Oral Health Part 2 – Review of 2000 SGR, Burden of Disease

>>Male Speaker: So, we’re moving over into
the overview sections of the agenda, and because you represent a diverse array of expertise,
this is designed to provide a very high-level introduction or baseline of content and information
for all participants. In that spirit, I am pleased to introduce
our first two speakers. Now, we’re going to need to keep our fingers
crossed here. Our first speaker that I’m going to introduce
is joining us virtually from his office at the University of Illinois in Chicago, Dr.
Caswell Evans. He is currently the Associate Dean for Prevention
and Public Health Sciences within the College of Dentistry at the University of Illinois
in Chicago. He is a graduate of Columbia University School
of Dental and Oral Surgery in New York City and earned a Master’s of Public Health Degree
from the University of Michigan. As has been stated, he was a scientific editor
and a project director for Oral Health in America: A Report of the Surgeon General (2000). He is a past president of the American Public
Health Association, the American Association of Public Health Dentistry, and the American
Board of Dental Public Health. He is also chairman of the DentaQuest Foundation
Board. After Dr. Evans, we’ll move right into Dr.
Gina Thornton-Evans, who is presenting on the oral health burden of disease. Dr. Gina Thornton-Evans is a dental officer
with the CDC in the Division of Oral Health. She received her Doctor of Dental Surgery
Degree from the University of Michigan School of Dentistry and a Master of Public Health
Degree from the University of Michigan School of Public Health. She serves as the agency lead — the CDC agency
lead for healthy people 2020-2030 and the oral health topic area within that. And she is also CDC’s director of the dental
public health residency program. Those are our next two speakers. And, crossed fingers, is this technology going
to work? I’d like to welcome Dr. Caswell Evans. [applause]>>Caswell Evans: Well thank you very much. I cannot see you, but hopefully you can see
me. Are you able to hear me?>>Multiple Speakers: Yes.>>Caswell Evans: Okay, and hopefully I’m
coming over clearly. I’m absolutely honored to be able to contribute
to this session, but I am so disappointed that I could not be with you. It’s a profound disappointment for me, as
I had circled the original date on my calendar and then re-circled this date as something
that I was very much looking forward to, but mother nature had other plans and the severe
storm we had just made travel out of O’Hare impossible. So, not to miss my shot with the 15 minutes
that I have been granted, I’m pleased to share some thoughts with you trying to connect the
Surgeon General’s Report on Oral Health (2000) with the surgeon general’s report to be produced
by 2020. The Surgeon General’s Report on Oral Health
(2000) released by Surgeon General David Satcher was a hallmark document that even today, as
has already been referenced this morning, is referenced widely and often. I recall fondly Ken Moritsugu at the time,
Dr. Moritsugu was the Deputy Surgeon General and essentially Chief of Staff for Surgeon
General David Satcher, and he often described the success of surgeon general’s reports as
the number of bounces down the road it experienced. And it seems to me that the Surgeon General’s
Report on Oral Health (2020) is a profound bounce down the road. We all hope that that report will have a long
life and be a powerful guidance document for years to come. Now, the intent of the report in 2000 was
to attract greater focus and attention to the issues of oral health. The report made a clear distinction between
oral health and the practice of dentistry. And in the intervening years that distinction
has become more widely understood and accepted. The 2000 report was specifically intended
to be evidence-based and provide a summary review of the literature. It was expected that the report would satisfy
the interest of a broad readership. That is, it would be understood and be useful
to the public, the media, health services providers, and experts in fields as well. The 2000 report presented findings that were
new to many and drew attention still palpable today. Among them, oral diseases and disorders, in
and of themselves affect health and well-being throughout life. That’s already been mentioned this morning. The mouth reflects general health and well-being. Oral diseases and conditions are associated
with other health problems. And again, these references have been made
earlier this morning. But, I’d like to make a few bridging comments
that may be useful as the 2020 report is being considered. These comments are under the headings of purpose,
expectations, terminology, themes, and finally findings and conclusions. Regarding purpose, as this will be the second
distinguished Surgeon General’s Report on Oral Health, the purpose and rationale for
the report should be made clear to the readers. Surgeon General Adams has already addressed
this, and I think his word should be — provided clear guidance. There are ample reasons why a second report
is needed, and those reasons should be detailed. Regarding expectations, over the years comments
have been made by — that some of the issues raised in the 2000 report have not changed. Perhaps are even worse. And consequently, for these people who have
made these comments, the report failed to lead to change and improvement in key areas. Now, the 2000 report was not structured as
a prescriptive document. In fact, it was prohibited from being proscriptive. The report contained a framework for action,
but not a plan for action. While the limitations of the report in that
regard were explained to stakeholder communities of interest, expectations were still raised
that the report, in and of itself, would turn these things around. We were fortunate that a second and subsequent
report, a national call to action to promote oral health, released under the leadership
of Surgeon General Richard Carmona in 2003 presented an action plan based upon the findings
of the 2000 report. Expectations will surely arise regarding the
2020 report, and I suggest that the report be clear in its application and its utility,
and that clarity should be provided as part of the front material for the report. Regarding terminology, increasingly the public
health literature now uses the term inequity and inequities rather than the term disparity
and disparities. While disparity connotes difference, inequity
connotes a lack of fairness or injustice. The term inequity opens the door for discussion
about equity and its significance to oral health. And while this may be a bridge too far for
the 2020 report, inequity also leads to the discussion of social justice related to oral
health. Themes. The themes presented in the draft outline
for the 2020 report. That is, the one dated August 17th, 2018,
are suitable and somewhat follow the thematic logic of the 2000 report. The lifespan theme of the 2020 report would
certainly cover emergent issues such as the oral effects of human papillomavirus, e-cigarettes,
and silver diamine fluoride, among others. And again, some of these have been mentioned
already this morning. Under themes, workforce has been a dramatic
and salient development since the 2000 report. And again, Surgeon General Adams hit this,
I think most appropriately in his comments. That theme is noted in the draft, and it should
receive full and careful attention. The 2020 surgeon general’s report could make
a major contribution by providing clarity and improving understanding regarding the
rapidly-emerging workforce development and issues. Now, the theme of integration — of oral health
integration, or medical-dental integration, or interprofessional education and practice
is also powerful and current, although aspirational at this time. Even so, expurgation of this theme by the
surgeon general could substantially illuminate this subject and result in a greater traction
for it on health sciences campuses. These campuses serve as the seminal point
for interprofessional education and practice. Access to care is a multi-factorial issue
referenced in the draft of proposed themes. While oral health and dental care are distinct,
they do merge in several domains, and access to care is one of those. There are troubling issues of inequity relative
to access to care when looked at from a demographic perspective. Among the conditions that have not changed
since 2000, and may have even gotten worse, can be summarized in the following generalization:
the portion of the population that is relatively least in need of care receives the most care. The portion of the population most in need
of care receives the least. This generalization affects the oral health
of individuals and populations and illustrates the inequities in access to care. One of the most memorable findings stated
in the 2000 report makes this point quite clearly. There are profound and consequential oral
health disparities within the U.S. population. Findings and conclusions. Readers of the 2020 report, having gone through
the what and the “so what?” will ask, “What can be done? By whom and how?” Anticipate that reaction, and I think that
reaction is — that reaction is being anticipated, again by the comments made earlier this morning. Providing some scaffolding within the report
for actions should be considered. This latter point circles back to the earlier
point about expectations. In closing, time is not an ally if the intent
is to have a report at the surgeon general’s level of quality completed for release by
2020. You may need to consider the breadth of subjects
covered, although depth of any subject should be curtailed only after great deal of consideration. This is a truly exciting development. I applaud Surgeon General Adams and his staff
and all those who will contribute to producing what should be an excellent report. A 2020 Surgeon General’s Report on Oral Health
that proves informative and useful for many years to come, it should have its own distinguished
record of bounces down the road. Hopefully the report and its findings will
have a long-term traction and provide a platform for improved oral health overall. It’s a distinct pleasure again for me to make
some comments and make a contribution to these deliberations. I do wish I could be there with so many friends
and colleagues and be able to participate further in these important discussions. Thank you for the opportunity and I appreciate
this moment. Thank you so much. [applause]>>Male Speaker: Thank you. Dr. Evans?>>Gina Thornton-Evans: Good afternoon. For the next 15 minutes or so, I will provide
an overview of the current burden of oral disease across a lifespan in the United States. This overview will focus on changes in oral
disease since the last surgeon general’s report, current disparities by race/ethnicity and
by income, and finally changes in dental insurance coverage and past year dental visits. A quick overview of the highlights I’ll discuss
are featured here on this slide. For very young children age two to five, untreated
dental decay declined. For children 6 to 11 years and adolescents
age 12-19 years, untreated dental caries declined and sealant prevalence increased. For working age adults age 20-64, untreated
dental caries remained roughly the same. And finally, for older adults age 65 years
and older, declines in untreated dental caries and tooth loss were observed, however disparities
still persist. The data presented in the next 10 slides or
so are taken mainly from two reports. Data on oral disease is taken from the soon-to-be-released
CDC surveillance report which will be available on CDC Division of Oral Health’s website. Changes in dental insurance coverage and past
year dental visits are from a recent report published by the Agency for Health Care Research
and Quality using the Medical Expenditure Panel Survey, or MEPS, as a data source. There are several oral health conditions ranked
in the top 30 most prevalent conditions globally out of 328. Untreated dental caries or tooth decay in
permanent teeth ranked number one. Severe periodontitis ranked number 11. Untreated dental caries or tooth decay in
primary teeth ranked number 17. And severe tooth loss having less than nine
teeth ranked number 29. These indicators can be found in the Global
Burden of Disease 2016 study. We’ll start with children and adolescents. And a quick note that was mentioned by previous
speakers is that untreated tooth decay and dental caries in children, if left untreated,
can result in high cost per dental procedure to fix, with estimates pointing to costs as
much as $2,500 per hospitalization in some states. And missed school for acute treatment needs,
which in a 2008 analysis of national survey data amounted to 34 million school hours missed,
adversely impacting school performance and grades. Before we move into the details of the next
few slides, I want to orient you to the color of the bars denoting the two time periods,
namely 1999-2004 in light blue and 2011-2016 in light gray. The bold star indicates significant change
between the two time periods and the bold black outline denotes significant disparities
in the current or most recent time period of 2011-2016. Overall, untreated tooth decay has declined. However, disparities persist for non-Hispanic
black, Mexican-American, and low-income children age two to five. Between the two time periods, untreated tooth
decay declined by 10 percentage points between 1999-2004 at 20.5 percent to 10.4 percent
in 2011-2016. This slide highlights the percent of children
age 6-11 and adolescents age 12-19 in a side-by-side comparison of untreated tooth decay in permanent
teeth by race/ethnicity. For untreated tooth decay, children age six
to 11 and adolescents age 12-19, dental care decreased overall in between the two time
periods. In 2011-2016 among children 6 to 11 and adolescents
age 12-19, disparities persisted for non-Hispanic black and Mexican-Americans, with the percentage
of untreated tooth decay being nearly twice that of non-Hispanic white children and adolescents. When we examine the prevalence of dental sealants
and untreated tooth decay among adolescents age 12-19 by family income, this slide highlights
our success story for children and adolescents. We’ve seen great improvement for low-income
adolescents as displayed by an increase of sealant prevalence by 16 percent and a reduction
in untreated dental decay for adolescents. And these trends are similar for younger children
age 6-11. So, what are some of the factors that may
have influenced progress made since the first surgeon general’s report? Specifically, for children and adolescents? The great thing here is that we can see from
this slide that there were increases in private dental coverage, public coverage, dental sealants,
dental visits also increased, perhaps contributing to some of the successes that we’ve just highlighted
for children and adolescents. As you move into your breakout groups, I would
encourage you all to discuss how access, coverage, and other policies may have influenced oral
health outcomes across the lifespan. Please consider perhaps the American Academy
of Pediatrics recommendation of changing the age of the first dental visit from age 3 to
when the first tooth erupts at age 1. Perhaps consider the 2004 U.S. Public Service
Task Force recommendation that primary care professions — professionals delivering fluoride
varnish to all children through age 5. Perhaps it was the pediatric dental care being
made a health-essential benefit — dental benefit. And then finally, Medicaid expanding the number
of children and adolescents eligible for dental benefits. So, let’s move on now to working-age adults. No real chain was — change was observed for
working-age adults between the two time periods. Disparity still persisted for non-Hispanic
blacks and Mexican-Americans as well as low-income adults. You can see by this slide that for Mexican-Americans
and non-Hispanic black adults, their untreated decay being almost twice that of non-Hispanic
white adults. And the prevalence among lower-income adults
being more than twice than that of higher income adults. We’ll now shift to periodontitis. In 2009-2014, approximately 42 percent of
adults age 30 years and older had some form of periodontitis that is mild, moderate, or
severe. Periodontitis is more prevalent among males
than females, Mexican-Americans and non-Hispanic black adults in comparison to non-Hispanic
white adults, it is also more prevalent among current smokers. Not on this slide, but worth mentioning, that
only 37.9 percent of adults with periodontitis reported seeing a dentist in the last six
to 12 months. This slide highlights severe periodontitis. As mentioned earlier, severe periodontitis
is one of the global burden of disease indicators and impacts quality of life. On this slide it shows that 10.4 percent of
adults age 45-64 have severe periodontitis and nine percent of older adults age 65 years
and older have severe periodontitis. In terms of access to dental coverage and
past dental visit, this slide shows that private coverage declined while public coverage increased,
but dental visits went down. This could be likely to factors that no initiatives
or particular policies focused on this age group. We’ll now shift to focus briefly on another
oral health condition, oropharyngeal cancer detected at stage one. Please note that these findings are from a
study that did not test for statistical significance, however the findings here show that overall
early detection of oropharyngeal cancer in stage one decreased from 32.6 percent as reported
in 2007 to 29.8 percent as reported in 2015. Also in 2015, 41.2 females — percent of females
with oropharyngeal cancer detected at stage one in comparison to 25.2 percent of males
being detected at the earliest stage or stage one. As you can also see by this graphic, the disparities
persisted for non-Hispanic blacks as well. Moving to the final life stage, adults age
65 years and older. This slide highlights the percentage of older
adults who have lost all their teeth, indicated by the lower portion of the — of the — in
light blue portion of the bar and the percentage of who are dentate, that is, those that have
at least one natural tooth, indicated by the upper portion of the bar in light gray. Within the dentate portion of the bar, we
also see the mean number of teeth in bold. Tooth loss has declined overall and by race/ethnicity
and income. People are keeping more of their teeth, however
there are disparities that still persist, specifically when you look at the number of
teeth as highlighted on this slide. Those having less than 20 teeth, as defined
by the World Health Organization, are a result of someone having a lack of a functional [unintelligible],
therefore limiting their food shape choices, among other challenges. We saw very little changes between the two
time periods for older adults, with the exception of higher-income older adults. Disparities still persist across racial/ethnic
groups and lower income levels. For older adults, private coverage increased. Potentially a factor for the decline of — in
untreated dental decay for higher-income older adults, and then public coverage increased
only by 1.5 percent, so essentially remaining the same. And older adults that had a past year dental
visit increased from 40.5 percent in 2000 to 46.7 percent in 2015. So, in summary, when we examine some of the
changes in oral health since the last surgeon general’s report, we see notable improvements
among children and adolescents as evidenced by a decrease in prevalence of untreated tooth
decay and increase sealant prevalence. In contrast, we could detect slight-to-minimal
improvements in untreated tooth decay prevalence among working-age adults. And among older adults, we could detect only
improvement among those of higher-income levels. However, all older adults are keeping more
of their natural teeth. Other areas for improvement include periodontitis,
which I indicated earlier is more prevalent among males, smokers, non-Hispanic blacks,
and Mexican-Americans. And oropharyngeal cancer cases detected at
stage one declined between the two time periods of 2007-2015. In closing, I would like to thank and acknowledge
the contributions of Dr. Susan Griffin, a health economist in the Division of Oral Health
for her significant contributions for this presentation and the development of this presentation,
and to Dr. Richard Manski, senior scholar, and Mr. Frederick Rohde, a survey statistician,
both from the Agency of Health Care Research and Quality. Thank you for your attention. [applause]>>Female Speaker: Produced by the U.S. Department
of Health and Human Services at taxpayer expense.

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