Preventing Cavities, Gum Disease, Tooth Loss, and Oral Cancers
At A Glance 2011
The Burden of Oral Disease
Oral health is often taken for granted, but it is an essential part of our everyday lives. Good oral health enhances our ability to speak, smile, smell, taste, touch, chew, swallow, and convey our feelings and emotions through facial expressions. However, oral diseases, which range from cavities to oral cancer, cause pain and disability for millions of Americans each year. For example,
Tooth decay (cavities) is a common, preventable problem for people of all ages. For children, untreated cavities can cause pain, dysfunction, school absences, difficulty concentrating, and poor appearance—problems that greatly affect a child's quality of life and ability to succeed. Children from lower-income families often do not receive timely treatment for tooth decay, and they are more likely to suffer from these problems.
Tooth decay is also a problem for many adults, and adults and children of some racial and ethnic groups experience more untreated decay.
- Periodontal (gum) disease is an infection caused by bacteria that gets under the gum tissue and begins to destroy the gums and bone. Teeth become loose, chewing becomes difficult, and teeth may have to be extracted. Gum disease also may be connected to damage elsewhere in the body; recent studies link oral infections with diabetes, heart disease, stroke, and premature, low-weight births. Further research is under way to examine these connections.
Most Oral Diseases Are Preventable
Many children and adults still go without simple measures that have been proven to be effective in preventing oral diseases and reducing dental care costs. An example is water fluoridation. Fluoride prevents tooth decay, and the most cost-effective way to deliver the benefits of fluoride to all residents of a community is through water fluoridation—that is, adjusting the fluoride in the public water supply to the appropriate level for decay prevention. However, only 27 states have met the Healthy People 2010 objective of having 75% of their citizens on public water systems with water fluoridation.
Fluoridation is cost effective. One CDC study found that in communities with more than 20,000 residents, every $1 invested in community water fluoridation yields about $38 in savings each year from fewer cavities treated.
Oral Health Problems Are Preventable, Common, and Painful
Tooth decay affects more than one-fourth of U.S. children aged 2–5 years and half of those aged 12–15 years. About half of all children and two-thirds of adolescents aged 12–19 years from lower-income families have had decay.
Children and adolescents of some racial and ethnic groups and those from lower-income families have more untreated tooth decay. For example, 40% of Mexican American children aged 6–8 years have untreated decay, compared with 25% of non-Hispanic whites. Among all adolescents aged 12–19 years, 20% currently have untreated decay.
Advanced gum disease affects 4%–12% of U.S. adults. Half of the cases of severe gum disease in the United States are the result of cigarette smoking. The prevalence of gum disease is three times higher among smokers than among people who have never smoked.
One-fourth of U.S. adults aged 65 or older have lost all of their teeth.
- More than 7,800 people, mostly older Americans, die from oral and pharyngeal cancers each year. This year, about 36,500 new cases of oral cancer will be diagnosed.
Another safe, effective way to prevent cavities is through the use of dental sealants—plastic coatings applied to the chewing surfaces of the back teeth, where most decay occurs. Yet only about one-third of children aged 6–19 years have sealants. Although children from lower-income families are almost twice as likely to have decay as those from higher-income families, they are only half as likely to have sealants.
Oral Health Problems Are Costly
Each year, Americans make about 500 million visits to dentists.
In 2010, an estimated $108 billion was spent on dental services in the United States.
CDC is the lead federal agency responsible for promoting oral health through public health interventions. Through its oral health activities, CDC
Helps states strengthen their oral health programs, reach people most affected by oral diseases, and expand the use of effective interventions to prevent oral diseases.
Promotes oral health in communities, schools, and health care settings nationwide.
Supports research to strengthen prevention efforts at the community level.
Evaluates the cost-effectiveness of prevention strategies.
Support for State-Based Programs
CDC provides 19 states with funds, technical assistance, and training to build strong oral health programs. This support helps states promote oral health, monitor oral health behaviors and problems, and conduct and evaluate prevention programs. CDC funding also allows states to enhance coordination and management of community water fluoridation programs and school-based dental sealant programs. CDC works with the Association of State and Territorial Dental Directors to guide states on oral health issues, improve state oral health program standards, and help states develop the expertise to assess oral health needs and conduct effective prevention programs.
Monitoring Oral Health in America
Routine surveys provide essential information about the oral health of Americans—for instance, which oral health problems are the most serious, how many people are receiving preventive services, which oral diseases are on the rise, and which groups of people are most at risk. This information can guide public health practice.
CDC supports Web-based systems that bring together oral health data from many sources and makes this information widely available to public health professionals and consumers. For example, the National Oral Health Surveillance System (http://www.cdc.gov/nohss) links data from various state-based systems, including state oral health surveys and the Behavioral Risk Factor Surveillance System. The State Dental Program Synopses (http://apps.nccd.cdc.gov/synopses/index.asp) present state population demographics and information about the activities and funding levels of state dental programs. CDC also manages the Data Resource Center (http://drc.hhs.gov), a joint project with the National Institute of Dental and Craniofacial Research, which assembles oral health data and other information needed to support research, policy development, and program evaluation.
In addition, CDC works to improve surveillance methods. Current measures of periodontal infections are extremely resource-intensive because they require clinical examinations. CDC is conducting research to develop self-report questions to measure periodontal disease status that can be easily included in state and local surveillance systems.
CDC helps state health departments collect, interpret, and share oral health data specific to their areas. States and communities use the data to monitor their progress in meeting Healthy People 2020 goals for oral health, target limited resources to people with the greatest needs, and compare their oral health problems with those of other states and the nation.
Providing Education and Sharing Expertise
CDC works to ensure that the public has the information needed to achieve optimal oral health throughout the lifespan. This information is shared directly or through public health professionals. CDC also provides national leadership in assessing the appropriate use of various forms of fluoride. CDC works with state and national partners to improve the quality of water fluoridation and to implement water fluoridation in more communities.
CDC provides fluoridation training to state drinking water system engineers, dental directors, and other public health staff members and manages a Web-based system that helps states monitor the quality of fluoridated water systems. Through the Web site and its partners, CDC educates people across the country on the appropriate use of fluoride products.
In addition, CDC convened expert work groups to review the state of the science supporting specific practices in school-based dental sealant programs and published updated guidelines for these programs in 2009. CDC published several studies that resulted from these efforts and is working with public and private partners to ensure that they understand the effectiveness and cost-effectiveness of these programs.
Supporting Prevention Science and New Approaches
CDC supports research designed to enhance the effectiveness of interventions to prevent oral diseases. In addition to recent research on the effectiveness of dental sealants, CDC has looked at fluoride use to see which interventions were successful at preventing and controlling tooth decay and how these interventions can be delivered most efficiently. CDC also conducts studies to assess the cost-effectiveness of water fluoridation and school-based dental sealant programs. CDC has developed computer software called the Sealant Efficiency Assessment for Locals and States (SEALS) that allows state and local programs to assess the benefit of providing sealants, including potential reductions in the cost of treating dental decay. CDC also supports demonstrations of new community approaches to promote adult oral health. These approaches include monitoring oral health status, expanding partnerships, supporting prevention research, and increasing public and professional awareness of common oral conditions, risk factors, and healthy behaviors. CDC has provided several grants to help states identify unmet oral health needs among older adults at high risk of oral diseases, as well as to identify community strategies to address these needs. Lessons learned from these projects are being shared with stakeholders involved in aging, public health, and dental public health activities.
Guiding Infection Control in Dentistry
Infection control in dental offices is essential to ensuring the public's safety and retaining its confidence. To help reduce the risk of transmitting infectious diseases in dental health care settings, CDC published the Guidelines for Infection Control in Dental Health-Care Settings—2003 (http://www.cdc.gov/mmwr). CDC recommendations guide infection control practices in dental offices nationally and globally; provide direction for the public, policy makers, and dental practitioners; and affect technology development in the dental industry. CDC also investigates possible disease transmission in dental offices and has provided guidance on emerging problems for clinicians, such as how to prevent the spread of H1N1 influenza.
Detecting Oral Cancer
Each year, more than 36,500 new cases of cancer of the mouth and throat (oral cavity and pharynx) are diagnosed, and more than 7,800 people die of these diseases. The 5-year survival rate for these cancers is only about 50%. Detection of cancer lesions in the early stages increases the survival rate for people with these cancers. CDC is exploring ways to improve data collection on oral cancers and their risk factors and is examining methods for identifying lesions at an earlier stage.
Expanding Access to Dental Sealants in Maine
Dental sealants are thin plastic coatings applied to the chewing surfaces of the back teeth, where most tooth decay in children occurs. They protect the chewing surfaces from decay by keeping bacteria and pieces of food out. A systematic review found that sealants provided in school-based programs can prevent up to 60% of tooth decay for 5 years. In Maine, 61% of third-grade students who were screened in a 2009 school survey had received dental sealants.
Providing high-quality, timely dental services can be challenging in Maine, particularly in rural areas where the distance between schools can be as much as 100 miles. In 2001, Washington County, the easternmost county on Maine's rocky coast, used a grant from the Maine Oral Health Program to expand its Washington County Children's Program (WCCP) to offer sealants to second-grade students at 17 schools. The program started with portable equipment that could be transported from school to school but was time-consuming to set up and break down. By 2003, the program was serving more than 800 students, and the concept of a mobile clinic was conceived. Funding from the Maine Health Access Foundation allowed the WCCP to buy and equip a truck—named the Tooth Ferry—to travel throughout the county.
Staffed by two dental hygienists, the Tooth Ferry brings Maine's dental sealant program to students at 28 schools in grades 2, 3, 7, and 8. During the 2008–2009 school year, the program served 2,219 students at 16 locations. Program staff also share information about other resources with school nurses and provide oral health education and preventive services to the county's Head Start center. Staff members identify children who need restorative dental care and make referrals to service providers in the community. In addition, staff members travel to Maine's blueberry fields during the summer to provide oral health services to migrant workers and their families.
The Maine Oral Health Program's ability to provide assistance to programs such as the WCCP was enhanced by CDC funding, which helps to support a state sealant coordinator.
Defending Water Fluoridation in New York
Community water fluoridation was named by CDC as one of 10 great public health achievements of the 20th century. It is an ideal preventive measure that has been shown to reduce tooth decay by about 25% in children and adults across the lifespan. Water fluoridation now reaches 72.4% of people served by community water systems. In New York State, 72.2% of people on community water systems receive optimally fluoridated drinking water.
The New York State Department of Health's Bureau of Dental Health, which receives CDC funding for preventive oral health programs, has been proactive in supporting community water fluoridation. This support includes training water plant operators and teaching community members how to address questions and challenges related to community water fluoridation.
The city of Plattsburgh has been fluoridating its drinking water since 1955. In 2008, CDC and the Clinton County Health Department (CCHD) gave the city an award for maintaining optimal fluoride levels. The positive media coverage attracted the attention of anti-fluoridation groups, which began lobbying the Plattsburgh City Council to discontinue fluoridation.
In January 2009, officials in the CCHD learned about these activities and recognized the need to educate the public about the benefits of fluoridated drinking water. They contacted the Bureau of Dental Health for relevant scientific studies on water fluoridation. The vice-president of the CCHD Board of Health was chosen to respond to opposition groups. Members of the New York State Oral Health Coalition also sent letters of support to the mayor, city council, and Board of Health.
In September 2009, the state water fluoridation specialist and a representative from the New York Rural Water Association (NYRWA) made a presentation on fluoridation to the CCHD Board of Health. The next day, NYRWA officials conducted an on-site visit to the Plattsburgh water system to answer technical questions from water plant personnel and make sure the fluoridation process was being properly implemented. CCHD staff members participated in the site visit, and in October 2009, they attended a state symposium on fluoridation.
CCHD staff members also developed a social marketing plan to educate county residents about the benefits of fluoridation. As part of this plan, a brochure promoting fluoridation was developed and distributed to community members by the county's Public Health Nursing Program, the Joint Council on Economic Opportunity, and the Special Supplemental Nutrition Program for Women, Infants, and Children. A presentation to educate community members also was developed.
During 2009, the county's directors of public health and environmental health, as well as local dentists, attended Plattsburgh City Council meetings to promote the benefits of water fluoridation. Opponents of fluoridation also provided information to city council members and the public. In November 2009, the Plattsburgh City Council voted 5 to 2 to continue fluoridating the city's drinking water.
Because of CDC support to the state Bureau of Dental Health, the state was well-positioned to help Plattsburgh address this challenge to community fluoridation and maintain the oral health benefits of fluoridation for its residents.
Promoting State Policies to Improve Access to Care in North Dakota
In North Dakota, statewide surveys have ranked dental care among the top three unmet health care needs for low-income residents. Access to oral health services is an ongoing concern for low-income, underserved, and uninsured populations in the state, as well as for members of some racial and ethnic groups. Public policies designed to increase access to oral health services can improve oral health for populations that experience health disparities in this area.
With CDC support, the Oral Health Program of the North Dakota Department of Health formed the North Dakota Oral Health Coalition, which brings together public, private, and grassroots organizations to improve the oral health of state residents. In November 2007, to identify future policy priorities, the coalition sponsored the North Dakota Children's Oral Health Conference. In 2008, the coalition set a policy agenda to support key legislation designed to increase access to dental care for underserved populations in North Dakota.
During the 2009 legislative session, the coalition's policy committee identified potential oral health champions, as well as sponsors and cosponsors in legislative committees where bills would be heard. The coalition also created an advocacy alert network and developed key messages that advocates could use when educating state policy makers on oral health issues.
Thanks to these efforts, five laws designed to improve access to dental care in North Dakota were enacted. Legislators increased Medicaid reimbursements for dental services, appropriated funds for mobile dental care services for low-income, underserved children, and set up a donated dental services program. They also set up a loan repayment program for dentists who practice in public health or nonprofit dental clinics and made it legal for dental hygienists to perform certain procedures in public health settings (e.g., schools) under general supervision.
These intensive advocacy efforts by a broad network of grassroots organizations and partners to educate state policy makers on policies that promote oral health are expected to make a major contribution to improving the oral health of disadvantaged residents of North Dakota.
Because these changes in state policy are new, it is too early to fully assess their effect. However, the increase in state reimbursements for dental services has already led to a 10% increase in the number of dentists in North Dakota who accept Medicaid. In addition, the law that allows dental hygienists to place dental sealants under general supervision will allow the Oral Health Program to implement a new school-based dental sealant program in 40 schools during the 2011–2012 school year.
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