Summary: Prevention of
Craniofacial Injuries

Health education and injury prevention
campaigns addressing the need for pro-
tective gear in sports and cycling activ-
ities can increase awareness and use.
More rapid adoption can occur through
legislation or regulation. Greater dis-
semination of safety measures for home
and workplace can similarly lower the
risk of falls and other unintentional
injuries. With regard to reducing inten-
tional injuries in the United States, cur-
rent and ongoing policy discussions,
legislative proposals, and research
efforts are necessary first steps toward
appropriate programs.

ORAL HEALTH PROMOTION
AND DISEASE PREVENTION
KNOWLEDGE AND
PRACTICES

To take full advantage of emerging sci-
ence-based health and health care prac-
tices, individuals, health care providers,
and policymakers need to be sufficient-
ly informed that they can take appro-
priate actions for themselves, for those
for whom they have responsibility, and
for the community at large. For the
individual, these actions include brush-
ing with a fluoride-containing denti-
frice for caries prevention, brushing
and flossing to prevent gingivitis and
periodontal diseases, and avoiding
tobacco and other substances that are
detrimental to health.

Lack of knowledge can affect care.
If parents are not familiar with the
importance and care of their child's pri-
mary teeth or if they do not know that
dental sealants exist, they are unlikely
to take appropriate action or seek pro-
fessional services. If the public is not
aware of the benefits of community
water fluoridation, public referenda
and funding for such interventions
are not likely to be supported. Similarly,
if individuals do not know that an
oral cancer examination exists, they
may not ask about the need for one.
However, it is well established that

Cotnmutnt)~ and Other ;\pproachcs to Promote Oral Health ;ind Prc\.cnt Oral Disease

BOX 7.2

Sports Injuries and Oral-Facial Trauma

The national concern regarding oral-facial injury is addressed in the Healthy People 2010
objective 15-31, which is to increase the proportion of public and private schools that require
use ofappropriate head,face,eye,and mouth protection for students participating in school-
sponsored physical activitiesThe National Youth Sports Safety Foundation estimates that
more than 3 million teeth will be knocked out in youth sporting activities this year,an injury
almost completely preventable by wearing a mouthguard. Even more significant, oral-facial
trauma from sports injuries will result in facial bone fractures,concussion, permanent brain
injury, temporomandibular dysfunction, blinding eye injuries, and even death.
Currently, no systematic monitoring for oral-facial injuries exists in the United States.
Progress toward a more broadly targeted Healthy People 2000 objective proved to be diffi-
cult to track because of the data requirements of monitoringall organizations,agencies,and
institutions sponsoring sporting and recreational events that pose risk of injury. By focusing
on schools,not only should the monitoring of progress be feasible, but healthy habits will be
formed early.The hope is that by the time the athletes reach young adulthood they will rec-
ognize the hazards posed by their athletic interests and, perhaps, be more comfortable using
protective devices than they would be without them.

It is estimated that as many as one third of all dental injuries are sports-related. A particu-
larly high proportion of all baseball injuries (41 percent) is estimated to occur to the head,
face, mouth, or eyes. Nowjack-Raymer and Gift (1996) reported that in 1991 more than 14
million U.S.school-aged youngsters participated in at least one sport that was listed on the
1991 National Health Interview Survey questionnaire, with more than 9 million of these
children in organized baseball or softball.

Baseball and softball are the most popular organized sports, with nearly one quarter of the
school-aged population playing. Unlike football, not all baseball/softball leagues or teams
require the use of safety equipment. In many cases, only selected positions such as catchers
and batters are covered by rules.Thus only 35 percent of players reported that they wore
headgear all or most of the time, and only 7 percent wore mouthguards all or most of the
time.

Further analysis of the interview data revealed a variety of socioenvironmental differences
in the wearing of headgear and mouthguards. Forty percent of males who played baseball
or softball reported wearing protective headgear"all or most of the time,"compared with
only 25 percent of females. Differences were also found by poverty level, with 36 percent of
those at or above poverty level wearing headgeaccompared with 24 percent ofthose below.
Better educated parents were somewhat more likely than less educated parents to have
responded that their child wore headgear"sometimes" (45 percent versus 38 percent) and
non-Hispanics reported occasional use more than Hispanics (43 percent versus 30 percent).
Parents of a greater percentage of baseball or softball players of high school age (12 percent)
than elementary school-aged players (6 percent) reported that their child wore a mouth-
guard"all or most ofthe time."Also,more black (17 percent) than white (6 percent) children
reported the use of mouthguards.
These socioeconomic differences might be greater were it not for the safety efforts of school
athletic programs.Still, many parents and coaches are not as proactive as they could be and
are not aware that facial injuries also occur in sports that are not considered high contact.
For example, basketball players typically do not wear mouthguards.Yet approximately 34
percent of all injuries to basketball players involve teeth and/or the oral cavity.
Examples of community-based interventions to prevent sports-related, oral-facial trauma
include the development of rules and regulations for the use of headgear and mouthguards
in sports where craniofacial injury is a risk; efforts to alert players, parents, sports officials,
and organizers to the potential for injury; better product design; and the creation of sup-
portive environments for sports-related equipment and recreation areas.

176         ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


I;no\vledge alone will not necessarily lead to appro-
prlate practices. For example, even if individuals
know that tobacco use is unhealthful and that it con-
tributes to multiple life-threatening illnesses, some
continue to smoke. The majority of people who need
such information most- those in low-income groups
,& those with lower levels of education-also are
the ones who lack the information and skills (oral
health literacy) to ask for and obtain specific preven-
tive semices or treatment options. Health profession-
als are in an ideal position to provide up-to-date
health information and care to their patients. They
also have an opportunity to enhance their knowledge
and practices as well as increase their communica-
tion to patients about the procedures they provide
and the reasons for these procedures.
Few national studies of public and professional
knowledge, attitudes, and practices exist. Highlights
from these as well as from state and local studies that
evaluated the prevention of dental caries, periodontal
diseases, and oral cancers are provided below.
Generally, the public is unable to discriminate
between methods that prevent dental caries and
those that prevent periodontal diseases (Corbin et al.
1985. Gift et al. 1994). This confusion has been
attributed to the prevailing marketing message that
refers to them as "plaque diseases" preventable by
thorough tooth cleaning with a toothbrush and floss.
In addition, the general public and health care
providers are not fully informed about the relative
value of fluoride and the appropriate recommended
applications of regimens to prevent dental caries
(Corbin et al. 1985, Gallup 1992, Gift et al. 1994,
O'Neil 1984). More work is needed to improve
knowledge and practices related to oral cancer pre-
vention as well. As with other areas of investigation,
additional survey research is needed to better
understand findings to date and to develop tailored
interventions. Research is ongoing to improve the
design of survey instruments and the wording of
questions to address cultural and ethnic differences
and interpretations.

Dental Caries Prevention

The Public

Most members of the general public, regardless of
socioeconomic level, tend to believe that the best way
to prevent dental caries is by brushing their teeth
(Corbin 1985, Gift et al. 1994, O'Neil 1984). In the
I990 National Health Interview Survey (NHIS),
respondents were asked the purpose of adding

fluoride to public drinking water. About two thirds of
the respondents 25 to 65 years of age knew that water
fluoridation helps prevent caries, compared with
only 51 percent and 49 percent of those 65 and older
and 18 to 24 years of age, respectively. Blacks and
Hispanics were less likely to know the value of this
preventive procedure than whites. In the same sur-
vey, when asked to indicate the one best way to pre-
vent tooth decay from five answers (limiting sugary
snacks, using fluorides, chewing sugarless gum,
brushing and flossing the teeth, and visiting the den-
tist every 6 months), only 7 percent of the respon-
dents answered correctly that fluoride was the most
effective (Gift et al. 1994). More than two thirds said
tooth brushing and flossing were the most effective.
These results paralleled those of earlier studies (Gift
et al. 1994, O'Neil 1984). A lower perceived value of
fluorides by the public in preventing dental caries
also was seen in the 1985 NHIS (Corbin et al. 1985).
In a survey of knowledge and beliefs of the public,
dentists, and dental researchers about the best way to
prevent dental caries, the public and the dentists
identified tooth brushing, whereas dental researchers
unanimously ranked fluorides, as most important
(O'Neil 1984). A small study among Latina mothers
showed that they believed that brushing with baking
soda is a good way to prevent dental caries; they
knew little about brushing with a fluoride-containing
dentifrice (Watson et al. 1999).

Dental sealants and appropriate use of fluoride
are critical for caries prevention. In the 1990 NHIS,
about 32 percent of the public had heard of dental
sealants, but among those only three fourths knew
the purpose of this preventive measure (Gift et al.
1994). In 1991 the Gallup Organization conducted a
poll for the American Academy of Pediatric Dentistry
among a national sample of 1,200 parents of children
16 years and younger. The results indicated that only
58 percent believed fluoride to be very important to
a child's oral health; another 36 percent considered it
to be somewhat important. Eight of 10 parents did
not know when a child should be prescribed fluoride
supplements, and virtually no one knew when sup-
plements should be stopped. Only 25 percent of par-
ents in nonfluoridated communities reportedly give
their children fluoride supplements (Gallup 1992).

Health Care Providers

In a national survey of U.S. dental hygienists' knowl-
edge, opinions, and practices regarding dental caries
etiology and prevention, over 90 percent agreed that
"adults benefit from the use of fluorides" and that
"root surface caries is an emerging problem." A little

Community and Other ,hpproaches to Promote Oral Health and Prevent Oral Disease

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          177


less than one third did not provide fluoride treat-
ments to adults. This same survey found that only 57
percent of the respondents recognized remineraliza-
tion as fluoride's most important mechanism of
action; rather, flossing was selected as the most effec-
tive procedure for preventing caries in adults. Also,
only 18 percent reported providing the recommend-
ed time for acidulated phosphate fluoride (APF) gel
treatment (Forrest 1998). A city-based suney of den-
tists and dental hygienists found that nearly 70 per-
cent of the offices used lower than recommended
topical fluoride application times and that some of
the fluoride products reportedly used had not been
clinically tested (Warren et al. 1996).

Periodontal Disease Prevention

The Public

In the 1990 NHIS the majority of household respon-
dents (79 percent) could identify one common sign
of "gum" disease. Level of education was directly
related to knowledge of gum disease. Eighty-nine
percent of those with more than a high school level
of education were able to name a common sign of
gum disease, compared with 79 percent of those with
a high school education and 60 percent of those with
less than a high school education (Gift et al. 1994).
A Roper report on oral health surveyed more
than 1,000 adults 18 and older, Eighty percent
reported that they did not believe they `have had peri-
odontal disease. However, 70 percent reported hav-
ing experienced at least one symptom of gum dis-
ease-bleeding gums; swollen, painful, or receding
gums; a change in bite; or loose teeth. Although 41
percent of the respondents said that losing their teeth
was their greatest fear regarding oral health, only 38
percent who had bleeding gums said they told their
dentists about the problem. Further, only 30 percent
of the respondents who had experienced warning
signs of gum disease were worried about developing
periodontal problems in the future. Fifty-eight per-
cent knew that plaque is the main cause of gum dis-
ease and that flossing alone will not prevent gum dis-
ease, whereas 77 percent knew that brushing alone
would not prevent gum disease. The majority (90
percent) knew that gum disease could strike anyone
at any age (Roper Report 1994).
In a recently reported study on the oral hygiene
practices of a convenience sample of 34,897 users
and nonusers of tobacco products who obtained den-
tal care in 75 dental practices, 74 percent reported
brushing twice a day and 36 percent reported flossing
once daily (Andrews 1998). Tobacco users brushed

and flossed much less frequently than nonusers.
Patients with more than a high school education
were less likely to use tobacco products and more
likely to brush at least 2 times a day and floss daily
than were those with less education.

A 1996 study of 1,000 U.S. adults showed that
nearly one third (29 percent) of respondents were
extremely or very concerned about getting gum dis-
ease. Concern was highest among younger respon-
dents 18 to 49 years of age and those who very or
somewhat frequently experienced bleeding gums.
Only 6 percent said they frequently suffered from
bleeding gums (2 percent very frequently and 4 per-
cent somewhat frequently). Only 13 percent said a
dental professional had diagnosed them with any
kind of periodontal disease (gingivitis, pyorrhea, and
periodontitis). Older respondents were somewhat
more likely than younger ones to have been diag-
nosed with gum disease, and 17 percent reported
experiencing  gingival bleeding occasionally
(Andrews 1998).

Health Care Providers

Studies of dental professionals regarding periodontal
disease prevention practices are limited. In 1989,
Dental Products Report launched a study to deter-
mine the involvement of general practitioners in
periodontal care. Overall, general dentists and their
hygienists have become more involved in the peri-
odontal exam phase of patient treatment. This posi-
tive trend suggests that periodontal diagnosis and
treatment are well integrated into general practice.
For example, when asked "what phases of periodon-
tal treatment are you providing at present?" 100 per-
cent reported gingival exam and evaluation, 97 per-
cent reported pocket probing, and 88 percent report-
ed providing patient education. The majority of den-
tists (67 percent) used as many as six measurement
sites per tooth. Nearly all (93 percent) reported hav-
ing a referral relationship with a periodontist (Dental
Products Report 1996).

Oral Cancer Prevention and Early
Detection

The Public
U.S. adults generally are ill-informed regarding risk
factors for and signs and symptoms of oral cancers.
Further, a 1990 national survey found that only 14
percent of adults 40 and older reported that they had
ever had an oral cancer examination. Of those, only
7 percent had had an exam within the last year

178        ORAL HWLTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


jiaro~v;t;: et al. 1995). In a statewide survey in
,t,tn.jand. 85 percent of the adults claimed to have
(,t,lrd of oral or mouth cancer, but only 28 percent
reported ever having an oral cancer examination
fjnrovvttz et al. 1996). A state-based study of veter-
.,t,++~ population at high risk for oral cancers-
l,,ur-td that they were ill-informed and misinformed
.tbout these cancers (Canto et al. 1998a). Finally, a
,tudv among Latin0 youths who reported use of
t(,b&o and alcohol found that they, too, were not
knoivfedgeable regarding risk factors for oral cancers
, C,tnto et al. 1998b).

lltalth Care Providers

.-J, recent national pilot survey of U.S. dentists found
that the respondents' knowledge regarding risk fac-
tors for and signs and symptoms of oral cancers and
their reported practice of examination procedures
\vcre limited (Yellowitz et al. 19.98). Most respon-
dents believ,ed they were adequately trained to pro-
VI& oral cancer examinations, and 70 percent pro-
b.ided annual oral cancer exams to patients 40 and
older. Seventy-four percent reported their knowledge
of oral cancers to be current, yet only 30 percent cor-
rcctly identified the age cohort most frequently diag-
nosed with oral cancers. Further, less than 50 percent
correctly identified the stage at which most oral can-
cer lesions are diagnosed, and nearly one third of
respondents could not identify the two most com-
mon sites of these lesions. Although 86 percent
claimed to assess their patients' current tobacco use,
only 50 percent assessed current alcohol use; rela-
tively few dentists assessed past alcohol or tobacco
use. There was a modest amount of misinformation
as well. For example, 65 percent believed, incorrect-
ly% that ill-fitting dentures and partials were a risk fac-
tor for oral cancers, and 47 percent believed, also
incorrectly, that poor oral hygiene was a risk factor.
Further, although the majority of dentists claimed to
provide oral cancer examinations to the majority of
their patients, a large proportion did not palpate the
lymph nodes-part of a comprehensive oral cancer
examination. These results confirm an earlier study
conducted among a convenience sample of Maryland
dentists and physicians in that both groups believed
their knowledge and skills related to oral cancer pre-
vention and early detection to be wanting (Yellowitz
and Goodman 1995).

A recent national survey among U.S. dental
hygienists found that although 98 percent agreed that
oral cancer examinations should be provided annual-
ly for adults 40 and older, only 64 percent reported
performing such an exam 100 percent of the time,

and nearly 17 percent reported not performing an
exam at any time (Forrest 1998). Further inconsis-
tencies were found between knowledge of risk factors
and performance. For example, although 94 percent
correctly identified alcohol use as a risk factor for
oral cancer, only 49 percent asked about alcohol use.
Less than a majority (45 percent) reported their
knowledge of oral cancers to be current. A majority
(61 percent) believed they were adequately trained to
palpate lymph nodes; still, only 24 percent reported
routine palpating of lymph nodes, while 51 percent
indicated they did not do so at any time.

Summary

Findings from national surveys, together with those
from local studies, suggest that there are opportuni-
ties for enhanced educational efforts for both the
public and health professionals to improve oral
health. These studies focus on the public and the
dental profession for selected diseases. New research
is needed to assess knowledge, attitudes, and prac-
tices of all health professionals and for other condi-
tions and risk factors related to oral health as well.

BUILDING UPON SUCCESS

As research and technology advance our understand-
ing of the causes of major craniofacial diseases and
disorders and lead to improved methods of diagnosis,
treatment, and prevention, opportunities for new
community-based prevention programs will grow.
Ultimately, the application of any preventive inter-
vention is driven by a combination of individual
behaviors, community interventions, and profession-
al practice, Only a few studies have taken into
account all three spheres of action in determining
health outcomes in a community (Arnljot et al. 1985,
Chen et al. 1997). Our knowledge of the effects of
multiple interventions is limited because most inter-
ventions were developed and tested singly

In the past half century, however, advances in
our understanding of oral diseases and the applica-
tion of multiple preventive measures have resulted in
continuing declines in the prevalence and severity of
both dental caries and periodontal diseases for a size-
able majority of Americans. For dental caries, for
example, experts now believe that most people can
maintain a low risk of the disease by a combination
of drinking fluoridated water and brushing daily with
a fluoride dentifrice. They recommend that addition-
al provider- and community-based dental prevention
programs be targeted to high-risk individuals and
groups.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

179


Community and Other Xpproaches to Promote Oral Health and Prc\~ent Oral Discasc

Many of the studies reviewed in this chapter
were conducted when higher rates of caries pre-
vailed, community water fluoridation was less wide-
spread, and use of fluoride dentifrices and supple-
ments was not as common as today. These facts must
be taken into consideration in contemporary deci-
sion making by public health professionals and poli-
cymakers. The validity and reliability of recommen-
dations will benefit from the systematic reviews of
the scientific evidence by the Task Force on
Community Preventive Services (2000) to be includ-
ed in a Guide to Community Preventive Services. Oral
health promotion strategies are among those current-
ly being evaluated.

reach those at high risk for disease. Similarly, focus-
ing community-based interventions on populations
at greatest risk will make optimal use of available
resources. However, continued research to under-
stand risk and improve ways to measure it is equally
important for the success of these ventures.

A review of progress in reaching the Healthy
People 2000 oral health objectives reveals relatively
little gain across many of the objectives (Table 7.8).
Progress in the next decade will require diligent
efforts to identify public health problems, mobilize
resources, and ensure that the necessary conditions
are in place and crucial services received. Public
health agencies will be instrumental in carrying out
these functions, and state and local dental directors
can perform a leadership role. Box 7.3 describes the
public health services that are essential if a commu-
nity is to realize fully the benefits of available disease

Future innovations include implementing pro-
grams in new settings, such as workplaces, senior
centers, and nursing homes, where individuals at
high risk can be reached. Even if these programs are
more expensive, the yield may be worth it if they  prevention and health promotion interventions

TABLE 7.8
Progress in meeting Healthy People 2000 oral health objectives

13.1   Reduce dental caries in children
    Reduce dental caries in adolescents
13.2   Reduce untreated dental decay in children
   Reduce untreated dental decay in adolescents
13.3   Increase adults who have never lost a
    permanent tooth
13.4   Reduce adults who have lost all their teeth
13.5   Reduce gingivitis among adults
13.6   Reduce destructive periodontal disease
13.7   Reduce oral and pharyngeal deaths in males
   Reduce oral and pharyngeal deaths in females
13.8   Increase sealants in children
    Increase sealants in adolescents
13.9   Increase persons on public water receiving
    fluoridated water
13.10  Increase topical/systemic fluorides among
     nonfluoridated
13.11  Increase caregivers using feeding
   practices that prevent early childhood caries
13.12  Increase oral health screening, referral, follow-up,
    first time school attendee
13.13  For long-term care,oral exam and services
   provided within 90 days
13.14  Increase use of oral health care system
    (adults)
13.15  Increase states with system for recording
   and referring orofacial clefts
13.16  Extend use of protective head, face, eye,
   and mouth equipment
13.17  Reduce smokeless tobacco use among males


Source: Adapted from NCHS 1999.

Age

6-8
15
b-a
15
35-44


65+
35-44
35-44
45-74
45-74
  8
14









35+









12-17
18-24

Baseline Data    HP 2000 Goal     Final Data     Summary

  54%        35%        52%     Prog
  78%         60%        61%     Prog +++
  28%         20%        29%      Reversed
  24%         15%        20%     Prog ++
  31%         45%        31%     No Change


  36%        20%        30%     Prog ++
  41%        30%        48%       Reversed
  25%        15%        22%      Prog +
.13.6%       10.5%       10.3%       Met
4.8%        4.1%        3.5%       Met
  11%        50%        23%     Prog ++
  8%        50%        24%     Prog ++
  61%        75%        62%      Prog


  50%        85%       No data       No data


  55%        75%       No data      No data


  66%        90%        75%     Prog ++


No data        100%      No data       No data


  54%        70%        63%     Prog ++


11 states      40 states      23 states     Prog ++


No data       No data       No data       No data


6.6%         4%        3.7%       Met
8.9%         4%        6.9%     Prog ++

180       ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


-  c i,mm~lnit\ .~nd 0thcr ,\pproaches to Promote Oral Health and Prevent Oral Disease

Box 7.3

Essential Public Health Services for Oral Health
The Association of State and Territorial Dental Directors'Guidelines
fur stare and Territorial Orul Health Programs (ASTDD 1997) identi-
fies the following essential public health services to improve oral
health:
I. Assessment

Assess oral health sratus and needs so that problems can
be identified and addressed.
Analyze determinunts of identified oral health needs,
including resources.

Assess the fluoridation status of water systems, and other
sources of fluoride.

Implement an oral he& surveillance system to identify,
investigate,and monitor oral health problems and health
hazards.

II. Policy Development

Developplans undpolicies through a collaborative process
that support individual and community oral health
efforts to address oral health needs.
Provide leadership to address oral health problems by
maintaining a strong oral health unit within the health
agency.

Mobilize community partnerships between and among
policymakers, professionals, organizations, groups, the
public, and others to identify and implement solutions to
oral health problems.

Ill. Assurance

A.


B.




C.







D.


E.




F.


G.

Inform, educate, and empower the public regarding oral
health problems and solutions.
Promote and enforce lutvs and regulufions that protect
and improve oral health, ensure safety, and assure
accountability for the public's well-being.
Linkpeople to needed population-based oral health serv-
ices, personal oral health services, and support services
and assure the availability, access, and acceptability of
these services by enhancing system capacity, including
directly supporting or providing services when necessary.
Support services and implementation of programs that
focus on primury und secondmy prevention.
Assure rhat the public health und personul heoltb
workforce has the capacity and expertise to effectively
address oral health needs.

Evaluate effectiveness, uccessibikty, und quulity of popula-
tion-based and personal oral health services.
Conduct reseurch ond support demonsfrution projects to
gain new insights and applications of innovative solutions
to oral health problems.

FINDINGS

   o  Community water fluoridation, an effective,
safe, and ideal public health measure, benefits indi-
viduals of all ages and socioeconomic strata.
Unfortunately, over one third of the U.S. population
(100 million persons) are without this critical public
health measure.

   0  Effective disease prevention measures exist
for use by individuals, practitioners, and communi-
ties. Most of these focus on dental caries prevention,
such as fluorides and dental sealants, where a combi-
nation of services is required to achieve optimal dis-
ease prevention. Daily oral hygiene practices such as
brushing and flossing can prevent gingivitis.
   0  Community-based approaches for the pre-
vention of other oral diseases and conditions, such as
oral and pharyngeal cancers and oral-facial trauma,
require intensified developmental efforts.
o Community-based preventive programs are
unavailable to substantial portions of the under-
served population.
   o  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.
   o  Disease prevention and health promotion
approaches, such as tobacco control, appropriate use
of fluorides for caries prevention, and folate supple-
mentation for neural tube defect prevention, high-
light opportunities for partnerships between commu-
nity-based programs and practitioners, as well as col-
laborations among health professionals.
    o  Many community-based programs require a
combined effort among social service, health care,
and education services at the local or state level.

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186         ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


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188

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


Personal and Provider Approaches
to Oral Health

c)ral health is not a given. It takes conscious and
rePeated efforts on the part of the individual, care-
(Ttvers, health care providers, and the community For
,`,
the individual, daily hygiene routines and healthy
ftfcstyle behaviors provide a frontline defense in dis-
c;rsc prevention and health promotion. Equally
important are periodic professional assessments of
the individual's oral health status, which may include
diagnostic, preventive, and therapeutic services and
counseling. Community activities complement per-
sonal and provider approaches to oral health. As dis-
cussed in the previous chapter, these include water
lluoridation, dental sealant applications for children,
tobacco cessation campaigns, the use of mouth-
guards in sports, and a variety of other school- and
community-based oral health promotion and disease
prevention activities. The interaction of these com-
ponents is critical to oral health, as it is to overall
health. In particular, there is now a better under-
standing of the relationship of individual health to
the health of the community in which the individual
lives, and the importance of this relationship is one of
the underlying premises of Healthy People 2010.
This chapter discusses actions individuals can take to
maintain their oral health and prevent disease, and
reviews emerging approaches taken by dentists and
other health care providers to promote oral health,
assess risks, and prevent disease.

INDIVIDUAL RESPONSIBILITY:
PERSONAL APPROACHES TO ORAL
HEALTH
Sound personal hygiene practices and adherence to a
healthy lifestyle are the mainstays of personal
approaches to oral health. Long before the germ the-
ory of disease, the need for tooth cleaning was recog-
nized-if only to rid the mouth of food debris, elim-
inate odor, and improve appearance, Tools developed

for this purpose have ranged from primitive tooth
sticks and picks, still used in parts of the world, to
the water irrigators and electronic toothbrushes
available in industrialized societies. An impressive
array of oral care products greets the shopper in
supermarkets and pharmacies today Beyond the
dozens of toothbrush shapes and sizes, there are
flavored and textured dental flosses, floss holders,
rubber tips, toothpicks, small brushes for cleaning
between teeth, scores of dentifrices, and a range
of fluoride-containing, antitartar, and antiseptic
mouthrinses.

Daily oral hygiene efforts contribute to the
prevention of dental caries and periodontal diseases,
The biofilm on tooth and root surfaces (dental
plaque) can be disrupted to a large extent by the
mechanical action of brushing and flossing. Daily
efforts are necessary, not only because of food intake,
but also because dental plaque is never completely
removed. It starts to build up even after the most
assiduous cleaning (or prophylaxis) in the dental
office and even after the application of a potent
antimicrobial mouthrinse. The oral and dental
tissues and structures thus require more intensive
daily care than do other body areas exposed to the
environment.

Daily Hygiene and Dental Caries
Prevention

The use of a fluoride-containing dentifrice is critical
for dental caries prevention. Even more beneficial
than the physical removal of plaque in toothbrushing
is the delivery of a small amount of fluoride to the
tooth surfaces. Investigators have conducted numer-
ous clinical trials on fluoride dentifrices using rigor-
ous designs and including randomized groups, dou-
ble-blind designs, and placebo controls. All together,
these studies provide strong evidence that using a

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          189


Personal and Provider ,\pproaches to Oral Health

fluoride dentifrice is effective (Clarkson et al. 1993,
Lewis and lsmail 1995, Stookey et al. 1993). Fluoride
dentifrices account for more than 90 percent of the
market in the United States, Canada, and other devel-
oped countries (Levy 1994).

  A fluoride dentifrice is an effective means of
reducing the prevalence of dental caries for all per-
sons. Although children's teeth should be cleaned
daily from the time they erupt, parents and caregivers
should consult a dentist or other health care provider
about the use of a fluoride dentifrice for children
under the age of 2. For children under 6, fluoride
dentifrices should be used in small amounts to mini-
mize swallowing of the product. Mild enamel fluoro-
sis can result from excessive dentifrice use, because
children under 6 do not have adequate control of the
swallowing reflex or may intentionally swallow a fla-
vored dentifrice. Experts recommend that for chil-
dren under 6, the parent or caregiver should super-
vise toothbrushing, apply a pea-sized amount (0.25
gram) of dentifrice to the toothbrush, and encourage
the child to spit out the excess (Bawden 1992).
Because the topical benefits of fluoride have been
shown to be highly effective, and daily exposure to
small amounts of fluoride can reduce the risk of den-
tal caries in all age groups, experts recommend that
all persons drink water with an optimal fluoride con-
centration in addition to brushing daily with a fluo-
ride dentifrice (Bawden 1992, CDC in press). This
combination provides a cost-effective and easy way to
prevent dental caries and is an excellent example of
the individual-community partnership. For persons
at low risk of dental caries, these two exposures to
fluoride may be the only ones necessary For persons
at moderate or high risk of dental caries, additional
fluoride may be helpful and can come from daily use
of another fluoride product. These can include
mouthrinses, prescribed supplements, and profes-
sionally applied topical fluoride products (CDC in
press).

brushing are effective at removing plaque and pre-
venting gingivitis (Walsh et al. 1989, Axelsson et al.
1991). Inter-proximal (between the teeth) cleaning is
also important in maintaining gingival health (Lang
et al. 1994). In one short-term evaluation of adults,
the addition of flossing to the daily regimen of brush-
ing resulted in an almost twofold reduction in gingi-
val inflammation (Graves et al. 1989). Because pre-
ventive measures in periodontics rely mainly on the
removal of bacterial plaque and calculus, methods
typically include personal oral hygiene measures
combined with professional diagnostic and prophy-
lactic measures (i.e., regular exam and cleaning).
Periodic professional care for removal of plaque and
calculus deposits has also been demonstrated to
improve the periodontal health of participants
(Cutress et al. 1991, Ronis et al. 1993).

Healthy Lifestyles

There is more to the individuals role in promoting
oral health and hygiene than brushing and flossing.
Other behaviors that have an influence on oral health
include use of tobacco and/or alcohol products, diet,
oral habits such as bruxing and clenching the teeth,
and use of helmets, mouthguards, or other protective
devices. Table 8.1 summarizes selected behaviors
that have an effect on oral, dental, and craniofacial
health status. These are described more fully in
Chapters 3, 7, and 10.

  Individuals can obtain credible information
regarding oral health from various sources, including
health care providers, professional organizations,
government agencies, and patient advocacy groups.
Increasingly, the World Wide Web is a source for
health care information. For example, the National
Oral Health Information Clearinghouse offers infor-
mation on oral health, with an emphasis on special
care patients and their health care providers.

Daily Hygiene and the Prevention of
Periodontal Diseases

Care Seeking

Toothbrushing and flossing also play a critical role in
the prevention of periodontal diseases. Unlike dental
caries prevention, prevention and control of gingivi-
tis and periodontitis are achieved directly through
the mechanical removal and disruption of dental
plaque (Genco and Newman 1996). Some dentifrices
also contain chemical therapeutics to control the for-
mation of tartar (calculus) (Mandel 1995) and to
reduce plaque formation and gingival inflammation
(Hancock 1996). Both manual and electric tooth-

In addition to self-care, individuals also need to seek
professional health care-both dental and medical-
on a regular basis and whenever a problem manifests.
The recall interval is based on the provider's assess-
ment of the individuals dental and medical history
and lifestyle behaviors, among other factors. In the
case of children and dependent adults, parents and
caregivers are responsible for teaching and encourag-
ing healthy behaviors and seeking timely and appro-
priate care. As noted at the outset, it is only through
the combination of individual and professional care,
reinforced by community-based health promotion

`90         ORIL HE.iLTl1 IN .\hlERIC.\: .4 REPORT OF THE SLIRGEON GENERAL


Personal and Provider r\pproaches to Oral Health

and disease prevention programs, that optimal oral
and general health can be achieved. The remainder of
this chapter focuses on the role of the professional in
oral health care.

PROVIDER-BASED CARE

The range of conditions and diseases that affect the
craniofacial complex is extensive and can provide
clinicians with important indications about the
patients general as well as oral health status.
Management of the oral health-general health inter-
face calls for interdisciplinary and coordinated care
and an enhanced role for primary care providers.
Dentists, oncologists, dermatologists, infectious dis-

ease specialists, hematologists, endocrinologists,
plastic surgeons, and rheumatologists are just a few
of the specialists who may be involved in the diagno-
sis and management of conditions affecting the cran-
iofacial complex.

Dentists, their allied staff, and medical and nurs-
ing personnel are in a unique position to incorporate
new approaches for prevention,' diagnostic, and
treatment strategies in their practices. Advances in
oral science are providing the basis for a shift in
emphasis from the repair and restoration of damaged
tissues to earlier diagnoses, control of infections, and
remineralization and regeneration of lost tissues. The
application of risk assessment strategies and inter-
ventions tailored to individuals and groups is

TABLE 8.1

Selected individual behaviors affecting oral, dental, and craniofacial health

Behavior

Diet and nutrition

                          Effect
Nutrition and diet contribute to oral and traniofaciai development and to the maintenance of these tissues throughout life.
Nutritional deficiencies during pregnancy can affect tooth size,enamel solubility,time of tooth eruption,salivary gland function,
saliva composition, epithelial tissue, and susceptibility to dental caries. Deleterious effects specific to the dentition include protein-
calorie malnutrition, deficiencies of vitamin A, ascorbic acid, vitamin 0, calcium, phosphorus, iron, and iodine,and excessive fluoride.
Linear enamel hypoplasia and hypomineralization during the first year of life increase susceptibility to dental caries in both decidu-
ous and permanent teeth.The physical consistency, sequence, and frequency of carbohydrate intake (primarily refined sugars) have
been linked to the development of caries. Reduced calcium intake is associated with greater levels of periodontal disease. Early
clinical signs of nutritional deficiencies and eating disorders are often seen in and around the mouth.Oral lesions may also affect
systemic nutrition. (See Chapter 10, Box 10.1.)

Oral hygiene and home
care practices
Care seeking

Regular toothbrushing with a fluoride-containing dentifrice prevents dental caries. Rinsing with fluoride mouthrinse can aid in
reducing caries and in the reminefalization of tooth structure. Regular toothbrushing and proper flossing can prevent gingivitis.
Seeking health care-both dental and medical-on a regular basis and whenever a problem manifests is important. In the case of
children or dependent adults, it calls for the caregivers to teach and encourage healthy behaviors and to seek appropriate care from a
variety of care providers. Prenatal care, as well as oral health care prior to major treatments such as chemotherapy, is critical to over-
all oral and craniofacial health.

Parafunctional habits






Tobacco use




Alcohol use

Habitual grinding (bruxism) and/or clenching teeth are forms of abnormal motor behavior.These habits often occur during sleep. As
with clenching and other oral habits such as frequent gum-chewing, bruxism can cause tooth wear and affect muscles of mastica-
tion.Treatment may begin with making the individual aware of the problem, providing an occlusal splint to prevent tooth wear, and
using behavioral strategies.
The use of tobacco in all forms increases the risk for oral and pharyngeal cancers,and smoking is a leading risk factor for periodontal
diseases. Increased risk for dental caries has been associated with spit tobacco use. In HIV-infected individuals, tobacco use is a risk
factor contributing to increased risk of the development of oral candidiasis. (See Chapter 10, Box 10.2.)
Alcohol alone, as well as acting synergistically with tobacco, greatly increases the risk for oral and pharyngeal cancers.
Independently, alcohol in excess is associated with circulatory and neurological problems, liver disease, and other organ-specific dis-
eases and disorders. Alcohol use in pregnancy can lead to birth defects, such as fetal alcohol syndrome and its associated craniofacial
defects and mental retardation.

Injury control practices  Proper use of helmets, mouthguards,safety belts, and other protective devices helps prevent injuries to the head, neck, and mouth.

`The term prevention, as used in this chapter, includes interventions aimed at reducing the incidence of disease in relatively
healthy patients. It includes both health promotion and specific protection to control one or more risk factors. Some strategies,
such as the prevention of tobacco use. are applicable to many oral diseases, including oral cancer, oral candidiasis, and peri-
odontal diseases, whereas other strategies are specific, such as the use of dental sealants and fluorides for caries prevention.

ORAL HEALTH IN AMERIa A REPORT OF THE SURGEON GENERAL

191


expanding with the increased understanding of risk
factors and the development of biomarkers that sig-
nal host resistance, susceptibility, and the presence
and progression of disease.

The changing demographics of the U.S. popula-
tion and a greater understanding of the relationship
between oral health and general health are presenting
new challenges. Making clinical decisions for
patients requires integrating a range of interacting
biological, psychological, social, cultural, and envi-
ronmental factors. In order for disease to manifest,
the etiologic agent(s) must be present, the host must
be susceptible, the environment conducive, and suf-
ficient time available for the factors to interact
(Figure 8.1). Early diagnosis and prompt treatment
require an understanding of the pathology and of the
diagnostic, prevention, and treatment modalities
available. As genetic information accumulates, chni-
cal judgments will increasingly be informed by
knowledge of an individual's genetic susceptibility or
resistance to particular diseases and disorders. The
development of tailored treatment plans will require
incorporating all these factors together with input
from the patient's health providers, taking into con-
sideration the patient's interests and needs. The fol-
lowing sections provide an overview of emerging
approaches to clinical management and highlight
selected diseases as examples.

Risk Assessment

Given the greater understanding of disease etiology,
epidemiology, patient characteristics, and genetic
information, it is becoming increasingly possible to
determine an individual's risk of disease and tailor
treatments accordingly Risk assessment for dentistry
has been defined as "the use of knowledge of factors

Personal and Pro\+der ;\pproaches to Oral Health

that are associated with dental disease to determine
which patients are more or less likely to prevent or
control their dental disease" (Douglass 1998). The
factors can include co-morbidities, medications used,
and patient characteristics such as sex, age, and
lifestyle behaviors, among others. By compiling such
factors and sorting them by risk category, patients
can be classified into high- or low-risk groups,
enabling providers to make more comprehensive
diagnoses and identify patients who would benefit
from more aggressive prevention strategies. Such
analyses conducted during the early stages of disease
can result in treatments that reverse or contain the
disease process (Douglass 1998). Knowledge of risk
factors for oral and cranioficial diseases and disor-
ders allows other health care providers to screen for
these risk factors and contribute to improving oral
health.

Risk assessment and disease prediction studies
have focused primarily on dental caries and peri-
odontal diseases (Genco 1996, Page and Beck 1997,
Pitts 1998, Powell 1998). In addition, risk factors for
oral and pharyngeal cancers have been explored
(Johnson 1991). The evidence base for risk assess-
ment is developing from population-based studies. It
involves a research process in which a suspected risk
factor is related in a multivariate model to other fac-
tors and confounders (Beck 1990). The resulting
model is tested in a second group of subjects, and a
targeted intervention study is conducted to confirm
the predictive validity of the risk factor.

Although the application of research findings of
risk assessment has begun in some practices, the pre-
diction of future disease at the individual patient
level has not yet been extensively studied. Douglass
(1998) has posed six clinically oriented questions
that need to be addressed if risk assessment is to be
adopted into routine clinical practice:

FIGL:RE 8.1
Factors involved in disease

  1.  Does the scientific theory or biologic logic of
the risk factor fit with our current body of knowledge
about the disease in question?
2. Has the technical merit of identifying the
risk factor (such as imaging technologies and bacter-
ial assays) been evaluated?
3. Has the efficacy of the risk factor in
predicting disease been evaluated in terms of
sensitivity, specificity, and positive and negative
predictive values?z
  4.  Has the potential effect of the risk factor on
the disease management decision been explored?
Can knowledge of the presence of a particular risk
factor or pattern of risk factors alter the treatment
plan?

192         ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


Personal and Provider L4pproaches to Oral Health

  j.  Has the influence of the risk factor on oral
/ItLllth outcomes been assessed?
6. Has the cost-effectiveness of collecting risk
factor data from each patient been evaluated? Is the
`Iddcd expense justified either by increased effective-
Il~s~ or by avoiding other expenses?

Diagnostic TeStS

l\$ereas risk assessment aims to predict future dis-
cast' and disease progression, diagnostic tests evalu-
ate a patient`s current status with regard to a specific
disease or disorder. They enable the provider to for-
mulate, in cooperation with the patient, a treatment
plan. In relation to dental caries and periodontal dis-
cases, the diagnosis ideally should not only detect the
presence of disease, but also distinguish between
active and arrested disease.

Today, most diagnostic tests for oral conditions
are based primarily on anatomic clinical evidence.
However, microbiological, pathological, immunolog-
ical, genetic, and tissue metabohte tests are increas-
ingly available and valuable. Table 8.2 cross-refer-
ences diseases with categories of diagnostic tests
available. The following sections describe elements of
a general health assessment and highlight risk assess-
ment, diagnosis, and prevention of selected diseases
and conditions.

Oral Health Assessment

An oral health assessment involves an evaluation of
an individual? overall health status, including any
risk factors and personal needs that can affect health
and treatment options. For the majority of craniofa-

cial conditions, this assessment and subsequent care
are coordinated with a range of health care providers,
with the intent of enhancing the patient's overall
health and well-being.

The information gathered for the assessment is
derived from patient information, extraoral and
intraoral clinical examinations, and imaging and
other diagnostic tests as needed. The patient provides
demographic and lifestyle behavior information and
a medical and dental history, including current com-
plaints, if any. Symptom analysis entails an addition-
al series of questions that explore symptom onset,
characteristics, and course. Figure 8.2 provides an
example of a medical history form used in dental
practice.

The clinician will take into consideration the
patient's general appearance and ability to function,
as noted by characteristics of facial symmetry or
asymmetry and speech. In addition, the patient's vital
signs may be assessed, and a thorough examination
of the head, neck, temporomandibular joints, and
other structures will be conducted. The intraoral por-
tion of the examination involves an extensive assess-
ment of the tissues: the lips and labial mucosa, buc-
cal mucosa and mucobuccal fold, the floor of the
mouth, tongue, hard and soft palate, oropharynx,
muscles of mastication, salivary glands and saliva,
gingiva, periodontium, and teeth.

Depending on the needs of the patient, the initial
physical examination is usually augmented by sup-
plementary data from radiographs and sometimes
by other diagnostic tests, including tissue biopsies
and samples of oral cells and fluids. Such samples can
be used to type specific bacteria, viruses, or fungi or
to detect elevated levels of tissue metabolites or

TABLE 8.2
Categories of diagnostic methods for selected oral, dental, and traniofacial diseases and disorders
     Diagnostic              Periodontal    Oral     Mucosal   Temporomandibular   Craniofacial
       Procedure         Caries    Diseases   Infections    Diseases      Disorders      Defects    Oral Cancers

Interview Patient history          o        o       o         o           o           o        o

Physical   Clinical examination        4        o       o         o           o           o         o
    Probing/caries          o
    Probing/periodontal                o

Imaging                    +        o                            o           o        o

Biologic  Histology/cytology                        o        o                               o
    Microbiology           o        o       o         o                               o
     Genetics/DNA                   *                o                      o         o

Gnsitivity is a measure of how often the test is positive when applied to patients known to have a particular disease or condition;
speci$city is a measure of how successful the test is in judging the absence of a disease or condition.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          193


Personal and Provider Approaches to Oral Health

FIGURE 8.2
Medical history form for use in dental practice

Medical History Form                Date

Name                                      Home Phone U

Address ~ Business Phone I

City                             State ~ Zip Code

Occupation                                    Social Security No.

Date of Birrh      /     I    Sex M F Height     Weight      Single      Married
      ---                  - -

Name of Spouse                Closest Relative             Phone (

If you are completing this form for another person,what is your relationshrp to that person?

Referred by
For the following questions, cirrle ym orno, whichever applies.Your answers are for our records only and will be considered confidential. Please note thafduring your initial visit you will be
asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.
1.  Are you in good health?. .......................................................................................................................................................................................................................................    Yes No

2.  Has there been any change in your genera) health wrthin the past year? ..........................................................................................................................................................    Yes No

3.  My last physical examination wason
4.  Are you now under the tare of a physician? ........................................................................................................................................................................................................    Yes No
  If so.what is the condition being treated?
5.  The name and address of my physician(s) IS
6.  Have you had anyserrous illness,operation,or been hosprtalized in the past 5 years! ......................................................................................................................................    Yes    No
  If so,what was the dlness or problem?
7.  Are you taking any medicine(s) including non-prescription medrcrne? ..............................................................................................................................................................    Yes No
  If so, what medicine(s) are you taking?
8.  Do you have or have you had any of the following diseases or problems?
  a.  Damaged heart valves orarmkial heart valves,inc)uding heart murmur or rheumatic heart disease.. ......................................................................................................    Yes No

  b.  Cardiovascular disease (heart trouble, heart attark,angina,toronary insufficiency,coronary occlusion, high blood pressure,
    arteriosclerosrs, stroke) ................................................................................................................................................................................................................................    Yes No

     1.  Do you have chest pain upon exertion? ..............................................................................................................................................................................................    Yes No

     2.  Are you ever short of breath after mild exercise or when lyrng down? ..............................................................................................................................................    Yes No

     3.  Do your ankles swell? ..........................................................................................................................................................................................................................    Yes No

     4.  Do you have Inborn heart defects? ..... .._._.._._................. ................. . ..................................................................................................................................................    Yes No

     5.  Do you have a cardiac pacemaker? ....................................................................................................................................................................................................    Yes No

  c.  Allergy.. ........................................................................................................................................................................................................................................................    Yes No

  d.  Sinus trouble ................................................................................................................................................................................................................................................    Yes No

  e.  Asthma or hay fever ....................................................................................................................................................................................................................................    Yes No

  f,  Fainting spells or serzures ............................................................................................................................................................................................................................    Yes No
  g. Persistent diarrhea or recent weight loss ......................................................................................................................... .....................~ ....................................................    Yes    NO

  h.  Diabetes  ....................................................................................................................................................................................................................................................    Yes No

  i.  Hepatrtisjaundite. or liver disease ..............................................................................................................................................................................................................    Yes No
  j.  AIDS or HIV infection ....................................................................................................................................................................................................................................    Yes No

  k.  Thyroid problems ........................................................................................................................................................................................................................................    Yes No

   I.  Respiratory problems.emphysema. bronthitisetc. ....................................................................................................................................................................................    Yes No

   m. Arthritis or painful swollen joints ................................................................................................................................................................................................................    Yes No

   n.  Stomach ulcer or hyperacrdity ......................................................................................................................................................................................................................    Yes No

   o.  Kidney trouble.. ............................................................................................................................................................................................................................................    Yes No
  p, Tuberculosis ..................................................................................................................................................................................................................................................    Yes NO

   q.  Persrstent cough or cough that produces blood ..........................................................................................................................................................................................    Yes No

   r.  Persrstent swollen glands in neck ................................................................................................................................................................................................................    Yes No

   I.  tow blood pressure ......................................................................................................................................................................................................................................    Yes No

   t.  Sexually transmitted disease.. ......................................................................................................................................................................................................................    Yes No

   u.  Epilepsy or other neurological disease ........................................................................................................................................................................................................    Yes No

   v.  Problems with mental health ......................................................................................................................................................................................................................    Yes No

   w.  Cancer ..........................................................................................................................................................................................................................................................    Yes No

   x.  Problems of the Immune system.. ................................................................................................................................................................................................................    Yes No

9.  Have you had abnormal bleeding? ......................................................................................................................................................................................................................    Yes No

   a.  Have you ever requrred a blood transfusion? ..............................................................................................................................................................................................    Yes No

194       ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


Personal and Provider Approaches to Oral Health

`3 Do you have any blood disorder such as anemia? ................................................................................................................................................................................................

, Have you ever had any treatment far a tumor or gmwth? ..................................................................................................................................................................................

1 2, Are you allergrc or have you had a reaction to:
  a,  to(alanesthetrcs. .........................................................................................................................................................................................................................................
             ...
  b.  Penitilhn or otherantrbrotrcs.. .......................................................................................................................... ..........................~....~..~...................................~..............~ ....

  (.  Sulfa drugs ..................................................................................................................................................................................................................................................

  d.  barbiturates. sedatives,or sleeping pills ........................................................................................................................ .....- .......................................................................
e. Aspinn ..........................................................................................................................................................................................................................................................

  f. Iodine ..........................................................................................................................................................................................................................................................

  g.  Codeine or other narcotics ............................................................................................................................................................................................................................

  h. Other

13 Have you had any serious trouble assocrated with any previous dental treatment? ........................................... ..~ .......................................................................................... II.
If so, explain
14. Do you have any disease, condition,or problem not listed above that you think I should know about? ............................................................................................................
If so, explain
15. Are you wearing contact lenses! ..........................................................................................................................................................................................................................

16. Are you weannq removable dental appliances? ..................................................................................................................................................................................................
17. Do you currently use tobacco of any type? ............................................................................................................................................................................................................
If so. which type?
18. Are you a former tobacco user? ................................................. ..~ .......................................................................................................................................................................
If so, which type of tobacco?
19. How many years have/did you use tobacco?
20. How much tobacco do/did you use a day?
2 1  If you have stopped using tobacco products, how long ago did you stop?
22. Have you ever used alcoholic beverages? ...................................................................................... ..~ ..................................................................................................................
23  How long ago did you stop using alcoholic beverages?
24. Do you currently use alcoholic beverages! ............................................................................................................................................................................................................
If so, which type?
25. How many times a week do you use alcoholic beverages!

Women

26. Are you pregnant? ................................................................................................................................................................................................................................................
27. Do you have any problems associated with your menstrual period? ..................................................................................................................................................................
18. Are you nursing! ..................................................................................................................................................................................................................................................
29. Are you taking birth contml pills? ........................................................................................................................................................................................................................

Yes    No

Yes    No

Yes

Yes

YeS

Yes

Yes

YeS

Yes



YeS



Yes



Yes

YeS

Yes



Yes

No

No

No

No

No

No

No

No

No

No

No

No

No

Yes



YeS

No

No

Yes    No

Yes    No

Yes    No
Yes    No

Chief Dental Complaint

1 certify that I have read and understand the above.1 acknowledge that my questions, ifany, about the inquiries set forth above have been answered to my satisfaction.
I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.

Signature of Patient

For completion by the dentist.
Comments on patient interview concerning medical history:
Signrfitant findings from questionnaire or oral interview:

Oental management considerations:

Date
Medical history update:
Date

Comments

Signature of Dentist

Signature

Source: Adapted from American Dental Arsociation,as reproduced in Rose and Steinberg 2DDO.

1

ORAL HE4LTH IN AMERICA: A REPORT OF THE SURGEON GENERAL          195


Personal and Provider Approaches to Oral Health

immune system factors associated with disease. The
number of such tests is increasing and will be sup-
plemented by genetic tests to indicate an individuals
susceptibility to specific diseases.

Currently, the assessment of oral and craniofacial
health and disease involves intraoral radiographs as
well as radiographic imaging, including arthrogra-
phy, motion-based tomography, and computed
tomography (Jeffcoat 1992). Intraoral radiographs
permit detection of lesions between teeth and are the
only widely available clinical test that can assess peri-
odontal bone support in situ (Jeffcoat et al. 1995).
Radiographs are an essential tool for treatment plan-
ning of complex prosthetic reconstructions as well as
a diagnostic method to assess periodontal progres-
sion. However, the mere presence of bone loss on a
radiograph does not imply progressive osseous
destruction, although it does increase the patient's
risk of future bone loss (Armitage 1996, Genco
2000). Radiographs have high specificity for disease
progression, and low sensitivity. Because all radi-
ographic examinations expose the patient to some,
albeit small, level of ionizing radiation, current
guidelines indicate that radiographs should not be
taken routinely (FDA 1987), but should be pre-
scribed after an initial assessment by the dentist.

(MRI) is also receiving increased attention for cran-
iofacial applications, such as for the assessment of
the temporomandibular joints. Finally, light-based
imaging of teeth and associated structures, using a
small intraoral camera, gives both the patient and the
provider a wide-screen view of the oral cavity, aiding
in patient education.

In the course of conducting a general assess-
ment, the clinician notes disease-specific signs and
symptoms. While examining the teeth, the clinician
may detect signs of relatively rare hereditary diseases
such as ectodermal dyplasias, or more common
destructive habits such as bruxism, where the enam-
el and at times the dentin may be abraded.
Examinations of the face a;d oral cavity may reveal
the effects of intentional and unintentional injuries.
With the results of the general assessment in hand,
the clinician will classify the patient's general and
oral health status and make treatment and/or referral
recommendations.

Image processing techniques, such as digital
radiography, enhance the clinicians ability to detect
small intraoral osseous changes over time and aid in
the detection of small changes in skeletal tissues
between examinations. Direct digital radiography
uses an intraoral detector to capture a radiographic
image of the diagnostic area of interest (Ellwood et al.
1997, Matsuda et al. 1997). Several proposed meth-
ods for quantitative estimation of lesion mass or vol-
umetry using digital subtraction radiography exist
(Armitage 1996). A recent multicenter validation
study has indicated that simulated lesions as small as
1 mg in mass may be detected with better than 90
percent sensitivity and specificity (Jeffcoat et al.
1996). These techniques are currently in use in clin-
ical trials.

A classification system adopted in 1962 by the
American Society of Anesthesiologists, used to cate-
gorize a patient's risk on the basis of physical status,
also has been applied, along with the patient's gener-
al and oral health risk assessment, to determine the
need for coordinated multidisciplinary referral and
whether care in a hospital is indicated rather than in
the dental office (Bricker et al. 1994) (Table 8.3).

Changing Approaches to Selected Diseases
and Conditions

The science and technology base is providing new
approaches to risk assessment, diagnosis, prevention,
and treatment. Highlights of selected diseases and
conditions follow.

Dental Caries

New diagnostic methods are also becoming
available as adjuncts to existing methods for caries
diagnosis. Comparing data between bite-wing radi-
ographs of potential occlusal fissure lesions, Lussi et
al. (1995) found that electrical resistance measure-
ment may provide a substantial improvement in
caries diagnosis.

Other imaging approaches are used to assess
craniofacial anatomy, temporomandibular joints,
maxillary sinuses, and other associated tissues, and
in the assessment of the size and quality of bone to
receive dental implants. Magnetic resonance imaging

Dental caries is caused by a transmissible microbial
infection that affects tooth mineral. A number of fac-
tors play a role in the initiation and progression of
the disease, including bacterial biofilm, specifically
the presence of mutans streptococci and species of
lactobacilli; the frequency of simple sugars in the
diet; the flow and composition of saliva; the avail-
ability of fluoride; the structure of tooth mineral in a
given individual; and oral hygiene behaviors. Sound
caries management takes all these factors into
account (Figure 8.3) (Burt and Ismail 1986). Today
there is the prospect that clinicians will be able to bal-
ance protective and pathologic factors and work with
the patient to control disease (Anderson et al. 1993,
Edelstein 1994, Featherstone 1996).

196         ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


-

Personal and Provider Approaches to Oral Health

f&j; .-\sscssmfflt. Reviews of caries risk prediction
,,,L,~cfs conclude that clinical variables, especially
I,.,Yt cnries experience, are the best predictors of new
c.,r,cs experience (Newbrun and Leverett 1990,
Pclwcff 1998). Table 8.4 shows a timeline summariz-
,t,? the strongest predictors of caries incidence based

on a review of the modeling literature. At the time of
initial tooth eruption, the presence of mutans strep-
tococci appears to be the primary predictor of future
caries. With continued tooth eruption, this variable
disappears as a primary predictor and is replaced by
the status of the

r\l)LE 8.3

American Society of Anesthesiologists- medical risk categories and associated
dental considerations

ASA Classification
physrcal status 1
A patient without systemic dis-
ease;a normal, healthy patient
Physical status 2
A patient with mild systemic
disease

        Dental Consideration


Routine dental therapy without modification


Routine dental therapy with possible treatment limitations
or special considerations (e.g., duration of therapy, stress of
therapy, prophylactic consideration, possible sedation, and
medical consultation)

most recently exposed or erupted
tooth surface. For example, the
presence of carious lesions in the
primary incisors has been found to
be the best predictor of caries in
the later-erupting primary molars
(Powell 1998).

Physical status 3

A patient with severe systemic dis-  Dental therapy with possible strict limitations or special
ease that limits activity but is not   considerations
incapacitating
Physical status 4
A patient with incapacitating sys-  Emergency dental therapy only, with severe limitations or
temic disease that is a constant   special considerations
threat to life

Source: Genco 2000,Rirk factors for periodontal diseare.In Rose LF,Genco BJ,Cohen DW, Mealey BL.Periodontal medicine.
Hamilton: B.C. Decker Inc. 2000:35-43. Copyright 2000 by B.C. Decker Inc. Reprinted by permission of B.C. Decker Inc. (2000).

r-
I

I-IC;1-RE 8.3
Multifactorial model of dental caries

Enamel crystal structure

Bacterial substrate
Protective factors

Source: Burt and lsmail1986.Copyright 1986 bylournolofDenfalReseorcb.Reprinted by
permission of lournalofDenta/ Research (2000).

Despite recent declines, dental
caries is a prevalent disease, with
some age and pdpulation groups
particularly  vulnerable  (see
Chapter 4). A guide for the identi-
fication of vulnerable patients and
the treatment of caries as an infec-
tious disease has been developed
(ADA 1995). Figure 8.4, from that
guide, proposes questions to be
considered at an initial examina-
tion. These questions, together
with information gathered at recall
examinations, allow classification
of child and adult patients into
high-, moderate-, and low-risk dis-
ease categories (Table 8.5). This
approach has been incorporated in
a variety of caries risk assessment
forms adopted by some dental
managed care programs (C.W.

schools and
Douglass, personal communication, 1999). Studies
are needed to determine the validity and reliability
of such approaches for different patient populations
and practice settings.

The use of tests to assess caries risk to determine
the activity status of preclinical disease is becoming
more widespread. A range of diagnostic aids for
caries activity testing are available. Microbial tests
can detect the presence and quantify the levels of
lactobacilli and mutans streptococci. The develop-
ment and use of these tests are based on studies that
have associated these microbes individually and
together with different types of carious lesion devel-
opment. Measurements of plaque and salivary pH
have been used to evaluate the oral environment
overall and to note the changes in pH that occur
after eating various foods. Salivary flow and compo-
sition analyses add another dimension. Decreased
flow has been related to caries susceptibility, as have
increases in viscosity. These factors warrant further
study to determine their sensitivity and specificity.

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL         197


Personal and Provider Approaches to Oral Health

Diagnosis. Clinical signs, patient-derived histor)l, and
radiographic images remain the primary means of
dental caries diagnosis. Tooth surface pitting and
cavitation, white and/or brown spots, areas soft to
tactile probing, and radiolucencies are used to detect
the effects of this disease. The most common
diagnostic approaches include visual inspection, the
use of an explorer (a probelike instrument) to
determine the integrity of the tooth surface, the use
of a light source to detect difference in reflectance
across tooth structure (transillumination), and
radiographs. Table 8.6 compares the reported
sensitivity and specificity of selected methods. No
single method stands out as superior with regard to
both sensitivity and specificity for all tooth surfaces.

The most basic diagnostic methods-visual
alone and visual examination with an explorer-have
limited sensitivity, but excellent specificity. The visu-
al examination may be combined with a radiograph-
ic series for the initial assessment. Bite-wing
radiographs are frequently used to diagnose inter-
proximal caries (between teeth) and for these sur-
faces provide excellent sensitivity and specificity.
Radiographic examination allows examination of
otherwise inaccessible areas. Specifically, the depth of
a lesion and its relationship to the pulp chamber can
be evaluated for interproximal lesions. However,
radiographs are of little value in detecting caries on
the occlusal surfaces of the teeth. For these surfaces,
a negative radiographic diagnosis does not imply lack
of a carious lesion in enamel.
  Precavitated carious lesions and caries in

restored teeth pose an additional diagnostic chal-
lenge. A review of the literature on the clinical diag-
nosis of precavitated carious lesions concluded that

visual detection of these lesions has low sensitivity
and moderate specificity &mail 1997). It is difficult
with these lesions to determine whether there is no
caries or whether only the enamel or outer layer of
dentin is involved. Carious lesions forming around
restorations are seen more frequently at the approxi-
ma1 and cervical margins of these restorations (Mjar
1985). Distinctive color changes around a restoration
alone are not diagnostic of active caries (Kidd 1990).

Currently, the progression of carious lesions is
the most definitive diagnostic parameter for disease
activity. Progression can be determined over specific
time intervals only by professional assessment.

Prevention. The primary prevention of dental caries
starts with adequate prenatal and perinatal nutrition
to ensure normal development of the teeth and sup-
porting structures. It continues with interventions
aimed at preventing transmission of cariogenic
microbes from caregivers to infants, and proceeds
with specific strategies employed across the life span.
These approaches include the provision of sufficient
fluoride, the use of dental sealants, the adoption of
healthy behaviors, including avoiding unhealthy
dietary practices and practicing appropriate oral
hygiene, and the timely use of care services.
Although many factors are brought to bear on the
primary prevention of dental caries, the combination
of fluoride in its multiple forms and dental sealants is
the foundation (as described in Chapter 7).

Fluoride is available in a variety of products that
can be used by health professionals, individuals, and
public programs. Topical solutions and gels,
mouthrinses, and dentifrices are available for daily,
weekly, or as-prescribed frequency. In addition,

TABLE 8.4
Timeline of strongest clinical predictors of caries incidence

Age(years)  0   1   2   3   4   5   6   7   8   9   10   11   12   13   14-21      22-45       >45

Dentition



Event



Predictor

Primary


Eruption primary molars


Mutans   dmfs, especially
streptococci primary incisors
    Mutans streptococci
      and lactobacilli

Mixed


Eruption first
permanent molar
dmfs, especially
primary molars
First molar occlusal
morphology
DMFS

Eruption second
permanent molar
DMFS,especially first
permanent molars
First molar occlusal
morphology
Incipient smooth
surface lesions

Early      Mature
permanent   permanent
     Progression of gingival recession


Incipient    Not studied    Coronal and root
smooth             DMFS
surface lesions          Number of teeth
DMFS              Periodontal
                disease

Note: dmfs = decayed, missing, or filled primary tooth surfaces; DMFS = decayed, missing, or filled permanent tooth surfaces.
Source: Powell 1998.Caries prediction:a review of the literature.CommunityDenristryondOralFpidemio/ogy 1998;26:361-71,Copyright 1998 by Munksgaard International Publishers Ltd.,
Copenhagen, Denmark.Reprinted by permission of Munksgaard International Publishers Ltd.,Copenhagen, Denmark (ZOOO).

198         ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL


FIGURE 8.4

Caries risk questions for initial examination

INITIAL VISIT-QUESTIONS TO CONSIDER

is there current caries activity?
Are there indications that yield potential for development of caries
within the next year?
. Prior DMFS (decayed, missing, or filled surfaces)
. Tooth morphology

. Medications that decrease saliva flow and/or affect viscosity of saliva
. Medical condition or treatment(s)

What is the individual's caries risk?
- tow
. Moderate
. High

What are the modifiable risk factors that may be responsible for or may
contribute to this caries activity?
. Insufficient systemic and topical fluoride
. Medications

. Poor oral hygiene habits or skills
. Deep pits and fissures without sealants
. Poor dietary habits

What can be done to prevent new caries or caries progression within the
next year?
. Sealants
. Increase fluoride use

* Oral hygiene instruction/education
. Dietary counseling
* Monitor bacterial count
+ Antimicrobial agents

. Conservative restorative techniques-to minimize removal of,

tooth structure

What is the prognosis for successful intervention?
* Patient compliance
. Clinician skill (diagnosis, intervention counseling)
* Prevention modalities are accepted/applied
* Severity at onset

Are there other considerations that may affect the decision process that
cannot be changed? (effect modifiers, confounders)
* Age
* Socioeconomic considerations

. Medically and/or physically compromising conditions

Source: American Dental Association Council on Access, Prevention and Inter-
professional Relations 199S.Caries diagnosis and risk assessment.A review of
preventive strategies and management.JADA; 126: 15.245,Copyright 1995 by
American Dental Association. Reprinted by permission of ADA Publishing Co. Inc. (2ooO).

fluoride-containing prophylactic pastes are available
for professional application (see Chapter 7). Clinical
judgment of risk factors determines the type and
frequency of interventions needed.

Although there is general agreement on the over-
all value of topical fluorides in reducing dental caries
(ADA 1986. 1994, Moss 1976, Stookey et al. 1993),

Personal and Provider Approaches to Oral Health

comparative clinical trials are needed to determine
which of the existing fluoride formulations (acidulat-
ed phosphate fluoride, stannous fluoride, amino-
fluoride, or sodium fluoride) and which delivery sys-
tem (gel, varnish, dentifrice, or solution) are most
efficacious.

A second line of defense is through control of the
etiologic agent. Chemotherapeutic agents (including
the antimicrobial mouthrinse agent chlorhexidine
and fluoride) can be used to reduce plaque. Dietary
measures aimed at reducing the frequency and quan-
tity of sugars and the substitution of sugars by sugar-
free sweeteners may effectively starve the bacteria.
The process of tooth demineralization and re-
mineralization has received significant attention
over the past four decades (Geiger et al. 1992,
Koulourides et al. 1961, Larsen and Fejerskov 1987,
Linton 1996, Silverstone et al. 1981, White 1988),
although the concept was documented in the early
1900s (Head 1912) (see Chapter 3). Investigators are
studying the effectiveness of therapeutic agents for
arresting carious lesions and remineralizing enamel
in populations at high risk for dental caries. For
example, a combined chlorhexidine-fluoride solution
can enhance remineralization of incipient lesions and
arrest caries in patients who suffer from radiation-
induced caries (Katz 1982). The use of a twice-daily
rinse with 0.05 percent sodium fluoride to prevent
demineralization and induce remineralization in sub-
jects with radiation-induced hyposalivation has also
been found to be effective (Meyerowitz et al. 1991).
This study also addressed the effects of chlorhexidine
use alone, which has been associated with tooth
staining, alterations in taste, and potential hypersen-
sitivity reactions (Ohtoshi et al. 1986, Okano et al.
1989). Schaeken et al. (1991) showed that the appli-
cation of 40 percent by weight chlorhexidine varnish
every 3 months enhanced remineralization of root
caries more than fluoride varnish, although both
treatments were associated with fewer filled root sur-
faces than the control group after 1 year. A chlorhex-
idine varnish has not yet been approved in the United
States, and large-scale, double-blind, placebo-con-
trolled clinical trials are not yet available to test the
effects of specific regimens in relation to caries risk.
  Studies also are evaluating interventions to pre-
vent mutans streptococci transmission. Find-
ings from cross-sectional studies indicate that infants
are initially infected by their parents, specifically
mothers, around the time the teeth erupt (Berkowitz
et al. 1975, Caufield et al. 1993, Kohler and Bratthall
1978). A longitudinal study using DNA fingerprint-
ing demonstrated that mothers were the source of the

ORAL HEALTH IN AMERIC.%: A REPORT OF THE SURGEON GENERAL

199


Personal and Provider Approaches to Oral Health

rABLE 8.5

Caries risk classification guidelines

Risk Category

    Age Category for Recall Patient9
Child/Adolescent                Adult

Low

No carious lesions in last year
Coalesced or sealed pits and fissures
Good oral hygiene
Appropriate fluoride use
Regular dental visits

No carious lesions in last 3 years
Adequately restored surfaces
Good oral hygiene
Regular dental visits

Moderate

One carious lesion in last year
Deep pits and fissures
Fair oral hygiene
Inadequate fluoride
White spots and/or interproximal
  radiolucencies
Irregular dental visits
Orthodontic treatment

One carious lesion in last 3 years
Exposed roots
Fair oral hygiene
White spots and/or interproximal
radiolucencies
Irregular dental visits
Orthodontic treatment

High

>2 carious lesions in last year
Past smooth surface caries
Elevated mutans streptococci count
Deep pits and fissures
No/little systemic and topical fluoride
  exposure
Poor oral hygiene
Frequent sugar intake
Irregular dental visits
Inadequate saliva flow
Inappropriate bottle feeding or nursing
(infants)

22 carious lesions in last 3 years
Past root caries; or large number of exposed
  roots
Elevated mutans streptococci count
Deep pits and fissures
Poor oral hygiene
frequent sugar intake
Inadequate use of topical fluoride
Irregular dental visits
Inadequate saliva flow

a At initial visit for new patient, if time of lasr caries experience cannot be determined,a person with no decayed missinV,
or filled surfaces (DMFS = o) would be classified as low risk. A person with past caries experience (DMFS > 0) and/or one
active lesion would be classified as moderate risk, A person with past caries experience and/or rWo active Caries or one
smooth surface lesion would be classified as high risk.
Parents of young children and expectant parents need additional tounseling on inappropriate nursing or bottle feeding
practices that can lead to the development of early childhood caries. Parents and caregivers should be advised to introduce
children to a cop in an effort to discontinue use of the bottle by the age of 1 year. Also, parents and caregivers should be
advised never to place anything other than plain water in a naptime or nighttime bottle.Children should not be allowed
to bottle feed at will and should be weaned from the bottle by the age of 1 year.
Many medically compromised individuals are likely to be assessed in the higher risk categories because of their use of
certain medications and possible xemstomia.
Source: Amencan Dental Association Council on Access and Interprofessional Relations 1995.Caries diagnosis and risk
assessment. A review of preventive strategies and management.lADA 1995; 126: 15-245. Copyright 1995 by American
Dental Association. Reprinted by permission of ADA Publishing Co. Inc.WIW.

TABLE 8.6

Sensitivity and specificity of selected dental caries diagnostic procedures

               Sensitivity  Specificity
            (percentage) (percentage)     References
Visual examination of noncavitated fissures   12-31     70-99  Lussi 1993,Ketley and Holt 1993
Examination using explorer          Id-24     70-99  Penning et aL1992,Lussi 1993
Radiographs of approximal lesions      so-90     as+   Grbndahl 1989,Benn and
                              Watson 1989

bacteria in their infants and the
degree of matching to maternal
strains was higher for female
infants than for males (Li and
Caufield 1995). Based on a study
of child-mother pairs (with the
child initially at 1 year of age), the
application of a 1.0 percent chlor-
hexidine rinse alternated with a
0.2 percent sodium fluoride gel to
the mother's teeth (3 times per day
on 2 consecutive days, twice per
year for 3 years) delayed, and in
some cases prevented, the colo-
nization of their children's teeth by
mutans streptococci (Tenovuo et
al. 1992). Timing of colonization
has been shown to be correlated
with caries prevalence. In a longi-
tudinal study that followed chil-
dren in $-month intervals from 15
months to 4 years of age, children
who were infected earlier had a
higher caries prevalence than
those in whom the infection was
detected at later ages. Studies also
have been aimed at reducing the
levels of cariogenic bacteria in the
infants themselves.

  Work continues on the devel-
opment of a caries vaccine. One
approach focuses on the produc-
tion and release of antibodies
against cariogenic bacteria anti-
gens (Russell et al. 1995). Specific
antigens have been purified and
synthesized. Another approach
involves biological replacement
therapy, where nonpathogenic
bacteria, instilled in the mouth,
prevent pathogenic bacteria from
colonizing (Hillman et al. 2000).
Yet another approach employs pas-
sive immunization in which anti-
bodies, produced outside the body
(in cultures, animals, eggs, or
plants), are applied to the teeth
and oral tissues to protect against
disease. A recent study indicated
that "plantibodies" painted on the
teeth could prevent mutans strep-
tococci colonization for 120 days,
the period of the experiment (Ma
et al. 1998).

200     ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL