Oral Health in America:
                                                                         .

A Report of the
Surgeon General

Department of Health and Human Services

U.S. PUBLIC HEALTH SERVICE


National Institute of Dental
and Craniofacial Research

Suggested Citation

U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General.
Rockville, MD: U.S. Department of Heal&ad Human Services, National Institute of Dental and Craniofacial
Research, National Institutes of Health, ZOO&
                                 __-. i


Message from Donna E. Shalala

Secretary of Health and Human Services

The intent of this first-ever Surgeon General's Report on Oral Health is to alert Americans to the
full meaning of oral health and its importance to general health and well-being. Great progress has
been made in reducing the extent and severity of common oral diseases. Successful prevention
measures adopted by communities, individuals, and oral health professionals have resulted in
marked improvements in the nation's oral and dental health.

The terms oral health and general health should not be interpreted as separate entities. Oral
health is integral to general health; this report provides important reminders that oral health means
more than healthy teeth and that you cannot be healthy without oral health. Further, the report
outlines existing safe and effective disease prevention measures that everyone can adopt to improve
oral health and prevent disease.

However, not everyone is experiencing the same degree of improvement. This Surgeon
General's report addresses the inequities and disparities that affect those least able to muster the
resources to achieve optimal oral health. For whatever the reason, ignoring oral health problems
can lead to needless pain and suffering, causing devastating complications to an individual's well-
being, with financial and social costs that significantly diminish quality of life and burden
American society

For a third decade, the nation has developed a plan for the prevention of disease and the pro-
motion of health, including oral health, embodied in the U.S. Department of Health and Human
Services document, Healthy People 2010. This Surgeon Generals Report on Oral Health empha-
sizes the importance of achieving the Healthy People goals to increase quality of life and eliminate
disparities. As a nation, we hope to address the determinants of health-individual and environ-
mental factors -in order to improve access to quality care, and to support policies and programs
that make a difference for our health. We hope to prevent oral diseases and disorders, cancer, birth
defects, AIDS and other devastating infections, mental illness and suicide, and the chronic diseases
of aging.

We trust that this Surgeon Generals report will ensure that health promotion and disease pre-
vention programs are enhanced for all Americans. This report proposes solutions that entail part-
nerships-government agencies and officials, private industry, foundations, consumer groups,
health professionals, educators, and researchers-to coordinate and facilitate actions based on a
National Oral Health Plan. Together, we can effect the changes we need to maintain and improve
oral health for all Americans.

ORAL HWLTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

. . .
III


Foreword

The growth of biomedical research since World War II has wrought extraordinary advances in the
health and well-being of the American people. The story is particularly remarkable in the case of
oral health, where we have gone from a nation plagued by the pains of toothache and tooth loss to
a nation where most people can smile about their oral health. The impetus for change-to take on
the challenge of addressing oral diseases as well as the many other health problems that shorten
lives and diminish well-being-led to the postwar growth of the National Institutes of Health. In
1948 the National Institute of Dental Research-now the National Institute of Dental and
Craniofacial Research-joined the National Cancer Institute and the National Heart, Lung, and
Blood Institute as the third of the National Institutes of Health.

The Institute's research initially focused on dental caries and studies demonstrating the effec-
tiveness of fluoride in preventing dental caries, research that ushered in a new era of health promo-
tion and disease prevention. The discovery of fluoride was soon complemented by research that
showed that both dental caries and periodontal diseases were bacterial infections that could be pre-
vented by a combination of individual, community, and professional actions. These and other appli-
cations of research discoveries have resulted in continuing improvements in the oral, dental, and
craniofacial health of Americans. Today, armed with the high-powered tools, automated equipment,
and imaging techniques of genetics and molecular and cell biology, scientists have set their sights
on resolving the full array of craniofacial diseases and disorders, from common birth defects such
as cleft lip and palate to the debilitating,chronic oral-facial pain conditions and oral cancers that
occur later in life.

The National Institute of Dental and Craniofacial Research has served as the lead agency for the
development of this Surgeon Generals Report on Oral Health. As part of the National Institutes of
Health, the Institute has had ready access to ongoing federal research and the good fortune to work
collaboratively with many other agencies and individuals, both within and outside government.
The establishment of a Federal Coordinating Committee provided a formal mechanism for the
exchange of ideas and information from other departments, including the U.S. Department of
Agriculture, Department of Education, Department of Justice, Department of Defense, Department
of Veterans Affairs, and Department of Energy Active participation in the preparation and review of
the report came from hundreds of individuals who graciously gave of their expertise and time. It
has been a pleasure to have had this opportunity to prepare the report, and we thank Surgeon
General David Satcher for inviting us to participate.

Despite the advances in oral health that have been made over the last half century, there is still
much work to be done. This past year we have seen the release of Healthy People 2010, which
emphasizes the broad aims of improving quality of life and eliminating health disparities. The
recently released U.S. General Accounting Office report on the oral health of low-income popula-
tions further highlights the oral health problems of disadvantaged populations and the effects on
their well-being that result from lack of access to care. Agencies and voluntary and professional
organizations have already begun to lay the groundwork for research and service programs that
directly and comprehensively address health disparities. The National Institutes of Health has
joined these efforts and is completing an agencywide action plan for research to reduce health dis-
parities. Getting a healthy start in life is critical in these efforts, and toward that end, a Surgeon

OR4L HE4LTH IN AMERICA: A REPORT OF THE SL'RGEON GENERAL


Foreword

General's Conference on Children and Oral Health, The Face of a Child, is scheduled for June
2000. Many other departmental and agency activities are under way
The report concludes with a framework for action to enable further progress in oral health. It
emphasizes the importance of building partnerships to facilitate collaborations to enhance educa-
tion, service, and research and eliminate barriers to care. By working together, we can truly make a
difference in our nation's health-a difference that will benefit the health and well-being of all our
citizens.

Ruth L Kirsckstein MD
Acting Director
National Institutes of Health

Harold C. Shvhin DDS
Director
National Institute of Dental
and Craniofacial Research

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


Preface

from the Surgeon Gened
U.S. public Health Service

AS we begin the twenty-first century, we can be proud of the strides we have made in improving
the oral health of the American people. At the turn of the last century, most Americans could
expect to lose their teeth by middle age. That situation began to change with the discovery of the
properties of fluoride, and the observation that people who lived in communities with naturally
fluoridated drinking water had far less dental caries (tooth decay) than people in comparable com-
munities without fluoride in their water supply Community water fluoridation remains one of the
great achievements of public health in the twentieth century-an inexpensive means of improving
oral health that benefits all residents of a community, young and old, rich and poor alike. We are
fortunate that additional disease prevention and health promotion measures exist for dental caries
and for many other oral diseases and disorders- measures that can be used by individuals, health
care providers, and communities.

Yet as we take stock of how far we have come in enhancing oral health, this report makes it
abundantly clear that there are profound and consequential disparities in the oral health of our citi-
zens. Indeed, what amounts to a "silent epidemic" of dental and oral diseases is affecting some pop-
ulation groups. This burden of disease restricts activities in school, work, and home, and often sig-
nificantly diminishes the quality of life. Those who suffer the worst oral health are found among
the poor of all ages, with poor children and poor older Americans particularly vulnerable. Members
of racial and ethnic minority groups also experience a disproportionate level of oral health prob-
lems. Individuals who are medically compromised or who have disabilities are at greater risk for
oral diseases, and, in turn, oral diseases further jeopardize their health.

The reasons for disparities in oral health are complex. In many instances, socioeconomic fac-
tors are the explanation. In other cases,, disparities are exacerbated by the lack of community pro-
grams such as fluoridated water supplies. People may lack transportation to a clinic and flexibility
in getting time off from work to attend to health needs. Physical disability or other illness may also
limit access to services. Lack of resources to pay for care, either out-of-pocket or through private or
public dental insurance, is clearly another barrier. Fewer people have dental insurance than have
medical insurance, and it is often lost when individuals retire. Public dental insurance programs are
often inadequate. Another major barrier to seeking and obtaining professional oral health care
relates to a lack of public understanding and awareness of the importance of oral health.

We know that the mouth reflects general health and well-being. This report reiterates that gen-
eral health risk factors common to many diseases, such as tobacco use and poor dietary practices,
also affect oral and craniofacial health. The evidence for an association between tobacco use and
oral diseases has been clearly delineated in 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). Recently, research findings have pointed to possible associations between chronic oral
infections and diabetes, heart and lung diseases, stroke, and low-birth-weight, premature births.
This report assesses these emerging associations and explores factors that may underlie these oral-
systemic disease connections.

To improve quality of life and eliminate health disparities demands the understanding, compas-
sion, and will of the American people. There are opportunities for all health professions, individu-
als. and communities to work together to improve health. But more needs to be done if we are to
make further improvements in America's oral health. We hope that this Surgeon Generals report

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


Preface

will inform the American people about the opportunities to improve oral health and provide a plat-
form from which the science base for craniofacial research can be expanded. The report should also
serve to strengthen the translation of proven health promotion and disease prevention approaches
into policy development, health care practice, and personal lifestyle behaviors. A framework for
action that integrates oral health into overall health is critical if we are to see further gains.

David Satcher MD, PhD
Surgeon General

. . .
VIII

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


Acknowledgments

This report was prepared by the Department of
Health and Human Set-vices under the direction of
the National Institutes of Health, National Institute
of Dental and Craniofacial Research.

Ruth L. Kirschstein MD
Acting Director, National Institutes of Health, DHHS,
Bethesda, MD

Harold C. Slavkin DDS
Director, National Institute of Dental and Craniofacial
Research, National Institutes of Health, DHHS,
Bethesda, MD

David Satcher MD, PhD
Assistant Secretary for Health and Surgeon General,
Office of Public Health and Science, Office of the
Secretary, Washington, DC
Nicole Lurie MD, MSPH
Prmcipal Deputy Assistant Secretary for Health, Office
of Public Health and Science, Office of the Secretary
\Vashington, DC

Beverly L. Malone PhD, RN, FAAN
Deputy Assistant Secretary for Health, Office of Public
Health and Science, Office of the Secretary,
Washington, DC

r\rthur Lawrence PhD
rissistant Surgeon General, USPHS, Deputy Assistant
Secretary for Health (Operations), Office of Public
Health and Science, Office of the Secretary,
W'ashington, DC

Kenneth Moritsugu MD, MPH
Deputy Surgeon General, LJSPHS, Office of the
Surgeon General, Office of the Secretary,
LVashington, DC

.-\l!an S. Noonan MD, dMPH
Captain, USPHS, Office of the Surgeon General,
Office of the Secretary, Washington, DC

*Indicates Coordinating Author

PROJECT TEAM

Caswell A. Evans DDS, MPH
Project Director and Executive Editor
Assistant Director, Los Angeles County Department
of Health Services, Los Angeles, CA
Dushanka V Kleinman DDS, MScD
Co-Executive Editor

Assistant Surgeon General, USPHS
Deputy Director, National Institute of Dental and
Craniofacial Research, National Institutes of Health,
DHHS, Bethesda, MD

William R. Maas DDS, MPH, MS
Assistant Surgeon General, Chief Dental Officer,
USPHS
Director, Division of Oral Health, Centers for Disease
Control and Prevention, DHHS, Atlanta, GA
Joan S. Wilentz MA

Science Writer and Editor, Bethesda, MD
Roseanne Price ELS

Editor, Silver Spring, MD
Marla Fogelman

Editor, Silver Spring, MD

CONTRIBUTORS
Margo Adesanya DDS

Staff Scientist, National Institute of Dental and
Craniofacial Research, National Institutes of Health,
DHHS, Bethesda, MD
Alfred0 Aguirre DDS, MS

Director and Associate Professor, Advanced Oral and
Maxillofacial Pathology, State University of New York
at Buffalo School of Dental Medicine, Buffalo, NY
*Ronald Andersen PhD, MA
Wasserman Professor of Health Services and Professor
of Sociology, University of California Los Angeles
School of Public Health, Los Angeles, CA

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

iX


Acknowledgments

Jay R. Anderson DMD, MHSA
Chief Dental Officer, Division of Community and
Migrant Health, Bureau of Primary Health Care,
Health Resources and Services Admmistration, DHHS,
Rockville, MD

Kenneth J. Anusavice PhD, DMD
Associate Dean for Research, Chair. Department of
Dental Biomaterials, University of Florida College of
Dentistry, Gainesville. FL
+Kathryn A. Atchison DDS, MPH
Professor and Associate Dean for Research, University
of California Los Angeles School of Dentistry, Los
Angeles, CA

James Bader DDS, MPH
Professor, University of North Carolina School of
Dentistry, Chapel Hill, NC
Charles Bertolami DDS, D.Med.Sc.
Dean. University of California San Francisco School of
Dentistry, San Francisco, CA
Aljernon Bolden DMD, MPH
Director, Community Health Programs and Co-
Director, Division of Dental Public Health, Boston
University Goldman School of Dental Medicine,
Boston. MA

L. Jackson Brown DDS, PhD
Associate Executive Director, American Dental
Association, Chicago, IL
Janet A. Bnmelle MS

Statistician (retired), National Institute of Dental and
Craniofacial Research, National Institutes of Health,
DHHS. Bethesda, MD

Brian A. Burt BDS, MPH, PhD
Professor of Dental Public Health, Department of
Epidemiology, University of Michigan School of Public
Health, Ann Arbor. MI

Nita Chainani-Wu DMD, MPH
University of California San Francisco School of
Dentistry. San Francisco, CA
David W. Chen MD, MPH
Commander, USPHS, Deputy Director, Division of
Associated, Dental, and Public Health Professions.
Bureau of Health Professions, Health Resources and
Services Administration, DHHS, Rockville, MD
Joseph Ciardi PhD

Consultant, National Institute of Dental and
Craniofacial Research, National Institutes of Health,
DHHS, Bethesda, MD

Betty DeBerry-Summer DDS, MPH
Captain. USPHS, Chief Dental Officer, Bureau of
Primary Health Care, Health Resources and Services
Administration, DHHS, Bethesda, MD
Teresa A. Dolan DDS, MPH
Professor and Associate Dean, University of Florida
College of Dentistry, Gainesville, FL

*Chester W. Douglass DMD, PhD
Professor and Chair, Department of Oral Health Policy
and Epidemiology, Harvard School of Dental Medicine.
Boston, MA

M. Ann Drum DDS, MPH
Captain, USPHS, Acting Director, Division of Research,
Education and Training, Maternal and Child Health
Bureau, Health Resources and Services Administration,
DHHS, Rockville, MD
Thomas E Drury PhD

Senior Scientist, National Institute of Dental and
Craniofacial Research, National Institutes of Health,
DHHS, Bethesda, MD

Burton L. Edelstein DDS, MPH ,
Director, Children's Dental Health Project, American
Academy of Pediatrics, Washington, DC
Frederick C. Eichmiller DDS
Director, Paffenbarger Research Center, American
Dental Association Health Foundation, National
Institute of Standards and Technology,
Gaithersburg, MD

Mary P Faine MS, RD, CD
Associate Professor and Director of Nutrition
Education, University of Washington School of
Dentistry, Seattle, WA

Denise J. Fedele DMD, MS
Chief Professional Development and Research in
Dental Care Clinical Research, Veterans
Administration Medical Health Care System,
Department of Veterans Affairs, Perrypoint, MD
Christopher H. Fox DMD, DMSc
Director of Professional Relations, Europe, Colgate-
Palmolive Co., New Jersey
Philip C. Fox DDS

Director, Research and Development Affiliation,
Amarillo Biosciences, Inc., Amarillo, TX
Lawrence J. Furman DDS, MPH
Captain, USPHS, Head, Department of Health Services,
U.S. Merchant Marine Academy, Kings Point, NY
Isabel Garcia DDS, MPH

Captain, USPHS, Special Assistant for Science Transfer,
National Institute of Dental and Craniofacial Research,
National Institutes of Health, DHHS, Bethesda, MD
*Robert J. Genco DDS, PhD
Distinguished Professor and Chair, Department of Oral
Biology, State University of New York at Buffalo School
of Dental Medicine, Buffalo, NY
Gretchen Gibson DDS, MPH
Director, Special Care Dental Clinics, Veterans
Administration North Texas Healthcare Systems,
Department of Veterans Affairs, Dallas, TX

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


Sharon M. Gordon DDS, MPH
Director, Office of Education, National Institute of
Dental and Craniofacial Research, National Institutes
of Health, DHHS, Bethesda, MD
&therine Hayes DMD, DMSc
;\ssistant Professor, Department of Oral Health Policy
and Epidemiology, Harvard School of Dental Medicine,
Boston, MA

.-\lice M. Horowitz PhD
Senior Scientist, National Institute of Dental and
Craniofacial Research, National Institutes of Health,
DHHS. Bethesda, MD

Herschel Horowitz DDS, MPH
Consultant, Dental Research and Public Health,
Bethesda, MD

lcffrev Hpman DDS, PhD
Epidemiologist, National Institute of Dental and
Craniofacial Research, National Institutes of Health,
DHHS, Bethesda, MD

.\mld I. lsmail BDS, MPH, DrPH
Professor, University of Michigan School of Dentistry,
&in Arbor, MI

. Marjorie Jeffcoat DMD
Rosen Professor and Chair, Department of
Periodontics, University of Alabama School of
Dentistry, Birmingham, AL
Clrndace Jones RDH, MPH
Captain, USPHS, Director, Dental Diseases Prevention
Program, Indian Health Service, DHHS, Rockville, MD
David Jones DDS, MPH
Captain, USPHS (retired), Rockville, MD
Judith A. Jones DDS, MPH
Scmor Research Associate, Veterans Administration
Center for Health Quality, Outcomes and Economic
Research, Department of Veterans Affairs and,
Associate Professor, Boston University Goldman
School of Dental Medicine, Bedford, MA
Kaumudi J. Joshipura BDS, DSc
Assistant Professor, Harvard School of Dental
Medicine, Boston, MA

l-in& M. Kaste DDS, PhD
.Associate Professor and Division Director, Division of
Dental Public Health and Oral Epidemiology, Medical
University of South Carolina College of Dental
bledicine, Charleston, SC
W'illiam Kohn DDS, MS

Captain, USPHS, Associate Director for Science,
Division of Oral Health, Centers for Disease Control
and Prevention, DHHS, Atlanta, GA
Man Sue Lancaster RN, MA
Health Education Specialist, Centers for Disease
Control and Prevention, DHHS, Atlanta, GA

Acknowledgments

Linda LeResche ScD

Research Professor, University of Washington School
of Dentistry, Seattle, WA
James Lipton DDS, PhD
Captain, USPHS, Assistant Director for Training and
Career Development, National Institute of Dental and
Craniofacial Research, DHHS, Bethesda, MD
Reginald Louie DDS, MPH
Captain, USPHS, Regional Dental Consultant, Health
Resources and Services Administration, DHHS, San
Francisco, CA
*Irwin D. Mandel DDS

Professor Emeritus, Columbia University School of
Dental and Oral Surgery, New York, NY
Stephen E. Marcus PhD           .
Epidemiologist, National Cancer Institute, National
Institutes of Health, DHHS, Bethesda, MD
Frank Martin DDS, MPH
Captain, USPHS, Assistant Chief, Dental Services
Branch (retired), Indian Health Service, DHHS,
Rockville, MD

Wendy E. Mouradian MD
Director, Children's Hospital and Regional Medical
Center, Departments of Pediatrics, Pediatric Dentistry,
Medical History and Ethics, University of Washington,
Seattle, WA

*Linda Niessen DMD, MPH, MPP
Professor, Baylor University College of Dentistry and
Vice President, DENTSPLY International, York, PA
Ruth E. Nowjack-Raymer RDH, MPH
Public Health Researcher, National Institute of Dental
and Craniofacial Research, National Institutes of
Health, DHHS, Bethesda, MD
Steven Offenbacher DDS, PhD, MMSc
Professor and Director, Center for Oral and Systemic
Diseases, University of North Carolina,
Chapel Hill, NC

H. Whitney Payne, Jr. DDS, MPH
Captain, USPHS, Chief of Dental Services, Federal
Correctional Institution, Federal Bureau of Prisons,
Department of Justice, Seogoville, TX
Edward Peters DMD

Instructor in Oral Health and Epidemiology,
Department of Oral Health Policy and Epidemiology,
Harvard School of Dental Medicine, Boston, MA
Douglas E. Peterson DMD, PhD
Professor and Head, Department of Oral Diagnosis,
University of Connecticut School of Dental Medicine,
Farmington, CT

Maryann Redford DDS, MPH
Health Scientist Administrator, National lnstitute of
Dental and Craniofacial Research, National Institutes
of Health, DHHS, Bethesda, MD

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

xi


*Susan Reisine PhD

Professor, University of Connecticut School of Dental
Medicine, Hartford, CT

John Rossetti DDS. MPH
Captain, USPHS, Chief Dental Officer, Health
Resources and Services Administration, DHHS,
Rockville, MD

#R. Gary Rozier DDS, MPH
Professor, Department of Health Policy
Administration, University of North Carolina School
of Public Health, Chapel Hill, NC
Susan Runner DDS, MA

Captain, USPHS, Branch Chief Dental Devices, Center
for Devices and Radiological Health, Food and Drug
Administration, Rockville, MD
John S. Rutkauskas DDS, MS
Executive Director, American Association of Pediatric
Dentistry, Chicago, IL
Margaret Scarlett DMD

Captain, USPHS, Office of the Secretary, Office of
Public Health and Science, DHHS, Washington, DC
Don Schneider DDS, MPH
Captain, USPHS, Chief Dental Officer, Health Care
Financing Administration, Center for Medicaid and
State Operations, DHHS, Baltimore, MD
Stephen T. Schultz DDS, MS. MPH
Lieutenant Commander. U.S. Navy National Institute
of Dental and Craniofacial Research, National
Institutes of Health, DHHS, Bethesda, MD
Robert H. Selwitz DDS, MPH
Captain, USPHS, Senior Dental Epidemiologist,
National Institute of Dental and Crariiofacial Research,
National Institutes of Health, DHHS. Bethesda, MD
Gerald Shklar DDS, MS

Charles A. Brackett Professor of Oral Pathology,
Harvard School of Dental Medicine, Boston, MA
Charles Shuler DMD, PhD
Director, Center for Craniofacial Molecular Biology,
George and Mary Lou Boone Professor of Craniofacial
Molecular Biology, University of Southern California
School of Dentistr): Los Angeles, CA
Gary Slade BDSc, DDPH, PhD
Assistant Professor, University of North Carolina
School of Dentistry Chapel Hill, NC
Ronald F! Strauss DMD, PhD
Professor, School of Dentistry and School of Medicine,
University of North Carolina, Chapel Hill, NC
Lawrence Tabak DDS, PhD
Senior Associate Dean for Research, University of
Rochester School of Medicine and Dentistry,
Rochester, NY

George W. Taylor DMD, DrPH
Assistant Professor of Dentistry, University of
Michigan School of Dentistry Ann Arbor. MI

Amardeep Singh Thind MD, PhD
Assistant Professor, University of California LOS
Angeles School of Public Health, Los Angeles, CA
Scott L. Tomar DMD, DrPH
Epidemiologist/Dental Officer, National Center for
Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, DHHS,
Atlanta, GA

Benedict I. Truman MD, MPH
Senior Scientist and Epidemiology Program Officer,
Centers for Disease Control and Prevention, DHHS,
Atlanta, GA

William Wathen DMD
Associate Dean, Center for Professional Development,
Baylor College of Dentistry, pallas, TX
*Jane A. Weintraub DDS, MPH
Lee Hysan Professor and Chair, Division of Oral
Epidemiology and Dental Public Health, University of
California San Francisco School of Dentistry, San
Francisco, CA

*B. Alex White DDS, DrPH
Assistant Program Director, Economic, Social, and
Health Services Research, Kaiser Permanente Center
for Health Research, Portland, OR
Deborah Winn PhD

Senior Investigator, National Institute of Dental and
Craniofacial Research, National Institutes of Health,
DHHS, Bethesda, MD
Athanasios I. Zavras DMD, MS, DMSc
Assistant Professor, Department of Health Policy and
Epidemiology Harvard School of Dental Medicine,
Boston, MA

SENIOR REVIEWERS

Clifton Dummett Sr. DDS
Distinguished Professor Emeritus, University
of Southern California School of Dentistry,
Los Angeles, CA

Helen C. Rodriguez-Trias MD, FAAP
Past-President, American Public Health Association,
Brookdale, CA

John Stamm DDS, DDPH, MScD
Dean, University of North Carolina School of
Dentistry, Chapel Hill, NC

REVIEWERS

Michael C. Alfano DMD, PhD
Dean, New York University College of Dentistry,
New York, NY

Myron Allukian Jr. DDS, MPH
Director, Oral Health, Boston Public Health
Commission, Boston, MA

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


;ilcs,a +,ntczak-Bouckoms DMD, ScD, MPH, MS
..lssistant Professor of Medicine, Tufts University
School of Medicine, Medford, MA
11oward L. Bailit DMD, PhD
H&h Policy and Primary Care Research Center,
L.niversitv of Connecticut Health Center,
Fimnington. CT

D.ivtd Barmes BDSc, DDSc, MPH
spccial Expert for International Health, National
Institute of Dental and Craniofacial Research, National
Institutes of Health. DHHS, Bethesda, MD
Brticc J. Baum DMD, PhD
C1,icf of Gene Therapy and Therapeutic Branch,
\;,tional Institute of Dental and Craniofacial Research,
x,tttonal Institutes of Health, DHHS, Bethesda, MD
\tq>ticn C. Bayne MS, PhD
Professor. University of North Carolina School of
Dcntistr): Chapel Hill, NC
j~11lc5 D. Beck PhD

Kcnan Professor, University of North Carolina School
of Dentistr): Chapel Hill, NC
I iigcnio Bcltran DMD, MPH, MS, BrPH
\cnior Research Fellow, Division of Oral Health,
(`cntcrs for Disease Control and Prevention, DHHS,
:\rl.m~a. GA

I It.iining Birkedal-Hansen DDS, PhD
scientific Director, National Institute of Dental and
(:raniofacial Research, National Institutes of Health,
DI 11~s. Bethesda. MD
li.~r~nn Boehm MPH

(`h~cf, Health Promotion Branch, National Institute of
Dental and Craniofacial Research, National Institutes
01 1 Icalth. DHHS, Bethesda, MD
~~`11l~m H. Bowen BDS. PhD
Wclscher Professor of Dentistry, School of Dentistry,
t:niversity of Rochester Medical Center, Rochester, NY
\orman S. Braveman PhD
.-\ssociate Director for Clinical, Behavioral and Health
Promotion Research, National Institute of Dental and
Craniofacial Research, National Institutes of Health,
I)IIH.S. Bethesda, MD

Bruce B. Brehm DMD, MPH
Lieutenant Colonel, U.S. Army, T&Service Center
for Oral Health Studies, Uniformed Services University
of the Health Sciences, Department of Defense,
Bethesda. MD
Patricia S. Byant PhD

Director. Behavioral and Health Promotion Research,
National Institute of Dental and Craniofacial Research,
National Institutes of Health, DHHS, Bethesda, MD
\laria Teresa Canto MS, DDS, MPH
Pubhc Health Research Specialist, National Institute of
Dental and Craniofacial Research, National Institutes
of Health. DHHS. Bethesda. MD

Acknowledgments

Eli Capilouto DMD, MPH, ScD
Dean, School of Public Health, University of Alabama
at Birmingham, Birmingham, AL
Victoria A. Cargill MD, MSCE
Medical Officer, Office of AIDS Research, National
Institutes of Health, DHHS, Bethesda, MD
D. Walter Cohen DDS
Chancellor Emeritus, Medical College of Pennsylvania,
Hahneman University, Philadelphia, PA
Lois K. Cohen PhD

Director, Office of International Health, National
Institute of Dental and Craniofacial Research, National
Institutes of Health, DHHS, Bethesda, MD
Robert J. Collins DMD, MPH       ,
Deputy Executive Director, International and
American Associations for Dental Research,
Alexandria, VA

Stephen B. Corbin DDS, MPH
Director of Health and Research Initiatives, Special
Olympics, Inc., Washington, DC
James G. Corrigan PhD
Evaluation Officer, National Institute of Dental and
Craniofacial Research, National Institutes of Health,
DHHS, Bethesda, MD

James J. Crall DDS, ScD
Chairman, Department of Pediatric Dentistry,
University of Connecticut School of Dental Medicine,
Farmington, CT

Ananda E Dasanayake BDS, MPH, PhD
Associate Professor, Department of Oral Biology
University of Alabama School of Dentistry,
Birmingham, AL

Dominick I? DePaola DDS, PhD
President and CEO, The Forsyth Institute, Boston, MA
Richard D'Eustachio DDS
Private Practice, Cherry Hill, NJ
Ray Dionne DDS, PhD
Captain, USPHS, Clinical Director, National Institute
of Dental and Craniofacial Research, National
Institutes of Health, DHHS, Bethesda, MD
Marylin Dodd RN, PhD
Professor. University of California San Francisco
School of Nursing, San Francisco, CA
Scott Dubowsky DMD, FAGD
Private Practice, Bayonne, NJ
Robert Dumbaugh DDS, MPH
Dental Executive Director, Palm Beach County Health
Department, Palm Beach, FL
Joel Epstein DMD, MSD
Research Associate Professor, Department of Oral
Medicine, University of Washington School of
Dentistry, Seattle, WA

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

. . .
XIII


Acknowledgments

Ronald Ettinger BDS, MDS, DDSc
Professor, Department of Prosthodontics and Dows
Institute for Dental Research, University of Iowa,
Iowa City, IA

Raymond Fonseca DMD
Dean, University of Pennsylvania School of Dental
Medicine, Philadelphia, PA
Allan J. Formicola DDS
Dean, School of Dental and Oral Surgev, Columbia
University, New York, NY
Jane L. Forrest Ed.D., RDH
Assistant Dean, Dental Hygiene Research and
Instructional Technology, Director, National Center for
Dental Hygiene Research, University of Southern
California School of Dentistry, Los Angeles, CA
Robert T. Frame DMD, MS, CHE
Assistant Under Secretary for Health for Dentistry,
Department of Veterans Affairs, Washington, DC
Raul I. Garcia DMD

Professor and Chair, Department of Health Policy,
Boston University Goldman School of Dental
Medicine, Boston, MA

Jay Alan Gershen DDS, PhD
Executive Vice Chancellor, University of Colorado
Health Sciences Center, Denver, CO
Michael Glick DMD

Professor of Oral Medicine, Director, Programs
for Medically Complex Patients, University of
Pennsylvania School of Dental Medicine,
Philadelphia, PA

Barbara E Gooch DMD, MPH
Dental Officer, Division of Oral Health, Centers for
Disease Control and Prevention, DHHS, Atlanta, GA
John Greene DMD, MPH
Dean Emeritus, University of California San Francisco
School of Dentistry, San Rafael, CA
Deborah Greenspan BDS, DSc, ScD (hc),
FDSRCS Ed (hon)

Professor of Clinical Oral Medicine, University of
California San Francisco School of Dentistry, San
Francisco, CA

John S. Greenspan BSc, BDS, PhD, FRCPath
Professor and Chair, Department of Stomatology,
University of California San Francisco School of
Dentistry, San Francisco, CA
Robert 0. Greer DDS, ScD
Professor of Pathology and Medicine, University of
Colorado Health Sciences Center, Schools of Medicine
and Dentistry, Denver, CO
David Grembowski PhD

Professor of Health Services and Dental Public Health
Sciences, University of Washington, Seattle, WA

Ellen R. Gritz PhD

Professor and Chair, Department of Behavioral
Science, M.D. Anderson Cancer Center, University of
Texas, Houston, TX

Kenneth A. Gruber PhD
Chief, Chronic Diseases Branch, National Institute of
Dental and Craniofacial Research, National Institutes
of Health, DHHS, Bethesda, MD
Kevin Hardwick DDS, MPH
Captain, USPHS, International Health Officer, National
Institute of Dental and Craniofacial Research, National
Institutes of Health, DHHS, Bethesda, MD
Hazel J. Harper DDS, MPH
Private Practice, Washington, DC
John Hauth MD

Professor, Interim Chairman and Director, Center for
Research in Women's Health, University of Alabama at
Birmingham, Birmingham, AL
Maxine Hayes MD, MPH
Assistant Secretary, Community and Family Health,
Washington State Department of Health, Olympia, WA
Marc W. Heft DMD, PhD
Professor and Director of the Claude Pepper
Center, University of Florida College of Dentistry,
Gainesville, FL

Joseph Henry DDS, PhD, ScD
Dean Emeritus, Howard University College of
Dentistry and Professor, Harvard School of Dental
Medicine, Boston, MA
Mark C. Herzberg DDS, PhD
Professor, University of Minnesota School of Dentistry,
Minneapolis, MN

Alan R. Hinman MD, MPH
Senior Consultant for Public Health Programs,
Taskforce for Child Survival and Development,
Decatur, GA

Cynthia Hodge DMD, MPH
Private Practice, Nashville, TN
Dorthe Holst DDS, MPH
Professor, Department of Community Dentistry,
University of Oslo, Oslo, Norway
John I? Howe III MD

President, University of Texas Health Science Center at
San Antonio, San Antonio, TX
David Johnsen DDS, MS

Dean and Professor of Pediatric Dentistry, University
of Iowa College of Dentistry, Iowa City, IA
Ralph Katz DMD, PhD

Professor, Department of Behavioral Science and
Community Health, University of Connecticut School
of Dental Medicine, Farmington, CT
H. Asuman Kiyak MA, PhD
Director, Institute on Aging and Professor, University
of Washington School of Dentistry, Seattle, WA

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


k\`znncth S. Komman DDS. PhD
Ch,,.f Scientific Officer, Interleukin Genetics, Inc.,
+n .\ntonio. TX

t:linI K;ousvelari DDS, DSc
llc31th Scientist Administrator, National Institute of
Dcnr.il and Craniofacial Research, National Institutes
,,f Health. DHHS, Bethesda, MD
I.,, .inth \: Kumar DDS, MPH
\~~,stant Director. Bureau of Dental Health, New York
?t.itc Department of Health, Albany, NY
I;.,\ mend Kuthy DDS, MPH
Prl,fcssor and Chair, Preventive and Community
Ilcntistn: UnivTersity of Iowa College of Dentistry,
~,wn City. IA

I r.1 l..imstcr DDS, MMSc
Prolcssor and Vice Dean, Columbia University School
(11 Dental and Oral Surgery, New York, NY
1'111lil' R. Lee MA, MD

I'rolcssor Emeritus of Social Medicine and Senior
.\dvtsor. Institute for Health Policy Studies,
I `nivcrsity of California San Francisco School of
\~cd~c~nc. San Francisco, CA
1c.1~ qucl Z. LeGeros BS, MS, PhD
I'rolcssor, Department of Dental Materials Science
,ind Director, Research Center for Minority Oral
I lc:ilth, New York University College of Dentistry,
Ncn York. NY

I).iv~tl Locker BDS, PhD
i'rofcssor. Faculty of Dentistry University of Toronto,
I~lronto. Canada

`111.11 t l-ockwood DDS, MPH
I)cntnl Officer/Epidemiologist, Division of Oral Health,
( cntcrs for Disease Control and Prevention, DHHS,
.\tl.inta. GA
I l.in)td 1.oe DDS

Director Emeritus, National Institute of Dental and
~~r.mtofacial Research, National Institutes of Health,
[)I IHS, Florida and Norway
(1 \I .yana Lopez DDS, MPH
I)ema1 Program Manager. City of Austin, Austin, TX
wd D. Macek DDS, PhD. MPH
.\sststant Professor. Department of Oral Health Care
hind Delivery, University of Maryland School of
Dcntisrry. Baltimore, MD

i)~llOrCS ?.I. Malvitz DrPH

c-litef. Surveillance Investigations and Research
BrJnch. Division of Oral Health, Centers for Disease
Control and Prevention, DHHS, Atlanta, GA
h'nIllS E Mangan PhD

Chief. Infectious Disease and Immunity Branch,
rntlonal Institute of Dental and Craniofacial Research.
xati"nal Institutes of Health, DHHS, Bethesda. MD

Acknowledgments

Kathleen Mangskau RDH, MPA
Director, North Dakota Oral Health Program, North
Dakota Department of Health, Bismarck, ND
Georgetta Manning-Cox DDS, MPH
Chairman, Community Dentistry and Associate
Professor, Howard University College of Dentistry,
Washington, DC

Don Marianos DDS, MPH
Consultant in Public Health, Pinetop, AZ
Gary C. Martin DDS, MPH
Lieutenant Colonel, U.S. Air Force, T&Service Center
for Oral Health Studies, Uniformed Services University
of the Health Sciences, Department of Defense,
Bethesda, MD                  .
Ricardo J. Martinez MD, MPH
Director, Division of Extramural Research, National
Institute of Dental and Craniofacial Research, National
Institutes of Health, DHHS, Bethesda, MD
Richard Mascola DDS

Private Practice, Jericho, NY
Carolyn Beth Mazzella RN
Assistant Surgeon General, USPHS, Office of the PHS
Chief Nurse, Health Resources and Services
Administration, DHHS, Rockville, MD
Kim McFarland DDS, MS
Dental Health Director, State of Nebraska, Nebraska
Department of Health, Lincoln, NE
J. Michael McGinnis MD
Senior Vice President and Director, Health Group, The
Robert Wood Johnson Foundation, Princeton, NJ
Robert Mecklenburg DDS, MPH
Coordinator, Tobacco and Oral Health Initiatives for
the Tobacco Control Research Branch, National Cancer
Institute, DHHS, Bethesda, MD
Roseann Mulligan DDS, MS
Professor and Chairman, Department of Dental
Medicine and Public Health, University of Southern
California School of Dentistry, Los Angeles, CA
Juan M. Navia PhD

Professor Emeritus, University of Alabama at
Birmingham, Birmingham, AL
Edward O'Neil PhD, MPA
Professor, Dental Public Health and Hygiene, Director,
Center for Health Professions, University of California,
San Francisco, San Francisco, CA
Roy C. Page DDS, PhD
Professor, Departments of Periodontics and Pathology,
Schools of Dentistry and Medicine, University of
Washington, Seattle, WA
No-Hee Park DMD, PhD
Dean, School of Dentistry, University of California
Los Angeles, Los Angeles, CA

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

xv


Acknowledgments

Steven Perlman DDS, MScD
Associate Professor of Pediatric Dentistry, Boston
University Goldman School of Dental Medicine,
Boston. MA

Poul Erik Petersen DDS, Dr Odont Sci, BA, MSC
Professor, University of Copenhagen, School of
Dentistry, Copenhagen N, Denmark
Kathy Phipps RDH, DrPH
Associate Professor, Oregon Health Sciences
University, Newport, OR
Scott Presson DDS, MPH
Captain, USPHS, Chief, Program Services Branch,
Division of Oral Health, Centers for Disease Control
and Prevention, DHHS, Atlanta, GA
Francisco Ramos-Gomez DDS, MS, MPH
Associate Professor, Department of Growth and
Development, University of California San Francisco,
San Francisco, CA

E. Diane Rekow DDS, PhD
Professor and Chair, Department of Orthodontics,
University of Medicine and Dentistry of New Jersey,
Newark, NJ

Michael Rethman DDS, MS
Colonel, U.S. Army, Chief of Periodontics, Tripler
Dental Clinic, Honolulu, HI
S. Timothy Rose DDS, MS
Private Practice, Appleton, WI
Bruce Rothwell DMD, MSD
Associate Professor and Chairman, University
of Washington, Restorative/Hospital Dentistry,
Seattle, WA

Shirley B. Russell PhD

Professor and Chairperson, Department of
Microbiology, Associate Dean for Research, Mehany
Medical College, Nashville, TN
Ann L Sandberg PhD

Chief, Neoplastic Diseases Branch, National Institute
of Dental and Craniofacial Research, National
Institutes of Health, DHHS, Bethesda, MD
Charles Sanders DDS

Dean, Howard University College of Dentistry,
Washington, DC

Michele J. Saunders DMD, MS, MPH
Endowed Professor of Clinical Dentistry, University of
Texas Health Science Center, San Antonio, TX
Crispian Scully MD, PhD, MDS
Dean, Director of Studies and Research, International
Centers for Excellence in Dentistry and Eastman
Dental Institute for Oral Health Care Sciences,
University College of London, London, England
Leslie W. Seldin DDS, PC
Private Practice, New York, NY

Aubrey Sheiham BDS, PhD, DHC
Professor, Department of Epidemiology and Public
Health, University College London Medical School,
London, England

Cynthia Sherwood DDS
Private Practice, Independence, KS
Mark D. Siegal DDS, MPH
Chief, Bureau of Oral Health Services, Ohio
Department of Health, Columbus, OH
Sol Silverman Jr. MA, DDS
Professor of Oral Medicine, University of California
San Francisco School of Dentistry, San Francisco, CA
Susan E Silverton MD, PhD
Assistant Professor and Enid Neidle Scholar,
University of PennsylvaniaSchool of Dental Medicine.
Philadelphia, PA

Jeanne Sinkford DDS, MS, PhD
Associate Executive Director, American Dental
Education Association, Washington, DC
Judy A. Small PhD

Chief, Craniofacial Anomalies and Injuries Branch,
National Institute of Dental and Craniofacial Research,
National Institutes of Health, DHHS, Bethesda, MD
Christian Stohler DMD, Dr.Med.Dent
William R. Mann Professor and Chair, Department of
Biologic and Materials Sciences, University of
Michigan School of Dentistry, Ann Arbor, MI
George Stookey PhD

Executive Associate Dean, Indiana University School
of Dentistry, Indianapolis, IN
Michael Till DDS, PhD
Dean, University of Minnesota School of Dentistry,
Minneapolis, MN

Richard Valachovic DMD, MPH
Executive Director, American Dental Education
Association, Washington, DC
Clemencia M. Vargas DDS, MPH, PhD
Assistant Professor, University of Maryland School of
Dentistry Baltimore, MD
Rueben Warren DDS, MPH, DrPH
Associate Administrator for Urban Affairs, The Agency
for Toxic Substances and Disease Registry, DHHS,
Atlanta, GA
Reginald Wells PhD

Deputy Commissioner, Administration for Children
and Families, Administration on Developmental
Disabilities, DHHS, Washington, DC
Terrie Wetle PhD

Deputy Director, National Institute on Aging, National
Institutes of Health, DHHS, Bethesda, MD
David A. Whiston DDS
Private Practice, Falls Church, VA

xvi

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


iiLicl~ \\`ilson DDS. MPH
Bureau Chief, State of Connecticut Department of
Pttblic Health, Avon, CT
LL,,lncth ~1. Yamada MD, PhD
Br.,nch Chief, Craniofacial Development Biology and
Rcseneration. National Institute of Dental and
crL,niofacial Research, National Institutes of Health,
DHHS. Bethesda. MD

EDITORIAL AND PRODUCTION
ASSISTANTS
Ihi Editorial Staff of the KEVRIC Company, Inc.,
~ilvcr Spring, MD

PROJECT ASSISTANTS
\rinl' Brcncnbach
\t.iirrlcc Champagne MA
~tt$~~mie A. Dopson MSW, MPH
h.ittirrinc E. Krizek
\I,ino I! Maertens
I 11~~1~ \IcAllister JD
I ,t't,rg:1;1 A. McIntyre
( .ltOcrinc YlcNish RDH, MHS

FEDERAL COORDINATING
COMMITTEE
I (II\ :\lbarelli

\g~ng Services Program Specialist, Administration on
.\g~ng, DHHS. Washington, DC
( lil.rvl :\ustein-Casnoff MPH
Ihrcctor, Public Health Policy, Office of the Assistant
yccrcrav for Planning and Evaluation, DHHS,
L\`:ishington, DC
\\ 1111,1m E Benson

\cting Principal Deputy Assistant Secretary for Aging
(retired), Administration on Aging, DHHS,
\\`,rshington, DC

\I~lhmdas Bhat BDS, MDS, DrPH
4c.mor Science Advisor, Office of International
ttealth Programs, U.S. Department of Energy,
Gcrmsntown, MD

[)~~I1113 Blum MS RD
~titrnionist, Department of Agriculture,
--\lesandria, VA

i-rlc Bothwell DDS, MPH, phD
CJPtam USPHS, Assistant Chief, Dental Services
Branch (retired), Indian Health Service, DHHS,
Rockville, MD

(1 Richard Buchanan DMD
DePuty Director for Dentistry, Department of Veterans
.iffairs, il?`ashington, DC

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

Acknowledgments

Claude Earl Fox MD, MPH
Administrator, Health Resources and Services
Administration, DHHS, Rockville, MD
Patricia A. Grady PhD, RN, FAAN
Director, National Institute of Nursing Research,
National Institutes of Health, DHHS, Bethesda, MD
Elizabeth Jacobson PhD
Deputy Director for Science, Center for Devices and
Radiological Health, Food and Drug Administration,
DHHS, Rockville, MD

Wanda K. Jones Dr. PH.
Deputy Assistant Secretary for Health, Office of
Women's Health, DHHS, Washington, DC
Lireka P Joseph Dr. PH.
Captain, USPHS. Director, Office of Health and
Industry Programs, Center for Devices and
Radiological Health, Food and Drug Administration,
DHHS, Rockville, MD

Douglas B. Kamerow MD, MPH
Assistant Surgeon General USPHS, Director, Center
for Practice and Technology Assessment, Agency for
Healthcare Research and Quality, DHHS,
Rockville, MD

Mireille B. Kanda MD, MPH
Director of Health and Disability Services, Head Start
Bureau, Agency for Children, Youth, and Families,
DHHS, Washington, DC
Rod F Kirk DDS

Captain, USPHS, Chief, Dental Program, Federal
Bureau of Prisons, Department of Justice,
Washington, DC

Kenneth W Kizer MD, MPH
Under Secretary for Health (retired), Department of
Veterans Affairs, Washington, DC
William Kohn DDS

Captain, USPHS, Associate Director for Science,
Division of Oral Health, Centers for Disease Control
and Prevention, DHHS, Atlanta, GA
Thomas M. I-eiendecker DDS, MPH
Commander, U.S. Navy, Assistant Professor, Tri-Service
Center for Oral Health Studies, Uniformed Services
University of the Health Sciences, Department of
Defense, Bethesda, MD

Lawrence McKinley DDS
Captain, U.S. Navy, Senior Consultant for Dentistry,
Tricare Management ,4ctivity, Department of Defense,
Falls Church, VA
Edward Sondik PhD

Director, National Center for Health Statistics,
Centers for Disease Control and Prevention, DHHS,
Hyattsville, MD

xvii


Acknowledgments

Sue Swenson
Commissioner, Administration on Developmental
Disabilities, Administration for Children and Families,
DHHS. Washington, DC
Jeanette Takamura

Ron J. Vogel
Acting Deputy Administrator of the Food and
Nutrition Programs, Food and Nutrition Service,
Department of Agriculture, Alexandria, VA

Assistant Secretary for Aging, Administration on
Aging, DHHS, Washington, DC

. . .
XVIII

,

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


Contents

Executive Summary
   THE CHALLENGE, 4
   THE CHARGE, 4

THE SCIENCE BASE FOR THE REPORT, 5
ORGANIZATION OF THE REPORT, 5
   Part One: What Is Oral Health? 5
   Part Two: What Is the Status of Oral Health in America? 6'
  Part Three: What Is the Relationship Between Oral Health
     and General Health and Well-being? 6
   Part Four: How Is Oral Health Promoted and Maintained
      and How Are Oral Diseases Prevented? 7
  Part Five: What Are the Needs and Opportunities to
      Enhance Oral Health? 9
MAJOR FINDINGS, 10
A FRAMEWORK FOR ACTION, 11
CONCLUSION, 13
REFERENCES, 13
PROJECT TEAM, 13

2ART ONE
( lt;tptcr 1

WHAT IS ORAL HEALTH?
The Meaning of Oral Health
   THE CHALLENGE, 19
   THE CHARGE, 19
   THE SCIENCE BASE FOR THE REPORT, 19
   ORGANIZATION OF THE REPORT, 20
       What Is Oral Health? 20
      What Is the Status of Oral Health in America? 20
     What Is the Relationship Between
         Oral Health and General Health and
        Well-being? 20

      How Is Oral Health Promoted and Maintained and
         How Are Oral Diseases Prevented? 21
     What Are the Needs and Opportunities to
          Enhance Oral Health? 21
      A Call to Action, 21
The Craniofacial Complex
   CONTACT AND COMMUNICATION, 23
      Taste and Smell, 23
     Touch, Temperature, and Pain, 24
     Speech, 25

THE ORAL GAVIN, 25
   The Oral Mucosa, 25
   The Teeth, 26
  The Salivary Glands, 26
  The Immune System, 27

15
17

23

ORAL HEALTH IN AMERICA: .X REPORT OF THE SURGEON GENERAL          xix


Contents

CRANIOFACIAL ORIGINS, 28
  Early Development, 29
   Genetic Controls, 30
THE AGING OF CRANIOFACIAL TISSUES, 31
   The Teeth, 31
   The Jaws, 31
   The Oral Mucosa, 32
   Sensory and Motor Functioning, 32
  The Salivary Glands, 32
FINDINGS, 32
REFERENCES. 33

PART TWO
Chapter 3

WHAT IS THE STATUS OF ORAL HEALTH IN AMERICA?
Diseases and Disorders                              ,

   DENTAL AND PERIODONTAL INFECTIONS, 37
      Dental Caries, 37
      Periodontal Diseases, 39
   SELECTED MUCOSAL INFECTIONS AND CONDITIONS, 42
       Oral Candidiasis, 42
     Herpes Simplex Virus Infections, 43
     Oral Human Papillomavirus Infections, 43
      Recurrent Aphthous Ulcers, 43
    ORAL AND PHARYNGEAL CANCERS AND
    PRECANCEROUS LESIONS, 44
     Heightening the Risk, 44
     Prevention and Management, 47
   DEVELOPMENTAL DISORDERS, 47
      Craniofacial Anomalies Caused by Altered
        Branchial Arch Morphogenesis, 47
      Cranial Bone and Dental Anomalies, 48
     Craniofacial Defects Secondary to Other
        Developmental Disorders, 49
     Craniofacial Manifestations of Single-Gene Defects, 49
   INJURY, 50
      Sports, 50
      Falls, 50

Motor Vehicle Collisions, 50
Violence, 51

SELECTED CHRONIC AND DISABLING CONDITIONS, 51
  Sjogren`s Syndrome, 51
   Acute and Chronic Oral-Facial Pain, 52
  Temporomandibular Disorders, 52
A MIRROR. A MODEL, AND A BETTER UNDERSTANDING
OF DISEASES AND DISORDERS, 53
FINDINGS, 53
REFERENCES, 53

35
37

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


Contents

Chapter -I

The Magnitude of the Problem
   WHO HAS WHAT DISEASES AND CONDITIONS? 63
      Dental Caries, Periodontal Diseases, and Tooth Loss, 63
     Oral and Pharyngeal Cancers and Precancerous Lesions, 67
      Selected Mucosal Infections and Diseases, 70
     Developmental Disorders, 71
      Injury, 72
     Chronic and Disabling Conditions, 73
   WHAT IS THE BURDEN OF DISEASE IN SELECTED
     POPULATIONS? CHALLENGES AND OPPORTUNITIES, 74
      Racial and Ethnic Minorities, 74
       Women's Health, 77
       Individuals with Disabilities, 78                      .
    UTILIZATION OF PROFESSIONAL CARE: WHAT DO WE
     KNOW ABOUT THE RELATIONSHIP OF ORAL HEALTH
     AND USE OF DENTAL SERVICES? 79
      Dental Care Utilization, 80
     Variation by Sex, Race/Ethnicity, Income,
         and Insurance, 81

61

Variation by Oral Health Status, 82
Reasons for Nonutilization, 83
Unmet Needs, 83

  Outcomes of Appropriate Levels of Access and
     Utilization: An Example, 83
ORAL HEALTH STATUS IN CHANGING TIMES, 87
FINDINGS, 89
REFERENCES, 89

PART THREE

t .Il;ipter 5

WHAT IS THE RELATIONSHIP BETWEEN ORAL
HEALTH AND GENERAL HEALT.H AND WELL-BEING?
Linkages with General Health
   THE MOUTH AND FACE AS A MIRROR OF HEALTH
     AND DISEASE, 97

95
97

Physical Signs and Symptoms of Disease and Risk Factors, 97
Oral Manifestations of HIV Infection and of Osteoporosis, 101
Oral-fluid-based Diagnostics:

  The Example of Saliva, 103
Conclusion, 104

THE MOUTH AS A PORTAL OF ENTRY FOR INFECTION, 104
   Oral Infections and Bacteremia, 104
   Oral Infections as a Result of Therapy, 105
   Infective Endocarditis, 107
  Oral Infections and Respiratory Disease, 108
   Oral Transmission of Infections, 108
   Conclusion, 109

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


Contents

CRANIOFACIAL ORIGINS, 28
   Early Development, 29
   Genetic Controls, 30
THE AGING OF CRANIOFACIAL TISSUES, 31
   The Teeth, 31
   The Jaws, 31
   The Oral Mucosa, 32
   Sensory and Motor Functioning, 32
   The Salivary Glands, 32
FINDINGS, 32
REFERENCES, 33

PART TWO
Chapter 3

WHAT IS THE STATUS OF ORAL HEALTH IN AMERICA?
Diseases and Disorders
   DENTAL AND PERIODONTAL INFECTIONS, 37
      Dental Caries, 37

35
37

   Periodontal Diseases, 39
SELECTED MUCOSAL INFECTIONS AND CONDITIONS, 42
   Oral Candidiasis, 42
  Herpes Simplex Virus Infections, 43
   Oral Human Papillomavirus Infections, 43
  Recurrent Aphthous Ulcers, 43
ORAL AND PHARYNGEAL CANCERS AND
PRECANCEROUS LESIONS, 44
  Heightening the Risk, 44
   Prevention and Management, 47
DEVELOPMENTAL DISORDERS, 47
   Craniofacial Anomalies Caused by Altered
     Branchial Arch Morphogenesis, 47
   Cranial Bone and Dental Anomalies, 48
   Craniofacial Defects Secondary to Other
     Developmental Disorders, 49
   Craniofacial Manifestations of Single-Gene Defects, 49
INJURY, 50
   Sports, 50
   Falls, 50

Motor Vehicle Collisions, 50
Violence, 5 1

SELECTED CHRONIC AND DISABLING CONDITIONS, 51
  Sjogren's Syndrome, 5 1
   Acute and Chronic Oral-Facial Pain, 52
   Temporomandibular Disorders, 52
A MIRROR, A MODEL, AND A BETTER UNDERSTANDING
OF DISEASES AND DISORDERS, 53
FINDINGS, 53
REFERENCES, 53

xx          ORAL HE4LTH IN .4MERICA: A REPORT OF THE SURGEON GENERAL


Contents

The Magnitude of the Problem
   WHO HAS WHAT DISEASES AND CONDITIONS? 63
      Dental Caries, Periodontal Diseases, and Tooth Loss, 63
     Oral and Pharyngeal Cancers and Precancerous Lesions, 67
      Selected Mucosal Infections and Diseases, 70
     Developmental Disorders, 71
      Injury, 72
     Chronic and Disabling Conditions, 73
   WHAT IS THE BURDEN OF DISEASE IN SELECTED
    POPULATIONS? CHALLENGES AND OPPORTUNITIES, 74
      Racial and Ethnic Minorities, 74
      Women's Health, 77
      Individuals with Disabilities, 78
  UTILIZATION OF PROFESSIONAL CARE: WHAT DO WE *
     KNOW ABOUT THE RELATIONSHIP OF ORAL HEALTH
     AND USE OF DENTAL SERVICES? 79
       Dental Care Utilization, 80
     Variation by Sex, Race/Ethnicity, Income,
          and Insurance, 81

61

Variation by Oral Health Status, 82
Reasons for Nonutilization, 83
Unmet Needs, 83

  Outcomes of Appropriate Levels of Access and
     Utilization: An Example, 83
ORAL HEALTH STATUS IN CHANGING TIMES, 87
FINDINGS, 89
REFERENCES, 89

PART THREE

(.Iq)tcr 5

WHAT IS THE RELATIONSHIP BETWEEN ORAL
HEALTH AND GENERAL HEALTH AND WELL-BEING?
Linkages with General Health
   THE MOUTH AND FACE AS A MIRROR OF HEALTH
     AND DISEASE, 97

Physical Signs and Symptoms of Disease and Risk Factors, 97
Oral Manifestations of HIV Infection and of Osteoporosis, 101
Oral-fluid-based Diagnostics:

  The Example of Saliva, 103
Conclusion, 104

THE MOUTH AS A PORTAL OF ENTRY FOR INFECTION, 104
   Oral Infections and Bacteremia, 104
  Oral Infections as a Result of Therapy, 105
   Infective Endocarditis, 107
  Oral Infections and Respiratory Disease, 108
   Oral Transmission of Infections, 108
   Conclusion, 109

95
97

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


Contents

ASSOCIATIONS AMONG ORAL INFECTIONS AND
DIABETES, HEART DISEASE/STROKE, AND
ADVERSE PREGNANCY OUTCOMES, 109
   The Periodontal Disease-Diabetes Connection, 109
   The Oral Infection-Heart Disease and Stroke Connection. 115
  Periodontal Disease and Adverse Pregnancy Outcomes, 120
   Conclusion, 122

Chapter 6

   IMPLICATIONS OF THE LINKAGES, 122
   FINDINGS, 123
   REFERENCES, 123
Effects on Well-being and Quality of Life                 133
   THE CULTURAL CONTEXT, 134
      Cultural Models, 134                     e

      Combining Perspectives, 134
   ORAL-HEALTH-RELATED QUALITY OF LIFE DIMENSIONS, 135
       Functional Dimensions, 135
      Psychosocial Dimensions, 137
       Indirect Economic Costs, 142
   RATINGS OF ORAL HEALTH, 144
      Global Ratings, 144
     Satisfaction Ratings, 144
   ORAL-HEALTH-RELATED QUALITY OF LIFE
    MEASURES, 144
   HEIGHTENED EXPECTATIONS, 146
   FINDINGS, 146
   REFERENCES, 147

PART FOUR


Chapter 7

HOW IS ORAL HEALTH PROMOTED AND
MAINTAiNED AND HOW ARE ORAL
DISEASES PREVENTED?
Community and Other Approaches to Promote Oral
Health and Prevent Oral Disease
    WEIGHING THE EVIDENCE THAT INTERVENTIONS
    WORK, 155

153


155

PREVENTION AND CONTROL OF DENTAL CARIES, 158
   Fluoride, 158

Fluoridation of Drinking Water, 160
School Water Fluoridation, 162
Dietary Fluoride Supplements, 162
Fluoride Mouthrinses, 165
Fluoride Varnishes, 165
Dental Sealants, 166

PREVENTION AND CONTROL OF PERIODONTAL DISEASES, 168
   Community Programs to Prevent Gingivitis, 169
   Prevention of Periodontitis, 169
   Summary, 169

PREVENTION AND CONTROL OF ORAL AND
PHARYNGEAL CANCERS, 169
  Community-based Interventions, 170
  Early Diagnosis of Oral and Pharyngeal Cancers, 171
   Summary 172

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


Contents

Chilpter 9

PREVENTION AND CONTROL OF CRANIOFACIAL
BIRTH DEFECTS, 172
   Summary, 173

PREVENTION AND CONTROL OF INTENTIONAL
AND UNINTENTIONAL INJURY, 173
  Craniofacial Injuries, 173
  Summary: Prevention of Craniofacial Injuries, 176
ORAL HEALTH PROMOTION AND DISEASE PREVENTION
KNOWLEDGE AND PRACTICES, 176
   Dental Caries Prevention, 177
   Periodontal Disease Prevention, 178
  Oral Cancer Prevention and Early Detection, 178
   Summary, 179

BUILDING UPON SUCCESS, 179
FINDINGS, 181
REFERENCES, 181

Personal and Provider Approaches to Oral Health
   INDIVIDUAL RESPONSIBILITY: PERSONAL APPROACHES
    TO ORAL HEALTH, 189
     Daily Hygiene and Dental Caries Prevention, 189
     Daily Hygiene and the Prevention of Periodontal Diseases, 190
     Healthy Lifestyles, 190
     Care Seeking, 190

PROVIDER-BASED CARE, 191
   Risk Assessment, 192
   Diagnostic Tests, 193

   Oral Health Assessment, 193
  Changing Approaches to Selected Diseases and Conditions, 196
  Chronic'Craniofacial Pain and Sensorimotor Conditions, 211
  Temporomandibular Disorders, 211
   Mucosal and Autoimmune Diseases, 212
FACTORS AFFECTING FUTURE HEALTH CARE PRACTICES, 212
   Evidence-based Practice, 213
   Clinical Practice Guidelines, 213
  Science and Technology Contributions, 214
  Broadening the Base for the Provision of Oral Health Care, 216
FINDINGS, 216
REFERENCES, 216

Provision of Oral Health Care
   COMPONENTS OF PROFESSIONAL CARE, 223
     The Dental Component, 223
     The Medical Component, 225
     The Public Health Component, 225
     Areas of Overlap, 227
   EXPENDITURES FOR ORAL HEALTH CARE, 227
   FINANCING AND REIMBURSEMENT, 229
       Insurance, 229

The Changing Market, 231
Federal and State Programs, 233

189

223

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL             . . .
                                                                XXIII


Contents

FACTORS AFFECTING THE CAPACITY TO MEET ORAL
HEALTH NEEDS, 234
   Numbers of Dental Personnel, 235
  Sex and Racial/Ethnic Composition of Dental Personnel, 236
   Student Indebtedness and Its Effects, 237
  Personnel Needs for Faculty and
      Clinical Research, 238
   Curriculum Needs, 238
  Taking Care of Those Most in Need, 239
TWENTY-FIRST CENTURY CHALLENGES:
WHAT LIES AHEAD? 239
FINDINGS, 240
REFERENCES, 241

PART FIVE

Chapter 10

WHAT ARE THE NEEDS AND OPPORTUNITIES TO
ENHANCE ORAL HEALTH?
Factors Affecting Oral Health over the Life Span
   HEALTH IN THE CONTEXT OF SOCIETY, 245
      Historical Models, 245
     Contemporary Models, 246
   CHANGING VULNERABILITIES THROUGHOUT LIFE, 249
      Children, 249

Adolescents and Young Adults, 257
Midlife Adults, 258

Chapter 11

Chapter 12

      Older Americans, 262
   ACHIEVING ORAL HEALTH THROUGHOUT LIFE, 267
   FINDINGS, 269
   REFERENCES, 269
Facing the Future
   THE PAST AND PRESENT AS PROLOGUE, 275
      The Pioneers, 275
      Vital Statistics, 275
     Health Improvement, 276
   DIVERSITY OF DISEASES AND PATIENTS, 276
   TRANSFORMING TREATMENTS, 276
   TRANSFORMING HEALTH PROFESSIONAL EDUCATION, 276
   TRANSFORMING HEALTH CARE, 277
   ORAL HEALTH-NOT YET FOR ALL, 277
   HOPE FROM SCIENCE AND TECHNOLOGY, 278
   A FRAMEWORK FOR ORAL HEALTH, 280
   REFERENCES, 281
A Call to Action
   MAJOR FINDINGS, 283
   A FRAMEWORK FOR ACTION, 284
   CONCLUSION, 287
Index

243
245

275

283

289

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


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

1


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


The Craniofacial Complex

Thus there is an opportunity for infectious agents or
their byproducts to penetrate the naked epithelial
barrier and initiate an inflammatory response, as hap-
pens in gingival disease.

Special cells in the basal layer of the oral mucosa
generate replacements for surface cells as they
wear out. The painful oral ulcers and oral mucositis
that may develop in patients undergoing radiation
or chemotherapy for head and neck cancer occur
because these cancer-killing agents attack all
cells undergoing rapid turnover, whether healthy or
cancerous.

The Teeth

The most prominent features of the oral cavity are the
teeth. The 20 primary, or deciduous, teeth erupt gen-
erally between 6 months and 2 to 3 years of age and
are succeeded by the permanent teeth beginning at
about age 6. The primary teeth enable infants to eat
solid foods, aid speech development, and serve as
placeholders for the permanent dentition. Keeping
primary teeth healthy is important, not only in spar-
ing an infant pain and disease, but also in preserving
the dimensions of the dental arches and lessening the
risk of dental caries in the permanent teeth. A period
of mixed primary and permanent dentition occurs
from about ages 6 to 13. There are 28 to 32 perma-
nent teeth, depending on whether the 4 wisdom
teeth (third molars), which are last to erupt, are pres-
ent. Teeth are anchored in the jaws by the periodon-
tal ligament. This ligament connects the cervix
(neck) of the tooth, at the junction between the
crown and root, to the gingiva. Below that, the liga-
ment connects the outer layer of the tooth root, the
cementum, to the adjacent alveolar bone (the part of
the jaw bone that supports the tooth roots).
The evolutionary forces that shaped the human
mouth designed an apparatus for optimal food
intake. The front four upper and lower incisor teeth
are chisel-shaped for biting, cutting, and tearing and
exert forces of 30 to 50 pounds. The canines, or
cuspids, are larger and stronger and have deeper
roots than the incisors; their conical cusps are
effective for ripping and tearing. The premolars, or
bicuspids, and the molars are designed for heavy
grinding and chewing, exerting forces as high as 200-
plus pounds. The temporomandibular joint, the most
complex synovial joint in the body, equips the
human jaw with extraordinary mobility, enabling
movements in three dimensions. Its range of motion
is controlled by three sets of muscles of
mastication-the masseter, temporalis, and pterygoid
muscles (Oberg 1994). Chewing reduces food to

small particles and mixes it with saliva to form a
bolus for swallowing.

The Salivary Glands

Saliva is the mixed product of multiple salivary
glands that lie under the mucosa. The three major
glands are the paired parotid, submandibular, and
sublingual glands. The parotids, near the ears, secrete
a watery saliva into the mouth via ducts in the
cheeks. The walnut-sized submandibular glands lie
in the floor of the mouth and secrete a mucous fluid.
The secretions of the almond-shaped sublingual
glands, also in the floor of the mouth but near the
front, usually join with those of the submandibular
glands. Tiny minor salivary glands are scattered with-
in the inner surfaces of the lips, cheeks, and soft and
hard palates; these secrete a mutinous saliva directly
onto the soft tissue surfaces.

Saliva moistens food and provides mutinous pro-
teins to lubricate the bolus for ease of swallowing.
The combined movements of the tongue and cheeks
move the bolus to the back of the mouth. Saliva also
contains the enzyme amylase, which initiates the
digestion of starch. By solubilizing food components
and facilitating their interaction with the taste buds
on the tongue and palate, saliva also contributes to
taste enhancement.

Tissue Protection

The main function of saliva is not-as is commonly
believed-to aid digestion, but to protect the integri-
ty of the oral tissues. The moment a baby passes
through the birth canal and takes its first breath,
microbes begin to take up residence in its mouth.
Later, as the teeth erupt, additional bacteria establish
colonies on tooth surfaces (Mandel 1989). Nearly
500 species of microbes in all, most of which are not
harmful, will colonize the oral cavity (Kroes et al.
1999). The microbes form a biofilm, in which their
numbers greatly exceed the number of human inhab-
itants on Earth.

Millions of years before there were toothbrushes,
dental floss, and water irrigators, evolutionary forces
generated protective mechanisms to combat poten-
tially harmful microbes. The physical flow of saliva
helps to dislodge pathogens (viruses, bacteria, and
yeast) from teeth and mucosal surfaces, just as tear-
ing and blinking, sneezing, and coughing and expec-
torating clear the eye, nose, and throat. Saliva can
also cause microbes to clump together so that they
can be swallowed before they become firmly
attached. Saliva can destroy orally shed infected

26

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


\vliite blood cells by virtue of its low salt content: the
,nfected cells-of higher salt content-swell and
lltlrst when exposed to fluids of lower salinity (Baron
C[ al. 1999).

Salivary secretions, like tears and other exocrine
+nd secretions, are rich in antimicrobial compo-
nents. Certain molecules in saliva, such as lysozyme,
lactoferrin, peroxidase, and histatins, can directly kill
Or inhibit a variety of microbes; the histatins are par-
ticularly potent antifungal agents (Xu et al. 1991).
Selreral salivary proteins exhibit antiviral properties,
including secretory leukocyte protease inhibitor
(SLPI), recently discovered to have the ability to
Inhibit HIV from invading cells (Shugars and Wahl
1998).

The ability of saliva to limit the growth of
pathogens, in some instances even preventing them
lrom establishing a niche in the biofilm community
in the first place, is a major determinant of general as
\vell as of oral health. When salivary flow is compro-
mised, the gateway to the body can open wide to
local as well as to systemic pathogens.

Barrier and Buffering Properties

Salivary components protect oral tissues in other
ways as well. Mucins have unique properties that
enable them to concentrate on mucosal surfaces and
provide an effective barrier against drying and physi-
cal and chemical irritants (Tabak 1995). They act as
natural waterproofing, control the permeability of
ihe tissue surfaces, and help limit penetration of
potential irritants and toxins in foods and beverages,
as well as toxic chemicals and potential carcinogens
In tobacco and tobacco smoke and from other
sources. This barrier function complements the bar-
rier formed by the oral mucosa itself. The mucosa has
a specific permeability coefficient that can change
under various conditions of stress, nutritional status,
and other challenges.

Saliva contains several effective buffering sys-
tems that can help maintain a normal pH when acidic
foods and beverages are introduced, thereby protect-
ing oral tissues against acidic attack. When swal-
lowed, these buffers protect the esophagus, helping
neutralize the reflux acids of conditions such as
heartburn and hiatal hernia (Sarosiek et al. 1996).

Wound Healing

Saliva also contains molecules that nurture and pre-
serve the oral tissues, even helping them to repair
and regenerate (Mandel 1989, Tabak 1995, Zelles et
al. 1993). Experimental studies have shown that
ivound healing is significantly enhanced by saliva, in

The Craniofacial Complex

part because of the presence of a potent molecule,
epidermal growth factor (EGF) (Zelles et al. 1995).
When swallowed, EGF can also protect the tissue
surfaces of the esophagus (Sarosiek et al. 1996).
Vascular endothelial growth factor (VEGF) has also
been identified in saliva. VEGF stimulates blood ves-
sels and may contribute to the remarkable healing
capacity of oral tissues (Taichman et al. 1998, Zelles
et al. 1995).

Caries Protection

Saliva also guards against dental caries (tooth decay),
the disease that has been the greatest threat to teeth.
Caries is caused by bacteria that generate acids that
attack tooth mineral (see Chapter 3). The buffering
systems in saliva, augmented by the neutralizing
components urea and ammonium, counter the acid
formation. The physical flow of saliva also helps
flush out sugars and food particles that are the bacte-
rial food source. Mineral salts in saliva-calcium and
phosphate-can remineralize tooth enamel, effec-
tively reversing the decay process. This regenerative
function is greatly enhanced by the presence of fluo-
ride in saliva. Finally, saliva forms a film on teeth
made up of selectively adsorbed proteins that have a
high affinity for tooth mineral. This acquired pellicle
is insoluble and limits the diffusion of acids into the
teeth and the dissolution of tooth mineral (Lamkin
and Oppenheim 1993).

The Immune System

The salivary glands and the oral mucosa, along with
the body's other mucosal linings and the lymphatic
circulation, constitute a major component of the
body's defense system-the mucosal immune system
(Mestecky 1987). When the area of the oral mucosa
is combined with the areas of the mucosal linings and
passageways of the respiratory, gastrointestinal, uri-
nav, and genital tracts, the total represents the largest
surface area of the body-nearly 400 square meters,
or 200 times larger than the total skin area.

The great majority of infectious diseases affect,
or are acquired through. mucosal surfaces. Immune
cells that line the mucous membranes throughout
the body secrete antibodies targeted to specific
disease-causing microbes (Mandel and Ellison 1985).
The mucosal immune system works in concert with
the bloodborne immune system to detect and dispose
of foreign substances and invading microbes.

The two components of the immune system con-
sist of molecules and cells that provide both broad
and specific defense mechanisms. In the broad group

ORAL HE4LTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           27


are some circulating white blood cells (monocytes
and granulocytes) associated with the inflammatory
response. These cells migrate to a site of injury or
infection and move into damaged tissues manifest-
ing the four signs of inflammation: swelling, heat,
redness, and pain. The cells promote an increase in
blood flow to begin the healing process, and they
recruit other cells able to engulf and dispose of the
offending organism.

The specific immune system is associated with
two major classes of immune cells: T cells and B cells.
T cells react to antigens (proteins associated with
microbes or irritants) and can stimulate B cells to
make antigen-specific antibodies. These are the Y-
shaped molecules called immunoglobulins.

T cells are the instruments of cell-mediated
immunity; they are able to detect telltale surface
markers on diseased or foreign cells that distinguish
them from normal body cells. Some T cells can kill
infected cells and cancer cells directly T cells are also
involved in the rejection of organ transplants.

Certain T cells are memory cells, preserving the
information from earlier encounters with specific
pathogens. Thus they are able to initiate more rapid
and effective responses in the event of a repeat
encounter with the pathogen. Helper T cells assist in
activating killer T and B cells. It is the loss of helper
T cells that leads to the many infections that cause ill-
ness and death in HIV disease. Still another group of
T cells, suppressor T cells, moderates the activities of
both B and T lymphocytes.

Activated T cells generate and release
cytokines-potent families of proteins, such as the
interleukins, that can stimulate immune cells to
divide, migrate, attack, and engulf invaders or partic-
ipate in the inflammatory response. Other cytokines
include varieties of tumor necrosis factor and
adhesins (proteins that facilitate the binding of
immune cells to each other or to blood vessel lin-
ings). Feedback mechanisms provide a system of
checks and balances to regulate cytokine production.

The immune system interacts with the nervous
and endocrine systems. For example,  immune
cytokines secreted into the brain can induce the fever
associated with infection: the high temperature may
help destroy the infectious agent. The brain's
response to stress also has repercussions for the
immune system. The hypothalamus-pituitary-adre-
nal axis is a major pathway activated in response to
stress, which results in the secretion of cortisol, the
stress hormone, from the adrenal glands. Cortisol
promotes the body's fight-or-flight mechanisms, but
via feedback loops, cortisol acts to depress immune
reactions.

Much of what we know about the immune sys-
tem has come from studies of serum factors, but
research in the last two decades has generated much
new information about mucosal immunity (McGhee
and Kiyono 1999). The mucosal immune system can
be divided into inductive and effector compartments.
The nasal-associated lymphoreticular tissues (NALT)
in the nasopharyngeal area (which includes the ton-
sils) and the gut-associated lymphoreticular tissues
(GALT) in gut tissue are inductive regions, where
foreign invaders are encountered. If, for example,
infectious bacteria are swallowed, they can stimulate
immune cells in GALT to circulate T and B cells
through the lymph system to various effector sites in
the gastrointestinal and uppe? respiratory tracts and
in the salivary and other exocrine glands. The B cells
in the gland produce antibodies, designated S-IgA, to
which is attached a secretory component (Mestecky
and Russell 1997). These antibodies are the domi-
nant type found in saliva, tears, breast milk, and
colostrum and in the gastrointestinal and genitouri-
nary tracts.

The uses of the mucosal immune system extend
beyond its normal surveillance and defense func-
tions. The tissues can be used as routes for delivery
of oral (swallowed) or nasal (inhaled) vaccines, as
sites for gene transfer to augment host defenses, and
as a means of invoking oral tolerance-the suppres-
sion of overactive or inappropriate immune respons-
es that occur in chronic inflammatory and autoim-
mune diseases (Baum and O'Connell 1995,
Hajishengallis and Michalek 1999).

CRANIOFACIAL ORIGINS

The extraordinary successes of research in molecular
genetics over the past decade, coupled with the
National Institutes of Healths project to map and
sequence the human genome, have proved to be a
boon in understanding craniofacial development.
The use of automated gene-sequencing equipment,
the Internet availability of genome databases, and the
ability to transfer genes or create "knockout" ani-
mals-in which a gene of interest has been eliminat-
ed-have greatly facilitated progress. The events that
govern the transformation of a fertilized human egg
cell into a healthy newborn with all organs and sys-
tems in place are being unfolded at the molecular
level. Families of master and regulatory genes have
been identified, and their role in controlling how the
body's general shape and specialized tissues and
organs are formed is coming to light.

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


Early Development

The Three Germ Cell Layers

gy the time the face and the mouth are ready to form,
the human embryo is in the third week of develop-
ment. The embryo has evolved from a sphere to an
oval two-layered disk with a head-to-tail orientation.
The outer layer is the epiblast and will become the
ectodermal germ layer. A narrow groove, called the
primitive streak, extends from the tail toward the
center of the disk, where it ends in a spot surround-
ing a small depression called the primitive pit.
Epiblast cells migrate toward the streak and pit,
detach from the surface, and slip downward to form
the two additional germ cell layers, the mesoderm
and, below that, the endoderm.

The ectodermal layer gives rise to tissues that
relate the body to the outside world: the nervous SYS-
tern; the sensory epithelium of the ears, nose, and
eyes; skin, hair, nails, salivary glands, tonsils, and
tooth enamel; and the pituitary.mammary, and sweat
glands. At the head end, the mesodermal layer gives
tise to a primitive connective tissue, called mes-
enchyme, which will interact with the ectoderm to
form parts of the head and mouth. The remaining
mesoderm develops into the muscle, cartilage, bone,
and subcutaneous skin tissue of the rest of the body.
The mesoderm is also the origin of the vascular and
urogenital systems (except for the bladder), the
spleen, and the adrenal cortex. The innermost, endo-
dermal layer provides the linings of the gut, the res-
piratory system, bladder, liver, pancreas, thyroid and
parathyroid glands, and parts of the middle ear.

Neural Tube and Neural Crest

Further migrations and descending movements of
cells result in the formation of the notochord, a solid
cord of cells along the midline that will become the
backbone. The ectoderm above the notochord next
thickens to form a neural plate. The sides of the plate
curve up and inward to form a neural tube, beginning
at the head, with fusion completed by the end of the
fourth week. The tail end of the tube will form the
spinal cord; the head end differentiates into the three
parts of the primitive brain: the forebrain, midbrain,
and hindbrain.

What happens next is of central importance to
the craniofacial complex: cells that were at the edges
of the neural plate break away to form neural crest
cells, which migrate to the forebrain area and to the
nearby branchial arches, a series of swellings on
either side of the embryo, adjacent to the hindbrain.
The hindbrain becomes organized into eight rhom-

bomeres, segments of future nerve tissue arranged in
an orderly fashion so that the first two rhombomeres
innervate branchial arch 1, and so on.

During the formation of the midbrain and hind-
brain, cranial neural crest cells migrate into the
developing facial areas and differentiate into neu-
ronal and nonneuronal tissues. The neuronal tissues
include the clusters of nerve cells (ganglia) that lie
adjacent to the spinal cord, parts of the ganglia of
four cranial nerves, and two of the meningeal layers
of the brain. The nonneuronal tissues include major
bones, cartilage, the dentin and cementum of teeth,
and the various types of connective tissues of the
craniofacial complex, as well as the muscles of the
eye. The branchial arches give ris6 to the bones, car-
tilage, nerves, muscles, and blood supply of succes-
sive segments of the head and neck.

The Face and Mouth

The branchial arches play a key role in the formation
of the facial structures. Toward the end of the fourth
week of gestation, a primitive mouth appears. This
"stomadeum" is flanked by a series of swellings, or
prominences, derived from the first pair of branchial
arches. A single frontonasal prominence forms the
upper border of the stomadeum. On either side of
this prominence are two thickened regions of ecto-
derm-the nasal placodes. At the sides of the stom-
adeum and below it are pairs of maxillary and
mandibular prominences.

In the course of the next 3 weeks, differential
growth and movements of the various prominences
and fusions of tissues that come together at the mid-
line will sculpt the bridge, crest, sides, and tip of the
nose, the upper and lower lips, and the upper and
lower jaws (Bhaskar and Orban 1990, Sadler and
Langman 1995).

The external merger at the midline of a pair of
prominences that helps to form the nose occurs
inside the mouth as well, resulting in an intermaxil-
laty segment that will contribute to the formation of
the four upper incisors and parts of a small triangu-
lar-shaped primary palate and the upper jaw. The
bulk of the palate, the secondary palate, forms from
shelflike outgrowths of the maxillary prominences.
These growths appear in the sixth week, and in the
following week fuse along the midline above the
tongue. (The tongue appears at approximately 4
weeks, the front two-thirds forming from the first
branchial arch, and the posterior third from parts of
the second, third, and fourth branchial arches.) The
palatal shelves also fuse with the primary palate
along a triangular border called the incisive foramen.

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


The Craniofacial Cornples

This border is considered the line of division among
clefting abnormalities. Lateral cleft lip, cleft upper
jaw, and clefts between the primary and secondary
palates are associated with defects anterior to the
incisive foramen. Cleft palate and cleft uvula occur
because of defects affecting closure of the palatal
shelves posterior to the foramen (Bhaskar and Orban
1990, Sadler and Langman 1995).

The Teeth

Tooth development begins in the sixth week with the
appearance of an epithelial band lining the upper and
lower jaws. A part of the band develops into a dental
lamina, which forms a series of projections into the
jaw. These are the tooth buds and correspond to the
sites of deciduous teeth. The epithelial tissue of the
bud develops into an enamel organ that forms a cap
over tissue that is differentiating in the jaw to become
the dental papilla. The two structures-the enamel
organ. derived from the epithelium, and the dental
papilla, derived from neural crest mesenchyme-
constitute the tooth germ.

With further development, the tooth germ
assumes a bell shape and separates from the oral
epithelium. At the same time, the internal epithelial
layer of the enamel organ undergoes a series of
infoldings that will shape the future crown of the
tooth.

Mineralization of the tooth begins at the late bell
stage. The first mineralized tissue to form is dentin,
which provides the foundation for the deposition of
enamel. The differentiation of the odontoblasts (the
dentin-producing cells) depends on organizing
influences from enamel organ cells. Thus the
development of these two different hard tissues is a
mutually dependent process.

  As dentin is laid down, the odontoblasts move
toward the center of the papilla, trailing thin cellular
processes, which become embedded in the mineral-
ized matrix. When dentin formation is completed,
dentin completely surrounds the pulp, protecting it
from injury. The enamel layer of the tooth starts to
form soon after the first dentin appears, synthesized
by special enamel-forming cells, or ameloblasts,
which develop from the enamel organ. The tooth
root, and its outer layer of cementum, form only after
the crown erupts.

Genetic Controls

Only in the last decade have scientists begun to
understand how certain genes and gene families
control embryonic development. Their findings have

come from detailed studies of species ranging from
fruit flies, nematodes, and zebrafish to frog, chick,
mouse, and human embryos. In many cases, the
simpler organism has been the source of discoveries
of genes or developmental processes that are highly
conserved in the course of evolution (Alberts et al.
1994).

Research on the fruit fly, for example, has
revealed that particular families of genes are respon-
sible for the fundamental head to thorax to tail pat-
terning of the fly's body. Another set of genes deter-
mines the back-to-front positioning of organs, and a
third set subdivides this general body plan into a
series of discrete segments. With further develop-
ment, yet another family of genes confers a position-
al memory on the cells within a segment. These
"homeotic selector" genes ensure that cells in one
part of a particular segment "know" that they are des-
tined to be wings and not legs, or to be eyes and not
antennae. In flies the homeotic genes are known as
Horn genes. Their arrangement on the fly chromo-
some is ordered with genes at one end of the chro-
mosome specifying the developmental destiny of
cells in the most anterior segments of the fly's body
and genes at the other end specifying the fate of cells
in the most posterior segments.

In the course of evolution, mammals have devel-
oped four overlapping sets of positional memory
gene clusters homologous to the fly's single Horn
complex. The four mammalian Hex gene families are
ordered in a similar anterior-posterior fashion along
four different chromosomes. The mammalian genes
appear to operate like the Horn genes: they code for
DNA-binding proteins that control gene expression.
The similarity from fly to human is particularly evi-
dent when maps of the expression domains of Horn
genes in anterior segments of the fly embryo are com-
pared to maps of Hex gene expression as seen in the
rhombomeres and branchial arches of mammals.

Molecular genetic studies of flies and other non-
mammalian species show some variation in how and
when the basic body patterns and repeating segments
are formed. Sometimes the head-to-tail pattern is laid
down in the egg cell before fertilization-dictated by
egg polarity genes. Although egg polarity genes do
not operate in humans, mutations have been found
in a human gene homologous to the fly egg polarity
gene and account for serious syndromes in which
there are defects in anterior organs, such as the pitu-
itary gland and heart.

None of these developmental controls work in
isolation. Much remains to be understood about the
genetic clock that determines when and where devel-
opmental genes act, how they interact, and what

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


mechanisms are used to sustain as well as terminate
their function. The systems that govern programmed
cell death are also important: normal development
depends as much on the elimination of cells as it does
on the orderly movement, proliferation, and differen-
tiation of cells.

When it comes to processes that control the
development of particular tissues or organs-bones,
skin, or heart-developmental biologists observe
that there is often an "organizer," that is, a cell or set
of cells that initiates the process. The organizer
induces changes in the behavior of neighboring cells
through cell-cell interactions, so that these cells
develop into the specified type-bone or skin or
heart muscle. The interaction with the neighboring
cell is often in the form of a signaling molecule, such
as a growth factor (e.g., transforming growth factor
b, epidermal growth factor, fibroblast growth factor)
that attaches to a receptor on the surface membrane
of the recipient cell. This interaction is translated to
the interior of the cell, where a chain of molecular
interactions eventually reaches the cell nucleus to
effect gene expression. One of the more startling dis-
coveries of the past decade has been the finding that
a series of mutations, each associated with a change
in only one nucleotide of the gene for the fibroblast
growth factor receptor-a so-called point muta-
tion-accounts for a range of organ defects seen in at
least a  half dozen craniofacial syndromes.
Interestingly, all these syndromes include craniosyn-
ostosis, a premature closure of the bones .that form
the skull.

THE AGING OF CRANIOFACIAL
TISSUES

Normal aging describes the developmental processes
that begin at conception, continue in childhood, and
merge gradually into maturation and senescence. The
milestones of development such as the age when
children teethe, begin to walk, talk, enter puberty,
attain their full height, and so on, are under genetic
and hormonal controls, subject to important envi-
ronmental factors such as nutrition and exercise.
Despite the complexity and interrelationships of the
variables involved, a reasonably accurate picture of
normal age-related changes in the craniofacial com-
plex is emerging (Ship 1999).

Barring major illness or injury, destructive
behaviors, or severe or unusual environmental cir-
cumstances, the cells, tissues, and fluids of the face
and mouth are hardy survivors, eminently durable
and functional over a long life span. For any given
individual the combination of life experience and

The Craniofacial Complex

lifestyle (including medical and dental history) cre-
ates a unique craniofacial portrait, one that inspired
George Orwell to remark, "By the age of fifty, a man
gets the face he deserves."

The Teeth

One of the more dramatic discoveries in biomedical
science in the twentieth century has been the realiza-
tion that tooth loss is not an inevitable consequence
of aging, but the result of disease or injury. Aging
does produce a number of other dental changes,
however. Teeth change in form and color with age.
Wear and attrition alter the biting and chewing sur-
faces, as do food choices and oral habits. The altered
surface structure produces a different pattern of light
reflection in older teeth, resulting in some yellowing
and a general loss of translucency (Mjor 1986). Fully
formed enamel is acellular, hence there is no meta-
bolic activity or turnover as occurs in skin, for exam-
ple. Dentin and cementum have limited cellular
activity. In contrast, tooth pulp and periodontal liga-
ment undergo relatively high levels of tissue
turnover.

Tooth surfaces can be eroded by chemical
dissolution from fruit acids and from acids from
sugars in foods such as soft drinks and candies. This
destructive process can occur at any age, resulting in
loss of translucency as well as some tissue loss from
demineralization (Zero 1996). Countering the
erosive forces are the natural components in saliva
that help remineralize the enamel surface, a process
that is enhanced when fluoride is present (see
"Caries Protection" above).

The cementum increases in thickness with age.
Gingival recession caused by normal aging exposes
the cementum to the oral environment (and is the
origin of the expression "long in the tooth"). The
exposed cementum can often be worn away mechan-
ically, exposing the underlying dentin, which can
then become hypersensitive. Dentin responds
through a series of protective changes that work to
close off the connections between dentin and nerves
in the pulp, reducing transmission of painful stimuli.

The Jaws

The bones of the maxilla and mandible that support
the teeth, called the alveolar processes, are, like bone
elsewhere in the body, subject to cellular turnover
in a coordinated process of bone resorption and

ORAL HEALTH IN AMERICAz A REPORT OF THE SURGEON GENERAL           31


formation. Alveolar bone is well adapted to
mechanical stresses, and changes continuously
during facial growth, tooth eruption, tooth wear, and
tooth loss.  This lifelong adaptation makes
orthodontic treatments to reposition teeth in adults
possible.

Because the primary function of alveolar bone is
to support the teeth, the loss of teeth will lead to
bone atrophy, making prosthetic replacements diffi-
cult. The rate of bone loss is affected by both local
disease such as periodontal disease and systemic con-
ditions such as osteoporosis (Bhaskar 1991).

The Oral Mucosa

The oral mucosa appears to age in much the same
way as skin does. The oral epithelium thins and
becomes less hydrated, increasing vulnerability to
injury The rate of cell division is slower, but the basic
cell architecture and patterning of cell types through-
out the oral cavity are maintained. It is not certain to
what extent these changes are a natural consequence
of aging; they may be due to altered protein synthe-
sis or lowered responsiveness to regulatory mole-
cules. They may also be an effect of diminished vas-
cularity, which could limit cellular access to oxygen
and nutrients (Mjor 1986).

Overall immune system function deteriorates
with age, and it is likely that mucosal immunity does
as well. Such a decline could result in an increased
risk of transmission of infectious agents across the
mucosa and probably contributes to delayed wound
healing in oral tissues with aging.

Sensory and Motor Functioning
The high density of sensory nerve endings in the
craniofacial tissues and their functional abilities are
well-preserved in aging. There may be minor increas-
es in threshold detection levels or in judgments of
intensity, but, for the most part, sensory cells can
turn over or have a built-in reserve capacity that
allows for near-optimal functioning in aging. The
exception is olfaction, which declines in both men
and women with age. This decrement in smell may
lead to some dissatisfaction with how foods taste and
increased use of flavor enhancers to compensate. But
for most people, the ability to enjoy food is not
appreciably diminished as time goes by. Any dramat-
ic change in sensory function-complaints of a con-
tinued unpleasant taste or smell or the sudden com-
plete loss of a sensory modality-should be taken
seriously as a sign of possible oral or systemic disease

-

or a side effect of medication and not dismissed as a
natural by-product of aging.

  The distribution of motor fibers in the craniofa-
cial tissues is also abundant and sufficiently fine-
tuned to allow for a full range of movement of the
tongue, jaws, and oral-facial muscles. There is some
loss of muscle tone in aging, along with changes in
tongue shape and function in articulating specific
speech sounds. Subtle changes may also occur in
preparing food for swallowing. As with sensory
changes, these developments do not seriously inter-
fere with motor function in healthy older adults.

The Salivary Glands

Studies of normative aging indicate that individuals
vary in the quantity of "whole" saliva they produce.
Whole saliva consists of the secretions of the various
salivary glands plus other oral contents, such as cells
shed from the mucosa. These individual patterns are
consistent across the life span. In healthy adults,
there is no diminution in the production of saliva
from the major salivary glands in the course of aging.

This constancy may seem surmising given the
morphological changes documented in aging salivary
glands. Both the parotid and the submandibular
glands lose between 20 and 30 percent of their essen-
tial tissue volume in the course of aging. The loss pri-
marily affects the acinar components, the cells that
secrete saliva. Increases in the number of ductal cells
and in fat, vascular, and connective tissues compen-
sate for this loss, however-vidence of the remark-
able functional reserve capacity of the glands, which
enables them to maintain a stable salivary output
across the life span (Baum 1986).

In contrast, studies of age-related changes in the
chemistry of salivary secretions suggest that there are
significant reductions in the concentration of mucins
from the submandibular gland (Navazesh et al.
1992>, which could result in reduced lubrication and
contribute to a sensation of mouth dryness. There are
also subtle changes in the protective ability of sali-
vary secretory IgA antibody (Smith et al. 1987).

FINDINGS

Natural selection has served Homo sapiens well in
evolving a craniofacial complex with remarkable
functions and abilities to adapt, enabling the organ-
ism to meet the challenges of an ever-changing envi-
ronment. An examination of the various tissues
reveals elaborate designs that have evolved to serve
the basic needs and functions of a complex mammal
as well as those that are uniqely human, such as

32

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


speech. The rich distribution of nerves, muscles, and
blood vessels in the region as well as extensive
endocrine and immune system connections is an
indication of the vital role of the craniofacial complex
in adaptation and survival over a long life span. In
particular,
   o  Genes controlling the basic patterning and
segmental organization of human development, and
specifically the craniofacial complex, are highly con-
served in nature. Mutated genes affecting human
development have counterparts in many simpler
organisms.

. 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.

   0  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.

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Baron S, Poast J, Cloyd MW. Why is HIV rarely trans-
mitted by oral secretions? Saliva can disrupt orally
shed, infected leukocytes. Arch Intern Med 1999 Feb
8;159(3):303-10,

Bhaskar SN. Maxilla and mandible (alveolar process).
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Bhaskar SN, Orban BJ. Orban's oral histology and
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Baum BJ. Age changes in salivary glands and salivary
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Geriatric dentistry Copenhagen: Munksgaard; 1986.
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Baiim BJ and O'Connell BC. The impact of gene thera-
py on dentistry J Am Dent Assoc 1995:126:179-89.
Caterina MJ, Schumacher MA, Tominaga M, Rosen TA,
Levine JD, Julius D. The capsaicin receptor: a heat-
activated ion channel in the pain pathway Nature
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Hajishengallis G, and Michalek SM. Current status of a
mucosal vaccine against dental caries. Oral Microbial
Immunol 1999;14:1-20.

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Johansson CB, Momma S, Clarke DL, Rishng M,
Lendahl U, Frisen J. Identification of a neural stem
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Kroes I, Lepp PW, Relman DA. Bacterial diversity with-
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Lamkin MS, Oppenheim FG. Structural features of sali-
vary function. Crit Rev Oral Biol Med 1993;4(3-
4):251-9.

Mandel ID. The role of saliva in maintaining oral home-
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Mandel ID, Ellison SA. The biological significance of
the nonimmunoglobulin defense factors. In: Pruit K,
Tenovuo J, editors. The lactoperoxidase system. New
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McGhee JR, Kiyono H. The mucosal immune system.
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ed. New York: Lippincott-Raven; 1999. p. 909-45.
Mestecky J. The common mucosal immune system and
current strategies for induction of immune respons-
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Jul;7(4):265-76.

Mestecky J, Russell MW Mucosal immunoglobulins
and their contribution to defense mechanisms: an
overview. Biochem Sot Trans 1997 May;25(2):457-
62.

Mjor IA. Age changes in the teeth. In: Holm-Pedersen P,
Liie H, editors. Geriatric dentistry. Copenhagen:
Munksgaard; 1986. p. 94-101.
Navazesh M, Mulligan RA, Kipnis V, Denny PA, Denny
PC. Comparison of whole saliva flow rates and
mucin concentrations in healthy Caucasian young
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Oberg S. Dissector for Netter's atlas of human anatomy:
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Sadler Tw, Langman J. Langman's medical embryology
Baltimore: Williams & Wilkins; 1995.
Sarosiek J, Scheurich CJ, Marcinkiewicz M, McCaIlum
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Ship JA. The oral cavity In: Hazzard WR et al., editors.
Principles of geriatric medicine and gerontology.
New York: McGraw-Hill; 1999.
Shugars DC, Wahl SM. The role of the oral environment
in HIV-l transmission. J Am Dent Assoc 1998
Ju1;129(7):851-8.

Smith DJ, Taubman MA, Ebersole JL. Ontogeny and
senescence of salivary immunity J Dent Res 1987
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Tabak L. In defense of the oral cavity: structure, biosyn-
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Taichman NS. Cruchley AT, Fletcher LM. Hagi-Pavli EP
Paleolog EM. Abrams WR, Booth V, Edwards RM,
Malamud D. Vascular endothelial growth factor in
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Wilentz J. The senses of man. New York: Thomas Y.
Crowell; 1968.

Xu T, Levitz SM, Diamond RD, Oppenheim FG.
Anticandidal activity of major human salivav his-
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Young PT. Role of hedonic processes in development of
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Zelles T, Purushotham KR, Macauley SP Oxford GE,
Humphreys-Beher MG. Saliva and growth factors:
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Zero DT. Etiology of dental erosion-extrinsic factors.
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34

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


What Is the Status of Oral Health
in America?

To begin to answer this question, Chapter 3 guides the reader through a discussion of oral diseases
and disorders in such categories as infections, inherited disorders, and neoplasms. Whether or not
an individual succumbs to the disease or disorder in question depends on subtle interactions of
genetic, environmental, and behavioral variables. Risk factors common to systemic diseases and
disorders, such as tobacco use, excessive alcohol use, and inappropriate dietary practices, also
contribute to many oral diseases and disorders. As more details on the causes of diseases unfold,
specific strategies for disease prevention can be developed.

Chapter 4 describes the magnitude of the problem facing the nation due to oral diseases and
disorders. These conditions are prevalent and complex, and they affect individuals across the life
span. Although major improvements have been seen nationally for most Americans, disparities
exist in some population groups as classified by age, sex, income, and race/ethnicity. National and
state-based epidemiologic data presented against the backdrop of demographic and socioeconomic
variables provide some information on racial and ethnic minorities, but serious shortcomings exist.
The paucity of data at national, state, and local levels extends to other populations, including indi-
viduals with disabilities, those with alternate sexual orientation, migrant populations, and the
homeless, and limits the capacity to fully document the magnitude of the problem and develop
needed programs. The chapter provides a basis for understanding disparities in oral health by pre-
senting available data on dental visits. More work is needed to understand the dimensions of oral
health problems in the United States and the reasons for differences among populations.

OR4L Hl%4LTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

35


Diseases and Disorders

As the gateway to the body, the mouth is challenged
by a constant barrage of invaders-bacteria, viruses,
parasites, fungi. Thus infectious diseases, notably
dental caries and periodontal diseases, predominate
among the ills that can compromise oral health.
Injuries take their toll as well, with the face and head
particularly vulnerable to sports injuries, motor vehi-
cle crashes, violence, and abuse. Less common but
very serious are oral and pharyngeal cancers, with a
5-year survival rate of hardly better than 50 percent
(Kosary et al. 1995). Birth defects and developmental
disorders frequently affect the craniofacial complex.
These appear most commonly as isolated cases of
cleft lip or palate, but clefting or other craniofacial
defects can also be part of complex hereditary dis-
eases or syndromes. Additionally, acute and chronic
pain can affect the oral-facial region, particulaily in
and around the temporomandibular (jaw) joint, and
accounts for a disproportionate amount of all types of
pain that drive individuals to seek health care.
Many systemic diseases such as diabetes, arthri-
tis, osteoporosis, and AIDS, as well as therapies for
systemic diseases, can directly or indirectly compro-
mise oral tissues. The World Health Organization's
International Classification of Diseases and
Stomatology currently lists more than 120 specific
diseases, distributed in 10 or more classes, that have
manifestations in the oral cavity (WHO 1992).
This chapter concentrates on six major oral dis-
ease categories: dental and periodontal infections;
mucosal disorders; oral and pharyngeal cancers;
developmental disorders; injuries; and a sampling of
chronic and disabling conditions, including Sjiigren's
syndrome and oral-facial pain.

DENTAL AND PERIODONTAL
INFECTIONS
The most common oral diseases are dental caries and
the periodontal diseases. Individuals are vulnerable
to dental caries throughout life, with 85 percent of
adults aged 18 and older affected. Periodontal dis-
eases are most often seen in maturity, with the major-
ity of adults experiencing some signs and symptoms
by the mid-30s. Certain rare forms of periodontal dis-
ease affect young people. The major oral health suc-
cess story of the past half century is that both caries
and periodontal diseases can be prevented by a com-
bination of individual, professional, and community
measures.

Dental Caries

The word.caries derives from the Latin for rotten, and
many cultures early on posited a tooth worm as the
cause of this rottenness. By the twentieth century,
caries came to describe the condition of having holes
in the teeth-cavities. This description, although not
incorrect, is misleading. In actuality, a cavity is a late
manifestation of a bacterial infection.
The bacteria colonizing the mouth are known as
the oral flora. They form a complex community that
adheres to tooth surfaces in a gelatinous mat, or
biofilm, commonly called dental plaque. A cariogenic
biofilm at a single tooth site may contain one-half-
billion bacteria, of which species of mutans
streptococci are critical components. These bacteria
are able to ferment sugars and other carbohydrates to
form lactic and other acids. Repeated cycles of acid
generation can result in the microscopic dissolution
of minerals in tooth enamel and the formation of an
opaque white or brown spot under the enamel
surface (Mandel 1979). Frequency of carbohydrate
consumption (Gustafsson et al. 1954), physical

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

37


Diseases and Disorders

characteristics of food (e.g., stickiness), and timing of
food intake (Burt and Ismail 1986) also play a role.

  The essential role of bacteria in caries initiation
was established in landmark experiments in the
1950s. Investigators observed that germ-free ani-
mals fed high-sugar diets remained caries-free until
the introduction of mutans streptococci (a particular
group of bacterial strains having a number of com-
mon characteristics, and which adhere tightly to the
tooth). Later experiments demonstrated the trans-
missibility of the bacteria from mother to litter and
from caries-infected to uninfected cage-mates
(Fitzgerald and Keyes 1960). Species of Lactobacillus,
Actinomyces. and other acid-producing streptococci
within the plaque may also contribute to the process
(Bowden 1990).

If the caries infection in enamel goes unchecked,
the acid dissolution can advance to form a cavity that
can extend through the dentin (the component of the
tooth located under the enamel) to the pulp tissue,
which is rich in nerves and blood vessels. The result-
ing toothache can be severe and often is accompanied
by sensitivity to temperature and sweets. Treatment
requires endodontic (root canal) therapy. If untreat-
ed, the pulp infection can lead to abscess, destruction
of bone, and spread of the infection via the blood-
stream.

Dental caries can occur at any age after teeth
erupt. Particularly damaging forms can begin early,
when developing primary teeth are especially vulner-
able. This type of dental caries is called early child-
hood caries (ECC). Some 6 out of 10 children in the
United States have one or more decayed or filled pri-
mary teeth by age 5 (U.S. Department of Health and
Human Services, National Center for Health
Statistics 1997). EGG may occur in children who are
given pacifying bottles of juice, milk, or formula to
drink during the day or overnight. The sugar con-
tents pool around the upper front teeth, mix with
cariogenic bacteria, and give rise to rapidly progress-
ing destruction (Ripa 1988). Other risk factors for
ECC include arrested development of tooth enamel,
chronic illness, altered salivary composition and vol-
ume (resulting from the use of certain medications or
malnourishment), mouth breathing, and blockage of
saliva flow in a bottle-fed infant (Bowen 1998, Seow
1998).

Although there have been continuing reductions
in dental caries in permanent teeth among children
and adolescents over the past few decades, caries
prevalence in the primary dentition may have stabi-
lized or increased slightly in some population groups
(Petersson and Bratthall 1996, Rozier 1995).
Reductions in caries in permanent teeth also have

been proportionately greater on the smooth surfaces
rather than on the pit-and-fissure surfaces character-
istic of chewing surfaces. The gingival tissues tend to
recede over time, exposing the tooth root to cario-
genie bacteria that can cause root caries. An impor-
tant risk factor for root caries in older people is the
use of medications that inhibit salivary flow, leading
to dry mouth (xerostomia).

Saliva contains components that can directly
attack cariogenic bacteria, and it is also rich in calci-
um and phosphates that help to remineralize tooth
enamel. Demineralization of enamel occurs when pH
levels fall as a result of acid production by bacteria. It
can be reversed at early stagesif the local environ-
ment can counteract acid production, restoring pH to
neutral levels. Remineralization can occur through
the replacement of lost mineral (calcium and phos-
phates) from the stores in saliva. Fluoride in saliva
and dental plaque and the buffering capacity of sali-
va also contribute to this process. Indeed. it is now
believed that fluoride exerts its chief caries-preven-
tive effect by facilitating remineralization. Several
studies have demonstrated that remineralization
results in an increase in tooth hardness and mineral
content. rendering the tooth surface more resistant to
subsequent acid attack (Larsen 1987, Linton 1996,
Retief 1983, Shannon 1978, Vissink et al. 1985,
White 1988).

Overt caries lesions develop when there is insuf-
ficient time for remineralization between periods of
acidogenesis, or when the saliva production is com-
promised. Over 400 medications list dry mouth as a
side effect, notably some antidepressants, antipsy-
chotics, antihistamines, decongestants, antihyperten-
sives, diuretics, and antiparkinsonian drugs (Sreebny
et al. 1992). The effects of xerostomia may be partic-
ularly severe in cancer patients receiving radiation to
the head or neck because the rays can destroy sali-
vary gland tissue rather than simply inhibiting sali-
vary secretion.

The professional application of dental sealants
(plastic films coated onto the chewing surfaces of
teeth) is an important caries-preventive measure that
complements the use of fluorides, The films prevent
decay from developing in the pits and fissures of
teeth, channels that are often inaccessible to brushing
and where fluoride may be less effective.

The rate of caries progression through enamel is
relatively slow (Berkey 1988, Ekanayake 1987,
Shwartz et al. 1984) and may be slower in patients
who have received regular fluoride treatment or who
consume fluoridated water (Pitts 1983, Shwartz et al.
1984). Because a large percentage of enamel lesions
remain unchanged over periods of 3 to 4 years, and

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


Diseases and Disorders

because progression rates through dentin are
comparably slow (Craig et al. 1981, Emslie 1959,
Kolehmainen and Rytomaa 1977), the application of
infection control and monitoring procedures to
assess caries risk status, lesion activity status,
evidence of lesion arrest, and evidence of lesion
remrneralization over extended periods of time is
recommended.

Experts believe that the earlier mutans strepto-
cocci are acquired in infancy, the higher the caries
risk. Most studies indicate that infants are infected
before their first birthday, around the time the first
incisors emerge. However, one study found the medi-
an age of acquisition to be 26 months, coinciding
with the emergence of the primary molars (Bowen
1998, Caufield et al. 1993, Seow 1998). DNA finger-
printing has demonstrated that the source of trans-
mission is usually the mother (Caufield et al. 1993).
It is not clear why some individuals are more sus-
ceptible and others more resistant to caries. Genetic
differences in the structure and biochemistry of
enamel proteins and crystals (Slavkin 1988), as well
as variations in the quality and quantity of saliva and
in immune defense mechanisms are among the fac-
tors under study. Analysis of mutans streptococci
genomes may also shed light, indicating which
species are particularly virulent and which genes
contribute to that virulence.

Even the most protective genetic endowment
and developmental milieu are unlikely to confer
resistance to decay in the absence of positive person-
al behaviors. These include sound dietary habits and
good oral hygiene, including the use of fluorides, and
seeking professional care. There are indications,
however, that some destructive oral habits are on the
rise, such as the use of smokeless (spit) tobacco
products by teenage boys. Although the chief con-
cern here lies in the long-term risk for oral cancers,
spit tobacco that contains high levels of sugar is also
associated with increased levels of decay of both
crown and root surfaces (Tomar and Winn 1998).

Periodontal Diseases

Like dental caries, the periodontal diseases are infec-
tions caused by bacteria in the biofilm (dental
plaque) that forms on oral surfaces. The basic divi-
sion in the periodontal diseases is between gingivitis,
which affects the gums, and periodontitis, which may
involve all of the soft tissue and bone supporting the
teeth. Gingivitis and milder forms of periodontitis are
common in adults. The percentage of individuals
with moderate to severe periodontitis, in which the

destruction of supporting tissue can cause the tooth
to loosen and fall out, increases with age.

Gingivitis

Gingivitis is an inflammation of the gums character-
ized by a change in color from normal pink to red,
with swelling, bleeding, and often sensitivity and ten-
derness. These changes result from an accumulation
of biofilm along the gingival margins and the
immune system's inflammatory response to the
release of destructive bacterial products. The early
changes of gingivitis are reversible with thorough
toothbrushing and flossing to reduce plaque.
Without adequate oral hygiene, however, these early
changes can become more severe, with'infiltration of
inflammatory cells and establishment of a chronic
infection. Biofilm on tooth surfaces opposite the
openings of the salivary glands often mineralizes to
form calculus or tartar, which is covered by unmin-
eralized biofilm-a combination that can exacerbate
local inflammatory responses (Mandel 1995). A gin-
gival infection may persist for months or years, yet
never progress to periodontitis.

Gingival inflammation does not appear until the
biofilm changes from one composed largely of gram-
positive streptococci (which can live with or without
oxygen) to one containing gram-negative anaerobes
(which cannot live in the presence of oxygen).
Numerous attempts have been made to pinpoint
which microorganisms in the supragingival (above
the gum line) plaque are the culprits in gingivitis.
Frequently   mentioned  organisms   include
Fusobacterium nucleatum, Veillonella parvula, and
species of Campylobacter and Treponema. But as
Ranney (1989) notes, "The complexity of the results
defies any attempt to define a discrete group clearly
and consistently associated with gingivitis."

Gingival inflammation may be influenced by
steroid hormones, occurring as puberty gingivitis,
pregnancy gingivitis, and gingivitis associated with
birth control medication or steroid therapy. The pres-
ence of steroid hormones in tissues adjacent to
biofilm apparently encourages the growth of certain
bacteria and triggers an exaggerated response to
biofilm accumulation (Caton 1989). Again, thorough
oral hygiene can control this response.

Certain prescription drugs can also lead to gingi-
val overgrowth and inflammation. These include the
antiepileptic drug phenytoin (Dilantin); cyclosporin,
used for immunosuppressive therapy in transplant
patients; and various calcium channel blockers used
in heart disease. Treatment often requires surgical
removal of the excess tissue followed by appropriate
personal and professional oral health care.

ORAL HEtZLTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

39


Diseases and Disorders

A form of gingivitis common 50 years ago but
relatively rare today is acute necrotizing ulcerative
gingivitis, also known as Vincent's infection or trench
mouth. This aggressive infection is characterized by
destruction of the gingiva between the teeth, sponta-
neous bleeding, pain, and oral odor. People under
extreme stress have an increased susceptibility.
Spirochetes and other bacteria have been found in
the connective tissue of those affected. An associa-
tion between smoking and this type of gingivitis is
well recognized and was demonstrated as early as
1946 (Pindborg 1947, 1949). This condition has
been seen in some HIV-positive patients (Murray
1994). Treatment requires a combination of profes-
sional periodontal treatment and antibacterial thera-
py along with professional smoking cessation assis-
tance as appropriate.

Adult Periodontitis

The most common form of adult periodontitis is
described as general and moderately progressing; a
second form is described as rapidly progressing and
severe, and is often resistant to treatment. The mod-
erately progressive adult form is characterized by a
gradual loss of attachment of the periodontal liga-
ment to the gingiva and bone along with loss of the
supporting bone. It is most often accompanied by
gingivitis (Genco 1990). It is not necessarily preced-
ed by gingivitis, but the gingivitis-related biofilm
often seeds the subgingival plaque. The destruction
of periodontal ligament and bone results in the for-
mation of a pocket between the tooth and adjacent
tissues, which harbors subgingival plaque. The cal-
culus formed in the pocket by inflammatory fluids
and minerals in adjacent tissues is especially damag-
ing (Mandel and Gaffar 1986).

The severity of periodontal disease is determined
through a series of measurements, including the
extent of gingival inflammation and bleeding, the
probing depth of the pocket to the point of resist-
ance, the clinical attachment loss of the periodontal
ligament measured from a fixed point on the tooth
(usually the cemento-enamel junction), and the loss
of adjacent alveolar bone as measured by x-ray
(Genco 1996). Severity is determined by the rate of
disease progression over time and the response of the
tissues to treatment.
Adult periodontitis often begins in adolescence
but is usually not clinically significant until the mid-
30s. Prevalence and severity increase but do not
accelerate with age (Beck 1996). One view proposes
that destruction occurs at a specific site during a
defined period, after which the disease goes into
remission (Socransky et al. 1984). The current view

is that the disease process may not be continuous but
rather progresses in random bursts in which short
periods of breakdown of periodontal ligament and
bone alternate with periods of quiescence. These
episodes occur randomly over time and at random
sites in the mouth. Part of the difficulty in determin-
ing the pattern of progression reflects variation in the
sensitivity of the instruments used to measure the
loss of soft tissue and bone. The latest generation of
probes finds evidence of both continuous and multi-
ple-burst patterns of loss in different patients and at
different times (Jeffcoat and Ready 1991).
Most researchers agree that periodontitis results
from a mixed infection but that a particular group of
gram-negative bacteria are key to the process and
markedly increase in the subgingival plaque. The
bacteria most frequently cited are Porphyromonas gin-
givalis, Prevotella intermedia, Bacteroides forsythus,
Treponema denticola, and Actinobacillus actino-
mycetemcomitans (Genco 1996). Their role in disease
initiation and progression is determined in part by
their "virulence factors." These include the ability to
colonize subgingival plaque, generate products that
can directly injure tissues, and elicit an inflammatory
or immune response. The potentially noxious bacte-
rial products include hydrogen sulfide, polyamines,
the fatty acids butyrate and propionate, lipopolysac-
charide (also known as endotoxin), and a number of
destructive enzymes. The interaction of this arsenal
with the host response is at the core of periodontal
pathology (Genco 1992, Socransky and Haffajee
1991, 1992). Sequencing of the genomes of several
key periodontal pathogens is under way and should
provide further insight into these pathogens as well
as catalyze new treatment approaches.

Delicate Balances. Neutrophils (a type of white blood
cell) and antibodies are the major immune defenses
against bacterial attack. Neutrophils move to the site
of infection, where they engulf bacteria and elaborate
antibacterial agents and enzymes to destroy bacteria.
Although stimulation of the immune system to attack
the offending bacteria is generally protective,
immune hyperresponsiveness and hypersensitivity
can be counterproductive, leading to the destruction
of healthy tissue. Nevertheless, the neutrophiuanti-
body axis is critical for full protection against peri-
odontal diseases (Genco 1992).

Also important is the release of certain potent
molecules called cytokines and prostaglandins,
especially prostaglandin E2 (PGE,) which can
contribute to tissue destruction. Cytokines are
proteins secreted by immune cells that help regulate
immune responses and also affect bone, epithelial,

-lo       ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


and connective  tissues.  Most prominent in
periodontal diseases are interleukin 1 (IL-l), tumor
necrosis factor OL (TNF-a), and interferon y (IFN-?I).
These cytokines mediate the processes of bone
resorption and connective tissue destruction.

Susceptibility and Resistance. PGE, may play a central
role in the tissue destruction that occurs in peri-
odontal diseases. Levels of PGE, in periodontal tissue
are low or undetectable in health, increase in gingivi-
tis, and rise significantly in periodontitis. Now there
is increasing evidence that the level of PGE, pro-
duced in response to bacterial challenge (especially
by endotoxin) can be used as a measure of suscepti-
bility (Offenbacher et al. 1993).
Presumably, the level of PGE, production is sub-
ject to genetic influence. Studies of identical and fra-
ternal twins, either reared together or apart, provide
evidence that genetic factors may indeed influence
susceptibility or resistance to the common adult form
of periodontitis (Michalowicz 1994). Recently, a
commercial test for a genetic marker of susceptibility
has been introduced. The marker is associated with
increased production of a particular form of inter-
leukin lfi (IL-lp) when stimulated by periodonto-
pathic bacteria (Kornman et al. 1997). Newman
(1996) found that nonsmoking adults who are posi-
tive for the marker are 6 to 19 times more likely to
develop severe periodontitis.

Susceptibility to adult periodontitis has also been
explored in relation to a variety of behavioral and
demographic variables as well as to the presence of
other diseases. One of the strongest behavioral asso-
ciations is with tobacco use. The risk of alveolar bone
loss for heavy smokers is 7 times greater than for
those who have not smoked (Grossi et al. 1995).
Cigarette smoking also may impair the normal host
response in neutralizing infection (Seymour 199 l),
resulting in the destruction of healthy periodontal
tissues adjacent to the site of infection (Lamster
1992). Smokers also have decreased levels of salivary
and serum immunoglobulins to Prevotella intermedia
and Fusobacterium nucleatum (Bennet and Reade
1982, Haber 1994) and depressed numbers of helper
T cells as well (Costabel et al. 1986). Finally smok-
ing alters the cells that engulf and dispose of bacte-
rla-neutrophils and other phagocytes-affecting
their ability to clear pathogens (Barbour et al. 1997).
Epidemiologic studies have found that such
additional factors as increasing age, infrequent dental
visits, low education level, low income, co-morbidi-
ties, and inclusion in certain racial or ethnic popula-
tions are associated with increased prevalence of

Diseases and Disorders

periodontitis (Page 1995). It is important that epi-
demiologic studies also take into consideration the
fact that tobacco use, oral hygiene, professional pro-
phylaxis, and routine dental care are correlated to
socioeconomic status, as are race and ethnicity. Sex is
another factor. Males tend to have higher levels of
periodontal diseases, presumably because of a histo-
ry of greater tobacco use and differences in personal
care and frequency of dental visits. However, female
hormones may play a protective role (as they do in
protecting against osteoporosis) (Genco 1996).
Certain systemic diseases heighten susceptibility
Epidemiological studies have confirmed that patients
with diabetes mellitus, both type 1 and type 2, are
more susceptible to periodontal diseases (Genco
1996). Measures such as the gingival index, pocket
depth, and loss of attachment are more severe if the
diabetic patients are smokers (Bridges et al. 1996).
The likelihood of periodontal disease increases
markedly when diabetes is poorly controlled. In con-
trast, periodontal diseases respond well to therapy
and can be managed successfully in patients with
well-controlled diabetes. Such therapy can result in
improvements in the diabetic condition itself
(Mealey 1996) (see Chapter 5).

There is some evidence that osteoporosis may be
a risk factor for periodontal disease. More clinical
attachment loss and edentulousness have been
reported in osteoporotic than in nonosteoporotic
women (Jeffcoat and Chestnut 1993). Two studies in
1996 showed that estrogen replacement therapy in
postmenopausal women not only gives protection
against osteoporosis, but also results in fewer teeth
lost to periodontal disease (Grodstein et al. 1996,
Jacobs et al. 1996).

The less common rapidly progressive form of
adult periodontitis typically affects people in their
early 20s and 30s. It is characterized by severe gingi-
val inflammation and rapid loss of connective tissue
and bone. Many patients have an inherent defect in
neutrophil response to infection. Several systemic
diseases have been associated with this form of peri-
odontal disease, including type 1 diabetes, Down
syndrome, Papillon-Lefevre syndrome, Chediak-
Higashi syndrome, and HIV infection (Caton 1989).
Specific bacteria associated with rapidly progressive
disease include Porphyrornonas gingivalis, PrevoteIla
inter-media, Eikenella corrodens, and Wolinella recta
(Scheutz et al. 1997). Most recently, mutations in the
cathepsin C gene have been associated with the
Papillon-Lefevre syndrome (Hart et al. 1999) and
how the defect can result in periodontal disease
(Toomers et al. 1999).

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

41


Diseases and Disorders

Refractory Periodontitis. Refractory periodontitis is
not a specific form of disease, but refers to cases in
which patients continue to exhibit progressive dis-
ease at multiple sites despite aggressive mechanical
therapy to remove biofilm and calculus, along with
the use of antibiotics. Refractory sites exhibit elevat-
ed levels of a number of different bacteria, with the
dominant species different in different subjects. It is
not known whether variations in pathogenicity of the
bacteria, defects in the subject's defense systems, or
combinations of these factors are responsible for the
refractory nature of the disease (Haffajee et al. 1988).
The adoption of new diagnostic technology to detect
predominant bacterial species, followed by selective
antibiotic treatment, may help resolve infection and
disease in these patients.

Early-onset Periodontitis

The forms of periodontitis occurring in adolescents
and young adults generally involve defects in neu-
trophil function (Van Dyke et al. 1980). Localized
juvenile periodontitis (LJP) mainly affects the first
molar and incisor teeth of teenagers and young
adults, with rapid destruction of bone but almost no
telltale signs of inflammation and very little
supragingival plaque or calculus. Actinobacillus actin-
ornycetemcomitans has been isolated at 90 to 100 per-
cent of diseased sites in these patients, but is absent
or appears in very low frequency in healthy or mini-
mally diseased sites (Socransky and Haffajee 1992).
It is possible that the bacteria are transmitted among
family members through oral contacts such as kiss-
ing or sharing utensils, because the same bacterial
strain appears in affected family members. However,
evidence of a neutrophil defect argues for a genetic
component. Another organism frequently associated
with LJP is Capnocytophaga ochracea. Neither of
these bacteria dominate in the generalized adult form
of the disease, where Porphyromonas gingivalis is con-
sidered of greatest significance (Schenkein and Van
Dyke 1994).

Prepubertal periodontitis is rare and can be
either general or localized. The generalized form
begins with the eruption of the primary teeth and
proceeds to involve the permanent teeth. There is
severe inflammation, rapid bone loss, tooth mobility,
and tooth loss. The localized form of the disease is
less aggressive, affecting only some primary teeth.
The infection involves many of the organisms associ-
ated with periodontitis, but the mix may differ some-
what, with Actinobacillus actinomycetemcomitans,
Prevotella interned@ Eikenella corrodens, and several
species of Capnocytophaga implicated (Caton 1989).

Defects in neutrophil function noted in both forms of
the disease (Schenkein and Van Dyke 1994) may
explain why patients are highly susceptible to other
infections as well (Suzuki 1988).

SELECTED MUCOSAL INFECTIONS
AND CONDITIONS

Like the skin, the mucosal lining of the mouth serves
to protect the body from injury This lining is itself
subject to a variety of infections and conditions,
ranging from benign canker sores to often fatal
cancers.

Oral Candidiasis

Chronic hyperplastic candidiasis is a red or white
lesion that may be flat or slightly elevated and may
adhere to soft or hard tissue surfaces, including den-
tal appliances. It is caused by species of Candida,
especially Candida albicans, the most common fungal
pathogen isolated from the oral cavity. Normally, the
fungi are present in relatively low numbers in up to
65 percent of healthy children and adults and cause
no harm (McCullough et al. 1996). Problems arise
when there is a change in oral homeostatis-the nor-
mal balance of protective mechanisms and resident
oral flora that maintain the health of the oral cavity-
so that defense mechanisms are compromised (Scully
et al. 1994). Under these circumstances the fungal
organisms can overgrow to cause disease. A primary
disruption in homeostasis occurs with the use of
antibiotics and corticosteroids, which can markedly
change the composition of the oral flora. Deficiencies
in the immune and endocrine systems are also
important. Indeed, the diagnosis of candidiasis in an
otherwise seemingly healthy young adult may be the
first sign of HIV infection. Other causes of candidia-
sis include cancer chemotherapy or radiotherapy to
the head and neck, xerostomia resulting from radia-
tion to the head and neck, medications, chronic
mucosal irritation, certain blood diseases, and other
systemic conditions. Also, tobacco use has been iden-
tified as a cofactor.

Candidiasis often causes symptoms of burning
and soreness as well as sensitivity to acidic and spicy
foods. Patients may complain of a foul taste in the
mouth. However, it can also be asymptomatic.
Genomic analysis of the Candida albicans genome is
helping investigators identify numerous genes that
code for virulence factors, including enzymes that
can facilitate adhesion to and penetration of mucous
membranes. At the same time, researchers are explor-
ing novel gene technologies to increase production of

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


`I family of native salivary proteins, the histatins, that
halve known anticandidal and other antimicrobial
effects.

  The most common form of oral candidiasis is
denture stomatitis. It occurs when tissues are trau-
matized by continued wearing of ill-fitting or inade-
quately cleaned dental appliances and is described as
chronic erythematous candidiasis. Another form,
candidal angular cheilosis, occurs in the folds at the
angles of the mouth and is closely associated with
denture sore mouth (Tyldesley and Field 1995).
Other common forms of Candida infection are
pseudomembranous candidiasis (thrush), which may
affect any of the mucosal surfaces, and acute erythe-
matous candidiasis, a red and markedly painful vari-
ant commonly seen in AIDS patients.

In most cases, Candida infection can be con-
trolled with antifungal medications used locally or
systemically Control is difficult, however, in patients
with immune dysfunction, as in AIDS, or other
chronic debilitating diseases, Often the organisms
become resistant to standard therapy, and aggressive
approaches are necessary (Tyldesley and Field 1995).
The spread of oral candidiasis to the esophagus or
lungs can be life-threatening and is one of the crite-
ria used to define frank AIDS (Samaranayake and
Holmstrup 1989).

Herpes Simplex Virus Infections

In any given year, about one-half-million Americans
will experience their first encounter with the herpes
simplex virus type 1 (HSV-l), the cause of cold sores.
That first encounter usually occurs in the oral region
and may be so mild as to go unnoticed. But in some
people, particularly young children and young
adults, infection may take the form of primary her-
petit stomatitis, with symptoms of malaise, muscle
aches, sore throat, and enlarged and tender lymph
nodes, prior to the appearance of the familiar cold
sore blisters. These blisters usually show up on the
lips, but any of the mucosal surfaces can be affected.
Bright-red ulcerated areas and marked gingivitis may
also be seen (Tyldesley and Field 1995).

Herpes viruses also cause genital infections,
which are transmitted sexually Both HSV- 1 and HSV-
2 have been found in oral and genital infections, with
HSV-1 predominating in oral areas and HSV-2 in gen-
ital areas (Wheeler 1988). Herpes viruses have also
been implicated as cofactors in the development of
oral cancers. Crowded living conditions can result in
greater contact with infected individuals, which aids
in transmission of HSV (Whitley 1992).

Diseases and Disorders

Normally the immune system mounts a success-
ful attack on the viruses, with symptoms abating by
the time neutralizing antibodies appear in the blood-
stream, in about 10 days. However, herpes viruses are
notorious for their ability to avoid immune detection
by taking refuge in the nervous system, where they
can remain latent for years. In oral herpes the virus
commonly migrates to the nearby trigeminal gan-
glion, the cluster of nerve cells whose fibers branch
out to the face and mouth. In about 20 to 40 percent
of people who are virus-positive, the virus may reac-
tivate, with infectious virus particles moving to the
oral cavity to cause recurrent disease (Scott et al.
1997).

  The usual site of a recurrent lesion is on or near
the lips. Recurrences are rarely severe, and lesions
heal in 7 to 10 days without scarring (Higgins et al.
1993). The recurrences may be provoked by a wide
range of stimuli, including sunlight, mechanical trau-
ma, and mild fevers such as occur with a cold.
Emotional factors may play a role as well.

Oral Human Papillomavirus Infections
There are more than 100 recognized strains of oral
human papillomavirus (HPV), a member of the
papovavirus family, implicated in a variety of oral
lesions (Regezi and Sciubba 1993). Most common
are papillomas (warts) found on or around the lips
and in the mouth. HPV is found in 80 percent of
these oral squamous papillomas (de Villiers 1989).
The virus has also been identified in 30 to 40 percent
of oral squamous cell carcinomas (Chang et al. 1990)
and has been implicated in cervical cancer as well.
Whether a cancer or nonmalignant wart develops
may depend on which virus is present or on which
viral genes are activated.

  Oral warts are most often found in children,
probably as a result of chewing warts on the hands.
In adults, sexual transmission from the anogenital
region can occur (Franchesi et al. 1996).

In general, viral warts spontaneously regress
after 1 or 2 years. The immune system normally
keeps HPV infections under control, as evidenced by
the increased prevalence of HPV-associated lesions in
HIV-infected patients and others with immuno-
deficiency

Recurrent Aphthous Ulcers
Recurrent aphthous ulcers (RAU), also referred to as
recurrent aphthous stomatitis, is the technical term
for canker sores, the most common and generally

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

43


mild oral mucosal disease. Between 5 and 25 percent
of the general population is affected, with higher
numbers in selected groups, such as health profes-
sional students (Axe11 et al. 1976, Embil et al. 1975,
Ferguson et al. 1984, Kleinman et al. 1991, Ship
1972, Ship et al. 1967).

  The disease takes three clinical forms: RAU
minor, RAU major, and herpetiform UU. The minor
form accounts for 70 to 87 percent of cases. The sores
are small, discrete, shallow ulcers surrounded by a
red halo appearing at the front of the mouth or the
tongue. The ulcers, which usually last up to 2 weeks,
are painful and may make eating or speaking diffi-
cult. About half of RAU patients experience recur-
rences every 1 to 3 months; as many as 30 percent
report continuous recurrences (Bagan et al. 1991).
RAU major accounts for 7 to 20 percent of cases
and usually appears as 1 to 10 larger coalescent
ulcers at a time, which can persist for weeks or
months (Bagan et al. 1991). Herpetiform R4U has
been reported as occurring in 7 to 10 percent of RAU
cases. The ulcers appear in crops of 10 to 100 at a
time, concentrating in the back of the mouth and
lasting for 7 to 14 days (Bagan et al. 1991, Rennie et
al. 1985).

R4U can begin in childhood, but the peak peri-
od for onset is the second decade (Lehner 1968).
About 50 percent of close relatives of patients with
R4U also have the condition (Ship 1965), and a high
correlation of R4U has been noted in identical but
not fraternal twins. Associations have been found
between R4U and specific genetic markers (Scully
and Porter 1989).

R4U has also been associated with hypersensi-
tivities to some foods, food dyes, and food preserva-
tives (Woo and Sonis 1996). Nutritional deficien-
cies-especially in iron, folic acid, various B vita-
mins, or combinations thereof-have also been
reported, and improvements noted with suitable
dietary supplements (Nolan et al. 1991).
  The two factors that have been found to have the
strongest association with R4U are immunologic
abnormality, possibly involving autoimmunity, and
trauma (Lehner 1968, Ship 1996. Woo and Sonis
1996).

Volunteers with and without a history of RAU
were studied for their reaction to the trauma of a nee-
dle prick to the inner cheek tissue. No ulcers devel-
oped in non-R4U subjects, but nearly half of those
prone to canker sores had a recurrence (Wray et al.
1981).

R4U also can occur in a number of systemic dis-
eases, including HIV infection, ulcerative colitis,
Crohn's disease, and Behcet's disease (Ship 1996). In

general, people who are immunocompromised are
more susceptible to RAU, as are people with a variety
of blood diseases.

EWU itself does not give rise to other illnesses
but is uncomfortable. Symptomatic treatment
includes topical analgesics, antibacterial rinses, topi-
cal corticosteroids, and a new prescription medica-
tion that reduces pain and healing time (Khandwala
et al. 1997, Ship 1996).

ORAL AND PHARYNGEAL CANCERS
AND PRECANCEROUS LESIONS
In 2000, oral or pharyngeal cancer will be diagnosed
in an estimated 30,200 Americans and will cause
more than 7,800 deaths (Greenlee et al. 2000). Over
90 percent of these cancers are squamous cell carci-
nomas-cancers of the epithelial cells. The most
common oral sites are on the tongue, the lips, and the
floor of the mouth. Oral cancer is the sixth most
common cancer in U.S. males and takes a dispropor-
tionate toll on minorities; it now ranks as the fourth
most common cancer among African American men
(Kosary et al. 1995). The prominent role of tobacco
use, especially in combination with alcohol, in caus-
ing these cancers is a major incentive to develop
effective health promotion and disease prevention
efforts.

Heightening the Risk

Oral cancer develops as a clone from a single geneti-
tally altered cell (Solt 1981). It generally has a long
latency period and invariably develops from a pre-
cancerous lesion on the oral mucosa, such as a white
leukoplakia, or more commonly, a reddish erythro-
plakia (Mashberg 1978, Shklar 1986). Both kinds of
lesions are usually induced by tobacco use alone or in
combination with heavy use of alcohol. The develop-
ment of squamous cell carcinoma from initial ery-
throplakia lesions has been well demonstrated exper-
imentally. Silverman (1998) reported rates of malig-
nant transformation for leukoplakias of between 0.13
and 17.5 percent. However, there is considerable
debate as to the actual malignant potential of the
leukoplakia lesion associated with the use of smoke-
less (spit) tobacco. Meaningful data for determining
a specific malignant transformation rate or relative
risk of oral cancer due to smokeless tobacco use are
difficult to obtain because of the confounding effects
of other habits such as concurrent smoking and alco-
hol consumption and because of the variations in
smokeless (spit) products and how they are used.

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


.\nother oral precancerous lesion that has
r,cclved attention is submucous fibrosis. It is com-
,nonly seen in India and Southeast Asia and is relat-
(`1 to betel nut use (Canniff et al. 1986).
Early epidemiologic studies identified behaviors
Guch as smoking and environmental factors such as
,sposure to solar radiation and x-rays as causes of
,rttraoral and lip cancers (Pindborg 1977).
Researchers then sought experimentally to explain
the mechanisms of initiation. In the 1980s and
I99Os. investigators exploited the techniques of
riiolecular biology and genetics to probe what was
going on deep inside the cell. These studies revealed
`m abundance of systemic and local factors, including
\,iral and fungal infections, that affect cell behavior.
Some factors stimulate cell division and others
ttthibit it-even to the point of initiating a program
of cell "suicide," called apoptosis. How a given cell
behaves at any given time in its life cycle is the net
result of the signals it receives from neighboring cells
and molecules, from circulating factors in the blood
or immune system, and from its own internal
controls. The following sections provide a brief
description of these factors and how they may
participate in enhancing the risk for the development
of oral cancers.

Tobacco and Alcohol

Tobacco and alcohol are the major risk factors for
oral cancers, and their effects have been studied for
many years (Rothman and Keller 1972, Decker and
Goldstein 1982). Tobacco contains substances that
are frankly carcinogenic or act as initiators or pro-
moters of carcinogenesis. Among these are N-
nitrosonornicotine. 4-nitroquinoline-N-oxide, and
benzpyrene. The most damaging carcinogens are
found in the tars of tobacco smoke, but many forms
of smokeless (spit) tobacco, including snuff, have
been implicated in the development of mouth cancer
(Advisory Committee to the Surgeon General 1986,
International Agency for Research on Cancer 1985,
Winn 1984). Other habits that have been related to
oral cancer include chewing betel nut in the presence
of tobacco, as is done primarily in Southeast Asia
(Hirayama 1966, Mehta et al. 1981), and, more
recently, using marijuana (Donald 1986).

The role of alcohol in oral carcinogenesis has
been demonstrated experimentally (Wight and
Ogden 1998) and appears to be related to its damag-
ing effect on the liver, Major metabolites of alcohol,
such as acetaldehyde-a known carcinogen in ani-
mals-may also be important. Alcohol is also
thought to act as a solvent that facilitates the pene-

Discscs and Disorders

tration of tobacco carcinogens into oral tissues. That
observation may partly explain why the combined
use of tobacco and alcohol produces a greater risk for
oral cancer than use of either substance alone.
Indeed, tobacco and alcohol, working in tandem, are
thought to account for 75 to 90 percent of all oral and
pharyngeal cancers in the United States (Blot et al.
1988).

Viruses

The role of viruses in causing cancer in animals was
established early in the century when Rous showed
that a virus, later named the Rous sarcoma virus
(RSV), caused tumors in chickens. The issue of
whether viruses could cause cancer in humans
remained unexplored until the mid-1970s when
Varmus and Bishop showed that RSV had a special
gene, which they called src (for sarcoma), that could
transform the cell it infected into a malignant cell
(Bishop et al. 1978). It was an oncogene, or cancer-
causing gene. The researchers subsequently, and sur-
prisingly, discovered that src was not native to the
virus, but had been picked up by some ancestor virus
from a chicken cell's own genome, where src had pre-
sumably played a role in the chicken cell's normal
growth and development. Somehow RSV was able to
subvert src when it infected a chicken cell to cause
the cell to divide uncontrollably. Varmus and Bishop
called the normal cellular src gene a proto-oncogene,
meaning that it had the potential to be converted to
an oncogene. Subsequent research led to the discov-
ery of other viruses that could cause tumors in ani-
mals and revealed the presence of proto-oncogenes in
birds and mammals. These genes could also be con-
verted to oncogenes, behaving exactly like those car-
ried by cancer viruses. In 1982 an oncogene isolated
from a human bladder cancer turned out to be virtu-
ally identical to rus, the oncogene found in a rat sar-
coma virus (Parada et al. 1982).
Viruses that have been implicated in oral cancer
include herpes simplex type 1 and human papillo-
mavirus. Epstein-Barr virus, also a herpes virus, is
now accepted as an oncogenic virus responsible for
Burkitt's lymphoma, occurring primarily in Africa,
and nasopharyngeal carcinoma, occurring primarily
in China. HPV is a major etiologic agent in cervical
cancer (Howley 1991), and has been found in associ-
ation with oral cancer as well (Sugerman and
Shillitoe 1997). HPV DNA sequences have been
found in oral precancerous lesions as well as in squa-
mous cell carcinomas (Adler-Storthz et al. 1986,
Syrjanen et al. 1988), and experimental evidence has
shown that HPV-16 can be an important cofactor in

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           45


46

-

Diseases and Disardcrs

oral carcinogenesis (Park et al. 1991, 1995). Herpes
simplex type 1 antibodies were demonstrated in
patients with oral cancer, and herpes was found to
induce dysplasia (abnormal cellular changes) in the
lips of hamsters when combined with the application
of tobacco tar condensate (Park et al. 1986).

More recently, human herpes virus 8, a newly
identified member of the herpes virus family, has
been found in Kaposi's sarcoma, an otherwise rare
cancer occurring in patients with AIDS. These
tumors often appear initially within the oral cavity
(Epstein and Scully 1992). Other uncommon oral
malignant tumors, such as Hodgkin's lymphoma and
non-Hodgkin's lymphoma, can also occur in the
mouths of AIDS patients.

tions in the ~53 gene detected in many types of can-
cer (Greenblatt et al. 1994, Hollstein et al. 1991),
including oral and pharyngeal cancer (Langdon and
Partridge 1992, Somers et al. 1992). The ~53 gene
has been called the "guardian of the genome" (Lane
1992) because of its ability to recognize damage to a
cells DNA and stop the process of growth and divi-
sion until the damage is repaired. If repair is not pos-
sible, ~53 can trigger apoptosis. Mutations in the ~53
gene in oral cancer have been linked to smoking and
alcohol use (Brennan et al. 1995).

Loss of Immunosurveillance and Control

  In addition to viruses, infection with strains of
the fungus Candida albicans has been linked to the
development of oral cancers via the fungal produc-
tion of nitrosamines, which are known carcinogens.

The immune system can, at first noted by Paul
Ehrlich in 1909, seek and destroy initial clones of
transformed cancer cells (Ehrlich 1957). Ehrlich
called this process immunosuweillance, and it has
been confirmed in experimental animals (Burnet
1970, Shklar et al. 1990) and in humans with
induced immunosuppression (Penn 1975).

Genetic Derangements

Of the more than 50 known oncogenes, many have
been reported to be present in oral cancer, and mul-
tiple oncogenes have been reported in oral and pha-
ryngeal cancer (Spandidos et al. 1985). Some of these
are &l-l, c-erb-B2, c-myc, ins-2, and members of the
rus family (Berenson et al. 1989, Bos 1989, Riviere et
al. 1990, Somers et al. 1990, 1992).

The genetic derangements that can give rise to
oral cancer, including many mutations associated
with the transformation of proto-oncogenes, have
received notable attention (Sidransky 1995, Wong et
al. 1996). In some instances a change in a single
nucleotide base-a point mutation-in a gene
encoding a proto-oncogene is enough to transform it
into an oncogene. Cancerous changes may also
involve alterations, deletions, and break points in
chromosomes that affect the position of genes.

  One mechanism of immunosurveillance involves
stimulating cytotoxic macrophages and lymphocytes
to migrate to the tumor site and release tumor necro-
sis factors (Y and l3 (Shklar and Schwartz 1988).
Another mechanism operative in oral cancer appears
to be stimulation of Langerhans cells, a special group
of immune cells, in the oral mucosa (Schwartz et al.
1985). Other immune cells implicated in tumor
rejection are natural killer cells and lymphokine-acti-
vated killer cells (Reif 1997).

  There is an increased incidence of cancer in
patients with AIDS or other immunodeficient condi-
tions or with induced immunosuppression prior to
organ transplantation.

In addition, there is evidence that smoking
depresses the immune system (Chretien 1978), and
this may be one of the ways in which smoking acts as
a major risk factor in oral cancer.

Mutations that disarm the cells DNA repair
mechanisms, as well as mutations in tumor suppres-
sor genes, which inhibit abnormal cell growth, play a
major role in cancer development. If an individual
inherits or acquires a mutation in one or more tumor-
suppressor genes, for example, the loss of this pro-
tective mechanism reduces the number of other dele-
terious changes needed for cancer to develop.

Growth Factors

Tumor suppressor genes suspected to be mutated
in oral and pharyngeal cancers include those for Rb,
~16 (MTSI, CDKNZ, or IN4a), and ~53. Todd et al.
(1995) recently reported a novel oral tumor suppres-
sor gene, named "deleted in oral cancer-l (doe-11." Of
the group of tumor suppressor genes, that coding for
~53 is considered of major importance, with muta-

Immune cells are potent generators of growth factors
and other molecules that can stimulate other cells to
migrate and proliferate. This capacity is important in
normal cell growth and turnover, in wound healing,
and in coping with infection. Unfortunately, the
release of growth factors can contribute to oral can-
cer by stimulating keratinocyte (oral epithelial cell)
proliferation (Aaronson 1991, Issing et al. 1993,
Wong 1993). Increased levels of transforming growth
factor (Y (TGF-a) and epidermal growth factor have
been found in oral and pharyngeal cancers and there-
fore could serve as markers for malignancy (Grandis
and Tweardy 1993). Nicotine at high doses stimulates

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


rhe release of growth hormones, among other
endocrine effects (Pomerleau and Pomerleau 1984,
se),ler et al. 1984, 1986).

prevention and Management

Studies of experimental carcinogenesis are elucidat-
ing the role of micronutrients in tumor development
& progression. Alpha tocopherol (vitamin E) also
has been studied as an antioxidant in nutritional
npproaches to the prevention or control of oral can-
cer. Antioxidants can trap free radicals, the highly
reactive molecules that build up in cells and can
damage DNA. The control of oral cancer and precan-
cerous lesions has been demonstrated experimental-
ly using a variety of antioxidant micronutrients, such
as retinoids, carotenoids, and glutathione, as well as
alpha tocopherol. For example, it was found that
alpha tocopherol inhibited tumor development and
tumor angiogenesis (blood vessel formation) in ham-
sters, as well as the expression of TGF-c~, a potent
angiogenesis stimulator (Shklar and Schwartz 1996).
*Animal research and tissue culture studies using ani-
mal- and human-derived cancer cell lines have
shown combinations of micronutrients to be more
effective than single micronutrients and to work syn-
ergistically. The nutrients not only were able to inhib-
it experimental carcinogenesis, but also could com-
pletely prevent tumor development and cause estab-
lished squamous cell carcinomas to regress (Shklar
and Schwartz 1993). The mechanisms of cancer con-
trol by micronutrients are gradually becoming clari-
fied and involve common pathways of activity at the
molecular level (Shklar and Schwartz 1994). Clinical
studies in humans have shown an inhibitory effect on
oral leukoplakia (Benner et al. 1993, Blot et al. 1993,
Garewal 1993, Garewal et al. 1990, Hong et al. 1986),
suggesting a potential role for nutrients in the overall
prevention and management of early oral cancer and
precancerous leukoplakia. However, a recommenda-
tion to employ such approaches clinically at this time
is premature.

DEVELOPMENTAL DISORDERS
The importance of the face as the bearer of identity,
character, intelligence, and beauty is universal.
Craniofacial birth defects, which can include such
manifestations as cleft lip or palate, eyes too closely
or widely spaced, deformed ears, eyes mismatched in
color, and facial asymmetries, can be devastating to
the parents and child affected. Surgery, dental care,
psychological counseling, and rehabilitation may

ORAL HErlLTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           47

Diseases and Disorders

help to ameliorate the problems but often at great
cost and over many years.

Although each developmental craniofacial dis-
ease or syndrome is relatively rare, the number of
children affected worldwide is in the millions. In
addition, craniofacial defects form a substantial com-
ponent of many other developmental birth defects,
largely because they occur very early in gestation,
when many of the same genes that orchestrate the
development of the brain, head, face, and mouth are
also directing the development of the limbs and
many vital internal organs, such as the heart, lungs,
and liver.

By about the third week after fertllization, the
three germ layers of the embryo-the ectoderm,
endoderm, and mesoderm-have formed, as well as
the first of four sets of paired swellings-the
branchial arches-that appear at the sides of the head
end of the embryo. (See Chapter 2 for more details on
this process.) Some craniofacial defects result from
failure of the arches to complete their morphogenet-
ic development. Other craniofacial defects are the
result of the abnormal differentiation of cells derived
from the ectoderm and endoderm or from ectomes-
enchyme cells, which originate in a part of the ecto-
derm (the neural crest), in interaction with future
connective tissue (the mesenchyme).

Craniofacial Anomalies Caused by Altered
Branchial Arch Morphogenesis

Cleft Lip/Palate and Cleft Palate

The most common of all craniofacial anomalies-and
among the most common of all birth defects-are
clefts of the lip with or without cleft palate and cleft
palate alone; these occur at a rate of 1 to 2 out of
1,000 births, resulting in over 8,000 affected new-
borns every year. Cleft lip/palate and cleft palate are
distinct conditions with different patterns of inheri-
tance and embryological origins (Lidral et al. 1997,
Murray et al. 1997). The male to female ratio of cleft
lip/palate is 2:l; the ratio for cleft palate alone is just
the reverse, 1:2.

These anomalies result from the failure of the
first branchial arches to complete fusion processes
(Murray 1995, Robert et al. 1996). Clefting can occur
independently or as part of a larger syndrome that
may include mental retardation and defects of the
heart and other organs. Not all cases of clefting are
inherited; a number of teratogens (environmental
agents that can cause birth defects) have been impli-
cated, as well as defects in essential nutrients such as


Diseases ;tnd Disorders

folic acid. Smoking by the mother during pregnancy
also increases the risk. It is becoming increasingly
evident that most diseases and disorders, not just
craniofacial anomalies, result from interactions
involving multiple genes and environmental factors.

Infants with clefts have difficulty with vital oral
functions such as feeding, breathing, speaking, and
swallowing. They are also susceptible to repeated res-
piratory infections. As these children grow. they must
cope with the social consequences of a facial defor-
mity, delayed and altered speech, frequent illness,
and repeated surgeries that may persist through late
adolescence.

Current molecular epidemiology investigations
have examined both syndromic and nonsyndromic
(isolated) cleft lip/palate and cleft palate. Linkage
studies have identified a number of candidate genes
(Lewanda and labs 1994), including MSXl , RAR, an
X-linked locus, and the genes for TGF-B3 and TGF-
a. The pattern of inheritance in cleft lip/palate and
cleft palate suggests that between 2 and 20 genes may
be involved, with one gene representing a major
component in the development of the cleft. One of
the common syndromic forms of cleft lip/palate, the
Van der Woude syndrome, is caused by an autosomal
dominant form of inheritance at a locus on chromo-
some 1 (Sander et al. 1995). Future molecular genet-
ic studies will be needed to provide the information
necessary for prenatal diagnosis, calculation of risk,
and potential gene therapy.

The Treacher Collins Syndrome-
Mandibulofacial Dysostosis

Children with the Treacher Collins syndrome have
downward-sloping eyelids; depressed cheekbones; a
large fishlike mouth; deformed ears with conductive
deafness; a small, receding chin and lower jaw; a
highly arched or cleft palate; and severe dental mal-
occlusion (Dixon 1996). These defects result from
defective cranial neural crest cell differentiation,
migration, and proliferation (see Chapter 2).
Consequently, the first branchial arch structures are
deficient, and all derivative craniofacial components
are affected.

The underdeveloped facial structures can con-
tribute to airway blockage and repeated upper respi-
ratory infections, either of which can be fatal. The
faulty development of the ears leads to a conductive
deafness. The severe facial deformities exacerbate the
psychological difficulties these youngsters face.
Investigators have identified the gene involved in
an autosomal dominant form of the syndrome (Wise

et al. 1997). The function of the gene is not yet
known, but its identity will provide opportunities for
prenatal diagnosis, gene therapy, and further under-
standing of craniofacial development.

The Pierre Robin Syndrome

Deficient development of the first-branchial-arch-
derived mandibular portion results in the lower jaw's
being set far back in relation to the forehead. As a
result, the tongue is set back and may obstruct the
posterior airway, compromising respiration (Elliott et
al. 1995, Tomaski et al. 1995) and, in severe cases,
leading to inadequate aeration and failure to thrive.
The infant is also at risk for the development of car
pulmonale, an enlargement of the right ventricle of
the heart that occurs secondarily to a chronic lung
condition. Cleft palate may be another consequence.

The DiGeorgeNelocardiofacial Syndrome

The primary defect in the DiGeorge syndrome results
from altered development of the fourth branchial
arch and the third and fourth pharyngeal pouches
(Goldmuntz and Emanuel 1997). Deficiencies affect-
ing the thymus, parathyroid glands, and the great
vessels that derive from these structures result. The
facial features are subtle and include a squared-off
nasal tip, small mouth, and widely spaced eyes.
Similar facial features, along with heart defects, are
seen in the velocardiofacial syndrome. Both syn-
dromes are associated with deletions on the long arm
of chromosome 22 (22qll) (Gong et al. 1997,
Gottlieb et al. 1997). Further characterization of this
chromosomal deletion region will provide informa-
tion on the specific gene(s) affected and its function
in craniofacial development.

The thymus defects severely compromise cellular
immunity, depriving the body of thymus-derived T
cells and paving the way for severe infectious disease.
Inadequate or missing parathyroid glands cause
severe hypocalcemia (low blood calcium levels) and
seizures. The great vessel abnormalities alter cardiac
output and lead to compromised circulation to heart
tissues.

Cranial Bone and Dental Anomalies

Defects in the timing of developmental events can
cause premature fusion of cranial bones.
Impairments of tooth development can result from
interruptions of the developmental sequence at sev-
eral different stages.

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


CraniosyIIoStOSeS

Some craniofacial anomalies are associated with so-
called master genes that orchestrate a program by
Ivhich the embryo assumes its basic shape.
Craniosynostosis, which occurs in approximately 1
out of 3,000 births, is one such anomaly. It results in
the premature fusion of the cranial sutures, a danger-
ous condition that puts pressure on the developing
brain. A number of diseases and syndromes, includ-
ing Crouzon's, Apert's, Boston-type craniosynostosis,
pfeiffer's, and Saethre-Chotzen, share this anomaly,
but differ in other features, which can include struc-
tural defects such as webbing of the hands and feet as
well as mental retardation. Boston-type craniosynos-
tosis has been linked to MSX2, one of the master
genes. Several of the other syndromes involve point
mutations at one or another locus in genes that code
for fibroblast growth factor receptors (FGFR 1,2, and
3) (Howard et al. 1997, Meyers et al. 1996).
Collectively, these genes are associated with cell reg-
ulation, either through mediating growth factor
effects or by serving as transcription factors (Cohen
1997).

Hereditary Hypodontia or Anodontia
Conditions of underdeveloped teeth (hypodontia) or
their complete absence (anodontia) have been corre-
lated with specific genes, such as MSXl and LEFl.
The complete absence of teeth alters the bony devel-
opment of the mandible and maxilla.

Amelogenesis Imperfecta and Dentinogenesis
Imperfecta

Amelogenesis imperfecta and dentinogenesis imper-
fecta are linked to defects in structural genes that
code for proteins essential to the development of
tooth enamel (amelogenesis imperfecta) or dentin
(dentinogenesis imperfecta). The teeth are weak and
extremely sensitive to temperature and pressure. The
ordinary forces of chewing are painful and can lead to
further wear and pain.

The enamel matrix genes include tuftelin,
ameloblastin, and amelogenin; researchers have
begun to link mutations in these genes with amelo-
genesis imperfecta. Similarly, genes labeled DSP and
DPP have been characterized for dentin matrix and
are associated with the inheritance of dentinogenesis
imperfecta.

Diseases and Disorders

Craniofacial Defects Secondary to Other
Developmental Disorders
A number of genetic diseases occur in which cranio-
facial defects are secondav to a more generalized
structural or biochemical defect.

Osteogenesis Imperfecta

Inherited mutations of collagen genes lead to a num-
ber of "brittle bone" diseases characterized by defects
in mineralized tissues that form from a collagen-rich
matrix. Osteogenesis imperfecta presents a spectrum
of deficiencies that includes fragile bones, clear or
blue sclera, deafness, loose ligaments, and painful
dentinogenesis imperfecta-like chaages in the teeth.

Epidermolysis Bullosa-Recessive Dystrophic
TYPe

The gene defect in epidermolysis bullosa-recessive
dystrophic type-manifests as blisters or bullae that
appear shortly after birth on skin areas following
minor trauma. Mutations in keratin genes that con-
tribute to the epithelial cell cytoskeleton have been
correlated with this condition.

The oral manifestations include both mucosal
bullae and altered teeth. Altered teeth with hypoplas-
tic enamel develop and exhibit an increased suscepti-
bility to caries. Oral bullae develop from even the
slightest mucosal trauma. The condition is painful
and dangerous because of the constant risk that the
bullae will become infected.

Craniofacial Manifestations of Single-Gene
Defects

In many craniofacial defects, mutations within a sin-
gle gene manifest as complex syndromes with varied
organ and limb defects as well as facial anomalies.

Ectodermal Dysplasias

The ectodermal dysplasias (EDs) are a family of
hereditary diseases first observed by Charles Darwin
over a century ago. They involve defects in two or
more tissues derived from the ectoderm-skin, hair,
teeth, nails, and sweat glands. The ectodermal struc-
tures fail to differentiate properly owing to altered
epithelial-mesenchymal signaling. A gene, EDA, at an
X-linked locus has been linked to the syndrome, and
ongoing research is aimed at determining the func-
tion of the gene and the molecular mechanism of the
syndromes (Kere et al. 1996, Zonana et al. 1994).

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           49


Diseases and Disorders

More recently, investigators have discovered genes
linked to autosomal (i.e., non-sex-linked) forms of
ED, displaying both dominant and recessive inheri-
tance (Monreal et al. 1999).

Oral manifestations of the ectodermal dysplasias
are associated with the teeth. Alterations in tooth
delrelopment can include hypodontia, anodontia,
and conically shaped teeth.

The Waardenburg Syndrome

The Waardenburg syndrome has been subdivided
into several types. All involve a variety of abnormali-
ties in the position and appearance of the nose and
eyes, with pigment changes that may cause one eye
to differ in color from the other. Other signs include
deafness, a mildly protruding jaw. cleft lip and palate,
and skeletal deformities (Reynolds et al. 1995). The
syndrome is inherited in an autosomal dominant
manner with complete penetrance and variable
expression. Specific genes associated with this syn-
drome are members of the homeobox family that reg-
ulate the transcription of other genes: Waardenburg
type 1 with PAX3; Waardenburg type 2 with IMITF,
3q14.1; and Waardenburg type 3 with PAX3, 2q35
(Asher et al. 1996).

Cleidocranial Dysplasia

The inheritance of a regulatory gene defect in clei-
docranial dysplasia leads to features that include
delayed tooth eruption, supernumerary teeth, altered
or missing collarbones, short stature. and possible
failure of cranial suture closure. The exact mecha-
nism of the associated gene, CBFAI, located on chro-
mosome 6, has not been determined but appears to
be essential for bone development.

INJURY

The common perception is that injuries are random
occurrences that are unpredictable and hence unpre-
ventable. In actuality, experts in the field make the
point that there are no basic scientific distinctions
between injury and disease (Haddon and Baker
1981). Injuries have been categorized as "intention-
al" and "unintentional." People identified as being at
risk for certain injuries. as well as the causes of those
injuries, can be targeted for appropriate prevention
strategies. Such an approach is broadly applicable to
sports, falls, and motor vehicle injuries (unintention-
al) as well as to injuries caused by abusive and vio-
lent behaviors (intentional).

Injuries are a major public health problem. out-
ranking cancer and heart disease as a leading cause of

death in some age groups of the population (Kraus
and Robertson 1992). Cranial injuries in particular
are a leading cause of mortality Oral-facial injuries
can bring disfigurement and dysfunction, greatly
diminishing the quality of life and contributing to
social and economic burdens (Reisine et al. 1989).
The leading causes of oral and craniofacial
injuries are sports. violence, falls, and motor vehicle
collisions (Kraus and Robertson 1992). Oral cavity
injuries may also be caused by foreign objects in food
(Hyman et al. 1993).

sports

Craniofacial sports injuries occur not only in contact
sports, but also in individual activities such as bicy-
cling, skating, and gymnastics, especially on trampo-
lines. Each sport predisposes its participants to a spe-
cific array of extrinsic risk factors (Pinkham and
Kohn 1991). These include physical contact, projec-
tiles such as balls and pucks, and the quality of the
playing field and equipment. In contact sports the
absence of protective equipment such as headguards
and mouthguards is a major risk factor. In a recent
survey of school-aged children in organized sports,
football was the only sport in which the majority of
participants used mouthguards and headgear
(Nowjack-Raymer and Gift 1996).
There are intrinsic risk factors as well, relating to
characteristics of the individual participant. These
include age, sex, injury history, body size, aerobic fit-
ness and muscle strength, central motor control, and
general mental ability (Taimela et al. 1990).

Falls

Falls are a major cause of trauma to teeth, primarily
to incisors. Unlike bone fractures, fractures of the
crowns of the teeth do not heal or repair, and affect-
ed teeth often have an uncertain prognosis. Problems
may develop later due to damage to the pulp.

Motor Vehicle Collisions

The effects of motor vehicle collisions may range
from minor and reversible effects to long-term med-
ical. surgical, and rehabilitative consequences. Post-
traumatic headaches and chronic oral-facial pain can
occur. Neuromuscular and glandular damage may
cause short- or long-term problems with chewing,
swallowing, and tearing or result in facial tics or
paralysis.

50

ORAL HEALTH IN :lILlERICS: ;I REPORT OF THE SURGEON GENERAL


Violence

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

SELECTED CHRONIC AND DISABLING
CONDITIONS

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

Sjiigren's Syndrome

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

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

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

Diseases and Disorders

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

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

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

51


Diseases and Disorders

Acute and Chronic Oral-Facial Pain

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

Atypical Facial Pain

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

Tic Douloureux

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

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

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

Temporomandibular Disorders

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

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

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

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

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


Diseases and Disorders

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

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

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

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

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

ORAL HE.4LTH IN AMERICr\

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

FINDINGS

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

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

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

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

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

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Diseases and Disorders

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

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

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

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

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

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

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


The Magnitude of the Problem

BOX 4.1
Glossary

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

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

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

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

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

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

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

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

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

62

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


The Magnitude of the Problem

WHO HAS WHAT DISEASES AND
CONDITIONS?

Dental Caries, Periodontal Diseases, and
Tooth Loss

Dental Caries

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

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

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

FIGURE 4.1

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

Caries I]\ 58.6

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

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

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

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

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

* Poor

teeth only) and permanent teeth) teeth only)
        Age

iource: NCHS 1996.

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

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

       * Poor children  W Nonpoor children

Source: NCHS 1996.

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


The Magnitude of the Problem

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

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

FIGURE 4.4

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

Non-Hispanic black  Mexican American `Non-Hispanic white

  W Poor children   H Nonpoor children

Source: NCHS 1996.

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

1

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

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

    0

      * Poor adults

Source: NCHS 1996.

O Nonpoor adults

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

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

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


The Magnitude of the Problem

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

periodontal Diseases

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

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

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

FIGURE 4.7

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

           94.5    95.7
     89.8 v
86.4              i
                     3

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

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

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

Sources: Adapted from NCHS 1996,Burt and Eklund 1999

FIGURE 4.8

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

Age

+ la-44
- 45-M
- 65+

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

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

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

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

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


The Magnitude of the Problem

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

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

FIGURE -t.lO

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

  50                      47.1
  45

a8  40
H  35
E  30
5  25

5  20
5  15
=
   10

   5

   0

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

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

Tooth Loss and Edentulism

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

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

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

FIGURE 4.11

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

    40                                       37.8      36.2

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

                      Age group
Socioeconomicstatus
tow   B Middle  * High

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

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

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

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

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

Oral and Pharyngeal Cancers and
Precancerous Lesions

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

FIGURE 4.12

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

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

Source: NCHS 1996.

The Magnitude of the Problem

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

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

FIGURE 4.13

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

28.6

12& is.2

Age

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

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

Sources: NCHS1975,1996.

TABLE 4.1

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

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

Source: Tomar 1997.

States with Lowest Percentage
      Percentage
State      Edentolous

Hawaii       13.9
California      16.2
Oregon       16.5
Arizona       18.5
Wisconsin      19.4

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

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

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

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

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

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

Z Female
H Male

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

Black

White

   Asian and
Pacific Islander
American Indian
and Alaska Native

Hispanica

0      5      10     15     20     25
        Rate per 100,000

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

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

FIGURE -t.15

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

   Prostate gland

  Lung & bronchus

    Colon/rectum

  Urinary bladder

    tymphomas

  Melanoma of skin

Oral cavity & pharynx

      Leukemia

   Kidney/renal

      Pancreas


           0    50    100    150    200    250

   Prostate gland

  Lung&bronchus

    Colon/recrum

Oral cavity&pharynx

      Stomach

  Urinary bladder

   Lymphomas

      Pancreas

   Kidney/renal

    Esophagus

           0    50    100    150    200   250

White males

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

Incidence rate per lW,OOO

Black males

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

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

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

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

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

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

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

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

I White patients

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

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

   90

80

* White patients

Stage at diagnosis

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

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


The Magnitude of the Problem

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

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

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

Tobacco-related Lesions

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

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

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

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

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

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

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

Selected Mucosal Infections and Diseases

Oral Herpes Simplex Virus Infections

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

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

FIGURE 4.19

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

35 -I

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


  O--

L

m Current user

Snuff user      Chewing tobacco user

Source: Adapted from Tomar et al. 1997.

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

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

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

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

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

Other Mucosal Lesions

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

FIGURE 4.20

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

  100

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

88.9

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

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

   20

   10

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

Had oral herpes lesion
in past 12 months

FIGURE 4.21

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

26.9

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

Age group

Source: Adapted from NCHS 1996

The Magnitude of the Problem

common:

Developmental Disorders

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

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


The Magnitude of the Problem

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

Cleft Lip/Palate

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

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

-

FIGURE 4.22

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

Hydrocephalus

Trisomy 21

Microcephalus

Obstruction kidney/ureter

Cleft lip & palate

Pyloric stenosis

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

Source: Schulman et al. 1993.

* Whites     * Blacks

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

Malocclusions

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

Injury

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

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

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

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

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

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

Chronic and Disabling Conditions

Oral-Facial Pain

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

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

The Magnitude of the Problem

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

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

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

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

FIGURE 4.23

Toothache is the most common source of oral-facial pain

  14
P
g  12
,"
8  10

;  8
L
;  6
P  4
f  2

  0

I     Toothache Oral sores Jaw joint Face/cheek  Burning

Pain category

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

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


The &lagnitude of the Problem

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

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

needed. This
subgroup in

Racial and Ethnic Minorities

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

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

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

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

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


than that for Mexican Americans and non-Hispanic
whites.

Hispanics

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

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

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

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

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

-

The Magnitude of the Problem

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

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

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

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

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

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


The Magnitude of the Problem

Hispanic subgroups. More than 20 different coun-
tries of varied cultural, socioeconomic, and political
backgrounds are currently included in this category
of the U.S. population. Narrowing the gap in oral
health between Hispanic and non-Hispanic groups
will require improved data on health status, barriers
to access, and disease factors underlying differences
in oral health in these populations.

Asians, Native Hawaiians, and Other Pacific
Islanders

National data for the oral health of Asian, Native
Hawaiian, and other Pacific Islander (ANHPI) groups
that can be generalized to the U.S. population are not
available. Instead the profile of disease and health in
this category is only available through studies of spe-
cific states and locales. Among all ethnic groups in
California in 1993 and 1994, Asian and Pacific
Islander American (APIA) children in Head Start had
the highest prevalence of early childhood caries-20
percent compared to 14 percent for all Head Start
children (Pollick et al. 1997). These data are compa-
rable to other survey findings of 16 to 20 percent and
29 percent early childhood caries among APIA chil-
dren in Hawaii and California, respectively (Greer
unpublished, Louie et al. 1990).

A California study of 6- to 8-year-olds found dis-
parities in the oral health status of APIA children in
the state when compared to all children nationally.
Among the California APIA children, 7.I percent had
untreated dental caries, with a significant portion of
this group requiring urgent dental treatment. By
comparison, NHANES III data indicate that in 1988
94, 29 percent of children in the United States aged 6
to 8 years had untreated dental decay

There is variation in oral health status among
subgroups of ANHPI children. In a recent survey in
Hawaii, the prevalence of early childhood caries
among APIA children was 16 percent, ranging from a
low of 8 percent among Japanese children to a high
of 25 percent among Filipino children. The preva-
lence of untreated dental caries in 6- to 8-year-old
APIA children was 39 percent, which ranged from a
low of 16 percent among Japanese children to 40 per-
cent among Native Hawaiians, 48 percent among
Southeast Asians, and 62 percent among non-Native
Hawaiian Pacific Islanders (Greer 1999).

Oral cancer incidence and mortality rates for
APIAs are lower than those for white non-Hispanics
and African Americans. However, nasopharyngeal
cancer incidence and mortality rates among Chinese
and Vietnamese populations are many times higher
than other groups (Miller et al. 1996), and therefore
pose a unique health problem for these subgroups.

Until recent years, vital statistics and other
health-related data were virtually nonexistent for the
APIA population. Data for this group generally
appeared in the "other" category of national surveys,
and thus were not helpful in determining specific
population-based oral or general health needs. Little
national focus has been given to defining and meas-
uring the oral health problems and related health
care needs of the APIA population. These needs are
now highlighted in the 2010 Healthy People Oral
Health Objectives. A few statewide oral health data
exist for some APIA child populations, but no ethnic
subgroupings can be assessed. Again, this category of
the U.S. population is extremely heterogeneous. It is
estimated that 76 percent is from one of five ethnic
origins and that 74 percent in 1990 were foreign
born. More than 63 percent live in four states:
California, New York, Hawaii, and Texas. Con-
sequently, determining the reasons for variations in
oral health will require additional data.

American Indian/Alaska Native Populations
Data on the oral health of American Indians and
Alaska Natives (AVAN) are available through studies
conducted by the Indian Health Service (IHS)
(Niendorfs 1994). The AVAN people constitute
about 1 percent of the U.S. population, or an esti-
mated 2.5 million people in 2000. Little is known or
can be easily determined about the general or oral
health status of the 1 million AVAN people not
served by the IHS system. For this reason, with the
exception of overall death rates obtained from census
data, the statistics described in this section will be
limited to the 1.5 million AVAN served by the IHS.
By and large, this group represents AVAN people liv-
ing on or near reservations.

Preliminary analyses of the IHS-wide Oral Health
Status Survey of over 13,000 dental patients in 1999
revealed that some conditions have worsened and
some improved since an earlier survey conducted in
1991 (IHS 1994, 2000). Across the IHS service pop-
ulation there was a statistically significant increase in
caries among adults over 55 as measured by the
decayed, missing, and filled teeth index. The decayed
and filled tooth rate increased from 7.5 to 8.8 teeth,
with no change in the average number of missing
teeth for this age group.

Among AVAN children across the IHS, there was
a significant decline in caries in the permanent den-
tition and a significant increase in caries in the pri-
mary dentition. Among children aged 2 to 5 years,
the increase in decayed and filled primary teeth sur-
faces went from 8.6 to 11.4. In general, AVAN popu-
lations have much greater rates of dental caries and

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


periodontal disease in all age groups than the gener-
al U.S. population. AVAN children aged 2 to 4 years
have 5 times the rate of dental decay compared to all
children, and 6- to 8-year-old AVAN children have
about twice the rate of dental caries experience. Rates
for untreated decay in these age groups are 2 to 3
times higher than in the same age groups in the gen-
eral U.S. population. Periodontal disease in AVAN
adults is 2.5 times greater than in the general U.S.
population. High prevalence rates of diabetes among
AVAN populations are a significant contributing fac-
tor to this periodontal disease (IHS 2000).

Substantial unmet dental needs and quality of
life issues have also been identified in IHS surveys,
which included studies of representative AWAN com-
munities with regard to the effect of oral conditions
on well-being and quality of life (Chen et al. 1997).
(See Chapter 6 for a general discussion.) One third of
schoolchildren report missing school because of den-
tal pain. Twenty-five percent of schoolchildren avoid
laughing or smiling, and 20 percent avoid meeting
other people because of the way their teeth look. As
a consequence of dental pain, almost a quarter of the
adults are unable to chew hard foods, almost 20 per-
cent report difficulty sleeping, and 15 percent limit
their work and leisure activities. Three quarters of
the elderly experience dental symptoms, and half
perceive their dental health as poor or very poor and
are unable to chew hard food. Almost half the adults
avoid laughing, smiling, and conversation with oth-
ers because of the way their teeth look.      .
Again, the available data allow for obtaining a

picture only of the AVAN population residing on
reservations where services, including dental servic-
es, have been provided by the IHS or contracted to
tribes or urban AI/AN organizations. In 1989,
American Indians, residing in the current reservation
states had a median household income of $19,897.
Almost one third (31.6 percent) of AVANs lived
below the poverty level. For some groups, diabetes
and high rates of tobacco and alcohol use are preva-
lent and contribute to poor oral health.

Women's Health

Analysis of data from NHANES III indicates that
women have benefited from the trend in general
improvements in oral health that has been enjoyed
by the U.S. population overall. Many, but not all, sta-
tistical indicators show women to have improved
their oral health status as compared to men
(NHANES III, Redford 1993). Adult females are less
likely than males at each age group to have severe
periodontal disease as measured by periodontal loss

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

The Magnitude of the Problem

of attachment of 6 mm or more for any tooth. Both
black and white females (6.0 and 6.0 per 100,000)
have a substantially lower incidence rate of oral and
pharyngeal cancers compared to black and white
males, respectively (20.8 and 14.9 per 100,000). A
higher prevalence of females than males have oral-
facial pain, including pain from oral sores, jaw joints,
face/cheek, and burning mouth syndrome. However,
there are large areas for which information for either
sex, even at the descriptive level, is only partial or
nonexistent. Data gaps regarding craniofacial in-
juries, soft tissue pathologies, and salivary gland dys-
functions are notable examples.

Most oral diseases and conditions are complex
and represent the product of interactions between
genetic, socioeconomic, behavioral, environmental,
and general health influences (Chapters 3 and 5).
Multiple factors may act synergistically to place sub-
groups of women at higher levels of risk for oral dis-
eases. For example, the comparative longevity of
women, compromised physical status over time, and
the combined effects of multiple chronic conditions
often with multiple medications, can result in
increased risk of oral disease (Redford 1993). Many
women live in poverty, are not insured, and are the
sole head of their household. For these women,
obtaining needed oral health care may be difficult. In
addition, gender-role expectations of women may
also affect their interaction with dental care providers
and could affect treatment recommendations as well
(Redford 1993).

During the past decade, women's health has
emerged as a significant issue in the nation's health
agenda. The scientific community is beginning to
respond to this concern by studying and reporting
the effects of sex and gender differences on health
and disease management. Although most of the effort
has focused upon women, comparisons with men's
health have begun to elucidate sex- and gender-
specific differences.

Research has demonstrated sex and gender dif-
ferences in the response to kappa opioid analgesics
for the control of postoperative pain (Gear et al.
1996). These findings have heightened conjecture
about differences in the female and male nervous sys-
tems in response to pain stimuli. There are studies in
mice that suggest that there are sex-specific respons-
es to pain and analgesics (Mogil et al. 1996, 1997).
Taken together, these findings could help explain
why women report certain painful conditions more
than men; for example, temporomandibular joint
disorders, trigeminal neuralgia, migraine headaches,
and burning mouth syndrome (USDHHS 1999).

77


The Magnitude of the Problem

  Recent research has also demonstrated sex and
gender differences in taste perception. Women are
more likely than men to be "supertasters" of a bitter
compound known as 6-n-propylthyiouracil (PROP)
(Bartoshuk et al. 1994). PROP supertasters experi-
ence more intense tastes (particularly for bitter and
sweet>, a greater sensation of oral burning in
response to alcohol, and more intense sensations
from fats in food (Bartoshuk et al. 1994, 1996, Tepper
and Nurse 1997). PROP supertasters also have more
fungiform papillae on their tongues than medium
PROP tasters or those who cannot taste PROP at all.

ioral and environmental differences-to name a
few-decreases the utility of those data that are avail-
able. For example, women are reported to be more
inclined to self-care, to visit the dentist more often,
and to be more likely to report symptoms such as
pain. However, the effects of these behaviors on their
oral health status cannot be determined fully Figure
4.24 suggests content areas in the study of women's
oral health.

Individuals with Disabilities

The Agenda for Research on Women`s Health for   No national studies have been conducted to deter-
the 2lst Century noted that the ability to interpret  mine the prevalence of oral and craniofacial diseases
oral health in the context of sex and gender was lim-  among the various populatiops with disabilities.
ited by large gaps in knowledge. For example, perti-  Several local and regional reports, however, provide
nent oral health data, even at the descriptive level, are  some relevant data in this regard. For example, some
partial or nonexistent for many conditions and dis-  smaller-scale studies show that the population with
eases for either sex. In addition, limited knowledge of  mental retardation or other developmental disabili-
etiologic factors, natural history of diseases, behav-  ties has significantly higher rates of poor oral hygiene

FIGURE 4.24
Content areas in the study of women's health

Oral Influences on Systemic Health
Evidence for links between oral infection
and diabetes

Women and the Health Care System
Treatment decision making
     lization of professional services

Systemic influences on Oral Health
Longevity
Multiple chronic conditions
Medication usage       -
Cognitive impairments
Physical confinement
Compromised functional status
Postmenopausal bone loss
HIV
Diabetes

  Diseases More Common in Women
   Than Men
  TMD, oral-facial pain, Sjogren's
/ syndrome,saiivary gland
  dysfunction, burning mouth,
  alterations in taste,
  pregnancy-associated oral changes

Societal Influences on Women's
Caregiving
Poverty     Gender role expectations
Underinsurance   Concern for aesthetics
Access to care    Craniofacial trauma

              Oral Diseases Affecting
                  the Most Women
                   Caries
                 Periodontal diseases
\ Gender Influences on Health Risk
  Dental care utilization
  Self-care
  Eating disorders
  Unprotected sexual activity

Source: Adapted from Chesney and Ozer 1995 and reprinted in USOHHS 1999.

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


and needs for periodontal disease treatment than the
general population, due, in part, to limitations in
individual understanding of and physical ability to
perform personal prevention practices or to obtain
needed services. There is a wide range of caries rates
among people with disabilities, but overall their rates
are higher than those of people without disabilities.
Much of the variation stems from where people
reside (e.g., in large institutions where services are
available versus in the community where services
must be secured from community practitioners).
Almost two thirds of community-based residential
facilities report that inadequate access to dental care
is a significant issue (Beck and Hunter 1985, White
et al. 1995, Waldman et al. 1998, Dwyer, Northern
Wisconsin Center for the Developmentally Disabled
unpublished data, 1996). Parents consistently report
dental care as one of the top needed services for their
children with disabilities regardless of age (Haveman
et al. 1997). Local studies of independent living cen-
ters reported that 24 to 30 percent of adults with
cerebral palsy, 14 percent with spinal cord injuries,
30 percent with head injuries, and 17 percent who
were deaf had dental problems (Arnett 1994). Results
from 1999 oral assessments of U.S. Special Olympics
athletes (all ages), based on an extremely conserva-
tive assessment protocol (without the use of x-rays,
mirrors, or explorers), and carried out by the Special
Olympics Special Smiles Program in 20 states, indi-
cate that 12.9 percent of the athletes reported some
form of oral pain, 39 percent demonstrated signs of
gingival infection. and nearly 25 percent had untreat-
ed decay (Special Olympics, Inc., unpublished data).
Note that this is a population that tends to be from
higher-income families.

The oral health problems of individuals with dis-
abilities are complex. These problems may be due to
underlying congenital anomalies as well as to inabil-
ity to receive the personal and professional health
care needed to maintain oral health. There are more
than 54 million individuals defined as disabled under
the Americans with Disabilities Act, including almost
a million children under age 6 and 4.5 million chil-
dren between 6 and 16 years of age. A greater per-
centage of males than females and of African
Americans than Hispanics and whites have disabili-
ties (Federal Interagency Forum 1997, Waldman et
al. 1999). Children with disabilities have chronic
physical, developmental, behavioral, and emotional
limitations, including mental retardation, autism,
attention deficit hyperactivity disorders, and cerebral
palsy. Also, children from families with incomes
below the poverty level are about one third more like-
ly than children in nonpoor families to have an exist-

The Magnitude of the Problem

ing special health care need. Similarly, children from
less educated households exhibit a higher likelihood
of a special health care need. Children in single-par-
ent families are about 40 percent more likely than
children from two-parent households to have special
health care needs (Newacheck et al. 1998).
Deinstitutionalization has resulted in highlighting
the problem these individuals have regarding access
to dental care as they move from childhood to adult-
hood. Availability of dental providers trained to serve
special needs populations and limited third-party
support for the delivery of complex services (see
Chapter 9) further complicate the issues entailed in
addressing the needs of this population.
Given the wide variability among groups with
disabilities, this review of oral health status and
needs is quite limited. More in-depth assessment and
analysis of the determinants of oral health status,
access to care, and the role of oral health in the over-
all quality of life and life expectancy of individuals
with disabilities are needed (see Chapter 10).

UTILIZATION OF PROFESSIONAL

CARE: WHAT DO WE KNOW ABOUT
THE RELATIONSHIP OF ORAL HEALTH
AND USE OF DENTAL SERVICES?

With few exceptions, maintenance of oral health
through a lifetime requires timely receipt of advice
for self-care, preventive therapies, early detection and
treatment of problems, and restoration of function.
Chapter 7 describes community-based and profes-
sional interventions that have played a significant
role in the improvement of oral health achieved over
the past 50 years; their full promise has not, howev-
er, been realized. Chapter 8 describes current and
emerging strategies for personal and provider
approaches to maintain and restore oral health, with
tooth-conserving approaches being employed more
and more frequently. As noted earlier, almost every-
one experiences oral diseases and conditions over
the course of a lifetime, and, unlike the common
cold, most diseases do not resolve over time.
Consequently, receipt of dental services complements
self-care as a critical factor in achieving and main-
taining good oral health.

Although certain counseling and screening serv-
ices provided by physicians are recommended (U.S.
Preventive Services Task Force 1996), data to indi-
cate how many persons receive such services or oral-
health-related recommendations from their physi-
cian are very limited. There are also no data on physi-
cian-based services for oral and craniofacial condi-
tions. The data that are available describe utilization

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           79


The Magnitude of the Problem

of dental visits. Unfortunately, most of these data are
cross-sectional, describing the experience of the pop-
ulation in any given year, but providing little detail
about how patterns of care over time contribute to
oral health. Nevertheless, utilization of care is used as
a surrogate measure of an individual's or a popula-
tion`s capacity to maintain or improve health status.
An understanding of utilization of dental visits and
differences in such visits among age, racial/ethnic,
sex, and income groups is important in identifying
opportunities for improvement in oral health that
would follow from timely receipt of professional care.
Characteristics of groups with different levels of
dental care utilization suggest barriers to care as well
as factors that predispose or enable access to dental
care. Explanations for variation in utilization are
alluded to in the following section, and are discussed
in further detail in Chapter 10. More studies are
needed to understand the dimensions of disease and
the role of professional care and use of services. Also,
for oral health in particular, the contributions of all
health professions and the interdisciplinary nature of
care need to be emphasized.

Dental Care Utilization

Visiting a health care provider at least once per year
and the number of visits made within the past year
are used as indicators of an individual's ability to
access professional services. Dental care utilization
statistics are traditionally based on an individual's
reporting "at least one dental visit in the past year,"
although there are variations with shorter recall
intervals and different forms of the question.
Depending on the question and survey method,
annual dental care use estimates vary The 1996
Medical Expenditures Panel Survey (MEPS) esti-
mates that 43 percent of the U.S. population 2 years
and older had at least one dental visit that year
(MEPS 2000). Responding to a variation of a ques-
tion that had been asked in many previous surveys,
some 65.1 percent of the U.S. population 2 years and
older reported in 1997 that they had visited a dentist
in the preceding year (NCHS 1997b), up from 55.0
percent in 1983 (Bloom et al. 1992). The average
number of visits per person remains at about two per
year. Further research is needed to understand rea-
sons for variations in estimates from different survey
approaches, but differences among persons with dif-
ferent characteristics are quite similar regardless of
survey method.

  Data from the 1997 National Health Interview
Survey, reprinted in Healthy People 2010, indicate
that the highest percentage reporting at least one

rABLE 4.3

Percentage of persons 25 years of age and older with a dental
kit within the preceding year, by selected patient character-
istics, selected years

1983d  19896 1990   1991   1993

lotalbrC
be
25 to 34 years
35 to 44 years
45 to 64 years
65 years and older
65 to 74 years
75 years and older

Sex'
Male
Female

Poverty statusLd
Below poverty
At or above poverty
Race and Hispanic origin'
White, non-Hispanic
Black, non-Hispanic
HispanV
Education'
Less than 12 years
12 years
13 years or more
Education, race, and
Hispanic origin'
Fewer than 12 years
White, non-Hispanic
Black, non-Hispanic
Hispanif
12 years
White, non-Hispanic
Black, non-Hispanic
Hispanif
13 years or more
White, non-Hispanic
Black,non-Hispanic
  Hispanif

53.9   58.9   62.3   58.2   60.8


59.0   60.9   65.1   59.1   60.3
60.3   65.9   69.1   64.8   66.9
54.1   59.9   62.8   59.2   62.0
39.3   45.8   49.6   41.2   51.7
43.8   50.0   53.5   51.1   56.3
31.8   39.0   43.4   41.3   44.9


51.7  542   58.8   55.5   58.2
55.9   61.4   65.6   60.8   63.4

30.4   33.3   38.2   33.0   35.9
55.8   62.1   65.4   61.9   64.3


56.6   61.8   64.9   61.5   64.0
39.1   43.3   49.1   44.3   47.3
42.1   48.9   53.8   43.1 46.2

35.1   36.9   41.2   35.2   38.0
54.8   58.2   61.3   56.7   58.7
70.9   73.9   75.7   72.2   73.8

36.1   39.1
31.7   32.0
33.8   36.5


56.6   59.8
40.5 44.8
48.7   56.5


72.6   75.8
54.4   57.2
58.4   66.2

41.8
37.9
42.7


62.8
51.1
59.9


77.3
64.4
67.9

38.1   41.2
33.0   33.1
28.9   33.0


58.8   60.4
43.1 48.2
49.5   54.6


74.2   75.8
61.7   61.3
61.2   61.8

a Data for 1983 and 1989 are not strictly comparable with data for later years. Data for
1983 and 1989 are based on responses to the question "About how long has it been
since you last went to a dentist?"Starting in 1990,data are based on the question
"During the past 12 months, how many visits did you make to a dentist?"
blncludes all other races not shown separately and unknown poverty status and educa-
tion level.
`Age adjusted.
dPoverty status is based on family income and family size using Bureau of the Census
poverty thresholds.
ePersons of Hispanic origin may be of any race.
Notes: Data are based on household interviews of a sample of the civilian noninstitu-
tionalized population.Denominators exclude persons with unknown dental data.
Estimates for 1983 and 1989 are based on data for all members of the sample house-
hold. Beginning in 1990, estimates are based on one adult member per sample house-
hold. Estimates for 1993 are based on responses during the last half of the year only.
Source: Data from NCHS 1989.

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


The Magnitude of the Problem

dental visit was third-grade children (82 percent).  Variation by Sex, RacelEthnicity, Income,
Those aged 25 years and older with less than a high  and Insurance
school education had the lowest rates (41 percent)
for annual dental visits as compared to those with at  Dental care utilization varies with sex and race/eth-
least some college education (74 percent) (USDHHS  nicity for individuals 25 and older (NCHS 1997a).
2000>.                  Females had slightly higher rates of utilization (67
                           percent) than males (63 percent).
                            Hispanic individuals had the low-
TABLE 4.4                        est utilization (53 percent), and
Age-adjusted percentage distribution of persons 2 years and older by interval since   non-Hispanic whites had the high-
last dental visit, by selected characteristics, 1989              est rates (68 percent). Table 4.3

                        Interval Since Last Dental Visit       provides an overview of utilization
                            from 1983 through 1993. A higher
                             1 Year to  2Years to        percentage of females reported a
                     All   LessThan LessThan LessThan SYears      dental visit than males in each sur-
                 Intervals   1 Year   2 Years   5 Years  or More Never   vey year. Fewer non-Hispanic
All ages               100.0    57.3    9.5    12.3    11.0   4.6   blacks and Hispanics reported a
Sex                                dental visit than non-Hispanic
  Male                100.0    54.1    9.6     13.4    12.1   4.9    whites in each survey year. Income
  Female               loo.0    59.9    9.4     11.2    10.1   4.4   and education are also key vari-
  Race                                ables in utilization. In 1993,
  White               100.0    59.5    9.1     11.6    10.5   4.4   almost twice as many individuals
  Black               100.0    43.2   12.3     16.9    15.1   5.8   25 and older living at or above the
  Other                100.0    51.6    9.7     14.0    10.8   6.7   poverty line had a dental visit than
Hispanic origin                          did those living below the poverty
  Non-Hispanic            100.0    58.5    9.4     12.0    10.8   4.1    line in 1993 (64.3 versus 35.9 per-
  Hispanic              100.0    46.0   10.5     14.6    13.0   9.7   cent). Similarly, almost twice as
   Mexican American         100.0    40.5    8.9     15.3    15.8   13.1   many individuals with 13 years or
  Other Hispanic           100.0    53.2    12.3     13.7     9.9   5.1    more of education had a visit than
  Place of residence                          did those with fewer than 12 years
  MSA'                100.0    58.4    9.4.    11.9    10.1   4.5    of education (73.8 versus 38.0 per-
  Central city             100.0    54.9   10.1     12.9    10.9   5.1    cent) in that same year.
  Not central city           100.0    60.6    9.0     11.3     9.6   .4.2      Data from the 1989 National
  Not MSA'              100.0    53.6    9.7     13.6    14.1   5.1    Health Interview Survey showed
Geographic region                        that the overall age-adjusted num-
  Northeast              100.0    60.7    10.4     10.7    9.0   3.5    ber of visits for blacks was 1.2 vis-
  Midwest              100.0    61.5    6.3     11.3    10.7   3.5
  South               100.0    52.2    10.3     13.9    13.6   5.9   its compared to 2.2 visits for
                                                                     et
   West                100.0    57.8    8.6    12.3     9.1   4.9    whites (Bloom al. 1992).
                                  Table 4.4 shows the percent-
  Education level
  Less than 9 years           100.0    30.6    9.9     18.4    30.6   5.9   age distributions of the interval
                                   since their most recent dental visit
  9 to 11 years             100.0    39.0    10.7     20.3    23.5   1.3
  12 years               100.0    54.6    10.6    15.0    14.4   0.5   for people aged 2 and older in

  13 years or more          100.0    70.2    8.5     10.3     6.9   0.2     selected demographic and socioe-
                            conomic categories. Individuals
Family income                             who have never visited a dentist
  Less than $10,000          100.0    42.2    10.9     16.3    20.1   7.0
                    100.0    43.9    11.8     17.4    16.1   6.6   ranged from high of 13.1
                                             a percent
  $10,000 to $19,999
  $20,000 to 534,999          100.0    58.2    10.5     3.2    10.4   4.6    of Mexican Americans to 5.8 per-

  $35,000 or more           100.0    72.5    7.8     8.5     5.5   2.9    cent of blacks and 4.4 of
                                                 percent

Dental insurance coverage                     whites. Eleven percent of the pop-
                                   ulation had not had a dental visit
  With private dental insurance     100.0    70.4    8.7     9.2     6.6   3.3
  Without private dental insurance    100.0    50.8    10.7     15.4    14.2   6.0    in 5 or more. Individuals
                                               years
                             with fewer than 9 years of educa-
  ' MSA = metropolitan statistical area.                    tion represented the highest pro-
  Source:Bloom et al. 1992.                     portion, 30.6 percent, of those
                            reporting no dental visit in 5 years

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           81


The Magnitude of the Problem

or more, compared with 6.9 percent of those with 13
years or more of education. A larger proportion of
individuals without private dental insurance had not
had a dental visit in 5 years or more compared with
those with private dental insurance (14.2 versus 6.6
percent). Hispanic individuals have the lowest rate of
dental insurance coverage-29.0 percent, compared
with 32.4 percent for non-Hispanic blacks and 41.8
percent for non-Hispanic whites (U.S. Bureau of the
Census 1997).

Professional care is necessary for several critical
dental disease prevention measures, such as the
application of dental sealants. Unfortunately, dental
sealants are 3 times less likely to be found on the
teeth of Mexican American and African American
children than among white children aged 5 to 17
(Selwitz et al. 1996). Asian and Pacific Islander
American children in California also demonstrated a
low rate of sealant use (Pollick et al. 1997).

Variation by Oral Health Status
Utilization of dental care is associated with self-
reported health status, as shown in Table 4.5. Of
those who reported "excellent" or "very good"
health, 61.4 percent had had a dental visit within the
past year, compared with about 45.1 percent of those
reporting "fair" or "poor" health. Functional limita-

TABLE 4.5
Age-adjusted percentage distribution of persons 2 years and older by interval since
last dental visit, by selected health characteristics, 1989

Interval Since Last Dental Visit

Assessed health status
Excellent or good
      very
Good
Fair or poor
Limitation of activity
Unable to carry on usual
activity
Limited in amount or kind
of major activity
Limited, but not in major
activity
Not limited in activity

Dentition status
Dentate
Edentulous

Source: Bloom et al. 1992.

All    Less Than   1 Year to
Intervals   1 Year    2 Years



100.0     61.4     9.3
100.0    ST.9     10.1
100.0     45.1     10.0




100.0     46.6     9.8


100.0    52.3     9.8


100.0     59.1     8.3
100.0     58.5     9.5



100.0    65.5     9.6
100.0     14.3     6.4

A study comparing individuals who had had a
dental visit in the past 12 months with those who had
not reported that dentate adults who had a recent
       visit were less likely to have
        untreated coronal and root caries,
       pulpal pathology, and retained
       tooth roots. They also were more
       likely to rate the general condition
       of their teeth and gums as excel-
       lent or very good (Drury and
         Redford 2000).

2 Years to
Less Than  5 Years
5 Years   or More   Never



11.2     9.0    4.3
13.9    12.6    5.8
16.6    17.4    5.9




15.6    16.6    5.1


14.0    14.4    4.1


12.8    11.7    4.2
12.0    10.1    4.6



12.8    10.1    0.5
19.8    55.2    0.4

  Examination of NHANES III
data by low socioeconomic status
(SES) provides an additional per-
spective. In a recent analysis, SES
was measured by a composite
index based on educational attain-
ment and the ratio of annual fami-
ly income to the poverty threshold.
Among all adults, people with
lower SES scores were nearly 9
times more likely to be edentulous
than those with higher SES scores.
Among the dentate, those with
lower SES scores were 6 times
more likely to have coronal decay
and nearly 4 times less likely to
have visited a dentist in the past 12
months (Drury et al. 1999).

tions are also related to dental service utilization. Of
those who reported no physical limitations in activi-
ties, 58.5 percent reported a dental visit within the
past year, compared to 46.6 percent of those who
were unable to carry out their usual activities (Table
4.5) (Bloom et al. 1992).

Whether a person had natural teeth was strongly
associated with dental care utilization (Table 4.5).
Dentate persons were more than 4 times more likely
to report a dental visit within the past year than eden-
tulous people: 65.5 versus 14.3 percent. Over half
(55.2 percent) of those who were edentulous reported
that they had not had a dental visit in 5 years or more.
Recent analyses of data from NHANES III show
that adults 18 and older who reported a dental visit
in the past 12 months were nearly 9 times more like-
ly to be dentate and 4.4 times more likely to have a
complete dentition than adults who did not report
visiting a dentist within the preceding 12 months.
Dentate adults who reported a dental visit in the past
12 months were 3.1 times less likely to have untreat-
ed coronal decay and 1.5 times less likely to have
gingivitis than dentate adults who did not report a
recent dental visit (T. Drury, NIDCR, personal com-
munication, 1999).

a2

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


--

Reasons for Nonutilization
Reasons for nonutilization of dental services are com-
plex. Principal reasons cited by respondents of all
ages (Bloom et al. 1992) are given in Table 4.6.
Slightly less than half of those reporting no dental
visit in the past year (46.8 percent) said that they per-
ceived having no dental problem. This perception
was the predominant response of individuals in all
demographic categories, except for those 65 and
older, who gave having no teeth as the predominant
reason. Younger individuals were more likely than
older to cite "no dental problem." Blacks were more
likely to report "no problems" (58.5 percent) as a rea-
son for no dental visit, compared to 44.3 percent of
whites (Bloom et al. 1992).

Having no teeth (14.3 percent) was the next
most frequently reported reason for no dental visit.
About half of the people 65 and older in the 1989
survey gave this as their reason for no dental visit-
39.2 percent of blacks compared to 51.2 percent of
whites.

The third most frequently cited reason was the
cost of care, mentioned by 13.7 percent of respon-
dents. Whites (14.3 percent) were more likely than
blacks (11.4 percent) to cite cost. Other surveys have
reported substantially higher percentages of individ-
uals indicating cost as a barrier, particularly those in
underserved or low-income areas (Bloom et al.
1992). The age group most sensitive to the cost of
care was 18- to 34-year-olds, 19.1 percent of whom
gave cost as the reason for no dental visit, Finally, a
small proportion of respondents (4.3 percent) report-
ed fear as a personal barrier to receipt of care.

Unmet Needs

Unmet health needs can be assessed in many ways.
Because oral diseases are common and do not resolve
over time in the absence of intervention, the lack of
dental visits is used as an indicator of unmet health
needs. In addition, the National Access to Care
Survey documented the extent of dental care that
individuals wanted but could not obtain ("wants") in
the total population and among various population
subgroups (Mueller et al. 1998). About 8.5 percent of
the U.S. population wanted, but did not obtain, den-
tal care in 1994 (Table 4.7). In contrast, only 5.6 per-
cent reported unmet medical or surgical care wants.
Adult women aged 19 to 64 reported the greatest
level of dental care wants; elderly people 65 and older
had the lowest level. Blacks, people in fair or poor
health or with one or more chronic conditions, and
people living in the South reported higher levels of
dental care wants than comparable groups. About

The Magnitude of the Problem

16.4 percent of those in households whose family
income was less than 150 percent of the poverty level
reported dental care wants. More than 22 percent of
the uninsured reported dental care wants. Insured
children with special health care needs were 4 times
more likely to report unmet need for dental care
(23.9 percent versus 6.1 percent) if they were unin-
sured than if they were insured, according to a recent
analysis of data from the National Health Interview
Survey (Newacheck et al. 2000).

Outcomes of Appropriate Levels of Access
and Utilization: An Example
The effects on health of a system of care with assured
access and positive expectations of care-seeking and
utilization behavior have been demonstrated by the
U.S. Department of Defense. There are currently over
1.4 million men and women on active duty in the
U.S. military. The population is predominantly male
(86 percent). The racial distribution is 68 percent
white, 20 percent black, 7 percent Hispanic, 3 per-
cent Asian, and 2 percent other groups. Slightly over
30 percent of active duty personnel are between the
ages of 20 and 24, and 91 percent are younger than
40. In 1997, 59 percent were married. Seventy-six
percent had a high school degree, and 19 percent
were college graduates.

Free dental care, one of the benefits provided to
active duty military personnel, eliminates one of the
significant barriers that has been identified as
limiting access to care for many in the civilian
population. In addition, military personnel are
required to receive a dental examination annually,
even if the individual perceives that he or she has "no
problem." Dental care is available to most military
personnel at their duty station, eliminating the need
to travel long distances. A comparison of the oral
health and utilization of dental care of the military
and civilian populations illustrates the impact of
elimination of these barriers to care on oral health,
even for persons from demographic groups that are
traditionally underserved.

In 1994 the Tri-Service Comprehensive Oral
Health Survey examined and administered question-
naires to 13,050 active duty military personnel using
a complex, weighted survey design to examine the
oral health status, dental treatment needs, dental uti-
lization, and perceived need for care in this popula-
tion (York et al. 1995). The study found that nearly
all (99.2 percent) active duty military personnel had
seen a dentist within the past 2 years. Eighty percent
of active duty personnel received a dental examina-
tion within the past year, 60 percent had a dental

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           83


The Magnitude of the Problem

TABLE 4.6
Percentage of persons with no dental visit in past year by reason reported, by selected characteristics, 1989

All with No Visits
in PastYear

Fear

cost

Access    No Dental
Problem    Problem

NoTeeth

Not     Other
Important    Reason

All ages
2to 17 years
18to34years
35to 64years
65 yearsandolder

Sex
Male
All ages
2to 17 years
18to 34years
35to64years
65 yearsandolder
Female
Allages
2to17years
18to 34years
35to64years
65 yearsand older

Race
White
All ages
2to 17years
18to34years
35to 64years
65yearsandolder
Black
All ages
2to 17 years
18to 34years
35to64 years
65 yearsand older
Other
All ages
2to17 years
18to 34years
35to 64years
65yearsandolder
Hispanic origin
Non-Hispanic
All ages
2tol7years
18to34years
3Sto64 years
65yearsandolder
Hispanic,total
All ages
2to 17 years
18to34years
35to64years
65yearsandolder

100.0
100.0
100.0
100.0
100.0





100.0
100.0
100.0
100.0
100.0


100.0
100.0
100.0
100.0
100.0





100.0
loo.0
loo.0
100.0
100.0


100.0
100.0
100.0
100.0
100.0


100.0
100.0
100.0
100.0
100.0




100.0
100.0
100.0
100.0
100.0


100.0
loo.0
100.0
100.0
100.0

4.3      13.7       1.1      46.8      14.3      2.3      8.7
1.3      15.0       1.5      56.8       0.2       1.9     11.9
5.9      19.1       2.4       52.4       0.7       3.2      9.5
5.8      12.8       1.5       43.3      17.8       2.2      a.4
2.2       4.1       1.1       31.2      49.7       1.1      3.9





4.0      13.0       1.5       49.1       12.1       2.6      9.3
1.2      14.9       1.3       56.2      o 0.2       2.0      12.1
5.5      17.5       2.0       54.8       0.6      *  3.4      9.7
5.4      11.2       1.5       45.4      16.1      2.8      9.5
1.7      4.0       1.0      33.6      48.6       1.3      3.5


4.6      14.3       1.8       44.4      16.6       1.9      a.1
1.5      15.2       1.6       57.4      o 0.2       1.8     11.6
6.5      21.0       2.9       49.5       0.8       3.0      9.3
6.2      14.4      1.5       41.1      19.5       1.6      7.3
2.5      4.2       1.2       22.5      50.6       0.9      4.1





4.4      14.3       1.8       44.3      15.7       2.4      9.4
1.3      16.4       1.7       54.0       0.2       2.0     13.3
6.2      20.7      2.6       49.6       0.7       3.4     10.6
5.8      13.0       1.6       41.3      19.0       2.4      9.1
2.1       3.7       1.1       30.5      51.2       1.1      3.9


4.0      11.4       1.0       58.5       8.8       1.5      5.1
1.3      10.7      "0.7       68.3      "0.2       1.2      6.6
4.9      13.3      1.5       63.8      "0.7       2.5      4.6
6.0      11.7       0.9       52.8      13.0       1.1      4.9
3.0      7.0      "1.0       36.6      39.2      "0.9      3.4


3.7      10.8       1.6       52.1       6.1       2.2      9.2
"1.7      11.4      "0.3       49.8       *o.o      '2.4      12.6
4.6      11.7      "2.5       59.4      "0.3      "2.2      8.8
4.6      10.8      "1.9       51.0       a.2      *2.6      7.7
"2.8      o 4.2      o 0.7       31.4       44.9      o 0.7     "5.9




4.3      13.0       1.7       45.7       15.6       2.2      9.1
1.3      14.4       1.3       56.2       0.2       1.9     12.8
6.0      18.9       2.5       51.6       0.7       3.2      10.1
5.8      12.0       1.5       42.5      18.8       2.2      a.7
2.1       4.0       1.1       30.9      50.4       1.1      3.9


4.0      19.1       1.8       56.1       3.5       2.6      5.9
1.6      18.4      2.4      59.5      '(0.1       2.2      7.3
5.2      20.1       1.5       57.9      "0.2       3.3      5.6
5.3      20.7       1.6      52.2       6.5      2.3      5.2
"4.6      a.2      "1.4       40.7      31.9      *1.6     *3.4

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


The Magnitude of the Problem

             All with No Visits                 Access     No Dental             Not     Other
              in Past Year    Fear     cost     Problem    Problem     No Teeth   Important    Reason
Hispanic, Mexican American
All ages            100.0      3.6      20.7       1.7       56.2       2.4       2.3      5.3
2 to 17 years          100.0      o 1.4      19.4      2.6       60.7      "0.1      2.2      5.5
18 to 34 years         100.0      4.7      21.0      "0.9       57.5      "0.1       2.8      4.8
35 to 64 years          100.0      5.2      24.3      o 1.4       50.1       4.5      o 1.7      6.4
65 and older
  years            100.0      "4.3     *11.1      "1.4       38.7      30.5      "1.8     *1.8
Hispanic, other
All ages             100.0      4.7      16.3       2.0       55.9       5.3       3.1      7.0
2 to 17 years          100.0      o 1.8      16.3      "1.9       56.9      "0.2      "2.0     11.3
18 to 34 years         100.0      6.2      18.5      *2.4       58.7       `0.4       4.4      7.0
35 to 64 years         100.0      5.5      16.3      o 1.8       54.9       8.9      `3.1      3.8
65 and older
  years            100.0      o ???      o 5.7      `1.4      42.8      33.2      "1.4    "4.9

Place of residence
MSA, total"
All ages             100.0      4.4      13.4       1.8       46.6      12.8       2.4      9.0
2 to 17 years          100.0      1.3      14.1       1.4       55.7       0.3       2.0     12.1
18 to 34years         100.0      5.7      18.5       2.6       51.6       0.5       3.3      9.6
35 to 64 years         100.0      6.1      12.6       1.6       43.1       16.0       2.4      8.7
65 and older
  years            100.0      2.3       4.2       1.1       31.4      47.6       1.2      4.0
MSA, central ciryd
All ages             100.0      4.4      14.0       1.7       48.0      11.9       2.6      7.8
2 to 17 years          100.0      1.6      14.6       1.4       56.5      "0.2       2.0     10.0
18 to 34 years         100.0      5.3      17.9      2.5       54.2       0.4      3.6      8.4
35 to 64 years         100.0      6.4      14.1       1.3       43.9       14.8       2.5      7.3
65 and older
  years            100.0      2.5       4.7       1.3       31.5       46.3       1.7      4.2
MSA, not central cityd
All ages             100.0      4.3      13.0       1.8       45.5      13.5       2.3      9.9
2 to 17 years          100.0      1.2      13.7       1.4       55.1      "0.4       2.0     13.7
18 to 34 years          100.0      6.0      19.0      2.6       49.5       0.6       3.1     10.6
35 to 64 years         100.0      5.8     11.6,      1.7       42.6      16.8       2.4      9.6
65 and older
  years            100.0      2.1       3.9       1.0       31.3      48.5       0.8      4.0

Not MSA'
All ages             100.0      4.1      14.4       1.4       47.7      18.8       1.7      8.0
2 to 17 years          100.0      1.3      18.0       1.6       60.0      *0.1       1.5     11.2
18to34years         100.0      6.9      21.1       1.7      55.4       1.2      2.7      9.1
35 to 64 years         100.0      4.9      13.1       1.2       43.8      23.1       1.6      7.7
65 and older
  years            100.0      2.0       3.9       1.0       30.7      55.2       0.9      3.5

Family incomeb
Less than $10,000
All ages            100.0      3.8      19.7       1.7       42.8      22.5       1.4      6.4
2 to 17 years          100.0      o 1.1      19.4      2.6       60.0      "0.3       1.9      9.6
18 to 34 years         100.0      5.7      28.8       2.4       51.7      *0.9       1.9      7.2
35 to 64 years         100.0      6.3      25.2      "1.1       35.5      25.1       1.4      5.4
65 and older
  years            loo.0      2.0       6.6      "0.9       27.4      57.4      *0.7      3.9
$10,000 to $19,999
All ages            100.0      4.0      18.8       1.5       47.0      17.4       1.7      6.5
2 to 17 years          100.0      1.4      21.9       1.4      58.8      -0.1       1.3      7.9
18 to 34 years         100.0      6.1      27.8       1.8       53.2       -0.5       2.4      7.9
35 to 64 years         100.0      4.7      19.2       1.5       43.6      21.7       1.6      5.7
65 and older
  years           100.0      3.0      3.4       1.2       31.4      51.9       1.3      4.3
$20,000 to $34,999
All ages            100.0      4.8      13.7       1.7       51.3      11.5       2.3     11.1
2 to 17 years          100.0      1.6      14.4      0.9       59.7      o 0.1      1 .7     13.8
18to34years         100.0      6.4      18.1       2.8       54.7       0.8       3.3     12.3
35 to 64 years          100.0      6.4      12.5       1.4       46.2      18.5      2.0     10.2
65 and older
  years            100.0      1.8       2.4      *1.3       38.5      47.7      "1.5      4.7
                                                 (continues)

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           85


The Magnitude of the Problem

TABLE 4.6 continued

             All with No Visits
              in Past Year
535,000 or more
All ages             100.0
2to17years          100.0
18 to 34 years         10u.o
35 to 64 years          100.0
65 and older
  years            100.0

lental insurance coverage
With dental insurance
All ages             loo.0
2 to 17 years          100.0
la to 34 years         100.0
35 to 64 years          loo.0
65 and older
  years           100.0
Without dental insurance
All ages             100.0
2 to 17 years          100.0
18 to 34 years          100.0
35 to 64 years         100.0
65 and older
  years            100.0
Insurance status unknown
All ages             100.0
2 to 17 years          100.0
18to34years          100.0
35 to 64 years         100.0
65 and older
  years            100.0

Limitation of activity
Unable to tarry on usual activity
All ages             100.0
2 to 17 years          100.0
18 to 34 years         100.0
35 to 64 years          100.0
65 and older
  years            100.0
Limited in amount or kind of
major activity
All ages             100.0
2 to 17 years          100.0
18 to 34 years          100.0
35 to 64 years         100.0
65 years and older        100.0
Limited, but not in major activity
All ages             100.0
2 to 17 years          100.0
18 to 34 years         100.0
35 to 64 years         100.0
65 years and older       100.0
Not limited in activity
All ages             100.0
2 to 17 years          100.0
18 to 34years         100.0
35 to 64 years          100.0
65 and older
  years           100.0

Fear     cost


5.9       6.8
1.1       5.8
7.0       9.2
7.8      6.0
"2.8      3.8





6.2       7.2
1.2       7.8
8.5       9.5
8.0      6.0
2.5      "1.6


4.0      18.5
1.6      20.5
5.5      26.7
5.4      18.9
2.3       4.9


1.6       3.9
"0.6      4.7
2.3       5.1
1.5       3.4
"1.4      "1.6





4.4      15.4
o 6.0     *27.6
7.4      25.3
5.4      18.3
"1.7       6.6




4.4      15.2
"1.7      18.9
6.9      30.2
6.1      17.6
2.4       5.1


4.4      12.4
`1.7      28.0
8.0      29.2
6.3      17.5
2.6       3.9



4.3      13.5
1.3      14.7
5.8      la.2
5.8      11.3
2.1      3.4

Access    No Dental
Problem    Problem


2.6       52.3
2.0       56.8
3.6       55.4
2.3      49.1
"1.6      37.9




2.5       53.2
1.2       61.4
4.1       55.5
2.2       48.8
"1.1       39.3


1.5       48.7
1.7       60.1
1.9       56.3
1.3       45.1
1.2       31.9


0.7       23.8
`1.0       25.7
*0.9       28.2
"0.3       20.8
"0.6       19.8





1.7       33.2
"0.0       36.6
"1.9       47.1
o 1.2       34.5
2.4       26.0

`1.9       34.5
o 2.5       58.0
"3.9      44.3
1.7       31.2
o 1.2       26.3


0.9       34.3
*2.2       53.0
"1.9      50.5
"0.8       35.3
o 0.6       28.2


1.7       49.6
1.4      56.9
2.4       52.9
1.5       46.1
0.9      34.3

No Teeth


8.1
`0.6
o 0.6
13.2
41.6




10.1
"0.3
0.8
17.4
44.7


17.2
"0.2
0.7
19.9
52.5


9.3
*0.1
"0.3
9.2
36.8




31.9
"0.0
"1.9
28.9
49.9




29.7
o 0.3
o o.a
27.1
54.3


35.8
"0.0
"1.4
24.0
54.4


10.4
0.2
0.6
15.1
47.3

Not     Other
Important    Reason


4.1     14.1
3.1      20.2
5.4     13.4
4.0     12.9
"2.0      4.4





3.4     15.2
2.4     18.8
5.1      16.3
3.1     13.7
*1.0      5.7


2.0      7.0
1.9      9.9
2.1      7.6
2.1      6.8
  1.2      3.9


0.8      2.9
*0.6      3.6
1.1      3.5
"0.7      2.0
`0.6      2.6





  1.1      6.2
"1.5     o 20.1
"1.9      6.1
"1.1      6.6
"0.7      4.6




  1.7      7.5
"2.0      9.1
o ???     10.4
  2.2      9.3
"1.1      3.9


  1.5      6.3
"1.7     "10.8
*1.7     10.3
*2.0      8.0
*1.2      3.9


  2.4      9.2
  1.9     11.9
  3.3      9.6
  2.4      8.6
  1.2      3.7

dMSA = metropolitan statistical area.
bPersons with unknown income not shown separately.
Note: Data are based on household interviews of the civilian noninstitutionalized population.
o = Figure does not meet the standard of reliability or precision (more than 30 percent relative standard error and numerator of percent or rate).
Source: Bloom et al. 1992.

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


The Magnitude of the Problem

rABLE +.7
istimated number and percentage of people with unmet health care Wants,
my selected characteristics, 1994
                                      Medical or
               Number of People   Dental Care    Surgical Care
                  (in millions)   (percentage)    (percentage)

hll people                  259.2        8.5        5.6
hge and sex
Children, 1 to 18 years               73.5        5.9a        2.9"
Adult men, 19 to 64 years            75.3        9.5        5.8
Adult women, 19 to 64 years           79.3       12.Y        9.3'
Elderly people, 65 years and older         31.1        3.6'        2.46

Race/ethnic@
White                     191.4        7.4         4.6
Black                     32.2       15.0'       10.2a
Hispanic                    23.9        a.2        6.2
Other                     11.7        9.9        8.6

Health status
Fair or poor                   24.6        16.1'       11.2'
Good or excellent               233.5        7.7        5.0

Number of chronic conditions
None                      158.6        7.3         4.6
One or more                 100.6       10.4        7.1

Geographical region
Northeast                   47.8        6.9         5.8
Midwest                     65.8        6.9        4.5
South                    92.6       11.2"        6.1
West                     53.1        7.4        5.9

Rural/urban status
Metropolitan statistical areas          208.2        8.6         5.6
Nonmetropolitan statistical areas         50.5        a.1         5.9

Education level of head of household
High school or less                117.5        9.4         6.8
Some post-high school             141.2        7.9        4.7

Family income status
Less than 150 percent of the poverty level     55.7       16.4a        9.1'
150 percent of the poverty level or more     174.3        6.3'        4.5

Health insurance status
Private                    166.6        5.9'        4.1
Medicare                    36.0        5.6'        3.1"
Medicaid                    22.2       12.2        8.0
Uninsured                   32.5       22.6'        14.9'

Type of private health insurance
Health maintenance organization/
independent practice association         45.1        5.5a        5.0
Preferred provider organization          30.7        4.6'        4.1
Fee-for-service                 73.5        5.3'        3.1"

d Rhe estimate differs from the percentage for the"all people"demographic at the 1 percent confidence level based
on a two-tailed f-test of the difference in weighted estimates.
Note: The standard error of each percentage is less than 30 percent of the percentage estimate.
Source: Mueller et al. 1998. Access to dental care in the United States.JADA 1998 April; 129(4):429-37. Copyright 1998 by
loumal ofthe American Dental Asrooation. Reprinted by permission of ADA Publishing Co. Inc. (2000).

prophylaxis, and 29 percent had at
least one tooth filled.
Edentulism is virtually nonex-
istent in the active duty military
population. Also, active duty mili-
tary personnel have a significantly
lower proportion of their decayed,
missing, and filled surfaces that are
untreated; this is primarily due to
dramatic improvements in the oral
health of active duty blacks when
compared to their civilian counter-
parts. Active duty whites also have
somewhat better oral health than
white civilians of a similar age.
The relative proportion of un-
filled surfaces as a component of
decayed and filled tooth surfaces
in the military and civilian popula-
tions is illustrated in Figure 4.25.

ORAL HEALTH STATUS IN
CHANGING TIMES
The burden of oral diseases and
conditions in the United States is
extensive and affects persons
throughout their life span. Birth
defects such as cleft lip/palate,
dental caries, and facial trauma are
common in the young. Periodontal
diseases, autoimmune disorders,
and other chronic disabling condi-
tions are seen in adults, while
complete tooth loss and oral cavity
and pharyngeal cancers are seen
more often in older Americans.
Because the most common oral
disease, dental caries, is so wide-
spread in the population, nearly
every American has experienced
oral disease.

The effects of oral diseases and
conditions on quality of life and
well-being  are discussed in
Chapter 6. In sum, conditions
such as cleft lip and palate and oral
cancer not only involve costly and
difficult surgeries and treatments,
they also alter facial appearance
and impair oral functioning. Pain
disorders and pain as a conse-
quence of dental disease are preva-
lent in certain groups and can
affect daily living.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

87


The Magnitudt of the Problctn

The available trend data reveal improvements in
dental health for most Americans; however, despite
improvements in dental status, disparities remain.
Diseases disproportionately affect some sex, income,
and racial/ethnic groups, and the magnitude of the
differences is striking. All the reasons for these dis-
parities are not clear. Some of the most common den-
tal diseases, such as dental caries, are preventable
(prevention of oral diseases and conditions is pre-
sented in Chapters 8 and 9). It appears, however, that
not all individuals are benefiting from interventions
that involve professional care, as represented by the
data on dental visits. At the same time, as presented
in Chapter 7, about 40 percent of the public does not
receive the benefits of community water fluoridation.
The emerging data on the effects of socioeconomic
status on oral health are beginning to explain some,
but not all, racial/ethnic differences. For other dis-
eases, health disparities appear not to be related to
professional services; a better understanding of the
reasons for these differences is needed.

  This review of available data on oral diseases and
conditions also reveals the lack or limitation of
national or state data on oral diseases for many pop-
ulation subgroups and for many conditions that
affect the craniofacial structures. Information on the
variables needed to explain health status differences,
such as detailed utilization and expenditure data and
data on services rendered, is limited as well. Data on
specific services-self-care, services provided by pro-
fessionals, and services that are commuhity-based-
are needed to understand the dimensions of oral
health. (Some of these services are described in
Chapters 7 and 8.) Although some data on expendi-
tures for care and health care personnel are available

  Available state data reveal variations within and
among states in patterns of oral health and disease
among population groups. Having state-specific and
local data that augment national data is critical in
identifying high-risk populations and areas and in
addressing health disparities. These data also are vital
in program evaluation, planning, and policy deci-
sions. Yet state and local data are almost nonexistent.
In recent years, the need for state and local data has
intensified as more programs are funded by local
authorities and responsibilities are shifted from
national to state-based levels.
The nation's health information system is under-
going constant change to meet the current and future
needs for health information. Consequently, many
factors influence how and what data are collected and
analyzed. These factors include emerging technolo-
gies, legislation about how data are to be collected,
and confidentiality and privacy concerns.
The need for epidemiologic and surveillance data
change as the understanding of specific diseases and
conditions evolves and as society's goals and priori-
ties change. The increasing focus on the long-term
benefits of disease prevention and health promotion
and the need to close the gap on disparities also
affects how and what data are collected. For example,
major initiatives such as the Department of Health
and Human Services's Healthy People 2010 have pro-
vided a framework for data collection and analysis
tied to specific objectives and have helped identify
        needs for new health data systems.
       The Healthy People initiative now
       includes objectives for the nation's
       health status as well as for preven-
       tive interventions and objectives
       that would improve infrastructure
       and capacity building to provide
       the necessary services and moni-
        toring.

FIGURE 4.25
The percentage of unfilled decayed surfaces is higher for civilian males
than for males in the U.S. military
   501

to (Chapter 9) complement the statistics needed to
assess oral health in the United States, almost all
these data come from cross-sectional surveys that do
not allow for analysis of the outcomes of disease and
related care.

,                                       I
18-19     20-24    25-29     30-34     35-39     40-44

Age group

      + Black civilian  -+ White civilian   - Black military  x White military
Source: York et al. 1995.

This overview of the magni-
tude of oral diseases and condi-
tions in America raises many ques-
tions still to be researched. If cer-
tain oral diseases are preventable,
why do we have populations with
extensive and untreated disease?
Once socioeconomic factors are
controlled, why do we see differ-
ences in services received? Why

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


are some conditions more prevalent in certain popu-
lations than in others? How will the rapidly changing
and projected demographics of America contribute to
future trends in oral and craniofacial health and dis-
ease? These and many other questions require more
research, new databases, and an active and trained
group of researchers.

FINDINGS
   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.feth-
nicity. For some diseases and conditions, the magni-
tude of the differences in oral health status among
population groups is striking.
   0  Oral diseases and conditions affect people
throughout their life span. Nearly every American
has experienced the most common oral disease, den-
tal caries.

   o  Conditions that severely affect the face and
facial 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.

REFERENCES

Albandar JM, Brown LJ, Lee H. Clinical features of
early-onset periodontitis. J Am Dent Assoc 1997
Oct;128(10):1393-9.

Albandar JM, Brunelle JA, Kingman A. Destructive peri-
odontal disease in adults 30 years of age and older in
the United States, 1988-1994. J Periodontol 1999
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93

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

The next two chapters establish that oral health is essential to general health and well-being.
Chapter 5 examines multiple linkages between oral and general health. The mouth and the face
reflect signs and symptoms of health and disease that can serve as an adjunct for diagnosis for
some conditions. Diagnostic tests using oral cells and fluids-especially saliva-are available to
detect drug abuse, hormonal changes, and specific diseases; and more are being developed. The
mouth is also a portal of entry for pathogens and toxins, which can affect the mouth and, if not
cleared by the many defense mechanisms that have evolved to protect the oral cavity, may spread to
the rest of the body Recent epidemiologic and experimental animal research provides evidence of
possible associations between oral infections-particularly periodontal disease-and diabetes,
cardiovascular disease, and adverse pregnancy outcomes, and this evidence is reviewed. The review
highlights the need for an aggressive research agenda to better delineate the specific nature of these
associations and the underlying mechanisms of action.

Chapter 6 looks at the impact of oral health problems on the quality of life and includes
examples of the kinds of questionnaires used to measure oral-health-related quality of life. Oral
health is highly valued by society and individuals, and the chapter begins with a brief description
of the reflections of those values in myth and folklore concerning facial appearance and the
meaning of teeth. It then explores dimensions beyond the biological and the physical to examine
how oral diseases and disorders can interfere with the functions of daily living, including
participation in work or school, and what is known about their psychosocial impacts and economic
costs. The deleterious effects of facial disfigurement and tooth loss may be magnified in a society
such as ours that celebrates youth and beauty Self-reported impacts of oral conditions on social
functions include limitations in communication, social interactions, and intimacy. Research on the
oral-health-related quality of life is needed to permit further exploration of the dimensions of oral
health and well-being.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

95


Linkages with General Health

The mouth and face are highly accessible parts of the
body, sensitive to and able to reflect changes
occurring internally. The mouth is the major portal of
entry to the body and is equipped with formidable
mechanisms for sensing the environment and
defending against toxins or invading pathogens. In
the event that the integrity of the oral tissues is
compromised, the mouth can become a source of
disease or pathological processes affecting other parts
of the body. It can also become a source of contagion
by means of contaminated fluids or materials passed
to others. This chapter explores what the mouth and
face can reveal about general health, describes the
role the mouth plays as a portal of entry for infection,
and concludes with studies that are associating oral
infections with serious systemic diseases and
conditions.

THE MOUTH AND FACE AS A MIRROR
OF HEALTH AND DISEASE
A physical examination of the mouth and face can
reveal signs of disease, drug use, domestic physical
abuse, harmful habits or addictions such as smoking,
and general health status. Imaging (e.g., x-ray, MRI,
SPECT) of the oral and craniofacial structures may
provide early signs of skeletal changes such as those
occurring with osteoporosis and musculoskeletal
disorders, and may also reveal salivary, congenital,
neoplastic, and developmental disorders. Oral cells
and fluids, especially saliva, can be tested for a wide
range of substances, and oral-based diagnostics are
increasingly being developed and used as a means to
assess health and disease without the limitations and
difficulties of obtaining blood and urine.

Physical Signs and Symptoms af Disease
and Risk Factors

A number of signs and symptoms of disease, lifestyle
behaviors, and exposure to toxins can be detected in
or around the craniofacial complex. Pathogens enter-
ing the mouth may proliferate locally with oral and
pharyngeal signs and symptoms; other pathogens
may enter the bloodstream directly or through lym-
phatic channels and cause generalized disease. Oral
signs suspected to be indications of systemic illness
may be confirmed by the presence of rash, fever,
headache, malaise, enlarged lymph nodes, or lesions
elsewhere on the body

Swollen parotid glands are a cardinal sign of
infection with the mumps virus and can also be seen
in individuals with Sjogren's syndrome and HIV The
salivary glands are also frequently involved in tuber-
culosis and histoplasmosis infections. Oral signs of
infectious mononucleosis, caused by Epstein-Barr
virus, include sore throat, gingival bleeding, and
multiple pinpoint-sized hemorrhagic spots (pettechi-
ae) on the oral mucosa. The oral signs and symptoms
associated with some viral, bacterial, and fungal
infections are listed in Table 5.1. There can be a large
overlap in the clinical appearance of oral manifesta-
tions of various diseases with different etiologies, and
the clinical diagnosis often involves ancillary proce-
dures, which may include laboratory tests, diagnostic
imaging, and biopsy.

Oral tissues may also reflect immune deficiency.
For example, nearly all HIV-infected individuals
develop oral lesions at some time during their illness
(Greenberg 1996, Greenspan and Greenspan 1996,
Phelan 1997). Other immunosuppressed individuals
may have the same lesions (Glick and Garfunkel
1992). However, the presentation and the extent, sev-
erity, and management of some of these lesions may
reflect nuances due to variation in the underlying

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           97


TABLE 5.1
Diseases and conditions causing lesions of the oral mucosa

Condition            Usual Location

Clinical Features

Course

Viral Diseases

Primary acute herpetic
gingivostomatitis (herpes
simplex virus type 1, rarely
type 2)

Recurrent herpes labialis

Recurrent intraoral herpes
simplex
Chickenpox (varicella-zoster
virus)

Herpes zoster (reactivation of   Cheek, tongue, gingiva, or
varicella-zoster virus)      palate

Infectious mononucleosis
(Epstein-Barr virus)

Oral mucosa

Warts (papillomavirus)

Herpangina (coxsackievirus
A; also possibly
coxsackievirus Band
echovirus)

Hand, foot, and mouth
disease (type A
coxsackieviruses)
Primary HIV infection

tip and oral mucosa

Mucocutaneous junction of lip,
perioral skin

Palate and gingiva

Gingiva and oral mucosa

Anywhere on skin and oral
mucosa

Oral mucosa, pharynx, tongue

Oral mucosa, pharynx, palms,
and soles

Gingiva, palate, and pharynx

Labial vesicles that rupture and crust, and intraoral
vesicles that quickly ulcerate;extremely painful;
acute gingivitis, fever, malaise, foul odor, and cervi-
cal lymphadenopathy; occurs primarily in infants,
thildren,and young adults

Eruption of groups of vesicles that may coalesce,
then rupture and crust; painful to pressure or spicy
foods

Small vesicles that rupture and coalesce; painful

Skin lesions may be accompanied by small vesicles
on oral mucosa that rupture to form shallow ulcers;
may coalesce to form large bullous lesions that
ulcerate; mucosa may have generalized erythema

Unilateral vesicular eruption and ulceration in lin-
ear pattern following sensory distribution of
trigeminal nerve or one of its branches
Fatigue, sore throat, malaise, low-grade fever, and
enlarged cervical lymph nodes; numerous small
ulcers usually appear several days before lym-
phadenopathy;gingivaI bleeding and multiple
petechiae at junction of hard and soft palates
Single or multiple papillary lesions, with thick,
white keratinized surfaces containing many point-
ed projections; cauliflower lesions covered with
normal-colored mucosa or multiple pink or pale
bumps (focal epithelial hyperplasia)

Sudden onset of fever, sore throat, and oropharyn-
geal vesicles, usually in children under 4 years,
during summer months;diffuse pharyngeal con-
gestion and vesicles (1 to 2 mm),grayish-white
surrounded by red areola;vesicles enlarge and
ulcerate

Fever, malaise, headache with oropharyngeal vesi-
cles that become painful, shallow ulcers

Acute gingivitis and oropharyngeal ulceration,
associated with febrile illness resembling mononu-
cleosis and including lymphadenopathy

Healsspontaneously in 10 to 14
days unless secondarily infected

lasts about 1 week, but condition
may be prolonged if secondary
infection occurs

Healspontaneously in about 1
week

Lesions heal spontaneously within
2 weeks

Gradual healing without scarring;
postherpetic neuralgia is common

Oral lesions disappear during con-
valescence

Lesions grow rapidly and spread

Incubation period 2 to 9 days;fever
for 1 to 4 days; recovery uneventful

Incubation period 2 to 18 days;
lesions heal spontaneously in 2 to 4
weeks

Followed by HIV seroconversion,
asymptomatic HIV infection,and
usually ultimately by HIV disease

98

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


Linkages with General Health

Condition              Usual Location

Clinical Features

Course

Bacterial or fungal diseases
Acute necrotizing ulcerative
gingivitis ("trench mouth,"
Vincent's infection)
Prenatal (congenital) syphilis

Gingiva



Palate, jaws, tongue, and teeth

Painful. bleeding gingiva characterized by necrosis   Continued destruction of tissue fol-
and ulceration of gingival papillae and margins   lowed by remission, but may recur
plus lymphadenopathy and foul odor
Gummatous involvement of palate, jaws, and facial  Tooth deformities in permanent
bones; Hutchinson's incisors, mulberry molars,     dentition irreversible
glossitis, mucous patches, and fissures of corners of
mouth

Primary syphilis (chancre)

Lesion appears where organism
enters body; may occur on lips,
tongue, or tonsillar area

Small papule developing rapidly into a large,    Healing of chancre in 1 to 2
painless ulcer with indurated border;unliteral    months, followed by secondary
lymphadenopathy;chancre and lymph nodes con-  syphilis in 6 to 8 weeks
taining spirochetes;serologic tests positive by
third to fourth week

Secondary syphilis

Oral mucosa frequently involved
with mucous patches,primarily
on palate, also at commissures
of mouth

Maculopapular lesions of oral mucosa,S to 10
mm in diameter with central ulceration covered
by grayish membrane; eruptions occurring on
various mucosal surfaces and skin accompanied
by fever, malaise, and sore throat

Lesions may persist from several
week5 to 1 year

Tertiary syphilis

Palate and tongue

Gummatous infiltration of palate or tongue fol-
lowed by ulceration and fibrosis; atrophy of
tongue papillae produces characteristic bald
tongue and glossitis

Gumma may destroy palate, caus-
ing complete perforation

Gonorrhea









Tuberculosis


Cervicofacial actinomycosis

Lesions may occur in mouth at   Earliest symptoms are burning or itching sensa-   Lesions may resolve with appropri-
site of inoculation or secondarily  tion, dryness, or heat in mouth followed by acute   ate antibiotic therapy
by hematogenous spread from a  pain on eating or speaking; tonsils and orophar-
primary focus elsewhere    ynx most frequently involved; oral tissues may be
           ' diffusely inflamed or ulcerated; saliva develops
           increased viscosity and fetid odor;submaxillary
           lymphadenopathy with fever in severe cases
Tongue, tonsillar area,soft    A solitary, irregular ulcer covered by a persistent   Lesions may persist
palate           exudate; ulcer has an undermined, firm border
Swellings in region of face, neck,  Infection may be associated with an extraction,   Acute form may last a few weeks;
and floor of mouth      jaw fracture, or eruption of molar tooth; in acute   chronic form lasts months or
           form resembles an acute pyogenic abscess, but   years; prognosis excellent; actin-
           contains yellow "sulfur granules" (gram-positive   omycetes respond to antibiotics
            mycelia and their hyphae)          (tetracyclines or penicillin) but
                               not antifungal drugs

Histoplasmosis

Any area in mouth, particularly
tongue, gingiva, or palate

Numerous small nodules may ulcerate; hoarse-
ness and dysphagia may occur because of lesions
in larynx usually associated with fever and
malaise

May be fatal

Candidiasis

Any area of oral mucosa

Pseudomembranous form has white patches that
are easily wiped off leaving red, bleeding, sore
surface; erythematous form is flat and red; rarely,
candidai leukoplakia appears as white patch in
tongue that does not rub off; angular cheilitis
due to Candida involves sore cracks and redness
at angle of mouth; Candida seen on KOH prepara-
tion in all forms

Responds to antifungals

(confinuesJ

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           99


Linkages with General Health

TABLE 3.1 continued

Condition             Usual Location

Clinical Features

Course

Dermatologic diseases

Mucous membrane
pemphigoid

Primarily mucous membranes
of the oral cavity, but may also
involve the eyes, urethra, vagi-
na,and rectum

Painful, grayish-white collapsed vesicles or bullae
with peripheral erythematous zone; gingival
lesions desquamate, leaving ulcerated area

Protracted course with remissions
and exacerbations; involvement of
different sites occurs slowly;glu-
cocorticoids may temporarily
reduce symptoms but do not
control the disease

Erythema multiforme
(Stevens-Johnson syndrome)




Pemphigus vulgaris

Primarily the oral mucosa and
skin of hands and feet






Oral mucosa and skin

Intraoral ruptured bullae surrounded by an
inflammatory area; lips may show hemorrhagic
crusts; the "iris," or "target" lesion, on the skin is
pathognomonic; patient may have severe signs of
toxicity
Ruptured bullae and ulcerated oral areas; mostly
in older adults

Onset very rapid; condition may
last 1 to 2 weeks; may be fatal;
acue episodes respond to
steroids


With repeated recurrence of bul-
lae, toxicity may lead to cachexia,
infection, and death within 2
years; often controllable with
steroids

Lichen planus




Other conditions

Oral mucosa and skin

White striae in mouth; purplish nodules on skin
at sites of friction;occasionally causes oral
mucosal ulcers and erosive gingivitis

Protracted course, may respond to
topical steroids

Recurrent aphthous ulcers









Behcet's syndrome




Traumatic ulcers

Anywhere on nonkeratinized   Single or clusters of painful ulcers with surround-   Lesions heal in 1 to 2 weeks but
oral mucosa (lips,tongue, buc-   ing erythematous border; lesions may be 1 to 2   may recur monthly or several
cat mucosa,floor of mouth, soft  mm in diameter in crops (herpetiform), 1 to S    times a year; topical steroids give
palate, oropharynx)      mm (minor),or 5 to 15 mm (major)       symptomatic relief;systemic glu-
                               cotorticoids may be needed in
                                severe cases; a tetracycline oral
                                suspension may decrease severity
                                of herpetiform ulcers
Oral mucosa,eyes,genitalia,   Multiple aphthous ulcers in mouth; inflammatory  Ulcers may persist for several
gut,and central nervous system  ocular changes; ulcerative lesions on genitalia;    weeks and heal without scarring
            inflammatory bowel disease and CNS disease
Anywhere on oral mucosa;den-   Localized, discrete ulcerated lesion with red bor-   Lesions usually heal in 7 to 10
tures frequently responsible for  der; produced by accidental biting of mucosa,    days when irritant is removed,
ulcers in vestibule       penetration by a foreign object, or chronic irrita-   unless secondarily infected
            tion by a denture

Source: Greenspan, in Fauci et al. 1998. Harrison's principles of internal medicine. Reprinted by permission from McGraw-Hill (2000). Copyright 2000 by McGraw-Hill.

systemic condition. For example, the linear gingival
erythema and necrotizing ulcerative periodontitis
sometimes seen in HIV infection have been difficult
to resolve with routine dental curettage and prophy-
laxis (Glick et al. 1994b).
The appearance  of soft or hard tissue
pigmentation is associated with a number of diseases
and treatments. Malignant melanoma can appear
in the mouth as brown or black flat or raised spots.
Kaposi's sarcoma can appear as a flat or raised pig-

mented lesion. Addison's disease causes blotches or
spots of bluish-black or dark brown pigmentation to
occur early in the disease. Congenital discrete brown
or black patches (nevi) can appear in any part of the
mouth. Pigmentation of the tooth crowns may be
seen in children with cystic fibrosis and porphyria
and those exposed to tetracycline during tooth
development.

  The oral tissues can also reflect nutritional status
and exposure to risk factors such as tobacco. The

100

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


tongue appears smooth in pernicious anemia. Group
B vitamin deficiency is associated with oral mucositis
and ulcers, glossitis, and burning sensations of the
tongue. Scurvy, caused by severe vitamin C deficien-
CY is associated with gingival swelling, bleeding,
ulceration, and tooth loosening. Lack of vitamin D in
utero or infancy impairs tooth development. Enamel
hypoplasia may result from high levels of fluoride or
from disturbances in calcium and phosphate metab-
olism. which can occur in hypoparathyroidism, gas-
troenteritis, and celiac disease. The mouth also can
reflect the effects of tobacco use, perhaps providing
the only visible evidence of its adverse effects.

Oral Manifestations of HIV Infection and
of Osteoporosis

The mouth can serve as an early warning system,
diagnostic of systemic infectious disease and predic-
tive of its progression, such as with HIV infection. In
the case where oral cells and tissues have counter-
parts in other parts of the body, oral changes may
indicate a common pathological process. During rou-
tine oral examinations and perhaps in future screen-
ing tests, radiographic or magnetic resonance imag-
ing of oral bone may be diagnostic of early osteo-
porotic changes in the skeleton. The following sec-
tions provide details.

HIV Infection

The progressive destruction of the body`s immune
system by HIV leads to a number of oral lesions, such
as oral candidiasis and oral hairy leukoplakia, that
have been used not only in diagnosis but also in
determining specific stages of HIV infection (CDC
1992, 1994, Montaner et al. 1992, Redfield et al.
1986, Royce et al. 1991, Seage et al. 1997). Oral can-
didiasis is rarely seen in previously healthy young
adults who have not received prior medical therapy
such as cancer chemotherapy or treatment with other
immunosuppressive drugs (Klein et al. 1984). It was
associated with AIDS as early as 1981 in the first
report of the syndrome (CDC 1981a) and was fre-
quently noted among otherwise asymptomatic HIV-
positive populations (Duffy et al. 1992, Feigal et al.
1991). Oral candidiasis may be the first sign of HIV
infection and often occurs as part of the initial phase
of infection-the acute HIV syndrome (Tindall et al.
1995). It tends to increase in prevalence with pro-
gression of HIV infection when CD4 lymphocyte
counts fall (Glick et al. 1994a, Lifson et al. 1994). It
also appears to be the most common oral manifesta-
tion in pediatric HIV infection (Kline 1996, Leggott

Linkages with General Health

1995, Ramos-Gomez et al. 1996) and has been
demonstrated to proceed to esophageal candidiasis, a
sign of overt AIDS (Saah et al. 1992). Both the pseudo-
membranous and the erythematous forms of candidi-
asis appear to be important predictors of progression
of HIV infection (Dodd et al. 1991, Klein et al. 1984,
1992).

Like oral candidiasis, oral hairy leukoplakia in
HIV-positive persons heralds more rapid progression
to AIDS (Glick et al. 1994a, Greenspan et al. 1987,
Lifson et al. 1994, Morfeldt-Manson et al. 1989). Oral
hairy leukoplakia is an oral lesion first reported in
the early days of the AIDS epidemic (Greenspan D et
al. 1984, Greenspan JS et al. 1985). Since its discov-
ery, hairy leukoplakia has been found in HIV-negative
persons with other forms of immunosuppression,
such as organ or bone marrow recipients and those
on long-term steroid therapy (Epstein et al. 1988,
Greenspan et al. 1989, ltin et al. 1988, King et al.
1994, Zakrzewska et al. 1995), and less frequently
among immunocompetent persons (Eisenberg et al.
1992, Felix et al. 1992).

In a comprehensive review of periodontal condi-
tions, Mealey (1996) noted that linear gingival ery-
thema and necrotizing ulcerative periodontitis may
be predictive of progression of HIV infection.
Necrotizing ulcerative periodontitis, a more serious
periodontal condition observed in HIV-infected per-
sons, is a good predictor of CD4+ cell counts of
under 200 per cubic millimeter, and in one study was
a strong predictor of rapid progression to death
(Glick et al. 1994a,b, Winkler and Robertson 1992,
Winkler .et al. 1988). In addition, the numerous
ulcerative and nonulcerative conditions that affect
the oral cavity (Aldous and Aldous 1991, Coates et
al. 1996, Cruz et al. 1996, Gandolfo et al. 1991, Itin
et al. 1993, Mealey 1996) may affect the biologic
activity of HIV and are affected by its treatments.
Other oral conditions, unexpected in the oral
cavity, have been noted in the early stages of HIV
infection. The increased incidence of Kaposi's sarco-
ma among young men in New York and California
was one of the earliest signs of the AIDS epidemic
(CDC 1981b). In addition, some conditions create a
problem for differential diagnosis. For example,
because involvement of the gingiva is common, early
non-Hodgkin's lymphoma lesions are frequently mis-
taken for common periodontal or dental infections
(Epstein and Silverman 1992).

The changing face of the HIV epidemic and
changes in the therapies used to manage complica-
tions are reflected in changes in the oral manifesta-
tions, which warrant continued surveillance and
research. The increasing resistance of microorganisms

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          101


Linkages with General Hdth

to antibiotics and antifungals is challenging. On the
other hand, the completion of the Candida albicans
genome may yield better treatments for this oppor-
tunistic infection.

Osteoporosis and Oral Bone Loss

With growing numbers of Americans living longer,
there have been concomitant increases in the num-
bers affected by age-related chronic degenerative dis-
eases. Prominent among these conditions are bone
and joint diseases. It is likely, for example, that some
temporomandibular joint disorders are manifesta-
tions of osteoarthritis, rheumatoid arthritis, or
myofascial pain. Paget's disease, characterized by
enlarged and deformed bone, can be particularly
painful and debilitating when it affects the cranial
and jaw bones.

Osteoporosis, a degenerative disease character-
ized by the loss of bone mineral and associated struc-
tural changes, has long been suspected as a risk fac-
tor for oral bone loss. In addition, measures of oral
bone loss have been proposed as potential screening
tests for osteoporosis (Jeffcoat 1998). Osteoporosis
affects over 20 million people in the United States,
most of whom are women, and results in nearly 2
million fractures per year (National Institute of
Arthritis, Musculoskeletal and Skin Diseases 2000).
The disease is more prevalent in white and Asian
American women than in black women.

Oral bone loss has been reported to be more
prevalent in women than in men. Studies by,Ortman
et al. (1989) found a higher percentage of women
than men with severe alveolar ridge resorption. This
finding parallels the findings of Humphries et al.
(1989), who showed that loss of bone mineral densi-
ty with age in edentulous adult mandibles was more
significant in women than in men. Also, the associa-
tion between estrogen status, alveolar bone density,
and history of periodontitis in postmenopausal
women has been studied (Payne et al. 1997).

  Most of the studies in this area have examined
bone loss in women, and most investigators have
reported a correlation between oral and skeletal bone
loss measured in a variety of ways. Studies of non-
osteoporotic women by Kribbs et al. (1990) showed
that mandibular bone mass is significantly correlated
with skeletal bone mass. Dual photon absorptiometry
measurements of jawbone volume in women with
osteoporosis have shown that reduction in mandibu-
lar bone mass is directly related to the reduction in
total skeletal mass density (Kribbs and Chesnut
1984, Kribbs et al. 1983, von Wowem 1985, 1988,
von Wowern et al. 1994). Kribbs et al. (1989) further
showed that mandibular mass is correlated with all

skeletal measures in osteoporotic women and that
the height of the edentulous ridge is correlated with
total body calcium and mandibular bone mineral
density. Hirai et al. (1993) found that the presence of
skeletal osteoporosis strongly affects the reduction of
the residual ridge in edentulous patients. A small
case-control study comparing older female patients
with osteoporotic fractures and non-osteoporotic
women without fractures found greater periodontal
attachment loss in the osteoporotic women than in
the controls (von Wowern et al. 1994).

Studies that have controlled for confounding fac-
tors also have found correlations between oral bone
loss and skeletal bone density. Controlling for pack-
years of smoking, education, body mass, and years
since menopause, Krall et al. (1994, 1996) found a
significant positive relationship between number of
teeth and bone mineral density of the spine and the
radius. In a cohort of 70 postmenopausal women,
Wactawski-Wende et al. (1996) measured skeletal
bone mineral density at the Wards triangle area of the
femur and compared it with periodontal disease
assessed by attachment loss and the height of alveo-
lar bone measured by radiographs. After adjusting for
age, years since menopause, estrogen use, body mass
index, and smoking, the investigators concluded that
osteopenia (low bone mass) is related to alveolar cres-
tal height and tooth loss in postmenopausal women.

  Methods used to measure oral and skeletal bone
loss have varied among investigators and have shown
different outcomes. Kribbs (1990) found that
patients in an osteoporotic group had lost more teeth,
had less mandibular bone, and had a thinner bone
measured at a part of the jaw (cortex at the gonion)
than a comparable non-osteoporotic group. However,
using periodontal attachment loss as an indicator of
mandibular bone loss, they found no differences
between the osteoporotic and the non-osteoporotic
group. Mohajery and Brooks (1992) compared non-
osteoporotic postmenopausal women with women
with mild to moderate osteoporosis and found no
correlation between mandibular and skeletal bone
mineral density This study raises questions about the
quantification of mild and moderate osteoporosis.
Defining healthy periodontal tissues as having no
periodontal pockets deeper than 5 millimeters,
Hildebolt et al. (1997) studied postmenopausal
women with healthy periodontal tissues and found
no relationship between periodontal attachment
loss and postcranial bone mineral density. How-
ever, preliminary studies from the oral ancillary study
of the NIH Women's Health Initiative report signi-
ficant correlations between mandibular basal
bone mineral density and hip bone mineral density

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


(I- = 0.74, P -C ,001) (Jeffcoat et al. in press). In this
study, digital subtraction radiography methods were
used for mandibular bone measurements, and dual-
energy X-ray absorptiometry (DXA) scans were used
for the hip bone measurements. The authors of this
study propose the possibility that high-quality intra-
oral radiographs may be used in the future for screen-
ing osteopenia.

Larger cross-sectional studies, as well as longitu-
dinal and mechanism studies, are needed to better
define the relationship between osteoporosis.
osteopenia. and oral bone loss, periodontal disease,
and tooth loss. The role of factors involved in the reg-

TABLE 3.2
Saliva/oral fluids: sampled analytes and current
FDA-approved tests

Category
Drugs of abusea

Analytes
Alcohol
Amphetamines
Barbiturates
Benzodiazepines
Cocaine
LSD
Marijuana
Nicotine
Opiates
PCP

FDA-Approved Tests
Cannabinoids
Cocaine
Cotinine
Methamphetamine
Opiates
PCP
Ethanol

AntibodieG

HIV
HPV
HHV-8/KSH
C. parvum
Helicobatter pylon'

HIV antibodies

Hormones

Cortisol
Progesterone
Testosterone
Substance P
Met-enkephalin

Estriol

Environmental toxinsd

Cadmium
Lead
Mercury

Therapeutics?

Antipyrine
Carbamazepine
Ciprofloxacin
lrinotecan
Lithium
Methotrexate
Phenytoin
Phenobarbital
Theophylline

~Coneetal.1993.1997.
Yonrtantine et al. 1997.
(Dabbr 1993,Ellison 1993.
*Gonzalez et al.1997, Joselow et al.1968.
eWilsOn 1993.
Source:Constantme et al. 1997.

Linkages with General Health

ulation of bone mineral density in men as well as in
postmenopausal women needs to be evaluated fur-
ther with reference to oral bone loss, tooth loss, and
periodontal disease. Variables such as sex, race,
dietary calcium and phosphorus, vitamin D intake,
exercise, body mass index, smoking, genetics, med-
ication use, reproductive history, and psychosocial
factors need to be assessed in depth. In addition, reli-
able and valid criteria and imaging technologies for
assessing osteoporosis and oral bone loss are needed
to better elucidate the full relationship between
skeletal and mandibular bone mineral density, peri-
odontal disease, alveolar ridge resorption, and tooth
loss.

Oral-fluid-based Diagnostics:
The Example of Saliva

The diagnostic value of salivary secretions to detect
systemic diseases has long been recognized (Mandel
1990), and oral fluids and tissues (buccal cells) are
increasingly being used to diagnose a wide range of
conditions. Saliva- and oral-based diagnostics use
readily available samples and do not require invasive
procedures. Researchers have detected antibodies in
saliva that are directed against viral pathogens such
as human immunodeficiency virus (Malamud 1997)
and hepatitis A virus (O'Farrell et al. 1997) or B virus
(Richards et al. 1996). Saliva is being used to detect
antibodies, drugs, hormones, and environmental tox-
ins (Malamud and Tabak 1993) (Table 5.2). The sim-
plest tests are those that detect the presence or
absence of a substance in the saliva, such as various
drugs. Greater technical challenges are presented for
tests that will be used for therapeutic monitoring
since accurate levels of a substance and/or its
metabolites are needed. In these instances the sali-
va/plasma concentration ratio must be determined
experimentally (Haeckel 1993). Tests beyond those
listed in Table 5.2 are currently on the market, but do
not yet have FDA approval. Saliva is also the fluid of
choice to assess the integrity of the mucosal immune
system (Mandel 1990).

Most recently, oral fluids have been used as a
source of microbial or host DNA. With the advent of
polymerase chain reaction methods, the DNA con-
tained within a single cell is sufficient for detection of
viruses (e.g., Kaposi's sarcoma-associated herpes
virus, Koelle et al. 1997; Epstein-Barr virus, Falk et
al. 1997; mumps virus, Afzal et al. 1997) or bacteria
(e.g., Helicobacter pylori, Reilly et al. 1997). Similarly,
DNA extracted from sloughed buccal epithelial cells
can be used to genotype persons. This has found
application in forensics (Roy et al. 1997) and may be

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          103


Linkages with General Health

used for diagnostic purposes in the future (van Schie
and Wilson 1997).

Saliva has the potential of replacing blood, the
current standard for testing many diseases and
conditions (e.g., diabetes, infectious disease,
Parkinson's disease, alcoholic cirrhosis, Sjogren`s
syndrome, and cystic fibrosis sarcoidosis). Important
goals for the future are the development of new
diagnostic tests for early disease detection, defining
individual patient risk of adverse response to drugs,
monitoring therapeutic progress, and determin-
ing outcomes of treatment. Key issues in the
development of a new generation of saliva diag-
nostics include their selectivity, sensitivity, response
time, dynamic range (values of interest), rep-
resentative sampling, and, perhaps most important,
their reliability or stability as well their ability to
assess multiple substances simultaneously

Conclusion

For the clinician the mouth and face provide ready
access to physical signs and symptoms of local and
generalized disease and risk factor exposure. These
signs and symptoms augment other clinical features
of underlying conditions. Comprehensive care of the
patient requires knowledge of these signs and symp-
toms, their role in the clinical spectrum of general
diseases and conditions, and their appropriate man-
agement. Oral biomarkers and surrogate measures
are also being explored as means of early diagnosis.
With further development and refinement, oral-
based diagnostics such as salivary tests can be-
come widely used and acceptable tools for individu-
als, health care professionals, researchers, and com-
munity programs. The continued refinement of
imaging techniques also has the potential of using
oral imaging to identify early signs of skeletal bone
degeneration.

THE MOUTH AS A PORTAL OF ENTRY
FOR INFECTION
Chapter 3 provides an overview of the effects of oral
microbial infections with viruses, bacteria, and fungi.
More than 500 bacterial strains have been identified
in dental biofilm, and more than 150 bacterial strains
have been isolated from dental pulp infections. More
recently, 37 unique and previously unknown strains
of bacteria were identified in dental plaque (biofilm)
(Kroes et al. 1999). Most oral lesions are opportunis-
tic infections, that is, they are caused by microorgan-
isms commonly found in the mouth, but normally
kept in check by the body's defense mechanisms.

These microorganisms can induce extensive local-
ized infections that compromise general well-being
in and of themselves. However, they also may spread
to other parts of the body if normal barriers are
breached. The oral mucosa is one such barrier that
provides critical defense against pathogens and other
challenges (Schubert et al. 1999). Salivary secretions
are a second major line of defense. Damage to the
oral mucosa from mechanical trauma, infection, or
salivary dysfunction with resulting derangements in
lubricatory and antimicrobial functions of saliva, as a
result of chemotherapy, radiation, and medications
causing hyposalivation, allows a portal of entry for
invading pathogens.

Oral Infections and Bacteremia

Oral microorganisms and cytotoxic by-products
associated with local infections can enter the blood-
stream or lymphatic system and cause damage or
potentiate an inappropriate immune response else-
where in the body. Dissemination of oral bacteria into
the bloodstream (bacteremia) can occur after most
invasive dental procedures, including tooth extrac-
tions, endodontic therapy, periodontal surgery, and
scaling and root planing. Even routine oral hygiene
procedures such as daily toothbrushing, subgingival
irrigation, and flossing may cause bacteremia.
However, these distant infections have been seen
more often in high-risk patients such as those who
are immunocompromised.

Oral bacteria have several mechanisms by which
they invade mucosal tissues, perhaps contributing
to their ability to cause bacteremias. For example,
oral bacteria and their products may invade the
periodontal tissues directly. Actinobacillus actino-
mycetemcomitans has been found in gingival
connective tissue in patients with localized juvenile
periodontitis (Christersson et al. 1987a,b, Meyer et
al. 1991, Riviere et al. 1991). Invasion of tissue by
Porphyromonas gingivalis has also been described in
vivo (Saglie et al. 1988) and in vitro (Njoroge et al.
1997, Sandros et al. 1993, 1994, Weinberg et al.
1997). Although oral bacteria can enter the blood
through injured or ulcerated tissue, bacterial
invasion of periodontal tissues represents another
possible mechanism.

In the immunocompetent individual, bacteremia
originating from the oral cavity is usually transient
and harmless. However, if the individuals immune
system is compromised, the normally harmless oral
bacteria may pose a significant risk. The morbidity
and mortality associated with oral foci of infections
are hard to assess. This is due to the formidable task

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


of tracking the source of an infection unless the
responsible pathogen is indigenous to a specific
anatomic location.

Viridans group streptococci (VGS) have a low
degree of virulence but can be associated with mor-
bidity and mortality under certain circumstances.
Increased pathogenicity of Streptococcus viridans is
most prominent in individuals with neutropenia (low
blood counts of circulating white blood cells called
neutrophils) and has been associated with a toxic-
shock-like syndrome (TSLS) or viridans streptococ-
cal shock syndrome (VSSS), as well as with adult res-
piratory distress syndrome (ARDS) (Bochud et al.
1994).

Although a high degree of morbidity is associat-
ed with viridans streptococcal bacteremia, a low inci-
dence of mortality has been reported (Heimdahl et al.
1989). Several studies have shown that under
adverse circumstances oral flora and oral infections
are associated with increased incidence of morbidity
and even mortality (Engelhard et al. 1995, Lucas et
al. 1998, Martin0 et al. 1995, Ruescher et al. 1998,
Sparrelid et al. 1998, Sriskandan et al. 1995).
Reduction of oral foci of infection decreases systemic
complications, specifically in severely neutropenic
patients undergoing chemotherapy (Heimdahl et al.
1984). In addition, hospital stays for patients with
oral mucositis undergoing autologous bone marrow
transplants were longer than for those without oral
mucositis (Ruescher et al. 1998).

Other cohorts identified at increased risk for sys-
temic complications due to oral bacteria include hos-
pitalized patients unable to perform adequate oral
hygiene, those receiving saliva-reducing medications,
and those taking antibiotics that alter the oral flora. A
positive dental plaque culture for aerobic pathogens
was significantly associated with the development of
hospital-acquired pneumonia and bacteremia in a
study of individuals in an intensive care unit (ICU)
(Fourrier et al. 1998).

In addition, several case reports have been pub-
lished implicating indigenous oral flora in the devel-
opment of brain abscesses (Andersen and Horton
1990, Andrews and Farnham 1990, Baker et al. 1999,
Gallagher et al. 1981, Goteiner et al. 1982, Saal et al.
1988). This serious condition is associated with a
mortality rate of almost 20 percent and full recovery
in only slightly more than 50 percent of all patients
(Goteiner et al. 1982). These data are based on single
case reports and most probably represent rare events.
However, they provide additional examples that
point to the potential pathogenicity of the normal
oral flora during special adverse circumstances.

Linkages with General Health

Oral Infections as a Result of Therapy

Chemotherapy

Oral mucositis can be a major dose-limiting problem
during chemotherapy with some anticancer drugs,
such as 5-fluorouracil, methotrexate, and doxoru-
bicin. It is estimated that approximately 400,000
patients undergoing cancer therapy each year will
develop oral complications (NIH 1990). Infection of
ulcerated mucous membranes often occurs after
chemotherapy, especially since patients are usually
immunocompromised. Bacterial, fungal, and viral
causes of mucositis have been identified (Feld 1997).
The mechanism by which cancer-chemotherapy-
induced mucositis occurs is likely associated with the
rapid rate of turnover of oral epithelial cells. In addi-
tion, other components likely include upregulation
of pro-inflammatory cytokines and metabolic by-
products of colonizing oral microflora (Sonis 1998).
Chemotherapy alters the integrity of the mucosa and
contributes to acute and chronic changes in oral tis-
sue and physiologic processes (Carl 1995). The
ulcerated mucosa is susceptible to infection by
microbial flora that normally inhabit the oral cavity,
as well as by exogenous organisms, and exacerbates
the existing mucositis. Further, these microflora can
disseminate systemically (Pizza et al. 1993, Rolston
and Bodey 1993). Compromised salivary function
can further elevate risk for systemic infection of oral
origin.

Both indigenous oral flora and hospital-acquired
pathogens have been associated with bacteremias and
systemic infection (Schubert et al. 1999). Changes in
infection profiles in myelosuppressed (immunosup-
pressed) cancer patients tend to occur in cyclic fash-
ion over many years. This evolving epidemiology is
caused by multiple factors including use of antibi-
otics. Gram-positive organisms including viridans
streptococci and enterococci are currently associated
with systemic infection of oral origin in myelosup-
pressed cancer patients. In addition, gram-negative
pathogens including I? aeruginosa, Neisseria spp., and
Escherichia coli remain of concern.

Cancer patients undergoing bone marrow radia-
tion who have chronic periodontal disease may also
develop acute periodontal infections with systemic
complications (Peterson et al. 1987). The extensive
ulceration of gingival sulcular epithelium associated
with periodontal disease is not directly observable
clinically, yet may represent a source for disseminat-
ed infection by an extensive array of organisms.
Inflammatory signs may be masked due to the under-
lying bone marrow suppression.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           105


Linkages with General Health

Viruses are also associated with clinically impor-
tant oral disease in patients receiving chemotherapy
(Ralston and Bodey 1993, Pizzo et al. 1993).
Infections caused by herpes simplex virus, varicella-
zoster virus, and Epstein-Barr virus typically result
from reactivation of a latent virus, whereas
cytomegalovirus infections can result via reactivation
of a latent virus or a newly acquired virus. The sever-
ity of the infection, including fatal outcome, depends
on the degree of immunocompromise.

Many agents and protocols have been investigat-
ed to manage or prevent mucositis (Peterson 1999,
Schubert et al. 1998). For example, various biologic
response modifiers, including transforming growth
factor p3 or keratinocyte growth factor, have been
under recent study in randomized clinical trials.
Allopurinol mouthwash and vitamin E have been
cited as agents that can decrease the severity of
mucositis. although more extensive testing is neces-
sary. Prostaglandin E2 was not shown to be effective
in prophylaxis of oral mucositis following bone mar-
row transplant; however, more recent studies indi-
cate possible efficacy when administered via a differ-
ent dosing protocol. Oral cryotherapy appears to be
efficacious in reducing severity of oral mucositis
caused by 54uorouracil and related compounds
(Rocke et al. 1993).

can require surgery to excise the dead tissue, which
can in turn leave the face badly disfigured as well as
functionally impaired (Field et al. 2000). The likeli-
hood of ORN is increased with trauma to the bone,
including that caused by tooth extraction (Murray et
al. 1980a, b). The risk is especially marked when the
trauma occurs near the time of radiation (Epstein et
al. 1987). Management includes elimination of acute
or potential dental and periodontal foci of disease,
increased patient participation in oral hygiene, use of
oral topical fluorides for caries prevention, and use of
antiviral, antifungal, or antimicrobial therapy for
management of infections associated with mucositis.

Combined Cancer Therapies

Local application of capsaicin preparations may
be effective in controlling oral mucositis pain as dis-
tinguished from tissue injury itself (Berger et al.
1995). Capsaicin and its analogs are the active ingre-
dients in chili peppers. Capsaicin's clinical potential
derives from the fact that it elevates the threshold for
pain in areas to which it is applied.

Rapid developments have occurred in the use of
blood cell growth factors for treatment of various
conditions, including the anemia of end-stage renal
disease, the neutropenia occurring with cancer care,
and the bone marrow toxicity and mucositis that can
follow aggressive chemotherapy or radiation therapy
(Sonis et al. 1997, Williams and Quesenberry 1992).
Sonis et al. (1997) found that topical application of
transforming growth factor beta (TGF-8) in the ham-
ster model of oral mucositis significantly reduced
basal cell proliferation and reduced the severity of
mucositis associated with 5-fluorouracil treatment.

Radiation Therapy

Radiation therapy disrupts cell division in healthy
tissue as well as in tumors and also affects the normal
structure and function of craniofacial tissues, includ-
ing the oral mucosa, salivary glands, and bone. Oral-
facial complications are common after radiation ther-
apy to the head and neck. The most frequent, and
often the most distressing, complication is mucositis,
but adverse reactions can affect all oral-facial tissues
(Scully and Epstein 1996).

Radiation can cause irreversible damage to the
salivary glands, resulting in dramatic increases in
dental caries. Oral mucosal alterations may become
portals for invasion by pathogens, which may be life-
threatening to immunosuppressed or bone-marrow-
suppressed patients. A less common but very serious
adverse consequence is destruction of bone cells and
bone death, called osteoradionecrosis (ORN). ORN
can result in infection of the bone and soft tissue and

Other growth factors considered for use in
reducing mucositis include granulocyte-monocyte
colony-stimulating factor and granulocyte colony-
stimulating factor. Bone morphogenetic proteins are
also in development for alleviating the toxicity and
mucositis that follow chemotherapy and radiation
therapy Other approaches to reducing mucositis and
adverse oral effects of chemotherapy and radiation
therapy include fractionating the dose of radiation,
and combining chemotherapy with growth factors or
with less toxic oncostatic agents. Although the oral
mucositis occurring in chemotherapy and in head
and  neck  radiation patients shares many
characteristics, distinct differences also exist (NIH
1990, Schubert et al. 1998, Wilkes 1998). For
example, in contrast to chemotherapy-associated
lesions, radiation damage is anatomically site-
specific; toxicity is localized to irradiated tissue
volumes. The degree of damage depends on
treatment-regimen-related factors, including the type
of radiation used, the total dose administered, the
fractionation, and field size. Thus, research involving
both cohorts of cancer patients remains essential to
enhancing patient management.

Development of new technologies to prevent
cancer-therapy-induced  oral  mucositis  could

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


substantially reduce the risk for oral and systemic
infections, oral pain, and the number of hospital
days. Improvement in quality of life and reduction in
health costs are also likely and desirable outcomes.

The new technologies could also provide a set-
ting in which novel classes of chemotherapeutic
drugs, utilized at increased doses, could be imple-
mented. These advances in turn could lead to
enhanced cancer patient survival and lengthen the
duration of disease remission.

Pharmaceuticals

A number of medications used to treat systemic dis-
eases can cause oral complications, ranging from
xerostomic effects to alterations in the surface struc-
ture of the enamel or mucosa. More than 400 over-
the-counter and prescription drugs have xerostomic
side effects (Sreebny and Schwartz 1997). These
include tricyclic antidepressants, antihistamines, and
diuretics. The dimensions and impact of these side
effects vary depending on the response of the indi-
vidual patient and the duration of medication use.

Staining of the teeth or mucosa is associated with
a variety of drugs, including tranquilizers, oral con-
traceptives, and antimalarials. The antibiotic tetracy-
cline can cause enamel hypoplasia when taken by the
mother during pregnancy and by children during
tooth development. The antimicrobial mouthrinse
agent chlorhexidine also can stain the teeth, but this
staining is external and can be removed by dental
prophylaxis.

Other drugs have been associated with gingival
overgrowth, including cyclosporin, which has been
used as an immunosuppressant in the United States
since 1984 to prevent rejection of transplanted
organs and bone marrow. This drug has also been
used in other countries for treatment of type 2 dia-
betes, rheumatoid arthritis, psoriasis, multiple sclero-
sis, malaria, sarcoidosis, and several other diseases
with an immunological basis (Adams and Davies
1984). Other drugs that cause gingival overgrowth
include calcium ion channel blocking agents used in
the treatment of angina pectoris and postmyocardial
syndrome, such as nifedipine and verapamil (Lucas
et al. 1985>, and phenytoin (sodium 5,5-phenylhy-
dantoin), used in the treatment of epilepsy and also
for management of other neurological disorders.
Treatment often consists of using an alternate drug,
although this is not always possible. Conservative
periodontal therapy can reduce the inflammatory
component of enlargement; however, surgery is often
required. Oral candidiasis is typically caused by
opportunistic overgrowth of Candida albicans. Drugs
that cause systemic bone marrow suppression, oral

Linkages with General Health

mucosal injury, or salivary compromise collectively
promote the risk for clinical infection. In addition,
antibiotics and concurrent steroid therapy often alter
oral flora, thereby creating an environment for fungal
overgrowth. In high-risk cancer patients, fungal
infection can cause severe morbidity and even death.

Infective Endocarditis

The purported connection between oral infection
and a specific heart disease, infective endocarditis,
has a long history. Endocarditis is caused by bacteria
that adhere to damaged or otherwise receptive sur-
faces of the tissue that lines heart valves (the endo-
cardium) (Weinstein and Schlesinger f974). Dental
and other surgical procedures may predispose sus-
ceptible patients to infective endocarditis by induc-
ing bacteremias (Lacassin et al. 1995). However, bac-
teremias from oral infections that occur frequently
during normal daily activities, coincidental even with
chewing food, toothbrushing, and flossing, con-
tribute more substantially to the risk of infective
endocarditis (Bayliss et al. 1983, Dajani et al. 1997,
Strom et al. 1998). Oral organisms are common etio-
logic agents of infective endocarditis (Bayliss et al.
1983). For example, strains of S. sanguis, as well as
gram-negative oral bacteria including Haemophilus
aphrophilus, A. actinomycetemcomitans, E. cormdens,
Capnocytophaga spp., and Fusobacterium nucleatum,
have been associated with bacterial endocarditis
(Barco 1991, Geraci and Wilson 1982, Kaye 1994,
Moulsdale et al. 1980).

  Infective endocarditis occurs with different incu-
bation periods, which differ in causative bacteria and
signs and symptoms. For example, Staphylococcus
aureus endocarditis may have a rapid onset and fatal
course if it affects the left side of the heart. With a
more indolent course, patients may often be unaware
of infection and may experience fever, night chills,
myalgia, and arthralgia for a considerable period of
time before diagnosis. The infection is often curable
if diagnosed and treated early

  The classic risk factors for endocarditis include
cardiac valve disorders (valvulopathies) that include
rheumatic and congenital heart disease, complex
cyanotic heart disease in children, and mitral valve
prolapse with regurgitation. Recent studies indicate
that the use of certain diet drugs (fenfluramine and
dexfenfluramine) has induced cardiac valvulopathy,
which may in some cases be transient. Among at-risk
persons, bacteremias are more likely to occur in
those with periodontal disease (Silver et al. 1977).
However, the oral pathogens causing periodontitis
have only rarely been shown to cause endocarditis.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          107


Linkages Lvith General Health

  Prevention of infective endocarditis from oral
bacteria depends on limiting the entry and dissemi-
nation of bacteria through the bloodstream and lym-
phatic circulation. Antibiotic prophylaxis for dental
procedures that are likely to provoke bacteremia has
historically been recommended (Dajani et al. 1997,
Durack 1995). A recent study, however, suggests that
receiving dental treatment does not significantly
increase the risk of infective endocarditis, even in
patients with valvular abnormalities (Strom at al.
1998). Further research is necessary to determine
whether some heart or valvular conditions or certain
dental procedures, such as surgery or scaling, would
require coverage with pre-procedural antibiotics and
others would be precluded.

Oral Infections and Respiratory Disease
Pathogens in the oral cavity can also gain access to
the airway, sometimes with serious consequences. In
adults, bacterial pneumonias are strongly associated
with aspiration of bacteria into the lower respiratory
tract, which is normally sterile. Common respiratory
pathogens such as Streptococcus pneumoniae,
Streptococcus pyogenes, Mycoplasma pneumoniae, and
Haemophilus inf7uenzae can colonize the oropharynx
and the lower airway. In addition, oral bacteria
including A. actinomycetemcomitans (Yuan et al.
1992), Actinomyces israelii (Morris and Sewell 1994,
Zijlstra et al. 1992), Capnocytophaga spp. (Lorenz
and Weiss 1994), Eikenella corrodens Uoshi et al.
1991), Prevotella inter-media, and Streptococcus con-
stellatus (Shinzato and Saito 1994) can be aspirated
into the lower airways (Scannapieco 1998, 1999).

Chronic obstructive pulmonary disease, charac-
terized by obstruction of airflow due to chronic bron-
chitis or emphysema and by recurrent episodes of
respiratory infection, has been associated with poor
oral health status (Hayes et al. 1998, Scannapieco et
al. 1998). A positive relationship between periodon-
tal disease and bacterial pneumonia has been shown
by Scannapieco and Mylotte (1996).

Although oral bacteria, including periodontal
pathogens, have the potential for causing respiratory
infections, the frequency and nature of such infec-
tions are not known and merit further study.

Oral Transmission of Infections

Besides being a portal of entry for infections, the
mouth is an important source of potentially patho-
genic organisms and is often the vehicle by which
infection is delivered to the bodies of others.
Microorganisms were not discovered in the mouth

until the seventeenth century, when van Leewenhoek
examined dental plaque using a microscope he
had constructed. In 1884, Koch demonstrated that
tuberculosis could be transmitted by airborne
droplets from the mouth and respiratory tract. Since
that time, we have learned that many common respi-
ratory infections, such as influenza, the common
cold, pneumonia, and tuberculosis, can be transmit-
ted from oral secretions. Before the development of
effective vaccines, orally transmitted diseases such as
chickenpox, measles, mumps, polio, and diphtheria
were a major source of morbidity and mortality in
childhood. Viral diseases such as hepatitis B, herpes
labialis, acute herpetic gingivostomatitis, cyto-
megalovirus, and infectious mononucleosis may also
originate from oral contact.        ,
Disease-causing microorganisms can be spread

by direct contact (with saliva or blood from the
mouth) or indirect contact (with saliva- or blood-
contaminated surfaces, including hands or lips),
droplet infection (from coughing, sneezing, or even
normal speech), or by aerosolized organisms. These
organisms can be inhaled, ingested, or taken in
through mucous membranes in the eyes, nose, or
mouth or through breaks in the skin. A number of
diseases can be spread via oral sexual contact, includ-
ing gonorrhea, syphilis, trichomoniasis, chlamydia,
and mononucleosis.

As mentioned earlier, the oral mucosa and saliva
provide significant defense against disease transmis-
sion. Epidemiological and animal studies are provid-
ing evidence, however, that the oral cavity may be the
site for transmission of serious systemic infections
despite the protective factors in saliva (see Chapter
2). Infection with HIV provides a case in point (Baba
et al. 1996, Dillon et al. 2000, Pope et al. 1997,
Ruprecht et al. 1999, Stahl-Hennig et al. 1999, Baron
et al. 2000).

Early in the 198Os, when AIDS was first identi-
fied in the United States, concern was expressed
about casual (i.e., nonsexual) transmission of HIV
(CDC 1983, 1985). Detailed household studies did
not demonstrate transmission of HIV, even when
family members shared eating utensils and tooth-
brushes with an HIV-affected member (Fischl et al.
1987, Rogers et al. 1990, Sande 1986). Similarly, sur-
veillance data collected over time showed no evi-
dence of casual transmission (Ward and Duchin
1997).

Only one nonoccupational episode of HIV trans-
mission has been attributed to blood-contaminated
saliva (CDC 1997); this incident involved intimate
kissing between sexual partners. There have been a
few cases of HIV transmission from performing oral

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


sex on a person infected with HIV, and it is also pos-
sible to become infected with HIV by receiving oral
sex. In the San Francisco Options Study of men who
have sex with men identified within 12 months of
HIV seroconversion, oral transmission represented
7.8 percent of primary HIV infections (Dillon et al.
2000). Rothenberg et al. (1998) reviewed epidemio-
logic studies and reports of 38 cases of oral transmis-
sion of HIV in the literature. They concluded that
although oral-genital contact may be less efficient
than needle-sharing or anal intercourse for the trans-
mission of HIV, its increased use by men who have
sex with men (Ostrow and DiFranceisco 1996,
Schwartz et al. 1995) and in crack cocaine smokers
(Faruque et al. 1996a,b) may increase its contribu-
tion to HIV transmission over time. Several studies
provide evidence that when the oral environment is
compromised, the mouth can be a potential site of
transmission of infectious microbes. Data from
Faruque et al. (1996a,b) and Wallace et al. (1996)
suggest that there is a positive association between
the presence of oral lesions resulting from crack co-
caine use, receptive oral intercourse, and HIV trans-
mission. A case report has documented the passage of
HIV from a partner who is HIV-positive to one who
is HIV-negative in the presence of periodontal disease
but in the absence of other risk factors (Padian and
Glass 1997). Because the type, duration, and fre-
quency of oral contact in past studies may not have
been specified, the risk could be somewhat higher for
oral transmission of HIV than previously reported.
The risk might also vary depending on factors such
as viral load, infectious dose, area of exposure, and
presence or absence of oral lesions. Additional stud-
ies are needed to evaluate the risk of oral-genital
transmission of HIV; some are under way (J.
Greenspan, K. Page-Schafer, personal communica-
tion, 1999).

Other sexually transmitted diseases (STDs) can
occur through oral contact. For example, pharyngeal
infection with Chlarnydia trachornatis has been found
in 3 to 6 percent of men and women attending STD
clinics. Most infections are asymptomatic (Holmes et
al. 1999). Another common sexually transmitted
infection, herpes simplex virus, commonly infects
the pharynx and is seen in 20 percent of patients with
primary genital herpes. The painless chancre of pri-
mary syphilis can be found in the oral cavity; howev-
er, there are no data on the prevalence of this site of
infection for Treponema pallidurn. Among persons
with gonorrhea, pharyngeal infection occurs in 3 to 7
percent of heterosexual men, 10 to 20 percent of het-
erosexual women, and 10 to 25 percent of men who
have sex with men (Holmes et al. 1999). Gonococcal

Linkages with General Health

infection can cause acute pharyngitis, but is usually
asymptomatic. The transmission of pharyngeal gon-
orrhea to sex partners had been thought to be rare.
However, in one study, 17 of 66 men who had sex
with men who had urethral gonorrhea reported
insertive oral sex as their only risk factor in the past
2 months (Lafferty et al. 1997).

Conclusion

The role of the mouth as a portal of entry for infec-
tion presents ever-new challenges for study. Although
oral tissues and fluids normally provide significant
barriers and protection against microbial infections,
at times these infections can not only cause local dis-
ease but, under certain circumstances, can dissemi-
nate to cause infections in other parts of the body.
The control of existing oral infections is clearly of
intrinsic importance and a necessary precaution to
prevent systemic complications.

ASSOCIATIONS AMONG ORAL
INFECTIONS AND DIABETES, HEART
DISEASE/STROKE, AND ADVERSE
PREGNANCY OUTCOMES
Recent studies have reported associations between
oral infections-primarily periodontal infections-
and diabetes, heart disease and stroke, and adverse
pregnancy outcomes, but sufficient evidence does
not yet exist to conclude that one leads to the other.
This section characterizes the nature of these associ-
ations by describing the quality of the evidence sup-
porting the reports. Both observational and experi-
mental studies were accepted as admissible evidence.
Table 5.3 presents the hierarchy of evidence used to
interpret these associations. Where there are opera-
tive mechanisms proposed that support an associa-
tion between oral infectious agents and the systemic
conditions in question, they are introduced at the
outset. These are followed by animal studies and then
by epidemiologic or population-based studies. The
evidence for each association is presented in the table
in rank order according to the rigor of the study
design.

The Periodontal Disease-Diabetes
Connection

There is growing acceptance that diabetes is associat-
ed with increased occurrence and progression of peri-
odontitis- so much so that periodontitis has been
called the "sixth complication of diabetes" (L6e 1993).

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          109


Linkages with General Health

The risk is independent of whether the diabetes
is type 1 or type 2. Type 1 diabetes is the
condition in which the pancreas produces little or no
insulin. It usually begins in childhood or adoles-
cence. In type 2 diabetes, secretion and utilization of
insulin are impaired; onset is typically after age 30.
Together, these two types of diabetes affect an esti-
mated 15.7 million people in the United States and
represent the seventh leading cause of death (NIDDK
1999). The goal of diabetic care is to lower blood glu-
cose levels to recommended levels. Some investiga-
tors have reported a two-way connection between
diabetes and periodontal disease, proposing that not
only are diabetic patients more susceptible to peri-
odontal disease, but the presence of periodontal dis-
ease affects glycemic control. This section explores
the bidirectional relationship, beginning with the
effects of diabetes on periodontal disease.

Effects of Diabetes on Periodontitis Prevalence
and Severity

Several reviews have described candidate mecha-
nisms to explain why individuals with diabetes may
be more susceptible to periodontitis (Grossi and
Genco 1998, Manouchehr-Pour and Bissada 1983,
Murrah 1985, Oliver and Tervonen 1994, Salvi et al.
1997, Wilton et al. 1988). These include vascular
changes, alterations in gingival crevicular fluid, alter-
ations in connective tissue metabolism, altered host
immunological and inflammatory response, altered
subgingival microflora, and hereditary patterns.
Studies were classified by type of diabetes and age of
study population (see Table 5.4).

Tq'pe 1 Diabetes. Ten reports focused principally on
children and adolescents with type 1 diabetes, com-
paring them with groups of similar ages without dia-
betes (Cianciola et al. 1982, de Pommereau et al.
1992, Faulconbridge et al. 1981, Firatli 1997, Firatli
et al. 1996, Goteiner et al. 1986, Harrison and Bowen
1987, Novaes et al. 1991, Pinson et al. 1995,
Ringelberg et al. 1977). All but one of the studies
(Goteiner et al. 1986) reported greater prevalence,
extent, or severity of at least one measure or index of
periodontal disease (e.g., gingival inflammation,
probing pocket depth, loss of periodontal attach-
ment, or radiographic evidence of alveolar bone loss)
among subjects with diabetes, even though these
investigations were conducted in a variety of coun-
tries across several continents.

Another set of studies on the relationship
between type 1 diabetes and periodontal disease
included subjects with and without diabetes between
the ages of 15 and 35 (Cohen et al. 1970, Galea et al.
1986, Guven et a1. 1996, Kjellman et al. 1970,
Rylander et al. 1987, Sznajder et al. 1978). All six
studies reported greater prevalence, extent, or sever-
ity of at least one measure or index of periodontal
disease.

  A third set of studies conducted in Scandinavia
looked at the relationship between periodontal dis-
ease and type 1 diabetes (or diabetes reported as
requiring insulin therapy without specification of
diabetes type) in adults between 20 and 70 years old.
Three of the four studies were cross-sectional
(Glavind et al. 1968, Hugoson et al.  1989,
Thorstensson and Hugoson 1993), and one was a
treatment  follow-up study (Tervonen and

TABLE 5.3

Hierarchy of evidence used in analyzing and interpreting results

Quality of Evidence
  I:  Evidence obtained from at least one properly randomized controlled trial.
11-l:  Evidence obtained from well-designed controlled trials without randomization.
11-2:  Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.
11-3:  Evidence obtained from multiple time series with or without the intervention.Dramatic results in uncontrolled experiments (such as the results of the
   introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence.
Ill:  Opinions of respected authorities, based on clinical experience; descriptive studies and case reports; or reports of expert committees.
Strength of Recommendation
A:  There is good evidence to support the recommendation.
  B:  There is fair evidence to support the recommendation.
  C:  There is insufficient evidence to recommend for or against, but recommendations may be made on other grounds.
  D:  There is fair evidence to support the recommendation that the intervention be excluded.
  E:  There is good evidence to support the recommendation that the intervention be excluded.

I Source: Adapted from U.S.Preventive ServicesTask Force 1996.

110        ORAL HEAL-I-H IN AMERICA: A REPORT OF THE SURGEON GENERAL


Linkages with General Health

TABLE 5.4
Summary of studies of the association between diabetes and periodontal diseases, classified by strength of evidence, diabetes type,
and age group

                           Number of            Measure of
                        Subjects     Agesb     Periodontal         Other
              Study    Diabetes a. Diabetes    a. Diabetes   Disease Status:      Diabetes-Related    Evidence
         Country   Design    Type"   b.Control     b.Control   Diabetes Effect     Variables Considered    Leveld

Firatli 1997

Cohen et al. 1970

Tervonen and
Karjalainen 1997

Novaes et al. 1996

Nelson et al. 1990

Taylor et al. 1998a

Taylor et al. 1998b

Goteiner et al.1986

Harrison and
Bowen 1987

Novaes et al. 1991

Cianciola et al.1982

de Pommereau
et al. 1992

Ringelberg
et al. 1977

Firatli et al. 1996

Pinson et al. 1995

Faulconbridge
et al. 1981

Kjellman et al.1970

Guven et al. 1996

Turkey

USA

Finland

Brazil

USA

USA

USA

USA

USA

Brazil

USA

France

USA

Turkey

USA

England

Sweden

Turkey

Prospective 1

Prospective 1"


Prospective 1

Prospective 2


Prospective 2


Prospective 2


Prospective 2


Cross-sectional 1

Cross-sectional 1


Cross-sectional 1

Cross-sectional 1

Cross-sectional 1

Cross-sectional 1


Cross-sectional 1

Cross-sectional 1

Cross-sectional 1


Cross-sectional 1"

Cross-sectional 1

a.44
b. 20

a.21
b.18

a.36
b.10

a. 30
b.30

a.720
b. 1,553

a.24
b.338

a.21
b. 338

a.169
b. 80

a. 30
b.30

a.30
`b.30

a. 263
b. 208

a.85
b.38

a.56
b.41

a. 77
b. 77

a. 26
b.24

a.94
b.94

a. 105
b. 52

a.10

a. 12.2 (mean)
b.12.3 (mean)

a.18,35
b.18,35
a.24,36
b.24,36

a. 30,77
b. 30,67
a. 15,55+
b. l&55+

a. 1557
b.1557

a. 15,49
b. 15,49
a.school ages
b.518

a.4,19
b.4,19

a.5,18
b.518

a.<10,>19
b.<10,>19

a.12,18
b.12,18

a.10,16
b.lO,lZ
a. 12.5 (mean)
b. 12.6 (mean)

a.7-18
b.7-18

a.5,17
b.5,17

a.l5,24
b.1524

a.18,27

Ging: 0s
Ppd:Os
Lpa:ls
Ging: 1s
Lpa:lr,ls
Ging:Oe
Ppd:lr
Lpa:le
Ppd:ls,lr
Lpa,ls,lr
XRBL:li, lp

XRBL: li, lr

XRBL: li, lr

Ging:Os
Lpa: Op, OS
PDI: OS

Ging: 1s
Lpa: lp
Ging: 1s
Ppd:Os
XRBL: 1s

Ging: lp
Lpa: lp
XRBL: lp, 1s
JPS: lp,ls
Ging:le
Lpa: Oe, Op, OS
XRBL: Oe, Op, OS
Ging: 1s
MGI: 1s

Ging:Os
Ppd: 1s
Lpa: 1s
Ging: 1s
Ppd: OS
Lpa: 0s
Ging: 1s

Ging: le
Ppd: 0s
XRBL: OS

Ging: le

Glycemic control
Duration of diabetes

None

Glycemic control
Duration of diabetes
Diabetes complications
Glycemic control

None

None

Glycemic control

None

Glycemic control

None

Duration of diabetes

Glycemic control
Duration of diabetes

None

Duration of diabetes

Glycemic control
Duration of diabetes

Duration of diabetes

Glycemic control
Diabetes complications

None

II-2

II-2



II-2

II-2



II-2



II-2


II-2



III

Ill



Ill

Ill

Ill

Ill



Ill

Ill

Ill



Ill

  Ill
(continues)

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          111


Linltagcs u-it11 General Health

TABLE 5.4 continued
                            Number of            Measure of
                        Subjects    Age+       Periodontal        Other
               Study   Diabetes   a.Diabetes   a. Diabetes     Disease Status:     Diabetes-Related      Evidence
         Country    Design   TYP@   b.Control    b.Control     Diabetes EffecF    Variables Considered      Leveld

Rylander et al. 1987   Sweden Cross-sectional 1      a.46     a.18,26     Ging: le, 1 p    Diabetes complications     Ill
                              b.41     b.19.25     Ppd: Oe
                                       Lpa:le,lp
                                    XRBL:Op
Sznajder et al. 1978   Argentina Cross-sectional 1"     a.20     a.9,29     Ging: 1s       None             Ill
                               b.26     b.9,29     Lpa: 0s
Galea et al. 1986     Malta   Cross-sectional l*     a.82     a. 5,29     Ppd:lp      Glycemic control        Ill
                           b.unknown b.5,29                Duration of diabetes
                                              Diabetes complications
Hugoson et al. 1989    Sweden  Cross-sectional 1      a.154    a. 20,70     Ging: le       Duration of diabetes      Ill
                              b. 77     b.20,70     Ppd:le,lp,ls
                                             XRBL: 1s

Giavind et al. 1968    Denmark Cross-sectional lx

a.51
b.51

a. 20,40
b. 20,4O

Duration of diabetes
Diabetes tomplications

Ill

Thorstensson and
Hugoson 1993

Sweden Cross-sectional 1

a.117
b. 99

a.40,70
b. 40,70

Duration of diabetes
Onset age

III

Morton et al. 1995




Shlossman et al. 1990


Emrich et al.1991


Wolf 1977




Benveniste
et al.1967

Finestone and
Boorujy 1967

Belting et al. 1964


Oliver and Tervonen
1993
Yavuzyilmaz et al.
1996
Bridges et al. 1996



Sandler and Stahl
1960

Bacic et al. 1988




Hove and Stallard
1970

Mauritius Cross-sectional 2




USA    Cross-sectional 2


USA    Cross-sectional 2


Finland Cross-sectional 1,2




USA    Cross-sectional 1,2*


USA    Cross-sectional 1,2*




USA    Cross-sectional 1,2"


USA   Cross-sectional 1,2


Turkey   Cross-sectional 1,2


USA    Cross-sectional 1,2




USA    Cross-sectional 1,2*


Yugoslavia Cross-sectional 1,2




USA    Cross-sectional 1,2"

a. 24
b.24


a. 736
b. 2,483

a. 254
b. 1,088

a.186
b.156


a.53
b.71

a. 189
b.64


a.78
b. 79

a.114
b.15,132

a.17
b.17

a.118
b.115


a.100
b. 3,894

a.222
b.189


a. 28
b. 16

a.26,76
b. 25,73


a.5 45+
b.5,45+
a. 15,55+
b.15,55+
a.16,60
b.l6,60


a.5,72
b.5,72.
a. 20,79
b. 20,79


a.20,79
b. 20,79
a.20,64
b.20,64
a.25,74
b. 19,29
a. 24,78
b. 24,78


a.20,69
b. 20,69
a. <20,6D+
b. <20,60+


a. 20,40+
b. 20,40+

Ging:Os
Ppd: OS
Lpa:ls
XRBL: 1s
Ging:Oe
Ppd:le,ls
XRBL: 1s
Ging: lp
Ppd: 1s
Lpa: 1s
Lpa: lp
XRBL: 1 p
Lpa:lp,ls
XRBL: lp, 1s
Ging: 1s
Lpa: 1s
XRBL: 1s
Ging: 0s
Ppd:Op,Os
PI: `Is




PI:ls


Ppd:le,lp
Lpa: le, Op,Os
Ppd:ls

Ging: OS
Ppd: 0s
Lpa: 1s
PDR: le


Ppd:le,lp,ls



Ging:Os
Ppd: OS
XRBL:Os

None




None


None


Glycemic control
Duration of diabetes
Diabetes complications
None


Glycemic control
Duration of diabetes
Diabetes complications
Diabetes severity


None


None


Glycemic control
Duration of diabetes


None


Glycemic control
Duration of diabetes
Diabetes complications
Duration of diabetes
Diabetes severity

Ill




III


Ill


III




Ill


Ill




Ill


III


III


ill




Ill


Ill




III

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


Linkages \vith General Health

Mackenzie and
Millard 1963
Sznajder et al. 1978


Dolan et al. 1997




Grossi et al. 1994




Tervonen and
Knuuttila 1986

                 Number of            Measure of
               Subjects    Age+     Periodontal        Other
      Study   Diabetes  a. Diabetes   a. Diabetes    Disease Status:      Diabetes-Related      Evidence
Country    Design   TYP@   b.Control    b.Control    Diabetes Effect<    Variables Considered      Leveld


USA    Cross-sectional 9     a. 124    a. 32,78      XRBL:Os       None             Ill
                   b.92     b.32,78
Argentina Cross-sectional 9     a.63     a. 30,49     Ging: 1s       None             Ill
                   b. 39     b. 30,50     Lpa: 1s

USA    Cross-sectional 9    Weighted   a.45,75+    Lpa:le,lp,ls    None             Ill
                    a. 107    b.45,75+
                  b.554

USA    Cross-sectional 9     a. 1,426    All: 25,74;    Lpa: Is, lp      None             Ill
                   b. 69     unknown for
                         diabetes

Finland Cross-sectional 9     a.50     a. <30,40+   Ging: le     Glycemic control        Ill
                    b.53     b.<30,40+   Ppd:le, lp
                                  XRBL: OS

Campbell 1972      Australia Cross-sectional 9     a. 70     a.17,39     PI:lp,ls      None             Ill
                              b.102    b.17,39

Albrecht et al. 1988   Hungary Cross-sectional 9     a. 1,360   a. 15,65+    Ging: 1s       None             Ill
                               b. 625    b. 15,65+     PI: OS

Szpunar et al.      USA    Cross-sectional 9      a.474    a. 6,65+      PI: 1s        None             Ill
1989 (NHANES I)                     b. 15,174   b.6,65+
Szpunar et al.      USA    Cross-sectional 9     a. 322    a. 15,65+     PI: 1s        None             III
1989 (HHANES)                     b. 8,040   b. 12,65+

`Diabetes type: 1 = type 1 diabetes mellitus; 2 = type 2 diabetes mellitur; 1,2 = both type 1 and type 2 diabetes mellitus;9 = diabetes type not specified and not clearly ascertaina-
ble from other information in the report; o = diabetes type not specified but ascertained by reviewer from other information in the report.
bAges:subjects'ages presented as minimum, maximum reported for those with diabetes and controls unless otherwise specified.
(Measure of periodontal disease status. Measures used include Ging = girigivitis or gingival bleeding; Ppd = probing pocket depth; Lpa = loss of periodontal attachment; XRBt =
radiographic bone loss;JPS = juvenile periodontal score; MGI = modified gingival index; PI = Russell's periodontal index; PDR = periodontal disease rate (proportion of teeth affected
by periodontal disease).The number following the measure corresponds to greater disease in those with diabetes (1) or no difference between those with diabetes and controls (0).
The letter followmg the number corresponds to the parameter(s) assessed in the study:e = extent;i = incidence; p = prevalence; s = severity; r = progression.
dlevels of evidence are delineated in Table 5.3.

Karjalainen 1997). All four studies reported greater
prevalence, extent, or severity of at least one measure
of periodontal disease.

Type 2 Diabetes. There are fewer reports on the rela-
tionship between type 2 diabetes and periodontal dis-
ease, particularly where type 2 diabetes is explicitly
identified or discernible from the ages of subjects.
Seven studies limited to subjects with type 2 diabetes
included a comparison group without diabetes. Two
of these studies included only adult subjects (Morton
et al. 1995, Novaes et al. 1996); the remaining five
were large population-based studies of diabetes and
periodontal disease in Pima Indians, a group with the
highest known prevalence of type 2 diabetes in the
world. The Pima Indian studies included subjects
aged 5 years and older (Shlossman et al. 1990) or 15
and older (Emrich et al. 1991, Nelson et al. 1990,

Taylor et al. 1998a,b). All seven studies reported
greater prevalence, extent, or severity of periodontal
disease among subjects with diabetes for at least one
measure of periodontal disease. Three of these stud-
ies were longitudinal (Nelson et al. 1990, Taylor et al.
1998a,b) and showed that the progression of peri-
odontal disease was greater in diabetes patients than
in individuals without diabetes.

In addition to finding significant differences in
various measures of periodontal status between sub-
jects with and without type 2 diabetes, a number of
these reports also provide estimates of association
and risk. Using periodontal attachment loss as the
measure, Emrich et al. (1991) estimated that people
with type 2 diabetes were 2.8 times more likely to
have destructive periodontal disease (odds ratio, 2.8;
95 percent CI, 1.9 to 4.1). When they used radi-
ographic bone loss as the measure and controlled for

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          113


Linkages with General Health

other important covariates, the estimate rose to 3.4
(odds ratio. 3.4; 95 percent CI, 2.3 to 5.2). Nelson et
al. (1990) quantified the increased risk of advanced
periodontal disease in Pima Indians with and without
type 2 diabetes, finding the prevalence of periodontal
disease in subjects with diabetes to be 2.6 times
greater (95 percent CI, 1.0 to 6.6) than that of sub-
jects without diabetes. Taylor et al. (1996), in anoth-
er analysis of data from the Pima Indians, reported
that type 2 diabetes was a significant risk factor for
more severe alveolar bone loss progression (odds
ratio, 4.2; 95 percent CI, 1.8 to 9.9), in addition to
being a significant risk factor for the prevalence of
alveolar bone loss.

Studies of individuals with Type 1 or Type 2 Diabetes.
Twelve reports included analyses in which subjects
with type 1 and type 2 diabetes were not separated.
All of these studies were cross-sectional and included
adults; two studies included children or adolescents
as well (Benveniste et al. 1967, Wolf 1977). Nine of
the 12 studies reported greater prevalence, extent, or
severity of periodontal disease among the diabetic
subjects for at least one measure or index of peri-
odontal disease (Bacic et al. 1988, Belting et al. 1964,
Bridges et al. 1996, Finestone and Boorujy 1967,
Hove and Stallard 1970, Oliver and Tervonen 1993,
Sandler and Stahl 1960, Yavuzyilmaz et al. 1996,
Wolf 1977).

Hove and Stallard (1970) and Benveniste et al.
(1967) did not find significant differences in peri-
odontal disease between subjects with and without
diabetes. The Hove and Stallard report included 28
subjects with diabetes and 16 without diabetes and
may not have had enough statistical power to detect
clinical differences, although they were able to detect
a significantly higher prevalence of gingival vascular
changes in subjects with diabetes. Benveniste et al.
(1967) commented that their results may have been
influenced by use of relatives without diabetes as the
comparison group and that the subjects with diabetes
were all under reasonably good control with either
insulin or dietary regulation. Both factors may have
minimized differences between the groups.

Diabetes Type Not Specified. The final set of reports on
the association between diabetes and periodontal dis-
eases consists of seven cross-sectional studies in
which the type of diabetes was not specified and was
not easily determined from other information pro-
vided. Four of the seven studies included only adults
(Dolan et al. 1997, Grossi et al. 1994, Mackenzie and
Millard 1963, Tervonen and Knuuttila 1986). In the
other three studies, subjects ranged in age from

childhood to older adulthood (Albrecht et al. 1988,
Campbell 1972, Szpunar et al. 1989). Szpunar et al.
(1989) presented analyses of two separate national
surveys (the National Health and Nutrition
Examination Survey, NHANES I, conducted between
1971 and 1974, and the Hispanic Health and
Nutrition Examination Survey, HHANES, conducted
between 1982 and 1984).

All seven studies found subjects with diabetes to
have increased prevalence, extent, and severity of
periodontal disease. The statistical significance of the
diabetes effect was markedly diminished in the final
linear regression model used by Szpunar et al. (1989)
in analysis of the NHANES I data: Two of the popu-
lation-based surveys, Grossi et al. (1994) and Dolan
et al. (1997), provided epidemiologic estimates of the
association of diabetes and attachment loss severity
with odds ratios of 2.3 (95 percent CI, 1.2 to 4.6) and
1.9 (95 percent CI, 1.3 to 3.0), respectively, while
controlling for other covariates.

Conclusion. Diabetes is a risk factor for the occur-
rence and prevalence of periodontal diseases.
Although there is insufficient evidence of a causal
association, the findings of greater prevalence, sever-
ity, or extent of at least one manifestation of peri-
odontal disease in individuals with diabetes is
remarkably consistent in the overwhelming majority
of studies. Furthermore, there are no studies with
superior design features in the literature to refute this
assessment. The studies were conducted in distinctly
different settings, with subjects from different ethnic
populations and of different ages, and with a variety
of measures of periodontal status. This inevitable
variation in methodology and study populations lim-
its the possibility that the same biases apply in all the
studies. There is a need for further research using
stronger designs that also control for confounding
variables such as socioeconomic status.

Glycemic Control

Several lines of evidence support the plausibility that
periodontal infections contribute to problems with
glycemic control, thus compromising the health of
diabetic patients. It has been reported that the chron-
ic release of tumor necrosis factor alpha (TNF-o) and
other cytokines such as those associated with peri-
odontitis interferes with the action of insulin and
leads to metabolic alterations (Hotamisligil et al.
1993, Flier 1993). Other studies have noted relation-
ships between insulin resistance and active inflam-
matory connective tissue diseases (Hallgren and
Lundquist 1983, Svenson et al. 1987), other clinical
diseases (Beck-Nielsen 1992, Beisel 1975), acute

114        ORAL HEALTH IN AMERIC4: .4 REPORT OF THE SURGEON GENERAL


infection (Drobny et al. 1984, Sammalkorpi 1989),
and periodontal disease (Grossi et al. 1999). Grossi
and Genco (1998) have proposed a model whereby
periodontal infection contributes to hyperglycemia
and complicates metabolic control in diabetes.

Clinical Studies. The effects of periodontal infection
on glycemic control have been investigated in a small
number of clinical studies that looked at metabolic
control at baseline and following various periodontal
treatments (see Table 5.5; Aldridge et al. 1995,
Christgau et al. 1998, Grossi et al. 1996, 1997, Miller
et al. 1992, Seppala and Ainamo 1994, Seppala et al.
1993, Smith et al. 1996, Westfelt et al. 1996, Williams
and Mahan 1960, Wolf 1977). One report is based on
an epidemiological cohort study (Taylor et al. 1996).
  The randomized controlled trials of Grossi et al.
(1997) involving populations with type 2 diabetes
found that use of the systemic antibiotic doxycycline
to treat periodontitis patients with diabetes resulted
in a transient (3 to 6 months) improvement in
glycemic control. On the other hand, the two con-
trolled trials conducted in London by Aldridge et al.
(1995) involving patients with type 1 diabetes found
no effect. Taken together, these three studies provide
inconsistent results and are limited in how well they
generalize to broader populations. A small uncon-
trolled study of 10 patients by Miller et al. (1992)
also reported an improvement in glycemic control of
diabetic patients whose periodontal disease was
treated with mechanical therapy and systemic doxy-
cycline. Five of the above-mentioned studies did not
include control groups (Miller et al. 1992, Seppala et
al. 1993, Smith et al. 1996, Williams and Mahan
1960, Wolf 1977), and four were not specifically
designed to address the relationship between peri-
odontal therapy and glycemic control (Grossi et al.
1996, Seppala et al. 1993, Smith et al. 1996, Westfelt
et al. 1996), although the data collected allowed the
investigators to address the issue. One nonrandom-
ized but controlled clinical trial of nonsurgical peri-
odontal therapy found no significant influence on
medical data for the diabetic patients (Christgau et al.
1998). A clear relationship between improvement in
periodontal health and glycemic control has not been
shown. The studies seem to suggest that antibiotic
treatments may help in glycemic control. A recent
longitudinal study indicates inflammation may be a
precursor to the onset of type 2 diabetes (Schmidt et
al. 1999). Thus periodontal infection may contribute
to that inflammation.

Conclusion. The body of literature concerning the
relationship between periodontal infection and

Linkages with General Health

impaired glycemic control is varied in the strength,
quantity, breadth, and consistency of evidence pre-
sented. The preliminary evidence, while encourag-
ing, does not support a clear-cut conclusion that
treating periodontal infection can contribute to man-
agement of glycemic control in type 1 or type 2 dia-
betes. As the table indicates, only studies using sys-
temic antibiotic treatment affected glycemic control
favorably. The results suggest that infections other
than periodontitis may be implicated or that inten-
sive treatment of periodontal infections with sys-
temic antibiotics is necessary to affect glycemic con-
trol favorably. Further rigorous controlled studies in
diverse populations are warranted.

The Oral Infection-Heart Disease and
Stroke Connection

During the past decade, infectious agents have
become recognized as causes of systemic diseases,
without fever or other traditional signs of infection.
Helicobacter pylori is associated with peptic ulcers
and, along with Chlamydia pneumoniae and
cytomegalovirus, is now thought to be associated
with increased risk for cardiovascular disease as well
as malignancies (Wu et al. 2000). Studies investigating
the relationship between oral and dental infections
and the risk for cardiovascular disease suggest that
there is potential for oral microorganisms, such as
periodontopathic bacteria, and their effects to be
linked with heart disease.

Mechanisms of Action

Infectious agents are thought to affect the risk of
heart disease through several possible mechanisms.
Bacteria or viruses originating in tissues such as the
lungs or oral mucosa may directly infect blood vessel
walls. Such infection may be largely asymptomatic,
but may cause local vascular inflammation and
injury, which would contribute to the development
of lipid-rich plaques and atherosclerosis. Bacteria or
viruses may also interact with white blood cells or
platelets, both of which integrate into the developing
atherosclerotic plaque. Cells of the blood vessel wall
and white blood cells and platelets can release
prostaglandins (especially PGE,), interleukins (espe-
cially IL-l), thromboxane B2 (TBX,), and tumor
necrosis factor alpha (TNF-ok). Bacterial products in
the blood may also stimulate liver production of
other pro-inflammatory or pro-coagulant molecules
such as C-reactive protein and fibrinogen. Microbes
may also stimulate expression of tissue factor, which
would activate coagulation. During the process of

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          115


Linkages with General Health

TABLE 5.5
Effects of periodontal disease and its treatment on glycemic control: clinical and epidemiological evidence

Study    Diabetes
Designa   Type

Number of subjects                        Metabolic
a.Treatment (ages)  Follow-up                   Control                     Evidence
b.Control (ages)    Time    Periodontal Therapy      Outcome    Effects on Metabolic Control     Levelb

Aldridge RCT
et al. 1995,
Study 1

Type 1

a.16(16-40)
b.15 (16-40)

2 months  Experimental group: oral    Glycated    Periodontal treatment had no     I
    hygiene instruction, scaling,   hemoglobin,  effect on change in glycated
    adjustment of restoration   fructosamine hemoglobin.
    margins, and reinforcement
    after 1 month;control group:
      no treatment

Aldridge   RCT
et al.1995,
Study 2




Grossi et RCT
al. 1996,
1997

Type 1





Type 2

a. 12 (20-60)
b. 10 (20-60)





a.89 (25-65)
b.24 (25-65)

2 months  Experimental group: oral    Glycated    Periodontal treatwnt had no     I
    hygiene instruction, scaling   hemoglobin  effect on change in glycated
    and root planing, extractions,        hemoglobin.
    root canal therapy; control
     group: no treatment

12 months  Experimental groups received  Glycated   The three groups receiving       I
    either systemic doxycycline or  hemoglobin  doxycycline and ultrasonic
    placebo and ultrasonic          bacterial curettage showed
    bactericidal curettage with         significant reductions
    irrigation using either water,        (P < 0.04) in mean glycated
    chlorhexidine, or povidone-        hemoglobin at 3 months.
     iodine

Christgau  Treatment Type 1   a.20 (30-66)    2 months  Scaling/root planing;     Glycated   No effect on glycated hemoglobin.   II-1
et al. 1998  study, non- and type 2  b.20 (30-66)        subgingival irrigation with   hemoglobin
      RCT                     chlorhexidine; oral hygiene
                           instruction; and extractions

Westfelt  Treatment Type 1    a. 20 (45-65)    5 years   Baseline oral hygiene     Glycated    "The mean value of HbAlc       II-1
et al. 1996  study, non- and type 2  b. 20 (45-65)        instruction,scaling and root   hemoglobin   between baseline and 24 months
      RCT                    planing followed by periodic        was not significantly different from
                          prophylaxis,oral hygiene            that between 24 and 60 months."
                            instruction, localized sub-
                         gingival plaque removal,and
                         surgery at sites with bleeding
                         on probing and a periodontal
                         probing depth of >5 mm
Smith   Treatment Type 1   a. 18 (26-57)    2 months  Scaling and root planing with   Glycated    Found no statistically or clinically   II-1
et al. 1996  study,non-        b.0            ultrasonics and curets; oral    hemoglobin  significant change in glycated
      RCT                     hygiene instruction            hemoglobin.
Taylor   Historical Type 2    No treatment or   24 years  Not applicable        Glycated    Those with severe periodontitis     II-2
et al. 1996  prospective      control subjects                   hemoglobin  were -6 times more likely to have
      cohort        49 (severe                          poor glycemic control at follow-up.
              periodontitis)
               56 (less severe
              periodontitis)
Miller   Treatment Type 1   a. 10 (not given)   8 weeks  Scaling and root planing,    Glycated    Found decrease in glycated       Ill
et al. 1992  study, non-        b.0           systemic doxycycline      hemoglobin,  hemoglobin and glycated albumin
      RCT                                glycated   in patients with improvement in
                                                 albumin    gingival inflammation (P < 0.01).
                                            Patients with no improvement in
                                         gingival inflammation had either
                                        no change or increase in glycated
                                         hemoglobin post treatment.

coagulation, platelets would become trapped in the
growing clot or thrombus. Microthrombus formation
is one of the key factors in the development of ather-
osclerotic plaques. As atherosclerotic plaques enlarge,

the lumen of the coronary blood vessels narrows and
the blood supply to the heart muscle becomes
reduced. A frank heart attack or myocardial infarc-
tion results when a larger part of the coronary artery

!!6         OR4L HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


Linkages with General Health

Study   Diabetes
DesigV   Type

Number of subjects
a.Treatment (ages) Follow-up
b.Control (ages)    Time

Periodontal Therapy

Metabolic
Control
Outcome

Effects on Metabolic Control

Evidence
Levelb

Seppala   Treatment Type 1
et al. 1993,  study, non-
Seppala and RCT
Ainamo

1994

a. 38 for 1 year;   2 years  Scaling and root planing,     Medical   Reported an improvement of the
22 for 2 years'        periodontal surgery,and     history for   HBAl levels of the PIDD and CIDD
26 PIDD-ly (48 + 6)       extractions           baseline    subjects (P < 0.068, r-test).
12 CIDD-lv (43 k 51                    control status;

16 PIDD-2;
6 CIDD-2y
b.0

glycosylated
hemoglobin
Al and blood
glucose for
assessing
response to
treatment

Williams  Descriptive Not speci-
and Mahan clinical   fied    a.9 (20-32)
1960    study          b.0

Wolf 1977  Treatment Type 1 and
    study, non- type 2   a. 117 (16-60)
     RCT           b.0

3-7   Extractions, scaling and
months  curettage, gingivectomy,
   systemic antibiotics

B-12   Scaling and home care
months  instruction, periodontal surgery,
    extractions,endodontic
    treatment, restorations, denture
   replacement or repair

Insulin
requirement;
diabetes
control (not
operationally
defined)

Blood glucose,
24-h urinary
glucose,
insulin dose

7 of 9 subjects had'kignificant"
reduction in insulin requirements.

2 RCT = randomized controlled trial.
b Levels of evidence are delineated in Table 5.3. Note that because this body of literature is small, this review does not distinguish between"well-designed"studies and
otherwise in assigning the evidence levels.
( PIDD = poorly controlled insulin-dependent diabetes;ClDD = controlled insulin-dependent diabetes.

Compared 23 subjects with
improved oral infections with 23
who had no improvement after
treatment for oral infection and
inflammation.The subjects with
improved oral inflammation and
infection tended to demonstrate
diabetes control improvement
(P < O.l).However,Wolf states in
discussion,"treatment of periodon-
tal inflammation and periapical
lesions . . does little to improve
the control of diabetes."

lumen becomes occluded. Failing to receive enough
blood, the heart muscle dies, resulting in an infarct.

Animal Studies

Bacteria originating in the oral cavity may also con-
tribute to platelet clotting or thrombosis, as proposed
by Herzberg et al. (1983, 1994). These investigators
have suggested that the association between peri-
odontal disease and cardiovascular disease may be
due in part to the potential for oral bacteria such as
S. sanguis and F? gingivalis to induce platelet aggrega-
tion. Platelets aggregate in response to these bacteria
as a result of mistaken identity: a protein structure on
the surface of certain common strains of S. sanguis
and I? gingivalis mimics the platelet-interactive
regions of collagen molecules (Erickson and
Herzberg 1993, Herzberg et al. 1994). Exposure of
flowing blood to collagen triggers clotting, the cen-

tral event in stopping blood flow. When an experi-
mental bacteremia was created with a strain of S. san-
guis that carried the collagen-like protein, rabbits
showed changes in blood pressure, electrocardio-
gram readings, heart rate, and cardiac contractility
(Herzberg and Meyer 1996, 1998). Platelets also
aggregated in the circulation, resulting in significant
declines in platelet counts. From the electrocardio-
graphic tracings, rabbit heart muscle also appeared co
have suffered ischemic damage. The investigators
concluded that oral bacteria carrying the collagen-
like protein induced platelet aggregation or clotting
in the bloodstream. These clots were of sufficient size
to obstruct coronary arteries and produce ischemic
heart damage, an early warning sign of a heart attack
or an infarction. Because S. sanguis is present in large
numbers in dental plaque and is a causative agent in
infective endocarditis, it is likely that these bacteria

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          117


Linkages with Gencrnl Health

have an opportunity to induce platelet clotting dur-
ing human bacteremias from oral sources. Bacteria-
induced platelet clotting could contribute to
microthrombosis during the development of athero-
sclerotic plaques and occlusive thrombus formation
with occasional myocardial infarction.

Population-based Studies

Any study investigating the possibility of a unique
role for oral pathogens as risk factors for cardiovascu-
lar disease, including atherosclerosis and the forma-
tion of a blood clot in a coronary artery of the heart,
which typically precedes myocardial infarction, must
take into consideration such known risk factors as
smoking, hypertension, obesity, diabetes, genetic sus-
ceptibility, and elevated cholesterol. Genco (1998)
and Beck et al. (1998) have recently reviewed studies
examining the associations between oral conditions
(including pe d
       rro ontitis) and atherosclerosis and
coronary heart disease, the latter of which affects 12
million people in the United States and is the leading
cause of death. These are summarized in Table 5.6.

Of the ten studies cited in the table, six are
prospective cohort studies, in which oral health sta-
tus was established at the outset (baseline) of the
study period and the subjects were followed at peri-
odic intervals to a previously defined endpoint, for
example, diagnosis of coronary heart disease or an
acute myocardial infarction, or death. Beck et al.
(1996) combined data from the \ieterans
Administration Dental Longitudinal Study and its
parent longitudinal study, the Normative Aging
Study, for a total of 203 cases and 891 noncases, to
determine whether periodontal disease, judged by
measuring alveolar crestal bone, is a risk factor for
cardiovascular disease. After adjusting for age, blood
pressure, cholesterol, and body mass index, the
investigators found that subjects with periodontal
disease were 1.5 times more likely to develop coro-
nary heart disease over a 2%year period than controls
(odds ratio of 1.5). Similarly, after adjusting for age,
smoking, and blood pressure, the investigators found
that veterans with periodontal disease were I.9 times
more likely to develop fatal coronary heart disease
(odds ratio of 1.9).

In a longitudinal study to eliminate the potential
confounding effects of smoking, Genco et al. (1997)
measured the incidence of periodontal disease and
cardiovascular disease in 1,372 American Indians of
the Gila River Indian Reservation. Although diabetes
is prevalent in this population, cigarette smoking is
rare in these individuals (a fact confirmed in this
study), so it was considered not to be a risk factor for
either cardiovascular disease or periodontal disease

in this study. Periodontal disease was measured at
baseline, and the incidence of cardiovascular disease
was followed over the next 10 years. When the analy-
sis was restricted to individuals under age 60, the risk
of cardiovascular disease was 2.7 times higher in sub-
jects with periodontal disease than in those with lit-
tle or no periodontal infection. This association was
seen even after adjusting for other risk factors for
cardiovascular disease or periodontal disease such as
age, sex, cholesterol, weight, high blood pressure,
diabetes, and insulin use. The investigators conclud-
ed that periodontal disease is an important risk fac-
tor for cardiovascular disease for individuals under
60 in this group, second only to the presence of
long-term diabetes. Further analysis of death due to
cardiovascular disease is needed in this population to
complete the study.

  Mattila and coworkers have conducted both
prospective and retrospective studies. A prospective
study (Mattila et al. 1995) showed that new episodes
of myocardial infarction occurred more frequently in
subjects with more extensive "dental" disease. The
authors used a measure of dental disease that includ-
ed a composite index that assessed caries, periodon-
titis, pericoronitis, and periapical lesions. The com-
posite index estimates the combined infectious load
that contributes to many possible oral infections.
After combining the prospective study data with data
from an earlier retrospective study (Mattila et al.
1989) and adjusting for age, triglyceride levels, cho-
lesterol, C-reactive protein, smoking, social class,
diabetes, and hypertension, the investigators found a
significant association between dental infections and
acute myocardial infarction in men under age 50 (P <
0.01). A more recent study (Mattila et al. 2000) com-
pared 85 patients with proven coronary heart disease
and 53 matched controls. This case-control study
showed that dental indices were higher among coro-
nary heart disease patients than controls, but the dif-
ferences were not statistically significant. Participants
in the study were older, which the authors believed
was the most likely reason for the results. In the first
National Health and Nutrition Examination Survey,
9,670 subjects were followed for over 14 years.
DeStefano et al. (1993) found that there was a 25 per-
cent increased risk of cardiovascular disease in indi-
viduals with periodontitis compared with those with
minimal periodontal disease. The strongest associa-
tion was seen in men under 50 (relative risk, 1.7). A
limitation of this study, which the authors acknowl-
edge, was the lack of baseiine data on smoking, a
major risk factor for both periodontal and cardiovas-
cular disease. Morrison et al. (1999) evaluated a ret-
rospective cohort study using participants in the

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


Linkages uTith General Health

TABLE 5.6
Summary of studies assessing the association between oral conditions, atherosclerosis, and coronary heart disease

Study
Designd

Subjects
(cases/
controls)

Oral Condition

Cardiovascular Outcome

Adjustment+

Association
(odds ratio or
relative risk)

Evidence
Level<

OeStefano
et al. 1993

Prospective  1,786/7,974

Mattila   Prospective    521162
et al. 1995

Joshiputa  Prospective  757/44,119
et al. 1996

Beck    Prospective   203/891
et al. 1996

Genco    Prospective   68/1,304
et al. 1997

Morrison   Retrospective  10,000
et al. 1999

Joshiputa  Prospective   42,151
et al. 1999

Mattila    Case-Control   100/102
et al. 1989

Gtau     Case-Control   166/166
et al. 1997

Mattila
et al. 2000

Case-control   85153

Russell's periodontal  Coronary heart disease
index       (admission to hospital or
        death)
Dental index (caries,  New acute myocatdial
periodontal disease,  infarction or death
pulpal infection)

Periodontal disease
(self-reported),
tooth loss due to
self-repotted
periodontal disease
Alveolar ctestal bone
10%

Alveolar crestal bone  New coronary heart
IO%          disease

Severe gingivitis;
petiodontitis;
edentulousness

New coronary heart
disease;tetebrovasculat
deaths

New coronary heart
disease

New coronary heart
disease,fatal coronary
heart disease,stroke

Number of teeth lost  lschemic stroke

Dental index (caries,
periodontal disease,  Acute myocatdial
pulpal infections)   infarctions
Dental index (caries,
periodontal disease, Stroke
petiapical infections)
Dental index (caries,
periodontal disease,  New coronary heart
pulpal infections)   disease

Age, sex, race, education, poverty,
marital status, cholesterol, BMI,
diabetes,smoking
Smoking, hypertension, age, sex,
triglycerides, socioeconomic
status, diabetes, lipids, BMI,
previous Ml
Age, BMI, exercise, smoking,
alcohol,vitamin C,family history,
Ml

Age, BMI, total cholesterol,
socioeconomic status, DBP, LDL,
smoking, cholesterol
Age, sex, smoking, BMI, diabetes,
cholesterol, hypertension
Age,sex,setum total cholesterol,
smoking,diabetes, hypertension

Age, smoking, obesity, alcohol,
exercise, aspirin, family history,
profession, hypertension,
hypetcholesterolemia

HDL, smoking, C-reactive protein,
hypertension, age, cholesterol,
diabetes, social class

Diabetes, preexisting vascular
disease, socioeconomic status,
smoking
Age, sex, smoking, socioeconomic
class, hypertension, number of
teeth, serum lipid levels

1.72 (1.1-2.68)
(only for men
under age 50)
Yes,P -c 0.01

1.67 (1.03-2.71)

.

1.5 (1.04-2.14)
1.9 (1.0-3.43)
2.8 (1.45-5.48)
2.68 (1.35-5.60)

1.37 (0.80-2.35)
for petiodontitis
1.90 (1.17-3.10)
for edentulousness
for fatal CHD

210 teeth 1.75
(1.03-2.99)
ll-15reeth 1.95
(1.07-3.64)
17-24 teeth 1.48
(1.02-2.13)

Yes, P < 0.01

Odds ratio 2.6
(1.18-5.70)

II-2




II-2






II-2







II-2




II-2


II-2







II-2









II-2




II-2



it-2

"Far the prospective studies, the total number of rubjects in the cohort is the sum of the two numbers given,the first number of which represents the subjects followed to the endpoint. For
the case-control studies, the first number represents the cases, and the second the controls.
bBMl = body mass index; MI = myotardial infarction; LOL = low-density lipoproteins; HDL = high-density lipoproteins.
[Levels of evidence are delineated in Table 5.3.

1970-72 National Canada Survey. In the younger  dence. This pattern of higher risk observed among

cohort, those under age 69, they found that gingivi-
tis, periodontitis, and edentulousness were related to
fatal coronary heart disease in a statistically signifi-
cant manner. However, in analyzing those over age
70, none of these dental conditions was associated
with fatal heart disease. These results were adjusted
for age, sex, serum total cholesterol, smoking status,
diabetes SWUS, hypertension status. and province of resi-

younger subjects may, to some extent, reflect the rel-
ative instability of risk estimates. However, it is also
possible that periodontal disease, like other co-mor-
bid relative risks for coronary heart disease, general-
ly declines with age (Semenciw et al. 1988).

Wu et al. (1999) found periodontal disease to be
a potential factor for coronary heart disease and
stroke based on an analysis of the first National

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          119


Linkages 11.ith Gencrd Health

Health and Nutrition Examination Survey and its 21-
year follow-up. In this analysis, periodontitis was
found to be a significant risk factor for cerebrovascu-
lar disease, in particular nonhemorrhagic stroke.
Compared with no periodontal disease, relative risk
(95 percent CI) for incident nonhemorrhagic stroke
was 2.11 (1.30 to 3.42) for periodontitis. There was
no significant relationship for gingivitis or edentu-
lousness, which were 1.24 (0.74 to 2.08) and 1.41
(0.96 to 2.06), respectively. The increased relative
risk for total cerebrovascular disease and nonhemor-
rhagic stroke was not seen for hemorrhagic stroke.
Similar relative risks for total cerebrovascular disease
and nonhemorrhagic stroke associated with peri-
odontitis were seen in white men and women and
African Americans. A conclusive statement about a
cause-and-effect relationship between periodontitis
and the risk of developing cerebrovascular disease, in
particular nonhemorrhagic stroke, cannot be made at
this time. The consistency of the findings in different
racial groups and the strength of the association war-
rant further examination of the potentially important
association between these two clinical conditions,
which are highly prevalent in the adult population.

cular disease or stroke. The methods used to measure
or identify periodontal disease ranged widely from
self-report, to composite indices that included dental
caries experience, to precise measures of periodonti-
tis severity. Nevertheless, there were consistent find-
ings of increased odds ratios and significant proba-
bility (P) values pointing to an association of peri-
odontal and other oral infections with an increased
risk for cardiovascular disease. Further studies are
needed to determine whether periodontal disease
alone or in the presence of other oral infections is an
independent risk factor for cardiovascular or cere-
brovascular disease. Research to elucidate the under-
lying pathological mechanisms is also essential.
Studies must also clarify the potentially confounding
effects of sex, age, socioeconomic level, and race/
ethnicity.

Periodontal Disease and Adverse
Pregnancy Outcomes

In the largest cohort studied, Joshipura et al.
(1996) found that among a group of male health pro-
fessionals who were relatively homogeneous socio-
economically and who self-reported preexisting peri-
odontal disease, those with 10 or fewer teeth were at
increased risk of new coronary heart disease, com-
pared with those with 25 or more teeth (relative risk,
1.67). These results were adjusted for sta'ndard car-
diovascular disease risk factors.

Preterm birth and low birth weight are considered
the leading perinatal problems in the United States
(Gibbs et al. 1992). Although infant mortality rates
have decreased substantially over the past genera-
tion, the incidence of low birth weight (just under
300,000 cases in 1995) has not shown a comparable
decline (Institute of Medicine 1985, USDHHS 1984).
Over 60 percent of the mortality of infants without
structural or chromosomal congenital defects can be
attributed to low birth weight (Shapiro et al. 1980).

Mechanisms of Action

In a case-control study of 166 patients with acute
cerebrovascular disease and I66 age- and sex-
matched controls, Grau et al. (1997) found that
"poor dental status" was independently associated
with cerebrovascular ischemia. These results were
based on a subgroup of patients and controls who
completed the dental examination. A modified form
of the Total Dental Index was used to measure dental
status. In an 8-year follow-up of 42,151 male health
professionals who were free of cardiovascular disease
at baseline, Joshipura et al. (1999) reported that
edentulousness was associated with an increased risk
of ischemic stroke after adjusting for age, smoking,
obesity, alcohol, exercise, aspirin, family history of
cardiovascular disease, profession, hypertension, and
hypercholesterolemia.

Periodontal disease may contribute to adverse out-
comes of pregnancy as a consequence of a chronic
oral inflammatory bacterial infection. Toxins or other
products generated by periodontal bacteria in the
mother may reach the general circulation, cross the
placenta, and harm the fetus. In addition, the
response of the maternal immune system to the
infection elicits the continued release of inflammato-
ry mediators, growth factors, and other potent
cytokines, which may directly or indirectly interfere
with fetal growth and delivery

Conclusion

None of the studies reviewed to date achieves the
level of rigor that can unequivocally establish peri-
odontitis as an independent risk factor for cardiovas-

  Evidence of increased rates of amniotic fluid
infection, chorioamnion infection, and histologic
chorioamnionitis supports an association between
preterm birth, low birth weight, and general infection
during pregnancy It is noteworthy that the largest
proportion of such infections occurred during the
pregnancies of the most premature births (Hillier et
al. 1988, 1995). The biological mechanisms involve
bacteria-induced activation of cell-mediated immuni-
ty leading to cytokine production and the synthesis

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


and release of prostaglandins, which may trigger
preterm labor (Hillier et al. 1988). Elevated levels of
prostaglandin as well as cytokines (interleukin-1 (IL-
I), interleukin-6 (IL-6), and tumor necrosis factor
alpha (TNF-a)) have been found in the amniotic
fluid of patients in preterm labor with amniotic fluid
infection (Romero et al. 1993), compared with levels
in patients with preterm labor without infection.

r\nimal Models

;\ variety of studies have used the pregnant hamster
model. Some investigators have examined the effects
of lipopolysaccharide, produced by oral gram-neg-
ative pathogens, on cytokine production (Collins et
al. I994a). In other studies, hamsters have been
infected with I? gingivalis, with or without prior
immunization. Collins et al. (1994b) challenged the
animals with nondisseminating, low levels of P gingi-
\aaIis, introduced in a subcutaneous chamber at a
dorsolumbar site. Although the doses were insuffi-
cient to induce fever or wasting, the hamster litters of
the infected animals showed a significant reduction
in fetal weight (24 percent) in comparison with con-
trol animals (P < 0.0001). This suppressive effect on
fetal weight was accompanied by a proportional
intrachamber rise in tumor necrosis factor alpha
(TNF-(-w) and prostaglandin E2 (PGE,) (P < 0.0001).
Immunization prior to mating did not provide pro-
tection from a challenge during pregnancy, but rather
potentiated the effects, indicating the potential
strength of a chronic infection.
  In another series of hamster studies, researchers
observed the effects of experimental periodontitis on
pregnancy outcomes and amniotic fluid mediators
(Offenbacher et al. 1998). The investigators noted a
20 percent decrease in fetal weight (P = 0.002).
Periodontal infection in the pregnant hamster also
was associated with a significant rise in intra-amniotic
PGEz from 3.31 + 1.1 to 13.5 f 4.1 micrograms per
milliliter (P = 0.03). These data suggest a link be-
tween oral infection and changes in the fetal envi-
ronment.

Epidemiologic Studies

Human case-control studies have demonstrated that
mothers of low-birth-weight infants born as a result
of either preterm labor or premature rupture of
membranes tend to have more severe periodontal dis-
ease than mothers with normal-birth-weight infants
(Offenbacher et al. 1996, 1998). A case was defined
as a mother whose baby weighed less than 2,500
grams and who had one or more of the following fac-
tors: gestational age of infant of less than 37 weeks;

Linkages with General Health

preterm labor; or preterm, premature rupture of
membranes. Controls were all normal-birth-weight,
full-term infants. In a case-control study of 124 sub-
jects, the mean clinical periodontal attachment level
for the mothers of low-birth-weight babies was 3.10
+ 0.74 (SD) millimeters (mm) per site (93 subjects)
versus 2.80 + 0.61 (SD) mm per site (31 subjects) for
mothers of normal-weight infants (P = 0.038 for all
cases and controls). For a subset of mothers for
whom this was the first child, the mean clinical peri-
odontal attachment level for those with low-birth-
weight babies was 2.98 + 0.84 (SD) mm per site (46
subjects) versus 2.56 + 0.54 (SD) mm per site for
controls (20 subjects) at P = 0.041 (Offenbacher et al.
1996). This subset was analyzed separately to avoid
the confounding effects of mothers %ith periodontal
disease who had previously given birth to low-birth-
weight infants but who later had normal-weight
infants.

Logistic regression models demonstrated that
severe periodontal disease was associated with a sev-
enfold increase in risk of low birth weight, after con-
trolling for known risk factors such as smoking, race,
alcohol use, age, nutrition, and genitourinary tract
infection. This study suggests an association between
periodontal disease and prematurity
In a subsequent case-control study of 44 sub-
jects, additional biochemical and microbial parame-
ters of periodontal disease status were studied to
assess the relationship of current periodontal status
to current pregnancy outcome (Offenbacher et al.
1998). Results indicate that PGE, levels in gingival
crevicular fluid were significantly higher in mothers
of low-birth-weight infants than in controls (131.4 +
21.8 (SE) versus 62.6 + 10.3 (SE) nanograms per mil-
liliter), respectively (at P = 0.02). Furthermore, with-
in the group of mothers of low-birth-weight infants
there was a significant inverse association between
birth weight, gestational age, and gingival crevicular
fluid PGE, levels (at P = 0.023 for current births).
These data suggest that the level of PGE, in gingival
crevicular fluid, serving as a marker of current peri-
odontal disease activity, varies inversely with birth
weight; that is, the higher the PGE, level, the lower
the birth weights. In this study the periodontal dis-
ease was more severe in mothers with adverse preg-
nancy outcomes, as determined by biochemical and
microbial biomarkers, but the difference in clinical
attachment levels did not reach statistical signifi-
cance (P = 0.11).

Studies also have been reported in other coun-
tries. In the United Kingdom a preliminary analysis
of 167 cases and 323 controls did not show an asso-
ciation between periodontal disease and pregnancy

ORAL HEALTH 1N AMERICA: A REPORT OF THE SURGEON GENERAL          121


Linkages with General Health

outcomes (Davenport et al. 1998); however, the
investigators did not control for confounding factors.
Dasayanake (1998) conducted a matched case-con-
trol study with 55 cases in Thailand. Gingivitis was
associated with a higher risk of having a growth-
restricted infant (odds ratio = 0.3; 95 percent CI, 0.12
to 0.72), controlling for mothers height, prenatal
care, dental caries status, and the infant's gender.
Smoking was not controlled for in this study.

Conclusion

As a remote gram-negative infection, periodontal dis-
ease may have the potential to affect pregnancy out-
come. Not all the obstetric risk factors that result in
babies being born too soon and too small have been
fully identified (Gibbs et al. 1992, McCormick 1985).
Oral infections have been investigated as a potential
risk factor for preterm labor or premature rupture of
membranes, which are major obstetric antecedents to
spontaneous preterm births. .4lthough the findings
from animal research and case-control studies are
promising, additional work, including longitudinal
studies, research on mechanisms, and intervention
trials, is needed to determine whether periodontitis is
a risk factor and what the mechanisms of action may
be for adverse pregnancy outcomes. In the United
States, longitudinal and intervention studies are
under way.

Conclusion

This critical look at the emerging associations among
oral infections and specific conditions establishes the
need for an aggressive research agenda to better
understand the specific aspects of these associations
and the underlying mechanisms. Prospective and
intervention studies are under way and should pro-
vide additional and stronger evidence of the presence
and direction of an association. It is essential for such
studies to include populations at known risk for the
underlying conditions as well as the general popula-
tion. Of the conditions reviewed, the relationship of
periodontal disease and diabetes has the strongest
evidence, demonstrating that the risk of periodontitis
is higher in individuals with diabetes. However, the
effect of periodontitis on glycemic control is less
clear, a reflection of the difficulty of controlling for
the effect of systemic antibiotic treatments used to
manage periodontal disease in diabetic patients in
clinical trials.

IMPLICATIONS OF THE LINKAGES
This review of oral health linkages with general
health reveals implications for the clinical practice of
both medicine and dentistry The recognition of well-
known and established signs and symptoms of oral
diseases may assist in the early diagnosis and prompt
treatment of some systemic diseases and disorders,
The presence of these signs also may lead to the insti-
tution of enhanced disease prevention and health
promotion procedures. All health professionals, and
the public, should be aware of these signs and symp-
toms. Individuals, practitioners, and community pro-
grams may also benefit from the accelerated develop-
ment and testing of readily accessible, acceptable,
and simple oral-based diagnostics.

A better understanding of the role of the oral cav-
ity and its components in protecting against infection
is needed. This information should permit the devel-
opment of interventions to enhance these compo-
nents. For example, research is under way investigat-
ing how to augment some of the natural antimicro-
bial molecules that are present in saliva and how to
use oral and nasal vaccination routes to enhance
immunity Also, host susceptibility factors contribut-
ing to the dissemination of oral infections to other
parts of the body should be investigated, especially in
populations at high risk for disease and infection. In
addition, further studies are needed to elucidate the
role of the mouth as a means of transmitting infec-
tious microbes. This in turn will allow the develop-
ment of interventions to prevent transmission and
curb .the progression of infections once established.

  The associations between oral infections and dia-
betes, heart disease and stroke, and adverse pregnan-
cy outcomes warrant a comprehensive and targeted
research effort. If any of these associations prove to
be causal, major changes in care delivery and in the
training of health professionals will be needed.

Awareness of the oral complications of medica-
tions and other therapies for disease management
and for health promotion needs to be enhanced
among health care professionals, the public, drug
manufacturers, and the research community. For
some of these therapies, known interventions exist
and should be followed before initiating the therapy
to minimize or modulate its side effects. To prevent
the oral complications of other therapies, new
approaches are needed. Ultimately, and ideally, the
side effects of therapies should be considered in the
development of new drugs and biologics.

122

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


FINDINGS

   o  Many systemic diseases and conditions have
oral manifestations. These manifestations may be the
initial sign of clinical disease and as such serve to
inform clinicians and individuals of the need for fur-
ther assessment.

   o  The oral cavity is a portal of entry as well as
the site of disease for microbial infections that affect
general health status.
   o  The oral cavity and its functions can be
adversely affected by many pharmaceuticals and
other therapies commonly used in treating systemic
conditions. The oral complications of these therapies
can compromise patient compliance with treatment.
   o  Individuals such as immunocompromised
and hospitalized patients are at greater risk for gen-
eral morbidity due to oral infections.
   o  Individuals with diabetes are at greater risk
for periodontal diseases.

o Animal and population-based studies have
demonstrated an association between periodontal
diseases and diabetes, cardiovascular disease, stroke,
and adverse pregnancy outcomes. Further research is
needed to determine the extent to which these asso-
ciations are causal or coincidental,

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Zakrzewska JM, Aly Z, Speight PM. Oral hairy leuko-
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282-4.

Zijlstra EE, Swart GR, Godfroy FJ, Degener JE.
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83-7.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


Effects on Well-being
and Quality of Life

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

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

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

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

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

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

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

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


Effects on Well-being and Quality of Life

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

THE CULTURAL CONTEXT

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

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

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

Cultural Models

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

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

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

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

Combining Perspectives

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

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

134

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

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

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

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

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

Effects on Well-being and Quality of Life

Functional Dimensions

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

Eating

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

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

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

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

135


Effects on IYell-being and Quality of Life

TABLE 6.1

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cultural Significance of Teeth

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

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

Effects on Well-being and Quality of Life

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


Effects on \X7ell-being and Quality of Life

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

Dental Problems and Social Function

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

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

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

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

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

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

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


Effects on Well-being and Quality of Life

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

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

Impacts of Oral-Facial Pain

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

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

SOCMI function Dimension(s) Assessed

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


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


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

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

       Percentage of Population Group Reporting Effect

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

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

             Elderly Persons in Floridad
                      6
                      3


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


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


     1                                  0
     3                                  0

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

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

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

Social Responses to Facial Appearance

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

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

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

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

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

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

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

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

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

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

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

Effects on I!Tell-being and Quality of Life

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

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

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

141


Effects on IYell-being and Quality of Life

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

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

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

Oral and Phatyngeal Cancers

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

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

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

Indirect Economic Costs

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

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


Effects on Well-being and Quality of Life

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Global Ratings

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

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

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

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

Satisfaction Ratings

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

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

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

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

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

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

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

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

Effects on Well-being and Quality of Life

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

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

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

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

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


Effects on Mirll-being and Quality of Life

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

Advances in public health and biomedical research in
HEIGHTENED EXPECTATIONS




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

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

FINDINGS

Examination of efforts to characterize the functional









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

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

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

TABLE 6.4
Studies of multidimensional quality of life measures

Gooch et al. 1989


Atchison and Dolan
1990

Hunt et al. 1995


Kresrin et al. 1996


Gift et al. 1997


Gilbert et al. 1997


Locker and Miller
1994


Locker and Slade
1994
Slade and Spencer
1994b

Leao and Sheiham
1995

Coates et al. 1996

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

Male veterans aged 47+

USaged 18+

Floridians aged 45+

Canadians aged 18+



Canadians aged SO+

Australians aged 60+

Brazilians aged 35-44

Australian dental patients

Numbers of
Individuals

902 female
756 male
1,000 female
755 male

440


1,242 male


760 female
555 male

491 female
383 male

299 female
244 male


168 female
144 male

660 female
557 male

303 female
359 male

635 (+795
previously
surveyed)

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

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

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

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

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


I~!~tZlmrIl,l~B tU

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

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

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

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

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

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

153

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

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

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

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

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

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

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

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

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

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

TABLE 7.1

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

Community Strategies                Professional Strategies             Individual Strategies

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

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

School-based and school-linked sealant programs



School-linked screening and referral

Periodontal diseases
Community-wide health promotion
intervention9

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


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



Cancer screening programs (such as health fairs)


Inherited disorders
Early detection programs

Trauma
Community-wide health promotion
intervention9

Mouth protector fittings for entire team

Provision of sealants
Prescriptions for antimicrobial agents


Individualized recall schedule


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

Monitoring and early detection of disease


Professional education and patient counseling on
risk factors



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


Interdisciplinary early detection programs


Professional education and patient counseling on
risk factors

Fabrication of mouth protectors

Asking about sealants
Use of antimicrobial agents


Self-initiated use of dental services


Being informed about strategies to prevent disease


Oral hygiene measures
Toothbrushing and flossing
Toothbrushing with dentifrices
Plaque control

Self-initiated use of dental services


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

Self-initiated use of dental services
Request for cancer screening





Being informed about strategies to prevent trauma


Use of mouth protectors and helmets

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

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

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

BO;Y 7.1

Glossary: The Nature of Community Health Programs

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

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

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

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

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

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

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

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

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

ORAL HEALTH IN AMERIC4: A REPORT OF THE SURGEON GENERAL

157

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

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

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

PREVENTION AND CONTROL OF
DENTAL CARIES

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

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

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

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

Fluoride

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

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

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

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

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

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

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

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

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

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

T:4BLE 7.2

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

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

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

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

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

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

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

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

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

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

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

Effectiveness

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

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

Fluoridation of Drinking Water

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

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

ORAL HFALTH IN AhlERICA: A REPORT OF THE SURGEON GENERAL

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

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

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

Costs and Cost-effectiveness

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

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

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

Access to Optimally Fluoridated Water in the
United States

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

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

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

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

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

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

FIGURE 7.1

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

Source: USOHHS1993.

HealthyPeople2010Goalof75Percent
0 Goalnotattained
m Goalattainedorexceeded

TABLE 7.3

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

Type of Fluoridation
Adjusted
Natural
Both

Source:USDHHS1993.

Population

134.6 million
10.0 million
144.6 million

Number of   Number of
Systems    Communities

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

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

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

School Water Fluoridation

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

Summary: School Water Fluoridation

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

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

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

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

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

Effectiveness of Home Use

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

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

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

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

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

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

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

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

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

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

Effectiveness of School-based Programs

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

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

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

Costs of School-based Programs

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

Summary: Dietary Fluoride Supplements

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

TABLE 7.5

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

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

Source: ADA 1995.

None      None
0.25      None
0.50      0.25
1.00      0.50

None
None
None
None

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

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

Fluoride Mouthrinses

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

School-based Programs

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

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

Effectiveness

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

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

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

Cost-effectiveness

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

Summary: School-based Fluoride Mouthrinse
Programs

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

Fluoride Varnishes

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

-

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

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

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

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

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

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

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

Effkacy

Dental Sealants

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

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

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

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

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

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

flfcctiveness

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

Community Dental Sealant Programs

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

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

--

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

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

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

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

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

167


Sealing Incipient Caries

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

Cost-effectiveness of Sealant Programs

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

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

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

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

Race and ethnicity
American Indian or Alaska Native (1999)b          37           26
Asian or Pacific Islander                  DSU          OSU
Asian                        DNC          DNC
Native Hawaiian and other Pacific Islander        DNC          DNC
Black or African American                  11            5
White                          26          19
Hispanic or Latin0                    DSU          DSU
Mexican American                    10            7
Nat Hispanic or Latin0                  25          DNA
Black or African American                 11            5
White                          29            18
E%                         24           14
Male                            22            16

Education level (head of household)
Less than high school                    17             4
High school graduate                    12            6
At least some college                    35            28

Disability status
Persons with disabilities                 DNC          DNC
Persons without disabilities               DNC          DNC

Selected opulations
Third-gra ! e students                    26           NA

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

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

PREVENTION AND
CONTROL OF
PERIODONTAL
DISEASES

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

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

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

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

Community Programs to Prevent
Gingivitis

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

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

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

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

Summary

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

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

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

169

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

Community-based Interventions

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

School-based Prevention Programs

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

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

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

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

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

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

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

school-based programs to prevent tobacco use.

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

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

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

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

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


Other Program Models

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

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

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

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

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

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

Early Diagnosis of Oral and Pharyngeal
Cancers

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

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

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

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

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

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

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

PREVENTION AND CONTROL OF
CRANIOFACIAL BIRTH DEFECTS

Summary

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

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

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

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

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

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

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

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

Summary

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

PREVENTION AND CONTROL OF
INTENTIONAL AND UNINTENTIONAL
INJURY

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

Craniofacial Injuries

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

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

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

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

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


TABLE 7.7

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

          Restraints and Airbags              Helmets

Mouthguards

Guidelines for use

Public policies

Utilization rates

Type of evidence for
effectiveness and PHS
ratings

Evidence for
effectiveness

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

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

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

* Hospital and trauma registry

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

* Modeling from insurance
studies (Sorenson 1993)

* Case-control study (Marine

et al. 1994)

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

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

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

. States with helmet use laws have higher

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

rates of helmet use

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

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

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

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

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

and Primosch 1989)

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

174

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


Restraints and Airbags

Helmets

Mouthguards

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

Risks

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

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

* Concern regarding higher risk
for death in children and small

women

* Case report of facial
desquamation from ruptured

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

Recommendations
(abstracted from CDC
1987,USOHHS 2000)

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

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

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

* Combine helmet use with education and

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

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

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

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

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

J

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

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

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

ORAL HE4LTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

175


Summary: Prevention of
Craniofacial Injuries

Health education and injury prevention
campaigns addressing the need for pro-
tective gear in sports and cycling activ-
ities can increase awareness and use.
More rapid adoption can occur through
legislation or regulation. Greater dis-
semination of safety measures for home
and workplace can similarly lower the
risk of falls and other unintentional
injuries. With regard to reducing inten-
tional injuries in the United States, cur-
rent and ongoing policy discussions,
legislative proposals, and research
efforts are necessary first steps toward
appropriate programs.

ORAL HEALTH PROMOTION
AND DISEASE PREVENTION
KNOWLEDGE AND
PRACTICES

To take full advantage of emerging sci-
ence-based health and health care prac-
tices, individuals, health care providers,
and policymakers need to be sufficient-
ly informed that they can take appro-
priate actions for themselves, for those
for whom they have responsibility, and
for the community at large. For the
individual, these actions include brush-
ing with a fluoride-containing denti-
frice for caries prevention, brushing
and flossing to prevent gingivitis and
periodontal diseases, and avoiding
tobacco and other substances that are
detrimental to health.

Lack of knowledge can affect care.
If parents are not familiar with the
importance and care of their child's pri-
mary teeth or if they do not know that
dental sealants exist, they are unlikely
to take appropriate action or seek pro-
fessional services. If the public is not
aware of the benefits of community
water fluoridation, public referenda
and funding for such interventions
are not likely to be supported. Similarly,
if individuals do not know that an
oral cancer examination exists, they
may not ask about the need for one.
However, it is well established that

Cotnmutnt)~ and Other ;\pproachcs to Promote Oral Health ;ind Prc\.cnt Oral Disease

BOX 7.2

Sports Injuries and Oral-Facial Trauma

The national concern regarding oral-facial injury is addressed in the Healthy People 2010
objective 15-31, which is to increase the proportion of public and private schools that require
use ofappropriate head,face,eye,and mouth protection for students participating in school-
sponsored physical activitiesThe National Youth Sports Safety Foundation estimates that
more than 3 million teeth will be knocked out in youth sporting activities this year,an injury
almost completely preventable by wearing a mouthguard. Even more significant, oral-facial
trauma from sports injuries will result in facial bone fractures,concussion, permanent brain
injury, temporomandibular dysfunction, blinding eye injuries, and even death.
Currently, no systematic monitoring for oral-facial injuries exists in the United States.
Progress toward a more broadly targeted Healthy People 2000 objective proved to be diffi-
cult to track because of the data requirements of monitoringall organizations,agencies,and
institutions sponsoring sporting and recreational events that pose risk of injury. By focusing
on schools,not only should the monitoring of progress be feasible, but healthy habits will be
formed early.The hope is that by the time the athletes reach young adulthood they will rec-
ognize the hazards posed by their athletic interests and, perhaps, be more comfortable using
protective devices than they would be without them.

It is estimated that as many as one third of all dental injuries are sports-related. A particu-
larly high proportion of all baseball injuries (41 percent) is estimated to occur to the head,
face, mouth, or eyes. Nowjack-Raymer and Gift (1996) reported that in 1991 more than 14
million U.S.school-aged youngsters participated in at least one sport that was listed on the
1991 National Health Interview Survey questionnaire, with more than 9 million of these
children in organized baseball or softball.

Baseball and softball are the most popular organized sports, with nearly one quarter of the
school-aged population playing. Unlike football, not all baseball/softball leagues or teams
require the use of safety equipment. In many cases, only selected positions such as catchers
and batters are covered by rules.Thus only 35 percent of players reported that they wore
headgear all or most of the time, and only 7 percent wore mouthguards all or most of the
time.

Further analysis of the interview data revealed a variety of socioenvironmental differences
in the wearing of headgear and mouthguards. Forty percent of males who played baseball
or softball reported wearing protective headgear"all or most of the time,"compared with
only 25 percent of females. Differences were also found by poverty level, with 36 percent of
those at or above poverty level wearing headgeaccompared with 24 percent ofthose below.
Better educated parents were somewhat more likely than less educated parents to have
responded that their child wore headgear"sometimes" (45 percent versus 38 percent) and
non-Hispanics reported occasional use more than Hispanics (43 percent versus 30 percent).
Parents of a greater percentage of baseball or softball players of high school age (12 percent)
than elementary school-aged players (6 percent) reported that their child wore a mouth-
guard"all or most ofthe time."Also,more black (17 percent) than white (6 percent) children
reported the use of mouthguards.
These socioeconomic differences might be greater were it not for the safety efforts of school
athletic programs.Still, many parents and coaches are not as proactive as they could be and
are not aware that facial injuries also occur in sports that are not considered high contact.
For example, basketball players typically do not wear mouthguards.Yet approximately 34
percent of all injuries to basketball players involve teeth and/or the oral cavity.
Examples of community-based interventions to prevent sports-related, oral-facial trauma
include the development of rules and regulations for the use of headgear and mouthguards
in sports where craniofacial injury is a risk; efforts to alert players, parents, sports officials,
and organizers to the potential for injury; better product design; and the creation of sup-
portive environments for sports-related equipment and recreation areas.

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


I;no\vledge alone will not necessarily lead to appro-
prlate practices. For example, even if individuals
know that tobacco use is unhealthful and that it con-
tributes to multiple life-threatening illnesses, some
continue to smoke. The majority of people who need
such information most- those in low-income groups
,& those with lower levels of education-also are
the ones who lack the information and skills (oral
health literacy) to ask for and obtain specific preven-
tive semices or treatment options. Health profession-
als are in an ideal position to provide up-to-date
health information and care to their patients. They
also have an opportunity to enhance their knowledge
and practices as well as increase their communica-
tion to patients about the procedures they provide
and the reasons for these procedures.
Few national studies of public and professional
knowledge, attitudes, and practices exist. Highlights
from these as well as from state and local studies that
evaluated the prevention of dental caries, periodontal
diseases, and oral cancers are provided below.
Generally, the public is unable to discriminate
between methods that prevent dental caries and
those that prevent periodontal diseases (Corbin et al.
1985. Gift et al. 1994). This confusion has been
attributed to the prevailing marketing message that
refers to them as "plaque diseases" preventable by
thorough tooth cleaning with a toothbrush and floss.
In addition, the general public and health care
providers are not fully informed about the relative
value of fluoride and the appropriate recommended
applications of regimens to prevent dental caries
(Corbin et al. 1985, Gallup 1992, Gift et al. 1994,
O'Neil 1984). More work is needed to improve
knowledge and practices related to oral cancer pre-
vention as well. As with other areas of investigation,
additional survey research is needed to better
understand findings to date and to develop tailored
interventions. Research is ongoing to improve the
design of survey instruments and the wording of
questions to address cultural and ethnic differences
and interpretations.

Dental Caries Prevention

The Public

Most members of the general public, regardless of
socioeconomic level, tend to believe that the best way
to prevent dental caries is by brushing their teeth
(Corbin 1985, Gift et al. 1994, O'Neil 1984). In the
I990 National Health Interview Survey (NHIS),
respondents were asked the purpose of adding

fluoride to public drinking water. About two thirds of
the respondents 25 to 65 years of age knew that water
fluoridation helps prevent caries, compared with
only 51 percent and 49 percent of those 65 and older
and 18 to 24 years of age, respectively. Blacks and
Hispanics were less likely to know the value of this
preventive procedure than whites. In the same sur-
vey, when asked to indicate the one best way to pre-
vent tooth decay from five answers (limiting sugary
snacks, using fluorides, chewing sugarless gum,
brushing and flossing the teeth, and visiting the den-
tist every 6 months), only 7 percent of the respon-
dents answered correctly that fluoride was the most
effective (Gift et al. 1994). More than two thirds said
tooth brushing and flossing were the most effective.
These results paralleled those of earlier studies (Gift
et al. 1994, O'Neil 1984). A lower perceived value of
fluorides by the public in preventing dental caries
also was seen in the 1985 NHIS (Corbin et al. 1985).
In a survey of knowledge and beliefs of the public,
dentists, and dental researchers about the best way to
prevent dental caries, the public and the dentists
identified tooth brushing, whereas dental researchers
unanimously ranked fluorides, as most important
(O'Neil 1984). A small study among Latina mothers
showed that they believed that brushing with baking
soda is a good way to prevent dental caries; they
knew little about brushing with a fluoride-containing
dentifrice (Watson et al. 1999).

Dental sealants and appropriate use of fluoride
are critical for caries prevention. In the 1990 NHIS,
about 32 percent of the public had heard of dental
sealants, but among those only three fourths knew
the purpose of this preventive measure (Gift et al.
1994). In 1991 the Gallup Organization conducted a
poll for the American Academy of Pediatric Dentistry
among a national sample of 1,200 parents of children
16 years and younger. The results indicated that only
58 percent believed fluoride to be very important to
a child's oral health; another 36 percent considered it
to be somewhat important. Eight of 10 parents did
not know when a child should be prescribed fluoride
supplements, and virtually no one knew when sup-
plements should be stopped. Only 25 percent of par-
ents in nonfluoridated communities reportedly give
their children fluoride supplements (Gallup 1992).

Health Care Providers

In a national survey of U.S. dental hygienists' knowl-
edge, opinions, and practices regarding dental caries
etiology and prevention, over 90 percent agreed that
"adults benefit from the use of fluorides" and that
"root surface caries is an emerging problem." A little

Community and Other ,hpproaches to Promote Oral Health and Prevent Oral Disease

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          177


less than one third did not provide fluoride treat-
ments to adults. This same survey found that only 57
percent of the respondents recognized remineraliza-
tion as fluoride's most important mechanism of
action; rather, flossing was selected as the most effec-
tive procedure for preventing caries in adults. Also,
only 18 percent reported providing the recommend-
ed time for acidulated phosphate fluoride (APF) gel
treatment (Forrest 1998). A city-based suney of den-
tists and dental hygienists found that nearly 70 per-
cent of the offices used lower than recommended
topical fluoride application times and that some of
the fluoride products reportedly used had not been
clinically tested (Warren et al. 1996).

Periodontal Disease Prevention

The Public

In the 1990 NHIS the majority of household respon-
dents (79 percent) could identify one common sign
of "gum" disease. Level of education was directly
related to knowledge of gum disease. Eighty-nine
percent of those with more than a high school level
of education were able to name a common sign of
gum disease, compared with 79 percent of those with
a high school education and 60 percent of those with
less than a high school education (Gift et al. 1994).
A Roper report on oral health surveyed more
than 1,000 adults 18 and older, Eighty percent
reported that they did not believe they `have had peri-
odontal disease. However, 70 percent reported hav-
ing experienced at least one symptom of gum dis-
ease-bleeding gums; swollen, painful, or receding
gums; a change in bite; or loose teeth. Although 41
percent of the respondents said that losing their teeth
was their greatest fear regarding oral health, only 38
percent who had bleeding gums said they told their
dentists about the problem. Further, only 30 percent
of the respondents who had experienced warning
signs of gum disease were worried about developing
periodontal problems in the future. Fifty-eight per-
cent knew that plaque is the main cause of gum dis-
ease and that flossing alone will not prevent gum dis-
ease, whereas 77 percent knew that brushing alone
would not prevent gum disease. The majority (90
percent) knew that gum disease could strike anyone
at any age (Roper Report 1994).
In a recently reported study on the oral hygiene
practices of a convenience sample of 34,897 users
and nonusers of tobacco products who obtained den-
tal care in 75 dental practices, 74 percent reported
brushing twice a day and 36 percent reported flossing
once daily (Andrews 1998). Tobacco users brushed

and flossed much less frequently than nonusers.
Patients with more than a high school education
were less likely to use tobacco products and more
likely to brush at least 2 times a day and floss daily
than were those with less education.

A 1996 study of 1,000 U.S. adults showed that
nearly one third (29 percent) of respondents were
extremely or very concerned about getting gum dis-
ease. Concern was highest among younger respon-
dents 18 to 49 years of age and those who very or
somewhat frequently experienced bleeding gums.
Only 6 percent said they frequently suffered from
bleeding gums (2 percent very frequently and 4 per-
cent somewhat frequently). Only 13 percent said a
dental professional had diagnosed them with any
kind of periodontal disease (gingivitis, pyorrhea, and
periodontitis). Older respondents were somewhat
more likely than younger ones to have been diag-
nosed with gum disease, and 17 percent reported
experiencing  gingival bleeding occasionally
(Andrews 1998).

Health Care Providers

Studies of dental professionals regarding periodontal
disease prevention practices are limited. In 1989,
Dental Products Report launched a study to deter-
mine the involvement of general practitioners in
periodontal care. Overall, general dentists and their
hygienists have become more involved in the peri-
odontal exam phase of patient treatment. This posi-
tive trend suggests that periodontal diagnosis and
treatment are well integrated into general practice.
For example, when asked "what phases of periodon-
tal treatment are you providing at present?" 100 per-
cent reported gingival exam and evaluation, 97 per-
cent reported pocket probing, and 88 percent report-
ed providing patient education. The majority of den-
tists (67 percent) used as many as six measurement
sites per tooth. Nearly all (93 percent) reported hav-
ing a referral relationship with a periodontist (Dental
Products Report 1996).

Oral Cancer Prevention and Early
Detection

The Public
U.S. adults generally are ill-informed regarding risk
factors for and signs and symptoms of oral cancers.
Further, a 1990 national survey found that only 14
percent of adults 40 and older reported that they had
ever had an oral cancer examination. Of those, only
7 percent had had an exam within the last year

178        ORAL HWLTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


jiaro~v;t;: et al. 1995). In a statewide survey in
,t,tn.jand. 85 percent of the adults claimed to have
(,t,lrd of oral or mouth cancer, but only 28 percent
reported ever having an oral cancer examination
fjnrovvttz et al. 1996). A state-based study of veter-
.,t,++~ population at high risk for oral cancers-
l,,ur-td that they were ill-informed and misinformed
.tbout these cancers (Canto et al. 1998a). Finally, a
,tudv among Latin0 youths who reported use of
t(,b&o and alcohol found that they, too, were not
knoivfedgeable regarding risk factors for oral cancers
, C,tnto et al. 1998b).

lltalth Care Providers

.-J, recent national pilot survey of U.S. dentists found
that the respondents' knowledge regarding risk fac-
tors for and signs and symptoms of oral cancers and
their reported practice of examination procedures
\vcre limited (Yellowitz et al. 19.98). Most respon-
dents believ,ed they were adequately trained to pro-
VI& oral cancer examinations, and 70 percent pro-
b.ided annual oral cancer exams to patients 40 and
older. Seventy-four percent reported their knowledge
of oral cancers to be current, yet only 30 percent cor-
rcctly identified the age cohort most frequently diag-
nosed with oral cancers. Further, less than 50 percent
correctly identified the stage at which most oral can-
cer lesions are diagnosed, and nearly one third of
respondents could not identify the two most com-
mon sites of these lesions. Although 86 percent
claimed to assess their patients' current tobacco use,
only 50 percent assessed current alcohol use; rela-
tively few dentists assessed past alcohol or tobacco
use. There was a modest amount of misinformation
as well. For example, 65 percent believed, incorrect-
ly% that ill-fitting dentures and partials were a risk fac-
tor for oral cancers, and 47 percent believed, also
incorrectly, that poor oral hygiene was a risk factor.
Further, although the majority of dentists claimed to
provide oral cancer examinations to the majority of
their patients, a large proportion did not palpate the
lymph nodes-part of a comprehensive oral cancer
examination. These results confirm an earlier study
conducted among a convenience sample of Maryland
dentists and physicians in that both groups believed
their knowledge and skills related to oral cancer pre-
vention and early detection to be wanting (Yellowitz
and Goodman 1995).

A recent national survey among U.S. dental
hygienists found that although 98 percent agreed that
oral cancer examinations should be provided annual-
ly for adults 40 and older, only 64 percent reported
performing such an exam 100 percent of the time,

and nearly 17 percent reported not performing an
exam at any time (Forrest 1998). Further inconsis-
tencies were found between knowledge of risk factors
and performance. For example, although 94 percent
correctly identified alcohol use as a risk factor for
oral cancer, only 49 percent asked about alcohol use.
Less than a majority (45 percent) reported their
knowledge of oral cancers to be current. A majority
(61 percent) believed they were adequately trained to
palpate lymph nodes; still, only 24 percent reported
routine palpating of lymph nodes, while 51 percent
indicated they did not do so at any time.

Summary

Findings from national surveys, together with those
from local studies, suggest that there are opportuni-
ties for enhanced educational efforts for both the
public and health professionals to improve oral
health. These studies focus on the public and the
dental profession for selected diseases. New research
is needed to assess knowledge, attitudes, and prac-
tices of all health professionals and for other condi-
tions and risk factors related to oral health as well.

BUILDING UPON SUCCESS

As research and technology advance our understand-
ing of the causes of major craniofacial diseases and
disorders and lead to improved methods of diagnosis,
treatment, and prevention, opportunities for new
community-based prevention programs will grow.
Ultimately, the application of any preventive inter-
vention is driven by a combination of individual
behaviors, community interventions, and profession-
al practice, Only a few studies have taken into
account all three spheres of action in determining
health outcomes in a community (Arnljot et al. 1985,
Chen et al. 1997). Our knowledge of the effects of
multiple interventions is limited because most inter-
ventions were developed and tested singly

In the past half century, however, advances in
our understanding of oral diseases and the applica-
tion of multiple preventive measures have resulted in
continuing declines in the prevalence and severity of
both dental caries and periodontal diseases for a size-
able majority of Americans. For dental caries, for
example, experts now believe that most people can
maintain a low risk of the disease by a combination
of drinking fluoridated water and brushing daily with
a fluoride dentifrice. They recommend that addition-
al provider- and community-based dental prevention
programs be targeted to high-risk individuals and
groups.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

179


Community and Other Xpproaches to Promote Oral Health and Prc\~ent Oral Discasc

Many of the studies reviewed in this chapter
were conducted when higher rates of caries pre-
vailed, community water fluoridation was less wide-
spread, and use of fluoride dentifrices and supple-
ments was not as common as today. These facts must
be taken into consideration in contemporary deci-
sion making by public health professionals and poli-
cymakers. The validity and reliability of recommen-
dations will benefit from the systematic reviews of
the scientific evidence by the Task Force on
Community Preventive Services (2000) to be includ-
ed in a Guide to Community Preventive Services. Oral
health promotion strategies are among those current-
ly being evaluated.

reach those at high risk for disease. Similarly, focus-
ing community-based interventions on populations
at greatest risk will make optimal use of available
resources. However, continued research to under-
stand risk and improve ways to measure it is equally
important for the success of these ventures.

A review of progress in reaching the Healthy
People 2000 oral health objectives reveals relatively
little gain across many of the objectives (Table 7.8).
Progress in the next decade will require diligent
efforts to identify public health problems, mobilize
resources, and ensure that the necessary conditions
are in place and crucial services received. Public
health agencies will be instrumental in carrying out
these functions, and state and local dental directors
can perform a leadership role. Box 7.3 describes the
public health services that are essential if a commu-
nity is to realize fully the benefits of available disease

Future innovations include implementing pro-
grams in new settings, such as workplaces, senior
centers, and nursing homes, where individuals at
high risk can be reached. Even if these programs are
more expensive, the yield may be worth it if they  prevention and health promotion interventions

TABLE 7.8
Progress in meeting Healthy People 2000 oral health objectives

13.1   Reduce dental caries in children
    Reduce dental caries in adolescents
13.2   Reduce untreated dental decay in children
   Reduce untreated dental decay in adolescents
13.3   Increase adults who have never lost a
    permanent tooth
13.4   Reduce adults who have lost all their teeth
13.5   Reduce gingivitis among adults
13.6   Reduce destructive periodontal disease
13.7   Reduce oral and pharyngeal deaths in males
   Reduce oral and pharyngeal deaths in females
13.8   Increase sealants in children
    Increase sealants in adolescents
13.9   Increase persons on public water receiving
    fluoridated water
13.10  Increase topical/systemic fluorides among
     nonfluoridated
13.11  Increase caregivers using feeding
   practices that prevent early childhood caries
13.12  Increase oral health screening, referral, follow-up,
    first time school attendee
13.13  For long-term care,oral exam and services
   provided within 90 days
13.14  Increase use of oral health care system
    (adults)
13.15  Increase states with system for recording
   and referring orofacial clefts
13.16  Extend use of protective head, face, eye,
   and mouth equipment
13.17  Reduce smokeless tobacco use among males


Source: Adapted from NCHS 1999.

Age

6-8
15
b-a
15
35-44


65+
35-44
35-44
45-74
45-74
  8
14









35+









12-17
18-24

Baseline Data    HP 2000 Goal     Final Data     Summary

  54%        35%        52%     Prog
  78%         60%        61%     Prog +++
  28%         20%        29%      Reversed
  24%         15%        20%     Prog ++
  31%         45%        31%     No Change


  36%        20%        30%     Prog ++
  41%        30%        48%       Reversed
  25%        15%        22%      Prog +
.13.6%       10.5%       10.3%       Met
4.8%        4.1%        3.5%       Met
  11%        50%        23%     Prog ++
  8%        50%        24%     Prog ++
  61%        75%        62%      Prog


  50%        85%       No data       No data


  55%        75%       No data      No data


  66%        90%        75%     Prog ++


No data        100%      No data       No data


  54%        70%        63%     Prog ++


11 states      40 states      23 states     Prog ++


No data       No data       No data       No data


6.6%         4%        3.7%       Met
8.9%         4%        6.9%     Prog ++

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


-  c i,mm~lnit\ .~nd 0thcr ,\pproaches to Promote Oral Health and Prevent Oral Disease

Box 7.3

Essential Public Health Services for Oral Health
The Association of State and Territorial Dental Directors'Guidelines
fur stare and Territorial Orul Health Programs (ASTDD 1997) identi-
fies the following essential public health services to improve oral
health:
I. Assessment

Assess oral health sratus and needs so that problems can
be identified and addressed.
Analyze determinunts of identified oral health needs,
including resources.

Assess the fluoridation status of water systems, and other
sources of fluoride.

Implement an oral he& surveillance system to identify,
investigate,and monitor oral health problems and health
hazards.

II. Policy Development

Developplans undpolicies through a collaborative process
that support individual and community oral health
efforts to address oral health needs.
Provide leadership to address oral health problems by
maintaining a strong oral health unit within the health
agency.

Mobilize community partnerships between and among
policymakers, professionals, organizations, groups, the
public, and others to identify and implement solutions to
oral health problems.

Ill. Assurance

A.


B.




C.







D.


E.




F.


G.

Inform, educate, and empower the public regarding oral
health problems and solutions.
Promote and enforce lutvs and regulufions that protect
and improve oral health, ensure safety, and assure
accountability for the public's well-being.
Linkpeople to needed population-based oral health serv-
ices, personal oral health services, and support services
and assure the availability, access, and acceptability of
these services by enhancing system capacity, including
directly supporting or providing services when necessary.
Support services and implementation of programs that
focus on primury und secondmy prevention.
Assure rhat the public health und personul heoltb
workforce has the capacity and expertise to effectively
address oral health needs.

Evaluate effectiveness, uccessibikty, und quulity of popula-
tion-based and personal oral health services.
Conduct reseurch ond support demonsfrution projects to
gain new insights and applications of innovative solutions
to oral health problems.

FINDINGS

   o  Community water fluoridation, an effective,
safe, and ideal public health measure, benefits indi-
viduals of all ages and socioeconomic strata.
Unfortunately, over one third of the U.S. population
(100 million persons) are without this critical public
health measure.

   0  Effective disease prevention measures exist
for use by individuals, practitioners, and communi-
ties. Most of these focus on dental caries prevention,
such as fluorides and dental sealants, where a combi-
nation of services is required to achieve optimal dis-
ease prevention. Daily oral hygiene practices such as
brushing and flossing can prevent gingivitis.
   0  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.

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188

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


Personal and Provider Approaches
to Oral Health

c)ral health is not a given. It takes conscious and
rePeated efforts on the part of the individual, care-
(Ttvers, health care providers, and the community For
,`,
the individual, daily hygiene routines and healthy
ftfcstyle behaviors provide a frontline defense in dis-
c;rsc prevention and health promotion. Equally
important are periodic professional assessments of
the individual's oral health status, which may include
diagnostic, preventive, and therapeutic services and
counseling. Community activities complement per-
sonal and provider approaches to oral health. As dis-
cussed in the previous chapter, these include water
lluoridation, dental sealant applications for children,
tobacco cessation campaigns, the use of mouth-
guards in sports, and a variety of other school- and
community-based oral health promotion and disease
prevention activities. The interaction of these com-
ponents is critical to oral health, as it is to overall
health. In particular, there is now a better under-
standing of the relationship of individual health to
the health of the community in which the individual
lives, and the importance of this relationship is one of
the underlying premises of Healthy People 2010.
This chapter discusses actions individuals can take to
maintain their oral health and prevent disease, and
reviews emerging approaches taken by dentists and
other health care providers to promote oral health,
assess risks, and prevent disease.

INDIVIDUAL RESPONSIBILITY:
PERSONAL APPROACHES TO ORAL
HEALTH
Sound personal hygiene practices and adherence to a
healthy lifestyle are the mainstays of personal
approaches to oral health. Long before the germ the-
ory of disease, the need for tooth cleaning was recog-
nized-if only to rid the mouth of food debris, elim-
inate odor, and improve appearance, Tools developed

for this purpose have ranged from primitive tooth
sticks and picks, still used in parts of the world, to
the water irrigators and electronic toothbrushes
available in industrialized societies. An impressive
array of oral care products greets the shopper in
supermarkets and pharmacies today Beyond the
dozens of toothbrush shapes and sizes, there are
flavored and textured dental flosses, floss holders,
rubber tips, toothpicks, small brushes for cleaning
between teeth, scores of dentifrices, and a range
of fluoride-containing, antitartar, and antiseptic
mouthrinses.

Daily oral hygiene efforts contribute to the
prevention of dental caries and periodontal diseases,
The biofilm on tooth and root surfaces (dental
plaque) can be disrupted to a large extent by the
mechanical action of brushing and flossing. Daily
efforts are necessary, not only because of food intake,
but also because dental plaque is never completely
removed. It starts to build up even after the most
assiduous cleaning (or prophylaxis) in the dental
office and even after the application of a potent
antimicrobial mouthrinse. The oral and dental
tissues and structures thus require more intensive
daily care than do other body areas exposed to the
environment.

Daily Hygiene and Dental Caries
Prevention

The use of a fluoride-containing dentifrice is critical
for dental caries prevention. Even more beneficial
than the physical removal of plaque in toothbrushing
is the delivery of a small amount of fluoride to the
tooth surfaces. Investigators have conducted numer-
ous clinical trials on fluoride dentifrices using rigor-
ous designs and including randomized groups, dou-
ble-blind designs, and placebo controls. All together,
these studies provide strong evidence that using a

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          189


Personal and Provider ,\pproaches to Oral Health

fluoride dentifrice is effective (Clarkson et al. 1993,
Lewis and lsmail 1995, Stookey et al. 1993). Fluoride
dentifrices account for more than 90 percent of the
market in the United States, Canada, and other devel-
oped countries (Levy 1994).

  A fluoride dentifrice is an effective means of
reducing the prevalence of dental caries for all per-
sons. Although children's teeth should be cleaned
daily from the time they erupt, parents and caregivers
should consult a dentist or other health care provider
about the use of a fluoride dentifrice for children
under the age of 2. For children under 6, fluoride
dentifrices should be used in small amounts to mini-
mize swallowing of the product. Mild enamel fluoro-
sis can result from excessive dentifrice use, because
children under 6 do not have adequate control of the
swallowing reflex or may intentionally swallow a fla-
vored dentifrice. Experts recommend that for chil-
dren under 6, the parent or caregiver should super-
vise toothbrushing, apply a pea-sized amount (0.25
gram) of dentifrice to the toothbrush, and encourage
the child to spit out the excess (Bawden 1992).
Because the topical benefits of fluoride have been
shown to be highly effective, and daily exposure to
small amounts of fluoride can reduce the risk of den-
tal caries in all age groups, experts recommend that
all persons drink water with an optimal fluoride con-
centration in addition to brushing daily with a fluo-
ride dentifrice (Bawden 1992, CDC in press). This
combination provides a cost-effective and easy way to
prevent dental caries and is an excellent example of
the individual-community partnership. For persons
at low risk of dental caries, these two exposures to
fluoride may be the only ones necessary For persons
at moderate or high risk of dental caries, additional
fluoride may be helpful and can come from daily use
of another fluoride product. These can include
mouthrinses, prescribed supplements, and profes-
sionally applied topical fluoride products (CDC in
press).

brushing are effective at removing plaque and pre-
venting gingivitis (Walsh et al. 1989, Axelsson et al.
1991). Inter-proximal (between the teeth) cleaning is
also important in maintaining gingival health (Lang
et al. 1994). In one short-term evaluation of adults,
the addition of flossing to the daily regimen of brush-
ing resulted in an almost twofold reduction in gingi-
val inflammation (Graves et al. 1989). Because pre-
ventive measures in periodontics rely mainly on the
removal of bacterial plaque and calculus, methods
typically include personal oral hygiene measures
combined with professional diagnostic and prophy-
lactic measures (i.e., regular exam and cleaning).
Periodic professional care for removal of plaque and
calculus deposits has also been demonstrated to
improve the periodontal health of participants
(Cutress et al. 1991, Ronis et al. 1993).

Healthy Lifestyles

There is more to the individuals role in promoting
oral health and hygiene than brushing and flossing.
Other behaviors that have an influence on oral health
include use of tobacco and/or alcohol products, diet,
oral habits such as bruxing and clenching the teeth,
and use of helmets, mouthguards, or other protective
devices. Table 8.1 summarizes selected behaviors
that have an effect on oral, dental, and craniofacial
health status. These are described more fully in
Chapters 3, 7, and 10.

  Individuals can obtain credible information
regarding oral health from various sources, including
health care providers, professional organizations,
government agencies, and patient advocacy groups.
Increasingly, the World Wide Web is a source for
health care information. For example, the National
Oral Health Information Clearinghouse offers infor-
mation on oral health, with an emphasis on special
care patients and their health care providers.

Daily Hygiene and the Prevention of
Periodontal Diseases

Care Seeking

Toothbrushing and flossing also play a critical role in
the prevention of periodontal diseases. Unlike dental
caries prevention, prevention and control of gingivi-
tis and periodontitis are achieved directly through
the mechanical removal and disruption of dental
plaque (Genco and Newman 1996). Some dentifrices
also contain chemical therapeutics to control the for-
mation of tartar (calculus) (Mandel 1995) and to
reduce plaque formation and gingival inflammation
(Hancock 1996). Both manual and electric tooth-

In addition to self-care, individuals also need to seek
professional health care-both dental and medical-
on a regular basis and whenever a problem manifests.
The recall interval is based on the provider's assess-
ment of the individuals dental and medical history
and lifestyle behaviors, among other factors. In the
case of children and dependent adults, parents and
caregivers are responsible for teaching and encourag-
ing healthy behaviors and seeking timely and appro-
priate care. As noted at the outset, it is only through
the combination of individual and professional care,
reinforced by community-based health promotion

`90         ORIL HE.iLTl1 IN .\hlERIC.\: .4 REPORT OF THE SLIRGEON GENERAL


Personal and Provider r\pproaches to Oral Health

and disease prevention programs, that optimal oral
and general health can be achieved. The remainder of
this chapter focuses on the role of the professional in
oral health care.

PROVIDER-BASED CARE

The range of conditions and diseases that affect the
craniofacial complex is extensive and can provide
clinicians with important indications about the
patients general as well as oral health status.
Management of the oral health-general health inter-
face calls for interdisciplinary and coordinated care
and an enhanced role for primary care providers.
Dentists, oncologists, dermatologists, infectious dis-

ease specialists, hematologists, endocrinologists,
plastic surgeons, and rheumatologists are just a few
of the specialists who may be involved in the diagno-
sis and management of conditions affecting the cran-
iofacial complex.

Dentists, their allied staff, and medical and nurs-
ing personnel are in a unique position to incorporate
new approaches for prevention,' diagnostic, and
treatment strategies in their practices. Advances in
oral science are providing the basis for a shift in
emphasis from the repair and restoration of damaged
tissues to earlier diagnoses, control of infections, and
remineralization and regeneration of lost tissues. The
application of risk assessment strategies and inter-
ventions tailored to individuals and groups is

TABLE 8.1

Selected individual behaviors affecting oral, dental, and craniofacial health

Behavior

Diet and nutrition

                          Effect
Nutrition and diet contribute to oral and traniofaciai development and to the maintenance of these tissues throughout life.
Nutritional deficiencies during pregnancy can affect tooth size,enamel solubility,time of tooth eruption,salivary gland function,
saliva composition, epithelial tissue, and susceptibility to dental caries. Deleterious effects specific to the dentition include protein-
calorie malnutrition, deficiencies of vitamin A, ascorbic acid, vitamin 0, calcium, phosphorus, iron, and iodine,and excessive fluoride.
Linear enamel hypoplasia and hypomineralization during the first year of life increase susceptibility to dental caries in both decidu-
ous and permanent teeth.The physical consistency, sequence, and frequency of carbohydrate intake (primarily refined sugars) have
been linked to the development of caries. Reduced calcium intake is associated with greater levels of periodontal disease. Early
clinical signs of nutritional deficiencies and eating disorders are often seen in and around the mouth.Oral lesions may also affect
systemic nutrition. (See Chapter 10, Box 10.1.)

Oral hygiene and home
care practices
Care seeking

Regular toothbrushing with a fluoride-containing dentifrice prevents dental caries. Rinsing with fluoride mouthrinse can aid in
reducing caries and in the reminefalization of tooth structure. Regular toothbrushing and proper flossing can prevent gingivitis.
Seeking health care-both dental and medical-on a regular basis and whenever a problem manifests is important. In the case of
children or dependent adults, it calls for the caregivers to teach and encourage healthy behaviors and to seek appropriate care from a
variety of care providers. Prenatal care, as well as oral health care prior to major treatments such as chemotherapy, is critical to over-
all oral and craniofacial health.

Parafunctional habits






Tobacco use




Alcohol use

Habitual grinding (bruxism) and/or clenching teeth are forms of abnormal motor behavior.These habits often occur during sleep. As
with clenching and other oral habits such as frequent gum-chewing, bruxism can cause tooth wear and affect muscles of mastica-
tion.Treatment may begin with making the individual aware of the problem, providing an occlusal splint to prevent tooth wear, and
using behavioral strategies.
The use of tobacco in all forms increases the risk for oral and pharyngeal cancers,and smoking is a leading risk factor for periodontal
diseases. Increased risk for dental caries has been associated with spit tobacco use. In HIV-infected individuals, tobacco use is a risk
factor contributing to increased risk of the development of oral candidiasis. (See Chapter 10, Box 10.2.)
Alcohol alone, as well as acting synergistically with tobacco, greatly increases the risk for oral and pharyngeal cancers.
Independently, alcohol in excess is associated with circulatory and neurological problems, liver disease, and other organ-specific dis-
eases and disorders. Alcohol use in pregnancy can lead to birth defects, such as fetal alcohol syndrome and its associated craniofacial
defects and mental retardation.

Injury control practices  Proper use of helmets, mouthguards,safety belts, and other protective devices helps prevent injuries to the head, neck, and mouth.

`The term prevention, as used in this chapter, includes interventions aimed at reducing the incidence of disease in relatively
healthy patients. It includes both health promotion and specific protection to control one or more risk factors. Some strategies,
such as the prevention of tobacco use. are applicable to many oral diseases, including oral cancer, oral candidiasis, and peri-
odontal diseases, whereas other strategies are specific, such as the use of dental sealants and fluorides for caries prevention.

ORAL HEALTH IN AMERIa A REPORT OF THE SURGEON GENERAL

191


expanding with the increased understanding of risk
factors and the development of biomarkers that sig-
nal host resistance, susceptibility, and the presence
and progression of disease.

The changing demographics of the U.S. popula-
tion and a greater understanding of the relationship
between oral health and general health are presenting
new challenges. Making clinical decisions for
patients requires integrating a range of interacting
biological, psychological, social, cultural, and envi-
ronmental factors. In order for disease to manifest,
the etiologic agent(s) must be present, the host must
be susceptible, the environment conducive, and suf-
ficient time available for the factors to interact
(Figure 8.1). Early diagnosis and prompt treatment
require an understanding of the pathology and of the
diagnostic, prevention, and treatment modalities
available. As genetic information accumulates, chni-
cal judgments will increasingly be informed by
knowledge of an individual's genetic susceptibility or
resistance to particular diseases and disorders. The
development of tailored treatment plans will require
incorporating all these factors together with input
from the patient's health providers, taking into con-
sideration the patient's interests and needs. The fol-
lowing sections provide an overview of emerging
approaches to clinical management and highlight
selected diseases as examples.

Risk Assessment

Given the greater understanding of disease etiology,
epidemiology, patient characteristics, and genetic
information, it is becoming increasingly possible to
determine an individual's risk of disease and tailor
treatments accordingly Risk assessment for dentistry
has been defined as "the use of knowledge of factors

Personal and Pro\+der ;\pproaches to Oral Health

that are associated with dental disease to determine
which patients are more or less likely to prevent or
control their dental disease" (Douglass 1998). The
factors can include co-morbidities, medications used,
and patient characteristics such as sex, age, and
lifestyle behaviors, among others. By compiling such
factors and sorting them by risk category, patients
can be classified into high- or low-risk groups,
enabling providers to make more comprehensive
diagnoses and identify patients who would benefit
from more aggressive prevention strategies. Such
analyses conducted during the early stages of disease
can result in treatments that reverse or contain the
disease process (Douglass 1998). Knowledge of risk
factors for oral and cranioficial diseases and disor-
ders allows other health care providers to screen for
these risk factors and contribute to improving oral
health.

Risk assessment and disease prediction studies
have focused primarily on dental caries and peri-
odontal diseases (Genco 1996, Page and Beck 1997,
Pitts 1998, Powell 1998). In addition, risk factors for
oral and pharyngeal cancers have been explored
(Johnson 1991). The evidence base for risk assess-
ment is developing from population-based studies. It
involves a research process in which a suspected risk
factor is related in a multivariate model to other fac-
tors and confounders (Beck 1990). The resulting
model is tested in a second group of subjects, and a
targeted intervention study is conducted to confirm
the predictive validity of the risk factor.

Although the application of research findings of
risk assessment has begun in some practices, the pre-
diction of future disease at the individual patient
level has not yet been extensively studied. Douglass
(1998) has posed six clinically oriented questions
that need to be addressed if risk assessment is to be
adopted into routine clinical practice:

FIGL:RE 8.1
Factors involved in disease

  1.  Does the scientific theory or biologic logic of
the risk factor fit with our current body of knowledge
about the disease in question?
2. Has the technical merit of identifying the
risk factor (such as imaging technologies and bacter-
ial assays) been evaluated?
3. Has the efficacy of the risk factor in
predicting disease been evaluated in terms of
sensitivity, specificity, and positive and negative
predictive values?z
  4.  Has the potential effect of the risk factor on
the disease management decision been explored?
Can knowledge of the presence of a particular risk
factor or pattern of risk factors alter the treatment
plan?

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


Personal and Provider L4pproaches to Oral Health

  j.  Has the influence of the risk factor on oral
/ItLllth outcomes been assessed?
6. Has the cost-effectiveness of collecting risk
factor data from each patient been evaluated? Is the
`Iddcd expense justified either by increased effective-
Il~s~ or by avoiding other expenses?

Diagnostic TeStS

l\$ereas risk assessment aims to predict future dis-
cast' and disease progression, diagnostic tests evalu-
ate a patient`s current status with regard to a specific
disease or disorder. They enable the provider to for-
mulate, in cooperation with the patient, a treatment
plan. In relation to dental caries and periodontal dis-
cases, the diagnosis ideally should not only detect the
presence of disease, but also distinguish between
active and arrested disease.

Today, most diagnostic tests for oral conditions
are based primarily on anatomic clinical evidence.
However, microbiological, pathological, immunolog-
ical, genetic, and tissue metabohte tests are increas-
ingly available and valuable. Table 8.2 cross-refer-
ences diseases with categories of diagnostic tests
available. The following sections describe elements of
a general health assessment and highlight risk assess-
ment, diagnosis, and prevention of selected diseases
and conditions.

Oral Health Assessment

An oral health assessment involves an evaluation of
an individual? overall health status, including any
risk factors and personal needs that can affect health
and treatment options. For the majority of craniofa-

cial conditions, this assessment and subsequent care
are coordinated with a range of health care providers,
with the intent of enhancing the patient's overall
health and well-being.

The information gathered for the assessment is
derived from patient information, extraoral and
intraoral clinical examinations, and imaging and
other diagnostic tests as needed. The patient provides
demographic and lifestyle behavior information and
a medical and dental history, including current com-
plaints, if any. Symptom analysis entails an addition-
al series of questions that explore symptom onset,
characteristics, and course. Figure 8.2 provides an
example of a medical history form used in dental
practice.

The clinician will take into consideration the
patient's general appearance and ability to function,
as noted by characteristics of facial symmetry or
asymmetry and speech. In addition, the patient's vital
signs may be assessed, and a thorough examination
of the head, neck, temporomandibular joints, and
other structures will be conducted. The intraoral por-
tion of the examination involves an extensive assess-
ment of the tissues: the lips and labial mucosa, buc-
cal mucosa and mucobuccal fold, the floor of the
mouth, tongue, hard and soft palate, oropharynx,
muscles of mastication, salivary glands and saliva,
gingiva, periodontium, and teeth.

Depending on the needs of the patient, the initial
physical examination is usually augmented by sup-
plementary data from radiographs and sometimes
by other diagnostic tests, including tissue biopsies
and samples of oral cells and fluids. Such samples can
be used to type specific bacteria, viruses, or fungi or
to detect elevated levels of tissue metabolites or

TABLE 8.2
Categories of diagnostic methods for selected oral, dental, and traniofacial diseases and disorders
     Diagnostic              Periodontal    Oral     Mucosal   Temporomandibular   Craniofacial
       Procedure         Caries    Diseases   Infections    Diseases      Disorders      Defects    Oral Cancers

Interview Patient history          o        o       o         o           o           o        o

Physical   Clinical examination        4        o       o         o           o           o         o
    Probing/caries          o
    Probing/periodontal                o

Imaging                    +        o                            o           o        o

Biologic  Histology/cytology                        o        o                               o
    Microbiology           o        o       o         o                               o
     Genetics/DNA                   *                o                      o         o

Gnsitivity is a measure of how often the test is positive when applied to patients known to have a particular disease or condition;
speci$city is a measure of how successful the test is in judging the absence of a disease or condition.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          193


Personal and Provider Approaches to Oral Health

FIGURE 8.2
Medical history form for use in dental practice

Medical History Form                Date

Name                                      Home Phone U

Address ~ Business Phone I

City                             State ~ Zip Code

Occupation                                    Social Security No.

Date of Birrh      /     I    Sex M F Height     Weight      Single      Married
      ---                  - -

Name of Spouse                Closest Relative             Phone (

If you are completing this form for another person,what is your relationshrp to that person?

Referred by
For the following questions, cirrle ym orno, whichever applies.Your answers are for our records only and will be considered confidential. Please note thafduring your initial visit you will be
asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.
1.  Are you in good health?. .......................................................................................................................................................................................................................................    Yes No

2.  Has there been any change in your genera) health wrthin the past year? ..........................................................................................................................................................    Yes No

3.  My last physical examination wason
4.  Are you now under the tare of a physician? ........................................................................................................................................................................................................    Yes No
  If so.what is the condition being treated?
5.  The name and address of my physician(s) IS
6.  Have you had anyserrous illness,operation,or been hosprtalized in the past 5 years! ......................................................................................................................................    Yes    No
  If so,what was the dlness or problem?
7.  Are you taking any medicine(s) including non-prescription medrcrne? ..............................................................................................................................................................    Yes No
  If so, what medicine(s) are you taking?
8.  Do you have or have you had any of the following diseases or problems?
  a.  Damaged heart valves orarmkial heart valves,inc)uding heart murmur or rheumatic heart disease.. ......................................................................................................    Yes No

  b.  Cardiovascular disease (heart trouble, heart attark,angina,toronary insufficiency,coronary occlusion, high blood pressure,
    arteriosclerosrs, stroke) ................................................................................................................................................................................................................................    Yes No

     1.  Do you have chest pain upon exertion? ..............................................................................................................................................................................................    Yes No

     2.  Are you ever short of breath after mild exercise or when lyrng down? ..............................................................................................................................................    Yes No

     3.  Do your ankles swell? ..........................................................................................................................................................................................................................    Yes No

     4.  Do you have Inborn heart defects? ..... .._._.._._................. ................. . ..................................................................................................................................................    Yes No

     5.  Do you have a cardiac pacemaker? ....................................................................................................................................................................................................    Yes No

  c.  Allergy.. ........................................................................................................................................................................................................................................................    Yes No

  d.  Sinus trouble ................................................................................................................................................................................................................................................    Yes No

  e.  Asthma or hay fever ....................................................................................................................................................................................................................................    Yes No

  f,  Fainting spells or serzures ............................................................................................................................................................................................................................    Yes No
  g. Persistent diarrhea or recent weight loss ......................................................................................................................... .....................~ ....................................................    Yes    NO

  h.  Diabetes  ....................................................................................................................................................................................................................................................    Yes No

  i.  Hepatrtisjaundite. or liver disease ..............................................................................................................................................................................................................    Yes No
  j.  AIDS or HIV infection ....................................................................................................................................................................................................................................    Yes No

  k.  Thyroid problems ........................................................................................................................................................................................................................................    Yes No

   I.  Respiratory problems.emphysema. bronthitisetc. ....................................................................................................................................................................................    Yes No

   m. Arthritis or painful swollen joints ................................................................................................................................................................................................................    Yes No

   n.  Stomach ulcer or hyperacrdity ......................................................................................................................................................................................................................    Yes No

   o.  Kidney trouble.. ............................................................................................................................................................................................................................................    Yes No
  p, Tuberculosis ..................................................................................................................................................................................................................................................    Yes NO

   q.  Persrstent cough or cough that produces blood ..........................................................................................................................................................................................    Yes No

   r.  Persrstent swollen glands in neck ................................................................................................................................................................................................................    Yes No

   I.  tow blood pressure ......................................................................................................................................................................................................................................    Yes No

   t.  Sexually transmitted disease.. ......................................................................................................................................................................................................................    Yes No

   u.  Epilepsy or other neurological disease ........................................................................................................................................................................................................    Yes No

   v.  Problems with mental health ......................................................................................................................................................................................................................    Yes No

   w.  Cancer ..........................................................................................................................................................................................................................................................    Yes No

   x.  Problems of the Immune system.. ................................................................................................................................................................................................................    Yes No

9.  Have you had abnormal bleeding? ......................................................................................................................................................................................................................    Yes No

   a.  Have you ever requrred a blood transfusion? ..............................................................................................................................................................................................    Yes No

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


Personal and Provider Approaches to Oral Health

`3 Do you have any blood disorder such as anemia? ................................................................................................................................................................................................

, Have you ever had any treatment far a tumor or gmwth? ..................................................................................................................................................................................

1 2, Are you allergrc or have you had a reaction to:
  a,  to(alanesthetrcs. .........................................................................................................................................................................................................................................
             ...
  b.  Penitilhn or otherantrbrotrcs.. .......................................................................................................................... ..........................~....~..~...................................~..............~ ....

  (.  Sulfa drugs ..................................................................................................................................................................................................................................................

  d.  barbiturates. sedatives,or sleeping pills ........................................................................................................................ .....- .......................................................................
e. Aspinn ..........................................................................................................................................................................................................................................................

  f. Iodine ..........................................................................................................................................................................................................................................................

  g.  Codeine or other narcotics ............................................................................................................................................................................................................................

  h. Other

13 Have you had any serious trouble assocrated with any previous dental treatment? ........................................... ..~ .......................................................................................... II.
If so, explain
14. Do you have any disease, condition,or problem not listed above that you think I should know about? ............................................................................................................
If so, explain
15. Are you wearing contact lenses! ..........................................................................................................................................................................................................................

16. Are you weannq removable dental appliances? ..................................................................................................................................................................................................
17. Do you currently use tobacco of any type? ............................................................................................................................................................................................................
If so. which type?
18. Are you a former tobacco user? ................................................. ..~ .......................................................................................................................................................................
If so, which type of tobacco?
19. How many years have/did you use tobacco?
20. How much tobacco do/did you use a day?
2 1  If you have stopped using tobacco products, how long ago did you stop?
22. Have you ever used alcoholic beverages? ...................................................................................... ..~ ..................................................................................................................
23  How long ago did you stop using alcoholic beverages?
24. Do you currently use alcoholic beverages! ............................................................................................................................................................................................................
If so, which type?
25. How many times a week do you use alcoholic beverages!

Women

26. Are you pregnant? ................................................................................................................................................................................................................................................
27. Do you have any problems associated with your menstrual period? ..................................................................................................................................................................
18. Are you nursing! ..................................................................................................................................................................................................................................................
29. Are you taking birth contml pills? ........................................................................................................................................................................................................................

Yes    No

Yes    No

Yes

Yes

YeS

Yes

Yes

YeS

Yes



YeS



Yes



Yes

YeS

Yes



Yes

No

No

No

No

No

No

No

No

No

No

No

No

No

Yes



YeS

No

No

Yes    No

Yes    No

Yes    No
Yes    No

Chief Dental Complaint

1 certify that I have read and understand the above.1 acknowledge that my questions, ifany, about the inquiries set forth above have been answered to my satisfaction.
I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.

Signature of Patient

For completion by the dentist.
Comments on patient interview concerning medical history:
Signrfitant findings from questionnaire or oral interview:

Oental management considerations:

Date
Medical history update:
Date

Comments

Signature of Dentist

Signature

Source: Adapted from American Dental Arsociation,as reproduced in Rose and Steinberg 2DDO.

1

ORAL HE4LTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          195


Personal and Provider Approaches to Oral Health

immune system factors associated with disease. The
number of such tests is increasing and will be sup-
plemented by genetic tests to indicate an individuals
susceptibility to specific diseases.

Currently, the assessment of oral and craniofacial
health and disease involves intraoral radiographs as
well as radiographic imaging, including arthrogra-
phy, motion-based tomography, and computed
tomography (Jeffcoat 1992). Intraoral radiographs
permit detection of lesions between teeth and are the
only widely available clinical test that can assess peri-
odontal bone support in situ (Jeffcoat et al. 1995).
Radiographs are an essential tool for treatment plan-
ning of complex prosthetic reconstructions as well as
a diagnostic method to assess periodontal progres-
sion. However, the mere presence of bone loss on a
radiograph does not imply progressive osseous
destruction, although it does increase the patient's
risk of future bone loss (Armitage 1996, Genco
2000). Radiographs have high specificity for disease
progression, and low sensitivity. Because all radi-
ographic examinations expose the patient to some,
albeit small, level of ionizing radiation, current
guidelines indicate that radiographs should not be
taken routinely (FDA 1987), but should be pre-
scribed after an initial assessment by the dentist.

(MRI) is also receiving increased attention for cran-
iofacial applications, such as for the assessment of
the temporomandibular joints. Finally, light-based
imaging of teeth and associated structures, using a
small intraoral camera, gives both the patient and the
provider a wide-screen view of the oral cavity, aiding
in patient education.

In the course of conducting a general assess-
ment, the clinician notes disease-specific signs and
symptoms. While examining the teeth, the clinician
may detect signs of relatively rare hereditary diseases
such as ectodermal dyplasias, or more common
destructive habits such as bruxism, where the enam-
el and at times the dentin may be abraded.
Examinations of the face a;d oral cavity may reveal
the effects of intentional and unintentional injuries.
With the results of the general assessment in hand,
the clinician will classify the patient's general and
oral health status and make treatment and/or referral
recommendations.

Image processing techniques, such as digital
radiography, enhance the clinicians ability to detect
small intraoral osseous changes over time and aid in
the detection of small changes in skeletal tissues
between examinations. Direct digital radiography
uses an intraoral detector to capture a radiographic
image of the diagnostic area of interest (Ellwood et al.
1997, Matsuda et al. 1997). Several proposed meth-
ods for quantitative estimation of lesion mass or vol-
umetry using digital subtraction radiography exist
(Armitage 1996). A recent multicenter validation
study has indicated that simulated lesions as small as
1 mg in mass may be detected with better than 90
percent sensitivity and specificity (Jeffcoat et al.
1996). These techniques are currently in use in clin-
ical trials.

A classification system adopted in 1962 by the
American Society of Anesthesiologists, used to cate-
gorize a patient's risk on the basis of physical status,
also has been applied, along with the patient's gener-
al and oral health risk assessment, to determine the
need for coordinated multidisciplinary referral and
whether care in a hospital is indicated rather than in
the dental office (Bricker et al. 1994) (Table 8.3).

Changing Approaches to Selected Diseases
and Conditions

The science and technology base is providing new
approaches to risk assessment, diagnosis, prevention,
and treatment. Highlights of selected diseases and
conditions follow.

Dental Caries

New diagnostic methods are also becoming
available as adjuncts to existing methods for caries
diagnosis. Comparing data between bite-wing radi-
ographs of potential occlusal fissure lesions, Lussi et
al. (1995) found that electrical resistance measure-
ment may provide a substantial improvement in
caries diagnosis.

Other imaging approaches are used to assess
craniofacial anatomy, temporomandibular joints,
maxillary sinuses, and other associated tissues, and
in the assessment of the size and quality of bone to
receive dental implants. Magnetic resonance imaging

Dental caries is caused by a transmissible microbial
infection that affects tooth mineral. A number of fac-
tors play a role in the initiation and progression of
the disease, including bacterial biofilm, specifically
the presence of mutans streptococci and species of
lactobacilli; the frequency of simple sugars in the
diet; the flow and composition of saliva; the avail-
ability of fluoride; the structure of tooth mineral in a
given individual; and oral hygiene behaviors. Sound
caries management takes all these factors into
account (Figure 8.3) (Burt and Ismail 1986). Today
there is the prospect that clinicians will be able to bal-
ance protective and pathologic factors and work with
the patient to control disease (Anderson et al. 1993,
Edelstein 1994, Featherstone 1996).

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


-

Personal and Provider Approaches to Oral Health

f&j; .-\sscssmfflt. Reviews of caries risk prediction
,,,L,~cfs conclude that clinical variables, especially
I,.,Yt cnries experience, are the best predictors of new
c.,r,cs experience (Newbrun and Leverett 1990,
Pclwcff 1998). Table 8.4 shows a timeline summariz-
,t,? the strongest predictors of caries incidence based

on a review of the modeling literature. At the time of
initial tooth eruption, the presence of mutans strep-
tococci appears to be the primary predictor of future
caries. With continued tooth eruption, this variable
disappears as a primary predictor and is replaced by
the status of the

r\l)LE 8.3

American Society of Anesthesiologists- medical risk categories and associated
dental considerations

ASA Classification
physrcal status 1
A patient without systemic dis-
ease;a normal, healthy patient
Physical status 2
A patient with mild systemic
disease

        Dental Consideration


Routine dental therapy without modification


Routine dental therapy with possible treatment limitations
or special considerations (e.g., duration of therapy, stress of
therapy, prophylactic consideration, possible sedation, and
medical consultation)

most recently exposed or erupted
tooth surface. For example, the
presence of carious lesions in the
primary incisors has been found to
be the best predictor of caries in
the later-erupting primary molars
(Powell 1998).

Physical status 3

A patient with severe systemic dis-  Dental therapy with possible strict limitations or special
ease that limits activity but is not   considerations
incapacitating
Physical status 4
A patient with incapacitating sys-  Emergency dental therapy only, with severe limitations or
temic disease that is a constant   special considerations
threat to life

Source: Genco 2000,Rirk factors for periodontal diseare.In Rose LF,Genco BJ,Cohen DW, Mealey BL.Periodontal medicine.
Hamilton: B.C. Decker Inc. 2000:35-43. Copyright 2000 by B.C. Decker Inc. Reprinted by permission of B.C. Decker Inc. (2000).

r-
I

I-IC;1-RE 8.3
Multifactorial model of dental caries

Enamel crystal structure

Bacterial substrate
Protective factors

Source: Burt and lsmail1986.Copyright 1986 bylournolofDenfalReseorcb.Reprinted by
permission of lournalofDenta/ Research (2000).

Despite recent declines, dental
caries is a prevalent disease, with
some age and pdpulation groups
particularly  vulnerable  (see
Chapter 4). A guide for the identi-
fication of vulnerable patients and
the treatment of caries as an infec-
tious disease has been developed
(ADA 1995). Figure 8.4, from that
guide, proposes questions to be
considered at an initial examina-
tion. These questions, together
with information gathered at recall
examinations, allow classification
of child and adult patients into
high-, moderate-, and low-risk dis-
ease categories (Table 8.5). This
approach has been incorporated in
a variety of caries risk assessment
forms adopted by some dental
managed care programs (C.W.

schools and
Douglass, personal communication, 1999). Studies
are needed to determine the validity and reliability
of such approaches for different patient populations
and practice settings.

The use of tests to assess caries risk to determine
the activity status of preclinical disease is becoming
more widespread. A range of diagnostic aids for
caries activity testing are available. Microbial tests
can detect the presence and quantify the levels of
lactobacilli and mutans streptococci. The develop-
ment and use of these tests are based on studies that
have associated these microbes individually and
together with different types of carious lesion devel-
opment. Measurements of plaque and salivary pH
have been used to evaluate the oral environment
overall and to note the changes in pH that occur
after eating various foods. Salivary flow and compo-
sition analyses add another dimension. Decreased
flow has been related to caries susceptibility, as have
increases in viscosity. These factors warrant further
study to determine their sensitivity and specificity.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL         197


Personal and Provider Approaches to Oral Health

Diagnosis. Clinical signs, patient-derived histor)l, and
radiographic images remain the primary means of
dental caries diagnosis. Tooth surface pitting and
cavitation, white and/or brown spots, areas soft to
tactile probing, and radiolucencies are used to detect
the effects of this disease. The most common
diagnostic approaches include visual inspection, the
use of an explorer (a probelike instrument) to
determine the integrity of the tooth surface, the use
of a light source to detect difference in reflectance
across tooth structure (transillumination), and
radiographs. Table 8.6 compares the reported
sensitivity and specificity of selected methods. No
single method stands out as superior with regard to
both sensitivity and specificity for all tooth surfaces.

The most basic diagnostic methods-visual
alone and visual examination with an explorer-have
limited sensitivity, but excellent specificity. The visu-
al examination may be combined with a radiograph-
ic series for the initial assessment. Bite-wing
radiographs are frequently used to diagnose inter-
proximal caries (between teeth) and for these sur-
faces provide excellent sensitivity and specificity.
Radiographic examination allows examination of
otherwise inaccessible areas. Specifically, the depth of
a lesion and its relationship to the pulp chamber can
be evaluated for interproximal lesions. However,
radiographs are of little value in detecting caries on
the occlusal surfaces of the teeth. For these surfaces,
a negative radiographic diagnosis does not imply lack
of a carious lesion in enamel.
  Precavitated carious lesions and caries in

restored teeth pose an additional diagnostic chal-
lenge. A review of the literature on the clinical diag-
nosis of precavitated carious lesions concluded that

visual detection of these lesions has low sensitivity
and moderate specificity &mail 1997). It is difficult
with these lesions to determine whether there is no
caries or whether only the enamel or outer layer of
dentin is involved. Carious lesions forming around
restorations are seen more frequently at the approxi-
ma1 and cervical margins of these restorations (Mjar
1985). Distinctive color changes around a restoration
alone are not diagnostic of active caries (Kidd 1990).

Currently, the progression of carious lesions is
the most definitive diagnostic parameter for disease
activity. Progression can be determined over specific
time intervals only by professional assessment.

Prevention. The primary prevention of dental caries
starts with adequate prenatal and perinatal nutrition
to ensure normal development of the teeth and sup-
porting structures. It continues with interventions
aimed at preventing transmission of cariogenic
microbes from caregivers to infants, and proceeds
with specific strategies employed across the life span.
These approaches include the provision of sufficient
fluoride, the use of dental sealants, the adoption of
healthy behaviors, including avoiding unhealthy
dietary practices and practicing appropriate oral
hygiene, and the timely use of care services.
Although many factors are brought to bear on the
primary prevention of dental caries, the combination
of fluoride in its multiple forms and dental sealants is
the foundation (as described in Chapter 7).

Fluoride is available in a variety of products that
can be used by health professionals, individuals, and
public programs. Topical solutions and gels,
mouthrinses, and dentifrices are available for daily,
weekly, or as-prescribed frequency. In addition,

TABLE 8.4
Timeline of strongest clinical predictors of caries incidence

Age(years)  0   1   2   3   4   5   6   7   8   9   10   11   12   13   14-21      22-45       >45

Dentition



Event



Predictor

Primary


Eruption primary molars


Mutans   dmfs, especially
streptococci primary incisors
    Mutans streptococci
      and lactobacilli

Mixed


Eruption first
permanent molar
dmfs, especially
primary molars
First molar occlusal
morphology
DMFS

Eruption second
permanent molar
DMFS,especially first
permanent molars
First molar occlusal
morphology
Incipient smooth
surface lesions

Early      Mature
permanent   permanent
     Progression of gingival recession


Incipient    Not studied    Coronal and root
smooth             DMFS
surface lesions          Number of teeth
DMFS              Periodontal
                disease

Note: dmfs = decayed, missing, or filled primary tooth surfaces; DMFS = decayed, missing, or filled permanent tooth surfaces.
Source: Powell 1998.Caries prediction:a review of the literature.CommunityDenristryondOralFpidemio/ogy 1998;26:361-71,Copyright 1998 by Munksgaard International Publishers Ltd.,
Copenhagen, Denmark.Reprinted by permission of Munksgaard International Publishers Ltd.,Copenhagen, Denmark (ZOOO).

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


FIGURE 8.4

Caries risk questions for initial examination

INITIAL VISIT-QUESTIONS TO CONSIDER

is there current caries activity?
Are there indications that yield potential for development of caries
within the next year?
. Prior DMFS (decayed, missing, or filled surfaces)
. Tooth morphology

. Medications that decrease saliva flow and/or affect viscosity of saliva
. Medical condition or treatment(s)

What is the individual's caries risk?
- tow
. Moderate
. High

What are the modifiable risk factors that may be responsible for or may
contribute to this caries activity?
. Insufficient systemic and topical fluoride
. Medications

. Poor oral hygiene habits or skills
. Deep pits and fissures without sealants
. Poor dietary habits

What can be done to prevent new caries or caries progression within the
next year?
. Sealants
. Increase fluoride use

* Oral hygiene instruction/education
. Dietary counseling
* Monitor bacterial count
+ Antimicrobial agents

. Conservative restorative techniques-to minimize removal of,

tooth structure

What is the prognosis for successful intervention?
* Patient compliance
. Clinician skill (diagnosis, intervention counseling)
* Prevention modalities are accepted/applied
* Severity at onset

Are there other considerations that may affect the decision process that
cannot be changed? (effect modifiers, confounders)
* Age
* Socioeconomic considerations

. Medically and/or physically compromising conditions

Source: American Dental Association Council on Access, Prevention and Inter-
professional Relations 199S.Caries diagnosis and risk assessment.A review of
preventive strategies and management.JADA; 126: 15.245,Copyright 1995 by
American Dental Association. Reprinted by permission of ADA Publishing Co. Inc. (2ooO).

fluoride-containing prophylactic pastes are available
for professional application (see Chapter 7). Clinical
judgment of risk factors determines the type and
frequency of interventions needed.

Although there is general agreement on the over-
all value of topical fluorides in reducing dental caries
(ADA 1986. 1994, Moss 1976, Stookey et al. 1993),

Personal and Provider Approaches to Oral Health

comparative clinical trials are needed to determine
which of the existing fluoride formulations (acidulat-
ed phosphate fluoride, stannous fluoride, amino-
fluoride, or sodium fluoride) and which delivery sys-
tem (gel, varnish, dentifrice, or solution) are most
efficacious.

A second line of defense is through control of the
etiologic agent. Chemotherapeutic agents (including
the antimicrobial mouthrinse agent chlorhexidine
and fluoride) can be used to reduce plaque. Dietary
measures aimed at reducing the frequency and quan-
tity of sugars and the substitution of sugars by sugar-
free sweeteners may effectively starve the bacteria.
The process of tooth demineralization and re-
mineralization has received significant attention
over the past four decades (Geiger et al. 1992,
Koulourides et al. 1961, Larsen and Fejerskov 1987,
Linton 1996, Silverstone et al. 1981, White 1988),
although the concept was documented in the early
1900s (Head 1912) (see Chapter 3). Investigators are
studying the effectiveness of therapeutic agents for
arresting carious lesions and remineralizing enamel
in populations at high risk for dental caries. For
example, a combined chlorhexidine-fluoride solution
can enhance remineralization of incipient lesions and
arrest caries in patients who suffer from radiation-
induced caries (Katz 1982). The use of a twice-daily
rinse with 0.05 percent sodium fluoride to prevent
demineralization and induce remineralization in sub-
jects with radiation-induced hyposalivation has also
been found to be effective (Meyerowitz et al. 1991).
This study also addressed the effects of chlorhexidine
use alone, which has been associated with tooth
staining, alterations in taste, and potential hypersen-
sitivity reactions (Ohtoshi et al. 1986, Okano et al.
1989). Schaeken et al. (1991) showed that the appli-
cation of 40 percent by weight chlorhexidine varnish
every 3 months enhanced remineralization of root
caries more than fluoride varnish, although both
treatments were associated with fewer filled root sur-
faces than the control group after 1 year. A chlorhex-
idine varnish has not yet been approved in the United
States, and large-scale, double-blind, placebo-con-
trolled clinical trials are not yet available to test the
effects of specific regimens in relation to caries risk.
  Studies also are evaluating interventions to pre-
vent mutans streptococci transmission. Find-
ings from cross-sectional studies indicate that infants
are initially infected by their parents, specifically
mothers, around the time the teeth erupt (Berkowitz
et al. 1975, Caufield et al. 1993, Kohler and Bratthall
1978). A longitudinal study using DNA fingerprint-
ing demonstrated that mothers were the source of the

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

199


Personal and Provider Approaches to Oral Health

rABLE 8.5

Caries risk classification guidelines

Risk Category

    Age Category for Recall Patient9
Child/Adolescent                Adult

Low

No carious lesions in last year
Coalesced or sealed pits and fissures
Good oral hygiene
Appropriate fluoride use
Regular dental visits

No carious lesions in last 3 years
Adequately restored surfaces
Good oral hygiene
Regular dental visits

Moderate

One carious lesion in last year
Deep pits and fissures
Fair oral hygiene
Inadequate fluoride
White spots and/or interproximal
  radiolucencies
Irregular dental visits
Orthodontic treatment

One carious lesion in last 3 years
Exposed roots
Fair oral hygiene
White spots and/or interproximal
radiolucencies
Irregular dental visits
Orthodontic treatment

High

>2 carious lesions in last year
Past smooth surface caries
Elevated mutans streptococci count
Deep pits and fissures
No/little systemic and topical fluoride
  exposure
Poor oral hygiene
Frequent sugar intake
Irregular dental visits
Inadequate saliva flow
Inappropriate bottle feeding or nursing
(infants)

22 carious lesions in last 3 years
Past root caries; or large number of exposed
  roots
Elevated mutans streptococci count
Deep pits and fissures
Poor oral hygiene
frequent sugar intake
Inadequate use of topical fluoride
Irregular dental visits
Inadequate saliva flow

a At initial visit for new patient, if time of lasr caries experience cannot be determined,a person with no decayed missinV,
or filled surfaces (DMFS = o) would be classified as low risk. A person with past caries experience (DMFS > 0) and/or one
active lesion would be classified as moderate risk, A person with past caries experience and/or rWo active Caries or one
smooth surface lesion would be classified as high risk.
Parents of young children and expectant parents need additional tounseling on inappropriate nursing or bottle feeding
practices that can lead to the development of early childhood caries. Parents and caregivers should be advised to introduce
children to a cop in an effort to discontinue use of the bottle by the age of 1 year. Also, parents and caregivers should be
advised never to place anything other than plain water in a naptime or nighttime bottle.Children should not be allowed
to bottle feed at will and should be weaned from the bottle by the age of 1 year.
Many medically compromised individuals are likely to be assessed in the higher risk categories because of their use of
certain medications and possible xemstomia.
Source: Amencan Dental Association Council on Access and Interprofessional Relations 1995.Caries diagnosis and risk
assessment. A review of preventive strategies and management.lADA 1995; 126: 15-245. Copyright 1995 by American
Dental Association. Reprinted by permission of ADA Publishing Co. Inc.WIW.

TABLE 8.6

Sensitivity and specificity of selected dental caries diagnostic procedures

               Sensitivity  Specificity
            (percentage) (percentage)     References
Visual examination of noncavitated fissures   12-31     70-99  Lussi 1993,Ketley and Holt 1993
Examination using explorer          Id-24     70-99  Penning et aL1992,Lussi 1993
Radiographs of approximal lesions      so-90     as+   Grbndahl 1989,Benn and
                              Watson 1989

bacteria in their infants and the
degree of matching to maternal
strains was higher for female
infants than for males (Li and
Caufield 1995). Based on a study
of child-mother pairs (with the
child initially at 1 year of age), the
application of a 1.0 percent chlor-
hexidine rinse alternated with a
0.2 percent sodium fluoride gel to
the mother's teeth (3 times per day
on 2 consecutive days, twice per
year for 3 years) delayed, and in
some cases prevented, the colo-
nization of their children's teeth by
mutans streptococci (Tenovuo et
al. 1992). Timing of colonization
has been shown to be correlated
with caries prevalence. In a longi-
tudinal study that followed chil-
dren in $-month intervals from 15
months to 4 years of age, children
who were infected earlier had a
higher caries prevalence than
those in whom the infection was
detected at later ages. Studies also
have been aimed at reducing the
levels of cariogenic bacteria in the
infants themselves.

  Work continues on the devel-
opment of a caries vaccine. One
approach focuses on the produc-
tion and release of antibodies
against cariogenic bacteria anti-
gens (Russell et al. 1995). Specific
antigens have been purified and
synthesized. Another approach
involves biological replacement
therapy, where nonpathogenic
bacteria, instilled in the mouth,
prevent pathogenic bacteria from
colonizing (Hillman et al. 2000).
Yet another approach employs pas-
sive immunization in which anti-
bodies, produced outside the body
(in cultures, animals, eggs, or
plants), are applied to the teeth
and oral tissues to protect against
disease. A recent study indicated
that "plantibodies" painted on the
teeth could prevent mutans strep-
tococci colonization for 120 days,
the period of the experiment (Ma
et al. 1998).

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

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

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

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

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

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

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

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

Periodontal Diseases

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

Personal and Provider `approaches to Oral Health

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

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

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

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

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

FIGURE 8.5

A new paradigm for the pathobiology of periodontitis

Microbial
challenge

TfzxTTl     Host

inflammaton

Cytokiner & o
prostanoids


Matrix *
metallo-
nrnthawc

Connective
tissue
and bone
metabolism

     Clinical
    signs of
* disease and

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

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


r

T,\BLE 8.7

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

Factor

Case Report     Case-Control
Studies       Studies

Cross-sectional
Studies

Longitudinal
Studies

intervention Studies

Specific bacteria
P ginqivdis
B. fonyrhus
p intermedia

Yes
Yes
Yes

Yes
Yes
Yes

Yes
Yes
Yes

Yes
Yes
Yes

Yes
Yes
Yes

Sex
Male

Age
Diabetes mellitus
Type 2

Type 1
Smoking
Osteoporosis
Stress, distress, coping

Yes

Yes


Yes


Yes

NR

Yes

Yes

NR

Yes


Yes


Yes

Yes

Yes

Yes

Yes

Yes


Yes


Yes

Yes

Yes

Yes

   NR
No (to 7th decade)


   Yes


   NR

   Yes

   NR

   NR

     NR

     NR


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

    NR

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

Yes

NR

NR

Yes

Yes

Yes

Yes

Yes

NR

NR

Yes

Yes

Yes (case series)
  NR

   NR

  Yes

NR

NR

NR

Yes

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

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

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

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

Clinical measurement
Bleeding on probing"    progression of periodontitis    2.7

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

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

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

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

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

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

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

-n:
cv-


Personal and Provider Xpproaches to Oral Health

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

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

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

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

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

TABLE 8.9

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

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

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

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

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

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

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

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

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

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

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

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

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

Personal and Provider Approaches to Oral Health

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

205

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

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

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

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

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

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

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

      Treatment
-

Strengths

Scaling and root planing with
manual instrument

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

Chemical plaque control
with mouthrinses and
dentifrices

Sustained release anti-
microbials

Systemic antibiotics

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

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

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

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

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

May be useful to treat aggressive
destructive periodontitis

Weaknesses

Type of Evidence

Requires attention to detail

Numerous longitudinal,
cohort, and randomized
clinical trials

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

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

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

longitudinal, cohort, and
randomized clinical trials

Randomized double-blind
clinical trials

Randomized double-blind
clinical trials

Randomized double-blind
clinical trials

Not indicated for gingivitis
Not indicated for most adult
periodontitis patients

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

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

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

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

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

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

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

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

r

TABLE 8.11
Periodontal disease: selected surgical procedures

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

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

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

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

Type of Evidence
Randomized clinical trials
Longitudinal studies

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

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


Personal and Provider Approaches to Oral Health

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

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

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

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

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

Cigar9
Never                                       1.0    -

Ever                                      1.8    -

Pipe+
Never                                       1.0    -

Ever                                        1.8    -

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

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

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

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

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

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


Personal and Provider Approaches to Oral Health

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Birth Defects

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

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

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

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

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

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

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

Chronic Craniofacial Pain and
Sensorimotor Conditions

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

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

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

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

Temporomandibular Disorders

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

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

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

Personal and Provider r\pproaches to Oral Health

ORAL HE4LTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

211


Personal and Provider ;\pproachcs to Oral Health

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

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

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

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

Mucosal and Autoimmune Diseases

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

TABLE 8.13
Diagnosis of temporomandibular disorders

Test       Application     Strengths      Weaknesses    Type of Evidence

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

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

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

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

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

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

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

Personal and Pro\.ider Approaches to Oral Health

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

Clinical Practice Guidelines

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

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

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

213

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

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

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

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

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

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

Statusa

Protocol

Full review


Protocol

Protocol

Protocol

Protocol

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

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

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

TABLE 8.14

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

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


Personal and Provider Approaches to Oral Health

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

r..iBLE 8.15

Characteristics of selected dental clinical practice guidelines

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

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

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

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

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

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

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

4                    4       4



4                    4       4

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


Personal and Provider Approaches to Oral Health

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

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

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

Broadening the Base for the Provision of
Oral Health Care

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

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

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

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


provision of Oral Health Care

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

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

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

COMPONENTS OF PROFESSIONAL
CARE

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

The Dental Component

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

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


Provision of Oral Health Care

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

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

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

1980   1990   1996    1997

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

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

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

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

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

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

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

I       1              I       ,       I       I

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

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

FIGURE 9.1

3,500

3,000

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

    0

c

0

5,000

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

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


The Medical Component

In the context of oral, dental, and craniofacial health

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

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

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

The Public Health Component

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

Provision of Oral Health Care

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

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

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           225


Provision of Oral Health Care

revenues. The Head Start programs of the
Administration for Children and Families (ACF)
provide health education services and in some cases
may pay for oral care services for enrolled low-
income children 5 years old and younger.

Many organizations have activities that could be
used to promote oral health, given appropriate col-
laboration. In this regard, studies of the federal oral
health infrastructure have emphasized the need for
federal programs to maximize partnerships within
and beyond the federal government. A 1989 report
recommended increasing the capacity of USDHHS
agencies to direct dental expertise to programs that
can affect oral health or dental care, and establishing
a mechanism for coordinating programs and sharing
expertise across agencies. The report recommended
that a national advisory committee be established to
assess opportunities, accomplishments, and needs
(USDHHS 1989). A 1994 report determined that the
collection and analysis of data related to oral health
and dental care had not been maintained at a level
consistent with analogous general health and health
care data used for public program planning, develop-
ment, and evaluation (SysteMetrics, Inc. 1994).
Despite some progress, many of the recommenda-
tions of these reports have not been implemented;
thus many of the deficiencies noted have not been
fully addressed.

Table 9.2 presents the scope of services and
activities supported by USDHHS agencies. It
identifies each agency's principal activities in terms of
the "essential public health services' conducted at
federal, state, and local levels. The approximate fiscal
year 2000 funding levels provide a sense of how the
proportion of oral health programs varies across
agencies

Local public health departments, community
health centers, nongovernmental organizations, den-
tal schools, and volunteer groups are examples of
entities that implement oral health programs in asso-
ciation with government agencies and the private
sector. These collaborations are enhanced by state
oral health programs as they direct and integrate
public health services. Not every state health agency
has an oral health program, however. Further, not all
state oral health programs have sufficient resources
to address oral health needs. For example, although
31 states and five territories currently have full-time
state dental directors, in 20 states (including the
District of Columbia), the state dental director posi-
tions are part time or vacant.Additionally, 21 states,
with 67 million people, have two or fewer full-time
equivalents staffing a state oral health program. In 25
states, fewer than 10 percent of the counties have oral
health programs in their local health departments
(ASTDD 1999).

The Association of State and Territorial Dental
Directors (ASTDD) recently assessed the resources
needed to achieve the objectives in Healthy People
2010. The study focused on the gaps in infrastructure
and capacity of state oral health programs.
Infrastructure consists of the systems, people, rela-
tionships, and resources that would enable state oral
health programs to perform public health functions.
Capacity describes the expertise and competence
needed to enable the implementation of strategies.
Box 7.3 describes the essential public health services
for oral health in the areas of assessment, policy
development, and assurance as noted in ASTDD's
Guidelines for State and Territorial Oral Health
Programs. In particular, states have high needs for
oral health surveillance systems and staff with epi-

TABLE 9.2

Scope of essential public health services supported by agencies of the U.S. Department of Health and Human Services

                                      AHRQ CDC   FDA HRSA IHS   NIH HCFA ACF
Monitor health status to identify and solve community health problems             x x           x x
Diagnose and investigate community health problems                          X        x x
Educate and empower people about health issues                   x x x x x x x x
Develop policies and plans that support individual and community efforts                X       x x            X
Enforce laws and regulations that protect health and ensure safety                       X               X
Link people to personal health services;ensure provision of care when otherwise unavailable              x x       x x
Ensure a competent public health and personal health care workforce              x x       x x x
Evaluate effectiveness, accessibility, and quality of personal and population-based services     x x       x x       x x
Conduct research for new insights and innovative solutions to health problems         x x x x        X
Oral health component (FY 2000) ($ millions)                          <l   <lO <3  <I50 <80 <250 2000 ~10
Total agency budget (FY 2000) ($ billions)                        >0,2 3.1 1.4   4.2   2.8 16   343 38
Oral health as proportion of agency budget                     <0.5% 0.3% 0.2% 0.3% 3%  1.5% <0.2% <O.l%

Sources: Data from PHS Oral Health Coordinating Committee, personal communication, 2000, Public Health Functions Steering Committee ZlXlo

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


,lcmiologic and other public health expertise
, .\jTDD 2000). Similar gaps occur in many local
17L,blic health departments that lack adequate oral
l&th programs or appropriately trained personnel
\ ct;DHHS 2000).

Public health agencies at all levels have identified
Ll,sparities in oral health and access to care, in terms
<,f both population subgroups and geographical
.,re3s. In 1998, there were 1,036 dental Health
professional Shortage Areas (HPSAs), which required
3,984 dentists. Of 686 consolidated Community
Health Center grantees, 385 (or 56 percent) provide
dental services 0. Anderson, HRSA, personal com-
munication, 1999).

Community Health Centers provide preventive
nnd basic dental care to 1.2 million patients nation-
\vide (HRSA 1998). Health Centers are located in
ruedically underserved urban and rural areas and tar-
get low-income, migrant, homeless, and other disad-
vantaged populations. Individuals pay for dental
services on a sliding fee scale adjusted by their abili-
ty to pay. Health Centers are a primary source of care
for 2.84 million Medicaid-eligible individuals, who
make up 33 percent of Health Center clients. An
additional 3.55 million uninsured patients represent
41 percent of their clients (HRSA 1998). Health
Centers that provide oral health care include it as
part of an integrated primary care system. In addi-
tion, federal programs such as the National Health
Service Corps offer scholarships and loan repayment
opportunities to encourage newly licensed dentists to
locate in underserved areas.

Areas of Overlap

The various components of oral health care work
together in diagnosis, prevention, and treatment
services. As mentioned above, dental and medical
specialists work on teams treating patients with cran-
iofacial birth defects. Oncologists, radiologists, oto-
laryngologists, plastic surgeons, and surgeons spe-
cializing in head and neck surgery similarly may part-
ner with oral and maxillofacial surgeons and prostho-
dontists in treating oral and pharyngeal cancers and
other tumors of the oral cavity and pharynx. Dentists
also are active members of general oncology teams.
They participate in the examination of patients about
to undergo chemotherapy, radiation, or bone marrow
transplantation, for example, to ensure that proven
preventive measures are taken before treatment to
minimize the effects of the therapy on the oral
mucosa, salivary glands, and dentition.

Private medical and public health professionals
often collaborate in implementing immunization

Provision of Oral Health Care

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL         227

programs and other preventive strategies to reduce a
specific disease or to change risk behaviors. Similarly,
dental personnel in the private and public sectors
cooperate in the implementation of mouthguard pro-
grams for sports injury prevention, statewide pro-
grams to apply sealants to the teeth of low-income
children, and the promotion of oral health self-care
behaviors. Private practitioners can deliver care that
is paid for by public programs or can work as con-
tractors to Migrant and Community Health Centers
and local health departments, among others. Finally,
all three components can work together to promote
programs that address cross-cutting issues such as
tobacco cessation and the prevention and control of
HIV disease, oral and pharyngeal c$ncers, and early
childhood caries.

EXPENDITURES FOR ORAL HEALTH
CARE

The $1.1 trillion spent in the United States on health
care services in 1998 includes the cost of hospital
care, physician and dental services, home health care,
nursing home care, prescription drugs, medical
equipment, private health insurance, public health
activities, and research and represents an increase of
5.6 percent from 1997 (HCFA 2000b). Analysts proj-
ect that this amount will double by 2007 to total
more than $2.1 trillion (HCFA 2000a).

Expenditures for dental services in the United
States in 1998 were $53.8 billion, a 5.3 percent
increase from 1997 and 4.7 percent of the total spent
on health care that year (Table 9.3 and Figure 9.2).
This figure is an undercount, however, because it rep-
resents only those costs associated with care deliv-
ered by dentists in practice settings. A generation ear-
lier, in 1960, $2 billion was spent on dental care,
which represented 7.3 percent of that year's total

FIGURE 9.2

Dental services as a percentage of total U.S. health care
expenditures by type of service, 1997

Dental Services

pital Care
34%

I  Source: HCFA 20OOa.

' Other
23%


Provision of Oral Health Care

health care expenditures. During the 197Os, dental
expenditures grew at approximately the same rate as
personal health care expenditures, with both exceed-
ing the growth of the economy overall. But starting in
1978, dental expenditures began to flatten and, until
1994, increased more slowly than expenditures for
personal health care. Since 1994, dental expenditures
have increased at a higher rate than personal health
care expenditures (Levit et al. 1998).

Real per capita dental care expenditures (1995
dollars) are currently at about the level they were in
the early 198Os, and in some years have declined
(Figure 9.3) (ADA 1997b, Beazoglou et al. 1993,
Beazoglou 1998). The American Dental Association
estimated that $174.12 was spent per capita in 1995
for dental services (ADA 1997b); HCFA estimated
the same year's per capita consumer expenditures for
dental services at $164 (U.S. Bureau of the Census
1998).

The annual percentage change in fees for med-
ical, physician, and dental services as measured by
the Consumer Price Index (CPI) has generally
exceeded that for the index as a whole (U.S. Bureau
of Labor Statistics 1999) (Table 9.4 and Figure 9.4).

followed those for other medical services; since 1983,
however, prices for dental services have increased at
a rate faster than those for physician and all medical
services. These trends signal different market forces
for dental care services as compared to other health
services.

In addition to dental care expenditures for serv-
ices provided by dentists in practice settings, the full
cost of oral health care in the United States must take
into consideration the breadth of oral, dental, and
craniofacial conditions for which services are provid-
ed in hospital and other institutional settings, often
by nondentists. For example, the Healthcare Cost
and Utilization Project (2000) estimated inpatient
hospital charges for diseases of the mouth and disor-
ders of the teeth and jaw to be $451 million in 1996.
Estimates for the management of severe early child-
hood caries range from $1,400 to $2,000, depending
on whether hospitalization is necessary (Griffin et al.
2000, Kanellis et al. 2000). In Iowa the average cost
of treating this condition in a hospital operating
room was estimated to be $2,578 (Damiano et al.
1996). In California, the lifetime cost per case for
cleft lip/palate repair is estimated at $101,000

Percentage changes in the dental CPI have-generally          _ _
                           (Waitzman et al. 1996).

TABLE 9.3
U.S. national health expenditures by source of funds and type of expenditure, 1998 ($ billions)

Private

Consumer

Government

                              All Private       Out of Private                  State and
                        Total    Funds    Total   Pocket Insurance Other     Total   Federal   Local
National health expenditures            1,149.l   626.4    574.6   199.5   375.0  51.8     522.7   376.9    145.8
Health services and supplies            1,113.7    613.4    574.6   199.5    375.0   38.8     500.4    360.4    140.0
Personal health care               1,019.3    574.5    536.5   199.5   337.0   37.9     444.9   343.6   101.3
Hospital care                    382.8   149.9    130.9    12.8   118.0   19.1     232.9    187.4    45.5
Physician services                  229.5    156.2    151.7   35.7    116.0   4.5      73.3    60.8    12.4
Dental services                    53.8    51.5     51.3    25.8    25.5   0.2      2.3     1.3     1.0
Other professional services               66.6    52.4     47.4    27.2    20.2   5.0      14.2    11.2     3.0
Home health care                   29.3    13.7     10.0    6.0     4.0   3.7      15.5    13.1     2.4
Drugs and other medical nondurables         121.9   103.1    103.1    55.4    47.8   -      18.8    10.7     8.1
Vision products and other medical durables       15.5     9.0     9.0    a.2     0.8   -      6.5    6.4     0.1
Nursing home care                   87.8    34.8     33.2    28.5     4.7   1.6      53.0    35.4    17.7
Other personal health care               32.1     3.8      -     -     -   3.8      28.3    17.1    11.2
Program administration and net cost of private
health insurance                   57.7    38.9     38.0    -    38.0   0.9      18.8    12.6     6.2
Government public health activities           36.6     -      -     -     -   -      36.6     4.2    32.4
Research and construction                35.3    13.0      -     -     -   13.0      22.3    16.5     5.8
Research                        19.9     1.6      -     -     -   1.6      18.3    15.5     2.8
Construction                       15.5    11.5      -     -     -   11.5      4.0     1.0     3.0

Note: Research and development expenditures of drug companies and other manufacturers and providers of medical equipment and supplies are excluded from research expenditures, but
are included in the expenditure class in which the product falls. Numbers may not add to totals because of rounding.
Source: HCFA 2000b.

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


Provision of Oral Health Care

FINANCING AND REIMBURSEMENT
Dental care is financed principally through private
~0ltrces. either as out-of-pocket payments made
directly to the dentist or through employment-based
dental insurance benefits. Since 1960, these two
sources have financed over 93 percent of all dental
expenditures (Figure 9.5). Table 9.5 shows the
change in contributions for dental expenditures from
1970 to 1996. The proportion of dental expenditures
that private dental insurance covers has increased
over the past two decades. Dental insurance now
contributes about 48 percent of dental expenditures,
as compared to 50.1 percent contributed by medical
insurance for physician services. In contrast, the per-
centage of out-of-pocket payments for dental servic-
ES is over 3 times that for physician services (Figure
o.6). Sharp differences are also evident in terms of
federal, state, and local government contributions to
the cost of dental care as compared to physician serv-
ices. Only 4.0 percent of dental care costs, or $2.3 bil-
lion in 1998, is financed publicly (largely through
federal-state Medicaid programs), compared to 32.2
percent for medical care. Few hospital dental servic-

services. In contrast, public sources pay a large part
of hospital costs for medical care.

Insurance

Insurance is a major determinant of dental utiliza-
tion: 70.4 percent of individuals with private dental
insurance reported seeing a dentist in the past year,
compared to 50.8 percent of those without dental
insurance (Bloom et al. 1992). Private dental care
benefits are available to most full-time employees (59
percent) in medium-sized and large businesses.
Fewer small businesses offer dental benefits. For the
22.6 million employees with employer-provided den-
tal benefits, dental care may be offered as part of a
comprehensive medical and dental plan or as a sepa-
rate plan. Firms often offer employees a choice of
medical plans as well as a separate dental plan that
can accompany any medical plan. For employees
with employer-provided dental benefits, 81 percent
received care through fee-for-service plans, 11 per-
cent from preferred provider organizations, and 8
percent from health maintenance organizations

es are reimbursed by Medicare, and state Medicaid   (HMOs) in 1998 (EBRI 1998)
programs may provide low reimbursement for dental

FIGURE 9.3

Per capita dental expenditures in current and real (1995) dollars, United States, 1970 to 1995

160

60

           4 Per Capita Expenditures  - Real (1995) Per Capita Expenditures

Sources: US. Bureau of the Census 1998, U.S. Bureau of Labor Statws 1999.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

229


Provision of Oral Health Care

Most participants in employer dental plans
receive benefits through a fee-for-service plan, which
reimburses patients or providers after services are
received. Such plans are commonly obtained through
a commercial insurer, or are self-insured (the firm
sets aside funds to meet expected charges), or are a
combination of the two. Among self-insured plans is
a type of dental plan called direct reimbursement,
which enables patients to pay the dentist directly
based on what they have been charged. The patients

TABLE 9.4
Consumer Price index for dental services, physician services, all medical care, and all
items, United States, 1960 to 1997

                   All     All    Dental/    Dental/   Dental/
      Dental   Physician   Medical    Items   Physician   All Medical  All Items

1960     27.0     21.9    22.3    29.6     1.23      1.21      0.91
1961     27.1     22.4    22.9     29.9     1.21      1.18      0.91
1962     27.8     23.1    23.5     30.2     1.20      1.18     0.92
1963     28.6     23.6    24.1    30.6     1.21      1.19     0.93
1964     29.4     24.2    24.6     31.0     1.21      1.20      0.95
1965     30.3     25.1     25.2    31.5     1.21     1.20     0.96
1966     31.3     26.5    26.3     32.4     1.18     1.19     0.97
1967     32.8     28.4    28.2    33.4     1.15      1.16     0.98
1968     34.6     30.0    29.9    34.8     1.15      1.16     0.99
1969     37.1     32.1    31.9    36.7     1.16     1.16      1.01
1970     39.2     34.5    34.0    38.8     1.14      1.15      1.01
1971     41.7     36.9    36.1     40.5    1.13      1.16     1.03
1972     43.4     38.0     37.3    41.8     1.14     1.16      1.04
1973     44.8     39.3    38.8     44.4     1.14      1.15      1.01
1974     48.2     42.9    42.4    49.3     1.12      1.14      0.98
1975     53.2     48.1     47.5    53.8     1.11     1.12     0.99
1976     56.5     53.5    52.0    56.9     1.06      1.09     0.99
1977     60.8     58.5     57.0    60.6     1.04     1.07      1.00
1978     65.1     63.4    61.8    65.2     1.03     1.05      1.00
1979     70.5     69.2    67.5     72.6     1.02      1.04     0.97
1980     78.9     76.5     74.9    82.4     1.03      1.05     0.96
1981     86.5     84.9    82.9    90.9     1.02      1.04     0.95
1982     93.1     92.9    92.5     96.5     1.00      1.01      0.96
1983     99.4     100.1    100.6     99.6     0.99     0.99     1.00
1984    107.5    107.0    106.8    103.9     1.00      1.01      1.03
1985     114.2    113.3    113.5    107.6     1.01      1.01      1.06
1986     120.6    121.5    122.0    109.6     0.99     0.99     1.10
1987    128.8    130.4    130.1    113.6    0.99     0.99     1.13
1988     137.5    139.8    138.6    118.3     0.98     0.99      1.16
1989    146.0     150.1    149.2    124.0     0.97      0.98      1.18
1990    155.8    160.8    162.8    130.7    0.97      0.96     1.19
1991     167.4    170.5    177.0    136.2     0.98     0.95      1.23
1992     178.7    181.2    190.1    140.3     0.99     0.94      1.27
1993     188.1     191.3    201.4    144.5     0.98     0.93     1.30
1994    197.1     199.8    211.0    148.2    0.99     0.93      1.33
1995    206.8    208.8    220.5    152.4     0.99     0.94     1.36
1996    216.5    216.4    228.2    156.9     1 .oo     0.95      1.38
1997    226.6    222.9    234.6    160.5     1.02     0.97      1.41

Source: U.S.BureauofLaborStatirtics 1999.

Dental insurance plans that reimburse dentists
by type of service performed typically cover technical
procedures but not counseling services, treatment
planning, or disease management. Diagnostic and
preventive care usually includes dental examinations,
prophylaxes, sealants, and radiographs. Restorative
      procedures may be limited to fill-
      ings, but may include crowns.
       Other services that may be covered
      include periodontal care, endo-
       dontic care, prosthetics, and oral
      surgery. Orthodontic care is cov-
       ered less often by dental plans than
       are other procedures. In addition,
      most plans limit orthodontic cov-
      erage to dependent children and
       set maximum allowable payments.
       Dental implants, cosmetic proce-
       dures, and some preexisting condi-
       tions typically are not covered.
         Dental insurance plans are
       similar to medical plans in defin-
      ing the terms of payment on a fee-
       for-service basis. Typically, they
      may pay a percentage of the fee;
      they may pay up to a specified dol-
      lar amount using a table of
       allowances; they may require the
       patient to pay initial costs up to a
        fixed amount (a deductible); or
       they may pay a varying percentage
       of dental charges, based on a
       patient's past use of dental services.
       In all cases, the patient pays the
       difference. Copayments are a larg-
      er percentage of the total cost of
        dental care than is the case for
         medical care.

Dental coverage varies by
race/ethnicity,   income,   and
educational levels. Whites (41.8
percent), people with 13 years or
more of education (51.4 percent),
and families with annual incomes
of $35,000 or more (60.8 percent)
have the highest percentage of
insurance  coverage in  their
demographic categories (Figure
9.7). Hispanic individuals have the
lowest percentage of coverage

are reimbursed by the plan based on their expendi-
tures, up to a predetermined limit for total expendi-
tures, but not according to the type of service they
receive.

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


Provision of Oral Health Care

-
T,\BLE 9.5
U.S. national expenditures on dental services, 1970 to 1996 ($ millions)

Total Dental
Expenditures

Out-of-Pocket   Private Health  Other Private    Public Funds
Payments     Insurance     funds    (Medicaid,etc.)

1970     4,669      4,240        212        0        217
1971      5,181      4,672        248        0        261
1972      5,516      4,934        292        0        290
1973     6,323      5,605        378        4        336
1974     7,076      6,130        550        7         389
1975     7,956      6,530        939        11        475
1976     8,972      6,965      1,486       15        506
1977     10,055      7,582      1,908       19        547
1978     10,957      7,918      2,504       22        512
1979     11,893      8,237      3,072       27        557
1980     13,323      8,833      3,811       27        652
1981     15,698      10,082      4,839       39        738
1982     16,953      10,547      5,737       43        626
1983     18,271      11,010      6,578       44        639
1984     19,833     11,578      7,613       51        591
1985     21,650     12,243      8,682       73        653
1986     23,108     12,658      9,677       81        693
1987     25,343     13,118      11,409       86        730
1988     27,460     13,845      12,758       94        763
1989     29,496     14,485     14,115       110        786
1990     31,566     15,389     15,134       124        919
1991     33,348     16,139     15,948       134       1,127
1992     37,013     17,782     17,686       143      1,402
1993     39,099      18,647     18,398       154       1.900
1994     41,665      19,727     19,798       167      1,974
1995     44,695     21,007     21,477       173      2,038
1996     47.551      22,116     23,166 .     183      2,086

Source: HCFA 2ODOb.

FIGURE 9.4                          IYIGI'RE 9.3

Ratio of dental services CPI to physician services CPI,all medical
care CPI, and all items (PI, 1960 to 1997

Percentage of total U.S. dental expenditures by
source and year, 1960 to 1996

1.60 -

1.40 -

1.20 -

1.00 -
`s
2 0.80 -

+ DentalServices    +- Dental Services
CPVAIIltemsCPI      CPI/AII Medical
             CareCPI
Source: U.S.Bureau of labor Statistics 1999.

-.- Dental Services
(PI/Physician
ServicesCPI

(29.7 percent), followed by blacks
(32.4 percent), a pattern seen in
medical insurance as well. Because
private dental insurance is
typically an employment-related
benefit, some individuals lose their
dental coverage when they retire.
As a consequence, people 65 and
older reported the lowest levels of
coverage (NCHS 1992).

Although over 14 percent of
children under 18 have no form of
private or public medical insur-
ance, more than twice that many,
23 million children, have no dental
insurance (Vargas et al. 2000). Over
15 percent of persons 18 and older
have no form of medical insur-
ance, but 3 times as many, over 85
million persons, have no form of
dental insurance (NCHS 2000).

The Changing Market

Increasingly, private dental insur-
ance plans are entering into con-
tractual agreements with dentists.
The purpose of these agreements is
to shift some or all of the financial
risk to the clinician, the benefici-
ary, or both. These alternative

                  Year
Sources: HCFA 2000b,U.S.BureauoftheCensus1998,U.S.BureauoflaborStatistics1999.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          231


Provision of Oral Health Care

reimbursement systems have been labeled "managed
dental care." As defined by the Physician Payment
Review Commission (1997), managed care is "any
system of health services payment or delivery
arrangements where the health plan attempts to con-
trol or coordinate use of health services by its
enrolled members in order to contain health expen-
ditures, improve quality, or both."

In dentistry the primary alternative reimburse-
ment systems in place are the dental health mainte-

FIGURE 9.6
Source of funds for dental and physician services,
United States,1997

Out of pocket

Private insurance

         0    10    20    30    40    50    60
               Percentage

         &I Dental Service   H Physician Service
Source:Yorketal.1995.

nance organization, dental preferred provider organi-
zation (PPO), and dental referral network. Between
1995 and 1996, dental HMO enrollment grew 17.7
percent; it grew another 8.6 percent between 1996
and 1997, for a total enrollment of approximately
26.5 million people. Dental PPO enrollment grew
30.9 percent in 1996 and 32.6 percent in 1997 to a
total of about 24.5 million people (Table 9.6). Dental
indemnity increased by 10.1 percent in 1996 and 2.6
percent in 1997 to about 90.6 million persons
(NADP 1998). By comparison, the Health Care
Financing Administration reported an increased shift
of employers and employees from indemnity to man-
aged care health plans, in the past several years.
According to HCFA, 86 percent of all insured work-
ers were covered by managed care health plans in
1998, an increase of 54 percent over 1993 (HCFA
2OOOb).

The rapid changes in the health care environ-
ment have emphasized the development of perform-
ance measures that can be used by both public and
private purchasers of care, consumers, and health
care professionals. Specifically, health care quality
oversight has focused on the collection and use of
data that provide the basis for assessing and moni-
toring care delivery performance. These performance

L

FIGURE 9.7

Dental insurance coverage, United States, 1989

Percentage of persons aged 2 and older who are covered by private
dental insurance, by sex
1

Male

Female

39.6

   0    10   20   30   40   50   60   70                0    10   20   30   40   50   60   70

Percentage of persons aged 2 and older who are covered by private      Percentage of persons with private dental insurance with an
dental insurance, by race/ethnicity                       education level of

White

Black

Hispanic b 29.7

,     I     I     I     I     I         /

0    10   20   30   40   50   60   70

Sources: ADA1997b.NCHS1992.

Percentage of families with private dental insurance with an
annual income of

Less than 9 years

9 to 11 years


   12 years


13 years or more                      51.4

         ,                  ,     ,     1     ,

        0    10   20   30   40   50   60   70

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


\,r outcome measures require development and test-
,nL, to determine their reliability and validity, and
~c&.~d on enhanced data collection and information
;,.stems for their application. An example of per-
lormance measures is the Health Plan Employer Data
.,,,d fnformation Set (HEDIS), a set of standardized
rr,e;rsures developed by the National Committee for
QLtality Assurance. Recently, pediatric oral health
lncasures have been reviewed and additional meas-
[rres proposed for HEDIS consideration (Crall et al.
1999). A framework for the development of outcome
IIlcasures for oral health care has been proposed
,rfong four dimensions: biologic, clinical, psychoso-
ctal. and economic. This schema is designed for
Potential use by patients, health care providers, pur-
chasers of care, and the public (Bader and Ismail
1999). Efforts are needed to proceed with the devel-
opment and testing of reliable and valid outcome
measures in all four dimensions for oral health care
and their incorporation into practice and programs.

Federal and State Programs

Medicaid

The Medicaid program, established as Title XIX of
the Social Security Amendments of 1965, was
designed to provide health care for all indigent and
medically indigent persons, with funding shared
between federal and state governments. Although
states differ in eligibility rules and expenditures for
services provided, amendments to the Medicaid pro-
gram instituted in 1968 required all states to include
dental care for individuals under 21 years of age as
part of the Early and Periodic Screening, Diag-
nostic, and Treatment (EPSDT) service. In addition,
the Omnibus Budget Reconciliation Act of 1989
required the provision of all medically needed dental
services for EPSDT beneficiaries beyond what is cov-
ered under the state's Medicaid plan. Medicaid funds

be eligible, family income may be
    -

TABLE 9.6
Estimated number of dental plan members and annual percentage change by mar-
ket sector and year, United States, 1995 to 1997

as high as twice the federal pover-
ty level, exceeding eligibility for
Medicaid. The states must cover
immunizations and well-child care

Provision of Oral Health Care

dental care for low-income individuals and persons
with disabilities at usual and customary fees, or the
Medicaid fee schedule rate, whichever is lower.
Although some states have increased their medical
reimbursement to 80 percent of usual and customary
fees, the norm is 47 percent (Colby 1994).
In 1998, total governmental outlays for dental
services were $2.3 billion ($1.3 billion federal, $1.0
billion state and local). Of this total, $2.0 billion rep-
resented dental Medicaid expenditures, which is
approximately 1.25 percent of the $159.6 billion des-
ignated for all Medicaid personal health care expen-
ditures, a proportion that is much lower than it was
in the early years of the Medicaid program (HCFA
2OOOb). Some states have tightened their eligibility
requirements and have reduced the range of covered
dental services for adults. States have not been able to
meet the mandatory components of the EPSDT den-
tal program, partly because of low levels of reim-
bursement to providers and difficulties regarding
access to care for eligible enrollees.
Eligibility for Medicaid, as with any form of
insurance coverage, does not ensure receipt of ade-
quate dental care. A 1996 report by the USDHHS
Inspector General estimated that 80.3 percent of eli-
gible infants, children, and youth up to 20 years of
age, for whom disease levels are known to be high
(see Chapter 4), did not receive preventive dental
services (USDHHS 1996). The report stated that the
reasons were complex and included the following
factors: few dentists see Medicaid patients, Medicaid
families give dental services low priority, and the
youngest patients are the least likely to obtain care.

The State Children's Health Insurance Program
Legislation passed by Congress in 1997 created the
State Children's Health Insurance Program, which
provides billions of dollars to states (supplemented
by required state contributions) to extend coverage
for health care to uninsured children. For a child to

Number of Members

Percentage  Percentage
Change 1995 Change 1996

within specified program require-
ments, but are otherwise free to

        Year End 1995  Year End 1996  Year End 1997    to 1996    to 1997   decide how the money is spent. By
Dental HMO     20,697,452   24,359,434   26,457,650     17.7      8.6    midsummer 1999, only 1.3 million
Dental PPO     14,085,181   18,442,216   24,460,062     30.9      32.6    of the 10 million uninsured chil-
Dental referral    1,920,330    5033,866    $453,264     162.1      a.3    dren had been enrolled in SCHIP
Dental indemnity   80,255,346   88,323,803   90,64O,826      10.1      2.6    with some states the to
                                                       funds
Total/average    116,958,309   136,159,319   i47,oii,ao2      16.4      8.0             using
                         expand Medicaid coverage and
5ource:Data from NADP 1998.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL         233


others designing new programs that may or may not
include dental care (see Chapter 10 for more details).

Medicare

Dental services covered under the Medicare program
are limited. Unlike Medicaid, Medicare (Title XVIII
of the Social Security Amendments of 1965) is
financed totally by the federal government; it was
originally designed to provide physician and hospital
services for all persons 65 and older, rich and poor
alike. Medicare is split into hospital insurance (Part
A) and physicians' services (Part B), the latter being
a voluntary supplemental insurance program paid for
by the individual.

Medicare was not designed to insure routine
dental care. Rather, as an exception to the statutory
exclusion from Medicare of dental services, it covers
dental services needed by hospitalized patients with
specific conditions. These include dental services in
connection with jaw fractures or with preparation of
patients for radiation in cases of oral and pharyngeal
cancers or as part of a comprehensive workup prior
to renal transplant surgery (Table 9.7). Total
Medicare payments for dental services in 1998 were
$0.1 billion (HCFA 2oOOb).

Recently, the Institute of Medicine (IOM) was
asked to study the short- and long-term benefits and
costs to the Medicare program of extending coverage
to include "medically necessary dental care" to bene-
ficiaries for a limited number of coqditions. In the
Medicare program, the term "medically necessary
dental services" is used narrowly to mean care that
occurs as the direct result of an underlying medical
condition or its treatment or that has a direct effect

on such a condition. Under this definition, care for
serious periodontal disease would not be "medically
necessary" unless, for example, it threatened the
health of someone with leukemia or was caused by
the disease or its treatment (and could otherwise be
health threatening if untreated). The IOM report
noted that such a restrictive definition may suggest
that "periodontal or other tooth-related infections are
somehow different from infections elsewhere" and
"imply that the mouth can be isolated from the rest
of the body, notions neither scientifically based nor
constructive for individual or public health."
The IOM committee concluded that it is reason-
able for Medicare to cover both tooth-preserving care
and extractions for patients undergoing radiation for
oral and pharyngeal cancers, and a dental examina-
tion, cleaning of teeth, and treatment of acute infec-
tions of the teeth or gingiva for a leukemia patient
prior to chemotherapy. The report suggested that fur-
ther study would enable recommendations to be
made-on a condition-by-condition basis-for cov-
erage of effective dental services needed in conjunc-
tion with surgery, chemotherapy, and radiation for
other conditions (Field et al. 1999).

FACTORS AFFECTiNG THE CAPACITY
TO MEET ORAL HEALTH NEEDS
The nation's capacity to provide care that is accessible
and acceptable to address the oral health needs and
wants of Americans in the next century is challenged
by numerous factors. Among them are concerns
about a declining dentist-to-population ratio, an
inequitable distribution of oral health care providers,
a low number of underrepresented minorities

TABLE 9.7
Current Medicare coverage for dental services

Clinical Condition                   Covered Service               Part A (hospital)  Part B (physician)
Underlying medical condition and clinical status require   Inpatient hospital services only                 X
hospitalization for dental care
Severity of dental procedure requires hospitalization for   Inpatient hospital services only                X
dental care
Any oral condition for which nondental services are covered  All dental services if incident to and an integral part of               X
                    covered procedure or service
Neoplastic jaw disease              Extractions prior to radiation                            X

Renal transplant surgery             Oral/dental examination on an inpatient basis          X          X
                                             (if dentist is on   (outpatient
                                         staff at hospital   payment for
                                                      where service    physicians only)
                                         is provided)

Source: HCFAZCOOb.

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


~,ppf~ing to dental schools, the effects of the cost of
Lfcntal education and graduation debt on decisions to
pursue a career in dentistry, the type and location of
practice upon graduation, current and expected
&ortages in personnel for dental school faculties and
CIral health research, and an evolving curriculum
\\-ith an ever-expanding knowledge base.

Numbers of Dental Personnel

The ratio of dentists to the total population is declin-
ing: in 1996, there were approximately 58.4 profes-
stonally active dentists per 100,000 people in the
C'mred States, down from 59.1 in 1990. The current
ratio equates to one dentist for every 1,700 people
IHRS~\ 1999). The dentist-to-population ratio is a
very crude measure of dental care capacity, because it
does not consider dentist productivity (affected by
hours worked, use of auxiliary personnel, and mix of
services provided) or location of practices relative to
underserved populations; there is no agreement
on the number that is optimal. Nevertheless, this
ratio does indicate trends. By 2020 the dentist-to-
population ratio is expected to drop to 53.7 per
100,000 (Figure 9.8). Moreover, it appears that the
absolute number of active dentists will decline after
2000. In part, this drop reflects the retirement of
older dentists (estimated to range from 2,500 to over
+.300 per year between 1996 and 2021 (HRSA 1999)
with insufficient numbers of new graduates (estimat-
ed at about 4,000 per year) replacing them (ADA
1999). In comparison, the ratio of active physicians
to population has been increasing; it was 251.6 per
100,000 in 1997, up from 226.1 in 1990 (HRSA
1999). The trend in the reduction of the dentist-to-
population ratio and the absolute number of dentists

implies a shortage of dentists in the future. This trend
may, however, be offset by innovation in dental prac-
tice. However, if the impact of future technology
changes is similar to that produced by changes over
the past 20 to 30 years, it will not substantially affect
the projections.

The entering supply of dentists and dental
hygienists depends on the number of graduates from
dental and dental hygiene schools. The number of
applicants to dental schools almost doubled between
1989 and 1997. However, the number of applicants
declined by 4 percent in 1998, with further declines
of 8 to 10 percent expected for 1999 and 2000. Based
on the sharp decline that has occurred in the number
of individuals taking the Dental Admissions Test,
similar declines may continue into the early 2000s.
During the 1989-97 time period, dental school first-
year enrollment increased only about 9 percent. Little
further growth in enrollment is anticipated because
the current infrastructure in dental education has
limited ability to expand, coupled with the declines
occurring in dental school applicants. Along with
concerns about a possible shortage of dentists, there
is concern that the pool of qualified applicants may
not be sufficient to supply a dental workforce that
meets the needs of society, as well as the needs of
dental education and research.

In contrast, the number of dental hygiene pro-
grams and students has increased almost 18 percent
since 1990. The number of first-year dental hygiene
students currently stands at 6,000, more than recov-
ering from the 15 percent decline that occurred in
these programs during the late 1970s through the
mid- 1980s. The last 4 years has seen a steady 11 per-
cent growth in dental hygiene positions.

The numbers of dentists and sites of health pro-

FIGURE 9.8
Dentistsper100,000U.S.population,l950to2020

70

60

      1950   1960   1970   1980   1990   2000   2005   2010   2015   2020

Sources: HRSA 1999,ADA 1996.

fession education programs have
been influenced by government
policies and social factors. During
the late 1950s an emerging short-
age of health care providers
(including dentists) was expected
arising from the "baby boom" that
began in  the late 1940s.
Beginning in the early 196Os, the
federal government supported an
expansion in the number of med-
ical and dental schools and in
class sizes. By the mid-1970s the
number of dental schools had
grown from 47 to 60. First-year
enrollments grew from 3,612 to
6,301. By the mid-1970s a possi-
ble oversupply of physicians and

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           -?C
                                                                a--


Pro\~ision of Oral Health Care

dentists became a concern. Government support for all
health profession education was substantially reduced.
Through the 1980s dental schools reduced their
enrollment by 37 percent. By 1993, six dental
schools, all affiliated with private universities, had
closed.

Following the growth in dental school enroll-
ments that has occurred since 1989, the 1998-99
first-year enrollment stood at 4,268 in 55 dental
schools located in 33 states, the Commonwealth of
Puerto Rico, and the District of Columbia. One more
dental school (at Northwestern University) is sched-
uled to close in 2001. One is scheduled to open in
2001, at the University of Nevada at Las Vegas (ADA
1996). Total dental school enrollment in 1998-99
was 17,033 students, down from a peak of 22,842 in
1980-81.

Sex and Racial/Ethnic Composition of
Dental Personnel

The number and percentage of women in the dental
and medical professions have continued to increase.
Thirty years ago, women represented 1.3 percent of
first-year enrollment in dental schools. By 1988, that
proportion had risen to 35.7 percent, a level that has
been relatively constant over the past 10 years.
Recent trends indicate that the proportion of women
in dentistry will continue to increase: by 2000, more
than 26,000 women will be active practitioners; this
is almost twice the number in 1990 (HRSA 1993,
1999). However, data from 1990 show `that the pro-
portion of dentists who were women (9.5 percent)
was smaller than the proportion of female physicians
(17.0 percent), female pharmacists (28.9 percent),
and female optometrists (14.6 percent). The percent-
age change in the numbers of first professional
degrees conferred to women by health field of study
and racdethnicity from 1981 through 1990 shows
that although dentistry is second lowest (next to allo-
pathic medicine), the percentage changes for
Hispanic women and American Indian/Alaska Native
(AIAN) women in dentistry were among the highest
(46.7 percent and 500.0 percent, respectively), even
though the actual numbers were low (HRSA 1993).

The participation of racial and ethnic minorities
in dentistry does not mirror the dramatic increase in
the entrance of women into the profession in the
course of a single generation. The demographic pro-
file of the U.S. population is changing rapidly, and is
likely to continue to do so, with continued increases
in racial and ethnic minority groups in comparison to
whites. However, these trends and projections are not
reflected in the dental or medical workforce.

The overall percentage of minority students has
increased significantly, to the point that, in 1998, a
little over 34 percent of the first-year students were
members of a minority group. This overall percent-
age is up from 13 percent in 1980. However, the pri-
mary increase has come among Asian/Pacific Islander
students, increasing from about 5 percent of enroll-
ment in 1980 to almost 25 percent in 1998. At the
same time, the proportion of black/African American,
HispanicLatino, and American Indian students,
together, has shown only a small percentage point
increase since 1980, from about 7.5 percent to nearly
10 percent. The percentage of first-year enrollment in
1998 for black/African American students was 4.4
percent. It was 4.9 percent fof Hispanic/Latin0 stu-
dents and 0.4 percent for American Indians. These
percentages for black/African American, Hispanic/
Latino, and American Indian students are far less
than their percentages in the U.S. population. In
addition, a specific look at black dental school grad-
uates during the 1980s and 1990s showed that
although the number of black female graduates had
increased, the increase was insufficient to offset the
decline in black male graduates (HRSA 1993).

In 1996, African Americans made up 12.0 per-
cent of the general population, but only 2.2 percent
of active dentists (Brown and Lazar 1999). Similarly
under-represented were Hispanics, who accounted for
10.7 percent of the population, but only 2.8 percent
of active dentists. The Hispanic population is the
fastest-growing segment of the population and by
2002 will exceed the number of blacks (U.S. Bureau
of the Census 2000). American Indians, 0.7 percent
of the population, represented only 0.2 percent of
active dentists. Table 9.8 shows the 1996 dentist-to-
population ratios by racdethnicity of the dentist.

As has been shown in Chapter 4 and elsewhere
in this report, oral health problems disproportionate-
ly affect disadvantaged populations among underrep-
resented minority groups. This disparity will not be
ameliorated through technology improvements or
increases in clinical productivity. Moreover, recent
data show that underrepresented racial and ethnic
minority dentists are more likely to provide care to
minority populations. In 1996, black dentists report-
ed that 61.8 percent of their patients were black, and
Hispanic dentists reported that Hispanic patients
made up 45.4 percent of their practice; 76.6 percent
of white dentists' patients were white (Brown and
Lazar 1999). A recent study of the role of black and
Hispanic physicians in the provision of care for
underserved populations demonstrated that these
physicians practiced in communities with a higher
percentage of their racial or ethnic group (Komaromy

-

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


21 31. 1996). Also, black physicians saw more
\lcdicaid patients, and Hispanic physicians more
l,n,nsured patients, than other physicians. If this pat-
tcm of treatment of Medicaid patients and the un-
,nsured is similar for dentists, the underrepresenta-
tlon of minority dentists may also contribute to the
unmet needs of minority patients. This issue war-
rants further research.

Regarding the importance of reaching parity in
lhe dental PrOfeSSiOn, the American Association of
Dental Schools comments, "The production of
underrepresented minority [IBM] dentists is totally
cJut of synch with projected U.S. demographics. The
L'.S. population is expected to increase by 60 percent,
reaching 394 million by 2050. At that time, nearly
half (48 percent) of the population will be constitut-
cd from racial and ethnic minority groups. Strategic
measures are needed to increase the number of URM
dental graduates that will improve access to care for
minorities throughout the nation" (AADS 1999).

Recruitment and retention of underrepresented
minorities and women into the health professions
will continue to be a challenge in the coming years.
Activities such as enrichment programs in science
and mathematics for grades K-12 and precollege are
designed to increase the interest and capacity of all
students, including women and underrepresented
minorities, in health professions and science careers,
These efforts will require careful design, implementa-
tion, and evaluation.

Student Indebtedness and Its Effects

The American Association of Dental Schools reports
that in 1998 graduates of dental schools had
incurred, on average, over $84,000 in educational
debt (G. Luke, AADS, personal communication, 1999).
Average debt ranged from $71,000 for graduates of
public schools to $98,000 for private/state-related
schools and $108,000 for private schools. This was
over I4 percent more than the educational debt of
graduating medical students. Specialty education

Provision of Oral Health Care

may result in additional debt. Setting up an office
involves additional costs.* In the end the burden of
debts to be repaid is a driving force in decision mak-
ing for many new graduates regarding career direc-
tion and practice site.

Fewer dentists establish practices in low-income
communities. The National Health Service Corps
(NHSC) was created in 1970 as a program of the U.S.
Public Health Service to provide financial assistance
to health professionals who agree to locate in a
Health Professional Shortage Area (HPSA). The
NHSC offers programs for both students and clini-
cians, including scholarships, loan repayment pro-
grams, and rotations in Community Health Centers.
Currently, there are approximately 2,526 clinicians,
including 306 dental care providers, delivering care
to more than 4.6 million people through these pro-
grams. Only about 6 percent of the dental need is
currently being met in the approved 1,198 dental
HPSAs with a population of 25.9 million. It is esti-
mated that an additional 4,873 dental care providers
are needed to meet the current demand. In fiscal year
(FY) 1999 the NHSC provided 139 new and contin-
uing dental loan repayment awards, valued at $9 mil-
lion. In FY 1998, there were 308 dental NHSC schol-
ars, a 40 percent increase since 1994. Outreach and
program development are critical to foster growth
and create opportunities for placing dentists in
underserved areas, where the needs are great.

In addition to the NHSC, the Indian Health
Service operates a loan repayment program to identi-
fy health professionals who will practice full-time at
an IHS facility or approved tribally managed site in
exchange for repayment of their eligible health pro-
fessions educational loans. Funding for this program
has remained level for the past 8 years, in spite of the
fact that student debt has nearly doubled during that
time.

Primary care dental residency programs support-
ed by Health Professions Training Funds also play a
role in meeting the oral health care needs of the
nation. An evaluation performed for the USDHHS

TABLE 9.8
U.S. dentist-to-population ratios by race/ethnic@ of the dentist, 1996



                         Total       Black

U.S. population                 265,189,OOO   31,933,oOO
Activedentists                   154,900      5,201
Numberofdentistsper 100,000 population          58.4       16.3
Numberofpeople per dentist             1:1,712      1 :6,140

Source: H&A1999

Hispanic

28,092,OOO
  5,178
   18.4
1 :5,425

Asian/Pacific    American
Islander     Indian

9,181,OOO    1,954,ooo
  10,693       194
   116.5        9.9
  1:859    1:10,072

White

194,029,OOO
133,634
   68.9
1:1,452

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          237


found that 87 percent of General Dentistry trainees
remain in primary care practice and over 30 percent
of General Dentistry program graduates receiving
federal support over the last 4 years entered practice
in underserved communities.

  The issue of indebtedness not only is an impor-
tant consideration for the graduate in deciding where
to practice, but also has become an obstacle to col-
lege students contemplating a career in dentistry and
other health professions. Moreover, it can affect the
choices graduates make about whether they will pur-
sue careers in academia or research. The National
Institutes of Health created three loan repayment
programs to attract health care professionals to
research in its facilities. In addition, innovative loan
repayment incentives, such as awarding "extramural"
loan repayment to researchers working in dental edu-
cation institutes, have been proposed to overcome
the current critical shortage of dental faculty/
researchers.

Personnel Needs for Faculty and
Clinical Research

The education and training of dentists and allied den-
tal health personnel are essential to the country%
capacity to meet its oral health needs. Dental educa-
tion institutions and their allied academic health cen-
ters play a critical role in providing the infrastructure
for oral, dental, and craniofacial research and contin-
uing education for dental professionals. A task force
report on the future of dental school faculty shows
that the number of faculty vacancies in the clinical
sciences has more than doubled in recent years, ris-
ing from 139 in 1992-93 to more than 300 in 1999
(AADS 1999). The task force projects that retire-
ments will rapidly increase in the coming decade
given the average age of the faculty (47 percent of all
faculty members are aged 50 and older, and 19 per-
cent are 61 and older). Kennedy (1990) estimated
that dental institutions need at least 208 to 218 new
faculty members each year, based on a faculty
turnover rate of approximately 33 percent every 5
years.

Curriculum Needs

New technologies such as telehealth, bioinformatics,
and virtual reality, as well as databases specifying
human, animal, and microbial genomes, are altering
public awareness, attitudes, and behavior regarding
health issues. The new knowledge and tools available
are also changing dramatically how health care pro-

fessionals are taught, how they learn, how they prac-
tice, and how they retain clinical practices.

These developments, along with new paradigms
for the treatment of oral, dental, and craniofacial dis-
eases and disorders, have led to several recent studies
of oral health professional education and curricula
(Field 1995). A 1995 Institute of Medicine study on
the future of dental education called for greater inte-
gration and collaboration of dental schools with the
parent university and academic health center, a com-
mitment to research programs and the building of
research capacity, and an enrichment of the curricu-
lum to incorporate new scientific knowledge and its
transformation into clinicalapplications. The report's
first strategic policy principle affirmed that "oral
health is an integral part of total health, and oral
health care is an integral part of comprehensive
health care, including primary care." Ideally, curricu-
la for all health professional schools should reflect
this principle by integrating knowledge and manage-
ment of oral and medical health and disease.

Work is beginning on revisions to educational
materials necessitated by these advances in research
and technology. Initial steps are being taken to
increase emphasis on interdisciplinary training, clin-
ical research, and orientation to cultural competency
in health professional education. The National
Coalition for Health Professional Education in
Genetics is promoting the incorporation of genetics,
genomics, and proteinomics into predoctoral pro-
grams to prepare future health professionals to inte-
grate genetics into practice. Other developments that
need to be addressed include HIV disease and other
emerging and reemerging infectious diseases, in-
creased understanding of gender health issues, man-
agement of chronic pain, and the growing numbers
of aging baby boomers and older Americans with
complex and chronic health problems. For example,
instruction on the special needs of individuals whose
oral health is compromised by systemic diseases or
disease treatments and on the heightened quality-of-
life expectations of young and middle-aged adults
should be incorporated into the curricula. In addi-
tion, in Area Health Education Centers in some
states, health profession students work together to
care for patients in underserved, rural, or disadvan-
taged populations.

The HIV/AIDS Dental Reimbursement program
assists dental education programs in meeting the
HIV/AIDS community's significant need for oral
health care services. This program trains dental
students and residents in the care and treatment of
those living with this chronic disease. A federal-

238

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


,tr5titutional partnership provides funds to dental
,uucation institutions to partially reimburse for the
iosts of providing oral health care services to people
li\.ing with HIV and AIDS.

AS the health professional curriculum evolves, so
must efforts in K-12 education and beyond to
,tllprove the publics health literacy. Efforts directed
tc>\vard improving science and health knowledge and
,ittitudes and at implementing health-promoting
practices have begun; these can contribute to an
enhanced partnership between patients and their
health care providers.

Taking Care of Those Most in Need

The capacity to care for those most in need requires
not only an adequate number of individuals to pro-
vide the care, but also an equitable distribution of
providers to ensure the availability of care. In addi-
tion, sufficient financial resources must be available
to support the delivery of and reimbursement for care
provided to those most in need. Attention must also
be given to a quality of care that ensures that the serv-
ices provided fulfill the needs and functional require-
ments of the patients. Although the proportion of the
population that uses dental services continues to
increase, disparities remain (see Chapter 4).

  A recent review of the literature related to access
to care has identified many of the factors associated
with these disparities. The lack of dental insurance
emerged as a highly significant factor (Isman and
lsman 1997). A series of reports demonstrates that
privately insured individuals of all ages are more like-
ly to get dental care when they need it than are the
uninsured (Bloom et al. 1997. Cohen et al. 1997,
Simpson et al. 1997). Lack of insurance was found to
be an even more significant barrier to gaining pri-
mary care access for children than either poverty or
minority status (Newacheck et al. 1997).

Once access to care has been established, there is
greater likelihood that individuals will adopt preven-
tive practices. Although a causal relationship has not
been established, Wagener et al. (1992) found that
brushing with a fluoride dentifrice and using dietary
fluoride supplements were more frequent among pre-
school children who had had a dental visit in the past
year than among those who had not. In contrast, as
discussed in Chapter 4, one of the most common rea-
sons cited by individuals in all income and education
groups for not having made a dental visit was that
they did not perceive that they had a problem. This
implies a lack of awareness that attaining and main-
taining good oral health and preventing disease

require not only self-care but also professional oral
health care.

Federal and state statistics show strong and con-
sistent racial and ethnic disparities among U.S. chil-
dren in disease occurrence and severity, untreated
dental disease, access to dental care, and use of pre-
ventive services (see Chapter 4). Vulnerable child
populations as well as the elderly, individuals with
disabilities, people with HIV, migrant workers, and
homeless persons pose an additional set of chal-
lenges. These populations require health care
providers sensitive to cultural and social issues who
are capable of addressing complex problems that
demand integrated dental and medical care. The oral,
dental, and craniofacial and medical care curricula
are vital in preparing dental and &her health care
providers to coordinate and integrate care for these
individuals.

  The issues of oral health and the underserved
have been addressed in a policy paper, Oral Health
for All: Policy Jor Available, Accessible and Accept-
able Care (Warren 1999). This report makes recom-
mendations regarding financial barriers to care,
integration of oral health services into health care
delivery, capacity to meet oral health needs, cultur-
al competency of health care providers, and educa-
tion and oral professional practice requirements
to meet the oral health care needs of underserved
populations.

A survey of dental care reported that more than
half of the responding private practice dentists pro-
vided some charitable care to low-income popula-
tions in 1996 (ADA 1998b). Although access-to-care
dental programs for low-income populations are sup-
ported by many dental societies, this generosity falls
well short of meeting the needs of these populations,
which also require community-based programs
(Waldman 1999) (see Chapter 7). Programs such as
Community and Migrant Health Centers serve hard-
to-reach populations. In 1996, more than half of such
centers provided dental services, serving more than 1
million people (J. Anderson, personal communica-
tion, 1999).

TWENTY-FIRST CENTURY
CHALLENGES: WHAT LIES AHEAD?
The United States is witnessing unprecedented
changes in demography, patterns of disease and
disorders, and the nature of health care. The
imperative to keep abreast of advances in science and
technology is already evident in dentistry and
medicine, aided by access to multiple information

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENER4L          239


Provision of Oral Health Care

systems. In addition to the Internet and continuing
dental education, the new century will see continued
growth in imaging systems, computer-assisted
technology, teledentistry and telemedicine. improved
diagnostics and therapeutics, and new biomaterials
and  other biotechnology products. Genetic
information will play an increasing role in assessing a
patient's risk for disease and in planning treatments.

Although some information is available on the
effectiveness, cost-effectiveness, and outcomes asso-
ciated with health care treatment, further research
will be needed to determine "best practices"-which
treatments work for which patients, under what cir-
cumstances, and at what cost. Treatment planning
will incorporate outcome measures and patient pref-
erences. Systematic reviews of the existing literature
will help promote an evidence-based approach to
dental and medical care. In addition, comprehensive
diagnostic and treatment codes, as well as a process
by which new technologies can be incorporated
appropriately, will be needed.

The dental profession has been at the forefront of
efforts to prevent disease and enhance general health
and the quality of life. Efforts such as community
water fluoridation, over-the-counter fluoride prod-
ucts, and dental sealants represent a preventive ori-
entation that has been associated with the dental pro-
fession for half a century. Dentistry is continuing to
be responsive to the ever-rising expectations of
patients. Increases in the provision of fee-for-service
cosmetic dentistry, adult orthodontics, and dental
implants are among the trends already in evidence
and expected to grow.

As the knowledge base regarding the relation-
ships between oral health and general health increas-
es, so too will the need for greater coordination of
dental and medical services. Efforts to improve car-
diac care, for example, may include treatment of
periodontal diseases. Prenatal care may come to
include a dental evaluation and treatment to reduce
the risk of preterm, low-birth-weight deliveries.
Regular oral examinations and periodontal treatment
for diabetic patients may become an important com-
ponent in disease control. Partnerships will need to
be expanded and new ones created among the private
dental, medical, and public health components.

A challenge facing the health professions will be
to expand community-based disease prevention and
personal oral health care to meet the needs of popu-
lations. Questions of access and barriers to care must
be addressed and satisfactory solutions found to
ensure that there is care for all who seek it.

The extent to which these predicted structural,
organizational, and thematic changes will affect the
nation's capacity and commitment to provide oral
health care is not certain. The nation's health promo-
tion and disease prevention objectives, which include
oral health objectives, serve as a critical guide. How
successful a changed care system will be in address-
ing the oral health needs and wants of the nation can
be measured in several ways. These include reduc-
tions in health disparities in the population, decreas-
es in the overall incidence and prevalence rates of
diseases for the entire population, improved func-
tional status, lower costs, reduced mortality rates,
and enhanced health and quality of life.

FINDINGS

   a  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.

   0  Expansion of community-based disease
prevention 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.
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 reim-
bursement rates, and administrative burdens for both
patient and provider.

240

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


   o  A narrow definition of "medically necessary
ci,.nt31 care" currently limits oral health services for
rl,anv insured persons, particularly the elderly.
   o  The dentist-to-population ratio is declining,
???????*? concern as to the capability of the dental
,,-orkforce to meet the emerging demands of society
.,t,d provide required services efficiently.
   o  An estimated 25 million individuals reside in
.trcas lacking adequate dental care services, as
defined by Health Professional Shortage Area (HPSA)
criteria.
   o  Educational debt has increased, affecting
both career choices and practice location.
   a  Disparities exist in the oral health profession
\corkforce 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.
   a  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 education:
oral, dental, and craniofacial research; and, ultimately,
the health of the public.
   o  Reliable and valid measures of oral health
outcomes do not exist and need to be developed, val-
idated, and incorporated into practice and programs.

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National Association of Dental Plans (NADP). 1998
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Simpson G, Bloom B, Cohen RA. Parsons PE. Access to
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Wagener DK, Nourjah P Horowitz AM. Trends in child-
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Waitzman N, Scheffler RM, Roman0 PS. The cost of
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Waldman HB. Why not Medicaid dentistry. NY State
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Warren RC. Oral health for all: policy for available.
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3;         ORAL HEALTH IN AMERIC.~: A REPORT OF THE SURGEON GENERAL


What Are the Needs and
Opportunities to Enhance
Oral Health?

Many factors have been implicated in determining oral health; and they have varying effects across
the life stages. These factors are discussed in Chapter 10, where the incorporation of determinants
of health in major public health initiatives such as Healthy People 2010 is highlighted. Essential
factors include individual biology and lifestyle, the physical and social environment (including
whether a community supports health-promoting measures such as water fluoridation), and the
organization of health care. These factors are not independent but interact. An individual with no
inherent health problems and a healthy lifestyle also needs to live in a healthy environment with
ready access to and ability to pay for health care services. Studies of oral health over the lifetime
highlight the interaction of these factors: The chapter focuses primarily on America's most
vulnerable populations-children and the elderly-where issues of access, insurance, and
reimbursement are critical in determining oral health and limit the delivery of care for individuals
with special needs and those residing in institutions.

Chapter 11 focuses on the future and the promise of research born of the revolutions in
genetics, biotechnology, and biomimetics- the new science of tissue repair and regeneration.
Global demographics and technologic innovations signal the need for health literacy and universal
access to care if we are to enhance oral health for all Americans.

Chapter 12 highlights the major findings and recommendations of the report. Everyone-
individuals, communities, policymakers, health care providers, educators, and researchers-has a
role in improving and promoting oral health. The major conclusion of the report is that oral health
is essential to general health and well-being. A National Oral Health Plan will facilitate the means
to improve the nation's oral health. The chapter concludes with five actions proposed toward that
end: strengthen understanding of oral health and disease by the public, practitioners, and
policymakers; accelerate building the science and evidence base; enhance health infrastructure and
program integration; reduce barriers to oral health care; and increase public-private partnerships to
address health disparities.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

243


Factors Affecting Oral Health
over the Life Span

When the World Health Organization (WHO)
expanded the definition of health in 1948 to mean a
complete state of physical, mental, and social well-
being, and not simply the absence of infirmity, the
move stimulated research to define the major factors
affecting health and well-being. Investigators devel-
oped model systems of "health-related quality of life"
and "oral-health-related quality of life." Chapter 6
describes such models and provides examples of
indices and instruments used to measure quality of
life. What these models have in common are factors
that include biological or physiological measures of
health, but also take into consideration an individ-
ual's ability to function normally in the routines of
daily living, experience symptom relief, and fulfill
usual roles in personal relationships and in family,
work, civic, and social interactions. The researchers
note that the factors are not mutually exclusive, but
interact, feeding back on one another. Often the
measurements include an individual's subjective
assessment of quality of life before and after the onset
of the disease or disorder and its treatment.

In the context of a broadened concept of health,
there is clearly more to attaining and maintaining
good health and quality of life than seeking regular
medical and dental checkups and performing daily
personal hygiene routines. Other factors that are
important have been incorporated in a number of
models of "determinants of health," which are
described in the next section. These models recog-
nize that the determinants themselves are subject to
change with changes in society and also vary in their
salience over the lifetime of an individual. The con-
cluding sections of the chapter illustrate this variabil-
ity by examining oral health at successive stages of
the life span, from childhood to old age. The vulner-
abilities of selected subpopulations within each age
group are highlighted, with particular emphasis on
the plight of poor children and many older
Americans.

HEALTH IN THE CONTEXT OF SOCIETY
Thinking about what makes people healthy has
inspired philosophers and historians over the cen-
turies. Following is a brief overview that points to
commonalities among the models proposed.

Historical Models

As early as the fifth century B.C., Hippocrates con-
sidered it essential that physicians know each
patient's way of life, habitation, work, and dietary
habits (Porter 1997). He counseled those who were
considering a new city of residence to take into
account the geography, water supply, and behavior of
the citizens, specifically whether they drank and ate
excessively, were lazy, or enjoyed exercise and hard
work (Rose 1993).

Recent accounts of the history of medicine and
public health similarly recognize the roles of envi-
ronment, lifestyle, and the health care provider in
determining health. Pine (1997) has described four
phases in the history of public health. Phase 1, from
the middle to the late lSOOs, was characterized by
urbanization and industrialization that significantly
contributed to suboptimal living conditions for
workers. Sanitary reforms were the hallmarks of pub-
lic health achievement during this period. In addi-
tion, epidemiological studies began to demonstrate
causal relationships between compromised health
status and conditions such as malnutrition and poor
hygiene.

The second phase, between 1880 and 1930, was
characterized by advances in bacteriology and
immunology. Increasingly, the prevention of disease
was being applied to populations as well as individu-
als. The third phase, from 1930 through 1974, was a
therapeutic period. The hospital became the essential
base and focus for medical services, and medical
treatment grew more complex. With the development

ORAL HEALTH IN AMERICA: .t REPORT OF THE SURGEON GENERAL          245


Factors Affecting Oral Health over the Life Span

of vaccines and antibiotics, along with the success of
surgical procedures, people began to rely on medical
interventions as the source of health. The biomedical
approach became paramount, and people began to
believe that health was delivered to them by health
professionals. The contributions of hygiene, sanita-
tion, and living conditions to health were dimin-
ished. Doyal and Doyal(l984) point out that success
depended on the maximal compliance of the patient.

Contemporary Models

The fourth phase of public health, 1974 to the pres-
ent, ushered in the modem era, referred to as "the
new public health" (Ashton 1993). This phase devel-
oped out of a realization that health care costs were
spiraling and there were few cures for an increasing
burden of chronic diseases. The biomedical approach

FIGURE 10.1

A conceptual model of influences on health in society and factors
that affect health through the life stages

Source: Dahlgren and Whitehead 1995. Reprinted by permission ofTransaction Publishers.
Figure 11.2,lnfluentes on health by Bemzevahhrdgeand Whitehead 1995.
Copyright 1995 byTransaction Publishers;all rights reserved.

alone could not solve all health problems. Rene
Dubos (1979, 1990) stated that theories of specific
etiology provided only a partial explanation for the
development of diseases; they could not explain
under what conditions a specific cause of disease
could be determined and was able to flourish.

McKeown (1979) cited three factors he believed
were responsible for the major reductions in disease:
the environment, economics, and behavior. His
analysis of data from numerous countries confirmed
that the achievements of medicine alone could not
explain improvements in health. The decline in mor-
tality from many diseases, including tuberculosis,
whooping cough, measles, scarlet fever, diphtheria,
and smallpox, had begun well before the develop-
ment of specific vaccines and therapies. He conclud-
ed that "the misinterpretation of the major influences,
particularly personal medical care, on past and future
improvements in health has led to misuse of
resources and distortion of the role of medicine"
(McKeown 1976).

`Taking a similar critical view, Cochrane (1971),
the physician  in whose honor the Cochrane
Collaboration of clinical trials was established, chal-
lenged the medical establishment to test medical pro-
cedures, including those long believed to be effective,
with rigorous randomized controlled trials, paying
particular attention to cost-benefit analyses. Long-
held traditions of dental care have also been ques-
tioned, resulting in increased emphasis on clinical
trials, systematic reviews of the oral health literature,
and evidence-based practice (Chapter 8).

In 1974, Marc Lalonde, then Minister of Health
of Canada, released a report that clearly articulated
that human biology and health care organization are
not the sole factors that determine health (Lalonde
1974). What is now known as the Lalonde Report, or

FIGURE 10.2

Relationships between the strategies in health services, health protection, and health promotion, the process of change they seek to
set into motion, the determinants of health they can influence, and the ultimate social and health benefits they are expected to yield

Community or population
health strategies

          Health
           services
Policies,
Technology,
Health        Health
&cation, - promotion
Financing,
Regulation
           Health
        protection

Processes of change
(immediate objectives)

and reinforcing behavior

Health field
objectives           Social and health benefits
          ,       I

-I   Access to  t-l   Reduced morbidity
       health services          and mortality

  t   +
1                ,   I  Improved quality of life

Regulating : l---L Environmental
environment           changes  t-l   Reduced social costs

Source:Green and Ottoson 1999,Community and population health.Copyright 1998 by The McGraw-Hill Companies.Reprinted by permission ofThe McGraw-Hill Companies (2000).

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


Factors Affecting oral Health over the Life Span

,hc Health Field Concept, emphasized that lifestyle  action, 4) developing personal skills, and 5) reorient-
.Inrl environment were of critical importance.     ing health services.

blonde defined four elements as determinants
,,f health: human biology, lifestyle, environment, and
[hc organization of health care. These elements were
,,,~~sidcred interdependent, and it was their dynamic
,lltcractions over the course of a lifetime that deter-
r,,,ned the level of health and well-being attained by
.,,I Individual. AS well, the elements and their inter-
.lctlon have implications for the level of health
.lrtalned by larger aggregations of people-from
neighborhoods to nations. Lalonde stated that most
of society`s efforts to improve health, and the bulk of
chrcct health expenditures, have been focused on the
fourth element-the organization of health care, yet
the main causes of sickness and death are rooted in
rhe other three elements.

In a model proposed by Dahlgren and Whitehead
(1995), the individual is surrounded by lifestyle fac-
tors, social and community influences, living and
working conditions, and general socioeconomic, cul-
tural. and environmental conditions (Figure 10.1).
Green and Ottoson (1999) integrate the J-alonde
Health Field Concept into a framework of population
health strategies, processes of change, determinants
of health, and ultimate social and health outcomes
(Figure 10.2).

At a subsequent WHO meeting in Ottawa,
Canada, a set of five actions to promote health and
quality of life, based on the four determinants, was
proposed. Implementation of these actions clearly
required going beyond the confines of a hospital, a
medical office, or a home. Specifically, the Ottawa
Charter for Health Promotion (WHO 1986) called
for 1) creating supportive environments, 2) building
healthy public policy, 3) strengthening community

Cohen and Gift (1995) acknowledge the role of
multiple determinants and quote the medical histori-
an, Henry Sigerist, who, in the r&d-1940s, stated,
"Health is promoted by providing a decent standard
of living, good labor conditions, education, physical
culture, means of rest, and recreation. The coordinat-
ed efforts of large groups are needed to this end, of
the statesman, labor, industry, of the educator and of
the [health care provider] who as an expert in mat-
ters of health must define norms and set standards"
(Sigerist 1946).

McGoldrick (1997) provides an overview of sev-
eral health behavior models in current use (Table
10.1). Some of these models have been applied to

oral-health-related  behavioral
research. Using the Health Belief
Model in a study of dental patients,
for example, Kuhner and Raetzke
(1989) reported that motivation
and perceived severity of the con-
dition were the primary predictors
of compliance with oral hygiene
instruction. Perceived benefits and
experience were also important.

TABLE 10.1
Examples of theories and models in health behavior

Basic Theories          Authors           Major Elements

Group-Dynamic Model    lewin, 1947,1951       Role-playing approach
Social Learning Theory    Rotter 1954, Bandura 1969,1977  Identification, reinforcement,
                       feedback,and reward
Theory of Reasoned Action  Ajzen and Fishbein 1977,198O   Attitude-behavior relations
Theory of Planned Behavior  Schifter and Ajzen 1985      Perceived behavioral control
Self-Efficacy Theory      Bandura 1982        Behavior determined by cognition of
                         individuals about their behavior

Health Belief Model     Rosenstock 1966,1974,     Behavior determined by
            Becker and Maiman 1975,    psychological readiness to take
             Becker et al. 1974         action

Health Action Model     Tones 1987,Tones et al. 1990   Interaction of knowledge, beliefs,
                       values, attitudes, drives, and
                        normative pressures
Theory of Social Behavior   Triandis 1979          Behavioral intention

Precede Framework      Green et al. 1980       Predisposing, reinforcing, and
                     enabling causes in educational
                     diagnosis and evaluation
Sense of Coherence Theory  Antonovsky 1979a,b     Salutogenic paradigm-focus on
                       successful coping
Health Promotion Model    Pender 1987        Cognitiveperceptual factors

Source: Adapted From Pine 1997.

The United States published a
first set of national health goals for
1990 in 1979. The goals focused
on the reduction of mortality in
four different age groups and
emphasized increased independ-
ence for older adults. Since then,
national health goals have been
established by the US. Depart-
ment of Health and Human Services
for each decade and published
under the title "Healthy People."
For Healthy People 2010 the broad
goal is to increase the quality and
years of healthy life. The concep-
tual framework, illustrated in
Figure 10.3, features at the center
determinants comparable to the

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          247


Factors Affecting Oral Health over the Life Span

elements in the Lalonde Report. They include the
interaction of individual biology, behavior, and the
social and physical environment amidst policies,
interventions, and access to quality health care.

The United States has invested heavily in ele-
ments of human biology and health care organiza-
tion. but the nation has also readily embraced the
notion that lifestyles influence health. Physical fit-
ness and self-care are concepts that mesh with the
individualistic spirit of U.S. society. Much attention
has been given to health education, behavior change,
and "healthy living."

Applications to Oral Health
Within oral health, the self-care approach is best
illustrated by the use of fluoride products for the
reduction of dental caries. The successful adoption of

FIGURE 10.3

Conceptual framework from Healthy People 2010 for a
systematic approach to health improvement

-

-

Determinants of Health
Policies and Interventions

Access to Quality Health Care

Source: USDHHS 2000.

self-care regimens has been reinforced through the
efforts of parents, caregivers, health educators, health
professionals, advertisers, manufacturers, and early
childhood programs such as Head Start that include
oral health initiatives.

The Andersen Model. The oral health research com-
munity has begun to assess the behavior/lifestyle
determinants of oral health as well. Andersen and
colleagues point out that over the years concepts of
health behavior have broadened from the biologic to
the psychosocial (Andersen et al. 1988, Gochman
1988). Andersen has been a pioneer in the develop-
ment of models of health determinants. The most
recent refinement of the Andersen Behavioral Model
(Figure 10.4) proposes that interactions among four
major categories are critical to understanding the
determinants of health. The first is the environment,
described as the broader context in which popula-
tions live and behaviors occur. It includes the exter-
nal environment and health care systems. The sec-
ond category, population characteristics, includes
three subsets: predisposing characteristics such as
sociodemographic features, enabling resources such
as those that enable the individual to pursue and
achieve good health, and the need for care, which is
defined by the individual's perceptions of necessary
preventive interventions or treatments. The third cat-
egory is the health behaviors themselves, and the
fourth category, outcomes, includes perceived and
evaluated health status and consumer satisfaction
(Andersen 1995).

In weighing the contributions of the various
determinants of oral health, Andersen et al. (1995)
suggest that the external environment, relating to
both specific and general health, is the primary
determinant of oral health behaviors and outcomes.
Oral-health-specific environmental determinants

FIGURE 10.4
An emerging model-Phase 4 of the Andersen behavioral model
  Environment         Population characteristics

Health behavior         Outcomes

Health Care
System
I
External
Environment

                               Personal
                             Health Practices
c Predisposing --)
Characteristics                    I -
                                 Use of
   t                 Health Services
                I
                                       I

Source: Andersen 1995,Copyright 1995 by JournolofHeakh andSociu/Behovior. Reprinted by permission of the American sociological Association (2000).

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


r ,nge from positive factors such as water fluoridation
tL, negative factors such as lack of food policies to
,fe.,f i\rith frequent sugar and carbohydrate intake.
The? define general environmental factors as those
[hat deal with the relative wealth of the society gen-
c.ri~l economic "climate," and the political and societal
~lorms that affect the delivery of oral health services.

!\;I,-l:place Effects. Several researchers (Karasek and
Theorell 1990, Marmot and Theorell 1988, Marmot
et al. 1984, Syme 1996) have found an association
between the level of control and flexibility people
have in their work setting and the types of health
conditions they develop and the subsequent levels of
severity of those conditions. Abegg et al. (1999)
looked at the relationship between oral hygiene per-
formances and levels of flexibility of work schedule.
They found a highly statistically significant relation-
ship between flexibility of work schedule and tooth-
cleaning frequency, range of oral hygiene aids used,
and level of dental plaque. These associations
remained even after adjusting for age, sex, socioeco-
nomic status, and marital status (Abegg et al. 1999).

Effects of Income Inequality

Investigators are also studying how socioeconomic
status affects oral health (Chapter 4). The degree of
income inequality between the richest and the poor-
est within a country, state, or neighborhood con-
tributes to the overall health of the population
(Kawachi et al. 1997, Kennedy et al. 1996). There is
conjecture from this research that increased income
inequality leads to decreased levels of social cohesion
and trust, or what has been described as a "disinvest-
ment in social capital" (Kawachi et al. 1997). This is
defined as "features of social organization, such as
civic participation, norms of reciprocity, and trust
in others, that facilitate cooperation for mutual ben-
efit." Results of other studies indicate that lower lev-
els of social trust are associated with higher rates of
coronary heart disease, cancer, stroke, and infant
mortality. However, study of healthy versus
unhealthy communities is a relatively new field and
offers an opportunity for oral health to be included.
Additional research is needed to determine the attrib-
utes of a community that either favor or diminish the
health of residents, what factors influence their
development, how attributes can be changed to
improve the health of a community, and how com-
munities can build social capital. There are indicators
of differentials in oral health status when poor and
nonpoor populations are compared.

Across numerous indicators, the poor are more
likely to have oral diseases, disorders, and condi-
tions. Poor children are less likely to have dental
sealants. In addition, the poor are less likely to visit a
dentist or dental hygienist in the course of a year. The
differentials in oral health status between the poor
and nonpoor cross the life span and are major social
indicators of the current status of oral health in
America today and provide a challenging baseline
against which improvements can be measured.

CHANGING VULNERABILITIES
THROUGHOUT LIFE

As all models of health determinahts recognize, the
health of individuals and of society at large is not
static. Vulnerabilities and risks for diseases and dis-
orders change over a lifetime and are affected by
chance events as well as deliberate actions of individ-
uals and communities, of the sort proposed in the
Ottawa Charter. The remainder of the chapter
describes .how oral health plays out across major life
stages and identifies selected aspects of biology,
behavior, environment, and the organization of
health care that affect oral health. The plight of vul-
nerable subpopulations, in particular, children and
older Americans, are highlighted. The information
presented includes data from national surveys, such
as those presented in Chapter 4, as well as studies of
convenience populations.

Children

In general, society gives special attention to the
developing years of childhood, acknowledging that
much of what happens to affect the health of a child
bears directly on the health and well-being of the
adult that child will become. In the case of oral
health, there is enough known about health promo-
tion and disease prevention to improve the oral
health and well-being of all children, beginning with
prenatal care. Adequate nutrition during pregnancy,
including adequate folate intake, avoidance of sub-
stances of abuse and therapeutic agents that have ter-
atogenic potential, and the elimination and control of
microbial infections in the mother increase the likeli-
hood of an infant's healthy start. (See Box 10.1 on the
effects of nutrients on oral health.) As more becomes
known about how the health of mothers and other
caregivers can affect the oral health of children, addi-
tional services may be warranted during the prenatal
period (Chapter 5). Subsequent nurturing of the
infant includes the home and health professional care
necessary to promote health and interventions that

-

Factors Affecting Oral Health over the Life Span

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          249


limit the infant's exposure to infections that con-
tribute to oral diseases.

Throughout the first two decades of growth and
development, children and young people are deeply
influenced by the social and environmental opportu-
nities and constraints imposed by families, commu-

BOX 10.1

The Role of Nutrition in Oral Health

General malnourishment impairs normal growth, development, and
maintenance of the body's tissues and organs and impairs immune
responses and wound healing.Reduced resistance of oral tissues to dis-
ease can lead to increased colonization by oral pathogens and more
sustained and severe oral infections.Clinical signs of malnutrition often
appear first in the oral cavity.

Craniofocio Development. Adequate maternal intake of folic acid dur-
ing pregnancy has been shown to be essential in preventing neural
tube defects (incomplete fusion of the neural tube in embryo), which
results in spinal cord defects after birth (Botto et al. 1999). Folic acid
also appears to be important in preventing clefting syndromes (in
which there is incomplete fusion in utero of paired labial or palatal tis-
sues at the midline) (Tolarova and Harris 1995).
Tooth Development Protein/calorie malnutrition and deficiencies in
ascorbic acid,vitamins A and D, calcium, phosphorus, and iodine affect
the human dentition (DePaola et al.l999).These deficiencies in devel-
opment can lead to tooth defects after teeth erupt, manifesting as
enamel hypoplasia and hypomineralization, either of which can
increase susceptibility to dental caries. Premature and very-low-birth-
weight infants frequently show enamel defects (Scow 1987). Since
tooth enamel is acellular, and hence not subject to turnover and repair,
enamel defects in development are permanent (Jonasson et al. 1999,
Jeffcoat 1998,Talbot and Craig 1998, Payne et al. 1999).
Supporting Bone. Adequate calcium intake, along with vitamin D and
other essential vitamins and minerals, is needed not only to build but
also to maintain healthy teeth and bones.The teeth are supported in
the jaws by projections of maxillary and mandibular trabecular bone
known as alveolar processes. When teeth are lost, alveolar bone
resorbs, reducing the height of the bony ridge supporting the teeth.
When serum calcium levels fall, withdrawal of calcium from alveolar
bone to meet other tissue needs may precede calcium withdrawal from
skeletal bone elsewhere in the body. Hence reduction in alveolar bone
mass may be an early indication of skeletal osteopenia (reduced bone
volume) or frank osteoporosis (Jeffcoat 1998,Jeffcoat et al.2000).
Orul Soft Tissues. Oral mucosa undergoes rapid turnover. In particular,
the gingival lining between the gums and the teeth (the sulcular
epithelium) is replaced every 3 to 7 days. Thus the tissue requires a
steady supply of nutrients to support DNA, RNA,and protein synthesis
(Alfano 1976).Diets poor in folate,ascorbic acid, iron,and zinc are asso-
ciated with increased permeability and decreased integrity of the sul-
cular epithelium. Protein, vitamins A and C, and zinc are important for
synthesis of connective tissue (largely collagen),which constitutes part

nities, and society. Although every healthy newborn
has the potential for success and good health, there
are profound disparities in children's experiences and
opportunities, which often manifest in inequities in
oral and general health, education, and well-being.
Many children achieve excellent oral health-sound

of the attachment apparatus supporting the teeth in the jaw (Alvares
and Siegel 1981,Vogel et al. 1986).The classic signs of scurvy,caused by
severe vitamin C deficiency, include gingival bleeding, tooth mobility,
and loss of connective tissue attachment. Painful oral lesions,including
inflammation and cracks at the corners of the mouth and vertical fis-
suring of the lips, are changes associated wfth riboflavin, iron, or pro-
tein deficiency. Inflammation, a burning sensation, and tenderness of
the tongue or palate are associated with deficiencies in B-complex
vitamins,protein,or iron.

Oral Defense Merhunisms. Chronic deficiencies of ascorbate and iron
may impair the function of white blood cells (especially polymor-
phonuclear leukocytes) in moving to sites of infection and initiating
immune defense mechanisms. Zinc is a component of many enzyme
systems and is also important in leukocyte activity (Hsu et al. 1991).
General OrolHeulth. Foods rich in fiber aid digestion and stimulate sali-
vary secretion. Salivary flow is important in initiating the digestion of
starch, in facilitating food tasting and swallowing, and in ensuring a
ready supply of components in the oral cavity that protect and main-
tain the oral tissues.

Nutrients Associated with Specific Diseases

Denfd Curies. The role of sugars and other carbohydrates is critical.
Nearly all carbohydrates have caries-promoting properties.Most sweet
foods contain a mixture of sugars (predominantly sucrose) and starch-
es, which can be fermented by cariogenic bacteria to dissolve tooth
mineral. Bacteria also use sucrose to generate glucans-sticky extra-
cellular molecules that promote theirattachment to tooth surfaces.The
physical consistency,frequency of consumption,and the order in which
foods are eaten affect cariogenicity. For example, following a sweet
with a nonsweet food such as an aged cheese may counteract the acid
attack on enamel. The presence of calcium and phosphates in the
cheese also is beneficial (Jensen 1999, Rugg-Gunn 1993). Caries in
tooth roots is produced by the same process as in tooth crowns and
involves the same dietary etiology (Papas et al. 1995), but may occur
more rapidly because the root mineral, cementum, and underlying
dentin are more soluble than enamel.

Perjodonrd Disease. Several studies have implicated deficiencies in
astorbate and folate with severity of gingivitis (Leggot et al. 1991, Pack
1984), but in general the role of nutrients in periodontal disease
appears to be related to conditions that lead to increases in dental
plaque, impaired host defenses, and weakened integrity of the peri-
odontal tissues. More recently, surveys indicate that calcium intake for
a large segment of the population is below recommended daily
amounts (NHANES Ill) and that reduced calcium intake is associated
with greater levels of periodontal disease in both men and women

:50


(Nishida et al. 2OOO).This is consistent with the findings of Krall et al.
(1997), who showed that calcium supplementation in postmenopausal
women with deficient calcium intake protected against tooth loss.
Orul ondPharyngeo/ Cuncers. High intakes of pickled vegetables, salted
meat and fish,spicy foods,charcoal-grilled meat, and beverages served
at very high temperatures have been found to be associated with oral
cancers in some countries (Winn 1995). Malnutrition has also been
found in association with the diagnosis of oral and pharyngeal cancers
(Bassett and Dobie 1983)Whether the malnutrition was the cause or
the effect is not clear.

OrolCuncer Prevention. A consistent finding across numerous studies is
that a diet high in fruit and vegetables is associated with a reduced risk
of oral cancer even when smoking and alcohol intake are taken into
account (Steinmetzand Potter 1996).ln a case-control study,risk of sec-
ond primary tumors in oral and pharyngeal cancer patients was
reduced in those with a high vegetable intake (Day et al. 1994). Fruits
and vegetables contain fiber, carotenoids, and vitamin C, which may be
important in cancer chemopreventionvitamin C may act as an antiox-
idant,protecting cell membranesand DNA from oxidative damage.Lack
of vitamin C may interfere with collagen synthesis and permit tumor
growth. Green leafy vegetables contain lutein, a carotenoid, xantho-
phyll, an antioxidant, and folic acid. Folic acid deficiency may interfere
with DNA methylation and DNA repair (Winn 1995)The only prospec-
tive cohort study ofdiet and oral cancer (>25,000 persons in Maryland)
showed that high serum total carotenoids and alpha tocopherol (vita-
min E) reduced the risk of oral cancer, but high serum gamma toco-
pherol and selenium increased cancer risk (Zheng et al. 1993).The use
of retinoids and P-carotene in controlled therapeutic doses shows pro-
tective effectsFewer new primary tumors in persons with previous oral
cancers and reversal or reduction in size of premalignant lesions have
been reported (Khuri et al. 1997, Papadimitrakopoulou and Hong
1997). For example, high doses of 13-cis-retinoic acid, though causing
significant toxicities, have been effective in the treatment of oral leuko-
plakia (Hong et al. 1990).

References

Alfano MC.Controversies,perspectives and clinical implications of nutri-
tion in periodontal disease.Dent Clin North Am 1976;20:519-48.
Alvares 0, Siegel I. Permeability of gingival sulcular epithelium in the
development of scorbutic gingivitis.1 Oral Pathol1981;10:40-8.
Bassett MR, Dobie RA. Patterns of nutritional deficiencies in head and
neck cancer.Otolaryngol Head Neck Surg 1983;91:119-25.
Botto LD, Moore CA, Khoury MJ, Erickson JD. Neural-tube defects. N Engl
J Med 1999;341:1509-19.

Day GL, Shore RE, Blot WJ, McLaughlin JK, Austin DL, Greenberg RS, Liff
JM, Preston-Martin S, Sarkar S, Schoenberg JB, et al. Dietary factors
and second primary cancers: a follow-up of oral and pharyngeal
cancer patients. Nutr Cancer 1994;21:223-32.
DePaola DP, Faine MR Palmer CA. Nutrition in relation to dental medi-
cine. In: Shils ME, Olson IA, Shike M, Ross CA, editors. Modern nutri-
tion in health and disease. Baltimore: Williams & Wilkins; 1999. p.
1099-124.

Hong WK, Lippman SW, ltri LM, Karp DO, Lee JS, Byers RM, Schantz SP,
Kramer AM, Lotan R, Peters LJ, et al. Prevention of secondary pri-

mary tumors with isothetincin in squamous-cell carcinoma of the
head and neck. N Engl I Med 1990;328:15-20.
Hsu DJ, Daniel JC,Gerson SJ. Effect of zinc deficiency on keratins in buc-
cal epithelial cells. Arch Oral Biol 1991;365:759-63.
Jeffcoat MK.Osteoporosis:a possible modifying factor in oral bone loss.
Ann Periodontol1998;3:312-21.

Jeffcoat MK, Lewis CE, Reddy MS, Wang CY, Redford, M. Post-
menopausal bone loss and its relationships to oral bone loss.
Periodontol2000; in press.

Jensen ME. Diet and dental caries. Dent Clin North Am 1999;43:615-33.
Jonasson G, Kiliaridis S, Gunnarsson R. Cervical thickness of the
mandibular alveolar process and skeletal bone mineral density.
Acta Odontol Stand 1999;57:155-61.
Khuri FR,Lippman SM, Spitz MR, Lotan R, Hong \"H(.Molecular epidemi-
ology and retinoid chemoprevention of head and neck cancer.J Natl
Cancer lnst 1997;89:199-211.

Krall EA, Dawson-Hughes B, Hannan MT, Kiel DP. Postmenopausal estro-
gen replacement and tooth retention.Am J Med 1997;102:536-42.
Leggott PJ, Robertson PB, Jacob RA, Zambon JJ, Walsh M, Armitage GC.
Effects of ascorbic acid depletion and supplementation on peri-
odontal health and subgingival microflora in humans. J Dent Res
1991;70:1531-6.

Nishida M, Grossi SG, Dunford RG, Ho AW,Trevisan M,Genco RJ.Calcium
and risk for periodontal disease. Periodontal 2000;70(7):in press.
Pack AR. Folate mouthwash: effects on established gingivitis in peri-
odontal patientsl Clin Periodontol1984;11:619-28.
Papadimitrakopoulou VA, Hong WK. Retinoids in head and neck
chemoprevention. Proc Sot Exp Med 1997;216:283-90.
Papas AS,Joshi A, Palmer CA,Giunta JL, Dwyer JT. Relationship of diet to
root caries. Am J Clin Nutr 1995;61 (Suppl):4255-95.
Payne JB, Reinhardt RA, Nummikoski PV, Patil KD. Longitudinal alveolar
bone loss in postmenopausal osteoporotidosteopenic women.
Osteoporos Int 1999;10:34-40.

Rugg-Gunn Al. Nutrition, diet and dental public health. Community
Dent Health 1993;1O(Suppl2):47-56.
Scow WK, Humphrys C,Tudehope DI. Increased prevalence of develop-
mental defects in low birth-weight, prematurely born children: a
controlled study. Pediatr Dent 1987;9(3):221-5.
Steinmetz KA, Potter JD. Vegetables, fruit and cancer prevention: a
review.J Am Diet Assoc 1996;96:1027-37.
Talbot L, Craig BJ. Osteoporosis and alveolar bone loss. Probe
1998;32:11-3.

Tolarova M, Harris J. Reduced recurrence of orofacial clefts after peri-
conceptual supplementation with high dose folic acid and multivi-
tamins.Teratology 1995;51:71-8.

Vogel RI, Lamster IB, Wechsler SA, Macedo B, Hartley I, Macedo JA.The
effects of megadoses of ascorbic acid on PMN chemotaxis and
experimental gingivitis. J Periodontol 1986;57:472-9.
Winn DM.Diet and nutrition in the etiology of oral cancer.Aml Clin Nutr
1995;61 (Suppl):437S-45s.

Zheng W, Blot WI, Diamond EL, Norjus ER Spate V, Morris IS, Comstock
GW.Serum micronutrients and the subsequent risk of oral and pha-
ryngeal cancer.Cancer Res 1993;53:795-8.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          'li


Factors `Affecting Oral Health over the Life Span

teeth, firm gums, healthy soft tissues, well-function-
ing bites, and beautiful smiles-but many do not.
One in every four U.S. children today is born
into poverty (U.S. Bureau of the Census 1998b) with
all of its associated barriers and constraints. Poverty
is a key indicator of poor oral health status among
children (Litt et al. 1995). Poor children suffer twice
as much dental caries as their more affluent peers
(Vargas et al. 1998). Studies have shown that the
children with the most advanced oral disease are
primarily found among America's most vulnerable
groups: the poor,  American Indians and other
minorities, homeless and migrant populations, chil-
dren with disabilities, and children with HIV (Isman
and Isman 1997).

orders, malocclusion, and unintentional injuries.
Other oral conditions in children such as mucosal
lesions may be a sign of risk behaviors such as tobac-
co use. All oral conditions may be exacerbated in
children with other special health care needs.

If untreated, oral diseases in children frequently
lead to serious general health problems and
significant pain, interference with eating, overuse of
emergency rooms, and lost school time (Edmunds
and Coye 1998). It has been estimated that 51
million school hours per year are lost because of
dental-related illness alone (Gift 1997).

The Institute of Medicine reports that 70 percent
of U.S. children are generally healthy and require
only regular preventive and intermittent medical
services. Twenty percent experience chronic prob-
lems, which may impose significant limitations on
their ability to function effectively and require regu-
lar treatments for their conditions. Only the remain-
ing 10 percent suffer from severe chronic conditions
necessitating intensive health services (Edmunds and
Coye 1998).

Adults concerned about the health of children,
particularly low-income and minority children, are
regularly confronted by the reality and consequences
of unmet oral health care needs. Although often
viewed as innocuous by those who enjoy excellent
dental health or have ready access to dental care, den-
tal and oral problems impact the very life experience
of affected children. Chronically poor oral health is
associated with diminished growth in toddlers (Acs
et al. 1992, Ayhan et al. 1996) and compromised
nutrition (Acs et al. 1999). Dental disease in children
also takes a personal and social toll. Observing dis-
advantaged inner-city schoolchildren, Kozol (1991)
noted, "although dental problems don't command
the instant fears associated with low birth weight,
fetal death, or cholera, they do have the conse-
quences of wearing down the stamina of children and
defeating their ambitions."

Similarly, the vast majority of America's children
today enjoy excellent oral health, but a significant
subset of children experience a high level of oral dis-
ease. Although it is no longer unusual to see children
smiling with a full set of unmarred teeth, millions of
other children have little to smile about. For them,
the daily reality is persistent dental pain, endurance
of dental abscesses, inability to eat comfortably or
chew well, embarrassment at discolored and dam-
aged teeth, and distraction from play and learning.

  In addition to the millions of children with
extreme dental problems, many times more
encounter more modest disease. For example, the
review of the Healthy People 2000 objectives found
that more than half of all second graders, children
aged 6 to 8, still experience cavities (USDHHS 1997).
Dental caries remains the single most common dis-
ease of childhood that is neither self-limiting, like the
common cold, nor amenable to a simple course of
antibiotics, like an ear infection (Edelstein and
Douglass 1995).

Like asthma, learning difficulties, and social
problems, dental caries is highly correlated with low
income, limited education, and social disadvantage.
In this regard, it may serve as a sentinel disease for
other pediatric conditions that are related to inade-
quate diet and hygiene and to family conditions and
a social environment that do not support healthy
lifestyles.

Some oral conditions, like other childhood ill-
nesses, affect children randomly, regardless of social
or economic status. Such conditions include cleft lip
and palate and other craniofacial developmental dis-

The numbers of poor and minority children are
increasing faster than other socioeconomic subsets of
U.S. children (Waldman 1996), and dental caries is
common in these children. Twenty-five percent of
these children have never visited a dentist before
entering kindergarten (USDHHS 1997), despite
widespread understanding that the dental caries
process is established before age 2 and the recom-
mendation of experts that children as young as 1 may
benefit from a dental visit (AAPD 1997, Green 1994,
USDHHS 2000). Parents are consistently concerned
about the dental needs of their children (Simpson et
al. 1997), and studies conducted in hospital emer-
gency rooms have found extensive dental needs
among children (Sheller et al. 1997, Unkel et al.
1989, Wilson et al. 1997). Dental care has recently
been noted as the most prevalent unmet health need
among American children (Newacheck et al. 2000).
These conditions are evident despite the advances in
the oral health sciences and the growing capacity of

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


,,raI health care providers to prevent common pedi-
jtnc oral diseases.

Children with disabilities present unique prob-
,erns and are at increased risk for oral infections,
~eI~,v~ in tooth eruption, periodontal disease, enamel
,,rc.ularities, and moderate-to-severe malocclusion
( lsman and Isman 1997). Their exposure to certain
ritedications and therapies, special diets, and their
LI,lficulty in maintaining daily hygiene further com-
promise their oral health (Casamassimo 1996). Also,
.iccess to professional care is a particular problem for
these children (see Chapter 4). Guides for dental pro-
fessionals serving children with special health care
needs are under development (USC 1999).

The Role of Insurance in Children's Oral Health
Disparities also occur in access to care. Medical
insurance is a strong predictor of access to dental
care. Children with no medical insurance are 2.5
times less likely than insured children to receive
dental care (Bloom et al. 1992, Monheit and
Cunningham 1992, Newacheck et al. 1997).
Children with no dental insurance were 3.0 times
more likely to have an unmet dental need than their
counterparts with either public or private insurance
(Newacheck et al. 2000, Waldman 1998). Dentists
daily observe that insured children are more likely to
obtain comprehensive, continuous, and coordinated
care and are more likely to be followed regularly for
semiannual preventive visits. It has long been recog-
nized that dental plans with low cost-sharing
requirements are likely to improve the oral health of
young people, especially those with the poorest oral
health (Bailit et al. 1985).

Children's general health also affects access to
dental care. Children with "fair or poor" general
health have nearly twice the unmet dental needs as
children with "good or excellent" health, according
to their parents (Simpson et al. 1997). As income
rises, unmet treatment needs drop off dramatically
Children from families with annual incomes of
$10,000 to $20,000 have 10 times more unmet den-
tal needs than children whose families earn more
than $50,000 per year (Simpson et al. 1997).

White children are more likely than children in
other ethnic and racial groups to have private dental
insurance coverage. When last surveyed nationally in
1989, about half (52 percent) of white children had
dental insurance, compared to only 39 percent of
black children and 32 percent of Mexican American
children. As family incomes increase, children are
more likely to be covered by dental insurance (USD-
HHS 1992).

In the United States, most health insurance is
provided through the workplace, and about 60 per-
cent of children are covered by private health insur-
ance through their parents' plans (U.S. Bureau of the
Census 1998a). A smaller percentage, about 31 per-
cent, enjoy dental insurance as well. There are at least
2.6 children without dental insurance for each child
without medical insurance (Vargas et al. 2000).

Over the last decade, employer-based coverage
for children has eroded, while publicly funded health
insurance through Medicaid and the State Children3
Health Insurance Program (SCHIP) has expanded to
cover over 2.5 percent of all children (U.S. Bureau of
the Census 1998a). The Congressional Budget Office
estimates that 2.5 million children will be insured
through SCHIF! However, even with this increase
many children will remain without dental coverage.

Properly funded dental insurance works. When
commercial-style, state-funded dental coverage
became available to modest-income families in west-
em Pennsylvania, the percentage of previously unin-
sured children (uninsured for more than 6 months)
who saw a dentist during one year of coverage
increased from 30 to 64 percent. The percentage of
parents who reported that their child had a regular
source of dental care increased from 51 to 86 percent.
The percentage of parents who claimed that their
children had unmet or delayed dental needs
decreased from 52 to 10 percent. In addition, the
number of dental visits fell as children's acute and
episodic care decreased and they began programs
of regular preventive and maintenance care (Lave et
al. 1998).

Publicly Funded Insurance for Children

Medicaid. Although pubIicly funded programs such
as Medicaid have succeeded dramatically in provid-
ing a "medical home" and regular medical care to
children from low-income families (Newacheck et al.
1997), Medicaid's record of ensuring regular access to
dentists and providing effective dental care is less
successful. Fewer than one in five Medicaid-covered
children received a single preventive dental visit dur-
ing a recent year-long study period, according to the
U.S. Inspector General (USDHHS 1996). The study
indicated that three fourths of states provided pre-
ventive services to fewer than 30 percent of eligible
children, and no state provided preventive dental
care to more than 50 percent of all eligible children.
More disturbing is the finding that few Medicaid chil-
dren who receive dental care get any services beyond
a cleaning and fluoride treatment, despite their need
for dental repair and fillings (Solomon 1998).

Factors Affecting Oral Health over the Lift SpLltl

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          253


Federal legislation enacted over three decades
ago established a guarantee of dental care to
Medicaid-eligible children through the Early and
Periodic Screening, Diagnostic and Treatment Service
(EPSDT; PL. 90-284). Final regulations, effective in
early 1972 (U.S. Bureau of the Census 1998a), ensure
comprehensive dental services-prevention, diagno-
sis, and treatment for "teeth and associated structures
of the oral cavity and disease, injury or impairment
that may affect the oral or general health of the recip-
ient"-and promise children access to dental servic-
es of sufficient "amount, duration, and scope" to
ensure oral health. Federal law also requires provi-
sion of enabling services such as transportation and
translation. In addition, revisions to the Social
Security Act in 1989 (OBRA 89) made several
changes to EPSDT services. States are now required
to set a distinct periodicity schedule for the provision
of dental services after consultation with recognized
dental organizations involved in child health care.
States are also required to provide any medically nec-
essary dental service coverable under Medicaid to an
EPSDT eligible child even if the service is not avail-
able to individuals age 21 and older under the
Medicaid state plan. Despite these laws and regula-
tions, inadequate funding, chronically poor pay-
ments to dentists, administrative burdens, and bene-
ficiary utilization patterns have limited the effective-
ness of this program (USDHHS 1996).

Increasingly, states are electing to purchase den-
tal care for low-income populations through man-
aged care organizations rather than to pay providers
directly for Medicaid. As states take on the role of
purchasers of care rather than claims payers, their
focus has turned to a concern for health outcomes.
However, participation of dentists in managed care
programs is low (AAPD 1997, ADA 199813, NADP
1998), and the effort to move dental Medicaid care
into managed care programs may further constrain
the availability of care.

A 1998 survey of state Medicaid authorities by
the National Conference of State Legislatures report-
ed that, on average, only 16 percent of dentists in the
35 responding states participate actively in Medicaid
(i.e., were compensated more than $10,000 in the
preceding 12 months for dental care to Medicaid-
enrolled patients). In 24 of these 35 states, fewer than
20 percent of active dentists participate actively
(Guiden 1998). The study also raised awareness that
common Medicaid payment rates for five typical
children's dental procedures rarely exceed 65 to 70
percent of dentists' usual fees (Guiden 1998), a per-
centage that represents dentists' typical overhead

costs in delivering those services (ADA 1998b). A
1998 federally sponsored national meeting, "Building
Partnerships to Improve Children's Access to
Medicaid Oral Health Services," also identified inad-
equate payments to dentists among multiple barriers
in Medicaid program administration. Barriers identi-
fied by the conference were categorized as financing
and funding issues, Medicaid policies and adminis-
trative procedures, supply and distribution of
providers, parental valuation of oral health, and lack
of a systematic approach to identifying and promot-
ing successful interventions (Spizak and Holt 1999).

Medicaid expenditures for dental care are low.
On average, state Medicaid agencies contribute only
2.3 percent of their child health expenditures to den-
tal care (Yudkowsky and *Tang 1997), whereas
nationally, the percentage of all child health expendi-
tures dedicated to dental care is more than 10 times
that rate, almost 30 percent (Lewit and Monheit
1992). A 1998 actuarial study of health care costs for
children (AAP 1998) calculated that 21 percent of
expenditures for a comprehensive package of health
services (including inpatient, outpatient, mental,
dental, vision, hearing, and pharmacy services, but
excluding orthodontic care) should be dedicated to
dentists' services. This study suggests that fully
$21.35 per child per month must be expended in
order to meet the dental care needs of covered chil-
dren. A similar study conducted by the Reforming
States Group (1999) determined that $17 to $18
per child per month is a necessary expenditure for
dental care, assuming that providers accept a modest
discount on their fees when serving low-income
children. In FY 1995, Medicaid expended only
$4.44 per enrolled child per month (Yudkowsky
and Tang 1997).

Although states vary widely in the percentage of
children covered by Medicaid and in the income lev-
els they require for eligibility, all states must entitle
child beneficiaries to comprehensive dental services
under EPSDT. .4 review of 15 state oral health and
dental access surveys (Tinanoff 1998) noted the fol-
lowing recurrent themes about Medicaid in relation
to children's oral health:

  o States show similar dental care issues for
Medicaid-enrolled children: high disease prevalence,
low provider participation, and insufficient funding.
   o  Children at the highest risk of having dental
caries are the least likely to have access to regular
dental care.

   o  Barriers to provider participation include low
reimbursement rates in a health care environment
that has high overhead; perception of administrative

254

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


problems with Medicaid programs; and patients who
do not fit the expectations of the dentist.

   .  Medicaid payments for dental care account
for less than 3 percent of total state Medicaid child
health expenditures in these states.

   .  The percentage of EPSDT eligibles with a
dental visit (an initial measure of access to care) fails
to reflect the insufficiency of reparative care to meet
children's acute dental health needs.

   o  Lack of access to dental services for
Medicaid recipients is perceived as the greatest pedi-
atric health care problem in many states.

   .  Untreated dental problems get progressively
worse and ultimately require more expensive inter-
ventions, often in a hospital emergency room or
operating room.

State Children's Health Insurance Program. Thirty
years after enacting Medicaid, the U.S. Congress in
1997 addressed the lack of medical coverage for over
10 million additional children by passing the State
Children's Health Insurance Program (SCHIP). The
Congressional Budget Office anticipates that this pro-
gram will extend health insurance to at least 2.5 mil-
lion more children and in the process will identify
many additional children who are eligible for, but not
enrolled in, Medicaid. SCHIP complements the
Medicaid program by providing health insurance to
children whose family income is above Medicaid eli-
gibility standards, generally up to 200 percent of the
federal poverty level. SCHIP differs from Medicaid in
that it is not an individual entitlement', and states
have broad latitude in designing and implementing
insurance programs for modest-income children.

The law provides no direct mandate regarding
services to be covered beyond immunizations and
well-baby, well-child care. Dental coverage is specifi-
cally cited as one of 28 services that can be funded
with SCHIP dollars. Although states are not required
to provide dental coverage, congressional report lan-
guage and presidential pronouncements are explicit
in emphasizing the need for dental care (ADA
1998a,b). Prior to signing the bill in August 1998,
President Clinton stated, "it is important that we
have an adequate benefit package for children, recog-
nizing that there are some problems that children
have in a way that is more profound than adults,
including problems with vision, with hearing and
with dental health." Upon signing the bill, he said,
"Because we have acted, millions of children all
across the country will be able to get medicine, and
have their sight and hearing tested and see dentists
and doctors for the first time."

States can elect to apply federal SCHIP funds to
expand Medicaid or they may use one of four options
to provide services under a separate SCHIP program:
1) develop a new state program based on benchmark
coverage, which is state employee coverage; 2) pro-
vide coverage under the SCHIP using benchmark-
equivalent health coverage, which requires the use of
an actuarial report to determine that coverage is at
least equivalent to one of the benchmark plans; 3)
apply existing comprehensive state-based coverage
available in New York, Florida, and Pennsylvania;
and 4) seek Secretary-approved coverage. Only 2
(Delaware and Colorado) of 56 states and territories
have not included substantial dental care for most
children covered by SCHII? Siates implementing
SCHIP have expanded access to dental care services
through a variety of mechanisms. Expanding cover-
age through Medicaid ensures that newly enrolled
children are entitled to dental coverage, although
these children face the same barriers as other
Medicaid children, as discussed previously. Even
with current levels of commercial dental insurance
and improved access through Medicaid and the new
SCHIP program, almost one quarter of children will
remain without dental coverage.

The Social and Professional Environment for
Prevention

Although science continues to reveal new opportuni-
ties to prevent disease and promote health, sufficient
understanding already exists to significantly reduce
common oral diseases for all children. One of the
most critical findings is that effective prevention
requires an early start.

The American Academy of Pediatric Dentistry
(AAPD 1997), the American Dental Association
(ADA 1997), and the Bright Futures health supervi-
sion consensus project (Green 1994) all recommend
that a toddler be seen by a dental professional at 12
months of age for an initial examination and risk
assessment for common oral diseases and injuries.
This first visit provides an opportunity for parents to
learn about multiple oral health issues-dental
caries, periodontal health. injury prevention, dental
development, oral habits, common soft tissue sores,
and bite development- as well as how to promote
their child's complete oral health (Nowak 1997).
Despite professional guidance and a Healthy People
2000 goal that 90 percent of children be seen by a
dentist before entering kindergarten, only 63 percent
of children have a dental visit before starting school
(USDHHS 1997).

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

255


Factors `Affecting Oral Health over the Life Span

Because growth and development is so pre-
dictable, it can be anticipated and guided through
education and carefully timed interventions. Applied
to oral health, "anticipatory guidance" allows par-
ents, children, and institutions to learn the stages of
oral, facial, and dental development and how to care
for the next stage of development (Nowak and
Casamassimo 1995). Tables 10.2, 10.3, 10.4. and
10.5 provide examples of the risk and risk reduction
methods related to periodontal diseases, dental
caries,  malocclusion,  and injury,  respectively
(Casamassimo 1996). Physical, behavioral, socioen-
vironmental, and disease and treatment-related fac-
tors are addressed.

Anticipatory guidance allows the parent, dental
team, other health care providers, and institutions
that care for the child to ensure a child's good oral
health, avoiding preventable pitfalls and problems by
knowing how a child's mouth changes over time. For

example, prevention of early child-
hood caries requires guidance to
caregivers before the child's teeth
erupt to prevent or limit the trans-
mission of microbial infections
from mother to child and to pro-
mote appropriate feeding prac-
tices even before the child has any
teeth in place (Grindefjord et al.
1995, Kohler et al. 1984, 1988, Li
and Caufield 1995, Tanzer 1995).
Similarly, anticipatory guidance
for oral health extends to safe-
guarding a house to prevent oral
bums and injuries and to teach
parents about the dangers of for-
eign objects in the mouths of tod-
dlers and preschoolers. Anticipat-
ing a young person`s interest in
sports requiring mouth guards or
head protection, discouraging
smoking and smokeless tobacco
before they are first used, and
encouraging teens to adopt hy-
giene practices that prevent peri-
odontal disease initiation also are
examples of guidelines that need
to be addressed by all individuals
and organizations responsible for
the child.

There is promise for further
eradication of common childhood
dental and oral infections. Edu-
cation regarding oral infections in
mothers and caregivers can con-

tribute to the infant's or toddler's general and oral
health. Current investigations suggest that pathogen-
ic exposures can be limited, children's resistance to
acquiring disease-causing bacteria can be enhanced,
physical and chemical barriers to transmission can
be erected, and early-stage disease can be reversed
with medications. Importantly, there is no one-size-
fits-all solution to disease prevention and suppres-
sion. Most acquired dental and oral disease of child-
hood is preventable. The challenge today is to bring
the promise of prevention to the most vulnerable
of our children and youth. Meeting the challenge will
require enhancing programs such as the Special
Supplemental Nutrition Program for Women,
Infants, and Children (WIG),, Head Start, along with
early child care, and community and school-based
centers.

Families have the capacity to support healthy
oral health practices, as well as to support and

TABLE 10.2

Risk and protective factors for periodontal diseases

Risk Factors                     Risk Reduction Methods

Physical Examples
Anatomical variations (e.g.,frenum)
Malpositioned and crowded teeth
Gingivitis
Puberty
Pregnancy
Mouthbreathing
Genetic predisposition (e.g., Down or Papillon
Lefevre syndrome)

Surgical correction
Orthodontic care
Treatment of disease
Preventive measures to address oral effects
Preventive measures to address oral effects
Management of mouthbeathing
Preventive intervention to minimize effects

Behavioral Examples
Inadequate oral hygiene
Tobacco use

Socioenvironmental Examples
Poor oral health and hygiene
Poverty
Disease- or Treatment-related Examples
Injury

Improved oral hygiene
Tobacco cessation


Access to care and improved oral hygiene
Access to care


Use of age-appropriate safety measures and
treatment of injury

Nutritional deficiencies (e.g.,vitamin C)
Metabolic disease (e.g., diabetes,
hypophosphatasia)
Neoplastic disease (e.g., leukemia or its
treatment)
Infectious disease (e.g., HIV/AIDS)

Healthy eating habits
Treatment of disease

Treatment of disease and preventive intervention
to minimize effects
Treatment of disease and preventive intervention
to minimize effects

Medications (e.g., Dilantin)
Poor-quality restorations
tlnrestored carious lesions

Source: Modified from Casamassimo 1996.

Preventive intervention to minimize effects
Restoration of carious lesions
Properly contoured and finished restorations

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


Factors Affecting Oral Health over the Life Span

encourage behaviors conducive to health and well-
being, no matter their income. Communities that
recognize children's oral health as an important pub-
lic good can provide resources and ensure services,
ranging from sealant programs, school education,
and fluoridation programs to candy-free aisles in gro-
cery stores and merchant campaigns to combat teen
smoking and drinking.

At the state and federal levels, however, the good
intentions of legislation have fallen short of adequate
implementation. Nevertheless, by linking the power
of growth and development with health promotion
activities, the nation has the potential to bring excel-
lent oral health to all children.

Health promotion covers a spectrum of efforts:
anticipating problems, preventing them from occur-
ring, and suppressing them when they first occur.
These efforts can be targeted to individual children or
entire communities of children, particularly children
at high risk for dental and oral problems.

TABLE 10.3

Risk and protective factors for dental caries

Risk Factors

Physical Examples

Risk Reduction Methods

Variations in tooth enamel; deep pits and
fissures; anatomically susceptible areas
Gastric reflux
High mutans streptococci count
Special health needs
Previous caries experience
History of baby bottle tooth decay
Behavioral Examples
Bottle used at night for sleep or "at will"
whileawake
Frequent snacking
Inadequate oral hygiene
Eating disorders, including self-induced
vomiting (bulimia)
Socioenvironmental Examples
Inadequate fluoride
Poor oral health and hygiene
Poverty
High parental levels of bacteria
(mutans streptococci)

Sealants (if possible) or observation

Management of condition
Reduction of mutans streptococci
Preventive intervention to minimize effects
Increased frequency of supervision visits
Increased frequency of supervision visits

Prevention of bottle habit and weaning from
bottle by 12 months
Reduction in snacking frequency
Improved oral hygiene
Referral for counseling


Optimal systemic and/or topical fluoride
Access to care and improved oral hygiene
Access to care
Good parental oral health and hygiene

Diseases orTreatment-related Examples
Special carbohydrate diet
Frequent intake of sugared medications

Reduced saliva flow from medication
or irradiation
Orthodontic appliances

Source: Modified from Casamassimo 1996.

Preventive intervention to minimize effects
Alternate medications or preventive intervention
to minimize effects
Saliva substitutes

Good oral hygiene for appliances

Adolescents and Young Adults

Data regarding oral health during adolescence and
young adulthood are not abundant. However, most
teenagers and young adults live healthy and active
lives. Indeed, these years represent a peak period of
biological fitness. This also is a time when individu-
als are exposed to and begin behaviors that may place
them at risk, such as tobacco and alcohol use and
poor dietary practices. For 12- to 17-year-olds who
use smokeless (spit) tobacco, for example, 34.9 per-
cent of current snuff users and 19.6 percent of cur-
rent chewing tobacco users had tobacco-related oral
lesions (Tomar et al. 1997). (See Box 10.2 on the
effects of tobacco on oral heajth.) Adolescents
become more mobile, traveling independently in
cars, motorcycles, and other vehicles, where the use
of safety belts and helmets is needed. Sexual prac-
tices begin during this time, further exposing indi-
viduals to infections that predispose them to general

and oral healih problems. Ideally,
the prevention of risk behaviors
begins earlier in life, but this stage
of life brings such a cascade of
events that even the most informed
and well-supported adolescent may
find it difficult to adhere to prac-
tices recommended by caregivers
and institutions.

This period of life also is
marked by rapid change as
individuals move from school to
work to marriage and parenting,
possibly relocating far from their
birthplace. Many young persons
who were fortunate to have health
insurance lose their coverage after
they leave college or are no longer
"dependents." Health status is
largely determined by lifestyle
behaviors and socioeconomic
factors reflecting education, career,
and income.

About one third of 15-year-
olds have experienced dental caries
in their permanent teeth, and
another 20 percent have untreated
dental decay. Poor adolescents have
higher disease rates and more
untreated disease. Periodontal dis-
eases, as defined by having 4 mm
or more of attachment loss, are
seen in about 3 percent of 1% to
24-year-olds, although it is in the

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

257


TABLE 10.4

Risk and protective factors for malocclusion

Risk Factors

Physical Examples
Congenital absence of teeth
Mouthbreathing
Variations in development (e.g., tooth
eruption delays and malpositioned teeth)
Muscular imbalances
Familial tendency for malocclusion
Conditions associated with malocclusion
(e.g., cleft lip/palate)
Behavioral Examples
Nonnutritive sucking habits
Disease- or Treatment-related Examples
Injury

adolescent years that early-onset
periodontitis is first diagnosed.
Young non-Hispanic blacks have
twice the proportion of periodon-
tal disease than either white or
Mexican Americans aged 30 to 49
years. Complete tooth loss is low
in this age group, with only an
estimated 0.4 percent of individu-
als aged 18 to 34 years having no
teeth (see Chapter 4).

Acquired problem from systemic condition
or its therapy
toss of space due to caries
Musculoskeletal conditions (e.g., cerebral palsy)
Skeletal growth disorders (e.g.,renal disease)

Source: Modified from Casamarrimo 1996.

   Risk Reduction Methods


Early intervention
Management of mouthbreathing
Early intervention

Early therapy
Early intervention
Early intervention




Elimination of habit


Use of age-appropriate safety measures
(e.g.,car safety seats, safety belts, stair gates,
mouth guards) and treatment of injury
Dental intervention as a part of medical care

Early intervention for caries
Dental intervention as a part of medical care
Dental intervention as a part of medical care

These years also mark the
period of life when intentional and
unintentional injuries take their
greatest tell. Because many of
these injuries affect the oral-facial
region, they have special relevance
to oral health. In particular, the
example  of oral-facial sports
injuries illustrates the roles of
behavior and socioeconomic envi-
ronment as determinants of health,
as well as pointing to several
actions, such as use of protective
head gear and mouth guards, that
can serve as correctives.

TABLE 10.3

Risk and protective factors for injury                      Midlife Adults

Risk Factors

Physical Examples
Lack of protective reflexes
Poor coordination
Protruding front teeth
Behavioral Examples
Failure to use safety measures appropriate
for infant/child/adolescent (e.g., car safety
seats, stair gates, mouth guards, safety belts)
Participation in contact sports
Socioenvironmental Examples
Substance abuse in family
Substance use by child or adolescent
Child abuse or neglect
Multiple family problems
Disease- or Treatment-related Examples
Overmedication
Hyperactivity

Source: Modified from Casamassimo 1996.

Risk Reduction Methods


Referral for appropriate therapy
Referral for appropriate therapy
Orthodontic care


Use of age-appropriate safety measures


Use of protective gear


Referral for counseling
Referral for counseling
Referral for counseling
Referral for counseling


Adjustment of medications
Management of condition

Adults between 35 and 65 have
been aptly called "the sandwich
generation"-caring simultane-
ously for aging parents and
dependent children, while trying
to maintain their own health,
careers, and family structure. This
population cohort is growing in
numbers in parallel with the ever-
increasing numbers of the elderly
Although many older Americans
will be self-sufficient for the rest of
their lives, about one third will
require higher levels of care
because of chronic or terminal
illness.

The demographic nature of
these middle-aged adults is com-
plex. In many families, both
spouses work and have moved
from their birthplaces. Many oth-
ers have divorced, remarried,
moved again, lost or changed jobs,
and experienced a variety of
midlife crises. Adding to the

258

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


60X 10.2

The Effects of Tobacco on Oral Health
The use of tobacco products-cigarettes, cigars, pipes, and smokeless
(spit) tobacco products (snuff and chewing tobacco)-has emerged as
a major preventable risk factor for a number of oral diseases and
disorders.

Oral and Pharyngeal Cancers

(igorenes. Tobacco smoke contains over 4,000 compounds, some of
which are carcinogenic, toxic, or mutagenic (USDHHS 1989). An exten-
sive review of the literature has clearly established a causal relationship
between cigarette smoking and oral cancer (USDHHS 1982, 1989).
Indeed, about 90 percent of oral cancer deaths are attributable to
smoking (Shopland 1995, USDHHS 1989), and smoking cessation can
significantly reduce the risk (USDHHS 1990).
Smokeless fSpitl p~bbbocco. These products are causally linked to oral and
pharyngeal cancers (IARC 1985, Nash 1986, USDHHS 1986). About 30
carcinogens have been found in spit tobacco, including tobacco-specif-
ic N-nitrosamines, benzo[alpha]pyrene, and formaldehyde (Hoffman
and Djordjevic 1997).Spit tobacco users have an oral cancer risk 4 to 6
times that of nonusers (Blot et al. 1988,Winn et al. 1981).Characteristic
mucosal lesions are associated with spit tobacco use (Axell et al. 1976,
Holmstrup and Pindborg 1988, Peacock et al. 1960, Pindborg and
Renstrup 1963) and can be found even among adolescent users (Greer
and Paulson 1983,OffenbacherandWeathers 1985,Poulson etal.1984,
Tomar et al. 1997b,Wolfe and Carlos 1987).They are considered poten-
tially premalignant (USDHHS 1986).

cigars ondPipes. Cigar smoke contains the same toxic and carcinogenic
compounds found in cigarette smoke (Hoffmann and Hoffmann 1998).
A recent review of case-control and cohort studies also shows a consis-
tent elevation in risk for oral and pharyngeal cancers among cigar
smokers,with cigar smokers having 2 to 22 times the risk of non-smok-
ers of cigars (USDHHS 1998)The risk of oral and pharyngeal cancers
increases with the number of cigars smoked per day and the depth of
inhalation.

Although data for pipe smoking and oral cancer risk are more limited
than data for use of other forms of tobacco, relative risk estimates from
longitudinal studies are similar for pipe smokers and cigarette smokers
(USDHHS 1982,1989).

Periodontal Diseases

Reviews of the literature have long implicated cigarette smoking as a
risk factor for periodontal diseases.More recent studies such as Grossi et
al. (1994, 1995) showed that smoking was a major risk factor for
periodontal disease in a group of 1,500 adults. Measured either by
radiographic bone height or probing attachment level, and after
adjusting for age, sex, socioeconomic status, and plaque and calculus
levels, the investigators found that smokers were 7 times more likely to
develop periodontal disease than nonsmokers.They also found a direct
linear dose-response relationship between the level of smoking,
assessed by pack years (number of cigarettes smoked per day times
years smoked), and destructive periodontitis. Smoking is also

a prognostic indicator: current smokers are at a significantly greater
risk for further loss of periodontal attachment than are nonsmokers,
with an odds ratio of 5.4 (95 percent confidence interval of 1.5 to
19.5).

Mechanisms explaining the association suggest that smoking depress-
es immune responses (Holt 1987, Sasagawa et al. 1985), including
diminishing white blood cell activity (Gala et al. 1984, Kenney et al.
1977)Toxic and vascular effects as well as effects on the subgingival
flora are also suggested. In addition, smokers do not heal as well as
nonsmokers after periodontal disease therapy and experience less
reduction in levels of periodontal pathogens (Grossi et al. 1997).The
negative effects of smoking can be reversed with cessation of tobacco
use. After 10 years, former smokers appear to be no more likely than
nonsmokers to have severe loss of periodontal attashment (Tomar and
Marcus 1998).

Spir Tobacco. Reports indicate that oral tobacco use results in gingival
recession at the usual site of snuff or chewing tobacco placement.
In a study ofadolescent males,Offenbacher and Weathers (1985) found
that 60 percent of users had gingival recession,compared with 14 per-
cent of nonusers.

Dental Caries

The strongest evidence for an association of tobacco use and risk for
dental caries relates to the use of chewing tobacco and increased risk
for root caries.The causative factor relates to the sugar content of the
product. Several popular brands of chewing tobacco have high levels of
fermentable sugars (between 30 and 60 percent by weight).In a cross-
sectional study of older adults in North Carolina,chewing tobacco users
had a higher number and percentage of root surfaces affected by caries
than those who used other forms of tobacco or had never or formerly
used tobacco (Tomar et al. 1997a).This finding was confirmed in an
analysis of data from NHANES Ill (Tomar and Winn 1998).

Trends in Tobacco Use

In 199547 million adults-25 percent ofthe U.S.adult population-
were smokers (CDC 1997LThis figure represents a steady decline horn
the 52 percent of the population reported to be smokers in 1965, the
year following the release of the first Surgeon General's Report on
Tobacco (Giovino et al.l995).The prevalence of smoking in women was
34 percent in 1%5,30 percent in 1979 (Giovino et al. 1994Land 23 per-
cent in 1995 (CDC 1997).
In contrast,cigarette smoking in adolescents has been increasing.Daily
smoking among high school seniors increased from 17 percent in 1992
to 22 percent in 1996 (Johnston et al. 1997). High school students who
reported smoking in the preceding month increased from 27.5 percent
in 1991 (USDHHS 1994) to 36 percent in 1997 (CDC 1998).
Spit tobacco use has also increased. Sales of moist snuff-the most
popular form of spit tobacco used by young people (Tomar et al.
1995)-have increased every year since the mid-1970s (FTC 1997,
Maxwell 1992, USDA 1997).About 20 percent of male high school stu-
dents reported using spit tobacco during the previous month (CDC

(continues)

Factors Affecting Oral Health over the Life Span

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL         259


BOX 10.2 continued

1996, Johnston et al. 1997). About 6 percent of adult males use spit
tobacco (CDC 1993). Nearly all regular users are male.
Aggressive marketing has also led to explosive growth of sales and con-
sumption of cigars, Between 1993 and 1997, cigar consumption
increased nearly 50 percent (Gerlach et al. 1998). In 1997,22 percent of
high school students smoked at least one cigar in the preceding 30 days
(CDC 1998).

Implications of Trends

For &u/and fburyngeal Cancers. The increases in spit tobacco and cigar
use among young people do not bode well for the oral and general
health of coming generations of Americans. Over the past 35 years the
decline in the incidence and mortality rates of oral cancer has been
attributable to declines in cigarette smoking primarily in adult white
males. Cigarette smoking among African American males over the
same time period was higher.This practice contributed to the higher
rates of oral cancer among black males during these years. However,
recent studies indicate precipitous declines in smoking among black
males, so that their smoking rates are approaching the rates seen in
white males (USDHHS 1998). Indeed,figures on smoking among ado-
lescent and younger African American adults have even been lower
than those for their white CounterpartsThese trends could result in
substantial reductions in the risk for oral cancer among African
Americans, were they to continue. Unfortunately, there is recent evi-
dence that cigarette smoking among African American high school stu-
dents is increasing (CDC 1998).

For Periodonto/ Diseases. The growing popularity of cigar smoking may
counter the declines in cigarette smoking and maintain the percentage
of periodontal disease attributable to tobacco use.

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demands of a spouse and children, the care of older
parents contributes yet another strain to caregivers
"in the middle." These caregivers are predominantly
female and may be dependent on their own income.
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own "passages" (Sheehy 1984).

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boomers bring to the aging process higher expecta-
tions about oral health throughout the lifecycle.

Maintaining the family's oral health may require
as many individual solutions as there are sandwich
generation members (Sanders 1997, Stern 1994,
Warner 1995). Healthy lifestyle decisions combined
with preventive measures at home will be as impor-
tant as regular professional care.

In addition to their own oral hygiene practices, a
key component of maintaining the oral health of
midlife Americans is the availability of dental bene-

Factors Affecting Oral Health over the Life Span

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           Z61


Factors .\ffccting Oral Health over the Life 5pn

fits. Six of 10 full-time employees are offered dental
benefits by their employers, according to a survey by
the US. Bureau of Labor Statistics (WWW.
e-dental.com/Virtual Community for the Dental
Industry, 12/30/99). These data are from a 1997 sur-
vey of firms with 100 or more employees in private
nonagricultural industries and are representative of
benefits available to 46 million workers. The dental
benefits, one of the less prevalent benefits for
employees, vary by occupation group and are higher
for professional and technical employees (64 per-
cent) than for blue-collar or service employees (56
percent). Among the estimated 22.6 million employ-
ees with employer-provided dental benefits, most
employees (81 percent) receive their care from tradi-
tional fee-for-service plans; 11 percent, from pre-
ferred provider organizations; and 8 percent, from
health maintenance organizations.
Ensuring the oral health of the middle-aged gen-
eration must take into account the shifting patterns
of need and the family's ability to cope, the education
and training of health care workers about geriatric
and family issues, general comprehensive communi-
ty education programs about aging, estate and taxa-
tion issues, housing, and social policies and pro-
grams that support all individuals in their quest for
self-sufficiency and individual responsibility

Older Americans

Continued growth of the population 65 and older
will have profound effects on health care in the
twenty-first century (National Institute on Aging
1997). By 1994 the number of persons 65 and older
had grown to 33.2 million and represented 13
percent of the population. Although the total U.S.
population is expected to increase by 42 percent over
the next half century, the number of men and women
65 and older will increase by 126 percent, those 85
and older by 316 percent, and centenarians by 956
percent-nearly 10 times the present number.

The baby boom generation currently makes up
almost one third of the U.S. population. By 2011,
when these men and women reach 65, they will swell
the ranks of older Americans and significantly bur-
den health care programs and organizations respon-
sive to the needs of older Americans (National
Institute on Aging 1997). Although members of this
generation can look forward to continued good oral
and general health, the challenge will be in providing
effective oral health care for those who are not in
good health, especially the oldest old, and those with
limited financial support.

Oral Health Status

Chapter 4 provides selected oral health data for older
Americans as a whole. There is great heterogeneity in
oral health status among older Americans. The extent
and severity of oral conditions varies across subpop-
ulations of this age group, and many have unmet
treatment needs. Even so, older Americans are retain-
ing their teeth more than ever before and hence
remain subject to oral diseases and disorders
(Douglass et al. 1998). Indeed, with more teeth at
risk, there will be an increase in coronal and espe-
cially root caries among the elderly, as well as peri-
odontal diseases and inadequate or absent prostheses
(Burt 1992). Oral and pharyngeal cancers are prima-
rily diagnosed in older Americans.
  For a closer look at the or%1 health of both insti-
tutionalized and homebound elderly, Dolan and
Atchison (1993) compiled data based on a compre-
hensive review of the literature. Although the long-
term care population is easily accessible in large
groups, oral examinations for research purposes can
be challenging. Patient consent and antibiotic pre-
medication are issues, as well as the fact that conven-
ience samples must be used because many patients
are unable to cooperate. The authors' summaries of
oral health status and perceived needs based on the
most comprehensive homebound and long-term care
oral health surveys are shown in Tables 10.6 and
10.7, respectively.

Table 10.6 describes eight studies, with 31 to
289 patients, with edentulous rates ranging from
23.8 to 62 percent. In these studies use of dental
services within the past year ranged from 8 to 100
percent. In a 1994 Home Health and Hospice sur-
vey, only 1 percent of patients reported having a
dental visit during that year (Dey 1996). Forty-
three to 83 percent of persons in six of the home-
bound studies in Table 10.6 recognized that they
had dental problems.

In the long-term care studies listed in Table 10.7,
45 to 65 percent of those surveyed were completely
without their natural teeth. One study found that 17
percent required immediate or emergency dental
care. By any standards in the United States, a high
degree of dental disease and dental care needs was
recognized in all four studies presented.

Daily oral care is an important and easily neg-
lected service that should be offered to this popula-
tion. Unlike many of the inevitable declines the frail
elderly face with their various diagnoses, the decline
in oral health can be stayed with good daily oral care.
Nursing staff participation in the daily oral care of
long-term care patients is crucial. Mouth care is often

262

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


considered an unpleasant task and is often delegated
to nursing auxiliaries, who have even less oral health
training than registered nursing staff, Seventy percent
of patients in long-term care facilities had unaccept-
able levels of oral hygiene (Kiyak et al. 1993,
McIntyre et al. 1986).

  Barriers to such needed care include lack of
knowledge about oral care by the nursing staff, per-
ceived lack of time for care, and lack of perceived
need for daily oral care by both caregivers and
patients, The resulting failure to provide daily oral

care will often doom oral health that had been previ-
ously well maintained.

Data on the oral health status of hospice patients
are scarce. Although not all hospice patients are eld-
erly, data from the 1994 Home and Hospice Care
Survey showed that 19.8 percent of those in hospice
care wore dentures. The terminally ill often suffer
from taste alterations, oral soreness, oral dryness, and
oral candidiasis or thrush (Aldred et al. 1991). In
most cases, the caregiver will perform daily oral care
and palliative oral care measures. Palliative care can

TABLE 10.6
Summary of published reports and abstracts on the oral health status and barriers to dental care for homebound elders

Steitel et al. 1979






Yellowitz et al. 1988
[abstract]


Kaste et al. 1989
[abstract], Marcus et
al. 1989 [abstract]


Aponte-Merced et al.
1990 [abstract]




Strayer et al. 1990
[abstract], Strayer et
al.1991 [abstract]


Yellowitz et al. 1991
Iabstract]

Sample
Size


64






107




289






50








67






123

Sample        Mean      Dental      Percentage
Description     Age (years)   Utilization      Edentulous        Findings

Two nonprofit     Approx. 75  25% visit in past    Approx. 60%    60% reported dental needs:
visiting nurse              year               dentate subjects more likely to
services, Seattle                                 seek care
                                Barrier: transportation
Recipients of visiting      NA  34% visit in past         NA    >50% reported mouth
nurse services, Utah           year               discomfort, painful tongue, dry
                               mouth, difficulty chewing
Homebound, >65       82.5   50% with no visit       62%    43% perceived dental need
years, recipients of         in 10 years              Barriers: transportation, cost,
home care services,                          needed physical assistance
Boston

Recipients of home       79.0  8% visit in past        59%    37% had dental complaint;
health services,             year               60% perceived dental need;
county health .         28% no visit in              84% wanted treatment
departments,           20 years
Alabama

Clients of urban         NA  Not reported          44%    80% perceived dental need
social service                            Barriers: transportation, cost,
agency, 60%                           physical impairments
homebound

Recipients, veterans       72.2  40% visit in past        33%    50% reported dental health
hospital-based home          year               fair/poor; 50-83% perceived
care, Denver and                               dental need
Minneapolis                            Barriers: 53% no perceived
                                   need; 25% had no dentist;
                                 22% transportation;
                                         22% cost

Strayer and lbrahim
1991


Williams and Butters
1992

31

Chart audit, patients
treated at Ohio State
University
Statewide survey to
identify the number
of homebound
persons in Kentucky

74.8




68.6

100%




53.8% visit in
past year

23.8%





NA

59.7% had
periodontal/preventive/
operative needs;
27.3% prosthodontic needs;
46.8% surgical needs;
2.7% of Kentucky households
have a homebound resident

Source: Dolan and Atchison 1993. Copyright 1993 by American Association of Dental Schools. Reprinted by permission of American Association of Dental Schools (2000).

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          263


Factors Affecting Oral Health over the Life Span

include oral moisturizers such as artificial saliva, ice
chips, a water atomizer, daily oral-cleaning or swab-
bing, and, if needed, treatment for yeast to relieve
oral pain.

Americans have the potential to experience a life-
time of oral health rather than a lifetime of oral
restorative care. Each of the following questions can
be applied to the major oral problems of the elderly,

TABLE 10.7

Summary of four published reports on the oral health status and barriers to dental care for nursing home residents

Sample           Mean
Description       Age (years)

Dental
Utilization

Percentage
Edentulous

Findings

Empy et al.1983

242 residents of 12 skilled
nursing facilities; stratified
random sample;Washington
state

81

mean time
since last
dental visit:
4.9 years

65.3%

Needing denture treatment: urban, semirural,
rural; 63,46,39%, respectively
Mean number of decayed teeth: 1.8,3.0,2.4,
respectively
Mean number of p>riodontally involved teeth:
1.9,0.7,1.1,respectively
80% who did not intend to visit dentist felt
"no need"
Median age of dentures: 15.5 years

California Dental     286 residents of a stratified       81     22% visit in      57%   17% had immediate dental needs
Association (CDA) 1986  random sample of nursing          past year           Dentate residents:mean number teeth: 17
            homes                                        12.9% carious
                                                 7.0% fractured
                                        49.6% periodontal disease
                                         75.8% needed 1+ quadrants scaling
                                            Prosthodontic needs:25% maxilla,28%
                                                 mandible
                                       Reasons for not seeking care:52% felt no need;
                                       24% transportation; 9% finances,
                                           9% illness; 43% oral mucosal disease

Veterans Administration  634 residents of sixVA          71    Not reported     50%   Dentate residents:
(VA) 1989       facilities: Florida, Illinois,                       3.7 decayed coronal surfaces (DFS = 18.6)
         Massachusetts;regional                       4.8 decayed root surfaces (DFS = 6.5)
         convenience sample                        Average periodontal attachment loss:
                                         2.5 mm, 27% pockets >4 mm
                                             Prosthodontic needs:35% maxilla,28%
                                                   mandible
                                                  40% denture-related oral lesions

Kiyak et al. 1993

1,063 residents of 31
nursing homes in
Washington state

range 72 to 98

Not reported

44.8%

Dentate residents:oral problems:
72% poor oral hygiene
36% root caries
26% coronal caries
24% retained root tips
18% significant tooth mobility
11% swelling,soft tissue lesions
10% dry mouth
Edentulous residents:oral problems:
46% loose dentures
18% sore or bleeding gums
15% poor oral hygiene
10% dry mouth
5.4% soft tissue lesions
63.8% had dental treatment needs

Source: Dolan and Atchison 1993,Copyright 1993 by American Association of Dental Schools. Reprinted by permission of American Association of Dental Schools (20001.

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


including coronal and root caries, periodontal dis-
eases, oral cancer, oral-facial pain, tooth loss, salivary
gland dysfunction, and oral mucosal diseases:

   o  How do we best identify elders at greatest
risk for oral diseases? Who is not at risk? How can
we improve diagnostic accuracy? When is increased
accuracy not related to improved outcomes?

   o  Can these diseases be prevented or delayed?
Which measures are most effective? Which have the
greatest benefit for the least cost?

   o  Once a person has the disease, which treat-
ments are most effective?

When measuring effectiveness, care should be
taken to consider the proximal outcomes, that is,
effects at the tissue level, as well as ultimate out-
comes, that is, how the overall effects of the treat-
ment affect a persons ability to function and be a pro-
ductive, contributing member of society

An important consideration in treating oral
health problems in the elderly is the relationship
between oral and general health. Too often, oral
health care is ignored or takes second place in light of
the high prevalence of such chronic and life-threat-
ening conditions as heart disease, stroke, cancer,
osteoporosis, and diabetes. Yet the evidence present-
ed in Chapter 5 speaks to associations linking oral
infectious diseases such as periodontitis to the
increased risk for cardiovascular, cerebrovascular,
and lung disease, to exacerbations of diabetes, and as
an early indicator of osteoporosis. In turn, to ignore
oral health care in the course of cancer radiation and
chemotherapy predisposes the patient to serious oral
infections, mucositis, severe pain, bone loss, and
potential abscesses. The 1988 Surgeon General's
Workshop on Health Promotion and Aging stated
that all health care providers should be educated in
the importance of oral health to overall health and
well-being (USDHHS 1988).

Insurance Issues. In light of the oral care needs of the
elderly and their vulnerability to systemic diseases,
the lack of dental insurance poses a serious barrier
(Jones et al. 1990, Niessen 1984). Medicare funds
cover only a negligible and select amount of care.
Many elders lose their dental insurance at retirement
(Niessen 1984). The situation may be worse for older
women. Because women overall have lower incomes
than men, lack of insurance and high copayments for
dental services may represent formidable obstacles to
care. In addition, women assume a disproportionate
burden as caregivers for family members of all ages:
the young, the sick, and the elderly (Niessen 1984).
This often disrupts employment and, consequently,
insurance coverage.

Thus, the majority of dental care rendered to
older patients is paid for out of pocket. Medicaid pro-
grams fund dental care for low-income and disabled
adults, including elders, in some but not all states
(ADA 1998b, Jones et al. 1990), but reimbursements
are scant, even in emergency situations. Where there
is reimbursement, it is often low and slow, adding yet
another disincentive for provision of oral care.
Medicaid funds the costs of the majority of patients
in long-term care, which means that they either have
spent their life earnings or were in poverty prior to
admission.

This lack of dental coverage is occurring at a
time when more and more of the new elderly will be
dentate and both want and need>are (Ettinger and
Beck 1982). Thus, funding dental care for elders is a
major obstacle.

Social Services. Decreased functional status and
increasing levels of dependence add barriers to den-
tal care for elders. It will be increasingly important
for community and social service programs to
respond to older residents' needs for assistance,
including transportation to meet their oral care
needs. For example, programs administered by the
Administration on Aging (AOA) that integrate oral
health into general health programs for the elderly
raise awareness about the benefits of good oral health
and its contribution to nutritional status and quality
of life (National Policy and Resource Center 1998).
For patients in long-term care settings, access to den-
tal care is even more problematic. Lack of adequate
compensation has been a barrier to increasing the
number of dentists who choose to pursue this type of
dental practice.

Trends

Despite advances in modern medicine that have
greatly increased life expectancy in the twentieth
century, there will be an increase in the number of
persons with acute and chronic diseases, including
arthritis, diabetes, osteoporosis, and senile dementia
(U.S. Bureau of the Census 1998b). As always, it is
necessary to distinguish between healthy elders who
age normally and remain active and community
dwelling and the frail elderly (Niessen and Jones
1991).

Most community-dwelling elders take both pre-
scription and over-the-counter drugs (Chrischilles et
al. 1992). Approximately 30 percent of all medica-
tions prescribed in the United States are for persons
over the age of 65, with an average of 8.1 medications
per patient in a long-term care facility (Gurwitz et al.
1990, Lamy 1989). Seventy-five to 94 percent of

Factors Affecting Oral Health o\cr the Life Span

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          265


Factors .\ffecting Oral Health over the Life Span

patients taking medications are taking at least one
drug that may have an oral side effect (Baker et al.
1991, Levy et al. 1988, Lewis et al. 1993). The most
common of these side effects is dry mouth, or xeros-
tomia. Others include abnormal homeostasis. soft tis-
sue lesions or reactions, taste changes, altered host
resistance, gingival overgrowth, burning oral sensa-
tions, increased caries due to high sugar content, and
involuntary oral movements.

At any given time, approximately 5 percent of the
population 65 and older live in a long-term care facil-
ity, and an estimated 43 percent of these elders will
require long-term care placement at some point in
their lives (Murtaugh et al. 1990). As discussed earli-
er, one result of elders' increased disability and
dependency is that middle-aged family members are
confronted with increased parental care concerns and
needs (U.S. Bureau of the Census 1990).

Determining the oral health status of home-
bound and hospice populations is challenging.
Statistics are reported by evaluating persons who
seek services for either home or hospice care.
Obviously, this underrepresents both populations by
leaving out those who refuse, are not aware of, or do
not qualify for services. As with long-term care, most
homebound are women, although the average age is
younger than for those in long-term care facilities.
This may represent a step in the continuum of care
before long-term care is necessary Fifty-five percent

of women are hospice patients, and hospice patients
are a much younger population than either the
homebound or those in long-term care.

  Table 10.8 lists the 10 chronic conditions seen
most frequently in the frail elderly These health
problems are important in relation to oral health
because they, or their treatments, may worsen oral
health or in turn be worsened in the presence of oral
disease (see Chapter 5). Long-term' care residents
have an average of 3.3 chronic conditions per person
(Adams and Marano 1995).

Although it is difficult to evaluate dementia
patients following strict research protocol. several
studies have noted high caries rates, poor oral
hygiene, and a high percentage with unmet dental
needs (Chapman and Shar 1991, Gordon 1988, Jones
et al. 1993). Patients with dementia depend heavily
on caregivers to provide daily oral care, and dental
care can be most challenging.

The Impact on Women
Redford (1993) examined the effects of biological,
behavioral, and societal factors on women's oral and
general health and treatment needs. Throughout
their lives, American women report more acute
symptoms, chronic conditions, and short- and long-
term disabilities than men; women's activities are
limited by health problems 25 percent more days
each year than men's (Verbrugge 1984, 1990). The

TABLE 10.8

Most common diagnoses of frail elderly k65) in nursing homes, receiving home health (homebound) and
hospice care by percentage of the population, 1994 to 1995

Rank       Nursing Home Resident               Homebound                Hospice

1    Diseases of circulatory system          Diseases of the circulatory system       Neoplasms

2     Mental disorders              Endocrine, nutritional, metabolic,       Diseases of the circulatory system
                       and immunity disorders

3    Diseases of nervous system and sense organs      Diseases of musruloskeletal         Diseases of the nervous system and
                       and connective tissue systems          sense organs

4    Injury and poisoning             injury and poisoning           Diseases of the respiratory system

5    Endocrine, nutritional, metabolic, and immunity    Diseases of the respiratory system       All other diagnoses
     disorders

6    Diseases of the respiratory system        Neoplasms              AIDS and infectious or parasitic diseasesa

7     Diseases of the musculoskeletal and connective    Ill-defined conditions           AIDS and infectious or parasitic diseasesa
    tissue systems

a    Diseases of the digestive system         Diseases of nervous system and sense organs

9    Diseases of the genitourinary system        Disease of skin and subcutaneous tissue

10    Neoplasms                Diseases of the digestive system

a Rates of the two categories are equal.
Sources: Data are from 1994 Home and Hosprce Care Survey and 1995 National Nursing Home Survey (Dey 1996,1997,Haupt 1997).

266        ORAL HE.ILTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


..gender gap" in physical disability widens with
advancing age (U.S. Bureau of the Census 1990).
\\`omen in nursing homes or personal care facilities
outnumber men three to one (NCHS 1991).

In the course of aging, significant numbers of
women experience compromised functional status,
physical confinement, medical conditions, and cog-
nitive impairments. The literature indicates that
these factors have placed women's oral health at risk.
At the same time, they may limit a woman's ability
to maintain oral hygiene self-care regimens, seek
professional dental services, tolerate dental treat-
ment, and comply with postoperative instructions

(Gift 1998).
Pharmacologic  regimens
common among women can
promote xerostomia, thereby in-
creasing the risk of caries,
periodontal diseases, and atro-
phic/disease changes in oral
mucosa (Atkinson and Fox
1992). As a consequence of
chemotherapy for breast cancer,
women may suffer inflammation
and ulceration of the oral
mucosa, oral infection, hemor-
rhage, neurotoxicity, and salivary
gland dysfunction (McCarthy
and Skillings 1992, National
Institutes of Health Consensus
Development Conference State-
ment:  Oral Implications of
Cancer Therapies 1990).

ACHIEVING ORAL

HEALTH THROUGHOUT
LIFE

Each life stage brings a unique set
of issues and considerations.
Ultimately, this overview identi-
fies the need for research on
health services, health promo-
tion, and disease prevention spe-
cific to populations at different
life stages and throughout the life
span. Our nation's young and old
exemplify the complexities of the
individual, family, community,
and institutional interactions that
shape health and well-being. The
middle years are not without
complexities, but represent a

r

time during which employment and responsibility
for caring for others play a critical role. Overlying the
age spectrum are other sociodemographic factors
that intensify the need to address each group and
each health issue in a manner that optimizes health
outcomes. In the overview of special populations
presented in Chapter 4, the impact of race and
ethnicity, socioeconomic status, and issues in relation
to the health of women and individuals with disabil-
ities clearly cut across all life stages. The nation`s
social and welfare programs, the organization of our
private systems of health care, and the values of the
many cultures that make up America contribute to

TABLE 10.9
Summary: Healthy People 2010 objectives-oral health
Objective                    Age(s)    2010 Baseline  2010 Goal

21.1  Reduce dental caries experience in children        2-4      18%      11%
    6-a                          52%      42%
    15                          61%      51%

21.2  Reduce untreated dental decay in children and adults    2-4      16%      9%
    6-8                        29%      21%
    15                         20%      15%
    35-44                        21%      15%

21.3  Increaseadults with teeth who have never lost a tooth   35-44      31%      42%

21.4  Reduce adults who have lost all their teeth        65-74    26%a      20%

21.5a  Reduce gingivitis among adults            35-44      48%      41%

21.5b  Reduce periodontal disease among adults        35-44     22%      14%
21.6 . Increase detection of Stage I oral cancer lesions      all      35%      50%

21.7  Increase number of oral cancer examinations       40+      9%      35%

21.8  Increase sealants in I-year-old first molars         8    23% (a 1st)     50%
   and in lCyear-old first and second molars        14   15% (a lst&2nd)   50%

21.9  Increase persons on public water receiving fluoridated H,O  all      62%      75%

21.10  Increase utilization of oral health (OH) system       2+      44%      56%

21.11  Increase preventive dental services for poor children    2-17      20%      57%

21.12  Increase number of school-based Health Centers with   K-l 2   developmental
    OH component                        unknown

21.13  Increase number ofCommunity Health Centersand     all      56%      75%
   local health departments with OH component

21.14  Increase utilization of dental service for those       all      17%      25%
   in long-term facilities, e.g., nursing homes
21.15  Increase states with system for recording         all       23        51
   and referring orofacial clefts

21.16  Increase the number of states with            all        0        51
    state-based surveillance systems

21.17  Increase the number of state and local dental       all   developmental
   programs with public health trained directors            unknown

aBased on self-report, National Health Interview Survey, 1996 (NCHS 1996).
Source:USDHHS 2000.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          267


the current status of health, including oral health,
and are the basis for further improvements.

The models described at the beginning of this
chapter provide a structure for designing strategies to
improve and promote health. Any one approach can
be used as a framework for action. The Healthy
People 2010 objectives provide a useful template for
driving many age-specific and disease/condition-spe-
cific outcomes. The multiple oral-health-related
objectives outlined there emphasize the importance
of risk behaviors and comorbidities that need to be
addressed in order to further improve oral, dental,
and craniofacial health (USDHHS 2000) (Table 10.9).

Recurrent themes in this chapter and other parts
of the report underscore the importance of access to
health care and health care services, the adoption of
healthy behaviors, and the role of individuals and all
health care providers in contributing to oral health.
Public policies, institutional care guidelines, and
community programs can reinforce what individuals
can do by providing a health-promoting environ-
ment. Toward that end, a recently published report
from the Center for Policy Alternatives (Warren
1999) examines and recommends health policies and
related actions to improve the oral health status of
the poor and underserved. Focus is placed on five
dimensions of oral health-finance, sustainability of
services, capacity to provide services, cultural com-
petency of care providers, and infrastructure to sup-
port professional practice. Policy recommendations
and proposed action steps are presented in terms of
the availability, accessibility, and acceptability of care.
Dental care services are emphasized over other
aspects of oral health maintenance, because much of
the unmet need warrants dental services for preven-
tion and treatment.

Health care providers, program administrators,
local, state, and government administrators, educa-
tors, scientists, and leaders, among others, have pro-
posed ways of promoting health and preventing dis-
ease that respond to the principal health determi-
nants presented in the chapter. Thus, efforts can be
directed toward changing the environment to make it
more life-enhancing; establishing new public health
policies; enhancing health literacy to encourage
healthy behaviors and lifestyles; working at the
microlevel of neighborhoods and communities on
health-related measures; and orienting health care to
meet the needs of a changing society

Building on programs and structures already in
place that have contributed to the improvements in
oral health is essential. Further advances in the oral
health of all Americans cannot be made unless the'
health needs of the underserved and vulnerable pop-

Factors I\ffecting Oral Health over the Life Span

ulations are addressed. The inability of federal and
state programs that are the primary source of funding
for services to these populations, specifically,
Medicaid, SCHIP and Medicare, to cover and ade-
quately reimburse for dental services has been duly
noted. The current review of access to dental care by
the Government Accounting Office should add to an
earlier review of EPSDT and further address barriers
to access and other issues that warrant attention. The
Institute of Medicine (IOM) study on the extension
of Medicare services to include medically necessary
dental services is an additional source of recommen-
dations to better address the health needs of vulnera-
ble populations and enhance health overall (Field et
al. 1999).

Other critical reviews of the problems entailed in
addressing the nation's oral health needs and
proposing solutions include the 1989 Public Health
Service Workshop on the Oral Health of Mothers
and Children (USDHHS 1989). Recommendations
covered the areas of public education, professional
education, coalitions, advocacy and collaboration,
health policy, and data collection, evaluation, and
research. These recommendations formed the basis
for the 2000 Surgeon General's Workshop on
Children and Oral Health. Similarly, the 1988
Surgeon Generals Workshop on Health Promotion
and Aging (USDHHS 1988) provided guidance for
steps to be taken to improve the oral health of the
nation's elders, all of which are still relevant. This
workshop provided the impetus to add objectives
on oral health status in nursing homes to Healthy
People 1990.

Ideally, organizations and agencies working
together can resolve the issue of barriers to care.
Concentrated efforts such as those focused on
improving the access of children to Medicaid oral
health services by the Health Care Financing
Administration, Health Resources and Services
Administration, American Dental Association, and
National Center for Education in Maternal and Child
Health are an example of how national organizations
can unite to make a difference. Still, activities are
needed at the local community level. The efforts of
Milgrom and colleagues provide one such example
for children eligible for Medicaid, with a focus on
early childhood caries (Milgrom and Weinstein 1999,
Milgrom et al. 1999). In implementing these efforts,
however, the capacity of current national, state, and
local programs as well as legislative mandates to meet
the oral health needs of all Americans must be
reviewed and strengthened, as necessary

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


Factors Affecting Oral Health over the Life Span

FINDINGS

   o  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.
   0  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

o 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.

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Facing the Future

The challenges for oral health in the twenty-first cen-
tury are formidable. First and foremost is the need to
ensure that all people have access to health care and
can acquire the health literacy necessay to make use
of health promotion and disease prevention informa-
tion and activities.

The century offers the promise of a new era for
health wrought by the convergence of six cultural
movements, an)' one of jvhich would be sufficient to
transform the human condition:

   o  The biological and biotechnology revolutions.
   0  A redistribution of the worldk people by
rapid and sizable migrations within countries and
across borders.

logical discoveries of the early anatomlsts and embry-
ologists-the founders of cell theory and brain
research-were followed by the brilliant innovations
of Pasteur, Koch, and Ehrlich, who established the
new fields of microbiology and immunology The
cumulative achievements of these pioneers set the
foundation for the diagnostic and therapeutic science
and art of dentistry, medicine, nursing, and pharma-
cology in the twentieth century

   o  Changing demographics in industrialized as
well as developing nations.

   o  Changing patterns of disease. including the
emergence and reemergence of infectious diseases.
and changes in the organization of health care.

The seeds were also sown for the convergence of
chemistry, physics, and biology in the field of molec-
ular biology as well as the convergence of Darwinism,
fruit fly genetics, and population genetics into the
modern evolutionary synthesis. These convergences
inspired the current quest to identify all 100,000
genes of the human genome and to assign functional
meanings to the motifs that are encoded within them.

   0  Instant worldwide communication through
the Internet, cable, satellite, and wireless technology.

Vital Statistics

   o  A continuing exponential rate of growth in
information technolog); specifically in computer
speed, memory, and complexit):

These global currents are changing the way we
live now and will have profound implications for the
future of the oral and general health and well-being
of all people.

THE PAST AND PRESENT AS
PROLOGUE

The growth of the world population and the
transcontinental movements of people are proving a
dominant force for change. The twentieth century
began with increased European and Asian migrations
to the United States. By 1900 the U.S. population had
reached 90 million residents and the Earth's popula-
tion was approaching 1 billion people. Life expectan-
cy in the United States was 47 years of age. Acute
viral and bacterial infections were the primary caus-
es of infant morbidity and mortality. Being edentu-
lous, or "toothless," was a normal expectation for
mature adults.

The Pioneers

The history and intellectual activity of the eighteenth
and nineteenth centuries set the seeds for the flower-
ing of biology in the twentieth and early twenty-first
centuries (Porter 1997). The scientific and techno-

For most of recorded human history and the
100,000 years of human prehistory, life expectancy
was very low. Life expectancy at the time of the
Roman Empire was approximately 28 years of age.
From the beginning of the first millennium A.D. to
1900, each year of history saw an average gain of
3 days in life expectancy. Each year since 1900,

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          275


Facing the Future

however, has seen a gain of 110 days in average life
expectancy (Rowe and Kahn 1998). Life expectancy
at birth in the United States has increased from 47
years in 1900 to approximately 76 years today While
the entire population of the United States has tripled
since 1900, the absolute number of older persons,
currently 33 million, has increased elevenfold (Finch
and Pike 1996, Rowe and Kahn 1998, p. 4). The U.S.
population is 270 million and will reach 300 million
in the next few decades. The Earth's population dou-
bled by 1950, doubled again by 1975. and currently
is 6 billion.

Health Improvement

Measures such as improved sanitation and housing,
prenatal care, immunizations, health education and
promotion, community water fluoridation, and den-
tal sealants have greatly improved oral health for the
majority of the population. Advances in science and
technology, health professional education, the sci-
ence of public health and clinical practice, and the
health literacy of the public will continue to improve
the health and well-being of Americans in the com-
ing years (Kevles 1997, Schwartz 1998). Ever larger
numbers of senior adults expect to retain a full or
nearly complete dentition and to live well into their
70s 8Os, and 90s free of pain and discomfort (Slavkin
1997a).

DIVERSITY OF DISEASES AND
PATIENTS
Those seeking care in the decades ahead will present
with a wide range of diseases and disorders, uneven-
ly distributed across populations. The very youngest
patients include children with complex hereditary or
congenital craniofacial defects in need of expert mul-
tidisciplinary teams to repair and restore form and
function. Early childhood caries, one of the most
severe forms of the disease, is especially prevalent
among poor children in some racial/ethnic groups in
America, such as American Indians and Mexican
Americans. Young adults are particularly vulnerable
to unintentional and intentional craniofacial injuries.
Middle-aged and older generations typically experi-
ence chronic diseases affecting the heart or lungs as
well as cancers, diabetes, and the various degenera-
tive diseases of joints and bones and the nervous sys-.
tern, all of which may affect or be affected by oral dis-
eases and their treatments.

TRANSFORMING TREATMENTS
The cultural movements that are changing the
human condition will likely transform treatments for
many of the complex disorders just described. The
instrumentation used to detect subtle genetic varia-
tions in each of the 100,000 genes in the human
genome will inexorably reveal which gene or genes
are defective in hundreds of inherited and acquired
craniofacial diseases or syndromes. On the horizon
are promotion measures to enhance health and elim-
inate exposures to teratogens, as well as surgical
techniques to correct the defects in utero, obviating
the need for costly multiple surgeries and rehabilita-
tion programs for affected children.
We are entering the "golden age of molecular
oral health" with gene-based diagnostics, therapeu-
tics, and biomaterials. Risk assessment for disease
will be based in part on understanding the genetic
variations that affect resistance or susceptibility, but
also will be determined in part by environmental fac-
tors, socioeconomic status, personal behaviors, and
lifestyle. The risk for early childhood caries is likely
to be determined by a combination of all these fac-
tors, as well as cultural beliefs and practices within
some populations. Elimination of all infections,
whether in the oral cavity or elsewhere, will be seen
as a critical part of health promotion.
Prevention of injuries will call for approaches
that are both culturally and age sensitive, in addition
to the coordinated efforts of policymakers and legis-
lators to mandate protective gear in sports and other
safety measures when necessary
Gene therapy will be applied to treat oral and
pharyngeal cancers and also will be used for the oral
and systemic delivery of endogenous and synthetic
molecules to treat salivary gland disorders, oral infec-
tions, and systemic disease. Highly specific drugs will
be developed for the management of chronic facial
pain such as trigeminal neuralgia and Bell's palsy.
  Should additional evidence in the early years of the
twenty-first century further indicate that oral infections
actually cause some cases of heart disease, pulmonary
disease, and stroke, or trigger the birth of premature,
low-birth-weight babies, treatment approaches will be
radically altered.

TRANSFORMING HEALTH
PROFESSIONAL EDUCATION
The scientific and technological bases of dentistry,
medicine, nursing, and pharmacy are expanding rap-
idly in parallel with the changing demographics of

276

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


the nation, the publics expectations for an enhanced
quality of life, and changes in the management and
financing of health care. Health professional schools,
often organized around academic health science
centers, are responding to these challenges and
opportunities.

Students and clinicians alike need to be prepared
to adopt evidence-based health care. Today and
tomorrow, students must be well versed in epidemi-
ology, biometry, bioinformatics, molecular biology,
bioengineering, and much more. In addition, they
must be prepared to adopt and implement new pre-
ventive strategies and comprehensive and molecular-
based diagnostics and therapeutics; to support
cost-effective community-based health programs:
and to anticipate all the challenges that promotion of
health entails. Clinical science or scientific evidence
in the new millennium will continue to evolve in
molecular dentistry and medicine with attendant
opportunities for addressing the social, legal, and
ethical implications. We must prepare clinicians for
the nuances and complexities of modern clinical
research-based results.

The previous chapters of this report provide the
documentation that can be used to assess health pro-
fessional education. Major progress in health promo-
tion, disease prevention, diagnostics, therapy and
therapeutics, and the socioeconomic and behavioral
factors that influence oral, dental, and craniofacial
health will further contribute to the transformation
of health professional education.

TRANSFORMING HEALTH CARE

We are currently witnessing a significant transforma-
tion in the financing and management of health care,
which is affecting all the health specialties. Care
providers are assuming new responsibilities and
functions, and changing employment patterns.
Traditionally, the management of health care has
been centered on the providers of services and hospi-
tals. Recently, the center has enlarged to include addi-
tional marketplace stakeholders, the purchasers of
health care and health care plans, and increasingly all
segments of society The interactions among all these
participants will shape health and health care for the
foreseeable future.

Risk assessment models are also being developed
and used to design treatment options tailored to
communities and to individual patients. Increased
use of information technology greater efforts to con-
duct community needs assessments, and greater
emphasis on enhanced quality of life expectations of

Facing the Future

patients, families, and communities are also in
evidence (USDHHS 2000).

The responsibility for oral and craniofacial care
involves all health professionals, so coordinated care
delivery and reimbursement will be critical.
Evidence-based systematic assessments and guide-
lines will contribute to clinical and public health
decision making. In addition, the linkage between
health care professions and public health and social
service activities will need to be strengthened.

These trends are complemented by greater
understanding of the psychosocial-behavioral aspects
of oral diseases and disorders. These advances will
continue to influence the nation's cgpacity to address
the breadth and depth of diseases and conditions
affecting oral health across the life span and their
relationship to general health and well-being.

  Access to the Internet and increased health and
science reporting in print and broadcast media have
created a more knowledgeable public motivated to
understand the value of healthy choices. However,
increasing numbers of patients are also questioning
traditional practices and seeking alternative and
complementary approaches.

ORAL HEALTH-NOT YET FOR ALL
Demographers predict that by 2050 there will be no
single racial/ethnic majority in the United States.
Rather, we will become an increasingly diverse nation
with diverse patterns of disease and levels of health.
This is especially evident for African American,
Latino, Asian and Pacific Islander, and American
Indian communities (Pamuk et al. 1998). Disparities
in educational advancement, job opportunities,
income and wealth, housing and neighborhood char-
acteristics, health access and status, and involvement
in the criminal justice system for various subpopula-
tions will remain unless steps are taken to reverse the
trends (Council of Economic Advisers 1998).

The proportion of school-aged children who are
caries-free in their permanent teeth has more than
doubled during the last 20 years. However, in states
such as California, Texas, Louisiana, Alabama,
Florida, and Georgia the trends are different; fewer
than one third of the children are caries-free in their
permanent dentition.

One attempt to come to the aid of poor children
is the State Children's Health Insurance Program
(SCHIP), federal legislation designed to help individ-
ual states meet the health needs of children (Council
of Economic Advisers 1998, NRC 1998). As of 1998,
more than 11 million children in America-l in 7

Ok&L HEALTH IN AMERI&4: A REPORT OF THE SURGEON GENERAL

277


Facing the Future

children-are estimated to be uninsured. Most of
these children live in families with working parents
who have jobs that do not provide health insurance
and who are unable to purchase health care insur-
ance (NRC 1998). Nationally, 1 in 6 African
American children and 1 in 4 Hispanic children are
uninsured, compared with 1 in 10 white children
(Council of Economic Advisers 1998, NRC 1998).
This limited health care access is particularly signifi-
cant in relation to oral health.

HOPE FROM SCIENCE AND
TECHNOLOGY

The biological and biotechnology revolutions will
accelerate, inspiring theory building and new models
of miniaturization and speed that can be applied to
improve oral health. The Human Genome Project
will be completed no later than 2003. The entire
human genetic lexicon will be accessible through the
Internet. To date, more than several hundred mutat-
ed craniofacial regulatory and structural genes have
been found to cause abnormal formation of oral. den-
tal, and craniofacial tissues and structures.

In addition, the genomes of many significant
viruses, bacteria, yeast, parasites, plants, and animals
are currently being deciphered, and these are revolu-
tionizing how we think about biology and human
diseases (Bodmer and McKie 1995, Chambers 1995,
Collins et al. 1998). At present, research is under way
to decipher the genetic lexicon of 60 microbes, 6 of
which are important oral pathogenic bacteria or
fungi. The evolution of this knowledge will yield
innovations in areas from clinical prevention to drug
and biomaterials discovery Figure 11.1 presents a

model of the possible interface between genomics
and molecular dentistry

Perhaps with the sole exception of trauma, all
human diseases have a genetic component. Genetic
dentistv and medicine are based on the paradigm
that changes or mutations in individual nucleotides
within genes or alleles result in variations or poly-
morphisms. These mutations are either inherited or
acquired after birth. For example, inherited muta-
tions in the amelogenin gene located on the human
X (and Y) chromosome can produce X-linked domi-
nant or recessive amelogenesis imperfecta, a painful
disease characterized by defective tooth enamel
(Backman 1997), and mutations in the fibroblast
growth factor receptor 2 gene can produce serious
craniofacial birth defects such as Crouzon's disease
and other syndromes with premature fusion of cra-
nial bones (craniosynostosis) (Cohen 1997).
Mutations in a number of transcription factors that
regulate development produce other craniofacial syn-
dromes (Slavkin 1999).

FIGURE 11.1
Interfaces between genomics and molecular dentistry
Oral Diseases with
Genetic Component

The human genome contains approximately
100,000 genes or alleles. The genome consists of 3
billion nucleotides or bases. Mutations changing one
or more bases, in one or more genes, can result in dis-
eases or disorders. Many environmental factors
termed mutagens, carcinogens, or teratogens can
cause mutations in one or more genes resulting in
human disease such as neoplastic diseases. The com-
pletion of the Human Genome Project in the next 2
years will afford an unprecedented opportunity to
advance our understanding of inherited as well as
acquired human diseases and disorders.
Scientific discoveries are rapidly defining single-
gene mutations, mapping these individual genes in
       their precise positions on each of
          the $6 human chromosomes.
       These findings are being used to
       diagnose inherited and acquired
       clinical phenotypes as well as "at-
       risk populations" throughout the
        human life span.

Health Promotion
?

/
i
// Diagnostics

Oral Pathogen --c Map p  Clone Understand
                                    )       --+ Preventive
Genomes     Gene(s)        Gene(s)       Function     Dentistry
1             \
         \

Genome of Oral,                         Therapeutics
Dental,and                          - gene therapy
Craniofacial Tissues                       - gene therapeutics

------------------------~
                     TIME

  These remarkable advances in
human molecular genetics are
identifying candidate genes for
developing targeted gene-mediated
therapeutic approaches to many
oral health diseases, ranging from
passive immunization for dental
caries, induction of new bone and
cartilage tissue, and regeneration
of periodontal tissues, to the arti-
ficial synthesis of saliva for pat-
ients suffering from xerostomia.

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


  Gene mutations also define the virulence of
microbes (viruses, bacteria, yeasts, and parasites), as
well as the fidelity of the human immune system.
blfcrobial as well as human genes are extremely sen-
sitive to environmental stress and can and do mutate,
resulting in antibiotic resistance. The genetic vari-
ance within microbial genomes such as the genome
of the yeast Candida albicans may be closely aligned
with the host changes associated with immunologi-
cally compromised patients. The HIV viral genome is
another particularly useful model for considering
viral mutation frequency during pathogenesis
(Slavkin 1996a). These discoveries provide the foun-
dations for gene-based diagnostics for disease detec-
tion; therapeutic drug development; and individual
predictors of drug response during the management
of chronic facial pain, osteoarthritis as related to tem-
poromandibular joint disease, and osteoporosis asso-
ciated with periodontal diseases.
We are beginning to understand that polymor-
phisms (variations) in multiple genes confer suscep-
tibility or resistance to chronic and disabling diseases
and disorders such as osteoporosis, periodontal dis-
eases, and temporomandibular disorders (Slavkin
1997b). In these examples, multiple genes and mul-
tiple gene-environment and gene-gene interactions
are associated with the molecular etiology and
pathophysiology of the disease process.
The function of most genes must inevitably be
studied and understood at the level of their encoded
proteins and protein-protein interactions, `for these
are the biologically active players of life. An enor-
mous number of genes encode protein information
that is highly conserved, that is, found in almost
identical form in such diverse organisms as fruit flies
and humans. Further scrutiny and analysis have
determined that specific motifs encoded in larger
domains of each protein serve as the "business" por-
tion of the protein, binding to a cell surface, aggre-
gating with other proteins, serving to catalyze a
chemical reaction, binding to zinc or calcium ions, or
serving other crucial functions in cell biology The
functional motifs are also being characterized in
terms of structural biology. The scientific and educa-
tional communities are building large databases and
then mining this information by using sophisticated
information technology.

These genomic databases provide remarkable
opportunities for the identification, design, and pro-
duction of a new generation of biomarkers for diag-
nostics; innovative biomaterials for repair and regen-
eration; and the development of highly sensitive and
specific drugs and vaccines to improve the health of
all people (Baum et al. 1998, Slavkin 1996b,c,

-

Facing the Future

1997a). Genomics has emerged as a major driver to
realign academic, industry, and government science
and technology to foster health, pharmaceutical,
biotechnology, agricultural, food, chemical, environ-
mental, energy, and computer science applications
(Kaku 1997, Rifkin 1998). Many of these applica-
tions profoundly influence oral health (Slavkin
1996d, 1998a,b).

This epic period will also herald the advent of
"biochemistry on a chip," used in connection with
body fluids such as saliva, cells, and tissues to diag-
nose diseases and disorders. The so-called chip tech-
nology will enable identification, quantitation, and
complex analyses on surfaces no larger than one-cen-
timeter square coupled to laser optical reader systems
and computer-assisted informatics. Prototypes are
already available to be tested against samples of sali-
va, cervical fluids, buccal mucosal cells, and blood
(Slavkin 1998b). This technology should revolution-
ize saliva-based diagnostics and prognostics in oral
health (Table 11.1). Major progress is also anticipat-
ed in bioengineering through nanotechnology, minia-
turization, and the innovations of design and fabrica-
tion of biomaterials. Anticipated advances include
the repair and regeneration of cartilage, bone, mus-
cle, nerve, salivary glands and saliva, and teeth
(cementum, dentin, enamel, and periodontal liga-
ment) (Slavkin 1996d, 1998a,b).

Additional scientific progress in the neuro-
sciences will have broad implications for the diagno-
sis and treatment of diseases and disorders of the
craniofacial complex including neuromuscular-relat-
ed conditions (e.g., facial and dental trauma, brux-
ism, autism, Mobius syndrome, Bells palsy, temporo-
mandibular joint disorders, trigeminal neuralgia,
Parkinson`s disease, and disorders of speech, smell,
and taste), the habilitation of craniofacial syndromes,
and the management of facial pain.

The field of biomimetics is an example of the
translation of human genomics into innovative
developments in biotechnology The idea is to use
biological strategies to solve human diseases and dis-
orders, essentially mimicking biological processes in
the design and fabrication of new biomaterials to
replace body parts or synthesize new drugs or
reagents. For example, biological cartilage can now
be designed and produced in artificial systems that
present three-dimensional forms for nose and ear
replacements as required in craniofacial birth defects,
head and neck trauma, and oral and pharyngeal can-
cer patients (Slavkin 199633, 1998a,b). Another
approach is to design and fabricate bioceramics to be
used in the replacement of human enamel or dentin
on the surfaces of teeth.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          279


Facing the Future

-

A FRAMEWORK FOR ORAL HEALTH
At the most basic level, local, state, and national
health care policies will continue to strive to improve
the health status of all Americans. Major reforms will
improve public health competency. Enlightened
health literacy will continue to influence quality of
life expectations. Many social, economic, and politi-
cal influences will continue to influence local, state,
and national priorities for health policies (Isaacs and
Knickman 1999). Included in these reforms will be
efforts to improve the oral and craniofacial health of
the American people.

Oral and craniofacial health issues will continue
to be diverse and complex. In this context, two major
themes remain: the need and demand for oral and
craniofacial health services; and the role, functions,
and mix of health professionals (Casamassib 1996,
USDHHS 1998).

First, need and demand will continue to be the
two drivers of the health service requirements of our
society. Need is an epidemiologically based and
clinically derived measure of the amount of disease
and adverse conditions that require treatment in
order for the population to be healthy Demand
measures a population's health literacy, willingness,
and capacity to utilize and finance health services.
Public health literacy or competency and proactive

TABLE 11.1

Examples of saliva fluid diagnostics

oral health education will increase demand as well as
delineate functions of oral health professionals for
2000 and beyond. Often, biomedical research
advances in terms of new pharmaceuticals, devices,
and procedures popularized in the media influence
quality of life expectations, demand for health
services, and the economy (Pardes et al. 1999). They
can also lead to the creation of new types of health
providers. Research also has the potential to reduce
the need, demand, and costs for health services
(McRae 1994). Thus outpatient surgery obviates the
need for hospitalization; immunization or anti-
biotics control infections; and community water
fluoridation, other fluorides., dental sealants, and
related oral health policies help prevent dental caries.
Second, the major changes in demography, pat-
terns of disease, and management of health care will
continue to shape the roles and functions of health
professionals. For example, significant increases in
the numbers of senior citizens (65 years and older)
with chronic facial pain, osteoarthritis, temporo-
mandibular joint disorders, type 2 diabetes, demen-
tia, osteoporosis, and oral and pharyngeal cancers
will challenge health care providers for the next 50
years. These conditions will necessitate interdiscipli-
nary and multidisciplinary approaches to care.
Coordination of professional care with that of indi-
       viduals, caregivers, and the com-
       munity will be needed to control
       costs and ensure early diagnosis
       and prompt treatment.

Detection of exposure to viruses by measuring antibodies specific for a viral antigen
Measles       Hepatitis A         HIV-1
Mumps       Hepatitis B         HIV-2
Rubella

Direct antigenic detection of microbes and biomarkers
Influenza A and B (neuraminidase)
Streptococcus group A (N-acetylglucosamine)
Salivary estradiol (pre-term labor indicator)
(A-15, EGFR, cathepsin-D,and Waf 1 (proposed breast cancer biomarkers)
Zinc-binding cystic fibrosis antigen (proposed biomarker)
Glutamic acid decarboxylase autoantibody (proposed predictive biomarker in type-l diabetes)
Culture of microbial organisms
Streptococcus mutans-dental caries
Luctobacillus ucidophilus-dental caries
Condido olbirans-oral candidiasis

Examples of hormones and drugs identified and measurable in saliva
aldosterone        progesterone     phenytoin antipyrine
cortisol            testosterone     theophilline
estrogens        carbamazepine     caffeine
insulin           lithium        cocaine
melatonin         methadone       continine

Sources: Derived from Malamud 1992,AGD 1996,Malamud andlabak 1993.

ethanol
marijuana
opiates

To ensure that all people have
access to health care and can
acquire the health literacy neces-
sary to make use of oral and
craniofacial health promotion
and disease prevention informa-
tion and activities, a complete
assessment of the nation's capacity
to achieve access for all is warrant-
ed. Federal, state, and local gov-
ernment programs, legislation,
and regulation; health professional
societies and organizations; pro-
fessional schools, colleges within
universities, and K-12 education;
patient groups; the private sector;
and the larger society have the
responsibility to achieve access to
oral health care for all.

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


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ORaL HFCALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

281


A Call to Action

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 achiev-
ing 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 centuq, many among us still experience
needless pain and suffering, complications that can
devastate overall health and well-being, and financial
and social costs that diminish the quality of life and
burden American society.

To maintain the health and well-being of
Americans already enjoying good oral health and to
address the gaps in oral health status of others
require actions at all levels of society, from individu-
als and neighborhoods to the nation as a whole. A
coordinated effort can overcome the educational,
environmental, social, health system, and financial
barriers that have created vulnerable populations
whose oral health is at risk.

MAJOR FINDINGS

Following are the major findings of the report. They
reflect the detailed findings highlighted at the end of
each chapter as well as the broad themes presented in
Chapter 1.

  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 particularly 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 cancers 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 breathing, 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.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          283


A Call to Action

Although common dental diseases are preventable,
not all members of society are informed about or able
to avail themselves of appropriate oral-health-pro-
moting 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 inte-
grated into many care programs. Social, economic,
and cultural factors and changing population demo-
graphics affect how health services are delivered and
used, and how people care for themselves. Reducing
disparities requires wide-ranging approaches that tar-
get populations at highest risk for specific oral dis-
eases 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
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
weakened immune systems, and oral signs and symp-
toms often are part of a general health condition.
Associations 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-
vention 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
and 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
All Americans can benefit from the development of a
National Oral Health Plan to improve quality of life
and eliminate health disparities by facilitating
collaborations among individuals, health care
providers, communities, and policymakers at all
levels of society and by taking advantage of existing
initiatives. Everyone 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. diagnostic, and treatment measures for

284

ORAL HEALTH IN AIIERICA: A REPORT OF THE SURGEON GENERAL


oral diseases and disorders are made available to all
Americans.  The following are the principal
components of the plan:

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 consid-
er oral signs and symptoms to be less important than
indications of general illness. As a result, they may
avoid or postpone needed care, thus exacerbating 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 understanding of the
meaning of oral health and the relationship of the
mouth to the rest of the body These messages should
take into account the multiple languages and cultur-
al traditions that characterize America's diversity.
  o Change policymakers' perceptions. Informed pol-
icymakers 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. @ising awareness of oral health among
legislators and public officials at all levels of govern-
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.

A Call to r\ction

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
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 lim-
ited 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 collection must
address differences among the subpopulations
making up racial and ethnic groups. More attention
must also be paid to demographic variables such as
age, sex, sexual orientation, and socioeconomic fac-
tors 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

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

285


L4 Cdl to Xction

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 nations 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 and accounts in part for the generally
poorer oral health of those who live at or near the
poverty line, lack health insurance, or lose their
insurance upon retirement. The level of reimburse-
ment for services also has been reported to be a prob-
lem and a disincentive tc, the participation of
providers in certain public programs. Professional
organizations and government agencies are cognizant
of these problems and are exploring solutions that
merit evaluation. Particular concern has been
expressed about the nations children, and initiatives
such as the State Children's Health Insurance
Program, while not mandating coverage for oral
health services, are a positive step. In addition, indi-
viduals whose health is physically, mentally, and
emotionally compromised need comprehensive inte-
grated care.

Use public-private partnerships to improve the oral
health of those who still suffer disproportionately
from oral diseases. The collective and complementa-
ry talents of public health agencies, private industry,
social 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,
to conduct research, and to provide health care serv-
ices and programs. These partnerships can build and
strengthen 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
the use of protective gear to prevent sports injuries.
In this way, partnerships uniting sports organiza-
tions, schools, the faith community, and other groups
and leaders, working in concert with the health com-
munity, can contribute to improved oral and general
health.

286

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


A Call to Action

CONCLUSION

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

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

287


Index

Page numbers followed by italicized b,f, and t
indicate boxes, figures, and tables, respectively.

A

Access
  barriers to

for elderly, 263, 265
insurance and, 12-13, 268
children and, 253
elderly and, 265

   as reason for nonutilization, 84t-86t
   removal of, 4, 12-13, 19, 268, 286
and dental care utilization, among military vs.
   civilian population, 83, 87, 88f
ACE See Administration for Children and Families
Acids

and caries, 37-38
saliva and, 27

  and tooth surfaces, 31
Actinobacillus actinomycetemcomilans
and adult periodontitis, 40
and bacteremia, 104
and early-onset periodontitis, 42, 205
and periodontal disease, 203t
Administration for Children and Families (ACF),
  226, 226t

Adolescents/young adults, 257-258. See also
  Children

Adult periodontitis, 40-42
bacterial activity in, 40, 203t, 204-205
diagnosis of, 204-205, 204t
immune response to, 40-41
progression of, 40
rapidly progressing, 40, 41, 207
refractory, 42
susceptibility factors, 41
systemic antibiotics for, 207
Adult respiratory distress syndrome CARDS), 105

African Americans. See also Race/ethnicity
  cancer in

incidence of, 68,68f
survival rates for, 68-69, 69f
children, insurance coverage of, 253, 278
congenital malformations in, 72, 72f
dental care among
nonutilization of, 83, 84t
utilization of, 80t, 81-82, 811
dental caries in, 63-64, 63f 64f
as dental personnel, 236-237, 237t
oral and pharyngeal cancers in
diagnosis of, 69, 69f
by sex, 68, 68f

oral health status of, 74-75
periodontal disease in, 65-66, 66f
and ratings of oral health, 144
tobacco use by, 260b
tooth loss in, by economic status, 67, 67f
toothaches among, prevalence of, 73
Age

and canker sores, prevalence of, 71, 71f
and dental care

  nonutilization, 83, 84t
  utilization, 80-81, 80t
and dental caries, by economic status and
racdethnicity, 63-64
and injuries, 72-73
and insurance coverage, 231
and oral-facial pain, prevalence of, 73, 73f
oral health data on, 2-3
oral health vulnerabilities according to,
  249-267

and oral herpes lesions, prevalence of, 70-71,
7v

and periodontal disease, 65-66, 65f, 203t
adult periodontitis, 41
by racdethnicity, sex, and economic status,
     65-66

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

289


Age (continued)

and ratings of oral health, 144
  and tooth loss, 66
Agency for Healthcare Research and Quality
  (AHRQ), 171, 172, 213, 225, 226t
Aging, and craniofacial complex, 3 1-32
AHRQ. See Agency for Healthcare Research and
Quality

AIDS. See also HIV infection
Candida infections with, 43
esophageal candidiasis with, 101
and oral cancer, 46
Alcohol, 191t

and disruption of oral homeostasis, oral
    candidiasis and, 42
systemic, for periodontitis, 206t, 207
Antibodies. See a/so IgA antibody; Immunoglobulins
in adult periodontitis, 40-41
in mucosal immune system, 28
oral fluids in diagnostic tests for, 103, 103t
Anticipatory guidance, for children, 256
Antigenic components, in identification of
periodontopathic bacteria, 205
Antimicrobial agents, for periodontal diseases, 206t,
  207

community programs, 171
as general health risk factor, 10
  in mouthwash, and oral cancer, 210
and oral cancer, 44-45, 46, 169, 208t, 209, 209t
tobacco and, combination of, and oral cancer,
    45, 208t, 209
Allodynia, 52

Antimicrobial components, in saliva, 27
Antioxidants, 47
Apert's syndrome, 49
Aphthous ulcers, recurrent, lesions caused by, 1OOt
Apoptosis

Allografts, 208-209
Alloplasts, 209

Allopurinol mouthwash, and mucositis, 106
Alpha tocopherol, 47, 251b
Alveolar bone. See also Jaw; Oral bone
aging and, 31-32
  loss of, 32

osteoporosis and, 102-103
risk factors for, 203t
smoking and, 41

  and oral cancer, 45, 46
Sjogren's syndrome and, 51
ARDS. See Adult respiratory distress syndrome
Arthritis, jaw manifestations of, 52
Ascorbate, and gingivitis, 250b
Asians/Native Hawaiians/Pacific Islanders. See also
  Chinese Americans; Vietnamese Americans
as dental personnel, 236, 237t
oral and pharyngeal cancers and, by sex, 68, 68f
  oral health status of, 76
Aspartate aminotransferase, in adult periodontitis,
  205

  nutrition and, 250b
regeneration of, 208-209
Amelogenesis imperfecta, 49, 278
American Indians/Alaska Natives
children of, oral health of, 76-77
as dental personnel, 236, 237~
oral and pharyngeal cancers and, by sex, 68, 68f
  oral clefts, 72
oral health status of, 76-77
Pima tribe, in diabetes-periodontal disease
   study, 113-l 14

Assaults. See Violence
ASSIST. See American Stop Smoking Intervention
Study for Cancer Prevention
Association of State and Territorial Dental Directors
  (ASTDD), 226-227
ASTDD. See Association of State and Territorial
  Dental Directors
Autografts, 208

Autoimmune disorders, 212
Sjogren's syndrome, 5 1

and precancerous lesions from smokeless (spit)
  tobacco, 70

B

and ratings of oral health, 144
American Society of Anesthesiologists. classification
of patients risk, 196, 197t
Americans Stop Smoking Intervention Study for
  Cancer Prevention (ASSIST), 17 1
Anaerobes, gram-negative, 39
Andersen behavioral model, 248-249, 248f
Anodontia

B cells, 28
Bacteremia

in ectodermal dysplasias, 50
hereditary, 49
Antibiotics

infective endocarditis and, 107-108
and microthrombosis, 117-l 18
  and oral infection, 104-105
Bacteria. See also specific bacteria
in adult periodontitis, 40,41, 204-205
  in dental caries, 37-38
in early-onset periodontitis, 42, 205
in gingivitis, 39
gram-negative, and adult periodontitis, 40
  in heart disease, 117-118

290         ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

lesions caused by, 99t
in periodontal disease, 202, 203t. 204-205
in refractory periodontitis, 42
Bacteroidesforsythus
in adult periodontitis, 40, 205
in periodontal disease, 203t
BANA test, in identification of periodontopathic
  bacteria, 205

Behcet's syndrome
lesions caused by, 1OOt
  and RAU, 44
Benzpyrene, 45

Betel nuts, and oral cancer, 45
Biofilm, 26, 37, 104. See also Plaque
and gingivitis, 39
Biomarkers
  future of, 279

  for oral cancer, 210
Biomimetics, 279
Biopsy

for mucosal disease diagnosis, 212
for oral cancer diagnosis, 210
Birth control medication, and gingivitis, 39
Birth defects, craniofacial, 47-50
clinical management of, 210-211
  cultural reactions to, 141
point mutations and, 31
prevalence of, 71-72
prevention and control of, 172-173, 210-211
   strategies for, 156t
secondary to other developmental disorders, 49
Bone grafts, 20&209
Bone loss. See Alveolar bone, loss of; Oral bone, loss
  of

Boston-type craniosynostosis, 49
Brain abscesses, oral flora and, 105
Branchial arch(es), 29
altered morphogenesis of, birth defects caused
   by 47-48

Bruxism, 52, 190, 191t
Burkitt's lymphoma, viral causes of, 45

C

Calcium

metabolism of, disturbances in, oral
   manifestations of, 101
and periodontal disease, 203t, 250ti251b
Calcium channel blockers, and gingivitis, 39, 107
Calculus

and adult periodontitis, 40
and gingivitis, 39
Campylobacter, and gingivitis, 39

Index

Canadian Task Force on the Periodic Health
  Examination, 156-158
Cancer. See also specific type
oral and pharyngeal, 4447, 209
   health care providers' knowledge about, 179
   HPV and, 43,4546,20Bt, 209,210
   prevention and management of, 47,
       169-172

community-based interventions,
  170-171

early diagnosis in, 171-172
nutrition in, 210, 251b
provider-based, 210
strategies for, 156t
public knowledge about,`178-179
quality of life with, 136, 142
risk factors in, 4447, 208t, 209-210,209t
nutrition and, 251b
statistics on

incidence rates, 67,68,68f, 74
mortality rates, by state, 70, 70t
site-specific, 69-70
sources for, 62

stage of diagnosis of, by racdethnicity,
69, 691

   survival rates, 67-69, 74
tobacco and, 259b, 260b
therapies. See also Chemotherapy; Radiation
   treatment

combined, and oral mucositis, 106-107
types of

   incidence rates for, 68,68f
   survival rates for, 69, 69f
Candida albicans
and oral cancer, 46, 209
and oral candidiasis, 42
Candida infections, 4243
Candidal angular cheilosis, 43
Candidiasis

esophageal, 101
lesions caused by, 99t
oral, 42-43

with HIV, 42, 43, 71, 101
prevalence of, 71

Canker sores, 4344. See Recurrent aphthous ulcers
  mm
prevalence of, 71, 71f
Capnocytophaga, and prepubertal periodontitis, 42
Capnocytophaga ochracea, and localized juvenile
periodontitis, 42
Capsaicin, 25

for oral mucositis pain, 106
Carbamazepine, and tic douloureux, 52

291


Index

Cardiovascular disease, oral infection and, 115-120
animal studies, 117-l 18
mechanisms of action in, 115-l 17
population-based studies, 118-120, 119t
Caries. See Dental caries
Carious lesions, precavitated, in restored teeth,
diagnosis of, 198

Carotenoids, 47, 251b
Cavities, 37. See also Dental caries
CDC. See Centers for Disease Control and
  Prevention

Celiac disease, oral manifestations of, 101
Cements, glass ionomer, in dental caries treatment,
  201

Center for Policy Alternatives, 268
Centers for Disease Control and Prevention (CDC),
  225, 226t

Cervical cancer, human papillomavirus (HPV) and,
  43,45

Cervicofacial actinomycosis, lesions caused by, 99t
Chediak-Higashi syndrome, and periodontal
  disease, 41

Chemotherapeutic agents, in plaque reduction, 199
Chemotherapy

oral candidiasis and, 42
oral infections from, 105
oral ulcers and oral mucositis from, 26
Chickenpox, oral lesions with, 98t
Children

anticipatory guidance for, 256
craniofacial birth defects in. See Birth defects,
  craniofacial

dental caries in, 2, 38, 252
by economic status and race/ethnicity,
    63-64

dental risk and protective factors for, 257~
dental sealants for, 167-168, 168t
with disabilities, 79, 253
enamel fluorosis in, 160
fluoride for

in dietary supplements, 162-165, 164t
  in mouthrinses, 165
  in school water, 162
from supplement programs, 164-165
future of oral care and, 277-278
injuries and, 258t, 722
insurance coverage, 231, 253, 277-278
Medicaid, 2, 253-255, 268
State Children's Health Insurance Program,
    13,233-234, 255, 277
malocclusion in, risk and protective factors for,
  258t

oral health of, 2, 249-253
barriers to, 13, 286

preventive environment for, 255-257,256t,
  257t, 258t

periodontal diseases in, risk and protective
  factors for, 256t

poverty and, 2, 252
violence and abuse, 51
Chinese Americans, nasopharyngeal cancer
incidence and mortality, 76
Chlorhexidine

to limit gingival inflammation, 205, 206~
to prevent mutans streptococci transmission,
  200

and remineralization, 199
teeth stains from, 107
Chronic and disabling oral cbnditions, 51-53, 73
Cigarettes, and oral and pharyngeal cancer, 259b.
  See also Tobacco

Cigars. See also Tobacco
and oral and pharyngeal cancer, 259b
  and oral cancer, 208r, 209
trends in smoking, 260b
Cleft lip/palate, 47-48
cost of, 228
prevalence of, 72, 721
quality of life with, 141-142
in Waardenburg syndrome, 50
Cleft palate, 47-48
Clefting abnormalities
from altered branchial arch morphogenesis,
     4748

incisive foramen and, 30
Cleidocranial dysplasia, 50
Cochrane Collaboration, 213, -214t, 246
Collagenase, in adult periodontitis, 205
COMMIT. See Community Intervention Trial for
Smoking Cessation

Community Health Centers, 227, 237
Community health programs. See also Public health
  programs
for craniofacial birth defects, 172-173
  for dental caries, 158-168
evidence of effectiveness of, 155-158
glossary of terms, 157b
for injury, 173-176
for oral and pharyngeal cancers, 169-172
for periodontal diseases, 168-169
strategies used, 156t

Community Intervention Trial for Smoking
  Cessation (COMMIT), 171
Corticosteroids, and disruption in oral homeostasis,
  oral candidiasis and, 42

Cosmetic dentistry, increased demand for, 137-138
Coxsackievirus, oral lesions with, 98t
Cranial bones, birth defects involving, 48-49

292         ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


Craniofacial complex
aging of, 31-32

contact and communication in, 23-25
diagram of, 22
functions of, 1. 17
oral cavity in, 25-28
origins and development of, 28-31
   early development of, 29-30
   genetic controls in, 30-31
    nutrition in, 250b
  research on, 4, 19
sensory functions of, 23
Craniofacial defects. See Birth defects, craniofacial
Craniosynostosis, 49, 278
and gene mutations, 31
Crohn's disease, and RAU, 44
Crouzon's disease, 49, 278
Cryotherapy, for mucositis, 106
Cuban Americans, oral health of, 75
Cyclosporin, and gingivitis, 39, 107
Cytokines, 28

and adult periodontitis, 40-41
and periodontal diseases, 203
and pregnancy, 120-l 2 1
Cytomegalovirus, and chemotherapy, 106

D

Demineralized bone, freeze-dried, in bone grafts,
  208-209

Dental appliances, 201
and chewing function, 135-136
  and oral candidiasis, 43, 71
Dental care. See also Oral health care system
active personnel in, 223-224, 224t, 235-236,
   2351
   composition of, by sex and racefethnicity,
      236-237, 237t

annual expenditures on, 223, 228, 228t, 231f,
  231t

per capita, 228, 2291
vs. total health care expenditures, 227,
   227f, 228f
costs of

indirect, 142-144, 143t
per capita, 228, 229f
as reason for nonutilization, 83, 84t-86t
vs. other medical services, 228, 230t, 231f
disciplines in, 224
evidence-based, 213, 246, 277
expenditures on, 227-228
by source
   1960-1996, 231f
    1998, 228t

vs. total health care expenditures, 227J
  228t

financing and reimbursement for, 228t,
   229-234, 231f, 231t, 232f
managed, 231-233, 233t, 254
among military personnel, vs. civilian
   population, 83, 87, 88f
nonutilization of, reasons for, 83, 84t-86t
population-to-dentist ratio, 224, 2245
for underserved populations, 239
unmet needs in, 83, 87t
   for children, 252-253
utilization of, 80-81, 190-191
   by sex, race/ethnicity, income, and
     insurance, 80t, 81-82, 81t
   variation by oral health status, 82, 82t
Dental caries, 37-39
changing clinical approach to, 196-201
   diagnosis of, 198, 2OOt
   multifactorial model in, 196, 197f
   prevention of, 198-200, 200t
   risk assessment in, 197, 198f, 198t, 199t,
       2OOt

treatment of, 201
in children, 2, 38, 252
by economic status and racdethnicity,
    63-64

risk and protective factors for, 257t
classification of, 201
nutrition and, 250b
prevalence of
by age, economic status, and racdethnicity,
     63-65
prevention of
community approaches to, 158-168
    dental sealants, 166-168
   dietary fluoride supplements, 162-165
   fluoridated drinking water, 160-162
    fluoride mouthrinses, 159t, 165
    fluoride varnishes, 165-166
    school water fluoridation, 162
  fluoride in, 2-3, 10, 18, 27, 38, 155,
     158-160
health care professionals' knowledge about,
     177-178
provider-based, 198-201
public's knowledge about, 177
  saliva and, 27, 38
strategies for, 156t
target population for, 159t
daily hygiene, 39, 189-190
progression of, 198
  rate of, 38-39
smokeless (spit) tobacco and, 39, 259b

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

293


Index

Dental caries (continued)
susceptibility to, 39
  tobacco and, 259b
  vaccine for, 200

Dental hygienists, 235
knowledge of dental caries prevention, 177-178
knowledge of periodontal disease prevention,
     178
Dental implants, 201
Dental plans. See Insurance
Dental plaque. See Plaque; Biofilm
Dental practice, 223-224
Dental schools

curriculum needs of, 237-238
enrollment, 235

   of minorities, 236
faculty vacancies, 237
graduate indebtedness, 237-238
Dental sealants, 38, 166-168
for children, 167-168, 168t
combined with fluoride-use, 167
cost-effectiveness of, 168
  in dental caries treatment, 201
effectiveness of, 159t, 166-167
prevalence of use, by racefethnicity, 82
Dentrifice, 159t, 176, 177, 179, 189-190
Dentinogenesis imperfecta, 49
Dentists

availability of, 224
charitable care by, 239
compensation of
from elderly in long-term care, 265
from Medicaid, 254
increased importance of, 191-192
knowledge of dental caries prevention, 177-178
knowledge of periodontal disease prevention,
  178

numbers of, 223-224, 224t, 235-236, 235f
visits to. See also Dental care, utilization of
   and susceptibility to adult periodontitis, 41
Denture sore mouth, 43
Denture stomatitis, 43, 71
Depression

atypical facial pain with, 52
with cancer, 142
with TMD, 140

Dermatologic diseases, lesions caused by, 1OOt
Developmental disorders, 47-50
clinical management of, 2 10-2 11
cultural reactions to, 141
prevalence of, 71-72
prevention and control of, 172-173
   strategies for, 156t
dfs, definition of, 62b

dft, definition of, 62b
Diabetes mellitus

and adult periodontitis, 41
and periodontal disease, 2, 17, 109-115
  research used in, llOt, lilt-113t
  treatment of, 206

type 1, and periodontal disease, 41, 110-113,
  114, 203t

type 2, and periodontal disease, 113-l 14, 203t
Diagnostic codes, dentistry, 216
Diagnostics, saliva and oral fluids in, 103-104, 103t,
  279, 280t

Diet. See also Nutrition
  effect on oral health, 191t'
and oral and pharyngeal cancer, 209t
poor, as general health risk factor, 4, 10, 18
DiGeorge syndrome, 48
Digital radiography, 196
Dilantin, and gingivitis, 39
Disability days, due to dental conditions, vs. other
conditions, 143, 143t
Disabled population, oral health of, 78-79
DMFS, definition of, 62b
DMFT, definition of, 62b
DNA

in identification of periodontopathic bacteria,
  205

saliva as source for, 103-104, 103t
Down syndrome, and periodontal disease, 41
Drug abuse, oral fluids for diagnosis of, 103, 103t
Dry mouth. See Xerostomia
  and dental caries, 38
and chewing function, 136
and Sjogren's syndrome, 51, 136
Dysplasia, 46

E

Early and Periodic Screening, Diagnostic and
  Treatment Service (EPSDT), 254
Early childhood dental caries (ECC), 38, 228
Early-onset periodontitis, 42
  bacteria linked to, 205
by sex and race/ethnicity, 66
systemic antibiotics for, 207
Eating problems, and quality of life, 135-136, 136t
ECC. See Early childhood dental caries
Ectodermal dysplasias (EDs), 49-50, 211
Edentulism

by age, economic status, sex and race/ethnicity,

  66-67
by economic status, 82
and heart disease, 119
by state, 67t

294         ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


and stroke, 120

EDS. See Ectodermal dysplasias
Education level

and dental care wants, 87t
and dental visits, 80t, 81, 81t
and insurance coverage, 23 1. 232f
and knowledge of periodontal disease, 178
and susceptibility to adult periodontitis, 41
Educational debt, 237-238
Efficacy, of health programs, vs. effectiveness,
  155-156

EGE See Epidermal growth factor
Egg polarity genes, 30
Eihenella corrodens
and adult periodontitis, 41
and prepubertal periodontitis, 42
Elastase, in adult periodontitis, 205
Elderly adults. See also Age
chronic health problems of, 266, 2661
eating problems of, 135-136, 136t
oral health of, 3, 262-266, 263t, 264t.
    trends in, 265-266
  research on, 262, 263t, 264t
sleep problems of, 137
social functioning of, 138-139, 139t
  women, 266-267
Electrical resistance measurement, 196
Enamel
age and, 31

demineralization of, 38. 199
remineralization of, 199
   fluoride and, 159
    saliva and, 27, 3 1. 38
Enamel fluorosis, 160
Enamel hypoplasia, 10 1
from tetracycline, 107
Endocarditis. infective, oral infection and, 107-108
Endocrine system
and disruption in oral homeostasis. oral can-
   didiasis and, 42
and immune system, 28
nicotine and, and oral and pharyngeal cancers,
     46-47
Environment

importance of, 248-249. 248f
improvement of, 268
   for children, 255-257, 268
Epidemiologic data, need for. See Data
Epidemiology< definition of, 62b
Epidermal growth factor (EGF), 27
and oral and pharyngeal cancers, 46
Epidermolysis bullosa-recessive dystrophic type, 49
Epithelial cells. cancers of. See Squamous cell carci-
  nomas, oral

In&s

Epithelium, 25-26
aging and, 32

nutrition and, 250b
EPSDT. See Early and Periodic Screening, Diagnostic
  and Treatment Service
Epstein-Barr virus

and chemotherapy, 106
and oral cancer, 45
and oral lesions, 98t
Erythema multiforme, lesions caused by, 1OOt
Erythroplakia lesions, 209
and squamous cell carcinoma, 44
Estrogen replacement therapy, and adult periodonti-
  tis, 41

Ethnicity See Race/ethnicity
Evidence-based practice, 213, 246, 277
Explorer, visual examination with, for dental caries
diagnosis, 198, 2OOt

F

Face. See also Craniofacial complex
appearance of, social responses to, 140-141
embryonic formation of, 29
as reflection of general health, 97-104
Falls, 50, 72-73. See also Injury
FDA. See Food and Drug Administration
Federal oral health infrastructure, 226-227, 226t
Federal support

for dental school programs, 235-236
  for educational debt, 237
Fibromyalgia, jaw manifestations of, 52
Fillings. See also Restorations
  materials used in, 201
Flossing, 39, 176, 190
  and bacteremia, 104
and dental caries prevention, 178
dental professionals' knowledge of, for dental
   caries prevention, 178
public knowledge of
   for dental caries prevention, 177
   and gum disease, 178
by tobacco users vs. nonusers, 178
Fluoride, 155, 158-160
dental professionals' knowledge about, 177
in dentifrices, 159t, 176, 177, 179, 189-190
in dietary supplements, 162-165
   dosage of, 163, 164t
    effectiveness of, 159t, 163-164
   public knowledge of, 177
in drinking water, 2-3, 18, 159t, 160-162
   access to, 161, 162f 162t, 163t
    costs of, 161

effectiveness of, 159t, 160-161

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

295


Indcs

Fluoride (continued)
   history of, 159

public knowledge of, 177
recommended concentration levels, 160
in schools, 159r, 162
enamel hypoplasia from high levels of, 101
in mouthrinses, 159r, 165
professionally applied, 159-160, 198-199
public knowledge about, 177
and rate of dental caries progression, 38-39
safety of, 160
in saliva, dental caries protection from, 27, 38,
  159

in varnishes, 159t, 165-166
Folate, and gingivitis, 250b
Folic acid

birth defects and, 47-48, 172
  cancer and, 251b
Food and Drug Administration (FDA), 225, 226t
Fungal diseases, lesions caused by, 99t
Fusobacterium nucleatum
and gingivitis, 39
and smoking, 41

G

Gastroenteritis, oral manifestations of, 101
Gene therapy, 276
Genes

and periodontal disease, 203, 203t
and resistance to dental caries, 39
Genetic derangements. See also Developmental
  disorders

and clefting abnormalities, 48
and oral cancer, 46
and periodontal disease, 41
Genetics

and control of embryonic development, 30-31
and future of oral health, 276, 278-279, 2785
and understanding craniofacial development, 28
Genomic databases, 279
Geographical region. See also Residence, place of
and dental care wants, 87t
Germ cell layers, in craniofacial development, 29
Gingiva

bleeding and inflammation of, as diagnostic
  test, 204, 204t

lesions of, diseases and conditions causing,
  98t-99t

recession of, age and, 31
surface of, 25

Gingival crevicular fluid, periodontal infection and,
  204t, 205

Gingival erythema, linear, and HIV, 101
Gingivitis, 3940
with adult periodontitis, 40
  and heart disease, 119
  from medication, 107
and pregnancy, 122
prevention of, 10, 168-169, 190, 191t, 205-206
by race/ethnicity, 66
Global ratings, of oral health, 144
Glossary, 62b
P-glucuronidase, in adult periodontitis, 205
Glutathione, 47
Glycemic control, affected by periodontal disease,
  114-115, 116t-117t
Gonorrhea

lesions caused by, 99t
pharyngeal, 109

Growth factors, 27
and oral cancer, 46-47
in reducing mucositis, 106
Guided tissue regeneration, 209
Guidelines, for clinical practice, 213-214, 215t
Guidelines for School Health Programs to Prevent
Tobacco Use and Addiction (CDC), 170
Gum disease, prevention of, public knowledge of,
178. See also Gingivitis; Periodontal disease
Gums. See Gingiva

H

Hand, foot, and mouth disease, oral lesions with,
  98t

HCFA. See Health Care Financing Administration
Head Start, 226
Health

biopsychosocial model of, 134
broadened meaning of, 2, 17-18
cultural perspectives on, 134-135
determinants of, theories and models of,
246-248,246f

  historical trends in
   life expectancy, 275-276
   science and technology, 275
World Health Organization (WHO) definition
   of, 133
Health care

evidence-based, 213, 246, 277
expenditures on, 227-228
Consumer Price Index for, 230t, 231f
per capita, 229f
by source of funds, 228t
by type of service, 227f 228t, 230t
federal and state programs for, 233-234

296

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


oral care in. See Dental care; Oral health care
  system

personnel in, collaboration with dental care
providers, 225, 227
trends in, 277

unmet needs in, 83, 87t
  utilization of, 190-191
Health Care Financing Administration (HCF,4), 225
Health Field Concept, Lalonde's, 247
Health maintenance organizations (HMOs), 229,
  232, 233t

Health Plan Employer Data and Information Set
  (HEDIS), 233

Health professional schools, future of, 276-277. See
  also Dental schools
Health Professional Shortage Area (HPSA), 227, 237
Health Resources and Services Administration.
  (HRSA), 225, 226t
Healthy People 2000, progress in meeting objectives
of, 180t

Healthy People 2010, 4, 19, 247-248, 248f
objectives of, by age, 268t
Heart disease. See Cardiovascular disease
HEDIS. See Health Plan Employer Data and
  Information Set

Herpangina. oral lesions with, 98t
Herpes labialis lesions
location, features, and course of, 98t
prevalence of, by racdethnicity, 71
Herpes simplex virus, 43
and chemotherapy, 106
lesions from, by population group, 70
and oral cancer, 4546, 209, 210
  oral lesions with, 98t
as pharyngeal infection, 109
type 1 (HSV-11, 43
   lesions from, 70, 71f
    and oral cancer, 45
type 2 (HSV-21, 43
Herpes zoster, oral lesions with, 98t
Herpetic gingivostomatitis, primary acute, oral
  lesions with, 98t

Herpetic stomatitis, primary, 43
Herpetiform recurrent aphthous ulcers, 44
HHANES. See Hispanic Health and Nutrition
Examination Survey
Hispanic Health and Nutrition Examination Survey
  (HHANES), 75

Hispanics. See also Cuban Americans; Mexican
  Americans; Puerto Ricans
  children of

insurance coverage of, 278
oral health of, 75

It&s

ORAL HEALTH IN AMERICA: A REPORT OF THE SLlRGEON GENERAL

dental care among
   nonutilization by, 84t-85t
   utilization by, BOt, 81-82, 81~
as dental personnel, 236-237, 237t
oral and pharyngeal cancers and, by sex, 68, 68f
oral health status of, 75-76
and ratings of oral health, 144
toothaches among, 73
Histoplasmosis, lesions caused by, 99t
HIV/AIDS Dental Reimbursement program,
  238-239
HIV infection

human papillomavints (HPV) and, 43, 71
and oral candidiasis, 42, 43, 71, 101
oral lesions with, 98t, 101-102
oral manifestations of, 97, 101-102
oral transmission of, 108-109
and periodontal disease, 41
  and RAU, 44
  and trench mouth, 40
HMOs. See Health maintenance organizations
Hodgkin's lymphoma, 46
Horn genes, 30
Homeotic genes, 30
Hormones, oral fluids in diagnostic tests for, 103,
  103t

Hospice patients, 263, 266, 266t
Hospitalized patients, and systemic complications
  due to oral bacteria, 105
Hospitals, oral health care at, 225
Hox genes, 30
HPSA. See Health Professional Shortage Area
HPV See Human papillomavirus
HRSA. See Health Resources and Services
  Administration

HSV- 1. See Herpes simplex virus, type 1
HSV-2. See Herpes simplex virus, type 2
Human genome, in understanding craniofacial
development, 28

Human Genome Project, 53, 278
Human immunodeficiency virus. See HIV infection
Human papillomavirus (HPV), 43
and oral cancer, 43,4546, 208t, 209, 210
prevalence of, 71
Hypodontia

in ectodermal dysplasias, 50
hereditary, 49

Hypoparathyroidism, oral manifestations of, 101

I

IFN-y. See Interferon y
IgA antibody, 32

297


IHS. See Indian Health Service
IL-l. See Interleukin 1
IL-lp. See Interleukin lb
Imaging technologies, 196
for dental caries diagnosis and treatment, 201
for oral cancer diagnosis, 210
  for TMD, 212t
Immune cells

in adult periodontitis, 40-41
and oral cancer, growth factors and, 46-47
types of, 28. See also B cells; T cells
Immune system, 27-28
disorders of, Sjiigren's syndrome, 51
and disruption in oral homeostasis, oral
   candidiasis and, 42
microbial genome research and, 279
  mucosal, 27-28

loan repayment program, 237
Infection, oral. See also Mucosal infections;
  Periodontal disease
  bacteremia and, 104-105
from cancer therapy, 105-107
infective endocarditis and, 107-108
protection against. See also Immune system
   by mucosal immune system, 27-28
   by saliva, 26-27

nutrition and, 25Ob
and RAU, 44

Immunoglobulins. 28. See also IgA antibody
smoking and, 41

respiratory disease and, 108
Inflammation, gingival. See Gingivitis
Injury, oral-facial, 50-51. See also Falls; Trauma
  in adolescents, 258
  in children, 2, 72, 258t
prevalence of, 72-73
prevention and control of, 191t
   community-based, 173-176, 174t-175t
    future of, 276
   helmet use, 173, 174t-175t, 176b
from sports, 50, 73, 173-176, 174t-175t, 176b,
     258

Immunosuppression
and bacteremia, 104-105
oral signs of, 97-100
Immunosurveillance and control, loss of, and oral
  cancer, 46

in young adults, 258
Insurance

changing market in, 231-233
coverage, 12-13, 229-231
by age, 231

Implants. See Dental implants
Incidence, definition of, 62b
Incidence rate, definition of, 62b
Incisive foramen, embryonic formation of, 29-30
Income

for children, 2, 253-255, 277-278
and dental care nonutilization, 86t
and dental care utilization, BOt, 81-82, 811,
  229

and adult periodontitis, 41
and children

dental caries and, 63-64, 63/ 64f
and insurance coverage, 253
  oral health and, 2, 252
dental care and

among children, 253
and dental care wants, 87t
by education level, 231, 232f
for elderly, 265

nonutilization of, 85t-86t
utilization of, BOt, 81-82, Bit
wants, 87t

and dental caries, 63-64, 63f, 64f
and edentulism, 82
and insurance coverage, 231, 2321
  for children, 253
low-income communities
dentists in, educational debt and, 237
expansion of care to, 239
and oral health, 249

employer-provided, 229-23 1, 26 l-262
    children and, 253
future goals in, 286
by income, 231, 232f
by sex and race/ethnicity, 230-231, 232f
Medicaid, 87t, 229, 233
for children, 2, 253-255, 268
for elderly, 265

Medicare, 234, 234t, 265
performance measures in, 232-233
as source of expenditures on dental services,
228t, 231f, 231t

among Hispanics, 75

and periodontal disease, 65-66, 66f
  and toothaches, 73
Indemnity plans, 232. 233t
Indian Health Service (IHS), 76-77, 225, 226~

State Children's Health Insurance Program,
   (SCHIP) 2, 13,233-234, 255, 277
  and utilization, Bit, 82
Interferon y (IFN-y), and adult periodontitis, 41
Interleukin 1 (IL-l)
and adult periodontitis, 41, 205
and periodontal disease, 203

298         ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


Interleukin 1 p (IL- l@)
and adult periodontitis, 41
and periodontal disease. 203
Interleukin 6, and adult periodontitis, 205
Interleukins, and heart disease, 115
Irrigation, to control gingival inflammation, 206t,
  207

J

Jaw (mandible and maxilla). See also Alveolar bone;
  Oral bone

aging and, 31-32
bone loss in, osteoporosis and, 102-103

K

Kaposi's sarcoma, 46, 101
Keratin, 25

Keratin genes, mutations in, and epidermolysis
  bullosa. 49

Keratinocytes, and oral cancer, 46
Killer cells, and oral cancer, 46

L

Lacrimal glands, Sjogren's syndrome and. 51
Lalonde Report, 246-247
Langerhans cells, and immunosurveillance, 46
Language

mechanisms of, 25
skills. of oral and pharyngeal cancer patients,
  136

Laser technologies, in dental caries diagnosis and
  treatment. 201

Leukoplakias, 44, 209
Lichen planus, lesions caused by, 1OOt
Life expectancy, 275-276
Lifestyle

of adolescents/young adults, 257-258
as determinant of health, 190, 191t, 246f,
    247-248
Lip cancer

incidence of, 69. 70
risk factors, 2081. 209t, 210
sun exposure, 169

Lips, lesions on, diseases and conditions causing,
  98t, 1OOt

LJP See Localized juvenile periodontitis
Local public health departments, 226, 286
Localized juvenile periodontitis (LJP), 42
Lymphocytes, and immunosurveillance, 46.

See also B cells; T cells

In&s

M

Macrophages, cytotoxic, and immunosurveillance,
  46

Magnetic resonance imaging (MRI), 196
Malocclusions

prevalence of, 72
quality of life with, 141-142
risk and protective factors for, 258r
Mandibulofacial dysostosis, 48
Marijuana, oral cancer and, 45, 208~ 209t
Masseter muscle, 26
Mastication, muscles of, 26
Mechanoreceptors, 24
Medicaid, 229, 233
for children, 2, 253-255, 268
  dental vs. other health expenditures for,
       254

and dental care wants, 87t
for elderly, 265
Medical care, in oral health care system, 225
Medicare, 234, 234t, 265
and dental care wants, 87t
Medications

and dental caries, 38
and disruption in oral homeostasis, oral
   candidiasis and, 42
and elderly oral health, 265-266
and gingivitis, 39
oral complications of, 107
Men

and adult periodontitis, susceptibility to, 41, 65,
w
cancer in

oral and pharyngeal, by racdethnicity and
sex, 68, 68f

types of, by racefethnicity, 68, 68f
and dental care nonutilization, 84t
and injuries, 73
and pain, 25

  prevalence of, 73, 73f
and periodontal disease, 203t
Metabolites, in detection of periodontal disease, 205
Mexican Americans
  children

insurance coverage of, 253
oral health of, 75
dental care utilization by, BOt, 81-82, Bit
and dental caries, susceptibility to, 63-64, 63f,
64f

tooth loss by, by economic status, 67, 67f
Microbes

genome research on, 279
oral transmission of, 108-109

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL         299


lndes

Microbes (continued)
protection against. See also Immune system
   by saliva, 26-27
Micronutrients. See also Nutrition
and cancer prevention, 47
fluoride as, 160
Military personnel, dental care among, vs. civilian
population, 83, 87, S8f
Mononucleosis, infectious, oral lesions with, 98t
Mortality rate, definition of, 62b
Motor vehicle collisions, 50, 73, 173
Mouth. See also Craniofacial complex; Oral cavity
  elements of, 1, 17. 25
embryonic formation of, 29
as gateway, 37
   for infection, 104-109
lesions in, diseases and conditions causing,
     98t-100t
as reflection of general health, 1-2, 10-11, 17,
    97-104, 284
Mouthguard use, 173-175, 174t-175t, 176b
Mouthrinses, fluoride, 159t, 165
MRI. See Magnetic resonance imaging
Mucins, 27
aging and, 32
Mucosal immune system, 27-28
Mucosal infections, 42-44, 70-71, 212
by race/ethnicity, socioeconomic status, and sex,
     70-71
Mucous membrane pemphigoid, lesions caused by,
  loot
Multiple sclerosis, and tic douloureux, 52
Mumps, swollen parotid glands with, 97
Mutans streptococci, 37, 38
median age of acquisition of, 39
  mother as source of, 199-200
as primary predictor of dental caries incidence,
    196-197, 198t
Mutations
and craniofacial syndromes, 3 1, 278-279
in keratin genes, and epidermolysis bullosa, 49
  and oral cancer, 46
and periodontal disease, 41

N

Nasopharyngeal carcinoma, 45, 76
National Facial Protection Month, 173
National Health and Nutrition Examination Survey
  (NHANES), 61,62
National Health lnteniew Survey (NHIS), 61
National Health Service Corps (NHSC), 237
National Institute for Dental and Craniofacial
  Research (NIDCR), 213

-

National Institutes of Health (NIH), 225, 226t
National Oral Cancer Strategic Planning
  Conference, 169-l 70
National Oral Health Plan, 21, 284-286
components of, 11-13, 284-286
National Preventive Dentistry Demonstration
Program, 167
Necrotizing ulcerative gingivitis, acute, lesions
caused by, 99t
Necrotizing ulcerative periodontitis, and HIV, 101
Nervous system, and immune system, 28
Neural crest, 29
defective development of, Treacher Collins
   syndrome and, 48    '

Neural tube, 29
Neutrophils
in adult periodontitis, 40-41
   smoking and, 41
in early-onset periodontitis, 42
NHANES. See National Health and Nutrition
Examination Survey
NHIS. See National Health Interview Survey
NHSC. See National Health Service Corps
Nicotine, endocrine effects of, and oral and
pharyngeal cancers, 46-47. See Tobacco
NIH. See National Institutes of Health
NIDCR. See National Institute of Dental and
  Craniofacial Research
4-nitroquinoline-N-oxide, 45
Nitrosamines, 46
N-nitrosonornicotine, 45
Nociceptors, 24
Non-Hodgkin's lyrnphoma, 46
misdiagnosis of, 101
Sjiigren's syndrome and, 5 1
Nonneuronal tissues, 29
Nose. See also Olfactory system
embryonic formation of, 29
Notochord, 29
Nursing homes, in oral health care system, 225
Nutrition, 191t, 250b. See also Diet
  and birth defects, 47-48, 172, 211
and cancer prevention, 47, 169, 25lb
and dental caries, 250b
  micronutrients in
   cancer prevention properties, 47
   fluoride as, 160
and oral cancer prevention, 209t, 210, 25lb
  oral tissue as reflection of, 100-101
and periodontal disease, 25Ob-25 1 b
prenatal and perinatal, 198
and quality of life, 135-136, 136t
  and RAU, 44

300         ORAL HEtLTH IN AMERIC.4: A REPORT OF THE SURGEON GENERAL


0

Olfactory system, 24
aging and, 32
Oncogenes
discovery of, 45

and oral and pharyngeal cancer, 46
Oral, definition of, 1, 17
Oral bone, loss of, osteoporosis, 102-103
Oral cavity. See also Mouth
  elements of, 25-28
manifestations of systemic disease in, 37,
    97-101, 98t-100t
Oral flora, 37

  and brain abscesses, 105
Oral fluids, diagnostic value of, 103-104, 103t, 279,
  280t
Oral health

barriers to, removal of, 4, 12-13, 19, 286
broad definition of, 2, 17-18, 133-134
costs of, 4, 19, 227-228, 227f, 228t, 229j, 230t
  indirect, 142-144, 143~
determinants of, 248-249
income inequality, 249
lifestyle, 190, 191t, 246f, 247-248, 283
workplace effects, 249
disparities in, 1, 4, 10, 17, 19, 88, 239, 284
enhancement of, 267-268
for adolescents and young adults, 257-258
  for adults, 258-262
  for children, 249-257
    insurance and, 253-255
   social and professional environment
      and, 255-257

for elderly adults, 262-267, 263t-264t
for elderly women, 266-267
expenditures for, 227-228, 227f, 228t
financing for, 228t, 229-234, 231f, 231&,
   232f

vs. total health care expenditures, 227,
   227f, 228t
future of, 280

diversity of diseases and patients in, 276
National Oral Health Plan, 284-286
  new treatments in, 276
and general health, 2, 4-5, 10-11, 17-18, 19,
  53, 285-286
in elderly, 265
implications of linkages between, 122
  risk factors in, 4, 10, 18
historical trends and, 275-276
meaning of, 5, 17-21, 20
of military personnel, vs. civilian population,
  83, 87, 88f

Index

objectives for, 267-268, 267~
personal approaches to, 189-191
care seeking, 190-191
daily hygiene, 189-190
   among elderly, 262-263
healthy lifestyle, 190, 191t
prevention measures, 3-4, 7-9, 10, 18. See also
  Oral health care system
in public health programs, 12
ratings of, 144
status of, 35-93

    and dental care wants, 87t
  trends in, 87-89
Oral health care system. See also ,Dental care
active personnel in, 223-224, 224t, 235-236,
   235f, 286
   by sex and racdethnicity, 11, 236-237,
      237t, 286

community approaches in
for craniofacial birth defects, 172-173
  for dental caries, 158-168
effectiveness of interventions by, 155-158,
     156t

glossary of terms for, 157b
for injury, 173-176
for oral and pharyngeal cancers, 169-172
for periodontal diseases, 168-169
expanding base of, 216
future of, 239-240
capacity to meet needs in, 234-239
molecular, and genomics, 278, 278f, 279
individual approaches in
care seeking in, 190-191
daily hygiene in, 189-190
   among elderly, 262-263
healthy lifestyles in, 190, 191~ 246f
   247-249, 248f

knowledge of and practice in, 176-179
professional components of
  dental care, 223-224
  medical care, 225
overlap among, 227
public health programs, 225-227
progress in, 179-180, 180t
provider-based care in, 191-212. See also
  Provider-based care
diagnostic tests in, 193, 193t
  future of, 212-216
  oral health assessment in, 193-196,
   194f-195f, 197t

risk assessment in, 192-193
public-private partnerships in, 13, 286
strategies for, 156t
underserved in, 239

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          301


Index

Oral hygiene, 189-190, 191t
and bacteremia, 104
and dental caries, 39, 189-190
among elderly, 262-263
and gingivitis, 39
and periodontal disease, 168-169, 190, 191t,
     203t

public practices survey, 178
workplace effects on, 249
Oral mucosa, 25-26
aging and, 32

lesions of, diseases and conditions causing,
  98t-100t

  nutrition and, 250b
staining of, 107
ORN. See Osteoradionecrosis
Osteogenesis imperfecta, 49
Osteoporosis

and adult periodontitis, susceptibility to, 41
and oral bone loss, 102-103
and periodontal disease, 203~
Osteoradionecrosis (ORN), 106
Ottawa Charter for Health Promotion, 247

P

Pain

facial, atypical, 52
oral, chronic, 24
oral-facial, 24-25, 52
   clinical management of, 211
    control of, 24
   impact of, 139-140
   prevalence of, 73, 73f
   sex differences, 25, 77
   sleep problems with, 137
Palate, 25

embryonic formation of, 29
lesions of, diseases and conditions causing,
  98t-100t

Papillae, as oral mucosa, 25
Papillomavirus, oral lesions with, 71, 98t
Papillon-Lefevre syndrome, and periodontal disease,
  41

Parotid glands, 26
aging and, 32
  swollen, 97

Pathogens, protection against. See also Immune
  system
by saliva, 27

Pathology, systemic, craniofacial disease as model
  of, 53

Pemphigus vulgaris, lesions caused by, 1OOt
Periodontal attachment

loss of

by age, sex, race/ethnicity, and income,
  65-66

   definition of, 62b
osteoporosis and, 102
Periodontal disease, 39-42
adult periodontitis. See Adult periodontitis
by age, sex, racdethnicity, and income, 65-66
from bone marrow radiation, 105
and cardiovascular disease, 115-120
clinical management of, 20 l-209
   diagnosis of, 203-205, 204t, 278
   prevention of, 205-206, 206t
   risk assessment in, 202-203, 203t
   treatment of, 206-209, 206t
  diabetes and, 2, 17, 109-114
   glycemic control affected by, 114-l 15,
       116t-117t

  research used in, 1 lot, 11 It-1 13t
early-onset. See Early-onset periodontitis
heart disease and stroke with, 115-120
  animal studies, 117-118
mechanisms of action in, 115-l 17
population-based studies, 118-120, 119t
nutrition and, 250b-25 1 b
pathogenesis of, 202
preexisting, as risk factor, 202, 203t
and pregnancy, adverse outcomes in, 120-122
prevention of, 10, 168-169, 256~
daily oral hygiene and, 168-169, 190, 191t,
     203t

   dental professionals' knowledge about, 178
   history of, 3, 18
   provider-based, 205-206, 206t
   public's knowledge about, 178
   strategies for, 156t
risk and protective factors for, 256~
  tobacco and, 259b, 260b
Periodontal ligament
regeneration procedures for, 208
sensitivity of, 24
  teeth in, 26
  tissue turnover in, 31
Periodontitis
adult. See Adult periodontitis
  and heart disease, 118-120
as mixed infection, 205
necrotizing ulcerative, and HIY 101
pathobiology of, 202, 2021
  and stroke, 119-120
Perioral skin, lesions of, diseases and conditions
causing, 98t
Pfeiffer's disease, 49
PGE,. See Prostaglandin E,

302         ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


PH

in dental caries risk assessment, 197
saliva and, 27

Phagocytes, in adult periodontitis, smoking and. 41
Pharmaceuticals. See Medications
Pharyngeal cancer. See Cancer, oral and pharyngeal
Pharynx, 25

herpes simplex virus and, 109
lesions of, diseases and conditions causing, 98t,
  loot

Phenytoin, and gingivitis, 39, 107
Phosphate metabolism, disturbances in, oral
  manifestations of, 101
Pierre Robin syndrome, 48
Pigmentation, of soft or hard oral tissue, as sign of
  disease, 100

Pipe smoking, and cancer, 208t, 259b
Plaque, 37, 104. See also Biofilm
control of, 39, 205-206, 206~
    chemical, 205
   with daily hygiene, 190
   professional, 206
  fluoride in, 159
public knowledge about, 178
subgingival, 40

Pocket depths, and periodontal disease diagnosis,
  204, 2041

Point mutations, birth defects and, 31
Polymeric resin composites, in dental caries
  treatment, 201

Population, trends in, 275-276, 280
Population groups
characteristics of, as determinant of health, 248,
    248f

data on, 10, 61-62. 88
disabled, oral health of, 78-79
diversity of, future of oral care and, 277
oral health disparities among, 1, 4, 10, 17, 19,

88, 239, 283-284

oral health services targeted to, 225, 239
racial/ethnic minorities. See Race/ethnicity;

   speciJc tninority group
  women. See Women
Pot~hyromonas gingivalis
in adult periodontitis, 40, 41, 205
in adverse pregnancy outcomes, 121
  and bacteremia, 104
  in heart disease, 117
in periodontal disease, 203t
Poverty: 249. See also Income
children in, oral health of, 2, 252
  and dental care utilization, 80, 80t, 81
and dental caries, susceptibility to, 63-64
and tooth loss and edentulism, 66, 67f

Index

  and toothaches, 73
PPOs. See Preferred provider organizations
Precancerous lesions
  HPV and, 45

  and oral cancer, 44-45
and smokeless (spit) tobacco. 70, 7Of
Precavitated carious lesions, in restored teeth, diag-
  nosis of, 198

Preferred provider organizations (PPOsI, 229, 232,
  233t
Pregnancy

adverse outcomes of, periodontal disease and,
  120-122

and dietary fluoride supplements, 163-164
gingivitis in, 39

Prenatal care, 172, 198, 210-211
Prenatal syphilis, lesions caused by 99t
Prepubertal periodontitis, 42
Prevalence, definition of, 62b
Prevalence rate, definition of, 62b
Prevotella intennedia
in adult periodontitis, 40, 41
in periodontal disease, 203t
in prepubertal periodontitis, 42
smoking and, 41
Private practice, 223-224, 227
Probes/instrumentation, sensitivity of, 40
Probing depths, and periodontal disease diagnosis,
  204. 204t

ProstaglandinG)
and adult periodontitis, 40-41
  and heart disease, 115
and pregnancy, 121
Prostaglandin E2
and adult periodontitis, 4041, 205
  and mucositis, 106
and periodontal disease, and low birth weight.
     121

Proto-oncogenes
discovery of, 45
  and oral cancer, 46
Provider-based care, 191-212
changing approach by
   to birth defects, 210-211
    to dental caries, 196-201
   to oral and pharyngeal cancers, 209-210
   to periodontal diseases, 201-209
for chronic craniofacial pain and sensorimotor
    conditions, 211

diagnostic tests in, 193, 193t
  dental caries, 198, 2OOt
oral and pharyngeal cancer, 210
periodontal diseases, 203-205, 204t
future of

ORAL HEALTH IN AMERICA: ,4 REPORT OF THE SURGEON GENERAL

303


Provider-based care (cot~ti~ud)
   broadening base in, 216
   clinical practice guidelines. 213-214, 215~
   evidence-based practice, 213
   science and technology contributions, 216
  for mucosal and autoimmune diseases, 212
oral health assessment by, 193-196, 194f-195f,
     197t
prevention by

oral-facial pain and, 139-140
social function and, 138-139, 139t
research on, 144-146, 146t

  of birth defects, 210-211
of dental caries, 198-200
of oral and pharyngeal cancer, 210
of periodontal diseases, 205-206, 206~
risk assessment by, 192-193
of dental caries, 197, 198t, 200t
of oral and pharyngeal cancer, 208~
    209-210, 209t

RaceIethnicity. See also specific minority group
and adult periodontitis, 41
and congenital malformations, 72, 72f
  and dental care

nonutilization, 84t-85t
utilization, 80t, 81-82, 81t
wants, 87t

and dental caries, suscepibility to, 63-64, 63f,
w

   of periodontal diseases, 202-203, 203t
for temporomandibular disorders, 211-212
Pseudomembranous candidiasis, 43
Pterygoid muscle, 26
Puberty gingivitis, 39
Public

future of oral care and, 277
and insurance coverage, 230-231, 2325
and malocclusions, 72
in oral health workforce, 12, 236-237, 237t,
  286

knowledge, attitudes, and practices of, 177-179,
  239, 280

perceptions of, 11, 285
Public health programs. See also Community health
programs; Medicaid; Medicare
for elderly, 265

                        R









facial appearance, 140-141
oral and phar)-ngeal cancers, 142




  ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

and periodontal disease, 41, 65-66, 66f
Radiation treatment
  oral candidiasis and, 42
  oral infections from, 106
oral ulcers and oral mucositis from, 26
periodontal disease from, 105
Radiographs, 196

  essential services for, 181b
in oral health care svstem, 12, 225-227, 286
Public-private partnerships, 13. 286
Puerto Ricans. oral health of, 75
Pulmonary disease. obstructive, and oral health, 108
Pulp tissue

infections in, 24, 38
tissue turnover in, 31

Q

Quality of life

cultural perspectives on, 134-135
heightened expectations of, 146
oral health in, 133-134
  functional dimensions of
   eating problems and. 135-136, 136~
   sleep problems and, 137
indirect costs of, 142-144, 143t
need for measurement of, 133-134
psychosocial dimensions of, 137-142
   cleft lip/palate and malocclusion,
       141-142

bite-wing, 198, 2OOt
in periodontal disease diagnosis, 204, 204t
Rapidly progressive periodontitis, 40, 41
systemic antibiotics for, 207
Ratings, of oral health, 144
RAU. See Recurrent aphthous ulcers
Recurrent aphthous ulcers (RAW, 43-44
prevalence of, 71, 71f
Refractory adult periodontitis, 42
systemic antibiotics for, 207
Reimbursement, direct, 230. See also Dental care,
financing and reimbursement
Relative survival rate, definition of, 62b
Remineralization, 27, 38, 159, 199
Research. See also Science base
  current, 4, 5, 11, 19, 20
in evidence-based practice, 213, 246
federal studies of oral health, 268
need for expansion of, 285-286
on quality of life, 144-146, 146t
surveys used for health data, 61-62
  trends in, 214-216

Respiratory disease, oral infections and, 108
Restorations

precavitated carious lesions in, diagnosis of, 198
procedures for, 201
Retinoids, 47

304


Rous sarcoma virus (RSV), and oral cancer, 45
RSV: See Rous sarcoma virus
Rural/urban status, and dental care wants, 87t
Ryan White Comprehensive AIDS Resources
  Emergency Act, 225

S

S-IgA, 28

Saethre-Chotzen syndrome, 49
Saliva, 26
aging and. 32

and cariogenic bacteria, 38
decreased flow of

  in dental caries risk assessment, 197
and chewing function, 136
diagnostic value of, 103-104, 103t, 279, 280t
fluoride and, 27, 38, 159
functions of

   barrier and buffering properties, 27
   dental caries prevention, 27
   tissue protection, 26-27
   wound healing, 27
and general health, 1, 17
immunoglobulins in, smoking and, 41
Salivary glands, 26
and aging, 32
and general health, 1, 17
  involvement in infections, 97
Sjogrens syndrome and, 51
Satisfaction ratings, of oral health, 144
Scaling and root planing, for plaque removal, 206,
  206t

SCHIP See State Children's Health Insurance
Program

School-based programs. See also Dental schools;
Health professional schools
dental sealant programs in, 167
dietary fluoride supplements in, 164-165
fluoridated drinking water in, 159t, 162
  fluoride mouthrinses in, 165
oral and pharyngeal cancer prevention
   programs in, 170

strategies employed by, 156t
tobacco prevention programs in, 170
Science base. See also Research
and evidence-based practice, 213, 246
need for expansion of, 11-12, 285-286
  in oral health, 5, 19-20
Scientific worldviews, 134-135
Scurvy, oral signs of, 101
Sealants. See Dental sealants
Secretory leukocyte protease inhibitor (SLPI), 27
Self-care. See Oral health care system, individual

Index

approaches in
Senses, 23-25, 32
Sex

and adult periodontitis, susceptibility to, 41, 65,
  65f
and dental care

nonutilization, 84t
utilization, 80t, 81-82, 81t
wants, 87t

of dental personnel, 236-237
and injuries, 73

and insurance coverage, 231, 232f
and oral and pharyngeal cancers, by race/eth-
nicity, 68, 68f

and oral clefts, 72
and oral health, 77-78
ratings of, 144
and pain, 25, 77

prevalence of, 73, 731
and periodontal disease, 203t
and Sjogren's syndrome, prevalence of, 73
and taste, 78

and TMDs, prevalence of, 73
  and tooth loss, 66
Sex hormones

and adult periodontitis, susceptibility to, 41
pain and, 25

Sexually transmitted diseases (STDs), oral transmis-
  sion of, 109

Single-gene defects, 49-50
Sjogren's syndrome, 51
prevalence of, 73

swollen parotid glands with, 97
Skin, lesions of, diseases and conditions causing,
  98t, loot

Sleep problems, and quality of life, 137
SLPI. See Secretory leukocyte protease inhibitor
Smell
aging and, 32
development and function of, 23, 24
Smokeless (spit) tobacco. See Tobacco
Smoking. See also Tobacco
  and birth defects, 48
  cessation of, 210
community intervention models, 171
  and oral cancer, 46
and periodontal disease, 203t, 206
  school-based intervention models, 170
  and trench mouth, 40

Social function, and dental problems, 138-139, L39r
Socioeconomic status. See Income
Sonic instruments, for plaque removal, 206, 206t
Spinal chord, early development of, 29
Spirochetes, and trench mouth, 40

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

305


Index

Sports injuries. 50, 73. 173-176. 17St-175t, 176b,
  258

Squamous cell carcinomas, oral. t-t
  HP\. and, 43, $5

Stannous fluoride. to limit gingixpal inflammation,
  205. 206t

State Children's Health Insurance Program (SCHIP),
  2. 13. 733-234, 255. 277
States

data from. need for. 10. 88. 284, 285
on edentulism. 67t
income of, and population-per-dentist ratio.
224. 224J

on mortality rates for oral and pharyngeal
  cancer, 70. 701

public health systems in, 226-227, 286
STDs. See Sexually transmitted diseases
Steroid hormones, and gingivitis, 39
Stevens-Johnson syndrome, lesions caused by, 100~
Streptococci. 39. See also Mutans streptococci
St)-cytocorcus snnguis. in heart disease, 107, 117
Stt~cptococcus Viriclatts, oral infections from, 105
Stress

and immune system, 28
and periodontal disease. 203~. 206
Stroke. oral infection and, 115-120
  animal studies. 117-l 18
  mechanisms of action in, 115-l 17
population-based studies. 118-120, 119~
Student indebtedness, 237-238
Sublingual glands, 26
Submandibular glands, 26
aging and. 32

Submucous fibrosis, and oral cancer, 45
Sugars

  and dental caries, 38, 250b
  intake reduction of, 199
in smokeless (spit) tobacco, 39
Surveillance data. 61-62
  need for. 12, 88-89
on quality- of life, 14-I-146, 146t
surveys used for. 61-62
Suni\.al rate. definition of, 62b
S!-philis. lesions caused by, 99t. 109

T

T cells. 78
smoking and, -41
Tar. tobacco
  carcinogens in, 45
dysplasia and. $6
Tartar. and gingtvttis, 39. See also Calculus

Task Force on Community Preventive Services, 158,
  180
Taste

development and function of, 23-24
  sex differences in, 78
Tear glands, Sjdgren's syndrome and, 51
Technology, future of, 278-279
Temperature, sensitivity to, 24-25
Temporalis muscle, 26
Temporomandibular disorders (TMDs), 52-53
and chewing function, 136
clinical management of, 211-212
diagnosis of, 211-212,212t
pain from, impact of, 139-140
prevalence of, 73
and quality of life, 145-146
  treatment for, 212
Temporomandibular joint, 26
Teratogens, 47-48
Tetracycline, enamel hypoplasia from, 107
TGF-(x. See Transforming growth factor 01
Therapeutics, oral fluids in diagnostic tests for, 103,
  103t

Thermoreceptors, 24
Thrombosis, from oral cavity bacteria, 117
Thromboxane B2, and heart disease, 115
Thrush, 43. See Candidiasis
prevalence of, 71

Tic douloureux, 52
TMDs. See Temporomandibular disorders
TNF-o. See Tumor necrosis factor OL
Tobacco, 191t

among adolescents, 259b
and adult periodontitis, susceptibility to, 41
and alcohol, combination of
  and oral cancer, 45, 208t, 209
and dental caries, 259b
as general health risk factor, 4, 10, 18
and oral and pharyngeal cancer, 259b, 260b
and oral cancer, 44-45, 169, 170, 208t, 209,
  209~

and oral candidiasis, 42
oral effects of, 101
and oral mucosal lesions, 70
and periodontal diseases, 169, 259b, 260b
and saliva, 27
smokeless (spit) tobacco
among adolescents, 257
  and dental caries, 259b
and oral and pharyngeal cancer, 44-45,
    208t, 259b

and oral mucosal lesions, 70, 7Of
and periodontal diseases, 259b

306         ORAL HEALTH 1N AMERICA: A REPORT OF THE SURGEON GENERAL


   prevention programs for, 170
   and tooth decay, 39
  trends in use of, 259b-260b
Tongue
  cancer in, 70
lesions of, diseases and conditions causing,
    98t-100t
Tooth/teeth, 26
aging of, 31
birth defects involving, 48-49, 50
   clenching of, 190, 191t, 212
conically shaped, in ectodermal dysplasias, 50
cultural significance of, 137-138
decay in. See Dental caries
embryonic development of, 30
grinding of, 52, 212
  loss of

by age, socioeconomic status, sex, and
   racdethnicity, 66-67
and chewing function, 135-136
malocclusions. See Malocclusions
nutrition in development of, 250b
pain in, 24
primary, 26

restored. See Restorations
staining of, 107
thermal sensitivity in, 24
trauma to
  from falls, 50
prevalence of, 72

Toothbrushing, 39, 176, 179, 190
  and bacteremia, 104
public knowledge of
   for dental caries prevention, 177
   for gum disease prevention, 178
public practices, 178
Toothaches, prevalence of, 73, 73f
Toothpaste. See Dentifrice
Touch, sense of, in mouth, 24
Toxic-shock-like syndrome (TSLS), 105
Toxins, saliva and, 27, 103, 103t
Transforming growth factor (Y (TGF-cy), and oral
and pharyngeal cancers, 46,47
Trauma. See nfso Injury, and oral-facial
prevention of, strategies for, 156~
  and R-IU, $4

Traumatic ulcers, lesions caused by, 1OOt
Treacher Collins syndrome, 48
Treatment(s). See also specqic disease
  future of, 276
   outcomes

as determinant of health, 248, 248f
measurement of, 133

Index

Trench mouth, 40
  lesions with, 99t

Treponema, and gingivitis, 39
Treponema denticola, in adult periodontitis, 40, 205
Triclosan copolymer, to limit gingival inflammation,
  205, 206t

Trigeminal ganglion, oral herpes and, 43
Trigeminal neuralgia, 52
TSLS. See Toxic-shock-like syndrome
Tuberculosis, lesions caused by, 99t
Tumor necrosis factor cx (TNF-o)
and adult periodontitis, 41, 205
and glycemic control, 114
and heart disease, 115
and pregnancy, 12 1
Tumor suppressor genes, mutations of, in oral and
pharyngeal cancer, 46

U

Ulcerative colitis, and RAU, 44
Ultrasonic instruments, for plaque removal, 206,

206t

U.S. Department of Agriculture, 225
U.S. Department of Defense, 225
U.S. Department of Health and Human Services

  (USDHHS), 225,226, 2261
U.S. Department of Justice, 225
U.S. Department of Transportation, 225
U.S. Department of Veterans Affairs, 225
U.S. Preventive Services Task Force, 156-158
USDHHS. See U.S. Department of Health and

Human Services

V

Van der Woude syndrome, 48
Varicella-zoster virus

and chemotherapy, 106
oral lesions with, 98t
Vascular endothelial growth factor (VEGF), 27
VEGF See Vascular endothelial growth factor
Veillonella pawula, and gingivitis, 39
Velocardiofacial syndrome, 48
Venereal warts, 71

VGS. See Viridans group streptococcei
Vietnamese Americans, nasophatyngeal cancer inci-
dence and mortality, 76
Vincent's infection, 40
lesions caused by, 99t
Violence, 51, 72-73
Viridans group streptococci (VGS), 105
Viridans streptococcal shock syndrome (VSSS), 105

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL           307


Viruses. See also spec$c virus
chemotherapy and, 106
lesions caused by, 98t
  oral cancer and, 45-46
Vitamin B deficiency, oral signs of, 101
Vitamin C deficiency
  and cancer, 25 1 b
oral signs of, 101
Vitamin D deficiency, oral signs of, 101
Vitamin E, 47

cancer and, 25 1 b
and mucositis, 106

VSSS. See Viridans streptococcal shock syndrome

W

Waardenburg syndrome, 50
Warts, viral, 43

  oral lesions with, 98t
Water fluoridation. See Fluoride, in drinking water
Well-being

  and oral diseases, 10, 11
and oral health, 2, 4-5, 18, 19
in World Health Organization (WHO)
   definition of health, 133
Western scientific worldviews, 134-135
WHO. See World Health Organization
WIC. See Women, Infants, and Children program
Wolinella recta, in adult periodontitis, 41
Women

and adult periodontitis, susceptibility to, 41, 65,
65f

and dental care nonutilization, 84t
as dental personnel, 236
in dentistry, 223-224, 224t
elderly, risk factors for, 266-267
and injuries, 73
and oral and pharyngeal cancers, 68, 68f
and oral bone loss, 102-103
oral health of, 77-78, 266-267
areas of study in, 78, 78f
and pain, 25, 77-78
prevalence of, 73, 73f
  TMDs, 52, 73

and Sjogren's syndrome, prevalence of, 73
Women, Infants, and Children (WIG) program, 225,
  256

Workplace effects, on oral health, 249
World Health Organization (WHO) 18, 133

X
Xenografts, 208
Xerostomia. See Dry mouth
  and dental caries, 38
  and oral candidiasis, 42
Xerostomic side effects, of medication, 107

Y

Yeast. See Candida albicans

308

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL