Oral Health

1
Oral Health
Milestones in Public Health Chapter 9
Lectures for Graduate Public Health Education
January 2011
2
Learning Objectives

• Describe the history of dentistry in becoming a
  profession
• Discuss the impact of major innovations in dental
  health
• Describe major oral diseases
• Explain the impact of fluoridation on oral health
• Describe the impact of dental sealants on oral
  health
• Identify health disparities in oral health

3
Lecture Outline

1. Looking Back
2. Milestones in Dental Innovation
3. Oral Health and Public Health
4. The Major Oral Diseases
5. Looking Ahead Oral Health Disparities

4
Oral Health

• Looking Back

5
Looking Back

• The Earliest known dentist, Hesi-Re, lived in
  Egypt around 2600 BC, where ancient skulls have
  been found with small holes in the jaw-bone,
  possibly representing efforts to alleviate the
  pressure of abscesses, secondary complications of
  dental caries
• Royalty in ancient Egypt, who had a diet rich in
  carbohydrates, show an 80 caries rate, while
  lower class ancient Egyptians had a very low
  caries rate due to lower carbohydrate consumption
• Dentistry was a part of medicine in ancient
  Mesopotamia. The code of Hammurabi (1900 BC)
  reveals that the government regulated the medical
  profession (including dentistry) as far back as
  2500 BC

Pfizer Inc. (2006). Chapter 9 Oral health
Looking back. In Milestones in public health
Accomplishments in public health over the last
100 year. (p.171). New York, NY Pfizer Inc.
6
Looking BackDentistry Becomes a Profession

• Historically, scientists, educators, and
  practitioners in the health field have
  disconnected the mouth from the rest of the body.
  As a result of the Maryland legislatures
  unwillingness to incorporate dentistry as a
  department at the University of Maryland medical
  school due to attendant costs, dentistry did not
  become a medical specialty, but rather its own
  discipline
• Dr. Chapin A. Harris, considered the father of
  American dental sciences, along with Dr. Horace
  H. Hayden, co-founded the Baltimore College of
  Dental Surgery, the world's first dental college,
  in 1840. Between 1840 and 1867, nine more
  freestanding dental schools were founded using
  the Baltimore model

7
Looking BackDentistry Becomes a Profession
(Cont.)

• In 1867, Harvard established the Harvard School
  of Dental Medicine in association with the
  Massachusetts General Hospital, becoming the
  first university-affiliated dental school
• By 1870, 85 of the 8,000 practicing dentists in
  the U.S. had trained under preceptors, or
  declared themselves as dentists, while only 15
  had graduated from dental schools
• According to the Bills of Mortality, dental
  infections and complications represented a
  leading cause of death during this time

Pfizer Inc. (2006). Chapter 9 Oral health
Looking back. In Milestones in public health
Accomplishments in public health over the last
100 year. (p.169). New York, NY Pfizer Inc.
8
Looking Back Dentistry Becomes a Profession
(Cont.)

• With the advent of more dental schools in the
  U.S. in the late 1800s, fewer dentists employed
  the preceptorship model for their education, and
  dental school graduates began to dominate the
  ranks of their profession
• By the mid 1920s, less than 3 of practicing
  dentists had trained under preceptorship
  arrangements
• The 1926 Gies Report advocated that incoming
  dental students should have at least two years of
  university education in addition to instruction
  on the basic biology of oral structure and the
  pathology of oral facial disease

Pfizer Inc. (2006). Chapter 9 Oral health
Looking back. In Milestones in public health
Accomplishments in public health over the last
100 year. (p.170). New York, NY Pfizer Inc.
9
Looking BackDentistry Becomes a Profession
(Cont.)

• According to Dr. Allan Formicola, president of
  the William J. Gies Foundation, the field of
  dentistry moved closer to becoming an oral
  specialty of medicine as a result of the Gies
  Report
• The report established stricter accreditation
  standards and admission requirements to dental
  schools
• This higher bar raised the caliber of and
  quality of dental students and education, and led
  to a new respect for dentistry

Dougherty, M. (2003, March 26). A biochemist who
lead dental history William Gies' 1926 report on
dental education is still relevant today. In
VIVO Columbia University Health Sciences, 2(6).
Retrieved June 13, 2010 from http//cumc.columbia.
edu/publications/in-vivo/Vol2_Iss06_mar26_03/medic
al-history.html
10
Looking BackDentistry Becomes a Profession
(Cont.)

• However, dental schools and dental societies
  continued to operate separately from medical
  schools and societies, and subsequently many
  health care professionals were never fully
  educated on the impact of oral disease on overall
  health

Pfizer Inc. (2006). Chapter 9 Oral health
Looking back. In Milestones in public health
Accomplishments in public health over the last
100 year. (p.169). New York, NY Pfizer Inc.
11
Looking BackDentistry Becomes a Profession
(Cont.)

• The dental health profession includes
• Dentists, dental hygienists, dental assistants,
  and dental laboratory technicians
• There are nine dental specialties
• Dental public health, endontics, oral and
  maxillofacial surgery, oral pathology,
  orthodontics, pediatric dentistry, periodontics,
  prosthodontics, and radiology

12
Oral Health

• Milestones in Dental Innovation

13
Milestones in Dental Innovations

• While significant improvements in preventive
  dentistry and oral health have occurred since
  dentistry became a profession in 1839, presently,
  the silent epidemic of tooth decay
  disproportionately affects the
• uninsured, inner-city and rural, low-income,
  developmentally disabled, homebound, and homeless
  populations

Pfizer Inc. (2006). Chapter 9 Oral health
Looking back. In Milestones in public health
Accomplishments in public health over the last
100 year. (p.170). New York, NY Pfizer Inc.
14
Milestones in Dental Innovations (Cont.)

• Toothbrushes
• Chewsticks, the first toothbrushes, borrowed from
  the Chinese and from Babylonians
• Tooth brushing became a daily routine after World
  War II
• Rejection rate of draftees during World War II
  due to oral health had been so high that
  standards had been lowered to meet targets

15
Milestones in Dental Innovations (Cont.)

• Toothpaste
• Origins of toothpaste can be traced back to
  ancient India and China as far back as 500 BC. In
  the 19th century, toothpaste more similar to what
  we know today was developed
• Procter and Gamble introduced fluoride in
  toothpaste in 1956, which is necessary to prevent
  tooth decay
• Without fluoride, toothpaste can help prevent gum
  disease but not tooth decay

16
Milestones in Dental Innovations (Cont.)

• Novocain
• Developed in 1905 by Alfred Einhorn as an
  analgesic substitute for cocaine in 1905. The
  trade name Novocain comes from a combination of
  the Latin word "novus," meaning "new," plus
  "cocaine"
• Dental Floss
• Silk thread floss developed by Levi Spear Parmly
  in 1815 and patented by Johnson and Johnson in
  1898
• Dr. Charles C. Bass (a physician) developed nylon
  floss and promoted its use during World War II
• Mouth Rinses and High Speed Drill

17
Oral Health

• Oral Health and Public Health

18

• Oral diseases are a neglected epidemic in our
  country, and the oral health disparities of the
  underserved are shameful. We need to reconnect
  the mouth to the rest of the body.
• Dr. Myron Allukianformer director of Oral
  Health Boston Public Health Commission

19
Oral Health and Public Health

• In spite of these milestones in dental
  innovations, presently, poor oral health
  continues to exist as a silent epidemic, where
  underserved populations disproportionately suffer
  from major and often preventable oral diseases,
  which results in great societal costs

20
Oral Health

• The Major Oral Diseases

21
Major Oral Diseases Dental Caries

• The most common chronic disease among children 5
  to 17 years five times more common than asthma
• Bacteria occur normally in the mouth
• Plaque begins to build up on teeth within 20
  minutes after eating (the time when most
  bacterial activity occurs). If this plaque is not
  removed thoroughly and routinely, tooth decay
  will begin and flourish

National Institute of Dental and Craniofacial
Research. (2010). Oral health in America A
report of the Surgeon General (executive
summary). Retrieved 6/13/2010 from
http//www.nidcr.nih.gov/DataStatistics/SurgeonGen
eral/Report/ExecutiveSummary.htm
22
Major Oral Diseases Dental Caries (Cont.)

• The acids in plaque dissolve the enamel
  surface of the tooth and create holes in the
  tooth (cavities). Cavities are usually painless
  until they grow very large and affect nerves or
  cause a tooth fracture. If left untreated, a
  tooth abscess can develop. Untreated tooth decay
  also destroys the internal structures of the
  tooth (pulp) and ultimately causes the loss of
  the tooth.

MedlinePlus. (2010). Dental cavities Cavities
are holes, or structural damage, in the teeth.
Retrieved 6/13/2010 from http//www.nlm.nih.gov/me
dlineplus/ency/article/001055.htm
23
Preventable Complications of Dental Caries Tooth
Abscesses
MedlinePlus.(2010). Tooth abscess Online image.
Retrieved 8/26/2008 from http//www.nlm.nih.gov/m
edlineplus/ency/imagepages/9979.htm
24
Early Childhood Caries

• Early childhood caries (ECC), also referred to as
  baby bottle tooth decay, stems from sweetened
  liquids that cling to the infants teeth
• ECC often occurs when a baby is regularly given a
  bottle with sugary liquid at bedtime or nap-time,
  most often affects the upper front teeth, and can
  cause severe tooth decay
• Although a preventable disease, ECC is prevalent
  in low-income families, and can cost as much as
  6,000 per child to treat (as general anesthesia
  may be required)

National Library of Medicine. Baby bottle tooth
decay Online image. Retrieved June 13, 2010
from http//www.nlm.nih.gov/medlineplus/mobileimag
es/ency/fullsize/9090_xlfs.png
25
Prevention of Dental Caries

• Good oral hygiene consists of
• Undergoing regular professional teeth cleaning
  every 6 months, brushing at least twice a day,
  flossing at least daily, and having x-rays done
  on a yearly basis
• Eating chewy, sticky foods (such as dried fruit
  or candy) as part of a meal rather than as a
  snack, and brushing the teeth or rinsing the
  mouth with water after eating these foods
• Minimizing snacking, which creates a constant
  supply of acid in the mouth
• Avoiding constant sipping of sugary drinks or
  frequent sucking on candy and mints

MedlinePlus. (2010). Tooth abscess in Dental
cavities Cavities are holes, or structural
damage, in the teeth. Retrieved 6/13/2008 from
http//www.nlm.nih.gov/medlineplus/ency/article/00
1055.htm
26
Prevention of Dental Caries Dental Sealants

• Dental sealants, thin plastic-like coating
  applied to the chewing surfaces of the molars can
  prevent cavities, as they block the accumulation
  of plaque in the deep grooves on vulnerable
  surfaces
• While sealants are generally applied on teeth of
  children, shortly after the molars erupt, older
  individuals may also benefit from their use

MedlinePlus. (2010). Tooth abscess in Dental
cavities Cavities are holes, or structural
damage, in the teeth. Retrieved 6/13/2008 from
http//www.nlm.nih.gov/medlineplus/ency/article/00
1055.htm
27
Prevention of Dental Caries Fluoride

• Fluoride is often recommended to protect against
  dental caries as studies have shown that people
  who ingest fluoride in their drinking water or by
  fluoride supplements have fewer dental caries.
  Fluoride protects the enamel against the action
  of acids
• Topical fluoride is also recommended to protect
  the surface of the teeth. This may include a
  fluoride toothpaste or mouthwash. Many dentists
  include application of topical fluoride solutions
  (applied to a localized area of the teeth) as
  part of routine visit"

MedlinePlus. (2010). Tooth abscess in Dental
cavities Cavities are holes, or structural
damage, in the teeth. Retrieved 6/13/2008 from
http//www.nlm.nih.gov/medlineplus/ency/article/00
1055.htm
28
Prevention of Dental Caries Community Water
Fluoridation

• Community water fluoridation has been ranked one
  of 10 great public health achievements in the
  20th century
• Fluoride occurs naturally in all drinking water
  in varying concentrations, according to
  geological features
• In 1931, Dr. Frederick S. McKay, proved that
  naturally occurring fluoride in the water supply
  could inhibit dental caries

Centers for Disease Control and Prevention (n.d.)
Preventing Chronic Diseases Invetsing Wisely in
Health - Preventing Dental Caries. Retrieved
8/26/2008 from http//www.dental.ufl.edu/Patients
/Files/PreventingDentalCaries.pdf
Pfizer Inc. (2006). Chapter 9 Oral health Case
study. In Milestones in public health
Accomplishments in public health over the last
100 year. (pp.176-178). New York, NY Pfizer Inc.
29
Prevention of Dental Caries Community Water
Fluoridation (Cont.)

• Dr. McKay collaborated with Dr. H. Treandly, Dean
  of the U.S. Public Health Service, to identify an
  adjusted fluoridation standard that would have
  the benefit of reducing dental caries while
  avoiding tooth discoloration
• Drs. McKay and Treandly concluded that the water
  fluoride standard should be one part per million.
  Several subsequent studies proved that this
  standard provided optimum dental caries
  protection with minimum staining of the teeth

Pfizer Inc. (2006). Chapter 9 Oral health. In
Milestones in public health Accomplishments in
public health over the last 100 year. (p. 178).
New York, NY Pfizer Inc.
30
Prevention of Dental Caries Community Water
Fluoridation (Cont.)

• In 1945, Grand Rapids, Michigan became the first
  city in the world to adjust its fluoride
  concentration to the new adjusted fluoride
  standard
• In 1950, the U.S. Public Health Service
  recommended community water fluoridation as a
  public health measure
• By the early 1980s, epidemiologic studies
  revealed that the prevalence of caries was
  decreasing throughout the U.S.

Pfizer Inc. (2006). Chapter 9 Oral health. In
Milestones in public health Accomplishments in
public health over the last 100 year. (pp.
178-179). New York, NY Pfizer Inc.
31
Prevention of Dental Caries Community Water
Fluoridation (Cont.)

• In 2005, 170 million people in the U.S. lived in
  fluoridated communities, including about 10
  million who lived in communities with naturally
  fluoridated water supplies
• The majority of communities (91) fluoridate
  administratively through local or state
  government
• In 2005, an additional 30-40 million people were
  estimated to live without public water supplies,
  depending on sources such as natural springs or
  drilled wells

Pfizer Inc. (2006). Chapter 9 Oral health. In
Milestones in public health Accomplishments in
public health over the last 100 year. (p. 179).
New York, NY Pfizer Inc.
32
Prevention of Dental Caries Community Water
Fluoridation (Cont.)

• Yet, community water fluoridation remains
  controversial to some people who oppose any form
  of government intervention and regard
  fluoridation as forced medication and violation
  of personal freedom
• In 2002 and 2004, 26 communities across the U.S.
  voted in referenda for fluoridation

Pfizer Inc. (2006). Chapter 9 Oral health. In
Milestones in public health Accomplishments in
public health over the last 100 year. (p. 180).
New York, NY Pfizer Inc.
33
Prevention of Dental Caries Community Water
Fluoridation (Cont.)

• 66 of individuals on public water systems more
  than 162 million people receive community water
  fluoridation
• Community water fluoridation effectively
  prevents dental caries in communities with
  varying disease prevalence
• Children in communities with water fluoridation
  experienced 29 fewer cavities

Centers for Disease Control and Prevention.
(n.d.). Preventing Chronic Diseases Invetsing
Wisely in Health - Preventing Dental Caries.
Retrieved August 26, 2008 from
http//www.dental.ufl.edu/Patients/Files/Preventin
gDentalCaries.pdf
34
Gum Diseases Gingivitis
MedlinePlus. (2009). Medical Encyclopedia,
Gingivitis Online image. Retrieved August
26,2008 from http//www.nlm.nih.gov/medlineplus/en
cy/imagepages/1136.htm
35
Gum Diseases Gingivitis (Cont.)

• Localized infection or inflammation of the soft
  tissues characterized by swelling and bleeding of
  the gums
• Bacteria in plaque around the teeth release
  enzymes (collagenases) that can erode the gum
  tissues.
• The inflamed gums swell, recede, bleed easily,
  and can loosen from the teeth
• Good oral hygiene is the best prevention against
  gingivitis because it removes the plaque that
  causes the disorder

MedlinePlus. (2010). Gingivitis is inflammation
of the gums (gingiva). Retrieved 6/13/2010 from
http//www.nlm.nih.gov/medlineplus/ency/article/00
1056.htm
36
Gum Diseases

• Peridontitis
• Also an infection of the soft tissues, involves
  the supporting alveolar bone around teeth with
  loss of peridontal attachment
• Prevalence increases with age and the condition
  disproportionately affects immunosuppressed
  individuals (e.g. HIV/AIDS)

37
Oral Cancer
Source (n.d.) Courtesy of Sonny Johansson, MD,
PhD image.
38
Oral Cancer (Cont.)

• Oral cancer includes cancers of the mouth and the
  pharynx, part of the throat
• About two-thirds of oral cancers occur in the
  mouth and about one-third are found in the
  pharynx
• An estimated 35,000 Americans will be diagnosed
  this year and approximately 7,500 deaths will
  occur from the disease 

National Institute of Dental and Craniofacial
Research. (2010). Oral cancer. Retrieved
5/15/2009 from http//www.nidcr.nih.gov/OralHealth
/Topics/OralCancer/OralCancer.htm
39
Oral Health

• Looking Ahead Oral Health Disparities

40
Looking Ahead Oral Diseases, Still a Neglected
Epidemic

• There are profound and consequential oral health
  disparities within the U.S. population
• The burden of oral diseases and conditions is
  disproportionately borne by individuals with low
  socioeconomic status at each life stage and by
  those who are vulnerable because of poor general
  health

US. Department of Health and Human Services.
(2003).  National call To action to promote oral
health A public-private partnership under the
leadership of The Office of the Surgeon General .
(No. 03-5303). Rockville, MD National Institutes
of Health
41
What Are Health Disparities?

• Differences in the incidence, prevalence,
  mortality, and burden of diseases and other
  health conditions that exist among specific
  population groups
• National Institutes of
  Health, US Department of Health and Human
  Services
• Differences in the incidence or prevalence of
  disease disability, or illness. These
  differences can be among racial/ethnic groups,
  socioeconomic groupings, gender groups, or other
  groupings

LaVeist, T. A. (2005). Minority Populations and
Health, An Introduction to Health Disparities in
the United States. San Francisco, CA Jossey-Bass
A Wiley
42
Oral Health Disparities

• According to the Surgeon General
• Poor children suffer twice as much dental caries
  as their more affluent peers
• Children living below the poverty line (annual
  income of 17,000 for a family of four) have more
  severe and untreated tooth decay

US. Department of Health and Human Services.
(2003).  National call To action to promote oral
health A public-private partnership under the
leadership of The Office of the Surgeon General .
(No. 03-5303). Rockville, MD National Institutes
of Health
43
What Factors Determine Oral Health?

• The major factors that determine oral and
  general health and well-being are
• Individual biology and genetics
• Environment, including its physical and
  socioeconomic aspects
• Personal behaviors and lifestyle
• Access to care
• Organization of health care
• These factors interact over the life span and
  determine the health of individuals, population
  groups, communities from neighborhoods to
  nations

US. Department of Health and Human Services.
(2003).  National call To action to promote oral
health A public-private partnership under the
leadership of The Office of the Surgeon General .
(No. 03-5303). Rockville, MD National Institutes
of Health
44
Determinants of Population Health

• Living and working conditions may include
• Psychosocial factors
• Employment status and occupational factors
• Socioeconomic status (income, education,
  occupation)
• The natural and builtc environments
• Public health services
• Health care services

Broad social, economic, cultural,
health, and environmental conditions
and policies at the global, national, state, and
local levels
Living and working conditions
Social, family and community networks
Individual behavior
Innate individual traits age, sex, race,
and biological factors --- The biology of disease
Over the life span
b
SOURCE The Future of the Publics Health (IOM,
2003) NOTES Adapted from Dahlgren and Whitehead,
1991. The dotted lines denote interaction
effects between and among the various levels of
health determinants (Worthman, 1999).
45
Access to Care

• Access to care makes a difference. A complex
  set of factors underlies access to care and
  includes the need to have an informed public and
  policymakers, integrated and culturally competent
  programs, and resources to pay and reimburse for
  the care. Among other factors, the availability
  of insurance increases access to care
• 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

US. Department of Health and Human Services.
(2003).  National call To action to promote oral
health A public-private partnership under the
leadership of The Office of the Surgeon General .
(No. 03-5303). Rockville, MD National Institutes
of Health
46
Medical Insurance and Access to Dental Care

• 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.

US. Department of Health and Human Services.
(2003).  National call To action to promote oral
health A public-private partnership under the
leadership of The Office of the Surgeon General .
(No. 03-5303). Rockville, MD National Institutes
of Health
47
Medicaid

• Medicaid is available only to certain low-income
  individuals and families who fit into an
  eligibility group that is recognized by federal
  and state law
• Medicaid is a state-administered program and each
  state sets its own guidelines regarding
  eligibility and services

Centers for Medicare Medicaid Services. (2010).
Overview Medicaid program - general information.
Retrieved 6/13/2010 from http//www.cms.gov/Medica
idGenInfo/
48
Medicaid and Dental Care

• 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

US. Department of Health and Human Services.
(2003).  National call To action to promote oral
health A public-private partnership under the
leadership of The Office of the Surgeon General .
(No. 03-5303). Rockville, MD National Institutes
of Health
49
Improving Oral Health in the U.S. Public Private
Partnerships

• 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.

US. Department of Health and Human Services.
(2003).  National call To action to promote oral
health A public-private partnership under the
leadership of The Office of the Surgeon General .
(No. 03-5303). Rockville, MD National Institutes
of Health
50
Public Private Partnerships in Oral Health

• Crest Healthy Smiles 2010
• Campaign addressing tooth decay in children
• Initiated by Proctor and Gamble in partnership
  with American Dental Association, Boys and Girls
  Clubs of America, and the American Academy of
  Dentistry
• Aims to reach 50 million children through full
  service dental clinics at Boys and Girls Clubs,
  oral health instruction, and preventive services
  provided by dental students in schools

Pfizer Inc. (2006). Chapter 9 Oral health
Looking back. In Milestones in public health
Accomplishments in public health over the last
100 year. (p.186). New York, NY Pfizer Inc.
51
Public Private Partnerships in Oral Health (Cont.)

• Case Western Sealant Program
• Case Western dental students apply sealants to
  the teeth of 15,000 second and sixth graders in
  Cleveland Public Schools every year

Pfizer Inc. (2006). Chapter 9 Oral health
Looking back. In Milestones in public health
Accomplishments in public health over the last
100 year. (p.187). New York, NY Pfizer Inc.
52
Conclusions

• Public health measures such as community water
  fluoridation and school-based dental sealant
  programs play an important role in addressing the
  neglected epidemic of oral disease
• Government support of dental health
  infrastructure through expanded dental insurance
  coverage, in addition to the creation of more
  public private partnerships may also improve the
  oral health of Americans