Valuing oral health: Accomplishments and challenges

Abstract

The importance of oral health and a functional dentition would seem to be evident. However, it also appears to be ignored or unnoticed from many standpoints. Evolutionarily, the dentition was critical to a person’s survival, serving as a tool, weapon, and means to acquire and consume nourishment. The demise of the dentition typically signaled the end of the life span, as being edentulous was incompatible with survival. As humans have transitioned to different diets and lifestyles, one might predict the importance of our dentition and oral health has diminished. But has it? There is no question that humans have been able to adapt and survive tooth loss and even complete edentulism better than hominids could a million years ago.1Lordkipanidze D. Vekua A. Ferring R. et al.The earliest toothless hominin skull.Nature. 2005; 4347034: 717-718Crossref Scopus (156) Google Scholar Although edentulism in the United States has declined substantially over the last 5 decades, it remains relatively high in adults 50 years or older (10%), particularly among those with chronic health problems.2Parker M.L. Thornton-Evans G. Wei L. Griffin S.O. Prevalence of and changes in tooth loss among adults aged ≥50 years with selected chronic conditions: United States, 1999-2004 and 2011-2016.MMWR Morb Mortal Wkly Rep. 2020; 69: 641-646Crossref PubMed Google Scholar,3Al-Zahrani M.S. Alhassani A.A. Melis M. Zawawi K.H. Depression is related to edentulism and lack of functional dentition: an analysis of NHANES data, 2005-2016.J Public Health Dent. 2021; 81: 206-213Crossref PubMed Scopus (2) Google Scholar We know that oral health goes well beyond just a healthy dentition to include having well-developed and healthy oral and craniofacial tissues and structures. It is not surprising that many studies inform us of the important relationships of oral and systemic health. For example, the impact of being edentulous on overall health is well-documented and involves multiple dimensions, such as nutritional status, mental health, and lifespan longevity.2Parker M.L. Thornton-Evans G. Wei L. Griffin S.O. Prevalence of and changes in tooth loss among adults aged ≥50 years with selected chronic conditions: United States, 1999-2004 and 2011-2016.MMWR Morb Mortal Wkly Rep. 2020; 69: 641-646Crossref PubMed Google Scholar, 3Al-Zahrani M.S. Alhassani A.A. Melis M. Zawawi K.H. Depression is related to edentulism and lack of functional dentition: an analysis of NHANES data, 2005-2016.J Public Health Dent. 2021; 81: 206-213Crossref PubMed Scopus (2) Google Scholar, 4Friedman P.K. Lamster I.B. Tooth loss as a predictor of shortened longevity: exploring the hypothesis.Periodontol 2000. 2016; 72: 142-152Crossref PubMed Scopus (47) Google Scholar We also know that tooth retention, particularly retaining 21 or more teeth (a functional dentition), is strongly associated with quality of life and well-being, and this important oral health metric has been improving.5Dye B.A. Weatherspoon D.J. Lopez Mitnik G. Tooth loss among older adults according to poverty status in the United States from 1999 through 2004 and 2009 through 2014.JADA. 2019; 150: 9-23.e3Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Having good oral health is complex and multifactorial, so it is not surprising that challenges persist in improving oral health for all. Common oral conditions remain endemic in the population despite our advancing knowledge as to their pathogenesis and treatment. So, how has oral health faired over the past several decades? In 2000 as we entered the 21st century, then surgeon general David Satcher, MD, PhD, produced the 2000 Surgeon General’s Report on Oral Health in America that had an overarching message that you do not have good health if you do not have good oral health.62000 surgeon general’s report on oral health in America.https://www.nidcr.nih.gov/research/data-statistics/surgeon-generalDate accessed: January 7, 2022Google Scholar The report helped emphasize that oral health goes well beyond a healthy dentition and that good oral health adds value to peoples’ lives. Marked disparities in oral health were noted between population groups in the United States based on sex, income, age, and race or ethnicity.62000 surgeon general’s report on oral health in America.https://www.nidcr.nih.gov/research/data-statistics/surgeon-generalDate accessed: January 7, 2022Google Scholar It was predicted in the report that the national dental care cost would exceed $60 billion in 2000.62000 surgeon general’s report on oral health in America.https://www.nidcr.nih.gov/research/data-statistics/surgeon-generalDate accessed: January 7, 2022Google Scholar Two decades later the cost of oral health care has more than doubled to over $140 billion, but it remains a small percentage of the overall health care cost in the United States.7Solana K. HPI: dental spending decreased in 2020—pandemic-related government relief program spending was $8.7 billion in 2020. ADA News. December 30, 2021. Accessed January 11, 2022. https://www.ada.org/publications/ada-news/2021/december/hpi-dental-spending-decreased-in-2020Google Scholar In 2017, Dr. Satcher published an update on the surgeon general’s oral health report noting that marked disparities in oral health status, although improved in some areas, continued to exist.8Satcher D. Nottingham J.H. Revisiting oral health in America: a report of the surgeon general.Am J Public Health. 2017; 107: S32-S33Crossref PubMed Scopus (33) Google Scholar One noted success was improvements addressing access to dental care facilitated by the Patient Protection and Affordable Care Act, which defined dental care for children as an essential health benefit.8Satcher D. Nottingham J.H. Revisiting oral health in America: a report of the surgeon general.Am J Public Health. 2017; 107: S32-S33Crossref PubMed Scopus (33) Google Scholar In December 2021, the National Institutes of Health released a much-anticipated follow-up to the 2000 surgeon general’s report on oral health.9Oral health America: advances and challenges—executive summary. US Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research, 2021https://www.ncbi.nlm.nih.gov/books/NBK576536/Date accessed: January 7, 2022Google Scholar Originally commissioned by then US Surgeon General Jerome M. Adams, MD, MPH, this new report, titled “Oral Health in America: Advances and Challenges” is now available at the National Institute of Dental and Craniofacial Research’s website. This report, which is a culmination of years of work by hundreds of project participants, provides a comprehensive review of oral health since 2000. The 6 sections of the report detail what we have learned, advances that have been made, areas that remain a challenge, and the work still needing to be done. Although advances in the prevention and management of caries have resulted in some caries prevalence decrease for a few groups, not all have benefited. Millions of people in the United States remain affected by periodontal disease, with older adults being more likely to be affected.9Oral health America: advances and challenges—executive summary. US Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research, 2021https://www.ncbi.nlm.nih.gov/books/NBK576536/Date accessed: January 7, 2022Google Scholar Yet, older adults are twice as likely as adults younger than 65 years to have a dental implant, and the prevalence has increased a staggering 500% since the first report on oral health was released in 2000, raising concerns for increasing perimplantitis in ageing people in the United States.9Oral health America: advances and challenges—executive summary. US Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research, 2021https://www.ncbi.nlm.nih.gov/books/NBK576536/Date accessed: January 7, 2022Google Scholar Our understanding of the etiopathology of both caries and periodontal disease has advanced, and this new knowledge provides the foundation for future improvements in effective disease management. The report details how new knowledge related to human papillomavirus and cancer are advancing health care with the development of protective vaccines. The report further presents new health care concerns such as electronic cigarettes that have changed the oral health care landscape since 2000. The 2021 report reflects on 20 years of research strengthening our understanding on how social determinants of health have a profound impact on oral health outcomes and how we continue to be challenged with oral health disparities resulting from racial or ethnic and economic factors. The financing of dental care remains markedly different from medical care, with a substantial portion of dental care being financed out of pocket by the patient.9Oral health America: advances and challenges—executive summary. US Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research, 2021https://www.ncbi.nlm.nih.gov/books/NBK576536/Date accessed: January 7, 2022Google Scholar The 2 surgeon generals’ reports on oral health, spanning 2 decades, have helped increase the visibility of oral health issues and have created awareness for the public, policy makers, health care providers, and health care payers about the importance and value of oral health. With this information as a backdrop, what actions should society take to help improve the oral health of all people in the United States? What resources are we willing to commit to ensure that future reviews show continued and hopefully more substantial improvements in oral health? Unfortunately, oral health care is still not considered an essential health benefit for all segments of the population in the United States. Debates as to how best to provide oral health care to adults continues to be controversial. Many adults are deferring oral health care owing to cost.10Williams S. Wei L. Griffin S.O. Thornton-Evans G. Untreated caries among US working-aged adults and association with reporting need for oral health care.JADA. 2021; 152: 55-64Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Proposals to include a dental benefit Medicare were met with mixed support and ultimately not included in the Biden administration’s Build Back Better infrastructure bill.11Garvin J. Medicare dental benefit not included in House of Representatives-passed legislation. ADA News. November 19, 2021. Accessed January 18, 2022. https://www.ada.org/publications/ada-news/2021/november/medicare-dental-benefit-not-included-in-house-passed-legislationGoogle Scholar Many remain opposed to government-supported health care or entitlements that bring us closer to universal dental coverage. The significant improvements in the oral health of children, as noted in the 2021 report, indicates that expanding access to dental care and bringing a population to near universal coverage does make a difference.9Oral health America: advances and challenges—executive summary. US Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research, 2021https://www.ncbi.nlm.nih.gov/books/NBK576536/Date accessed: January 7, 2022Google Scholar What are the best approaches for improving the oral health of our people and our communities is a hard and challenging question. As the 2021 report states, the United States is ageing, and older adults are retaining more teeth; yet disparities in tooth retention are increasing, creating conditions for much larger challenges to overcome if they are not addressed.9Oral health America: advances and challenges—executive summary. US Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research, 2021https://www.ncbi.nlm.nih.gov/books/NBK576536/Date accessed: January 7, 2022Google Scholar There will no doubt be multiple proposals and complex solutions. Making a difference over the next decade will require funding for oral health research and resources for care, especially for those at high risk for disease, the vulnerable and underserved.What are the best approaches for improving the oral health of our people and our communities is a hard and challenging questionMaking a difference over the next decade will require funding for oral health research and resources for care, especially for those at high risk for disease, the vulnerable and underserved. What are the best approaches for improving the oral health of our people and our communities is a hard and challenging question Making a difference over the next decade will require funding for oral health research and resources for care, especially for those at high risk for disease, the vulnerable and underserved. As the 2021 report expressed, we have made progress but there is clearly much more that needs to be done. Let us begin by investing additional resources into preventing and managing oral diseases, finding ways to make dental care an essential health benefit for all, and promoting oral health for a healthier nation.