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Title: Oral Health


1
Oral Health
Milestones in Public Health Chapter 9
Complete, Combined Lectures for Undergraduate,
Graduate Public Health, and Medical and Clinical
Education Levels
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
  • Looking Back
  • Milestones in Dental Innovation
  • Oral Health and Public Health
  • The Major Oral Diseases
  • 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 WW 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
  • 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.g
    ov/medlineplus/ency/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 (Cont.)
  • 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 Cancer (Cont.)
  • Risk factors include
  • Male gender
  • Alcohol and tobacco use
  • Age over 40 years old
  • For lip cancer, sun exposure is a risk factor

40
Oral Cancer (Cont.)
  • The majority of oral cancers are preventable
  • 75 of oral cancers are related to tobacco use,
    alcohol use, or both
  • Of all cancers, oral and pharyngeal cancers show
    the largest disparity in five-year survival rates
    between whites (56) and African-Americans (36)

41
Oral Cancer (Cont.)
  • The vast majority of oral cancers are squamous
    cell carcinomas
  • Oral leukoplakia requires follow-up with biopsies
    as it may be a precursor of squamous cell
    carcinoma

42
Oral Leukoplakia
Source (1980) Courtesy of Jan Hirsch, MD, PhD.,
image.
43
Oral Health
  • Looking Ahead Oral Health Disparities

44
Looking Ahead Oral Diseases, Still a Neglected
Epidemic
  • There are profound and consequential health 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
45
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
46
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
47
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
48
Determinants of Population Health
49
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
50
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
51
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/
52
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
53
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
54
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
    Dentsitry
  • 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.
55
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.
56
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
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