Oral Health in the United States

In the United States, progress has been made in reducing the extent and severity of common oral diseases.1,11,12 Over the past half century, major strides in oral health have been seen nationally for many Americans, yet oral diseases remain common and widespread in the United States.^1,11–16 Oral diseases and conditions still afflict most people at some time throughout their lifespan.^1,13

Factors that contribute to this burden of oral disease include poverty, literacy levels, limited oral health education and promotion efforts, and lack of access to timely and affordable clinical oral health services.* In addition to poor living conditions, major risk factors relate to unhealthy lifestyles (e.g., poor diet and nutrition, oral hygiene, use of tobacco and alcohol, etc.) and limited availability and accessibility of clinical oral health services. Several oral diseases are linked to noncommunicable chronic diseases primarily because of common risk factors. Moreover, general diseases often have oral manifestations (e.g., diabetes or HIV/AIDS). Furthermore, many communities lack dental public health programs, face limited capacity for oral health services, and have inadequate facilities and an inequitable distribution of dental professionals.†

Safe and effective disease prevention measures do exist to improve oral health and prevent oral disease.† These preventive measures include population-based measures (e.g., community water fluoridation, tobacco cessation programs, and school-based dental sealant and fluoride programs), self-care (e.g., daily oral hygiene, healthy diets), and personal oral health services (e.g., clinical dental visits, examination for oral cancer).^18–27 However, these measures are not consistently used by individuals or promoted by professionals and communities. In addition, several nations have not assured universal access to community preventive services such as community water fluoridation, salt fluoridation, school-based dental sealants, or oral health promotion in schools. For example, 31% of persons on public water supplies do not receive fluoridated water in the United States.²⁸ Furthermore, 68% of 8-year-old children and 86% of 14-year-old adolescents have not received any dental sealants on a permanent molar tooth in the United States, according to the 1999–2004 National Health and Nutrition Examination Survey (NHANES).^1,13 Preventive measures need to be adopted and applied by communities, individuals, and professionals to ensure marked improvements of the nation’s oral health.†

Social Impact of Oral Diseases

Oral diseases are progressive and cumulative and become more complex over time.11,12,23 These diseases can jeopardize physical growth, development, self-concept, and the capacity to learn. They influence eating and communicating.²⁹ Oral diseases affect economic productivity and compromise a person’s ability to work at home or on the job or to concentrate in school.^30,31

The social impact of oral disease is substantial.30,31 More than 51 million school hours are lost each year as a result of dental problems.¹¹ Poor children experience nearly 12 times more restricted activity days than their counterparts from higher income families. Among those who lost school time, youngsters from low-income families, members of minority communities, and families without insurance missed more hours.³⁰ Children with early childhood caries—often a severe and painful form of dental caries—can demonstrate failure to thrive and be underweight.³² Serious lifetime functional, aesthetic, and social consequences can be outcomes for children and adults with severe developmental and acquired oral and facial conditions.¹¹ The Centers for Disease Control and Prevention (CDC) estimated that 16.2 years of life were lost per person who died prematurely of oral and pharyngeal cancer.¹¹ This figure exceeds the average 15.4 years lost for all cancer sites.

Dental diseases in adults affect their economic productivity and compromise their ability to get jobs. Employed American adults lose more than 164 million hours of work each year because of dental disease or dental visits.¹¹ Among those who miss work, women, African Americans, low-wage earners, employees with less education, and the uninsured miss the greatest number of hours. Employees of service industries lose from 2 to 3.5 times more hours of work than executives or professional workers.³¹

Oral diseases influence an individual’s ability to eat, communicate, and interact in society.²⁹ The 2003–2004 NHANES evaluated oral health quality of life for the first time using a subset of seven Oral Health Impact Profile (OHIP) questions (e.g., the NHANES-OHIP among dentate adults aged 18 years and older as shown in Table 5-1).²⁹ The survey found that 6.8% of dentate individuals reported painful aching in mouth fairly often or very often, whereas 12.7% indicated this occurred occasionally.²⁹ Another 6.4% reported being self-conscious or embarrassed because of their teeth or mouth fairly often or very often, and 6.5% responded that this happened occasionally. Among adults, 5.6% reported that eating was uncomfortable fairly often or very often, and 11.2% stated occasional discomfort when eating foods because of problems with their teeth or mouth.

A study supported by the WHO found that among Navajo schoolchildren living in parts of the Navajo reservation in Arizona and New Mexico, 25% avoided laughing or smiling and 20% avoided meeting other people because of the way their teeth looked. Because of dental pain, almost 25% of Navajo adults were unable to chew hard foods, and nearly 20% reported difficulty sleeping.³³

Despite a tremendous decline in dental caries in children in the United States since the 1950s, tooth decay remains the single most common chronic disease of childhood.¹¹ It is five times more common than asthma and seven times more common than hay fever.¹¹

Early childhood caries affects the primary teeth of infants and young children 1 to 5 years of age.¹⁵ Sometimes referred to as baby bottle tooth decay or nursing caries, it can be a devastating condition, often requiring thousands of dollars and a hospital visit with general anesthesia during treatment.⁴⁰ Substantial pain, psychologic stress, health risks, and expense are associated with restorative care for children affected by early childhood caries.⁴¹ Infant feeding practices, in which children are put to bed with formula or other sweetened drinks and fall asleep while feeding, have been associated with this condition.⁴¹

The average number of decayed and filled teeth (DFT) among 2- to 4-year-olds remained unchanged over the 25 years leading to 2000.¹⁵ According to the NHANES, 25% of young children 2 to 4 years of age experienced dental caries in their primary dentition during the years 1999–2004, which is an increase from 18% in 1988–1994.^1,13 Of these children, 19% had untreated caries in their primary teeth. Eighty-one percent of these children were free of dental caries.

The prevalence of dental caries among school-age children declined within the United States in the 1980s and 1990s. The decline is the result of various preventive measures such as community water fluoridation and increased use of fluoride toothpastes and mouthrinses, as well as the application of dental sealants.¹¹ But these improvements for children seemed to have stalled and for some indicators actually regressed in the 2000s.¹³ More than half (53%) of children aged 6 to 8 years experienced dental caries in their primary or permanent teeth in 1999–2004, according to the NHANES.^1,13 This proportion has increased from 52% in the years 1988–1994.

The proportion of untreated dental caries in school-age children has plateaued overall.¹³ Twenty-nine percent of 6- to 8-year-olds had untreated dental caries in 1999–2004, up from 28% in 1988–1994.^1,13 In the years 1988–1994, by the third grade, 60% of students had experienced tooth decay, and 33% of these third-graders had untreated dental caries.¹

Caries experience is cumulative and thus is higher among adolescents than among young children.¹³ By age 15 years, nearly two thirds (56%) of teenagers had experienced dental caries in their permanent dentition, according to a national survey in 1999–2004.^1,13 Forty-four percent of these teens were caries-free. In comparison, 61% of adolescents during the period 1988–1994 had experienced dental caries.^1,13 In the years 1999–2004, 18% of teens 15 years of age had untreated tooth decay and were in need of treatment.^1,13 This proportion has decreased slightly from 20% of teens with untreated dental caries in the period 1988–1994.¹³

As with general health, oral health status in the United States tends to vary based on social and demographic factors.42,43 Dental caries, however, remains a significant problem in specific populations, particularly among poor children and adults from certain racial and ethnic groups.^{1,11,13,44,45} Most tooth decay is experienced by only a few children.⁴⁶ National data indicate that for those aged 2 to 5 years, 75% of dental caries in the primary dentition was found in 8% of the population.⁴⁶ Also, for those 6 years and older, 75% of dental caries in the permanent dentition was found in 33% of the population.⁴⁵

Children from minority racial and ethnic groups (e.g., American Indian, Alaska Native, Asian or Pacific Islander, Mexican American, and black or African American) whose parents have less than a high school education or who have a low income are often markedly at increased risk for dental caries.42–44 Minority children 2 to 4 years of age in the United States are more likely to experience dental caries than white children.^1,13 Also, preschool-age African-American and Mexican-American children have more untreated tooth decay compared with their white peers.^1,13 America’s youngest and poorest children, aged 2 to 4 years and living below the poverty level, have more than 2 times as much dental caries as children of higher-income families (>200% federal poverty level).^1,13

Also, the level of untreated dental caries among African-American children aged 6 to 8 years (37%) and Mexican-American children (41%) was greater than for white children (25%) in the United States in 1999–2004.1,13 A statewide oral health survey in California found 69% of Asian or Pacific Islander children 6 to 8 years of age had dental caries in 1993–1994.¹⁵ In 1999, the oral health survey of Native Americans reported that 71% of American Indian or Alaska Native children 6 to 8 years of age had untreated dental caries.¹⁵ Oral health disparities for dental caries are also found among adolescents in the United States. Oral health disparities for dental caries among children and adolescents are shown in Figures 5-1 to 5-3.

Dental sealants can be very effective in preventing dental caries on the pit and fissure surfaces of teeth, but few children receive them.1,13,20,24a The percentage of school-age children with dental sealants has risen among specific groups in recent years as the public and private sectors increasingly provide this preventive measure, dental insurance pays for dental sealants, and parents request sealants for their children.^20,24a Despite the effectiveness of dental sealants, only 32% of children 8 years of age and 21% of adolescents 14 years of age in the United States received dental sealants in 1999–2004.^1,13 Disparities in dental sealants have been shown among children based on race and ethnicity. In 1999–2004, 38% of white children 8 years of age had received sealants compared with 23% of their African-American and 19% of their Mexican-American peers had dental sealants.^1,13 This same survey found 23% of white adolescents 14 years of age had a dental sealant compared with 10% of their African-American and 18% of their Mexican-American counterparts.^1,13 Also, disparities for dental sealants have been shown for family income and parental education.^1,13 As few as 21% of poor 8-year-old children had dental sealants, in contrast to 42% of children from families with higher income levels, according to NHANES 1999–2004.^1,13

In 1990, the NHIS found that 23% of adults in the United States reported that dental sealants prevented dental caries.⁴⁷ Hispanic adults (12%), African-American adults (12%), and adults with less than a high school education were less likely to know the purpose of dental sealants than white adults (25%).⁴⁷ Figure 5-4 illustrates disparities for dental sealants among children 8 years of age and adolescents 14 years of age.

Periodontal Diseases

During the period 1988–1994, nearly half (48%) of adults 35 to 44 years of age had gingivitis (inflammation of the gums).¹ This figure represented an increase from the 41% of young adults with gingivitis in 1985–1986.⁵⁵ Periodontal diseases will probably remain a consideration in the future as tooth loss from dental caries declines and more adults retain their permanent dentition.¹⁵

Destructive periodontal disease (defined as loss of attachment of 4 mm or greater) affected 16% of dentate adults 35 to 44 years of age in 1999–2004.1,13 The incidence of this problem declined among young adults from 22% in 1988–1994.^1,13 Destructive periodontal disease seemed to increase with age, according to the most recent NHANES.¹¹

Gingivitis occurred frequently among American Indians, Alaska Natives, Mexican Americans, adults with low incomes, and adults with less than a high school education.1,11 Among certain population groups, the prevalence of destructive periodontal disease was higher. In 1999–2004, 23% of African-American, 16% of Mexican-American, 14% of white adults (35 to 44 years of age) had destructive periodontal disease.^1,13 In addition, gender differences were found in the same survey, with 12% of female adults and 20% of male adults (35 to 44 years of age) with destructive periodontal disease.^1,13 In addition, disparities for destructive periodontal disease have been shown among American Indian and Alaska Native adults, adults with low family incomes, adults with less than a high school education, and individuals smoking currently.^1,11 At all ages, more severe periodontal disease is seen among males and adults at the lowest income levels.¹¹ Figure 5-5 describes the disparities for destructive periodontal disease.

Tooth Loss

Fewer adults are undergoing tooth extraction because of dental caries or periodontal disease. The percentage of people who have lost all of their natural teeth has been declining over the past half century.¹¹ Of adults 35 to 44 years of age, 38% had never lost a permanent tooth during the period 1999–2004.^1,13 Differences were found by gender, as males (42%) were more apt to have permanent tooth loss than females (34%).^1,13 White adults (41%) and Mexican-American adults (37%) were less likely to have any loss of permanent teeth compared with African-American (27%) adults (35 to 44 years of age) in 1999–2004.^1,13

Approximately 24% of the American population aged 65 to 74 years was edentulous (i.e., have lost all of their natural teeth) in 1999–2004.1,13 Among persons aged 65 to 74 years in 1999–2004, 43% of persons with less than a high school education were edentulous compared with 11% of persons with at least some college.^1,13 In this same age group, edentulousness was also higher among older African-American (26%) than among white (23%) and Mexican-American (18%) older adults.⁵ Disparities related to tooth loss are shown in Figure 5-6.

Oral and Pharyngeal Cancer

Oral and pharyngeal cancers include different malignant tumors that affect the oral cavity and pharynx and are largely a preventable type of cancer.56,57 Most of these tumors are squamous cell carcinomas.^56,57 These may include cancers of the lip, tongue, floor of the mouth, palate, gingival and alveolar mucosa, buccal mucosa, and oropharynx.⁵⁷ The American Cancer Society estimates that in 2010, 36,540 people will be found to have oral and pharyngeal cancers and 7880 persons will die of these cancers in the United States.² These cancers occur more frequently than Hodgkin lymphoma, and cancers of the brain, cervix, ovary, liver, bone, testis, and stomach.² Oral cancer accounts for 3% of all cancers diagnosed among males annually in the United States.²

Oral cancer rates have increased approximately 15% from the mid-1970s until 2004, according to the National Cancer Institute (NCI) survey.⁵⁸ There are significant disparities in some population groups, with higher rates of increase in minority men. Overall, 10.5 adults per 100,000 will develop oral cancer.² Oral cancer today occurs more often in males than in females with incidence rates more than twice as high in men as in women.^2,57,58 Oral cancer rates are significantly higher for males (15.5 per 100,000) than for females (6.1 per 100,000). Incidence has been declining in men since 1975 and in women since 1980, although recent studies have shown that incidence is increasing for those cancers related to human papillomavirus (HPV) infection.^2,57,58 Age is also a factor, as oral cancer rates tend to increase with age. The increase becomes more rapid after age 50 and peaks between 60 and 70 years of age.^2,57,58

Disparities related to oral and pharyngeal cancers have been shown in national reports.2,57,58 The occurrence of oral and pharyngeal cancers varies by race and ethnicity.^2,57,58 Oral cancer rates are higher for specific groups of males. African-American and white males have 17.2 and 15.7 new cases of oral and pharyngeal cancers per 100,000 per year, respectively, whereas Asians or Pacific Islanders, American Indian and Alaska Natives, and Hispanics have 10.9, 9.7, and 9.2 new cases per year, respectively, according to the Surveillance, Epidemiology, and End Results (SEER) Program, 2008.⁵⁸ In the United States, oral and pharyngeal cancers constituted the ninth most common cancer among all men and sixth most common cancer among African-American men.³⁶

An estimated 7880 deaths from oral cavity and pharynx cancers are expected in 2010.² Death rates have decreased by more than 2% per year since 1980 in men and since 1990 in women.² In addition, oral and pharyngeal cancer deaths (per 100,000) differ among population groups.¹ In 2006, oropharyngeal cancer deaths for the overall population were 2.5 per 100,000, whereas they were 3.8 for males and 1.4 for females.¹ Differences among racial and ethnic groups were shown in 2006, with 3.2 oropharyngeal cancer deaths per 100,000 for African Americans, 2.4 for whites, 2.1 for American Indian and Alaska Natives, 2.0 for Asians and Pacific Islanders, and 1.5 for Hispanics.¹ Differences were shown by education level with 4.3 per oral and pharyngeal cancer deaths per 100,000 with less than a high school education compared with 2.5 for high school graduates and 1.0 for individuals with at least some college education.¹

The NCI reported that oral cancer survival rates have increased approximately 15% from the mid-1960s until 2003.⁵⁸ In spite of this improvement, significant disparities remain in some population groups. Disparities in survival rates between white and black males have remained throughout this time period. For all stages combined, about 83% of persons with oral cavity and pharynx cancer survive 1 year after diagnosis.² Overall, 60% of persons with the diagnosis of oral cancer are alive 5 years after the diagnosis. Oral cancer survival rates are significantly lower for African Americans.⁵⁸ The 5-year survival rates for oral cancer are 61% for white males, 64% for white females compared with 35% for African-American males and 54% for African-American females.⁵⁸

Diagnosing oral cancer at an early stage significantly increases 5-year survival rates. Only 35% of all individuals with oral and pharyngeal cancers were diagnosed at an early stage in 2000.¹ The rate is 40% for females and 33% for males.¹ Disparities by race and ethnicity have been reported, with only 21% of African Americans and 24% of American Indian and Alaska Natives having their oral cancer detected at the earliest stage compared with 29% of Asians and Pacific Islanders, 35% of Hispanics, and 37% of whites.¹ African-American males have experienced increases in both death rates and new case rates, and their 5-year survival rate is much poorer than that for whites (35% versus 61%).⁵⁸ African-American males have the highest incidence of and the lowest survival rates from oral and pharyngeal cancers. At every stage of diagnosis, the survival rate for African Americans is lower compared with other groups.⁵⁸

Only 13% of adults (40 years of age and older) in the United States reported ever having an oral cancer examination, according to the most recent data reported from the NHIS in 1998.¹ Males (12%) were less likely to receive an annual oral cancer examination compared with females (14%).¹ Respondents who were more likely to have had an oral cancer examination included those with at least some college education (19%), whereas those with less than a high school education (5%) and high school graduates (10%) were less apt to report an examination for oral cancer.¹ Also, disparities for receipt of an annual oral cancer examination were noted for individuals based on race and ethnicity. Only 6% of Hispanic/Latinos and 7% of African Americans had an oral cancer examination, whereas 12% of Asians and Pacific Islanders and 14% of whites received an oral examination.¹

Known risk factors for oral cancer include all forms of smoked and smokeless tobacco products and excessive consumption of alcohol. Combinations of tobacco and alcohol represent substantially greater risk factors than either substance consumed alone. Many studies have reported a synergism between smoking and alcohol use, resulting in a thirtyfold increased risk in individuals who both smoke and drink heavily.51,59 The vast majority of oral cancers are attributed to the use of tobacco (smoked and smokeless tobacco) and alcohol use.^2,59 Those who chew tobacco are at high risk for oral lesions that can lead to oral cancer.^2,57 In 2005, 21% of adults smoked cigarettes, 2.3% used smokeless (“spit”) tobacco, 2.2% smoked cigars, and 0.5% smoked pipes.¹ Twenty-six percent of high school students reported using tobacco in the past month; of these students, 20% smoked cigarettes, 14% smoked cigars, 8% used spit tobacco, and 2.9% smoked bidis in 2006.¹ Other factors that can place a person at risk for these cancers are viral infections, immunodeficiencies, poor nutrition, exposure to ultraviolet light (a major cause of cancer to the lips), and certain occupational exposures.^2,57 Human papillomavirus (HPV) infection is associated with certain types of oropharyngeal cancer.^51,57

Overall, levels of knowledge about risk factors for oral cancer are low. In 2002, a statewide telephone study assessed awareness of oral cancer, knowledge of its major risk factors and clinical signs, and oral cancer examination experiences among Florida adults aged 40 years and older.⁶⁰ In Florida, 15% of adults 40 years of age and older had never heard of oral cancer and another 40% reportedly knew little or nothing about it.⁶⁰ About 50% of adults did not think oral white or red patches or bleeding could indicate oral cancer and 28% correctly identified three of the major risk factors for oral cancer.⁶⁰ After hearing an oral cancer examination described, only 19% of adults reported receiving one within the past year.⁶⁰ African-American and Hispanic individuals were significantly less likely than white respondents to have received a recent oral cancer examination.⁶⁰ Persons with low levels of education, those who lacked a regular dentist or source of preventive medical care, and adults who knew few or none of the clinical signs of oral cancer also were less likely to have received a recent oral cancer examination.⁶⁰

There was extensive misinformation and a general lack of knowledge among adults about the signs, symptoms, and risk factors for oral and pharyngeal cancers in Florida. According to the NHIS in 1990, similar gaps in knowledge were reported among racial and ethnic groups, as well as disparities in frequency of recent visits for dental and medical care were identified nationally.⁶¹ This lack of awareness and knowledge in adults regarding oral cancer and low levels of reported examination is a major concern and this is particularly crucial among groups experiencing disproportionately high incidence and late stage diagnosis for oral cancer. Increasing awareness of this disease and promoting primary and secondary prevention is essential to lessen the oral cancer burden and reduce disparities in its outcomes. Consideration needs to be given to income levels, education, availability of proper health care, and use of tobacco and alcohol by different population groups when examining disparities related to oropharyngeal cancers. Figure 5-7 shows a comparison of the disparities related to early detection of oral and pharyngeal cancers based on race and ethnicity.

Cleft lip with or without cleft palate is one of the more common birth defects in the United States.⁶² Cleft lip and/or palate can be isolated or one component of an inherited disease or syndrome.⁶² Both genetic and environmental factors contribute to oral clefts. Although clefts can be repaired to varying degrees with surgery, researchers are working to understand the developmental processes that lead to clefting and how to prevent the condition or more effectively treat it. The lifetime cost of providing care to children born each year with cleft lip or cleft palate is estimated to be $697 million.⁵⁸

Currently, there is a lack of national data for cleft lip or palate. The National Birth Defects Prevention Network (NBDPN) collects cleft lip and palate data annually from 11 states (Alabama, Arkansas, California, Georgia, Hawaii, Iowa, Massachusetts, North Carolina, Oklahoma, Texas, and Utah), which provides a means for estimating national data.⁵⁸ The average prevalence of cleft lip and palate was estimated as 6.39 per 10,000 live births for cleft palate and 10.48 per 10,000 live births for cleft lip with or with cleft palate.⁵⁸ The annual number of births affected each year in the United States was 2567 with cleft palate and 4209 with cleft lip with or without cleft palate, 1999 to 2001.⁵⁸

States should have an efficient mechanism in place for identification, recording, referral, and follow-up of infants with oral clefts and craniofacial anomalies for treatment. Of 50 states plus the District of Columbia, 32 reported referral and reporting systems for children and youth with a cleft lip and/or palate in 2006.¹ Care by a multidisciplinary team has been shown to be an effective approach in providing services for people across the lifespan with craniofacial anomalies. Thus continued access to an integrated health care system is essential for children and adults to received necessary dental and health care services.