November 4, 2019
Dr. Jeffrey M. Zirger
Lead, Information Collection Review Office,
Office of Scientific Integrity, Office of Science,
Centers for Disease Control and Prevention
1600 Clifton Road NE, MS–D74
D74, Atlanta, Georgia 30329
Re: Proposed Data Collection Submitted for Public Comment and Recommendations (Docket No. CDC–2019–0076)
The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the Centers for Disease Control and Prevention regarding the proposed CDC Oral Health Management Information System ("OHMIS") data collection project (Docket No. CDC–2019–0076). Representing more than 107,000 registered dietitian nutritionists (RDNs),1 nutrition and dietetic technicians, registered (NDTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States. We are committed to accelerating improvements in the nation’s health and well-being through food and nutrition.
The Academy supports the CDC's efforts to monitor the performance of states funded to implement evidence-based prevention strategies to improve oral health, determine and tailor technical assistance to the states, and share quality improvement findings.
Importance of Oral Health and Prevention
Oral health is essential to a healthy diet at all life stages. There is a strong body of evidence connecting oral health to a healthy diet and overall health. Dental caries is the most prevalent disease in the U.S. and it is completely preventable through routine dietary and oral health practices that include brushing teeth twice daily with a fluoridated toothpaste, flossing, adopting actions to increase saliva (e.g., chewing sugar free gum), drinking fluoridated water, not smoking or using other tobacco products, and limiting intake frequency of dietary fermentable2 carbohydrates.
As Table 1 shows, the prevalence of dental caries is high for all age groups. Dental caries can begin with the primary teeth in infancy and continue for permanent teeth. For Americans who do not or are unable to seek treatment due to lack of access or funds, untreated dental caries worsen over time and may lead to pain and tooth loss which can decrease desire and ability to chew. Dental caries often result in poor intake of nutrient-dense foods;3 infection; speech impairment; lost days of work or school; and in rare cases death.4,5,6 Black non-Hispanics, individuals of lower socioeconomic status, and individuals with less education bare a disproportionate share of this burden.
Table 1 – Prevalence of Dental Caries in the U.S. Population United States, National Health and Nutrition Examination Survey, 1999-20047
|Age||Percent with dental caries (primary teeth)||Percent with untreated dental caries (primary teeth)||Percent with dental caries (permanent teeth)||Percent with untreated dental caries (permanent teeth)|
|*Includes missing or filled permanent teeth.|
Oral health preventive practices allow for intake of nutrient dense foods at all life stages. Dental caries can affect nutrient intakes of individuals throughout the lifespan, most notably for children and seniors. The consequences of dental caries include pain and infection, often leading to reduced consumption of fruits, vegetables, and proteins recommended by the Dietary Guidelines for Americans.8,9,10 When the consumption of these food groups is limited, important nutrients such as fiber, iron, and calcium are decreased in the diet. In lieu of difficult to chew nutrient-dense foods, consumers often turn to higher calorie options that often lack key micronutrients. Since the relationship between diet and oral health is symbiotic, diet can affect oral health.11 Prevention is shown to be the most cost-effective way of addressing oral health.12,13
Most U.S. oral care organizations stress that infants should begin oral health preventive practices and have their first dentist visit soon after the eruption of the first tooth and/or before one year of age. Dental caries formation can begin in infancy and lead to disrupted nutrient intake in children and adolescents.14,15 Without a full set of teeth, children and adolescents may limit food choices and compromise their nutrient intakes.16 Furthermore, children may experience other detrimental effects on cognition, school performance, attention and performance of complex tasks, and behavior, due to nutritional deficiencies.17 Oral health is essential to overall health in the prenatal period.18 Increased maternal salivary bacteria level is associated with oral infection among children and predicts increased early childhood caries rate occurrence.19>
Many individuals assume that tooth loss is a part of aging, when in fact; it does not need to be a part of aging at all. For those over 65 years, the prevalence of dental caries exceeds that of hypertension and arthritis. Edentulism, or loss of teeth, is declining as adults take better care of their teeth.20,21 For individuals with partial or full dentures, their intakes of twenty key nutrients including vitamin A, vitamin C, vitamin B6, folic acid, calcium, iron, fiber and protein can be inadequate.22,23 Involuntary weight loss and frailty also plaque older individuals with dentures; demonstrated by an inverse association with number of natural teeth and BMI, waist circumference, blood pressure, and fasting blood glucose.24 Tooth loss has been significantly associated with increased rates of metabolic syndrome even when adjusting for age, race/ethnicity, gender, income, physical activity, smoking, and energy intake.25
Impacts of the Oral Health Management Information System
The OHMIS will allow CDC to construct a comprehensive view of the work in each of the 20 state health programs participating in the State Actions to Improve Oral Health Outcomes cooperative agreement, standardize reporting across states, document program successes and challenges, determine and tailor technical assistance to states, and share quality improvement findings.
Once populated, the OHMIS will also be able to serve as a data source for Healthy People 2030, which will benchmark the nation against 11 oral health objectives throughout the next decade.26 The prevention-oriented objectives in HP2030 include increasing the overall use of the oral health care system, increasing the use of preventive dental visits among low-income youth, and reducing the proportion of children, adolescents, and adults with untreated tooth decay.
The creation of the OHMIS is also well aligned with the pending report from the Office of the Surgeon General that will document the nation’s progress in oral health in the twenty years since the Surgeon General's 2000 Report on Oral Health, identify existing knowledge gaps, and articulate a vision for the future.27 Among the stated priorities of the report (anticipated in 2020) are a review of health promotion and disease prevention activities related to oral health and the state of oral health care access and coverage as it relates to prevention and treatment for dental diseases.
The monitoring, evaluation, and dissemination activities made possible by the Oral Health Management Information System will help states, CDC, and other federal agencies better understand and implement evidence-based prevention strategies to improve oral health, which is essential for a healthy diet and overall health.
Jeanne Blankenship, MS, RDN
Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics
Hannah Martin, MPH, RDN
Legislative & Government Affairs
Academy of Nutrition and Dietetics
1 The Academy approved the optional use of the credential "registered dietitian nutritionist (RDN)" "by "Registered dietitians (RDs)" to more accurately convey who they are and what they do as the nation's food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.
2 U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2005 – 2010 Dietary Guidelines for Americans. 6th Edition. December 2015. Available at https://health.gov/dietaryguidelines/dga2005/report/.
3 Beaudette J, Fritz P, Sullivan P, Ward W. Oral Health, Nutritional Choices, and Dental Fear and Anxiety. Dentistry Journal. 2017;5(1):8. doi:10.3390/dj5010008.
4 Norris, L. J. 2007. Testimony of the Public Justice Center on May 2, 2007 to the Subcommittee on Domestic Policy Committee on Oversight and Government Reform, U.S. House of Representatives (110th Congress), on the story of Deamonte Driver and ensuring oral health for children enrolled in Medicaid.
5 Otto, M. 2007. For want of a dentist. Washington Post, February 28, P. B01.
6 Casamassimo, P. S., S. Thikkurissy, B. L. Edelstein, and E. Maiorini. 2009. Beyond the DMFT: The human and economic cost of early childhood caries. Journal of the American Dental Association 140(6):650-657.
7 National Institute of Dental and Craniofacial Research. Dental Caries (Tooth Decay). https://www.nidcr.nih.gov/research/data-statistics/dental-caries. Accessed May 26, 2017.
8 Acs G, Lodolini G, Kaminski S, Cisneros GJ. Effect of nursing caries on body weight in a pediatric population. Pediatric Dentistry 1992;14:302-5.
9 Nowjack_Raymer R, Sheiham A. Association of Edentulism and Diet and Nutrition in US Adults. Journal of Dental Research. 2003. http://journals.sagepub.com/doi/abs/10.1177/154405910308200209. Accessed March 5, 2018.
10 Savoca M et al. Impact of Denture Usage Patterns on Dietary Quality and Food Avoidance amount Older Adults. J Nutr Gerontol Geriatr. 2011; 30(1): 86–102. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3545413/. Accessed on March 5, 2018.
11 Touger-Decker R, Mobley C et al. Academy of Nutrition and Dietetics. 2013. Position of the Academy of Nutrition and Dietetics: Oral health and nutrition. Journal of the Academy Of Nutrition and Dietetics 113(5):693–701.
12 Sharon SC, Connolly IM, Murphree KR. A review of the literature: the economic impact of preventive dental hygiene services. J Dent Hyg. 2005; 79(1): 11.
13 Stearns SC et al. Cost-effectiveness of preventive oral health care in medical offices for young Medicaid enrollees. Arch Pediatr Adolesc Med. 2012 Oct; 166(10): 945-51.
14 Rainchuso L. 2013. Improving oral health outcomes from pregnancy through infancy. Journal of Dental Hygiene. 87(6):330–335.
15 Divaris K, Vann WF, Baker AD, Lee JY. 2012. Examining the accuracy of caregivers' assessments of young children's oral health status. Journal of the American Dental Association 143(11):1237–1247.
16 Ervin RB, Kit BK, Carroll MD, Ogden CL. 2012. Consumption of Added Sugar among U.S. Children and Adolescents, 2005–2008. Hyattsville, MD: National Center for Health Statistics. http://www.cdc.gov/nchs/data/data briefs/db87.htm.
17 Tufts University, Center on Hunger, Poverty and Nutrition Policy. 1994. Statement on the Link between Nutrition and Cognitive Development in Children. Medford, MA: Tufts University, Center on Hunger, Poverty and Nutrition Policy. http://www.eric.ed.gov/ PDFS/ED374903.pdf.
18 Rainchuso L. 2013. Improving oral health outcomes from pregnancy through infancy. Journal of Dental Hygiene. 87(6):330–335.
19 Chaffee BW, Gansky SA, Weintraub JA, Featherstone JD, Ramos-Gomez FJ. 2014. Maternal oral bacterial levels predict early childhood caries development. Journal of Dental Research 93(3):238–244.
20 QuickStats: Prevalence of Edentualism in Adults Aged ≥65 Years, by Age Group and Race/Hispanic Origin — National Health and Nutrition Examination Survey, 2011–2014. MMWR Morb Mortal Wkly Rep 2017;66:94. DOI: http://dx.doi.org/10.15585/mmwr.mm6603a12.
21 Dye BA, Li X, Beltrán-Aguilar ED. Selected oral health indicators in the United States, 2005–2008. NCHS data brief, no 96. Hyattsville, MD: National Center for Health Statistics. 2012.
22 Nowjack-Raymer R, Sheiham A. Association of Edentulism and Diet and Nutrition in US Adults. Journal of Dental Research. 2003. http://journals.sagepub.com/doi/abs/10.1177/154405910308200209. Accessed March 5, 2018.
23 Savoca M et al. Impact of Denture Usage Patterns on Dietary Quality and Food Avoidance amount Older Adults. J Nutr Gerontol Geriatr. 2011; 30(1): 86–102. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3545413/. Accessed on March 5, 2018.
24 Kamdem B. et al. Relationship between oral health and Fried's frailty criteria in community-dwelling older persons. BMC Geriatric. 2017; 17: 174. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5539633/. Accessed March 5, 2018.
25 Zhu and Hollis. Associations between the number of natural teeth and metabolic syndrome in adults. J Clin. Perio. 2015. http://onlinelibrary.wiley.com/doi/10.1111/jcpe.12361/abstract. Accessed March 2, 2018.
26 HHS Office of Disease Prevention and Health Promotion. Proposed Objectives for Inclusion in Healthy People 2030. Healthypeople.gov. 2018. https://www.healthypeople.gov/sites/default/files/ObjectivesPublicComment508_1.17.19.pdf. Accessed November 2, 2019.
27 National Institutes of Health. Notice To Announce Commission of a Surgeon General's Report on Oral Health. Federalregister.gov. 2018. https://www.federalregister.gov/documents/2018/07/27/2018-16096/notice-to-announce-commission-of-a-surgeon-generals-report-on-oral-health. Accessed November 2, 2019.