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Improving Access to Oral Health Care for Vulnerable and Underserved Populations 2 Oral Health Status and Utilization Many of the country’s most vulnerable populations face the greatest oral health needs and the largest barriers to accessing oral health care. Because oral health is inextricably linked to overall health, the effects of poor oral health are felt far beyond the mouth. Oral health providers, policy makers, and other stakeholders need to coalesce around a common ground of basic preventive strategies, health literacy, and quality of care principles to improve the oral health of the entire U.S. population. This chapter begins with a discussion of the connection between oral health and overall health. Next, the chapter gives a brief overview of the oral health status and access to oral health care for the nation as a whole. The specific oral health needs and access issues for individual vulnerable and underserved populations follows. Finally, the chapter considers several barriers to improving access to oral health care (and ultimately, oral health status) including poor oral health literacy, inadequate use of preventive services, and relative lack of oral health quality measures. These barriers are briefly considered here, as a fuller discussion of literacy, prevention, and quality measures can be found in the IOM report Advancing Oral Health in America (IOM, 2011). THE CONNECTION BETWEEN ORAL HEALTH AND OVERALL HEALTH For people suffering from dental, oral, or craniofacial diseases, the link between oral health and general health and well-being is beyond dispute. However, for policy makers, payers, and health care professionals, a chasm
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Improving Access to Oral Health Care for Vulnerable and Underserved Populations has divided them. Dental coverage is provided and paid for separately from general health insurance (see Chapter 5), dentists are trained separately from physicians (see Chapter 3), and legislators often fail to consider oral health in health care policy decisions. In effect, the oral health care field has remained separated from general health care. Recently, however, researchers and others have placed a greater emphasis on establishing and clarifying the oral-systemic linkages. BOX 2-1 Dental, Oral, and Craniofacial The word oral 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 connections 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. SOURCE: HHS, 2000b. The surgeon general’s report Oral Health in America emphasized that oral health care is broader than dental care, and that a healthy mouth is more than just healthy teeth (see Box 2-1). The report described the mouth as a mirror of health or disease occurring in the rest of the body in part because a thorough oral examination can detect signs of numerous general health problems, such as nutritional deficiencies and systemic diseases, including microbial infections, immune disorders, injuries, and some cancers (HHS, 2000b). For example, oral lesions are often the first manifestation of HIV infection, and may be used to predict progression from HIV to AIDS (Coogan et al., 2005). Sexually transmitted HP-16 virus has been established as the cause of a number of oropharyngeal cancers (Marur et al., 2010; Shaw and Robinson, 2010). Dry mouth (xerostomia) is an early symptom of Sjogren’s syndrome, one of the most common autoimmune disorders (Al-Hashimi, 2001); xerostomia is also a side effect for a large number of prescribed medications (Nabi et al., 2006; Uher et al., 2009; Weinberger et al., 2010). Further, there is mounting evidence that oral health complications not only reflect general health conditions, but also exacerbate them. Infections
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Improving Access to Oral Health Care for Vulnerable and Underserved Populations that begin in the mouth can travel throughout the body. For example, periodontal bacteria have been found in samples removed from brain abscesses (Silva, 2004), pulmonary tissue (Suzuki and Delisle, 1984), and cardiovascular tissue (Haraszthy et al., 2000). Periodontal disease has been associated with adverse pregnancy outcomes (Albert et al., 2011; Offenbacher et al., 2006; Radnai et al., 2006; Scannapieco et al., 2003b; Tarannum and Faizuddin, 2007), respiratory disease (Scannapieco and Ho, 2001), cardiovascular disease (Blaizot et al., 2009; Offenbacher et al., 2009b; Scannapieco et al., 2003a; Slavkin and Baum, 2000), and diabetes (Chávarry et al., 2009; Löe, 1993; Taylor, 2001; Teeuw et al., 2010). Poor oral health may be associated with several other types of morbidity (both individual and societal) including chronic pain, loss of days from school (Gift et al., 1992, 1993), and inappropriate use of emergency departments (Cohen et al., 2011; Davis et al., 2010). Oral health affects speech, nutrition, growth and function, social development, and quality of life (HHS, 2000b). In rare cases, untreated oral disease in children has led to death (Otto, 2007). The impact of poor oral health extends to a child’s family and community through lost work hours and the cost of hospital admissions, for example. Figure 2-1 illustrates the range of consequences of early childhood caries in a morbidity and mortality pyramid. OVERVIEW OF ORAL HEALTH STATUS AND ACCESS TO ORAL HEALTH CARE IN THE UNITED STATES Although there is a wide range of diseases and conditions that manifest themselves in or near the oral cavity itself, this report will focus primarily on access to services for the prevention, diagnosis, and treatment of two diseases and their sequelae: dental caries and periodontal diseases. Dental caries, or tooth decay, is caused by a bacterial infection (most commonly Streptococcus mutans) that is often passed from person to person (e.g., from mother to child). Oral Health in America called dental caries the most common chronic disease of childhood (HHS, 2000b), and it is among the most common diseases in the world (WHO, 2010d). Despite decades of knowledge of how to prevent dental caries, they remain a significant problem for all age groups. Periodontal disease is generally broken into two categories: gingivitis and periodontitis. Gingivitis is an inflammation of the tissue surrounding the teeth that results from a buildup of dental plaque between the tissue and the teeth. It is generally due to poor oral hygiene. Untreated gingivitis can result in periodontitis, the breakdown of the ligament that connects the teeth to the jaw bone, and the destruction of the bone that supports the teeth in the jaw. At least 8.5 percent of adults (ages 20-64) and 17.2 percent of older adults (age 65 and older) in the United States have periodontal disease (NIDCR, 2011a,b).
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Improving Access to Oral Health Care for Vulnerable and Underserved Populations FIGURE 2-1 Proposed early childhood caries morbidity and mortality pyramid. SOURCE: Casamassimo et al., 2009. Copyright © 2009 American Dental Association. All rights reserved. Reproduced by permission. A Note on Data Sources The following sections document the oral health status and access to care for various populations. Data was drawn from published studies that rely on a number of data sources, including the National Health and Nutrition Examination Survey (NHANES), the National Health Interview Survey, the Medical Expenditure Panel Survey (MEPS), and smaller-scale surveys. While the magnitude of disparities in oral health and access to care may differ among the various sources, similar conclusions can be drawn from them about disparities in oral health status and access to care. Other researchers have noted similar trends in the past (Macek et al., 2002). Therefore, the committee felt comfortable using a variety of data sources, both national and smaller scale. The committee did not have the ability
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Improving Access to Oral Health Care for Vulnerable and Underserved Populations to analyze raw data and thus relied on published sources. As a result, the committee did not always use the most recent survey data, because it has not been analyzed in the published literature. In particular, many published studies on oral health status rely on NHANES data from 1988-1994 and 1999-2004, and consequently the committee also relied heavily on those data. While NHANES has included an oral health assessment in subsequent years, the data collected is less detailed and not easily comparable to earlier data. Until 2004, NHANES collected tooth-level data, meaning that a dentist evaluated the teeth of each survey respondent to determine the number of decayed, missing, or filled teeth and surfaces (CDC, 2010b). Beginning in 2005, the oral health survey moved to person-level surveillance for caries, meaning that each survey respondent was evaluated only for the presence or absence of any decayed, missing, and filled teeth (CDC, 2010b; Dye et al., 2011a). The Patient Protection and Affordable Care Act required the Centers for Disease Control and Prevention (CDC) to return to person-level surveillance for NHANES, although funding has not been appropriated.1 Overall Oral Health Status In April 2007, the National Center for Health Statistics of the CDC released a comprehensive assessment of the oral health status of the U.S. population (Dye et al., 2007). Using data provided by two iterations of NHANES (NHANES III, 1988-1994, and NHANES, 1999-2004), which is the most comprehensive survey on oral health status in the United States, the assessment concluded that “Americans of all ages continue to experience improvements in their oral health” (Dye et al., 2007). Specifically, the report noted that among older adults, edentulism (complete tooth loss) and periodontitis (gum disease) had declined. Among adults, CDC observed improvements in the prevalence of dental caries, tooth retention, and periodontal health. For adolescents and youth, dental caries decreased, while dental sealants (used to prevent tooth decay) became more prevalent. Encouragingly, the increase in dental sealants was consistent among all racial and ethnic groups, although non-Hispanic black and Mexican American children and adolescents continue to have a lower prevalence of sealants than white children and adolescents, and low-income children receive fewer dental sealants than those who live above 200 percent of the federal poverty level (FPL). While the data from the NHANES surveys showed improvements in certain indicators of oral health status across two intervals of time, Americans’ overall health status in the 1999-2004 period remained discouraging. 1 Patient Protection and Affordable Care Act, Public Law 148, 111th Cong., 2nd sess. (March 23, 2010), §4102.
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Improving Access to Oral Health Care for Vulnerable and Underserved Populations For example, over 25 percent of adults 20 to 64 years of age and nearly 20 percent of respondents over age 65 were experiencing untreated dental caries at the time of their examination. Even young children experienced high rates of caries: nearly 28 percent of children ages 2-5 years had caries experience, and 20 percent have untreated caries. Moreover, caries prevalence among preschool children increased between 1988-1994 and 1999-2004 (Dye et al., 2010). In addition, disturbing disparities remain in oral health status for many underserved and vulnerable populations, which will be discussed in detail later in this chapter. Access to Oral Health Care Limited and uneven access to oral health care contributes to both poor oral health and disparities in oral health. More than half of the population (56 percent) did not visit a dentist in 2004 (Manski and Brown, 2007), and in 2007, 5.5 percent of the population reported being unable to get or delaying needed dental care, significantly higher than the numbers that reported being unable to get or delaying needed medical care or prescription drugs (Chevarley, 2010). Nearly all measures indicate that vulnerable and underserved populations access oral health care in particularly low numbers. For example, poor children are more likely to report unmet dental need than those with higher incomes (Bloom et al., 2010), non-Hispanic black and Hispanic children and adults are less likely to have seen a dentist in the past 6 months than non-Hispanic white populations (Bloom et al., 2010; Pleis et al., 2010), and less than 20 percent of eligible Medicaid beneficiaries received preventive dental services in 2009 (CMS, 2010). These disparities and others will be discussed in more detail later in this chapter. Healthy People: Benchmarks for Oral Health Since 1980, the Department of Health and Human Services (HHS) has used the Healthy People process to set the country’s health-promotion and disease-prevention agenda (Koh, 2010). Healthy People is a set of health objectives for the nation, consisting of (1) overarching goals for improving the overall health of all Americans, and (2) more specific objectives in a variety of focus areas, including oral health. Every 10 years, HHS evaluates the progress that has been made on Healthy People goals, develops new goals, and sets new benchmarks for progress. The goals are developed by relevant HHS agencies, with input from external stakeholders and the public. Healthy People 2020 objectives were released in December 2010 and are listed in Box 2-2. Healthy People 2010 came to a close with the announcement of the Healthy People 2020 benchmarks in late 2010. Progress on the Healthy
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Improving Access to Oral Health Care for Vulnerable and Underserved Populations People 2010 goals was mixed, although final data have yet to be analyzed (Koh, 2010; Sondik et al., 2010; Tomar and Reeves, 2009). At the midcourse review in 2006, no oral health objectives had met or exceeded their targets (HHS, 2006). Encouragingly, however, progress was made in a number of categories, including decreasing caries among adolescents (although not among younger children), increasing the proportion of children with dental sealants, increasing the proportion of adults with no permanent tooth loss, and increasing the proportion of the population with access to community water fluoridation (HHS, 2006; Tomar and Reeves, 2009). In contrast, several objectives moved away from their targets. For example, the proportion of children aged 2 to 4 years with dental caries increased from 18 to 22 percent, and the proportion of untreated dental caries in this population increased from 16 to 17 percent (HHS, 2006). In addition, the number of oral and pharyngeal cancers detected at an early stage decreased. ORAL HEALTH STATUS AND ACCESS TO ORAL HEALTH CARE FOR VULNERABLE AND UNDERSERVED POPULATIONS While there has been some improvement in the oral health of the U.S. population overall, underserved populations continue to suffer disparities in both their disease burden and access to needed services. For example, dental caries remain a significant problem in certain specific populations such as low-income children and racial and ethnic minorities (Edelstein and Chinn, 2009). According to NHANES, twice as many poor children ages 2 to 11 have at least one untreated decayed tooth, compared to nonpoor children (Dye et al., 2007). In addition, low-income children also receive fewer dental sealants (Dye et al., 2007). Minority children are more likely to have dental decay than white children, and their decay is more severe (IHS, 2002; Vargas and Ronzio, 2006). When migrant and seasonal farmworkers in Michigan were asked which health care service would benefit them the most, the most common response was dental services, ahead of pediatric care, transportation, and interpretation, among other services (Anthony et al., 2008). This section will explore the disparities in status and access to care for a variety of vulnerable and underserved populations. Children and Adolescents Children While not all children are underserved, many children are vulnerable to developing oral diseases, particularly dental caries. The U.S. Government Accountability Office (GAO) recently reported that according to NHANES, dental disease in children has not decreased, noting that about
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Improving Access to Oral Health Care for Vulnerable and Underserved Populations one in three children aged 2-18 enrolled in Medicaid had untreated tooth decay, and one in nine had untreated decay in three or more teeth (GAO, 2008). The lack of adequate dental treatment may affect children’s speech, nutrition, growth and function, social development, and quality of life (HHS, 2000b). In spite of these significant problems, according to MEPS, only about 25 percent of children under the age of 6, 59 percent of children ages 6-12, and 48 percent of adolescents ages 13-20 had a dental visit in 2004 (Manski and Brown, 2007). BOX 2-2 Healthy People 2020: Oral Health Objectives Oral health of children and adolescents 1. Reduce the proportion of children and adolescents who have dental caries experience in their primary or permanent teeth. 2. Reduce the proportion of children and adolescents with untreated dental decay. Oral health of adults 3. Reduce the proportion of adults with untreated dental decay. 4. Reduce the proportion of adults who have ever had a permanent tooth extracted because of dental caries or periodontal disease. 5. Reduce the proportion of adults aged 45-74 with moderate or severe periodontitis. 6. Increase the proportion of oral and pharyngeal cancers detected at the earliest stage. Access to preventive services 7. Increase the proportion of children, adolescents, and adults who used the oral health care system in the past year. 8. Increase the proportion of low-income children and adolescents who received any preventive dental service during the past year. 9. Increase the proportion of school-based health centers with an oral health component. 10. Increase the proportion of local health departments and Federally Qualified Health Centers that have an oral health component. 11. Increase the proportion of patients that receive oral health services at Federally Qualified Health Centers each year. Oral health interventions 12. Increase the proportion of children and adolescents who have received dental sealants on their molar teeth. 13. Increase the proportion of the U.S. population served by community water systems with optimally fluoridated water. 14. Increase the proportion of adults who receive preventive interventions in dental offices. Monitoring and surveillance systems 15. Increase the number of states and the District of Columbia that have a system for recording and referring infants and children with cleft lips and cleft palates to craniofacial anomaly rehabilitative teams. 16. Increase the number of states and the District of Columbia that have an oral and craniofacial health surveillance system. Public health infrastructure 17. Increase the number of health agencies that have a public dental health program directed by a dental professional with public health training. SOURCE: HHS, 2010. A number of factors are related to the likelihood that a child has visited the dentist in the past year, including insurance status, race, ethnicity, being born outside the United States, language spoken at home, whether the child’s mother has a regular source of dental care (Grembowski et al., 2008; Lewis et al., 2007). Dentally uninsured children receive fewer dental services than insured children (Kenney et al., 2005; Lewis et al., 2007;
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Improving Access to Oral Health Care for Vulnerable and Underserved Populations Manski and Brown, 2007). The data on dental visits for publicly insured children, however, are mixed. Some data indicate that publicly insured children are less likely to receive dental services and receive fewer dental services on average than privately insured children (Manski and Brown, 2007); however, studies that control for race and income (among other factors) indicate that publicly and privately insured children are equally likely to have a preventive dental visit (Kenney et al., 2005; Lewis et al., 2007). African American and Latino children are less likely to have had a preventive dental visit (Lewis et al., 2007) or any dental contact in the past year than white children (Bloom et al., 2010). This may contribute to the low levels of dental visits among publicly insured children in uncontrolled estimates, since African American and Latino children are more likely to be enrolled in Medicaid (Kaiser Family Foundation, 2009). Children born outside the United States and children whose primary language at home is not English are both less likely than reference groups to have a preventive
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Improving Access to Oral Health Care for Vulnerable and Underserved Populations dental visit in the past 12 months (Lewis et al., 2007). In addition, lowincome children whose parents regularly visit the dentist are more likely to visit the dentist, according to surveys done in Washington state and Detroit (Grembowski et al., 2008; Sohn et al., 2007). Adolescents As noted above, adolescents, generally those aged 10-19 (IOM, 2009), have a high prevalence of oral disease. Risk factors for dental caries are similar to those for other age groups, but adolescents’ risk for oral and perioral injury is exacerbated by behaviors such as the use of alcohol and illicit drugs, driving without a seatbelt, cycling without a helmet, engaging in contact sports without a mouth guard, and using firearms (IOM, 2009). Other concerns among adolescent populations, which are not unique to this age group, include damage caused by the use of all forms of tobacco, erosion of teeth and damage to soft tissues caused by eating disorders, oral manifestations of sexually transmitted infections (e.g., soft tissue lesions) as a result of oral sex, and increased risk of periodontal disease during pregnancy. In an online Harris Interactive poll of nearly 1,200 adolescents, respondents frequently mentioned having access to affordable, convenient, and high-quality dental care as what they would most like to change to make health services more helpful (IOM, 2009). Homeless Populations Homeless people have poorer oral health than the general population. However, no national data are available on the oral health status of homeless populations, and the few available studies may skew the results due to sample size, the population surveyed (e.g., people who present at a clinic), and inability to reach the chronically homeless, among other factors. In a national survey, homeless veterans reported higher rates of oral pain, more decayed teeth, and fewer filled teeth than the general population (Gibson et al., 2003). Many homeless veterans reported having oral pain either currently or within the past year (Conte et al., 2006). Similarly, in a small survey of homeless adolescents in Seattle, over 50 percent reported having sensitive teeth, 39 percent reported a toothache, and 27 percent reported sore or bleeding gums (Chi and Milgrom, 2008). In addition, homeless people in these surveys were more likely than the general population to perceive their oral health as poor (Chi and Milgrom, 2008; Gibson et al., 2003). Homeless people also struggle to access oral health care. A national survey of homeless people found that dental care was the most commonly reported unmet health need (Baggett et al., 2010). In fact, homeless people
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Improving Access to Oral Health Care for Vulnerable and Underserved Populations surveyed at a free dental screening had not seen a dentist in, on average, 5.7 years (Conte et al., 2006). Homeless populations face a multitude of barriers to both maintaining good oral health and accessing oral health care. They are more likely to engage in behaviors detrimental to oral health such as smoking and using other types of tobacco products (Conte et al., 2006; Gibson et al., 2003), heavy alcohol use (Gibson et al., 2003), and substance abuse (Chi and Milgrom, 2008). They also may lack toothbrushes, toothpaste, clean water, or a place to brush their teeth (Chi and Milgrom, 2008). Homeless people often lack dental coverage, and homeless children struggle to maintain Medicaid coverage because they do not have a permanent address. Over one-third of homeless people at a free dental screening answered that they did not know where to seek dental care if needed (Conte et al., 2006). Low-Income Populations Socioeconomic status, as measured by poverty status,2 is a strong determinant of oral health (Vargas et al., 1998). In every age group, persons in the lower-income group are more likely to have had dental caries experience and more than twice as likely to have untreated dental caries in comparison to their higher-income counterparts (Dye et al., 2007). Poor children ages 2-8 have more than twice the rate of dental caries experience as nonpoor children (Dye et al., 2010). Despite the fact that most children living below the FPL are eligible to receive dental care through Medicaid, many children in this income group have untreated decay (Dye et al., 2007). Among adults, tooth extraction is a common treatment for advanced dental decay when financial resources are limited. Consistently, total tooth loss, or edentulism, among persons 65 years of age and over is more frequent among those living below the FPL than among those living at twice the FPL (Dye et al., 2007). Poor children and adults receive significantly fewer dental services than the population as a whole (Dye et al., 2007; Lewis et al., 2007; Stanton and Rutherford, 2003). The likelihood of visiting a dentist decreases with decreasing income (Haley et al., 2008; Manski et al., 2004), and people who live below the FPL are less than half as likely to have visited a dentist in the past year as those who make over 400 percent of the FPL (Manski and Brown, 2007). Children whose families make below 200 percent of the FPL are less than half as likely to have a preventive dental visit than children living in higher-income families (Stanton and Rutherford, 2003). 2 For the purposes of this report, poor refers to individuals and families with income below the FPL; near-poor refers income between 100 and 199 percent of FPL; and nonpoor refers to income above 200 percent of the FPL.
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Improving Access to Oral Health Care for Vulnerable and Underserved Populations Fedorowicz, Z., M. Nasser, and N. Wilson. 2009. Adhesively bonded versus non-bonded amalgam restorations for dental caries. Cochrane Database of Systematic Reviews (4):CD007517. Feldman, C., M. Giniger, M. Sanders, R. Saporito, H. Zohn, and S. Perlman. 1997. Special Olympics, special smiles: Assessing the feasibility of epidemiologic data collection. Journal of the American Dental Association 128(12):1687-1696. Fisher-Owens, S. A., S. A. Gansky, L. J. Platt, J. A. Weintraub, M. J. Soobader, M. D. Bramlett, and P. W. Newacheck. 2007. Influences on children’s oral health: A conceptual model. Pediatrics 120(3):e510-e520. Fontana, M., and D. Zero. 2007. Bridging the gap in caries management between research and practice through education: The Indiana University experience. Journal of Dental Education 71(5):579-591. Forrest, J. L., A. M. Horowitz, and Y. Shmuely. 2000. Caries preventive knowledge and practices among dental hygienists. Journal of Dental Hygiene 74(3):183-195. Gaffield, M. L., B. J. Colley, D. M. Malvitz, and R. Romaguera. 2001. Oral health during pregnancy: An analysis of information collected by the pregnancy risk assessment monitoring system. Journal of the American Dental Association 132(7):1009-1016. GAO (Government Accountability Office). 2008. Extent of dental disease in children has not decreased, and millions are estimated to have untreated tooth decay. Washington, DC: U.S. Government Accountability Office. Garcia, R. I., R. E. Inge, L. Niessen, and D. P. DePaola. 2010. Envisioning success: The future of the oral health care delivery system in the United States. Journal of Public Health Dentistry 70(Supp. 1):S58-S65. Gelskey, S. C. 1999. Cigarette smoking and periodontitis: Methodology to assess the strength of evidence in support of a causal association. Community Dentistry and Oral Epidemiology 27(1):16-24. Gibson, G., R. Rosenheck, J. Tullner, R. Grimes, C. Seibyl, A. Rivera-Torres, H. Goodman, and M. Nunn. 2003. A national survey of the oral health status of homeless veterans. Journal of Public Health Dentistry 63(1):30-37. Gift, H. C., S. T. Reisine, and D. C. Larach. 1992. The social impact of dental problems and visits. American Journal of Public Health 82(12):1663-1668. Gift, H. C., S. T. Reisine, and D. C. Larach. 1993. Erratum: The social impact of dental problems and visits. American Journal of Public Health 83(6):816. Gift, H. C., S. B. Corbin, and R. E. Nowjack-Raymer. 1994. Public knowledge of prevention of dental disease. Public Health Reports 109(3):397-404. Glassman, P., and P. Subar. 2008. Improving and maintaining oral health for people with special needs. Dental Clinics of North America 52(2):447-461. Glassman, P., T. Henderson, M. Helgeson, C. Meyerowitz, R. Ingraham, R. Isman, D. Noel, R. Tellier, and K. Toto. 2005. Oral health for people with special needs: Consensus statement on implications and recommendations for the dental profession. Journal of the California Dental Association 33(8):619-623. Graham, M. A., S. L. Tomar, and H. L. Logan. 2005. Perceived social status, language and indentified dental home among Hispanics in Florida. Journal of the American Dental Association 136(11):1572-1582. Grembowski, D., C. Spiekerman, and P. Milgrom. 2008. Linking mother and child access to dental care. Pediatrics 122(4):e805-e814. Griffin, S. O., B. F. Gooch, S. A. Lockwood, and S. L. Tomar. 2001a. Quantifying the diffused benefit from water fluoridation in the United States. Community Dentistry and Oral Epidemiology 29(2):120-129. Griffin, S. O., K. Jones, and S. L. Tomar. 2001b. An economic evaluation of community water fluoridation. Journal of Public Health Dentistry 61(2):78-86.
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