Publication of this first Surgeon General's Report on Oral Health marks a milestone in the history of oral health in America. The report elaborates on the meaning of oral health and explains why oral health is essential to general health and well-being. In the course of the past 50 years, great progress has been made in understanding the common oral diseases—dental caries (tooth decay) and periodontal (gum) diseases—resulting in marked improvements in the nation's oral health. Most middle-aged and younger Americans expect to retain their natural teeth over their lifetime and do not expect to have any serious oral health problems.
The major message of this Surgeon General's report is that oral health is essential to the general health and well-being of all Americans and can be achieved by all Americans. However, not all Americans are achieving the same degree of oral health. In spite of the safe and effective means of maintaining oral health that have benefited the majority of Americans over the past half century, many among us still experience needless pain and suffering, complications that devastate overall health and well-being, and financial and social costs that diminish the quality of life and burden American society. What amounts to "a silent epidemic" of oral diseases is affecting our most vulnerable citizens—poor children, the elderly, and many members of racial and ethnic minority groups (GAO 2000). (See box entitled "The Burden of Oral Diseases and Disorders.")
The word oral refers to the mouth. The mouth includes not only the teeth and the gums (gingiva) and their supporting tissues, but also the hard and soft palate, the mucosal lining of the mouth and throat, the tongue, the lips, the salivary glands, the chewing muscles, and the upper and lower jaws. Equally important are the branches of the nervous, immune, and vascular systems that animate, protect, and nourish the oral tissues, as well as provide 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 and their joints function like other musculoskeletal 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 the oral-systemic disease connections.
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 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.
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, decline in decay was evident for many Americans. The application of science to improve 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 diseases 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 researching 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. Standards established to determine the quality of the evidence, based on the study design and its rigor, were used where appropriate. 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 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 Chapter 5, tables present information on the association of oral infections and systemic conditions, and in Chapter 7, tables exhibit oral disease prevention and health promotion measures. 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.
The report was generated with the advice and support of a Federal Coordinating Committee composed of representatives of agencies with oral health components and interests. The chapters were based on papers submitted by experts working under the guidance of a coordinating author for each chapter. Independent peer review was conducted for all sections of the report at various stages in the process, and the full manuscript was reviewed by a number of senior reviewers as well as the relevant federal agencies. All who contributed are listed in the Acknowledgments section of the full report.
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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.
Part One: What Is Oral Health?
The meaning of oral health is explored in Chapter 1, and the interdependence of oral health with general health and well-being is 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. Our craniofacial complex has evolved to have remarkable functions and abilities to adapt, enabling us to meet the challenges of an ever-changing environment. An examination of the various tissues reveals elaborate designs that serve complex needs and functions, including the uniquely human function of speech. The rich distribution of nerves, muscles, and blood vessels in the region as well as extensive endocrine and immune system connections are indicators of the vital role of the craniofacial complex in adaptation and survival over a long life span. In particular, the following findings are noted:
- Genes controlling the basic patterning and segmental organization of human development, and specifically the craniofacial complex, are highly conserved in nature. Mutated genes affecting human development have counterparts in many simpler organisms.
- There is considerable reserve capacity or redundancy in the cells and tissues of the craniofacial complex, so that if they are properly cared for, the structures should function well over a lifetime.
- The salivary glands and saliva subserve tasting and digestive functions and also participate in the mucosal immune system, a main line of defense against pathogens, irritants, and toxins.
- Salivary components protect and maintain oral tissues through antimicrobial components, buffering agents, and a process by which dental enamel can be remineralized.
Part Two: 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. The findings include:
- Microbial infections, including those caused by bacteria, viruses, and fungi, are the primary cause of the most prevalent oral diseases. Examples include dental caries, periodontal diseases, herpes labialis, and candidiasis.
- The etiology and pathogenesis of diseases and disorders affecting the craniofacial structures are multifactorial and complex, involving an interplay among genetic, environmental, and behavioral factors.
- Many inherited and congenital conditions affect the craniofacial complex, often resulting in disfigurement and impairments that may involve many body organs and systems and affect millions of children worldwide.
- Tobacco use, excessive alcohol use, and inappropriate dietary practices contribute to many diseases and disorders. In particular, tobacco use is a risk factor for oral cavity and pharyngeal cancers, periodontal diseases, candidiasis, and dental caries, among other diseases.
- Some chronic diseases, such as Sjögren's syndrome, present with primary oral symptoms.
- Oral-facial pain conditions are common and often have complex etiologies.
Chapter 4 constitutes an oral health status report card for the United States, describing the magnitude of the problem. Where data permit, the chapter also describes the oral health of selected population groups, as well as their dental visit behavior. The findings include:
- 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.
Part Three: What Is the Relationship Between Oral Health and General Health and Well-being?
Chapters 5 and 6 address key issues in the report's charge—the relationship of oral health to general health and well-being. Chapter 5 explores the theme of the mouth as reflecting general health or disease status. Examples are given of how oral tissues may signal the presence of disease, disease progression, or exposure to risk factors, 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 final sections review the literature regarding emerging associations between oral diseases and diabetes, heart disease and stroke, and adverse pregnancy outcomes. The findings include:
- Many systemic diseases and conditions have oral manifestations. These manifestations may be the initial sign of clinical disease and as such serve to inform clinicians and individuals of the need for further assessment.
- The oral cavity is a portal of entry as well as the site of disease for microbial infections that affect general health status.
- The oral cavity and its functions can be adversely affected by many pharmaceuticals and other therapies commonly used in treating systemic conditions. The oral complications of these therapies can compromise patient compliance with treatment.
- Individuals such as immunocompromised and hospitalized patients are at greater risk for general morbidity due to oral infections.
- Individuals with diabetes are at greater risk for periodontal diseases.
- Animal and population-based studies have demonstrated an association between periodontal diseases and diabetes, cardiovascular disease, stroke, and adverse pregnancy outcomes. Further research is needed to determine the extent to which these associations are causal or coincidental.
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. The chapter introduces anthropological and ethnographic literature to underscore the cultural values and symbolism attached to facial appearance and teeth. An examination of efforts to characterize the functional and social implications of oral and craniofacial diseases reveals the following findings:
- Oral health is related to well-being and quality of life as measured along functional, psychosocial, and economic dimensions. Diet, nutrition, sleep, psychological status, social interaction, school, and work are affected by impaired oral and craniofacial health.
- Cultural values influence oral and craniofacial health and well-being and can play an important role in care utilization practices and in perpetuating acceptable oral health and facial norms.
- Oral and craniofacial diseases and their treatment place a burden on society in the form of lost days and years of productive work. Acute dental conditions contribute to a range of problems for employed adults, including restricted activity, bed days, and work loss, and school loss for children. In addition, conditions such as oral and pharyngeal cancers contribute to premature death and can be measured by years of life lost.
- Oral and craniofacial diseases and conditions contribute to compromised ability to bite, chew, and swallow foods; limitations in food selection; and poor nutrition. These conditions include tooth loss, diminished salivary functions, oral-facial pain conditions such as temporomandibular disorders, alterations in taste, and functional limitations of prosthetic replacements.
- Oral-facial pain, as a symptom of untreated dental and oral problems and as a condition in and of itself, is a major source of diminished quality of life. It is associated with sleep deprivation, depression, and multiple adverse psychosocial outcomes.
- Self-reported impacts of oral conditions on social function include limitations in verbal and nonverbal communication, social interaction, and intimacy. Individuals with facial disfigurements due to craniofacial diseases and conditions and their treatments may experience loss of self-image and self-esteem, anxiety, depression, and social stigma; these in turn may limit educational, career, and marital opportunities and affect other social relations.
- Reduced oral-health-related quality of life is associated with poor clinical status and reduced access to care.
Part Four: 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 health promotion and disease prevention measures with a focus on community efforts in preventing oral disease. It continues with a discussion of the knowledge and practices of the public and health care providers and indicates opportunities for broad-based and targeted health promotion. The findings include:
- Community water fluoridation, an effective, safe, and ideal public health measure, benefits individuals of all ages and socioeconomic strata. Unfortunately, over one third of the U.S. population (100 million people) are without this critical public health measure.
- Effective disease prevention measures exist for use by individuals, practitioners, and communities. Most of these focus on dental caries prevention, such as fluorides and dental sealants, where a combination of services is required to achieve optimal disease prevention. Daily oral hygiene practices such as brushing and flossing can prevent gingivitis.
- Community-based approaches for the prevention of other oral diseases and conditions, such as oral and pharyngeal cancers and oral-facial trauma, require intensified developmental efforts.
- Community-based preventive programs are unavailable to substantial portions of the underserved population.
- There is a gap between research findings and the oral disease prevention and health promotion practices and knowledge of the public and the health professions.
- Disease prevention and health promotion approaches, such as tobacco control, appropriate use of fluorides for caries prevention, and folate supplementation for neural tube defect prevention, highlight opportunities for partnerships between community-based programs and practitioners, as well as collaborations among health professionals.
- Many community-based programs require a combined effort among social service, health care, and education services at the local or state level.
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. The findings include:
- Achieving and maintaining oral health require individual action, complemented by professional care as well as community-based activities.
- Individuals can take actions, for themselves and for persons under their care, to prevent disease and maintain health. Primary prevention of many oral, dental, and craniofacial diseases and conditions is possible with appropriate diet, nutrition, oral hygiene, and health-promoting behaviors, including the appropriate use of professional services. Individuals should use a fluoride dentifrice daily to help prevent dental caries and should brush and floss daily to prevent gingivitis.
- All primary care providers can contribute to improved oral and craniofacial health. Interdisciplinary care is needed to manage the oral health–general health interface. Dentists, as primary care providers, are uniquely positioned to play an expanded role in the detection, early recognition, and management of a wide range of complex oral and general diseases and conditions.
- Nonsurgical interventions are available to reverse disease progression and to manage oral diseases as infections.
- New knowledge and the development of molecular and genetically based tests will facilitate risk assessment and management and improve the ability of health care providers to customize treatment.
- Health care providers can successfully deliver tobacco cessation and other health promotion programs in their offices, contributing to both overall health and oral health.
- Biocompatible rehabilitative materials and biologically engineered tissues are being developed and will greatly enhance the treatment options available to providers and their patients.
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 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.
- Dental, medical, and public health delivery systems each provide services that affect oral and craniofacial health in the U.S. population. Clinical oral health care is predominantly provided by a private practice dental workforce.
- Expenditures for dental services alone made up 4.7 percent of the nation's health expenditures in 1998—$53.8 billion out of $1.1 trillion. These expenditures underestimate the true costs to the nation, however, because data are unavailable to determine the extent of expenditures and services provided for craniofacial health care by other health providers and institutions.
- The public health infrastructure for oral health is insufficient to address the needs of disadvantaged groups, and the integration of oral and general health programs is lacking.
- Expansion of community-based disease prevention and lowering of barriers to personal oral health care are needed to meet the needs of the population.
- Insurance coverage for dental care is increasing but still lags behind medical insurance. For every child under 18 years old without medical insurance, there are at least two children without dental insurance; for every adult 18 years or older without medical insurance, there are three without dental insurance.
- Eligibility for Medicaid does not ensure enrollment, and enrollment does not ensure that individuals obtain needed care. Barriers include patient and caregiver understanding of the value and importance of oral health to general health, low reimbursement rates, and administrative burdens for both patient and provider.
- A narrow definition of "medically necessary dental care" currently limits oral health services for many insured persons, particularly the elderly.
- The dentist-to-population ratio is declining, creating concern as to the capability of the dental workforce to meet the emerging demands of society and provide required services efficiently.
- An estimated 25 million individuals reside in areas lacking adequate dental care services, as defined by Health Professional Shortage Area (HPSA) criteria.
- Educational debt has increased, affecting both career choices and practice location.
- Disparities exist in the oral health profession workforce and career paths. The number of underrepresented minorities in the oral health professions is disproportionate to their distribution in the population at large.
- Current and projected demand for dental school faculty positions and research scientists is not being met. A crisis in the number of faculty and researchers threatens the quality of dental education; oral, dental, and craniofacial research; and, ultimately, the health of the public.
- Reliable and valid measures of oral health outcomes do not exist and need to be developed, validated, and incorporated into practice and programs.
Part Five: 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 socioeconomic 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 with an emphasis on barriers and ways to raise the level of oral health for children and older Americans. The findings include:
- The major factors that determine oral and general health and well-being are individual biology and genetics; the environment, including its physical and socioeconomic aspects; personal behaviors and lifestyle; access to care; and the organization of health care. These factors interact over the life span and determine the health of individuals, population groups, and communities—from neighborhoods to nations.
- The burden of oral diseases and conditions is disproportionately borne by individuals with low socioeconomic status at each life stage and by those who are vulnerable because of poor general health.
- Access to care makes a difference. A complex set of factors underlies access to care and includes the need to have an informed public and policymakers, integrated and culturally competent programs, and resources to pay and reimburse for the care. Among other factors, the availability of insurance increases access to care.
- Preventive interventions, such as protective head and mouth gear and dental sealants, exist but are not uniformly used or reinforced.
- Nursing homes and other long-term care institutions have limited capacity to deliver needed oral health services to their residents, most of whom are at increased risk for oral diseases.
- Anticipatory guidance and risk assessment and management facilitate care for children and for the elderly.
- Federal and state assistance programs for selected oral health services exist; however, the scope of services is severely limited, and their reimbursement level for oral health services is low compared to the usual fee for care.
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.
Chapter 12, the final chapter, iterates the themes of the report and groups the findings from the earlier chapters into eight major categories. These findings, as well as a suggested framework for action to guide the next steps in enhancing the oral health of the nation, are presented below.
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Oral diseases and disorders in and of themselves affect health and well-being throughout life. The burden of oral problems is extensive and may be particularly severe in vulnerable populations. It includes the common dental diseases and other oral infections such as cold sores and candidiasis that can occur at any stage of life, as well as birth defects in infancy and the chronic facial pain conditions and oral cancers seen in later years. Many of these conditions and their treatments may undermine self-image and self-esteem, discourage normal social interaction, cause other health problems, and lead to chronic stress and depression as well as incur great financial cost. They may also interfere with vital functions such as breathing, food selection, eating, swallowing, and speaking and with activities of daily living such as work, school, and family interactions.
Safe and effective measures exist to prevent the most common dental diseases—dental caries and periodontal diseases. Community water fluoridation is safe and effective in preventing dental caries in both children and adults. Water fluoridation benefits all residents served by community water supplies regardless of their social or economic status. Professional and individual measures, including the use of fluoride mouthrinses, gels, dentifrices, and dietary supplements and the application of dental sealants, are additional means of preventing dental caries. Gingivitis can be prevented by good personal oral hygiene practices, including brushing and flossing.
Lifestyle behaviors that affect general health such as tobacco use, excessive alcohol use, and poor dietary choices affect oral and craniofacial health as well. These individual behaviors are associated with increased risk for craniofacial birth defects, oral and pharyngeal cancers, periodontal disease, dental caries, and candidiasis, among other oral health problems. Opportunities exist to expand the oral disease prevention and health promotion knowledge and practices of the public through community programs and in health care settings. All health care providers can play a role in promoting healthy lifestyles by incorporating tobacco cessation programs, nutritional counseling, and other health promotion efforts into their practices.
There are profound and consequential oral health disparities within the U.S. population. Disparities for various oral conditions may relate to income, age, sex, race or ethnicity, or medical status. Although common dental diseases are preventable, not all members of society are informed about or able to avail themselves of appropriate oral-health-promoting measures. Similarly, not all health providers may be aware of the services needed to improve oral health. In addition, oral health care is not fully integrated into many care programs. Social, economic, and cultural factors and changing population demographics affect how health services are delivered and used, and how people care for themselves. Reducing disparities requires wide-ranging approaches that target populations at highest risk for specific oral diseases and involves improving access to existing care. One approach includes making dental insurance more available to Americans. Public coverage for dental care is minimal for adults, and programs for children have not reached the many eligible beneficiaries.
More information is needed to improve America's oral health and eliminate health disparities. We do not have adequate data on health, disease, and health practices and care use for the U.S. population as a whole and its diverse segments, including racial and ethnic minorities, rural populations, individuals with disabilities, the homeless, immigrants, migrant workers, the very young, and the frail elderly. Nor are there sufficient data that explore health issues in relation to sex or sexual orientation. Data on state and local populations, essential for program planning and evaluation, are rare or unavailable and reflect the limited capacity of the U.S. health infrastructure for oral health. Health services research, which could provide much needed information on the cost, cost-effectiveness, and outcomes of treatment, is also sorely lacking. Finally, measurement of disease and health outcomes is needed. Although progress has been made in measuring oral-health-related quality of life, more needs to be done, and measures of oral health per se do not exist.
The mouth reflects general health and well-being. The mouth is a readily accessible and visible part of the body and provides health care providers and individuals with a window on their general health status. As the gateway of the body, the mouth senses and responds to the external world and at the same time reflects what is happening deep inside the body. The mouth may show signs of nutritional deficiencies and serve as an early warning system for diseases such as HIV infection and other immune system problems. The mouth can also show signs of general infection and stress. As the number of substances that can be reliably measured in saliva increases, it may well become the diagnostic fluid of choice, enabling the diagnosis of specific disease as well as the measurement of the concentration of a variety of drugs, hormones, and other molecules of interest. Cells and fluids in the mouth may also be used for genetic analysis to help uncover risks for disease and predict outcomes of medical treatments.
Oral diseases and conditions are associated with other health problems.Oral infections can be the source of systemic infections in people with weakened immune systems, and oral signs and symptoms often are part of a general health condition. Associations between chronic oral infections and other health problems, including diabetes, heart disease, and adverse pregnancy outcomes, have also been reported. Ongoing research may uncover mechanisms that strengthen the current findings and explain these relationships.
Scientific research is key to further reduction in the burden of diseases and disorders that affect the face, mouth, and teeth. The science base for dental diseases is broad and provides a strong foundation for further improvements in prevention; for other craniofacial and oral health conditions the base has not yet reached the same level of maturity. Scientific research has led to a variety of approaches to improve oral health through prevention, early diagnosis, and treatment. We are well positioned to take these prevention measures further by investigating how to develop more targeted and effective interventions and devising ways to enhance their appropriate adoption by the public and the health professions. The application of powerful new tools and techniques is important. Their employment in research in genetics and genomics, neuroscience, and cancer has allowed rapid progress in these fields. An intensified effort to understand the relationships between oral infections and their management, and other illnesses and conditions is warranted, along with the development of oral-based diagnostics. These developments hold great promise for the health of the American people.
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A Framework for Action
All Americans can benefit from the development of a National Oral Health Plan to improve quality of life and eliminate health disparities by facilitating collaborations among individuals, health care providers, communities, and policymakers at all levels of society and by taking advantage of existing initiatives. Everyone has a role in improving and promoting oral health. Together we can work to broaden public understanding of the importance of oral health and its relevance to general health and well-being, and to ensure that existing and future preventive, diagnostic, and treatment measures for oral diseases and disorders are made available to all Americans. The following are the principal components of the plan:
Change perceptions regarding oral health and disease so that oral health becomes an accepted component of general health.
- Change public perceptions. Many people consider oral signs and symptoms to be less important than indications of general illness. As a result, they may avoid or postpone needed care, thus exacerbating the problem. If we are to increase the nation's capacity to improve oral health and reduce health disparities, we need to enhance the public's understanding of the meaning of oral health and the relationship of the mouth to the rest of the body. These messages should take into account the multiple languages and cultural traditions that characterize America's diversity.
- Change policymakers' perceptions. Informed policymakers at the local, state, and federal levels are critical in ensuring the inclusion of oral health services in health promotion and disease prevention programs, care delivery systems, and reimbursement schedules. Raising awareness of oral health among legislators and public officials at all levels of government is essential to creating effective public policy to improve America's oral health. Every conceivable avenue should be used to inform policymakers—informally through their organizations and affiliations and formally through their governmental offices—if rational oral health policy is to be formulated and effective programs implemented.
- Change health providers' perceptions. Too little time is devoted to oral health and disease topics in the education of nondental health professionals. Yet all care providers can and should contribute to enhancing oral health. This can be accomplished in several ways, such as including an oral examination as part of a general medical examination, advising patients in matters of tobacco cessation and diet, and referring patients to oral health practitioners for care prior to medical or surgical treatments that can damage oral tissues, such as cancer chemotherapy or radiation to the head and neck. Health care providers should be ready, willing, and able to work in collaboration to provide optimal health care for their patients. Having informed health care professionals will ensure that the public using the health care system will benefit from interdisciplinary services and comprehensive care. To prepare providers for such a role will involve, among other factors, curriculum changes and multidisciplinary training.
Accelerate the building of the science and evidence base and apply science effectively to improve oral health. Basic behavioral and biomedical research, clinical trials, and population-based research have been at the heart of scientific advances over the past decades. The nation's continued investment in research is critical for the provision of new knowledge about oral and general health and disease for years to come and needs to be accelerated if further improvements are to be made. Equally important is the effective transfer of research findings to the public and health professions. However, the next steps are more complicated. The challenge is to understand complex diseases caused by the interaction of multiple genes with environmental and behavioral variables—a description that applies to most oral diseases and disorders—and translate research findings into health care practice and healthy lifestyles.
This report highlights many areas of research opportunities and needs in each chapter. At present, there is an overall need for behavioral and clinical research, clinical trials, health services research, and community-based demonstration research. Also, development of risk assessment procedures for individuals and communities and of diagnostic markers to indicate whether an individual is more or less susceptible to a given disease can provide the basis for formulating risk profiles and tailoring treatment and program options accordingly.
Vital to progress in this area is a better understanding of the etiology and distribution of disease. But as this report makes clear, epidemiologic and surveillance databases for oral health and disease, health services, utilization of care, and expenditures are limited or lacking at the national, state, and local levels. Such data are essential in conducting health services research, generating research hypotheses, planning and evaluating programs, and identifying emerging public health problems. Future data collection must address differences among the subpopulations making up racial and ethnic groups. More attention must also be paid to demographic variables such as age, sex, sexual orientation, and socioeconomic factors in determining health status. Clearly, the more detailed information that is available, the better can program planners establish priorities and targeted interventions.
Progress in elucidating the relationships between chronic oral inflammatory infections, such as periodontitis, and diabetes and glycemic control as well as other systemic conditions will require a similar intensified commitment to research. Rapid progress can also occur with efforts in the area of the natural repair and regeneration of oral tissues and organs. Improvements in oral health depend on multidisciplinary and interdisciplinary approaches to biomedical and behavioral research, including partnerships among researchers in the life and physical sciences, and on the ability of practitioners and the public to apply research findings effectively.
Build an effective health infrastructure that meets the oral health needs of all Americans and integrates oral health effectively into overall health.The public health capacity for addressing oral health is dilute and not integrated with other public health programs. Although the Healthy People 2010 objectives provide a blueprint for outcome measures, a national public health plan for oral health does not exist. Furthermore, local, state, and federal resources are limited in the personnel, equipment, and facilities available to support oral health programs. There is also a lack of available trained public health practitioners knowledgeable about oral health. As a result, existing disease prevention programs are not being implemented in many communities, creating gaps in prevention and care that affect the nation's neediest populations. Indeed, cutbacks in many state budgets have reduced staffing of state and territorial dental programs and curtailed oral health promotion and disease prevention efforts. An enhanced public health infrastructure would facilitate the development of strengthened partnerships with private practitioners, other public programs, and voluntary groups.
There is a lack of racial and ethnic diversity in the oral health workforce. Efforts to recruit members of minority groups to positions in health education, research, and practice in numbers that at least match their representation in the general population not only would enrich the talent pool, but also might result in a more equitable geographic distribution of care providers. The effect of that change could well enhance access and utilization of oral health care by racial and ethnic minorities.
A closer look at trends in the workforce discloses a worrisome shortfall in the numbers of men and women choosing careers in oral health education and research. Government and private sector leaders are aware of the problem and are discussing ways to increase and diversify the talent pool, including easing the financial burden of professional education, but additional incentives may be necessary.
Remove known barriers between people and oral health services. This report presents data on access, utilization, financing, and reimbursement of oral health care; provides additional data on the extent of the barriers; and points to the need for public-private partnerships in seeking solutions. The data indicate that lack of dental insurance, private or public, is one of several impediments to obtaining oral health care and accounts in part for the generally poorer oral health of those who live at or near the poverty line, lack health insurance, or lose their insurance upon retirement. The level of reimbursement for services also has been reported to be a problem and a disincentive to the participation of providers in certain public programs. Professional organizations and government agencies are cognizant of these problems and are exploring solutions that merit evaluation. Particular concern has been expressed about the nation's children, and initiatives such as the State Children's Health Insurance Program, while not mandating coverage for oral health services, are a positive step. In addition, individuals whose health is physically, mentally, and emotionally compromised need comprehensive integrated care.
Use public-private partnerships to improve the oral health of those who still suffer disproportionately from oral diseases. The collective and complementary talents of public health agencies, private industry, social services organizations, educators, health care providers, researchers, the media, community leaders, voluntary health organizations and consumer groups, and concerned citizens are vital if America is not just to reduce, but to eliminate, health disparities. This report highlights variations in oral and general health within and across all population groups. Increased public-private partnerships are needed to educate the public, to educate health professionals, to conduct research, and to provide health care services and programs. These partnerships can build and strengthen cross-disciplinary, culturally competent, community-based, and community-wide efforts and demonstration programs to expand initiatives for health promotion and disease prevention. Examples of such efforts include programs to prevent tobacco use, promote better dietary choices, and encourage the use of protective gear to prevent sports injuries. In this way, partnerships uniting sports organizations, schools, the faith community, and other groups and leaders, working in concert with the health community, can contribute to improved oral and general health.
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The past half century has seen the meaning of oral health evolve from a narrow focus on teeth and gingiva to the recognition that the mouth is the center of vital tissues and functions that are critical to total health and well-being across the life span. The mouth as a mirror of health or disease, as a sentinel or early warning system, as an accessible model for the study of other tissues and organs, and as a potential source of pathology affecting other systems and organs has been described in earlier chapters and provides the impetus for extensive future research. Past discoveries have enabled Americans today to enjoy far better oral health than their forebears a century ago. But the evidence that not all Americans have achieved the same level of oral health and well-being stands as a major challenge, one that demands the best efforts of public and private agencies and individuals.
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Health Care Financing Administration (HCFA). National Health Expenditures projections: 1998-2008. Office of the Actuary. 2000 Apr 25.
U.S. Department of Health and Human Services (USDHHS). Healthy People 2010 (Conference Edition, in two volumes). Washington; 2000 Jan.
U.S. General Accounting Office (GAO). Oral health in low-income populations. GAO/HEHS-00-72. 2000 Apr.
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Caswell A. Evans DDS, MPH
Project Director and Executive Editor
Assistant Director, Los Angeles County Department of Health Services
Dushanka V. Kleinman DDS, MScD
National Institute of Dental and Craniofacial Research, National Institutes of Health
William R. Maas DDS, MPH, MS
Chief Dental Officer, U.S. Public Health Service
Director, Division of Oral Health, Centers for Disease Control and Prevention
Harold C. Slavkin DDS
Director, National Institute of Dental and Craniofacial Research, National Institutes of Health
Joan S. Wilentz MA
Science Writer and Editor
Roseanne Price ELS
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