PROGRESS REPORT FOR:
Oral Health
ON JULY 28, 1995, the U.S. Public Health Service (PHS) conducted a review of
progress on Healthy People 2000 objectives for Oral Health. The Director of the National
Institute of Dental Research (NIDR), National Institutes of Health (NIH) and the Director
of the Division of Oral Health, National Center for Preventive Services of the Centers for
Disease Control and Prevention (CDC) reviewed strategies and barriers toward achievement
of the year 2000 targets. They were joined for the review by invited guests from both the
public and private sectors.
Dr. Slavkin, the new NIDR director, began the review by commenting that comprehensive
care should include oral health. He suggested that new coalitions be built to align
education, social services, and health services with oral health care. Dr. Marianos of CDC
addressed initiatives to fluoridate community water supplies, prevent early childhood
caries, and ensure the safety of both patients and dental workers through adherence to
recommended infection control practices in the delivery system. Dr. Gift of NIH reviewed
the state of oral health in the Nation and focused on the socioeconomic risk factors that
pose challenges for achieving the year 2000 targets.
Objective 13.1 seeks to reduce dental caries. Between the 1986-87 baseline and the
1988-91 update, there has been modest change in the prevalence rates (54-52 percent) of
dental caries in children. Among adolescents aged 15, dental caries has decreased over
this same time period from 78 percent to 65 percent. Objective 13.2 seeks to reduce
untreated dental caries. Between the 1986-87 baseline and the 1988-91 update, there has
been an apparent increase from 28 percent to 31 percent of children aged 6-8 with
untreated dental caries. Special population groups_children whose parents have less than a
high school education, American Indian/Alaska Native and Hispanic children_had higher
rates of untreated dental caries, and that percentage increased over the past three years
since the baseline. The percentage of adolescents aged 15 with untreated dental decay has
remained at 24 percent.
Possibly the most effective strategy known to prevent dental caries is fluoridation. In
this 50th year of water fluoridation, 62 percent of the people served by community water
systems have optimally fluoridated water. Although new water systems have initiated
fluoridation, the proportion of people receiving optimally fluoridated water remains
virtually unchanged from the 1989 baseline of 61 percent. Low levels of fluoridation are
found in the western States, New Jersey, and New Hampshire.
Another strategy to prevent dental caries, particularly on permanent molars, is dental
sealants. Among children aged 8, the proportion having one or more dental sealants
increased from 11 percent to 21 percent between 1986-87 and 1988-91. Among adolescents
aged 14, the use of sealants increased from 8 to 28 percent over the same period. To reach
the year 2000 target of 50 percent of children and adolescents having dental sealants
requires continued efforts. One participant commented that oral health services,
particularly fluorides and sealants, need to be considered as core population-based
prevention services that address infectious and communicable diseases_"oral health
immunizations."
Since the publication of Healthy People 2000, increased attention has been given to the
prevention of early childhood caries, also known as baby bottle tooth decay. One risk
factor for this condition is bottle-feeding behavior. Baseline data from 1991 show that 55
percent of parents and caregivers of children aged 6-23 months reported using appropriate
feeding practices_namely not giving a bottle at bedtime or giving the baby only water in a
bottle at bedtime.
Objective 13.12 seeks to increase to at least 90 percent the proportion of children
entering school who have received an oral health screening. In 1986, 66 percent of
children aged 5 had visited the dentist in the past year, compared with 63 percent in
1991. This movement away from the year 2000 target is cause for concern about whether
children have sufficient access to preventive dental services. When lifetime prevalence of
dental visits is examined, it is not until the age of 7 that 90 percent of children have
ever visited the dentist. For black children, it is not until the age of 10; for uninsured
children, age 11; and for Hispanic children not until age 16 that 90 percent have ever had
a dental visit.
Objective 13.3 seeks to increase the proportion of people aged 35-44 who have never
lost a permanent tooth because of dental caries or periodontal disease. The 1985-86
baseline was 31 percent compared with the 1988-91 update of 32 percent. For objective
13.4, the proportion of people aged 65 and older who have lost all of their natural teeth
declined from 36 percent in 1986 to 30 percent in 1993.
The discussion turned to the need to maintain focus on oral health and be diligent in
encouraging and enhancing prevention at the individual, professional, and community
levels. While many of the indicators of oral health demonstrate progress, lack of access
to dental services, particularly for Medicaid-eligible children, is of concern. One study
showed that, on average, children were enrolled in Medicaid for 3 years but had only one
dental visit. A soon-to-be-released Office of the Inspector General report on the Medicaid
Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program found that only one in
five children were seen for dental screening services despite a program requirement that
children be screened annually and followed up for dental services. Inadequate
reimbursement, reluctance to treat Medicaid eligibles or young children, and cancelled
appointments were cited in the study as problems. In Washington State, the ABCD Project, a
partnership between the Spokane Dental Society, Spokane Health District, Medicaid program,
and the University of Washington, is training some 90 dentists to see young children under
age 3 and is training families on practicing good oral hygiene, keeping appointments, and
behaving appropriately in the dental office.
The Assistant Secretary for Health raised a concern about the poor oral health status
of American Indians. The Indian Health Service (IHS) staff responded that while there has
been an increase in fluoridation in Indian communities, the biggest challenge is
maintenance of systems_only 60 percent are functioning at an optimal level. While there
has been progress over the past 15 years, particularly in the proportion of school-aged
American Indian children who have dental sealants, there is still a gap with the total
population that needs to be closed. IHS is responding with a public health focus and
family-oriented services. Participants noted major concerns about the public health
infrastructure for oral health throughout the Nation. These include the lack of focus on
oral health in school health education and school health services; the distribution of
resources to train oral health care providers and to address oral health problems; and the
lack of incentives for employment in public health settings.
The discussion turned to the risks of spit (smokeless) tobacco. A representative from
Kaiser Permanente talked about a program to ensure that both medical and dental
practitioners deliver the same message to their young patients. A number of professional
and public education programs were mentioned. Other initiatives suggested included
increasing the tax on spit tobacco and restricting accessibility to the product by minors.
One participant compared the tax rates_2® cents on a can compared with 25 cents on a pack
of cigarettes_and estimated a half billion dollars in lost tax revenue a year. Higher
prices as a result of taxation have been shown to be a deterrent to tobacco use by
children and youth.
The discussion turned to the unmet needs of adults, including homebound and
institutionalized. Root caries among older adults is becoming more common as individuals
retain their teeth. More services could be provided by dental hygienists and expanded duty
dental assistants if State practice acts were altered. The progress review concluded with
a summary of action items for achieving Healthy People 2000 objectives. These include more
effective outreach to minority and low-income people_particularly through the Medicaid
program. As managed care increases in the Medicaid program, it will be important to ensure
coverage of dental services, sustain enrollment, and encourage the appropriate utilization
of services. PHS agencies should work with the Health Care Financing Administration to
address oral health care issues in the Medicaid program. Stronger links in preschool and
school health programs for oral health education and services should be created and
maintained. Within PHS, the emphasis on oral health should be sustained by strengthening
the professional base, by increasing training opportunities in public health dentistry,
enhancing appropriate skills among a variety of health care providers in prevention of
oral diseases, and providing policy guidelines, technical assistance, and resources for
States and communities to pursue population-based preventive services. Prevention programs
and tax policies on spit tobacco should be examined. Communication among States,
communities, and the private sector on successful models of preventive activities should
be enhanced. PHS should pursue national surveillance initiatives to ensure adequate
information about the oral health status of Americans and support State surveillance
activities. Linkages with the private sector must be sustained to ensure that the oral
health status of Americans continues to improve.
Back to Progress Review Page
