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ORAL HEALTH
LITERACY
W O R K S H O P S U M M A R Y
Maria Hewitt, Rapporteur
Roundtable on Health Literacy
Board on Population Health and Public Health Practice
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Gov-
erning Board of the National Research Council, whose members are drawn from
the councils of the National Academy of Sciences, the National Academy of Engi-
neering, and the Institute of Medicine.
This study was supported by contracts between the National Academy of Sciences
and Aetna, the Agency for Healthcare Research and Quality (HHSP233200900537P),
the American College of Physicians Foundation, America’s Health Insurance
Plans, GlaxoSmithKline, the Health Resources and Services Administration
(HHSH25034004T), Humana, Johnson & Johnson, the East Bay Foundation (Kai-
ser Permanente), Merck and Co., Inc., the Missouri Foundation for Health (09-
0290-HL-09), and the UnitedHealth Group. Any opinions, findings, conclusions,
or recommendations expressed in this publication are those of the author(s) and
do not necessarily reflect the view of the organizations or agencies that provided
support for this project.
International Standard Book Number-13: 978-0-309-26289-7
International Standard Book Number-10: 0-309-26289-5
Additional copies of this report are available from the National Academies Press,
500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202)
334-3313; http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page
at: www.iom.edu.
Copyright 2013 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost
all cultures and religions since the beginning of recorded history. The serpent
adopted as a logotype by the Institute of Medicine is a relief carving from ancient
Greece, now held by the Staatliche Museen in Berlin.
Suggested citation: IOM (Institute of Medicine). 2013. Oral health literacy: Workshop
summary. Washington, DC: The National Academies Press.
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“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
—Goethe
Advising the Nation. Improving Health.
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The National Academy of Sciences is a private, nonprofit, self-perpetuating
society of distinguished scholars engaged in scientific and engineering research,
dedicated to the furtherance of science and technology and to their use for the
general welfare. Upon the authority of the charter granted to it by the Congress
in 1863, the Academy has a mandate that requires it to advise the federal govern-
ment on scientific and technical matters. Dr. Ralph J. Cicerone is president of the
National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter
of the National Academy of Sciences, as a parallel organization of outstanding
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ing the federal government. The National Academy of Engineering also sponsors
engineering programs aimed at meeting national needs, encourages education
and research, and recognizes the superior achievements of engineers. Dr. Charles
M. Vest is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of
Sciences to secure the services of eminent members of appropriate professions
in the examination of policy matters pertaining to the health of the public. The
Institute acts under the responsibility given to the National Academy of Sciences
by its congressional charter to be an adviser to the federal government and, upon
its own initiative, to identify issues of medical care, research, and education.
Dr. Harvey V. Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of
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Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and
vice chair, respectively, of the National Research Council.
www.national-academies.org
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PLANNING COMMITTEE ON ORAL HEALTH LITERACY1
SHARON BARRETTT, Health Literacy Staff Consultant, Association of
Clinicians for the Underserved
BENARD P. DREYER, Professor of Pediatrics, New York University
School of Medicine, and Chair, American Academy of Pediatrics
Health Literacy Program Advisory Committee
ALICE M. HOROWITZ, Research Associate Professor, School of Public
Health, University of Maryland
CLARENCE PEARSON, Consultant, Global Health Leadership and
Management
RIMA RUDD, Senior Lecturer on Society, Human Development &
Health, Harvard School of Public Health
1 Institute
of Medicine planning committees are solely responsible for organizing the
workshop, identifying topics, and choosing speakers. The responsibility for the published
workshop summary rests with the workshop rapporteur and the institution.
v
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ROUNDTABLE ON HEALTH LITERACY1
GEORGE ISHAM (Chair), Medical Director and Chief Health Officer,
HealthPartners
WILMA ALVARADO-LITTLE, Director, Community Engagement/
Outreach Center for the Elimination of Minority Health Disparities,
University of Albany
CINDY BRACH, Senior Health Policy Researcher, Center for Delivery,
Organization, and Markets, Agency for Healthcare Research and
Quality
BENARD P. DREYER, Professor of Pediatrics, New York University
School of Medicine, and Chair, American Academy of Pediatrics
Health Literacy Program Advisory Committee
LEONARD EPSTEIN, Senior Advisor, Clinical Quality and Culture,
Health Resources and Services Administration
LAURIE FRANCIS, Senior Director of Clinic Operations and Quality,
Oregon Primary Care Association
DEBBIE FRITZ, Director, Policy and Standards, Health Management
Innovations Division, GlaxoSmithKline
MARTHA GRAGG, Vice President of Program, Missouri Foundation
for Health
JILL GRIFFITHS, Vice President, Communications, Aetna
LINDA HARRIS, Team Leader, Health Communication and eHealth
Team, Office of Disease Prevention and Health Promotion, U.S.
Department of Health and Human Services
BETSY L. HUMPHREYS, Deputy Director, National Library of
Medicine, National Institutes of Health
JOAN KELLY, Director, Consumer Experience, Humana, Inc.
JEAN KRAUSE, Executive Vice President and Chief Executive Officer,
American College of Physicians Foundation
MARGARET LOVELAND, Senior Director, Global Medical Affairs,
Merck & Co., Inc.
PATRICK McGARRY, Senior Manager for Health Activities and
Programs, American Academy of Family Physicians
RUTH PARKER, Professor of Medicine, Emory University School of
Medicine
KAVITA PATEL, Managing Director for Clinical Transformation and
Delivery, The Brookings Institution
1
Institute
of Medicine forums and roundtables do not issue, review, or approve individual
documents. The responsibility for the published workshop summary rests with the work-
shop rapporteur and the institution.
vi
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CLARENCE PEARSON, Consultant, Global Health Leadership and
Management
SUSAN PISANO, Director of Communications, America’s Health
Insurance Plans
ANDREW PLEASANT, Health Literacy and Research Director, Canyon
Ranch Institute
SCOTT C. RATZAN, Vice President, Global Health, Johnson & Johnson
WILL ROSS, Associate Dean for Diversity, Associate Professor of
Medicine, Washington University School of Medicine
RIMA RUDD, Senior Lecturer on Society, Human Development &
Health, Harvard School of Public Health
STEVEN RUSH, Director, Health Literacy Innovations Program,
UnitedHealth Group
PAUL M. SCHYVE, Senior Vice President, The Joint Commission
PATRICK WAYTE, Vice President, Marketing and Health Education,
American Heart Association
WINSTON F. WONG, Medical Director, Community Benefit,
Disparities Improvement and Quality Initiatives, Kaiser Permanente
IOM Staff
LYLA M. HERNANDEZ, Roundtable Director
ANDREW LEMERISE, Research Associate
ANGELA MARTIN, Senior Program Assistant
ROSE MARIE MARTINEZ, Director, Board on Population Health and
Public Health Practice
vii
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Reviewers
This report has been reviewed in draft form by individuals chosen
for their diverse perspectives and technical expertise, in accordance with
procedures approved by the National Research Council’s Report Review
Committee. The purpose of this independent review is to provide candid
and critical comments that will assist the institution in making its pub-
lished report as sound as possible and to ensure that the report meets
institutional standards for objectivity, evidence, and responsiveness to
the study charge. The review comments and draft manuscript remain
confidential to protect the integrity of the process. We wish to thank the
following individuals for their review of this report:
Patrick McGarry, American Academy of Family Physicians
Dionne J. Richardson, Mississippi State Department of Health
Gary Rozier, University of North Carolina at Chapel Hill
Pamella Vodicka, Health Resources and Services Administration
Although the reviewers listed above have provided many construc-
tive comments and suggestions, they were not asked to endorse the final
draft of the report before its release. The review of this report was overseen
by Hugh Tilson, University of North Carolina at Chapel Hill. Appointed
by the Institute of Medicine, he was responsible for making certain that
an independent examination of this report was carried out in accordance
with institutional procedures and that all review comments were carefully
considered. Responsibility for the final content of this report rests entirely
with the rapporteur and the institution.
ix
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Acknowledgments
Without the support of the sponsors of the Institute of Medicine
Roundtable on Health Literacy it would not have been possible to plan
and conduct the workshop on oral health literacy which this report sum-
marizes. Sponsorship for the Roundtable comes from Aetna, the Agency
for Healthcare Research and Quality, the American College of Physi-
cians Foundation, America’s Health Insurance Plans, GlaxoSmithKline,
the Health Resources and Services Administration, Humana, Johnson &
Johnson, the East Bay Foundation (Kaiser Permanente), Merck and Co.,
Inc., the Missouri Foundation for Health, and the UnitedHealth Group.
The Roundtable wishes to express its appreciation to Congressman
Elijah Cummings for taking the time from his busy schedule to give an
inspiring keynote presentation that set the stage for the remainder of
the day. The roundtable is also grateful to the speakers at the workshop
who provided presentations that stimulated discussion and encouraged
exploration of issues surrounding oral health literacy. The speakers are
RADM William Bailey, Marsha Butler, Mary Lee Conicella, Kimon Divaris,
Ralph Fucillio, Alice M. Horowitz, Amid Ismail, Matt Jacob, Dushanka
Kleinman, Gregory B. McClure, Kathy O’Loughlin, Gary Podschun,
Lindsey Robinson, and Scott Wolpin.
The Roundtable would also like to thank the members of the work-
shop planning committee for their efforts in developing an excellent
workshop agenda. Members of the planning committee were Sharon
Barrett, Benard P. Dreyer, Alice M. Horowitz, Clarence Pearson, and Rima
Rudd.
xi
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Contents
1 INTRODUCTION 1
2 KEYNOTE ADDRESS 5
The Importance of Oral Health Literacy, 5
3 OVERVIEW AND STATEMENT OF THE PROBLEM 11
Background Overview: Exploring the Invisible Barrier to
Achieving Oral Health, 11
Statement of the Problem—Why Is Oral Health Important and
What Role Does Health Literacy Play in the Etiology of
Dental/Oral Diseases?, 15
Discussion, 20
4 WHAT SHOULD ONE LOOK FOR IN AN ORAL HEALTH
LITERACY ASSESSMENT? 27
Assessment of Oral Health Literacy: One Approach, 27
Discussion, 30
5 ORAL HEALTH LITERACY PROGRAMS 33
Community Perspective on the Importance of Oral
Health Literacy, 33
Oral Health Literacy: How Can We Impact Vulnerable
Populations?, 36
xiii
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xiv CONTENTS
Dentist-Patient Communication Techniques Used in the
United States: The Results of a National Survey, 41
Oral Health and Primary Prevention, 49
Discussion, 53
6 STATE ACTIVITIES IN ORAL HEALTH LITERACY 65
Oral Health Literacy Activities in State Oral Health Programs, 65
Activities of the California Dental Association, 69
State Activities: North Carolina, 73
Discussion, 76
7 NATIONAL ACTIVITIES IN ORAL HEALTH LITERACY 79
National Activities in Oral Health Literacy, U.S. Department of
Health and Human Services, 79
Health Literacy in Dentistry, 84
Aetna: Activities in Oral Health Literacy, 88
DentaQuest Foundation Oral Health 2014 Initiative, 92
Discussion, 96
8 CLOSING REMARKS 101
REFERENCES 107
APPENDIXES
A Workshop Agenda 111
B Speaker Biosketches 117
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Tables, Boxes, and Figures
TABLES
3-1 The U.S. Population Responses to Selected OHIP-7 Questions,
NHANES III (n = 6,183), 18
5-1 Dentists’ Routine Use of Oral Health Literacy Techniques, 45
5-2 Results of Pew’s Oregon Survey Designed to Test Messages That
Would Bolster Support for Water Fluoridation, 52
7-1 State Oral Health Programs Funded by the DentaQuest
Foundation, 95
BOXES
7-1 The Definition of Health Literacy in Dentistry, 85
7-2 Examples of Health Literacy Questions, 91
FIGURES
3-1 Oral health literacy framework, 12
3-2 Framework for understanding oral health literacy, 17
3-3 Untreated caries prevalence by education and age group, 18
3-4 Trends in untreated decay in the United States, 20
xv
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xvi TABLES, BOXES, AND FIGURES
5-1 A checklist to prevent dental caries, 39
5-2 Percent of dentists and number of techniques used, 46
5-3 Practice characteristics and differences in mean numbers of
techniques used, 47
5-4 Percent of techniques used routinely, 47
5-5 Penetration of fluoridated water systems, 50
7-1 Systems change for optimal oral health, 94
