Executive Summary

publication of this first Surgeon Generals Report on
Oral Health marks a milestone in the history of oral
health in America. The report elaborates on the
meaning of oral health and explains why oral health
is essential to general health and well-being. In the
course of the past 50 years, great progress has been
made in understanding the common oral diseases-
dental caries (tooth decay) and periodontal (gum)
diseases-resulting in marked improvements in the
nations oral health. Most middle-aged and younger
Americans expect to retain their natural teeth over
their lifetime and do not expect to have any serious
oral health problems.

The major message of this Surgeon Generals
report is that oral health is essential to the general
health and well-being of all Americans and can be
achieved by all Americans. However, not all
Americans are achieving the same degree of oral
health. In spite of the safe and effective means of
maintaining oral health that have benefited the
majority of Americans over the past half century,
many among us still experience needless pain and
suffering, complications that devastate overall health
and well-being, and financial and social costs that
diminish the quality of life and burden American
society. What amounts to "a silent epidemic" of oral
diseases is affecting our most vulnerable citizens-
poor children, the elderly, and many members of
racial and ethnic minority groups (GAO 2000). (See
box entitled "The Burden of Oral Diseases and
Disorders.")

  The word oval refers to the mouth. The mouth
includes not only the teeth and the gums (gingiva)
and their supporting tissues, but also the hard and
soft palate, the mucosal lining of the mouth and
throat, the tongue, the lips, the salivary glands, the
chewing muscles, and the upper and lower jaws.
Equally important are the branches of the nervous,
immune, and vascular systems that animate, protect,

and nourish the oral tissues, as well as provide con-
nections to the brain and the rest of the body. The
genetic patterning of development in utero further
reveals the intimate relationship of the oral tissues to
the developing brain and to the tissues of the face and
head that surround the mouth, structures whose
location is captured in the word craniofacial.

A major theme of this report is that oral health
means much more than healthy teeth. It means
being free of chronic oral-facial pain conditions, oral
and pharyngeal (throat) cancers, oral soft tissue
lesions, birth defects such as cleft lip and palate, and
scores of other diseases and disorders that affect the
oral, dental, and craniofacial tissues, collectively
known as the craniofacial complex. These are tissues
whose functions we often take for granted, yet they
represent the very essence of our humanity. They
allow us to speak and smile; sigh and kiss; smell,
taste, touch, chew, and swallow; cry out in pain; and
convey a world of feelings and emotions through
facial expressions. They also provide protection
against microbial infections and environmental
insults.

The craniofacial tissues also provide a useful
means to understanding organs and systems in less
accessible parts of the body. The salivary glands are a
model of other exocrine glands, and an analysis of
saliva can provide telltale clues of overall health or
disease. The jawbones and their joints function like
other musculoskeletal parts. The nervous system
apparatus underlying facial pain has its counterpart
in nerves elsewhere in the body. A thorough oral
examination can detect signs of nutritional defi-
ciencies as well as a number of systemic diseases,
including microbial infections, immune disorders,
injuries, and some cancers. Indeed, the phrase the
mouth is a mirror has been used to illustrate the
wealth of information that can be derived from
examining oral tissues.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

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Executive Summar)

New research is pointing to associations between
chronic oral infections and heart and lung diseases,
stroke, and low-birth-weight, premature births.
Associations between periodontal disease and dia-
betes have long been noted. This report assesses
these associations and explores mechanisms that
might explain the oral-systemic disease connections.
The broadened meaning of oral henlth parallels
the broadened meaning of Ilealth. In 1948 the World
Health Organization expanded the definition of
health to mean "a complete state of physical, mental,
and social well-being, and not just the absence of
infirmity." It follows that oral health must also
include well-being. Just as we now understand that
nature and nurture are inextricably linked, and mind
and body are both expressions of our human biology,
so, too, we must recognize that oral health and
general health are inseparable. We ignore signs and
symptoms of oral disease and dysfunction to our

The Burden of Oral Diseases and Disorders

Oral diseases are progressive and cumulative and become more com-
plex over time.They can affect our ability to eat,the foods we choose,
how we look, and the way we communicate.These diseases can affect
economic productivity and compromise our ability to work at home, at
school, or on the job. Health disparities exist across population groups
at all ages. Over one third of the U.S. population (100 million people)
has no access to community water fluoridation. Over 108 million chil-
dren and adults lack dental insurance, which is over 2.5 times the num-
ber who lack medical insurance. The following are highlights of oral.
health data for children, adults, and the elderly. (Refer to the full report
for details of these data and their sources.)

Children

  o Cleft lip/palate, one of the most common birth defects, is esti-
mated to affecl 1 out of 600 live births for whites and 1 out of 1,850 live
births for African Americans.

  o Other birth defects such as hereditary ectodermal dysplasias,
where all or most teeth are missing or misshapen,cause lifetime prob-
lems that can be devastating to children and adults.
  o Dental caries (tooth decay) is the single most common chronic
childhood disease-5 times more common than asthma and 7 times
more common than hay fever.
  o Over 50 percent of 5- to g-year-old children have at least one
cavity or filling, and that proportion increases to 78 percent among 17-
year-olds. Nevertheless, these figures represent improvements in the
oral health of children compared to a generation ago.
  o There are striking disparities in dental disease by income. Poor
children suffer twice as much dental caries as their more affluent peers,
and their disease is more likely to be untreated.These poor-nonpoor

detriment. Consequently, a second theme of the
report is that oral health is integral to general
health. You cannot be healthy without oral health.
Oral health and general health should not be
interpreted as separate entities. Oral health is a
critical component of health and must be included in
the provision of health care and the design of
community programs.

The wider meanings of oral and health in no wa)
diminish the relevance and importance of the t\vo
leading dental diseases, caries and the periodontal
diseases. They remain common and widespread.
affecting nearly everyone at some point in the life
span. What has changed is what we can do about
them.

Researchers in the 1930s discovered that people
living in communities with naturally fluoridated
water supplies had less dental caries than people
drinking unfluoridated water. But not until the end

differences continue into adolescence. One out of four children in
America is born into poverty,and children living below the poverty line
(annual income of $17,000 for a family of four) have more severe and
untreated decay.

  o Unintentional injuries,manyofwhich include head,mouth,and
neck injuries, are common in children.
  o Intentional injuries commonly affect the craniofacial tissues.
  o Tobacco-related oral lesions are prevalent in adolescents who
currently use smokeless (spit) tobacco.
  o Professional care is necessary for maintaining oral health, yet
25 percent of poor children have not seen a dentist before entering
kindergarten.
  o Medical insurance is a strong predictor of access to dental care.
Uninsured children are 2.5 times less likely than insured children to
receive dental care.Children from families without dental insurance are
3 times more likely to have dental needs than children with either pub-
lic or private insurance. For each child without medical insurance, there
are at least 2.6 children without dental insurance.

  o Medicaid has not been able to fill the gap in providing dental
care to poor children. Fewer than one in five Medicaid-covered children
received a single dental visit in a recent year-long study period.
Although new programs such as the State Children's Health Insurance
Program WHIP) may increase the number of insured children, many
will still be left without effective dental coverage.

o The social impact of oral diseases in children is substantial.
More than 51 million school hours are lost each year to dental-related
illness. Poor children suffer nearly 12 times more restricted-activity
days than children from higher-incomefamilies.Pain and suffering due
to untreated diseases can lead to problems in eating, speaking, and
attending to learning.

2           ORAL HEi4LTH IN .4MERIC;\: A REPORT OF THE SURGEON GENERAL


-

Executive Summary

(,f \\.-orld War 11 were the investigators able to design
,Ind implement the community clinical trials that
<onfirmed their observations and launched a better
,,pproach to the problem of dental caries: prevention.
soon after, adjusting the fluoride content of commu-
nity water supplies was pursued as an important pub-
lic health measure to prevent dental caries.
,\lthough this measure has not been fully imple-
[nented. the results have been dramatic. Dental caries
began to decline in the 1950s among children who
cTrc\v up in fluoridated cities, and by the late 197Os,
&cline in decay was evident for many Americans.
The application of science to improve diagnostic,
rrcatment, and prevention strategies has saved bil-
IIons of dollars per year in the nation's annual health
hill. Even more significant, the result is that far fewer
people are edentulous (toothless) today than a gen-
cration ago.

The theme of prevention gained momentum as
pioneering investigators and practitioners in the
1950s and 1960s showed that not only dental caries
but also periodontal diseases are bacterial infections.
The researchers demonstrated that the infections
could be prevented by increasing host resistance to
disease and reducing or eliminating the suspected
microbial pathogens in the oral cavity, The applica-
tions of research discoveries have resulted in contin-
uing improvements in the oral health of Americans,
new approaches to the prevention and treatment of
dental diseases, and the growth of the science.

The significant role that scientists, dentists, den-
tal hygienists, and other health professionals have
played in the prevention of oral disease and disabili-
ty leads to a third theme of this report: safe and effec-
tive disease prevention measures exist that every-
one can adopt to improve oral health and prevent
disease. These measures include daily oral hygiene

Adults

OlderAdults

  o Most adults show signs of periodontal or gingival diseases.
Severe periodontal disease (measured as 6 millimeters of periodontal
attachment loss) affects about 14 percent of adults aged 45 to 54.
  o Clinical symptoms of viral infections, such as herpes labialis
(cold sores), and oral ulcers (canker sores) are common in adulthood,
affecting about 19 percent of adults 25 to 44 years of age.
  o Chronic disabling diseases such as temporomandibular disor-
ders, SjSgren's syndrome, diabetes, and osteoporosis affect millions of
Americans and compromise oral health and functioning.
  o Pain is a common symptom of craniofacial disorders and is
accompanied by interference with vital functions such as eating, swal-
lowing,and speech.Twenty-two percent of adults reported some form
of oral-facial pain in the past 6 months. Pain is a major component of
trigeminal neuralgia, facial shingles (post-herpetic neuralgia), tem-
poromandibular disorders,fibromyalgia, and Bell's palsy.
  o Population growth as well as diagnostics that are enabling ear-
lier detection of cancer means that more patients than ever before are
undergoing cancer treatments. More than 400,000 of these patients
will develop oral complications annually.
  o Immunocompromised patients, such as those with HIV infec-
tion and those undergoing organ transplantation,are at higher risk for
oral problems such as candidiasis.
  o Employed adults lose more than 164 million hours of work each
year due to dental disease or dental visits.
  o For every adult 19 years or older without medical insurance,
there are three without dental insurance.

  o A little less than two thirds of adults report having visited a
dentist in the past 12 months. Those with incomes at or above the
poverty level are twice as likely to report a dental visit in the past 12
months as those who are below the poverty level,

  o Twenty-three percent of 65- to 76year-olds have severe peri-
odontal disease (measured as 6 millimeters of periodontal attachment
loss). (Also, at all ages men are more likely than women to have more
severe disease, and at all ages people at the lowest socioeconomic lev-
els have more severe periodontal disease.)

  o About 30 percent of adults 65 years and older are edentulous,
compared to 46 percent 20 years ago.These figures are higher for those
living in poverty.

o ($1 and pharyngeal cancers are diagnosed in about 30,000
Americans annually; 8,000 die from these diseases each year. These
cancers are primarily diagnosed in the elderly. Prognosis is poor.The 5-
year survival rate for white patients is 56 percent; for blacks,it is only 34
percent.

o Most older Americans take both prescription and over-the-
counter drugs. In all probability, at least one of the medications used
will have an oral side effect-usually dry mouth.The inhibition of sali-
vary flow increases the risk for oral disease because saliva contains
antimicrobial components as well as minerals that can help rebuild
tooth enamel after attack by acid-producing, decay-causing bacteria.
Individuals in long-term care facilities are prescribed an average of
eight drugs.

  o At any given time, 5 percent of Americans aged 65 and older
(currently some 1.65 million people) are living in a long-term care facil-
ity where dental care is problematic.

  o Many elderly individuals lose their dental insurance when they
retire.The situation may be worse for older women,who generally have
lower incomes and may never have had dental insurance. Medicaid
funds dental care for the low-income and disabled elderly in some
states, but reimbursements are low. Medicare is not designed to reim-
burse for routine dental care.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

3


Executive Summar)

procedures and other lifestyle behaviors, community
programs such as community water fluoridation and
tobacco cessation programs, and provider-based
interventions such as the placement of dental
sealants and examinations for common oral and pha-
ryngeal cancers. It is hoped that this Surgeon
General's report will facilitate the maturing of the
broad field of craniofacial research so that gains in
the prevention of craniofacial diseases and disorders
can be realized that are as impressive as those
achieved for common dental diseases.
  At the same time, more needs to be done to
ensure that messages of health promotion and dis-
ease prevention are brought home to all Americans.
In this regard, a fourth theme of the report is that
general health risk factors, such as tobacco use and
poor dietary practices, also affect oral and craniofa-
cial health. The evidence for an association between
tobacco use and oral diseases has been clearly delin-
eated in almost every Surgeon General's report on
tobacco since 1964, and the oral effects of nutrition
and diet are presented in the Surgeon Generals report
on nutrition (1988). All the health professions can
play a role in reducing the burden of disease in
America by calling attention to these and other risk
factors and suggesting appropriate actions.
Clearly, promoting health and preventing dis-
eases are concepts the American people have taken to
heart. For the third decade the nation has developed
a plan for the prevention of disease and the promo-
tion of health, embodied in the U.S. Department of
Health and Human Services (2000) document,
Healthy People 2010. As a nation, we hope to elimi-.
nate disparities in health and prevent oral diseases,
cancer, birth defects, AIDS and other devastating
infections, mental illness and suicide, and the chron-
ic diseases of aging. To live well into old age free of
pain and infirmity, and with a high quality of life, is
the American dream.

Scientists today take that dream seriously in
researching the intricacies of the craniofacial com-
plex. They are using an ever-growing array of sophis-
ticated analytic tools and imaging systems to study
normal function and diagnose disease. They are com-
pleting the mapping and sequencing of human, ani-
mal, microbial, and plant genomes, the better to
understand the complexities of human development,
aging, and pathological processes. They are growing
cell lines, synthesizing molecules, and using a new
generation of biomaterials to revolutionize tissue
repair and regeneration. More than ever before, they
are working in multidisciplinary teams to bring new
knowledge and expertise to the goal of understand-
ing complex human diseases and disorders.

THE CHALLENGE

This Surgeon Generals report has much to say about
the inequities and disparities that affect those least
able to muster the resources to achieve optimal oral
health. The barriers to oral health include lack of
access to care, whether because of limited income or
lack of insurance, transportation, or the flexibility to
take time off from work to attend to personal or fam-
ily needs for care. Individuals with disabilities and
those with complex health problems may face addi-
tional barriers to care. Sometimes, too, the public,
policymakers, and providers may consider oral
health and the need for care to be less important than
other health needs, pointing to the need to raise
awareness and improve health literacy

Even more costly to the individual and to socie-
ty are the expenses associated with oral health prob-
lems that go beyond dental diseases. The nation's
yearly dental bill is expected to exceed $60 billion in
2000 (Health Care Financing Administration 2000).
However, add to that expense the tens of billions of
dollars in direct medical care and indirect costs of
chronic craniofacial pain conditions such as tem-
poromandibular disorders, trigeminal neuralgia,
shingles, or burning mouth syndrome; the $100,000
minimum individual lifetime costs of treating cranio-
facial birth defects such as cleft lip and palate; the
costs of oral and pharyngeal cancers; the costs of
autoimmune diseases; and the costs associated with
the unintentional and intentional injuries that so
often affect the head and face. Then add the social
and psychological consequences and costs. Damage
to the craniofacial complex, whether from disease,
disorder, or injury, strikes at our very identity We see
ourselves, and others see us, in terms of the face we
present to the world. Diminish that image in any way
and we risk the loss of self-esteem and well-being.

Many unanswered questions remain for scien-
tists, practitioners, educators, policymakers, and the
public. This report highlights the research challenges
as well as pointing to emerging technologies that may
facilitate finding solutions. Along with the quest for
answers comes the challenge of applying what is
already known in a society where there are social,
political, economic, behavioral, and environmental
barriers to health and well-being.

THE CHARGE

The realization that oral health can have a significant
impact on the overall health and well-being of the
nation's population led the Office of the Surgeon
General, with the approval of the Secretary of Health
and Human Services, to commission this report.

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


Recognizing the gains that have been made in disease
prevention while acknowledging that there are popu-
lations that suffer disproportionately from oral health
problems, the Secretary asked that the report "define,
describe, and evaluate the interaction between oral
health and health and well-being [quality of life],
through the life span in the context of changes in
society" Key elements to be addressed were the
determinants of health and disease, with a primary
focus on prevention and "producing health" rather
than "restoring health"; a description of the burden
of oral diseases and disorders in the nation; and the
evidence for actions to improve oral health to be
taken across the life span. The report also was to fea-
ture an orientation to the future, highlighting lead-
ing-edge technologies and research findings that can
be brought to bear in improving the oral health of
individuals and communities.

THE SCIENCE BASE FOR THE REPORT
This report is based on a review of the published
scientific literature. Standards established to
determine the quality of the evidence, based on the
study design and its rigor, were used where
appropriate. In addition, the strength of the
recommendations, where they are made, is based on
evidence of effectiveness for the population of
interest. The scope of the review encompassed the
international English literature. Recent systematic
reviews of the literature are referenced, as are selected
review articles. A few referenced articles are in press,
and there are occasional references to recent abstracts
and personal communications.

The science base in oral health has been evolving
over the past half century Initial research in this area
was primarily in the basic sciences, investigating
mechanisms of normal development and pathology
in relation to dental caries and periodontal diseases.
Prevention research has included controlled clinical
studies, with and without randomization, as well as
community trials and demonstration research. More
recent research has broadened the science base to
include studies of the range of craniofacial diseases
and disorders and is moving from basic science to
translational, clinical, and health services research.

The clinical literature includes the full range of
studies, from randomized controlled studies to case
studies. Most of the literature includes cross-section-
al and cohort studies, with some case-control studies,
General reviews of the literature have been used for
Chapters 2 through 10. Chapter 4 includes both pub-
lished and new analyses of national and state data-
bases that have been carefully designed and for which

Executive Summary

quality assurance has been maintained by the
Centers for Disease Control and Prevention. Studies
of smaller populations are also included where rele-
vant. In Chapter 5, tables present information on the
association of oral infections and systemic condi-
tions, and in Chapter 7, tables exhibit oral disease
prevention and health promotion measures. The
published literature related to the development of
new technologies, their potential impact, and the
need for further research are described in the course
of addressing the requested futures orientation.

The report was generated with the advice and
support of a Federal Coordinating Committee
composed of representatives of agencies with oral
health components and interests. The chapters were
based on papers submitted by experts working under
the guidance of a coordinating author for each
chapter. Independent peer review was conducted for
all sections of the report at various stages in the
process, and the full manuscript was reviewed by a
number of senior reviewers as well as the relevant
federal agencies. All who contributed are listed in the
Acknowledgments section of the full report.

ORGANIZATION OF THE REPORT

The report centers on five major questions, which
have been used to structure the report into five parts.

Part One: What Is Oral Health?

The meaning of oral health is explored in Chapter 1,
and the interdependence of oral health with general
health and well-being is a recurrent theme through-
out the volume.

Chapter 2 provides an overview of the craniofa-
cial complex in development and aging, how the tis-
sues and organs function in essential life processes,
and their role in determining our uniquely human
abilities. Our craniofacial complex has evolved to
have remarkable functions and abilities to adapt,
enabling us to meet the challenges of an ever-chang-
ing environment. An examination of the various tis-
sues reveals elaborate designs that serve complex
needs and functions, including the uniquely human
function of speech. The rich distribution of nerves,
muscles, and blood vessels in the region as well as
extensive endocrine and immune system connec-
tions are indicators of the vital role of the craniofacial
complex in adaptation and survival over a long life
span. In particular, the following findings are noted:

   o  Genes controlling the basic patterning and
segmental organization of human development, and
specifically the craniofacial complex, are highly

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

5


Executive Summar)

conserved in nature. Mutated genes affecting human
development have counterparts in many simpler
organisms.
   o  There is considerable reserve capacity or
redundancy in the cells and tissues of the craniofacial
complex, so that if they are properly cared for, the
structures should function well over a lifetime.

   o  The salivary glands and saliva subserve tast-
ing and digestive functions and also participate in the
mucosal immune system, a main line of defense
against pathogens, irritants, and toxins.
   o  Salivary components protect and maintain
oral tissues through antimicrobial components,
buffering agents, and a process by which dental
enamel can be remineralized.

Part Iwo: What Is the Status of Oral
Health in America?

Chapter 3 is a primer describing the major diseases
and disorders that affect the craniofacial complex.
The findings include:
   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 inter-
play 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
inappropriate dietary practices contribute to many
diseases and disorders. In particular, tobacco use is a
risk factor for oral cavity and pharyngeal cancers,
periodontal 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.

Chapter 4 constitutes an oral health status report
card for the United States, describing the magnitude
of the problem. Where data permit, the chapter also
describes the oral health of selected population

groups, as well as their dental visit behavior. The
findings include:
   o  Over the past five decades, major improve-
ments in oral health have been seen nationally for
most Americans.

   o  Despite improvements in oral health status,
profound disparities remain in some population
groups as classified by sex, income, age, and race/eth-
nicity. For some diseases and conditions, the magni-
tude of the differences in oral health status among
population groups is striking.
   o  Oral diseases and conditions affect people
throughout their life span. Nearly every American
has experienced the most common oral disease, den-
tal caries.               .
   Conditions that severely affect the face and
facia; expression, such as birth defects, craniofacial
injuries, and neoplastic diseases, are more common
in the very young and in the elderly
   o  Oral-facial pain can greatly reduce quality of
life and restrict major functions. Pain is a common
symptom for many of the conditions affecting oral-
facial structures.

   o  National and state data for many oral and
craniofacial diseases and conditions and for popula-
tion groups are limited or nonexistent. Available state
data reveal variations within and among states in pat-
terns of health and disease among population groups.

   o  Research is needed to develop better meas-
ures of disease and health, to explain the differences
among population groups, and to develop interven-
tions targeted at eliminating disparities.

Part Three: What Is the Relationship
Between Oral Health and General Health
and Well-being?
Chapters 5 and 6 address key issues in the report`s
charge-the relationship of oral health to general
health and well-being. Chapter 5 explores the theme
of the mouth as reflecting general health or disease
status. Examples are given of how oral tissues may
signal the presence of disease, disease progression, or
exposure to risk factors, and how oral cells and fluids
are increasingly being used as diagnostic tools. This
is followed by a discussion of the mouth as a portal
of entry for infections that can affect local tissues and
may spread to other parts of the body The final sec-
tions review the literature regarding emerging associ-
ations between oral diseases and diabetes, heart dis-
ease and stroke, and adverse pregnancy outcomes.

6

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


The findings include:               cancers contribute to premature death and can be
   0  Many systemic diseases and conditions have  measured by years of life lost.
oral manifestations. These manifestations may be the     o Oral and craniofacial diseases and condi-
initial sign of clinical disease and as such serve to  tions contribute to compromised ability to bite, chew,
inform clinicians and individuals of the need for fur-   and swallow foods; limitations in food selection; and
ther assessment.                 poor nutrition. These conditions include tooth loss,
   o  The oral cavity is a portal of entry as well as  diminished salivary functions, oral-facial pain condi-
the site of disease for microbial infections that affect  tions such as temporomandibular disorders, alter-
general health status.                ations in taste, and functional limitations of prosthet-
   a  The oral cavity and its functions can be  ic replacements.
adversely affected by many pharmaceuticals and      Oral-facial pain, as a symptom of untreated
other therapies commonly used in treating systemic  dent:1 and oral problems and as a condition in and of
conditions. The oral complications of these therapies  itself, is a major source of diminished quality of life.
can compromise patient compliance with treatment.   It is associated with sleep deprivation, depression,
o Individuals such as immunocompromised  and multiple adverse psychosocial*outcomes.
and hospitalized patients are at greater risk for gen-       o  Self-reported impacts of oral conditions on
eral morbidity due to oral infections.           social function include limitations in verbal and non-

   0  Individuals with diabetes are at greater risk   verbal communication, social interaction, and inti-
for periodontal diseases.              macy Individuals with facial disfigurements due to
o Animal and population-based studies have   craniofacial diseases and conditions and their treat-
demonstrated an association between periodontal  ments may experience loss of self-image and self-
diseases and diabetes, cardiovascular disease, stroke,  esteem, anxiety, depression, and social stigma; these
and adverse pregnancy outcomes. Further research is  in turn may limit educational, career, and marital
needed to determine the extent to which these asso-  opportunities and affect other social relations.
ciations are causal or coincidental.                      o  Reduced oral-health-related quality of life is
Chapter 6 demonstrates the relationship between  associated with poor clinical status and reduced
oral health and quality of life, presenting data on the    access to care.
consequences of poor oral health and altered appear-
ance on speech, eating, and other functions, as well
as on self-esteem, social interaction, education,   Part Four: How Is Oral Health Promoted

career achievement, and emotional state. The chapter   and Maintained and How Are Oral
introduces anthropological and ethnographic litera-   Diseases Prevented?
ture to underscore the cultural values and symbolism  The `next three chapters review how individuals,
attached to facial appearance and teeth. An examina-  health care practitioners, communities, and the
tion of efforts to characterize the functional and  nation as a whole contribute to oral health. Chapter
social implications of oral and craniofacial diseases  7 reviews the evidence for the efficacy and effective-
reveals the following findings:            ness of health promotion and disease prevention
   o  Oral health is related to well-being and qual-  measures with a focus on community efforts in pre-
ity of life as measured along functional, psychosocial,  venting oral disease. It continues with a discussion of
and economic dimensions. Diet, nutrition, sleep,  the knowledge and practices of the public and health
psychological status, social interaction, school, and  care providers and indicates opportunities for broad-
work are affected by impaired oral and craniofacial  based and targeted health promotion. The findings
health.                             include:

   o  Cultural values influence oral and craniofa-       o  Community water fluoridation, an effective,
cial health and well-being and can play an important  safe, and ideal public health measure, benefits indi-
role in care utilization practices and in perpetuating  viduals of all ages and socioeconomic strata.
acceptable oral health and facial norms.        Unfortunately, over one third of the US. population
  o Oral and craniofacial diseases and their  (100 million people) are without this critical public
treatment place a burden on society in the form of   health measure.
lost days and years of productive work. Acute dental      Effective disease prevention measures exist
conditions contribute to a range of problems for  for .use by  individuals,  practitioners, and
employed adults, including restricted activity, bed   communities. Most of these focus on dental caries
days, and work loss, and school loss for children. In  prevention, such as fluorides and dental sealants,
addition, conditions such as oral and pharyngeal  where a combination of services is required to

Executive Summar)

-

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


Executive Sumtnar)

achieve optimal disease prevention. Daily oral
hygiene practices such as brushing and flossing can
prevent gingivitis.

o Community-based approaches for the pre-
vention of other oral diseases and conditions, such as
oral and pharyngeal cancers and oral-facial trauma,
require intensified developmental efforts.

   o  Community-based preventive programs are
unavailable to substantial portions of the under-
served population.

   o  There is a gap between research findings and
the oral disease prevention and health promotion
practices and knowledge of the public and the health
professions.

o Disease prevention and health promotion
approaches, such as tobacco control, appropriate use
of fluorides for caries prevention, and folate supple-
mentation for neural tube defect prevention, high-
light opportunities for partnerships between commu-
nity-based programs and practitioners, as well as col-
laborations among health professionals.

   o  Many community-based programs require a
combined effort among social service, health care,
and education services at the local or state level.

Chapter 8 explores the role of the individual and
the health care provider in promoting and maintain-
ing oral health and well-being. For the individual,
this means exercising appropriate self-care and
adopting healthy behaviors. For the provider, it
means incorporating the knowledge emerging from
the science base in a timely manner for prevention
and diagnosis, risk assessment and risk management,
and treatment of oral diseases and disorders. The
chapter focuses largely on the oral health care
provider. The management of oral and craniofacial
health and disease necessitates collaborations among
a team of care providers to achieve optimal oral and
general health. The findings include:

o Achieving and maintaining oral health
require individual action, complemented by profes-
sional care as well as community-based activities.

   o  Individuals can take actions, for themselves
and for persons under their care, to prevent disease
and maintain health. Primary prevention of many
oral, dental, and craniofacial diseases and conditions
is possible with appropriate diet, nutrition, oral
hygiene, and health-promoting behaviors, including
the appropriate use of professional services.
Individuals should use a fluoride dentifrice 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. Inter-

disciplinary care is needed to manage the oral
health-general health interface. Dentists, as primary
care providers, are uniquely positioned to play an
expanded role in the detection, early recognition, and
management 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.

o New knowledge and the development of
molecular and genetically based tests will facili-
tate 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.

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

Chapter 9 describes the roles of dental practi-
tioners and their teams, the medical community and
public health agencies at local, state, and national
levels in administering care or reimbursing for the
costs of care. These activities are viewed against the
changing organization of U.S. health care and trends
regarding the workforce in research, education, and
practice.

   0  Dental, medical, and public health delivery
systems each provide services that affect oral and
craniofacial health in the U.S. population. Clinical
oral health care is predominantly provided by a pri-
vate practice dental workforce.

   a  Expenditures for dental services alone made
up 4.7 percent of the nation's health expenditures in
1998-$53.8 billion out of $1.1 trillion. These
expenditures underestimate the true costs to the
nation, however, because data are unavailable to
determine the extent of expenditures and services
provided for craniofacial health care by other health
providers and institutions.

o The public health infrastructure for oral
health is insufficient to address the needs of disad-
vantaged groups, and the integration of oral and gen-
eral health programs is lacking.
   Expansion of community-based disease
prevzntion and lowering of barriers to personal oral
health care are needed to meet the needs of the
population.
   0  Insurance coverage for dental care is
increasing but still lags behind medical insurance.

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


For every child under 18 years old without medical
insurance, there are at least two children without
dental insurance; for every adult 18 years or older
without medical insurance, there are three without
dental insurance.

o Eligibility for Medicaid does not ensure
enrollment, and enrollment does not ensure that
individuals obtain needed care. Barriers include
patient and caregiver understanding of the value and
importance of oral health to general health, low
reimbursement rates, and administrative burdens for
both patient and provider.

   o  A narrow definition of "medically necessary
dental care" currently limits oral health services for
many insured persons, particularly the elderly.

   a  The dentist-to-population ratio is declining,
creating concern as to the capability of the dental
workforce to meet the emerging demands of society
and provide required services efficiently

   o  An estimated 25 million individuals reside in
areas lacking adequate dental care services, as
defined by Health Professional Shortage Area (HPSA)
criteria.

   0  Educational debt has increased, affecting
both career choices and practice location.

   o  Disparities exist in the oral health profession
workforce and career paths. The number of under-
represented minorities in the oral health professions
is disproportionate to their distribution in the popu-
lation at large.

o Current and projected demand for dental
school faculty positions and research scientists is
not being met. A crisis in the number of faculty and
researchers threatens the quality of dental educa-
tion; oral, dental, and craniofacial research; and, ulti-
mately, the health of the public.

   0  Reliable and valid measures of oral health
outcomes do not exist and need to be developed, val-
idated, and incorporated into practice and programs.

Part Five: What Are the Needs and
Opportunities to Enhance Oral Health?
Chapter 10 looks at determinants of oral health in
the context of society and across various life stages.
Although theorists have proposed a variety of models
of health determinants, there is general consensus
that  individual  biology,  the physical and
socioeconomic environment, personal behaviors and
lifestyle, and the organization of health care are key
factors whose interplay determines the level of oral
health achieved by an individual. The chapter
provides examples of these factors with an emphasis

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

Executive Summary

on barriers and ways to raise the level of oral health
for children and older Americans. The findings
include:

   0  The major factors that determine oral and
general health and well-being are individual biology
and genetics; the environment, including its physical
and socioeconomic aspects; personal behaviors and
lifestyle; access to care; and the organization of health
care. These factors interact over the life span and
determine the health of individuals, population
groups, and communities-from neighborhoods to
nations.

   o  The burden of oral diseases and conditions is
disproportionately borne by individuals with low
socioeconomic status at each life stage and by those
who are vulnerable because of poor general health.

   a  Access to care makes a difference. A complex
set of factors underlies access to care and includes the
need to have an informed public and policymakers,
integrated and culturally competent programs, and
resources to pay and reimburse for the care. Among
other factors, the availability of insurance increases
access to care.

   o  Preventive interventions, such as protective
head and mouth gear and dental sealants, exist but
are not uniformly used or reinforced.

   o  Nursing homes and other long-term care
institutions have limited capacity to deliver needed
oral health services to their residents, most of whom
are at increased risk for oral diseases.

o Anticipatory guidance and risk assessment
and management facilitate care for children and for
the elderly

   0  Federal and state assistance programs for
selected oral health services exist; however, the scope
of services is severely limited, and their reimburse-
ment level for oral health services is low compared to
the usual fee for care.

Chapter 11 spells out in greater detail the prom-
ise of the life sciences in improving oral health in the
coming years in the context of changes in
American-and global-society. The critical role of
genetics and molecular biology is emphasized.

Chapter 12, the final chapter, iterates the themes
of the report and groups the findings from the earlier
chapters into eight major categories. These findings,
as well as a suggested framework for action to guide
the next steps in enhancing the oral health of the
nation, are presented below.

9


Executive Sutnmar~

MAJOR FINDINGS

Oral diseases and disorders in and of themselves
affect health and well-being throughout life. The
burden of oral problems is extensive and may be par-
ticularly severe in vulnerable populations. It includes
the common dental diseases and other oral infections
such as cold sores and candidiasis that can occur at
any stage of life, as well as birth defects in infancy
and the chronic facial pain conditions and oral can-
cers seen in later years. Many of these conditions and
their treatments may undermine self-image and self-
esteem, discourage normal social interaction, cause
other health problems, and lead to chronic stress and
depression as well as incur great financial cost. They
may also interfere with vital functions such as breath-
ing, food selection, eating, swallowing, and speaking
and with activities of daily living such as work,
school, and family interactions.

Safe and effective measures exist to prevent the
most common dental diseases-dental caries and
periodontal diseases. Community water fluoridation
is safe and effective in preventing dental caries in
both children and adults. Water fluoridation benefits
all residents served by community water supplies
regardless of their social or economic status.
Professional and individual measures, including the
use of fluoride mouthrinses, gels, dentifrices, and
dietary supplements and the application of dental
sealants, are additional means of preventing dental
caries. Gingivitis can be prevented by good personal
oral hygiene practices, including brushing and
flossing.

Lifestyle behaviors that affect general health
such as tobacco use, excessive alcohol use, and
poor dietary choices affect oral and craniofacial
health as well. These individual behaviors are asso-
ciated with increased risk for craniofacial birth
defects, oral and pharyngeal cancers, periodontal dis-
ease, dental caries, and candidiasis, among other oral
health problems. Opportunities exist to expand the
oral disease prevention and health promotion knowl-
edge and practices of the public through community
programs and in health care settings. All health care
providers can play a role in promoting healthy
lifestyles by incorporating tobacco cessation pro-
grams, nutritional counseling, and other health pro-
motion efforts into their practices.

There are profound and consequential oral
health disparities within the U.S. population.
Disparities for various oral conditions may relate to
income. age, sex, race or ethnicity, or medical status.
Although common dental diseases are preventable,
not all members of society are informed about or able
to avail themselves of appropriate oral-health-

promoting measures. Similarly, not all health
providers may be aware of the services needed to
improve oral health. In addition, oral health care is
not fully integrated into many care programs. Social,
economic, and cultural factors and changing pop-
ulation demographics affect how health services are
delivered and used, and how people care for
themselves. Reducing disparities requires wide-
ranging approaches that target populations at high-
est risk for specific oral diseases and involves
improving access to existing care. One approach
includes making dental insurance more available to
Americans. Public coverage for dental care is
minimal for adults, and programs for children have
not reached the many eligible beneficiaries.

More information is needed to improve
America's oral health and eliminate health dispari-
ties. We do not have adequate data on health, dis-
ease, and health practices and care use for the U.S.
population as a whole and its diverse segments,
including racial and ethnic minorities, rural popula-
tions, individuals with disabilities, the homeless,
immigrants, migrant workers, the very young, and
the frail elderly Nor are there sufficient data that
explore health issues in relation to sex or sexual ori-
entation. Data on state and local populations, essen-
tial for program planning and evaluation, are rare or
unavailable and reflect the limited capacity of the
U.S. health infrastructure for oral health. Health serv-
ices research, which could provide much needed
information on the cost, cost-effectiveness, and out-
comes of treatment, is also sorely lacking. Finally,
measurement of disease and health outcomes is need-
ed. Although progress has been made in measuring
oral-health-related quality of life, more needs to be
done, and measures of oral health per se do not exist.

The mouth reflects general health and well-
being. The mouth is a readily accessible and visible
part of the body and provides health care providers
and individuals with a window on their general
health status. As the gateway of the body, the mouth
senses and responds to the external world and at the
same time reflects what is happening deep inside the
body The mouth may show signs of nutritional defi-
ciencies and serve as an early warning system for dis-
eases such as HIV infection and other immune sys-
tem problems. The mouth can also show signs of
general infection and stress. As the number of sub-
stances that can be reliably measured in saliva
increases, it may well become the diagnostic fluid of
choice, enabling the diagnosis of specific disease as
well as the measurement of the concentration of a
variety of drugs, hormones, and other molecules of
interest. Cells and fluids in the mouth may also be

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


used for genetic analysis to help uncover risks for
disease and predict outcomes of medical treatments.
Oral diseases and conditions are associated
with other health problems. Oral infections can be
the source of systemic infections in people with
Lveakened immune systems, and oral signs and symp-
tams often are part of a general health condition.
.issociations between chronic oral infections and
other health problems, including diabetes, heart dis-
ease. and adverse pregnancy outcomes, have also
been reported. Ongoing research may uncover mech-
anisms that strengthen the current findings and
explain these relationships.

Scientific research is key to further reduction in
the burden of diseases and disorders that affect the
face, mouth, and teeth. The science base for dental
diseases is broad and provides a strong foundation
for further improvements in prevention; for other
craniofacial and oral health conditions the base has
not yet reached the same level of maturity. Scientific
research has led to a variety of approaches to improve
oral health through prevention, early diagnosis, and
treatment. We are well positioned to take these pre-
vcntion measures further by investigating how to
develop more targeted and effective interventions
and devising ways to enhance their appropriate adop-
tion by the public and the health professions. The
application of powerful new tools and techniques is
Important. Their employment in research in genetics
and genomics, neuroscience, and cancer has allowed
rapid progress in these fields. An intensified effort to
understand the relationships between oral infections
;md their management, and other illnesses and con-
ditions is warranted, along with the development of
oral-based diagnostics. These developments hold
great promise for the health of the American people.

A FRAMEWORK FOR ACTION
.\I1 Americans can benefit from the development of a
National Oral Health Plan to improve quality of life
`md eliminate health disparities by facilitating collab-
orations among individuals, health care providers,
communities, and policymakers at all levels of socie-
1)' and by taking advantage of existing initiatives.
B\,eryone has a role in improving and promoting oral
health. Together we can work to broaden public
understanding of the importance of oral health and
its relevance to general health and well-being, and to
ensure that existing and future preventive, diagnos-
tic, and treatment measures for oral diseases and dis-
orders are made available to all Americans. The fol-
lowmg are the principal components of the plan:

Executive Summary

Change perceptions regarding oral health and dis-
ease so that oral health becomes an accepted com-
ponent of general health.
   o  Change public perceptions. Many people con-
sider oral signs and symptoms to be less important
than indications of general illness. As a result, they
may avoid or postpone needed care, thus exacerbat-
ing the problem. If we are to increase the nation's
capacity to improve oral health and reduce health
disparities, we need to enhance the public's under-
standing of the meaning of oral health and the rela-
tionship of the mouth to the rest of the body These
messages should take into account the multiple lan-
guages and cultural traditions that characterize
America's diversity.

o Change policymakers' perceptions. Informed
policymakers at the local, state, and federal levels are
critical in ensuring the inclusion of oral health serv-
ices in health promotion and disease prevention pro-
grams, care delivery systems, and reimbursement
schedules. Raising awareness of oral health among
legislators and public officials at all levels of govem-
ment is essential to creating effective public policy to
improve America's oral health. Every conceivable
avenue should be used to inform policymakers-
informally through their organizations and affilia-
tions and formally through their governmental
offices-if rational oral health policy is to be formu-
lated and effective programs implemented.

   o  Change health providers'perceptions. Too little
time is devoted to oral health and disease topics in
the education of nondental health professionals. Yet
all care providers can and should contribute to
enhancing oral health. This can be accomplished in
several ways, such as including an oral examination
as part of a general medical examination, advising
patients in matters of tobacco cessation and diet, and
referring patients to oral health practitioners for care
prior to medical or surgical treatments that can dam-
age oral tissues, such as cancer chemotherapy or
radiation to the head and neck. Health care providers
should be ready, willing, and able to work in collabo-
ration to provide optimal health care for their
patients. Having informed health care professionals
will ensure that the public using the health care sys-
tem will benefit from interdisciplinary services and
comprehensive care. To prepare providers for such a
role will involve, among other factors, curriculum
changes and multidisciplinary training.

Accelerate the building of the science and evidence
base and apply science effectively to improve oral
health. Basic behavioral and biomedical research,
clinical trials, and population-based research have

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

11


Executiire Summar)

been at the heart of scientific advances over the past
decades. The nation's continued investment in
research is critical for the provision of new knowl-
edge about oral and general health and disease for
years to come and needs to be accelerated if further
improvements are to be made. Equally important is
the effective transfer of research findings to the pub-
lic and health professions. However, the next steps
are more complicated. The challenge is to understand
complex diseases caused by the interaction of multi-
ple genes with environmental and behavioral vari-
ables-a description that applies to most oral dis-
eases and disorders-and translate research findings
into health care practice and healthy lifestyles,
This report highlights many areas of research
opportunities and needs in each chapter. At present,
there is an overall need for behavioral and clinical
research, clinical trials, health services research, and
community-based demonstration research. Also,
development of risk assessment procedures for indi-
viduals and communities and of diagnostic markers
to indicate whether an individual is more or less sus-
ceptible to a given disease can provide the basis for
formulating risk profiles and tailoring treatment and
program options accordingly.

Vital to progress in this area is a better under-
standing of the etiology and distribution of disease.
But as this report makes clear, epidemiologic and sur-
veillance databases for oral health and disease,
health services, utilization of care, and expenditures
are limited or lacking at the national, state, and local
levels. Such data are essential in conducting health
services research, generating research hypotheses,
planning and evaluating programs, and identifying
emerging public health problems. Future data collec-
tion must address differences among the subpopula-
tions making up racial and ethnic groups. More
attention must also be paid to demographic variables
such as age, sex, sexual orientation, and socioeco-
nomic factors in determining health status. Clearly,
the more detailed information that is available, the
better can program planners establish priorities and
targeted interventions.

Progress in elucidating the relationships between
chronic oral inflammatory infections, such as peri-
odontitis, and diabetes and glycemic control as well
as other systemic conditions will require a similar
intensified commitment to research. Rapid progress
can also occur with efforts in the area of the natural
repair and regeneration of oral tissues and organs.
Improvements in oral health depend on multidisci-
plinary and interdisciplinary approaches to biomed-
ical and behavioral research, including partnerships
among researchers in the life and physical sciences,

and on the ability of practitioners and the public to
apply research findings effectively.

Build an effective health infrastructure that meets
the oral health needs of all Americans and inte-
grates oral health effectively into overall health. The
public health capacity for addressing oral health is
dilute and not integrated with other public health
programs. Although the Healthy People 2010 objec-
tives provide a blueprint for outcome measures, a
national public health plan for oral health does not
exist. Furthermore, local, state, and federal resources
are limited in the personnel, equipment, and facilities
available to support oral health programs. There is
also a lack of available trained public health practi-
tioners knowledgeable about oral health. As a result,
existing disease prevention programs are not being
implemented in many communities, creating gaps in
prevention and care that affect the nation's neediest
populations. Indeed. cutbacks in many state budgets
have reduced staffing of state and territorial dental
programs and curtailed oral health promotion and
disease prevention efforts. An enhanced public
health infrastructure would facilitate the develop-
ment of strengthened partnerships with private prac-
titioners, other public programs, and voluntary
groups.

There is a lack of racial and ethnic diversity in
the oral health workforce. Efforts to recruit members
of minority groups to positions in health education,
research, and practice in numbers that at least match
their representation in the general population not
only would enrich the talent pool, but also might
result in a more equitable geographic distribution of
care providers. The effect of that change could well
enhance access and utilization of oral health care by
racial and ethnic minorities.

A closer look at trends in the workforce disclos-
es a worrisome shortfall in the numbers of men and
women choosing careers in oral health education and
research. Government and private sector leaders are
aware of the problem and are discussing ways to
increase and diversify the talent pool, including eas-
ing the financial burden of professional education,
but additional incentives may be necessary.

Remove known barriers between people and oral
health services. This report presents data on access,
utilization, financing, and reimbursement of oral
health care; provides additional data on the extent of
the barriers; and points to the need for public-private
partnerships in seeking solutions. The data indicate
that lack of dental insurance, private or public, is one
of several impediments to obtaining oral health care

12

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


.& accounts in part for the generally poorer oral
J&th of those who live at or near the poverty line,
\.{ck health insurance, or lose their insurance upon
ntirement. The level of reimbursement for services
.,]so has been reported to be a problem and a disin-
(cntive to the participation of providers in certain
public programs. Professional organizations and gov-
crnment agencies are cognizant of these problems
.Ind are exploring solutions that merit evaluation.
P,micular concern has been expressed about the
nntions children, and initiatives such as the State
ihlldren's Health Insurance Program, while not man-
Listing coverage for oral health services, are a positive
\~cp. In addition, individuals whose health is physi-
call!: mentally, and emotionally compromised need
comprehensive integrated care.

~1s~ public-private partnerships to improve the oral
health of those who still suffer disproportionately
from oral diseases. The collective and complementa-
rv talents of public health agencies, private industry,
s~~cial services organizations, educators, health care
providers, researchers, the media, community lead-
ers. voluntary health organizations and consumer
groups, and concerned citizens are vital if America is
not just to reduce, but to eliminate, health disparities.
This report highlights variations in oral and general
health within and across all population groups.
Increased public-private partnerships are needed to
educate the public, to educate health professionals,
IO conduct research, and to provide health care serv-
ices and programs. These partnerships can build and
5trengthen cross-disciplinary, culturally competent,
community-based, and community-wide efforts and
demonstration programs to expand initiatives for
health promotion and disease prevention. Examples
of such efforts include programs to prevent tobacco
use, promote better dietary choices, and encourage
rhc use of protective gear to prevent sports injuries.
In this way, partnerships uniting sports organiza-
t~ons. schools, the faith community, and other groups
.md leaders, working in concert with the health com-
munity, can contribute to improved oral and general
health.

CONCLUSION

The past half century has seen the meaning of oral
health evolve from a narrow focus on teeth and gin-
$va to the recognition that the mouth is the center of

Executive Summar)

vital tissues and functions that are critical to total
health and well-being across the life span. The mouth
as a mirror of health or disease, as a sentinel or early
warning system, as an accessible model for the study
of other tissues and organs, and as a potential source
of pathology affecting other systems and organs has
been described in earlier chapters and provides the
impetus for extensive future research. Past discover-
ies have enabled Americans today to enjoy far better
oral health than their forebears a century ago. But the
evidence that not all Americans have achieved the
same level of oral health and well-being stands as a
major challenge, one that demands the best efforts of
public and private agencies and individuals.

REFERENCES

Health Care Financing Administration (HCFA).
National Health Expenditures projections: 199%
2008. Office of the Actuary. http:l/www.hcfa.gov/
stats/NHE-Proj/. 2000 Apr 25.
U.S. Department of Health and Human Services
(USDHHS). Healthy People 2010 (Conference
Edition, in two volumes). Washington; 2000 Jan.
U.S. General Accounting Office (GAO). Oral health in
low-income populations. GAO/HEHS-00-72. 2000
Apr.

PROJECT TEAM
Caswell A. Evans DDS, MPH
Project Director and Executive Editor
Assistant Director, Los Angeles County Department
of Health Services

Dushanka V. Kleinman DDS, MScD
Co-Executive Editor
Deputy Director, National Institute of Dental and
Craniofacial Research, National Institutes of Health
William R. Maas DDS, MPH, MS
Chief Dental Officer, U.S. Public Health Service
Director, Division of Oral Health,
Centers for Disease Control and Prevention
Harold C. Slavkin DDS
Director,  National Institute of Dental and
Craniofacial Research, National Institutes of Health
Joan S. Wilentz MA
Science Writer and Editor
Roseanne Price ELS
Editor
Marla Fogelman
Editor

July 2000

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

13


What Is Oral Health?

-The two chapters that follow explore the answer to this question, an answer that continues to
evolve throughout the report. Oral health means more than healthy teeth and the absence of
disease. It involves the ability of individuals to carry out essential functions such as eating and
speaking as well as to contribute fully to society. Chapter 1, the introduction, explains how the
meaning of oral health has developed in tandem with progress in understanding the two chief
clcntal diseases4ental caries and periodontal diseases-which historically have been the major
preoccupation of patients, providers, and research investigators alike. There is a marvelous success
story here regarding the role of fluoride.in preventing dental caries and the research that proved
that dental caries and periodontal diseases are infections and can be prevented. These investigations
were complemented by studies of the tissues of the mouih and adjacent areas-the craniofacial
complex. Chapter 2 describes the tissues and organs of the craniofacial complex, providing a
primer and guide to their essential features that emphasizes the ways they contribute to the
richness of human experience, and at the same time protect and nurture the human body.

OR4L HEALTH IN AMERICA: .4 REPORT OF THE SURGEON GENERAL

15


The Meaning of Oral Health

The intent of this first-ever Surgeon General's report
on oral health is to alert Americans to the full mean-
ing of oral health and its importance in relation to
general health and well-being. Great progress has
been made in reducing the extent and severity of
common oral diseases, and recent history has seen
marked improvements in the nation's oral and dental
health, thanks to successful prevention measures
adopted by communities, individuals, and oral health
professionals. However, not everyone is experiencing
the same degree of improvement. What amounts to a
"a silent epidemic" of dental and oral diseases is
affecting some population groups-a burden of dis-
ease that restricts activities in school, work, and
home, and often significantly diminishes the quality
of life.

  The word oral, both in its Latin root and in com-
mon usage, refers to the mouth. The mouth includes
not only the teeth and the gums (gingiva) and their
supporting connective tissues, ligaments, and bone,
but also the hard and soft palate, the soft mucosal tis-
sue lining of the mouth and throat, the tongue, the
lips, the salivary glands, the chewing muscles, and
the upper and lower jaws, which are connected to the
skull by the temporomandibular joints. Equally
important are the branches of the nervous, immune,
and vascular systems that animate, protect, and nour-
ish the oral tissues, as well as provide the connec-
tions to the brain and the rest of the body. The genet-
ic patterning of development in utero further reveals
the intimate relationship of the oral tissues to the
developing brain and to the tissues of the face and
head that surround the mouth, structures whose
location is captured in the word craniofacial.

A major theme of this report is that oral health
means much more than healthy teeth. It means
being free of chronic oral-facial pain conditions, oral
and pharyngeal (throat) cancers, oral soft tissue
lesions, birth defects such as cleft lip and palate, and

scores of other diseases and disorders that affect the
oral, dental, and craniofacial tissues, collectively
known as the craniofacial complex. These are tissues
whose functions we often take for granted, yet they
represent the very essence of our humanity. They
allow us to speak and smile; sigh and kiss; smell,
taste, touch, chew, and swallow; cry out in pain; and
convey a world of feelings and emotions through
facial expressions. They also provide protection
against microbial infections and environmental
insults.

The craniofacial tissues also provide a useful
means to understanding organs and systems in less
accessible parts of the body. The salivary glands are a
model of other exocrine glands, and an analysis of
saliva can provide telltale clues of overall health or
disease. The jawbones are examples of other skeletal
parts. The nervous system apparatus underlying
facial pain has its counterpart in nerves elsewhere in
the body.

A thorough oral examination can detect signs of
nutritional deficiencies as well as a number of sys-
temic diseases, including microbial infections,
immune disorders, injuries, and some cancers.
Indeed, the phrase the mouth is a mirror has been
used to illustrate the wealth of information that can
be derived from examining oral tissues.

New research is pointing to associations between
chronic oral infections and heart and lung diseases,
stroke, and low-birth-weight, premature births.
Associations between periodontal disease and
diabetes have long been noted. This report assesses
these associations and explores mechanisms
that might explain these oral-systemic disease
connections.

In parallel with the broadened meaning of oral
health, the meaning of health has evolved. The stan-
dard definition of health, "freedom from disease,
defect, or pain," defines what health is not, rather

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

17


The Meaning of Oral Health

than what it is. A more positive definition, one that
the World Health Organization established in 1948,
states that health is a complete state of physical, men-
tal, and social well-being, and not just the absence of
infirmity.

tic, treatment, and prevention strategies has saved
billions of dollars per year in the nation's annual
health bill. Even more significant, the result is that
far fewer people are edentulous (toothless) today
than a generation ago.

The broadened meaning of oral health parallels
the broadened meaning of health. In 1948 the World
Health Organization expanded the definition of
health to mean "a complete state of physical, mental,
and social well-being, and not just the absence of
infirmity." It follows that oral health must also
include well-being. Just as we now understand that
nature and nurture are inextricably linked, and mind
and body are both expressions of our human biology,
so, too, we must recognize that oral health and
general health are inseparable. We ignore signs and
symptoms of oral disease and dysfunction to our
detriment. Consequently, a second theme of the
report is that oral health is integral to general
health. You cannot be healthy without oral health.
Oral health and general health should not be
interpreted as separate entities. Oral health is a
critical component of health and must be included in
the provision of health care and the design of
community programs.

The theme of prevention gained momentum as
pioneering investigators and practitioners in the
1950s and 1960s showed that not only dental caries
but also periodontal diseases are bacterial infections.
The researchers demonstrated that the infections
could be prevented by increasing host resistance to
disease and reducing or eliminating the suspected
microbial pathogens in the oral cavity The applica-
tions of research discoveries have resulted in contin-
uing improvements in the oral health of Americans,
new approaches to the prevqntion and treatment of
dental diseases, and the growth of the science.

The wider meanings of oral and health in no way
diminish the relevance and importance of the two
leading dental diseases, caries (tooth decay) and the
periodontal diseases. They remain common and
widespread, affecting nearly everyone at some point
in the life span. What has changed is what we can do
about them.

At the start of the twentieth' century, most
Americans expected to be toothless by age 45, and
most were. Expectations have changed, and most
people now assume that they will maintain their
teeth over their lifetime, and take active measures to
do so. Researchers in the 1930s discovered that peo-
ple living in communities with naturally fluoridated
water supplies had less dental caries than people
drinking unfluoridated water. But not until the end
of World War II were the investigators able to design
and implement the community clinical trials that
confirmed their observations and launched a better
approach to the problem of dental caries: prevention.
Soon after, adjusting the fluoride content of commu-
nity water supplies was pursued as an important pub-
lic health measure to prevent dental caries.

The significant role that scientists, dentists, den-
tal hygienists, and other health professionals have
played in the prevention of oral disease and disabili-
ty leads to a third theme of this report: safe and effec-
tive disease prevention measures exist that every-
one can adopt to improve oral health and prevent
disease. These measures include daily oral hygiene
procedures and other lifestyle behaviors, community
programs such as community water fluoridation and
tobacco cessation programs, and provider-based
interventions such as the placement of dental
sealants and examinations for common oral and pha-
ryngeal cancers. It is hoped that this Surgeon
General's report will facilitate the maturing of the
broad field of craniofacial research so that gains in
the prevention of craniofacial diseases and disorders
can be realized that are as impressive as those
achieved for common dental diseases.

Although this measure has not been fully imple-
mented, the results have been dramatic. Dental caries
began to decline in the 1950s among children who
grew up in fluoridated cities, and by the late 197Os,
declines in decay were evident for many Americans.
The application of oral science to improved diagnos-

At the same time, more needs to be done to
ensure that messages of health promotion and dis-
ease prevention are brought home to all Americans.
In this regard, a fourth theme of the report is that
general health risk factors, such as tobacco use and
poor dietary practices, also affect oral and craniofa-
cial health. The evidence for an association between
tobacco use and oral diseases has been clearly delin-
eated in almost every Surgeon General's report on
tobacco since 1964, and the oral effects of nutrition
and diet are presented in the Surgeon General's report
on nutrition (1988). All the health professions can
play a role in reducing the burden of disease in
America by calling attention to these and other risk
factors and suggesting appropriate actions.

Clearly, promoting health and preventing disease
are concepts the American people have taken to
heart. For the third decade the nation has developed
a plan for the prevention of disease and the promo-

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


tlon of health, embodied in the U.S. Department of
fjealth and Human Services (2000) document,
Healthy People 2010. As a nation, we hope to elimi-
rlatc disparities in health and prevent oral diseases,
imcer, birth defects, AIDS and other devastating
,nfcctions. mental illness and suicide, and the chron-
,c diseases of aging. To live well into old age free of
,,am and infirmity, and with a high quality of life, is
the American dream.

Scientists today take that dream seriously in pur-
suing the intricacies of the craniofacial complex.
They are using an ever-growing array of sophisticat-
ed analytic tools and imaging systems to study nor-
mal function and diagnose disease, They are com-
pleting the mapping and sequencing of human, ani-
mal, microbial, and plant genomes, the better to
understand the complexities of human development,
aging, and pathological processes. They are growing
cell lines, synthesizing molecules, and using a new
generation of biomaterials to revolutionize tissue
repair and regeneration. More than ever before, they
are working in multidisciplinary teams to bring new
knowledge and expertise to the goal of understand-
ing complex human diseases and disorders.

THE CHALLENGE

This Surgeon Generals report has much to say about
the inequities and disparities that affect those least
able to muster the resources to achieve optimal oral
health. The barriers to oral health include !ack of
access to care, whether because of limited income or
lack of insurance, transportation, or the flexibility to
take time off from work to attend to personal or fam-
ily needs for care. Individuals with disabilities and
those with complex health problems may face addi-
tional barriers to care. Sometimes, too, the public,
policymakers, and providers may consider oral
health and the need for care to be less important than
other health needs, pointing to the need to raise
awareness and improve health literacy.

Even more costly to the individual and to socie-
ty are the expenses associated with oral health prob-
lems that go beyond dental diseases. The nation's
yearly dental bill is expected to exceed $60 billion in
2000 (Health Care Financing Administration 2000).
However, add to that expense the tens of billions of
dollars in direct medical care and indirect costs of
chronic craniofacial pain conditions such as
temporomandibular disorders, trigeminal neuralgia,
shingles, or burning mouth syndrome; the $100,000
minimum individual lifetime costs of treating cranio-
facial birth defects such as cleft lip and palate; the
costs of oral and pharyngeal cancers; the costs of

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           19

The Meaning of Oral Health

autoimmune diseases; and the costs associated with
the unintentional and intentional injuries that so
often affect the head and face. Then add the social
and psychological consequences and costs. Damage
to the craniofacial complex, whether from disease,
disorder, or injury, strikes at our very identity. We see
ourselves, and others see us, in terms of the face we
present to the world. Diminish that image in any way
and we risk the loss of self-esteem and well-being.

Many unanswered questions remain for scien-
tists, practitioners, educators, policymakers, and the
public. This report highlights the research challenges
as well as pointing to emerging technologies that may
facilitate finding solutions. Along with the quest for
answers comes the challenge of applying what is
already known in a society where there are social,
political, economic, behavioral, and environmental
barriers to health and well-being.

THE CHARGE

The realization that oral health can have a significant
impact on the overall health and well-being of the
nation's population led the Office of the Surgeon
General, with the approval of the Secretary of Health
and Human Services, to commission this report.
Recognizing the gains that have been made in disease
prevention while acknowledging that there are popu-
lations that suffer disproportionately from oral health
problems, the Secretary asked that the report "define,
describe, and evaluate the interaction between oral
health and health and well-being [quality of life],
through the life span in the context of changes in
society." Key elements to be addressed were the
determinants of health and disease, with a primary
focus on prevention and "producing health" rather
than "restoring health"; a description of the burden
of oral diseases and disorders in the nation; and the
evidence for actions to improve oral health to be
taken across the life span. The report also was to fea-
ture an orientation to the future, highlighting lead-
ing-edge technologies and research findings that can
be brought to bear in improving the oral health of
individuals and communities.

THE SCIENCE BASE FOR THE REPORT
This report is based on a review of the published
scientific literature. Where appropriate, standards
established to determine the quality of the evidence,
based on the study design and its rigor, were used. In
addition, the strength of the recommendations,
where they are made,  is based on evidence of
effectiveness for the population of interest. The scope


The gleaning of Oral Health

of the review encompassed the international English
literature. Recent systematic reviews of the literature
are referenced, as are selected review articles. A few
referenced articles are in press, and there are
occasional references to recent abstracts and personal
communications.

The science base in oral health has been evolving
over the past half century. Initial research in this area
was primarily in the basic sciences, investigating
mechanisms of normal development and pathology
in relation to dental caries and periodontal diseases.
Prevention research has included controlled clinical
studies, with and without randomization, as well as
community trials and demonstration research. More
recent research has broadened the science base to
include studies of the range of craniofacial diseases
and disorders and is moving from basic science to
translational, clinical, and health services research.

  The clinical literature in the oral health sciences
includes the full range of studies, from randomized
controlled studies to case studies. Most of the litera-
ture includes cross-sectional and cohort studies, with
some case-control studies. General reviews of the lit-
erature have been used for Chapters 2 through 10.
Chapter 4 includes both published and new analyses
of national and state databases that have been care-
fully designed and for which quality assurance has
been maintained by the Centers for Disease Control
and Prevention. Studies of smaller populations are
also included where relevant, In Chapters 5 and 7,
evidence tables are presented for the discussion of
the association of oral infections and'systemic condi-
tions and for oral disease prevention and health pro-
motion measures, respectively Experts in the respec-
tive fields contributed to the report, and independent
expert peer review was conducted for all sections of
the report. The published literature related to the
development of new technologies, their potential
impact, and the need for further research are
described in the course of addressing the requested
futures orientation.

ORGANIZATION OF THE REPORT
The report centers on five major questions, which
have been used to structure the report into five parts.

What Is Oral Health?
The meaning of oral health is discussed in the open-
ing pages of this chapter, and the interdependence of
oral health with general health and well-being is, as
noted, a recurrent theme throughout the volume.
Chapter 2 provides an overview of the craniofacial

complex in development and aging, how the tissues
and organs function in essential life processes, and
their role in determining our uniquely human abili-
ties. The later chapters elaborate further on the
meaning of oral health. Of particular importance is
the discussion of oral health in relation to well-being
and quality of life described in Chapter 6.

What is the Status of Oral Health in
America?

Chapter 3 is a primer describing the major diseases
and disorders that affect the craniofacial complex.
Chapter 4 constitutes an oral health status report
card on the noninstitutionalized civilian population
of the United States, describing the magnitude of the
problem. It is based on the most recent national and
state data available for a range of craniofacial dis-
eases, disorders, and conditions. In general, the
national data provide information categorized by sex,
age, income (poor versus nonpoor), and broad racial
and ethnic categories. In addition, the chapter
includes a profile of the oral and general health of
selected population groups. These include racial and
ethnic groups such as African Americans, Hispanics,
Asians, Native Hawaiians and Other Pacific Islanders,
and American Indians/Alaska Natives. The health
status of women and individuals with disabilities is
highlighted. Although it is clearly desirable to
describe the health status of additional populations,
data are insufficient or lacking for groups defined by
sexual orientation or rural residency or categorized
as homeless, migrant workers, or incarcerated. As an
initial step toward understanding the burden of dis-
ease in relation to the provision of care, available data
on the number of dental visits are provided.

What Is the Relationship Between
Oral Health and General Health and
Well-being?

Chapters 5 and 6 address key issues in the charge-
the relationship of oral health to general health and
well-being. Chapter 5 explores the theme of the
mouth as a mirror that in some measure can reflect
general health or disease status. Examples are given
of how oral tissues may signal the presence of dis-
ease, disease progression, or risk factor exposure lev-
els, and how oral cells and fluids are increasingly
being used as diagnostic tools. This is followed by a
discussion of the mouth as a portal of entry for infec-
tions that can affect local tissues and may spread to
other parts of the body The next section reviews the

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


The Meaning of Oral Health

literature regarding emerging associations between
oral diseases and disorders and diabetes, heart dis-
ease and stroke, and adverse pregnancy outcomes.

Chapter 6 demonstrates the relationship between
oral health and quality of life, presenting data on the
consequences of poor oral health and altered appear-
ance on speech, eating, and other functions, as well
i~ on self-esteem, social interaction, education, career
achievement, and emotional state. Anthropological and
ethnographic literature is introduced to underscore
the cultural values and symbolism attached to facial
appearance and teeth.

How Is Oral Health Promoted and

Maintained and How Are Oral Diseases
Prevented?

The next three chapters review how individuals,
health care practitioners, communities, and the
nation as a whole contribute to oral health. Chapter
i reviews the evidence for the efficacy and effective-
ness of oral health promotion and disease prevention
measures with a focus on community efforts in pre-
venting dental disease. It continues with a discussion
of the need to expand efforts in such areas as oral
cancer prevention.

Chapter 8 explores the role of the individual and
the health care provider in promoting and maintain-
tng oral health and well-being. For the individual,
this means exercising appropriate self-care and
adopting healthy behaviors. For the provider, it
means incorporating the knowledge emerging from
the science base in a timely manner for prevention
Ltnd diagnosis, risk assessment and risk management,
and treatment of oral diseases and disorders. The
chapter focuses largely on the oral health care
provider. The management of oral and craniofacial
health and disease necessitates collaborations among
a team of care providers to achieve optimal oral and
general health.

Chapter 9 describes the roles of dental practi-
ttoners and their teams, the medical community, and
public health agencies at local, state, and national
let.& in administering oral health care or reimburs-
tng for the costs of care. These activities are viewed
Wtnst the changing organization of U.S. health care

and trends regarding the workforce in research, edu-
cation, and practice.

What Are the Needs and Opportunities to
Enhance Oral Health?

Chapter 10 looks at determinants of oral health in
the context of society and across various life stages.
Although theorists have proposed a variety of models
of health determinants, there is general consensus
that individual biology, the physical and socio-
economic environment, personal behaviors and
lifestyle, and the organization of health care are key
factors whose interplay determines the level of oral
health achieved by an individual. The chapter
provides examples of these factors and, in the latter
half, illustrates their varying effects at different stages
of the life span, with an emphasis on children and
older Americans. Barriers and ways to raise the level
of oral health that can be achieved at each life stage
are presented.

Chapter 11 spells out in greater detail the prom-
ise of the life sciences in improving oral health in the
coming years in the context of changes in
American-and global-society. The critical role of
genetics and molecular biology is emphasized.

A Call to Action

Chapter 12, the final chapter, summarizes the major
findings of the report and suggests actions to guide
the next steps in enhancing the oral health of the
nation. The need for partnerships between public
and private sectors in carrying out a proposed
National Oral Health Plan is emphasized. To ensure
progress, these partnerships need to include individ-
ual patients and the general public and to reflect all
population groups in the nation. All the health care
disciplines need to be involved, along with industry,
academia, and government, as well as health care
organizations, health professional associations,
health insurers, and patient groups. United by the
evidence that oral health is essential to general health
and well-being, the combined forces and collective
wisdom of all interested parties and stakeholders can
make optimal oral health a reality for all people.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

21



The Craniofacial Complex

The first line a child draws on a face is usually the
mouth. The mouth is the center of communication
and contact. Along with the eyes, ears, and nose, it is
positioned near the brain, ensuring close integration
and coordination, We use the craniofacial complex-
the oral, dental, and the other craniofacial tissues
that house the organs of taste, vision, hearing, and
smell-to experience and interact with the world
around us. These sense organs have evolved to serve
as superb information processors and aids to sur-
vival. At the most elemental level, they enable us to
sense our environment-from alerting us to preda-
tors or poisons to recognizing family friends, or
prospective mates.

Our ability to act on the nerve signals from these
organs results from the abundant supply of paired
cranial nerves that innervate the craniofacial tissues.
No place in the body is as rich in both the number of
sensory nerves and the ratio of motor nerves to mus-
cle fibers as the face, and, within it, the mouth and
teeth. The nerve circuits not only trigger protective
reflexes to make us blink, gape, and start in surprise,
but also enable us to perform countless functions we
take for granted. We speak and taste and chew and
swallow. We express our feelings through smiles and
scowls; we grimace and cry out in pain; we murmur
endearments and kiss our loved ones.

Beyond the special senses of vision, hearing,
taste, and smell, the craniofacial complex includes
nerve endings sensitive to the body's position in
space and to touch, pressure, temperature, and pain.
In sum, if the brain is the command-and-control cen-
ter of the body, evolution has ensured that the staff
reporting from the field and carrying out orders are
stationed a strategic few inches away, in the craniofa-
cial complex.

,

CONTACT AND COMMUNICATION

Taste and Smell

The developmental process by which vital nerve cen-
ters came to be concentrated in the head, mouth, and
teeth began early in evolution. Even paramecia have
mouths, as do worms, bugs, and all more complex
organisms. The mouth appears in the human embryo
during the third week of development. By the thir-
teenth or fourteenth week, the fetal mouth can open
in response to stimulation of the lower lip. During
the next 2 months, the fetus will practice protruding
and then pursing the lips, eventually achieving the
ability to suck vigorously at 29 weeks. In the mean-
time, inspiratory gasps, tongue movements, lip curl-
ing, and swallowing responses will have been estab-
lished (Wilentz 1968).

At birth, the taste buds are found on the roof of
the mouth and in the throat, as well as on the tip,
sides, and back of the tongue. Taste buds, such as
those on the tip of the tongue, are particularly subject
to wear and tear, and may be replaced every 2 weeks.
The total number of buds diminishes over time, but
there appears to be considerable reserve capacity, SO
there is normally little loss in the sense of taste as we
age.

It has been said that taste is 90 percent smell, and
to some extent that is true. The taste cells that line
the buds respond to only five known qualities: sweet,
sour, salty, bitter, and glutamate. The experience of
taste is a complex mixture of smell, temperature,
taste, and texture.

The day-old newborn responds to sweet stimuli.
Suckling, the first oral function following the cry, is
enhanced by the presence of lactose, the sugar in
breast milk. Liquids sweetened with sugar or honey
have been used widely after birth to stimulate
appetite, and later to wean children from breast-

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

23


The Craniofacial Complex

feeding. The ability to recognize a sweet taste clearly
has survival value, enabling the recognition and
selection of carbohydrates-a vital source of energy

The other taste modalities are also physiological-
ly important. A sour taste, for example, can signal an
unripe fruit. However, sour substances may be
involved in more subtle biochemistry, such as main-
taining the body's ion balance. They also satisfy thirst
and promote digestion by stimulating the secretion of
saliva. A bitter taste is sufficiently unpleasant to
evoke aversion, a useful response given that many
bitter-tasting plant alkaloids are toxic. A salty taste
indicates the presence of sodium, which is essential
to maintaining the fluid balance between cells and
the extracellular compartment.

Humans probably began as herbivores before the
advent of hunting and gathering and retained taste-
discriminating ability as an evolutionary advantage.
The combination of taste and smell remains impor-
tant not only for the maintenance of an optimal diet
(Young 1977), but also clearly for the pleasures of
eating.

Unlike taste cells, olfactory cells can respond to
many thousands of odorants, including ones that
have been newly synthesized. Millions of olfactory
receptors line a postage-stamp-sized area in the
upper part of the nose, the olfactory epithelium.
Although some smells may be judged universally as
unpleasant or foul, others are subject to learning and
cultural conditioning. For example, a ripe Roquefort
cheese may delight some people, but repel others.

The primary receptor cells of the olfactory sys-
tem are neurons with fine hairs at one end that proj-
ect into the olfactory epithelium to pick up the olfac-
tory stimulus. The cells translate the stimulus to
nerve impulses transmitted to the brain along the
two olfactory nerves-one from each nostril.
Olfactory neurons have the unusual ability to regen-
erate (although recent studies suggest that neurons
in other parts of the adult brain may also have this
ability Uohansson et al. 1999). Olfactory pathways
are widely distributed in the brain, relaying to emo-
tional and cognitive centers in the cortex. These con-
nections undoubtedly account for the ability of odors
to stir old memories as well as stimulate a range of
feelings, from fear to sexual arousal.

Touch, Temperature, and Pain

The mouth also contains large numbers of nerve end-
ings, similar to those found elsewhere in the body,
that are sensitive to touch (mechanoreceptors), hot
and cold temperatures (thermoreceptors), and pain
(nociceptors). The dense concentration of these

receptors in the facial skin, joints, muscle, and oral
soft tissues, relayed to an image of the body mapped
onto the sensory cortex of the brain, accounts for the
finesse with which we can discriminate the qualities
and precise location of these sensations. In particular,
the periodontal ligament, which anchors the teeth in
the jaws, is a tactilely sensitive tissue providing
important feedback with regard to mastication
(chewing) and dental occlusion (bite). As a test of
this sensibility, a human hair placed between the tips
of the fingers will rarely be sufficient to stimulate the
nerve endings, but the same hair placed between the
lips or incisors will instantly be felt.

Pain and thermal sensitivity in the teeth are
transmitted through nerve * endings in the pulp.
Because the pulp is in a narrow canal composed of
connective tissue, blood vessels, and nerves and sur-
rounded by hard tissue, any infection or inflamma-
tion that would normally cause tissue to swell creates
pressure on the pulpal nerves. That pressure, along
with bacterial or immune system products that stim-
ulate the nerve endings, produces the severe pain of
pulpal infections.

  Neuroscientists have long studied oral-facial
pain, not only because of its importance in oral dis-
ease, but also because it provides an accessible model
of pain elsewhere in the body. These investigations
have greatly enriched our understanding of the basic
mechanisms of pain perception and modulation.
They have helped delineate the complex pathways
and multiple transmitters that convey pain signals to
the brain and spinal cord, as well as the mechanisms
and molecules that can modulate and inhibit noci-
ceptive input. These studies have also exploited new
brain-imaging techniques to confirm the wide distri-
bution of pain pathways and relay centers in the cere-
bral hemispheres and cerebellum.

This research has generated new approaches to
the control of acute and chronic pain. These
approaches include the use of nonsteroidal, anti-
inflammatory drugs and long-acting local anesthetics
for acute oral and dental pain, and the use of more
potent drugs, drug combinations, and other kinds of
therapies to treat chronic pain. Researchers have
emphasized the importance of adequate pain control
in patients with chronic pain conditions. Otherwise,
the constant barrage of signals can effect long-term
changes in the brain that actually worsen the pain
(producing hyperalgesia) and cause normally non-
painful stimuli to be perceived as painful (a condition
called allodynia). Unrelieved chronic pain may also
suppress the immune system.

Recently investigators discovered a link between
certain taste sensations, pain, and temperature. Their

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


findings indicate that capsaicin, the ingredient that
makes hot peppers taste hot, binds to a receptor on
the surface of nociceptors that also responds to nox-
,ous heat. The researchers have cloned the gene for
the capsaicin receptor (called vanilloid receptor 1);
they believe it is involved in several chronic pain con-
ditions, especially those where inflammation plays a
role, such as viral and diabetic neuropathy, rheuma-
toid arthritis, and oral mucositis pain caused by can-
cer chemotherapy or radiation (Caterina et al. 1997).

There is evidence that the prevalence of a num-
ber of pain conditions varies by gender and that men
and women respond differently to different analgesic
drugs. These findings have prompted studies aimed
at determining whether there are sex differences in
pain anatomy and neurochemistry and whether (and
how) nociception is affected by sex hormones.

Speech

Human speech and language are the faculties that
most distinguish us from other higher primates; they
are also the links that bind people together in diverse
social groups and cultures.

Central to speech are laryngeal mechanisms
involving the vocal cords. Equally critical are the res-
piratory system, the pharynx, and the nasal and oral
cavities. The tongue is the most important structure
of the peripheral speech mechanisms, working in
conjunction with the lips, teeth, and palate to pro-
duce a rich repertoire of sounds. Abnornialities in
oral structures, from missing or malformed teeth and
malocclusion to cleft lip and palate, can seriously
affect articulation. The movements of speech are
orchestrated by brain centers that coordinate the
muscles of mastication, facial expression, and jaw
movements.

Hearing impairments can also affect speech. To
learn to speak, children must be able to hear others
and monitor the feedback from their own voices.
Congenital deafness and the serious hearing defects
associated with some craniofacial syndromes (see
Chapter 3) can severely compromise speech
acquisition.

THE ORAL CAVITY

The mouth is the gateway to the body, performing
dozens of functions that place high demands on its
unique hard and soft tissues. The point of entry is the
lips, which open into the oral cavity, The cheeks form
the sides of the cavity, and the roof is formed by the
Palate, which separates the mouth from the nose
above and the pharynx (throat) behind. The anterior

palate is hard, formed by underlying bone, and serves
as a shield against trauma to the face and head. The
posterior palate is soft, composed of muscles and
connective tissue that blend into the walls of the
pharynx. Hanging from the rear of the soft palate is
the uvula, a mass of muscle and connective tissue.
Under the tongue is the floor of the mouth, com-
posed primarily of muscle and salivary glands. The
paired tonsils and adenoids, important components
of the immune system, lie at the sides of the palate
and within the nasopharynx, respectively.

The pharynx opens into channels leading either
to the lungs for respiration or the esophagus for fur-
ther digestion and passage to the stomach. This is a
point of vulnerability: should fooh or some other
obstruction lodge in the airway, it could lead to death
by asphyxiation.

Externally, the oral cavity is bounded by the
maxilla (the upper jaw bone), attached to the crani-
um, and the mandible (the lower jaw), attached to
the temporal bone of the skull by the temporo-
mandibular joint.

The Oral Mucosa

Except for the teeth, the oral tissues are covered by a
mucous membrane called the oral mucosa, which
varies in color from pink to brownish purple,
depending on an individual's skin color. Like skin,
the oral mucosa acts as a major barrier against chem-
ical irritants and mechanical forces; it can even with-
stand temperatures that would be painful to the skin.
In areas subject to chewing forces and food move-
ments, the surface layer is relatively hard, composed
of epithelial cells filled with insoluble keratin, the
fibrous protein found in skin, nails, hair, and animal
horn. Elsewhere-in the mucosal lining of the
cheeks, for example-the surface layers are softer
and more flexible, enabling the mobility we need to
speak, chew, and make facial expressions. To aid in
their barrier function, surface mucosal cells are
square-shaped and closely juxtaposed, with special-
ized organelles and cell products that promote cell-
cell adherence. The cells can also secrete sticky mol-
ecules to plug gaps between them and further impede
penetration by damaging chemicals or microorgan-
isms. Still another type of oral mucosa forms the peb-
bly surface of the back and sides of the tongue.
Lining the depths of these surface "papillae" are the
taste buds.

Interestingly, the epithelium that lines the gingi-
val surface completely lacks a keratin layer, yet this
"naked" epithelium lies next to one of the most dense
concentrations of bacteria to be found in the body.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           25