Community and Other Approaches to Promote Oral Health and Prevent Oral Disease Summary: Prevention of Craniofacial Injuries Health education and injury prevention campaigns addressing the need for pro- tective gear in sports and cycling activ- ities can increase awareness and use. More rapid adoption can occur through legislation or regulation. Greater dis- semination of safety measures for home and workplace can similarly lower the risk of falls and other unintentional injuries. With regard to reducing inten- tional injuries in the United States, cur- rent and ongoing policy discussions, legislative proposals, and research efforts are necessary first steps toward appropriate programs. ORAL HEALTH PROMOTION AND DISEASE PREVENTION KNOWLEDGE AND PRACTICES To take full advantage of emerging sci- ence-based health and health care prac- tices, individuals, health care providers, and policymakers need to be sufficient- ly informed that they can take appro- priate actions for themselves, for those for whom they have responsibility, and for the community at large. For the individual, these actions include brush- ing with a fluoride-containing denti- frice for caries prevention, brushing and flossing to prevent gingivitis and periodontal diseases, and avoiding tobacco and other substances that are detrimental to health. Lack of knowledge can affect care. If parents are not familiar with the importance and care of their child's pri- mary teeth or if they do not know that dental sealants exist, they are unlikely to take appropriate action or seek pro- fessional services. If the public is not aware of the benefits of community water fluoridation, public referenda and funding for such interventions are not likely to be supported. Similarly, if individuals do not know that an oral cancer examination exists, they may not ask about the need for one. However, it is well established that BOX 7.2 Sports Injuries and Oral-Facial Trauma The national concern regarding oral-facial injury is addressed in the Healthy People 2010 objective 15-31, which is to increase the proportion of public and private schools that require use of appropriate head, face, eye, and mouth protection for students participating in school- sponsored physical activities. The National Youth Sports Safety Foundation estimates that more than 3 million teeth will be knocked out in youth sporting activities this year, an injury almost completely preventable by wearing a mouthguard. Even more significant, oral-facial trauma from sports injuries will result in facial bone fractures, concussion, permanent brain injury, temporomandibular dysfunction, blinding eye injuries, and even death. Currently, no systematic monitoring for oral-facial injuries exists in the United States. Progress toward a more broadly targeted Healthy People 2000 objective proved to be diffi- cult to track because of the data requirements of monitoring all organizations, agencies, and institutions sponsoring sporting and recreational events that pose risk of injury. By focusing on-schools, not only should the monitoring of progress be feasible, but healthy habits will be formed early. The hope is that by the time the athletes reach young adulthood they will rec- ognize the hazards posed by their athletic interests and, perhaps, be more comfortable using protective devices than they would be without them. It is estimated that as many as one third of all dental injuries are sports-related. A particu- larly high proportion of all baseball injuries (41 percent) is estimated to occur to the head, face, mouth, or eyes. Nowjack-Raymer and Gift (1996) reported that in 1991 more than 14 million U.S. school-aged youngsters participated in at least one sport that was listed on the 1991 National Health Interview Survey questionnaire, with more than 9 million of these children in organized baseball or softball. Baseball and softball are the most popular organized sports, with nearly one quarter of the school-aged population playing. Unlike football, not all baseball/softball leagues or teams require the use of safety equipment. In many cases, only selected positions such as catchers and batters are covered by rules. Thus only 35 percent of players reported that they wore headgear all or most of the time, and only 7 percent wore mouthguards all or most of the time. Further analysis of the interview data revealed a variety of socioenvironmental differences in the wearing of headgear and mouthguards. Forty percent of males who played baseball or softball reported wearing protective headgear “all or most of the time,” compared with only 25 percent of females. Differences were also found by poverty level, with 36 percent of those at or above poverty level wearing headgear, compared with 24 percent of those below. Better educated parents were somewhat more likely than less educated parents to have responded that their child wore headgear “sometimes” (45 percent versus 38 percent) and non-Hispanics reported occasional use more than Hispanics (43 percent versus 30 percent). Parents of a greater percentage of baseball or softball players of high school age (12 percent) than elementary school-aged players (6 percent) reported that their child wore a mouth- guard “all or most of the time.” Also, more black (17 percent} than white (6 percent) children reported the use of mouthguards. These socioeconomic differences might be greater were it not for the safety efforts of school athletic programs. Still, many parents and coaches are not as proactive as they could be and are not aware that facial injuries also occur in sports that are not considered high contact. For example, basketball players typically do not wear mouthguards. Yet approximately 34 percent of all injuries to basketball players involve teeth and/or the oral cavity. Examples of community-based interventions to prevent sports-related, oral-facial trauma include the development of rules and regulations for the use of headgear and mouthguards in sports where craniofacial injury is a risk; efforts to alert players, parents, sports officials, and organizers to the potential for injury; better product design; and the creation of sup- portive environments for sports-related equipment and recreation areas. 176 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL Community and Other Approaches to Promote Oral Health and Prevent Oral Disease knowledge alone will not necessarily lead to appro- priate practices. For example, even if individuals know that tobacco use is unhealthful and that it con- tributes to multiple life-threatening illnesses, some continue to smoke. The majority of people who need such information most—those in low-income groups and those with lower levels of education—also are the ones who lack the information and skills (oral health literacy) to ask for and obtain specific preven- tive services or treatment options. Health profession- als are in an ideal position to provide up-to-date health information and care to their patients. They also have an opportunity to enhance their knowledge and practices as well as increase their communica- tion to patients about the procedures they provide and the reasons for these procedures. Few national studies of public and professional knowledge, attitudes, and practices exist. Highlights from these as well as from state and local studies that evaluated the prevention of dental caries, periodontal diseases, and oral cancers are provided below. Generally, the public is unable to discriminate between methods that prevent dental caries and those that prevent periodontal diseases (Corbin et al. 1985, Gift et al. 1994). This confusion has been attributed to the prevailing marketing message that refers to them as “plaque diseases” preventable by thorough tooth cleaning with a toothbrush and floss. In addition, the general public and health care providers are not fully informed about the relative value of fluoride and the appropriate recommended applications of regimens to prevent dental caries (Corbin et al. 1985, Gallup 1992, Gift et al. 1994, (Neil 1984). More work is needed to improve knowledge and practices related to oral cancer pre- vention as well. As with other areas of investigation, additional survey research is needed to better understand findings to date and to develop tailored interventions. Research is ongoing to improve the design of survey instruments and the wording of questions to address cultural and ethnic differences and interpretations. Dental Caries Prevention The Public Most members of the general public, regardless of socioeconomic level, tend to believe that the best way to prevent dental caries is by brushing their teeth (Corbin 1985, Gift et al. 1994, O'Neil 1984). In the 1990 National Health Interview Survey (NHIS), respondents were asked the purpose of adding fluoride to public drinking water. About two thirds of the respondents 25 to 65 years of age knew that water fluoridation helps prevent caries, compared with only 51 percent and 49 percent of those 65 and older and 18 to 24 years of age, respectively. Blacks and Hispanics were less likely to know the value of this preventive procedure than whites. In the same sur- vey, when asked to indicate the one best way to pre- vent tooth decay from five answers (limiting sugary snacks, using fluorides, chewing sugarless gum, brushing and flossing the teeth, and visiting the den- tist every 6 months), only 7 percent of the respon- dents answered correctly that fluoride was the most effective (Gift et al. 1994). More than two thirds said tooth brushing and flossing were the most effective. These results paralleled those of earlier studies (Gift et al. 1994, O'Neil 1984). A lower perceived value of fluorides by the public in preventing dental caries also was seen in the 1985 NHIS (Corbin et al. 1985). In a survey of knowledge and beliefs of the public, dentists, and dental researchers about the best way to prevent dental caries, the public and the dentists identified tooth brushing, whereas dental researchers unanimously ranked fluorides, as most important (O'Neil 1984). A small study among Latina mothers showed that they believed that brushing with baking soda is a good way to prevent dental caries; they knew little about brushing with a fluoride-containing dentifrice (Watson et al. 1999). Dental sealants and appropriate use of fluoride are critical for caries prevention. In the 1990 NHIS, about 32 percent of the public had heard of dental sealants, but among those only three fourths knew the purpose of this preventive measure (Gift et al. 1994). In 1991 the Gallup Organization conducted a poll for the American Academy of Pediatric Dentistry among a national sample of 1,200 parents of children 16 years and younger. The results indicated that only 58 percent believed fluoride to be very important to a child’s oral health; another 36 percent considered it to be somewhat important. Eight of 10 parents did not know when a child should be prescribed fluoride supplements, and virtually no one knew when sup- plements should be stopped. Only 25 percent of par- ents in nonfluoridated communities reportedly give their children fluoride supplements (Gallup 1992). Health Care Providers In a national survey of U.S. dental hygienists’ knowl- edge, opinions, and practices regarding dental caries etiology and prevention, over 90 percent agreed that “adults benefit from the use of fluorides” and that “root surface caries is an emerging problem.” A little ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 177 Community and Other Approaches to Promote Oral Health and Prevent Oral Disease less than one third did not provide fluoride treat- ments to adults. This same survey found that only 57 percent of the respondents recognized remineraliza- tion as fluorides most important mechanism of action; rather, flossing was selected as the most effec- tive procedure for preventing caries in adults. Also, only 18 percent reported providing the recommend- ed time for acidulated phosphate fluoride (APF) gel treatment (Forrest 1998). A city-based survey of den- tists and dental hygienists found that nearly 70 per- cent of the offices used lower than recommended topical fluoride application times and that some of the fluoride products reportedly used had not been clinically tested (Warren et al. 1996). Periodontal Disease Prevention The Public In the 1990 NHIS the majority of household respon- dents (79 percent) could identify one common sign of “gum” disease. Level of education was directly related to knowledge of gum disease. Eighty-nine percent of those with more than a high school level of education were able to name a common sign of gum disease, compared with 79 percent of those with a high school education and 60 percent of those with less than a high school education (Gift et al. 1994). A Roper report on oral health surveyed more than 1,000 adults 18 and older. Eighty percent reported that they did not believe they have had peri- odontal disease. However, 70 percent reported hav- ing experienced at least one symptom of gum dis- ease—bleeding gums; swollen, painful, or receding gums; a change in bite; or loose teeth. Although 41 percent of the respondents said that losing their teeth was their greatest fear regarding oral health, only 38 percent who had bleeding gums said they told their dentists about the problem. Further, only 30 percent of the respondents who had experienced warning signs of gum disease were worried about developing periodontal problems in the future. Fifty-eight per- cent knew that plaque is the main cause of gum dis- ease and that flossing alone will not prevent gum dis- ease, whereas 77 percent knew that brushing alone would not prevent gum disease. The majority (90 percent) knew that gum disease could strike anyone at any age (Roper Report 1994). In a recently reported study on the oral hygiene practices of a convenience sample of 34,897 users and nonusers of tobacco products who obtained den- tal care in 75 dental practices, 74 percent reported brushing twice a day and 36 percent reported flossing once daily (Andrews 1998). Tobacco users brushed and flossed much less frequently than nonusers. Patients with more than a high school education were less likely to use tobacco products and more likely to brush at least 2 times a day and floss daily than were those with less education. A 1996 study of 1,000 U.S. adults showed that nearly one third (29 percent) of respondents were extremely or very concerned about getting gum dis- ease. Concern was highest among younger respon- dents 18 to 49 years of age and those who very or somewhat frequently experienced bleeding gums. Only 6 percent said they frequently suffered from bleeding gums (2 percent very frequently and 4 per- cent somewhat frequently). Gnly 13 percent said a dental professional had diagnosed them with any kind of periodontal disease (gingivitis, pyorrhea, and periodontitis). Older respondents were somewhat more likely than younger ones to have been diag- nosed with gum disease, and 17 percent reported experiencing gingival bleeding occasionally (Andrews 1998). Health Care Providers Studies of dental professionals regarding periodontal disease prevention practices are limited. In 1989, Dental Products Report launched a study to deter- mine the involvement of general practitioners in periodontal care. Overall, general dentists and their hygienists have become more involved in the peri- odontal exam phase of patient treatment. This posi- tive trend suggests that periodontal diagnosis and treatment are well integrated into general practice. For example, when asked “what phases of periodon- tal treatment are you providing at present?” 100 per- cent reported gingival exam and evaluation, 97 per- cent reported pocket probing, and 88 percent report- ed providing patient education. The majority of den- tists (67 percent) used as many as six measurement sites per tooth. Nearly all (93 percent) reported hav- ing a referral relationship with a periodontist (Dental Products Report 1996). Oral Cancer Prevention and Early Detection The Public USS. adults generally are ill-informed regarding risk factors for and signs and symptoms of oral cancers. Further, a 1990 national survey found that only 14 percent of adults 40 and older reported that they had ever had an oral cancer examination. Of those, only 7 percent had had an exam within the last year 178 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL Community and Other Approaches to Promote Oral Health and Prevent Oral Disease Horowitz et al. 1995). In a statewide survey in \farvland. 85 percent of the adults claimed to have heard of oral or mouth cancer, but only 28 percent reported ever having an oral cancer examination Horowitz et al. 1996), A state-based study of veter- yns—a population at high risk for oral cancers— ‘ound that they were ill-informed and misinformed about these cancers (Canto et al. 1998a). Finally, a study among Latino youths who reported use of tobacco and alcohol found that they, too, were not knowledgeable regarding risk factors for oral cancers Canto et al. 1998b). Health Care Providers 4 recent national pilot survey of U.S. dentists found that the respondents’ knowledge regarding risk fac- tors for and signs and symptoms of oral cancers and their reported practice of examination procedures were limited (Yellowitz et al. 1998). Most respon- dents believed they were adequately trained to pro- vide oral cancer examinations, and 70 percent pro- vided annual oral cancer exams to patients 40 and older. Seventy-four percent reported their knowledge of oral cancers to be current, yet only 30 percent cor- rectly identified the age cohort most frequently diag- nosed with oral cancers. Further, less than 50 percent correctly identified the stage at which most oral can- cer lesions are diagnosed, and nearly one third of respondents could not identify the two most com- mon sites of these lesions. Although 86 percent claimed to assess their patients’ current tobacco use, only 50 percent assessed current alcohol use; rela- tively few dentists assessed past alcohol or tobacco use. There was a modest amount of misinformation as well. For example, 65 percent believed, incorrect- ly, that ill-fitting dentures and partials were a risk fac- tor for oral cancers, and 47 percent believed, also incorrectly, that poor oral hygiene was a risk factor. Further, although the majority of dentists claimed to provide oral cancer examinations to the majority of their patients, a large proportion did not palpate the lymph nodes—part of a comprehensive oral cancer examination. These results confirm an earlier study conducted among a convenience sample of Maryland dentists and physicians in that both groups believed their knowledge and skills related to oral cancer pre- vention and early detection to be wanting (Yellowitz and Goodman 1995). A recent national survey among U.S. dental hygienists found that although 98 percent agreed that oral cancer examinations should be provided annual- ly for adults 40 and older, only 6+ percent reported performing such an exam 100 percent of the time, and nearly 17 percent reported not performing an exam at any time (Forrest 1998). Further inconsis- tencies were found between knowledge of risk factors and performance. For example, although 94 percent correctly identified alcohol use as a risk factor for oral cancer, only 49 percent asked about alcohol use. Less than a majority (45 percent) reported their knowledge of oral cancers to be current. A majority (61 percent) believed they were adequately trained to palpate lymph nodes; still, only 24 percent reported routine palpating of lymph nodes, while 51 percent indicated they did not do so at any time. Summary Findings from national surveys, together with those from local studies, suggest that there are opportuni- ties for enhanced educational efforts for both the public and health professionals to improve oral health. These studies focus on the public and the dental profession for selected diseases. New research is needed to assess knowledge, attitudes, and prac- tices of all health professionals and for other condi- tions and risk factors related to oral health as well. BUILDING UPON SUCCESS As research and technology advance our understand- ing of the causes of major craniofacial diseases and disorders and lead to improved methods of diagnosis, treatment, and prevention, opportunities for new community-based prevention programs will grow. Ultimately, the application of any preventive inter- vention is driven by a combination of individual behaviors, community interventions, and profession- al practice. Only a few studies have taken into account all three spheres of action in determining health outcomes in a community (Arnijot et al. 1985, Chen et al. 1997). Our knowledge of the effects of multiple interventions is limited because most inter- ventions were developed and tested singly. In the past half century, however, advances in our understanding of oral diseases and the applica- tion of multiple preventive measures have resulted in continuing declines in the prevalence and severity of both dental caries and periodontal diseases for a size- able majority of Americans. For dental caries, for example, experts now believe that most people can maintain a low risk of the disease by a combination of drinking fluoridated water and brushing daily with a fluoride dentifrice. They recommend that addition- al provider- and community-based dental prevention programs be targeted to high-risk individuals and groups. ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 179 Community and Other Approaches to Promote Oral Health and Prevent Oral Disease Many of the studies reviewed in this chapter were conducted when higher rates of caries pre- vailed, community water fluoridation was less wide- spread, and use of fluoride dentifrices and supple- ments was not as common as today. These facts must be taken into consideration in contemporary deci- sion making by public health professionals and poli- cymakers. The validity and reliability of recommen- dations will benefit from the systematic reviews of the scientific evidence by the Task Force on Community Preventive Services (2000) to be includ- ed in a Guide to Community Preventive Services. Oral health promotion strategies are among those current- ly being evaluated. Future innovations include implementing pro- grams in new settings, such as workplaces, senior centers, and nursing homes, where individuals at high risk can be reached. Even if these programs are more expensive, the yield may be worth it if they reach those at high risk for disease. Similarly, focus- ing community-based interventions on populations at greatest risk will make optimal use of available resources. However, continued research to under- stand risk and improve ways to measure it is equally important for the success of these ventures. A review of progress in reaching the Healthy People 2000 oral health objectives reveals relatively little gain across many of the objectives (Table 7.8). Progress in the next decade will require diligent efforts to identify public health problems, mobilize resources, and ensure that the necessary conditions are in place and crucial services received. Public health agencies will be instrumental in carrying out these functions, and state arrd local dental directors can perform a leadership role. Box 7.3 describes the public health services that are essential if a commu- nity is to realize fully the benefits of available disease prevention and health promotion interventions. TABLE 7.8 Progress in meeting Healthy People 2000 oral health objectives Age Baseline Data HP 2000 Goal Final Data Summary 13.1 Reduce dental caries in children 6-8 54% 35% 52% Prog Reduce dental caries in adolescents 15 78% 60% 61% Prog +++ 13.2 Reduce untreated dental decay in children 6-8 28% 20% 29% Reversed Reduce untreated dental decay in adolescents 15 24% 15% 20% Prog ++ 13.3 Increase adults who have never lost a 35-44 31% 45% 31% No Change permanent tooth 13.4 Reduce adults who have lost all their teeth 65+ 36% 20% 30% Prog ++ 13.5 Reduce gingivitis among adults 35-44 41% 30% 48% Reversed 13.6 Reduce destructive periodontal disease 35-44 25% 15% 22% Prog + 13.7 Reduce oral and pharyngeal deaths in males 45-74 13.6% 10.5% 10.3% Met Reduce oral and pharyngeal deaths in females 45-74 4.8% 4.1% 3.5% Met 13.8 Increase sealants in children 8 11% 50% 23% Prog ++ Increase sealants in adolescents 14 8% 50% 24% Prog ++ 13.9 Increase persons on public water receiving 61% 75% 62% Prog fluoridated water 13.10 Increase topical/systemic fluorides among 50% 85% No data No data nonfluoridated 13.11 Increase caregivers using feeding 55% 75% No data No data practices that prevent early childhood caries 13.12 _ Increase oral health screening, referral, follow-up, 66% 90% 75% Prog ++ first time school attendee 13.13 For long-term care, oral exam and services No data 100% No data No data provided within 90 days 13.14 Increase use of oral health care system 35+ 54% 70% 63% Prog ++ (adults) 13.15 Increase states with system for recording 11 states 40 states 23 states Prog ++ and referring orofacial clefts 13.16 Extend use of protective head, face, eye, No data No data No data No data and mouth equipment 13.17 Reduce smokeless tobacco use among males 12-17 6.6% 4% 3.7% Met 18-24 8.9% 4% 6.9% Prog ++ Source: Adapted from NCHS 1999, 180 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL Community and Other Approaches to Promote Oral Health and Prevent Oral Disease BOX 7.3 Essential Public Health Services for Oral Health The Association of State and Territorial Dental Directors’ Guidelines for State and Territorial Oral Health Programs (ASTDD 1997) identi- fies the following essential public health services to improve oral health: |. Assessment A. Assess oral health status and needs so that problems can be identified and addressed. B, Analyze determinants of identified oral health needs, including resources. C._ Assess the fluoridation status of water systems, and other sources of fluoride. D. Implement an oral heath surveillance system to identify, investigate, and monitor oral health problems and health hazards. I. Poticy Development A. Develop plans and policies through a collaborative process that support individual and community oral health efforts to address oral heaith needs. B. Provide leadership to address oral health problems by maintaining a strong oral health unit within the health agency. (. Mobilize community partnerships between and among policymakers, professionals, organizations, groups, the public, and others to identify and implement solutions to oral health problems. Hl. Assurance A. Inform, educate, and empower the public regarding oral health problems and solutions. B. Promote and enforce laws and regulations that protect and improve oral health, ensure safety, and assure accountability for the public’s well-being. C._ Link people to needed population-based oral health serv- ices, personal oral health services, and support services and assure the availability, access, and acceptability of these services by enhancing system capacity, including directly supporting or providing services when necessary. D. Support services and implementation of programs that focus on primary and secondary prevention. E. Assure that the public health and personal health workforce has the capacity and expertise to effectively address oral health needs. F. Evaluate effectiveness, accessibility, and quality of popula- tion-based and personal oral health services. G. Conduct research and support demonstration projects to gain new insights and applications of innovative solutions to oral health problems. FINDINGS e Community water fluoridation, an effective, safe, and ideal public health measure, benefits indi- viduals of all ages and socioeconomic strata. Unfortunately, over one third of the U.S. population (100-million persons) are without this critical public health measure. e Effective disease prevention measures exist for use by individuals, practitioners, and communi- ties. Most of these focus on dental caries prevention, such as fluorides and dental sealants, where a combi- nation of services is required to achieve optimal dis- ease prevention. Daily oral hygiene practices such as brushing and flossing can prevent gingivitis. e Community-based approaches for the pre- vention of other oral diseases and conditions, such as oral and pharyngeal cancers and oral-facial trauma, require intensified developmental efforts. e Community-based preventive programs are unavailable to substantial portions of the under- served population. e There is a gap between research findings and the oral disease prevention and health promotion practices and knowledge of the public and the health professions. e Disease prevention and health promotion approaches, such as tobacco control, appropriate use of fluorides for caries prevention, and folate supple- mentation for neural tube defect prevention, high- light opportunities for partnerships between commu- nity-based programs and practitioners, as well as col- laborations among health professionals. e Many community-based programs require a combined effort among social service, health care, and education services at the local or state level. 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Fluorine and fluo- rides: environmental health criteria 36. Geneva: World Health Organization; 1984. World Health Organization (WHO). Fluorides and oral health. Geneva: The World Health Organization; 1994. Yellowitz JA, Goodman HS. Assessing physicians’ and dentists’ oral cancer knowledge, opinions and prac- tices. ] Am Dent Assoc 1995 Jan;126(1):53-60. Yellowitz JA, Horowitz AM, Goodman HS, Canto MT, Farooq NS. Knowledge, opinions and practices of general dentists regarding oral cancer: a pilot survey. J Am Dent Assoc 1998 May;129(5):579-83. 188 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL ee Personal and Provider Approaches to Oral Health Oral health is not a given. It takes conscious and repeated efforts on the part of the individual, care- givers, health care providers, and the community. For ihe individual, daily hygiene routines and healthy lifestyle behaviors provide a frontline defense in dis- vase prevention and health promotion. Equally important are periodic professional assessments of the individual's oral health status, which may include diagnostic, preventive, and therapeutic services and counseling. Community activities complement per- sonal and provider approaches to oral health. As dis- cussed in the previous chapter, these include water fluoridation, dental sealant applications for children, tobacco cessation campaigns, the use of mouth- guards in sports, and a variety of other school- and community-based oral health promotion and disease prevention activities. The interaction of these com- ponents is critical to oral health, as it is to overall health. In particular, there is now a better under- standing of the relationship of individual health to the health of the community in which the individual lives, and the importance of this relationship is one of the underlying premises of Healthy People 2010. This chapter discusses actions individuals can take to maintain their oral health and prevent disease, and reviews emerging approaches taken by dentists and other health care providers to promote oral health, assess risks, and prevent disease. INDIVIDUAL RESPONSIBILITY: PERSONAL APPROACHES TO ORAL HEALTH Sound personal hygiene practices and adherence to a healthy lifestyle are the mainstays of personal approaches to oral health. Long before the germ the- ory of disease, the need for tooth cleaning was recog- nized—if only to rid the mouth of food debris, elim- inate odor, and improve appearance. Tools developed for this purpose have ranged from primitive tooth sticks and picks, still used in parts of the world, to the water irrigators and electronic toothbrushes available in industrialized societies. An impressive array of oral care products greets the shopper in supermarkets and pharmacies today. Beyond the dozens of toothbrush shapes and sizes, there are flavored and textured dental flosses, floss holders, rubber tips, toothpicks, small brushes for cleaning between teeth, scores of dentifrices, and a range of fluoride-containing, antitartar, and antiseptic mouthrinses. Daily oral hygiene efforts contribute to the prevention of dental caries and periodontal diseases. The biofilm on tooth and root surfaces (dental plaque) can be disrupted to a large extent by the mechanical action of brushing and flossing. Daily efforts are necessary, not only because of food intake, put also because dental plaque is never completely removed. It starts to build up even after the most assiduous cleaning (or prophylaxis) in the dental office and even after the application of a potent antimicrobial mouthrinse. The oral and dental tissues and structures thus require more intensive daily care than do other body areas exposed to the environment. Daily Hygiene and Dental Caries Prevention The use of a fluoride-containing dentifrice is critical for dental caries prevention. Even more beneficial than the physical removal of plaque in toothbrushing is the delivery of a small amount of fluoride to the tooth surfaces. Investigators have conducted numer- ous clinical trials on fluoride dentifrices using rigor- ous designs and including randomized groups, dou- ble-blind designs, and placebo controls. All together, these studies provide strong evidence that using a ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 189 Personal and Provider Approaches to Oral Health fluoride dentifrice is effective (Clarkson et al. 1993, Lewis and Ismail 1995, Stookey et al. 1993). Fluoride dentifrices account for more than 90 percent of the market in the United States, Canada, and other devel- oped countries (Levy 1994). A fluoride dentifrice is an effective means of reducing the prevalence of dental caries for all per- sons. Although children’s teeth should be cleaned daily from the time they erupt, parents and caregivers should consult a dentist or other health care provider about the use of a fluoride dentifrice for children under the age of 2. For children under 6, fluoride dentifrices should be used in small amounts to mini- mize swallowing of the product. Mild enamel fluoro- sis can result from excessive dentifrice use, because children under 6 do not have adequate control of the swallowing reflex or may intentionally swallow a fla- vored dentifrice. Experts recommend that for chil- dren under 6, the parent or caregiver should super- vise toothbrushing, apply a pea-sized amount (0.25 gram) of dentifrice to the toothbrush, and encourage the child to spit out the excess (Bawden 1992). Because the topical benefits of fluoride have been shown to be highly effective, and daily exposure to small amounts of fluoride can reduce the risk of den- tal caries in all age groups, experts recommend that all persons drink water with an optimal fluoride con- centration in addition to brushing daily with a fluo- ride dentifrice (Bawden 1992, CDC in press). This combination provides a cost-effective and easy way to prevent dental caries and is an excellent example of the individual-community partnership. For persons at low risk of dental caries, these two exposures to fluoride may be the only ones necessary. For persons at moderate or high risk of dental caries, additional fluoride may be helpful and can come from daily use of another fluoride product. These can include mouthrinses, prescribed supplements, and _profes- sionally applied topical fluoride products (CDC in press). Daily Hygiene and the Prevention of Periodontal Diseases Toothbrushing and flossing also play a critical role in the prevention of periodontal diseases. Unlike dental caries prevention, prevention and control of gingivi- tis and periodontitis are achieved directly through the mechanical removal and disruption of dental plaque (Genco and Newman 1996). Some dentifrices also contain chemical therapeutics to control the for- mation of tartar (calculus) (Mandel 1995) and to reduce plaque formation and gingival inflammation (Hancock 1996). Both manual and electric tooth- brushing are effective at removing plaque and pre- venting gingivitis (Walsh et al. 1989, Axelsson et al. 1991). Interproximal (between the teeth) cleaning is also important in maintaining gingival health (Lang et al. 1994). In one short-term evaluation of adults, the addition of flossing to the daily regimen of brush- ing resulted in an almost twofold reduction in gingi- val inflammation (Graves et al. 1989). Because pre- ventive measures in periodontics rely mainly on the removal of bacterial plaque and calculus, methods typically include personal oral hygiene measures combined with professional diagnostic and prophy- lactic measures (ie., regular €xam and cleaning). Periodic professional care for removal of plaque and calculus deposits has also been demonstrated to improve the periodontal health of participants (Cutress et al. 1991, Ronis et al. 1993). Healthy Lifestyles There is more to the individual’s role in promoting oral health and hygiene than brushing and flossing. Other behaviors that have an influence on oral health include use of tobacco and/or alcohol products, diet, oral habits such as bruxing and clenching the teeth, and use of helmets, mouthguards, or other protective devices. Table 8.1 summarizes selected behaviors that have an effect on oral, dental, and craniofacial health status. These are described more fully in Chapters 3, 7, and 10. Individuals can obtain credible information regarding oral health from various sources, including health care providers, professional organizations, government agencies, and patient advocacy groups. Increasingly, the World Wide Web is a source for health care information. For example, the National Oral Health Information Clearinghouse offers infor- mation on oral health, with an emphasis on special care patients and their health care providers. Care Seeking In addition to self-care, individuals also need to seek professional health care—both dental and medical— on a regular basis and whenever a problem manifests. The recall interval is based on the provider's assess- ment of the individual’s dental and medical history and lifestyle behaviors, among other factors. In the case of children and dependent adults, parents and caregivers are responsible for teaching and encourag- ing healthy behaviors and seeking timely and appro- priate care. As noted at the outset, it is only through the combination of individual and professional care, reinforced by community-based health promotion 790 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL Personal and Provider Approaches to Oral Health and disease prevention programs, that optimal oral and general health can be achieved. The remainder of this chapter focuses on the role of the professional in oral health care. PROVIDER-BASED CARE The range of conditions and diseases that affect the craniofacial complex is extensive and can provide clinicians with important indications about the patient's general as well as oral health status. Management of the oral health-general health inter- face calls for interdisciplinary and coordinated care and an enhanced role for primary care providers. Dentists, oncologists, dermatologists, infectious dis- ease specialists, hematologists, endocrinologists, plastic surgeons, and rheumatologists are just a few of the specialists who may be involved in the diagno- sis and management of conditions affecting the cran- iofacial complex. Dentists, their allied staff, and medical and nurs- ing personnel are in a unique position to incorporate new approaches for prevention,’ diagnostic, and treatment strategies in their practices. Advances in oral science are providing the basis for a shift in emphasis from the repair and restoration of damaged tissues to earlier diagnoses, control of infections, and remineralization and regeneration of lost tissues. The application of risk assessment strategies and inter- ventions tailored to individuals and groups is systemic nutrition. (See Chapter 10, Box 10.1.) Oral hygiene and home care practices (are seeking all oral and craniofacial health. Parafunctional habits using behavioral strategies. Tobacco use Alcohol use defects and mental retardation. injury control practices calorie malnutrition, deficiencies of vitamin A, asco Linear enamel hypoplasia and hypomineralization ous and permanent teeth. The physical consistency, been linked to the development of caries. Reduced clinical signs of nutritional deficiencies and eating with clenching and other oral habits such as frequent tion. Treatment may begin with making the individua TABLE 8.1 Selected individual behaviors affecting oral, dental, and craniofacial health Behavior Effect Diet and nutrition Nutrition and diet contribute to oral and craniofacial development and to the maintenance of these tissues throughout life. Nutritional deficiencies during pregnancy can affect tooth size, enamel solubility, time of tooth eruption, salivary gland function, saliva composition, epithelial tissue, and susceptibility to dental caries. Deleterious effects specific to the dentition include protein- rbic acid, vitamin D, calcium, phosphorus, iron, and iodine, and excessive fluoride. during the first year of life increase susceptibility to dental caries in both decidu- sequence, and frequency of carbohydrate intake (primarily refined sugars) have calcium intake is associated with greater levels of periodontal disease. Early disorders are often seen in and around the mouth. Oral lesions may also affect Regular toothbrushing with a fluoride-containing dentifrice prevents dental caries. Rinsing with fluoride mouthrinse can aid in reducing caries and in the remineyalization of tooth structure. Requiar toothbrushing and proper flossing can prevent gingivitis. Seeking health care—both dental and medical—on a regular basis and whenever a problem manifests is important. In the case of children or dependent adults, it alls for the caregivers to teach and encourage healthy behaviors and to seek appropriate care from a variety of care providers. Prenatal care, as well as oral health care prior to major treatments such as chemotherapy, is critical to over- Habitual grinding (bruxism) and/or clenching teeth are farms of abnormal motor behavior. These habits often occur during sleep. As gum-chewing, bruxism can cause tooth wear and affect muscles of mastica- | aware of the problem, providing an occlusal splint to prevent tooth wear, and The use of tobacco in all forms increases the risk for oral and pharyngeal cancers, and smoking is a leading risk factor for periodontal diseases. Increased risk for dental caries has been associated with spit tobacco use. In HIV-infected individuals, tobacco use is a risk factor contributing to increased risk of the development of oral candidiasis. (See Chapter 10, Box 10.2.) Alcohol alone, as well as acting synergistically with tobacco, greatly increases the risk for oral and pharyngeal cancers. independently, alcohol in excess is associated with circulatory and neurological problems, liver disease, and other organ-specific dis- eases and disorders. Alcohol use in pregnancy can lead to birth defects, such as fetal alcohol syndrome and its associated craniofacial Proper use of helmets, mouthguards, safety belts, and other protective devices helps prevent injuries to the head, neck, and mouth. _ ‘The term prevention, as used in this chapter, includes interventions aimed at reducing the incidence of disease in relatively healthy patients. It includes both health promotion and specific protection to control one or more risk factors. Some strategies, such as the prevention of tobacco use, are applicable to many odontal diseases, whereas other strategies are specific, such as t ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL oral diseases, including oral cancer, oral candidiasis, and peri- he use of dental sealants and fluorides for caries prevention. 191 Personal and Provider Approaches to Oral Health expanding with the increased understanding of risk factors and the development of biomarkers that sig- nal host resistance, susceptibility, and the presence and progression of disease. The changing demographics of the U.S. popula- tion and a greater understanding of the relationship between oral health and general health are presenting . new challenges. Making clinical decisions for patients requires integrating a range of interacting biological, psychological, social, cultural, and envi- ronmental factors. In order for disease to manifest, the etiologic agent(s) must be present, the host must be susceptible, the environment conducive, and suf- ficient time available for the factors to interact (Figure 8.1). Early diagnosis and prompt treatment require an understanding of the pathology and of the diagnostic, prevention, and treatment modalities available. As genetic information accumulates, clini- cal judgments will increasingly be informed by knowledge of an individual's genetic susceptibility or resistance to particular diseases and disorders. The development of tailored treatment plans will require incorporating all these factors together with input from the patient's health providers, taking into con- sideration the patient's interests and needs. The fol- lowing sections provide an overview of emerging approaches to clinical management and highlight selected diseases as examples. Risk Assessment Given the greater understanding of disease etiology, epidemiology, patient characteristics, and genetic information, it is becoming increasingly possible to determine an individual's risk of disease and tailor treatments accordingly. Risk assessment for dentistry has been defined as “the use of knowledge of factors FIGURE 8.1 Factors involved in disease Etiolagic Agent(s) Environment and Behavior Patient Susceptibility that are associated with dental disease to determine which patients are more or less likely to prevent or control their dental disease” (Douglass 1998). The factors can include co-morbidities, medications used, and patient characteristics such as sex, age, and lifestyle behaviors, among others. By compiling such factors and sorting them by risk category, patients can be classified into high- or low-risk groups, enabling providers to make more comprehensive diagnoses and identify patients who would benefit from more aggressive prevention strategies. Such analyses conducted during the early stages of disease can result in treatments that reverse or contain the disease process (Douglass 1998). Knowledge of risk factors for oral and craniofacial diseases and disor- ders allows other health care providers to screen for these risk factors and contribute to improving oral health. Risk assessment and disease prediction studies have focused primarily on dental caries and peri- odontal diseases (Genco 1996, Page and Beck 1997, Pitts 1998, Powell 1998). In addition, risk factors for oral and pharyngeal cancers have been explored Johnson 1991). The evidence base for risk assess- ment is developing from population-based studies. It involves a research process in which a suspected risk factor is related in a multivariate model to other fac- tors and confounders (Beck 1990). The resulting model is tested in a second group of subjects, and a targeted intervention study is conducted to confirm the predictive validity of the risk factor. Although the application of research findings of risk assessment has begun in some practices, the pre- diction of future disease at the individual patient level has not yet been extensively studied. Douglass (1998) has posed six clinically oriented questions that need to be addressed if risk assessment is to be adopted into routine clinical practice: 1. Does the scientific theory or biologic logic of the risk factor fit with our current body of knowledge about the disease in question? 2. Has the technical merit of identifying the risk factor (such as imaging technologies and bacter- ial assays) been evaluated? 3. Has the efficacy of the risk factor in predicting disease been evaluated in terms of sensitivity, specificity, and positive and negative predictive values?” 4. Has the potential effect of the risk factor on the disease management decision been explored? Can knowledge of the presence of a particular risk factor or pattern of risk factors alter the treatment plan? 192 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL Personal and Provider Approaches to Oral Health 5, Has the influence of the risk factor on oral health outcomes been assessed? 6. Has the cost-effectiveness of collecting risk factor data from each patient been evaluated? Is the added expense justified either by increased effective- ness or by avoiding other expenses? Diagnostic Tests \Whereas risk assessment aims to predict future dis- ease and disease progression, diagnostic tests evalu- ate a patients current status with regard to a specific disease or disorder. They enable the provider to for- mulate, in cooperation with the patient, a treatment plan. In relation to dental caries and periodontal dis- cases, the diagnosis ideally should not only detect the presence of disease, but also distinguish between active and arrested disease. Today, most diagnostic tests for oral conditions are based primarily on anatomic clinical evidence. However, microbiological, pathological, immunolog- ical, genetic, and tissue metabolite tests are increas- ingly available and valuable. Table 8.2 cross-refer- ences diseases with categories of diagnostic tests available. The following sections describe elements of a general health assessment and highlight risk assess- ment, diagnosis, and prevention of selected diseases and conditions. Oral Health Assessment An oral health assessment involves an evaluation of an individual's overall health status, including any risk factors and personal needs that can affect health and treatment options. For the majority of craniofa- cial conditions, this assessment and subsequent care are coordinated with a range of health care providers, with the intent of enhancing the patient's overall health and well-being. The information gathered for the assessment is derived from patient information, extraoral and intraoral clinical examinations, and imaging and other diagnostic tests as needed. The patient provides demographic and lifestyle behavior information and a medical and dental history, including current come- plaints, if any. Symptom analysis entails an addition- al series of questions that explore symptom onset, characteristics, and course. Figure 8.2 provides an example of a medical history form used in dental practice. The clinician will take into consideration the patient’s general appearance and ability to function, as noted by characteristics of facial symmetry or asymmetry and speech. In addition, the patient's vital signs may be assessed, and a thorough examination of the head, neck, temporomandibular joints, and other structures will be conducted. The intraoral por- tion of the examination involves an extensive assess- ment of the tissues: the lips and labial mucosa, buc- cal mucosa and mucobuccal fold, the floor of the mouth, tongue, hard and soft palate, oropharynx, muscles of mastication, salivary glands and saliva, gingiva, periodontium, and teeth. Depending on the needs of the patient, the initial physical examination is usually augmented by sup- plementary data from radiographs and sometimes by other diagnostic tests, including tissue biopsies and samples of oral cells and fluids. Such samples can be used to type specific bacteria, viruses, or fungi or to detect elevated levels of tissue metabolites or [rs BLE 8.2 Categories of diagnostic methods for selected oral, dental, and cran Diagnostic Periodontal Oral Procedure Caries Diseases Infections Interview Patient history Sa Sg a Physical Clinical examination ° So o Probing/caries ° Probing/periodontal o Imaging a Sd Biologic —_-Histology/cytology o Microbiology o o o Genetics/DNA o iofacial diseases and disorders Mucosal Temporomandibular Craniofacial Diseases Disorders Defects Oral Cancers Cd od ¢ Oo aa CY ° « o o Sa o o ° o ° OO Sensitivity is a measure of how often the test is positive when applied to patients known to have a particular disease or condition; specificity is a measure of how successful the test is in judging the absence of a disease or condition. ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 193 Personal and Provider Approaches to Oral Health FIGURE 8.2 Medical history form for use in dental practice Medical History Form Date Name Home Phone (___} Address _ Business Phone (___) City State Zip Code Occupation Social Security No. Date of Birth ss / /___ Sex MF Height Weight Single Married Name of Spouse Closest Relative Phone (___) if you are completing this form for another person, what is your relationship to that person? Referred by For the following questions, circle yes or no, whichever applies. Your answers are for our records only and will be considered confidential. Please note thaf during your initial visit you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. 1. Are you in good health? Yes No 2. Has there been any change in your general health within the past year? Yes No 3. My last physical examination was on 4. Are you now under the care of a physician? Yes No If so, what is the condition being treated? 5S, The name and address of my physician(s) is 6. Have you had any serious illness, operation, or been hospitalized in the past 5 years? Yes No If so, what was the illness or problem? 7. Are you taking any medicine(s) including non-prescription medicine? Yes No Ifso, what medicine(s) are you taking? 8. Do you have or have you had any of the following diseases or problems? a. Damaged heart valves or artificial heart valves, including heart murmur or rheumatic heart disease Yes No b. Cardiovascular disease {heart trouble, heart attack, angina, coronary insufficiency, coronary occlusion, high blood pressure, arteriosclerosis, stroke) Yes No 1, Do you have chest pain upon exertion? Yes No 2. Are you ever short of breath after mild exercise or when lying down? Yes No 3. Do your ankles swell? Yes No 4. Do you have inborn heart defects? : : Yes No 5. Do you have a cardiac pacemaker? Yes No «Allergy Yes No d. Sinus trouble Yes No e. Asthma or hay fever Yes No f. Fainting spells or seizures Yes No g. Persistent diarrhea or recent weight loss Yes No h. Diabetes Yes No i. Hepatitis, jaundice, or liver disease Yes No j. AIDS or HIV infection Yes No k. Thyroid problems Yes No t. Respiratory problems, emphysema, bronchitis, etc. Yes No m. Arthritis or painful swollen joints Yes No n. Stomach ulcer or hyperacidity Yes No 0. Kidney trouble Yes No p. Tuberculosis Yes No q. Persistent cough or cough that produces blood Yes No r. Persistent swollen glands in neck Yes No s. Low blood pressure Yes No t. Sexually transmitted disease Yes No u. Epilepsy or other neurological disease Yes No vy. Problems with mental health Yes No w. Cancer Yes No x. Problems of the immune system Yes No 9. Have you had abnormal bleeding? Yes No a. Have you ever required a blood transfusion? Yes No 194 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL Personal and Provider Approaches to Oral Health eee +9. Do you have any bload disorder such as anemia? ........ Yes No +1, Have you ever had any treatment for a tumor or growth? Yes No “2. Are you allergic or have you had a reaction to: a, _ Local anesthetics 7” . . a . . Yes No b. Penicillin or other antibiotics epwiseeereeees Yes No «Sulfa drugs ..... Yes No g, _Barbiturates, sedatives, OF sleeping pills . eoeeee . Yes No e. Aspirin. + Yes No §HOdiMe i nsnnensnnnnnrnnnninnt EET Yes No g. Codeine or ther Narcotics nenwsnsewemnnrsnnnnnnenennninrnnnrann LSS SET eee Yes No h. Other ; 13. Have you had any serious trouble associated with any previous dental treatment? .......-.-s-se . Yes No if-so, explain 14. Do you have any disease, condition, or problem not fisted above that you think | should KNOW BDOUL? ..sssseessecenseeerssneentee Yes No If so, explain 15. Are you wearing contact a Yes No 16, Are you wearing removable dental appliances? .nevnesseneeneatnnnnrermnneare eS Tpeeeeene . Yes No 17. Do you currently u Yes No Ifso, which type? : 18, Are youa former tabacco user? i Yes No Ifo, which type of tobacco? 19, How many years have/did you use tobacco? 20. How much tobacco do/did you use a day? _ 21. Ifyou have stopped using tobacco products, how long ago did you stop? 22. Have you ever used alcoholic DeVEraGeS? .asentsceeseenessrnetntnntnnncentenesty Yes No 23. How long ago did you stop using alcoholic beverages? 24, Do you currently u vecensaasanssaravansnennearsssnansnneesteet . . Yes No If'so, which type? 25, How many times a week do you use alcoholic beverages? Women 26. Are you pregnant? ......... vescueseasssanessanensnysensbitessaneeonseQQ@sQeew0e™ Yes No 27. Do you have any problems associated with your menstrual POTIOG? aseeeeeeseseens Yes No 28. Are you nursing? pennssceeseees - . + Yes No 29. Are you taking birth control Pills? escnseneeeneesnetemtnnnnarnnrrannn Yes No Chief Dental Complaint ae { certify that I have read and understand the above. acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. twill not hold my dentist, or any other member of his/her staff, responsible for any errors or amissions that | may have made in the completion of this farm. Signature of Patient For completion by the dentist. Comments on patient interview concerning medical history: Significant findings from questionnaire or oral interview: ee ental management considerations: i Oate Signature of Dentist Medical history update: Comments Signature Oe Source: Adapted from American Dental Association, as reproduced in Rose and Steinberg 2000. ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 195 Personal and Provider Approaches to Oral Health immune system factors associated with disease. The number of such tests is increasing and will be sup- plemented by genetic tests to indicate an individual's susceptibility to specific diseases. Currently, the assessment of oral and craniofacial health and disease involves intraoral radiographs as well as radiographic imaging, including arthrogra- phy, motion-based tomography, and computed tomography (Jeffcoat 1992). Intraoral radiographs permit detection of lesions between teeth and are the only widely available clinical test that can assess peri- odontal bone support in situ (Jeffcoat et al. 1995). Radiographs are an essential tool for treatment plan- ning of complex prosthetic reconstructions as well as a diagnostic method to assess periodontal progres- sion. However, the mere presence of bone loss on a radiograph does not imply progressive osseous destruction, although it does increase the patient’ risk of future bone loss (Armitage 1996, Genco 2000). Radiographs have high specificity for disease progression, and low sensitivity. Because all radi- ographic examinations expose the patient to some, albeit small, level of ionizing radiation, current guidelines indicate that radiographs should not be taken routinely (FDA 1987), but should be pre- scribed after an initial assessment by the dentist. Image processing techniques, such as digital radiography, enhance the clinician's ability to detect small intraoral osseous changes over time and aid in the detection of small changes in skeletal tissues between examinations. Direct digital radiography uses an intraoral detector to capture a radiographic image of the diagnostic area of interest (Ellwood et al. 1997, Matsuda et al. 1997). Several proposed meth- ods for quantitative estimation of lesion mass or vol- umetry using digital subtraction radiography exist (Armitage 1996). A recent multicenter validation study has indicated that simulated lesions as small as 1 mg in mass may be detected with better than 90 percent sensitivity and specificity Qeffcoat et al. 1996). These techniques are currently in use in clin- ical trials. New diagnostic methods are also becoming available as adjuncts to existing methods for caries diagnosis. Comparing data between bite-wing radi- ographs of potential occlusal fissure lesions, Lussi et al. (1995) found that electrical resistance measure- ment may provide a substantial improvement in caries diagnosis. Other imaging approaches are used to assess craniofacial anatomy, temporomandibular joints, maxillary sinuses, and other associated tissues, and in the assessment of the size and quality of bone to receive dental implants. Magnetic resonance imaging (MRD is also receiving increased attention for cran- iofacial applications, such as for the assessment of the temporomandibular joints. Finally, light-based imaging of teeth and associated structures, using a small intraoral camera, gives both the patient and the provider a wide-screen view of the oral cavity, aiding in patient education. In the course of conducting a general assess- ment, the clinician notes disease-specific signs and symptoms. While examining the teeth, the clinician may detect signs of relatively rare hereditary diseases such as ectodermal dyplasias, or more common destructive habits such as bruxism, where the enam- el and at times the dentin may be abraded. Examinations of the face and oral cavity may reveal the effects of intentional and unintentional injuries. With the results of the general assessment in hand, the clinician will classify the patient's general and oral health status and make treatment and/or referral recommendations. A classification system adopted in 1962 by the American Society of Anesthesiologists, used to cate- gorize a patient’ risk on the basis of physical status, also has been applied, along with the patient's gener- al and oral health risk assessment, to determine the need for coordinated multidisciplinary referral and whether care in a hospital is indicated rather than in the dental office (Bricker et al. 1994) (Table 8.3). Changing Approaches to Selected Diseases and Conditions The science and technology base is providing new approaches to risk assessment, diagnosis, prevention, and treatment. Highlights of selected diseases and conditions follow. Dental Caries Dental caries is caused by a transmissible microbial infection that affects tooth mineral. A number of fac- tors play a role in the initiation and progression of the disease, including bacterial biofilm, specifically the presence of mutans streptococci and species of lactobacilli; the frequency of simple sugars in the diet; the flow and composition of saliva; the avail- ability of fluoride; the structure of tooth mineral in a given individual; and oral hygiene behaviors. Sound caries management takes all these factors into account (Figure 8.3) (Burt and Ismail 1986). Today there is the prospect that clinicians will be able to bal- ance protective and pathologic factors and work with the patient to control disease (Anderson et al. 1993, Edelstein 1994, Featherstone 1996). 196 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL Personal and Provider Approaches to Oral Health Risk Assessment. Reviews of caries risk prediction models conclude that clinical variables, especially past caries experience, are the best predictors of new wanes experience (Newbrun and Leverett 1990, Powell 1998). Table 8.4 shows a timeline summariz- ing the strongest predictors of caries incidence based on a review of the modeling literature. At the time of initial tooth eruption, the presence of mutans strep- tococci appears to be the primary predictor of future caries. With continued tooth eruption, this variable disappears as a primary predictor and is replaced by the status of the most recently exposed or erupted tooth surface. For example, the ——— TABLE 8.3 American Society of Anesthesiologists—medical risk categories and associated dental considerations ASA Classification Dental Consideration presence of carious lesions in the primary incisors has been found to be the best predictor of caries in the later-erupting primary molars (Powell 1998). Physical status 1 A patient without systemic dis- ease; a normal, healthy patient Physical status 2 A patient with mild systemic disease medical consultation) Physical status 3 A patient with severe systemic dis- ease that limits activity but is not incapacitating considerations Physical status 4 A patient with incapacitating sys- temic disease that is a constant threat to life special considerations Routine dental therapy without modification Routine dental therapy with possible treatment limitations or special considerations (e.g., duration of therapy, stress of therapy, prophylactic consideration, possible sedation, and Dental therapy with possible strict limitations or special Emergency dental therapy only, with severe limitations or Despite recent declines, dental caries is a prevalent disease, with some age and pépulation groups particularly vulnerable (see Chapter 4). A guide for the identi- fication of vulnerable patients and the treatment of caries as an infec- tious disease has been developed (ADA 1995). Figure 8.4, from that guide, proposes questions to be considered at an initial examina- tion. These questions, together with information gathered at recall examinations, allow classification of child and adult patients into high-, moderate-, and low-risk dis- ease categories (Table 8.5). This Source: Genco 2000. Risk factors for periodontal disease. In Rose LF, Genco RJ, Cohen DW, Mealey BL. Periodontal medicine. Hamilton:B.C. Decker Inc. 2000:35-43. Copyright 2000 by B.C. Decker Inc. Reprinted by permission of B.C. Decker Inc. (2000). approach has been incorporated in a variety of caries risk assessment FIGURE 8.3 Multifactorial model of dental caries Host Enamel crystal structure { Enamel minerals: Agent i GPF §. mutans | Saliva quantity Lactobacilli \ Saliva quality Other bacteria \, Immune response Host behavior Host attitudes Environment Plaque quantity Plaque quality Enzymes Minerals Bacterial substrate Protective factors Socioeconomics Culture Source: Burt and Ismail 1986. Copyright 1986 by Journal of Dental Research. Reprinted by permission of Journal of Dental Research (2000). forms adopted by some dental schools and managed care programs (C.W. Douglass, personal communication, 1999). Studies are needed to determine the validity and reliability of such approaches for different patient populations and practice settings. The use of tests to assess caries risk to determine the activity status of preclinical disease is becoming more widespread. A range of diagnostic aids for caries activity testing are available. Microbial tests can detect the presence and quantify the levels of lactobacilli and mutans streptococci. The develop- ment and use of these tests are based on studies that have associated these microbes individually and together with different types of carious lesion devel- opment. Measurements of plaque and salivary pH have been used to evaluate the oral environment overall and to note the changes in pH that occur after eating various foods. Salivary flow and compo- sition analyses add another dimension. Decreased flow has been related to caries susceptibility, as have increases in viscosity. These factors warrant further study to determine their sensitivity and specificity. ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 197 Personal and Provider Approaches to Oral Health Diagnosis. Clinical signs, patient-derived history, and radiographic images remain the primary means of dental caries diagnosis. Tooth surface pitting and cavitation, white and/or brown spots, areas soft to tactile probing, and radiolucencies are used to detect the effects of this disease. The most common diagnostic approaches include visual inspection, the use of an explorer (a probelike instrument) to determine the integrity of the tooth surface, the use of a light source to detect difference in reflectance across tooth structure (transillumination), and radiographs. Table 8.6 compares the reported sensitivity and specificity of selected methods. No single method stands out as superior with regard to both sensitivity and specificity for all tooth surfaces. The most basic diagnostic methods—visual alone and visual examination with an explorer—have limited sensitivity, but excellent specificity. The visu- al examination may be combined with a radiograph- ic series for the initial assessment. Bite-wing radiographs are frequently used to diagnose inter- proximal caries (between teeth) and for these sur- faces provide excellent sensitivity and specificity. Radiographic examination allows examination of otherwise inaccessible areas. Specifically, the depth of a lesion and its relationship to the pulp chamber can be evaluated for interproximal lesions. However, radiographs are of little value in detecting caries on the occlusal surfaces of the teeth. For these surfaces, a negative radiographic diagnosis does not imply lack of a carious lesion in enamel. Precavitated carious lesions and caries in restored teeth pose an additional diagnostic chal- lenge. A review of the literature on the clinical diag- nosis of precavitated carious lesions concluded that visual detection of these lesions has low sensitivity and moderate specificity (Ismail 1997). It is difficult with these lesions to determine whether there is no caries or whether only the enamel or outer layer of dentin is involved. Carious lesions forming around restorations are seen more frequently at the approxi- mal and cervical margins of these restorations (Mjor 1985). Distinctive color changes around a restoration alone are not diagnostic of active caries (Kidd 1990). Currently, the progression of carious lesions is the most definitive diagnostic parameter for disease activity. Progression can be determined over specific time intervals only by professional assessment. Prevention. The primary prevention of dental caries starts with adequate prenatal and perinatal nutrition to ensure normal development of the teeth and sup- porting structures. It continues with interventions aimed at preventing transmission of cariogenic microbes from caregivers to infants, and proceeds with specific strategies employed across the life span. These approaches include the provision of sufficient fluoride, the use of dental sealants, the adoption of healthy behaviors, including avoiding unhealthy dietary practices and practicing appropriate oral hygiene, and the timely use of care services. Although many factors are brought to bear on the primary prevention of dental caries, the combination of fluoride in its multiple forms and dental sealants is the foundation (as described in Chapter 7). Fluoride is available in a variety of products that can be used by health professionals, individuals, and public programs. Topical solutions and gels, mouthrinses, and dentifrices are available for daily, weekly, or as-prescribed frequency. In addition, TABLE 8.4 Timeline of strongest clinical predictors of caries incidence Age (years) 0 1 2 3 4 ~=«°55 6 7 8 9 0 4H 12. «1301421 22-45 >45 Dentition — Primary Mixed Early Mature permanent permanent Event Eruption primary molars Eruption first Eruption second Progression of gingival recession permanent molar permanent molar Predictor Mutans dmifs, especially dmfs, especially DMFS, especially first Incipient Not studied Coronal and root streptococci’ primary incisors primary molars permanent molars smooth DMFS Mutans streptococci First molar occlusal First motar occlusal surface lesions Number of teeth and lactobacilli morphology morphology DMFS Periodontal DMFS Incipient smooth disease surface lesions Note: dmfs = decayed, missing, or filled primary tooth surfaces; DMFS = decayed, missing, or filled permanent tooth surfaces. Source: Powell 1998. Caries prediction: a review of the literature. Community Dentistry and Oral Epidemiology 1998; 26:361-71. Copyright 1998 by Munksgaard International Publishers Ltd., Copenhagen, Denmark. Reprinted by permission of Munksgaard International Publishers Ltd., Copenhagen, Denmark (2000). 198 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL Personal and Provider Approaches to Oral Health FIGURE 8.+ Caries risk questions for initial examination INITIAL VISIT—QUESTIONS TO CONSIDER |s there current caries activity? Are there indications that yield potential for development of caries within the next year? « Prior DMFS (decayed, missing, or filled surfaces) + Tooth morphology + Medications that decrease saliva flow and/or affect viscosity of saliva « Medical condition or treatment(s) What is the individual's caries risk? * Low + Moderate * High What are the modifiable risk factors that may be responsible for or may contribute to this caries activity? » Insufficient systemic and topical fluoride + Medications * Poor oral hygiene habits or skills « Deep pits and fissures without sealants + Poor dietary habits What can be done to prevent new caries or caries progression within the next year? + Sealants + {Increase fluoride use * Oral hygiene instruction/education * Dietary counseling + Monitor bacterial count + Antimicrobial agents « Conservative restorative techniques—to minimize removal of tooth structure What is the prognosis for successful intervention? + Patient compliance * Clinician skill (diagnosis, intervention counseling) + Prevention modalities are accepted/applied + Severity at onset Are there other considerations that may affect the decision process that cannot be changed? (effect modifiers, confounders) + Age + Socioeconomic considerations * Medicatly and/or physically compromising conditions Source: American Dental Association Council on Access, Prevention and inter- professional Relations 1995. Caries diagnosis and risk assessment. A review of preventive strategies and management. JADA; 126: 15-245. Copyright 1995 by American Dental Association. Reprinted by permission of ADA Publishing Co. Inc. (2000). fluoride-containing prophylactic pastes are available for professional application (see Chapter 7). Clinical judgment of risk factors determines the type and frequency of interventions needed. Although there is general agreement on the over- all value of topical fluorides in reducing dental caries (ADA 1986, 1994, Moss 1976, Stookey et al. 1993), comparative clinical trials are needed to determine which of the existing fluoride formulations (acidulat- ed phosphate fluoride, stannous fluoride, amino- fluoride, or sodium fluoride) and which delivery sys- tem (gel, varnish, dentifrice, or solution) are most efficacious. A second line of defense is through control of the etiologic agent. Chemotherapeutic agents (including the antimicrobial mouthrinse agent chlorhexidine and fluoride) can be used to reduce plaque. Dietary measures aimed at reducing the frequency and quan- tity of sugars and the substitution of sugars by sugar- free sweeteners may effectively starve the bacteria. The process of tooth demineralization and re- mineralization has received significant attention over the past four decades (Geiger et al. 1992, Koulourides et al. 1961, Larsen and Fejerskov 1987, Linton 1996, Silverstone et al. 1981, White 1988), although the concept was documented in the early 1900s (Head 1912) (see Chapter 3). Investigators are studying the effectiveness of therapeutic agents for arresting carious lesions and remineralizing enamel in populations at high risk for dental caries. For example, a combined chlorhexidine-fluoride solution can enhance remineralization of incipient lesions and arrest caries in patients who suffer from radiation- induced caries (Katz 1982). The use of a twice-daily rinse with 0.05 percent sodium fluoride to prevent demineralization and induce remineralization in sub- jects with radiation-induced hyposalivation has also been found to be effective (Meyerowitz et al. 1991). This study also addressed the effects of chlorhexidine use alone, which has been associated with tooth staining, alterations in taste, and potential hypersen- sitivity reactions (Ohtoshi et al. 1986, Okano et al. 1989). Schaeken et al. (1991) showed that the appli- cation of 40 percent by weight chlorhexidine varnish every 3 months enhanced remineralization of root caries more than fluoride varnish, although both treatments were associated with fewer filled root sur- faces than the control group after 1 year. A chlorhex- idine varnish has not yet been approved in the United States, and large-scale, double-blind, placebo-con- trolled clinical trials are not yet available to test the effects of specific regimens in relation to caries risk. Studies also are evaluating interventions to pre- vent mutans streptococci transmission. Find- ings from cross-sectional studies indicate that infants are initially infected by their parents, specifically mothers, around the time the teeth erupt (Berkowitz et al. 1975, Caufield et al. 1993, Kohler and Bratthall 1978). A longitudinal study using DNA fingerprint- ing demonstrated that mothers were the source of the ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 199 Personal and Provider Approaches to Oral Health TABLE 8.5 Caries risk classification guidelines Age Category for Recall Patients? Risk Category Child/Adolescent Adult Low No carious lesions in last year No carious lesions in last 3 years Coalesced or sealed pits and fissures Adequately restored surfaces Good oral hygiene Good oral hygiene Appropriate fluoride use Regular dental visits Regular dental visits Moderate One carious lesion in last year One carious lesion in last 3 years Deep pits and fissures Exposed roots Fair oral hygiene Fair oral hygiene Inadequate fluoride White spots and/or interproximal White spots and/or interproximal radiolucencies radiolucencies {regular dental visits {rreqular dental visits Orthodontic treatment Orthodontic treatment High >? carious lesions in last year >? carious lesions in last 3 years Past smooth surface caries Past root caries; or large number of exposed Elevated mutans streptococci count roots Deep pits and fissures Elevated mutans streptococci count No/little systemic and topical fluoride Deep pits and fissures exposure Poor oral hygiene Poor oral hygiene Frequent sugar intake Frequent sugar intake Irregular dental visits Inadequate saliva flow Inappropriate bottle feeding or nursing (infants) Inadequate use of topical fluoride Irregular dental visits {nadequate saliva flow aAt initial visit for new patient, if time of last caries experience cannot be determined, a person with no decayed, missing, or filled surfaces (DMFS = 0) would be classified as low risk. A person with past caries experience (DMFS > 0) and/or one active lesion would be classified as moderate risk. A person with past caries experience and/or two active caries or one smooth surface lesion would be classified as high risk. Parents of young children and expectant parents need additional counseling on inappropriate nursing or bottle feeding practices that can lead to the development of early childhood caries. Parents and caregivers should be advised to introduce children to a cup in an effort to discontinue use of the bottle by the age of 1 year. Also, parents and caregivers should be advised never to place anything other than plain water in a naptime or nighttime bottle. Children should not be allowed to bottle feed at will and should be weaned from the bottle by the age of 1 year. Many medically compromised individuals are likely to be assessed in the higher risk categories because of their use of certain medications and possible xerostomia. Source: American Dental Association Council on Access and Interprofessional Relations 1995. Caries diagnosis and risk assessment. A review of preventive strategies and management. JADA 1995; 126: 15-245. Copyright 1995 by American Dental Association. Reprinted by permission of ADA Publishing Co. inc. {2000}. TABLE 8.6 Sensitivity and specificity of selected dental caries diagnostic procedures Sensitivity Specificity bacteria in their infants and the degree of matching to maternal strains was higher for female infants than for males (Li and Caufield 1995). Based on a study of child-mother pairs (with the child initially at 1 year of age), the application of a 1.0 percent chlor- hexidine rinse alternated with a 0.2 percent sodium fluoride gel to the mother’s teeth (3 times per day on 2 consecutive days, twice per year for 3 years) delayed, and in some cases prevented, the colo- nization of their children’s teeth by mutans streptococci (Tenovuo et al. 1992). Timing of colonization has been shown to be correlated with caries prevalence. In a longi- tudinal study that followed chil- dren in 4-month intervals from 15 months to 4 years of age, children who were infected earlier had a higher caries prevalence than those in whom the infection was detected at later ages. Studies also have been aimed at reducing the levels of cariogenic bacteria in the infants themselves. Work continues on the devel- opment of a caries vaccine. One approach focuses on the produc- tion and release of antibodies against cariogenic bacteria anti- gens (Russell et al. 1995). Specific antigens have been purified and synthesized. Another approach involves biological replacement therapy, where nonpathogenic bacteria, instilled in the mouth, prevent pathogenic bacteria from colonizing (Hillman et al. 2000). Yet another approach employs pas- sive immunization in which anti- bodies, produced outside the body (in cultures, animals, eggs, oT plants), are applied to the teeth and oral tissues to protect against disease. A recent study indicated that “plantibodies” painted on the teeth could prevent mutans strep- tococci colonization for 120 days, the period of the experiment (Ma (percentage) (percentage) References Visual examination of noncavitated fissures 12-31 70-99 Lussi 1993, Ketley and Holt 1993 Examination using explorer 14-24 70-99 Penning et al. 1992, Lussi 1993 Radiographs of approximal lesions 50-90 85+ Grindahl 1989, Benn and Watson 1989 et al. 1998). 200 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL