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Chapter 4: The Magnitude of the Problem

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The range of oral, dental, and craniofacial diseases and conditions that take a toll on the U.S. population is extensive. This chapter provides highlights of diseases and conditions affecting the U.S. population using available national and state data to describe the burden of disease in the United States. To capture the dimensions and extent of these diseases and conditions, the data are presented where possible by demographic measures such as race/ethnicity, sex, age, education, and economic status. Statistics and trends are presented for each of the six categories of oral diseases and disorders whose etiology and pathogenesis are described in Chapter 3: dental and periodontal infections, oral and pharyngeal cancers, mucosal infections and conditions, developmental disorders, intentional and unintentional injuries, and chronic and disabling conditions. Included are conditions as common as dental caries and periodontal diseases as well as relatively rare clefting syndromes. Also mentioned are conditions that are more common in certain demographic subpopulations—for example, Sjögren's syndrome and temporomandibular disorders, which are more common in women, and injuries, which are more common in men. (See Box 4.1 for a glossary of terms used in this chapter.)

There is no single measure of oral health or the burden of oral diseases and conditions, just as there is no single measure of overall health or overall disease. As a result, this chapter assembles clinical and epidemiologic measures for specific conditions affecting the craniofacial structures. Note too that the chapter presents an incomplete picture. State-specific data on oral diseases are extremely limited. There is a paucity of national data on rare conditions as well as on the health of selected populations and their subgroups. Some characteristics and unique needs of these populations are highlighted, and a number of questions raised. More extensive analyses of the differences among racial/ethnic, sex, and income groups are warranted. The relationship of oral health to the use of dental services is described. However, the effects of health care visits and of specific services rendered need further study.

Most of the data in the figures and tables presented in this chapter are derived from large, nationally representative surveys of the U.S. civilian, noninstitutionalized population. These include complex sample surveys, such as the National Health and Nutrition Examination Survey (NHANES), which use a sample of individuals selected with known probability to estimate the prevalence of particular characteristics and conditions in the nation as a whole. The multipurpose NHANES provides data on the frequency of the most common oral diseases and conditions. The most recent survey, NHANES III, was conducted by the National Center for Health Statistics (NCHS) of the Centers for Disease Control between 1988 and 1994. Trained interviewers gathered demographic, health, and related data from eligible households. Selected persons in these households were invited to a mobile examination center, where they underwent multiple health assessments, including an oral examination by a trained dentist (NCHS 1996). Related surveys such as the National Health Interview Survey (NHIS) also use complex survey sampling and household interviews to obtain health information about the U.S. population (Kovar 1989). The NHIS conducted in 1989 included data on oral-facial pain conditions; several of these surveys have captured data on dental visits. The most extensive dental utilization survey that provides demographic and socioeconomic data and data on reasons for not visiting a dentist was conducted in 1989.

Surveys conducted by the National Institute of Dental and Craniofacial Research of a probability sample of U.S. schoolchildren in 1979-80 and 1986-87 (Snowden and Miller-Chisholm 1992) used similar oral examination procedures as in NHANES. Because school attendance is high in the United States, these surveys are considered representative of noninstitutionalized children throughout the United States and are used in this chapter.

Record-based surveys are another approach to obtaining health data for the nation as a whole or for selected broad areas. Mortality statistics are obtained by determining the number of deaths in the United States and dividing that figure by the total U.S. population as determined from U.S. Census data (Kovar 1989). Cancer statistics are derived from population-based cancer registries in selected large geographic areas of the United States using reports of cancer occurrences from hospitals, doctors, and laboratories. This data system, maintained by the National Cancer Institute, is called the Surveillance, Epidemiology, and End Results program (Ries et al. 1999). Birth certificate registries in geographic areas and surveys of health care facilities provide valuable information from record-based systems about other aspects of oral and craniofacial health such as birth defects (Schulman et al. 1993). The Centers for Disease Control and Prevention's Behavioral Risk and State Surveillance System provides essential state data on edentulousness (Tomar 1997). In selected cases, survey findings other than from national probability surveys are used. State-specific data are provided for those conditions for which there are data from most states—that is, cancer mortality statistics and self-reports of edentulism.

Economic status is derived from annual income data. Unless otherwise stated, "poor" is defined in this chapter as an annual income below the U.S. poverty level. For both national and other surveys, the race and ethnicity terms used in this report are consistent with the terms used in the supporting documentation as referenced in the text and cited in the reference list. Available national data for most conditions are limited primarily to Hispanic, non-Hispanic black, and non-Hispanic white populations, due to the sampling design of the national surveys. The NHANES III oversampled Mexican Americans, so the data from that survey are available for this subpopulation of Hispanics.

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WHO HAS WHAT DISEASES AND CONDITIONS?

Dental Caries, Periodontal Diseases, and Tooth Loss

Dental Caries

Dental caries is one of the most common childhood diseases. In this section, decayed refers to teeth with caries that have not been treated. The term filled refers to treated caries. Dental caries refers to both decayed and filled teeth. Among 5- to 17-year-olds, dental caries is more than 5 times as common as a reported history of asthma and 7 times as common as hay fever (Figure 4.1). Prevalence increases with age. The majority (51.6 percent) of children aged 5 to 9 years had at least one carious lesion or filling in the coronal portion of either a primary or a permanent tooth. This proportion increased to 77.9 percent for 17-year-olds and 84.7 percent for adults 18 or older. Additionally, 49.7 percent of people 75 years or older had root caries affecting at least one tooth (NCHS 1996, NHANES III).

Despite progress in reducing dental caries, individuals in families living below the poverty level experience more dental decay than those who are economically better off. Furthermore, the caries seen in these individuals is more likely to be untreated than caries in those living above the poverty level (Figure 4.2); more than one third (36.8 percent) of poor children aged 2 to 9 have one or more untreated decayed primary teeth, compared to 17.3 percent of nonpoor children.

In addition to poverty level, the proportion of teeth affected by dental caries also varies by age and race/ethnicity. Poor Mexican American children aged 2 to 9 have the highest number of primary teeth affected by dental caries (a mean of 2.4 decayed or filled teeth) compared to poor non-Hispanic blacks (mean 1.5) and non-Hispanic whites (mean 1.9). Among the nonpoor, Mexican American 2- to 9-year-olds have the highest number of affected teeth (mean 1.8), followed by non-Hispanic blacks (1.3) and non-Hispanic whites (1.0).

There are also differences by race/ethnicity and poverty level in the proportion of untreated decayed teeth for all age groups. Poor Mexican American children aged 2 to 9 have the highest proportion of untreated decayed teeth (70.5 percent), followed by poor non-Hispanic black children (67.4 percent) (Figure 4.3). Nonpoor children have lower proportions of untreated decayed teeth, although the group with the lowest proportion (non-Hispanic whites) still has an average of 37.3 percent of decayed teeth untreated.

Poor adolescents aged 12 to 17 in each racial/ethnic group have a higher percentage of untreated decayed permanent teeth than the corresponding nonpoor adolescent group (Figure 4.4). Poor Mexican American (47.2 percent) and poor non-Hispanic black adolescents (43.6 percent) have more than twice the proportion of untreated decayed teeth than poor non-Hispanic white adolescents (20.7 percent). For nonpoor adolescents the proportion of untreated decayed permanent teeth is highest in non-Hispanic black adolescents (41.7 percent)—a proportion only slightly lower than for this group's poor counterparts (43.6 percent). The mean number of permanent teeth affected by dental caries (decayed or filled) for this age group is similar among Mexican Americans (2.7), non-Hispanic whites (2.5), and non-Hispanic blacks (2.3). As income level increases, the percentage of adolescents with decayed teeth decreases and the proportion of decayed teeth that have been filled increases (Vargas et al. 1998).

Adult populations (aged 18 and older) show a similar pattern, with the proportion of untreated decayed teeth higher among the poor than the nonpoor (Figure 4.5). Regardless of poverty level status, adult non-Hispanic blacks and Mexican Americans have higher proportions of untreated decayed teeth than their non-Hispanic white counterparts.

Improvements have been noted over the past 25 to 30 years with regard to dental caries. Among most age groups, the average number of teeth per person affected by dental caries has decreased, and the average number of teeth per person that show no signs of infection, as well as the proportion of the population that is caries-free, has increased.

Since 1971-74, major increases have been noted in the percentage of children and adolescents aged 5 to 17 who have never experienced dental caries in their permanent teeth. Younger adults have experienced a decline in dental caries during this time period, as measured by the average number of teeth without decay or fillings (Figure 4.6). These trends are not found among those 55 to 74 years of age.

The number of untreated decayed teeth per person across all age groups has also declined.

Periodontal Diseases

The presence of periodontal disease is measured clinically in several ways, one of which is by calculating the loss of periodontal attachment. Figure 4.7 shows that most adults 25 years and older have at least 2 mm or more loss of attachment. The disease is more serious as the amount of attachment loss and number of tooth sites affected increase. More severe disease can be defined as having 4 mm or more loss of attachment in at least one site. The percentage of adults with 6 mm or more loss of attachment at one or more sites increases at older age groups, with 19.0 percent of 55- to 64-year-olds and 23.4 percent of 65- to 74-year-olds having this amount of loss or more. Figure 4.8 displays these data in a different format and shows that a small but increasing percentage of the population at each older age group has severe disease.

At all ages, men are more likely than women to have at least one tooth site with a 6 mm or more loss of attachment (Figure 4.9). In addition to age and sex, the prevalence of periodontal loss of attachment also varies by racial/ethnic group (Figure 4.10). A higher percentage of non-Hispanic black persons at each age group have at least one tooth site with 6 mm or more of periodontal attachment loss as compared to other groups. Within each racial/ethnic group, the highest percentage affected is found among individuals 70 years and older. At every age, a higher proportion of those at the lowest socioeconomic status (SES) level have at least one site with attachment loss of 6 mm or more, compared to those at higher SES levels (Figure 4.11) (Burt and Eklund 1999).1

Gingivitis as measured by gingival bleeding, a sign of inflammation, is more evident among Mexican Americans (63.6 percent) than among non-Hispanic blacks (55.7 percent) and non-Hispanic whites (48.6 percent) (Albandar et al. 1999).

Early-onset periodontitis, a severe, rapidly progressive disease occurring in individuals under age 35, has been reported to be 4 times more common in males than in females (Löe and Brown 1991); among 13- to 17-year-olds, it has been found to be highest among African Americans (10.0 percent), as compared with Hispanics (5.0 percent) and whites (1.3 percent) (Albandar et al. 1997).

Tooth Loss and Edentulism

Although teeth are lost for a number of reasons, including trauma, orthodontic treatment, and removal of third molars (wisdom teeth), most teeth are lost because of periodontal disease or dental caries (Phipps and Stevens 1995, Neissen and Weyant 1989). By age 17, more than 7.3 percent of U.S. children have lost at least one permanent tooth because of caries; by age 50, Americans have lost an average of 12.1 teeth, including the third molars.

Men and women are nearly equally likely to be edentulous. Overall, a higher percentage of individuals living below the poverty level are edentulous than are those living above (Figure 4.12). Individuals with incomes equal to or above twice the poverty level have a rate of edentulism of 6.9 percent. This rate is less than half the rate for those with incomes below twice the poverty level (14.3 percent).

Although the overall rate of edentulism for adults 18 and older is approximately 10 percent (9.7 percent), the rate increases with age, so that about a third (33.1 percent) of those 65 and older are edentulous. Comparisons across race/ethnicity for the population 18 years and older indicate that the edentulous rate for non-Hispanic whites is 10.9 percent; for non-Hispanic blacks, it is 8.0 percent; and for Mexican Americans, 2.4 percent. Non-Hispanic whites, both poor and nonpoor, have the highest rates of edentulism compared to non-Hispanic blacks and Mexican Americans. Of the three population groups, Mexican Americans are the least likely to lose all of their teeth, and the proportion of Mexican Americans who are edentulous varies only slightly by economic status. A lower proportion of U.S. adults have lost all their natural teeth now than was the case two decades ago (Figure 4.13). The decline is most pronounced at older ages.

Edentulism is one of a few conditions for which state-specific data exist. These data reveal a wide variation in the percentages of the population aged 65 and older who have no teeth, from a low of 13.9 percent in Hawaii to a high of 47.9 percent in West Virginia; this is more than a threefold difference (Table 4.1) (Tomar 1997). Reasons for these differences are unknown at this time.

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Oral and Pharyngeal Cancers and Precancerous Lesions

Oral and Pharyngeal Cancers

Every year, about 1.2 million people develop cancer in the United States (based on 2000 estimates). Sites in the oral cavity and pharynx (throat) account for about 30,200 cases, or 2.4 percent of all cancers, and about 7,800 Americans die from these cancers each year (ACS 1999). The life of each person with these cancers is shortened by an average of 16.5 years. The median age at diagnosis of oral and pharyngeal cancer is 64, and the rate of occurrence increases with age. More than 95 percent of oral cancers occur in individuals aged 35 and older (Ries et al. 1999).

The overall 5-year survival rate for people with oral and pharyngeal cancers is 52 percent, which is worse than that for—among others—cancers of the prostate, corpus and uterus, breast, bladder, larynx, cervix, colon, and rectum in both blacks and whites (Ries et al. 1999). People with oral cancers detected at an early stage have a 5-year survival rate of 81.3 percent; however, only 35 percent of individuals with oral and pharyngeal cancers are diagnosed at an early stage. The 5-year survival rate drops to 21.6 percent among people diagnosed with advanced-stage cancers (Ries et al. 1999). Compared to patients with other types of cancer, oral and pharyngeal cancer patients who survive have the highest rate of development of new cancers in the mouth or in other parts of the body (Winn and Blot 1985).

Incidence rates for oral and pharyngeal cancers are higher for black individuals than for whites: 12.5 cases versus 10.0, respectively, per 100,000 people each year. In the United States, Asians and Pacific Islanders (7.9 per 100,000), American Indians and Alaska Natives (6.4 per 100,000), and Hispanics (5.8 per 100,000) have lower incidence rates than whites and blacks (Wingo et al. 1999).

Figure 4.14 provides incidence rates for selected racial/ethnic groups by sex. Males have higher incidence rates than females; specifically, they are 2.6 times more likely to develop oral and pharyngeal cancers than women (Ries et al. 1999). The incidence rates of oral and pharyngeal cancers for black males are 39.6 percent higher than for white males (20.8 versus 14.9, respectively, per 100,000 males per year). Rates for black and white females are the same (6.0 per 100,000 females per year) (Ries et al. 1999). Oral and pharyngeal cancers are the seventh most common cancer among white males and the fourth most frequently diagnosed cancer among black males (Figure 4.15) (Wingo et al. 1999).

As for many other cancer sites, the overall 5-year survival rate for oral and pharyngeal cancers is lower for blacks than for whites: 34 versus 56 percent (Ries et al. 1999) (Figure 4.16). However, only 19 percent of blacks with oral and pharyngeal cancers are diagnosed when the cancer is at the local, and more easily treatable, stage, compared to 38 percent for whites (Figure 4.17). At every stage of diagnosis, the survival rate for blacks is lower than for whites (Figure 4.18). The occurrence of cancers in specific sites within the oral cavity and pharynx varies by sex and race/ethnicity. A relatively rare subtype of pharyngeal cancer, nasopharyngeal cancer, occurs more often in American males and females of Chinese descent than among other racial/ethnic groups (Miller et al. 1996). Blacks are twice as likely as whites to develop cancers of the pharynx: 6.0 and 2.9 per 100,000 per year, respectively (Ries et al. 1999). Individuals with cancers of the pharynx generally have a worse survival rate than those with cancers in oral cavity sites: 5-year pharyngeal cancer survival rates range from 53.3 to 29.5 percent, depending on the subsite, whereas oral cavity cancer survival rates range from 94.3 to 48.3 percent. The incidence of lip cancer, a highly treatable cancer, is more common in whites than among blacks (1.2 per 100,000 persons per year compared to 0.1).

Overall, the incidence rate for oral cavity and pharyngeal cancers is decreasing, with an estimated annual percentage decrease of 0.5 percent per year between 1973 and 1996. There are wide variations in the incidence of site-specific cancers. The largest annual declines in incidence were noted for lip cancer (–3.4 percent per year between 1973 and 1996) (Ries et al. 1999). In contrast, the incidence of tongue cancer, the most common form of oral and pharyngeal cancer, may be increasing among young men (Day et al. 1994).

Although overall mortality rates for oral and pharyngeal cancers declined by 1.6 percent per year between 1973 and 1996, the 5-year survival rate for individuals with oral and pharyngeal cancers has shown no improvement for the past 25 years (Ries et al. 1999).

Mortality statistics by state allow for analysis of deaths due to oral cavity and pharyngeal cancers. Table 4.2 highlights the wide variation in mortality found in the country. The highest rate is in the District of Columbia—6.7 per 100,000 population; this is nearly 5 times the lowest rate, 1.4 in Utah. Again, reasons for this variation need to be studied (Ries et al. 1999).

Tobacco-related Lesions

Tobacco use has been estimated to account for over 90 percent of cancers of the oral cavity and pharynx (Peto et al. 1995) and thus represents the greatest single preventable risk factor for oral cancer. Both smoking and spit (smokeless) tobacco (moist snuff and chewing tobacco) are associated with a number of other oral conditions, including oral mucosal lesions, that may progress to oral cancer (Silverman 1998).

One type of tobacco-related lesion is seen in people who use spit tobacco. A national survey of U.S. schoolchildren in 1985-86 showed that 6.1 percent of males and 0.1 percent of females used spit tobacco. The survey also showed that 34.9 percent of current snuff users aged 12 to 17 and 19.6 percent of current adolescent chewing tobacco users had a spit tobacco lesion (Figure 4.19) (Tomar et al. 1997). The prevalence of tobacco-related lesions increased with increasing duration and frequency of spit tobacco use.

In some American Indian tribes, both adolescent males and females commonly use spit tobacco and have an especially high frequency of spit tobacco lesions. On a Sioux reservation, 37.0 percent of students in grades 7 through 12 used spit tobacco. Spit tobacco lesions occurred in over one third of those tobacco-using adolescents (CDC 1988). In another study of Navajo adolescents, three fourths of male adolescents (75.4 percent) and one half of female adolescents (49.0 percent) used spit tobacco. Of Navajo adolescents who used spit tobacco, 25.5 percent had spit tobacco lesions—29.6 percent of males and 17.0 percent of females (Wolfe and Carlos 1987).

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Selected Mucosal Infections and Diseases

Oral Herpes Simplex Virus Infections

The prevalence of recurrent herpes lesions is estimated to be between 15 and 40 percent (Scully 1989). The proportion of the U.S. population with herpes simplex virus type 1 (HSV-1) antibodies is 68.2 percent (as evidenced by positive antibody titer). The proportion reporting a history of herpes lesions in the past 12 months is 17.7 percent. The presence of antibodies and occurrence of herpes lesions vary by age (Figure 4.20). The frequency of recurrence also varies greatly, ranging from once to several times per year.

Infection with the oral herpes simplex virus has been related to socioeconomic factors, with 75 to 90 percent of individuals from lower socioeconomic populations developing antibodies by the end of the first decade of life (Whitley 1993a,b). In comparison, 30 to 40 percent of individuals from middle and upper socioeconomic groups evidence antibodies by the middle of the second decade of life.

The prevalence of one or more herpes labialis lesions within the past 12 months is 8.4 percent for non-Hispanic blacks, 16.2 percent for Mexican Americans, and 19.7 percent for non-Hispanic whites (NHANES III).

Recurrent Aphthous Ulcers

Various epidemiologic studies of recurrent aphthous ulcers have indicated that the prevalence in the general population can vary from 5 to 25 percent (Axéll et al. 1976, Embil et al. 1975, Ferguson et al. 1984, Ship 1972, Ship et al. 1967). In NHANES III, 17.2 percent of persons reported having a recurrent aphthous ulcer within the past 12 months, and occurrences were most common among young adults (18 to 24 years old) (Figure 4.21). In selected population groups, the prevalence of recurrent aphthous ulcers can be as high as 50 to 60 percent (Miller and Ship 1977, Ship et al. 1961, 1977).

Other Mucosal Lesions

Other mucosal conditions contribute to the burden of oral diseases. The following are among the most common:

  • Oral candidiasis (commonly called thrush) is a particular problem for individuals with impaired immune function. A prevalence of 9.4 percent has been reported in renal transplant patients (King et al. 1994); Samaranayake (1992) reports prevalences between 43 and 93 percent among HIV-infected patients. It is estimated that 3.6 percent of full denture wearers have candidiasis.

  • Denture stomatitis, a condition in which the mucosa underneath a denture becomes inflamed and sometimes painful, affects 25.6 percent of people aged 18 and older who have two full dentures. Additionally, 32.2 percent of those with one full denture are affected, 26.7 percent of those with one or more partial dentures, and 0.87 percent of those who do not have full or partial dentures.

  • Oral human papillomavirus infections, oral and genital papillomas (or condyloma acuminata, also called venereal warts), are especially common among HIV-positive patients. Human papillomaviruses may be associated with some oral leukoplakias with a high risk for malignant transformation (Palefsky et al. 1995).
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Developmental Disorders

Numerous developmental disorders affect the oral, dental, and craniofacial complex. These include congenitally missing teeth (all or specific tooth types); congenital problems involving tooth enamel, pulp, or dentin; and craniofacial birth defects or syndromes. Cleft lip and palate are the most common congenital anomalies and may occur as isolated defects or as part of other syndromes. Other craniofacial defects and syndromes that have been the focus of recent genetics research include ectodermal dysplasias, Treacher Collins syndrome, Apert's syndrome, and Waardenburg syndrome. Craniofacial defects and syndromes have many serious consequences including unusual facial features; severe functional problems; and the need for extensive surgical, medical, and rehabilitative interventions and prosthetic devices.

Cleft Lip/Palate

Oral clefts are one of the most common classes of congenital malformations in the United States, with prevalence rates in the general population of 1.2 per 1,000 births for cleft lip with or without cleft palate and 0.56 per 1,000 births for cleft palate alone (Schulman et al. 1993). These conditions affect facial appearance throughout life. The rate of oral clefts for whites is more than 3 times that for blacks (1.7 versus 0.5 per 1,000 live births) (Figure 4.22). Oral clefts are more common among North American Indians (3.7 per 1,000 births) (Lowry et al. 1989). Cleft palate occurs more frequently in females, whereas cleft lip or cleft lip/palate is more common in males (Burman 1985, Fraser and Calnan 1961, Habib 1978, Owens et al. 1985).

Malocclusions

Malocclusions can occur due to congenital or acquired misalignments (crowding) of the teeth or jaws. In a national study of individuals between 8 and 50 years old, 25 percent were found to have no crowding of the incisors (front teeth), whereas 11 percent were found to have severe crowding (Brunelle et al. 1996). About 9 percent had a posterior crossbite, where there is poor contact of the back upper and lower chewing surfaces. This crossbite was most common in non-Hispanic whites. Severe overjet—where the upper front teeth project far forward—was found in approximately 8 percent of this population, with a similar percentage demonstrating a severe overbite—where the front top and bottom teeth greatly overlap when the mouth is closed. Less than 5 percent of non-Hispanic whites had an open bite, an inability to bring the upper and lower front teeth together.

Injury

Injuries to the head, face, and teeth are very common. They can range in severity from the very mild to those that cause death. Although injuries have a major impact on oral health, data on the number and severity of head and face injuries in the United States are very limited.2 Most of our knowledge about the number of injuries that occurs comes from more severe injuries that involve a visit to the emergency room.

In 1993 and 1994, there were 20 million visits per year to emergency departments for craniofacial injuries. Less serious injuries can be treated on an outpatient basis. More than 5.9 million injuries in 1991 were treated by dentists in private offices (Gift and Bhat 1993). Overall, 25 percent of all persons aged 6 to 50 have had an injury that resulted in damage to one or more anterior teeth (Kaste et al. 1996a). An estimated 2.9 million emergency room visits for all age groups related to tooth or mouth injuries between 1997 and 1998. Twenty-five percent of these injuries were seen in children under the age of 4 (NCHS 1997b).

The leading causes of head and face injuries that result in emergency room visits include falls, assaults, sports injuries, and motor vehicle collisions (De Wet 1981, Pinkham and Kohn 1991, Sane 1988). In the National Health Care Survey of emergency rooms, assaults and falls each accounted for 31 percent of visits related to head and face injury. Other studies have reported that up to 19 percent of head and face injuries are sports-related (McDonald 1994), and 5 percent of head and 19 percent of face injuries result from riding bicycles and tricycles (U.S. Consumer Product Safety Commission 1987).

There are differences in rates of emergency room visits for head and face injuries among demographic groups. Males had higher rates than females, except among older adults. The rates of injury were higher for younger and older adults than for those in the middle years.

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Chronic and Disabling Conditions

Oral-Facial Pain

Oral-facial pain can greatly reduce quality of life. These types of pain may be due to tooth-related infections, mucosal sores, and irritations, and may include burning sensations, pain in the jaw joint area, and aching pain across the face or cheek. Over 39 million people, or 22 percent of adults 18 years of age and older in the civilian U.S. population, experienced at least one of five types of oral-facial pain during a recent 6-month period (Lipton et al. 1993). Based on the results of a national study of the prevalence and distribution of oral-facial pain, it is estimated that during a 6-month period, 1 American adult in 8 (12.2 percent) suffers from toothache, 1 in 12 (8.4 percent) from painful oral sores, 1 in 19 (5.3 percent) from jaw joint pain, and 1 in 71 (1.4 percent) from face or cheek pain (Lipton et al. 1993).

The prevalence of toothache and pain due to oral sores decreases with age, whereas the prevalence of burning mouth pain increases with age. Women are twice as likely as men to report two specific types of oral-facial pain: jaw joint pain and face/cheek pain (Figure 4.23). Non-Hispanic blacks and Hispanics were slightly more likely to report toothache than non-Hispanic whites (Lipton et al. 1993). Adults living in poverty were more likely to report toothaches than adults living above the poverty level (Vargas et al. 2000).

Temporomandibular Disorders

Symptoms of temporomandibular disorders (TMDs) vary but may include severe pain in the jaw musculature, severe pain or difficulty when opening the mouth and chewing, headaches, and ear pain. Based upon assessments of pain in or around the jaw joint, these disorders are estimated to affect 10 million Americans (Lipton et al. 1993).

Data from the few available population-based epidemiologic studies indicate that the prevalence of self-reported pain symptoms and clinical signs of TMD pain is between 5 and 15 percent, with peak prevalence in young and middle-aged adults (20 to 40 years of age) (Von Korff 1995).

Although physical signs associated with TMDs have been shown to occur with nearly equal frequency among men and women, clinical studies have found that women in the third and fourth decades of life were much more likely than men of the same age to have sought care for reported facial pain in the temporomandibular region (Carlsson and LeResche 1995).

Sjögren's Syndrome

Sjögren's syndrome, an autoimmune disorder that causes xerostomia (dry mouth), difficulty in swallowing, and xerophthalmia (dry eyes), is estimated to affect 1 to 2 million people in the United States (Talal 1992). The diagnosis is most often made in women in middle age. One estimate of the average annual incidence rate for Sjögren's syndrome, based on the Olmsted County, Minnesota, medical database, is about 3 to 5 cases per 100,000 population; this may be low, however (Pillemer et al. 1995). As with most other autoimmune conditions (e.g., rheumatoid arthritis, systemic lupus erythematosis), Sjögren's syndrome affects more women than men. The female-to-male ratio depends on the study, but may be as high as 9:1 (Fox 1996).

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WHAT IS THE BURDEN OF DISEASE IN SELECTED POPULATIONS? CHALLENGES AND OPPORTUNITIES

The national data provide a broad-brush picture of America's oral health. For selected populations, however, oral health and disease status has a different profile. By 2050 about 50 percent of the U.S. population is expected to be Asian, non-Hispanic black, Hispanic, and American Indian (Council of Economic Advisers 1998). Currently available data for these groups present a picture of disease that is generally poorer than that for non-Hispanic whites. These subgroups present a unique cluster of health, socioeconomic, and cultural issues. At the same time, data for the subgroups within each of these categories are lacking. In addition to racial/ethnic groups, other groups such as individuals with disabilities, the homeless, incarcerated individuals, and migrant workers have unique needs and challenges. Cutting across all subgroups are gender-specific health issues. For improvements to be made in America's overall health, a better understanding of the full dimension of the problems faced by these populations and development of specific solutions are needed. This part of the chapter examines each subgroup in greater depth.

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Racial and Ethnic Minorities

Although there have been gains in oral health status for the population as a whole, they have not been evenly distributed across subpopulations. Non-Hispanic blacks, Hispanics, and American Indians and Alaska Natives generally have the poorest oral health of any of the racial and ethnic groups in the U.S. population. Other health statistics, such as life expectancy and infant mortality, indicate that the general health of these groups is varied and also poor compared to other population groups (Council of Economic Advisers 1998). To address the elimination of these disparities in health—and also in housing, education, and other indicators of social and economic well-being—the administration has launched "The President's Initiative on Race: One America in the 21st Century." Recommendations for improving the oral and general health status of racial and ethnic minorities are also a prominent feature of Healthy People 2010, the goal-setting health agenda developed for the decade by the USDHHS (2000).

African Americans

Numerous studies over the decades have compared the health status of blacks and whites in American society, but relatively little systematic attention has been focused on the oral health of blacks. Although the overall oral health status of Americans has been improving, many oral diseases and conditions among blacks remain a serious problem—despite the fact that for almost three decades these disparities have been highlighted and recommendations made for addressing health issues including research, education, human resources, and delivery systems (National Dental Association 1972). These recommendations still represent opportunities for improvement in the oral health status of African Americans.

Baseline data for the Healthy People 2010 objectives establish that, for children aged 2 to 4 years, 24.0 percent of non-Hispanic blacks have experienced dental caries in their primary teeth, compared to 15.0 percent for their non-Hispanic white counterparts. For children aged 6 to 8, there were no differences among the races; but for 15-year-olds, a higher percentage of non-Hispanic blacks were affected than of whites. In addition the percentage of people of all ages who had untreated caries was substantially higher for blacks than for whites—about twice as many. Higher levels of gingivitis and periodontal loss of attachment were also seen in non-Hispanic blacks as compared to non-Hispanic whites.

A greater percentage of non-Hispanic blacks 18 years and older have missing teeth when compared to non-Hispanic whites. Relative to non-Hispanic whites, however, non-Hispanic blacks aged 18 and older are less likely to have lost all their teeth (edentulism) regardless of whether they are poor.

African American males have the highest incidence rate of oral cavity and pharyngeal cancers in the United States compared with women and other racial/ethnic groups (Wingo et al. 1999). The distribution of oral cancer cases reveals that blacks also have a higher proportion of pharyngeal cancer than oral cavity cancer compared to whites. Also, the 5-year relative survival rate (1989-95) for oral cancer was much lower among blacks than whites: 34 versus 56 percent (American Cancer Society (ACS) 1999). This latter finding may be related to the fact that a high percentage of these cancers are diagnosed in later stages of disease in blacks as compared to whites (ACS 1999).

On the other hand, for several conditions, African Americans have a lower disease burden than do whites. The incidence rate for cleft lip and cleft palate in African Americans is 0.54 per 1,000, about a third the rate for whites (1.70 per 1,000). Also the prevalence of having one or more herpes labialis lesion within the past 12 months is 50 percent less than that for Mexican Americans and non-Hispanic whites.

Hispanics

Disparities in oral and general health status between Hispanic and non-Hispanic populations in the United States have been long recognized. Yet the health profile of Hispanics is incomplete due to insufficient sampling of subgroups in national surveys, inconsistent or inadequate assessment of ethnicity, or ambiguities in reporting of ethnic identity (Hahn 1992). Recent efforts to improve data collection, identify subgroups, and provide more baseline data for Hispanics have addressed the situation somewhat, but much work remains to ensure accurate data for health planning and research (Delgado and Estrada 1993).

Among preschool Hispanic children early childhood caries is a particular concern. Two reports have documented early childhood caries among 12.9 percent of Hispanic children examined in San Antonio and 37 percent of predominantly Hispanic children in San Francisco (Garcia-Godoy et al. 1994, Ramos-Gomez 1999). Most recently, national survey data suggest that a higher proportion of Mexican American children ages 12 to 23 months may experience dental caries than other race/ethnicity groups (Kaste et al. 1996b).

Preliminary data from NHANES III indicate that young Mexican American children aged 2 to 4 are more likely to have experienced dental caries in their primary teeth, have on average more decayed and filled tooth surfaces, and have more untreated disease than either non-Hispanic white or non-Hispanic black children (Kaste et al. 1996b). Mexican American children aged 2 to 5 years—especially those from lower-income households—were more likely than their African American and non-Hispanic white counterparts to have one or more decayed primary teeth (Vargas et al. 1998).

Dental caries continues to affect large numbers of school-age children and youth, as only 30 percent of Mexican Americans, 32 percent of non-Hispanic whites, and 41 percent of non-Hispanic blacks 12 to 17 years of age were free of caries in their permanent teeth (USDHHS 1996). However, most of the dental caries in the permanent teeth of non-Hispanic white children aged 12 to 17 had been treated or filled (87 percent), compared to 63 percent for Mexican Americans and 60 percent for non-Hispanic blacks.

The only large-scale survey that permits comparison among Hispanic subgroups is the Hispanic Health and Nutrition Examination Survey (HHANES 1982-84). After controlling for age, sex, income, and education, HHANES results show that Cuban American and Puerto Rican adults had about twice as many missing teeth as Mexican Americans. Puerto Ricans and Cuban Americans also had on average more filled teeth than Mexican Americans. Puerto Rican children and adults under 45 years old had more gingivitis than Cuban Americans and Mexican Americans; the highest prevalence of periodontal disease was reported among Puerto Ricans compared to the two other Hispanic groups (Ismail and Szpunar 1990).

A national survey found that employed Hispanic adults were twice as likely to have untreated dental caries as non-Hispanic whites. In this study, gingivitis and periodontal problems (attachment loss and pockets) were also among the more common problems among the Hispanic adults studied (Watson and Brown 1995).

Analysis of a more recent survey (NHANES III) that sampled Mexican Americans is particularly revealing. After adjusting for age, sex, educational attainment, and annual family income, Mexican American adults are similar to their white non-Hispanic counterparts on most oral health indicators. However, among Mexican Americans, individuals in families with less than $20,000 annual income were 1.6 times less likely to have an intact dentition, 3.1 times more likely to have any untreated decay on the crowns of their teeth, and 4.2 times more likely to have severely decayed teeth (very large cavities or only the roots of teeth remaining) than non-Hispanic whites (Garcia and Drury 1999). Also, Mexican Americans were less likely to be edentulous regardless of poverty status than either non-Hispanic whites or non-Hispanic blacks (Drury et al. 1999).

These findings confirm the importance of controlling for sociodemographic factors in reporting on oral health status as well as the need to assess other factors related to health status. As a group, Hispanics have lower median incomes, higher poverty rates, more unemployment, and less education than non-Hispanic whites (Ramirez 1999). However, sociodemographic factors are just one aspect of the questions raised when attempting to understand differences in oral health. The effect of financial barriers and nonfinancial factors such as language, culture, dietary patterns, and behaviors on access, care seeking, and health outcomes must also be examined. Variations in conditions such as diabetes also may contribute to differences in oral health.

It is estimated that Hispanics will surpass African Americans as the country's largest minority group by 2020 (U.S. Bureau of the Census 2000). Aggregate statistics obscure substantial variations within Hispanic subgroups. More than 20 different countries of varied cultural, socioeconomic, and political backgrounds are currently included in this category of the U.S. population. Narrowing the gap in oral health between Hispanic and non-Hispanic groups will require improved data on health status, barriers to access, and disease factors underlying differences in oral health in these populations.

Asians, Native Hawaiians, and Other Pacific Islanders

National data for the oral health of Asian, Native Hawaiian, and other Pacific Islander (ANHPI) groups that can be generalized to the U.S. population are not available. Instead the profile of disease and health in this category is only available through studies of specific states and locales. Among all ethnic groups in California in 1993 and 1994, Asian and Pacific Islander American (APIA) children in Head Start had the highest prevalence of early childhood caries—20 percent compared to 14 percent for all Head Start children (Pollick et al. 1997). These data are comparable to other survey findings of 16 to 20 percent and 29 percent early childhood caries among APIA children in Hawaii and California, respectively (Greer unpublished, Louie et al. 1990).

A California study of 6- to 8-year-olds found disparities in the oral health status of APIA children in the state when compared to all children nationally. Among the California APIA children, 71 percent had untreated dental caries, with a significant portion of this group requiring urgent dental treatment. By comparison, NHANES III data indicate that in 1988-94, 29 percent of children in the United States aged 6 to 8 years had untreated dental decay.

There is variation in oral health status among subgroups of ANHPI children. In a recent survey in Hawaii, the prevalence of early childhood caries among APIA children was 16 percent, ranging from a low of 8 percent among Japanese children to a high of 25 percent among Filipino children. The prevalence of untreated dental caries in 6- to 8-year-old APIA children was 39 percent, which ranged from a low of 16 percent among Japanese children to 40 percent among Native Hawaiians, 48 percent among Southeast Asians, and 62 percent among non-Native Hawaiian Pacific Islanders (Greer 1999).

Oral cancer incidence and mortality rates for APIAs are lower than those for white non-Hispanics and African Americans. However, nasopharyngeal cancer incidence and mortality rates among Chinese and Vietnamese populations are many times higher than other groups (Miller et al. 1996), and therefore pose a unique health problem for these subgroups.

Until recent years, vital statistics and other health-related data were virtually nonexistent for the APIA population. Data for this group generally appeared in the "other" category of national surveys, and thus were not helpful in determining specific population-based oral or general health needs. Little national focus has been given to defining and measuring the oral health problems and related health care needs of the APIA population. These needs are now highlighted in the 2010 Healthy People Oral Health Objectives. A few statewide oral health data exist for some APIA child populations, but no ethnic subgroupings can be assessed. Again, this category of the U.S. population is extremely heterogeneous. It is estimated that 76 percent is from one of five ethnic origins and that 74 percent in 1990 were foreign born. More than 63 percent live in four states: California, New York, Hawaii, and Texas. Consequently, determining the reasons for variations in oral health will require additional data.

American Indian/Alaska Native Populations

Data on the oral health of American Indians and Alaska Natives (AI/AN) are available through studies conducted by the Indian Health Service (IHS) (Niendorfs 1994). The AI/AN people constitute about 1 percent of the U.S. population, or an estimated 2.5 million people in 2000. Little is known or can be easily determined about the general or oral health status of the 1 million AI/AN people not served by the IHS system. For this reason, with the exception of overall death rates obtained from census data, the statistics described in this section will be limited to the 1.5 million AI/AN served by the IHS. By and large, this group represents AI/AN people living on or near reservations.

Preliminary analyses of the IHS-wide Oral Health Status Survey of over 13,000 dental patients in 1999 revealed that some conditions have worsened and some improved since an earlier survey conducted in 1991 (IHS 1994, 2000). Across the IHS service population there was a statistically significant increase in caries among adults over 55 as measured by the decayed, missing, and filled teeth index. The decayed and filled tooth rate increased from 7.5 to 8.8 teeth, with no change in the average number of missing teeth for this age group.

Among AI/AN children across the IHS, there was a significant decline in caries in the permanent dentition and a significant increase in caries in the primary dentition. Among children aged 2 to 5 years, the increase in decayed and filled primary teeth surfaces went from 8.6 to 11.4. In general, AI/AN populations have much greater rates of dental caries and periodontal disease in all age groups than the general U.S. population. AI/AN children aged 2 to 4 years have 5 times the rate of dental decay compared to all children, and 6- to 8-year-old AI/AN children have about twice the rate of dental caries experience. Rates for untreated decay in these age groups are 2 to 3 times higher than in the same age groups in the general U.S. population. Periodontal disease in AI/AN adults is 2.5 times greater than in the general U.S. population. High prevalence rates of diabetes among AI/AN populations are a significant contributing factor to this periodontal disease (IHS 2000).

Substantial unmet dental needs and quality of life issues have also been identified in IHS surveys, which included studies of representative AI/AN communities with regard to the effect of oral conditions on well-being and quality of life (Chen et al. 1997). (See Chapter 6 for a general discussion.) One third of schoolchildren report missing school because of dental pain. Twenty-five percent of schoolchildren avoid laughing or smiling, and 20 percent avoid meeting other people because of the way their teeth look. As a consequence of dental pain, almost a quarter of the adults are unable to chew hard foods, almost 20 percent report difficulty sleeping, and 15 percent limit their work and leisure activities. Three quarters of the elderly experience dental symptoms, and half perceive their dental health as poor or very poor and are unable to chew hard food. Almost half the adults avoid laughing, smiling, and conversation with others because of the way their teeth look.

Again, the available data allow for obtaining a picture only of the AI/AN population residing on reservations where services, including dental services, have been provided by the IHS or contracted to tribes or urban AI/AN organizations. In 1989, American Indians, residing in the current reservation states had a median household income of $19,897. Almost one third (31.6 percent) of AI/ANs lived below the poverty level. For some groups, diabetes and high rates of tobacco and alcohol use are prevalent and contribute to poor oral health.

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Women's Health

Analysis of data from NHANES III indicates that women have benefited from the trend in general improvements in oral health that has been enjoyed by the U.S. population overall. Many, but not all, statistical indicators show women to have improved their oral health status as compared to men (NHANES III, Redford 1993). Adult females are less likely than males at each age group to have severe periodontal disease as measured by periodontal loss of attachment of 6 mm or more for any tooth. Both black and white females (6.0 and 6.0 per 100,000) have a substantially lower incidence rate of oral and pharyngeal cancers compared to black and white males, respectively (20.8 and 14.9 per 100,000). A higher prevalence of females than males have oral-facial pain, including pain from oral sores, jaw joints, face/cheek, and burning mouth syndrome. However, there are large areas for which information for either sex, even at the descriptive level, is only partial or nonexistent. Data gaps regarding craniofacial injuries, soft tissue pathologies, and salivary gland dysfunctions are notable examples.

Most oral diseases and conditions are complex and represent the product of interactions between genetic, socioeconomic, behavioral, environmental, and general health influences (Chapters 3 and 5). Multiple factors may act synergistically to place subgroups of women at higher levels of risk for oral diseases. For example, the comparative longevity of women, compromised physical status over time, and the combined effects of multiple chronic conditions often with multiple medications, can result in increased risk of oral disease (Redford 1993). Many women live in poverty, are not insured, and are the sole head of their household. For these women, obtaining needed oral health care may be difficult. In addition, gender-role expectations of women may also affect their interaction with dental care providers and could affect treatment recommendations as well (Redford 1993).

During the past decade, women's health has emerged as a significant issue in the nation's health agenda. The scientific community is beginning to respond to this concern by studying and reporting the effects of sex and gender differences on health and disease management. Although most of the effort has focused upon women, comparisons with men's health have begun to elucidate sex- and gender-specific differences.

Research has demonstrated sex and gender differences in the response to kappa opioid analgesics for the control of postoperative pain (Gear et al. 1996). These findings have heightened conjecture about differences in the female and male nervous systems in response to pain stimuli. There are studies in mice that suggest that there are sex-specific responses to pain and analgesics (Mogil et al. 1996, 1997). Taken together, these findings could help explain why women report certain painful conditions more than men; for example, temporomandibular joint disorders, trigeminal neuralgia, migraine headaches, and burning mouth syndrome (USDHHS 1999).

Recent research has also demonstrated sex and gender differences in taste perception. Women are more likely than men to be "supertasters" of a bitter compound known as 6-n-propylthyiouracil (PROP) (Bartoshuk et al. 1994). PROP supertasters experience more intense tastes (particularly for bitter and sweet), a greater sensation of oral burning in response to alcohol, and more intense sensations from fats in food (Bartoshuk et al. 1994, 1996, Tepper and Nurse 1997). PROP supertasters also have more fungiform papillae on their tongues than medium PROP tasters or those who cannot taste PROP at all.

The Agenda for Research on Women's Health for the 21st Century noted that the ability to interpret oral health in the context of sex and gender was limited by large gaps in knowledge. For example, pertinent oral health data, even at the descriptive level, are partial or nonexistent for many conditions and diseases for either sex. In addition, limited knowledge of etiologic factors, natural history of diseases, behavioral and environmental differences—to name a few—decreases the utility of those data that are available. For example, women are reported to be more inclined to self-care, to visit the dentist more often, and to be more likely to report symptoms such as pain. However, the effects of these behaviors on their oral health status cannot be determined fully. Figure 4.24 suggests content areas in the study of women's oral health.

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Individuals with Disabilities

No national studies have been conducted to determine the prevalence of oral and craniofacial diseases among the various populations with disabilities. Several local and regional reports, however, provide some relevant data in this regard. For example, some smaller-scale studies show that the population with mental retardation or other developmental disabilities has significantly higher rates of poor oral hygiene and needs for periodontal disease treatment than the general population, due, in part, to limitations in individual understanding of and physical ability to perform personal prevention practices or to obtain needed services. There is a wide range of caries rates among people with disabilities, but overall their rates are higher than those of people without disabilities. Much of the variation stems from where people reside (e.g., in large institutions where services are available versus in the community where services must be secured from community practitioners). Almost two thirds of community-based residential facilities report that inadequate access to dental care is a significant issue (Beck and Hunter 1985, White et al. 1995, Waldman et al. 1998, Dwyer, Northern Wisconsin Center for the Developmentally Disabled unpublished data, 1996). Parents consistently report dental care as one of the top needed services for their children with disabilities regardless of age (Haveman et al. 1997). Local studies of independent living centers reported that 24 to 30 percent of adults with cerebral palsy, 14 percent with spinal cord injuries, 30 percent with head injuries, and 17 percent who were deaf had dental problems (Arnett 1994). Results from 1999 oral assessments of U.S. Special Olympics athletes (all ages), based on an extremely conservative assessment protocol (without the use of x-rays, mirrors, or explorers), and carried out by the Special Olympics Special Smiles Program in 20 states, indicate that 12.9 percent of the athletes reported some form of oral pain, 39 percent demonstrated signs of gingival infection, and nearly 25 percent had untreated decay (Special Olympics, Inc., unpublished data). Note that this is a population that tends to be from higher-income families.

The oral health problems of individuals with disabilities are complex. These problems may be due to underlying congenital anomalies as well as to inability to receive the personal and professional health care needed to maintain oral health. There are more than 54 million individuals defined as disabled under the Americans with Disabilities Act, including almost a million children under age 6 and 4.5 million children between 6 and 16 years of age. A greater percentage of males than females and of African Americans than Hispanics and whites have disabilities (Federal Interagency Forum 1997, Waldman et al. 1999). Children with disabilities have chronic physical, developmental, behavioral, and emotional limitations, including mental retardation, autism, attention deficit hyperactivity disorders, and cerebral palsy. Also, children from families with incomes below the poverty level are about one third more likely than children in nonpoor families to have an existing special health care need. Similarly, children from less educated households exhibit a higher likelihood of a special health care need. Children in single-parent families are about 40 percent more likely than children from two-parent households to have special health care needs (Newacheck et al. 1998). Deinstitutionalization has resulted in highlighting the problem these individuals have regarding access to dental care as they move from childhood to adulthood. Availability of dental providers trained to serve special needs populations and limited third-party support for the delivery of complex services (see Chapter 9) further complicate the issues entailed in addressing the needs of this population.

Given the wide variability among groups with disabilities, this review of oral health status and needs is quite limited. More in-depth assessment and analysis of the determinants of oral health status, access to care, and the role of oral health in the overall quality of life and life expectancy of individuals with disabilities are needed (see Chapter 10).

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UTILIZATION OF PROFESSIONAL CARE: WHAT DO WE KNOW ABOUT THE RELATIONSHIP OF ORAL HEALTH AND USE OF DENTAL SERVICES?

With few exceptions, maintenance of oral health through a lifetime requires timely receipt of advice for self-care, preventive therapies, early detection and treatment of problems, and restoration of function. Chapter 7 describes community-based and professional interventions that have played a significant role in the improvement of oral health achieved over the past 50 years; their full promise has not, however, been realized. Chapter 8 describes current and emerging strategies for personal and provider approaches to maintain and restore oral health, with tooth-conserving approaches being employed more and more frequently. As noted earlier, almost everyone experiences oral diseases and conditions over the course of a lifetime, and, unlike the common cold, most diseases do not resolve over time. Consequently, receipt of dental services complements self-care as a critical factor in achieving and maintaining good oral health.

Although certain counseling and screening services provided by physicians are recommended (U.S. Preventive Services Task Force 1996), data to indicate how many persons receive such services or oral-health-related recommendations from their physician are very limited. There are also no data on physician-based services for oral and craniofacial conditions. The data that are available describe utilization of dental visits. Unfortunately, most of these data are cross-sectional, describing the experience of the population in any given year, but providing little detail about how patterns of care over time contribute to oral health. Nevertheless, utilization of care is used as a surrogate measure of an individual's or a population's capacity to maintain or improve health status. An understanding of utilization of dental visits and differences in such visits among age, racial/ethnic, sex, and income groups is important in identifying opportunities for improvement in oral health that would follow from timely receipt of professional care.

Characteristics of groups with different levels of dental care utilization suggest barriers to care as well as factors that predispose or enable access to dental care. Explanations for variation in utilization are alluded to in the following section, and are discussed in further detail in Chapter 10. More studies are needed to understand the dimensions of disease and the role of professional care and use of services. Also, for oral health in particular, the contributions of all health professions and the interdisciplinary nature of care need to be emphasized.

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Dental Care Utilization

Visiting a health care provider at least once per year and the number of visits made within the past year are used as indicators of an individual's ability to access professional services. Dental care utilization statistics are traditionally based on an individual's reporting "at least one dental visit in the past year," although there are variations with shorter recall intervals and different forms of the question. Depending on the question and survey method, annual dental care use estimates vary. The 1996 Medical Expenditures Panel Survey (MEPS) estimates that 43 percent of the U.S. population 2 years and older had at least one dental visit that year (MEPS 2000). Responding to a variation of a question that had been asked in many previous surveys, some 65.1 percent of the U.S. population 2 years and older reported in 1997 that they had visited a dentist in the preceding year (NCHS 1997b), up from 55.0 percent in 1983 (Bloom et al. 1992). The average number of visits per person remains at about two per year. Further research is needed to understand reasons for variations in estimates from different survey approaches, but differences among persons with different characteristics are quite similar regardless of survey method.

Data from the 1997 National Health Interview Survey, reprinted in Healthy People 2010, indicate that the highest percentage reporting at least one dental visit was third-grade children (82 percent). Those aged 25 years and older with less than a high school education had the lowest rates (41 percent) for annual dental visits as compared to those with at least some college education (74 percent) (USDHHS 2000).

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Variation by Sex, Race/Ethnicity, Income, and Insurance

Dental care utilization varies with sex and race/ethnicity for individuals 25 and older (NCHS 1997a). Females had slightly higher rates of utilization (67 percent) than males (63 percent). Hispanic individuals had the lowest utilization (53 percent), and non-Hispanic whites had the highest rates (68 percent). Table 4.3 provides an overview of utilization from 1983 through 1993. A higher percentage of females reported a dental visit than males in each survey year. Fewer non-Hispanic blacks and Hispanics reported a dental visit than non-Hispanic whites in each survey year. Income and education are also key variables in utilization. In 1993, almost twice as many individuals 25 and older living at or above the poverty line had a dental visit than did those living below the poverty line in 1993 (64.3 versus 35.9 percent). Similarly, almost twice as many individuals with 13 years or more of education had a visit than did those with fewer than 12 years of education (73.8 versus 38.0 percent) in that same year.

Data from the 1989 National Health Interview Survey showed that the overall age-adjusted number of visits for blacks was 1.2 visits compared to 2.2 visits for whites (Bloom et al. 1992).

Table 4.4 shows the percentage distributions of the interval since their most recent dental visit for people aged 2 and older in selected demographic and socioeconomic categories. Individuals who have never visited a dentist ranged from a high of 13.1 percent of Mexican Americans to 5.8 percent of blacks and 4.4 percent of whites. Eleven percent of the population had not had a dental visit in 5 years or more. Individuals with fewer than 9 years of education represented the highest proportion, 30.6 percent, of those reporting no dental visit in 5 years or more, compared with 6.9 percent of those with 13 years or more of education. A larger proportion of individuals without private dental insurance had not had a dental visit in 5 years or more compared with those with private dental insurance (14.2 versus 6.6 percent). Hispanic individuals have the lowest rate of dental insurance coverage—29.0 percent, compared with 32.4 percent for non-Hispanic blacks and 41.8 percent for non-Hispanic whites (U.S. Bureau of the Census 1997).

Professional care is necessary for several critical dental disease prevention measures, such as the application of dental sealants. Unfortunately, dental sealants are 3 times less likely to be found on the teeth of Mexican American and African American children than among white children aged 5 to 17 (Selwitz et al. 1996). Asian and Pacific Islander American children in California also demonstrated a low rate of sealant use (Pollick et al. 1997).

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Variation by Oral Health Status

Utilization of dental care is associated with self-reported health status, as shown in Table 4.5. Of those who reported "excellent" or "very good" health, 61.4 percent had had a dental visit within the past year, compared with about 45.1 percent of those reporting "fair" or "poor" health. Functional limitations are also related to dental service utilization. Of those who reported no physical limitations in activities, 58.5 percent reported a dental visit within the past year, compared to 46.6 percent of those who were unable to carry out their usual activities (Table 4.5) (Bloom et al. 1992).

Whether a person had natural teeth was strongly associated with dental care utilization (Table 4.5). Dentate persons were more than 4 times more likely to report a dental visit within the past year than edentulous people: 65.5 versus 14.3 percent. Over half (55.2 percent) of those who were edentulous reported that they had not had a dental visit in 5 years or more.

Recent analyses of data from NHANES III show that adults 18 and older who reported a dental visit in the past 12 months were nearly 9 times more likely to be dentate and 4.4 times more likely to have a complete dentition than adults who did not report visiting a dentist within the preceding 12 months. Dentate adults who reported a dental visit in the past 12 months were 3.1 times less likely to have untreated coronal decay and 1.5 times less likely to have gingivitis than dentate adults who did not report a recent dental visit (T. Drury, NIDCR, personal communication, 1999).

A study comparing individuals who had had a dental visit in the past 12 months with those who had not reported that dentate adults who had a recent visit were less likely to have untreated coronal and root caries, pulpal pathology, and retained tooth roots. They also were more likely to rate the general condition of their teeth and gums as excellent or very good (Drury and Redford 2000).

Examination of NHANES III data by low socioeconomic status (SES) provides an additional perspective. In a recent analysis, SES was measured by a composite index based on educational attainment and the ratio of annual family income to the poverty threshold. Among all adults, people with lower SES scores were nearly 9 times more likely to be edentulous than those with higher SES scores. Among the dentate, those with lower SES scores were 6 times more likely to have coronal decay and nearly 4 times less likely to have visited a dentist in the past 12 months (Drury et al. 1999).

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Reasons for Nonutilization

Reasons for nonutilization of dental services are complex. Principal reasons cited by respondents of all ages (Bloom et al. 1992) are given in Table 4.6. Slightly less than half of those reporting no dental visit in the past year (46.8 percent) said that they perceived having no dental problem. This perception was the predominant response of individuals in all demographic categories, except for those 65 and older, who gave having no teeth as the predominant reason. Younger individuals were more likely than older to cite "no dental problem." Blacks were more likely to report "no problems" (58.5 percent) as a reason for no dental visit, compared to 44.3 percent of whites (Bloom et al. 1992).

Having no teeth (14.3 percent) was the next most frequently reported reason for no dental visit. About half of the people 65 and older in the 1989 survey gave this as their reason for no dental visit—39.2 percent of blacks compared to 51.2 percent of whites.

The third most frequently cited reason was the cost of care, mentioned by 13.7 percent of respondents. Whites (14.3 percent) were more likely than blacks (11.4 percent) to cite cost. Other surveys have reported substantially higher percentages of individuals indicating cost as a barrier, particularly those in underserved or low-income areas (Bloom et al. 1992). The age group most sensitive to the cost of care was 18- to 34-year-olds, 19.1 percent of whom gave cost as the reason for no dental visit. Finally, a small proportion of respondents (4.3 percent) reported fear as a personal barrier to receipt of care.

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Unmet Needs

Unmet health needs can be assessed in many ways. Because oral diseases are common and do not resolve over time in the absence of intervention, the lack of dental visits is used as an indicator of unmet health needs. In addition, the National Access to Care Survey documented the extent of dental care that individuals wanted but could not obtain ("wants") in the total population and among various population subgroups (Mueller et al. 1998). About 8.5 percent of the U.S. population wanted, but did not obtain, dental care in 1994 (Table 4.7). In contrast, only 5.6 percent reported unmet medical or surgical care wants. Adult women aged 19 to 64 reported the greatest level of dental care wants; elderly people 65 and older had the lowest level. Blacks, people in fair or poor health or with one or more chronic conditions, and people living in the South reported higher levels of dental care wants than comparable groups. About 16.4 percent of those in households whose family income was less than 150 percent of the poverty level reported dental care wants. More than 22 percent of the uninsured reported dental care wants. Insured children with special health care needs were 4 times more likely to report unmet need for dental care (23.9 percent versus 6.1 percent) if they were uninsured than if they were insured, according to a recent analysis of data from the National Health Interview Survey (Newacheck et al. 2000).

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Outcomes of Appropriate Levels of Access and Utilization: An Example

The effects on health of a system of care with assured access and positive expectations of care-seeking and utilization behavior have been demonstrated by the U.S. Department of Defense. There are currently over 1.4 million men and women on active duty in the U.S. military. The population is predominantly male (86 percent). The racial distribution is 68 percent white, 20 percent black, 7 percent Hispanic, 3 percent Asian, and 2 percent other groups. Slightly over 30 percent of active duty personnel are between the ages of 20 and 24, and 91 percent are younger than 40. In 1997, 59 percent were married. Seventy-six percent had a high school degree, and 19 percent were college graduates.

Free dental care, one of the benefits provided to active duty military personnel, eliminates one of the significant barriers that has been identified as limiting access to care for many in the civilian population. In addition, military personnel are required to receive a dental examination annually, even if the individual perceives that he or she has "no problem." Dental care is available to most military personnel at their duty station, eliminating the need to travel long distances. A comparison of the oral health and utilization of dental care of the military and civilian populations illustrates the impact of elimination of these barriers to care on oral health, even for persons from demographic groups that are traditionally underserved.

In 1994 the Tri-Service Comprehensive Oral Health Survey examined and administered questionnaires to 13,050 active duty military personnel using a complex, weighted survey design to examine the oral health status, dental treatment needs, dental utilization, and perceived need for care in this population (York et al. 1995). The study found that nearly all (99.2 percent) active duty military personnel had seen a dentist within the past 2 years. Eighty percent of active duty personnel received a dental examination within the past year, 60 percent had a dental prophylaxis, and 29 percent had at least one tooth filled.

Edentulism is virtually nonexistent in the active duty military population. Also, active duty military personnel have a significantly lower proportion of their decayed, missing, and filled surfaces that are untreated; this is primarily due to dramatic improvements in the oral health of active duty blacks when compared to their civilian counterparts. Active duty whites also have somewhat better oral health than white civilians of a similar age.

The relative proportion of unfilled surfaces as a component of decayed and filled tooth surfaces in the military and civilian populations is illustrated in Figure 4.25.

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ORAL HEALTH STATUS IN CHANGING TIMES

The burden of oral diseases and conditions in the United States is extensive and affects persons throughout their life span. Birth defects such as cleft lip/palate, dental caries, and facial trauma are common in the young. Periodontal diseases, autoimmune disorders, and other chronic disabling conditions are seen in adults, while complete tooth loss and oral cavity and pharyngeal cancers are seen more often in older Americans. Because the most common oral disease, dental caries, is so widespread in the population, nearly every American has experienced oral disease.

The effects of oral diseases and conditions on quality of life and well-being are discussed in Chapter 6. In sum, conditions such as cleft lip and palate and oral cancer not only involve costly and difficult surgeries and treatments, they also alter facial appearance and impair oral functioning. Pain disorders and pain as a consequence of dental disease are prevalent in certain groups and can affect daily living.

The available trend data reveal improvements in dental health for most Americans; however, despite improvements in dental status, disparities remain. Diseases disproportionately affect some sex, income, and racial/ethnic groups, and the magnitude of the differences is striking. All the reasons for these disparities are not clear. Some of the most common dental diseases, such as dental caries, are preventable (prevention of oral diseases and conditions is presented in Chapters 8 and 9). It appears, however, that not all individuals are benefiting from interventions that involve professional care, as represented by the data on dental visits. At the same time, as presented in Chapter 7, about 40 percent of the public does not receive the benefits of community water fluoridation. The emerging data on the effects of socioeconomic status on oral health are beginning to explain some, but not all, racial/ethnic differences. For other diseases, health disparities appear not to be related to professional services; a better understanding of the reasons for these differences is needed.

This review of available data on oral diseases and conditions also reveals the lack or limitation of national or state data on oral diseases for many population subgroups and for many conditions that affect the craniofacial structures. Information on the variables needed to explain health status differences, such as detailed utilization and expenditure data and data on services rendered, is limited as well. Data on specific services—self-care, services provided by professionals, and services that are community-based—are needed to understand the dimensions of oral health. (Some of these services are described in Chapters 7 and 8.) Although some data on expenditures for care and health care personnel are available to (Chapter 9) complement the statistics needed to assess oral health in the United States, almost all these data come from cross-sectional surveys that do not allow for analysis of the outcomes of disease and related care.

Available state data reveal variations within and among states in patterns of oral health and disease among population groups. Having state-specific and local data that augment national data is critical in identifying high-risk populations and areas and in addressing health disparities. These data also are vital in program evaluation, planning, and policy decisions. Yet state and local data are almost nonexistent. In recent years, the need for state and local data has intensified as more programs are funded by local authorities and responsibilities are shifted from national to state-based levels.

The nation's health information system is undergoing constant change to meet the current and future needs for health information. Consequently, many factors influence how and what data are collected and analyzed. These factors include emerging technologies, legislation about how data are to be collected, and confidentiality and privacy concerns.

The need for epidemiologic and surveillance data change as the understanding of specific diseases and conditions evolves and as society's goals and priorities change. The increasing focus on the long-term benefits of disease prevention and health promotion and the need to close the gap on disparities also affects how and what data are collected. For example, major initiatives such as the Department of Health and Human Services's Healthy People 2010 have provided a framework for data collection and analysis tied to specific objectives and have helped identify needs for new health data systems. The Healthy People initiative now includes objectives for the nation's health status as well as for preventive interventions and objectives that would improve infrastructure and capacity building to provide the necessary services and monitoring.

This overview of the magnitude of oral diseases and conditions in America raises many questions still to be researched. If certain oral diseases are preventable, why do we have populations with extensive and untreated disease? Once socioeconomic factors are controlled, why do we see differences in services received? Why are some conditions more prevalent in certain populations than in others? How will the rapidly changing and projected demographics of America contribute to future trends in oral and craniofacial health and disease? These and many other questions require more research, new databases, and an active and trained group of researchers.

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FINDINGS

  • Over the past five decades, major improvements in oral health have been seen nationally for most Americans.

  • Despite improvements in oral health status, profound disparities remain in some population groups as classified by sex, income, age, and race/ethnicity. For some diseases and conditions, the magnitude of the differences in oral health status among population groups is striking.

  • Oral diseases and conditions affect people throughout their life span. Nearly every American has experienced the most common oral disease, dental caries.

  • Conditions that severely affect the face and facial expression, such as birth defects, craniofacial injuries, and neoplastic diseases, are more common in the very young and in the elderly.

  • Oral-facial pain can greatly reduce quality of life and restrict major functions. Pain is a common symptom for many of the conditions affecting oral-facial structures.

  • National and state data for many oral and craniofacial diseases and conditions and for population groups are limited or nonexistent. Available state data reveal variations within and among states in patterns of health and disease among population groups.

  • Research is needed to develop better measures of disease and health, to explain the differences among population groups, and to develop interventions targeted at eliminating disparities.

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1 In this section, income levels are defined as low (less than 185 percent of the U.S. poverty level or below), middle (185.1 percent to 350 percent of the poverty level), and high (350.1 percent of the poverty level or higher). return to text


2 This section reports national data that should provide some estimation of the scope of craniofacial injuries in the population. However, the findings may not be directly comparable because they are from different sources and different times, and because those at risk for each type of injury are not quantified in most cases. return to text

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