Fluoridation

"In the 1990 Objectives, water fluoridation was the foundation for the prevention of dental disease," says Myron Allukian representing the American Association of Public Health Dentistry. "That should continue in the year 2000." There was widespread consensus on that issue among those testifying. Witnesses urge that the 1990 target of having 95 percent of the population on community water systems receive the benefits of fluoridation, be carried over to the Year 2000 Health Objectives, although many think it an unrealistic goal. (#435)

According to Allukian, 60 percent of the population served by community water supplies had fluoridated water in 1975; by 1985, this had increased to only 61.4 percent.³ (#435) John Brown of the University of Texas Health Science Center at San Antonio says that the promotion of water supply fluoridation is static: "Its benefits must be more effectively explained, so that those with this measure will defend it and those without it will acquire it." (#029)

The ASTDD calls for changes in a 1990 objective that at least 50 percent of school children living in fluoride-deficient areas without community water systems should be served by an optimally fluoridated school water supply. He says that no real progress has been made toward this goal and there is no real prospect of attaining it. The ASTDD recommends replacing this objective with one that includes alternative ways to receive fluoride, such as mouth rinses, tablets, or both. (#106) The importance of using fluoride dentifrice twice daily is also underscored. (#154)

Infants and Children

Many witnesses agree that a new objective aimed at preventing baby bottle tooth decay should be added; a public education campaign that alerts parents and other care givers to the problem could dramatically reduce its incidence. (#154; #242; #353; #445; #705)

Baby bottle tooth decay occurs when baby bottles filled with liquids containing natural or added sugars-such as milk, infant formula, fruit juice, or a soft drink—are used as pacifiers. When an infant who is awake takes in the liquid, the sugars are diluted with saliva and swallowed. However, if the infant falls asleep the sugars have time to react with bacteria and form acids that cause serious cavities. Discontinuing the use of liquids containing natural or added sugars in bedtime bottles would prevent this problem.

The national prevalence of baby bottle tooth decay is not known. In Head Start programs in San Antonio, 10-20 percent of preschoolers show the rampant form of this condition, according to Brown. (#029) David Johnsen of Case Western Reserve University estimates that 15 percent of urban and rural under-served children and over 50 percent of children in some Native American groups have the condition. He recommends that the prevalence be determined and high-risk groups identified. (#109)

Another new objective proposed by many witnesses involves the use of pit and fissure sealants to prevent dental caries in children. Sealants are a significant advance in caries prevention that were not addressed by the oral health objectives for the year 1990. Witnesses call for all children to have access to this procedure at public and private dental clinics. (#242; #353; #445) The eradication of caries in children is now a realistic goal, according to Stephen Moss of New York University, who notes that a survey of pediatric dentists' own children found that 90 percent of those less than 12 years old had no cavities. (#439)

The American Academy of Pediatric Dentistry emphasizes that sealants and two other proven preventive strategies—fluoride dentrifice and systemic fluoride—should be the focus of the Year 2000 Health Objectives on reduction of caries. Members of the academy and witnesses from other dental professional groups, as well as from the sugar industry, call for eliminating those of the 1990 objectives aimed at reducing the availability of cariogenic foods in schools. Those objectives are criticized for being untenable and unmeasurable, for failing to take into account uncertainties about which foods pose the most serious oral health threats, and for distracting attention from proven methods of reducing caries. (#154; #197)

Adults

For adults, witnesses focused on caries, periodontal disease, oral trauma, and oral cancers. Public education, personal dental hygiene, and regular dental care were identified as important prevention strategies for adults.

As the population ages, the number of adults with caries is increasing, according to Jane Weintraub of the University of Michigan, who explains that caries (not gum disease as was previously thought) are the major cause of tooth loss in adults.⁴ The 1990 Objectives set targets for caries reduction in only one age group: nine year olds. Weintraub and others recommend that targets be expanded to include other ages, even adults, and that specific types of caries be included in some objectives. (#391)

Much of the adult population has periodontal disease, according to Dan Middaugh of the University of Washington.⁵ To reduce the rates, new initiatives aimed at increasing public awareness of the importance of daily oral hygiene and regular professional care will be necessary, witnesses say. (#353) Although some testifiers note that the relationship between gingivitis and periodontal disease in adults is not clear (#029; #106), most witnesses favor continuing to include it in the objectives.

The American Cancer Society estimates that there are 30,600 new cases of oral cancer a year.⁶ As Woodrow Myers of the Indiana State Board of Health says:

Smokeless tobacco has been linked to cancer, specifically oral cancer. Use of oral snuff increases the risk of oral cancer several fold, and among long-term snuff dippers, the excess risk of cancers of the cheek and gum may reach fiftyfold. Smokeless tobacco use is responsible for the development of a portion of oral leukoplakias in both teenage and adult users. (#405)

According to Percy Butcher of the American Dental Association, reductions in tobacco and alcohol use are important preventive strategies for oral cancers. (#242) Several witnesses expressed concern about the use of smokeless tobacco, particularly among youth and young adults. The testimony in this area is summarized in Chapter 10. Although smokeless tobacco use is a separate topic, a few witnesses recommended that it be included under oral health to emphasize its link to oral disease.

Increased public awareness of the risk factors and symptoms of oral cancer is necessary to decrease the morbidity and mortality from it; early detection and treatment of oral cancer result in higher cure rates. (#249; #262)

Another condition recommended for the new objectives is oral trauma. Although a 1990 objective concerned the use of mouthguards, there is some feeling that it must to be strengthened. Other strategies mentioned for preventing oral traumas include the use of seat-belts. (#391)

Older Adults

Some of the most compelling testimony about adult oral health needs concerned the elderly. None of the 1990 Objectives addressed this group specifically, although the elderly are the fastest growing segment of the population in this country and have serious dental health needs, according to witnesses. The American Society for Geriatric Dentistry (ASGD) notes that as more elderly keep their natural teeth, caries are an increasing problem. Also, as the numbers of elderly increase, so will the need for dental service, witnesses point out. The at-risk elderly must be identified so that prevention programs aimed at reducing caries can be introduced, according to the ASGD. (#062)

Oral mucosa disease is another problem for the elderly with dentures, the ASGD says, and a goal for the year 2000 should be to reduce the prevalence of oral mucosal lesions in the aging population by 50 percent. (#062)

Special attention also must be given to the oral health of the institutionalized elderly. The ASGD notes that they have a far greater need for dental care than those who are not institutionalized. (#062) Testimony reveals that in many institutions, elderly residents are not offered regular dental care. A new Texas law requiring that nursing home residents be offered dental services (at their own expense) on a regular basis is hailed as a model. (#306) The ASGD suggests that oral health programs be mandatory at all nursing homes by the year 2000. (#062)

Underserved Populations: Problems and Strategies

The theme sounded most often in the testimony on oral health is the disparity in oral health among population subgroups. In addition to the elderly, other subgroups identified include Blacks, Native Americans, Hispanics, residents of some rural areas, migrant workers, the handicapped, the homeless, the institutionalized or homebound, and low-income people. Objective setting should reflect the special needs of these groups, according to witnesses.

Allukian says that children in inner-city Boston have 55 percent more surfaces affected by tooth decay than the national average and that Black children in the United States have 2.5 times as many untreated cavities as White children. He also reports that a study of the homeless in Boston, in which the median age was 33, found that 97 percent needed treatment; 18 percent had pain or infection at the time of screening; 9 percent had suspicious soft tissue lesions; and 28 percent had not been to a dentist for an average of 14 years. (#435)

Newman says that although Native Americans on reservations have dental coverage through the Indian Health Service, oral health care is not always available locally. As a result, many Native Americans suffer from poor oral health. She describes the needs in rural Washington State where she works.

The Indian Health Service in this area needs to refocus their attention on education, preventive therapies, and doing outreach to those Native Americans who are not receiving care. I see that a large number of Indian children are not receiving the oral health care that they need. I hear constant complaints of toothaches from school children. It is not uncommon to see rampant decay in these children. (#163)

The barriers to access faced by these groups typically involve the availability of providers, sociocultural issues, and cost. Brown describes the problem in San Antonio.

Effective oral disease prevention measures and oral health promotion activities are not reaching the community, especially those groups most at risk. Resources are disparate, often difficult to locate, duplicated, of poor quality in some instances and absent in others. Often ethnic, cultural, educational, and language diversity of communities is not sufficiently taken into account. Existing networks such as well baby clinics, WIC [Special Supplemental Food Program for Women, Infants and Children] programs, school systems, workplace health programs, health care facilities for the homeless, migrant health workers, community health centers, nutrition centers, retirement centers, and nursing homes need to be utilized to promote oral health and prevent oral disease by scientifically-based effective measures. (#029)

Implementation

The need for more and better data about oral health is intertwined throughout much of the testimony, especially as it relates to underserved populations. (#062; #106; #109) For example, Butcher states that because certain ethnic and socioeconomic groups have higher decayed, missing, or filled surfaces scores than the population as a whole, 'such groups should be over-sampled to reflect more precisely the degree of difference." (#242) The American Association of Public Health Dentistry emphasizes the need to develop baseline data for each objective, so that progress can be measured throughout the decade. "Later data collection," it states, "can more comprehensively describe other aspects or dimensions of the objective" but is ''no substitute for the understanding provided by baseline data.' (#156)

Witnesses pointed out that health professionals, including dentists, hygienists, and even physicians, could play an expanded role in delivering preventive services to underserved populations. Hygienists can be especially useful in reaching the elderly, according to Betty Waedemon of the American Dental Hygienists' Association. (#306)

Waedemon says that hygienists could provide important preventive services in nursing homes. Many nursing homes cannot afford to have a dentist on staff, and the residents' dental needs are neglected, according to witnesses. Waedemon says that hygienists would be less expensive than dentists; therefore, institutions may be able to afford to have one on staff full-or part-time. (#306)

More dentists also should be trained in geriatric dentistry, according to the ASGD, which explains that dentists should have an understanding of normal and pathological aging, communication skills, and other specialized areas to treat the elderly effectively. Very few programs in the United States offer such training; thus, specific targets in this area are proposed for the year 2000. (#062; #306)

Several dental hygienists mentioned their role in bringing preventive services to groups such as the handicapped or those living in remote areas where dental services are unavailable, but said that restrictions on their practice can limit those opportunities. States may restrict them to working under either direct or general supervision of a dentist. In Washington State, for example, hygienists can work under the general supervision of a dentist in institutions, but they must have direct supervision in homes or private practice, according to testimony. Hygienists such as Newman say that these restrictions should be relaxed. (#163)

Physicians and other health providers also can play an important role in encouraging good dental health and identifying oral cancers or other conditions, according to testimony. They should be prepared for that role and encouraged to become involved in oral disease prevention. (#154)

Mobile dental units can help bring preventive services to those who are hard to reach. The ASGD reports that mobile units operating out of dental schools can be effective in long-term care institutions if they are designed properly. (#062) Other witnesses note their value in remote areas and for populations that are unable or unlikely to come to a clinic. (#041)

Several testifiers note that one approach to providing preventive dental services to underserved children is expanding school-based programs. Brown proposes that by the year 2000, at least 50 percent of school children be participating in school-based comprehensive health programs. He says that these should include fluoride and dental sealant programs, assessments and referral systems, comprehensive oral health education, and mouthguard programs. (#029)

Financial barriers to obtaining preventive dental services also were discussed. Many witnesses said that Medicare and Medicaid, as well as private insurers, should cover comprehensive preventive dental services. Several witnesses called for including dental services in more employee benefit packages. Weintraub proposes that by the year 2000, 75 percent of employed adults have dental insurance. In 1985, 58 percent of the employed population was covered to some extent, according to testimony.⁷ (#391)

References

1.

National Center for Health Statistics: Health United States, 1989 (DHHS Publication No. [PHS] 90-1232), 1990.

2.

Opinion Research Corporation: Dental care: What people know. Surveying the 'knowledge gap". A study on attitudes about dental health conducted by Opinion Research Corporation, 1983.

3.

U.S. Department of Health and Human Services: The 1990 Health Objectives for the Nation: A Midcourse Review. Washington, D.C.: U.S. Government Printing Office, 1987.

4.

Balit HL, Btaun R, Maryniuk GH, et al.: Is periodontal disease the primary cause of tooth extraction in adults? J Am Dent Assoc 114:40-45, 1987. [PubMed: 3468166]

5.

Corbin SB, Kleinman DV, Lane JM: New opportunities for enhancing oral health: Moving toward the 1990 objectives for the nation. Public Health Rep 100(5):515-524, 1985. [PMC free article: PMC1425068] [PubMed: 3931166]

6.

Silverberg E, Lubera JA: Cancer statistics, 1989. CA Cancer J Clin 39(1):3-20, 1989. [PubMed: 2492874]

7.

National Institute for Dental Research: Oral Health of United States Adults. The National Survey of Oral Health in U.S. Employed Adults and Seniors: 1985-1986. National Findings. (NIH Publication No. 87-2868), August 1987.

Testifiers Cited in Chapter 26

029 Brown, John; University of Texas Health Science Center at San Antonio

041 Swanson, Terri; Colorado Dental Hygienists' Association

062 Ettinger, Ronald; American Society for Geriatric Dentistry

106 Isman, Robert; The Association of State and Territorial Dental Directors

109 Johnsen, David; Case Western Reserve University

154 Moss, Stephen; American Academy of Pediatric Dentistry

156 Easley, Michael; American Association of Public Health Dentistry

163 Newman, Cyndi; Clallam County Department of Health (Washington)

197 Setton, Sarah; The Sugar Association

242 Butcher, Percy; American Dental Association

249 Davis, A. Conan; Alabama Department of Public Health

262 Fleming, Lisa; Alabama Dental Hygienists' Association

306 Waedemon, Betty; American Dental Hygienists' Association

353 Middaugh, Dan; University of Washington

369 Truhe, Thomas; Princeton Dental Resource Center

391 Weintraub, Jane; University of Michigan

405 Myers, Jr., Woodrow; Indiana State Board of Health

435 Allukian Jr., Myron; Boston Department of Health and Hospitals

439 Moss, Stephen; New York University

445 Greenfield, William; New York University

705 Johnson, Dana; Colorado Dental Association