Surgeon General

Oral Health in America: A Report of the Surgeon General

The U.S. surgeon general released this year the nation’s first official report on oral health. This document elaborates on the meaning of oral health and explains why oral health is essential to general health and well-being. We have reprinted here an abridged version of the report’s Executive Summary. The full report can be accessed at http://www.nidcr.nih.gov/sgr/sgr.htm.

Publication of this first Surgeon General’s Report on Oral Health marks a milestone in the history of oral health in America. The report elaborates on the meaning of oral health and explains why oral health is essential to general health and well-being. In the course of the past 50 years, great progress has been made in understanding the common oral diseases -- dental caries and periodontal diseases -- resulting in marked improvements in the nation’s oral health. Most middle-aged and younger Americans expect to retain their natural teeth over their lifetime and do not expect to have any serious oral health problems.

The major message of this surgeon general’s report is that oral health is essential to the general health and well-being of all Americans and can be achieved by all Americans. However, not all Americans are achieving the same degree of oral health. In spite of the safe and effective means of maintaining oral health that have benefited the majority of Americans over the past half century, many among us still experience needless pain and suffering, complications that devastate overall health and well-being, and financial and social costs that diminish the quality of life and burden American society. What amounts to "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 (U.S. General Accounting Office 2000) (Table).

A major theme of this report is that oral health means much more than healthy teeth. It means being free of chronic oral-facial pain conditions, oral and pharyngeal cancers, oral soft tissue lesions, birth defects such as cleft lip and palate, and scores of other diseases and disorders that affect the oral, dental, and craniofacial tissues, collectively known as the craniofacial complex.

New research is pointing to associations between chronic oral infections and heart and lung diseases, stroke, and low-birth-weight, premature births. Associations between periodontal disease and diabetes have long been noted. This report assesses these associations and explores mechanisms that might explain the oral-systemic disease connections.

The broadened meaning of oral health parallels the broadened meaning of health. In 1948 the World Health Organization expanded the definition of health to mean "a complete state of physical, mental, and social well-being, and not just the absence of infirmity." It follows that oral health must also include well-being. Just as we now understand that nature and nurture are inextricably linked, and mind and body are both expressions of our human biology, so, too, we must recognize that oral health and general health are inseparable. We ignore signs and symptoms of oral disease and dysfunction to our detriment. Consequently, a second theme of the report is that oral health is integral to general health. You cannot be healthy without oral health. Oral health and general health should not be interpreted as separate entities. Oral health is a critical component of health and must be included in the provision of health care and the design of community programs.

The wider meanings of oral and health in no way diminish the relevance and importance of the two leading dental diseases, caries and the periodontal diseases. They remain common and widespread, affecting nearly everyone at some point in the life span. What has changed is what we can do about them.

Researchers in the 1930s discovered that people living in communities with naturally fluoridated water supplies had less dental caries than people drinking unfluoridated water. But not until the end of World War II were the investigators able to design and implement the community clinical trials that confirmed their observations and launched a better approach to the problem of dental caries: prevention. Soon after, adjusting the fluoride content of community water supplies was pursued as an important public health measure to prevent dental caries.

Although this measure has not been fully implemented, the results have been dramatic. Dental caries began to decline in the 1950s among children who grew up in fluoridated cities, and by the late 1970s, decline in decay was evident for many Americans. The application of science to improve diagnostic, treatment, and prevention strategies has saved billions of dollars per year in the nation’s annual health bill. Even more significant, the result is that far fewer people are edentulous today than a generation ago.

The significant role that scientists, dentists, dental hygienists, and other health professionals have played in the prevention of oral disease and disability leads to a third theme of this report: Safe and effective disease prevention measures exist that everyone can adopt to improve oral health and prevent disease. These measures include daily oral hygiene procedures and other lifestyle behaviors, community programs such as community water fluoridation and tobacco cessation programs, and provider-based interventions such as the placement of dental sealants and examinations for common oral and pharyngeal cancers. It is hoped that this surgeon general’s report will facilitate the maturing of the broad field of craniofacial research so that gains in the prevention of craniofacial diseases and disorders can be realized that are as impressive as those achieved for common dental diseases.

At the same time, more needs to be done to ensure that messages of health promotion and disease prevention are brought home to all Americans. In this regard, a fourth theme of the report is that general health risk factors, such as tobacco use and poor dietary practices, also affect oral and craniofacial health. The evidence for an association between tobacco use and oral diseases has been clearly delineated in almost every surgeon general’s report on tobacco since 1964, and the oral effects of nutrition and diet are presented in the surgeon general’s report on nutrition (1988). All the health professions can play a role in reducing the burden of disease in America by calling attention to these and other risk factors and suggesting appropriate actions.

The Science Base for the Report

This report is based on a review of the published scientific literature. Standards established to determine the quality of the evidence, based on the study design and its rigor, were used where appropriate. In addition, the strength of the recommendations, where they are made, is based on evidence of effectiveness for the population of interest.

Organization of the Report

The report centers on five major questions, which have been used to structure the report into five parts.

Part One: What Is Oral Health?

The meaning of oral health is explored in Chapter 1, and the interdependence of oral health with general health and well-being is a recurrent theme throughout the volume.

Chapter 2 provides an overview of the craniofacial complex in development and aging, how the tissues and organs function in essential life processes, and their role in determining our uniquely human abilities.

Part Two: What Is the Status of Oral Health in America?

Chapter 3 is a primer describing the major diseases and disorders that affect the craniofacial complex. The findings include:

* Microbial infections, including those caused by bacteria, viruses, and fungi, are the primary cause of the most prevalent oral diseases. Examples include dental caries, periodontal diseases, herpes labialis, and candidiasis.

* Tobacco use, excessive alcohol use, and inappropriate dietary practices contribute to many diseases and disorders. In particular, tobacco use is a risk factor for oral cavity and pharyngeal cancers, periodontal diseases, candidiasis, and dental caries, among other diseases.

Some chronic diseases, such as Sjögren’s syndrome, present with primary oral symptoms.

Oral-facial pain conditions are common and often have complex etiologies.

Chapter 4 constitutes an oral health status report card for the United States, describing the magnitude of the problem. The findings include:

* Despite improvements in oral health status, profound disparities remain in some population groups as classified by sex, income, age, and race/ethnicity. For some diseases and conditions, the magnitude of the differences in oral health status among population groups is striking.

* National and state data for many oral and craniofacial diseases and conditions and for population groups are limited or nonexistent. Available state data reveal variations within and among states in patterns of health and disease among population groups.

Part Three: What Is the Relationship Between Oral Health and General Health and Well-Being?

Chapters 5 and 6 address key issues in the report’s charge -- the relationship of oral health to general health and well-being. Chapter 5 explores the theme of the mouth as reflecting general health or disease status. The findings include:

* The oral cavity and its functions can be adversely affected by many pharmaceuticals and other therapies commonly used in treating systemic conditions. The oral complications of these therapies can compromise patient compliance with treatment.

* Animal and population-based studies have demonstrated an association between periodontal diseases and diabetes, cardiovascular disease, stroke, and adverse pregnancy outcomes. Further research is needed to determine the extent to which these associations are causal or coincidental.

Chapter 6 demonstrates the relationship between oral health and quality of life, presenting data on the consequences of poor oral health and altered appearance on speech, eating, and other functions, as well as on self-esteem, social interaction, education, career achievement, and emotional state. An examination of efforts to characterize the functional and social implications of oral and craniofacial diseases reveals findings that include:

* Oral-facial pain, as a symptom of untreated dental and oral problems and as a condition in and of itself, is a major source of diminished quality of life. It is associated with sleep deprivation, depression, and multiple adverse psychosocial outcomes.

* Self-reported impacts of oral conditions on social function include limitations in verbal and nonverbal communication, social interaction, and intimacy. Individuals with facial disfigurements due to craniofacial diseases and conditions and their treatments can experience loss of self-image and self-esteem, anxiety, depression, and social stigma; these in turn may limit educational, career, and marital opportunities and affect other social relations.

Part Four: How Is Oral Health Promoted and Maintained and How Are Oral Diseases Prevented?

The next three chapters review how individuals, health care practitioners, communities, and the nation as a whole contribute to oral health. Chapter 7 reviews the evidence for the efficacy and effectiveness of health promotion and disease prevention measures with a focus on community efforts in preventing oral disease. The findings include:

* Community water fluoridation, an effective, safe, and ideal public health measure, benefits individuals of all ages and socioeconomic strata. Unfortunately, over one third of the U.S. population (100 million people) are without this critical public health measure.

* Community-based preventive programs are unavailable to substantial portions of the underserved population.

Chapter 8 explores the role of the individual and the health care provider in promoting and maintaining oral health and well-being. The findings include:

* All primary care providers can contribute to improved oral and craniofacial health. Interdisciplinary care is needed to manage the oral health-general health interface. Dentists, as primary care providers, are uniquely positioned to play an expanded role in the detection, early recognition, and management of a wide range of complex oral and general diseases and conditions.

* New knowledge and the development of molecular and genetically based tests will facilitate risk assessment and management, and improve the ability of health care providers to customize treatment.

Chapter 9 describes the roles of dental practitioners and their teams, the medical community, and public health agencies at local, state, and national levels in administering care or reimbursing for the costs of care. These activities are viewed against the changing organization of U.S. health care and trends regarding the workforce in research, education, and practice.

* The dentist-to-population ratio is declining, creating concern as to the capability of the dental workforce to meet the emerging demands of society and provide required services efficiently.

* Current and projected demand for dental school faculty positions and research scientists is not being met. A crisis in the number of faculty and researchers threatens the quality of dental education; oral, dental, and craniofacial research; and, ultimately, the health of the public.

Part Five: What Are the Needs and Opportunities to Enhance Oral Health?

Chapter 10 looks at determinants of oral health in the context of society and across various life stages. The findings include:

* Preventive interventions, such as protective head and mouth gear and dental sealants, exist but are not uniformly used or reinforced.

* Federal and state assistance programs for selected oral health services exist; however, the scope of services is severely limited, and their reimbursement level for oral health services is low compared to the usual fee for care.

Chapter 11 spells out in greater detail the promise of the life sciences in improving oral health in the coming years in the context of changes in American -- and global -- society. The critical role of genetics and molecular biology is emphasized.

Chapter 12, the final chapter, iterates the themes of the report and groups the findings from the earlier chapters into eight major categories. These findings, as well as a suggested framework for action to guide the next steps in enhancing the oral health of the nation, are presented below.

Major Findings

Oral diseases and disorders in and of themselves affect health and well-being throughout life. The burden of oral problems is extensive and may be particularly severe in vulnerable populations. It includes the common dental diseases and other oral infections, such as cold sores and candidiasis, that can occur at any stage of life, as well as birth defects in infancy, and the chronic facial pain conditions and oral cancers seen in later years. Many of these conditions and their treatments may interfere with vital functions such as breathing, eating, swallowing, and speaking and with activities of daily living such as work, school, and family interactions.

Safe and effective measures exist to prevent the most common dental diseases --dental caries and periodontal diseases. Community water fluoridation is safe and effective in preventing dental caries in both children and adults. Water fluoridation benefits all residents served by community water supplies regardless of their social or economic status. Professional and individual measures are additional means of preventing dental caries.

Lifestyle behaviors that affect general health such as tobacco use, excessive alcohol use, and poor dietary choices affect oral and craniofacial health as well. These individual behaviors are associated with increased risk for craniofacial birth defects, oral and pharyngeal cancers, periodontal disease, dental caries, and candidiasis, among other oral health problems. Opportunities exist to expand the oral disease prevention and health promotion knowledge and practices of the public through community programs and in health care settings.

There are profound and consequential oral health disparities within the U.S. population. Disparities for various oral conditions may relate to income, age, sex, race or ethnicity, or medical status. Although common dental diseases are preventable, not all members of society are informed about or able to avail themselves of appropriate oral health-promoting measures. Similarly, not all health providers may be aware of the services needed to improve oral health. In addition, oral health care is not fully integrated into many care programs. Social, economic, and cultural factors and changing population demographics affect how health services are delivered and used, and how people care for themselves.

More information is needed to improve America’s oral health and eliminate health disparities. We do not have adequate data on health, disease, and health practices and care use for the U.S. population as a whole and its diverse segments, including racial and ethnic minorities, rural populations, individuals with disabilities, the homeless, immigrants, migrant workers, the very young, and the frail elderly. Nor are there sufficient data that explore health issues in relation to sex or sexual orientation. Data on state and local populations, essential for program planning and evaluation, are rare or unavailable and reflect the limited capacity of the U.S. health infrastructure for oral health.

The mouth reflects general health and well-being. The mouth is a readily accessible and visible part of the body and provides health care providers and individuals with a window on their general health status. As the gateway of the body, the mouth senses and responds to the external world and at the same time reflects what is happening deep inside the body. The mouth may show signs of nutritional deficiencies and serve as an early warning system for diseases such as HIV infection and other immune system problems. The mouth can also show signs of general infection and stress. As the number of substances that can be reliably measured in saliva increases, it may well become the diagnostic fluid of choice.

Oral diseases and conditions are associated with other health problems. Oral infections can be the source of systemic infections in people with weakened immune systems, and oral signs and symptoms often are part of a general health condition. Associations between chronic oral infections and other health problems, including diabetes, heart disease, and adverse pregnancy outcomes, have also been reported. Ongoing research may uncover mechanisms that strengthen the current findings and explain these relationships.

Scientific research is key to further reduction in the burden of diseases and disorders that affect the face, mouth, and teeth. The science base for dental diseases is broad and provides a strong foundation for further improvements in prevention; for other craniofacial and oral health conditions, the base has not yet reached the same level of maturity. Scientific research has led to a variety of approaches to improve oral health through prevention, early diagnosis, and treatment. We are well-positioned to take these prevention measures further by investigating how to develop more targeted and effective interventions and devising ways to enhance their appropriate adoption by the public and the health professions. An intensified effort to understand the relationships between oral infections and their management, and other illnesses and conditions is warranted, along with the development of oral-based diagnostics.

A Framework For Action

All Americans can benefit from the development of a National Oral Health Plan to improve quality of life and eliminate health disparities by facilitating collaborations among individuals, health care providers, communities, and policymakers at all levels of society and by taking advantage of existing initiatives. Everyone has a role in improving and promoting oral health. Together we can work to broaden public understanding of the importance of oral health and its relevance to general health and well-being, and to ensure that existing and future preventive, diagnostic, and treatment measures for oral diseases and disorders are made available to all Americans. The following are the principal components of the plan:

Change perceptions regarding oral health and disease so that oral health becomes an accepted component of general health.

* Change public perceptions. Many people consider oral signs and symptoms to be less important than indications of general illness. As a result, they may avoid or postpone needed care, thus exacerbating the problem. If we are to increase the nation’s capacity to improve oral health and reduce health disparities, we need to enhance the public’s understanding of the meaning of oral health and the relationship of the mouth to the rest of the body. These messages should take into account the multiple languages and cultural traditions that characterize America’s diversity.

* Change policymakers' perceptions. Informed policymakers at the local, state, and federal levels are critical in ensuring the inclusion of oral health services in health promotion and disease prevention programs, care delivery systems, and reimbursement schedules. Raising awareness of oral health among legislators and public officials at all levels of government is essential to creating effective public policy to improve America's oral health. Every conceivable avenue should be used to inform policymakers -- informally through their organizations and affiliations and formally through their governmental offices -- if rational oral health policy is to be formulated and effective programs implemented.

* Change health providers' perceptions. Too little time is devoted to oral health and disease topics in the education of nondental health professionals. Yet all care providers can and should contribute to enhancing oral health. This can be accomplished in several ways, such as including an oral examination as part of a general medical examination, advising patients in matters of diet and tobacco cessation, and referring patients to oral health practitioners for care prior to medical or surgical treatments that can damage oral tissues, such as cancer chemotherapy or radiation to the head and neck.

Accelerate the building of the science and evidence base and apply science effectively to improve oral health. Basic behavioral and biomedical research, clinical trials, and population-based research have been at the heart of scientific advances over the past decades. The nation’s continued investment in research is critical for the provision of new knowledge about oral and general health and disease for years to come and needs to be accelerated if further improvements are to be made. Equally important is the effective transfer of research findings to the public and health professions. However, the next steps are more complicated. The challenge is to understand complex diseases caused by the interaction of multiple genes with environmental and behavioral variables -- a description that applies to most oral diseases and disorders -- and translate research findings into health care practice and healthy lifestyles.

This report highlights many areas of research opportunities and needs in each chapter. At present, there is an overall need for behavioral and clinical research, clinical trials, health services research, and community-based demonstration research. Also, development of risk assessment procedures for individuals and communities and of diagnostic markers to indicate whether an individual is more or less susceptible to a given disease can provide the basis for formulating risk profiles and tailoring treatment and program options accordingly.

Vital to progress in this area is a better understanding of the etiology and distribution of disease. But as this report makes clear, epidemiologic and surveillance databases for oral health and disease, health services, utilization of care, and expenditures are limited or lacking at the national, state, and local levels. Such data are essential in conducting health services research, generating research hypotheses, planning and evaluating programs, and identifying emerging public health problems. Future data collection must address differences among the subpopulations making up racial and ethnic groups. More attention must also be paid to demographic variables such as age, sex, sexual orientation, and socioeconomic factors in determining health status. Clearly, the more detailed information that is available, the better can program planners establish priorities and targeted interventions.

Progress in elucidating the relationships between chronic oral inflammatory infections, such as periodontitis, and diabetes and glycemic control as well as other systemic conditions will require a similar intensified commitment to research. Rapid progress can also occur with efforts in the area of the natural repair and regeneration of oral tissues and organs. Improvements in oral health depend on multidisciplinary and interdisciplinary approaches to biomedical and behavioral research, including partnerships among researchers in the life and physical sciences, and on the ability of practitioners and the public to apply research findings effectively.

Build an effective health infrastructure that meets the oral health needs of all Americans and integrates oral health effectively into overall health. The public health capacity for addressing oral health is dilute and not integrated with other public health programs. Although the Healthy People 2010 objectives provide a blueprint for outcome measures, a national public health plan for oral health does not exist. Furthermore, local, state, and federal resources are limited in the personnel, equipment, and facilities available to support oral health programs. There is also a lack of available trained public health practitioners knowledgeable about oral health. As a result, existing disease prevention programs are not being implemented in many communities, creating gaps in prevention and care that affect the nation’s neediest populations. Indeed, cutbacks in many state budgets have reduced staffing of state and territorial dental programs and curtailed oral health promotion and disease prevention efforts. An enhanced public health infrastructure would facilitate the development of strengthened partnerships with private practitioners, other public programs, and voluntary groups.

A closer look at trends in the workforce discloses a worrisome shortfall in the numbers of men and women choosing careers in oral health education and research. Government and private sector leaders are aware of the problem and are discussing ways to increase and diversify the talent pool, including easing the financial burden of professional education, but additional incentives may be necessary.

Remove known barriers between people and oral health services. This report presents data on access, utilization, financing, and reimbursement of oral health care; provides additional data on the extent of the barriers; and points to the need for public-private partnerships in seeking solutions. The data indicate that lack of dental insurance, private or public, is one of several impediments to obtaining oral health care and accounts in part for the generally poorer oral health of those who live at or near the poverty line, lack health insurance, or lose their insurance upon retirement. The level of reimbursement for services also has been reported to be a problem and a disincentive to the participation of providers in certain public programs. Professional organizations and government agencies are cognizant of these problems and are exploring solutions that merit evaluation. Particular concern has been expressed about the nation’s children, and initiatives such as the State Children’s Health Insurance Program, while not mandating coverage for oral health services, are a positive step. In addition, individuals whose health is physically, mentally, and emotionally compromised need comprehensive integrated care.

Use public-private partnerships to improve the oral health of those who still suffer disproportionately from oral diseases. The collective and complementary talents of public health agencies, private industry, social services organizations, educators, health care providers, researchers, the media, community leaders, voluntary health organizations and consumer groups, and concerned citizens are vital if America is not just to reduce, but to eliminate, health disparities. This report highlights variations in oral and general health within and across all population groups. Increased public-private partnerships are needed to educate the public, to educate health professionals, to conduct research, and to provide health care services and programs. These partnerships can build and strengthen cross-disciplinary, culturally competent, community-based, and community-wide efforts and demonstration programs to expand initiatives for health promotion and disease prevention. Examples of such efforts include programs to prevent tobacco use, promote better dietary choices, and encourage the use of protective gear to prevent sports injuries. In this way, partnerships uniting sports organizations, schools, churches, and other community groups and leaders, working in concert with the health community, can contribute to improved oral and general health.

Conclusion

The past half century has seen the meaning of oral health evolve from a narrow focus on teeth and gingiva to the recognition that the mouth is the center of vital tissues and functions that are critical to total health and well-being across the life span. The mouth as a mirror of health or disease, as a sentinel or early warning system, as an accessible model for the study of other tissues and organs, and as a potential source of pathology affecting other systems and organs has been described in earlier chapters and provides the impetus for extensive future research. Past discoveries have enabled Americans today to enjoy far better oral health than their forebears a century ago. But the evidence that not all Americans have achieved the same level of oral health and well-being stands as a major challenge, one that demands the best efforts of public and private agencies and individuals.

References

Health Care Financing Administration (HCFA), National Health Expenditures projections: 1998-2008. Office of the Actuary. http://www.hcfa.gov/stats/NHE-Proj/. 2000 Apr 25.

US Department of Health and Human Services (USDHHS), Healthy People 2010 (Conference Edition, in two volumes). Washington; 2000 Jan.

US General Accounting Office (GAO), Oral health in low-income populations. GAO/HEHS-00-72. 2000 Apr.

Project Team

Caswell A. Evans, DDS, MPH, project director and executive editor, assistant director, Los Angeles County Department of Health Services

Dushanka V. Kleinman, DDS, MScD, co-executive editor, and deputy director, National Institute of Dental and Craniofacial Research, National Institutes of Health

William R. Maas, DDS, MPH, MS, chief dental officer, U.S. Public Health Service; director, Division of Oral Health Centers for Disease Control and Prevention

Harold C. Slavkin DDS, director, National Institute of Dental and Craniofacial Research
National Institutes of Health

Joan S. Wilentz, MA, science writer and editor

Roseanne Price, ELS, editor

Marla Fogelman, editor

Table. 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 more than 2.5 times the number who lack 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 is the single most common chronic childhood disease -- five times more common than asthma and seven times more common than hay fever.

* More than 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 ago.

* 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 family of four) have more severe and untreated decay.

* Unintentional injuries -- many of which include head, mouth, and neck injuries -- are common in children.

* Intentional injuries commonly affect the craniofacial tissues.

* Tobacco-related oral lesions are prevalent in adolescents who currently use smokeless tobacco.

* 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 three 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 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 mm of periodontal attachment loss) affects about 14 percent of adults aged 45 to 54.

* Clinical symptoms of viral infections, such as herpes labialis and oral ulcers are common in adulthood, affecting about 19 percent of adults 25 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 as eating, swallowing, and speech. Twenty-two percent of adults reported some form of oral-facial pain in the past six months. Pain is a major component of trigeminal neuralgia, facial shingles (post-herpetic neuralgia), temporomandibular disorders, fibromyalgia, and Bell’s palsy.

* Population growth and diagnostics that are enabling earlier detection of cancer mean that more patients are undergoing cancer treatments. More than 400,000 of these patients will develop oral complications every year.

* 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 without 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 months. Those with incomes 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 level.

Older Adults

* Twenty-three percent of 65- to 74-year-olds have severe periodontal disease (measured as 6 mm of periodontal attachment loss). (Also, at all ages, men are more likely than women to have more severe disease; 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 five-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.