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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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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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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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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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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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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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70 ADVANCING ORAL HEALTH IN AMERICA
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