2

Oral Health and Overall
Health and Well-Being

A number of factors influence oral health status and may act as obstacles to improving the oral health of the nation. Patients and health care professionals need to understand the importance of oral health, especially its connection to overall health, and apply that knowledge in practice. In addition, patients need to have the knowledge, understanding, ability, and means to access oral health care, and professionals must be available to provide care. Oral health may also be affected by several social determinants of health such as race, income, living conditions, and working conditions.

This chapter presents an overview of the inextricable link between oral health and overall health and well-being, as well as the many factors that can affect oral health improvement. First, the connection between oral health and overall health, including the implications of poor oral health, is briefly discussed. Next, the overall health status of the American population is reviewed, and the oral health status and utilization patterns of various vulnerable and underserved populations are considered. The chapter continues with the examination of preventive oral health interventions for many oral diseases. Finally, the chapter concludes with a discussion of basic health literacy issues (including oral health literacy), especially how they affect the ability of individuals, communities, and practitioners to improve oral health status. The specific roles of the U.S. Department of Health and Human Services (HHS) in health literacy and prevention are discussed in Chapter 4.



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2 Oral Health and Overall Health and Well-Being A number of factors influence oral health status and may act as ob- stacles to improving the oral health of the nation. Patients and health care professionals need to understand the importance of oral health, especially its connection to overall health, and apply that knowledge in practice. In addition, patients need to have the knowledge, understanding, ability, and means to access oral health care, and professionals must be available to pro- vide care. Oral health may also be affected by several social determinants of health such as race, income, living conditions, and working conditions. This chapter presents an overview of the inextricable link between oral health and overall health and well-being, as well as the many factors that can affect oral health improvement. First, the connection between oral health and overall health, including the implications of poor oral health, is briefly discussed. Next, the overall health status of the American popula- tion is reviewed, and the oral health status and utilization patterns of vari- ous vulnerable and underserved populations are considered. The chapter continues with the examination of preventive oral health interventions for many oral diseases. Finally, the chapter concludes with a discussion of basic health literacy issues (including oral health literacy), especially how they affect the ability of individuals, communities, and practitioners to improve oral health status. The specific roles of the U.S. Department of Health and Human Services (HHS) in health literacy and prevention are discussed in Chapter 4. 31

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32 ADVANCING ORAL HEALTH IN AMERICA THE LINK BETWEEN ORAL HEALTH AND OVERALL HEALTH For people suffering from dental, oral, or craniofacial pain, the link between oral health and general well-being is beyond dispute. However, for policy makers, payers, and health care professionals, a chasm dividing the two has developed over time and continues to exist today. In effect, the oral health care field has remained separated from general health care (e.g., medicine, pharmacy, nursing, allied health professions). Recently, however, researchers and others have placed a greater emphasis on establishing and clarifying the oral-systemic linkages. The surgeon general’s report Oral Health in America made it clear that oral health care is broader than dental care and that a healthy mouth is more than just healthy teeth (see Box 2-1). The report described 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, in- cluding microbial infections, immune disorders, injuries, and some cancers (HHS, 2000b). Oral lesions are often the first manifestation of HIV infec- tion and may be used to predict progression from HIV to AIDS (Coogin et al., 2005). Sexually transmitted HP-16 virus has been established as the cause of a number of vaginal as well as oropharyngeal cancers (Marur et al., 2010; Shaw and Robinson, 2010). Dry mouth (xerostomia) is an early symptom of Sjogren’s syndrome, one of the most common autoimmune disorders (Al-Hashimi, 2001), and is also a side effect for a large number B OX 2-1 Dental, Oral, and Craniofacial The word oral refers to the mouth. The mouth includes not only the teeth and the gums (gingiva) and their supporting tissues but also the hard and soft palate, the mucosal lining of the mouth and throat, the tongue, the lips, the salivary glands, the chewing muscles, and the upper and lower jaws. Equally important are the branches of the nervous, im- mune, and vascular systems that animate, protect, and nourish the oral tissues, as well as provide connections to the brain and the rest of the body. The genetic patterning of development in utero further reveals the intimate relationship of the oral tissues to the developing brain and to the tissues of the face and head that surround the mouth, structures whose location is captured in the word craniofacial. SOURCE: HHS, 2000b.

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33 ORAL HEALTH AND OVERALL HEALTH AND WELL-BEING of prescribed medications (Nabi et al., 2006; Uher et al., 2009; Weinberger et al., 2010). Further, there is mounting evidence that oral health complications not only reflect general health conditions but also exacerbate them. Infections that begin in the mouth can travel throughout the body. For example, peri- odontal bacteria have been found in samples removed from brain abscesses (Silva, 2004), pulmonary tissue (Suzuki and Delisle, 1984), and cardiovas- cular tissue (Haraszthy et al., 2000). Periodontal disease may be associated with adverse pregnancy outcomes (Offenbacher et al., 2006; Scannapieco et al., 2003b; Tarannum and Faizuddin, 2007; Vergnes and Sixou, 2007), respiratory disease (Scannapieco and Ho, 2001), cardiovascular disease (Blaizot et al., 2009; Janket et al., 2003; Paraskevas, 2008; Scannapieco et al., 2003a; Slavkin and Baum, 2000), coronary heart disease (Bahekar et al., 2007), and diabetes (Chávarry et al., 2009; Löe, 1993; Taylor, 2001; Teeuw et al., 2010). However, the relationship between periodontal disease and these systemic diseases is not well understood, and there is conflicting evidence about whether periodontal treatment affects outcomes for these systemic conditions (Beck et al., 2008; Fogacci et al., 2011; Jeffcoat et al., 2003; Lopez et al., 2002, 2005; Macones et al., 2010; Michalowicz et al., 2006; Newnham et al., 2009; Offenbacher et al., 2006, 2009; Paraskevas et al., 2008; Polyzos et al., 2009, 2010; Sadatmansouri et al., 2006; Simpson et al., 2010; Tarannum and Faizuddin, 2007; Teeuw et al., 2010; Uppal et al., 2010). Although there is a wide range of diseases and conditions that mani- fest themselves in or near the oral cavity itself, discussions of oral health tend to focus on the diagnosis and treatment of two types of diseases and their sequelae: dental caries and periodontal diseases. The most common of those diseases, dental caries, is a common chronic disease in the United States (Dye et al., 2007) and among the most common diseases in the world (WHO, 2010e). As mentioned previously, periodontal disease has been as- sociated with numerous systemic diseases throughout the body from heart disease to diabetes (Bahekar et al., 2007; Chávarry et al., 2009). There is some degree of tragedy in this situation because both dental caries and periodontal disease are highly preventable. Dental caries was described in the surgeon general’s report as “the sin- gle most common chronic childhood disease” (HHS, 2000b). Most people remain unaware that dental caries is caused by a bacterial infection (e.g., Streptococcus mutans) that is often passed from person to person (e.g., from mother to child). Aside from dental health implications, nontreatment of dental caries may be associated with several types of morbidity (both individual and societal), including loss of days from school (Gift et al., 1992, 1993), inappropriate use of emergency departments (Cohen et al., 2011; Davis et al., 2010), orofacial pain (Nomura et al., 2004; Traebert et

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34 ADVANCING ORAL HEALTH IN AMERICA al., 2005), and inability for military forces to deploy (Bray, 2006). In fact, while the death of Deamonte Driver made headlines and sparked a national debate about the importance of oral health care (Norris, 2007; Otto, 2007), there have been other similar cases in recent times (Casamassimo et al., 2009; Jackson, 2007). In spite of decades of knowledge of how to prevent dental caries, this disease remains a significant problem for all age groups. OVERALL ORAL HEALTH STATUS Evidence on how well the current oral health system is performing can be found in the mouths of the American people. And while evidence sug- gests that oral health has been improving in most of the U.S. population, many sub-groups are not faring as well (Dye et al., 2007). The National Health and Nutrition Examination Survey One of the most important functions HHS has performed over time has been monitoring the oral health status of the nation. The department has conducted a number of national data collection efforts through the National Center for Health Statistics of the Centers for Disease Control and Prevention (CDC), as well as other agencies within the department. The National Health and Nutrition Examination Survey (NHANES) is the main source for oral health information in the United States; data are col- lected from a representative sample of the civilian U.S. population through interviews and clinical examinations. In April 2007, the National Center for Health Statistics released a com- prehensive assessment of U.S. oral health status (Dye et al., 2007). Using data provided by two iterations of the NHANES (NHANES III, 1988–1994 and NHANES 1999–2004), the assessment concluded that most Americans experienced improvements in their oral health over the two time periods (Dye et al., 2007). Specifically, the report noted that among older adults, edentulism (complete tooth loss) and periodontitis (gum disease) had de- clined. Among adults, the CDC observed improvements in the prevalence of dental caries, tooth retention, and periodontal health. For adolescents and youths, dental caries decreased, while dental sealants (thin plastic coatings applied to the grooves on the chewing surfaces of the back teeth to protect them from dental caries) became more prevalent. Among poor Mexican- American children ages 6–11, untreated dental caries decreased from 51 to 42 percent (Dye et al., 2010). The proportion of adolescents age 12–19 with caries in their permanent dentition decreased (Edelstein and Chinn, 2009). More children have received at least one dental sealant on a perma- nent tooth; the prevalence increased from 22 to 30 percent among children ages 6–11 and from 18 to 38 percent in adolescents ages 12–19 (Dye et al.,

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35 ORAL HEALTH AND OVERALL HEALTH AND WELL-BEING 2007). Encouragingly, the increase was consistent among all racial and eth- nic groups, although non-Hispanic black and Mexican-American children and adolescents continue to have a lower prevalence of sealants than do whites, and poor children receive fewer dental sealants than those who live above 200 percent of the federal poverty line (Dye et al., 2007). While the data from the NHANES surveys showed improvements in oral health status across two intervals of time, the most current information on American oral health status was not especially favorable. For example, the latter survey found that more than a quarter of adults ages 20–64 and nearly one-fifth of respondents over age 65 were experiencing untreated dental caries at the time of their examination (Dye et al., 2007). Further, caries prevalence among preschool children increased between 1988–1994 and 1999–2004 (Dye et al., 2007). Based on the NHANES results, Table 2-1 provides an overview of the U.S. population’s oral health status during the 1999–2004 time period. The percentage of persons with caries experi- ence increases with age, in part because once cavitated, this is a nonrevers- ible disease measured by active and treated disease. While a fifth of children 6–11 years of age have had caries, this proportion increases to more than half of children 12 to 19 years of age and to 90-plus percent of adults 20 years and over. Socioeconomic status, measured by poverty status in this case, is a strong determinant of oral health (Vargas et al., 1998). In every age group, persons in the lower-income group were more likely to have had caries experience and more than twice as likely to have untreated dental caries compared with their higher-income counterparts. Among persons age 65 and over, edentulism is more frequent among those living below the poverty level than among those living at twice the poverty level (Dye et al., 2007). In addition, a significant proportion of the population continues to suffer from periodontal disease. According to the most recent NHANES survey, at least 8.5 percent of adults (ages 20–64) and 17.2 percent of older adults (age 65 and older) in the United States suffer from periodontal dis- ease (NIDCR, 2011a,b), and in fact, the periodontal examination used in NHANES may have understated the true incidence of periodontal disease by 50 percent or more (Eke et al., 2010). Healthy People Since 1980, HHS has used the Healthy People process to set the coun- try’s health-promotion and disease-prevention agenda (Koh, 2010). Healthy People is a set of health objectives for the nation consisting of overarching goals for improving the overall health of all Americans and more specific objectives in a variety of focus areas, including oral health. Every 10 years, HHS evaluates the progress that has been made on Healthy People goals

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36 ADVANCING ORAL HEALTH IN AMERICA TABLE 2-1 Prevalence of Caries Experience and Untreated Caries by Age and Poverty Status (1999–2004) Caries Prevalence Caries Untreated Population Characteristics Experience Caries Age and Dentition Percentage Percentage 2–11 primary teeth Total 2– to 11-year olds 42.2 22.9 2–5 years 27.9 20.5 6–11 years 51.2 24.5 Poverty < 100% 54.3 32.5 100–200% 48.8 28.4 > 200% 32.3 15.0 6–11 permanent teeth Total 6– to 11-year olds 21.1 7.7 Poverty < 100% 28.3 11.8 100–200% 24.1 11.9 > 200% 16.3 3.6 12–19 permanent teeth Total 12– to 19-year olds 59.1 19.6 Poverty < 100% 65.6 27.1 100–200% 64.4 27.0 > 200% 54.0 12.9 20–64 permanent teeth Total 20– to 64-year olds 91.6 25.5 20–34 85.6 27.9 35–49 94.3 25.6 50–64 95.6 22.1 Poverty < 100% 88.7 43.9 100–200% 88.9 39.3 > 200% 93.1 18.0 65+ permanent teeth Total 65+ 93.0 18.2 Poverty < 100% 83.5 33.2 100–200% 90.9 23.8 > 200% 95.5 14.2 SOURCE: Dye et al., 2007.

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37 ORAL HEALTH AND OVERALL HEALTH AND WELL-BEING and objectives, develops new goals and objectives, and sets new bench- marks for progress. The objectives are drafted by relevant HHS agencies, with extensive input from external stakeholders and the public. The oral health objectives are developed by four co-lead agencies—the CDC, Health Resources and Services Administration (HRSA), the Indian Health Service, and the National Institutes of Health (NIH)—with input from the Office of Disease Prevention and Health Promotion, the Office of Minority Health, the Office on Women’s Health, and the National Center for Health Statis- tics, as well as comments from dental professional organizations, including state and local dental directors (Dye, 2010). (See Chapter 4 for more on the history of Healthy People as well as a description of Healthy People 2020 goals and objectives.) Progress on the Healthy People 2010 goals was mixed (Koh, 2010; Sondik et al., 2010; Tomar and Reeves, 2009). At the midcourse review in 2006, no oral health objectives had met or exceeded their targets (HHS, 2006). Encouragingly, however, progress was made in a number of catego- ries, including decreasing caries among adolescents (although not among younger children), increasing the proportion of children with dental seal- ants, increasing the proportion of adults with no permanent tooth loss, and increasing the proportion of the population with access to community wa- ter fluoridation (HHS, 2006; Tomar and Reeves, 2009). In contrast, several objectives moved away from their targets. For example, the proportion of children age 2 to 4 years with dental caries increased from 18 to 22 percent, and the proportion of untreated dental caries in this population increased from 16 to 17 percent (HHS, 2006). In addition, the number of oral and pharyngeal cancers detected at an early stage decreased. Oral Health Status: Beyond the Teeth Oral health is more than healthy teeth, and oral diseases and disorders are more than caries and periodontal disease. Oral diseases and disorders can be either acute (e.g., broken tooth) or chronic (e.g., caries) and have a number of different causes, including inheritance (e.g., cleft lip and palate), infection (e.g., caries), neoplasia (e.g., oral, nasal, and pharyngeal cancers), and neuromuscular (e.g., temporomandibular joint disorder). Although car- ies and periodontal disease are the most commonly discussed oral diseases, other oral diseases also have a significant burden. Between 1999 and 2001, the annual prevalence of cleft lip in the United States was approximately 1 in 1,000 live births (NIDCR, 2010). The overall incidence of head and neck cancers is falling due to declining use of cigarettes and other tobacco products; however, an increasing number of younger women without the typical risk factors (tobacco and alcohol use) have been diagnosed with oral cancers, causing speculation about the relationship between human papil-

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38 ADVANCING ORAL HEALTH IN AMERICA loma virus and oral cancer (D’Souza et al., 2007; Mork et al., 2001; Sturgis and Cinciripini, 2007). In 2010, there were more than 36,000 new cases of oral and pharyngeal cancer (Altekruse et al., 2010). Although early-stage oral cancers are treatable, the mortality rate is relatively high because most oral cancers are diagnosed at a later stage (HHS, 2000b). This problem is particularly acute for African Americans, who are more likely to be diag- nosed at a late stage and who have a much lower 5-year survival rate than whites do (about 42 percent for African Americans compared to about 63 percent for whites) (Altekruse et al., 2010). ORAL HEALTH STATUS AND ORAL HEALTH CARE UTILIZATION BY SPECIFIC POPULATIONS While some data show improvements in the U.S. oral health status overall, underserved and vulnerable populations continue to suffer dispari- ties in both their disease burden and access to needed services. Dental caries remains a significant problem in certain populations such as poor children and racial and ethnic minorities of all ages (Dye, 2010; Dye et al., 2007). In addition, limited and uneven use of oral health care services contributes to both poor oral health and disparities in oral health. More than half of the population (56 percent) did not visit a dentist in 2004 (Manski and Brown, 2007), and in 2007, 5.5 percent of the population reported being unable to get or delaying needed dental care, higher than the percentage that reported being unable to get or delaying needed medical care or prescription drugs (Chevarley, 2010). In this section, the particular issues of some underserved populations are highlighted. The specific challenges of these populations and others are being examined more in depth by the IOM Committee on Oral Health Access to Services. Age Groups Dental disease is also a problem across the age spectrum. In this sec- tion, special challenges for children, adolescents, and older adults are highlighted. Children Over the decades, many different sources have noted the burden of dental disease on children. The surgeon general’s report identified dental caries as “the single most common chronic childhood disease—five times more common than asthma and seven times more common than hay fever” (HHS, 2000b). Over 27 percent of children ages 2 to 5 have early child- hood caries (defined as caries in children ages 1 to 5 years old), and more

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39 ORAL HEALTH AND OVERALL HEALTH AND WELL-BEING than 50 percent of children ages 6 to 11 have caries in their primary teeth (Dye et al., 2007; Ismail and Sohn, 1999). More than 20 percent of those caries are untreated (Dye et al., 2007). The lack of adequate dental treat- ment may affect children’s speech, nutrition, growth and function, social development, and quality of life (HHS, 2000b). For school-age children in particular, oral disease can impose restrictions in their daily activities; in excess of 51 million school hours are lost each year due to dental-related illness (HHS, 2000b). In addition, 14 percent of children 6–12 years old have had toothache severe enough during the past six months to have com- plained to their parents, and many others may have suffered silently with the same symptoms (Lewis and Stout, 2010). Adolescents Adolescents, generally those age 10–19 (IOM, 2009), have risk factors for dental caries similar to those for other age groups, but adolescents’ risk for oral and perioral injury is especially exacerbated by behaviors such as the use of alcohol and illicit drugs, driving without a seat belt, cycling without a helmet, engaging in contact sports without a mouth guard, and using firearms (IOM, 2009). Other concerns among adolescent populations (that may be similar to those of other age groups) include damage caused by the use of all forms of tobacco, erosion of teeth and damage to soft tis- sues caused by eating disorders, oral manifestations of sexually transmitted infections (e.g., soft tissue lesions) as a result of oral sex, and increased risk of periodontal disease during pregnancy. Adults Adults ages 20 to 64 have similar risk factors for oral disease as other age groups, although because oral disease accumulates with age, adults generally have more oral disease than do their younger cohorts. In addition, adults may have difficulty obtaining dental insurance, because many states offer limited or no dental benefits to adults through Medicaid (Kaiser Fam- ily Foundation, 2011). In 2007, 5 percent of adults were covered by public dental insurance, an additional 65.5 percent had private coverage, and 35.5 percent lacked dental insurance altogether (Manski and Brown, 2010). Older Adults Both the prevalence of periodontal disease and the percentage of teeth with caries increase as the population ages (Dye et al., 2007; Vargas et al., 2001). Older adults often have chronic diseases that may exacerbate their oral health, and vice versa. Older adults are more likely to have serious

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40 ADVANCING ORAL HEALTH IN AMERICA medical issues and functional limitations, which can deter them from seek- ing dental care (Dolan et al., 1998; Kiyak and Reichmuth, 2005). Older adults who spend more on medication and medical visits are less likely to use dental services (Kuthy et al., 1996). Moreover, dental insurance is generally linked to employment, and upon retirement, most older adults lose their dental insurance (Manski et al., 2010). Despite these challenges, the oral health of older adults is improving: between NHANES III and NHANES 1999–2004, the prevalence of caries, periodontal disease, and edentulism among older adults all decreased (Dye et al., 2007). While federal law requires long-term care facilities that receive Medi- care or Medicaid funding to provide access to dental care, only 80 percent of facilities report doing so (Dolan et al., 2005). Even when dental care is available, many residents do not regularly receive dental care, and many oral health problems go undetected (Dolan et al., 2005). Only 19 percent of dentists report providing treatment in long-term care facilities in the past, and only 37 percent showed interest in doing so in the future (Dolan et al., 2005). In the absence of dentists, nursing home staff must identify residents’ oral health needs, but nurses (as well as many other health pro- fessionals) are not adequately trained to identify or treat many oral health issues (Dolan et al., 2005; IOM, 2008). People with Special Health Care Needs It appears that people with special health care needs1 have poorer oral health than the general population has (Anders and Davis, 2010; Owens et al., 2006). Most, though not all, studies indicate that the overall prevalence of caries in people with special needs is either the same as the general popu- lation or slightly lower (Anders and Davis, 2010; López Pérez et al., 2002; Seirawan et al., 2008; Tiller et al., 2001). But, available data indicate that people with special needs suffer disproportionately from periodontal dis- ease and edentulism, have more untreated caries, have poorer oral hygiene, and receive less care than the general population does (Anders and Davis, 2010; Armour et al., 2008; Havercamp et al., 2004; Owens et al., 2006). However, high-quality data on the oral health of people with special needs in the United States is scarce (Anders and Davis, 2010). People with special health care needs are a difficult population to reach, in part because of their diversity, and also because they are geographically dispersed. Moreover, it is also difficult to analyze national data on this population because their numbers are not large enough to produce reliable statistics. Many of the 1 For the purpose of this report, people with special health care needs are people who have difficulty accessing oral health care due to complicated medical, physical, or psychological conditions (Glassman and Subar, 2008).

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41 ORAL HEALTH AND OVERALL HEALTH AND WELL-BEING available studies of people with special health care needs were conducted with populations that are not representative of the special needs community as a whole (Feldman et al., 1997; Owens et al., 2006; Reid et al., 2003). Disparities in oral health for people with special needs are due to a variety of reasons. People with special needs often take medications that cause a reduced saliva flow, which promotes caries and periodontal disease (HHS, 2000b). Additionally, people with special needs often have impaired dexterity and thus rely on others for oral hygiene (Shaw et al., 1989). They also face systematic barriers to oral health care such as transportation bar- riers (especially for those with physical disabilities), cost, and health profes- sionals that are not trained to work with special needs patients or dental offices that are not physically suited for them (Glassman and Subar, 2008; Glassman et al., 2005; Stiefel, 2002; Yuen et al., 2010). Poor Populations Poor children are more likely to have untreated dental caries and less likely to receive sealants than nonpoor children, despite having almost uni- versal access to dental insurance through Medicaid (Dye et al., 2007; HHS, 2000b). Poor children and adults receive fewer dental services than does the population as a whole (Dye et al., 2007; Lewis et al., 2007; Stanton and Rutherford, 2003). Encouragingly, however, a recent analysis of NHANES data indicated that the largest increase in dental sealant use occurred among poor children, although they continue to lag behind higher-income children (Dye and Thornton-Evans, 2010). The increase among poor children may be due to school-based sealant programs, which in 17 states reach children in 25 percent or more of schools serving low-income families (Pew Center on the States, 2010). The likelihood of visiting a dentist decreases with decreasing income, and people from poor families are less likely to have visited a dentist within the previous year and less likely to have a preven- tive dental visit (Manski and Brown, 2007; Stanton and Rutherford, 2003). Pregnant Women and Mothers The oral health care of women is important for the health of the women as well as for the effects it has on their children. The oral health status of children has been linked both with the oral health status of their mother as well as their mother’s educational level (Fisher-Owens et al., 2007; Ramos-Gomez et al., 2002; Weintraub, 2007; Weintraub et al., 2010). For some populations of children, evidence suggests that children’s use of oral health care services is higher when their mothers have regular access to care (Grembowski et al., 2008; Isong et al., 2010). Arguably, the oral health care of children begins during pregnancy. For example, use of folic acid supple-

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