal progression.
At least 15 different organisms have been associ-
ated with adult periodontitis. The 3 species most

TABLE 8.9

Strengths and weaknesses of tests and methods used to diagnose periodontal diseases

           Application         Strengths              Weaknesses        Type of Evidence
Periodontal screening  All patients in every   Cost-effective, quick, easy; detects    Does not provide a tooth-by-tooth    Epidemiologic studies
and recording (PSR)   practice        patients with periodontal disease.    assessment for later comparison during
                                  maintenance. A full periodontal
                                  examination is needed for this purpose.
Probing pocket depths  All patients      Shallow probing depths are associated  Moderate to deep pockets in single    Longitudinal studies
                  with lack of future disease progression.  probing depth examination will not
                                 distinguish with certainty which teeth
                                   will undergo progressive periodontal
                                           destruction.

Gingival inflammation  Assessed in all patients   Absence of inflammation is associated   Presence of inflammation will not    Longitudinal studies
                   with a lack of future progression. In   distinguish with certainty which teeth
                   treated patients, bleeding on probing is  will undergo progressive periodontal
                        associated with an increased risk for   destruction.
                   progressive loss of attachment.
Radiographic evidence  At-risk patients as     Absence of bone loss is associated with  Presence of bone loss on a single    Longitudinal studies
of bone loss      determined by PSR    a lower risk of future progression.    radiograph will not distinguish with
         screening or periodontal                certainty which teeth will undergo
           examination                     progressive periodontal destruction.
Microbial/plaque tests  High-risk or refractory  Absence of supragingival plaque is   At this time, routine testing offers    Cross-sectional and
         patients         associated with lack of disease     limited benefit in adult periodontitis.  Longitudinal studies
                    progression.
                   In compromised or refractory patients,                  Case reports
                  may be useful in determining the
                  presence of pathogens.
Biochemical profiles in  Not yet determined   A number of biochemical markers may  At present, there are no specific     Cross-sectional and
gingival crevicular fluid            identify individuals at risk.      biochemical profiles that characterize  Longitudinal studies
                                  specific periodontal diseases.

204         ORAL HMLTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


,trongly linked are Porphyromonas gingivalis,
R`tctcroides forsytk and Treponema denticola.
,~itt,r&aciflus actinomycetemcomitans is most strong-
1,. linked to early-onset periodontitis (Haffajee and
;ocransky 1994). No single bacterial species has
been &own to satisfy Koch's postulates (Moore 1987,
locransky and Haffajee 1992>, leading some investi-
<,qtors to suspect that periodontitis is a mixed infec-
<"
tton (Ranney 1993). As a result, diagnostic tests for
periodontal diseases have included assessments of
the presence and amount of several putative
tnrcrobes in the subgingival plaque.

Routine bacterial testing of patients with adult
periodontitis is not usually necessary and indeed is
not supported by the preponderance of the evidence
(Armitage 1996, AAP 1996). In formulating treat-
ment programs for special patient populations and as
a research tool, however, the tests can be very help-
ful. Such patients include those refractory to previous
therapy, patients with rapidly progressive or early-
onset periodontitis, and certain medically compro-
mised patients.

The traditional method for assessing the subgin-
gival flora is by culturing samples extracted from the
site of infection. Culturing allows the clinician to
determine the antibiotic sensitivity of the organisms,
but it is technique-sensitive: scrupulous care is
required when sampling the periodontal pocket. This
is especially true for microbes that are strict anaer-
obes, because they are killed by even brief ,exposure
to air. The requirement that bacteria have time to
grow also precludes chairside testing.

With the advent of molecular biology, bacterial
species can be identified by their DNA (Moncla et al.
1988, Savitt et al. 1988, 1990) or by unique antigenic
components (Zambon et al. 1986). Either method
will detect putative periodontopathic bacteria quick-
ly and with a high degree of sensitivity and specifici-
ty, usually above 90 percent. The tests do not indicate
whether there is actual disease, however. Nor do the
tests reveal anything about the antibiotic sensitivity
of the detected bacteria. Because DNA is very stable,
the tests can be applied to nonliving plaque samples,
simplifying the collection process. Kits are available
that allow DNA testing to be performed in the dental
office; otherwise the samples are sent to a reference
laboratory.

  Other tests are available for the detection of
groups of putative periodontopathic bacteria
(Loesche 1986). The BANA test detects a trypsin-like
enzyme that is present in P gingivalis, T. denticola,
and B.forsythus (Loesche et al. 1990). Somewhat less
accurate than the tests described above, the BANA

test is 92 percent sensitive and 70 percent specific in
detecting these groups of bacteria.

Once a periodontal infection is established, tell-
tale metabolic changes occur in the body as a result
of inflammation, injury, or death of tissue. A sample
of fluid exudate from the gingiva (gingival crevicular
fluid) in an affected pocket can be analyzed for these
changes. They include elevated levels of
prostaglandin E, (Cavanaugh et al. 1998,
Offenbacher et al. 1986), interleukin 1 and inter-
leukin 6 (Cavanaugh et al. 1998, Geivelis et al. 1993,
Masada et al. 1990, Tsai et al. 1995), tumor necrosis
factor (Rossomando et al. 1990), B-glucuronidase
(Lamster et al. 1994, 1995), aspartate aminotrans-
ferase (Chambers et al. 1991, Persson and Page
1992), elastase (Armitage et al. 1994, Palcanis et al.
1992), and collagenase (Lee et al. 1995). Most of
these analyses are based on inserting a filter paper
strip into the isolated pocket to collect the fluid and
testing for the metabolite of interest. A positive result
usually indicates that inflammatory or destructive
pathways have been triggered, but provides no clues
concerning the etiologic factor or factors. Because of
differences in experimental designs in the clinical
studies, it is difficult to compare the sensitivity and
specificity of each metabolite in detecting disease.

Prevention. Because periodontal diseases are plaque-
associated infections, prevention and management of
the early signs of these diseases depend on effective
plaque control. This can be accomplished using both
mechanical and chemotherapeutic approaches (Table
8.10). The prophylaxis performed in the dental office
on periodontally healthy patients reduces plaque and
removes stains and calculus. How often patients
should be recalled for such preventive procedures is
based on an assessment of risk factors such as the
patients age, oral hygiene, personal habits (e.g.,
smoking and diet), and a medical history indicating a
heightened risk of infection (such as noted with dia-
betes or HIV infection) (Hancock 1996, Mealey
1996).

Chemical plaque control has become an impor-
tant part of the clinician's armamentarium and may
be prescribed for patient care at home (Table 8.10).
Reviews of the literature by Hancock (1996) and
Drisko (1996) provide detailed supporting evidence.
Significant reductions in gingival inflammation have
been demonstrated for chlorhexidine, triclosan co-
polymer when used in conjunction with a fixed com-
bination of essential oils, and stannous fluoride. The
magnitude of gingival inflammation reduction was
greatest for chlorhexidine. The evidence supporting

Personal and Provider Approaches to Oral Health

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

205


these effects includes multiple randomized, double-
blind, controlled clinical trials.

Treatment. Once periodontal disease is established.
the resultant bone and connective tissue loss may be
quiescent or actively progressing. The goal of treat-
ment is to determine whether the disease is active in
order to prevent further tissue loss. This entails pro-
fessional plaque removal and careful instruction of
the patient on scrupulous self-care.

The concept of management of a patient's risk
factors as part of treatment is reasonably well docu-
mented for individuals who smoke and those who
are diabetic and may be important for other risk fac-
tors such as stress (Genco et al. 1999) and low
dietary calcium (Nishida et al. in press). Several stud-
ies have shown that treatment of periodontal disease
in smokers is not as successful as in nonsmokers
(Grossi et al. 1996). Thus, the management of smok-
ing as a risk factor will contribute to the success of
periodontal therapy. Furthermore, it appears that
treatment of diabetic patients with periodontal dis-

ease may require more intense therapy since several
studies have shown that antibiotic therapy is suc-
cessful not only in reducing periodontal disease, but
also in reducing glycated hemoglobin (Grossi and
Genco 1998).

Professional plaque removal typically employs
scaling and root planing, in which hardened deposits
of plaque and other debris are removed from the peri-
odontal pocket and the tooth root surface is
smoothed over. The effectiveness of scaling and root
planing has been demonstrated repeatedly in longi-
tudinal, cohort, and randomized clinical trials and
was reviewed by Cobb (1996). Demonstrated bene-
fits include decreased gingival inflammation,
decreased probing depth, and facilitation of mainte-
nance of clinical attachment level. The evidence indi-
cates that similar results may be obtained with ultra-
sonic and sonic instruments as with manual instru-
ments. Regardless of the methods used, meticulous
attention to detail is required to achieve optimal
results (Cobb 1996).

-l-ABLE 8.10
Periodontal diseases: mechanical therapy and chemotherapeutics

Category ofTreatment
Professional mechanical
therapy-used in the
treatment of gingivitis
and periodontitis

      Treatment
-

Strengths

Scaling and root planing with
manual instrument

Decreases gingival inflammation
by 40 to 60 percent
Decreases probing depth
Facilitates gain in clinical
attachment level

Chemical plaque control
with mouthrinses and
dentifrices

Sustained release anti-
microbials

Systemic antibiotics

Ultrasonic and sonic scalindand   Results are similar to manual
root planing         scaling and root planing
Chlorhexidine        Significant reductions in gingival
Triclosan co-polymer or triclosan  inflammation
zinc-citrate
Essential oils
Stannous fluoride

Supra- and subgingival irrigation  Aids in the reduction of
used as an adjunct to brushing   gingivitis

intrapocket resorbable or non-
resorbable delivery systems
containing a tetracycline
antibiotic

When used as an adjunct to
scaling and root planing, gains in
clinical attachment level and
decreases in probing depth and
bleeding

Tetracyclines, metronidazole,
spiromycin, clindamycin, and
combinations such as
metronidazole and amoxicillin

May be useful to treat aggressive
destructive periodontitis

Weaknesses

Type of Evidence

Requires attention to detail

Numerous longitudinal,
cohort, and randomized
clinical trials

No clear evidence that there is
a substantial long-term
benefit for periodontitis
except to control co-existing
inflammation

No clear evidence that there is
a substantial long-term
benefit for periodontitis

Few reported side effects
include transient discomfort,
erythema, recession, allergy,
and rarely candidiasis

longitudinal, cohort, and
randomized clinical trials

Randomized double-blind
clinical trials

Randomized double-blind
clinical trials

Randomized double-blind
clinical trials

Not indicated for gingivitis
Not indicated for most adult
periodontitis patients

Assessment of risk-benefit
ratio
Randomized double-blind
clinical trials
Randomized double-blind
clinical trials, longitudinal
assessment of patients

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


Topical administration of antimicrobial agents
,i,rllrlbutes to the control of gingival inflammation
r.ll,]c 8.10). Supragingival irrigation (e.g., applying
.I ,Ct of Lvater under pressure) may be used as an
.,ciillnct to toothbwshing and has been shown to aid
,,, the reduction of gingival inflammation. However,
[,`, clear substantial long-term benefits for the treat-
i,,cnt of periodontitis have been shown if irrigation is
.,Pl?lied subgingivally.

Surgical therapy is employed to provide access
to root surfaces and bony defects for debridement
,,ncl root planing. Surgery can facilitate regeneration,
,ll~~ment the gingiva, and promote root coverage
,T;lble 8.11). It is also necessary in placing dental
Implants.

Palcanis (1996) reviewed the evidence regarding
surgical therapy. The overall goal is to make plaque
control easier for the patient, thereby reducing dis-
case progression. Many surgical techniques are avail-
.Ible. Extensive randomized clinical trials and longi-
tudinal studies form the basis of the evidence for the
efficacy of these procedures (Kaldhal et al. 1996,
Knowles et al. 1979, Pihlstrom et al. 1983, Ramfjord
ct al. 1987). All procedures decrease pocket depth,
,I&, with the exception of gingivectomy, all increase
clinical attachment level. A caveat to be noted, how-
ct'er. is that procedures designed to reduce probing
depth may increase gum recession, exposing the root
and possibly compromising aesthetics. Thus, selec-
tion of a particular surgical procedure must always be
based on the individual needs of the patient,
Regardless of the approach selected, maintenance is
important to long-term success.

Systemic administration of antibiotics, including
the tetracyclines,j metronidazole, spiromycin, and
clindamycin, has been extensively studied and
reviewed (Drisko 1996). The risk of generating
antibiotic resistance in bacteria precludes the use of
systemic agents in treating simple gingivitis (AAP
1996). Similarly, systemic antibiotics should not be
used for the routine first-line treatment of common
forms of adult periodontitis (AAP 1996, Drisko
1996). The preponderance of evidence from well-
controlled, randomized, blinded clinical trials indi-
cates that the agents do not offer sufficient benefit to
overcome risks of either drug sensitivity or the emer-
gence of antibiotic-resistant pathogens.

The situation is different in cases of aggressive
forms of periodontitis, such as early-onset, rapidly
progressive, or refractory periodontitis, which affect
less than 10 percent of periodontitis patients.
Randomized, double-blind clinical trials, as well as
longitudinal assessments, indicate that the use of sys-
temic antibiotics can slow disease progression in
these patients (AAP 1996, Drisko 1996).

To circumvent the problems of systemic therapy,
investigators have applied antimicrobial agents
directly into the pocket. Antimicrobials incorporat-
ed into either resorbable and nonresorbable inter-
pocket delivery systems have been studied in ran-
domized, double-blind, controlled clinical trials and
are now FDA approved and on the market (Goodson
et al. 1991, Jeffcoat et al. 1998). When used as an
adjunct to scaling and root planing, gains in clinical
attachment level and decreases in probing depth
and gingival bleeding were demonstrated. Because

r

TABLE 8.11
Periodontal disease: selected surgical procedures

Category and Goal
Pocket therapy-
provides access to root
surfaces and bony
defects, reduces probing
depths,facilitates plaque
controLand enhances
restorative and cosmetic
dentistry

  Procedures
Modified Widman Flap to
provide access to roots and
bony defects for
debridement
Apically repositioned flap
with or without bony
recontouring
Gingivectomy

    Strengths
All procedures decrease pocket depth.
With the exception of gingivectomy, all
increase clinical attachment level.
After 5 years,greatest reduction in probing
depth with osseous recontouring.
Apically repositioned flap with or without
bony recontouring used in crown-
lengthening procedures to provide biologic
width.

  Weaknesses
Procedures designed to
reduce probing depths
may increase recession.
Lack of professional
maintenance and
patient compliance can
be detrimental to long-
term success.

Type of Evidence
Randomized clinical trials
Longitudinal studies

`Certain systemic tetracyclines. notably doxvcvcline, are safe and effective in low doses for prevention of bone loss associated
                              , I
Myth periodontitis. DoxVcvcIine hvclate (lo-mg capsule) is approved for twice-a-dav use for up to 9 months for this indication.
At these low doses. the hdxycycline appears to reduce the elevated collagenase activity, rather than function as an antimicrobial.

ORAL HEz4LTH IN AMERIC4: A REPORT OF THE SURGEON GENERAL          207


Personal and Provider Approaches to Oral Health

these delivery systems are relative-
ly new, there is a paucity of evi-
dence addressing their long-term
effectiveness.

TABLE 8.12a
Odds ratios for risk factors for oral and pharyngeal cancers

For patients who have lost sig-
nificant bone and/or connective tis-
sue, there are a number of regener-
ation procedures to facilitate the
growth of new periodontal liga-
ment; cementum, and alveolar
bone over previously diseased root
surfaces. The evidence base for
bone-grafting techniques using
either natural or synthetic bone
materials has been reviewed by
Garrett (1996). Natural bone grafts
may use autografts, in which bone
is transferred from one site to
another in the same patient; allo-
grafts, which use bone grafts from a
human donor; and xenografts,
which use tissues from other
species. Limited case report evi-
dence shows that extraoral auto-
genous bone, such as hip grafts,
has high potential for bone growth
(Garrett 1996). Extraoral sites
require a second surgical site, and
in some cases fresh grafts may be
associated with root resorption.
Case report evidence indicates
bone fill exceeding 50 percent of
the osseous defect may be achieved
(Garrett 1996). Controlled studies
comparing grafted to nongrafted
sites report significant improve-
ments in clinical attachment levels
and bone gain, but the magnitude
of gain is less than that indicated in
case reports.

  Freeze-dried demineralized
bone represents one of the most
frequently used and well-studied
bone graft materials in periodon-
tics. Freeze-dried demineralized
bone is an allograft material, har-
vested, prepared, and demineral-
ized prior to grafting. The deminer-
alization step is important because
it retains the activity of bone mor-

                               Both Sexes   Males Females
Cigarette9
Never                                       1.0    1.0
Ever                                        1.9    3.0
Smoking status,adjusted for alcohol drinkingd
None                                       1.0    1.0
Short duration/former                                 1.1    1.0
1 to 19 day for 20+ years
    per                                      1.6    3.0
20 to 39 day for 20+ years
    per                                    2.8    4.4
40+ per day for 20+ years                              4.4    10.2

Cigar9
Never                                       1.0    -

Ever                                      1.8    -

Pipe+
Never                                       1.0    -

Ever                                        1.8    -

Smokeless tobacco among nonsmokers3
Never                                           -    1.0
Ever                                            -    6.2
Number of drinks of beer per week,adjusting for smokinga
<l                                       1.0    1.0
1to4                                         1.1    2.2
5to14                                     1.7    2.9
15to29                                      3.4    2.3
30+                                         4.7    18.0
Number of drinks of hard liquor per week,adjusting forsmokinga
<l                                       1.0    1.0
1 to4                                       1.0    1.3
sto14                                       1.3    1.5
15 to 29                                     2.6    4.9
30+                                        5.5    7.8

Alcohol and tobacco combineda
No alcohol or cigarettes                              1.0    -
Both 30+ drinks per week and 40+ cigarettes per day for 20+ years          23.0 -
lip cancer: lifetime quartiles of lifetime sun exposurec
Lowest                                1.0
Highest                               13.5
Marijuana used
Never                               1.0
Ever                                  2.6
Human papillomavirus,Type 16e
Present                               2.3
Absent                                 1.0

Note: First row for each factor is the referent group. Dashes indicate not studied or too few to analyze.
*Blot et al. 1988.
bpitz et al. 1988.
`Pagoda and Preston-Martin 1996.
dZheng et al. 1999.
5chwarfz et al. 1998.

phogenetic proteins-compounds in the graft mate-
rial found to be essential for new bone formation
Wrist 1965, Urist and Iwata 1973). Case reports and
controlled clinical trials have demonstrated the bone-

forming potential of such material, with some vari-
ability in the amount of bone fill achieved (Garrett
1996). Because allografts are derived from donor tis-
sues, proper collection, handling, and storage are

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


Personal and Provider Approaches to Oral Health

r.\BLE 8.12b
odds ratios for protective factors for oral and pharyngeal cancers

                              Both Sexes   Males Females
Diet high in fruits, by quartiles of intakea
First (lowest intake)                          1.0
Second                             0.6
Third                               0.4
Fourth (highest intake)                       0.4
years since quit smoking cigarettes4
Never smoked                                    1.0    1.0
0 (never)                                    3.4    4.7
1 lo9                                       1.1    1.9
loto 19                                      1.1    0.8
20+                                     0.7 0.4
lip cancer: daily use of lip protection (mostly colored lipstick)b
None                                            -    1.0
51 per day                                         -    3.2
22 per day                                         -    7.3

Note: First row for each factor is the referent group. Dashes indicate not studied or too few to analyze.
dBlot et al. 1988.
bPogoda and Preston-Martin 1996.

essential to ensure viability and prevent contam-
ination with viruses or other pathogens (Mellon&
1995).
Alloplasts represent a class of synthetic
resorbable or non-resorbable graft materials. When
evaluated in controlled clinical trials, they demon-
strated improvements in probing depth and attach-
ment level (Garrett 1996). Histology, however, indi-
cates that, in general, synthetic grafts act priinarily as
space fillers, with little, if any, regeneration.
Beginning in the 1980s a number of investigators
explored a procedure called guided tissue regenera-
[eon. The idea was to employ either a resorbable or
non-resorbable membrane at the diseased site that
would selectively allow passage of cells able to regen-
erate periodontal attachment apparatus and bone,
while prohibiting migration of non-regenerative cells
such as fibroblasts. The evidence for the efficacy of
guided tissue regeneration ranged from randomized
controlled clinical trials to case reports (Garrett
1996). Although less evidence is available for
resorbable membranes than for non-resorbable mem-
branes, significant improvements in clinical attach-
ment levels have been shown compared to debride-
ment alone. Most favorable results are reported for
bone loss between the roots of mandibular tooth
defects (Class II furcations). Less favorable results
were reported in maxillary molar and Class III
(through and through) furcation defects (Garrett
1996).

Oral and Pharyngeal Cancers
Oral and pharyngeal cancers, like
other neoplastic diseases, are
caused by mutations in cell regula-
tory genes. The mutations con-
tribute to carcinogenesis by pro-
moting uncontrolled cell growth,
suppressing the function of tumor
suppressor genes, promoting the
growth of new blood vessels
(angiogenesis) to nourish the
growing tumor, or facilitating
metastasis. A model depicting the
genetic progressign for oral and
pharyngeal cancers has been pro-
posed (Califano et al. 1996).

Potentially malignant lesions
can present in a variety of ways
and can include erythroplakia or
leukoplakia (red or white flat
lesions, respectively), ulceration,
failure of a wound to heal, lym-

phadenopathp mduration, dysphagia, and tissue
growth. Erythroplakia lesions are considered to have
a higher rate of malignancy than leukoplakia
(Silverman 1990). Candida albicans infection of a
leukoplakia lesion appears to increase the risk of
malignant transformation (Field et al. 1989,
Scully 1995). In addition, infections with strains of
human papillomavirus (HPV) and herpes simplex
virus (HSV) have been implicated in the etiology of
oral cancers. Other potentially predisposing factors
include chronic iron deficiency anemia, erosive
lichen planus, oral submucous fibrosis, and actinic
keratosis.

Risk Assessment. Risk assessment for oral and pha-
ryngeal cancers (Table 8.12a) includes an evaluation
of the patient's exposure to tobacco and alcohol and
an examination to identify suspicious lesions and
conditions thought to predispose to cancer. All
tobacco products (see Chapters 3 and 10) have been
associated with oral and pharyngeal cancers. The risk
of oral cancer is increased 6 to 28 times in current
smokers. Alcohol is also a risk factor for oral cancer,
and combined with tobacco use accounts for 75 to 90
percent of oral cancer in the United States (Blot et al.
1988, Vokes et al. 1993). A dose-response relation-
ship has been demonstrated for cigar smokers, and
the overall risk of cancer is 7 to 10 times higher
among users than for those who never smoked (NC1
1998). In addition, individuals who have had oral
cancer are at increased risk for a second primary

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           209


cancer, and this risk is higher than that for other can-
cers (Boice et al. 1985, Winn and Blot 1985).

  Other factors, such as infection with HPV or
HSV as noted earlier, and use of high-alcohol-content
mouthwashes, also have been associated with oral
cancers (Flaitz and Hicks 1998, Sugerman and
Shillitoe 1997, Winn et al. 1991). Lip cancer is asso-
ciated with exposure to the sun (Pogoda and Preston-
Martin 1996).

  Biomarkers-measurable alterations in mole-
cules derived from human tissues or fluids-are
being developed to identify those at risk for oral can-
cer and to identify which patients may benefit from
specific treatments (Lippman et al. 1993, Patterson et
al. 1996, Sidransky 1997). These markers may also
be able to predict oral cancer recurrence or the occur-
rence of new primaries (Shin et al. 1996).

Diagnosis. At present, the diagnosis of oral and pha-
ryngeal cancers involves a systematic extra- and
intraoral physical examination to identify lesions and
conditions that may be precancerous or indicate a
predisposition to cancer (USDHHS 1998). Biopsies
are essential to confirm the clinical observations. The
sensitivity and specificity of a brush biopsy have been
established in a multisite clinical trial (Sciubba
1999). Imaging technology may also be employed to
determine the extent of the lesion. Although the sen-
sitivity and specificity of the physical examination
have not been established in clinical studies, it is
clear that persons with localized oral and pharyngeal
cancers have a better prognosis than persons whose
cancers were detected with regional or distant spread
(Ries et al. 1999). A thorough examination for oral
and pharyngeal cancers is recommended by the
American Cancer Society annually for individuals
over 40 and for individuals who are exposed to
known risks (Murphy et al. 1995).

Prevention. Primary prevention of oral and pharyn-
geal cancers involves avoiding known carcinogenic
agents (Blot et al. 1988, Vokes et al. 1993), primarily
tobacco in any form and excessive use of alcohol. In
addition, the use of lip balms with ultraviolet radia-
tion blockers is recommended (see Table 8.12b). A
high dietary intake of fruits and vegetables may
reduce oral and pharyngeal cancer risk by as much as
30 to 50 percent (McLaughlin et al. 1988). Dentists,
physicians, and nurse practitioners among others are
in a critical position to counsel patients on tobacco
and alcohol use, pointing out that tobacco cessation
lowers the risk for oral and pharyngeal cancers (Blot
et al. 1988). Physicians. dentists, and other health
care professionals have been shown to be effective in

increasing tobacco cessation rates (Cohen et al. 1989,
Ockene et al. 1991, Stevens et al. 1995, Wilson et al.
1988). A prime reference for use in national and
international antismoking efforts is the Clinical
Practice Guideline on Smoking Cessation (Number
180) developed by the Agency for Health Care Policy
and Research (Fiore 1997).

Treatment. Diagnosis of cancer at an early stage can be
followed by prompt and conservative treatment of
the affected tissues. Some early lesions may be suc-
cessfully treated with excisional biopsy; more
advanced cases will require additional surgery, radia-
tion, and/or chemotherapy ($hah and Lydiatt 1995,
Vokes and Athanasiadis 1996). Preservation of func-
tion and appearance is emphasized. Advanced can-
cers require follow-up reconstruction and rehabilita-
tion to improve function and aesthetics.

Birth Defects

There are hundreds of genetic diseases and syn-
dromes as well as congenital anomalies that affect the
craniofacial, oral, and dental tissues. However, some
craniofacial anomalies may be spontaneous and man-
ifest only at the time of birth. Chapter 3 describes a
number of these disorders. Rapidly advancing knowl-
edge of the genetics of development and of mutations
associated with specific birth defects is aiding in the
development of screening tests for genetic disorders
and identifying high-risk individuals and families.

A complete diagnosis of the craniofacial disorder
may involve a multidisciplinary team of experts in
imaging, genetics, and other areas. Similarly, long-
term management of the disorder, often extending to
adulthood, generally calls for a team of specialists,
including physicians and dentists, surgeons, nurses,
rehabilitation experts, speech pathologists, psycholo-
gists, and social workers. Quality of life considera-
tions, including social and psychological effects of
birth defects such as cleft lip and palate, are taken
into account (see Chapters 3 and 6).

Prevention. Primary prevention involves minimizing
exposure to known teratogens, and genetic counsel-
ing as appropriate. The importance of educating par-
ents or potential parents on behavioral risk factors,
especially tobacco and alcohol use, the teratogenic
potential of certain prescription drugs, and the need
for adequate nutrition in the perinatal period is
emphasized. In a study by Tolarova and Harris
(1995), supplementation of the diet by multivitamins
and folic acid during the periconceptional period
(i.e., before, during, and after conception) markedly

210          OR4L HE4LTH IN AMERIC4: A REPORT OF THE SURGEON GENERAL


,flrr,,ttished the occurrence of cleft lip and palate in a
,,,,,I,-risk group. Unfortunately, only about 29 per-
L2`;7t of vvomen of childbearing age consume recom-
r,,cndcd amounts of these essential nutrients (Werler
cl .tl, 1999). The evidence associating moderate to
.(\-erc periodontal disease in pregnant women with
l,,\v-Lveight preterm births warrants attention to the
,inI,ortance of maintaining optimal oral health in
l,rc.nancy; The oral care clinician can contribute to
I,trth defect prevention not only by treating oral dis-
c.;tjc. but also by providing educational messages to
I,,tticnts to promote the birth of healthy, full-term
tdlies.

~~~~ttmcnt. A number of birth defects may not be
.ipparent at birth because they are not manifested
until later in development. One example is the ecto-
&-ma1 dysplasias (EDs), disorders characterized by
,ihnormalities of skin, hair, sweat glands, and teeth.
Dentists are essential in the management of care for
children with these disorders, who must be repeated-
Iv fitted with dentures throughout childhood. More
rcccntly, clinical studies have demonstrated that fit-
ting ectodermal dysplasia patients as young as 12
years old with dental implants not only is effective,
but also provides greater functional utility and satis-
faction (Guckes et al. 1998, Kearns et al. 1999). As
with other complex craniofacial anomalies, manage-
ment by a multidisciplinary team is the best
approach, with experts able to advise on the various
oral. skin, and sweat gland complications. '

Mutations have recently been identified for sev-
eral forms of ED, including the anhydrotic form
(absence of sweat glands). Ultimately, the develop-
ment of genetic diagnostic tests can confirm the diag-
nosis in the child and permit counseling of parents.

Chronic Craniofacial Pain and
Sensorimotor Conditions

X variety of problems involving pain and other sen-
sorimotor abnormalities affect the craniofacial com-
plex. These conditions can include burning mouth
syndrome, trigeminal neuralgia, various facial
palsies, postherpetic neuralgia affecting branches of
the trigeminal nerve, temporomandibular disorders,
fibromyalgia, and disorders of taste or olfaction.
Some of these are infectious in origin (e.g., posther-
petit neuralgia and some taste disorders); some are
traumatic (e.g., some cases of temporomandibular
disorder); and for others, the cause or causes are
unknown (see Chapter 3). Patients with facial palsies
and trigeminal neuralgia are generally referred to
neurologists for treatment. Disorders of taste and

smell also require neurological consultation as well
as brain imaging because they can be symptomatic of
brain tumors.

Pain relief may also improve function and can be
combined with adjunctive measures such as the use
of hot or cold compresses and behavioral treatments
such as relaxation and imaging therapy to reduce
muscle tension. The variety of pain medications has
greatly increased in recent years. They include
aspirin and other nonsteroidal anti-inflammatory
drugs, tricyclic antidepressants, new antiepileptic
drugs, the selective serotonin re-uptake inhibitors,
and the more potent opiate family of drugs.
If the pain problem has recently developed,
providers take steps to prevent the pain from becom-
ing chronic. This will entail a general health assess-
ment to determine whether there are co-morbidities,
including other pain problems, as well as patient
questionnaires to provide information on how the
pain problem is affecting overall health and well-
being. The data collected will record the extent to
which the problem interferes with work, social inter-
action, and sleep, whether the patient is experiencing
mood changes and symptoms of depression, and
what coping skills are manifest. Such patient profiles
allow for more selective treatment tailored to the
needs of the individual patient.

Patients in whom pain has become chronic and
intractable may be referred to an established pain
clinic for multidisciplinary treatment and may also
be alerted to patient organizations where individuals
with similar pain problems can find information and
support.

Temporomandibular Disorders

Among the common types of craniofacial pain likely
to be seen by oral care providers are temporo-
mandibular disorders, characterized by symptoms of
pain and dysfunction in and around the temporo-
mandibular joints or the masticatory muscles.

Temporomandibular disorders may occur as a
result of injury, arthritis, or fibromyalgia or for
unknown reasons. Approaches used to obtain a dif-
ferential diagnosis of these conditions can range from
a physical examination that may include palpation
and measuring the mouth opening, to the use of
complex imaging and instrumentation, including
procedures such as arthroscopy (Table 8.13) (Clark
et al. 1993, NIH 1996, Kao 1995, Rao et al. 1990).

Diagnosis of temporomandibular disorders is
based on the physical examination and a complete
medical and dental history, including information
about hearing, speech, and swallowing problems,

Personal and Provider r\pproaches to Oral Health

ORAL HE4LTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

211


Personal and Provider ;\pproachcs to Oral Health

as well as pain and dysfunction. This infor-
mation can be complemented by data from imaging
and other diagnostic tests (Clark et al. 1993, NIH
1996). Evaluation encompasses examination of
oral-facial tissues, musculature, and neurological
function.

Particular attention is paid to measures of the
range of motion, mouth opening, existence of any
parafunctional conditions (e.g., clenching, grinding),
and the presence of joint or muscle tenderness and
cutaneous hyperalgesia. Features of the reliability
studies on the examination methods have been
reviewed (Clark et al. 1993, Mohl et al. 1990).
Psychosocial assessments using validated instru-
ments can determine the extent to which pain and
dysfunction diminish the patient's quality of life
(Dworkin 1994) and can suggest appropriate treat-
ments (NIH 1996, Travel1 and Simons 1983, Zarb
1994).

The evidence base for the efficacy of treatment
modalities is severely limited and has resulted in a
wide range of diagnostics and therapies. Treatments
range from conservative and reversible approaches to
joint surgical procedures. At present the evidence is
insufficient to warrant prophylactic intervention for
management of these disorders (NIH 1996).

Currently available epidemiological evidence
suggests that temporomandibular disorders can fre-
quently resolve over time and that conservative,
reversible approaches are the treatments of choice.
Ideally, the practitioner and the patient should work
together to develop a treatment plan that is evidence-
based and patient-centered, taking into consideration
all etiologic factors, the level of pain and dysfunction
the patient is experiencing, and their impact on the
patients quality of life (see Chapter 3).

Mucosal and Autoimmune Diseases

Microbial infections and autoimmune disorders con-
tribute to a range of mucosal and gingival conditions.
The physical examination may be sufficient to iden-
tify the lesions associated with herpes virus infec-
tions (cold sores), papillomaviruses (oral warts), or
fungal infection (commonly, infection by Candida
albicans), with definitive diagnosis confirmed by
cytology, biopsy, culture, or in situ hybridization.
The patient's history and immune status can supply
additional information indicating risk factors,
including the presence of systemic diseases. Selected
major mucosal diseases and associated clinical find-
ings are described in Chapter's 3 and 5. Tissue biopsy
is critical for the diagnosis of many mucosal diseases.
In addition, oral sites may be convenient biopsy sites
for autoimmune diseases such as Sjogren's syndrome,
which have both a systemic and an oral-facial com-
ponent. Although the evidence base in terms of ran-
domized, double-blind, controlled clinical trials for
the treatment of oral manifestations of mucocuta-
neous disorders is limited, treatment options gener-
ally depend on the severity and extent of the disease.
Because many of the available drugs may have signif-
icant side effects, evaluation of the risk-benefit ratio
for the patient is always of great importance.
Coordination of care with other health care providers
is warranted.

TABLE 8.13
Diagnosis of temporomandibular disorders

Test       Application     Strengths      Weaknesses    Type of Evidence

Clinical exam   All patients     Important to rule   Does not provide   Epidemiologic
              out contributing fat-  information on    studies
                  tars/other disease  etiology
                      states
Radiographic  All patients      Rules out structural  Depending on type  Epidemiologic
survey             problems     of survey, certain    studies
                            information is lost
Specialized   Patients with history  May locate the disk,  Depending on type  Epidemiologic
imaging     and exams indicative  rule out or indicate  of survey, informa-   studies;
(arthrography,  of anatomic alter-   anatomic change   tion may not be    case reports
CT, MRI, etc.)   ations                   obtained

FACTORS AFFECTING FUTURE
HEALTH CARE PRACTICES
The last decades of the twentieth century were wit-
ness to major improvements in the prevention, diag-
nosis, and treatment of oral diseases-a trend that
will continue to accelerate the paradigm shift in the
       management of oral diseases from
       repair of damaged tissues to the
         control of infections. In addition,
       modification of risk factor expo-
       sures will result in improvements
       in health and in the management
         of disease. A closer look into fac-
          tors that will affect the future of
       oral health care requires an
         overview of the current state of
       guidelines for oral care and the sta-
       tus of evidence-based practice. The
       approaches used to determine the
       evidence for practice and the
       development of guidelines for care
       are an emerging field of activity.
        Education in the health profes-
       sions is already emphasizing the

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


,rnportance of relying on randomized, controlled
iIlnical trials, the gold standard for judging the mer-
,ts of proposed interventions, wherever possible.

E\idence-based Practice
During the 1990% "evidence-based medicine" em-
crged as both popular phraseology and practice phi-
losophy The origins of evidence-based medicine go
back to mid-nineteenth-century Paris and earlier, yet
the approach is still a relatively young discipline that
is now rapidly evolving (Sackett et al. 1996).
El.idence-based medicine has been defined as the
integration of "individual clinical expertise with the
best available external clinical evidence from system-
atic research" and with patients' choices (Sackett et
al. 1996). The skills required include defining a clin-
1ca1 problem, critically appraising the relevant litera-
ture. and deciding whether and how to integrate this
information into practice (Evidence-Based Medicine
Working Group 1992). Evidence-based medicine is
neither a "cookbook" nor an ivory tower approach
(Sackett et al. 1996).

The philosophy is being adopted across a range
of disciplines, leading to the terms "evidence-based
dentistry" and "evidence-based nursing," among oth-
ers The practice of evidence-based dentistry "incor-
porates the judicious use of the best evidence avail-
able from systematic reviews, when possible, with
knowledge of patients' preferences and clinicians'
experiences to make recommendations for the provi-
sion of the right care, for the right patient, and at the
right time" (Ismail et al. 1999).

The reliance on evidence using systematic
reviews of the literature has led to initiatives in the
United States, Canada, and Europe to enhance the
conduct and use of systematic reviews. The Agency
for Healthcare Research and Quality (AHRQ) created
12 evidence-based practice centers in 1997 to con-
duct systematic reviews and develop evidence
reports. The Cochrane Collaboration and the Centre
for Reviews and Dissemination at the University of
York are examples of prominent activities in the
United Kingdom to support systematic reviews. The
Cochrane Oral Health Review Group, one of 50 spe-
cialty  review groups within the Cochrane
Collaboration, has a number of systematic reviews
completed or under way of interest to oral health
practitioners (see Table 8.14) (Tavender 1999). In
Canada, considerable contributions to the field have
been made by McMaster University and the Canadian
Coordinating Office for Health Technology
Assessment.

Personal and Pro\.ider Approaches to Oral Health

In the United States, the National Institute of
Dental and Craniofacial Research joined efforts with
AHRQ in 1999 to designate one of AHRQ's Evidence-
based Practice Centers to conduct reviews on oral,
dental. and craniofacial diseases and disorders. The
work of this center should significantly strengthen
the scientific base of knowledge related to the diag-
nosis and management of oral, dental, and craniofa-
cial conditions. Examples of topics that will be
reviewed include the management of dental caries,
and dental care of medically compromised patients,
including patients with HIV disease.

Clinical Practice Guidelines

The development of clinical practice guidelines is
one of the intended outcomes of evidence-based
reviews. The classic definition for clinical practice
guidelines describes them as "systematically devel-
oped statements to assist practitioner and patient
decisions about appropriate health care for specific
clinical circumstances" (Field and Lohr 1992). A
1995 review of the status of clinical practice guide-
lines in dentistry (Shugars and Bader 1995) found
that a limited number of guidelines were available
and that few extant guidelines met all of the des-
irable attributes for guidelines identified by the
Institute of Medicine (Field and Lohr 1992). Most
notably a majority of guidelines were based on con-
sensus among selected professionals, with little evi-
dence of support from the scientific literature. Since
1995, the number of dental practice guidelines has
grown slowly but steadily. Table 8.15 lists selected
sets of guidelines that, taken together, represent an
estimated 50 percent of all current published dental
guidelines intended for national distribution. When
36 national dental organizations representing clinical
aspects of dentistry and dental practice were sur-
veyed in early 1999, 12 of 22 responding organiza-
tions indicated that they had developed guidelines
(J.D. Bader, personal communication, 1999), 8 of
which are listed in the table. Some of these guidelines
have not been widely distributed, are not published
in the scientific literature, nor are available on the
sponsoring organization's Web site. Not shown are
guidelines developed by care delivery organizations
for use in their clinical practices. These are generally
not available for public or external professional
scrutiny

The table provides information on two important
characteristics of clinical practice guidelines: the
extent to which they are evidence-based and their
level of specificity, which will determine their clinical
applicability. Clinical applicability is a key feature of

OR4L HEALTH 1N AMERICA: A REPORT OF THE SURGEON GENERAL

213


practice guidelines, and it is heightened as the
amount of specific information in a guideline is
increased to identify patient and condition character-
istics to which the guideline applies. As the "evi-
dence-based" concept gains popularity, there is a
growing expectation that clinical practice guidelines
will reflect systematic evaluation of the relevant liter-
ature and will present an evaluation of the strength of
the evidence for each recommendation (Ismail et al.
1999). Such information, which ensures the content
validity of the guidelines, not only helps practitioners
and patients understand exactly what is and is not
known about the effectiveness of proposed treat-
ments, but also identifies research needed to evaluate
current practice. A less comprehensive but still use-
ful approach to identifying the scientific support for
clinical interventions is the traditional approach of
citing specific studies and reviews when discussing
specific treatments. Practice guidelines without
explicit linkages to the literature, such as those sup-
ported only by selected citations not linked to specif-
ic statements and those without any citations, can
still be useful, but users have less assurance that the
content is valid.

As the expectations for the content and use of
clinical practice guidelines mature, "perhaps the
main task of guideline development [will be] to sum-
marize the strength of the evidence for the effective-
ness of a given clinical practice in relation to risks
and costs" (Fletcher and Fletcher 1998). Thus, prac-

tice guidelines will need to be revised considerably to
incorporate the literature on treatment outcomes as
they become available. Currently, information on
both the effectiveness of specific dental treatments
and the range of outcomes examined is extremely
limited (Bader and Shugars 1995). For example,
none of the guidelines in the table address patient
preference or patient utility issues. Dental organiza-
tions have the opportunity to address these informa-
tion gaps as practice guidelines are developed.
Professional dental organizations are the most likely
developers, but other organizations can also be vig-
orous participants. Finally, organizations developing
guidelines should also develop a plan for their dis-
semination, evaluation, and revision. The existence
of guidelines does not ensur;e that appropriate treat-
ment decisions will be made. Passive distribution of
clinical practice guidelines is generally ineffective in
altering practice, whereas more active, multifaceted
interventions can achieve some measure of desired
change (Bero et al. 1998).

Science and Technology Contributions
During the past several decades, there have been
major improvements in the prevention, diagnosis,
and treatment of oral diseases. Enhanced disease pre-
vention and health promotion will require the partic-
ipation of all health professions, especially in
addressing common risk factors such as tobacco,

Systematic reviews on oral health topics conducted by the Cochrane Collaboration
Oral Health Review Group

Interventions for treating oral leukoplakia
Prevention of oral mucositis or oral candidiasis for patients with cancer receiving
chemotherapy (excluding oral and pharyngeal cancers)
Treatment of oral candidiasis for patients receiving chemotherapy or radiotherapy
Treatment of oral mucositis or its associated pain for patients receiving chemotherapy
or radiotherapy

Statusa

Protocol

Full review

Protocol

Protocol

Protocol

Protocol

Guided tissue regeneration for periodontal intrabone defects               Protocol
Orthodontic treatments for posterior cross-bites                     Full review
Interventions for treating oral lichen planus                       Full review
Potassium-nitrate-containing dentifrice for dentin hypersensitivity            Protocol

dPr~tocols are the introduction, objectives, materials,and methods for reviews currently being prepared.
Source: Tavender 1999.

alcohol, and inappropriate dietary
practices. The field 01 diagnostic
tests for oral diseases should con-
tinue to expand, enabling clini-
cians to analyze the risk of disease
and disease progression for indi-
vidual patients. Full assessment of
the strengths and weaknesses of
new diagnostic tests and evalua-
tion of when they are best used
will be key to proper interpretation
of the results, permitting tailored
referrals and treatments. Treatment
options for individual patients are
increasing, including the regenera-
tion of lost bone and connective
tissue. Restorative materials are
continuously improving, resulting
in safe, effective, and aesthetic
restorations. The growing field of
biomimetics should continue to
revolutionize oral health and oral
health care. Development of bio-
compatible restorative and implant

TABLE 8.14

Topical fluoride for preventing dental caries in children and adolescents
Pit-and-fissure sealants for preventing decay in the permanent teeth of children
and adolescents

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


Personal and Provider Approaches to Oral Health

,I~;lterials will continue, as well as development of    Science is continuing to reveal the intricacies and
IIc\~ biologically engineered substitutes for lost bone,  complexities of disease etiology and pathogenesis. In
c,lnnective tissue, and diseased articular disks, to  turn, the classification and diagnosis of diseases and
Ilame several possibilities. Harnessing other basic sci-  conditions will improve and lead to tailored treat-
c`l~ce knowledge will enable the development of new  ment options. The recent efforts to understand and
[hcrapies such as genetically engineered growth fac-  define early childhood caries are an example of this
tors. Improved understanding of the genetic risk fac-  evolutionary process (lsmail et al. 1999). This exam-
tors. limitation of exposures to teratogens, and atten-  ple further demonstrates that disease definitions are
tion to diet may markedly diminish the occurrence of  important for population-based research (Drury et al.
congenital anomalies such as cleft lip and palate.     1999, Kaste et al. 1999).

r..iBLE 8.15

Characteristics of selected dental clinical practice guidelines

                               Use of the Scientific Literature       Level of Specificity/Applicability
                      Strength Text Linked Selected None   Algorithm   Recom-    Lists of
                             Evaluated to Citations Citations Cited    or Protocol mendations Considerations

ULprofessional dental organizations
American Dental Association
  dental practice parameters (1996)'                                    4                        4
American Association of Endodontists
  appropriateness of care guidelines (1994)                           4                             4
American Association of Orthodontists
  clinical practice guidelines (1996)                                4                             4
American Association of Oral and Maxillofacial Surgeons
  parameters of care (1995)                                   4     4                       4
American Academy of Pediatric Dentistry
  Guidelines (1998)                                        4     4                       4
American Academy of Periodontology
  parameters of care (1996)                                   4                             4
American College of Prosthodontists
  parameters of care (1996)                                   4                            4
American Cleft Palate-Craniofacial Association
  parameters (1993)                                       4     4

U.S. government agencies
U.S. Preventive Services Task Force
  counseling to prevent dental and periodontal
  disease (1996)                           4       4      4                    4
Office of Medical Applications of Research

management oftemporomandibular disorders (1996)       4                                   4
Food and Drug Administration

  selection of patients for x-ray examinations (1987)                4      4             4       4
Other organizations
American Heart Association
  prevention of bacterial endocarditis (1997)             4       4                    4       4
Workshop on Guidelines for Sealant Use Proceedings (1995)             4
Canadian Task Force on Preventive Health Care
  prevention of periodontal disease (1993)             4       4                           4
Canadian Paediatric Society

  the use of fluorides in infants and children (1996)
Task Force on Periodontal Regeneration of lntrabony Pocket+
  periodontal regeneration of intrabony defects (1995)

`Refers to publication date of collected set of guidelines.
bCorporate sponsorship.

4                    4       4

4                    4       4

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          215


Personal and Provider Approaches to Oral Health

One area critical to the ability of dentists to adopt
new treatment modalities or diagnostic techniques is
the development of diagnostic codes. In contrast to
medicine, these diagnostic codes currently have no
impact on reimbursement. However, the develop-
ment and introduction of such codes are essential for
the conduct of needed outcomes research, and their
widespread use is necessary for practice-based
research. Such codes permit the documentation of
preexisting conditions, monitoring of disease pro-
gression, and provision of surveillance data in public
health programs. A pilot study in a Canadian public
health program has proposed and implemented a set
of diagnostic codes (Leake et al. 1999). The
American Dental Association has undertaken the
development of a comprehensive set of diagnostic
codes, expected to be released in the near future.

hygiene, and health-promoting behaviors, including
the appropriate use of professional services.
Individuals should use a fluoride dentrifice daily to
help prevent dental caries and should brush and floss
daily to prevent gingivitis.
   o  All primary care providers can contribute to
improved oral and craniofacial health. lnterdisci-
plinary care is needed to manage the oral health-gen-
eral health interface. Dentists, as primary care
providers, are uniquely positioned to play an expand-
ed role in the detection, early recognition, and man-
agement of a wide range of complex oral and general
diseases and conditions.

o Nonsurgical interventions are available to
reverse disease progression and to manage oral dis-
eases as infections.

Broadening the Base for the Provision of
Oral Health Care

Further biologic, scientific, and technological
advances and changes in the organization of health
care delivery will continue to alter future profession-
al and individual health care practices (see Chapters
9 and 11). The increased knowledge of risk factors,
the importance of monitoring disease progression
and treatment effects, and the ability to diagnose con-
ditions and intervene earlier will necessitate
increased involvement of all health professionals in
oral health care and may reflect changes in care pro-
vision and referral patterns. Management of condi-
tions such as oral and pharyngeal cancers, cleft
lip/palate, and chronic pain requires multidiscipli-
nary teams. The promotion of oral health and the
prevention of oral disease are at a turning point. A
systematic approach to integrate the scientific find-
ings into evidence-based assessments will provide
clearer guidance to all health care professions and the
public. To capitalize on the rapidly emerging science
base, the active participation of a full range of health
care providers and individuals and the community is
needed.

   o  New knowledge and the development of
molecular and genetically based tests will facilitate
risk assessment and management and improve the
ability of health care providers to customize treatment.
   o  Health care providers can successfully deliv-
er tobacco cessation and other health promotion pro-
grams in their offices, contributing to both overall
health and oral health.

   Biocompatible rehabilitative materials and
biolzgically engineered tissues are being developed
and will greatly enhance the treatment options avail-
able to providers and their patients.

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


provision of Oral Health Care

,\cfricving optimal oral, dental, and craniofacial
t&th requires a commitment to self-care and pre-
\.cnti\fe behaviors as well as the receipt of appropriate
f'rofcssional care. Community-wide approaches to
,tlpport oral health and the role of professional serv-
ices are covered in Chapters 7 and 8, respectively.
..\lthough the services provided by dental practition-
crs are the first that come to mind when people con-
,~dcr the nation's resources to address the diseases
nnd disorders that affect the craniofacial complex, the
dental component is augmented by two other com-
ponents-medicine and public health. These three
do not constitute a single system of care, but serve as
individual components variously involved in the pro-
motion of health and the provision of services to
Individuals and families, communities, and the pop-
ulation at large. The linkages and overlaps among the
components mirror those between oral and general
health described elsewhere in this report (e.g.,
Chapters 2, 3, 5, and 6), and may also play a role in
the disparities noted in Chapter 4.

As has been noted in previous chapters, data
regarding the contributions to oral health care made
by the medical and public health components are not
nearly as available as those that describe the contri-
butions made by dental practitioners. Most of this
care is provided by dentists in private practice.
Expenditures for their services represented over 96
percent of the estimated $53.8 billion spent on den-
tal care in 1998, or 4.7 percent of the 91.1 trillion
spent on all health care in the United States that year
(HCFA 2OOOb). Although they surely undercount the
contributions of the medical and public health com-
ponents, these expenditures indicate the burden that
oral diseases and conditions place on the American
people, as well as their willingness to invest in the
prevention, treatment, and rehabilitation of oral con-
ditions-a reflection of the value they place on oral
health.

  There have been notable acflievements in oral
health over the years, among them the dramatic and
continuing reduction in the prevalence of dental
caries in sizable population groups (see Chapter 4).
This has led to an impressive decline in tooth loss,
with the result that the majority of Americans can
now expect to retain their natural teeth over their
lifetimes. At the same time, all three components
have participated in the revolutions in biomedical
and behavioral sciences and technology that have
deepened our understanding of the biological, envi-
ronmental, behavioral, and genetic origins of many
oral, dental, and craniofacial diseases. Americans
today can benefit from oral health services that are
among the best in the world. Moreover, as new and
improved preventive, diagnostic, and treatment
measures emerge (see Chapter 8), they create further
opportunities for improving the nation's oral health.

COMPONENTS OF PROFESSIONAL
CARE

The dental, medical, and public health contributions
to oral health differ dramatically in their size, focus,
financing, and resources. Following is a brief descrip-
tion of each component and their areas of overlap.

The Dental Component

Comprehensive oral health care in America is largely
supplied by a private dental care system composed of
dentists, dental hygienists, dental assistants, labora-
tory technicians, and other professional staff in inde-
pendent dental offices. The estimated numbers of
active dental personnel are presented in Table 9.1. Of
the 156,500 professionally active dentists in the
United States in 1997, 91.7 percent were in private
practice (ADA 1998a). Women constitute 14.4 per-
cent of the total, and minorities 11.1 percent (ADA

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          223


Provision of Oral Health Care

1998a). Other professionals, who are educators, bio-
medical and behavioral science researchers, techni-
cians, manufacturers of dental products, and admin-
istrators, complement this workforce.

In contrast to medicine, where only 40 percent of
physicians were in primary care practices in 1990,
approximately 80 percent of dentists are general
practitioners (ADA 1998a). The remainder qualify as
specialists in one or more of the nine disciplines for-
mally  recognized  by the American Dental
Association: orthodontics, oral and maxillofacial sur-
gery, oral and maxillofacial radiology, periodontics,
pediatric dentistry, endodontics, prosthodontics,
dental public health, and oral and maxillofacial
pathology More than half of these specialists are
orthodontists or oral surgeons (ADA 1998a). A small
number of dental practitioners focus on special inter-
est areas such as anesthesiology or oral medicine.
There has been little change in the approximately

TABLE 9.1
Estimated numbers of active oral health personnel,
United States, selected years

1980   1990   1996    1997

Dentists          121,900  147,500  154,900  156,500
Dental hygienists       54,000  81,000  94,000   NA
Dental assistants      156,000  201,000  212,000   NA
Dental laboratory technicians  43,000  50,000  53,000   NA

Note: NA = not available.
Source: HRSA 1999.

4 to 1 ratio of general dentists to specialists in the
past 10 years.

New technologies and changing patterns of dis-
ease are broadening the scope of dental practice. The
average general practitioner and staff now engage in
more preventive services than in years past (ADA
1990). A reduction in the number of amalgam and
resin restorations per patient per year from 1980 to
1995 has also been noted (Eklund et al. 1997).
Although dentists perform fewer extractions and
restorations, preserving the teeth of an aging popula-
tion has increased the need for crowns and peri-
odontal treatment.

Since oral health is an integral part of total
health, most dentists provide primary care services to
their patients. In addition to educating patients on
oral health care, dentists and their staff may counsel
patients on tobacco and other substance use and
cessation, nutrition, and dietary practices. In
addition, information that dentists obtain from a
patient's history and from screening and diagnostic
tests may suggest the presence of systemic disease,
warranting a referral of the patient to other health
care professionals.

Dental services are provided in a practice model
that is different from that used by the medical pro-
fession. Most private dental practices consist of one
dentist (68.7 percent) or two dentists (19.6 percent).
The remaining practices (11.7 percent) are group
practices of three or more dentists who share expens-
es and revenues. This distribution of dentists by prac-
tice size, along with the number of hours worked per
week, has remained remarkably constant over the

The association between state mean per capita income and the population-to-dentist
ratio, by individual state, United States, 1995

I       1              I       ,       I       I

10,000   15,000   20,000   25,000   30,DOo   35,000
   Mean per capita income (dollars)

years (ADA 1998a). The size,
number, and location of dental
practices are important determi-
nants of availability of care and
accessibility to services, as well as
of the unit cost of care. Figure 9.1
shows the association between
the availability of dentists and
state mean per capita income
(Burt and Eklund 1999). Dental
care is also provided in dental
schools and public health clinics,
hospitals, nursing homes, and
other institutional settings. These
are sometimes the principal
source of oral health care for
communities and special popula-
tion groups with limited access to
health care.

FIGURE 9.1

3,500

3,000

t; 2,500
`G
5 2,000
f 1,500
$
.-
5 1,000
2
8 500

    0

c

0

5,000

Source: ADA 1997a.Reprinted by permission ofAmerican Dental Association,SurveyCenter.Distributionofdentists by region
and rtatel995.Copynght 1997 by American Dental Association,SurveyCenter.

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


The Medical Component

In the context of oral, dental, and craniofacial health

care, the medical component includes dentists,
physicians, nurses, and allied health professionals
whose services are provided through hospitals, nurs-
ing homes, ambulatory care facilities, and health pro-
fessional offices. Data on the nature and extent of
such oral health services, as well as on the number of
nondental professionals who supply them, are limit-
ed. For some conditions-particularly developmen-
tal anomalies, injuries, infectious diseases, pain syn-
dromes, and oral and pharyngeal cancers-the med-
ical component provides comprehensive care, often
working in tandem with dental specialists and gener-
al practitioners. For example, physicians and oral
and maxillofacial surgeons may plan treatments
together and operate on individuals born with cleft
lip/palate to repair the clefts as the children age.
Orthodontists, pediatric dentists, prosthodontists,
and other dental specialists, speech and hearing ther-
apists, plastic surgeons, neurologists, radiologists,
nutritionists. psychologists, other health profession-
als, and social workers are also part of the craniofa-
cial team.

Collaboration and coordination between physi-
cians and dentists are needed to provide integrated
medical and oral health care for cardiac patients and
those undergoing chemo- and radiation therapy or
implant and organ transplant procedures. Nondental
health care personnel in long-term and geriatric care
facilities may be the principal sources of oral health
care given to residents.

Although most hospitals have dental personnel
on staff to handle emergency situations, emergency
room physicians and other hospital personnel are
often called on to initiate treatment of acute oral-
facial injury or pain of dental origin, with referrals to
dentists for follow-up. Also, patients with chronic
oral-facial pain conditions are sometimes treated by
family practice, internal medicine, or neurology
physicians, sometimes with referral to dental or other
medical specialists.

The Public Health Component

Federal, state, and local government agencies sup-
port a range of oral health activities and programs
benefiting individuals and communities. This com-
ponent includes health professionals and administra-
tors who participate in publicly funded care delivery
programs, research, disease surveillance, policy
development, and implementation of programs
aimed at preventing disease and promoting health.

Provision of Oral Health Care

Federal agencies under the jurisdiction of the
U.S. Department of Health and Human Services
(USDHHS) and the U.S. Departments of Defense,
Veterans Affairs, Agriculture, Education, Transporta-
tion, and Justice, among others, serve public health
needs in diverse ways. These agencies may include
units or programs specifically dedicated to oral
health, as well as components that collect, organize,
or make available information or services related to
oral health as part of general health programs. For
example, the National Institutes of Health (NIH) is
the primary federal agency supporting biomedical
and behavioral research and research training.
Assurance of the safety of foods, cosmetics, drugs,
and devices is provided through the regulatory
authorities of the Food and Drug Administration
(FDA). The Centers for Disease Control and
Prevention (CDC) focuses on state-based programs
for monitoring and preventing disease and, through
the National Center for Health Statistics, orchestrates
the collection of nationally representative health
information and population data. The Agency for
Healthcare Research and Quality (AHRQ) uses evi-
dence-based practice centers to evaluate literature
relevant to the management of diseases and condi-
tions, conducts national expenditure and care utiliza-
tion surveys, and supports research directed at
understanding health care systems. The Medicaid,
Medicare, and newly enacted State Children's Health
Insurance Program (SCHIP) programs are directed
by the Health Care Financing Administration
(HCFA), which funds a variety of care services pre-
scribed by law or regulation.

Several federal agencies provide direct services
to specific, often disadvantaged populations or to
military personnel and their dependents. The U.S.
Departments of Defense, Transportation, and
Veterans Affairs, the U.S. Department of Justice's
Bureau of Prisons, and the USDHHS's Indian
Health Service (IHS) and Health Resources and
Services Administration (HRSA) provide oral health
care directly to selected populations. Oral health
education also is provided through the U.S.
Department of Agriculture's Women, Infants and
Children (WIG) program. In addition, HRSA
provides funds for health professional education
and administers the Ryan White Comprehensive
AIDS Resources Emergency Act. States, counties,
and  cities  also  support dental programs
for disadvantaged populations under federally
mandated and funded Maternal and Children's
Health Programs or as part of Medicaid or the
State Children's Health Insurance Program. They
may also provide direct support through tax

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