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MAJOR FINDINGS
A FRAMEWORK FOR ACTION
CONCLUSION |
The major message of this Surgeon General’s report is that oral health is essential to the general health and well-being of all Americans and can be achieved by all Americans. However, not all Americans are achieving the same degree of oral health. In spite of the safe and effective means of maintaining oral health that have benefited the majority of Americans over the past half century, many among us still experience needless pain and suffering, complications that can devastate overall health and well-being, and financial and social costs that diminish the quality of life and burden American society.
To maintain the health and well-being of Americans already enjoying good oral health and to address the gaps in oral health status of others require actions at all levels of society, from individuals and neighborhoods to the nation as a whole. A coordinated effort can overcome the educational, environmental, social, health system, and financial barriers that have created vulnerable populations whose oral health is at risk.
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MAJOR FINDINGS
Following are the major findings of the report. They reflect the detailed findings highlighted at the end of each chapter as well as the broad themes presented in Chapter 1.
Oral diseases and disorders in and of themselves affect health and well-being throughout life. The burden of oral problems is extensive and may be particularly severe in vulnerable populations. It includes the common dental diseases and other oral infections such as cold sores and candidiasis that can occur at any stage of life, as well as birth defects in infancy and the chronic facial pain conditions and oral cancers seen in later years. Many of these conditions and their treatments may undermine self-image and self-esteem, discourage normal social interaction, cause other health problems, and lead to chronic stress and depression as well as incur great financial cost. They may also interfere with vital functions such as breathing, food selection, eating, swallowing, and speaking and with activities of daily living such as work, school, and family interactions.
Safe and effective measures exist to prevent the most common dental diseases—dental caries and periodontal diseases. Community water fluoridation is safe and effective in preventing dental caries in both children and adults. Water fluoridation benefits all residents served by community water supplies regardless of their social or economic status. Professional and individual measures, including the use of fluoride mouthrinses, gels, dentifrices, and dietary supplements and the application of dental sealants, are additional means of preventing dental caries. Gingivitis can be prevented by good personal oral hygiene practices, including brushing and flossing.
Lifestyle behaviors that affect general health such as tobacco use, excessive alcohol use, and poor dietary choices affect oral and craniofacial health as well. These individual behaviors are associated with increased risk for craniofacial birth defects, oral and pharyngeal cancers, periodontal disease, dental caries, and candidiasis, among other oral health problems. Opportunities exist to expand the oral disease prevention and health promotion knowledge and practices of the public through community programs and in health care settings. All health care providers can play a role in promoting healthy lifestyles by incorporating tobacco cessation programs, nutritional counseling, and other health promotion efforts into their practices.
There are profound and consequential oral health disparities within the U.S. population. Disparities for various oral conditions may relate to income, age, sex, race or ethnicity, or medical status. Although common dental diseases are preventable, not all members of society are informed about or able to avail themselves of appropriate oral-health-promoting measures. Similarly, not all health providers may be aware of the services needed to improve oral health. In addition, oral health care is not fully integrated into many care programs. Social, economic, and cultural factors and changing population demographics affect how health services are delivered and used, and how people care for themselves. Reducing disparities requires wide-ranging approaches that target populations at highest risk for specific oral diseases and involves improving access to existing care. One approach includes making dental insurance more available to Americans. Public coverage for dental care is minimal for adults, and programs for children have not reached the many eligible beneficiaries.
More information is needed to improve America’s oral health and eliminate health disparities. We do not have adequate data on health, disease, and health practices and care use for the U.S. population as a whole and its diverse segments, including racial and ethnic minorities, rural populations, individuals with disabilities, the homeless, immigrants, migrant workers, the very young, and the frail elderly. Nor are there sufficient data that explore health issues in relation to sex or sexual orientation. Data on state and local populations, essential for program planning and evaluation, are rare or unavailable and reflect the limited capacity of the U.S. health infrastructure for oral health. Health services research, which could provide much needed information on the cost, cost-effectiveness, and outcomes of treatment, is also sorely lacking. Finally, measurement of disease and health outcomes is needed. Although progress has been made in measuring oral-health-related quality of life, more needs to be done, and measures of oral health per se do not exist.
The mouth reflects general health and well-being. The mouth is a readily accessible and visible part of the body and provides health care providers and individuals with a window on their general health status. As the gateway of the body, the mouth senses and responds to the external world and at the same time reflects what is happening deep inside the body. The mouth may show signs of nutritional deficiencies and serve as an early warning system for diseases such as HIV infection and other immune system problems. The mouth can also show signs of general infection and stress. As the number of substances that can be reliably measured in saliva increases, it may well become the diagnostic fluid of choice, enabling the diagnosis of specific disease as well as the measurement of the concentration of a variety of drugs, hormones, and other molecules of interest. Cells and fluids in the mouth may also be used for genetic analysis to help uncover risks for disease and predict outcomes of medical treatments.
Oral diseases and conditions are associated with other health problems. Oral infections can be the source of systemic infections in people with weakened immune systems, and oral signs and symptoms often are part of a general health condition. Associations between chronic oral infections and other health problems, including diabetes, heart disease, and adverse pregnancy outcomes, have also been reported. Ongoing research may uncover mechanisms that strengthen the current findings and explain these relationships.
Scientific research is key to further reduction in the burden of diseases and disorders that affect the face, mouth, and teeth. The science base for dental diseases is broad and provides a strong foundation for further improvements in prevention; for other craniofacial and oral health conditions the base has not yet reached the same level of maturity. Scientific research has led to a variety of approaches to improve oral health through prevention, early diagnosis, and treatment. We are well positioned to take these prevention measures further by investigating how to develop more targeted and effective interventions and devising ways to enhance their appropriate adoption by the public and the health professions. The application of powerful new tools and techniques is important. Their employment in research in genetics and genomics, neuroscience, and cancer has allowed rapid progress in these fields. An intensified effort to understand the relationships between oral infections and their management, and other illnesses and conditions is warranted, along with the development of oral-based diagnostics. These developments hold great promise for the health of the American people.
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A FRAMEWORK FOR ACTION
All Americans can benefit from the development of a National Oral Health Plan to improve quality of life and eliminate health disparities by facilitating collaborations among individuals, health care providers, communities, and policymakers at all levels of society and by taking advantage of existing initiatives. Everyone has a role in improving and promoting oral health. Together we can work to broaden public understanding of the importance of oral health and its relevance to general health and well-being, and to ensure that existing and future preventive, diagnostic, and treatment measures for oral diseases and disorders are made available to all Americans. The following are the principal components of the plan:
Change perceptions regarding oral health and disease so that oral health becomes an accepted component of general health.
- Change public perceptions. Many people consider oral signs and symptoms to be less important than indications of general illness. As a result, they may avoid or postpone needed care, thus exacerbating the problem. If we are to increase the nation’s capacity to improve oral health and reduce health disparities, we need to enhance the public’s understanding of the meaning of oral health and the relationship of the mouth to the rest of the body. These messages should take into account the multiple languages and cultural traditions that characterize America’s diversity.
- Change policymakers’ perceptions. Informed policymakers at the local, state, and federal levels are critical in ensuring the inclusion of oral health services in health promotion and disease prevention programs, care delivery systems, and reimbursement schedules. Raising awareness of oral health among legislators and public officials at all levels of government is essential to creating effective public policy to improve America’s oral health. Every conceivable avenue should be used to inform policymakers—informally through their organizations and affiliations and formally through their governmental offices—if rational oral health policy is to be formulated and effective programs implemented.
- Change health providers’ perceptions. Too little time is devoted to oral health and disease topics in the education of nondental health professionals. Yet all care providers can and should contribute to enhancing oral health. This can be accomplished in several ways, such as including an oral examination as part of a general medical examination, advising patients in matters of tobacco cessation and diet, and referring patients to oral health practitioners for care prior to medical or surgical treatments that can damage oral tissues, such as cancer chemotherapy or radiation to the head and neck. Health care providers should be ready, willing, and able to work in collaboration to provide optimal health care for their patients. Having informed health care professionals will ensure that the public using the health care system will benefit from interdisciplinary services and comprehensive care. To prepare providers for such a role will involve, among other factors, curriculum changes and multidisciplinary training.
Accelerate the building of the science and evidence base and apply science effectively to improve oral health. Basic behavioral and biomedical research, clinical trials, and population-based research have been at the heart of scientific advances over the past decades. The nation’s continued investment in research is critical for the provision of new knowledge about oral and general health and disease for years to come and needs to be accelerated if further improvements are to be made. Equally important is the effective transfer of research findings to the public and health professions. However, the next steps are more complicated. The challenge is to understand complex diseases caused by the interaction of multiple genes with environmental and behavioral variables—a description that applies to most oral diseases and disorders—and translate research findings into health care practice and healthy lifestyles.
This report highlights many areas of research opportunities and needs in each chapter. At present, there is an overall need for behavioral and clinical research, clinical trials, health services research, and community-based demonstration research. Also, development of risk assessment procedures for individuals and communities and of diagnostic markers to indicate whether an individual is more or less susceptible to a given disease can provide the basis for formulating risk profiles and tailoring treatment and program options accordingly.
Vital to progress in this area is a better understanding of the etiology and distribution of disease. But as this report makes clear, epidemiologic and surveillance databases for oral health and disease, health services, utilization of care, and expenditures are limited or lacking at the national, state, and local levels. Such data are essential in conducting health services research, generating research hypotheses, planning and evaluating programs, and identifying emerging public health problems. Future data collection must address differences among the subpopulations making up racial and ethnic groups. More attention must also be paid to demographic variables such as age, sex, sexual orientation, and socioeconomic factors in determining health status. Clearly, the more detailed information that is available, the better can program planners establish priorities and targeted interventions.
Progress in elucidating the relationships between chronic oral inflammatory infections, such as periodontitis, and diabetes and glycemic control as well as other systemic conditions will require a similar intensified commitment to research. Rapid progress can also occur with efforts in the area of the natural repair and regeneration of oral tissues and organs. Improvements in oral health depend on multidisciplinary and interdisciplinary approaches to biomedical and behavioral research, including partnerships among researchers in the life and physical sciences, and on the ability of practitioners and the public to apply research findings effectively.
Build an effective health infrastructure that meets the oral health needs of all Americans and integrates oral health effectively into overall health. The public health capacity for addressing oral health is dilute and not integrated with other public health programs. Although the Healthy People 2010 objectives provide a blueprint for outcome measures, a national public health plan for oral health does not exist. Furthermore, local, state, and federal resources are limited in the personnel, equipment, and facilities available to support oral health programs. There is also a lack of available trained public health practitioners knowledgeable about oral health. As a result, existing disease prevention programs are not being implemented in many communities, creating gaps in prevention and care that affect the nation’s neediest populations. Indeed, cutbacks in many state budgets have reduced staffing of state and territorial dental programs and curtailed oral health promotion and disease prevention efforts. An enhanced public health infrastructure would facilitate the development of strengthened partnerships with private practitioners, other public programs, and voluntary groups.
There is a lack of racial and ethnic diversity in the oral health workforce. Efforts to recruit members of minority groups to positions in health education, research, and practice in numbers that at least match their representation in the general population not only would enrich the talent pool, but also might result in a more equitable geographic distribution of care providers. The effect of that change could well enhance access and utilization of oral health care by racial and ethnic minorities.
A closer look at trends in the workforce discloses a worrisome shortfall in the numbers of men and women choosing careers in oral health education and research. Government and private sector leaders are aware of the problem and are discussing ways to increase and diversify the talent pool, including easing the financial burden of professional education, but additional incentives may be necessary.
Remove known barriers between people and oral health services. This report presents data on access, utilization, financing, and reimbursement of oral health care; provides additional data on the extent of the barriers; and points to the need for public-private partnerships in seeking solutions. The data indicate that lack of dental insurance, private or public, is one of several impediments to obtaining oral health care and accounts in part for the generally poorer oral health of those who live at or near the poverty line, lack health insurance, or lose their insurance upon retirement. The level of reimbursement for services also has been reported to be a problem and a disincentive to the participation of providers in certain public programs. Professional organizations and government agencies are cognizant of these problems and are exploring solutions that merit evaluation. Particular concern has been expressed about the nation’s children, and initiatives such as the State Children’s Health Insurance Program, while not mandating coverage for oral health services, are a positive step. In addition, individuals whose health is physically, mentally, and emotionally compromised need comprehensive integrated care.
Use public-private partnerships to improve the oral health of those who still suffer disproportionately from oral diseases. The collective and complementary talents of public health agencies, private industry, social services organizations, educators, health care providers, researchers, the media, community leaders, voluntary health organizations and consumer groups, and concerned citizens are vital if America is not just to reduce, but to eliminate, health disparities. This report highlights variations in oral and general health within and across all population groups. Increased public-private partnerships are needed to educate the public, to educate health professionals, to conduct research, and to provide health care services and programs. These partnerships can build and strengthen cross-disciplinary, culturally competent, community-based, and community-wide efforts and demonstration programs to expand initiatives for health promotion and disease prevention. Examples of such efforts include programs to prevent tobacco use, promote better dietary choices, and encourage the use of protective gear to prevent sports injuries. In this way, partnerships uniting sports organizations, schools, the faith community, and other groups and leaders, working in concert with the health community, can contribute to improved oral and general health.
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CONCLUSION
The past half century has seen the meaning of oral health evolve from a narrow focus on teeth and gingiva to the recognition that the mouth is the center of vital tissues and functions that are critical to total health and well-being across the life span. The mouth as a mirror of health or disease, as a sentinel or early warning system, as an accessible model for the study of other tissues and organs, and as a potential source of pathology affecting other systems and organs has been described in earlier chapters and provides the impetus for extensive future research. Past discoveries have enabled Americans today to enjoy far better oral health than their forebears a century ago. But the evidence that not all Americans have achieved the same level of oral health and well-being stands as a major challenge, one that demands the best efforts of public and private agencies and individuals.
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