Prevent and control oral and craniofacial diseases,
conditions, and injuries and improve access to related services.
Oral health is an essential and integral component of health
throughout life. No one can be truly healthy unless he or she is free from the
burden of oral and craniofacial diseases and conditions.[1] Millions of people in the United
States experience dental caries, periodontal diseases, and cleft lip and cleft
palate, resulting in needless pain and suffering; difficulty in speaking,
chewing, and swallowing; increased costs of care; loss of self-esteem;
decreased economic productivity through lost work and school days; and, in
extreme cases, death.[2] Further, oral and pharyngeal
cancers, which primarily affect adults over age 55 years, result in significant
illnesses and disfigurement associated with treatment, substantial cost, and
more than 8,000 deaths annually.[3]
Poor oral health and untreated oral diseases and conditions
can have a significant impact on quality of life. Millions of people in the
United States are at high risk for oral health problems because of underlying
medical or handicapping conditions, ranging from very rare genetic diseases to
more common chronic diseases such as arthritis and diabetes.[4] Oral and facial pain affects a
substantial proportion of the general population.2, [5]
Dental caries is the single most common chronic disease of
childhood, occurring five to eight times as frequently as asthma, the second
most common chronic disease in children.1
Despite the reduction in cases of caries in recent years, more than half of all
children have caries by the second grade, and, by the time students finish high
school, about 80 percent have caries.[6] Unless arrested early, caries is irreversible.
Early childhood caries (ECC) affects the primary teeth of
infants and young children aged 1 to 6 years.[7] The exact cause of ECC is unknown,
but factors such as large family size, nutritional status of the mother and the
infant, and the transfer of infectious organisms from caregiver to infant are
under study.[8], [9] Infant feeding
practices in which children are put to bed with formula or other sweetened
drinks or sweetened pacifiers, especially if a child falls asleep while
feeding, have been associated with ECC.[10] Some professional associations
recommend that a child should first visit a dentist at age 1 year.[11]
Since the early 1970s, the cases of dental caries in permanent teeth have
declined dramatically among school-aged children.1
This decline is the result of various preventive regimens such as community
water fluoridation and increased use of toothpastes and rinses that contain
fluoride. Dental caries, however, remains a significant problem in some
populations, particularly certain racial and ethnic groups and poor children.[12] National data indicate that 80
percent of dental caries in the permanent teeth found in children is concentrated
in 25 percent of the child and adolescent population.[13] Increased use of dental sealants,
toothbrushing with fluoridated toothpaste, community water fluoridation, and
sound dietary practices are needed to reduce tooth decay.
Data from the third National Health and Nutrition
Examination Survey (NHANES III) indicated that 30 percent of all adults had
untreated dental decay; 85 percent had ever experienced dental caries. More
than 37 percent of dentate persons aged 65 years or older in the United States
had at least one decayed or filled root surface.[14]
If current trends continue, the baby boomer generation will lose fewer teeth as
they age but will have more teeth that are at risk for dental caries throughout
life.
Oral and pharyngeal cancers comprise a diversity of
malignant tumors that affect the oral cavity and pharynx; virtually all of
these tumors are squamous cell carcinomas. Some 31,000 new cases of oral and
pharyngeal cancers were expected to be diagnosed in 1999, and approximately
8,100 persons were expected to die from the disease.3
Oral and pharyngeal cancers occur more frequently than leukemia, Hodgkin’s
disease, and cancers of the brain, cervix, ovary, liver, pancreas, bone,
thyroid gland, testes, and stomach. Oral and pharyngeal cancers are the 7th
most common cancers found among white males (4th most common among black men)
and the 14th most common among U.S. women. The 5-year survival rate for oral
and pharyngeal cancers is only 53 percent,[15] and most of these cancers are diagnosed
at late stages.[16] Only 13 percent of U.S. adults aged
40 years or older reported having had an oral cancer examination in the past
year,[17] which is the recommended interval.[18]
Cleft lip and cleft palate are among the more common birth
defects in the United States. These congenital defects occur in about 1 per
1,000 live births.[19], [20] States should have an effective,
efficient mechanism in place for identifying, recording, and referring for
treatment infants with these conditions. Primary prevention of these
craniofacial anomalies involves minimizing exposure to known causes of
malformations and, where indicated, providing genetic counseling.
Oral diseases and conditions may have a significant impact
on general health; some poor general health conditions also may affect oral
health status. Chemotherapy for cancer may cause inflammation and infection of
oral mucous tissues. Head and neck radiotherapy and medications taken for many
chronic conditions can affect the salivary glands, resulting in decreases in or
loss of salivary flow, which, in turn, contribute to the ability to chew and
speak and to dental decay.1
Studies point to associations between periodontal diseases and low birth weight
and premature births,[21], [22], [23] as well as between periodontitis and
heart disease and stroke.[24], [25], [26] The initiation and progression of
periodontal infections are affected by systemic factors and habits,[27] including tobacco use, uncontrolled
diabetes, stress, and genetic factors.
For patients with special risks, invasive dental procedures
may result in infective endocarditis;[28]
infections of artificial knee, hip, and shoulder joints; and complications
associated with organ and bone marrow transplantation. Oral complications
associated with human immunodeficiency virus (HIV) infection also can have a significant
impact on overall health, resulting in loss of appetite, painful mouth sores,
weight loss, hospitalization, and potentially life-threatening fungal infections.1
Many persons in the United States do not receive essential
dental services.[29] Through increased access to
appropriate and timely care, individuals can enjoy improved oral health.
Barriers to care include cost; lack of dental insurance, public programs, or
providers from underserved racial and ethnic groups; and fear of dental visits.
Additionally, some people with limited oral health literacy may not be able to
find or understand information and services.
To promote oral health and prevent oral diseases, oral
health literacy among all groups is necessary. In addition, oral health
services—preventive and restorative—should be available, accessible, and
acceptable to all persons in the United States. In areas where different
languages, culture, and health care beliefs would otherwise be barriers to
care, a cadre of clinically and culturally competent providers must be
available to provide care.
Of the 16,926 undergraduate dental students enrolled in U.S.
dental schools in 1996–97, fewer than 1,000 were African American, and fewer
than 1,000 were Hispanic.[30] Native Americans continue to
constitute less than 1 percent of the total undergraduate dental enrollment.30
Strategic measures are needed to increase the number of individuals from
certain racial and ethnic groups who seek careers in dentistry and public
health, now and in the future. With the current health disparities and
projected demographic changes in the U.S. population, such measures are needed
for all aspects of oral health: education, research, health promotion, and
clinical services within the private and public sectors.
One subject of oral health interest, daily brushing with a
fluoride-containing toothpaste, is not addressed because data for tracking
progress will not be available during the first half of the decade (2000-2005).
Cases of dental caries in the permanent teeth of school-aged
children have been declining in the United States since the early 1970s.1
The proportion of untreated dental caries in permanent dentition of school-aged
children also has been declining overall but has increased in the primary
dentition among children aged 6 to 8 years.[31], [32] Fewer adults
are having teeth extracted because of dental decay or periodontal disease, and
the percentage of persons who have lost all of their natural teeth has been
declining steadily.1
The percentage of school-aged children with dental sealants
has risen in recent years as the public and private sectors increasingly use
the procedure, dental insurance pays for dental sealants, and parents request
sealants for their children.32
No increase, however, has occurred among children in low-income populations.
Community water fluoridation grew rapidly from its inception
in 1945 until about 1980; since then, the proportion of the U.S. population
living in communities with fluoridated water supplies has remained at 60 to 62
percent.[33] About 100 million persons still lack
the benefits of community water fluoridation.
Over the past 20 years, deaths from oral and pharyngeal
cancers have declined by about 25 percent, and new cases have declined by 10
percent, but the 5-year survival rate has remained unchanged. African American
men, however, have experienced increases in both death rates and new case
rates.15
Spending for dental services in the United States has risen
steadily but has remained fairly constant as a proportion of personal health
care spending—about 5 percent in 1997.1
Dental insurance coverage has not increased. Only 44 percent of persons in the
United States have some form of private dental insurance (most with limited
coverage and with high copayments), 9 percent have public dental insurance
(Medicaid and Children’s Health Insurance Program), 2 percent have other dental
insurance, and 45 percent have no dental insurance.[34]
As with general health, oral health status tends to vary in
the United States on the basis of sociodemographic factors. For example, the
level of untreated dental caries among African American children aged 6 to 8
years (36 percent) and Hispanic children (43 percent) is greater than for white
children (26 percent);6
as few as 3 percent of poor children have dental sealants compared to the
national average (23 percent).6
Further, the 5-year survival rate is lower for oral and pharyngeal cancers
among African Americans than whites (34 percent versus 56 percent);[16] adults with less than a high school
education (5 percent) and those with a high school education (10 percent) were
less likely than those with some college (19 percent) to have had an oral
cancer examination in the past year;17
adults with some college (15 percent) have 2 to 2.5 times less destructive periodontal
disease than those with high school (28 percent) and with less than high school
(35 percent) levels of education.6
Among persons aged 65 years and older, 39 percent of persons with less than a
high school education were edentulous (had lost all their natural teeth) in 1997,
compared with 13 percent of persons with at least some college.[35]
Promotion of oral health requires self-care and professional
care as well as population-based initiatives. Several national surveys show
that the proportion of the U.S. population that annually makes at least one
dental visit and the average number of visits made vary significantly by age,
race, dental status, level of education, and family income6, 35, [36] For example, the Medical Expenditure
Panel Survey in 199636
indicated that about 44 percent of the total population over age 2 visited a
dentist in the past year; 50 percent of non-Hispanic whites, 30 percent of
Hispanics, and 27 percent of non-Hispanic blacks had a visit while 55 percent
of those with some college and only 24 percent of those with less than a high
school education had a past-year visit. Approximately twice as many adults with
teeth had a dental visit compared to adults without teeth.35
An increased focus on oral health by Federal, State, and
professional organizations that occurred at the end of the 1990s should help
achieve improvements in oral health and quality of life for individuals and
communities. If initiatives, partnerships, and collaborations flourish in this
environment of heightened interest, then oral health literacy will increase,
access to preventive and restorative services for persons in need will improve,
surveillance of oral diseases or conditions will be enhanced, and appropriate
research will explore new ways to improve oral health for everyone in the
United States.
Recent legislation in three States requires the widespread
implementation of water fluoridation, which should lead to more communities
with optimally fluoridated water. By the end of the 20th century, dental caries
was limited in many children to pit and fissure tooth surfaces, for which
dental sealants are ideal. Opportunities to encourage the dental profession to
adopt and implement this preventive technology and for dental insurance
companies to pay for sealants must be promoted. Every opportunity must be taken
to educate the public about the value of sealants for children shortly after
their permanent molars erupt. Opportunities must be expanded to target certain
preventive procedures to poor, largely inner-city and rural children in
school-based or school-linked programs.
Reducing deaths from oral and pharyngeal cancers and
improving the early detection of both types of cancer require immediate
attention. Efforts must be made to continue the momentum begun in the 1990s
that focused on reducing the number of new cases of oral and pharyngeal cancers
and improving survival.[37], [38]
Specifically, dental personnel need to provide
comprehensive oral cancer examinations on a routine basis for persons aged 40
years and older or who are otherwise at high risk. Dental personnel also need
to provide counseling to patients to stop tobacco use and limit alcohol use,
both of which are associated with oral and pharyngeal cancers.
The 21st century may provide the opportunity to reduce the
burden of birth defects, such as cleft lip and cleft palate. As local and State
surveillance systems of developmental anomalies are created or expanded,
opportunities should be explored to integrate cleft lip and cleft palate into
those systems. If studies confirm the beneficial effects of folic acid in
preventing cleft lip and cleft palate, then programs incorporating the use of
folic acid should be implemented and monitored.
In general, access to primary preventive and early
intervention services must be improved, and barriers to the dental care system
should be removed. Many persons of all ages are receiving professional services
in the oral health care system, but more emphasis must be placed on vulnerable
populations who need professional care.
More than half the 17 Healthy People 2000 oral health
objectives show progress, and 1 was met. One objective has moved away from the
target, and two have shown mixed results. Data since baseline are not available
for four of the objectives. The objective of reducing deaths from oral and
pharyngeal cancers was met. Dental decay has declined in persons aged 15 years
nearly to its target, although less progress has occurred in children aged 6 to
8 years. Similar trends are apparent in those two age groups for untreated
dental decay. Elderly persons show improvement in edentulousness, but the
number of persons aged 35 to 44 years who had never lost a tooth from caries or
periodontal disease fails to show improvement. An increased proportion of
children are receiving dental sealants, but further improvement is needed.
Little change has occurred in the proportion of the U.S. population served by
fluoridated water systems.
Note: Unless
otherwise noted, data are from the Centers for Disease Control and Prevention, National Center for Health Statistics, Healthy People 2000
Review, 1998–99.
Oral Health
Goal: Prevent and control oral and craniofacial diseases,
conditions, and injuries and improve access to related services.
|
Number
|
Objective Short Title
|
|
21-1
|
Dental caries experience
|
|
21-2
|
Untreated dental decay
|
|
21-3
|
No permanent tooth loss
|
|
21-4
|
Complete tooth loss
|
|
21-5
|
Periodontal diseases
|
|
21-6
|
Early detection of oral and
pharyngeal cancers
|
|
21-7
|
Annual examinations for oral and
pharyngeal cancers
|
|
21-8
|
Dental sealants
|
|
21-9
|
Community water fluoridation
|
|
21-10
|
Use of oral health care system
|
|
21-11
|
Use of oral health care system by
residents in long-term care facilities
|
|
21-12
|
Dental services for low-income
children
|
|
21-13
|
School-based health centers with oral
health component
|
|
21-14
|
Health centers with oral health
service components
|
|
21-15
|
Referral for cleft lip or palate
|
|
21-16
|
Oral and craniofacial State-based
surveillance system
|
|
21-17
|
Tribal, State, and local dental
programs
|
21-1a. Reduce the proportion of young children
with dental caries experience in their primary teeth.
Target: 11 percent.
Baseline: 18
percent of children aged 2 to 4 years had dental caries experience in 1988–94.
Target setting
method: Better than the best.
Data sources:
National Health and Nutrition Examination Survey (NHANES), CDC, NCHS; Oral
Health Survey of Native Americans, 1999, IHS; California Oral Health Needs
Assessment of Children, Dental Health Foundation, 1993–94.
Throughout
childhood and adolescence, many opportunities exist for the primary prevention
of dental decay. The earliest opportunity to prevent dental decay occurs during
prenatal counseling about diet, oral hygiene practices, appropriate uses of
fluorides, and the transmission of bacteria from parents to children. Early
childhood caries, sometimes referred to as baby bottle tooth decay or nursing
caries, can be a devastating condition, often requiring thousands of dollars
and a hospital visit with general anesthesia for treatment.8, 9
The pain, psychological trauma, health risks, and costs associated with
restoration of these carious teeth for children affected by ECC can be
substantial.10
Dental care for pregnant females, counseling, reinforcement of health promoting
behaviors with caregivers of children, and intervention by dental and other
professionals to improve parenting practices (use of fluorides, use of
professional services, and diet) provide the best available means of preventing
this serious oral disease.
The
average number of decayed and filled teeth among 2- to 4-year-olds has remained
unchanged over the past 25 years.1
Children whose parents or caregivers have less than a high school education or
whose parents and caregivers are Hispanic, American Indians, or Alaska Natives
appear to be at markedly increased risk for developing ECC.4
21-1b. Reduce the proportion of children with
dental caries experience in their primary and permanent teeth.
Target: 42
percent.
Baseline: 52
percent of children aged 6 to 8 years had dental caries experience in 1988–94.
Target setting
method: Better than the best.
Data sources: National
Health and Nutrition Examination Survey (NHANES), CDC, NCHS; Oral Health Survey
of Native Americans, 1999, IHS; California Oral Health Needs Assessment of
Children, 1993–94, Dental Health Foundation; Hawai’i Children’s Oral Health
Assessment, 1999, State of Hawaii Department of Health.
Children
aged 6 to 8 years are at an important stage of dental development. They still
have the majority of their primary teeth, and their permanent first molars and
incisors are erupting into their mouths. Maintaining optimal oral health for
these children is important for their current functional oral health and for
their long-term health. Between the time the first permanent molars erupt into
the mouth and before vulnerable pits and fissures are infected, children should
be assessed for their need for dental sealants.
21-1c. Reduce the proportion of adolescents with
dental caries experience in their permanent teeth.
Target: 51
percent.
Baseline: 61
percent of adolescents aged 15 years had dental caries experience in 1988–94.
Target setting
method: Better than the best.
Data sources: National
Health and Nutrition Examination Survey(NHANES),
CDC, NCHS; Oral Health Survey of Native Americans, 1999, IHS; California Oral
Health Assessment of Children, 1993–94, Dental Health Foundation.
Caries
experience is cumulative, thus higher among adolescents than among young children.
Effective personal preventive measures—for example, tooth brushing with
fluoride toothpastes—need to be applied throughout adolescence, as children
become more independent in their oral hygiene and dietary habits. Regular
dental visits provide an opportunity to assess oral hygiene and dietary
practices and to place sealants on vulnerable permanent teeth that erupt during
this life stage (including second permanent molars at around age 12 years).
|
Children and
Adolescents,
Selected Ages, 1988–94 (unless noted)
|
Dental Caries Experience
|
|
21-1a.
Aged 2 to 4 Years
|
21-1b.
Aged 6 to 8 Years
|
21-1c.
Aged 15 Years
|
|
Percent
|
|
TOTAL
|
18
|
52
|
61
|
|
Race and ethnicity
|
|
American Indian or Alaska Native
|
76*
(1999)
|
90*
(1999)
|
89*
(1999)
|
|
Asian or Pacific Islander
|
DSU
|
DSU
|
DSU
|
|
Asian
|
34†
(1993–94)
|
90†
(1993–94)
|
DSU†
(1993–94)
|
|
Native
Hawaiian and other
Pacific Islander
|
DNC
|
79‡ (1999)
|
DNC
|
|
Black or African American
|
24
|
50
|
70
|
|
White
|
15
|
51
|
60
|
|
|
|
Hispanic or Latino
|
DSU
|
DSU
|
DSU
|
|
Mexican American
|
27
|
68
|
57
|
|
Not Hispanic or Latino
|
17
|
49
|
62
|
|
Black or African American
|
24
|
49
|
69
|
|
White
|
13
|
49
|
61
|
|
Gender
|
|
Female
|
19
|
54
|
63
|
|
Male
|
18
|
50
|
60
|
|
Education level (head of household)
|
|
Less than high school
|
29
|
65
|
59
|
|
High school graduate
|
18
|
52
|
63
|
|
At least some college
|
12
|
43
|
61
|
|
Disability status
|
|
Persons with disabilities
|
DNC
|
DNC
|
DNC
|
|
Persons without disabilities
|
DNC
|
DNC
|
DNC
|
|
Select populations
|
|
3rd grade students
|
NA
|
60
|
NA
|
DNA = Data have not been analyzed. DNC = Data are not
collected. DSU = Data are statistically unreliable. NA = Not applicable.
*Data are for IHS service areas.
†Data are
for California.
‡Data are for Hawaii.
Primary teeth should be
retained until they come out naturally and are replaced by the permanent teeth.
Healthy retained primary teeth enhance self-image; decayed or missing primary
teeth may cause a child to be self-conscious and reluctant to smile. Children
need to eat nutritious foods to develop normally. The pain and infection of
rampant dental disease compromise their ability to eat well. Moreover, early
tooth loss caused by dental decay can result in impaired speech development,
failure to thrive, absence from and inability to concentrate in school, and
reduced self-esteem.
Children aged 2 to 4 years
are least likely to have been seen by a dentist, whereas a much larger
proportion have been taken to a health provider for medical care or counseling.[39] Thus these latter providers should
be trained to examine and identify major oral diseases of toddlers and refer
those with problems for necessary care.
To avoid pain and discomfort, decayed primary teeth need to
be restored, particularly molars in children aged 6 to 8 years. Retention of
primary molars until they fall out normally (age 10 to 12 years) allows
adequate dental arch space for the eruption of succeeding permanent premolars
and avoids the tipping forward of first permanent molars, possibly creating
serious orthodontic problems. Carious permanent teeth should be repaired
promptly so that fillings may be kept small and as much natural tooth as
possible conserved. Often, fillings have to be replaced several times during
life; each time, additional tooth structure has to be removed, weakening the
tooth. Preventing the initial cavity by appropriate use of fluorides and
sealants is preferable to restoring the tooth after disease has occurred.
By age 15 years, all
permanent teeth other than third molars have erupted, and vulnerable chewing
surfaces of permanent second molars have been exposed to cariogenic factors for
2 or 3 years. Further, by this age, approximately 75 percent of adolescents
have experienced dental decay.6
Approximately 30 percent of
adults have untreated dental decay.6
Untreated dental decay can lead to extensive dental treatment and can be quite
costly. If decay is left unheeded, an individual can experience pain, abscess,
and extraction of the tooth.
Among adults aged 35 to 44
years, twice as many blacks or African Americans (46 percent) as whites (23
percent) have tooth decay. More than three times as many persons with less than
a high school education (51 percent) have untreated dental decay than adults
with some college education (16 percent).6
Dental decay is just as preventable in adults as it is in children. Access to
community water fluoridation benefits adults as well as children. Access to
other preventive interventions is critical, as well as access to dental
treatment to restore the tooth.
DNA = Data have not been analyzed. DNC = Data are not
collected. DSU = Data are statistically unreliable. NA = Not applicable.
*Data are for IHS service areas.
†Data are
for California.
‡Data are for Hawaii.
