milestones in health care: chapter 9

8/14/2019 Milestones in Health Care: Chapter 9

1/23

MlkwlI),' Chapt,, ') (),1I H,.,1th L""k",..: 1I"k I ()7

Chapter 9Oral HealthLooking Back

The mouth is a mirror. reflecting the health of the restof the body. Assoc iations between the mouth and d iseaseselsewhere in the body - in the hear t and lungs , for exampl e - are well-documented. St ill , people don't always recognize oral health as a key measure of overall health. Despitenotable advances in reducing the prevalence of dentalcaries, or tooth decay, during tbe past century, the UnitedStates still has a long way to go to make good oral health,and the improved quality of life it promotes, a public healthpriority.Poor oral health remains a silent epidemic. Disadvantagedpopubtion s afe disproportion:ltely the victims of oraldisc:lses, resulting in great soclct:ll COsts. From missed hours

at sc hool and work. to periodo ntal di se ase that leads toprelll :ltlJ re low birth-weight b:lbics, to heart disease :lndstroke assoc iated with oral infections, the costs quicklymount. In 1994, low- income child ren had almost 12 tim esmore days of missed school du e to dental problems than


2/23

l6 g M,I"lnn" Chapl


3/23

,In the late 1800s ..a g rowing numberof schools ofdentistry werefounded in tbeUnited States andgraduates beganto predominatelt l the ranks ofpracticing dentists.

DiClioliary (if Del/lill Sri('lI(e, which saw five editions datingto 1898.In 1840, as co-founder of the Baltimore College of DentalSurgery with Hayden, H:trris became its first dean :md aprofessor of practical dentistry, then the school's secondpresident upon Hayden's death in 1844. The Baltimo re:College of Dental Surgery was latef to merge with theUniversity of Maryland School of Dcmistry in 1923.Between 1840 and 1867, nine morc :l . l1 tonomOl lS dentalschools were founded in the United States using th e13altimore model. In 1867, Harvard established the HarvardSchool of Dental Medicine in association with the Massachusetts General Hospital, becoming the first llniversityaffiliated dental schooL13 y 1870, only 15 percent of the 8,000 practicing dentis tsin the United States had gradua ted from demal schools; therest were trained Linder preceptor arrangements or simplyprocl:!imed themselves as dentists. Dental infections andco mplications from tooth extractions we re among the mostCOll l l l lon causes of death. Indeed , the Bills of Mortality listed dental infections and complications as leading causes ofdeath from the 1600s through rhe 1800s. [n the late1800s, til{' preceptor model of dental t raining shifted dramatically, as a growing number of schools of dentistry werefOllnded in the United States and as gr:ldu:ltes beg:ln topredominate in th e ranks of practicing dentists. In 1894,th e Universi ty of Michigan School of Dentistry bec:lmethe first dent:al school to ofTer gr:aduate courses in dentistry.By the mid- 1920s, less than three percen t of practiclllgdentists had tr:lined under preceptor arrangements. [nth e 19205, after the transforming Flexner R eport of 1910on medical education, the Carneg ie Foundation fundedDr. Will ilTll J. Gies of Columbia University to study existingdental schools, most of which were merely trlde scho olsllllaffiliat..::d with tmiversitics. [n 1926, Gies published wh:l[came to be known as the Gies R eport. Th e report ld vOC:ltcd for incoming dental students to have at least twO yearsof unive rsity education and for the teaclllng of tht, basicbiology of oral structure l nd the pathology of oral-f:1cialdisease. Widely adopted, the repon's rccomtllendltiOllsbeg:lll transforming Americ:lll dcnt:ll educJtion into anorll specialty of medicine. With the growi ng interest


4/23

in dental education, more university- based dental schoolsand newly formed dental soc ict ies took hold. Thcy continlied to operate separately from medical schools and mcdicalsocieties, however, and as a consequence, many health careprofessionals we re neve r fully educated on the impact oforal d iseases on overall health.The de nt al health profession co nsists of dentists ,dental hyg ienists, dental assistan ts and dental laboratorytechnicians. Nine dental specialties dental publichealth, endodontics, oral and maxillofacial surgery, oralpathology, orthodont ics, pediatric dentistry, periodontics,prosthodontics and radiology - arc joined by other oralhealth specialties within medicine. Endocrinologists dealwith sa livary glands, neurologists address the mouth'snervous sys tem, and orthopedic surgeons correct musculoskele ta l defects.. . Dramat ic improvements in oral health occurred oncedentist ry became a profession in 1839. For the next 100years, the United States led the world in research andinnovations and paved the way for preventive dent islrY.Although dental caries and periodo ntal diseases we re farmore prevalent a century ago, today the silent epidemic oftooth decay con tinucs unabated. T his is espec ially true inlow- income , inner-c ity :lIld rurll popubtions ln d amongdevelopmentally disabled people and other underservedgroups, such as the homeless, homebound and medicallycompromised. Preventive dentistry's Slccess story has yetto reach everyone who can benefit, and until it docs, poororal health remains a neglected epidem ic.The Beginnings of Oral Hea1thDen tal infections were a common cause of death in :lllcicntpeoples, often the result of cxtensive dc ntal caries. R ates ofdt:ntal caries correlated largely to diet. Diets heavy on meattcnded to lower caries rates, while diets rich in vegetablestended to increase them. In pre-Columbian Amer ica, forexample, pre-contact Zuni Indians had high vegetable dietsand a caries rate o f 75 percent. Pre -co ntact Eskim os, on theother hand, with a diet rich in meat, had the lowest rate ofdental carics - :lbout o ne percent. Once refined sugar wasintroduced to their diet, howcver, the c:lrics ratc amongEskimos soared.

,DramaticImprovementsin ora l healthoccur red oncedentistr y becamea professio n !111839.


5/23

Hesi-Re, rariieHJmuZI'II demisI.

Archeologists in Egypt discovered thaC lowcr-cbss peoplein ancient Egypt show a very low caries rate while royalty,with di('ts rich in carbohydrates, show an 80 percent cariesrate. In Egypt, ancient skulls have been found with smallholes drilled through the jawbone, thought to be a way toalleviate the pressure of abscesses, a secondary complicationof dental caries. The earltest known dentist, Hesi- R e, datesfrom the Zoscr dynasty in Egypt around 2600 Uc. In addition to ancient Egypt, wntten records of oral health carehave been handed down by ancienr civilizat iom in China,India , Mesopotamia, Greece and Rome and by more recentcivilizations in the Islamic Middle East and MedievalEurope and in Mexico and Central America. [ n anc ientMesopotamia, dentistry was part of medic ine, its histo rypreserved by the Sumerians as f.1r back as 2800 fiC th roughideograms, bter to be translated by Assyri:l11 :ll1d l3abylonian students and copied on clay tablets w ith cun eiformwriting. Th e Code of Halllrnurabi (1900 BC) shows that asfar back as 2500 BC the government regulated the medicalprofession, and with it. dentistry.

MiJestones in Dental InnovationsToo{/,[uus" csChewsticks, the first too thbrushes, were borrowed fromthe Chinese and Babylonians and first mentioned as aCOllllllon method for cleaning the teeth by the R omans.They are still common today in many parts of Africa andmany Islamic countries. In Islam, oral hygicne is part of [hc

-liwlllbmsil drill ill j\ 'f l l ' York City, /9/3.


6/23

religion, and the use of the chewstick, called the Miswak orSiwak, is a daily ritual. Any stick of fibrous material, Slll31lcrin diamete r than a pencil and abou t six inches long, willdo. One end is chewed umil the fibers sepa rate and theseare then used to clean the surfaces of teeth, one at a time.Early bristle roothbrushes, mvcmed by the Chinese, weremlde from the neck bristles of cold-climate pigs. [n modern times, nylon roothbrushes date only from 1938, whenD uPom introduced them. It was only after World War I[that tooth-brushing became a daily routine for mostAmericans, when returning soldiers kept up an enforcedmilitary discipline. In fact, the rejection rate of draftees

PlcJl!1er1jillillg rOOl/rpasrc ruves j " ri,e 18905.during World War II due to poor oral health had been sohigh that standards had been lowered to meet targets.7()()(f'jJaStl'The roOts of tOothpaste can be traced to ancient Chinaand Indil as far back as 500 BC. Toothpaste more simibrto what we know today beg:m to be developed in the18005. In 1824. Dr. Peabody added soap to toothpaste;and in the 1850s, D r. Harris added chalk. In 1873, Colgatebegan to mass-produce seemed toothpaste in a jar. In1892, Dr. Sheffield's Creme Dentifrice, the creation ofDr. WashingtOn Sheffield of Connec ticut, became the firsttoothpaste put into l collapsible tube. [n 1896, ColgateDental Cream became the first toothpaste packaged incollapsible tubes to become widely available, and it was

A dlf:ws/;c!.: cal/I'da M;swllk.


7/23

Alfred Eillhom

/)r. Charlrj C. Bass

no t until 1986 that the pump dispenser, introduced frolllEurope, began to compete with the collapsible tube.Colgate's research led the way to introducing fluoride totoothpaste, but Procter & Gamble and its Crest brand werefirst out of the gate with fluoride toothpaste in 1956. Fortoothpaste to be effective in preventing tooth decay, it musthave fluoride. Without fluoride, toothpaste can help preventgum disease but not tooth decay.NlolI'" RillsesAnother means for cleaning teeth, discovered by theP...omans, was the mOllth sponge. Long branches and vineswere collected, scorched to remove the bark and thenwoven illfo a tight ball. When a bite of thi s sponge waschewed, it released a foaming substance,:l1l astringent thatwas alte rnately rm sed and spit Qut dllring the 20 minutesthe chewing normally took.lVOI!/JwillC

In 1905. the chemist Alfred Einhorn researched easy-toLIse and safe anesthes ia for dental pro cedures. He refinedth e chemica l procaine until it was eITective and named itNovocaine. Th is synthetic loca l allesthetic h;lcl 1I0ne of theaddictive properties of cocaine, which had been introducedas an ophthalmologic ;lnesthetic in 1884 by Dr. Carl Koller,a co lleague of Sigmund Freud in Vienna, and as a blockingagem in o ral sllfgery by the Am erican surgeon, Dr. WilliamHalHcd.DelHal FlossDental floss has existed in one form or anoth er sinceancient times. The creato r of modern dental floss, a NewOrleans dentist named Levi Spear Parmly, was born in1790 and died in 1859. In 1815, he began to promoteflossing with a string of silk thread. It was no t until 1882that a co mpany in Randolph, Massachusetts, bt'gan tomanuf.1Ctlire unwaxed silk flo ss for home use. The Johnson& Johnson Company of New I3rullswick, New J ersey,paremed demal floss in 1898 and continues to be lhemajor manufacturer today. Dr. Charles C. l3ass developednylon floss during World War II and made flossing theimport:tm part of oral hygiene it is today.


8/23

/-ligh-Speed Dril/[n [957 , John Bo rden introduced a high -speed, air-driven,cont ra -a ngle hand piece for drilling teeth. Ca lled theAlroror and an immediate com mercial success, the drillobtained speeds of up to 300,000 rotations pe r minute andlaunched a new era of high-speed denti stry.

The Major O ra l D iseasesDClifal CariesT he three general types of tooth deC:ly arc coronal (o n thecrowns of teeth), root sur(1.ce (o n the roots of tee th) andrecurtent (reoccurring tooth decay). The elderly are especially vulnerable to root surface decay, bu t 84 perce nt of17 -year-old sc hool children have had tooth decay, with anaverage of eight affected surfaces; and 99 percent of adultsaged 40 to 44 have had tONh decay, w ith an average of 30affected surfaces .GII111 DiseasesGingivitis and periodontitis are th e two co mmoninfections of the so ft tissues (gum ) surrounding teeth.Gingiviti s, a localized infection o r inflammation of thesoft tissues character ized by swe lling and bleeding of thegums, disproportionatel y affects ce rtain pop ulatio ns,especially Native Amer icans and Alaskan Natives, MexicanAmericans and low- in come individu:t! s. Periodo ntit is, alsoan infection or inflammation of the so ft t issues, involvesthe supporting al veo lar bone around teeth wi th loss ofpe riodontal attachment. [ts prevalence increases with age,and it disproportio n:ttcly affects immunosuppressedindividu als, such as those with HIV / AIDS.Oral Cal/cerA se rious epidemic, oral and ph aryngeal cancers affectmorc tha n 30,000 Americans each ycar, and :tboU[ 7,800die annually. Men over 40 years of age :Ire most at riskdue co tobacco :lnd alcoho l use, which are associatedwith ove r 70 percent of ora l and phary nge :l l cancers.Oral cancer incidence may increase in [he fUUlre due tothe g rowing lise of smo keless tobaccos, especially amongteenagers. Of all cancers, oral and pl1:lryngeal cancers show

Corollalloolll dr(ay.


9/23

,Completetooth loss, oreden cui ism , wasonce much morewidely preval entthan it is today.

th e largest discrepancy in five-year surviva l rates betweenEUTo-Americans (56 percent) and Afr ican-A mericans (36percent).Olher Oral Diseases.. . Compl ete tooth loss, or cdcntulislll, was Orlce mu chmore widely prevalent th an it is today. Still , of those aged65 and older, 30 percent have no tee th at all. Crookedteeth, another widespread epidemic, cause seve re or ve rysevere malocclus ion in an estim ated 29 pe rce nt of adolescents. Finally. cle ft lip an d palate :l.ffect on e o ut of 700Americans born each year. [ I


10/23

Case StudyFluoridationThe link between fluoride and healthy teeth is the greatdiscovery and success story for better oral health in thepast 100 years. Community water fluoridation is one of thegreat preventive health measures in history. Wh o first linkedfluoride in drinking water with decreased de ntal caries, andhow was the discovery applied to the puhlic's hea lth?Fluoride, whether present in tap water, toothpaste and ofa lrinses or as a topical application administered by dentists ororal hygienists, has become an integral part of better oralhygiene for most Amer icans. Fluoride occurs naturally in alldrinking water, in greater or lesser concentrations accordingto geological feawres, and is odorless, colorless and tastelessat the recommended level.The fluoridation movcmclH can be traced to the earlyye:lfS of the 20th cc ntury, when dentists began to focus onIlatllf:llly fluor idated w:ttef for its prevcmivc :tction on dentalcaries, or tOoth dec:ty. The most f.1mous ex:tmple was n:lmedthe Colorado Urown Stain phenomenon by its discoverer,Frederick S. McKay, a young dentist wh o established hispr:tctice in Color:ldo Springs. In 1908, Dr. Mc Kay beganto invcstig:lte why people in particu!:tr communities inColor:tdo had severe tooth discoloration, known as dentalfluorosis , o r more popularly. mottled enamel. In 1909, heenlisted the collabor:ttion of a renowned demal re searcher,Dr. G.Y. B!:tck of Northwestern University, wh o w:ts luredto Colorado by :t report of the Colorado Springs Dcnt:t lSociety showing th:tt ncarly 90 pe rcent of the city's locallyborn children were subject to the bligh t of mottled enamel.Together, ll iack :tnd McKay determined that childrenwaiting for their secondary teeth to erupt were at high riskof Colorado Brown Stain, while adults wh ose teeth hadcalcified without the stain were no longer at risk. Before13lack's death in 1915, the two also realized that teethamicted with Color:tdo Brown St:tin were inexplicablyresis tan t to decay.In 1923, McKay's hUllch that the Colotado Brown St:tinphenomenon mig ht result from an ingredient in water was

Drs. Black (left) a/!dNIcK/If (right) lIisilC%rddo SpfillJ.!Sto JIII/tSligl/t/' brow/ISll1ill pill'/loml'l/o/!.


11/23

,The resultsshowed a highpresence of natu-rally occurringfluoride, somc-rlllng he couldnO t believe, havingnever heard offluoride in wate r.

given a boost in Oakley, Idaho. Parents in Oakley wc realarmed by a sudden onset of severe tooth discoloration intheir children and invited McKay to investigate. Th e com-munity had recently constructed a communal pipeline toa warm spring five miles away. Mc Kay eval uated this newsource of water and while it appeared normal according tohis tests, he nonetheless 3dvIsed the community to ceaseusing the p ipeline and begin llsing a nearby spring instead.Over the next few years, he dete rmined that the new waterSOllTce had the effect of ending new cases of mottled enamelin children and that affected child ren were ;lIsa relieved of theblight when their secondary teeth erupted.Sep:lT:ltely. ;lIsa in 1909, Dr. EL. R obertson realized thatpeople drinking water from ;l newly du g we ll in l3auxite,Arkansas. were showing signs of severe mottled en:ll1lel. Theblight beC:lllle so widespread tha.t the wel l W:lS closed in1927. McKay, hea ring of the trouble II I Bauxite, a companytown owned by the Alumi nulll Company of Ame rica, tr:lV-ded there wi th Dr. Grover Ke mpf of the U.S. Public He:llthService to investigate.They were surprised to lea rn thatmonIed ena.mel was nonexistent in a. tow n five miles away,but their tests with the available technology failed to de ter-mine the c:msative agent for the chi ld ren 's monied enamelin Bauxite. Their report reached the desk of H.V. Churchill,ALCOA's chief chemist in PennsylvJnia., who had spentyears defending aluminum cookwa re trom charges it waspoisonous. [n 1930. to a.void yet anoth er co ntroversy,he rall a photOspectrogra phic analysis on wa ter from theBauxite well. The resu lts showed a high presence ofnatura lly occurr ing fluoride, someth ing he could no t believe,having llever heard of fluoride in wate r. He tested a secon dsample from the well with the same result. He immediatelywrote a kttcr to Mc Kay, inviting him to send watersamples from Colorado. Mc Kay sprang to act ion, andChurchill's photospectrographic analyses of the Coloradowater samples also showed fl uoride as the :lgent causingdiscoloratloll.[n [931, Mc Kay fina lly knew that fluoride was the na w ra lelement in d rin ki ng water that caused the Colorado Urow llStain pheno menon. H is single-minded investigation overseveral decades proved tha.t naturally abundant fluo ride in


12/23

the water su pply would mottle tooth enamel but at thesame time inhibit dental caries. To McKay, the question washow to harness fluoride at a dosage that would IIlhibit bothdental caries :lIld mottled ename l.In the 1930s, McKay collaborated with Dr. H.Trendly De:1Ilof the U.S. Public Health Service to determine if fluoridecould be added to drinking water to prevent cavities. Th eycollaborated Oi l several classic studies, Olle an epidemiologicstudy involving 32 comlllunities with naturally fluoridatedwater sup plies, and established a community fluorosis index.Their associates conducted furthe r studies that predicted theoptimal amount of fluoridation for preventing both too thdecay and discoloration. [n effect, they were searching for anadjusted fluori dation standard that would h :lVC the benefit ofreduc in g dental caries while avo iding tooth discoloration ,and they concluded that the standard sho uld be one part permillion (1 ppm).

Gr,md Rapids sc!loa/rhildre" {o l /N l l ' I i salil'o samples OI1(c a ycar from194510 196010 help dcn/isls sl1Idy II,e rffias (ifjlrlOridllliol1.World War [[ interrupted further studies, but on January 25,1945. Grand R apids, Mi chigan, be.came the first city illthe world to adjust its water fluoride concentration to thenew adjusted fluoridation stand ard . [The 60th annive rsaryof fluoridation was observed, therefore, in early 200S1Newbmgh, New York, added sodium fluoride to its watersupply in June 1945, and later that month, Brantford,Ontario, did the same. [n February 1947, Evanston, Illinois,

Dr. H . "ii-cmlly DCIII!


13/23

,Three nationalsurveys complet-ed between 1971and 1987 showedthat childrendemonstrateda co ntinu eddecrease in car iesprevalence.

fluoridated its water supply. Four nearby communitieswith simibr dCIllogr3phics were used as the control group -Muskegon 111 Michig:m, Kingston in Ne w York, Sarnia inOntario, and Oak Park in ll!inois. Careful tracking of ratesof clemal caries ensued over 15 years, and the studiesconcurred that onc p:ln fl uoride per million parts of acOllllllunity's drinking water was the optimal standard,giving maXImum protection against dental caries w ith1ll1llimUI1l stJining of the teeth.Emboldened after just five years by the success of thesesmC\ies, the U.S. Public Health Service in 1950 recom-mended co mmunity water fluoridation as a public healthmeasure. The American Dental Assoc iation seconded thatrecommendation six months late r. [n the initial studiesdating from 1945 conductcd by the u.s. Public H ealthService, the prevalence of caries decreased 48 percent to70 percent :llTlong 12- to 14-year-olds who had lived inthe four original fluoridated communities their entire lives.In other communitics studied, the prevalence of carl esdecreased 45 percent to 94 percent (median 58 percent)among children wh o had been exposed [0 fluoridation forten years. Uy the early I980s. epidemiologic evidence indi-cated that the prevalence of dental caries was decliningthroughout thc United States. . . Three national surveyscompleted between 1971 and 1987 showed that childrendemonstrated a continued decrease in caries prevalence.Today, 60 years after Grand Rapids led the way, 170 Illlllionpeople live in fluoridated cOlllllluni ti es in the United States,including an estimated 10 million wh o live in cOllllllunitieswith wate r supplies that arc naturally fluoridated at the opti-Il lUIll level (I ppm). Another 30 to 40 million people areestimated to live withou t public water supplies, de pendingon slIch sources as drilled wells o r natural springs. Desp iteconclusive proof that co mmunity water fluoridation at theaccepted standard benefitS or:!l health, with no known sideeffectS, the remaining population of the United States livein communities without fluorida ted water supplies. Only afew of the top 50 ci ties in the U.S. have yet to be fluoridat-ed, including Portland (Oregon), San Antonio (Texas) andSan Jose (California). Tucson, Arizona, voted to fluoridate in1992, bur as of early 2005 had no t yet fluori dated, a case in


14/23

point for how long it can take to fluoridate a communit y.San Diego and the surrOl!nding cOllnties, involving 100water districts and nearly 18 million people, approved fluoridation in 2003 but allowed 30 months for it to take effect.While the benefits of fluoridation to the public's health areincontrovertible and not at all controvers ial to scientists andpublic health professionals, the notion of community waterfluorid:ttion still sparks controversy among people whooppose any form of government intervention ill privatelives and wh o regard it as forced medication and a violationof personal freedom. Although opponents often base theircounterclaims to fluoridation on quack science, masked bythe twin complaints of safety and effectiveness, adversepublicity has succeeded in delaying communi ty fluoridation.In 1980, for example, 41 fluoridation referenda were heldin the U.S. bur only eight were approved. In the periodbetween 1977 and 1982, approximately 25 percent offluoridation referenda passed. In both 2002 and 2004,26commun ities across the country voted in referenda forfluor idation , while in 2003, 14 communities vote.d forfluoridation. Most communities (91 percent) fluoridateadministratively through local or state government.,.. Fonun3tely, the furor caused by opponents of fluorid:Hion has dissipated slowly in the past two decades, withthe underlying science holding sway more and more. Since1980, however, progress in fluoridating the water in commu-nities with central water supplies has been disappointing.Only II states, the District of Co lumbia and Puerto ["-licohave passed laws that require fluoridation, usually only incommunities of a certain size (California, Connecticllt,Delaware, Georgia, Kentucky, l!linois, Minnesota, Nebraska,Nevada, Ohio, South Dakota). In the last great tumult, inCa lifornia in 1995, opponents of fluoridation suffered astinging defeat when the state legislature mandated fluoridation in communities with public water systems servingmore than 10,000 households. Nonetheless, many opponentshave persisted witb legal challenges. Michigan, for example,changed the wording in its law and made fluoridationvoluntary rather than mandatory. In the 30 years from 1954to 1984, more than a dozen cases reached the U.S. SupremeCOllrt. None of the cases were actually heard by the court;

Fortunately, thefuror ca used byopponents offluo ridation hasdissipated slow lyin the past twOdecades, with theunderlying sc iencebolding swaymore and more.


15/23

they were dism issed either for lack of a substantial federalquestion or because they were simply not commented upon.Long-rallge studies show conclusively that children whogrow lip frolll infancy until age six drinking fluoridatedwater are much less prone to dental caries and other orald iseases, perhaps for the reSt of thei r lives. The United Statesled the way in harnessing fluoride as a natural preventivefor demal caries and leads the way with the largest Ilumbe rof people II I the world living in fluoridated communit ies . In2002, more than 67 percent of the U.S. population wholived in COllllllunities with public wate r supply systemsreceived fluoridated water. Still, much work remains to bedone to ensure that the greatest possible number of peoplebenefit frOIll community water fluoridation. Because oralhC3lth impacts the quality of everyone's life, and becausefluori da tion can be shown to help keep students in schoo l,learning. and workers at work, working. every communitywithout water fluoridation should carefully consider the evidellce. Overwhelmingly. the evidence shows that comm uni ti es with fluoridated water supp lies have reduced the prevalence of dental caries in their populations. a


16/23

182 MiI


17/23

Dr. M}'rou I IIII/kiau ,forma dirmor oj OmlHeil/til , 80S{0I1 PHbli(Healtll CommiHioll.

Looking AheadOral Diseases, Stil l a Neglected EpidemicO ral health mu St become a higher priority at the local.state and nat ional levels if oral health disparities arc to beimproved and resolved. Dr. M yron Allukian, a reti red director of ora l health at the Boston Public Health Commissionand a former president of the American Publi c HealthAssociat io n , says, " Fluoridation and community-based prevent ion mu st be the foundation for better oral health." In2000, the U.S. Surgeon General issued its firs t-ever Rt'purf011 Oral Hea lth, with a call to action that has yet to be rea lized. Am o ng the report's recommend.1tions, loc.11 and statehealth departments and every other level of the publichealth system are ca lled upon to emph asize o ral health to amu ch greater degree and to crea te dental health programswith properly trained staff to address a neglected epid em IC.Report on Oral Health by the u.s. Surgeon GeneralTht, lllajor findings of th e report arc 3 S follows:1. Oral diseases and disorders in and of themselves affect

health and well-being throughout li fe.2. Safe and effective measureS exist to prevent the most

co mmon dental diseases - dental car ies and petlodoncaldiseases.

3. Lifestyle be havio rs that .1ffect general health such astobacco usc, excessive alcohol use, and poo r dietarychoices affect oral and craniofac ial health as we ll.

4 There are profound and consequential oral healthdispari ti es within the U.S. population.

5. More information is needed to improve Amer ica's oralhealth and eliminate health disparities.

6. The mauch reflects gene ral health and wellness.7. Oral diseases and conditions are associa ted with Otherhealth problems.8. Scientific research is key to fllfther reduction in the

burde n of diseases and disorders that affect the f:1ce,mouth and teeth .


18/23

~ i f - ' ~ 1 8 4 M l l ~ , t u , ' ~ ' eh,'pt,, '} Or,! H ~ J l l h Lo"\;,,,!,=Ah"Jd . .... ." :_ I, _ - .. . ' . - : ~ l .


19/23

"Bleeding gums,impacred teethan d rotting teethare routme matters for the ch ildren I have inte rviewed in theSouth Bronx.Children get usedto feeling constant pain .. . . "

. IS5

past year. Oral cancers are more prevalem thancervical cancer, yet most women receive pap smearsroutinely.

O f nursing home residents in the United St:ltes, 81pe rcent h:lve nOt had an :lllllll:l1 oral exam. For the 19percent who did, the exam often comes only after theresident has bc..::n rmhed by ambuian..::e for emergencycare.

Currently, only about half of the United States population has some form of dental insurance. [f a diabeticperson presents with a leg ulcer, medical insurancewould cover care, but if th:lt s:lme individual presentswith :I mouth ulce r, his care would not be coveredwithout dental insurance.

As a percentage of tocal health cxpendiwn:s, de ntalservice expenditures have decreased 28 percent, from6.4 percent in 1970 co about 4.6 pe rcent today.

The most vulnenble in the popubtion are most :It riskfor or:ll diseases and suffer their worst effects. Studies showthat up to 97 percent of homeless people need dental care;over h:llf of He:ld Start ch ildren in sOllle locations havehad early childhood caries (ECC); almost half of abusedchildren have orofacial trauma; and so al l .Jonathan Kozol,the education critic ;l.Ild author of Deat" lit (11/ EarlyAJ!e, winn..::r ofth..:: Nation:l.l Uook Award in 1968, andSavage II/eql/alities, a best-seller published in 1992, writes .

"Uleedmg gUIllS, im pacted teeth and rotting teethare routine matters for tht: chIldren [ have Illtervl..::wedIn the South Uronx. Children get used to feeling COllSt;!ntpain . They go to sleep w ith it. They go to school with it... . Children live fo r months with pain th:lt grown - lipswould find unendurable."Since 1997, with the introduction of the State Children'sH ealth Insurance Program (SCH IP), nearly every state h:l.sbegun to offer dental benefits to low-income children. [nmost cases, SC H IP affords bo th preventive and diagnosticcare, providing a new vehicle to reach :I large segment ofthe U.S. population previously underserved with dent:l.lcare. In 2003, seven states had already exceeded HealthyPeople 20)0 goals, while many others were quicklyapproaching the goals. By providing dental care to lo\\'-


20/23

income people, usually for the first time, SC H IP savesgrowing numbers of children from unendurable pain. Morcimportant, SCHIP also provides families with peace ofmind.Publi c- Pr ivate PartnershipsPartnerships between the public sector and private industrycan provide access to quality dental care for underservedchildren. One such approach is the Crest " Healthy Smiles2010" campaign initiated by Procter & Gamble in 2001with the backing of the Ame rican Demal Association, theBoys & Girls Clubs of America and the American Academyof Pediatric Dentistry. "Healthy Smiles 2010" aims to reach50 111111iol1 children this decade to alleviate the silelltepidemic of tooth decay, the most commall chronic childhood disease, Tooth decay in children is five times 1110reprevalent than asthma and seven times more rrevalentthan hay feve r. Key initiatives in the campaign are "GiveKids a Smile" Day in February, the Crest First GradeProgram, and Crest "Smile Shoppes," full-service delHalclinics established in Boys & Girls Clubs in six U.S. cities.As well, more than 1,000 Boys & Girls Clubs throughoutthe country have become "CaVIty-Free Zones" thanks toan oral health curriculum for children in grades K-3 setup in on-the-spot education centers in the clubs.Perhaps most critical, Crest won the comminllemof dental schools throughout the country to send dentalstudents into schools in their communities to providepreventive treatment and oral health instruction tochildren, especially underserved and at-risk children.. . "Creating public-private partnerships can help affectchange in the oral health of ou r country. These collectiveefforts can help educate both the public and health professionals, as well as provide the health care services and oralcare tools needed to he lp end the current disparity in ou rnation 5 oral hC:llth," said D r. David Satcher who, as U.S.Surgeon General, oversaw rhe publication of the Report011 Oral Healr" in 2000. The Crest " H ealthy Smiles 2010"campaign d istributes millions of toothpaste tubes andtoothbrushes to children free of charge every year, andchildren learn bow and when to brush their teeth, criticalsteps to good oral hygiene

,"Creating pllblicprivate partnerships can helpaffect change inthe oral health ofOllr country."

, - ,- ..' l ' ." .


21/23

Dr. Edu,",d M. Hu,/der!

A Sealant Success StoryAnother example of public-private partnerships is theCase Western sealant program in Cleveland, Ohio. Thepresident of Case Western Reserve University, Dr. EdwardM. Hundert, came from the medical school at theUniversity of R ochester. where as dean, he focused onpublic health and eliminating disparities in care amongethnic groups. After he arrived at Case Western R eservein 2002, Hunder t moved quickly to involve studentsin Cleveland. His constant refrain has been to give studentsreal-life experiences by helping the community. To thisend, Case Western dental students currently app ly sealantto the teeth of 15,000 second- and sixth-graders in theCleveland Publi c Schools eve ry year. "Our philosophy isthat the external things we're doing are the things th:1[will set our university apart," Hunder t said.For now, the dental sealant program symbolizes IllOSt visibl yCase Western's engage men t with Cleveland and, for dentalstudents, has become the high point of their year. "It's awonderful thlllg 01 1 all sides," said Dr. James Lalul11andier.the chairman of co mmunity dentistry, " [n this countty, 80percent of dental disease is in 20 percent of the children,and these are rhe 20 percent. Srudents arrive at the medicalschoo l and dental school with a desire to help people, andif YOll get thern into clinical work quickly, they don't losethat desire.""W hen yo u sit down for the first t ime to USe a probe inthe mouth, it's a big moment," said Oliver Thuernagle, astudent from Idaho. " I'm from a place where you don'tlock the door when yO LL go on vacat ion , and here [ amat schools where you sign ill and they check you for gUlls,"Thuernagle said. "We saw children whose teeth had erupted only five months ago and were already rotten to thecore. You refer them to someone wh o will take care of thecavities. But you wish you were there five months ago ."The Challenges AheadTo address oral health needs, the !lumber one priority ofpublic health policymakers should be to extend communitywater fluoridation as widely as possible. As Dr. Allukiansays, "F) uondation IS nature's way to preven t tOoth decay."Th e seco nd priority should be to make school-based dental


22/23

I" 0'" 188 1\1,]


23/23

Photo c ,editsI'.g" 1(,7: D,'""" ~ x . " I \ " ' g J g" l _ 'c,',h. t: I 'l , , , , lkdJCORBIS.f > . , ~ < ' I hX: B a l l n 1 \ o t ~ r : , , 1 1 ~ ! ( ~ "r n"",,1 ~ n r f : < ' r y , (oun,',)" Ihl' N'II">!,,I Muw"'"or Iknl l l l r ) .1',ll'" 1611: Dr. ( : h ~ p U l A. I1.1rr", , ""r""i" Ih" N,Hlunal l,brJry of /l.k,II(II'''.1"'l'" 171: H,,i-R,. ( Ar'!"", lcoI1Oj

milestones in health care: chapter 9

Documents