Oral Health, U.S. 2002 Annual Report
EXECUTIVE SUMMARY
The goal of Oral Health U.S., 2002 is to provide an easily accessible
compilation of indicators that utilize most recent national data available to
describe the current status of oral and craniofacial health. Wherever possible
trends in national data are examined. Subsequent volumes of the annual report
will allow changes over time to be clearly visualized. The format used
emphasizes discrete bullets and graphical presentation. Data tables are
gathered in a single section at the end of the report to provide more detailed
information.
Organization of Oral Health U.S., 2002
The report is divided into 17 sections, encompassing clinical indicators,
delivery of services, accessibility to care, the impact of oral diseases, and
links to systemic health. Those indicators explicitly discussed in Healthy
People 2010 objectives are indicated by an asterisk in the Table of Contents.
Technical notes briefly describe the national surveys used as the major data
sources. In some cases publications have been used as data sources when they
represent rigorous analyses of current national data or when national data are
not available. In addition, technical notes also describe the analytic
methodology used.
Oral Health Indicators
The first section deals with dental caries, the most common infectious disease
of childhood. By their senior year in high school 80% of adolescents in the
United States have had at least one carious lesion. Untreated dental caries may
result in pain, infection, and potential tooth loss. Among children and adults,
a higher percentage of Mexican Americans and non-Hispanic blacks have untreated
decay than do non-Hispanic whites. Poverty and lower education levels are also
associated with untreated decay.
Section 2 deals with preventive interventions that reduce caries. Fluoride, in
the water supply, toothpaste, rinses, and tablets, or applied by a dental
professional, has had a major impact on caries. It is estimated that 87% of the
U.S. population uses a public water system and 66% of these people receive
optimally fluoridated water.
Dental sealants are particularly effective in preventing dental caries on pits
and fissures. A higher percentage of non-Hispanic white children and
adolescents receive sealants than do either non-Hispanic blacks or Mexican
Americans. A higher percentage of children with sealants also come from
families with higher incomes. Although the American Dental Association
recognized the effectiveness of sealants in the 1970s, the majority of children
do not yet receive sealants. The demographic distribution of sealant usage
suggests that many of the children most at risk for caries do not get sealants.
Section 3 addresses periodontal disease prevalence and severity. Gingivitis, a
mild, reversible form of periodontal disease involving inflammation and
bleeding of the gums, is found in 54% of the U.S. population aged 20 years and
older. Destructive periodontitis, defined in the Healthy People 2010 objectives
as one or more sites with 4 millimeters of loss of attachment, affects
approximately 26% of those 20 years of age or older. Cigarette smoking is a
major risk factor. Periodontal disease is also more common in diabetics and in
people who are older, male, and non-Hispanic black.
Today most younger people anticipate keeping their teeth into old age.
Approximately 30% of the adult U.S. population have not lost any teeth to oral
disease. A higher percentage of people who are younger, better educated, have
higher incomes, and are non-Hispanic white or Mexican American are in this
group (section 4). Twenty-five percent of Americans aged 65 to 74 years are
edentulous. Edentulism can have a major influence on quality of life. Its
effects can be minimized by the use of well-fitting dentures. Dentures are worn
by the vast majority (83%) of individuals who are edentulous in either or both
arches.
The relationship between a clinical measure of oral health status and a person's
self-perception of health is not always straightforward. Some individuals have
low expectations for their oral health and may be, in some sense, satisfied at
levels that are not professionally acceptable. A higher percentage of people
who are younger, better educated, have never smoked, and live above the poverty
line assess their oral health status as good or better. Mexican Americans are
less likely than non-Hispanic whites or blacks to assess their oral health
status favorably (section 5).
Oral health is also affected by congenital anomalies, infections not associated
with dental caries, pain, and craniofacial injuries. These are discussed in
sections 9 through 11. Orofacial pain represents approximately 40% of the cost
of chronic pain in the United States. Emergency room visits for craniofacial
injuries comprise 11.3% percent of all emergency room visits.
Access to oral health care is discussed from several perspectives in section 7.
The use of dental services in the United States varies greatly according to
sociodemographic factors. However, even when poverty status and dental
insurance are accounted for, non-Hispanic blacks and Hispanics are less likely
to visit a dentist than are non-Hispanic whites.
Several national surveys provide estimates of the oral health care system use.
Recent Medical Expenditure Panel Surveys (MEPS) reported that about 40-45% of
the U.S. population visited a dentist in the past year. People who were
younger, female, better educated and had a higher income were more likely to
have seen a dentist in the past year. A higher percentage of children age 2 to
14 had a dental visit than any other age group.
Preventive services, including examinations, dental prophylaxes, radiographs,
fluoride treatments, and restorations, are an important component of oral
health care. Data from the 1997 MEPS suggested that a higher percentage of
non-Hispanic whites received preventive services than did Hispanics or
non-Hispanic blacks. This was true for both poor children and children from
higher income families. Poor children were less likely than children from
higher income families to receive preventive services.
There are a number of reasons for not seeking dental care. Cost is a major issue
for many people. In 1971-1975, 34.1% of the adult U.S. population did not
receive care for a dental problem due to cost. These individuals were likely to
be older, poorer, and female. The use of dental services is greater among
people who have a dentist to whom they usually go. In 1971-1975, 68.4% of
adults (25-74 years of age) reported having a personal dentist.
Access to care is also enhanced by adequate dental insurance. In 1997, 56% of
adults asked about dental insurance in the Behavioral Risk Factor Surveillance
System had some form of dental insurance, compared to 86% who had medical
insurance. The percentage of people with dental insurance was higher among
those with higher incomes and educational attainment. Non-Hispanic blacks were
slightly more likely than non-Hispanic whites to have dental insurance (60.8%
vs. 56.4%).
Dental care was primarily paid for out of pocket during the 1960 to 1980 period.
However, between 1980 and 1999 private dental insurance coverage increased, so
that the amounts paid out of pocket and by private dental insurance were nearly
equal. Although public funds used for dental expenses have increased slightly
over the past four decades, they are still much lower than expenditures from
either private insurance or out-of-pocket sources.
As of September 2001, only 3 states and the District of Columbia had less than
50% of their population in areas not underserved by dental health professionals
(section 16). Besides the District of Columbia, they include California, West
Virginia, and Oklahoma.
Healthy People 2010 objectives have identified increasing the numbers of health
professionals from underrepresented racial and ethnic groups as an integral
part of addressing access to care issues. Data from the American Dental
Association Survey Center indicate that in 1995-1997, 2% of dentists were black
and 3.5% were Hispanic. In 1996-1998, 16.5% of dentists were female. Most
female and minority dentists are under 40 years of age. The percentages of
black dental school graduates in 1999 and 2000 were 4.2% and 5.7%,
respectively, while 5.0% and 5.3% were Hispanic. These percentages are
considerably below the representation of these groups in the general
population.
The use of tobacco products (especially cigarette smoking) has been strongly
linked to development of numerous oral diseases, including oral and pharyngeal
cancers, and periodontal diseases (section 12). In 1999, 34.8% of high school
students reported being current smokers compared to 30.5% in 1993. Cigars are
currently used by 17.7% of high school students. In 1999, 46.5 million adults
in the United States were current smokers, including 25.7% of men and 21.5% of
women.
Smokeless tobacco use is also strongly linked to oral soft tissue lesions in
both young people and adults. Data from the 1986-1987 National Survey of Oral
Health in U.S. School Children indicated that 1.5% of students age 12 to 17 had
smokeless tobacco lesions. In NHANES III, 5.3% of adult participants also had
smokeless tobacco lesions. The prevalence of these lesions is greatest among
those 24-35 years of age. Lesions are found primarily in males. Non-Hispanic
whites are about twice as likely to have them than are non-Hispanic blacks.
Tobacco and alcohol use cause approximately 75% of oral and pharyngeal cancers.
These cancers, discussed in section 13, represent about 3% of all cancers.
Their 5-year survival rate is about 52%, which is one of the lowest for all
cancers. Oral cancer therapy is frequently associated with disfigurement,
diminished speech fluency, and difficulty in eating and swallowing and results
in substantial decreases in quality of life. Oral and pharyngeal cancers are
much more frequent in males than in females and in blacks than in whites. They
are rarely found in people below 40 years of age. Stage at diagnosis is
critical to survival, with 5-year survival rates between 1989 and 1994 of 55%
for all stages, 82% for localized, 43% for regional spread, and 21% for
individuals whose cancers had distant metastases. Blacks are significantly more
likely to be diagnosed with advanced disease than are whites and their 5-year
survival rates are much lower. The survival rate is also lower for males and
for those with lower education levels.
A screening examination consisting of visual/tactile examination of the mouth
and palpation of the tongue, floor of the mouth, and lymph nodes in the neck
can detect oral cancer at an earlier stage and lead to increased survival.
While the percentage of adults aged 40 and above who were screened in the past
year increased between 1992 (7.6%) and 1998 (14.7%), the vast majority of
people are not being screened.
Xerostomia, the perception of dry mouth, is discussed in section 14. It affects
the ability to chew, swallow, and speak. While there is sometimes no clear
relationship between xerostomia and hyposalivation, xerostomia generally occurs
when salivation levels are lower than 50% of normal range. Hyposalivation
frequently results in rampant tooth decay and can lead to other oral health
problems. There is no national prevalence data on xerostomia although data are
currently being collected. Smaller studies show a prevalence rate among older
individuals (generally age 65 and older) of about 20%, with estimates ranging
between 10% and 40%. Xerostomia is found more frequently in women than in men,
and is strongly associated with medication use.
During the last decade the importance of oral health to general health and
specific interactions between the oral and craniofacial complex and the rest of
the body have become clearer. As an example, the possible role of periodontal
disease in a range of conditions including cardiovascular disease and low birth
weight has received increased attention. Conversely, many diseases and
medications have profound oral effects. Section 15 discusses oral
manifestations of systemic diseases and the prevalence of some of these
disorders.
Conclusion
Oral Health U.S., 2002 provides a graphic overview of currently
available national oral health data. It establishes a baseline that will be
used in future reports to track trends, emerging problems, and progress in
understanding and treating conditions related to oral health and to monitor
reduction in disparities in oral health and access to oral health care.
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