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2
Oral Health Status and Utilization
M
any of the country’s most vulnerable populations face the greatest
oral health needs and the largest barriers to accessing oral health
care. Because oral health is inextricably linked to overall health,
the effects of poor oral health are felt far beyond the mouth. Oral health
providers, policy makers, and other stakeholders need to coalesce around a
common ground of basic preventive strategies, health literacy, and quality
of care principles to improve the oral health of the entire U.S. population.
This chapter begins with a discussion of the connection between oral
health and overall health. Next, the chapter gives a brief overview of the
oral health status and access to oral health care for the nation as a whole.
The specific oral health needs and access issues for individual vulnerable
and underserved populations follows. Finally, the chapter considers several
barriers to improving access to oral health care (and ultimately, oral health
status) including poor oral health literacy, inadequate use of preventive
services, and relative lack of oral health quality measures. These barriers
are briefly considered here, as a fuller discussion of literacy, prevention, and
quality measures can be found in the IOM report Advancing Oral Health
in America (IOM, 2011).
THE CONNECTION BETWEEN ORAL
HEALTH AND OVERALL HEALTH
For people suffering from dental, oral, or craniofacial diseases, the link
between oral health and general health and well-being is beyond dispute.
However, for policy makers, payers, and health care professionals, a chasm
41
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42 IMPROVING ACCESS TO ORAL HEALTH CARE
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.
has divided them. Dental coverage is provided and paid for separately from
general health insurance (see Chapter 5), dentists are trained separately
from physicians (see Chapter 3), and legislators often fail to consider oral
health in health care policy decisions. In effect, the oral health care field has
remained separated from general health care. 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 emphasized 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 or 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). For example, oral lesions are often the first manifestation
of HIV infection, and may be used to predict progression from HIV to
AIDS (Coogan et al., 2005). Sexually transmitted HP-16 virus has been
established as the cause of a number of 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); xerostomia is also a side effect for a large
number 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
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ORAL HEALTH STATUS AND UTILIZATION
that begin in the mouth can travel throughout the body. For example,
periodontal bacteria have been found in samples removed from brain ab-
scesses (Silva, 2004), pulmonary tissue (Suzuki and Delisle, 1984), and
cardiovascular tissue (Haraszthy et al., 2000). Periodontal disease has
been associated with adverse pregnancy outcomes (Albert et al., 2011;
Offenbacher et al., 2006; Radnai et al., 2006; Scannapieco et al., 2003b;
Tarannum and Faizuddin, 2007), respiratory disease (Scannapieco and
Ho, 2001), cardiovascular disease (Blaizot et al., 2009; Offenbacher et al.,
2009b; Scannapieco et al., 2003a; Slavkin and Baum, 2000), and diabetes
(Chávarry et al., 2009; Löe, 1993; Taylor, 2001; Teeuw et al., 2010).
Poor oral health may be associated with several other types of mor-
bidity (both individual and societal) including chronic pain, loss of days
from school (Gift et al., 1992, 1993), and inappropriate use of emergency
departments (Cohen et al., 2011; Davis et al., 2010). Oral health affects
speech, nutrition, growth and function, social development, and quality of
life (HHS, 2000b). In rare cases, untreated oral disease in children has led
to death (Otto, 2007). The impact of poor oral health extends to a child’s
family and community through lost work hours and the cost of hospital
admissions, for example. Figure 2-1 illustrates the range of consequences of
early childhood caries in a morbidity and mortality pyramid.
OVERVIEW OF ORAL HEALTH STATUS AND ACCESS
TO ORAL HEALTH CARE IN THE UNITED STATES
Although there is a wide range of diseases and conditions that manifest
themselves in or near the oral cavity itself, this report will focus primarily
on access to services for the prevention, diagnosis, and treatment of two
diseases and their sequelae: dental caries and periodontal diseases. Dental
caries, or tooth decay, is caused by a bacterial infection (most commonly
Streptococcus mutans) that is often passed from person to person (e.g.,
from mother to child). Oral Health in America called dental caries the
most common chronic disease of childhood (HHS, 2000b), and it is among
the most common diseases in the world (WHO, 2010d). Despite decades
of knowledge of how to prevent dental caries, they remain a significant
problem for all age groups. Periodontal disease is generally broken into two
categories: gingivitis and periodontitis. Gingivitis is an inflammation of the
tissue surrounding the teeth that results from a buildup of dental plaque
between the tissue and the teeth. It is generally due to poor oral hygiene.
Untreated gingivitis can result in periodontitis, the breakdown of the liga-
ment that connects the teeth to the jaw bone, and the destruction of the
bone that supports the teeth in the jaw. 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 have periodontal disease (NIDCR, 2011a,b).
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44 IMPROVING ACCESS TO ORAL HEALTH CARE
DEATH
Infection
Sedation
HOSPITAL COSTS
Morbidity Resulting
from General Anesthesia
Costs of Hospital Admission
Costs of Antibiotics and
Analgesics Provided at Discharge
Misuse of Emergency Department
Resources
FAMILY-ASSOCIATED MORBIDITY
Parental and Family Stress
Loss of Work Time and Employment
Child’s Loss of School Hours, Attentiveness,
and Academic Performance
Costs Associated with Travel and Child Care
Eating and Sleeping Dysfunctions
Disturbed Pain Perception
COSTS ASSOCIATED WITH
EARLY CHILDHOOD CARIES
Days Missed from School
Days Missed from Work
Morbidity Associated with Treatment
Chewing of Lip or Cheek
Inappropriate Use of Over-the-Counter Pain Medication
FIGURE 2-1
R01947 Figure 2.eps
Proposed early childhood caries morbidity and mortality pyramid.
SOURCE: Casamassimo et al., 2009. Copyright © 2009 American Dental Association. All rights
reserved. Reproduced by permission.
A Note on Data Sources
The following sections document the oral health status and access
to care for various populations. Data was drawn from published studies
that rely on a number of data sources, including the National Health and
Nutrition Examination Survey (NHANES), the National Health Interview
Survey, the Medical Expenditure Panel Survey (MEPS), and smaller-scale
surveys. While the magnitude of disparities in oral health and access to care
may differ among the various sources, similar conclusions can be drawn
from them about disparities in oral health status and access to care. Other
researchers have noted similar trends in the past (Macek et al., 2002).
Therefore, the committee felt comfortable using a variety of data sources,
both national and smaller scale. The committee did not have the ability
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ORAL HEALTH STATUS AND UTILIZATION
to analyze raw data and thus relied on published sources. As a result, the
committee did not always use the most recent survey data, because it has
not been analyzed in the published literature. In particular, many published
studies on oral health status rely on NHANES data from 1988–1994 and
1999–2004, and consequently the committee also relied heavily on those
data. While NHANES has included an oral health assessment in subsequent
years, the data collected is less detailed and not easily comparable to earlier
data. Until 2004, NHANES collected tooth-level data, meaning that a den-
tist evaluated the teeth of each survey respondent to determine the number
of decayed, missing, or filled teeth and surfaces (CDC, 2010b). Beginning in
2005, the oral health survey moved to person-level surveillance for caries,
meaning that each survey respondent was evaluated only for the presence
or absence of any decayed, missing, and filled teeth (CDC, 2010b; Dye et
al., 2011a). The Patient Protection and Affordable Care Act required the
Centers for Disease Control and Prevention (CDC) to return to person-level
surveillance for NHANES, although funding has not been appropriated.1
Overall Oral Health Status
In April 2007, the National Center for Health Statistics of the CDC
released a comprehensive assessment of the oral health status of the U.S.
population (Dye et al., 2007). Using data provided by two iterations of
NHANES (NHANES III, 1988–1994, and NHANES, 1999–2004), which
is the most comprehensive survey on oral health status in the United States,
the assessment concluded that “Americans of all ages continue to experi-
ence improvements in their oral health” (Dye et al., 2007). Specifically, the
report noted that among older adults, edentulism (complete tooth loss) and
periodontitis (gum disease) had declined. Among adults, CDC observed
improvements in the prevalence of dental caries, tooth retention, and peri-
odontal health. For adolescents and youth, dental caries decreased, while
dental sealants (used to prevent tooth decay) became more prevalent. En-
couragingly, the increase in dental sealants was consistent among all racial
and ethnic groups, although non-Hispanic black and Mexican American
children and adolescents continue to have a lower prevalence of sealants
than white children and adolescents, and low-income children receive fewer
dental sealants than those who live above 200 percent of the federal poverty
level (FPL).
While the data from the NHANES surveys showed improvements in
certain indicators of oral health status across two intervals of time, Ameri-
cans’ overall health status in the 1999–2004 period remained discouraging.
1 Patient Protection and Affordable Care Act, Public Law 148, 111th Cong., 2nd sess.
(March 23, 2010), §4102.
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46 IMPROVING ACCESS TO ORAL HEALTH CARE
For example, over 25 percent of adults 20 to 64 years of age and nearly
20 percent of respondents over age 65 were experiencing untreated dental
caries at the time of their examination. Even young children experienced
high rates of caries: nearly 28 percent of children ages 2–5 years had car-
ies experience, and 20 percent have untreated caries. Moreover, caries
prevalence among preschool children increased between 1988–1994 and
1999–2004 (Dye et al., 2010). In addition, disturbing disparities remain in
oral health status for many underserved and vulnerable populations, which
will be discussed in detail later in this chapter.
Access to Oral Health Care
Limited and uneven access to oral health care 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, significantly higher than the numbers that
reported being unable to get or delaying needed medical care or prescrip-
tion drugs (Chevarley, 2010). Nearly all measures indicate that vulnerable
and underserved populations access oral health care in particularly low
numbers. For example, poor children are more likely to report unmet dental
need than those with higher incomes (Bloom et al., 2010), non-Hispanic
black and Hispanic children and adults are less likely to have seen a dentist
in the past 6 months than non-Hispanic white populations (Bloom et al.,
2010; Pleis et al., 2010), and less than 20 percent of eligible Medicaid ben-
eficiaries received preventive dental services in 2009 (CMS, 2010). These
disparities and others will be discussed in more detail later in this chapter.
Healthy People: Benchmarks for Oral Health
Since 1980, the Department of Health and Human Services (HHS) has
used the Healthy People process to set the country’s health-promotion and
disease-prevention agenda (Koh, 2010). Healthy People is a set of health
objectives for the nation, consisting of (1) overarching goals for improving
the overall health of all Americans, and (2) more specific objectives in a
variety of focus areas, including oral health. Every 10 years, HHS evalu-
ates the progress that has been made on Healthy People goals, develops
new goals, and sets new benchmarks for progress. The goals are developed
by relevant HHS agencies, with input from external stakeholders and the
public. Healthy People 2020 objectives were released in December 2010
and are listed in Box 2-2.
Healthy People 2010 came to a close with the announcement of the
Healthy People 2020 benchmarks in late 2010. Progress on the Healthy
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ORAL HEALTH STATUS AND UTILIZATION
People 2010 goals was mixed, although final data have yet to be ana-
lyzed (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 categories, including decreasing caries among adolescents (al-
though not among younger children), increasing the proportion of children
with dental sealants, increasing the proportion of adults with no permanent
tooth loss, and increasing the proportion of the population with access to
community water fluoridation (HHS, 2006; Tomar and Reeves, 2009). In
contrast, several objectives moved away from their targets. For example,
the proportion of children aged 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 AND ACCESS TO ORAL HEALTH CARE
FOR VULNERABLE AND UNDERSERVED POPULATIONS
While there has been some improvement in the oral health of the U.S.
population overall, underserved populations continue to suffer disparities in
both their disease burden and access to needed services. For example, dental
caries remain a significant problem in certain specific populations such as
low-income children and racial and ethnic minorities (Edelstein and Chinn,
2009). According to NHANES, twice as many poor children ages 2 to 11
have at least one untreated decayed tooth, compared to nonpoor children
(Dye et al., 2007). In addition, low-income children also receive fewer
dental sealants (Dye et al., 2007). Minority children are more likely to
have dental decay than white children, and their decay is more severe (IHS,
2002; Vargas and Ronzio, 2006). When migrant and seasonal farmworkers
in Michigan were asked which health care service would benefit them the
most, the most common response was dental services, ahead of pediatric
care, transportation, and interpretation, among other services (Anthony et
al., 2008). This section will explore the disparities in status and access to
care for a variety of vulnerable and underserved populations.
Children and Adolescents
Children
While not all children are underserved, many children are vulnerable
to developing oral diseases, particularly dental caries. The U.S. Govern-
ment Accountability Office (GAO) recently reported that according to
NHANES, dental disease in children has not decreased, noting that about
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48 IMPROVING ACCESS TO ORAL HEALTH CARE
B OX 2-2
Healthy People 2020: Oral Health Objectives
Oral health of children and adolescents
1. educe the proportion of children and adolescents who have dental
R
caries experience in their primary or permanent teeth.
2. educe the proportion of children and adolescents with untreated
R
dental decay.
Oral health of adults
3. educe the proportion of adults with untreated dental decay.
R
4. educe the proportion of adults who have ever had a permanent
R
tooth extracted because of dental caries or periodontal disease.
5. educe the proportion of adults aged 45–74 with moderate or severe
R
periodontitis.
6. ncrease the proportion of oral and pharyngeal cancers detected at
I
the earliest stage.
Access to preventive services
7. ncrease the proportion of children, adolescents, and adults who
I
used the oral health care system in the past year.
8 ncrease the proportion of low-income children and adolescents who
I
received any preventive dental service during the past year.
9. ncrease the proportion of school-based health centers with an oral
I
health component.
10. ncrease the proportion of local health departments and Federally
I
Qualified Health Centers that have an oral health component.
one in three children aged 2–18 enrolled in Medicaid had untreated tooth
decay, and one in nine had untreated decay in three or more teeth (GAO,
2008). The lack of adequate dental treatment may affect children’s speech,
nutrition, growth and function, social development, and quality of life
(HHS, 2000b). In spite of these significant problems, according to MEPS,
only about 25 percent of children under the age of 6, 59 percent of children
ages 6–12, and 48 percent of adolescents ages 13–20 had a dental visit in
2004 (Manski and Brown, 2007).
A number of factors are related to the likelihood that a child has vis-
ited the dentist in the past year, including insurance status, race, ethnicity,
being born outside the United States, language spoken at home, whether
the child’s mother has a regular source of dental care (Grembowski et al.,
2008; Lewis et al., 2007). Dentally uninsured children receive fewer dental
services than insured children (Kenney et al., 2005; Lewis et al., 2007;
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ORAL HEALTH STATUS AND UTILIZATION
11. ncrease the proportion of patients that receive oral health services
I
at Federally Qualified Health Centers each year.
Oral health interventions
12. ncrease the proportion of children and adolescents who have re-
I
ceived dental sealants on their molar teeth.
13. ncrease the proportion of the U.S. population served by community
I
water systems with optimally fluoridated water.
14. ncrease the proportion of adults who receive preventive interven-
I
tions in dental offices.
Monitoring and surveillance systems
15. ncrease the number of states and the District of Columbia that have
I
a system for recording and referring infants and children with cleft
lips and cleft palates to craniofacial anomaly rehabilitative teams.
16. ncrease the number of states and the District of Columbia that have
I
an oral and craniofacial health surveillance system.
Public health infrastructure
17. Increase the number of health agencies that have a public dental
health program directed by a dental professional with public health
training.
SOURCE: HHS, 2010.
Manski and Brown, 2007). The data on dental visits for publicly insured
children, however, are mixed. Some data indicate that publicly insured
children are less likely to receive dental services and receive fewer dental
services on average than privately insured children (Manski and Brown,
2007); however, studies that control for race and income (among other
factors) indicate that publicly and privately insured children are equally
likely to have a preventive dental visit (Kenney et al., 2005; Lewis et al.,
2007). African American and Latino children are less likely to have had a
preventive dental visit (Lewis et al., 2007) or any dental contact in the past
year than white children (Bloom et al., 2010). This may contribute to the
low levels of dental visits among publicly insured children in uncontrolled
estimates, since African American and Latino children are more likely to
be enrolled in Medicaid (Kaiser Family Foundation, 2009). Children born
outside the United States and children whose primary language at home is
not English are both less likely than reference groups to have a preventive
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50 IMPROVING ACCESS TO ORAL HEALTH CARE
dental visit in the past 12 months (Lewis et al., 2007). In addition, low-
income children whose parents regularly visit the dentist are more likely to
visit the dentist, according to surveys done in Washington state and Detroit
(Grembowski et al., 2008; Sohn et al., 2007).
Adolescents
As noted above, adolescents, generally those aged 10–19 (IOM, 2009),
have a high prevalence of oral disease. Risk factors for dental caries are
similar to those for other age groups, but adolescents’ risk for oral and
perioral injury is exacerbated by behaviors such as the use of alcohol and
illicit drugs, driving without a seatbelt, cycling without a helmet, engaging
in contact sports without a mouth guard, and using firearms (IOM, 2009).
Other concerns among adolescent populations, which are not unique to
this age group, include damage caused by the use of all forms of tobacco,
erosion of teeth and damage to soft tissues 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. In an online Harris Interactive poll of nearly 1,200 adolescents,
respondents frequently mentioned having access to affordable, convenient,
and high-quality dental care as what they would most like to change to
make health services more helpful (IOM, 2009).
Homeless Populations
Homeless people have poorer oral health than the general population.
However, no national data are available on the oral health status of home-
less populations, and the few available studies may skew the results due to
sample size, the population surveyed (e.g., people who present at a clinic),
and inability to reach the chronically homeless, among other factors. In a
national survey, homeless veterans reported higher rates of oral pain, more
decayed teeth, and fewer filled teeth than the general population (Gibson
et al., 2003). Many homeless veterans reported having oral pain either
currently or within the past year (Conte et al., 2006). Similarly, in a small
survey of homeless adolescents in Seattle, over 50 percent reported having
sensitive teeth, 39 percent reported a toothache, and 27 percent reported
sore or bleeding gums (Chi and Milgrom, 2008). In addition, homeless
people in these surveys were more likely than the general population to
perceive their oral health as poor (Chi and Milgrom, 2008; Gibson et al.,
2003). Homeless people also struggle to access oral health care. A national
survey of homeless people found that dental care was the most commonly
reported unmet health need (Baggett et al., 2010). In fact, homeless people
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ORAL HEALTH STATUS AND UTILIZATION
surveyed at a free dental screening had not seen a dentist in, on average,
5.7 years (Conte et al., 2006).
Homeless populations face a multitude of barriers to both maintaining
good oral health and accessing oral health care. They are more likely to
engage in behaviors detrimental to oral health such as smoking and using
other types of tobacco products (Conte et al., 2006; Gibson et al., 2003),
heavy alcohol use (Gibson et al., 2003), and substance abuse (Chi and
Milgrom, 2008). They also may lack toothbrushes, toothpaste, clean water,
or a place to brush their teeth (Chi and Milgrom, 2008). Homeless people
often lack dental coverage, and homeless children struggle to maintain
Medicaid coverage because they do not have a permanent address. Over
one-third of homeless people at a free dental screening answered that they
did not know where to seek dental care if needed (Conte et al., 2006).
Low-Income Populations
Socioeconomic status, as measured by poverty status,2 is a strong
determinant of oral health (Vargas et al., 1998). In every age group, per-
sons in the lower-income group are more likely to have had dental caries
experience and more than twice as likely to have untreated dental caries
in comparison to their higher-income counterparts (Dye et al., 2007). Poor
children ages 2–8 have more than twice the rate of dental caries experience
as nonpoor children (Dye et al., 2010). Despite the fact that most children
living below the FPL are eligible to receive dental care through Medicaid,
many children in this income group have untreated decay (Dye et al., 2007).
Among adults, tooth extraction is a common treatment for advanced dental
decay when financial resources are limited. Consistently, total tooth loss,
or edentulism, among persons 65 years of age and over is more frequent
among those living below the FPL than among those living at twice the FPL
(Dye et al., 2007).
Poor children and adults receive significantly fewer dental services than
the population as a whole (Dye et al., 2007; Lewis et al., 2007; Stanton
and Rutherford, 2003). The likelihood of visiting a dentist decreases with
decreasing income (Haley et al., 2008; Manski et al., 2004), and people
who live below the FPL are less than half as likely to have visited a dentist
in the past year as those who make over 400 percent of the FPL (Manski
and Brown, 2007). Children whose families make below 200 percent of
the FPL are less than half as likely to have a preventive dental visit than
children living in higher-income families (Stanton and Rutherford, 2003).
2 For the purposes of this report, poor refers to individuals and families with income below
the FPL; near-poor refers income between 100 and 199 percent of FPL; and nonpoor refers to
income above 200 percent of the FPL.
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72 IMPROVING ACCESS TO ORAL HEALTH CARE
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