In the 17th session in the second series of assessments of
Healthy People 2010, Acting Assistant Secretary for Health Donald
Wright chaired a Progress Review on Oral Health. He was assisted by staff of
the co-lead agencies for this Healthy People 2010 focus area, the
Centers for Disease Control and Prevention (CDC), the National Institutes of
Health (NIH), the Health Resources and Services Administration (HRSA), and the
Indian Health Service (IHS). Also participating in the review were
representatives from other offices and agencies within the U.S. Department of
Health and Human Services (HHS) and from the U.S. Department of Justice Bureau
of Prisons. Dr. Wright noted that the great strides in improving the
Nations oral health over the past 50 years have been a major public
health success story. Most of the gains have resulted from application of
effective prevention and control measures. The most serious barrier to further
improvement is difficulty in accessing prevention and treatment services, a
burden that falls heaviest on residents in rural areas or inner cities, certain
racial and ethnic populations, children, older adults, and persons of lower
socioeconomic status.
The complete November 2000 text for the Oral Health focus area of
Healthy People 2010 is available online at www.healthypeople.gov/document/html/volume2/21oral.htm.
Revisions to the focus area chapter that were made after the January 2005
Midcourse Review are available at www.healthypeople.gov/data/midcourse/html/focusareas/fa21toc.htm.
Additional data used in the Progress Review for this focus areas
objectives and their detailed definitions can be accessed at wonder.cdc.gov/data2010.
For comparison with the current state of the focus area, the report on the
first-round Progress Review (held on March 17, 2004) is archived at www.healthypeople.gov/data/2010prog/focus21/2004fa21.htm.
The meeting agenda, tabulated data for all focus area objectives, charts, and
other materials used in the Progress Review can be found at a companion site
maintained by the CDC National Center for Health Statistics (NCHS): www.cdc.gov/nchs/about/otheract/hpdata2010/focusareas/fa21-oral2.htm.
Data Trends
In his overview of data for the focus area, Richard Klein of the
NCHS Health Promotion Statistics Branch noted that dental caries (tooth decay)
is the most common chronic disease in children. Despite increases in
insurance coverage, nearly three times as many children lacked dental insurance
as lacked medical insurance in both 1995 and 2003–04. Of the
objectives and subobjectives in the focus area that were continued after the
Midcourse Review of Healthy People 2010, 2 have met or exceeded their
targets, 6 are improving, 1 moved away from the target, 11 have shown little or
no progress, and 6 are without data for measuring progress. Mr. Klein
then examined in greater detail the 12 objectives and subobjectives in the
focus area that were highlighted in the Progress Review. These had to do
with the oral health of children and adults and with the dental health care
system and its use.
(Obj. 21-1c): Dental caries in children aged 15
years declined from a prevalence of 61 percent in the period 19881994 to
56 percent in 19992004. The 2010 target is 51 percent.
(Obj. 21-1b): The prevalence of dental caries in
primary or permanent teeth among children aged 6 to 8 years changed little
between 19881994, when it was 52 percent, and 19992004 (53
percent). Among Mexican American children in that age group, the prevalence in
19992004 was 69 percent. The target for all population groups is 42
percent.
(Obj. 21-1a): Among young children aged 2 to 4
years, the prevalence of dental caries in primary teeth increased from 18
percent in 19881994 to 24 percent in 19992004. By comparison with
older children, caries in preschool children increased significantly in the
past decade. This trend could portend a future increase in caries in older
children, as influenced by changes in diet or food consumption patterns. The
target is 11 percent.
(Obj. 21-9): In 2006, 69 percent of the U.S.
population was served by community water fluoridation, an increase from 62
percent in 1992. The target is 75 percent.
(Obj. 21-8a): Dental sealants provide a physical
barrier and effectively protect the pits and fissures on the biting surfaces of
teeth from dental decay. Application of dental sealants for children aged 8
years increased from a prevalence of 23 percent in 19981994 to 32 percent
in 19992004. Over that period, sealant application for children aged 8
years increased among all racial and ethnic groups for whom data were
available: from 29 percent to 38 percent among non Hispanic whites; from 11
percent to 23 percent among non-Hispanic blacks; and from 10 percent to 19
percent among Mexican Americans. The target for all population groups is 50
percent.
(Obj. 21-12): Among low-income youth aged 19
years and younger, provision of annual preventive dental services (i.e.,
examination, x-ray, fluoride treatment, cleaning, or sealant application)
increased from 25 percent in 1996 to 31 percent in 2004. The target is 66
percent.
(Obj. 21-10): The proportion of persons aged 2
years and older (age-adjusted) who had visited a dentist in the previous year
changed little between 1996 (44 percent) and 2004 (45 percent). Among racial
and ethnic groups for whom data were available, the proportions of persons in
that age group who made such visits in or just prior to 2004 were as follows:
non-Hispanic white, 50 percent; Asian/Pacific Islander, 44 percent; American
Indian/Alaska Native, 33 percent; non-Hispanic black, 30 percent; and Hispanic,
29 percent. The proportion of persons aged 25 years and older with at least
some college education who made such visits in or just prior to 2004 was 59
percent, a significantly higher proportion than for high school graduates in
that age category (41 percent) and for those in that age category who had not
completed high school (20 percent). The target for all population groups is 56
percent.
(Obj. 21-4): In the period 19992004, 24
percent of older adults aged 65 to 74 years had lost all their natural teeth,
compared with 29 percent in 19981994. Among racial and ethnic groups for
whom data were available, the proportions of older adults who had complete
tooth loss in 19992004 were as follows: non Hispanic black, 26 percent;
non-Hispanic white, 23 percent; and Mexican American, 18 percent. Among older
adults in the age group who had some college education, the proportion who had
complete tooth loss in 19992004 was 11 percent (surpassing the target),
compared with 43 percent of those in the age group who had not completed high
school. The target for all population groups is 22 percent.
(Obj. 21-5b): Among adults aged 35 to 44 years,
the proportion who had destructive periodontal disease (i.e., loss of
attachment = 4mm in one or more periodontal sites) decreased from 22 percent in
19981994 to 16 percent in 19992004. Significant reductions over
this period were recorded for all racial and ethnic groups surveyed. By gender
and by racial or ethnic group for which data were available, the proportions in
19992004 were as follows: female, 12 percent (surpassing the target);
male, 20 percent; non-Hispanic white, 14 percent; Mexican American, 16 percent;
and non-Hispanic black, 23 percent. The target for all population groups is 14
percent.
(Obj. 21-14): Local health departments and
community-based health centers serve groups that traditionally have limited
access to dental servicesfor example, minorities and persons with low
income. The proportion of local health departments and community-based health
centers that offered onsite oral health services increased from 52 percent in
1997 to 70 percent in 2006. The target is 75 percent.
(Obj. 21-17a): The number of State and local
dental programs that were directed by a dental professional with public health
training increased from 39 in 2003 to 51 in 2006, surpassing the target of 41.
Over the same period and at a roughly proportionate ratio, the number of State
and local dental programs serving a population of at least 250,000 increased
from 123 to 152.
(Obj. 21-17b): The number of IHS and Tribal
dental programs that were directed by a dental professional with public health
training increased from 9 in 2003 to 10 in 2006. The target is 9. Over the same
period and at a roughly proportionate ratio, the number of IHS and Tribal
dental programs serving a population of at least 30,000 increased from 32 to
34.
Key Challenges and Current Strategies
In presentations that followed the data overview, the principal
themes were introduced by William Maas, Director, Division of Oral Health, CDC
National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP);
Isabel Garcia, Deputy Director, NIH National Institute of Dental and
Craniofacial Research (NIDCR); Jay Anderson, Chief Dental Officer, HRSA Bureau
of Primary Health Care; and Patrick Blahut, Deputy Director, IHS Division of
Oral Health. Their statements and Progress Review briefing materials identified
a number of barriers to achieving the objectives, as well as activities under
way to meet these challenges, including the following:
Barriers
-
In general, decisionmakers and parents have low levels of
awareness that oral health is integral to general health and that most oral
disease can be prevented or controlled.
-
Dental care providers who will accept Medicaid fees are in
short supply because reimbursement fees are widely considered to be set at too
low a level. In addition, there is a paucity of providers who will treat very
young childrenan age group with a high incidence of decay.
-
Severe Early Childhood Caries is a destructive presentation of
dental decay that often involves multiple teeth, including front teeth. Left
untreated, this decay can cause pain and affect a childs ability to chew
and speak properly. Treatment for advanced cases involves general anesthesia in
the operating room, incurring both risk to the patient and high financial
cost.
-
The increase in the prevalence of dental caries among
preschool children may reflect unhealthy eating choices and reduced attention
on the part of child caregivers to good oral hygiene practices, including
optimal fluoride exposure through tooth-brushing and fluoridated water.
-
Nominal fluoridation of water supplies does not guarantee that
area consumers will receive the optimum benefits of this preventive practice.
For best results, water supply managers must ensure that the desirable
concentration of fluoride ions is consistently achieved week after
week.
-
Despite the proven benefits of water fluoridation, both for
adults as well as children, formidable barriers continue to impede more
widespread adoption of this public health practice, including lack of
sufficient personnel at the State level, costs, maintenance, public
misperceptions about safety, and political opposition.
-
Population-based surveillance of periodontal disease is
virtually nonexistent at the State and local levels, even though most public
health activities are designed to target State and local populations.
-
A 1999 survey documented in detail the great discrepancy in
oral health status between the U.S. population in general and Native Americans,
who continue to be in acute need of preventive, emergency, and restorative
dental health services. For example, 76 percent of Native American children
have had decay and 67 percent have active, untreated decay. Among Native
American children aged 2 to 5 years, IHS dentists found an average of six
decayed teeth surfaces per child, compared with a prevalence of approximately
one decayed survace among the general U.S. population of this age
group.
-
For reasons of salary levels, length of commitment, more
attractive employment opportunities elsewhere, and other factors, recruitment
and retention of dental health care professionals has become a continuing and
worsening problem for IHS. Currently, 32 percent of full-time dental positions
in IHS are vacant, an all-time high.
Activities and Outcomes
-
The combined oral health activities of the five HRSA Bureaus
provide safety-net dental services for the Nation.
-
The increase in the proportion of low-income children
receiving annual preventive dental services can be attributed in part to
favorable changes between 1996 and 2000 in the dental Medicaid program and the
State Childrens Health Insurance Program.
-
CDC/NCCDPHP is helping to develop public health law-related
educational information to support oral health partners and the legal community
in conducting analyses of public health legal principles and issues relating to
community water fluoridation.
-
IHS hospitals and clinics in 35 States offer dental services
to approximately 3 million Native Americans at no cost to the patients. The
number of federally recognized Tribes and the number of individuals enrolled in
those Tribes have grown rapidly in the past four decades. At present, IHS is
seeking a contractor in the private sector to create a model electronic dental
record, a development that should improve the comprehensiveness and efficiency
of data collection and analysis.
-
HRSA completed a pilot program in 2007 in which dentists were
trained to provide primary care interventions for children under 2 years of
age. Widespread adoption of such an approach to the provision of dental health
services would help to fill a gap in professional instruction, since schools of
dentistry have not, traditionally, provided their students training in dealing
with very young children, a group whose risk of developing dental caries has
increased in recent years.
-
Annually, NIH/NIDCR distributes about 130,000 copies of
publications to inform the public about the risk factors, signs, and symptoms
of oral cancer and the steps involved in an oral cancer examination. NIDCR is
now developing a new series of materials for distribution by community groups
around the country to raise African American mens awareness of their high
risk for the disease and the need for early detection.
-
In 2008, CDC/NCCDPHP, in partnership with the American Dental
Association, expects to release updated recommendations to inform the dental
profession of the science base supporting the effectiveness of sealants
delivered in the non-ideal conditions of school settings.
-
Recipients of IHS dental health care services have the highest
rates for dental sealant application in the world; the Agency places more than
a quarter million sealants each year. A survey of 8- and 14-year-old IHS
clients found that their average levels of such applications were 10 percent
higher than the targets set for the pertinent Healthy People 2010
objectives.
-
In 2001, NIH/NIDCR established five Centers for Research to
Reduce Oral Health Disparities. Each received a 7-year award. The centers
assembled multidisciplinary research teams and forged partnerships with State
and local health agencies and other organizations. One resulting center study
showed that only 14 percent of tooth decay in one particular impoverished urban
neighborhood could be explained by classical individual risk factors, strongly
suggesting that prevailing social, economic, and environmental factors must be
taken into account in programs to improve the oral health status of people with
low income. NIH/NIDCR recently recompeted the program, with plans for the next
generation of centers to test the effectiveness of interventions on a wider
scale.
-
To sustain and improve the ability to conduct surveillance of
periodontal disease at the State and local levels, CDC/NCCDPHP has developed a
promising nonclinical alternative for surveillance using self-report measures
to predict the prevalence of periodontal disease. This new approach will be
further tested in the 20092010 National Health and Nutrition Examination
Survey (NHANES). If successful, this approach can be adapted to available
interview-based surveillance systems.
-
NIH/NIDCR is supporting new technologies to measure subtle
changes in the mineral content of dental enamel that signal the earliest stages
of caries. One technology under development is a nondestructive imaging system
that records changes in the way that polarized light backscatters from enamel
in order to distinguish between normal and demineralized tissue.
-
The newly organized HRSA Bureau of Clinician Recruitment and
Service is the organizational home of the National Health Service Corps (NHSC),
in which approximately 475 dentists, whose professional training was supported
by the NHSC, are fulfilling their service obligation by providing oral health
services, mostly to low-income people living in clinically underserved areas of
the country.
-
Seven NIH Institutes are funding the largest long-term
epidemiologic study of health and disease in Hispanic populations living in the
United States. The Hispanic Community Health Study will run for over 6 years
and include as many as 16,000 participants. The study includes an oral health
component funded by NIH/NIDCR to estimate the prevalence of oral
diseases.
-
The HRSA Office of Rural Health Policy supports dental health
services for underserved populations in the most impoverished rural counties in
the United States. Selection of the recipients of grant funds from the office
is frequently influenced by an areas degree of disparity with respect to
Healthy People 2010 objectives.
-
CDC/NCCDPHP and NIH/NIDCR played a key role in the development
and release of A National Call to Action to Promote Oral Health, a
public-private partnership under the Office of the Surgeon General. The five
action areas called for are to 1) change perceptions of oral health, 2)
overcome barriers to care, 3) build the science base, 4) increase workforce
diversity, and 5) increase collaboration among public health agencies,
nongovernmental agencies, private practitioners, and others.
Approaches for Consideration
Participants in the Progress Review made the following suggestions
for public health professionals and policymakers to consider as steps to enable
further progress toward achievement of the objectives for Oral Health:
-
Endeavor to increase the oral health literacy of
decisionmakers and parents, specifically in connection with the need for early
intervention to prevent dental caries in young children. Enhance efforts to
increase the proportion of underrepresented racial and ethnic minorities in the
dental workforce who are compatible with the populations in highest need of
care.
-
To achieve greater integration of oral and general health
programs, promote more active collaboration among public agencies and private
health organizations, private practitioners, and other health disciplines.
-
Explore the possibility of adapting the less expensive
community version of NHANES for use in collecting data on oral health status on
Indian reservations. Intensify efforts to develop new or refined diagnostic
tools for detecting dental diseases in their early or precursor
stages.
-
Expand school-based sealant programs.
-
Develop measures for periodontal disease surveillance that
demand fewer resources and that can be integrated into State and local
surveys.
-
Make efforts to induce health professions schools to introduce
students to career opportunities offered by IHS and by the HRSA-supported
Community Health Centers.
Contacts for information about Healthy People
2010 focus area 21Oral Health:
-
Centers for Disease Control and Prevention, Gina
Thornton-Evans, gina.thorntonevans@cdc.hhs.gov
-
National Institutes of Health, Timothy
Iafolla, timothy.iafolla@nih.hhs.gov
-
Health Resources and Services Administration, Jay
Anderson, jay.anderson@hrsa.hhs.gov
-
Indian Health Service, Patrick Blahut,
patrick.blahut@ihs.hhs.gov
-
National Center for Health Statistics, Insun
Kim, insun.kim@cdc.hhs.gov
-
Office of Disease Prevention and Health Promotion
(coordinator of the Progress Reviews), Christopher Barrett,
christopher.barrett@hhs.gov
|
[Signed May 6, 2008] Donald Wright, M.D.,
M.P.H. Principal Deputy Assistant Secretary for Health
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