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OCR for page 191
26. Oral Health
Testimony on oral health covered the entire life span,
from infancy to old age. The 53 witnesses who ad-
dressed oral health as a major part of their testimony
discussed prevention of tooth decay and gum disease-
the focus of the 1990 oral health objectives-as well as
other areas such as access to dental health services,
professional education, oral cancer, and the role of
dental hygienists in achieving oral health goals.
Discussions of health priorities and preventive
health strategies sometimes overlook oral health or
treat it as an adjunct to other health goals. However,
the witnesses who addressed oral health needs and
objectives make it clear that this is a critical part of
health-particularly preventive action taken to improve
health in terms of personal well-being and to reduce
lost work hours and costs. f~l63; #391J Expendi-
tures for dental care in 1987 reached $35 billion and
have continued to increase." (~156) According to
pyndi Newman, representing the American n~.ntn
Hygienists' Association:
It has been obvious in the past that oral health
has been considered separate from general total
body health. I would like to suggest that it
should be considered an integral part of total
health. Oral health must be a basic component
of all health education, treatment, and main-
tenance programs. Good oral health must no
longer be considered optional for health status.
(#163)
Witnesses also highlighted some new opportunities
for making significant gains in oral health. For exam-
ple, research in the last decade has made eradication
of dental caries a realistic goal, according to Stephen
Moss of New York University. (#439) New objec-
tives were proposed to reflect that progress.
However, testimony also revealed areas in which
progress is lagging. One such area is communing wa-
ter supply fluoridation. Fluoridation has been called
the foundation of oral health, yet many communities
are still without systemic fluoridation.
One issue that arose repeatedly is the vast disparity
in oral health across various population subgroups;
objectives should reflect or target the dental health
needs of -'I
_ ~ , ~
Subgroups identified include the elderly, institutional
these groups. according to witnesses
ized, homeless, handicapped, minorities, migrant
workers, and low-income people. Although specific
objectives on oral health are proposed, witnesses feel
that the process of setting objectives and measuring
progress toward them is impeded by incomplete data
on the oral health status and needs of many popula-
tion subgroups. The Association of State and Territo-
rial Dental Directors (ASTDD) says that an objective
for 1990, that calls for a system to periodically assess
oral health status, needs, and use of services is the
single most important national dental health objective.
(~106)
Another intervention discussed was professional
education. Thomas Truhe of the Princeton Dental
Resource Center says that the public receives most of
its information on dental health from dentists, but
fewer than 40 percent of practicing dentists consider
their profession a primary source of information.2 He
believes that new research findings and other impor-
tant information should be disseminated more
effectively to dental professionals so that they can be
better educators. (~369)
FLUORIDATION
"In the 1990 Objectives, water fluoridation was the
foundation for the prevention of dental disease," says
Myron Allukian representing the American Associa-
tion of Public Health Dentistry. "That should con-
tinue in the year 2000." There was widespread con-
sensus on that issue among those testifying. Wit-
nesses urge that the 1990 target of having 95 percent
of the population on community water systems receive
the benefits of fluoridation, be carried over to the
Year 2000 Health Objectives, although many think it
an unrealistic goal. (~435)
According to Allukian, 60 percent of the popula-
tion served by community water supplies had fluori-
dated water in 1975; by 1985, this had increased to
only 61.4 percent.3 (#435) John Brown of the
University of Texas Health Science Center at San
Antonio says that the promotion of water supply
fluoridation is static: "Its benefits must be more
effectively explained, so that those with this measure
will defend it and those without it will acquire it."
(#029)
The ASTDD calls for changes in a 1990 objective
Oral Health 191
OCR for page 192
that at least 50 percent of school children living in
fluoride-deficient areas without community water
systems should be served by an optimally fluoridated
school water supply. He says that no real progress
has been made toward this goal and there is no real
prospect of attaining it. The ASTDD recommends
replacing this objective with one that includes alter-
native ways to receive fluoride, such as mouth rinses,
tablets, or both. (#106) The importance of using
fluoride dentifrice twice daily is also underscored.
(#154)
INFANTS AND CHILDREN
Many witnesses agree that a new objective aimed at
preventing baby bottle tooth decay should be added;
a public education campaign that alerts parents and
other care givers to the problem could dramatically
reduce its incidence. (#154; #242; #353; #445;
#705)
Baby bottle tooth decay occurs when baby bottles
filled with liquids containing natural or added
sugars-such as milk, infant formula, fruit juice, or a
soft drink-are used as pacifiers. When an infant who
is awake takes in the liquid, the sugars are diluted
with saliva and swallowed. However, if the infant falls
asleep the sugars have time to react with bacteria and
form acids that cause serious cavities. Discontinuing
the use of liquids containing natural or added sugars
in bedtime bottles would prevent this problem.
The national prevalence of baby bottle tooth decay
is not known. In Head Start programs in San Anto-
nio, 10-20 percent of preschoolers show the rampant
form of this condition, according to Brown. (#029)
David Johnsen of Case Western Reserve University
estimates that 15 percent of urban and rural under-
se~ved children and over 50 percent of children in
some Native American groups have the condition. He
recommends that the prevalence be determined and
high-risk groups identified. f#l09)
Another new objective proposed by many witnesses
involves the use of pit and fissure sealants to prevent
dental caries in children. Sealants are a significant
advance in caries prevention that were not addressed
by the oral health objectives for the year 1990. Wit-
nesses call for all children to have access to this
procedure at public and private dental clinics. (~242;
#353; #445) The eradication of caries in children is
now a realistic goal, according to Stephen Moss of
New York University, who notes that a survey of pe-
diatric dentists' own children found that 90 percent
of those less than 12 years old had no cavities. (~439)
192 Healthy People 2000: Citizens Chart the Course
The American Academy of Pediatric Dentistry
emphasizes that sealants and two other proven
preventive strategies-fluoride dentrifice and systemic
fluoride-should be the focus of the Year 20C0 Health
Objectives on reduction of caries. Members of the
academy and witnesses from other dental professional
groups, as well as from the sugar industry, call for
eliminating those of the 1990 objectives aimed at
reducing the availability of cariogenic foods in schools.
Those objectives are criticized for being untenable and
unmeasurable, for failing to take into account
uncertainties about which foods pose the most serious
oral health threats, and for distracting attention from
proven methods of reducing caries. (~154; #197)
ADULTS
For adults, witnesses focused on caries, periodontal
disease, oral trauma, and oral cancers. Public educa-
tion, personal dental hygiene, and regular dental care
were identified as important prevention strategies for
adults.
As the population ages, the number of adults with
caries is increasing, according to Jane Weintraub of
the University of Michigan, who explains that caries
(not gum disease as was previously thought) are the
major cause of tooth loss in adults.4 The 1990 Objec-
tives set targets for caries reduction in only one age
group: nine year olds. Weintraub and others recom-
mend that targets be expanded to include other ages,
even adults, and that specific types of caries be
included in some objectives. (#391J
Much of the adult population has periodontal
disease, according to Dan Middaugh of the University
of Washington.5 To reduce the rates, new initiatives
aimed at increasing public awareness of the impor-
tance of daily oral hygiene and regular professional
care will be necessary, witnesses say. f#353) A1-
though some testifiers note that the relationship be-
tween gingivitis and periodontal disease in adults is
not clear (~029; #106), most witnesses favor continu-
ing to include it in the objectives.
The American Cancer Society estimates that there
are 30,600 new cases of oral cancer a year.6 As
Woodrow Myers of the Indiana State Board of Health
says:
Smokeless tobacco has been linked to cancer,
specifically oral cancer. Use of oral snuff
increases the risk of oral cancer several fold, and
among long-term snuff dippers, the excess risk
of cancers of the cheek and gum may reach
OCR for page 193
fiftyfold. Smokeless tobacco use is responsible
for the development of a portion of oral leuko
plakias in both teenage and adult users. (~405)
According to Percy Butcher of the American Den-
tal Association, reductions in tobacco and alcohol use
are important preventive strategies for oral cancers.
(~242J Several witnesses expressed concern about
the use of smokeless tobacco, particularly among
youth and young adults. The testimony in this area
is summarized in Chapter 10. Although smokeless
tobacco use is a separate topic, a few witnesses
recommended that it be included under oral health to
emphasize its link to oral disease.
Increased public awareness of the risk factors and
symptoms of oral cancer is necessary to decrease the
morbidity and mortality from it; early detection and
treatment of oral cancer result in higher cure rates.
(~249; #262)
Another condition recommended for the new
objectives is oral trauma. Although a 1990 objective
concerned the use of mouthguards, there Is some
feeling that it must to be strengthened. Other strate-
gies mentioned for preventing oral traumas include
the use of seatbelts. (~391)
OLDER ADULTS
Some of the most compelling testimony about adult
oral health needs concerned the elderly. None of the
1990 Objectives addressed this group specifically,
although the elderly are the fastest growing segment
of the population in this country and have serious
dental health needs, according to witnesses. The
American Society for Geriatric Dentistry (ASGD)
notes that as more elderly keep their natural teeth,
caries are an increasing problem. Also, as the num-
bers of elderly increase, so will the need for dental
service, witnesses point out. The at-risk elderly must
be identified so that prevention programs aimed at
reducing caries can be introduced, according to the
ASGD. (#062)
Oral mucosa disease is another problem for the
elderly with dentures, the ASGD says, and a goal for
the year 2000 should be to reduce the prevalence of
oral mucosal lesions in the aging population by 50
percent. ¢~062)
Special attention also must be given to the oral
health of the institutionalized elderly. The ASGO
notes that they have a far greater need for dental care
than those who are not institutionalized. (#062)
Testimony reveals that in many institutions, elderly
residents are not offered regular dental care. A new
Texas law requiring that nursing home residents be
offered dental services (at their own expense) on a
regular basis is hailed as a model. (~306) The
ASGD suggests that oral health programs be man-
dato~y at all nursing homes by the year 2000. (~062)
UNDERSERVED POPULATIONS: PROBLEMS
AND STRATEGIES
The theme sounded most often in the testimony on
oral health is the disparity in oral health among
population subgroups. III addition to the elderly,
other subgroups identified include Blacks, Native
Americans, Hispanics, residents of some rural areas,
migrant workers, the handicapped, the homeless, the
institutionalized or homebound, and low-income
people. Objective setting should reflect the special
needs of these groups, according to witnesses.
Allukian says that children in inner-city Boston
have 55 percent more surfaces affected by tooth decay
than the national average and that Black children in
the United States have 2.5 times as many untreated
cavities as White children. He also reports that a
study of the homeless in Boston, in which the median
age was 33, found that 97 percent needed treatment;
18 percent had pain or infection at the time of
screening; 9 percent had suspicious soft tissue lesions;
and 28 percent had not been to a dentist for an
average of 14 years. (#435)
Newman says that although Native Americans on
reservations have dental coverage through the Indian
Health Service, oral health care is not always available
locally. As a result, many Native Americans suffer
from poor oral health. She describes the needs in
rural Washington State where she works.
The Indian Health Service in this area needs to
refocus their attention on education, preventive
therapies, and doing outreach to those Native
Americans who are not receiving care. I see
that a large number of Indian children are not
receiving the oral health care that they need. I
hear constant complaints of toothaches from
school children. It is not uncommon to see
rampant decay in these children. (~163)
The barriers to access faced by these groups
typically involve the availability of providers, sociocul-
tural issues, and cost. Brown describes the problem
in San Antonio.
Oral Health 193
OCR for page 194
Effective oral disease prevention measures and
oral health promotion activities are not reaching
the community, especially those groups most at
risk. Resources are disparate, often difficult to
locate, duplicated, of poor quality in some
instances and absent in others. Often ethnic,
cultural, educational, and language diversity of
communities is not sufficiently taken into
account. Existing networks such as well baby
clinics, WIC [Special Supplemental Food Pro-
gram for Women, Infants and Children] prog-
rams, school systems, workplace health
programs, health care facilities for the homeless,
migrant health workers, community health
centers, nutrition centers, retirement centers,
and nursing homes need to be utilized to pro-
mote oral health and prevent oral disease by
scientifically-based effective measures. (#029J
IMPLEMENTATION
The need for more and better data about oral health
is intertwined throughout much of the testimony,
especially as it relates to underserved populations.
(#062; #106; #109) For example, Butcher states that
because certain ethnic and socioeconomic groups have
higher decayed, missing, or filled surfaces scores than
the population as a whole, "such groups should be
over-sampled to reflect more precisely the degree of
difference." (#242J The American Association of
Public Health Dentistry emphasizes the need to devel-
op baseline data for each objective, so that progress
can be measured throughout the decade. neater data
collection," it states, "can more comprehensively
describe other aspects or dimensions of the objective"
but is "no substitute for the understanding provided
by baseline data." (#156)
Witnesses pointed out that health professionals,
including dentists, hygienists, and even physicians,
could play an expanded role in delivering preventive
services to underserved populations. Hygienists can
be especially useful in reaching the elderly, according
to Betty Waedemon of the American Dental Hygien-
ists' Association. (#306)
Waedemon says that hygienists could provide im-
portant preventive services in nursing homes. Many
nursing homes cannot afford to have a dentist on
staff, and the residents' dental needs are neglected,
according to witnesses. Waedemon says that hygien-
ists would be less expensive than dentists; therefore,
institutions may be able to afford to have one on staff
full- or part-time. (~306)
194 Healthy People 2000: Citizens Chart the Course
More dentists also should be trained in geriatric
dentistry, according to the ASGD, which explains that
dentists should have an understanding of normal and
pathological aging, communication skills, and other
specialized areas to treat the elderly effectively. Very
few programs in the United States offer such training;
thus, specific targets in this area are proposed for the
year 2000. (#062; #306)
Several dental hygienists mentioned their role in
bringing preventive services to groups such as the
handicapped or those living in remote areas where
dental services are unavailable, but said that restric-
tions on their practice can limit those opportunities.
States may restrict them to working under either
direct or general supervision of a dentist. In Wash-
ington State, for example, hygienists can work under
the general supervision of a dentist in institutions, but
they must have direct supervision in homes or private
practice, according to testimony. Hygienists such as
Newman say that these restrictions should be relaxed.
(#163J
Physicians and other health providers also can play
an important role in encouraging good dental health
and identifying oral cancers or other conditions,
according to testimony. They should be prepared for
that role and encouraged to become involved in oral
disease prevention. (#154)
Mobile dental units can help bring preventive
services to those who are hard to reach. The ASGD
reports that mobile units operating out of dental
schools can be effective in long-term care institutions
if they are designed properly. (~062J Other wit-
nesses note their value in remote areas and for
populations that are unable or unlikely to come to a
clinic. (~041)
Several testifiers note that one approach to provid-
ing preventive dental services to underserved children
is expanding school-based programs. Brown proposes
that by the year 2000, at least 50 percent of school
children be participating in school-based comprehen-
sive health programs. He says that these should
include fluoride and dental sealant programs, assess-
ments and referral systems, comprehensive oral health
education, and mouthguard programs. (#029)
Financial barriers to obtaining preventive dental
services also were discussed. Many witnesses said that
Medicare and Medicaid, as well as private insurers,
should cover comprehensive preventive dental services.
Several witnesses called for including dental services
in more employee benefit packages. Weintraub pro-
poses that by the year 2000, 75 percent of employed
adults have dental insurance. In 1985, 58 percent of
OCR for page 195
- - - ~
the employed population was covered to some extent.
according to testimony.7 (~391)
REFERENCES
1. National Center for Health Statistics: Health United States, 1989 (DHHS Publication No. [PHS] 90-1232),
2. Opinion Research Corporation: Dental care: What people know. Sulveying the Knowledge gaps. A study on
attitudes about dental health conducted by Opinion Research Corporation, 1983
3. U.S. Department of Health and Human Services: The 1990 Health Objectives for the Nation: A Midcourse
Review. Washington, D.C.: U.S. Government Printing Office, 1987
4. Balit HL, Btaun R. Ma~rniuk GH, et al.: Is periodontal disease the primary cause of tooth extraction in
adults? J Am Dent Assoc 114:40-45, 1987
5. Corbin SB, Kleinman DV, Lane JM: New opportunities for enhancing oral health: Moving toward the 1990
objectives for the nation. Public Health Rep 100~5~:515-524, 1985
6. Silverberg E, Lubera JA: Cancer statistics, 1989. CA Cancer J Clin 39~1~:3-20, 1989
7. National Institute for Dental Research: Oral Health of United States Adults. The National Sulvey of Oral
Health in U.S. Employed Adults and Seniors: 1985-1986. National Findings. (NIH Publication No. 87-2~),
August 1987
TESTIFIERS CITED IN CHAPTER 26
029 Brown, John; University of Texas Health Science Center at San Antonio
041 Swanson, Terri; Colorado Dental Hygienists' Association
062 Ettinger, Ronald; American Society for Geriatric Dentistry
106 Isman, Robert; The Association of State and Territorial Dental Directors
109 Johnsen, David; Case Western Reserve University
154 Moss, Stephen; American Academy of Pediatric Dentistry
156 Easley, Michael; American Association of Public Health Dentistry
163 Newman, Cyndi; Clallam County Department of Health (Washington)
197 Setton, Sarah; The Sugar Association
242 Butcher, Perter; American Dental Association
249 Davis, ~ Conan; Alabama Department of Public Health
262 Fleming, Lisa; Alabama Dental Hygienists' Association
306 Waedemon, Betty; American Dental Hygienists' Association
353 Middaugh, Dan; University of Washington
369 Truhe, Thomas; Princeton Dental Resource Center
391 Weintraub, Jane; University of Michigan
405 Myers, Jr., Woodrow; Indiana State Board of Health
435 Allukian Jr., Myron; Boston Department of Health and Hospitals
439 Moss, Stephen; New York University
445 Greenfield, William; New York University
705 Johnson, Dana; Colorado Dental Association
Oral Health 195
Representative terms from entire chapter:
dental health
