The Magnitude of the Problem Hispanic subgroups. More than 20 different coun- tries 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 spe- cific 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 compa- rable to other survey findings of 16 to 20 percent and 29 percent early childhood caries among APIA chil- dren in Hawaii and California, respectively (Greer unpublished, Louie et al. 1990). A California study of 6- to 8-year-olds found dis- parities in the oral health status of APIA children in the state when compared to all children nationally. Among the California APIA children, 7.I 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 preva- lence 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 per- cent 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 meas- uring 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. Con- sequently, 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 (AVAN) are available through studies conducted by the Indian Health Service (IHS) (Niendorfs 1994). The AVAN people constitute about 1 percent of the U.S. population, or an esti- mated 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 AVAN 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 AVAN served by the IHS. By and large, this group represents AVAN people liv- ing 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 pop- ulation 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 AVAN children across the IHS, there was a significant decline in caries in the permanent den- tition and a significant increase in caries in the pri- mary dentition. Among children aged 2 to 5 years, the increase in decayed and filled primary teeth sur- faces went from 8.6 to 11.4. In general, AVAN popu- lations have much greater rates of dental caries and 76 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL periodontal disease in all age groups than the gener- al U.S. population. AVAN children aged 2 to 4 years have 5 times the rate of dental decay compared to all children, and 6- to 8-year-old AVAN 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 gen- eral U.S. population. Periodontal disease in AVAN adults is 2.5 times greater than in the general U.S. population. High prevalence rates of diabetes among AVAN populations are a significant contributing fac- tor 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 AWAN com- munities 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 den- tal 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 per- cent 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 oth- ers because of the way their teeth look. . Again, the available data allow for obtaining a picture only of the AVAN population residing on reservations where services, including dental servic- es, 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 AVANs lived below the poverty level. For some groups, diabetes and high rates of tobacco and alcohol use are preva- lent and contribute to poor oral health. 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, sta- tistical 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 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL The Magnitude of the Problem 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 in- juries, soft tissue pathologies, and salivary gland dys- functions 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 sub- groups of women at higher levels of risk for oral dis- eases. 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 dif- ferences 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 sys- tems in response to pain stimuli. There are studies in mice that suggest that there are sex-specific respons- es 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). 77 The Magnitude of the Problem 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 experi- ence 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. ioral and environmental differences-to name a few-decreases the utility of those data that are avail- able. 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. Individuals with Disabilities The Agenda for Research on Women`s Health for No national studies have been conducted to deter- the 2lst Century noted that the ability to interpret mine the prevalence of oral and craniofacial diseases oral health in the context of sex and gender was lim- among the various populatiops with disabilities. ited by large gaps in knowledge. For example, perti- Several local and regional reports, however, provide nent oral health data, even at the descriptive level, are some relevant data in this regard. For example, some partial or nonexistent for many conditions and dis- smaller-scale studies show that the population with eases for either sex. In addition, limited knowledge of mental retardation or other developmental disabili- etiologic factors, natural history of diseases, behav- ties has significantly higher rates of poor oral hygiene FIGURE 4.24 Content areas in the study of women's health Oral Influences on Systemic Health Evidence for links between oral infection and diabetes Women and the Health Care System Treatment decision making lization of professional services Systemic influences on Oral Health Longevity Multiple chronic conditions Medication usage - Cognitive impairments Physical confinement Compromised functional status Postmenopausal bone loss HIV Diabetes Diseases More Common in Women Than Men TMD, oral-facial pain, Sjogren's / syndrome,saiivary gland dysfunction, burning mouth, alterations in taste, pregnancy-associated oral changes Societal Influences on Women's Caregiving Poverty Gender role expectations Underinsurance Concern for aesthetics Access to care Craniofacial trauma Oral Diseases Affecting the Most Women Caries Periodontal diseases \ Gender Influences on Health Risk Dental care utilization Self-care Eating disorders Unprotected sexual activity Source: Adapted from Chesney and Ozer 1995 and reprinted in USOHHS 1999. 78 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 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 cen- ters 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 conserva- tive assessment protocol (without the use of x-rays, mirrors, or explorers), and carried out by the Special Olympics Special Smiles Program in 20 states, indi- cate 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 untreat- ed 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 dis- abilities are complex. These problems may be due to underlying congenital anomalies as well as to inabil- ity 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 chil- dren between 6 and 16 years of age. A greater per- centage of males than females and of African Americans than Hispanics and whites have disabili- ties (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 like- ly than children in nonpoor families to have an exist- The Magnitude of the Problem ing special health care need. Similarly, children from less educated households exhibit a higher likelihood of a special health care need. Children in single-par- ent 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 adult- hood. 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 over- all quality of life and life expectancy of individuals with disabilities are needed (see Chapter 10). 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 profes- sional interventions that have played a significant role in the improvement of oral health achieved over the past 50 years; their full promise has not, howev- er, 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 every- one 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 main- taining good oral health. Although certain counseling and screening serv- ices provided by physicians are recommended (U.S. Preventive Services Task Force 1996), data to indi- cate how many persons receive such services or oral- health-related recommendations from their physi- cian are very limited. There are also no data on physi- cian-based services for oral and craniofacial condi- tions. The data that are available describe utilization ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 79 The Magnitude of the Problem of dental visits. Unfortunately, most of these data are cross-sectional, describing the experience of the pop- ulation 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 popula- tion`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. 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) esti- mates 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 ques- tion 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 rea- sons for variations in estimates from different survey approaches, but differences among persons with dif- ferent 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 rABLE 4.3 Percentage of persons 25 years of age and older with a dental kit within the preceding year, by selected patient character- istics, selected years 1983d 19896 1990 1991 1993 lotalbrC be 25 to 34 years 35 to 44 years 45 to 64 years 65 years and older 65 to 74 years 75 years and older Sex' Male Female Poverty statusLd Below poverty At or above poverty Race and Hispanic origin' White, non-Hispanic Black, non-Hispanic HispanV Education' Less than 12 years 12 years 13 years or more Education, race, and Hispanic origin' Fewer than 12 years White, non-Hispanic Black, non-Hispanic Hispanif 12 years White, non-Hispanic Black, non-Hispanic Hispanif 13 years or more White, non-Hispanic Black,non-Hispanic Hispanif 53.9 58.9 62.3 58.2 60.8 59.0 60.9 65.1 59.1 60.3 60.3 65.9 69.1 64.8 66.9 54.1 59.9 62.8 59.2 62.0 39.3 45.8 49.6 41.2 51.7 43.8 50.0 53.5 51.1 56.3 31.8 39.0 43.4 41.3 44.9 51.7 542 58.8 55.5 58.2 55.9 61.4 65.6 60.8 63.4 30.4 33.3 38.2 33.0 35.9 55.8 62.1 65.4 61.9 64.3 56.6 61.8 64.9 61.5 64.0 39.1 43.3 49.1 44.3 47.3 42.1 48.9 53.8 43.1 46.2 35.1 36.9 41.2 35.2 38.0 54.8 58.2 61.3 56.7 58.7 70.9 73.9 75.7 72.2 73.8 36.1 39.1 31.7 32.0 33.8 36.5 56.6 59.8 40.5 44.8 48.7 56.5 72.6 75.8 54.4 57.2 58.4 66.2 41.8 37.9 42.7 62.8 51.1 59.9 77.3 64.4 67.9 38.1 41.2 33.0 33.1 28.9 33.0 58.8 60.4 43.1 48.2 49.5 54.6 74.2 75.8 61.7 61.3 61.2 61.8 a Data for 1983 and 1989 are not strictly comparable with data for later years. Data for 1983 and 1989 are based on responses to the question "About how long has it been since you last went to a dentist?"Starting in 1990,data are based on the question "During the past 12 months, how many visits did you make to a dentist?" blncludes all other races not shown separately and unknown poverty status and educa- tion level. `Age adjusted. dPoverty status is based on family income and family size using Bureau of the Census poverty thresholds. ePersons of Hispanic origin may be of any race. Notes: Data are based on household interviews of a sample of the civilian noninstitu- tionalized population.Denominators exclude persons with unknown dental data. Estimates for 1983 and 1989 are based on data for all members of the sample house- hold. Beginning in 1990, estimates are based on one adult member per sample house- hold. Estimates for 1993 are based on responses during the last half of the year only. Source: Data from NCHS 1989. 80 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL The Magnitude of the Problem dental visit was third-grade children (82 percent). Variation by Sex, RacelEthnicity, Income, Those aged 25 years and older with less than a high and Insurance school education had the lowest rates (41 percent) for annual dental visits as compared to those with at Dental care utilization varies with sex and race/eth- least some college education (74 percent) (USDHHS nicity for individuals 25 and older (NCHS 1997a). 2000>. Females had slightly higher rates of utilization (67 percent) than males (63 percent). Hispanic individuals had the low- TABLE 4.4 est utilization (53 percent), and Age-adjusted percentage distribution of persons 2 years and older by interval since non-Hispanic whites had the high- last dental visit, by selected characteristics, 1989 est rates (68 percent). Table 4.3 Interval Since Last Dental Visit provides an overview of utilization from 1983 through 1993. A higher 1 Year to 2Years to percentage of females reported a All LessThan LessThan LessThan SYears dental visit than males in each sur- Intervals 1 Year 2 Years 5 Years or More Never vey year. Fewer non-Hispanic All ages 100.0 57.3 9.5 12.3 11.0 4.6 blacks and Hispanics reported a Sex dental visit than non-Hispanic Male 100.0 54.1 9.6 13.4 12.1 4.9 whites in each survey year. Income Female loo.0 59.9 9.4 11.2 10.1 4.4 and education are also key vari- Race ables in utilization. In 1993, White 100.0 59.5 9.1 11.6 10.5 4.4 almost twice as many individuals Black 100.0 43.2 12.3 16.9 15.1 5.8 25 and older living at or above the Other 100.0 51.6 9.7 14.0 10.8 6.7 poverty line had a dental visit than Hispanic origin did those living below the poverty Non-Hispanic 100.0 58.5 9.4 12.0 10.8 4.1 line in 1993 (64.3 versus 35.9 per- Hispanic 100.0 46.0 10.5 14.6 13.0 9.7 cent). Similarly, almost twice as Mexican American 100.0 40.5 8.9 15.3 15.8 13.1 many individuals with 13 years or Other Hispanic 100.0 53.2 12.3 13.7 9.9 5.1 more of education had a visit than Place of residence did those with fewer than 12 years MSA' 100.0 58.4 9.4. 11.9 10.1 4.5 of education (73.8 versus 38.0 per- Central city 100.0 54.9 10.1 12.9 10.9 5.1 cent) in that same year. Not central city 100.0 60.6 9.0 11.3 9.6 .4.2 Data from the 1989 National Not MSA' 100.0 53.6 9.7 13.6 14.1 5.1 Health Interview Survey showed Geographic region that the overall age-adjusted num- Northeast 100.0 60.7 10.4 10.7 9.0 3.5 ber of visits for blacks was 1.2 vis- Midwest 100.0 61.5 6.3 11.3 10.7 3.5 South 100.0 52.2 10.3 13.9 13.6 5.9 its compared to 2.2 visits for et West 100.0 57.8 8.6 12.3 9.1 4.9 whites (Bloom al. 1992). Table 4.4 shows the percent- Education level Less than 9 years 100.0 30.6 9.9 18.4 30.6 5.9 age distributions of the interval since their most recent dental visit 9 to 11 years 100.0 39.0 10.7 20.3 23.5 1.3 12 years 100.0 54.6 10.6 15.0 14.4 0.5 for people aged 2 and older in 13 years or more 100.0 70.2 8.5 10.3 6.9 0.2 selected demographic and socioe- conomic categories. Individuals Family income who have never visited a dentist Less than $10,000 100.0 42.2 10.9 16.3 20.1 7.0 100.0 43.9 11.8 17.4 16.1 6.6 ranged from high of 13.1 a percent $10,000 to $19,999 $20,000 to 534,999 100.0 58.2 10.5 3.2 10.4 4.6 of Mexican Americans to 5.8 per- $35,000 or more 100.0 72.5 7.8 8.5 5.5 2.9 cent of blacks and 4.4 of percent Dental insurance coverage whites. Eleven percent of the pop- ulation had not had a dental visit With private dental insurance 100.0 70.4 8.7 9.2 6.6 3.3 Without private dental insurance 100.0 50.8 10.7 15.4 14.2 6.0 in 5 or more. Individuals years with fewer than 9 years of educa- ' MSA = metropolitan statistical area. tion represented the highest pro- Source:Bloom et al. 1992. portion, 30.6 percent, of those reporting no dental visit in 5 years ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 81 The Magnitude of the Problem 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). 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 limita- TABLE 4.5 Age-adjusted percentage distribution of persons 2 years and older by interval since last dental visit, by selected health characteristics, 1989 Interval Since Last Dental Visit Assessed health status Excellent or good very Good Fair or poor Limitation of activity Unable to carry on usual activity Limited in amount or kind of major activity Limited, but not in major activity Not limited in activity Dentition status Dentate Edentulous Source: Bloom et al. 1992. All Less Than 1 Year to Intervals 1 Year 2 Years 100.0 61.4 9.3 100.0 ST.9 10.1 100.0 45.1 10.0 100.0 46.6 9.8 100.0 52.3 9.8 100.0 59.1 8.3 100.0 58.5 9.5 100.0 65.5 9.6 100.0 14.3 6.4 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 excel- lent or very good (Drury and Redford 2000). 2 Years to Less Than 5 Years 5 Years or More Never 11.2 9.0 4.3 13.9 12.6 5.8 16.6 17.4 5.9 15.6 16.6 5.1 14.0 14.4 4.1 12.8 11.7 4.2 12.0 10.1 4.6 12.8 10.1 0.5 19.8 55.2 0.4 Examination of NHANES III data by low socioeconomic status (SES) provides an additional per- spective. In a recent analysis, SES was measured by a composite index based on educational attain- ment and the ratio of annual fami- ly 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). tions are also related to dental service utilization. Of those who reported no physical limitations in activi- ties, 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 eden- tulous 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 like- ly 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 untreat- ed 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 com- munication, 1999). a2 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL -- Reasons for Nonutilization Reasons for nonutilization of dental services are com- plex. 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 per- ceived 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 rea- son 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 respon- dents. Whites (14.3 percent) were more likely than blacks (11.4 percent) to cite cost. Other surveys have reported substantially higher percentages of individ- uals 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) report- ed fear as a personal barrier to receipt of care. 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, den- tal care in 1994 (Table 4.7). In contrast, only 5.6 per- cent 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 The Magnitude of the Problem 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 unin- sured than if they were insured, according to a recent analysis of data from the National Health Interview Survey (Newacheck et al. 2000). 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 per- cent 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 question- naires to 13,050 active duty military personnel using a complex, weighted survey design to examine the oral health status, dental treatment needs, dental uti- lization, and perceived need for care in this popula- tion (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 examina- tion within the past year, 60 percent had a dental ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 83 The Magnitude of the Problem TABLE 4.6 Percentage of persons with no dental visit in past year by reason reported, by selected characteristics, 1989 All with No Visits in PastYear Fear cost Access No Dental Problem Problem NoTeeth Not Other Important Reason All ages 2to 17 years 18to34years 35to 64years 65 yearsandolder Sex Male All ages 2to 17 years 18to 34years 35to64years 65 yearsandolder Female Allages 2to17years 18to 34years 35to64years 65 yearsand older Race White All ages 2to 17years 18to34years 35to 64years 65yearsandolder Black All ages 2to 17 years 18to 34years 35to64 years 65 yearsand older Other All ages 2to17 years 18to 34years 35to 64years 65yearsandolder Hispanic origin Non-Hispanic All ages 2tol7years 18to34years 3Sto64 years 65yearsandolder Hispanic,total All ages 2to 17 years 18to34years 35to64years 65yearsandolder 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 loo.0 loo.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 loo.0 100.0 100.0 100.0 4.3 13.7 1.1 46.8 14.3 2.3 8.7 1.3 15.0 1.5 56.8 0.2 1.9 11.9 5.9 19.1 2.4 52.4 0.7 3.2 9.5 5.8 12.8 1.5 43.3 17.8 2.2 a.4 2.2 4.1 1.1 31.2 49.7 1.1 3.9 4.0 13.0 1.5 49.1 12.1 2.6 9.3 1.2 14.9 1.3 56.2 o 0.2 2.0 12.1 5.5 17.5 2.0 54.8 0.6 * 3.4 9.7 5.4 11.2 1.5 45.4 16.1 2.8 9.5 1.7 4.0 1.0 33.6 48.6 1.3 3.5 4.6 14.3 1.8 44.4 16.6 1.9 a.1 1.5 15.2 1.6 57.4 o 0.2 1.8 11.6 6.5 21.0 2.9 49.5 0.8 3.0 9.3 6.2 14.4 1.5 41.1 19.5 1.6 7.3 2.5 4.2 1.2 22.5 50.6 0.9 4.1 4.4 14.3 1.8 44.3 15.7 2.4 9.4 1.3 16.4 1.7 54.0 0.2 2.0 13.3 6.2 20.7 2.6 49.6 0.7 3.4 10.6 5.8 13.0 1.6 41.3 19.0 2.4 9.1 2.1 3.7 1.1 30.5 51.2 1.1 3.9 4.0 11.4 1.0 58.5 8.8 1.5 5.1 1.3 10.7 "0.7 68.3 "0.2 1.2 6.6 4.9 13.3 1.5 63.8 "0.7 2.5 4.6 6.0 11.7 0.9 52.8 13.0 1.1 4.9 3.0 7.0 "1.0 36.6 39.2 "0.9 3.4 3.7 10.8 1.6 52.1 6.1 2.2 9.2 "1.7 11.4 "0.3 49.8 *o.o '2.4 12.6 4.6 11.7 "2.5 59.4 "0.3 "2.2 8.8 4.6 10.8 "1.9 51.0 a.2 *2.6 7.7 "2.8 o 4.2 o 0.7 31.4 44.9 o 0.7 "5.9 4.3 13.0 1.7 45.7 15.6 2.2 9.1 1.3 14.4 1.3 56.2 0.2 1.9 12.8 6.0 18.9 2.5 51.6 0.7 3.2 10.1 5.8 12.0 1.5 42.5 18.8 2.2 a.7 2.1 4.0 1.1 30.9 50.4 1.1 3.9 4.0 19.1 1.8 56.1 3.5 2.6 5.9 1.6 18.4 2.4 59.5 '(0.1 2.2 7.3 5.2 20.1 1.5 57.9 "0.2 3.3 5.6 5.3 20.7 1.6 52.2 6.5 2.3 5.2 "4.6 a.2 "1.4 40.7 31.9 *1.6 *3.4 84 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL The Magnitude of the Problem All with No Visits Access No Dental Not Other in Past Year Fear cost Problem Problem No Teeth Important Reason Hispanic, Mexican American All ages 100.0 3.6 20.7 1.7 56.2 2.4 2.3 5.3 2 to 17 years 100.0 o 1.4 19.4 2.6 60.7 "0.1 2.2 5.5 18 to 34 years 100.0 4.7 21.0 "0.9 57.5 "0.1 2.8 4.8 35 to 64 years 100.0 5.2 24.3 o 1.4 50.1 4.5 o 1.7 6.4 65 and older years 100.0 "4.3 *11.1 "1.4 38.7 30.5 "1.8 *1.8 Hispanic, other All ages 100.0 4.7 16.3 2.0 55.9 5.3 3.1 7.0 2 to 17 years 100.0 o 1.8 16.3 "1.9 56.9 "0.2 "2.0 11.3 18 to 34 years 100.0 6.2 18.5 *2.4 58.7 `0.4 4.4 7.0 35 to 64 years 100.0 5.5 16.3 o 1.8 54.9 8.9 `3.1 3.8 65 and older years 100.0 o ??? o 5.7 `1.4 42.8 33.2 "1.4 "4.9 Place of residence MSA, total" All ages 100.0 4.4 13.4 1.8 46.6 12.8 2.4 9.0 2 to 17 years 100.0 1.3 14.1 1.4 55.7 0.3 2.0 12.1 18 to 34years 100.0 5.7 18.5 2.6 51.6 0.5 3.3 9.6 35 to 64 years 100.0 6.1 12.6 1.6 43.1 16.0 2.4 8.7 65 and older years 100.0 2.3 4.2 1.1 31.4 47.6 1.2 4.0 MSA, central ciryd All ages 100.0 4.4 14.0 1.7 48.0 11.9 2.6 7.8 2 to 17 years 100.0 1.6 14.6 1.4 56.5 "0.2 2.0 10.0 18 to 34 years 100.0 5.3 17.9 2.5 54.2 0.4 3.6 8.4 35 to 64 years 100.0 6.4 14.1 1.3 43.9 14.8 2.5 7.3 65 and older years 100.0 2.5 4.7 1.3 31.5 46.3 1.7 4.2 MSA, not central cityd All ages 100.0 4.3 13.0 1.8 45.5 13.5 2.3 9.9 2 to 17 years 100.0 1.2 13.7 1.4 55.1 "0.4 2.0 13.7 18 to 34 years 100.0 6.0 19.0 2.6 49.5 0.6 3.1 10.6 35 to 64 years 100.0 5.8 11.6, 1.7 42.6 16.8 2.4 9.6 65 and older years 100.0 2.1 3.9 1.0 31.3 48.5 0.8 4.0 Not MSA' All ages 100.0 4.1 14.4 1.4 47.7 18.8 1.7 8.0 2 to 17 years 100.0 1.3 18.0 1.6 60.0 *0.1 1.5 11.2 18to34years 100.0 6.9 21.1 1.7 55.4 1.2 2.7 9.1 35 to 64 years 100.0 4.9 13.1 1.2 43.8 23.1 1.6 7.7 65 and older years 100.0 2.0 3.9 1.0 30.7 55.2 0.9 3.5 Family incomeb Less than $10,000 All ages 100.0 3.8 19.7 1.7 42.8 22.5 1.4 6.4 2 to 17 years 100.0 o 1.1 19.4 2.6 60.0 "0.3 1.9 9.6 18 to 34 years 100.0 5.7 28.8 2.4 51.7 *0.9 1.9 7.2 35 to 64 years 100.0 6.3 25.2 "1.1 35.5 25.1 1.4 5.4 65 and older years loo.0 2.0 6.6 "0.9 27.4 57.4 *0.7 3.9 $10,000 to $19,999 All ages 100.0 4.0 18.8 1.5 47.0 17.4 1.7 6.5 2 to 17 years 100.0 1.4 21.9 1.4 58.8 -0.1 1.3 7.9 18 to 34 years 100.0 6.1 27.8 1.8 53.2 -0.5 2.4 7.9 35 to 64 years 100.0 4.7 19.2 1.5 43.6 21.7 1.6 5.7 65 and older years 100.0 3.0 3.4 1.2 31.4 51.9 1.3 4.3 $20,000 to $34,999 All ages 100.0 4.8 13.7 1.7 51.3 11.5 2.3 11.1 2 to 17 years 100.0 1.6 14.4 0.9 59.7 o 0.1 1 .7 13.8 18to34years 100.0 6.4 18.1 2.8 54.7 0.8 3.3 12.3 35 to 64 years 100.0 6.4 12.5 1.4 46.2 18.5 2.0 10.2 65 and older years 100.0 1.8 2.4 *1.3 38.5 47.7 "1.5 4.7 (continues) ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 85 The Magnitude of the Problem TABLE 4.6 continued All with No Visits in Past Year 535,000 or more All ages 100.0 2to17years 100.0 18 to 34 years 10u.o 35 to 64 years 100.0 65 and older years 100.0 lental insurance coverage With dental insurance All ages loo.0 2 to 17 years 100.0 la to 34 years 100.0 35 to 64 years loo.0 65 and older years 100.0 Without dental insurance All ages 100.0 2 to 17 years 100.0 18 to 34 years 100.0 35 to 64 years 100.0 65 and older years 100.0 Insurance status unknown All ages 100.0 2 to 17 years 100.0 18to34years 100.0 35 to 64 years 100.0 65 and older years 100.0 Limitation of activity Unable to tarry on usual activity All ages 100.0 2 to 17 years 100.0 18 to 34 years 100.0 35 to 64 years 100.0 65 and older years 100.0 Limited in amount or kind of major activity All ages 100.0 2 to 17 years 100.0 18 to 34 years 100.0 35 to 64 years 100.0 65 years and older 100.0 Limited, but not in major activity All ages 100.0 2 to 17 years 100.0 18 to 34 years 100.0 35 to 64 years 100.0 65 years and older 100.0 Not limited in activity All ages 100.0 2 to 17 years 100.0 18 to 34years 100.0 35 to 64 years 100.0 65 and older years 100.0 Fear cost 5.9 6.8 1.1 5.8 7.0 9.2 7.8 6.0 "2.8 3.8 6.2 7.2 1.2 7.8 8.5 9.5 8.0 6.0 2.5 "1.6 4.0 18.5 1.6 20.5 5.5 26.7 5.4 18.9 2.3 4.9 1.6 3.9 "0.6 4.7 2.3 5.1 1.5 3.4 "1.4 "1.6 4.4 15.4 o 6.0 *27.6 7.4 25.3 5.4 18.3 "1.7 6.6 4.4 15.2 "1.7 18.9 6.9 30.2 6.1 17.6 2.4 5.1 4.4 12.4 `1.7 28.0 8.0 29.2 6.3 17.5 2.6 3.9 4.3 13.5 1.3 14.7 5.8 la.2 5.8 11.3 2.1 3.4 Access No Dental Problem Problem 2.6 52.3 2.0 56.8 3.6 55.4 2.3 49.1 "1.6 37.9 2.5 53.2 1.2 61.4 4.1 55.5 2.2 48.8 "1.1 39.3 1.5 48.7 1.7 60.1 1.9 56.3 1.3 45.1 1.2 31.9 0.7 23.8 `1.0 25.7 *0.9 28.2 "0.3 20.8 "0.6 19.8 1.7 33.2 "0.0 36.6 "1.9 47.1 o 1.2 34.5 2.4 26.0 `1.9 34.5 o 2.5 58.0 "3.9 44.3 1.7 31.2 o 1.2 26.3 0.9 34.3 *2.2 53.0 "1.9 50.5 "0.8 35.3 o 0.6 28.2 1.7 49.6 1.4 56.9 2.4 52.9 1.5 46.1 0.9 34.3 No Teeth 8.1 `0.6 o 0.6 13.2 41.6 10.1 "0.3 0.8 17.4 44.7 17.2 "0.2 0.7 19.9 52.5 9.3 *0.1 "0.3 9.2 36.8 31.9 "0.0 "1.9 28.9 49.9 29.7 o 0.3 o o.a 27.1 54.3 35.8 "0.0 "1.4 24.0 54.4 10.4 0.2 0.6 15.1 47.3 Not Other Important Reason 4.1 14.1 3.1 20.2 5.4 13.4 4.0 12.9 "2.0 4.4 3.4 15.2 2.4 18.8 5.1 16.3 3.1 13.7 *1.0 5.7 2.0 7.0 1.9 9.9 2.1 7.6 2.1 6.8 1.2 3.9 0.8 2.9 *0.6 3.6 1.1 3.5 "0.7 2.0 `0.6 2.6 1.1 6.2 "1.5 o 20.1 "1.9 6.1 "1.1 6.6 "0.7 4.6 1.7 7.5 "2.0 9.1 o ??? 10.4 2.2 9.3 "1.1 3.9 1.5 6.3 "1.7 "10.8 *1.7 10.3 *2.0 8.0 *1.2 3.9 2.4 9.2 1.9 11.9 3.3 9.6 2.4 8.6 1.2 3.7 dMSA = metropolitan statistical area. bPersons with unknown income not shown separately. Note: Data are based on household interviews of the civilian noninstitutionalized population. o = Figure does not meet the standard of reliability or precision (more than 30 percent relative standard error and numerator of percent or rate). Source: Bloom et al. 1992. 86 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL The Magnitude of the Problem rABLE +.7 istimated number and percentage of people with unmet health care Wants, my selected characteristics, 1994 Medical or Number of People Dental Care Surgical Care (in millions) (percentage) (percentage) hll people 259.2 8.5 5.6 hge and sex Children, 1 to 18 years 73.5 5.9a 2.9" Adult men, 19 to 64 years 75.3 9.5 5.8 Adult women, 19 to 64 years 79.3 12.Y 9.3' Elderly people, 65 years and older 31.1 3.6' 2.46 Race/ethnic@ White 191.4 7.4 4.6 Black 32.2 15.0' 10.2a Hispanic 23.9 a.2 6.2 Other 11.7 9.9 8.6 Health status Fair or poor 24.6 16.1' 11.2' Good or excellent 233.5 7.7 5.0 Number of chronic conditions None 158.6 7.3 4.6 One or more 100.6 10.4 7.1 Geographical region Northeast 47.8 6.9 5.8 Midwest 65.8 6.9 4.5 South 92.6 11.2" 6.1 West 53.1 7.4 5.9 Rural/urban status Metropolitan statistical areas 208.2 8.6 5.6 Nonmetropolitan statistical areas 50.5 a.1 5.9 Education level of head of household High school or less 117.5 9.4 6.8 Some post-high school 141.2 7.9 4.7 Family income status Less than 150 percent of the poverty level 55.7 16.4a 9.1' 150 percent of the poverty level or more 174.3 6.3' 4.5 Health insurance status Private 166.6 5.9' 4.1 Medicare 36.0 5.6' 3.1" Medicaid 22.2 12.2 8.0 Uninsured 32.5 22.6' 14.9' Type of private health insurance Health maintenance organization/ independent practice association 45.1 5.5a 5.0 Preferred provider organization 30.7 4.6' 4.1 Fee-for-service 73.5 5.3' 3.1" d Rhe estimate differs from the percentage for the"all people"demographic at the 1 percent confidence level based on a two-tailed f-test of the difference in weighted estimates. Note: The standard error of each percentage is less than 30 percent of the percentage estimate. Source: Mueller et al. 1998. Access to dental care in the United States.JADA 1998 April; 129(4):429-37. Copyright 1998 by loumal ofthe American Dental Asrooation. Reprinted by permission of ADA Publishing Co. Inc. (2000). prophylaxis, and 29 percent had at least one tooth filled. Edentulism is virtually nonex- istent in the active duty military population. Also, active duty mili- tary 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 counter- parts. Active duty whites also have somewhat better oral health than white civilians of a similar age. The relative proportion of un- filled surfaces as a component of decayed and filled tooth surfaces in the military and civilian popula- tions is illustrated in Figure 4.25. 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 condi- tions 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 wide- spread 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 conse- quence of dental disease are preva- lent in certain groups and can affect daily living. ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 87 The Magnitudt of the Problctn 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 dis- parities are not clear. Some of the most common den- tal diseases, such as dental caries, are preventable (prevention of oral diseases and conditions is pre- sented 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 dis- eases, 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 pop- ulation 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 pro- fessionals, and services that are commuhity-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 expendi- tures for care and health care personnel are available 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 deci- sions. 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 under- going 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 technolo- gies, 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 priori- ties 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 pro- vided 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 preven- tive interventions and objectives that would improve infrastructure and capacity building to provide the necessary services and moni- toring. FIGURE 4.25 The percentage of unfilled decayed surfaces is higher for civilian males than for males in the U.S. military 501 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. , I 18-19 20-24 25-29 30-34 35-39 40-44 Age group + Black civilian -+ White civilian - Black military x White military Source: York et al. 1995. This overview of the magni- tude of oral diseases and condi- tions in America raises many ques- tions still to be researched. If cer- tain oral diseases are preventable, why do we have populations with extensive and untreated disease? Once socioeconomic factors are controlled, why do we see differ- ences in services received? Why 38 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL are some conditions more prevalent in certain popu- lations than in others? How will the rapidly changing and projected demographics of America contribute to future trends in oral and craniofacial health and dis- ease? These and many other questions require more research, new databases, and an active and trained group of researchers. FINDINGS o Over the past five decades, major improve- ments in oral health have been seen nationally for most Americans. o Despite improvements in oral health status, profound disparities remain in some population groups as classified by sex, income, age, and race.feth- nicity. For some diseases and conditions, the magni- tude of the differences in oral health status among population groups is striking. 0 Oral diseases and conditions affect people throughout their life span. Nearly every American has experienced the most common oral disease, den- tal caries. o 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 o Oral-facial pain can greatly reduce quality of life and restrict major functions. 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PR-9503. Connecticut and Denmark. Bethesda (MD): U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute; 1985. ORAL HEALTH IN AMERICA: .4 REPORT OF THE SURGEON GENERAL 93 What Is the Relationship Between Oral Health and General Health and Well-being? The next two chapters establish that oral health is essential to general health and well-being. Chapter 5 examines multiple linkages between oral and general health. The mouth and the face reflect signs and symptoms of health and disease that can serve as an adjunct for diagnosis for some conditions. Diagnostic tests using oral cells and fluids-especially saliva-are available to detect drug abuse, hormonal changes, and specific diseases; and more are being developed. The mouth is also a portal of entry for pathogens and toxins, which can affect the mouth and, if not cleared by the many defense mechanisms that have evolved to protect the oral cavity, may spread to the rest of the body Recent epidemiologic and experimental animal research provides evidence of possible associations between oral infections-particularly periodontal disease-and diabetes, cardiovascular disease, and adverse pregnancy outcomes, and this evidence is reviewed. The review highlights the need for an aggressive research agenda to better delineate the specific nature of these associations and the underlying mechanisms of action. Chapter 6 looks at the impact of oral health problems on the quality of life and includes examples of the kinds of questionnaires used to measure oral-health-related quality of life. Oral health is highly valued by society and individuals, and the chapter begins with a brief description of the reflections of those values in myth and folklore concerning facial appearance and the meaning of teeth. It then explores dimensions beyond the biological and the physical to examine how oral diseases and disorders can interfere with the functions of daily living, including participation in work or school, and what is known about their psychosocial impacts and economic costs. The deleterious effects of facial disfigurement and tooth loss may be magnified in a society such as ours that celebrates youth and beauty Self-reported impacts of oral conditions on social functions include limitations in communication, social interactions, and intimacy. Research on the oral-health-related quality of life is needed to permit further exploration of the dimensions of oral health and well-being. ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 95 Linkages with General Health The mouth and face are highly accessible parts of the body, sensitive to and able to reflect changes occurring internally. The mouth is the major portal of entry to the body and is equipped with formidable mechanisms for sensing the environment and defending against toxins or invading pathogens. In the event that the integrity of the oral tissues is compromised, the mouth can become a source of disease or pathological processes affecting other parts of the body. It can also become a source of contagion by means of contaminated fluids or materials passed to others. This chapter explores what the mouth and face can reveal about general health, describes the role the mouth plays as a portal of entry for infection, and concludes with studies that are associating oral infections with serious systemic diseases and conditions. THE MOUTH AND FACE AS A MIRROR OF HEALTH AND DISEASE A physical examination of the mouth and face can reveal signs of disease, drug use, domestic physical abuse, harmful habits or addictions such as smoking, and general health status. Imaging (e.g., x-ray, MRI, SPECT) of the oral and craniofacial structures may provide early signs of skeletal changes such as those occurring with osteoporosis and musculoskeletal disorders, and may also reveal salivary, congenital, neoplastic, and developmental disorders. Oral cells and fluids, especially saliva, can be tested for a wide range of substances, and oral-based diagnostics are increasingly being developed and used as a means to assess health and disease without the limitations and difficulties of obtaining blood and urine. Physical Signs and Symptoms af Disease and Risk Factors A number of signs and symptoms of disease, lifestyle behaviors, and exposure to toxins can be detected in or around the craniofacial complex. Pathogens enter- ing the mouth may proliferate locally with oral and pharyngeal signs and symptoms; other pathogens may enter the bloodstream directly or through lym- phatic channels and cause generalized disease. Oral signs suspected to be indications of systemic illness may be confirmed by the presence of rash, fever, headache, malaise, enlarged lymph nodes, or lesions elsewhere on the body Swollen parotid glands are a cardinal sign of infection with the mumps virus and can also be seen in individuals with Sjogren's syndrome and HIV The salivary glands are also frequently involved in tuber- culosis and histoplasmosis infections. Oral signs of infectious mononucleosis, caused by Epstein-Barr virus, include sore throat, gingival bleeding, and multiple pinpoint-sized hemorrhagic spots (pettechi- ae) on the oral mucosa. The oral signs and symptoms associated with some viral, bacterial, and fungal infections are listed in Table 5.1. There can be a large overlap in the clinical appearance of oral manifesta- tions of various diseases with different etiologies, and the clinical diagnosis often involves ancillary proce- dures, which may include laboratory tests, diagnostic imaging, and biopsy. Oral tissues may also reflect immune deficiency. For example, nearly all HIV-infected individuals develop oral lesions at some time during their illness (Greenberg 1996, Greenspan and Greenspan 1996, Phelan 1997). Other immunosuppressed individuals may have the same lesions (Glick and Garfunkel 1992). However, the presentation and the extent, sev- erity, and management of some of these lesions may reflect nuances due to variation in the underlying ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 97 TABLE 5.1 Diseases and conditions causing lesions of the oral mucosa Condition Usual Location Clinical Features Course Viral Diseases Primary acute herpetic gingivostomatitis (herpes simplex virus type 1, rarely type 2) Recurrent herpes labialis Recurrent intraoral herpes simplex Chickenpox (varicella-zoster virus) Herpes zoster (reactivation of Cheek, tongue, gingiva, or varicella-zoster virus) palate Infectious mononucleosis (Epstein-Barr virus) Oral mucosa Warts (papillomavirus) Herpangina (coxsackievirus A; also possibly coxsackievirus Band echovirus) Hand, foot, and mouth disease (type A coxsackieviruses) Primary HIV infection tip and oral mucosa Mucocutaneous junction of lip, perioral skin Palate and gingiva Gingiva and oral mucosa Anywhere on skin and oral mucosa Oral mucosa, pharynx, tongue Oral mucosa, pharynx, palms, and soles Gingiva, palate, and pharynx Labial vesicles that rupture and crust, and intraoral vesicles that quickly ulcerate;extremely painful; acute gingivitis, fever, malaise, foul odor, and cervi- cal lymphadenopathy; occurs primarily in infants, thildren,and young adults Eruption of groups of vesicles that may coalesce, then rupture and crust; painful to pressure or spicy foods Small vesicles that rupture and coalesce; painful Skin lesions may be accompanied by small vesicles on oral mucosa that rupture to form shallow ulcers; may coalesce to form large bullous lesions that ulcerate; mucosa may have generalized erythema Unilateral vesicular eruption and ulceration in lin- ear pattern following sensory distribution of trigeminal nerve or one of its branches Fatigue, sore throat, malaise, low-grade fever, and enlarged cervical lymph nodes; numerous small ulcers usually appear several days before lym- phadenopathy;gingivaI bleeding and multiple petechiae at junction of hard and soft palates Single or multiple papillary lesions, with thick, white keratinized surfaces containing many point- ed projections; cauliflower lesions covered with normal-colored mucosa or multiple pink or pale bumps (focal epithelial hyperplasia) Sudden onset of fever, sore throat, and oropharyn- geal vesicles, usually in children under 4 years, during summer months;diffuse pharyngeal con- gestion and vesicles (1 to 2 mm),grayish-white surrounded by red areola;vesicles enlarge and ulcerate Fever, malaise, headache with oropharyngeal vesi- cles that become painful, shallow ulcers Acute gingivitis and oropharyngeal ulceration, associated with febrile illness resembling mononu- cleosis and including lymphadenopathy Healsspontaneously in 10 to 14 days unless secondarily infected lasts about 1 week, but condition may be prolonged if secondary infection occurs Healspontaneously in about 1 week Lesions heal spontaneously within 2 weeks Gradual healing without scarring; postherpetic neuralgia is common Oral lesions disappear during con- valescence Lesions grow rapidly and spread Incubation period 2 to 9 days;fever for 1 to 4 days; recovery uneventful Incubation period 2 to 18 days; lesions heal spontaneously in 2 to 4 weeks Followed by HIV seroconversion, asymptomatic HIV infection,and usually ultimately by HIV disease 98 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL Linkages with General Health Condition Usual Location Clinical Features Course Bacterial or fungal diseases Acute necrotizing ulcerative gingivitis ("trench mouth," Vincent's infection) Prenatal (congenital) syphilis Gingiva Palate, jaws, tongue, and teeth Painful. bleeding gingiva characterized by necrosis Continued destruction of tissue fol- and ulceration of gingival papillae and margins lowed by remission, but may recur plus lymphadenopathy and foul odor Gummatous involvement of palate, jaws, and facial Tooth deformities in permanent bones; Hutchinson's incisors, mulberry molars, dentition irreversible glossitis, mucous patches, and fissures of corners of mouth Primary syphilis (chancre) Lesion appears where organism enters body; may occur on lips, tongue, or tonsillar area Small papule developing rapidly into a large, Healing of chancre in 1 to 2 painless ulcer with indurated border;unliteral months, followed by secondary lymphadenopathy;chancre and lymph nodes con- syphilis in 6 to 8 weeks taining spirochetes;serologic tests positive by third to fourth week Secondary syphilis Oral mucosa frequently involved with mucous patches,primarily on palate, also at commissures of mouth Maculopapular lesions of oral mucosa,S to 10 mm in diameter with central ulceration covered by grayish membrane; eruptions occurring on various mucosal surfaces and skin accompanied by fever, malaise, and sore throat Lesions may persist from several week5 to 1 year Tertiary syphilis Palate and tongue Gummatous infiltration of palate or tongue fol- lowed by ulceration and fibrosis; atrophy of tongue papillae produces characteristic bald tongue and glossitis Gumma may destroy palate, caus- ing complete perforation Gonorrhea Tuberculosis Cervicofacial actinomycosis Lesions may occur in mouth at Earliest symptoms are burning or itching sensa- Lesions may resolve with appropri- site of inoculation or secondarily tion, dryness, or heat in mouth followed by acute ate antibiotic therapy by hematogenous spread from a pain on eating or speaking; tonsils and orophar- primary focus elsewhere ynx most frequently involved; oral tissues may be ' diffusely inflamed or ulcerated; saliva develops increased viscosity and fetid odor;submaxillary lymphadenopathy with fever in severe cases Tongue, tonsillar area,soft A solitary, irregular ulcer covered by a persistent Lesions may persist palate exudate; ulcer has an undermined, firm border Swellings in region of face, neck, Infection may be associated with an extraction, Acute form may last a few weeks; and floor of mouth jaw fracture, or eruption of molar tooth; in acute chronic form lasts months or form resembles an acute pyogenic abscess, but years; prognosis excellent; actin- contains yellow "sulfur granules" (gram-positive omycetes respond to antibiotics mycelia and their hyphae) (tetracyclines or penicillin) but not antifungal drugs Histoplasmosis Any area in mouth, particularly tongue, gingiva, or palate Numerous small nodules may ulcerate; hoarse- ness and dysphagia may occur because of lesions in larynx usually associated with fever and malaise May be fatal Candidiasis Any area of oral mucosa Pseudomembranous form has white patches that are easily wiped off leaving red, bleeding, sore surface; erythematous form is flat and red; rarely, candidai leukoplakia appears as white patch in tongue that does not rub off; angular cheilitis due to Candida involves sore cracks and redness at angle of mouth; Candida seen on KOH prepara- tion in all forms Responds to antifungals (confinuesJ ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 99 Linkages with General Health TABLE 3.1 continued Condition Usual Location Clinical Features Course Dermatologic diseases Mucous membrane pemphigoid Primarily mucous membranes of the oral cavity, but may also involve the eyes, urethra, vagi- na,and rectum Painful, grayish-white collapsed vesicles or bullae with peripheral erythematous zone; gingival lesions desquamate, leaving ulcerated area Protracted course with remissions and exacerbations; involvement of different sites occurs slowly;glu- cocorticoids may temporarily reduce symptoms but do not control the disease Erythema multiforme (Stevens-Johnson syndrome) Pemphigus vulgaris Primarily the oral mucosa and skin of hands and feet Oral mucosa and skin Intraoral ruptured bullae surrounded by an inflammatory area; lips may show hemorrhagic crusts; the "iris," or "target" lesion, on the skin is pathognomonic; patient may have severe signs of toxicity Ruptured bullae and ulcerated oral areas; mostly in older adults Onset very rapid; condition may last 1 to 2 weeks; may be fatal; acue episodes respond to steroids With repeated recurrence of bul- lae, toxicity may lead to cachexia, infection, and death within 2 years; often controllable with steroids Lichen planus Other conditions Oral mucosa and skin White striae in mouth; purplish nodules on skin at sites of friction;occasionally causes oral mucosal ulcers and erosive gingivitis Protracted course, may respond to topical steroids Recurrent aphthous ulcers Behcet's syndrome Traumatic ulcers Anywhere on nonkeratinized Single or clusters of painful ulcers with surround- Lesions heal in 1 to 2 weeks but oral mucosa (lips,tongue, buc- ing erythematous border; lesions may be 1 to 2 may recur monthly or several cat mucosa,floor of mouth, soft mm in diameter in crops (herpetiform), 1 to S times a year; topical steroids give palate, oropharynx) mm (minor),or 5 to 15 mm (major) symptomatic relief;systemic glu- cotorticoids may be needed in severe cases; a tetracycline oral suspension may decrease severity of herpetiform ulcers Oral mucosa,eyes,genitalia, Multiple aphthous ulcers in mouth; inflammatory Ulcers may persist for several gut,and central nervous system ocular changes; ulcerative lesions on genitalia; weeks and heal without scarring inflammatory bowel disease and CNS disease Anywhere on oral mucosa;den- Localized, discrete ulcerated lesion with red bor- Lesions usually heal in 7 to 10 tures frequently responsible for der; produced by accidental biting of mucosa, days when irritant is removed, ulcers in vestibule penetration by a foreign object, or chronic irrita- unless secondarily infected tion by a denture Source: Greenspan, in Fauci et al. 1998. Harrison's principles of internal medicine. Reprinted by permission from McGraw-Hill (2000). Copyright 2000 by McGraw-Hill. systemic condition. For example, the linear gingival erythema and necrotizing ulcerative periodontitis sometimes seen in HIV infection have been difficult to resolve with routine dental curettage and prophy- laxis (Glick et al. 1994b). The appearance of soft or hard tissue pigmentation is associated with a number of diseases and treatments. Malignant melanoma can appear in the mouth as brown or black flat or raised spots. Kaposi's sarcoma can appear as a flat or raised pig- mented lesion. Addison's disease causes blotches or spots of bluish-black or dark brown pigmentation to occur early in the disease. Congenital discrete brown or black patches (nevi) can appear in any part of the mouth. Pigmentation of the tooth crowns may be seen in children with cystic fibrosis and porphyria and those exposed to tetracycline during tooth development. The oral tissues can also reflect nutritional status and exposure to risk factors such as tobacco. The 100 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL