(Nishida et al. 2000). This is consistent with the findings of Krall et al. (1997), who showed that calcium supplementation in postmenopausal women with deficient calcium intake protected against tooth loss. Oral and Pharyngeal Cancers. High intakes of pickled vegetables, salted meat and fish, spicy foods, charcoal-grilled meat, and beverages served at very high temperatures have been found to be associated with oral cancers in some countries (Winn 1995). Malnutrition has also been found in association with the diagnosis of oral and pharyngeal cancers (Bassett and Dobie 1983). Whether the malnutrition was the cause or the effect is not clear. Oral Cancer Prevention. A consistent finding across numerous studies is that a diet high in fruit and vegetables is associated with a reduced risk of oral cancer even when smoking and alcohol intake are taken into account (Steinmetz and Potter 1996).In a case-control study, risk of sec- ond primary tumors in oral and pharyngeal cancer patients was reduced in those with a high vegetable intake (Day et al. 1994). Fruits and vegetables contain fiber, carotenoids, and vitamin C, which may be important in cancer chemoprevention. Vitamin C may act as an antiox- idant, protecting cell membranes and DNA from oxidative damage. Lack of vitamin C may interfere with collagen synthesis and permit tumor growth. Green leafy vegetables contain lutein, a carotenoid, xantho- phyll, an antioxidant, and folic acid. Folic acid deficiency may interfere with DNA methylation and DNA repair (Winn 1995). The only prospec- tive cohort study of diet and oral cancer (>25,000 persons in Maryland) showed that high serum total carotenoids and alpha tocopherol (vita- min £) reduced the risk of oral cancer, but high serum gamma toco- pherol and selenium increased cancer tisk (Zheng et al. 1993). The use of retinoids and 8-carotene in controlled therapeutic doses shows pro- tective effects. Fewer new primary tumors in persons with previous oral cancers and reversal or reduction in size of premalignant lesions have been reported (Khuri et al. 1997, Papadimitrakopoulou and Hong 1997). For example, high doses of 13-cis-retinoic acid, though causing significant toxicities, have been effective in the treatment of oral leuko- plakia (Hong et al. 1990). References Alfano MC. Controversies, perspectives and clinical implications of nutri- tion in periodontal disease. Dent Clin North Am 1976;20:519-48. Alvares 0, Siegel |. Permeability of gingival sulcular epithelium in the development of scorbutic gingivitis. J Oral Pathol 1981;10:40-8. Bassett MR, Dobie RA. Patterns of nutritional deficiencies in head and neck cancer. Otolaryngol Head Neck Surg 1983;91:119-25. Botto LD, Moore CA, Khoury Mi, Erickson JD. Neural-tube defects. N Engl J Med 1999;341:1509-19. Day GL, Shore RE, Blot WJ, McLaughlin JK, Austin DL, Greenberg RS, Liff JM, Preston-Martin S, Sarkar S, Schoenberg JB, et al. Dietary factors and second primary cancers: a follow-up of oral and pharyngeal cancer patients. Nutr Cancer 1994;21:223-32. DePaola DP Faine MP. Palmer CA. Nutrition in relation to dental medi- cine. in: Shils ME, Olson JA, Shike M, Ross CA, editors. Modern nutri- tion in health and disease. Baltimore: Williams & Wilkins; 1999. p. 1099-124. Hong WK, Lippman SW, Itri LM, Karp DD, Lee JS, Byers RM, Schantz SP, Kramer AM, Lotan R, Peters LI, et al. Prevention of secondary pri- mary tumors with isothetincin in squamous-cell carcinoma of the head and neck. N Engl J Med 1990;328:15-20. Hsu DJ, Daniet JC, Gerson SJ. Effect of zinc deficiency on keratins in buc- cal epithelial cells. Arch Oral Biol 1991;365:759-63. Jeffcoat MK. Osteoporosis: a possible modifying factor in oral bane loss. Ann Periodontol 1998;3:312-21. , Jeffcoat MK, Lewis CE, Reddy MS, Wang CY, Redford, M. Post- menopausal bone loss and its relationships to oral bone loss. Periodontol 2000; in press. Jensen ME. Diet and dental caries. Dent Clin North Am 1999;43:615-33. Jonasson G, Kiliaridis S, Gunnarsson R. Cervical thickness of the - mandibular alveolar process and skeletal bone mineral density. Acta Odontol Scand 1999;57:155-61. Khuri FR, Lippman SM, Spitz MR, Lotan R, Hong WA. Molecular epidemi- ology and retinoid chemoprevention of head and neck cancer.) Natl Cancer Inst 1997;89:199-211. Krall EA, Dawson-Hughes B, Hannan MT, Kiel DP. Postmenopausal estro- gen replacement and tooth retention. Am J Med 1997;102:536-42. Leggott PJ, Robertson PB, Jacob RA, Zambon JJ, Walsh M, Armitage GC. Effects of ascorbic acid depletion and supplementation on peri- odontal health and subgingival microflora in humans. J Dent Res 1991;70:1531-6. Nishida M, Grossi SG, Dunford RG, Ho AW, Trevisan M, Genco RJ.Calcium and risk for periodontal disease. Periodontol 2000;70(7):in press. Pack AR. Folate mouthwash: effects on established gingivitis in peri- odontal patients. J Clin Periodontol 1984;11:61 9-28. Papadimitrakopoulou VA, Hong WK. Retinoids in head and neck chemoprevention. Proc Soc Exp Med 1997;216:283-90. Papas AS, Joshi A, Palmer CA, Giunta JL, Dwyer JT. Relationship of diet to root caries. Am J Clin Nutr 1995;61(Suppl):4255-95. Payne JB, Reinhardt RA, Nummikoski PV, Patil KD. Longitudinal alveolar bone loss in postmenopausal osteaporotic/osteopenic women. Osteoporos Int 1999;10:34-40. Rugg-Gunn AJ. Nutrition, diet and dental public health. Community Dent Health 1993;10(Suppl 2):47-56. Seow WK, Humphrys C, Tudehope DI. Increased prevalence of develop- mental defects in low birth-weight, prematurely born children: a controlled study. Pediatr Dent 1987;9(3):221-5. Steinmetz KA, Potter JD. Vegetables, fruit and cancer prevention: a review. | Am Diet Assoc 1996;96:1027-37. Talbot L, Craig BJ. Osteoporosis and alveolar bone floss. Probe 1998;32:11-3. Tolarova M, Harris J. Reduced recurrence of orofacial clefts after peri- conceptual supplementation with high dose folic acid and multivi- tamins. Teratology 1995;51:71-8. Vogel RI, Lamster 1B, Wechsler SA, Macedo B, Hartley L, Macedo JA.The effects of megadoses of ascorbic acid on PMN chemotaxis and experimental gingivitis. J Periodontol 1986;57:472-9. Winn DM. Diet and nutrition in the etiology of oral cancer. Am J Clin Nutr 1995;61 (Suppl):4375-455. Zheng W, Blot WJ, Diamond EL, Norjus EP Spate V, Morris JS, Comstock GW.Serum micronutrients and the subsequent risk of oral and pha- ryngeal cancer. Cancer Res 1993;53:795-8. ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL Factors Affecting Oral Health over the Lile span Factors Affecting Oral Health over the Life Span teeth, firm gums, healthy soft tissues, well-function- ing bites, and beautiful smiles—but many do not. One in every four U.S. children today is born into poverty (U.S. Bureau of the Census 1998b) with all of its associated barriers and constraints. Poverty is a key indicator of poor oral health status among children (Litt et al. 1995). Poor children suffer twice as much dental caries as their more affluent peers (Vargas et al. 1998). Studies have shown that the children with the most advanced oral disease are primarily found among America’s most vulnerable groups: the poor, American Indians and other minorities, homeless and migrant populations, chil- dren with disabilities, and children with HIV (sman and Isman 1997). If untreated, oral diseases in children frequently lead to serious general health problems and significant pain, interference with eating, overuse of emergency rooms, and lost school time (Edmunds and Coye 1998). It has been estimated that 51 million school hours per year are lost because of dental-related illness alone (Gift 1997). The Institute of Medicine reports that 70 percent of U.S. children are generally healthy and require only regular preventive and intermittent medical services. Twenty percent experience chronic prob- lems, which may impose significant limitations on their ability to function effectively and require regu- lar treatments for their conditions. Only the remain- ing 10 percent suffer from severe chronic conditions necessitating intensive health services (Edmunds and Coye 1998). Similarly, the vast majority of America’s children today enjoy excellent oral health, but a significant subset of children experience a high level of oral dis- ease. Although it is no longer unusual to see children smiling with a full set of unmarred teeth, millions of other children have little to smile about. For them, the daily reality is persistent dental pain, endurance of dental abscesses, inability to eat comfortably or chew well, embarrassment at discolored and dam- aged teeth, and distraction from play and learning. Like asthma, learning difficulties, and social problems, dental caries is highly correlated with low income, limited education, and social disadvantage. In this regard, it may serve as a sentinel disease for other pediatric conditions that are related to inade- quate diet and hygiene and to family conditions and a social environment that do not support healthy lifestyles. Some oral conditions, like other childhood ill- nesses, affect children randomly, regardless of social or economic status. Such conditions include cleft lip and palate and other craniofacial developmental dis- orders, malocclusion, and unintentional injuries. Other oral conditions in children such as mucosal lesions may be a sign of risk behaviors such as tobac- co use. All oral conditions may be exacerbated in children with other special health care needs. Adults concerned about the health of children, particularly low-income and minority children, are regularly confronted by the reality and consequences of unmet oral health care needs. Although often viewed as innocuous by those who enjoy excellent dental health or have ready access to dental care, den- tal and oral problems impact the very life experience of affected children. Chronically poor oral health is associated with diminished growth in toddlers (Acs et al. 1992, Ayhan et al. 1996) and compromised nutrition (Acs et.al. 1999). Dental disease in children also takes a personal and social toll. Observing dis- advantaged inner-city schoolchildren, Kozol (1991) noted, “although dental problems don’t command the instant fears associated with low birth weight, fetal death, or cholera, they do have the conse- quences of wearing down the stamina of children and defeating their ambitions.” In addition to the millions of children with extreme dental problems, many times more encounter more modest disease. For example, the review of the Healthy People 2000 objectives found that more than half of all second graders, children aged 6 to 8, still experience cavities (USDHHS 1997). Dental caries remains the single most common dis- ease of childhood that is neither self-limiting, like the common cold, nor amenable to a simple course of antibiotics, like an ear infection (Edelstein and Douglass 1995). The numbers of poor and minority children are increasing faster than other socioeconomic subsets of US. children (Waldman 1996), and dental caries is common in these children. Twenty-five percent of these children have never visited a dentist before entering kindergarten (USDHHS 1997), despite widespread understanding that the dental caries process is established before age 2 and the recom- mendation of experts that children as young as 1 may benefit from a dental visit (AAPD 1997, Green 1994, USDHHS 2000). Parents are consistently concerned about the dental needs of their children (Simpson et al. 1997), and studies conducted in hospital emer- gency rooms have found extensive dental needs among children (Sheller et al. 1997, Unkel et al. 1989, Wilson et al. 1997). Dental care has recently been noted as the most prevalent unmet health need among American children (Newacheck et al. 2000). These conditions are evident despite the advances in the oral health sciences and the growing capacity of 252 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL oral health care providers to prevent common pedi- anc oral diseases. Children with disabilities present unique prob- tems and are at increased risk for oral infections, delavs in tooth eruption, periodontal disease, enamel irregularities, and moderate-to-severe malocclusion {sman and Isman 1997). Their exposure to certain medications and therapies, special diets, and their difficulty in maintaining daily hygiene further com- promise their oral health (Casamassimo 1996). Also, access to professional care is a particular problem for these children (see Chapter 4). Guides for dental pro- fessionals serving children with special health care needs are under development (USC 1999). The Role of Insurance in Children’s Oral Health Disparities also occur in access to care. Medical insurance is a strong predictor of access to dental care. Children with no medical insurance are 2.5 times less likely than insured children to receive dental care (Bloom et al. 1992, Monheit and Cunningham 1992, Newacheck et al. 1997). Children with no dental insurance were 3.0 times more likely to have an unmet dental need than their counterparts with either public or private insurance (Newacheck et al. 2000, Waldman 1998). Dentists daily observe that insured children are more likely to obtain comprehensive, continuous, and coordinated care and are more likely to be followed regularly for semiannual preventive visits. It has long been recog- nized that dental plans with low cost-sharing requirements are likely to improve the oral health of young people, especially those with the poorest oral health (Bailit et al. 1985). Children’s general health also affects access to dental care. Children with “fair or poor” general health have nearly twice the unmet dental needs as children with “good or excellent” health, according to their parents (Simpson et al. 1997). As income rises, unmet treatment needs drop off dramatically. Children from families with annual incomes of $10,000 to $20,000 have 10 times more unmet den- tal needs than children whose families earn more than $50,000 per year (Simpson et al. 1997). White children are more likely than children in other ethnic and racial groups to have private dental insurance coverage. When last surveyed nationally in 1989, about half (52 percent) of white children had dental insurance, compared to only 39 percent of black children and 32 percent of Mexican American children. As family incomes increase, children are more likely to be covered by dental insurance (USD- HHS 1992). Factors Affecting Oral Health over the Life Span In the United States, most health insurance is provided through the workplace, and about 60 per- cent of children are covered by private health insur- ance through their parents’ plans (U.S. Bureau of the Census 1998a). A smaller percentage, about 31 per- cent, enjoy dental insurance as well. There are at least > 6 children without dental insurance for each child without medical insurance (Vargas et al. 2000). Over the last decade, employer-based coverage for children has eroded, while publicly funded health insurance through Medicaid and the State Children’s Health Insurance Program (SCHIP) has expanded to cover over 25 percent of all children (U.S. Bureau of the Census 1998a). The Congressional Budget Office estimates that 2.5 million children will be insured through SCHIP. However, even with this increase many children will remain without dental coverage. Properly funded dental insurance works. When commercial-style, state-funded dental coverage became available to modest-income families in west- ern Pennsylvania, the percentage of previously unin- sured children (uninsured for more than 6 months) who saw a dentist during one year of coverage increased from 30 to 64 percent. The percentage of parents who reported that their child had a regular source of dental care increased from 51 to 86 percent. The percentage of parents who claimed that their children had unmet or delayed dental needs decreased from 52 to 10 percent. In addition, the number of dental visits fell as children’s acute and episodic care decreased and they began programs of regular preventive and maintenance care (Lave et al. 1998). Publicly Funded Insurance for Children Medicaid. Although publicly funded programs such as Medicaid have succeeded dramatically in provid- ing a “medical home” and regular medical care to children from low-income families (Newacheck et al. 1997), Medicaid’s record of ensuring regular access to dentists and providing effective dental care is less successful. Fewer than one in five Medicaid-covered children received a single preventive dental visit dur- ing a recent year-long study period, according to the U.S. Inspector General (USDHHS 1996). The study indicated that three fourths of states provided pre- vyentive services to fewer than 30 percent of eligible children, and no state provided preventive dental care to more than 50 percent of all eligible children. More disturbing is the finding that few Medicaid chil- dren who receive dental care get any services beyond a cleaning and fluoride treatment, despite their need for dental repair and fillings (Solomon 1998). ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 253 Factors Affecting Oral Health over the Life Span Federal legislation enacted over three decades ago established a guarantee of dental care to Medicaid-eligible children through the Early and Periodic Screening, Diagnostic and Treatment Service (EPSDT; PL. 90-284). Final regulations, effective in early 1972 (U.S. Bureau of the Census 1998a), ensure comprehensive dental services—prevention, diagno- sis, and treatment for “teeth and associated structures of the oral cavity and disease, injury or impairment that may affect the oral or general health of the recip- ient”—and promise children access to dental servic- es of sufficient “amount, duration, and scope” to ensure oral health. Federal law also requires provi- sion of enabling services such as transportation and translation. In addition, revisions to the Social Security Act in 1989 (OBRA 89) made several changes to EPSDT services. States are now required to set a distinct periodicity schedule for the provision of dental services after consultation with recognized dental organizations involved in child health care. States are also required to provide any medically nec- essary dental service coverable under Medicaid to an EPSDT eligible child even if the service is not avail- able to individuals age 21 and older under the Medicaid state plan. Despite these laws and regula- tions, inadequate funding, chronically poor pay- ments to dentists, administrative burdens, and bene- ficiary utilization patterns have limited the effective- ness of this program (USDHHS 1996). Increasingly, states are electing to purchase den- tal care for low-income populations through man- aged care organizations rather than to pay providers directly for Medicaid. As states take on the role of purchasers of care rather than claims payers, their focus has turned to a concern for health outcomes. However, participation of dentists in managed care programs is low (AAPD 1997, ADA 1998b, NADP 1998), and the effort to move dental Medicaid care into managed care programs may further constrain the availability of care. A 1998 survey of state Medicaid authorities by the National Conference of State Legislatures report- ed that, on average, only 16 percent of dentists in the 35 responding states participate actively in Medicaid (i.e., were compensated more than $10,000 in the preceding 12 months for dental care to Medicaid- enrolled patients). In 24 of these 35 states, fewer than 20 percent of active dentists participate actively (Guiden 1998). The study also raised awareness that common Medicaid payment rates for five typical children’s dental procedures rarely exceed 65 to 70 percent of dentists’ usual fees (Guiden 1998), a per- centage that represents dentists’ typical overhead costs in delivering those services (ADA 1998b). A 1998 federally sponsored national meeting, “Building Partnerships to Improve Children's Access to Medicaid Oral Health Services,” also identified inad- equate payments to dentists among multiple barriers in Medicaid program administration. Barriers identi- fied by the conference were categorized as financing and funding issues, Medicaid policies and adminis- trative procedures, supply and distribution of providers, parental valuation of oral health, and lack of a systematic approach to identifying and promot- ing successful interventions (Spizak and Holt 1999). Medicaid expenditures for dental care are low. On average, state Medicaid agencies contribute only 2.3 percent of their child health expenditures to den- tal care (Yudkowsky and-Tang 1997), whereas nationally, the percentage of all child health expendi- tures dedicated to dental care is more than 10 times that rate, almost 30 percent (Lewit and Monheit 1992). A 1998 actuarial study of health care costs for children (AAP 1998) calculated that 21 percent of expenditures for a comprehensive package of health services (including inpatient, outpatient, mental, dental, vision, hearing, and pharmacy services, but excluding orthodontic care) should be dedicated to dentists’ services. This study suggests that fully $21.35 per child per month must be expended in order to meet the dental care needs of covered chil- dren. A similar study conducted by the Reforming States Group (1999) determined that $17 to $18 per child per month is a necessary expenditure for dental care, assuming that providers accept a modest discount on their fees when serving low-income children. In FY 1995, Medicaid expended only $4.44 per enrolled child per month (Yudkowsky and Tang 1997). Although states vary widely in the percentage of children covered by Medicaid and in the income lev- els they require for eligibility, all states must entitle child beneficiaries to comprehensive dental services under EPSDT. A review of 15 state oral health and dental access surveys (Tinanoff 1998) noted the fol- lowing recurrent themes about Medicaid in relation to children’s oral health: e States show similar dental care issues for Medicaid-enrolled children: high disease prevalence, low provider participation, and insufficient funding. e Children at the highest risk of having dental caries are the least likely to have access to regular dental care. e Barriers to provider participation include low reimbursement rates in a health care environment that has high overhead; perception of administrative 254 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL roblems with Medicaid programs, and patients who do not fit the expectations of the dentist. e Medicaid payments for dental care account for less than 3 percent of total state Medicaid child health expenditures in these states. e The percentage of EPSDT eligibles with a dental visit (an initial measure of access to care) fails to reflect the insufficiency of reparative care to meet children’s acute dental health needs. e Lack of access to dental services for Medicaid recipients is perceived as the greatest pedi- atric health care problem in many states. e Untreated dental problems get progressively worse and ultimately require more expensive inter- ventions, often in a hospital emergency room OF operating room. State Childrens Health Insurance Program. Thirty years after enacting Medicaid, the U.S. Congress in 1997 addressed the lack of medical coverage for over 10 million additional children by passing the State Children’s Health Insurance Program (SCHIP). The Congressional Budget Office anticipates that this pro- gram will extend health insurance to at least 2.5 mil- lion more children and in the process will identify many additional children who are eligible for, but not enrolled in, Medicaid. SCHIP complements the Medicaid program by providing health insurance to children whose family income is above Medicaid eli- gibility standards, generally up to 200 percent of the federal poverty level. SCHIP differs from Medicaid in that it is not an individual entitlement, and states have broad latitude in designing and implementing insurance programs for modest-income children. The law provides no direct mandate regarding services to be covered beyond immunizations and well-baby, well-child care. Dental coverage is specifi- cally cited as one of 28 services that can be funded with SCHIP dollars. Although states are not required to provide dental coverage, congressional report lan- guage and presidential pronouncements are explicit in emphasizing the need for dental care (ADA 1998a,b). Prior to signing the bill in August 1998, President Clinton stated, “it is important that we have an adequate benefit package for children, recog- nizing that there are some problems that children have in a way that is more profound than adults, including problems with vision, with hearing and with dental health.” Upon signing the bill, he said, “Because we have acted, millions of children all across the country will be able to get medicine, and have their sight and hearing tested and see dentists and doctors for the first time.” Factors Affecting Oral Health over the Life Span States can elect to apply federal SCHIP funds to expand Medicaid or they may use one of four options to provide services under a separate SCHIP program: 1) develop a new state program based on benchmark coverage, which is state employee coverage; 2) pro- vide coverage under the SCHIP using benchmark- equivalent health coverage, which requires the use of an actuarial report to determine that coverage is at least equivalent to one of the benchmark plans; 3) apply existing comprehensive state-based coverage available in New York, Florida, and Pennsylvania, and +) seek Secretary-approved coverage. Only 2 (Delaware and Colorado) of 56 states and territories have not included substantial dental care for most children covered by SCHIP’ States implementing SCHIP have expanded access to dental care services through a variety of mechanisms. Expanding cover- age through Medicaid ensures that newly enrolled children are entitled to dental coverage, although these children face the same barriers as other Medicaid children, as discussed previously. Even with current levels of commercial dental insurance and improved access through Medicaid and the new SCHIP program, almost one quarter of children will remain without dental coverage. The Social and Professional Environment for Prevention Although science continues to reveal new opportuni- ties to prevent disease and promote health, sufficient understanding already exists to significantly reduce common oral diseases for all children. One of the most critical findings is that effective prevention requires an early start. The American Academy of Pediatric Dentistry (AAPD 1997), the American Dental Association (ADA 1997), and the Bright Futures health supervi- sion consensus project (Green 1994) all recommend that a toddler be seen by a dental professional at 12 months of age for an initial examination and risk assessment for common oral diseases and injuries. This first visit provides an opportunity for parents to learn about multiple oral health issues—dental caries, periodontal health, injury prevention, dental development, oral habits, common soft tissue sores, and bite development—as well as how to promote their child’s complete oral health (Nowak 1997). Despite professional guidance and a Healthy People 2000 goal that 90 percent of children be seen by a dentist before entering kindergarten, only 63 percent of children have a dental visit before starting school (USDHHS 1997). ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 255 Factors Affecting Oral Health over the Life Span Because growth and development is so pre- dictable, it can be anticipated and guided through education and carefully timed interventions. Applied to oral health, “anticipatory guidance” allows par- ents, children, and institutions to learn the stages of oral, facial, and dental development and how to care for the next stage of development (Nowak and Casamassimo 1995). Tables 10.2, 10.3, 10.4, and 10.5 provide examples of the risk and risk reduction methods related to periodontal diseases, dental caries, malocclusion, and injury, respectively (Casamassimo 1996). Physical, behavioral, socioen- vironmental, and disease and treatment-related fac- tors are addressed. Anticipatory guidance allows the parent, dental team, other health care providers, and institutions that care for the child to ensure a child's good oral health, avoiding preventable pitfalls and problems by knowing how a child’s mouth changes over time. For example, prevention of early child- hood caries requires guidance to tribute to the infant’s or toddler's general and oral health. Current investigations suggest that pathogen- ic exposures can be limited, children’s resistance to acquiring disease-causing bacteria can be enhanced, physical and chemical barriers to transmission can be erected, and early-stage disease can be reversed with medications. Importantly, there is no one-size- fits-all solution to disease prevention and suppres- sion. Most acquired dental and oral disease of child- hood is preventable. The challenge today is to bring the promise of prevention to the most vulnerable of our children and youth. Meeting the challenge will require enhancing programs such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Head Start, along with early child care, and community and school-based centers. Families have the capacity to support healthy oral health practices, as well as to support and caregivers before the child's teeth erupt to prevent or limit the trans- mission of microbial infections from mother to child and to pro- TABLE 10.2 Risk Factors Risk and protective factors for periodontal diseases Risk Reduction Methods mote appropriate feeding prac- tices even before the child has any teeth in place (Grindefjord et al. 1995, Kohler et al. 1984, 1988, Li Physical Examples and Caufield 1995, Tanzer 1995). ruber Similarly, anticipatory guidance Pregnancy for oral health extends to safe- Mouthbreathing guarding a house to prevent oral burns and injuries and to teach parents about the dangers of for- eign objects in the mouths of tod- dlers and preschoolers. Anticipat- ing a young persons interest in sports requiring mouth guards or head protection, discouraging smoking and smokeless tobacco before they are first used, and encouraging teens to adopt hy- giene practices that prevent peri- odontal disease initiation also are examples of guidelines that need to be addressed by all individuals and organizations responsible for the child. There is promise for further Lefevre syndrome} Behavioral Examples Inadequate oral hygiene Tobacco use Poverty Injury hypophosphatasia) treatment) Anatomical variations (e.g., frenum) Malpositioned and crowded teeth Genetic predisposition (e.g., Down or Papillon Socioenvironmental Examples Poor oral health and hygiene Disease- or Treatment-related Examples Nutritional deficiencies (e.g., vitamin C) Metabolic disease (e.., diabetes, Neoplastic disease (e.g., leukemia or its Infectious disease (e.g., HIV/AIDS) Surgical correction Orthodontic care Treatment of disease Preventive measures to address oral effects Preventive measures to address oral effects Management of mouthbeathing Preventive intervention to minimize effects Improved oral hygiene Tobacco cessation Access to care and improved oral hygiene Access to care Use of age-appropriate safety measures and treatment of injury Healthy eating habits Treatment of disease Treatment of disease and preventive intervention to minimize effects Treatment of disease and preventive intervention to minimize effects eradication of common childhood dental and oral infections. Edu- cation regarding oral infections in mothers and caregivers can con- 256 Medications (e.g., Dilantin) Poor-quality restorations Unrestored carious lesions Preventive intervention to minimize effects Restoration of carious lesions Properly contoured and finished restorations Source: Modified from Casamassimo 1996. ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL encourage behaviors conducive to health and well- being, no matter their income. Communities that recognize children’s oral health as an important pub- lic good can provide resources and ensure services, ranging from sealant programs, school education, and fluoridation programs to candy-free aisles in gro- cery stores and merchant campaigns to combat teen smoking and drinking. At the state and federal levels, however, the good intentions of legislation have fallen short of adequate implementation. Nevertheless, by linking the power of growth and development with health promotion activities, the nation has the potential to bring excel- lent oral health to all children. Health promotion covers a spectrum of efforts: anticipating problems, preventing them from occur- ring, and suppressing them when they first occur. These efforts can be targeted to individual children or entire communities of children, particularly children at high risk for dental and oral problems. Factors Affecting Oral Health over the Life Span Adolescents and Young Adults Data regarding oral health during adolescence and young adulthood are not abundant. However, most teenagers and young adults live healthy and active lives. Indeed, these years represent a peak period of biological fitness. This also is a time when individu- als are exposed to and begin behaviors that may place them at risk, such as tobacco and alcohol use and poor dietary practices. For 12- to 17-year-olds who use smokeless (spit) tobacco, for example, 34.9 per- cent of current snuff users and 19.6 percent of cur- rent chewing tobacco users had tobacco-related oral lesions (Tomar et al. 1997). (See Box 10.2 on the effects of tobacco on oral health.) Adolescents become more mobile, traveling independently in cars, motorcycles, and other vehicles, where the use of safety belts and helmets is needed. Sexual prac- tices begin during this time, further exposing indi- viduals to infections that predispose them to general and oral health problems. Ideally, TABLE 10.3 Risk and protective factors for dental caries Risk Factors Risk Reduction Methods the prevention of risk behaviors begins earlier in life, but this stage of life brings such a cascade of events that even the most informed and well-supported adolescent may Physical Examples Variations in tooth enamel; deep pits and fissures; anatomically susceptible areas Sealants (if possible) or observation find it difficult to adhere to prac- tices recommended by caregivers and institutions. Gastric reflux High mutans streptococci count Special health needs Previous caries experience History of baby bottle tooth decay Behavioral Examples Bottle used at night for sleep or “at will” while awake Frequent snacking Inadequate oral hygiene Eating disorders, including self-induced vomiting (bulimia) Socioenvironmental Examples Inadequate fluoride Poor oral health and hygiene Poverty High parental levels of bacteria (mutans streptococci) Diseases or Treatment-related Examples Special carbohydrate diet Frequent intake of sugared medications Reduced saliva flaw from medication or irradiation Orthodontic appliances Management of condition Reduction of mutans streptococci Preventive intervention to minimize effects Increased frequency of supervision visits Increased frequency of supervision visits Prevention of bottle habit and weaning from bottle by 12 months Reduction in snacking frequency Improved oral hygiene Referral for counseling Optimal systemic and/or topical fluoride Access to care and improved oral hygiene Access to care Good parental oral health and hygiene Preventive intervention to minimize effects Alternate medications or preventive intervention to minimize effects Saliva substitutes Good oral hygiene for appliances Source: Modified from Casamassimo 1996, This period of life also is marked by rapid change as individuals move from school to work to marriage and parenting, possibly relocating far from their birthplace. Many young persons who were fortunate to have health insurance lose their coverage after they leave college or are no longer “dependents.” Health status is largely determined by lifestyle behaviors and socioeconomic factors reflecting education, career, and income. About one third of 15-year- olds have experienced dental caries in their permanent teeth, and another 20 percent have untreated dental decay. Poor adolescents have higher disease rates and more untreated disease. Periodontal dis- eases, as defined by having 4 mm or more of attachment loss, are seen in about 3 percent of 18- to 24-year-olds, although it is in the ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 257 Factors Affecting Oral Health over the Life span Variations in development (e.g., tooth eruption delays and malpositioned teeth) Muscuiar imbalances Familial tendency for malocclusion Conditions associated with malocclusion (e.g., cleft lip/palate) Behavioral Examples Nonnutritive sucking habits Disease- or Treatment-related Examples Injury Acquired problem from systemic condition or its therapy Loss of space due to caries Musculoskeletal conditions (e.g., cerebral palsy) Skeletal growth disorders (e.g., renal disease) TABLE 10.4 Risk and protective factors for malocclusion Risk Factors Risk Reduction Methods Physical Examples Congenital absence of teeth Early intervention Mouthbreathing Management of mouthbreathing Early intervention Early therapy Early intervention Early intervention Elimination of habit Use of age-appropriate safety measures (e.g, car safety seats, safety belts, stair gates, mouth guards) and treatment of injury Dental intervention as a part of medical care Early intervention for caries Dental intervention as a part of medical care Dental intervention as a part of medical care Source: Modified from Casamassimo 1996. TABLE 10.5 Risk and protective factors for injury Risk Factors Risk Reduction Methods Physical Examples Lack of protective reflexes Poor coordination Protruding front teeth Behavioral Examples Failure to use safety measures appropriate for infant/child/adolescent (e.g., car safety seats, stair gates, mouth guards, safety belts) Participation in contact sports Socioenvironmental Examples Substance abuse in family Substance use by child or adolescent Child abuse or neglect Multiple family problems Disease- or Treatment-related Examples Overmedication Hyperactivity Referral for appropriate therapy Referral for appropriate therapy Orthodontic care Use of age-appropriate safety measures Use of protective gear Referral for counseling Referral for counseling Referral for counseling Referral for counseling Adjustment of medications Management of condition Source: Modified from Casamassime 1996. adolescent years that early-onset periodontitis is first diagnosed. Young non-Hispanic blacks have twice the proportion of periodon- tal disease than either white or Mexican Americans aged 30 to 49 years. Complete tooth loss is low in this age group, with only an estimated 0.4 percent of individu- als aged 18 to 34 years having no teeth (see Chapter 4). These years also mark the period of life when intentional and unintentional injuries take their greatest tell, Because many of these injuries affect the oral-facial region, they have special relevance to oral health. In particular, the example of oral-facial sports injuries illustrates the roles of behavior and socioeconomic envi- ronment as determinants of health, as well as pointing to several actions, such as use of protective head gear and mouth guards, that can serve as correctives. Midlife Adults Adults between 35 and 65 have been aptly called “the sandwich generation”—caring simultane- ously for aging parents and dependent children, while trying to maintain their own health, careers, and family structure. This population cohort is growing in numbers in parallel with the ever- increasing numbers of the elderly. Although many older Americans will be self-sufficient for the rest of their lives, about one third will require higher levels of care because of chronic or terminal illness. The demographic nature of these middle-aged adults is com- plex. In many families, both spouses work and have moved from their birthplaces. Many oth- ers have divorced, remarried, moved again, lost or changed jobs, and experienced a variety of midlife crises. Adding to the 258 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL BOX 10.2 The Effects of Tobacco on Oral Health The use of tobacco products—cigarettes, cigars, pipes, and smokeless (spit) tobacco products (snuff and chewing tobacco) —has emerged as 3 major preventable risk factor for a number of oral diseases and disorders. Oral and Pharyngeal Cancers Cigarettes. Tobacco smoke contains over 4,000 compounds, some of which are carcinogenic, toxic, or mutagenic (USDHHS 1989). An exten- sive review of the literature has clearly established a causal relationship between cigarette smoking and oral cancer (USDHHS 1982, 1989). Indeed, about 90 percent of oral cancer deaths are attributable to smoking (Shopland 1995, USDHHS 1989}, and smoking cessation can significantly reduce the risk (USDHHS 1999). : Smokeless (Spit) Tobacco. These products are causally linked to oral and pharyngeal cancers (IARC 1985, Nash 1986, USDHHS 1986). About 30 carcinogens have been found in spit tobacco, including tobacco-specif- ic N-nitrosamines, benzo[alphalpyrene, and formaldehyde (Hoffman and Djordjevic 1997). Spit tobacco users have an oral cancer risk 4 to 6 times that of nonusers (Blot et al. 1988, Winn et al. 1981). Characteristic mucosal lesions are associated with spit tobacco use (Axéll et al. 1976, Holmstrup and Pindborg 1988, Peacock et al. 1960, Pindborg and Renstrup 1963) and can be found even among adolescent users (Greer and Poulson 1983, Offenbacher and Weathers 1985, Poulson et al. 1984, Tomar et al. 1997b, Wolfe and Carlos 1987). They are considered poten- tially premalignant (USDHHS 1986). Cigars and Pipes. Cigar smoke contains the same toxic and carcinogenic compounds found in cigarette smoke (Hoffmann and Hoffmann 1998). Arecent review of case-control and cohort studies also shows a consis- tent elevation in risk for oral and pharyngeal cancers among cigar smokers, with cigar smokers having 2 to 22 times the risk of non-smok- ers of cigars (USDHHS 1998). The risk of oral and pharyngeal cancers increases with the number of cigars smoked per day and the depth of inhalation. Although data for pipe smoking and oral cancer risk are more limited than data for use of other forms of tobacco, relative risk estimates from longitudinal studies are similar for pipe smokers and cigarette smokers (USDHHS 1982, 1989). Periodontal Diseases Reviews of the literature have long implicated cigarette smoking as a risk factor for periodontal diseases. More recent studies such as Grossi et al. (1994, 1995) showed that smoking was a major risk factor for periodontal disease in a group of 1,500 adults. Measured either by radiographic bone height or probing attachment level, and after adjusting for age, sex, socioeconomic status, and plaque and calculus levels, the investigators found that smokers were 7 times more likely to develop periodontal disease than nonsmokers. They also found a direct linear dose-response relationship between the level of smoking, assessed by pack years (number of cigarettes smoked per day times years smoked), and destructive periodontitis. Smoking is also a prognostic indicator: current smokers are at a significantly greater risk for further loss of periodontal attachment than are nonsmokers, with an odds ratio of 5.4 (95 percent confidence interval of 1.5 to 19.5). Mechanisms explaining the association suggest that smoking depress- es immune responses (Holt 1987, Sasagawa et al. 1985), including diminishing white blood cell activity (Gala et al. 1984, Kenney et al. 1977). Toxic and vascular effects as well as effects on the subgingival flora are also suggested. In addition, smokers do not heal as well as nonsmokers after periodontal disease therapy and experience less reduction in levels of periodontal pathogens (Grossi et al. 1997). The negative effects of smoking can be reversed with cessation of tobacco use. After 10 years, former smokers appear to be no more likely than nonsmokers to have severe loss of periodontal attaghment (Tomar and Marcus 1998). Spit Tobacco. Reports indicate that oral tobacco use results in gingival recession at the usual site of snuff or chewing tobacco placement. Ina study of adolescent males, Offenbacher and Weathers (1985) found that 60 percent of users had gingival recession, compared with 14 per- cent of nonusers. Dental Caries The strongest evidence for an association of tobacco use and risk for dental caries relates to the use of chewing tobacco and increased risk for root caries. The causative factor relates to the sugar content of the product. Several popular brands of chewing tobacco have high levels of ~ fermentable sugars (between 30 and 60 percent by weight). In a cross- sectional study of older adults in North Carolina, chewing tobacco users had a higher number and percentage of root surfaces affected by caries than those who used other forms of tobacco or had never or formerly used tobacco (Tomar et al. 1997a). This finding was confirmed in an analysis of data from NHANES Ill (Tomar and Winn 1998). Trends in Tobacco Use In 1995, 47 million adults—25 percent of the U.S. adutt population— were smokers (CDC 1997). This figure represents a steady decline from the 52 percent of the population reported to be smokers in 1965, the year following the release of the first Surgeon General's Report on Tobacco (Giovino et al. 1995). The prevalence of smoking in women was 34 percent in 1965, 30 percent in 1979 (Giovino et al. 1994), and 23 per- cent in 1995 (CDC 1997). in contrast, cigarette smoking in adolescents has been increasing. Daily smoking among high school seniors increased from 17 percent in 1992 to 22 percent in 1996 (Johnston et al. 1997). High school students who reported smoking in the preceding month increased from 27.5 percent in 1991 (USDHHS 1994) to 36 percent in 1997 (CDC 1998}. Spit tobacco use has also increased. Sales of moist snuff—the most popular form of spit tobacco used by young people (Tomar et al. 1995)—have increased every year since the mid-1970s (FIC 1997, Maxwell 1992, USDA 1997). About 20 percent of male high school stu- dents reported using spit tobacco during the previous month (CDC (continues) ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL Factors Affecting Oral Health over the Life Span 259 Factors Affecting Oral Health over the Life Span 260 BOX 10.2 continued 1996, Johnston et al. 1997). About 6 percent of adult males use spit tobacco (CDC 1993). Nearly all regular users are male. Aggressive marketing has also led to explosive growth of sales and con- sumption of cigars. Between 1993 and 1997, cigar consumption increased nearly 50 percent (Gerlach et al. 1998).In 1997, 22 percent of high school students smoked at least one cigar in the preceding 30 days (CDC 1998). Implications of Trends For Oral and Pharyngeal Cancers. The increases in spit tobacco and cigar use among young people do not bode well for the oral and general - health of coming generations of Americans. Over the past 35 years the decline in the incidence and mortality rates of oral cancer has been attributable to dectines in cigarette smoking primarily in adult white males. Cigarette smoking among African American males over the same time period was higher. This practice contributed to the higher rates of oral cancer among black males during these years. However, recent studies indicate precipitous declines in smoking among black males, so that their smoking rates are approaching the rates seen in white males (USDHHS 1998). Indeed, figures on smoking among ado- lescent and younger African American adults have even been lower than those for their white counterparts. These trends could result in substantial reductions in the risk for oral cancer among African Americans, were they to continue. Unfortunately, there is recent evi- dence that cigarette smoking among African American high school stu- dents is increasing (CDC 1998). For Periodontal Diseases. The growing popularity of cigar smoking may counter the declines in cigarette smoking and maintain the percentage of periodontal disease attributable to tobacco use. References Axéll T, Mornstad H, Sundstrom B. The relation of the clinical picture to the histopathology of snuff dipper’s lesions in a Swedish popula- tion. J Oral Pathol 1976;5:229-36. Blot W!, McLaughlin JK, Winn DM, Austin DF, Greenberg RS, Preston- Martin S, Bernstein L, Schoenberg JB, Stemhagen A, Fraumeni JF Jr. Smoking and drinking in relation to oral and pharyngeal cancer. Cancer Res 1988;48:3282-7. Centers for Disease Control (CDC). Use of smokeless tobacco among adults—United States, 1991. MMWR Morb Mortal Wkly Rep 1993(a};42:263-6. Centers for Disease Control and Prevention (CDC). Tobacco use and sources of cigarettes among high school students—United States, 1995. MMWR Morb Mortal Wkly Rep 1996;45(20):413-8. Centers for Disease Control and Prevention (CDC). Cigarette smoking among adults—United States, 1995. MMWR Morb Mortal Wkly Rep 1997;46:1217-20. Centers for Disease Control and Prevention (CDQ). Tobacco use among high school students—United States, 1997. MMWR Morb Mortal Wkly Rep 1998;47:229-33. federal Trade Commission (FTC). 1997 smokeless tobacco report to Congress. Washington: Federal Trade Commission; 1997. Gala D, Kreilick RW, Hoss W, Matchett S. Nicotine-induced membrane perturbation of intact human granulocytes spin-labeled with 5- doxylstearic acid. Biochim Biophys Acta 1984;778:503-10. Gerlach KK, Cummings KM, Hyland A, Gilpin EA, Johnson MD, Pierce JP. Trends in cigar consumption and smoking prevalence. In: National Cancer Institute. Cigars: health effects and trends. Smoking and Tobacco Control Monograph 9. Bethesda (MD): U.S. Department of Health and Human Services, Public Health Service, National institutes of Health; 1998. p. 21-53. NIH Pub. no. 98-4302. Giovino GA, Schooley MW, Zhu BP. Chrismon JH, Tomar SL, Peddicord JP. Merritt RK, Husten CG, Eriksen MP.Surveillance for selected tobacco- use behaviors—United States, 1900-1994. MMWR Morb Mortal _ Wkly Rep 1994;43(SS-3):1-43. Giovino GA, Henningfield JE, Tomar SL, Escobedo LG, Slade J. Epidemiology of tobacco use and dependence. Epidemiol Rev 1995;17:48-65. Greer RO, Poulson TC. Oral tissue alterations associated with the use of smokeless tobacco by teen-agers. Part I. Clinical findings. Oral Surg 1983;56:275-84. Grossi SG, Zambon JJ, Ho AW, Koch G, Dunford RG, Machtei EE, Norderyd OM, Genco RJ. Assessment of risk for periodontal disease. |. Risk indicators for attachment loss. J Periodontol 1994;65:260-7. Grossi SG, Genco RJ, Machtei EE, Ho AW, Koch G, Dunford R, Zambon JJ, Hausmann EE, Assessment of risk for periodontal disease. II. Risk indicators for alveolar bone loss. J Periodontal 1995;66:23-9. Grossi SG, Zambon J, Machtei EE, Schifferle R, Andreana S, Genco RI, Cummins D, Harrap G. Effects of smoking and smoking cessation on healing after mechanical periodontal therapy. J Am Dent Assoc 1997;128:599-607. Hoffmann D, Djordjevic MV. Chemical composition and carcinogenicity of smokeless tobacco. Adv Dent Res 1997;11:322-9. Hoffmann D, Hoffmann |. Chemistry and toxicology. In: National Cancer Institute. Cigars: health effects and trends. Smoking and Tobacco Control Monograph 9. Bethesda (MD): U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health; 1998. p. 55-104. NIH Pub, no, 98-4302. Holmstrup P, Pindborg JJ. Oral mucosal lesions in smokeless tobacco users. CA Cancer J Clin 1988;38:134-41. Holt PG. Immune and inflammatory function in cigarette smokers. Thorax 1987;42:241-9. International Agency for Research on Cancer (IARC). Tobacco habits other than smoking; betel-quid and areca-nut chewing; and some related nitrosamines. IARC Working Group. Lyon, 1984 Oct 23-24. IARC Monogr Eval Carcinog Risk Chem Hum 1985 Sep;37:1-268. Johnston LD, Bachman JG, 0’Malley PM. Monitoring the future: ques- tionnaire responses from the nation’s high school seniors, 1995. Ann Arbor (MI): Survey Research Center, Institute for Social Research, University of Michigan; 1997. Kenney EB, Kraal JH, Saxe SR, Jones J. The effect of cigarette smoke on human oral polymorphonuclear leukocytes. J Periodont Res 1977;12:227-34. ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL Maxwell JC Jr. The Maxwell consumer report: the smokeless tobacco industry in 1991.Richmond (VA): Wheat, Butcher, and Singer; 1992. Nash DB. Health implications of smokeless tobacco: a National Institutes of Health Consensus Development Conference. Ann Intern Med 1986;104:436-7. Offenbacher S, Weathers DR. Effects of smokeless tobacco on the peri- odontal, mucosal and caries status of adolescent males. J Oral Pathol 1985;14:169-81. Peacock EE, Greenberg BC, Brawley BW. The effect of snuff and tobacco on the production of oral carcinoma: an experimental and epi- demiological study. Ann Surg 1960;151:542-50. Pindborg JJ, Renstrup G. Studies in oral leukoplakias. Il. Effect of snuff on oral epithelium. Acta Derm Venereol 1963;43:271-6. Poulson TC, Lindenmuth JE, Greer RO. A comparison of the use of smokeless tobacco in rural and urban teenagers. CA Cancer J Clin 1984;34:248-67. Sasagawa S, Suzuki K, Sakatani 7, Fujikura T. Effects of nicotine on the functions of human polymorphonuclear leukocytes in vitro. J Leuk Biol 1985;37:493-502. Shopland DR. Tobacco use and its contribution to early cancer mortali- ty with a special emphasis on cigarette smoking. Environ Health Perspect 1995; 103(Suppl 8):131-42. Tomar SL, Marcus SE. Cigarette smoking and periodontitis among U.S. adults. J Dent Res 1998;77(Spec No B):830 (abstract 1585]. Tomar SL, Winn DM. Coronal and root caries among U.S. adult users of chewing tobacco. J Dent Res 1998;77(Spec No A):256 [abstract 1205}. Tomar SL, Giovino GA, Eriksen MP. Smokeless tobacco brand preference and brand switching among US adolescents and young adults. Tob Control 1995;4(1):67-72. . Tomar SL, Weintraub JA, Gansky SA. Coronal and root caries among long-term users of chewing tobacco. J Dent Res 1997a;76(Spec No):372 [abstract 2872]. Tomar SL, Winn DM, Swango GA, Giovino GA, Kleinman DV. Oral mucos- al smokeless tobacco lesions among adolescents in the United States. J Dent Res 1997b;76(6):1277-86. U.S. Department of Agriculture (USDA). Tobacco situation and outlook report. TBS-239. Washington: U.S. Department of Agriculture, Commodity Economics Division, Economic Research Service; 1997. U.S. Department of Health and Human Services (USDHHS). The heaith consequences of smoking: cancer. Rockville (MO): U.S. Department demands of a spouse and children, the care of older parents contributes yet another strain to caregivers “in the middle.” These caregivers are predominantly female and may be dependent on their own income. They may be single and faced with dealing with their own “passages” (Sheehy 1984). The baby boomers will be the first U.S. genera- tion to age while maintaining their natural dentition. They are the first to benefit from the caries preventive effect of widespread community water fluoridation and fluoride dentifrices. As a result, the baby Factors Affecting Oral Health over the Life Span of Health and Human Services, Public Health Service, Office on Smoking and Health; 1982. DHHS Pub. no. PHS 82-50179. U.S. Department of Health and Human Services (USDHHS). The health consequences of using smokeless tobacco: a report of the Advisory Committee to the Surgeon General, 1986. Washington: U.S. Department of Health and Human Services, Public Health Service; 1986. NIH Pub. no, 86-2874. U.S. Department of Health and Human Services (USDHHS). Reducing the health consequences of smoking: 25 years of progress. A report of the Surgeon General. Rockville (MD): U.S. Department of Health -and Human Services, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1989. DHHS Pub.no. CDC 89-8411.” U.S. Department of Health and Human Services (USDHHS). The heaith benefits of smoking cessation: a report of the Surgeon General. Atlanta:U.S. Department of Health and Human Services, Centers for Disease Control, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1990. DHHS Pub. no. CDC 90-8416. U.S. Department of Health and Human Services (USDHHS). Preventing tobacco usé among young people: a report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1994. US. Department of Health and Human Services (USDHHS). Tobacco use among U.S. racial/ethnic minority groups: African Americans, American Indians and Alaskan Natives, Asian Americans and Pacific Islanders, and Hispanics. A report of the Surgeon General. Atlanta: J.5. Department of Heaith and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1998. Winn DM, Blot WJ, Shy CM, Pickle LW, Toledo A, Fraumeni JF. Snuff dip- ping and oral cancer among women in the southern United States. N Engl J Med 1981;304:745-9. Wolfe MD, Carlos JP. Oral health effects of smokeless tobacco use in Navajo Indian adolescents. Community Dent Oral Epidemiol 1987;15:230-5. boomers bring to the aging process higher expecta- tions about oral health throughout the lifecycle. Maintaining the family’s oral health may require as many individual solutions as there are sandwich generation members (Sanders 1997, Stern 1994, Warner 1995). Healthy lifestyle decisions combined with preventive measures at home will be as impor- tant as regular professional care. In addition to their own oral hygiene practices, a key component of maintaining the oral health of midlife Americans is the availability of dental bene- ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 261 Factors Affecting Oral Health over the Life Span fits. Six of 10 full-time employees are offered dental benefits by their employers, according to a survey by the U.S. Bureau of Labor Statistics (www. e-dental.com/Virtual Community for the Dental Industry, 12/30/99). These data are from a 1997 sur- vey of firms with 100 or more employees in private nonagricultural industries and are representative of benefits available to 46 million workers. The dental benefits, one of the less prevalent benefits for employees, vary by occupation group and are higher for professional and technical employees (64 per- cent) than for blue-collar or service employees (56 percent). Among the estimated 22.6 million employ- ees with employer-provided dental benefits, most employees (81 percent) receive their care from tradi- tional fee-for-service plans; 11 percent, from pre- ferred provider organizations; and 8 percent, from health maintenance organizations. Ensuring the oral health of the middle-aged gen- eration must take into account the shifting patterns of need and the family’s ability to cope, the education and training of health care workers about geriatric and family issues, general comprehensive communi- ty education programs about aging, estate and taxa- tion issues, housing, and social policies and pro- grams that support all individuals in their quest for self-sufficiency and individual responsibility. Older Americans Continued growth of the population 65 and older will have profound effects on health care in the twenty-first century (National Institute on Aging 1997). By 1994 the number of persons 65 and older had grown to 33.2 million and represented 13 percent of the population. Although the total US. population is expected to increase by 42 percent over the next half century, the number of men and women 65 and older will increase by 126 percent, those 85 and older by 316 percent, and centenarians by 956 percent—nearly 10 times the present number. The baby boom generation currently makes up almost one third of the U.S. population. By 2011, when these men and women reach 65, they will swell the ranks of older Americans and significantly bur- den health care programs and organizations respon- sive to the needs of older Americans (National Institute on Aging 1997). Although members of this generation can look forward to continued good oral and general health, the challenge will be in providing effective oral health care for those who are not in good health, especially the oldest old, and those with limited financial support. Oral Health Status Chapter 4 provides selected oral health data for older Americans as a whole. There is great heterogeneity in oral health status among older Americans. The extent and severity of oral conditions varies across subpop- ulations of this age group, and many have unmet treatment needs. Even so, older Americans are retain- _ing their teeth more than ever before and hence remain subject to oral diseases and disorders (Douglass et al. 1998). Indeed, with more teeth at risk, there will be an increase in coronal and espe- cially root caries among the elderly, as well as peri- odontal diseases and inadequate or absent prostheses (Burt 1992). Oral and pharyngeal cancers are prima- rily diagnosed in older Americans. For a closer look at the oral health of both insti- tutionalized and homebound elderly, Dolan and Atchison (1993) compiled data based on a compre- hensive review of the literature. Although the long- term care population is easily accessible in large groups, oral examinations for research purposes can be challenging. Patient consent and antibiotic pre- medication are issues, as well as the fact that conven- ience samples must be used because many patients are unable to cooperate. The authors’ summaries of oral health status and perceived needs based on the most comprehensive homebound and long-term care oral health surveys are shown in Tables 10.6 and 10.7, respectively. Table 10.6 describes eight studies, with 31 to 289 patients, with edentulous rates ranging from 23.8 to 62 percent. In these studies use of dental services within the past year ranged from 8 to 100 percent. In a 1994 Home Health and Hospice sur- vey, only 1 percent of patients reported having a dental visit during that year (Dey 1996). Forty- three to 83 percent of persons in six of the home- bound studies in Table 10.6 recognized that they had dental problems. In the long-term care studies listed in Table 10.7, 45 to 65 percent of those surveyed were completely without their natural teeth. One study found that 17 percent required immediate or emergency dental care. By any standards in the United States, a high degree of dental disease and dental care needs was recognized in all four studies presented. Daily oral care is an important and easily neg- lected service that should be offered to this popula- tion. Unlike many of the inevitable declines the frail elderly face with their various diagnoses, the decline in oral health can be stayed with good daily oral care. Nursing staff participation in the daily oral care of long-term care patients is crucial. Mouth care is often 262 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL considered an unpleasant task and is often delegated to nursing auxiliaries, who have even less oral health training than registered nursing staff. Seventy percent of patients in long-term care facilities had unaccept- able levels of oral hygiene (Kiyak et al. 1993, Mcintyre et al. 1986). Barriers to such needed care include lack of knowledge about oral care by the nursing staff, per- ceived lack of time for care, and lack of perceived need for daily oral care by both caregivers and patients. The resulting failure to provide daily oral Factors Affecting Oral Health over the Life Span care will often doom oral health that had been previ- ously well maintained. Data on the oral health status of hospice patients are scarce. Although not all hospice patients are eld- erly, data from the 1994 Home and Hospice Care Survey showed that 19.8 percent of those in hospice care wore dentures. The terminally ill often suffer from taste alterations, oral soreness, oral dryness, and oral candidiasis or thrush (Aldred et al. 1991). In most cases, the caregiver will perform daily oral care and palliative oral care measures. Palliative care can TABLE 10.6 Summary of published reports and abstracts on the oral health status and barriers to dental care for homebound elders of homebound persons in Kentucky Sample Sample Mean Dental Percentage Size Description Age (years) Utilization Edentulous Findings Steitel et ai. 1979 64 Two nonprofit Approx.75 25% visit in past Approx. 60% 60% reported dental needs, visiting nurse year dentate subjects more likely to services, Seattle seek care , Barrier: transportation Yellowitz et al. 1988 107 Recipients of visiting NA 34% visit in past NA >50% reported mouth [abstract] nurse services, Utah year discomfort, painful tongue, dry mouth, difficulty chewing Kaste et al. 1989 289 Homebound, >65 82.5 50% with no visit 62% 43% perceived dental need [abstract], Marcus et years, recipients of in 10 years Barriers: transportation, cast, al. 1989 [abstract] home care services, needed physical assistance Boston Aponte-Merced et al. 50 Recipients of home 79.0 8% visit in past 59% 37% had dental complaint; 1990 [abstract] health services, year 60% perceived dental need; county health 28% no visit in 84% wanted treatment departments, 20 years Alabama Strayer et al. 1990 67 Clients of urban NA Not reported 44% 80% perceived dental need [abstract], Strayer et social service Barriers: transportation, cost, al. 1997 [abstract] agency, 60% physical impairments homebound Yellowitz et al. 1991 123 Recipients, veterans 72.2 40% visit in past 33% 50% reported dental health {abstract} hospital-based home year fair/poor; 50-83% perceived cafe, Denver and dental need Minneapolis Barriers: 53% no perceived need; 25% had no dentist; 22% transportation; 22% cost Strayer and Ibrahim 34 Chart audit, patients 748 100% 23.8% 59.7% had 1991 treated at Ohio State periodontal/preventive/ University operative needs; Williams and Butters Statewide survey to 68.6 53.8% visit in NA 27.3% prosthodontic needs; 1992 identify the number past year 46.8% surgical needs; 2.7% of Kentucky households have a homebound resident Source: Dolan and Atchison 1993. Copyright 1993 by American Association of Dental Schools. Reprinted by permission of American Association of Dental Schools (2000). ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 263 Factors Affecting Oral Health over the Life Span include oral moisturizers such as artificial saliva, ice chips, a water atomizer, daily oral-cleaning or swab- bing, and, if needed, treatment for yeast to relieve oral pain. Americans have the potential to experience a life- time of oral health rather than a lifetime of oral restorative care. Each of the following questions can be applied to the major oral problems of the elderly, TABLE 10.7 Empy et al. 1983 California Dental Association (CDA) 1986 Veterans Administration (VA) 1989 Kiyak et al, 1993 Mean Age (years) Sample Description 242 residents of 12 skilled 81 nursing facilities; stratified random sample; Washington state 286 residents of a stratified 81 random sample of nursing homes , 634 residents of six VA 7] facilities: Florida, Illinois, Massachusetts; regional convenience sample 1,063 residents of 31 nursing homes in Washington state range 72 to 98 Dental Utilization mean time since last dental visit: 4,9 years 22% visit in past year Not reported Not reported Percentage Edentulous 65.3% 57% 50% 44.8% Summary of four published reports on the oral health status and barriers to dental care for nursing home residents Findings Needing denture treatment: urban, semirural, rural; 63, 46, 39%, respectively Mean number of decayed teeth: 1.8, 3.0, 2.4, respectively Mean number of periodontally involved teeth: 1.9,0.7, 1.1, respectively 80% who did not intend to visit dentist felt “no need” Median age of dentures: 15.5 years 17% had immediate dental needs Dentate residents: mean number teeth: 17 12.9% carious 7.0% fractured 49.6% periodontal disease 75.8% needed 1+ quadrants scaling Prosthodontic needs: 25% maxilla, 28% mandible Reasons for not seeking care: 52% felt no need; 24% transportation; 9% finances, 9% illness; 43% oral mucosal disease Dentate residents: 3.7 decayed coronal surfaces (DFS = 18.6) 4.8 decayed root surfaces (DFS = 6.5) Average periodontal attachment loss: 2.5 mm, 27% pockets >4 mm Prosthodontic needs: 35% maxilla, 28% mandible 40% denture-related oral lesions Dentate residents: oral problems: 72% poor oral hygiene 36% root caries 26% coronal caries 24% retained root tips 18% significant tooth mobility 11% swelling, soft tissue lesions 10% dry mouth Edentulous residents: oral problems: 46% loose dentures 18% sore ar bleeding gums 15% poor oral hygiene 10% dry mouth 5.4% soft tissue lesions 63.8% had dental treatment needs Source: Dolan and Atchison 1993. Copyright 1993 by American Association of Dental Schools. Reprinted by permission of American Association of Dental Schools (2000). 264 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL including coronal and root caries, periodontal dis- eases, oral cancer, oral-facial pain, tooth loss, salivary gland dysfunction, and oral mucosal diseases: e How do we best identify elders at greatest risk for oral diseases? Who is not at risk? How can we improve diagnostic accuracy? When is increased accuracy not related to improved outcomes? e Can these diseases be prevented or delayed? Which measures are most effective? Which have the greatest benefit for the least cost? e Once a person has the disease, which treat- ments are most effective? When measuring effectiveness, care should be taken to consider the proximal outcomes, that is, effects at the tissue level, as well as ultimate out- comes, that is, how the overall effects of the treat- ment affect a person's ability to function and be a pro- ductive, contributing member of society. An important consideration in treating oral health problems in the elderly is the relationship between oral and general health. Too often, oral health care is ignored or takes second place in light of the high prevalence of such chronic and life-threat- ening conditions as heart disease, stroke, cancer, osteoporosis, and diabetes. Yet the evidence present- ed in Chapter 5 speaks to associations linking oral infectious diseases such as periodontitis to the increased risk for cardiovascular, cerebrovascular, and lung disease, to exacerbations of diabetes, and as an early indicator of osteoporosis. In turn, to ignore oral health care in the course of cancer radiation and chemotherapy predisposes the patient to serious oral infections, mucositis, severe pain, bone loss, and potential abscesses. The 1988 Surgeon General's Workshop on Health Promotion and Aging stated that all health care providers should be educated in the importance of oral health to overall health and well-being (USDHHS 1988). Insurance Issues. In light of the oral care needs of the elderly and their vulnerability to systemic diseases, the lack of dental insurance poses a serious barrier (Jones et al. 1990, Niessen 1984). Medicare funds cover only a negligible and select amount of care. Many elders lose their dental insurance at retirement (Niessen 1984). The situation may be worse for older women. Because women overall have lower incomes than men, lack of insurance and high copayments for dental services may represent formidable obstacles to care. In addition, women assume a disproportionate burden as caregivers for family members of all ages: the young, the sick, and the elderly (Niessen 1984). This often disrupts employment and, consequently, insurance coverage. Factors Affecting Oral Health over the Life Span Thus, the majority of dental care rendered to older patients is paid for out of pocket. Medicaid pro- grams fund dental care for low-income and disabled adults, including elders, in some but not all states (ADA 1998b, Jones et al. 1990), but reimbursements are scant, even in emergency situations. Where there is reimbursement, it is often low and slow, adding yet another disincentive for provision of oral care. Medicaid funds the costs of the majority of patients in long-term care, which means that they either have spent their life earnings or were in poverty prior to admission. This lack of dental coverage is occurring at a time when more and more of the new elderly will be dentate and both want and need care (Ettinger and Beck 1982). Thus, funding dental care for elders is a major obstacle. Social Services. Decreased functional status and increasing levels of dependence add barriers to den- tal care for elders. It will be increasingly important for community and social service programs to respond to older residents’ needs for assistance, including transportation to meet their oral care needs. For example, programs administered by the Administration on Aging (AOA) that integrate oral health into general health programs for the elderly raise awareness about the benefits of good oral health and its contribution to nutritional status and quality — of life (National Policy and Resource Center 1998). For patients in long-term care settings, access to den- tal care is even more problematic. Lack of adequate compensation has been a barrier to increasing the number of dentists who choose to pursue this type of dental practice. Trends Despite advances in modern medicine that have greatly increased life expectancy in the twentieth century, there will be an increase in the number of persons with acute and chronic diseases, including arthritis, diabetes, osteoporosis, and senile dementia (U.S. Bureau of the Census 1998b). As always, it is necessary to distinguish between healthy elders who age normally and remain active and community dwelling and the frail elderly (Niessen and Jones 1991). Most community-dwelling elders take both pre- scription and over-the-counter drugs (Chrischilles et al. 1992). Approximately 30 percent of all medica- tions prescribed in the United States are for persons over the age of 65, with an average of 8.1 medications per patient in a long-term care facility (Gurwitz et al. 1990, Lamy 1989). Seventy-five to 94 percent of ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 265 Factors Affecting Oral Health over the Life Span patients taking medications are taking at least one drug that may have an oral side effect (Baker et al. 1991, Levy et al. 1988, Lewis et al. 1993). The most common of these side effects is dry mouth, or xeros- tomia. Others include abnormal homeostasis, soft tis- sue lesions or reactions, taste changes, altered host resistance, gingival overgrowth, burning oral sensa- tions, increased caries due to high sugar content, and involuntary oral movements. At any given time, approximately 5 percent of the population 65 and older live in a long-term care facil- ity, and an estimated 43 percent of these elders will require long-term care placement at some point in their lives (Murtaugh et al. 1990). As discussed earli- er, one result of elders’ increased disability and dependency is that middle-aged family members are confronted with increased parental care concerns and needs (U.S. Bureau of the Census 1990). Determining the oral health status of home- bound and hospice populations is challenging. Statistics are reported by evaluating persons who seek services for either home or hospice care. Obviously, this underrepresents both populations by leaving out those who refuse, are not aware of, or do not qualify for services. As with long-term care, most homebound are women, although the average age is younger than for those in long-term care facilities. This may represent a step in the continuum of care before long-term care is necessary. Fifty-five percent of women are hospice patients, and hospice patients are a much younger population than either the homebound or those in long-term care. Table 10.8 lists the 10 chronic conditions seen most frequently in the frail elderly. These health problems are important in relation to oral health because they, or their treatments, may worsen oral health or in turn be worsened in the presence of oral disease (see Chapter 5). Long-term: care residents have an average of 3.3 chronic conditions per person (Adams and Marano 1995). Although it is difficult to evaluate dementia patients following strict research protocol, several studies have noted high caries rates, poor oral hygiene, and a high percentage with unmet dental needs (Chapman and Shar 1991, Gordon 1988, Jones et al. 1993). Patients with dementia depend heavily on caregivers to provide daily oral care, and dental care can be most challenging. The Impact on Women Redford (1993) examined the effects of biological, behavioral, and societal factors on women’s oral and general health and treatment needs. Throughout their lives, American women report more acute symptoms, chronic conditions, and short- and long- term disabilities than men; women’s activities are limited by health problems 25 percent more days each year than men’s (Verbrugge 1984, 1990). The TABLE 10.8 Most common diagnoses of frail elderly (>65) in nursing homes, receiving home health (homebound) and hospice care by percentage of the population, 1994 to 1995 Rank Nursing Home Resident Homebound Hospice 1 Diseases of circulatory system Diseases of the circulatory system Neoplasms 2 Mental disorders Endocrine, nutritional, metabolic, Diseases of the circulatory system and immunity disorders 3 Diseases of nervous system and sense organs Diseases of musculoskeletal Diseases of the nervous system and and connective tissue systems sense organs 4 Injury and poisoning injury and poisoning Diseases of the respiratory system 5 Endocrine, nutritional, metabolic, and immunity Diseases of the respiratory system All other diagnoses disorders 6 Diseases of the respiratory system Neoplasms AIDS and infectious or parasitic diseases* 7 Diseases of the musculoskeletal and connective \\-defined conditions AIDS and infectious or parasitic diseases? tissue systems 8 Diseases of the digestive system Diseases of nervous system and sense organs 9 Diseases of the genitourinary system Disease of skin and subcutaneous tissue 10 Neoplasms Diseases of the digestive system a Rates of the two categories are equal. Sources: Data are from 1994 Home and Hospice Care Survey and 1995 National Nursing Home Survey (Dey 1996, 1997, Haupt 1997). 266 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL “gender gap” in physical disability widens with advancing age (U.S. Bureau of the Census 1990). Women in nursing homes or personal care facilities outnumber men three to one (NCHS 1991). In the course of aging, significant numbers of women experience compromised functional status, physical confinement, medical conditions, and cog- nitive impairments. The literature indicates that these factors have placed women's oral health at risk. At the same time, they may limit a woman's ability to maintain oral hygiene self-care regimens, seek professional dental services, tolerate dental treat- ment, and comply with postoperative instructions Factors Affecting Oral Health over the Life Span time during which employment and responsibility for caring for others play a critical role. Overlying the age spectrum are other sociodemographic factors that intensify the need to address each group and each health issue in a manner that optimizes health outcomes. In the overview of special populations presented in Chapter 4, the impact of race and ethnicity, socioeconomic status, and issues in relation to the health of women and individuals with disabil- ities clearly cut across all life stages. The nation’s social and welfare programs, the organization of our private systems of health care, and the values of the many cultures that make up America contribute to (Gift 1998). Pharmacologic regimens common among women can TABLE 10.9 promote xerostomla, thereby in- | summary: Healthy People 2010 objectives—oral health creasing the risk of caries, periodontal diseases, and atro- Objective Age(s) 2010 Baseline 2010 Goal phic/disease changes in oral 21.1 Reduce dental caries experience in children 24 18% 11% mucosa (Atkinson and Fox 6-8 52% 42% 1992). As a consequence of 15 61% 51% chemotherapy for breast cancer, 21.2 Reduce untreated dental decay in children and adults 2-4 16% 9% women may suffer inflammation 6-8 29% 21% and ulceration of the oral 15 20% 15% mucosa, oral infection, hemor- 35-44 27% 15% rhage, neurotoxicity, and salivary 21.3 Increase adults with teeth who have neverlast atooth 35-44 31% 42% Saran Ana (MeCartity 21.4 Reduce adults who have lost all their teeth 65-74 26% 20% an illings 1992, Nationa ge . , 21.5a Reduce gingivitis among adults 35-44 48% 41% Institutes of Health Consensus 5 : : ° Development Conference State- 21.5 Reduce periodontal disease among adults 35-44 22% 14% ment: Oral Implications of 21.6 Increase detection of Stage | oral cancer lesions all 35% 50% Cancer Therapies 1990). 21.7 Increase number of oral cancer examinations 40+ 9% 35% 21.8 Increase sealants in 8-year-old first molars 8 23% (a Ist) 50% ACHIEVING ORAL and in 14-year-old first and second molars 14 15% (a 1st&2nd) 50% : as . ‘ HEALTH THROU GHOUT 21.9 Increase persons on public water receiving fluoridated H,0 all 62% 75% LIFE 21.10 Increase utilization of oral health (OH) system 2+ 44% 56% Each life stage brings a unique set 21.11 _ Increase preventive dental services for poor children 2-17 20% 57% of issues and considerations. 31.12 _ Increase number of school-based Health Centers with K-12 developmental Ultimately, this overview identi- OH component unknown fies the need for research on 21.13 Increase number of Community Health Centers and all 56% 75% health services, health promo- local health departments with OH component tion, and disease prevention spe- 21.14 Increase utilization of dental service for those all 17% 25% oe to populations at different in long-term facilities, e.g., nursing homes ue “. and throughout the i 21.15 Increase states with system for recording all 23 51 span. ur nations young anw° and referring orofacial clefts exemplify the complexities of the re : . 71.16 Increase the number of states with all 0 51 individual, family, community, . tates . . state-based surveillance systems and institutional interactions that shape health and well-being. The 21.17 Increase the number of state and local dental all developmental middle years are not without programs with public health trained directors unknown complexities, but represent a aBased on self-report, National Health Interview Survey, 1996 (NCHS 1996). Source: USDHHS 2000. ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 267 Factors Affecting Oral Health over the Life Span the current status of health, including oral health, and are the basis for further improvements. The models described at the beginning of this chapter provide a structure for designing strategies to improve and promote health. Any one approach can be used as a framework for action. The Healthy People 2010 objectives provide a useful template for driving many age-specific and disease/condition-spe- cific outcomes. The multiple oral-health-related objectives outlined there emphasize the importance of risk behaviors and comorbidities that need to be addressed in order to further improve oral, dental, and craniofacial health (USDHHS 2000) (Table 10.9). Recurrent themes in this chapter and other parts of the report underscore the importance of access to health care and health care services, the adoption of healthy behaviors, and the role of individuals and all health care providers in contributing to oral health. Public policies, institutional care guidelines, and community programs can reinforce what individuals can do by providing a health-promoting environ- ment. Toward that end, a recently published report from the Center for Policy Alternatives (Warren 1999) examines and recommends health policies and related actions to improve the oral health status of the poor and underserved. Focus is placed on five dimensions of oral health—finance, sustainability of services, capacity to provide services, cultural com- petency of care providers, and infrastructure to sup- port professional practice. Policy recommendations and proposed action steps are presented in terms of the availability, accessibility, and acceptability of care. Dental care services are emphasized over other aspects of oral health maintenance, because much of the unmet need warrants dental services for preven- tion and treatment. Health care providers, program administrators, local, state, and government administrators, educa- tors, scientists, and leaders, among others, have pro- posed ways of promoting health and preventing dis- ease that respond to the principal health determi- nants presented in the chapter. Thus, efforts can be directed toward changing the environment to make it more life-enhancing; establishing new public health policies; enhancing health literacy to encourage healthy behaviors and lifestyles; working at the microlevel of neighborhoods and communities on health-related measures; and orienting health care to meet the needs of a changing society. Building on programs and structures already in place that have contributed to the improvements in oral health is essential. Further advances in the oral health of all Americans cannot be made unless the health needs of the underserved and vulnerable pop- ulations are addressed. The inability of federal and state programs that are the primary source of funding for services to these populations, specifically, Medicaid, SCHIP, and Medicare, to cover and ade- quately reimburse for dental services has been duly noted. The current review of access to dental care by the Government Accounting Office should add to an earlier review of EPSDT and further address barriers to access and other issues that warrant attention. The Institute of Medicine (IOM) study on the extension of Medicare services to include medically necessary dental services is an additional source of recommen- dations to better address the health needs of vulnera- ble populations and enhance health overall (Field et al. 1999). Other critical reviews of the problems entailed in addressing the nation’s oral health needs and proposing solutions include the 1989 Public Health Service Workshop on the Oral Health of Mothers and Children (USDHHS 1989). Recommendations covered the areas of public education, professional education, coalitions, advocacy and collaboration, health policy, and data collection, evaluation, and research. These recommendations formed the basis for the 2000 Surgeon General’s Workshop on Children and Oral Health. Similarly, the 1988 Surgeon General’s Workshop on Health Promotion and Aging (USDHHS 1988) provided guidance for steps to be taken to improve the oral health of the nation’s elders, all of which are still relevant. This workshop provided the impetus to add objectives on oral health status in nursing homes to Healthy People 1990. Ideally, organizations and agencies working together can resolve the issue of barriers to care. Concentrated efforts such as those focused on improving the access of children to Medicaid oral health services by the Health Care Financing Administration, Health Resources and Services Administration, American Dental Association, and National Center for Education in Maternal and Child Health are an example of how national organizations can unite to make a difference. Still, activities are needed at the local community level. The efforts of Milgrom and colleagues provide one such example for children eligible for Medicaid, with a focus on early childhood caries (Milgrom and Weinstein 1999, Milgrom et al. 1999). In implementing these efforts, however, the capacity of current national, state, and local programs as well as legislative mandates to meet the oral health needs of all Americans must be reviewed and strengthened, as necessary. 268 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL FINDINGS e The major factors that determine oral and general health and well-being are individual biology and genetics; the environment, including its physical and socioeconomic aspects; personal behaviors and lifestyle; access to care; and the organization of health care. These factors interact over the life span and determine the health of individuals, population groups, and communities—from neighborhoods to nations. e The burden of oral diseases and conditions is disproportionately borne by individuals with low socioeconomic status at each life stage and by those who are vulnerable because of poor general health. e Access to care makes a difference. A complex set of factors underlies access to care and includes the need to have an informed public and policymakers, integrated and culturally competent programs, and resources to pay and reimburse for the care. 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The century offers the promise of a new era for health wrought by the convergence of six cultural movements, any one of which would be sufficient to transform the human condition: e = The biological and biotechnology revolutions. e A redistribution of the worlds people by rapid and sizable migrations within countries and across borders. e Changing demographics in industrialized as well as developing nations. e Changing patterns of disease. ineluding the emergence and reemergence of infectious diseases, and changes in the organization of health care. e Instant worldwide communication through the Internet, cable, satellite, and wireless technology. e A continuing exponential rate of growth in information technology, specifically in computer speed, memory, and complexity. These global currents are changing the way we live now and will have profound implications for the future of the oral and general health and well-being of all people. THE PAST AND PRESENT AS PROLOGUE The Pioneers The history and intellectual activity of the eighteenth and nineteenth centuries set the seeds for the flower- ing of biology in the twentieth and early twenty-first centuries (Porter 1997). The scientific and techno- logical discoveries of the early anatomists and embry- ologists—the founders of cell theory and brain research—were followed by the brilliant innovations of Pasteur, Koch, and Ehrlich, who established the new fields of microbiology and immunology. The cumulative achievements of these pioneers set the foundation for the diagnostic and therapeutic science and art of dentistry, medicine, nursing, and pharma- cology in the twentieth century. The seeds were also sown for the convergence of chemistry, physics, and biology in the field of molec- ular biology, as well as the convergence of Darwinism, fruit fly genetics, and population genetics into the modern evolutionary synthesis. These convergences inspired the current quest to identify all 100,000 genes of the human genome and to assign functional meanings to the motifs that are encoded within them. Vital Statistics The growth of the world population and the transcontinental movements of people are proving a dominant force for change. The twentieth century began with increased European and Asian migrations to the United States. By 1900 the U.S. population had reached 90 million residents and the Earth’s popula- tion was approaching 1 billion people. Life expectan- cy in the United States was 47 years of age. Acute viral and bacterial infections were the primary caus- es of infant morbidity and mortality. Being edentu- lous, or “toothless,” was a normal expectation for mature adults. For most of recorded human history and the 100,000 years of human prehistory, life expectancy was very low. Life expectancy at the time of the Roman Empire was approximately 28 years of age. From the beginning of the first millennium A.D. to 1900, each year of history saw an average gain of 3 days in life expectancy. Each year since 1900, ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 275