National Call To Action To Promote Oral Health
A Public-Private Partnership
under the leadership of
The Office of the Surgeon General
Acknowledgements
We express our appreciation to the many voluntary and professional organizations,
private and government agencies, foundations, and universities that contributed
to the development of this document. We thank them for their existing
and future efforts to improve the nation’s health through promoting oral
health and for their commitment to public-private partnerships.
Suggested Citation
U.S. Department of Health and Human Services. National Call to Action
to Promote Oral Health. Rockville, MD: U.S. Department of Health
and Human Services, Public Health Service, National Institutes of Health, National
Institute of Dental and Craniofacial Research. NIH Publication No. 03-5303,
Spring 2003.
Preface from the Surgeon General
The great and enduring strength of American democracy lies in its commitment
to the care and well-being of its citizens. The nation’s long-term
investment in science and technology has paid off in ever-expanding ways to
promote health and prevent disease. We can be proud that these advances
have added years to the average life span and enhanced the quality of life. But
an “average” is necessarily derived from all values along a continuum
and it is here that we come to recognize gaps in health and well-being. Not
all Americans are benefiting equally from improvements in health and health
care. America’s continued growth in diversity has resulted in a
society with broad educational, cultural, language, and economic differences
that hinder the ability of some individuals and groups from realizing the gains
in health enjoyed by many. These health disparities were highlighted
in the year 2000 Surgeon General’s report: Oral Health in America where
it was reported that no less than a “silent epidemic of oral diseases
is affecting our most vulnerable citizens—poor children, the elderly,
and many members of racial and ethnic minority groups.” The report
also highlighted the disabling oral and craniofacial aspects of birth defects.
The report was a wake-up call, raising a powerful voice against the silence.
It called upon policymakers, community leaders, private industry, health professionals,
the media, and the public to affirm that oral health is essential to general
health and well-being and to take action. No one should suffer
from oral diseases or conditions that can be effectively prevented and treated. No
schoolchild should suffer the stigma of craniofacial birth defects nor be found
unable to concentrate because of the pain of untreated oral infections. No
rural inhabitant, no homebound adult, no inner city dweller should experience
poor oral health because of barriers to access to care and shortages of resources
and personnel.
Now that call to action has been taken up. Under a broad coalition of
public and private organizations and individuals, orchestrated by the principals
who led the development of the National Call To Action To Promote Oral Health
has been generated. We applaud the efforts of these partners to heed the
voices of their fellow Americans. At regional meetings across the country concerned
citizens addressed the critical need to resolve inequities in oral health affecting
their communities. More than that, ideas and programs were described to
explain what groups at local, state or regional levels were doing or could do
to resolve the issues.
Combining this store of knowledge and experience with private and public plans
and programs already under way has enabled the partnership to extract the set
of five principal actions and implementation strategies that constitute the
National Call To Action To Promote Oral Health. These actions crystallize
the necessary and sufficient tasks to be undertaken to assure that all
Americans can achieve optimal oral health. It is abundantly clear that
these are not tasks that can be accomplished by any single agency, be it the
Federal government, state health agencies, or private organizations. Rather,
just as the actions have been developed through a process of collaboration and
communication across public and private domains, their successful execution
calls for partnerships that unite private and public groups focused on common
goals. The seeds for such future collaborative efforts have already been
sown by all those who participated in the development of this Call To Action.
We appreciate their dedication and take it as our mutual responsibility to further
partnership activities and monitor their impact on the health of the public.
We are confident that sizable rewards in health and well-being can accrue for
all Americans as these actions are implemented.
Richard H. Carmona, M.D., M.P.H., F.A.C.S.
VADM, USPHS
Surgeon General and Acting Assistant
Secretary for Health
Table of Contents
Introduction
The National Call To Action To Promote Oral Health is addressed to
professional organizations and individuals concerned with the health of their
fellow Americans. It is an invitation to expand plans, activities, and
programs designed to promote oral health and prevent disease, especially to
reduce the health disparities that affect members of racial and ethnic groups,
poor people, many who are geographically isolated, and others who are vulnerable
because of special oral health care needs. The National Call To Action
To Promote Oral Health, referred to as the Call To Action, reflects
the work of a partnership of public and private organizations who have specified
a vision, goals, and a series of actions to achieve the goals. It is their
hope to inspire others to join in the effort, bringing their expertise and experience
to enrich the partnership and thus accelerate a movement to enhance the oral
and general health and well-being of all Americans.
Origins of the Call To Action
Oral Health in America: A Report of the Surgeon General alerted Americans
to the importance of oral health in their daily lives[1]. The
Report, issued in May 2000, provided state-of-the-science evidence on the growth
and development of oral, dental and craniofacial tissues and organs; the diseases
and conditions affecting them; and the integral relationship between oral health
and general health, including recent reports of associations between
chronic oral infections and diabetes, osteoporosis, heart and lung conditions,
and certain adverse pregnancy outcomes. The text further detailed how
oral health is promoted, how oral diseases and conditions are prevented and
managed, and what needs and opportunities exist to enhance oral health. Major
findings and themes of the report are highlighted in Table 1.
Table 1: Major Findings and Themes from Oral Health in America: A Report
of the Surgeon General
Oral health is more than healthy teeth.
Oral diseases and disorders in and of themselves affect health and well-being
throughout life.
The mouth reflects general health and well-being.
Oral diseases and conditions are associated with other health problems.
Lifestyle behaviors that affect general health such as tobacco use,
excessive alcohol use, and poor dietary choices affect oral and craniofacial
health as well.
Safe and effective measures exist to prevent the most common dental
diseases—dental caries and periodontal diseases.
There are profound and consequential oral health disparities within
the U.S. population.
More information is needed to improve America’s oral health and
eliminate health disparities.
Scientific research is key to further reduction in the burden of diseases
and disorders that affect the face, mouth, and teeth.
Source: U.S. Department of Health and Human Services.
Oral Health in America: A Report of the Surgeon General. Rockville,
MD: U.S. Department of Health and Human Services, National Institute of
Dental and Craniofacial Research, National Institutes of Health, 2000:
10-11.
The Report’s message was that oral health is essential to general health
and well-being and can be achieved. However, a number of barriers hinder
the ability of some Americans from attaining optimal oral health. The Surgeon
General’s Report concluded with a framework for action, calling for a
national oral health plan to improve quality of life and eliminate oral health
disparities.
The Rationale for Action
The rationale for action is based on data from the Surgeon General’s
Report (Table 2). These and other data on the economic, social, and personal
burdens of oral diseases and disorders show that although the nation has made
substantial improvements in oral health, more must be done.
Table 2. The Burden of Oral Diseases and Disorders
The Burden of Oral Diseases and Disorders
Oral diseases are progressive and cumulative and become more complex
over time. They can affect our ability to eat, the foods we choose,
how we look, and the way we communicate. These diseases can affect
economic productivity and compromise our ability to work at home, at
school, or on the job. Health disparities exist across population
groups at all ages. Over one third of the U.S. population (100
million people) has no access to community water fluoridation. Over
108 million children and adults lack dental insurance, which is over
2.5 times the number who lacks medical insurance. The following
are highlights of oral health data for children, adults, and the elderly. (Refer
to the full report for details of these data and their sources).
Children
- Cleft lip/palate, one of the most common birth defects, is estimated
to affect 1 out of 600 live births for whites, and 1 out of 1,850 live
births for African Americans.
- Other birth defects such as hereditary ectodermal dysplasias, where
all or most teeth are missing or misshapen, cause lifetime problems
that can be devastating to children and adults.
- Dental caries (tooth decay) is the single most common chronic childhood
disease – 5 times more common than asthma and 7 times more common
than hay fever.
- Over 50 percent of 5- to 9-year-old children have at least one cavity
or filling, and that proportion increases to 78 percent among 17-year-olds. Nevertheless,
these figures represent improvements in the oral health of children
compared to a generation gap.
- There are striking disparities in dental disease by income. Poor
children suffer twice as much dental caries as their more affluent
peers, and their disease is more likely to be untreated. These
poor-nonpoor differences continue into adolescence. One out of four
children in America is born into poverty, and children living below
the poverty line (annual income of $17,000 for a single family of four)
have more severe and untreated decay.
- Tobacco-related oral lesions are prevalent in adolescents who currently
use smokeless (spit) tobacco.
- Unintentional injuries, many of which include head, mouth, and neck
injuries, are common in children.
- Intentional injuries commonly affect the craniofacial tissues.
- Professional care is necessary for maintaining oral health, yet 25
percent of poor children have not seen a dentist before entering kindergarten.
- Medical insurance is a strong predictor of access to dental care. Uninsured
children are 2.5 times less likely than insured children to receive
dental care. Children from families without dental insurance
are 3 times more likely to have dental needs than children with either
public or private insurance. For each child without medical insurance,
there are at least 2.6 children without dental insurance.
- Medicaid has not been able to fill the gap in providing dental care
to poor children. Fewer than one in five Medicaid-covered children
received a single dental visit in a recent year-long study period. Although
new programs such as the State Children’s Health Insurance Program
(SCHIP) may increase the number of insured children, many will still
be left without effective dental coverage.
- The social impact of oral diseases in children is substantial. More
than 51 million school hours are lost each year to dental-related illness. Poor
children suffer nearly 12 times more restricted-activity days than
children from higher-income families. Pain and suffering due
to untreated diseases can lead to problems in eating, speaking, and
attending to learning.
Adults
- Most adults show signs of periodontal or gingival diseases. Severe
periodontal disease (measured as 6 millimeters of periodontal attachment
loss) affects about 14 percent of adults aged 45-54.
- Clinical symptoms of viral infections, such as herpes labialis (cold
sores), and oral ulcers (canker sores) are common in adulthood affecting
about 19 percent of adults 22 to 44 years of age.
- Chronic disabling diseases such as temporomandibular disorders,
Sjögren’s syndrome, diabetes, and osteoporosis affect millions
of Americans and compromise oral health and functioning
- Pain is a common symptom of craniofacial disorders and is accompanied
by interference with vital functions such a eating, swallowing, and
speech. Twenty-two percent of adults reported some form of oral-facial
pain in the past 6 months. Pain is a major component of trigeminal
neuralgia, facial shingles (post-herptic neuralgia), temporomandibular
disorders, fibromyalgia and Bell’s palsy
- Population growth as well as diagnostics that are enabling earlier
detection of cancer means that more patients than ever before are undergoing
cancer treatments. More than 400,000 of these patients will develop
oral complications annually.
- Immunocompromised patients, such as those with HIV infection and
those undergoing organ transplantation, are at higher risk for oral
problems such as candidiasis.
- Employed adults lose more than 164 million hours of work each year
due to dental disease or dental visits
- For every adult 19 years or older with medical insurance, there are
three without dental insurance.
- A little less than two thirds of adults report having visited a dentist
in the past 12 moths. Those with income at or above the poverty
level are twice as likely to report a dental visit in the past 12 months
as those who are below the poverty line.
Older Adults
- Twenty-three percent of 65- to 74-year-olds have severe periodontal
disease (measured as 6 millimeters of periodontal attachment loss). (Also,
at all ages men are more likely than women to have more severe diseases,
and at all ages people at the lowest socioeconomic levels have more
severe periodontal disease.)
- About 30 percent of adults 65 years and older are edentulous, compared
to 46 percent 20 years ago. These figures are higher for those
living in poverty.
- Oral and pharyngeal cancers are diagnosed in about 30,000 Americans
annually; 8,000 die from these diseases each year. These cancers
are primarily diagnosed in the elderly. Prognosis is poor. The
5-year survival rate for white patients is 56 percent; for blacks,
it is only 34 percent.
- Most older Americans take both prescription and over-the-counter
drugs. In all probability, at least one of the medications used
will have an oral side effect – usually dry mouth. The
inhibition of salivary flow increases the risk for oral disease because
saliva contains antimicrobial components as well as minerals that can
help rebuild tooth enamel after attack by acid-producing, decay-causing
bacteria. Individuals in long-term care facilities are prescribed
an average of eight drugs.
- At any given time, 5 percent of Americans aged 65 and older (currently
some 1.65 million people) are living in a long-term care facility where
dental care is problematic.
- Many elderly individuals lose their dental insurance when they retire. The
situation may be worse for older women, who generally have lower incomes
and may never have had dental insurance. Medicaid funds dental
care for the low-income and disabled elderly in some states, but reimbursements
are low. Medicare is not designed to reimburse for routine dental
care.
Source: U.S. Department of Health and Human
Services. Oral Health in America: A Report of the Surgeon General. Rockville,
MD: U.S. Department of Health and Human Services, National Institute
of Dental and Craniofacial Research, National Institutes of Health, 2000:2-3.
The nation’s total bill for dental services was estimated by the Department
of Health and Human Services’ Centers for Medicare and Medicaid Services
to be $70.1 billion in 2002; this figure underestimates the true cost because
it does not take into account the indirect expenses of oral health problems,
nor the cost of services by other health care providers. These other providers
include specialists who treat people with craniofacial birth defects, such as
cleft lip or palate, and children born with genetic diseases that result in malformed
teeth, hair, skin, and nails, as happens in the ectodermal dysplasias. Patients
with oral cancers, chronic pain conditions such as temporomandibular (jaw) disorders,
autoimmune disease such as Sjögren’s syndrome (which leads to the
destruction of the salivary and tear glands) and victims of unintentional or
intentional facial injury are examples of other groups of patients who may require
costly and long-term oral and medical services. Beyond these expenses
are the millions of school and work hours lost every year because of oral health
problems.
Partnering for Progress
Aware that the Report had reinforced and stimulated a number of ongoing activities,
but seeing a need to facilitate communication and coordination of the nation’s
efforts, the Office of the Surgeon General extended an open invitation to organizations
to launch the development of the Call To Action. The resulting
Partnership Network (Appendix 1) was charged to enumerate promising existing
initiatives to enhance oral health, with an emphasis on those related to the
Surgeon General’s Report and to the Healthy People 2010 oral
objectives[2], and to expand
these efforts by enlisting the expertise of individuals, health care providers,
communities, and policymakers at all levels of society. Input was captured
through convening listening sessions held in five cities and by using Internet
websites. The listening sessions were much like town hall meetings, providing
opportunities to present the issues and solutions and attracting participants
with diverse points of view. The testimony proved to be extremely valuable
in demonstrating the extent to which oral health concerns extend beyond the
oral health community and in providing a wealth of ideas and activities for
resolving the issues (Appendix 2). The text that follows expresses the
vision, goals, and actions proposed for the Call To Action.
Vision and Goals
The Vision
of the Call To Action is
To advance the general health and well-being of all
Americans by creating critical partnerships at all levels of society to engage
in programs to promote oral health and prevent disease.
The Goals
of the Call To Action reflect those of Healthy
People 2010:
To promote oral health.
To improve quality of life.
To eliminate oral health disparities.
As a force for change to enhance the nation’s overall health and well-being,
the Call To Action urges that oral health promotion, disease prevention,
and oral health care have a presence in all health policy agendas set at local,
state, and national levels. For this to happen, the public, health professionals,
and policymakers must understand that oral health is essential to general health
and well-being at every stage of life. In addition, the oral health community
must be ready to act in efforts to address the nation’s overall health
agenda.
The Actions
Each of the five actions that follow should be read as a call for a response
from the individuals and groups who are most concerned and in a position to
act—whether as community leaders, volunteers, health care professionals,
research investigators, policymakers, and other concerned parties, or as public
and private agencies able to bring their organizational mandates and strengths
to the issues. The groups and individuals responding need to work as
partners, sharing ideas and coordinating activities to capitalize on joint
resources and expertise to achieve common goals. The actions proposed
reflect ideas and approaches outlined in the Surgeon General’s Report
and emphasized in public testimony during listening sessions. Note, however,
that individual Network members may not necessarily concur with every assessment
or conclusion in the text that follows.
The theme that emerged was that people care about their oral health, are able
to articulate the problems they face, and can devise ingenious solutions to
resolve them--often through creative partnerships. Ultimately, the measure
of success for any of any of these actions will be the degree to which individuals
and communities--the people of the nation itself--gain in overall health and
well-being. To achieve those ends, the partners have proposed four guiding
principles: Actions should be 1) culturally sensitive, 2) science based, 3)
integrated into overall health and well-being efforts, and 4) routinely evaluated.
Action 1. Change Perceptions of Oral Health
For too long, the perception that oral health is in some way less important
than and separate from general health has been deeply ingrained in American
consciousness. Activities to overcome these attitudes and beliefs can
start at the grassroots level, which can then lead to a coordinated national
movement to increase oral health literacy, defined as the degree to which individuals
have the capacity to obtain, process, and understand basic oral and craniofacial
information and services needed to make appropriate health decisions.
By raising Americans’ level of awareness and understanding of oral health,
people can make informed decisions and articulate their expectations of what
they, their communities, and oral health professionals can contribute to improving
health; health professionals and researchers can benefit from work with oral
health partners; and policymakers can commit to including oral health
in health policies. In this way, the prevention, early detection, and
management of diseases of the dental, oral, and craniofacial tissues can become
integrated in health care, community-based programs, and social services, and
promote the general health and well-being of all Americans.
Implementation strategies to change perceptions
are needed at local, state, regional, and national levels and for all population
groups. All stakeholders should work together and use data in order to:
Change public perceptions
- Enhance oral health literacy.
- Develop messages that are culturally sensitive and linguistically competent.
- Enhance knowledge of the value of regular, professional oral health care.
- Increase the understanding of how the signs and symptoms of oral infections
can indicate general health status and act as a marker for other diseases.
Change policymakers’ perceptions
- Inform policymakers and administrators at local, state, and federal levels
of the results of oral health research and programs and of the oral health
status of their constituencies.
- Develop concise and relevant messages for policymakers.
- Document the health and quality-of-life outcomes that result from the inclusion
(or exclusion) of oral health services in programs and reimbursement schedules.
Change health providers’ perceptions
- Review and update health professional educational curricula and continuing
education courses to include content on oral health and the association between
oral health and general health.
- Train health care providers to conduct oral screenings as part of routine
physical exams and make appropriate referrals.
- Promote interdisciplinary training of medical, oral health, and allied
health professional personnel in counseling patients about how to reduce
risk factors common to oral and general health.
- Encourage oral health providers to refer patients to other health specialists
as warranted by examinations and history. Similarly, encourage medical
and surgical providers to refer patients for oral health care when medical
or surgical treatments that may impact oral health are planned.
Action 2. Overcome Barriers by Replicating Effective Programs and Proven
Efforts
Reduce disease and disability. While the effectiveness of preventive
interventions such as community water fluoridation and school-based dental
sealants applied to children at risk have been persuasively demonstrated, very
few states have implemented both measures sufficiently to meet their health
objectives. Private and public agencies have conducted pilot projects
and demonstration programs to inform the public and health professionals on
ways to reduce the burden of oral disease through education, behavior change,
risk reduction, early diagnosis, and disease prevention management. Local
efforts to engage and educate community leaders in activities to improve oral
health have been developed. The designs and outcomes of those programs
should be well documented, evaluated, and made available to others. The
Guide to Community Preventive Service[3] and
The Guide to Clinical Preventive Services [4] provide criteria and
strong foundations for evaluating the scientific evidence and promoting effective
interventions. Testimony at the listening sessions also
identified programs and interventions that warrant consideration.
Having accurate data on disease and disabilities for a given population is
critical. Program success depends on how well the program is designed
and implemented to address the defined problems. While available data
reveal variations within and among states and population groups in patterns
of health and disease, there are many subpopulations for which data are limited
or nonexistent.
Improve oral health care access. Health disparities are commonly
associated with populations whose access to health care services is compromised
by poverty, limited education or language skills, geographic isolation, age,
gender, disability, or an existing medical condition. While Medicaid,
State Children’s Health Insurance Programs (SCHIP), and private organizations
have expanded outreach efforts to identify and enroll eligible persons and
simplify the enrollment process, they have not completely closed the gap. Adults
lacking language skills or reading competence may not know that they or their
children are eligible for dental (or medical) services. In addition,
some 25 million Americans live in dental care shortage areas, as defined by
Health Professional Shortage Area criteria.
Those who seek care may be faced with health practitioners who lack the training
and cultural competence to communicate effectively in order to provide needed
services. Programs that have overcome these barriers, including outreach
efforts and community service activities conducted through dental schools and
other health professional schools and residency programs, should be highlighted
and replicated.
Compounding health disparity problems is the lack of adequate reimbursement
for oral care services in both public and private programs. Private insurance
coverage for dental care is increasing, but still lags behind medical insurance. Inadequate
reimbursement has been reported for many Medicaid and SCHIP programs. Eligibility
for Medicaid does not ensure enrollment, and enrollment does not ensure that
individuals obtain needed care. Several states are demonstrating the
potential for improving children’s oral health access by conducting outreach
programs to the public and improving provider participation through operational
changes. These improvements include increasing dental reimbursement to
competitive levels, eliminating bureaucratic administrative barriers, contracting
out the management of dental benefit plans, and modeling commercial insurance
programs to eliminate patient stigma associated with Medicaid.
The federal effort to address gaps in care through new funding for oral health
services at Community Health Centers and Migrant Health Centers is also a positive
step. Appendix 2 describes a number of approaches for improving oral
health care access that were presented in testimony. No matter which
approach is taken, a necessary first step is to establish close working relationships
with the groups in question so that strategies tailored to their varying and
continuing health needs can be developed.
Enhance health promotion and health literacy. Public policies
and community interventions to make health care and information more accessible
have been effective. So have been efforts to encourage healthier lifestyles
and increase interventions for prevention or early detection of disease by
changing the environment (the places where people work, play, learn, or live). Expansion
of community-based health promotion and disease prevention programs, including
increasing understanding of what individuals can do to enhance oral health,
is essential if the needs of the public are to be met. Policies and programs
concerning tobacco cessation, dietary choices, wearing protective gear for
sports, and other lifestyle-related efforts not only will benefit oral health,
but are natural ways to integrate oral health promotion with promotion of general
health and well-being.
Many Americans don’t know why oral health is important, they don’t
know all they can do to preserve their oral health, and may not recognize signs
indicating that they are in trouble. Several oral health campaigns are
raising awareness of why oral health is important and how to access care, such
as a nationwide campaign by the American Dental Association emphasizing the
importance of the early diagnosis of oral cancer. It is encouraging that
messages like these are being communicated--through public service announcements,
campaigns, and all the venues available in today’s media-conscious culture. More
needs to be done to increase the health literacy of the public.
Implementation strategies to overcome barriers
in oral health disparities need to engage all groups, particularly those most
vulnerable, in the development of oral health care programs that work to eliminate
health disparities and aim to:
Identify and reduce disease and disability
- Implement science-based interventions appropriate for individuals and
communities.
- Enhance oral health-related content in health professions school curricula,
residencies, and continuing education programs, by incorporating new findings
on diagnosis, treatment and prevention of oral diseases and disorders.
- Build and support epidemiologic and surveillance databases at national,
state, and local levels to identify patterns of disease and populations at
risk. Data are needed on oral health status, disease, and health services
utilization and expenditures, sorted by demographic variables for various
populations. Surveys should document baseline status, monitor progress,
and measure health outcomes.
- Determine, at community or population levels, oral health care needs and
system requirements, including appropriate reimbursement for services, facility
and personnel needs, and mechanisms of referral.
- Encourage partnerships among research, provider, and educational communities
in activities, such as organizing workshops and conferences, to develop ways
to meet the education, research, and service needs of patients who need special
care and their families.
- Refine protocols of care for special care populations based on the emerging
science base.
Improve access to oral health care
- Promote and apply programs that have demonstrated effective improvement
in access to care.
- Create an active and up-to-date database of these programs.
- Explore policy changes that can improve provider participation in public
health insurance programs and enhance patient access to care.
- Remove barriers to the use of services by simplifying forms, letting individuals
know when and how to obtain services, and providing transportation and child
care as needed. Assist low-income patients in arranging and keeping oral
health appointments.
- Facilitate health insurance benefits for diseases and disorders affecting
craniofacial, oral, and dental tissues, including genetic diseases such as
the ectodermal dysplasias, congenital anomalies such as clefting syndromes,
autoimmune diseases such as Sjögren’s syndrome, and chronic orofacial
pain conditions such as temporomandibular disorders.
- Ensure an adequate number and distribution of culturally competent providers
to meet the needs of individuals and groups, particularly in health-care
shortage areas.
- Make optimal use of oral health and other health care providers in improving
access to oral health care.
- Energize and empower the public to implement solutions to meet their oral
health care needs.
- Develop integrated and comprehensive care programs that include oral health
care and increase the number and types of settings in which oral health services
are provided.
- Explore ways to sustain successful programs.
- Apply evaluation criteria to determine the effectiveness of access programs
and develop modifications as necessary.
Enhance health promotion and health literacy
- Apply strategies to enhance the adoption and maintenance of proven community-based
and clinical interventions, such as community water fluoridation and dental
sealants application.
- Identify the knowledge, opinions, and practices of the public, health
care providers, and policymakers with regard to oral diseases and oral health.
- Engage populations and community organizations in the development of health
promotion and health literacy action plans.
- Publicize successful programs that promote oral health to facilitate their
replication.
- Develop and support programs promoting general health that include activities
supporting oral health (such as wearing oral facial protection, tobacco cessation,
good nutrition).
Action 3. Build the Science Base and Accelerate Science Transfer
Advances in health depend on biomedical and behavioral research aimed at understanding
the causes and pathological processes of diseases. This can lead to interventions
that will improve prevention, diagnosis, and treatment. Too many people
outside the oral health community are uninformed about, misinformed about,
or simply not interested in oral health. Such lack of understanding and
indifference may explain why community water fluoridation and school-based
dental sealant programs fall short of full implementation, even though the
scientific evidence for their effectiveness has been known for some time and
was reaffirmed with the release of Oral Health in America. These
and other effective preventive and early detection programs should be expanded—especially
to populations at risk.
Biomedical and behavioral research in the 21st century will provide the knowledge
base for an ever-evolving health care practice. This scientific underpinning
requires the support of the full range of research from basic studies to large-scale
clinical trials. To achieve a balanced science portfolio it is essential
to expand clinical studies, especially the study of complex oral diseases that
involve the interactions of genetic, behavioral, and environmental factors. Clinical
trials are needed to test interventions to diagnose and manage oral infections,
complications from systemic diseases and their treatment, congenital and acquired
defects, and other conditions. Oral health research must also pursue
research on chronic oral infections associated with heart and lung disease,
diabetes, and premature low-birth-weight babies. Such research must be
complemented by prevention and behavioral science research (including community-based
approaches and ways to change risk behavior), health services research to explore
how the structure and function of health care services affect health outcomes,
and by population health and epidemiology research to understand potential
associations among diseases and possible risk factors. Surveys are needed
to establish baseline health data for America’s many subpopulations as
well as to monitor changing patterns of disease.
No one can foresee the findings from genetic studies in the years ahead, but
without question these advances will profoundly affect health, even indicating
an individual’s susceptibility to major diseases and disorders. Hybrid
sciences of importance to oral health are also on the rise. For example,
bioengineering studies are establishing the basis for repair and regeneration
of the body’s tissues and organs—including teeth, bones, and joints--
and ultimately full restoration of function. Oral diagnostics, using
saliva or oral tissue samples, will contribute to overall health surveillance
and monitoring.
If the public and their care providers are to benefit from research, efforts
are needed to transfer new oral knowledge into improved means of diagnosis,
treatment, and prevention. The public needs to be informed, accurately
and often, of findings that affect their health. They need clear descriptions
of the results from research and demonstration projects concerning lifestyle
behaviors and disease prevention practices. At the same time, research
is needed to determine the effect of oral health literacy on oral health. Communities
and organizations must also be able to reap the benefits of scientific advances,
which may contribute to changes in the reimbursement and delivery of services,
as well as enhance knowledge of risk factors. Advances in science and
technology also mean that life-long learning for practitioners is essential,
as is open lines of communication among laboratory scientists, clinicians,
and the academic faculties that design the curricula, write the textbooks,
and teach the classes that prepare the next generation of health care providers.
Implementation strategies to build a balanced science base and accelerate
science transfer should benefit all consumers, especially those in poorest
oral health or at greatest risk. Specifically there is a need to:
Enhance applied research (clinical and population-based studies, demonstration
projects, health services research) to improve oral health and prevent disease
- Expand intervention studies aimed at preventing and managing oral infections
and complex diseases, including new approaches to prevent dental caries and
periodontal diseases.
- Intensify population-based studies aimed at the prevention of oral cancer
and oral-facial trauma.
- Conduct studies to elucidate potential underlying mechanisms and determine
any causal associations between oral infections and systemic conditions.
If associations are demonstrated, test interventions to prevent or lower
risk of complications.
- Develop diagnostic markers for disease susceptibility and progression
of oral diseases.
- Develop and test diagnostic codes for oral diseases that can be used in
research and in practice.
- Investigate risk assessment approaches for individuals and communities,
and translate them into optimal prevention, diagnosis, and treatment measures.
- Develop biologic measures of disease and health that can be used as outcome
variables and applied in epidemiologic studies and clinical trials.
- Develop reliable and valid measures of patients’ oral health outcomes
for use in programs and in practice.
- Support research on the effectiveness of community-based and clinical
interventions.
- Facilitate collaborations among health professional schools, state health
programs, patient groups, professional associations, private practitioners,
industries, and communities to support the conduct of clinical and community-based
research as well as accelerate science transfer.
Accelerate the effective transfer of science into public health and private
practice
- Promote effective disease prevention measures that are underutilized.
- Routinely transfer oral health research findings to health professional
school curricula and continuing education programs and incorporate appropriate
curricula from other health professions-- medical, nursing, pharmacy, and
social work--into dental education.
- Communicate research findings to the public, clearly describing behaviors
and actions that promote health and well-being.
- Explore ways to accelerate the transfer of research findings into delivery
systems, including appropriate changes in reimbursement for care.
- Routinely evaluate the scientific evidence and update care recommendations.
Action 4. Increase Oral Health Workforce Diversity, Capacity, and Flexibility
Meet patient needs. The patient pool of any health care provider
tends to mirror the provider’s own racial and ethnic background[5]. As such, the
provider can play a catalytic role as a community spokesperson, addressing
key health problems and service needs. While the number of women engaged
in the health professions is increasing, the number of underrepresented racial
and ethnic minorities is decreasing and remains limited. Specific racial
and ethnic groups are underrepresented in the active dental profession compared
to their representation in the general population: African Americans comprise
2.2 percent of active dentists versus 12 percent of the population; Hispanics
comprise 2.8 percent of active dentists versus 10.7 percent of the population;
Native Americans comprise 0.2 percent of active dentists versus 0.7 percent
of the population. The reasons are complex but certainly include the
high cost of dental school education (upwards of $100,000 indebtedness for
dentist graduates). Efforts to address these problems at all levels—from
improving K-12 education in science and math to providing scholarships and
loan forgiveness programs for college and pre-doctoral programs--are essential
if a truly representative health workforce is to be achieved. Efforts
require full community participation, mentorship, and creative outreach as
well as building upon federal or state legislation and programs.
Enhance oral health workforce capacity. The lack of progress in supplying
dental health professional shortage areas with needed professional personnel
underscores the need for attention to the distribution of care providers, as
well as the overall capacity of the collective workforce to meet the anticipated
demand for oral health care as public understanding of its importance increases. Dental
school recruitment programs that offer incentives to students who may want
to return to practice in rural areas and inner cities are in a prime position
to act. Through these programs schools increase the diversity of the
oral health workforce. To effect change in oral health workforce capacity,
more training and recruitment efforts are needed. The lack of personnel
with oral health expertise at all levels in public health programs remains
a serious problem, as does the projected unmet oral health faculty and researcher
needs. In public health programs, oral health professionals are needed
to implement surveillance, assess needs, and target population-based preventive
programs. Oral health professionals in state health agencies frequently
promote integration of federal, state, and local strategies and serve as the
linking agent for public-private collaborations. Currently, there is
an acknowledged crisis in the ability to recruit faculty to dental schools
and to attract clinicians into research careers. Dental school faculty
and oral health researchers are needed to address the various scientific challenges
and opportunities oral health presents, and to help transfer emerging knowledge
to the next generation of health care providers. The lack of trained
professionals ultimately results in a loss in the public’s health. Efforts
are underway to address these needs, but the rate of recruitment and retention
is slow. Scholarships and loan forgiveness programs have made a difference,
but more public investment in developing health workforce personnel is needed.
Enhance flexibility and develop local solutions. The movement
of some states towards more flexible laws, including licensing experienced
dentists by credentials is a positive one and today, 42 states currently permit
this activity. The goal of moving society toward optimal use of its health
professionals is especially important in a society that has become increasingly
mobile, especially since the oral health workforce has projected shortages
that are already evident in many rural locales. State practice act changes
that would permit, for example, alternative models of delivery of needed care
for underserved populations, such as low-income children or institutionalized
persons, would allow a more flexible and efficient workforce. Further,
all health care professionals, whether trained at privately or publicly supported
medical, dental, or allied health professional schools, need to be enlisted
in local efforts to eliminate health disparities in America. These activities
could include participating in state-funded programs for reducing disparities,
part-time service in community clinics or in health care shortage areas, assisting
in community-based surveillance and health assessment activities, participating
in school-based disease prevention efforts, and volunteering in health-promotion
and disease-prevention efforts such as tobacco cessation programs.
Implementation strategies to increase diversity, capacity, and flexibility
must be applied to all components of the workforce: research, education,
and both private and public health administration and practice. Efforts
are needed to:
Change the racial and ethnic composition of the workforce to meet patient
and community needs
- Document the outcomes of existing efforts to diversify the workforce in
practice, education, and research.
- Develop ways to expand and build upon successful recruitment and retention
programs, and develop and test new programs that focus on individuals from
underrepresented groups.
- Document the outcomes of existing efforts to recruit individuals into careers
in oral health education, research, and public and private health practice.
- Create and support programs that inform and encourage individuals to pursue
health and science career options in high school and during graduate years.
Ensure a sufficient workforce pool to meet health care needs
- Expand scholarships and loan repayment efforts at all levels.
- Specify and identify resources for conducting outreach and recruitment.
- Develop mentoring programs to ensure retention of individuals who have
been successfully recruited into oral health careers.
- Facilitate collaborations among professional, government, academic, industry,
community organizations, and other institutions that are addressing the needs
of the oral health workforce.
- Provide training in communication skills and cultural competence to health
care providers and students.
Secure an adequate and flexible workforce
- Assess the existing capacity and distribution of the oral health workforce.
- Study how to extend or expand workforce capacity and productivity to address
oral health in health care shortage areas.
- Work to ensure oral health expertise is available to health departments
and to federal, state, and local government programs.
- Determine the effects of flexible licensure policies and state practice
acts on health care access and oral health outcomes.
Action 5. Increase Collaborations
The private sector and public sector each has unique characteristics and strengths. Linking
the two can result in a creative synergy capitalizing on the talent and resources
of each partner. In addition, efforts are needed within each sector to
increase the capacity for program development, for building partnerships, and
for leveraging programs. A sustained effort is needed right now to build
the nation’s oral health infrastructure to ensure that all sectors of
society--the public, private practitioners, and federal and state government
personnel--have sufficient knowledge, expertise, and resources to design, implement,
and monitor oral health programs. Leadership for successfully directing
and guiding public agency oral health units is essential. Further, incentives
must be in place for partnerships to form and flourish.
Disease prevention and health promotion campaigns and programs that affect
oral and general health--such as tobacco control, diet counseling, health education
aimed at pregnant women and new mothers, and support for use of oral facial
protection for sports—can benefit from collaborations among public health
and health care practicing communities. Interdisciplinary care is needed
to manage the general health-oral health interface. Achieving and maintaining
oral health requires individual action, complemented by professional care and
community-based activities. Many programs require the combined efforts
of social service, education, and health care services at state and local levels. Most
importantly, the public in the form of voluntary organizations, community groups,
or as individuals, must be included in any partnership that addresses oral
and general health.
Implementation strategies to enhance partnering
are key to all strategies in the Call To Action. Successful
partnering at all levels of society will require efforts to:
- Invite patient advocacy groups to lead efforts in partnering for programs
directed towards their constituencies.
- Strengthen the networking capacity of individuals and communities to address
their oral health needs.
- Build and nurture broad-based coalitions that incorporate views and expertise
of all stakeholders and that are tailored to specific populations, conditions,
or programs.
- Strengthen collaborations among dental, medical, and public health communities
for research, education, care delivery, and policy development.
- Develop partnerships that are community-based, cross-disciplinary, and
culturally sensitive.
- Work with the Partnership Network and other coalitions to address the
four actions previously described: change perceptions, overcome barriers,
build a balanced science base, and increase oral health workforce diversity,
capacity, and flexibility.
- Evaluate and report on the progress and outcomes of partnership efforts.
- Promote examples of state-based coalitions for others to use as models.
The Need for Action Plans
with Monitoring and Evaluation Components
Activities proposed to advance any or all of the actions described above must
incorporate schemes for planning and evaluation, coordination, and accountability. Because
planning and evaluation are key elements in the design and implementation of
any program, the need to create oral health action plans is emphasized.
Whether individuals are moved to act as volunteers in a community program,
as members of a health voluntary or patient advocacy organization, employees
in a private or public health agency, or health professionals at any level
of research, education, or practice, the essential first step is to conduct
a needs assessment and develop an oral health plan. Because the concept of
integrating oral health with general health is intrinsic to the goals of this
Call To Action, oral health plans should be developed with the intent of incorporating
them into existing general health plans. Healthy People 2010 objectives
can be used to help guide needs assessment and to establish program goals and
health indicators for outcome measures. At the state level many, but
not all, states have already developed oral health plans; however, not all
of these plans have been integrated into the state’s general health plan
and policies. While a detailed plan is necessary to guide collaboration
on the many specific actions necessary for enhancing oral health, integration
of key components into the state’s general health plan will assure that
oral health is included where appropriate in other state health initiatives.
At any level, formal plans with goals, implementation steps, strong evaluation
components, and monitoring plans will facilitate setting realistic timelines,
guidelines, and budgets. The oral health plan will serve as a blueprint,
one that can be a tool for enlisting collaborators and partners and attracting
funding sources to ensure sustainability. Building this plan into existing
health programs will maximize the integration of oral health into general health
programs—not only by incorporating the expertise of multidisciplinary
professional teams, but also allowing the plan to benefit from economies of
scale by adding on to existing facilities, utilizing existing data and management
systems, and serving the public at locations already known to patients.
To facilitate establishing, monitoring and
revising written plans and ensure their progress:
- Use the Healthy People 2010 objectives to help establish program
goals and guide the needs assessment and development of health indicators
for outcome measures.
- Develop and nurture a consortium of stakeholders.
- Align plan priorities with the views and expertise of primary stakeholders.
- Build upon existing plans within your organization, state, or local community
or apply aspects of plans established at other locations to suit program
needs.
- Ensure that cultural sensitivity is utilized in the design, development,
implementation, and evaluation of plans.
- Emphasize the value of incorporating oral health into general health plans
by educating the public, health professionals, and policymakers about oral
health and its relation to general health and well-being.
- Integrate existing oral health plans into general health plans.
- Establish and maintain a strong surveillance and evaluation effort.
- Regularly report on progress to all stakeholders and policymakers.
- Commit resources to ensure that oral health programs and systems
include staff with sufficient time, expertise, and information systems, and
address oral health needs.
Next Steps
This National Call To Action To Promote Oral Health provides the basis
for integrating efforts of current and future members of the Partnership Network
to facilitate improvement of the nation’s health through oral health activities.
The five actions outlined in this report require public-private partnerships
at all levels of society and a commitment from those who are involved in health
programs to contribute expertise and resources. The Partnership Network
members will serve to foster communication and collaborations and will act as
a forum to measure progress toward these actions in coordination with the Healthy
People 2010 initiative.
Appendix 1
Partnership Network Members (as of November 2001)
Academy of General Dentistry
American Academy of Pediatrics
American Academy of Pediatric Dentistry
American Association of Public Health Dentistry
American Association of Women Dentists
American College of Nurse-Midwives
American Dental Association
American Dental Hygienists’ Association
American Dental Trade Association
American Dental Education Association
American Medical Association
American Public Health Association
American Society of Dentistry for Children
Association of Maternal and Child Health Programs
Association of Academic Health Centers
Association of Clinicians for the Underserved
Association of Maternal and Child Health Programs
Association of Schools of Public Health
Association of State and Territorial Health Officials
Association of State and Territorial Dental Directors
Bureau of Dental Health, New York State Health Department
Campbell Hoffman Foundation
Center for Child Health Research
Children’s Defense Fund
Children’s Dental Health Project
Colorado Department of Public Health and Environment Oral Health Program
Connecticut Health Foundation
Consumer Health Care Products Association
Delta Dental Plans Association
Delta Dental/Washington Dental Service
DENTSPLY InternationalFamilies USA
Family Voices (Federation for Children with Special Needs)
Friends of NIDCR
Colgate Palmolive Company
Grantmakers In Health
Henry Schein, Inc.
Hispanic Dental Association
Illinois Department of Public Health
International Association for Dental Research, American Association for Dental
Research
Maryland Department of Health and Mental Hygiene
National Oral Health Policy Center
Minority Health Communications
National Association of Child Advocates
National Association of Children’s Hospitals
National Association of Community Health Centers
National Association of County and City Health Officials
National Association of Local Boards of Health
National Association of State Medicaid Directors
National Maternal and Child Oral Health Resource Center
National Conference of State Legislatures
National Dental Association
National Foundation for Ectodermal Dysplasias
National Governors’ Association
National Health Law Program
National Health Policy Forum
National Association of Urban-Based HMOs
New York State Department of Health
Oral Health America
Reforming States Group
Research America
Ronald McDonald House Charities
Special Olympics and Special Olympics University
The Children’s National Medical Center
The Robert Wood Johnson Foundation
The Rotunda
Urban Institute Health Policy Center
Washington Dental Service Foundation
W.K. Kellogg Foundation
Women’s and Children’s Health Policy Center
Appendix 2
What People Said
The sections that follow are derived from the presentations of individuals
and organizations at the five regional listening sessions held during winter
and spring 2002 and from the written testimony received. The issues identified
in the Surgeon General’s Report were restated in terms of objectives and
grouped into five objectives: 1. Change perceptions, 2. Overcome barriers, 3.
Enhance research and its application, 4. Strengthen infrastructure, and 5. Expand
partnerships. These objectives formed the basis for summarizing the testimony
and for the Actions described in the text. By describing general approaches
as well as some specific programs and projects underway, this appendix can serve
as a resource to aid responses to the Call To Action. Some programs
might lend themselves to replication at other sites; others may inspire new
and ingenious plans, programs, and partnerships. As background, each of
the five objectives is preceded by a text box quoting relevant portions of Oral
Health in America: A Report of the Surgeon General.
While it was expected that many of those who testified came from segments
of the oral health community, it was especially gratifying that many of the
respondents spoke from other perspectives. They were community leaders,
concerned citizens, representatives of health voluntary organizations, and
other nonprofit organizations and foundations, and employees of public agencies
at all levels of local, state, and federal government.
A Rich Repertoire...
The listening sessions exemplified the kind of democracy-in-action associated
with town meetings in America. The people who attended reflected the
racial and ethnic diversity of the community’s population and demonstrated
the degree of innovation and creativity Americans can achieve when committed
to resolve critical health issues. Participants were ingenious
in describing coalitions, partnerships, and funding opportunities involving
all kinds of entities: a community church working with the local dental society,
a state health agency cooperating with a private foundation and volunteer dental
professionals, a dental insurance corporation subsidizing treatment costs to
improve access to services for poor people, school nurses working with parents,
dental hygienists, and local dentists to implement dental screening programs
and referrals for care, and private philanthropies financing mobile vans to
reach people in remote areas. Several organizations detailed how they
had competed for small federal grants, which they used to plan and conduct
pilot programs. Several dental schools described using private foundation
grants to fund community outreach programs utilizing dental students. Clearly
there is no one-size-fits-all remedy to the health problems that the nations’ communities
and populations experience.
…but an Uncertain Future
However, not every program was a demonstrable success. Indeed, more than
one presenter expressed concern that their efforts were piecemeal and the future
was cloudy: programs could last only as long as the resources and funding.
In one case, a program that was built on the promise of partial support had
to cease when state funding was cut back. Thus the listening sessions
were also a declaration that more long-term strategies must be pursued and public
awareness of the importance of oral health must grow. The commitment of communities
to build the public-private partnerships by expending the social, political,
and economic will at federal, state, and local levels can yield long-lasting
health benefits for all community members.
Testimony Highlights
Objective 1: Change perceptions of the public, policymakers,
and health providers regarding oral health and disease so that oral health
becomes an accepted component of general health.
What the report said
The mouth is the major portal of entry to the body and is equipped with
formidable mechanisms for sensing the environment and defending against
toxins or invading pathogens. In the event that the integrity of
the oral tissues is compromised, the mouth can become a source of disease
or pathological processes affecting other parts of the body…. The
mouth and face act as a mirror that can reveal signs of disease, drug
use, domestic physical abuse, harmful habits or addiction such as smoking,
and general health status. Imaging…may provide oral signs
of skeletal changes such as those occurring with osteoporosis and musculoskeletal
disorders, and may also reveal salivary, congenital, neoplastic, and
developmental disorders. Oral-based diagnostics are increasingly
being developed and used as a means to assess health and disease without
the limitations and difficulties of obtaining blood and urine.
Oral diseases and disorders in and of themselves affect health
and well-being across the life span. They include the common dental
diseases, dental caries and the periodontal diseases, and other oral
infections, such as cold sores and candidiasis, as well as birth defects
occurring in infancy and chronic craniofacial pain conditions and oral
cancers seen in later years…. Diseases and disorders that result
in dental and craniofacial defects damage self-image, self-esteem, and
well-being. Oral-facial pain and loss of sensori-motor functions limit
food choices and the pleasures of eating, restrict social contact, and
inhibit intimacy… .Patients with oral and pharyngeal cancers may
experience loss of taste, loss of chewing ability, difficulty in speaking,
pain, and the psychological stress and depression associated with disfigurement.
Oral complications of many systemic diseases also compromise the quality
of life, Problems of speaking, chewing, taste, smell and swallowing
are common in neurodegenerative conditions such as Parkinson’s
disease; oral complications of AIDS include pain, dry mouth, and Kaposi’s
sarcoma; cancer therapy can result in painful ulcers, mucositis, and
rampant dental caries; periodontal disease is a complication of diabetes
and osteoporosis. Prescription and non-prescription drugs often
have the side effect of dry mouth.
Oral infections can be the source of systemic infections, especially
in people with weakened immune systems, while oral signs and symptoms
are often a significant feature of a general health problem, such as
the autoimmune disease, Sjøgren’s syndrome.
Most intriguing of all, are associations reported between chronic oral
infections and serious health problems, such as diabetes, heart and lung
disease, and adverse pregnancy outcomes. Investigators are actively
engaged in research to confirm initial findings and discover the mechanisms
involved.
Source: U.S. Department of Health and Human Services. Oral Health
in America: A Report of the Surgeon General. Rockville, MD: U.S.
Department of Health and Human Services, National Institute of Dental
and Craniofacial Research, National Institutes of Health, 2000. pp.133,
283-284.
Addressing the Issue
The testimony reinforced the concept that oral health is secondary and separate
from general health is one that is deeply ingrained in American consciousness
and hence may be the pivotal and most difficult barrier to overcome. Cultural
historians can point to a tradition in Europe and America in which dentistry
was long associated with tooth extractions performed by itinerant surgeons
who were reviled as charlatans, despised as sources of acute pain and suffering,
and abundantly caricatured in art and literature. Something of this stigma
associated with dentistry and its practitioners remains today, not only in
terms of the way the profession is popularly depicted in filmsand comedy routines,
but also in terms of its ranking in the hierarchy of health and medical specialties. The
very fact that dental education was established separately from medical training,
as was the practice of dentistry, may have unwittingly contributed to the stigma—and
may also in part account for why a lack of perceived need remains one of the
major reasons that many people do not seek regular dental care. Thus,
efforts to achieve acceptance of the intrinsic importance of oral health and
its interdependence with general health must be directed to medical practitioners
and other health professionals and researchers, as well as to educators, policymakers,
and the general public. This point was brought home to attendees at one
regional meeting during which a woman testified that in all her years as a
diabetic patient in which her physicians referred her to specialists such as
ophthalmologists and neurologists for potential diabetes complications, no
one had ever once suggested that she see a dentist concerning her oral health
status. At another hearing it was reported that medical residents in
a prenatal clinic were interested to learn that women with moderately severe
periodontal disease might be at risk for pre-term and low birth weight infants. Even
with that knowledge, however, they would not act on any new findings such as
these, without an official recommendation from the American College of Obstetricians
and Gynecologists.
“No physician or other medical specialist I saw ever
suggested I see a dentist.”
-- a woman with diabetes
Associations between oral infections and systemic conditions continue to be
reported, and if the results of studies prove a cause-effect relationship,
their widespread communication may very well effect a significant change in
the practices and programs of health professionals as well as policymakers
and the general public. In the meantime, the various programs described
at the listening sessions to explain the oral health-general health connection
are helping to make a difference. In so doing, they also reveal to what
extent otherwise well-educated Americans, even health care providers, are uninformed
about the multiple defense, repair, and maintenance functions performed by
oral tissues as gatekeepers to the body, the fine-tuned sensory-motor skills
of orofacial nerves and muscles, and the necessary role of oral hygiene and
nutrition in keeping oral tissues healthy.
Listening session participants gave a number of examples of public relations
awareness campaigns conducted at local and state levels, the exemplary use
of public service announcements, and even dental product infomercials on the
Internet with educational content.
Model programs in which volunteer oral health professionals educate segments
of the population at the places where they congregate -older Americans at senior
centers, primary grade students in school, pregnant women seen in prenatal
clinics- offer the possibility of stimulating high interest by tailoring the
message to the specific oral health problems and appropriate interventions
for the given audience. Programs that test training methods for nurses
and physicians to conduct oral health evaluations, make appropriate dental
referrals, and apply preventive interventions such as fluoride varnishes or
dental sealants were seen as ways to integrate oral health services with medical
care and pave the way for a time when such practices will be routinely accepted. An
example of a well-thought-out awareness campaign was the Watch Your Mouth program
in Washington state, which used radio and print advertisements to educate the
public on the importance of oral health. The campaign also included an
evaluation component allowing before-and-after statistical analyses of effectiveness.
With regard to educating policymakers, there is no question that the advocacy
of members of consumer and health voluntary organizations (e.g., Sjögren’s
Syndrome, March of Dimes, The Temporomandibular Joint Association, National
Foundation for Ectodermal Dysplasias) as well as oral health research and professional
organizations, has done much to inform and raise the consciousness of these
leaders and with positive effects. These advocates have used persuasive
and well-documented arguments concerning the impact of oral health—and
its lack—on the health, education, financing, and productivity of large
segments of the constituencies the legislators represent. On the principle
of strength through numbers, coalitions of such groups, especially partnering
oral health patient organizations with medical disease organizations (e.g.,
heart, cancer, diabetes, arthritis) might achieve a greater impact, while underscoring
that oral health and general health are inextricably linked.
Changing the Paradigm
Nonetheless, no matter how well meaning and constructive local, state, and
regional efforts at changing perceptions have been, the best route to overcoming
the cultural, historical, legal, and structural impediments to accepting oral
health as essential to general health and well-being may be to create a broad
awareness and education program that would be coordinated at the national level. This
program could foster the necessary paradigm shift in perception. Such
a program--supported by a broad coalition of patient and consumer groups, private
and public research and practitioner organizations--could achieve collectively
what no one group has yet been able to achieve singly.
Objective 2: Remove known barriers between people and oral
health services.
What the Report said:
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 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.
Source: U.S. Department of Health and Human Services. Oral Health
in America: A Report of the Surgeon General. Rockville, MD: U.S.
Department of Health and Human Services, National Institute of Dental
and Craniofacial Research, National Institutes of Health, 2000. p.
286.
Addressing the Issue
Concern about barriers to care was by far the issue that most engaged speakers
at the Call To Action listening sessions, eliciting the widest range
of proposals and programs. There was unanimous agreement that rates of reimbursement
for oral health care under the Medicaid program are low and, as a result of
many state budget shortfalls in recent years, will be subject to further cuts. These
budgetary limitations have also affected State Children’s Health Insurance
Programs, in which dental care is only an option. States that have made
concerted legislative efforts to raise Medicaid reimbursement rates to levels
consistent with customary fees in the area have seen improvements in the number
of poor patients served and providers willing to treat patients covered under
Medicaid. Speakers also expressed hope that Medicare, which specifically
excludes dental services other than in exceptional cases, such as when dental
care is integral to treating a medical condition, could some day be expanded
to cover oral health care for seniors.
“When did we allow dental care to become medically
unnecessary in the first place?”
--An advocate for special care
dentistry
While participants argued for coordinated and large-scale efforts at legislative
and corporate reforms to extend coverage and improve oral heath care benefits
for Americans who lack dental insurance or have extremely limited coverage,
a number of speakers described programs and demonstration projects targeted
to particular risk groups. Rather than wait for policy changes and insurance
reforms, they saw the urgency to create innovative access and delivery programs
to serve poor children, members of racial and ethnic minorities, the elderly,
rural residents, or individuals with disabilities and other special care needs.
A few examples of targeted programs that have been launched in recent years
have been chosen from the listening sessions to illustrate their variety and
are described below. Subject to evaluation of their overall effectiveness
and cost, they might be adapted to other venues. In all cases, it was
clear that it was the dedication and drive of a few key individuals determined
to turn dreams into realities that enabled these programs to be implemented. Whether
a school nurse or principal, a health agency official, dental hygienist, a
clergyman, academic faculty member, practicing dentist or physician, a private
foundation director, or a local community leader, these were people who sought
out and obtained the trust, cooperation, commitment, and funding from multiple
sources to get their programs going and keep them going.
A dental school-based program for children with special care needs. The
College of Dental Medicine of the Medical University of South Carolina in Charleston
developed a demonstration project that provided the screening and referral
of children to a state-wide network of dentists willing and able to treat children
with complex care needs. Administrators have used this project to enrich
the education of dental students through clinical rotations and an expanded
special care curriculum and to increase the competencies of practicing dentists
to serve special care patients through continued education courses. The
project has also advanced research by collecting data on the oral health problems
seen in special care patients and by correlating these problems with the underlying
health problem. The project resulted in greatly increased services, the
publication of a dental directory for parents, and an extension of special
care seminars and courses for other health professionals and administrators.
SABER promotora model. Much of the appeal of this model is its
grassroots origin in a Hispanic community in southern California. As the program
director indicates, “The model is based on naturally occurring networks
and linkages that exist in the Latino community.” Promotoras are
community health advocates who serve as role models for behavior change and
work in traditional ways to provide culturally appropriate dental health education
and information, while promoting the bonding of neighbors, friends, and family.
Meeting the needs of rural communities. “Rural communities
are the canaries in the workforce coal mines,” was the way one federal
dentist described the ever-growing shortage of dental care providers in rural
and frontier communities. These communities are also unlikely to have
access to a fluoridated water supply and adequate transportation to larger
cities and towns. What is impressive is how some communities have taken
it upon themselves to meet the challenges. For example, three rural communities
in New York State have each implemented a different approach to the provision
of care: a mobile dental clinic, a primary care-based dental clinic at a critical
access hospital, and a freestanding satellite dental clinic. These facilities
reflect the commitment of partners that included community and consumer groups,
foundations, dental associations, hospitals, government agencies, and the dental
school of the State University of New York at Buffalo.
Care for institutionalized elderly. A nonprofit charitable organization,
Apple Tree Minnesota, was first designed to serve indigent elderly living in
institutions and has since been expanded to serve poor children. The
program brings dental care to individuals through mobile dental vans that work
out of stationary clinics as hubs. The program also conducts needs assessment
to support a role in public policy development and advocacy and creates regional
advisory councils to develop grassroots advocates. The program has been
replicated in other states, but because funding for care comes from Medicaid
there have been severe shortfalls, which must be made up by seeking other sources
of revenue.
An Indian Health Service prenatal dental education program for Native American
mothers. This Oklahoma program was designed to provide oral health
care to expectant mothers and to advise them on ways to prevent early childhood
dental caries by adopting appropriate feeding practices to their babies and
teaching appropriate oral hygiene for newborns (as well as the mothers). The
program has a strong evaluation component that includes follow-up interviews
with participants. Such a program provides an opportunity for integrating
oral health education and services in a hospital where women are already
being seen in an obstetrics unit.
Private practitioners reach out. The Georgia Dental Association
in partnership with the Georgia Medicaid agency were effective at the level
of the legislature and governor in increasing the state’s investment
in oral health. In 2002 Georgia was the only state to receive an increase
in Medicaid funding for dental care – a 3.5 percent increase in provider
reimbursement rates. Georgia also successfully reduced administrative
barriers, such as prior authorization requirements and burdensome provider
applications. As a result, the number of dentists signing up to provide
care to Medicaid patients continues to increase. Dentists themselves
orchestrated a Medicaid promotional campaign called Take 5, encouraging each
dentist to take on five new Medicaid patients.
Objective 3: Accelerate the building of the scientific and
evidence base and accelerate the application of research findings to improve
oral health.
What the Report Said
The science base for dental diseases is broad and provides a strong
foundation for further improvements in prevention; for other craniofacial
and oral conditions the base has not reached the same level of maturity…The
nation’s continued investment in research is critical for the provision
of new knowledge about oral and general health and disease…However
the next steps are more complicated. The challenge is to understand complex
diseases caused by interaction of multiple genes with environment and
behavioral variables—a description that applies to most oral diseases
and disorders—and translate research findings into health care
practices and healthy lifestyles. 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 a basis for formulating risk
profiles and tailoring treatment and program options accordingly.
Source: U.S. Department of Health and Human Services. Oral Health
in America: A Report of the Surgeon General. Rockville, MD: U.S.
Department of Health and Human Services, National Institute of Dental
and Craniofacial Research, National Institutes of Health, 2000. p.284-285.
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Addressing the Issue
Support for continued research to advance oral health science, particularly
in exploring the oral health-general health connection, was implicit in the
testimony of many individuals addressing the Call To Action. Clearly,
additional well-designed research studies that can explore the role of chronic
oral infections as risk factors for adverse pregnancy outcomes, poorly controlled
diabetes, heart and lung diseases, and the potential role of oral infections
in other conditions are needed. The major private oral health research
organization, the American Association for Dental Research (AADR), stated that
it was committed to promoting the goals of the Call To Action and
is encouraging its section members to follow up with symposia at annual meetings.
Also, the research agenda of the American Dental Association sets out
many of the profession’s research needs and can be used as a blueprint
for research studies.
Many who testified at the listening sessions concentrated on the need to put
research into practice. They spoke as community leaders, care providers,
directors of clinics and public health and health care financing agencies,
and as representatives of dental schools, schools of dental hygiene, and dental
societies. Participants expressed frustration that known ways of preventing
oral disease and promoting oral health are still not being adopted by individuals
and communities, often where the needs are greatest. Many noted that
in the 21st century, over a third of Americans fail to enjoy the benefits of
community water fluoridation—one of the most effective and inexpensive
means of preventing dental caries. Similarly, the need to increase applications
of dental sealants and topical fluorides were emphasized. In addition,
the need for epidemiology and surveillance studies to determine the scope of
oral health problems and project future service needs at local, state, and
national levels was stressed. There was also a call for expanding health
services research and the use of outcomes measures to determine the effectiveness
and cost-effectiveness of various prevention and treatment modalities as well
as ways of delivering oral care services. Calls for the adoption of a
universal oral survey assessment form and for research to develop diagnostic
markers and other measures of risk assessment were also strongly recommended
as ways to facilitate surveillance and epidemiology studies as well as providing
optimal tailor-made oral health care to patients.
Comments made at the listening sessions highlighted the need for further research
on biomaterials and their health effects, as well as on the science transfer
of proven dietary preventive measures. For example, there was some discussion
of the use of xylitol and other cariostatic sugar substitutes to prevent dental
Objective 4: Ensure the adequacy of public and private health
personnel and resources to meet the oral health needs of all Americans and
enable the integration of oral health effectively with general health. The
focus is on having a responsive, competent, diverse, and flexible workforce.
What the report said
The public health capacity for addressing oral health is dilute and
not integrated with other public health programs…Local, state,
and federal resources are limited in the personnel, equipment, and facilities
available to support oral health program. 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…cutbacks
in many state budgets have reduced staffing of state and territorial
dental programs and curtailed oral health promotion and disease prevention
programs.
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.
A closer look at trends in the workforce discloses a worrisome shortfall
in the numbers of men and women choosing careers in the education of
oral health professionals and the conduct of oral health research.
Source: U.S. Department of Health and Human Services. Oral Health
in America: A Report of the Surgeon General. Rockville, MD: U.S.
Department of Health and Human Services, National Institute of Dental
and Craniofacial Research, National Institutes of Health, 2000. p.286.
Addressing the Issue
If anything, testimony at the regional listening sessions affirmed that the
oral health infrastructure has continued to deteriorate with additional shortfalls
in personnel and budgets. Within the public sector, it is essential to
have a strong federal oral health infrastructure that provides stability and
support for state public oral health efforts. These state programs can
then advise and provide technical assistance to community oral health programs.
The Centers for Medicare and Medicaid Services has appointed a dental officer
in recognition of the importance of having an oral health expert who can stimulate
effective and efficient programs at the state and local levels as they relate
to Medicaid and the State Children’s Health Insurance Program. But
the shortfall of oral health expertise in other state and federal agencies—individuals
who can stimulate, facilitate, and ensure strong public-private partnerships—is
critical. At present, 12 out of 50 states and 7 territories lack a permanent
full time dental director. A similar lack of dental public health expertise
exists in state agencies managing multi-million dollar Medicaid programs and
the State Children’s Health Insurance Program. The only remedy to
this problem is to employ enough staff to enable states to conduct essential
public health activities. One spokesperson defined the “minimum
staffing requirement” to include dental public health experts and a support
staff of epidemiologists, dental hygienists, public health educators, and information
resource managers. Their collective expertise is essential to conduct
needs assessments, surveillance studies, maintain databases such as the National
Oral Health Surveillance System, identify dental shortage areas and underserved
populations, and develop, implement, and evaluate preventive programs and state
oral health plans.
Many public health programs and activities rely for their performance on long-established
partnerships with other public health agencies and with private sector dental
practitioners. Indeed, public health dentists also frequently serve as faculty
members of dental schools, teaching dental public health classes. But
absent an authoritative oral health administrator within critical state health
agencies--a central hub--the system falls apart and the public’s health
suffers.
Turning to the problems of personnel needs within the education, research,
and practitioner community, there was widespread support for programs to expand
recruitment, especially of racial and ethnic minority dental students, by easing
dental school indebtedness through loan repayment programs, the quid pro quo
variously being willingness to serve in dental shortage areas, treat underserved
and Medicaid patients, or participate in federal oral health research activities. State
practice act changes that would allow a more flexible and efficient workforce
were recommended. Some listening session participants argued for greater
autonomy in practice rules, emphasizing the educational and preventive services
they could perform in non-traditional sites such as nursing homes and schools,
if they were free to practice under general dentist supervision. Dental
hygienists and non-dental health professionals offered alternative approaches
to care delivery, providing examples of how they can contribute to meeting
oral health needs at the local and state levels through screenings, patient
education, and preventive care.
Objective 5: Expand public-private partnerships and build
upon common goals to improve the oral health of those who suffer disproportionately
from oral diseases.
What the Report Said
The collective and complementary talents of public health agencies,
private industry, social service 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 programs.
Source: U.S. Department of Health and Human Services. Oral Health
in America: A Report of the Surgeon General. Rockville, MD: U.S.
Department of Health and Human Services, National Institute of Dental
and Craniofacial Research, National Institutes of Health, 2000. p.286.
Addressing the Issue
The establishment of the Partnership Network in the development of the National
Call To Action To Promote Oral Health exemplifies how well this objective
has been taken to heart. The partners will play a key role in disseminating
the goals and objectives of the Call To Action and, as discussed in
the final section, can propose how best to monitor and provide oversight in
the implementation of the actions proposed.
In addition, abundant evidence from the listening sessions provides further
examples of the creative public-private partnerships that are already being
forged at all levels of community, state, and federal government. To
facilitate partnership building, several sources can be mentioned that have
been helpful in enabling groups to come together to develop oral health programs. For
example, the Health Resources and Services Administration (HRSA) provided support
for state dental health agencies to hold state summits, where interested private
and public groups can come together to assess needs and opportunities. Other
states have used technical assistance provided by the National Governors Association
to convene problem-solving teams to develop state oral health plans.
Several states have received grants from the Centers for Disease Control and
Prevention to improve basic oral health services, including support for program
leadership, monitoring oral health risk factors, and developing and evaluating
prevention programs. HRSA has a new cooperative agreement program where
dental faculty train general pediatric and family medicine residents to provide
basic components of oral health assessments to children from birth to five
years who are medically or dentally underserved and at high risk for oral health
problems. The National Institutes of Health also has a grant program
targeted to health professional schools for enhancing faculty research skills
and enriching curricula. Foundations such as the Robert Wood Johnson,
W. K. Kellogg, and The Pew Charitable Trust are among a number of private foundations
concerned with health and health care in America that have supported health
services research and demonstration projects. Grantmakers In Health has
provided guidance to the broad array of foundations all across the nation by
highlighting private and public sector initiatives to meet oral health challenges
and suggesting additional strategies involving foundation participation.
Certainly the media can be enlisted in alerting the public to oral health
concerns; they have been and can continue to be a lightning rod in many areas
of health, especially in terms of populations at risk. Often their accounts
name individuals and organizations that are actively engaged in the health
issues in question. Among them are consumer groups and health voluntary
organizations, which have played significant roles in raising awareness, expanding
research, and improving care and treatment. Often these organizations
have started as grassroots groups formed by a few individuals and families
concerned with a health problem and have grown into effective national and
international organizations.
The enthusiasm and commitment demonstrated by the scores of attendees at the
regional listening sessions and from the many written submissions are testimony
that a critical mass of Americans view oral health as a priority and need.
They demonstrated and expressed the willingness and ability to be recruited
to work as partners to achieve the vision and goals of the National Call
To Action To Promote Oral Health.
[1] U.S. Department of Health and Human Services. Oral
Health in America: A Report of the Surgeon General. Rockville,
MD: U.S. Department of Health and Human Services, National Institute
of Dental and Craniofacial Research, National Institutes of Health, 2000:2-3.
(http://www.nidcr.nih.gov/)
[2] U.S. Department of Health and Human Services.
Healthy People 2010. 2nd ed. 2 vols. Washington, DC: U.S. Government Printing
Office, November 2000. (http://www.healthypeople.gov/)
[3] Interventions to Prevent Dental Caries, Oral
and Pharyngeal Cancers, and Sports-related Craniofacial In- juries: Systematic
Reviews of Evidence, Recommendations from the U.S. Task Force on Community
Preventive Services, and Expert Commentary. Am J Prev Med 2002; 1-84;
23(1S)
[4] U.S. Preventive Services Task Force. Guide
to Clinical Preventive Services, 2nd Edition, Williams and Wilkins,
Baltimore. 1996; 953p.
[5] Brown LJ, Lazar V. Minority dentists: why do we
need them? Closing the gap. Washington Office of Minority Health, U.S. Department
of Health and Human Services; 1999 Jul. p.6-7.
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