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 developed 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 individual’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 recognize 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 concluding sections of the chapter illustrate this variability by examining oral health at successive stages of the life span, from childhood to old age. The vulnerabilities of selected subpopulations within each age group are highlighted, with particular emphasis on the plight of poor children and many older Americans.
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HEALTH IN THE CONTEXT OF SOCIETY
Thinking about what makes people healthy has inspired philosophers and historians over the centuries. Following is a brief overview that points to commonalities among the models proposed.
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As early as the fifth century B.C., Hippocrates considered 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 environment, 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 1800s, was characterized by urbanization and industrialization that significantly contributed to suboptimal living conditions for workers. Sanitary reforms were the hallmarks of public health achievement during this period. In addition, 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 individuals. 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 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, sanitation, and living conditions to health were diminished. Doyal and Doyal (1984) point out that success depended on the maximal compliance of the patient.
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The fourth phase of public health, 1974 to the present, ushered in the modern era, referred to as “the new public health” (Ashton 1993). This phase developed 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 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 mortality from many diseases, including tuberculosis, whooping cough, measles, scarlet fever, diphtheria, and smallpox, had begun well before the development of specific vaccines and therapies. He concluded 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, challenged the medical establishment to test medical procedures, 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 questioned, 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 the Health Field Concept, emphasized that lifestyle and environment were of critical importance.
Lalonde defined four elements as determinants of health: human biology, lifestyle, environment, and the organization of health care. These elements were considered interdependent, and it was their dynamic interactions over the course of a lifetime that determined the level of health and well-being attained by an individual. As well, the elements and their interaction have implications for the level of health attained by larger aggregations of people—from neighborhoods to nations. Lalonde stated that most of society’s efforts to improve health, and the bulk of direct 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 the other three elements.
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 action, 4) developing personal skills, and 5) reorienting health services.
In a model proposed by Dahlgren and Whitehead (1995), the individual is surrounded by lifestyle factors, social and community influences, living and working conditions, and general socioeconomic, cultural, and environmental conditions (Figure 10.1). Green and Ottoson (1999) integrate the Lalonde 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).
Cohen and Gift (1995) acknowledge the role of multiple determinants and quote the medical historian, Henry Sigerist, who, in the mid-1940s, stated, “Health is promoted by providing a decent standard of living, good labor conditions, education, physical culture, means of rest, and recreation. The coordinated 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 matters of health must define norms and set standards” (Sigerist 1946).
McGoldrick (1997) provides an overview of several 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 condition were the primary predictors of compliance with oral hygiene instruction. Perceived benefits and experience were also important.
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 independence for older adults. Since then, national health goals have been established by the U.S. Department 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 conceptual framework, illustrated in Figure 10.3, features at the center determinants comparable to the 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 elements of human biology and health care organization, but the nation has also readily embraced the notion that lifestyles influence health. Physical fitness 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 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 community 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 development 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 populations live and behaviors occur. It includes the external environment and health care systems. The second 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 category 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 range from positive factors such as water fluoridation to negative factors such as lack of food policies to deal with frequent sugar and carbohydrate intake. They define general environmental factors as those that deal with the relative wealth of the society, general economic “climate,” and the political and societal norms that affect the delivery of oral health services.
Workplace 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 performances and levels of flexibility of work schedule. They found a highly statistically significant relationship 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, socioeconomic 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 poorest within a country, state, or neighborhood contributes 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 “disinvestment 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 benefit.” Results of other studies indicate that lower levels 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 attributes 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 communities 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 conditions. 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.
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CHANGING VULNERABILITIES THROUGHOUT LIFE
As all models of health determinants recognize, the health of individuals and of society at large is not static. Vulnerabilities and risks for diseases and disorders change over a lifetime and are affected by chance events as well as deliberate actions of individuals 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 vulnerable 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.
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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 promotion 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 substances of abuse and therapeutic agents that have teratogenic potential, and the elimination and control of microbial infections in the mother increase the likelihood 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, additional 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 limit the infant’s exposure to infections that contribute to oral diseases.
Throughout the first two decades of growth and development, children and young people are deeply influenced by the social and environmental opportunities and constraints imposed by families, communities, 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 teeth, firm gums, healthy soft tissues, well-functioning 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, children with disabilities, and children with HIV (Isman and Isman 1997).
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 problems, which may impose significant limitations on their ability to function effectively and require regular treatments for their conditions. Only the remaining 10 percent suffer from severe chronic conditions necessitating intensive health services (Edmunds and Coye 1998).
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 disease. 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 damaged teeth, and distraction from play and learning.
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 inadequate diet and hygiene and to family conditions and a social environment that do not support healthy lifestyles.
Some oral conditions, like other childhood illnesses, affect children randomly, regardless of social or economic status. Such conditions include cleft lip and palate and other craniofacial developmental disorders, malocclusion, and unintentional injuries. Other oral conditions in children such as mucosal lesions may be a sign of risk behaviors such as tobacco use. All oral conditions may be exacerbated in children with other special health care needs.
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, dental 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 disadvantaged 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 consequences of wearing down the stamina of children and defeating their ambitions.”
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 disease 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).
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 recommendation 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 emergency 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 oral health care providers to prevent common pediatric oral diseases.
Children with disabilities present unique problems and are at increased risk for oral infections, delays in tooth eruption, periodontal disease, enamel irregularities, and moderate-to-severe malocclusion (Isman and Isman 1997). Their exposure to certain medications and therapies, special diets, and their difficulty in maintaining daily hygiene further compromise their oral health (Casamassimo 1996). Also, access to professional care is a particular problem for these children (see Chapter 4). Guides for dental professionals 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 recognized 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 dental 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 (USDHHS 1992).
In the United States, most health insurance is provided through the workplace, and about 60 percent of children are covered by private health insurance through their parents’ plans (U.S. Bureau of the Census 1998a). A smaller percentage, about 31 percent, 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 Children’s Health Insurance Program (SCHIP) has expanded to cover over 25 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 SCHIP. 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 western Pennsylvania, the percentage of previously uninsured 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 publicly funded programs such as Medicaid have succeeded dramatically in providing 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 during a recent year-long study period, according to the U.S. Inspector General (USDHHS 1996). The study indicated that three fourths of states provided preventive 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 children who receive dental care get any services beyond a cleaning and fluoride treatment, despite their need for dental repair and fillings (Solomon 1998).
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; P.L. 90-284). Final regulations, effective in early 1972 (U.S. Bureau of the Census 1998a), ensure comprehensive dental services—prevention, diagnosis, 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 recipient”—and promise children access to dental services of sufficient “amount, duration, and scope” to ensure oral health. Federal law also requires provision 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 necessary dental service coverable under Medicaid to an EPSDT eligible child even if the service is not available to individuals age 21 and older under the Medicaid state plan. Despite these laws and regulations, inadequate funding, chronically poor payments to dentists, administrative burdens, and beneficiary utilization patterns have limited the effectiveness of this program (USDHHS 1996).
Increasingly, states are electing to purchase dental care for low-income populations through managed 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 1998b, 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 reported 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 percentage 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 inadequate payments to dentists among multiple barriers in Medicaid program administration. Barriers identified by the conference were categorized as financing and funding issues, Medicaid policies and administrative procedures, supply and distribution of providers, parental valuation of oral health, and lack of a systematic approach to identifying and promoting 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 dental care (Yudkowsky and Tang 1997), whereas nationally, the percentage of all child health expenditures 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 children. 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 levels they require for eligibility, all states must entitle child beneficiaries to comprehensive dental services under EPSDT. A review of 15 state oral health and dental access surveys (Tinanoff 1998) noted the following recurrent themes about Medicaid in relation to children’s oral health:
- States show similar dental care issues for Medicaid-enrolled children: high disease prevalence, low provider participation, and insufficient funding.
- Children at the highest risk of having dental caries are the least likely to have access to regular dental care.
- Barriers to provider participation include low reimbursement rates in a health care environment that has high overhead; perception of administrative 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.
- Lack of access to dental services for Medicaid recipients is perceived as the greatest pediatric health care problem in many states.
- Untreated dental problems get progressively worse and ultimately require more expensive interventions, 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 program will extend health insurance to at least 2.5 million 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 eligibility 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 specifically cited as one of 28 services that can be funded with SCHIP dollars. Although states are not required to provide dental coverage, congressional report language 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, recognizing 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) provide 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 SCHIP. States implementing SCHIP have expanded access to dental care services through a variety of mechanisms. Expanding coverage 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 opportunities 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 supervision 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).
Because growth and development is so predictable, it can be anticipated and guided through education and carefully timed interventions. Applied to oral health, “anticipatory guidance” allows parents, 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, socioenvironmental, and disease and treatment-related factors 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 childhood caries requires guidance to caregivers before the child’s teeth erupt to prevent or limit the transmission of microbial infections from mother to child and to promote appropriate feeding practices 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 safeguarding a house to prevent oral burns and injuries and to teach parents about the dangers of foreign objects in the mouths of toddlers and preschoolers. Anticipating 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 hygiene practices that prevent periodontal 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. Education regarding oral infections in mothers and caregivers can contribute to the infant’s or toddler’s general and oral health. Current investigations suggest that pathogenic 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 suppression. Most acquired dental and oral disease of childhood 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 (WIC), 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 encourage behaviors conducive to health and well-being, no matter their income. Communities that recognize children’s oral health as an important public good can provide resources and ensure services, ranging from sealant programs, school education, and fluoridation programs to candy-free aisles in grocery 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 excellent oral health to all children.
Health promotion covers a spectrum of efforts: anticipating problems, preventing them from occurring, 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.
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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 individuals 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 percent of current snuff users and 19.6 percent of current chewing tobacco users had tobacco-related oral lesions (Tomar et al. 1997). (See Box 10.2 on the effects of tobacco on oral health.) Adolescents become more mobile, traveling independently in cars, motorcycles, and other vehicles, where the use of safety belts and helmets is needed. Sexual practices begin during this time, further exposing individuals to infections that predispose them to general and oral health 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 practices 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 diseases, as defined by having 4 mm or more of attachment loss, are seen in about 3 percent of 18- to 24-year-olds, although it is in the adolescent years that early-onset periodontitis is first diagnosed. Young non-Hispanic blacks have twice the proportion of periodontal 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 individuals aged 18 to 34 years having no teeth (see Chapter 4).
These years also mark the period of life when intentional and unintentional injuries take their greatest toll. 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 environment 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.
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Adults between 35 and 65 have been aptly called “the sandwich generation”—caring simultaneously 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 complex. In many families, both spouses work and have moved from their birthplaces. Many others have divorced, remarried, moved again, lost or changed jobs, and experienced a variety of midlife crises. Adding to the 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. They may be single and faced with dealing with their own “passages” (Sheehy 1984).
The baby boomers will be the first U.S. generation to age while maintaining their natural dentition. They are the first to benefit from the caries preventive effect of widespread community water fluoridation and fluoride dentifrices. As a result, the baby boomers bring to the aging process higher expectations 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 important 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 benefits. Six of 10 full-time employees are offered dental benefits by their employers, according to a survey by the U.S. Bureau of Labor Statistics (www.e-dental.com/Virtual Community for the Dental Industry, 12/30/99). These data are from a 1997 survey 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 percent) than for blue-collar or service employees (56 percent). Among the estimated 22.6 million employees with employer-provided dental benefits, most employees (81 percent) receive their care from traditional fee-for-service plans; 11 percent, from preferred provider organizations; and 8 percent, from health maintenance organizations.
Ensuring the oral health of the middle-aged generation 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 community education programs about aging, estate and taxation issues, housing, and social policies and programs that support all individuals in their quest for self-sufficiency and individual responsibility.
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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 burden health care programs and organizations responsive 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 subpopulations of this age group, and many have unmet treatment needs. Even so, older Americans are retaining 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 especially root caries among the elderly, as well as periodontal diseases and inadequate or absent prostheses (Burt 1992). Oral and pharyngeal cancers are primarily diagnosed in older Americans.
For a closer look at the oral health of both institutionalized and homebound elderly, Dolan and Atchison (1993) compiled data based on a comprehensive 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 premedication are issues, as well as the fact that convenience 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 survey, 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 homebound 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 neglected service that should be offered to this population. 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 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 unacceptable 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, perceived 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 previously well maintained.
Data on the oral health status of hospice patients are scarce. Although not all hospice patients are elderly, 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 include oral moisturizers such as artificial saliva, ice chips, a water atomizer, daily oral-cleaning or swabbing, and, if needed, treatment for yeast to relieve oral pain.
Americans have the potential to experience a lifetime 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, including coronal and root caries, periodontal diseases, oral cancer, oral-facial pain, tooth loss, salivary gland dysfunction, and oral mucosal diseases:
- 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?
- Can these diseases be prevented or delayed? Which measures are most effective? Which have the greatest benefit for the least cost?
- Once a person has the disease, which treatments 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 outcomes, that is, how the overall effects of the treatment affect a person’s ability to function and be a productive, 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-threatening conditions as heart disease, stroke, cancer, osteoporosis, and diabetes. Yet the evidence presented 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 programs 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 care (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 dental 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 dental 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.
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 prescription and over-the-counter drugs (Chrischilles et al. 1992). Approximately 30 percent of all medications 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 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 xerostomia. Others include abnormal homeostasis, soft tissue lesions or reactions, taste changes, altered host resistance, gingival overgrowth, burning oral sensations, 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 facility, 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 earlier, 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 homebound 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 “gender gap” in physical disability widens with advancing age (U.S. Bureau of the Census 1990). Women 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 cognitive 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 treatment, and comply with postoperative instructions (Gift 1998).
Pharmacologic regimens common among women can promote xerostomia, thereby increasing the risk of caries, periodontal diseases, and atrophic/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, hemorrhage, neurotoxicity, and salivary gland dysfunction (McCarthy and Skillings 1992, National Institutes of Health Consensus Development Conference Statement: Oral Implications of Cancer Therapies 1990).
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ACHIEVING ORAL HEALTH THROUGHOUT LIFE
Each life stage brings a unique set of issues and considerations. Ultimately, this overview identifies the need for research on health services, health promotion, and disease prevention specific 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 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 disabilities 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 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-specific outcomes. The multiple oral-health-related objectives outlined there emphasize the importance of risk behaviors and co-morbidities 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 environment. 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 competency of care providers, and infrastructure to support 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 prevention and treatment.
Health care providers, program administrators, local, state, and government administrators, educators, scientists, and leaders, among others, have proposed ways of promoting health and preventing disease that respond to the principal health determinants 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 populations 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 adequately 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 recommendations to better address the health needs of vulnerable 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 General’s 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.
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- 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.
- 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.
- 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.
- Preventive interventions, such as protective head and mouth gear and dental sealants, exist but are not uniformly used or reinforced.
- 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.
- Anticipatory guidance and risk assessment and management facilitate care for children and for the elderly.
- Federal and state assistance programs for selected oral health services exist; however, the scope of services is severely limited, and their reimbursement level for oral health services is low compared to the usual fee for care.
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Abegg C, Marcenes W, Croucher R, Sheiham A. The relationship between tooth cleaning behaviour and flexibility of working time schedule. J Clin Periodontol 1999;26:448-52.
Acs G, Lodolini G, Kaminsky S, Cisneros GJ. Effect of nursing caries on body weight in a pediatric population. Pediatr Dent 1992;14:302-5.
Acs G, Shulman R, Ng MW, Chussid S. The effect of dental rehabilitation on the body weight of children with early childhood caries. Pediatr Dent 1999;21(2):109-13.
Adams PF, Marano MA. Current estimate from the National Health Interview Survey, 1994. National Center for Health Statistics; 1995. Vital Health Stat 10 (193).
Ajzen I, Fishbein M. Attitude-behavior relations: a theoretical analysis and review of empirical research. Psychol Bull 1977;84:888-918.
Ajzen I, Fishbein M. Understanding attitudes and predicting social behavior. Englewood Cliffs (NJ): Prentice-Hall; 1980.
Aldred MJ, Addy M, Bagg J, Finlay I. Oral health in the terminally ill: a cross sectional pilot survey. Spec Care Dentist 1991;11(2):59-62.
American Academy of Pediatric Dentistry (AAPD). Infant oral health care guidelines. Pediatr Dent 1997; 1970.
American Academy of Pediatrics (AAP). An analysis of the costs to provide health care coverage to the children and adolescent population aged 0 to 21 years. Elk Grove Village (IL): American Academy of Pediatrics; 1998.
American Dental Association (ADA). Dental practice survey. Your child’s teeth. Chicago: American Dental Association; 1997.
American Dental Association (ADA), Edelstein BL. Oral health services in the Child Health Insurance Program, Children’s Dental Health Project Washington DC and the American Dental Association Task Force on CHIP resource packet. Chicago: American Dental Association; 1998a.
American Dental Association (ADA), Survey Center. Survey of state dental programs in Medicaid. Chicago: American Dental Association; 1998b.
Andersen R. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav 1995;36:1-10.
Andersen R, Davies JK, Kickbush I, et al. Health behavior research and health promotion. Oxford: Oxford Medical Publications; 1988.
Andersen R, Marcus M, Mahshigan M. A comparative systems perspective on oral health promotion and disease prevention. In: Cohen LK, Gift HC, editors. Disease prevention and oral health promotion: socio-dental sciences in action. Copenhagen: Munksgaard; 1995. p. 307-40.
Antonovsky A. Health, stress and coping. San Francisco: Jossey-Bass; 1979a.
Antonovsky A. The sense of coherence as a determinant of health. In: Matarazzo JD, Weiss SM, Herd JA, et al., editors. Behavioral health. A handbook of health enhancement and disease prevention. New York: John Wiley and Sons; 1979b. p. 114-29.
Ashton J. Institutes of public health and medical schools: grasping defeat from the jaws of victory? J Epidemiol Community Health 1993;47:165-8.
Atkinson JC, Fox PC. Salivary gland dysfunction. Clin Geriatr Med 1992 Aug 8(3):499-511.
Ayhan H, Suskan E, Yildirim S. The effect of nursing or rampant caries on height, body weight and head circumference. J Clin Pediatr Dent 1996;20:209-12.
Bailit H, Newhouse J, Brook R, Duan N, Goldberg G, Hanley J, Kamberg C, Spolsky V, Black A, Lohr K. Does more generous dental insurance coverage improve oral health? J Am Dent Assoc 1985;110(5):701-7.
Baker HA, Levy SM, Chrischilles EA. Medications with dental significance; usage in a nursing home population. Spec Care Dentist 1991;11:19-25.
Bandura A. Principles of behaviour modification. New York: Holt, Rinehart and Winston; 1969.
Bandura A. Social learning theory. London: Prentice Hall; 1977.
Bandura A. Self-efficacy mechanism in human agency. Am Psychol 1982;37:122-47.
Becker MH, Maiman LA. Sociobehavioral determinants of compliance with health and medical care recommendations. Med Care 1975;13:10-24.
Becker MH, Drachman RH, Kirscht JP. A new approach to explaining sick-role behavior in low-income populations. Am J Public Health 1974 Mar;64(3):205-16.
Bloom B, Gift HC, Jack SS. Dental service and oral health, United States, 1989. Vital Health Stat 1992;10:1-95.
Burt BA. Epidemiology of dental diseases in the elderly. Clin Geriatr Med 1992 Aug;8(3):447-59.
Casamassimo P. Bright futures in practice: oral health. Arlington (VA): National Center for Education in Maternal and Child Health; 1996.
Chapman PJ, Shar RM. Normative dental treatment needs of Alzheimer patients. Austr Dent J 1991;36(2):141-4.
Chrischilles EA, Foley DJ, Wallace RB, Lemke JH, Semla TP, Hanlon JT, Glynn RJ, Ostfeld AM, Guralnik JM. Use of medications by persons 65 and over: data from the established populations for epidemiologic studies of the elderly. J Gerontol A Biol Sci Med Sci 1992;47(5):M137-44.
Cochrane AL. Effectiveness and efficiency; random reflections on health services. London: Nuffield Provincial Hospital Trust; 1971.
Cohen LK, Gift HC. Introduction. In: Cohen LK, Gift HC. Disease prevention and oral health promotion: socio-dental sciences in action. Copenhagen: Munksgaard; 1995. p. 17-31.
Dahlgren G, Whitehead M. Tackling inequalities: a review of policy initiatives. In: Benzeval M, Judge K, Whitehead M, editors. Tackling inequality in health: an agenda for action. London: Kings Fund Institute; 1995.
Dey AN. Characteristics of elderly home health care users: data from the 1994 National Home and Hospice Care Survey. Advance data from vital and health statistics. Hyattsville (MD): National Center for Health Statistics; 1996. Abstract no. 279.
Dey AN. Characteristics of elderly nursing home residents: data from the 1995 National Nursing Home Survey. Advance data from vital and health statistics. Hyattsville (MD): National Center for Health Statistics; 1997. Abstract no. 289.
Dolan TA, Atchison KA. Implications of access, utilization and need for oral health care by the non-institutionalized and institutionalized elderly on the dental delivery system. J Dent Educ 1993 Dec;57(12):876-87.
Douglass CW, Ostry L, Shih A. Denture usage in the United States: a 25 year prediction. J Dent Res 1998;77(SI A):209. Abstract no. 829.
Douglass J, Wei Y, Zhang BX, Tinanoff N. Dental caries in preschool Beijing and Connecticut children as described by a new caries analysis model. Community Dent Oral Epidemiol 1994;22:94-9.
Doyal L, Doyal L. Western scientific medicine: a philosophical and political prognosis. In: Birke L, Silvertown J, editors. More than the parts: biology and politics. London: Pluto Press; 1984. p. 82-109.
Dubos R. Mirage of health. New York: Harper Colophan; 1979.
Dubos RJ. The world of Rene Dubos: a collection of his writings. In: Piel G, Segerber O, editors. New York: Henry Holt and Company; 1990.
Duperon DF. Early childhood caries: a continuing dilemma. J Calif Dent Assoc 1995;23(2):15-25.
Edelstein BL, Douglass CW. Dispelling the myth that 50 percent of U.S. schoolchildren have never had a cavity. Public Health Rep 1995;110:522-30.
Edmunds M, Coye MJ, editors. America’s children: health insurance and access to care. Committee on Children, Health Insurance and Access to Care, Division of Health Care Services, Institute of Medicine. Washington: National Academy Press; 1998.
Ettinger R, Beck J. The new elderly: what the dental profession can expect. Spec Care Dentist 1982;2:62-9.
Field MJ, Lawrence RL, Zwanzier L, editors. Extending Medicare coverage for preventive and other services. Committee on Medicare Coverage Extensions, Institute of Medicine. Washington: National Academy Press; 1999.
Gift HC. Oral health outcomes research—challenges and opportunities. In: Slade GD, editor. Measuring oral health and quality of life. Chapel Hill: University of North Carolina Department of Dental Ecology; 1997.
Gift HC. Issues of aging and oral health promotion. Gerodontics 1998 Oct;4(5):194-206.
Gochman DS. Health behavior: emerging research perspectives. New York: Plenum Press; 1988.
Gordon SR. Survey of dental need among veterans with severe cognitive impairment. Gerodontics 1988;4:158-9.
Green LW, Ottoson JM. Community and population health. 8th ed. Boston: McGraw-Hill; 1999.
Green L, Kreuter MW, Deeds SG, Partridge KB. Health education planning. A diagnostic approach. Mountain View (CA): Mayfield Publishing Company; 1980.
Green M, editor. Bright futures: guidelines for health supervision of infants, children, and adolescents. Arlington (VA): National Center for Education in Maternal and Child Health; 1994.
Grindefjord M, Dahllof G, Nilsson B, Modeer T. Prediction of dental caries development in 1-year-old children. Caries Res 1995;29:343-8.
Guiden M. Dental health for kids moves to the forefront. State health notes 19(280). Forum for State Health Policy Leadership, National Conference of State Legislatures; 1998 Jul 6.
Gurwitz JH, Soumerai SB, Avorn J. Improving medication prescribing and utilization in the nursing home. J Am Geriatr Soc 1990;38:542-52.
Haupt BJ. Characteristics of patients receiving hospice care services: United States, 1994. Advance data from vital and health statistics. Hyattsville (MD): National Center for Health Statistics; 1997. Abstract no. 282.
Isman R, Isman B. Access to oral health services in the U.S. 1997 and beyond. Chicago: Oral Health America; 1997.
Jones JA, Adelson RA, Niessen LC, Gilbert GH. Issues in financing dental care for the elderly. J Public Health Dent 1990;50:268-75.
Jones JA, Lavallee N, Alman J, Sinclair C, Garcia RI. Caries incidence in patients with dementia. Gerodontology 1993;10(2):76-82.
Karasek R, Theorell T. Healthy work: stress, productivity, and the reconstruction of working life. New York: Basic Books; 1990.
Kawachi I, Kennedy BP, Lochner K, Prothrow-Stith D. Social capital, income inequality, and mortality. Am J Public Health 1997 Sep;87(9):1491-8.
Kennedy BP, Kawachi I, Prothrow-Stith D. Income distribution and mortality: cross-sectional ecological study of the Robin Hood index in the United States. BMJ 1996 Apr 20;312(7037):1004-7.
Kiyak HA, Grayston MN, Crinean CL. Oral health problems and needs of nursing home residents. Community Dent Oral Epidemiol 1993;12:49-52.
Kohler B, Andreen I, Jonsson B. The effect of caries-preventive measures in mothers on dental caries and the oral presence of the bacteria Streptococcus mutans and lactobacilli in their children. Arch Oral Biol 1984;29:879-83.
Kohler B, Andreen I, Jonsson B. The earlier the colonization by mutans streptococci, the higher the caries prevalence at four years of age. Oral Microbiol Immunol 1988;3:14-7.
Kozol J. Savage inequalities: children in America’s schools. New York: Crown Publishers, Inc.; 1991.
Kuhner MK, Raetzke PB. The effect of health beliefs on the compliance of periodontal patients with oral hygiene instructions. J Periodontol 1989;60:51-6.
Lalonde M. A new perspective on the health of Canadians. Ottawa: Health and Welfare Canada; 1974.
Lamy PP. Pharmacotherapeutics in the elderly. Md Med J 1989;38:144-8.
Lave JR, Keene CR, Chyongchious JL, Ricci EM, Amersbach G, LaVallee CP. Impact of a children’s health insurance program on newly enrolled children. JAMA 1998;279(22):1820-5.
Levy SM, Baker HA, Semla TP, Kohout FJ. Use of medication with dental significance by a noninstitutionalized elderly population. Gerodontics 1988;14:119-25.
Lewin K. Group decision and social change. In: Newcomb T, Hartley E. Readings in social psychology. New York: Holt; 1947. p. 197-211.
Lewin K. Field theory in social science. New York: Harper; 1951.
Lewis IK, Hanlon JT, Hobbins MJ, Beck JD. Use of medications with potential oral adverse drug reaction in community-dwelling elderly. Spec Care Dentist 1993;13(4):171-6.
Lewit EM, Monheit AC. Expenditures on health care for children and pregnant women. U.S. health care for children. Future Child 1992;2(2):95-114.
Li Y, Caufield PW. The fidelity of initial acquisition of mutans streptococci by infants from their mothers. J Dent Res 1995;74:681-5.
Litt MD, Reisine S, Tinanoff N. Multidimensional causal model of dental caries development in low income preschool children. Public Health Rep 1995;110:605-17.
Marmot M, Theorell T. Social class and cardiovascular disease: the contribution of work. Int J Health Serv 1988;18:659-74.
Marmot MG, Shipley MJ, Rose G. Inequalities in death: specific explanations of a general pattern. Lancet 1984;1:1003-6.
McCarthy GM, Skillings JR. Orofacial complications of chemotherapy for breast cancer. Oral Sugr Oral Med Oral Pathol 1992 Aug;74(2):172-8.
McGoldrick PM. Principles of health behaviour and health education. In: Pine CM, editor. Community oral health. Oxford: Reed Educational & Professional Publishing Ltd.; 1997. p. 188-205.
McIntyre RT, Jackson M, Shosenburg JW. Dental health status and treatment needs of institutionalized seniors. Ont Dent 1986;63:12-4,18-23.
McKeown T. The modern rise of population. London: E Arnold; 1976.
McKeown T. The role of medicine: dream, mirage or nemesis. Oxford: Basil Blackwell Publisher Ltd.; 1979. p. 1-207.
Milgrom P, Weinstein P. Early childhood caries. A team approach to prevention and treatment. Seattle: University of Washington; 1999. p. 148.
Milgrom P, Hujoel P, Grembowski D, Fong R. A community strategy for Medicaid child dental services. Public Health Rep 1999;114:528-32.
Monheit AC, Cunningham PJ. Children without health insurance. Future Child 1992;2:154-70.
Murtaugh C, Kemper P, Spillman B. The risk of nursing home use in later life. Med Care 1990;28(10):952-62.
National Association of Dental Plans (NADP). 1998 Dental HMO/PPO industry profile. Dallas (TX): National Association of Dental Plans; 1998. Available from: http://www.nadp.org/page.asp%7ElngSectionID%7E0.
National Center for Health Statistics (NCHS). Vital and Health Statistics, health United States, 1990. Hyattsville (MD): Public Health Service; 1991.
National Center for Health Statistics (NCHS). Current estimates from the National Health Interview Survey 1996. Series 10, No. 200. Hyattsville (MD): Public Health Service; 1996.
National Institute on Aging. Aging in the United States—past, present, and future. Washington: National Institute on Aging; 1997.
National Policy and Resource Center on Nutrition and Aging. Oral health and older adults: community issues. Washington: National Policy and Resource Center on Nutrition and Aging; 1998.
Newacheck PW, Stoddard JJ, Hughes DC, Pearl M. Children’s access to health care: the role of social and economic factors. In: Stein RE, editor. Health care for children: what’s right, what’s wrong, what’s next. New York: United Hospital Fund; 1997.
Newacheck PW, Hughes DC, Hung YY, Wong S, Stoddard JJ. The unmet health needs of America’s children. Pediatrics 2000 Apr;105(4 Pt 2):989-97.
Niessen LC. Extending dental insurance through retirement. Spec Care Dentist 1984;4:84-6.
Niessen LC, Jones JA. Oral health and aging: dental implications of a grayer America. J Calif Dent Assoc 1991 Aug;19(8):29-38.
Nowak AJ. Rationale for the timing of the first oral evaluation. Pediatr Dent 1997;19:8-11.
Nowak AJ, Casamassimo PS. Using anticipatory guidance to provide early dental intervention. J Am Dent Assoc 1995 Aug;126(8):1156-63.
Pender NS. Health promotion in nursing practice. 2nd ed. East Norwalk (CT): Appelton and Lange; 1987.
Pine CM. Introduction, principles and practice of public health. In: Pine CM, editor. Community oral health. Oxford: Reed Educational and Professional Publishing, Ltd.; 1997. p. 1-10.
Porter R. The greatest benefit to mankind: a medical history of humanity. London: Harper Collins Publishers; 1997. p. 1-764.
Redford M. Beyond pregnancy gingivitis: bringing a new focus to women’s oral health. J Dent Educ 1993;57:742-8.
Reforming States Group and Milbank Memorial Fund. Pediatric dental care in CHIP and Medicaid: paying for what kids need, getting value for state payments. New York: Reforming States Group, Milbank Memorial Fund Publishing; 1999. p. 23.
Rose G. Strategy of preventive medicine. Oxford: Oxford University Press; 1993. p. 7-62.
Rosenstock IM. Why people use health services. Milbank Memorial Fund Q 1966;44:94-127.
Rosenstock IM. The health belief model and preventive behavior. Health Education Mongraphs 1974;2:354-86.
Rotter JB. Social learning and clinical psychology. New York: Prentice Hall; 1954.
Sanders L. Sandwich generation: one family tries to ease the bite. [homepage on the Internet]. New York: McGraw-Hill Companies, Inc. Available from: http://www.businessweek.com [cited 1997 Jul 11].
Schifter DE, Ajzen I. Intention, perceived control and weight loss: an application of the theory of planned behavior. J Pers Soc Psychol 1985;49:843-51.
Sheehy G. Passages. New York: Bantam; 1984.
Sheller B, Williams BJ, Lombardi SM. Diagnosis and treatment of dental caries-related emergencies in a children’s hospital. Pediatr Dent 1997;19:470-5.
Sigerist HE. The university at the crossroads: addresses and essays. New York: Henry Schuman; 1946. p. 127.
Simpson G, Bloom B, Cohen RA, Parsons PE. Access to health care. Part I: Vital Health Stat 1997;197:1-47.
Solomon LS. Rules of the game: how public policy affects local health care markets. Health Aff (Millwood) 1998 Jul-Aug;17(4):140-8.
Spizak S, Holt K, editors. Building partnerships to improve children’s access to Medicaid oral health services: national conference proceedings. Arlington (VA): National Center for Education in Maternal and Child Health; 1999.
Stern PN. Variation on the sandwich generation. Health Care Wom Int 1994;15(1):v-vi.
Syme SL. To prevent disease: the need for a new approach. In: Blane D, Brunner E, Wilkinson R, editors. Health and social organization: towards a health policy for the twenty-first century. New York: Routledge; 1996. p. 21-31.
Tanzer JM. Dental caries is a transmissible infectious disease: the Keyes and Fitzgerald revolution. J Dent Res 1995;74:1536-42.
Tinanoff N. State surveys of oral health needs and dental care access for children, summary of 15 state reports. Children’s Dental Health Project. Washington: American Association of Dental Schools; 1998.
Tomar SL, Winn DM, Swango GA, Giovino GA, Kleinman DV. Smokeless tobacco lesions among adolescents in the United States. J Dent Res 1997;76(6):1277-86.
Tones K. Devising strategies for preventing drug misuse: the role of the health action model. Health Educ Res 1987;2:305-17.
Tones K, Tilford S, Robinson YK. Health education: effectiveness and efficiency. London: Chapman and Hall; 1990.
Triandis HC. Values, attitudes and interpersonal behavior. In: Page MM, editor. Nebraska symposium on motivation; beliefs, attitudes and values. Lincoln: University of Nebraska Press; 1979. p. 195-259.
University of Southern California (USC) University Affiliated Program, Childrens Hospital Los Angeles. Planning guide for dental professionals serving children with special health care needs [draft]. 1999 Sep.
U.S. Bureau of the Census. Current population reports, special studies. The need for personal assistance with everyday activities: recipients and caregivers. Washington: U.S. Department of Commerce; 1990. p. 70-19.
U.S. Bureau of the Census. Department of Labor code of federal regulations, 42 EBRI. Washington: U.S. Department of Commerce; 1998a.
U.S. Bureau of the Census. Washington: U.S. Department of Commerce; 1998b Jan 20.
U.S. Department of Health and Human Services (USDHHS). In: Abdellah EG, Moore SR, editors. Surgeon General’s workshop on health promotion and aging. Proceedings 1988. Washington: U.S. Department of Health and Human Services; 1988. p. 109.
U.S. Department of Health and Human Services (USDHHS). Equity and access for mothers and children: strategies from the Public Health Service workshop on oral health of mothers and children. Washington: U.S. Department of Health and Human Services, Public Health Service, Health Resources and Services Administration, Maternal and Child Health Bureau; 1989. DHHS Pub. no. HRS-MCH-90-4.
U.S. Department of Health and Human Services (USDHHS), Public Health Service (PHS). Current estimates from the national health interview survey, 1991. Series 10, no. 184. Hyattsville (MD): U.S. Department of Health and Human Services; 1992 Dec. p. 82, 83, 106. DHHS Pub no. PHS 93-1512.
U.S. Department of Health and Human Services (USDHHS). Office of Inspector General. Children’s dental services under Medicaid—access and utilization. San Francisco: Office of Evaluation and Inspections; 1996 Apr. OEI-09-93-00240.
U.S. Department of Health and Human Services (USDHHS). Healthy People 2000 review 1997. Hyattsville (MD): National Center for Health Statistics; 1997.
U.S. Department of Health and Human Services (USDHHS). Healthy People 2010 (conference edition, in two volumes). Washington: U.S. Department of Health and Human Services; 2000 Jan.
Unkel JH, McKibben DH, Fenton SJ, Nazif MM, Mouri A, Schuit K. Comparison of odontogenic and non-odontogenic facial cellulitis in a pediatric hospital population. 1997 USDHHS. Pediatr Dent 1989;19:476-9.
Vargas CM, Crall JJ, Schneider DA. Sociodemographic distribution of pediatric dental caries. NHANES III 1988-1994. Hyattsville (MD): National Center for Health Statistics; 1998.
Vargas CM, Isman RE, Crall JJ. Comparison of children’s medical and dental insurance coverage by socioeconomic characteristics, U.S. 1995. Submitted for publication, 2000.
Verbugge LM. A health profile for older women with comparisons to older men. Res Aging 1984;6(3).
Verbugge LM. Pathways of health and death. In: Apple RD, editor. Women, health, and medicine in America. A historical handbook. New York: Garland Publishing Inc.; 1990.
Waldman HB. Mid-1990’s profile of U.S. children and the conditions in which they live. J Dent Child 1996 Jul-Aug;63(4)285-90.
Waldman HB. More children are unable to get dental care than any other single health service. J Dent Child 1998 May-June;65(3):204-8.
Warner KL. The rewards of the sandwich generation. J Pract Nurs 1995;45(4):16-20.
Warren RC. Oral health for all: policy for available, accessible, and acceptable care. Washington: Center for Policy Alternatives; 1999.
Wilson S, Smith GA, Preish J, Casamassimo PS. Nontraumatic dental emergencies in a pediatric emergency department. Clin Pediatr 1997;36:333-7.
World Health Organization (WHO). Ottawa charter for health promotion. Geneva: World Health Organization; 1986.
Yudkowsky BK, Tang SFS. Medicaid state reports—FY 1995. Elk Grove Village (IL): American Academy of Pediatrics; 1997.
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