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Advancing Oral Health in America 1 Introduction Can you imagine a time when we fully incorporate mental and dental health into our thinking about health? What is it about problems above the neck that seems to exclude them so often from policy about health care? —Harvey V. Fineberg, President, Institute of Medicine Institute of Medicine Annual Meeting, October 12, 2009 (Fineberg, 2009) The history of efforts of the U.S. Department of Health and Human Services (HHS) to improve the oral health of the nation can probably be encapsulated by one central theme: the need for the mouth to rejoin the body. However, HHS’ attempts to assume a leadership role in oral health over the last several decades have been challenged by ambiguous goal setting; a decreasing presence of dental leaders; and a lack of resources, accountability, and coordination among federal departments and agencies. The landmark surgeon general’s report Oral Health in America was successful in raising the profile of oral health and expanding the conversation to include not just teeth but complete oral and craniofacial health as well (HHS, 2000). The report continues to be regarded as a benchmark for oral health care reform. Despite numerous oral health initiatives, not enough has been done to address the “silent epidemic” the surgeon general described (HHS, 2000). Oral Health in America identified dental caries1 as “the single most common chronic childhood disease (HHS, 2000).” Today, dental caries remains a common chronic disease across the life span in the United States as well as around the world (Dye et al., 2007; Petersen, 2008; WHO, 2007). Many Americans do not have access to oral health insurance or care. Oral health status among many population groups remains poor. Dentistry remains substantially separated from the rest of health care, and oral health is often overlooked in policy discussions about the nation’s health care system. In its most recent attempt to provide leadership in improving the oral health of 1 The term dental caries is used in the singular and refers to the disease commonly known as tooth decay (Dorland’s Illustrated Medical Dictionary, 31st ed., s.v. “caries”).
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Advancing Oral Health in America the United States, in 2010 HHS announced a department-wide Oral Health Initiative to create new initiatives in oral health and improve coordination (and align resources) among agencies with existing initiatives (HHS, 2010a,b). In launching this effort, HHS underscored the same key message: oral health is integral to overall health. ORAL HEALTH AND OVERALL HEALTH The surgeon general’s report referred to the mouth as a mirror of health and disease occurring in the rest of the body in part because a thorough oral examination can detect signs of numerous general health problems, such as nutritional deficiencies and systemic diseases, including microbial infections, immune disorders, injuries, and some cancers (HHS, 2000). In addition, there is mounting evidence that oral health complications not only reflect general health conditions but also exacerbate and even initiate them. Periodontal disease has been associated with adverse pregnancy outcomes (Albert et al., 2011; Offenbacher et al., 2006; Scannapieco et al., 2003b; Tarannum and Faizuddin, 2007; Vergnes and Sixou, 2007), respiratory disease (Scannapieco and Ho, 2001), and cardiovascular disease (Blaizot et al., 2009; Janket et al., 2003; Scannapieco et al., 2003a; Slavkin and Baum, 2000). Periodontal disease has been also shown to affect glycemic control in patients with diabetes (Löe, 1993; Taylor, 2001; Teeuw et al., 2010). Gies noted the seriousness of the oral-systemic connection nearly a century ago, stating “[c]ertain common and simple disorders of the teeth may involve prompt or insidious development of serious and possibly fatal ailments in other parts of the body” (Gies, 1926). Popular attention to oral health issues and the connection between oral health and overall health increased dramatically in 2007 with the death of Deamonte Driver, a 12-year-old Maryland boy who died when bacteria from an untreated tooth infection spread to his brain (Norris, 2007, 2010; Otto, 2007). Driver’s death transformed the oral health discussion as more people—including members of Congress—have begun to recognize the potential seriousness of untreated oral disease. In fact, this tragedy is credited with spurring Congress to require that states provide dental services in their Children’s Health Insurance Program (CHIP) benefit packages during the program’s federal reauthorization (Iglehart, 2009). Unfortunately, Driver is not the only child to die directly as a result of oral infection (Casamassimo et al., 2009). The impact of poor oral health is not limited to health alone. Costs of care can be high, and there are also costs related to lack of care, including lost work hours, lost school time, and increased cost of caring for advanced disease. In an often cited study based on the 1989 National Health Interview Survey (NHIS), the authors found that 164 million hours of work
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Advancing Oral Health in America were missed annually as a result of dental visits or problems, with more hours being lost by lower-level workers (Gift et al., 1992). In addition, they found that 51 million hours of school were missed by school-age children for dental visits or problems, with the most hours being lost by female, Hispanic, lower-income, and uninsured children. Anecdotal evidence suggests that having visibly missing teeth may be associated with difficulties in finding a job, and a recent study suggests that fluoride exposure during childhood has a strong, statistically significant effect on women’s earnings (Eckholm, 2006; Glied and Neidell, 2008; Hyde et al., 2006; Shipler, 2004). For over a century, poor oral health has been a factor in the readiness of military troops to be deployed (DOD, 2002; King and Hynson, 2007; Marburger et al., 2003; Teweles and King, 1987). INFLUENCES ON ORAL HEALTH AND THE ORAL HEALTH CARE SYSTEM A number of factors contribute to poor oral health, including the relative lack of attention to oral health among nondental health care professionals,2 uneven and limited access to oral health care and dental coverage, social determinants of oral health, and the limited oral health literacy of the population. As poor oral health is a multifactorial problem, solutions will need to come from several different areas. In addition, appropriate quality measures in oral health care are necessary to reform the oral health care system to appropriately balance concerns for cost, quality, and access. Absence from General Health Care Oral health care has been largely absent from general health care. Nurses, physicians, and other health care professionals have generally not been trained in providing oral health services or screenings (Danielsen et al., 2006; Jablonski, 2010; Mouradian et al., 2005). In addition, dental professionals are generally educated and trained separately from other health care professionals, which reinforces the separation of care as well as lack of training in appropriate referrals between professionals (Mouradian et al., 2003; Pierce et al., 2002). Recently, several efforts have been made to introduce basic oral health care into primary health care. 2 Dental professionals include dentists, dental hygienists, dental assistants, dental laboratory technicians, and new and emerging dental professionals (e.g., dental therapists). Nondental health care professionals refers to all other types of health care professionals, including, but not limited to, nurses, pharmacists, physician assistants, and physicians.
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Advancing Oral Health in America • The University of Washington Medical School developed and implemented an oral health curriculum for medical students that led to improvements in students’ knowledge of and attitudes toward providing oral health care (Mouradian et al., 2006). • Since 2006, all residencies in family medicine have been required to include formal training in oral health (Douglass et al., 2009). • In 2005, New York University placed a college of nursing within the college of dentistry (Spielman et al., 2005). As part of the interdisciplinary educational model, pediatric nurse practitioner students work alongside dental students to provide care in school clinics and Head Start programs (Hallas and Shelley, 2009). Lack of Coverage Many people do not have dental coverage (Manski and Brown, 2007). Even with coverage, out-of-pocket costs can still be prohibitively expensive (Manski and Brown, 2007). Dental coverage is a major determinant of access to and utilization of oral health care (Brickhouse et al., 2008; Fisher and Mascarenhas, 2007, 2009; Manski and Brown, 2007). Typical sources of health care insurance—Medicare, Medicaid, and employers—often do not cover oral health care. Medicaid and CHIP include comprehensive dental benefits for children, but coverage for adults is optional, covers only emergency care in most states, and is often cut when state budgets are tight (CMS, 2011; Veschusio, 2011). Many employers do not offer dental plans as a benefit; these plans are more likely to be offered in larger companies and to higher-wage employees (Ford, 2009). Most adults lose employer-sponsored dental benefits when they retire (Manski et al., 2009), and “routine dental care” is specifically excluded from the traditional Medicare benefits package.3 The estimates of the number of Americans who are uninsured for dental care vary widely, but it is clear that the rate of dental uninsurance is much greater than that of medical uninsurance. For example, it has been estimated that as many as 130 million U.S. adults and children lack dental coverage (NADP, 2009). Poor Oral Health Literacy and Communication Nearly all aspects of oral health care require health literacy: scheduling a dental appointment, determining how much fluoride toothpaste to use on a toddler’s toothbrush, understanding when to stop using a baby bottle, recognizing potential complications of a root canal, completing a Medicaid application, understanding media campaigns that promote community 3 Social Security Act §1862(a)(12).
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Advancing Oral Health in America water fluoridation—some degree of literacy and knowledge is required for each task. Yet only 12 percent of the population has proficient health literacy (Kutner et al., 2006). Compounding the problem of low health literacy are the inadequate communication skills of health care professionals. Professionals use medical jargon, provide too much information at once, and fail to confirm that the patient understood the information provided (Williams et al., 2002). As the U.S. population grows more diverse, more will need to be understood about the importance of cultural competence in communication. For example, the cultural and linguistic misunderstandings in health care can be a contributing factor to adverse events such as unnecessary emergency room visits and longer hospital stays (OMH, 2001). Social Determinants of Health Aside from health literacy, other social determinants may also affect oral health and inequalities in oral health. The World Health Organization (WHO) describes social determinants of health as a combination of structural determinants (“the unequal distribution of power, income, goods, and services”) and daily living conditions (“the conditions in which people are born, grow, live, work, and age”) (CSDH, 2008). Commonly examined social determinants include factors such as income, education, occupation, community structure, cultural beliefs and attitudes, social networks, and availability of health services (Patrick et al., 2006). Social gradients in dental decay, periodontal disease, oral cancer, and tooth loss have all been reported (Dye and Thornton-Evans, 2010; Kwan and Petersen, 2010; Sondik et al., 2010). Recognizing the relationship between social determinants of health and oral health outcomes is important for developing interventions. Limited and Uneven Access Several factors described thus far, and other factors, contribute to limited and uneven access to oral health care. While access to oral health care has modestly improved over time, many people—typically those who are most vulnerable—still do not get the services they need. In 2007, only 5.5 percent of the population reported being unable to obtain, or had delays in receiving, needed dental care—but this was higher than the numbers that reported being unable to obtain, or had delays in receiving, needed medical care or prescription drugs (Chevarley, 2010). Accessing care is particularly difficult for certain populations, including people who live below the federal poverty line, African Americans, Hispanics, children insured by Medicaid and CHIP, residents of rural areas, people with disabilities, and migrant and seasonal farmworkers (Anthony et al., 2008; Glassman and Subar,
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Advancing Oral Health in America 2008; Manski and Brown, 2007; Probst et al., 2007; Skillman et al., 2010; Stanton and Rutherford, 2003; Vargas et al., 2003). Access to care is complex; it is not just a matter of having available services or being able to afford the care; it also requires having the health literacy, knowledge, and skills to perceive that care is needed as well as to understand how to navigate the oral health care system. Other factors include the availability of transportation and the availability of services provided during nonworking hours (Maserejian et al., 2008). For example, even when individuals have dental coverage, they often still do not receive needed services. Just over one-third of children insured by Medicaid received any dental care in 2004–2005, compared to more than half of children with private health insurance (GAO, 2008). A 2010 report from the U.S. Government Accountability Office (GAO) showed that in many states, most dentists treat few or no Medicaid or CHIP patients (GAO, 2010). The report also showed that “both health centers and the [National Health Service Corps] program report continued need for additional dentists and other dental providers to treat children and adults in underserved areas” (GAO, 2010). Lack of Quality Assessment Few quality measures are used in oral health, and no general standards exist for the quality assessment of oral health care (Bader, 2009). In part, quality assessment for oral health is limited by the absence of a universally accepted and used diagnostic coding system. By focusing on procedural codes instead, dental records and billing systems capture the number of oral health procedures conducted, but they do not provide any insight as to the diagnosis or oral health status of each patient. Quality assessment in oral health is also limited due to the absence of a strong evidence base for most treatments and therefore a lack of evidence-based practice guidelines. Oral health research is challenged in part because the typical dental practice design has only one or two dentists. As is the case in the overall health care system, it can be difficult to obtain outcomes data due to the need to gather data from multiple practices as well as the variety of forms that are used to collect the same data. Existing quality measurement tends to focus on patient perceptions and oral health-related quality of life but not treatment outcomes. Without quality measures linking provider interventions and patient outcomes, patients lack information to support decision making about their oral health care and research efforts into oral health best practices will continue to be limited.
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Advancing Oral Health in America STUDY CHARGE AND APPROACH In February 2010, with support from the Health Resources and Services Administration (HRSA), the Institute of Medicine (IOM) formed the Committee on an Oral Health Initiative to assess the current oral health care system and to advise HHS on actions that should be taken for an HHS oral health initiative (see Box 1-1). The committee met in person five times during the course of the study. It commissioned one technical paper and heard testimony from a wide range of experts during two public workshops. Staff and committee members also met with and received information from a wide variety of stakeholders and interested individuals. Scope While this report provides a brief description of oral health and oral health care in the United States overall, the report focuses mainly on the role HHS can play in shaping oral health in America and, in particular, on the ways in which HHS can have the most impact. There are a wide range of diseases and conditions that manifest themselves in or near the oral cavity—inherited, infectious, and neoplastic diseases and disorders (both acute and chronic). For the purposes of this report, the committee focused mainly on two classes of diseases and their sequelae that cause a great amount of morbidity: dental caries and periodontal diseases. While HHS is not directly responsible for the functioning of the overall oral health system, it has the opportunity to serve as a leader in improving the oral health of the nation, and there is a need for it to rise to this opportunity. BOX 1-1 The Committee on an Oral Health Initiative Statement of Task The IOM, Board on Health Care Services, in collaboration with the Board on Children, Youth, and Families, will undertake a study to • Assess the current oral health care system for the entire U.S. population; • Examine preventive oral care interventions, their use and promotion; • Explore ways of improving health literacy for oral health; • Review elements of a potential HHS oral health initiative, including possible or current regulations, statutes, programs, research, data, financing, and policy; and • Recommend strategic actions for HHS agencies and, if relevant and important, other actors, as well as ways to evaluate this initiative.
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Advancing Oral Health in America The committee recognizes that many important factors influence the oral health of Americans, including social determinants, settings of care, workforce, financing, quality assessment, access, literacy, and education. A detailed examination of each of these areas is beyond the scope of this report. Therefore, the committee limited its examination of many of these issues and focused instead on how they relate to possible or current HHS policies and programs. Consequently, the findings, conclusions, and recommendations contained within this report are not exhaustive and will not on their own resolve many of the problems that exist in the nation’s oral health care system. The committee is also cognizant of the sizable role that other stakeholders play in this system, including those at the state and local levels as well as private practitioners. This report should be viewed as a complementary piece of a larger solution that will require efforts from all members of the oral health community. Use of the term oral health in this report is intended to promote this comprehensive view. For example, the term oral health care professional is used to refer to any health care professional who provides oral health care. This may include, but not be limited to, dental hygienists, dentists, nurses, physician assistants, and physicians. The term dental is used in (1) cases that apply only to the professions of dentists, dental hygienists, dental assistants, and, in some cases, dental laboratory technicians and newer dental professionals such as dental therapists; (2) cases in which it is historically accurate to use the term; and (3) cases of insurance coverage, in which dental insurance or dental coverage is used to refer to coverage for oral health care and health insurance is used to refer to all other health care (e.g., medical care). In addition, the committee maintains that similar to criticisms of the overall “health care system,” a true “oral health care system” does not exist—but is, in fact, a conglomeration of facilities and people that provide care in a variety of unrelated individual systems. This lack of a definable system has contributed, in part, to the existing burden of oral diseases. However, for the purposes of this report, the term system is used to describe this uncoordinated spectrum of individual systems of care. It is also important to note that this report process occurred simultaneously with a report being produced by IOM’s Committee on Oral Health Access to Services. While the two studies have related statements of task, the two projects had separate committees, meetings, and review processes. At the time of the writing of this report, the report from the Committee on Oral Health Access to Services was scheduled to be delivered approximately
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Advancing Oral Health in America 2 months after this one. The two committees were not made aware of the other’s conclusions or recommendations. Previous IOM Work More than 30 years have passed since the IOM’s first significant look at oral health issues, Public Policy Options for Better Dental Health (IOM, 1980), which considered the inclusion of dental services under national health insurance plans. At that time, the IOM found that while methods to prevent and reduce disease were well known, there was a substantial unmet need for oral health care in the United States. The committee explicitly recognized the lack of a national plan for the prevention of disease, the significant financial barriers to access for many Americans, and the omission of oral health from larger public policy discussions. The IOM recommended the inclusion of oral health services in any national health insurance plan, the delivery of preventive services (at a minimum) to children in school-based settings, the use of dental hygienists and assistants (with appropriate training) to provide preventive care in school-based settings, the development of a system for quality and utilization review of dental services, and the institution of a population-based information system. Little has changed since that report both in regard to the need for oral health care as well as in the way that oral health care is delivered and paid for. More than 15 years ago, the IOM focused on dental education issues in Dental Education at the Crossroads (IOM, 1995). In that report, the committee envisioned a future in which dentistry is more integrated in the overall health care system (e.g., education, research, and patient care); dental students have more diverse, hands-on clinical experiences; dental schools contribute to the larger health care community (e.g., research, technology transfer, service to community); dental leaders cooperate to reform accreditation and licensing; and stakeholders continue to test alternative models of education, practice, and performance assessment. The committee laid out four broad objectives: to improve knowledge of what works; to encourage prevention at both the individual and the community level; to reduce disparities; and to promote attention to oral health by those outside of the dental fields. The concerns articulated in that report largely remain, and the overall vision has yet to be realized. In 2009, the IOM held a 3-day public workshop on the oral health workforce (IOM, 2009d). The first day focused on the connection between oral health and overall health and well-being, oral health needs and the status of access to care, demographics and trends of the oral health workforce, and delivery systems. The second day addressed challenges of the current system (e.g., financing, leadership, regulation, quality assessment), professional ethics, the international experience, and workforce strategies
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Advancing Oral Health in America for improving access to oral health care. On the final day of the workshop, speakers and attendees discussed the role that each stakeholder has in improving access to oral health care. Many other IOM studies that did not focus solely on oral health have highlighted particular oral health issues (e.g., the particular needs of adolescent populations, rural populations, and older adults) and made recommendations related to oral health (IOM, 1992, 2000, 2005b, 2008, 2009a). Previous IOM reports recommended that the National Institute of Dental and Craniofacial Research (NIDCR) of the National Institutes of Health (NIH) should implement programs to increase the number of dental school applicants interested in oral health research, should require that loan forgiveness recipients spend a significant amount of time on research, and should fund required years of the D.D.S./Ph.D. program (IOM, 2005a) and that the NIH should expand medical and dentist scientist training programs “specifically for training investigators in the skills of performing patient-oriented clinical research” (IOM, 1994). Among its most recent reports, the IOM found that the training of dentists and dental hygienists in the care of older adults is inadequate (IOM, 2008); that existing oral health services are generally insufficient to meet the needs of many adolescents (IOM, 2009a); that management of periodontal disease and the effectiveness of various delivery models in the prevention of dental caries in children ranked among the top 100 priority areas for comparative effectiveness research in health care (IOM, 2009c); and that the HHS and U.S. public health and health care workforces suffer from “shortages of primary care physicians and professionals in certain fields, such as oral health, mental health, and nursing (IOM, 2009b). In 2009, the IOM produced the report HHS in the 21st Century, which provided a comprehensive examination of HHS’ organization (IOM, 2009b). That committee assessed the overall structure of HHS in relation to its mission, activities, governance, and data collection efforts. While not speaking explicitly to oral health care, many reports in IOM’s history related to primary care, health literacy, access to care, diversity, nutrition, and improving public health have implications for all oral health care professionals (IOM, 1993, 1996, 1997, 2002, 2004a,b, 2005b). In 2002, the IOM examined the future health of the American public and stated: Adequate population health cannot be achieved without making comprehensive and affordable health care available to every person residing in the United States. It is the responsibility of the federal government to lead a national effort to examine the options available to achieve stable health care coverage of individuals and families and to assure the implementation of plans to achieve that result. (IOM, 2002)
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Advancing Oral Health in America In view of the strong links between oral health and overall health, the committee reaffirms the statement above in that the federal government (most notably HHS) has a real and pressing responsibility to help ensure that oral health care is comprehensive and available. OVERVIEW OF THE REPORT This chapter has provided a brief introduction of the poor oral health status of Americans and its causes, as well as an overview of the study charge and the committee’s approach to the work. Chapter 2 broadens the discussion of the link between oral health and overall health and then provides a more detailed overview of the oral health status of Americans, including various subpopulations. The chapter then focuses on two important elements of the committee’s charge—prevention and oral health literacy—both of which are central to improving oral health outcomes. Chapter 3 describes the oral health care delivery and payment systems. It briefly discusses the predominant private practice model, as well as the provision of care through the oral health safety net. It discusses the financing of oral health care through private and public sources. The chapter also describes the oral health workforce, detailing the various professional types, including the nondental workforce and new and emerging members of the dental team. A brief discussion follows regarding how the health care workforce, particularly the dental workforce, is regulated. Finally, the chapter discusses the current and future roles of quality measurement to assess the quality of oral health care. While Chapters 2 and 3 provide much of the background on the current status of oral health and oral health care overall in the United States, Chapter 4 expounds upon the role for HHS. It details historical and current efforts HHS has taken to reform oral health care, including the recent launch of the HHS Oral Health Initiative of 2010. It gives an overview of the department’s wide-ranging activities directed to improving oral health care delivery and financing, including its role in the direct delivery of oral health care, health literacy, disease prevention, and education. The chapter also describes the general activities of other federal departments and agencies that are related to oral health care. Chapter 5 contains the committee’s blueprint for a new oral health initiative. The chapter begins with conclusions about lessons from past HHS oral health initiatives. It then discusses the committee’s framework for devising a new oral health initiative. Next, the chapter describes the committee’s major conclusions and final recommendations to HHS as to where HHS should place its efforts in improving the oral health of the nation. The report concludes with three key elements the committee believes are necessary for the success of the initiative.
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Advancing Oral Health in America In addition, the report contains four appendixes. Appendix A contains a list of key acronyms used throughout the report. Appendix B contains several organizational charts that describe where key oral health activities occur within HHS. Appendix C lists the agendas of the committee’s workshops. Finally, Appendix D contains biographical sketches of the committee members and IOM project staff. REFERENCES Albert, D. A., M. D. Begg, H. F. Andrews, S. Z. Williams, A. Ward, M. Lee Conicella, V. Rauh, J. L. Thomson, and P. N. Papapanou. 2011. An examination of periodontal treatment, dental care, and pregnancy outcomes in an insured population in the United States. American Journal of Public Health 101(1):151-156. Anthony, M., J. M. Williams, and A. M. Avery. 2008. Health needs of migrant and seasonal farmworkers. Journal of Community Health Nursing 25(3):153-160. Bader, J. D. 2009. Challenges in quality assessment of dental care. Journal of the American Dental Association 140(12):1456-1464. Blaizot, A., J. N. Vergnes, S. Nuwwareh, J. Amar, and M. Sixou. 2009. Periodontal diseases and cardiovascular events: Meta-analysis of observational studies. International Dental Journal 59(4):197-209. Brickhouse, T. H., R. G. Rozier, and G. D. Slade. 2008. Effects of enrollment in Medicaid versus the State Children’s Health Insurance Program on kindergarten children’s untreated dental caries. American Journal of Public Health 98(5):876-881. Casamassimo, P. S., S. Thikkurissy, B. L. Edelstein, and E. Maiorini. 2009. Beyond the DMFT: The human and economic cost of early childhood caries. Journal of the American Dental Association 140(6):650-657. Chevarley, F. M. 2010. Percentage of persons unable to get or delayed in getting needed medical care, dental care, or prescription medicines: United States, 2007. Statistical Brief 282. Rockville, MD: Agency for Healthcare Research and Quality. CMS (Centers for Medicare and Medicaid Services). 2011. Medicaid dental coverage: Overview. http://www.cms.gov/MedicaidDentalCoverage/ (accessed September 13, 2011). CSDH (Commission on Social Determinants of Health). 2008. Closing the gap in a generation: Health equity through action on the social determinants of health. Geneva, Switzerland: World Health Organization. Danielsen, R., J. Dillenberg, and C. Bay. 2006. Oral health competencies for physician assistants and nurse practitioners. Journal of Physician Assistant Education 17(4):12-16. DOD (Department of Defense). 2002. Policy on standardization of oral health and readiness classifications. https://secure.ucci.com/non-ldap/forms/addp/forms/readiness-policy.pdf (accessed January 3, 2011). Douglass, A. B., M. Deutchman, J. Douglass, W. Gonsalves, R. Maier, H. Silk, J. Tysinger, and A. S. Wrightson. 2009. Incorporation of a national oral health curriculum into family medicine residency programs. Family Medicine 41(3):159-160. Dye, B., and G. Thornton-Evans. 2010. Trends in oral health by poverty status as measured by Healthy People 2010 objectives. Public Health Reports 125(6):817-830. Dye, B. A., S. Tan, V. Smith, B. G. Lewis, L. K. Barker, G. Thornton-Evans, P. I. Eke, E. D. Beltran-Aguilar, A. M. Horowitz, and L. Chien-Hsun. 2007. Trends in oral health status: United States, 1988-1994 and 1999-2004. Hyattsville, MD: United States Department of Health and Human Services, National Center for Health Statistics.
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