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26. Oral Health Testimony on oral health covered the entire life span, from infancy to old age. The 53 witnesses who ad- dressed oral health as a major part of their testimony discussed prevention of tooth decay and gum disease- the focus of the 1990 oral health objectives-as well as other areas such as access to dental health services, professional education, oral cancer, and the role of dental hygienists in achieving oral health goals. Discussions of health priorities and preventive health strategies sometimes overlook oral health or treat it as an adjunct to other health goals. However, the witnesses who addressed oral health needs and objectives make it clear that this is a critical part of health-particularly preventive action taken to improve health in terms of personal well-being and to reduce lost work hours and costs. f~l63; #391J Expendi- tures for dental care in 1987 reached $35 billion and have continued to increase." (~156) According to pyndi Newman, representing the American n~.ntn Hygienists' Association: It has been obvious in the past that oral health has been considered separate from general total body health. I would like to suggest that it should be considered an integral part of total health. Oral health must be a basic component of all health education, treatment, and main- tenance programs. Good oral health must no longer be considered optional for health status. (#163) Witnesses also highlighted some new opportunities for making significant gains in oral health. For exam- ple, research in the last decade has made eradication of dental caries a realistic goal, according to Stephen Moss of New York University. (#439) New objec- tives were proposed to reflect that progress. However, testimony also revealed areas in which progress is lagging. One such area is communing wa- ter supply fluoridation. Fluoridation has been called the foundation of oral health, yet many communities are still without systemic fluoridation. One issue that arose repeatedly is the vast disparity in oral health across various population subgroups; objectives should reflect or target the dental health needs of -'I _ ~ , ~ Subgroups identified include the elderly, institutional these groups. according to witnesses ized, homeless, handicapped, minorities, migrant workers, and low-income people. Although specific objectives on oral health are proposed, witnesses feel that the process of setting objectives and measuring progress toward them is impeded by incomplete data on the oral health status and needs of many popula- tion subgroups. The Association of State and Territo- rial Dental Directors (ASTDD) says that an objective for 1990, that calls for a system to periodically assess oral health status, needs, and use of services is the single most important national dental health objective. (~106) Another intervention discussed was professional education. Thomas Truhe of the Princeton Dental Resource Center says that the public receives most of its information on dental health from dentists, but fewer than 40 percent of practicing dentists consider their profession a primary source of information.2 He believes that new research findings and other impor- tant information should be disseminated more effectively to dental professionals so that they can be better educators. (~369) FLUORIDATION "In the 1990 Objectives, water fluoridation was the foundation for the prevention of dental disease," says Myron Allukian representing the American Associa- tion of Public Health Dentistry. "That should con- tinue in the year 2000." There was widespread con- sensus on that issue among those testifying. Wit- nesses urge that the 1990 target of having 95 percent of the population on community water systems receive the benefits of fluoridation, be carried over to the Year 2000 Health Objectives, although many think it an unrealistic goal. (~435) According to Allukian, 60 percent of the popula- tion served by community water supplies had fluori- dated water in 1975; by 1985, this had increased to only 61.4 percent.3 (#435) John Brown of the University of Texas Health Science Center at San Antonio says that the promotion of water supply fluoridation is static: "Its benefits must be more effectively explained, so that those with this measure will defend it and those without it will acquire it." (#029) The ASTDD calls for changes in a 1990 objective Oral Health 191

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that at least 50 percent of school children living in fluoride-deficient areas without community water systems should be served by an optimally fluoridated school water supply. He says that no real progress has been made toward this goal and there is no real prospect of attaining it. The ASTDD recommends replacing this objective with one that includes alter- native ways to receive fluoride, such as mouth rinses, tablets, or both. (#106) The importance of using fluoride dentifrice twice daily is also underscored. (#154) INFANTS AND CHILDREN Many witnesses agree that a new objective aimed at preventing baby bottle tooth decay should be added; a public education campaign that alerts parents and other care givers to the problem could dramatically reduce its incidence. (#154; #242; #353; #445; #705) Baby bottle tooth decay occurs when baby bottles filled with liquids containing natural or added sugars-such as milk, infant formula, fruit juice, or a soft drink-are used as pacifiers. When an infant who is awake takes in the liquid, the sugars are diluted with saliva and swallowed. However, if the infant falls asleep the sugars have time to react with bacteria and form acids that cause serious cavities. Discontinuing the use of liquids containing natural or added sugars in bedtime bottles would prevent this problem. The national prevalence of baby bottle tooth decay is not known. In Head Start programs in San Anto- nio, 10-20 percent of preschoolers show the rampant form of this condition, according to Brown. (#029) David Johnsen of Case Western Reserve University estimates that 15 percent of urban and rural under- se~ved children and over 50 percent of children in some Native American groups have the condition. He recommends that the prevalence be determined and high-risk groups identified. f#l09) Another new objective proposed by many witnesses involves the use of pit and fissure sealants to prevent dental caries in children. Sealants are a significant advance in caries prevention that were not addressed by the oral health objectives for the year 1990. Wit- nesses call for all children to have access to this procedure at public and private dental clinics. (~242; #353; #445) The eradication of caries in children is now a realistic goal, according to Stephen Moss of New York University, who notes that a survey of pe- diatric dentists' own children found that 90 percent of those less than 12 years old had no cavities. (~439) 192 Healthy People 2000: Citizens Chart the Course The American Academy of Pediatric Dentistry emphasizes that sealants and two other proven preventive strategies-fluoride dentrifice and systemic fluoride-should be the focus of the Year 20C0 Health Objectives on reduction of caries. Members of the academy and witnesses from other dental professional groups, as well as from the sugar industry, call for eliminating those of the 1990 objectives aimed at reducing the availability of cariogenic foods in schools. Those objectives are criticized for being untenable and unmeasurable, for failing to take into account uncertainties about which foods pose the most serious oral health threats, and for distracting attention from proven methods of reducing caries. (~154; #197) ADULTS For adults, witnesses focused on caries, periodontal disease, oral trauma, and oral cancers. Public educa- tion, personal dental hygiene, and regular dental care were identified as important prevention strategies for adults. As the population ages, the number of adults with caries is increasing, according to Jane Weintraub of the University of Michigan, who explains that caries (not gum disease as was previously thought) are the major cause of tooth loss in adults.4 The 1990 Objec- tives set targets for caries reduction in only one age group: nine year olds. Weintraub and others recom- mend that targets be expanded to include other ages, even adults, and that specific types of caries be included in some objectives. (#391J Much of the adult population has periodontal disease, according to Dan Middaugh of the University of Washington.5 To reduce the rates, new initiatives aimed at increasing public awareness of the impor- tance of daily oral hygiene and regular professional care will be necessary, witnesses say. f#353) A1- though some testifiers note that the relationship be- tween gingivitis and periodontal disease in adults is not clear (~029; #106), most witnesses favor continu- ing to include it in the objectives. The American Cancer Society estimates that there are 30,600 new cases of oral cancer a year.6 As Woodrow Myers of the Indiana State Board of Health says: Smokeless tobacco has been linked to cancer, specifically oral cancer. Use of oral snuff increases the risk of oral cancer several fold, and among long-term snuff dippers, the excess risk of cancers of the cheek and gum may reach

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fiftyfold. Smokeless tobacco use is responsible for the development of a portion of oral leuko plakias in both teenage and adult users. (~405) According to Percy Butcher of the American Den- tal Association, reductions in tobacco and alcohol use are important preventive strategies for oral cancers. (~242J Several witnesses expressed concern about the use of smokeless tobacco, particularly among youth and young adults. The testimony in this area is summarized in Chapter 10. Although smokeless tobacco use is a separate topic, a few witnesses recommended that it be included under oral health to emphasize its link to oral disease. Increased public awareness of the risk factors and symptoms of oral cancer is necessary to decrease the morbidity and mortality from it; early detection and treatment of oral cancer result in higher cure rates. (~249; #262) Another condition recommended for the new objectives is oral trauma. Although a 1990 objective concerned the use of mouthguards, there Is some feeling that it must to be strengthened. Other strate- gies mentioned for preventing oral traumas include the use of seatbelts. (~391) OLDER ADULTS Some of the most compelling testimony about adult oral health needs concerned the elderly. None of the 1990 Objectives addressed this group specifically, although the elderly are the fastest growing segment of the population in this country and have serious dental health needs, according to witnesses. The American Society for Geriatric Dentistry (ASGD) notes that as more elderly keep their natural teeth, caries are an increasing problem. Also, as the num- bers of elderly increase, so will the need for dental service, witnesses point out. The at-risk elderly must be identified so that prevention programs aimed at reducing caries can be introduced, according to the ASGD. (#062) Oral mucosa disease is another problem for the elderly with dentures, the ASGD says, and a goal for the year 2000 should be to reduce the prevalence of oral mucosal lesions in the aging population by 50 percent. ~062) Special attention also must be given to the oral health of the institutionalized elderly. The ASGO notes that they have a far greater need for dental care than those who are not institutionalized. (#062) Testimony reveals that in many institutions, elderly residents are not offered regular dental care. A new Texas law requiring that nursing home residents be offered dental services (at their own expense) on a regular basis is hailed as a model. (~306) The ASGD suggests that oral health programs be man- dato~y at all nursing homes by the year 2000. (~062) UNDERSERVED POPULATIONS: PROBLEMS AND STRATEGIES The theme sounded most often in the testimony on oral health is the disparity in oral health among population subgroups. III addition to the elderly, other subgroups identified include Blacks, Native Americans, Hispanics, residents of some rural areas, migrant workers, the handicapped, the homeless, the institutionalized or homebound, and low-income people. Objective setting should reflect the special needs of these groups, according to witnesses. Allukian says that children in inner-city Boston have 55 percent more surfaces affected by tooth decay than the national average and that Black children in the United States have 2.5 times as many untreated cavities as White children. He also reports that a study of the homeless in Boston, in which the median age was 33, found that 97 percent needed treatment; 18 percent had pain or infection at the time of screening; 9 percent had suspicious soft tissue lesions; and 28 percent had not been to a dentist for an average of 14 years. (#435) Newman says that although Native Americans on reservations have dental coverage through the Indian Health Service, oral health care is not always available locally. As a result, many Native Americans suffer from poor oral health. She describes the needs in rural Washington State where she works. The Indian Health Service in this area needs to refocus their attention on education, preventive therapies, and doing outreach to those Native Americans who are not receiving care. I see that a large number of Indian children are not receiving the oral health care that they need. I hear constant complaints of toothaches from school children. It is not uncommon to see rampant decay in these children. (~163) The barriers to access faced by these groups typically involve the availability of providers, sociocul- tural issues, and cost. Brown describes the problem in San Antonio. Oral Health 193

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Effective oral disease prevention measures and oral health promotion activities are not reaching the community, especially those groups most at risk. Resources are disparate, often difficult to locate, duplicated, of poor quality in some instances and absent in others. Often ethnic, cultural, educational, and language diversity of communities is not sufficiently taken into account. Existing networks such as well baby clinics, WIC [Special Supplemental Food Pro- gram for Women, Infants and Children] prog- rams, school systems, workplace health programs, health care facilities for the homeless, migrant health workers, community health centers, nutrition centers, retirement centers, and nursing homes need to be utilized to pro- mote oral health and prevent oral disease by scientifically-based effective measures. (#029J IMPLEMENTATION The need for more and better data about oral health is intertwined throughout much of the testimony, especially as it relates to underserved populations. (#062; #106; #109) For example, Butcher states that because certain ethnic and socioeconomic groups have higher decayed, missing, or filled surfaces scores than the population as a whole, "such groups should be over-sampled to reflect more precisely the degree of difference." (#242J The American Association of Public Health Dentistry emphasizes the need to devel- op baseline data for each objective, so that progress can be measured throughout the decade. neater data collection," it states, "can more comprehensively describe other aspects or dimensions of the objective" but is "no substitute for the understanding provided by baseline data." (#156) Witnesses pointed out that health professionals, including dentists, hygienists, and even physicians, could play an expanded role in delivering preventive services to underserved populations. Hygienists can be especially useful in reaching the elderly, according to Betty Waedemon of the American Dental Hygien- ists' Association. (#306) Waedemon says that hygienists could provide im- portant preventive services in nursing homes. Many nursing homes cannot afford to have a dentist on staff, and the residents' dental needs are neglected, according to witnesses. Waedemon says that hygien- ists would be less expensive than dentists; therefore, institutions may be able to afford to have one on staff full- or part-time. (~306) 194 Healthy People 2000: Citizens Chart the Course More dentists also should be trained in geriatric dentistry, according to the ASGD, which explains that dentists should have an understanding of normal and pathological aging, communication skills, and other specialized areas to treat the elderly effectively. Very few programs in the United States offer such training; thus, specific targets in this area are proposed for the year 2000. (#062; #306) Several dental hygienists mentioned their role in bringing preventive services to groups such as the handicapped or those living in remote areas where dental services are unavailable, but said that restric- tions on their practice can limit those opportunities. States may restrict them to working under either direct or general supervision of a dentist. In Wash- ington State, for example, hygienists can work under the general supervision of a dentist in institutions, but they must have direct supervision in homes or private practice, according to testimony. Hygienists such as Newman say that these restrictions should be relaxed. (#163J Physicians and other health providers also can play an important role in encouraging good dental health and identifying oral cancers or other conditions, according to testimony. They should be prepared for that role and encouraged to become involved in oral disease prevention. (#154) Mobile dental units can help bring preventive services to those who are hard to reach. The ASGD reports that mobile units operating out of dental schools can be effective in long-term care institutions if they are designed properly. (~062J Other wit- nesses note their value in remote areas and for populations that are unable or unlikely to come to a clinic. (~041) Several testifiers note that one approach to provid- ing preventive dental services to underserved children is expanding school-based programs. Brown proposes that by the year 2000, at least 50 percent of school children be participating in school-based comprehen- sive health programs. He says that these should include fluoride and dental sealant programs, assess- ments and referral systems, comprehensive oral health education, and mouthguard programs. (#029) Financial barriers to obtaining preventive dental services also were discussed. Many witnesses said that Medicare and Medicaid, as well as private insurers, should cover comprehensive preventive dental services. Several witnesses called for including dental services in more employee benefit packages. Weintraub pro- poses that by the year 2000, 75 percent of employed adults have dental insurance. In 1985, 58 percent of

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- - - ~ the employed population was covered to some extent. according to testimony.7 (~391) REFERENCES 1. National Center for Health Statistics: Health United States, 1989 (DHHS Publication No. [PHS] 90-1232), 2. Opinion Research Corporation: Dental care: What people know. Sulveying the Knowledge gaps. A study on attitudes about dental health conducted by Opinion Research Corporation, 1983 3. U.S. Department of Health and Human Services: The 1990 Health Objectives for the Nation: A Midcourse Review. Washington, D.C.: U.S. Government Printing Office, 1987 4. Balit HL, Btaun R. Ma~rniuk GH, et al.: Is periodontal disease the primary cause of tooth extraction in adults? J Am Dent Assoc 114:40-45, 1987 5. Corbin SB, Kleinman DV, Lane JM: New opportunities for enhancing oral health: Moving toward the 1990 objectives for the nation. Public Health Rep 100~5~:515-524, 1985 6. Silverberg E, Lubera JA: Cancer statistics, 1989. CA Cancer J Clin 39~1~:3-20, 1989 7. National Institute for Dental Research: Oral Health of United States Adults. The National Sulvey of Oral Health in U.S. Employed Adults and Seniors: 1985-1986. National Findings. (NIH Publication No. 87-2~), August 1987 TESTIFIERS CITED IN CHAPTER 26 029 Brown, John; University of Texas Health Science Center at San Antonio 041 Swanson, Terri; Colorado Dental Hygienists' Association 062 Ettinger, Ronald; American Society for Geriatric Dentistry 106 Isman, Robert; The Association of State and Territorial Dental Directors 109 Johnsen, David; Case Western Reserve University 154 Moss, Stephen; American Academy of Pediatric Dentistry 156 Easley, Michael; American Association of Public Health Dentistry 163 Newman, Cyndi; Clallam County Department of Health (Washington) 197 Setton, Sarah; The Sugar Association 242 Butcher, Perter; American Dental Association 249 Davis, ~ Conan; Alabama Department of Public Health 262 Fleming, Lisa; Alabama Dental Hygienists' Association 306 Waedemon, Betty; American Dental Hygienists' Association 353 Middaugh, Dan; University of Washington 369 Truhe, Thomas; Princeton Dental Resource Center 391 Weintraub, Jane; University of Michigan 405 Myers, Jr., Woodrow; Indiana State Board of Health 435 Allukian Jr., Myron; Boston Department of Health and Hospitals 439 Moss, Stephen; New York University 445 Greenfield, William; New York University 705 Johnson, Dana; Colorado Dental Association Oral Health 195