ORAL HEALTH

LITERACY

WORKSHOP SUMMARY

Maria Hewitt, Rapporteur

Roundtable on Health Literacy

Board on Population Health and Public Health Practice

INSTITUTE OF MEDICINE
     OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.

www.nap.edu



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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 engineers. It is autonomous in its administration and in the selection of its mem- bers, sharing with the National Academy of Sciences the responsibility for advis- 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 Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in pro- viding services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the 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