The intent of this first-ever Surgeon General’s report on oral health is to alert Americans to the full meaning of oral health and its importance in relation to general health and well-being. Great progress has been made in reducing the extent and severity of common oral diseases, and recent history has seen marked improvements in the nation’s oral and dental health, thanks to successful prevention measures adopted by communities, individuals, and oral health professionals. However, not everyone is experiencing the same degree of improvement. What amounts to a “a silent epidemic” of dental and oral diseases is affecting some population groups—a burden of disease that restricts activities in school, work, and home, and often significantly diminishes the quality of life.
The word oral, both in its Latin root and in common usage, refers to the mouth. The mouth includes not only the teeth and the gums (gingiva) and their supporting connective tissues, ligaments, and bone, but also the hard and soft palate, the soft mucosal tissue lining of the mouth and throat, the tongue, the lips, the salivary glands, the chewing muscles, and the upper and lower jaws, which are connected to the skull by the temporomandibular joints. Equally important are the branches of the nervous, immune, and vascular systems that animate, protect, and nourish the oral tissues, as well as provide the connections to the brain and the rest of the body. The genetic patterning of development in utero further reveals the intimate relationship of the oral tissues to the developing brain and to the tissues of the face and head that surround the mouth, structures whose location is captured in the word craniofacial.
A major theme of this report is that oral health means much more than healthy teeth. It means being free of chronic oral-facial pain conditions, oral and pharyngeal (throat) cancers, oral soft tissue lesions, birth defects such as cleft lip and palate, and scores of other diseases and disorders that affect the oral, dental, and craniofacial tissues, collectively known as the craniofacial complex. These are tissues whose functions we often take for granted, yet they represent the very essence of our humanity. They allow us to speak and smile; sigh and kiss; smell, taste, touch, chew, and swallow; cry out in pain; and convey a world of feelings and emotions through facial expressions. They also provide protection against microbial infections and environmental insults.
The craniofacial tissues also provide a useful means to understanding organs and systems in less accessible parts of the body. The salivary glands are a model of other exocrine glands, and an analysis of saliva can provide telltale clues of overall health or disease. The jawbones are examples of other skeletal parts. The nervous system apparatus underlying facial pain has its counterpart in nerves elsewhere in the body.
A thorough oral examination can detect signs of nutritional deficiencies as well as a number of systemic diseases, including microbial infections, immune disorders, injuries, and some cancers. Indeed, the phrase the mouth is a mirror has been used to illustrate the wealth of information that can be derived from examining oral tissues.
New research is pointing to associations between chronic oral infections and heart and lung diseases, stroke, and low-birth-weight, premature births. Associations between periodontal disease and diabetes have long been noted. This report assesses these associations and explores mechanisms that might explain these oral-systemic disease connections.
In parallel with the broadened meaning of oral health, the meaning of health has evolved. The standard definition of health, “freedom from disease, defect, or pain,” defines what health is not, rather than what it is. A more positive definition, one that the World Health Organization established in 1948, states that health is a complete state of physical, mental, and social well-being, and not just the absence of infirmity.
The broadened meaning of oral health parallels the broadened meaning of health. In 1948 the World Health Organization expanded the definition of health to mean “a complete state of physical, mental, and social well-being, and not just the absence of infirmity.” It follows that oral health must also include well-being. Just as we now understand that nature and nurture are inextricably linked, and mind and body are both expressions of our human biology, so, too, we must recognize that oral health and general health are inseparable. We ignore signs and symptoms of oral disease and dysfunction to our detriment. Consequently, a second theme of the report is that oral health is integral to general health. You cannot be healthy without oral health. Oral health and general health should not be interpreted as separate entities. Oral health is a critical component of health and must be included in the provision of health care and the design of community programs.
The wider meanings of oral and health in no way diminish the relevance and importance of the two leading dental diseases, caries (tooth decay) and the periodontal diseases. They remain common and widespread, affecting nearly everyone at some point in the life span. What has changed is what we can do about them.
At the start of the twentieth century, most Americans expected to be toothless by age 45, and most were. Expectations have changed, and most people now assume that they will maintain their teeth over their lifetime, and take active measures to do so. Researchers in the 1930s discovered that people living in communities with naturally fluoridated water supplies had less dental caries than people drinking unfluoridated water. But not until the end of World War II were the investigators able to design and implement the community clinical trials that confirmed their observations and launched a better approach to the problem of dental caries: prevention. Soon after, adjusting the fluoride content of community water supplies was pursued as an important public health measure to prevent dental caries.
Although this measure has not been fully implemented, the results have been dramatic. Dental caries began to decline in the 1950s among children who grew up in fluoridated cities, and by the late 1970s, declines in decay were evident for many Americans. The application of oral science to improved diagnostic, treatment, and prevention strategies has saved billions of dollars per year in the nation’s annual health bill. Even more significant, the result is that far fewer people are edentulous (toothless) today than a generation ago.
The theme of prevention gained momentum as pioneering investigators and practitioners in the 1950s and 1960s showed that not only dental caries but also periodontal diseases are bacterial infections. The researchers demonstrated that the infections could be prevented by increasing host resistance to disease and reducing or eliminating the suspected microbial pathogens in the oral cavity. The applications of research discoveries have resulted in continuing improvements in the oral health of Americans, new approaches to the prevention and treatment of dental diseases, and the growth of the science.
The significant role that scientists, dentists, dental hygienists, and other health professionals have played in the prevention of oral disease and disability leads to a third theme of this report: safe and effective disease prevention measures exist that everyone can adopt to improve oral health and prevent disease. These measures include daily oral hygiene procedures and other lifestyle behaviors, community programs such as community water fluoridation and tobacco cessation programs, and provider-based interventions such as the placement of dental sealants and examinations for common oral and pharyngeal cancers. It is hoped that this Surgeon General’s report will facilitate the maturing of the broad field of craniofacial research so that gains in the prevention of craniofacial diseases and disorders can be realized that are as impressive as those achieved for common dental diseases.
At the same time, more needs to be done to ensure that messages of health promotion and disease prevention are brought home to all Americans. In this regard, a fourth theme of the report is that general health risk factors, such as tobacco use and poor dietary practices, also affect oral and craniofacial health. The evidence for an association between tobacco use and oral diseases has been clearly delineated in almost every Surgeon General’s report on tobacco since 1964, and the oral effects of nutrition and diet are presented in the Surgeon General’s report on nutrition (1988). All the health professions can play a role in reducing the burden of disease in America by calling attention to these and other risk factors and suggesting appropriate actions.
Clearly, promoting health and preventing disease are concepts the American people have taken to heart. For the third decade the nation has developed a plan for the prevention of disease and the promotion of health, embodied in the U.S. Department of Health and Human Services (2000) document, Healthy People 2010. As a nation, we hope to eliminate disparities in health and prevent oral diseases, cancer, birth defects, AIDS and other devastating infections, mental illness and suicide, and the chronic diseases of aging. To live well into old age free of pain and infirmity, and with a high quality of life, is the American dream.
Scientists today take that dream seriously in pursuing the intricacies of the craniofacial complex. They are using an ever-growing array of sophisticated analytic tools and imaging systems to study normal function and diagnose disease. They are completing the mapping and sequencing of human, animal, microbial, and plant genomes, the better to understand the complexities of human development, aging, and pathological processes. They are growing cell lines, synthesizing molecules, and using a new generation of biomaterials to revolutionize tissue repair and regeneration. More than ever before, they are working in multidisciplinary teams to bring new knowledge and expertise to the goal of understanding complex human diseases and disorders.
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This Surgeon General’s report has much to say about the inequities and disparities that affect those least able to muster the resources to achieve optimal oral health. The barriers to oral health include lack of access to care, whether because of limited income or lack of insurance, transportation, or the flexibility to take time off from work to attend to personal or family needs for care. Individuals with disabilities and those with complex health problems may face additional barriers to care. Sometimes, too, the public, policymakers, and providers may consider oral health and the need for care to be less important than other health needs, pointing to the need to raise awareness and improve health literacy.
Even more costly to the individual and to society are the expenses associated with oral health problems that go beyond dental diseases. The nation’s yearly dental bill is expected to exceed $60 billion in 2000 (Health Care Financing Administration 2000). However, add to that expense the tens of billions of dollars in direct medical care and indirect costs of chronic craniofacial pain conditions such as temporomandibular disorders, trigeminal neuralgia, shingles, or burning mouth syndrome; the $100,000 minimum individual lifetime costs of treating craniofacial birth defects such as cleft lip and palate; the costs of oral and pharyngeal cancers; the costs of autoimmune diseases; and the costs associated with the unintentional and intentional injuries that so often affect the head and face. Then add the social and psychological consequences and costs. Damage to the craniofacial complex, whether from disease, disorder, or injury, strikes at our very identity. We see ourselves, and others see us, in terms of the face we present to the world. Diminish that image in any way and we risk the loss of self-esteem and well-being.
Many unanswered questions remain for scientists, practitioners, educators, policymakers, and the public. This report highlights the research challenges as well as pointing to emerging technologies that may facilitate finding solutions. Along with the quest for answers comes the challenge of applying what is already known in a society where there are social, political, economic, behavioral, and environmental barriers to health and well-being.
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The realization that oral health can have a significant impact on the overall health and well-being of the nation’s population led the Office of the Surgeon General, with the approval of the Secretary of Health and Human Services, to commission this report. Recognizing the gains that have been made in disease prevention while acknowledging that there are populations that suffer disproportionately from oral health problems, the Secretary asked that the report “define, describe, and evaluate the interaction between oral health and health and well-being [quality of life], through the life span in the context of changes in society.” Key elements to be addressed were the determinants of health and disease, with a primary focus on prevention and “producing health” rather than “restoring health”; a description of the burden of oral diseases and disorders in the nation; and the evidence for actions to improve oral health to be taken across the life span. The report also was to feature an orientation to the future, highlighting leading-edge technologies and research findings that can be brought to bear in improving the oral health of individuals and communities.
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THE SCIENCE BASE FOR THE REPORT
This report is based on a review of the published scientific literature. Where appropriate, standards established to determine the quality of the evidence, based on the study design and its rigor, were used. In addition, the strength of the recommendations, where they are made, is based on evidence of effectiveness for the population of interest. The scope of the review encompassed the international English literature. Recent systematic reviews of the literature are referenced, as are selected review articles. A few referenced articles are in press, and there are occasional references to recent abstracts and personal communications.
The science base in oral health has been evolving over the past half century. Initial research in this area was primarily in the basic sciences, investigating mechanisms of normal development and pathology in relation to dental caries and periodontal diseases. Prevention research has included controlled clinical studies, with and without randomization, as well as community trials and demonstration research. More recent research has broadened the science base to include studies of the range of craniofacial diseases and disorders and is moving from basic science to translational, clinical, and health services research.
The clinical literature in the oral health sciences includes the full range of studies, from randomized controlled studies to case studies. Most of the literature includes cross-sectional and cohort studies, with some case-control studies. General reviews of the literature have been used for Chapters 2 through 10. Chapter 4 includes both published and new analyses of national and state databases that have been carefully designed and for which quality assurance has been maintained by the Centers for Disease Control and Prevention. Studies of smaller populations are also included where relevant. In Chapters 5 and 7, evidence tables are presented for the discussion of the association of oral infections and systemic conditions and for oral disease prevention and health promotion measures, respectively. Experts in the respective fields contributed to the report, and independent expert peer review was conducted for all sections of the report. The published literature related to the development of new technologies, their potential impact, and the need for further research are described in the course of addressing the requested futures orientation.
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ORGANIZATION OF THE REPORT
The report centers on five major questions, which have been used to structure the report into five parts.
What Is Oral Health?
The meaning of oral health is discussed in the opening pages of this chapter, and the interdependence of oral health with general health and well-being is, as noted, a recurrent theme throughout the volume. Chapter 2 provides an overview of the craniofacial complex in development and aging, how the tissues and organs function in essential life processes, and their role in determining our uniquely human abilities. The later chapters elaborate further on the meaning of oral health. Of particular importance is the discussion of oral health in relation to well-being and quality of life described in Chapter 6.
What Is the Status of Oral Health in America?
Chapter 3 is a primer describing the major diseases and disorders that affect the craniofacial complex. Chapter 4 constitutes an oral health status report card on the noninstitutionalized civilian population of the United States, describing the magnitude of the problem. It is based on the most recent national and state data available for a range of craniofacial diseases, disorders, and conditions. In general, the national data provide information categorized by sex, age, income (poor versus nonpoor), and broad racial and ethnic categories. In addition, the chapter includes a profile of the oral and general health of selected population groups. These include racial and ethnic groups such as African Americans, Hispanics, Asians, Native Hawaiians and Other Pacific Islanders, and American Indians/Alaska Natives. The health status of women and individuals with disabilities is highlighted. Although it is clearly desirable to describe the health status of additional populations, data are insufficient or lacking for groups defined by sexual orientation or rural residency or categorized as homeless, migrant workers, or incarcerated. As an initial step toward understanding the burden of disease in relation to the provision of care, available data on the number of dental visits are provided.
What Is the Relationship Between Oral Health and General Health and Well-being?
Chapters 5 and 6 address key issues in the charge—the relationship of oral health to general health and well-being. Chapter 5 explores the theme of the mouth as a mirror that in some measure can reflect general health or disease status. Examples are given of how oral tissues may signal the presence of disease, disease progression, or risk factor exposure levels, and how oral cells and fluids are increasingly being used as diagnostic tools. This is followed by a discussion of the mouth as a portal of entry for infections that can affect local tissues and may spread to other parts of the body. The next section reviews the literature regarding emerging associations between oral diseases and disorders and diabetes, heart disease and stroke, and adverse pregnancy outcomes.
Chapter 6 demonstrates the relationship between oral health and quality of life, presenting data on the consequences of poor oral health and altered appearance on speech, eating, and other functions, as well as on self-esteem, social interaction, education, career achievement, and emotional state. Anthropological and ethnographic literature is introduced to underscore the cultural values and symbolism attached to facial appearance and teeth.
How Is Oral Health Promoted and Maintained and How Are Oral Diseases Prevented?
The next three chapters review how individuals, health care practitioners, communities, and the nation as a whole contribute to oral health. Chapter 7 reviews the evidence for the efficacy and effectiveness of oral health promotion and disease prevention measures with a focus on community efforts in preventing dental disease. It continues with a discussion of the need to expand efforts in such areas as oral cancer prevention.
Chapter 8 explores the role of the individual and the health care provider in promoting and maintaining oral health and well-being. For the individual, this means exercising appropriate self-care and adopting healthy behaviors. For the provider, it means incorporating the knowledge emerging from the science base in a timely manner for prevention and diagnosis, risk assessment and risk management, and treatment of oral diseases and disorders. The chapter focuses largely on the oral health care provider. The management of oral and craniofacial health and disease necessitates collaborations among a team of care providers to achieve optimal oral and general health.
Chapter 9 describes the roles of dental practitioners and their teams, the medical community, and public health agencies at local, state, and national levels in administering oral health care or reimbursing for the costs of care. These activities are viewed against the changing organization of U.S. health care and trends regarding the workforce in research, education, and practice.
What Are the Needs and Opportunities to Enhance Oral Health?
Chapter 10 looks at determinants of oral health in the context of society and across various life stages. Although theorists have proposed a variety of models of health determinants, there is general consensus that individual biology, the physical and socio-economic environment, personal behaviors and lifestyle, and the organization of health care are key factors whose interplay determines the level of oral health achieved by an individual. The chapter provides examples of these factors and, in the latter half, illustrates their varying effects at different stages of the life span, with an emphasis on children and older Americans. Barriers and ways to raise the level of oral health that can be achieved at each life stage are presented.
Chapter 11 spells out in greater detail the promise of the life sciences in improving oral health in the coming years in the context of changes in American—and global—society. The critical role of genetics and molecular biology is emphasized.
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A Call to Action
Chapter 12, the final chapter, summarizes the major findings of the report and suggests actions to guide the next steps in enhancing the oral health of the nation. The need for partnerships between public and private sectors in carrying out a proposed National Oral Health Plan is emphasized. To ensure progress, these partnerships need to include individual patients and the general public and to reflect all population groups in the nation. All the health care disciplines need to be involved, along with industry, academia, and government, as well as health care organizations, health professional associations, health insurers, and patient groups. United by the evidence that oral health is essential to general health and well-being, the combined forces and collective wisdom of all interested parties and stakeholders can make optimal oral health a reality for all people.
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