Oral Health Alliance Comments to ODPHP/HHS re Healthy People 2030 Proposed Objectives

Don Wright, MD, MPH, Deputy Assistant Secretary for Health
Office of Disease Prevention and Health Promotion
Office of the Assistant Secretary for Health
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201

RE: Comments on the Proposed Healthy People 2030 Objectives
Submitted by e-mail: HP2030@hhs.gov

Dear Dr. Wright:

An Alliance for Oral Health Preventive Practices, with representatives from dental, nutrition, and public health professional organizations, groups representing children and older adults, industry, and consumer groups, urges the Department of Health and Human Services (HHS) Office of Disease Prevention and Health Promotion to consider an additional and unique Healthy People 2030 Objective focusing on individuals adopting oral health promotion across the lifespan, especially pregnant women, young children, and older adults. Given the substantial prevalence of dental caries in primary teeth and untreated dental caries in permanent teeth, the Alliance recommends an objective ─ "increasing the prevalence of individuals across the life span who routinely perform oral health preventive practices – brush with fluoridated toothpaste, floss, drink fluoridated water, chew sugar-free gum, avoid fermentable carbohydrates, and do not smoke."

The Alliance affirms the proposed 11 core oral health 2030 objectives, especially OH-2030—11, which focuses on increasing optimally fluoridated community water systems and OH-2030-09, which focuses on preventive dental visits services; however, individuals must adopt routine oral health preventive practices to curb dental caries at the earliest ages and continue the routine through their oldest years. Like general health, oral health status of individuals in the United States tends to vary based on social and economic conditions. Ensuring that all Americans, regardless of social or economic conditions, have the capacity to routinely brush, floss, drink, and chew, using low-cost and easily accessible oral health preventive practices, is essential to preventing dental caries and promoting health throughout the nation.

The Alliance also supports the Developmental Objective OH-2030-D01 to increase the states that have oral and craniofacial health surveillance system. It is important that the surveillance system includes questions about frequency of brushing, flossing, chewing, drinking fluoridated water, smoking, and consuming fermentable carbohydrates.

The proposed HP 2030 Maternal, Infant, and Child Health Objectives MICH-2030-08 – Increase the proportion of pregnant women who receive early and adequate prenatal care should include oral health education on preventive practices including brush with fluoridated toothpaste, floss, drink fluoridated water, chew sugar-free gum, don't smoke, and avoid fermentable carbohydrates, as part of prenatal care. Under the Older Adult Core Objectives, there are none that embrace increasing proportion of elderly who adopt oral health preventive practices; however, adding a Core Objective under Oral Health that covers individuals across the life span would cover older adults.

To be included in Healthy People 2030 Objectives, DHHS has requested that any proposed core objective meet the following five criteria. Our recommended Oral Health Preventive Practices Core Objective meets these criteria, as described in detail beneath each.

1. Have a reliable, nationally representative data source with baseline data no older than 2015

The National Health and Nutrition Examination Survey (NHANES) provides specific and ongoing data on individual behaviors of brushing teeth, use and type of toothpaste, flossing, chewing sugarfree gum, smoking, and dietary intake of fermentable carbohydrates. Information about community water fluoridation is gathered through Water Fluoridation Reporting System at the Centers for Disease Control and Prevention (CDC).

2. Have two additional data points during the decade

As an ongoing nationally representative survey, NHANES would provide specific and ongoing data on individual behaviors of brushing teeth, use and type of toothpaste, flossing, chewing sugarfree gum, smoking, and dietary intake of fermentable carbohydrates. Given the proposed OH-2030-D01 Objective, an oral and craniofacial health surveillance system could provide the ongoing data to track progress for the proposed 2030 Oral Health Core Objective.

3. Be of National importance

a. Direct impact or influence on health

  1. Poor oral health has been associated with serious systemic medical conditions, including stroke, infection (i.e. pneumonia), diabetes, and heart attack and with mortalities in adults.1
  2. Rates of dental caries match or exceed rates of obesity in individuals at all ages and require individuals to adopt behaviors early in life that prevent dental caries.
  3. Painful and missing teeth can limit dietary intakes of fruits, vegetables, whole grain breads and other foods requiring chewing for children and older adults.2,3 These foods are recommended in the Dietary Guidelines and provide fiber, calcium, iron, and other essential vitamins and minerals.

b. Broad and Comprehensive Applicability

A report from the American Dental Association (ADA) Health Policy Institute (HPI), 2015 Oral Health and Well-Being in the United States4, details the impact of oral health on the lives of adult Americans including physical, social, and emotional well-being. To assess participant well-being, the survey looked at self-reported measures from the 2008 National Health Interview Survey, the 2007-2008 National Health and Nutrition Examination Survey, and the 2013 World Health Organization Oral Health Survey, which drew on the Oral Impact on Daily Performance Index. The ADA-HPI report found that 42% of low income adults reported the state of their mouth or teeth made it difficult to bite or chew and 29% reported that it affected their ability to interview for a job.

Preventing dental caries early and throughout life can improve social interactions, school performance5, military readiness and effectiveness6 , and job opportunities. Starting education about the benefits of oral health preventive practices during pregnancy and extending through childhood and old age helps individuals at all ages avoid the negative effects of tooth loss and painful teeth. As parents model the 3 behaviors children should and do adopt, helping parents demonstrate their own dental hygiene habits is essential.7

c. Substantial burden

Lack of transportation, income, dental insurance, fear, and other barriers keep individuals at all ages from receiving dental care and oral hygiene education. There are substantial burdens of poor oral health beginning with pregnant women and extending from infancy through the senior years.

Because the oral health of pregnant women directly impacts birth outcomes and infant oral health, public policies should -support comprehensive dental services for vulnerable women of childbearing age. Oral health promotion should include education of women and their health care providers' ways to prevent oral disease from occurring, and referral for dental services when disease is present."8

Many individuals assume that losing teeth is a normal consequence of aging when, in fact, tooth loss is not inevitable. For those over 65 years of age, the prevalence of dental caries exceeds that of hypertension and arthritis. Although edentulism (complete loss of teeth) is declining as adults take better care of their teeth,9,10 studies have found that individuals with partial or full dentures had lower consumption of 20 key nutrients including vitamin A, vitamin C, vitamin B6, folic acid, Vitamin D, calcium, iron, and protein.11,12 This correlated with diets low in dairy, dark green vegetables, yellow vegetables, fiber, and protein.13,14 Those with dentures often suffer from involuntary weight loss and frailty.15 Tooth loss has been significantly associated with increased rates of metabolic syndrome and increased waist circumference even when adjusting for age, race/ethnicity, sex, income, physical activity, smoking, and energy intake.16 Many of these older adults have higher intake of refined sugars and lower intake of green and yellow vegetables. The number of natural teeth was found to be inversely associated with BMI, waist circumference, blood pressure, and fasting blood glucose.22 Eighty-eight percent of persons over the age of 60 are taking one or more medications.17 A common side effect of prescription drugs is dry mouth, which can lead to dental caries, infection, and difficulty speaking and swallowing. The number of teeth an individual maintains has been found to be a predictor of cardiovascular mortality.18

Several current surveys are tracking reports from adults over age 50 about their dental health and care, although little is regularly collected from long term care facilities. Two examples and their main findings, include:

  • State of Decay19 , a report by Oral Health America, ranks the oral health plans and activities of all 50 states and District of Columbia based on proportion of those over age 65 years with severe tooth loss (defined as the loss of 6 or more teeth), the percent served by community water fluoridation, the percent with a dental visit in the preceding 12 month, Medicaid coverage for dental services, existence of state oral health plans that include older adult objectives, and the administration of Basic Screening Surveys that include older Americans.
  • University of Michigan National Poll on Healthy Aging produced the September 2017 report, Dental Care at Midlife - Unmet Need, Uncertain Future20 on dental care among a nationally representative sample of 1,066 adults age 50–64 years that found:
    • 60% of respondents were prevention-focused and received regular cleanings; 17% had inconsistent prevention visits and only received occasional cleanings; and 23% only sought dental care when there was a serious problem;
    • 38% had problems that caused pain, difficulty eating, missed work, or other health problems; the proportion was 61% among those who only went to dentist when a problem arose;
    • 51% had concerns about dental coverage after retirement; and
    • Among those with unmet dental needs, 69% did not receive needed care because of cost. Being afraid of the dentist (20%), finding time to go (18%), and finding a dentist (14%) were also reported as major factors contributing to unmet dental needs.

d. National public health priority

DHHS has identified oral health as one of the twelve health indicators. As Table 1 clearly shows, there is a high prevalence of dental caries, treated and untreated, across all age groups, demonstrating that caries is a major chronic disease across the lifespan.

Table 1 – Prevalence of Dental Caries in the U.S. Population United State, National Health and Nutrition Examination Survey 2015-2016 for Children Ages 2-1921 2011-2012 for Adults Ages 20-75+22

Age in years Percent with dental caries (Includes decayed, missing, or filled permanent teeth) Percent with untreated dental caries
2-5 21.4 8.8
6-11 50.5 15.3
12-19 53.8 13.4
20-34 82.1 27.3
35-49 93.6 27.0
50-64 97.4 25.5
65-74 96.0 18.5
75+ 96.6 19.4

Data from the 2016 National Survey of Children's Health (indicator 4.2a)23 showed 79% of respondents had one or more visits for check-up, dental cleaning, dental sealant or fluoride treatments in preceding 12 months. Of those who received care, 72% had their teeth cleaned24. The 2016 National Survey of Children's Health found that almost 57% of children did not receive instruction on oral health care25 as part of preventive dental care or did not receive any preventive dental care. That survey also found that 55% of children aged 1–17 years did not receive preventive dental care during the preceding 12 months or did not receive fluoride treatments26 during their preventive dental visit. For infants and children, parents will model and teach the oral health preventive practices that are essential for a lifetime.

4. Have effective, evidence-based interventions available to achieve the objective and improve health

Many of the state and city oral health prevention programs include prevention or education, but specific education on oral health preventive practices for individuals are not identified. Based on the 2018 State Synopsis27, 69% of state oral health programs had a sealant program, 67% had an oral health literacy or education program, and 69% had a fluoride varnish program. An Oral Health Objective stating increasing individuals adopting preventive oral health practices would help focus dental education efforts on these 5 issues for all ages. Listed and described below are numerous effective education programs that can teach individuals across the lifespan oral health preventive practices.

Prenatal Education
In the article, Health in Pre-conception and During Pregnancy; Implications for Birth Outcomes and Infant Oral Health28, the authors note, "Educational and behavioral interventions that reduce caries activity through appropriate use of fluorides, dietary guidelines, chlorhexidine gels and varnishes, and xylitol29, can reduce a woman's caries activity and salivary cariogenic flora, thereby improving her own oral health and, at the same time, also reducing the risk of transmission to her offspring. In two landmark Swedish studies30,31, children of mothers who had their cariogenic oral flora suppressed were less likely to experience cavities, more likely to develop cavities later if they were affected and had fewer cavities than children of control mothers."

Postnatal Education
The Nutrition Program Reducing Caries32 showed that, of 500 mother‐child pairs who completed 4-year follow‐up, 54% of the children in the intervention group developed early childhood caries, compared with 69% of children in the controls group.. Severe early childhood caries incidence was reduced by 32% in the intervention group and the mean number of affected teeth was also lower for the intervention group (3.25) compared with the control group (4.15). Home nutritional advice during the first year of life decreased caries incidence and severity at four years of age in the targeted low-income community.

Child Development Centers
Among its many recommendations, the policy of the American Academy of Pediatrics (AAP) on Oral Health in Child Care Centers33 includes: "provide oral health education for children that promotes good oral health hygiene and dietary practices and provision of fluoridated drinking water for consumption throughout the day."

The AAP National Center on Early Childhood Health and Wellness and the National Resource Center for Health and Safety in Child Care and Early Education have established standards that include routine oral hygiene activities and oral health education for young children.34

WIC Programs
One study, Caries Prevalence of Children in an Infant Oral Health Educational Program at a WIC Clinic35, compared the prevalence of caries between children whose parents had previously participated in an infant oral health education program at a WIC clinic with those whose parents had not participated in such a program. The study results showed that parents' previous WIC education program participation was highly associated with development of fewer caries lesions in the children. The research indicated that WIC could have a positive impact on caries prevention. However, oral health prevention education is not a routine part of a WIC visit.

Public programs aimed at 0–2 years old
One study on the cost-effectiveness of a long-term oral health education program for the prevention of early childhood caries found that "a dental health education program of home visits with mothers of young infants to prevent early childhood caries and starting at 8 months of age, gave better benefit costs and costs effectiveness ratios than other preventive programs."36

Importance of behavior-oriented education on oral health preventive practices

  • "The Boundaries between Caries and Periodontal Diseases,"37 a joint workshop between the European Federation of Periodontology (EFP) and the European Organization for Caries Research, reported several key findings relevant to oral health preventive practices:
    • the most important behavioral factor, affecting both dental caries and periodontal diseases, is routinely performed oral hygiene with fluoride;
    • psychological approaches aimed at changing behavior may improve the effectiveness of oral health education;
    • management of both dental caries and gingivitis relies heavily on efficient self‐ performed oral hygiene, that is tooth brushing with a fluoride‐containing toothpaste and interdental cleaning;
    • prophylaxis, oral hygiene instruction and motivation, dietary guidance, and fluoride application are effective in managing dental caries and gingivitis.

Benefits of programs with oral health preventive practices for older adults

  • Routine preventive oral health care in hospitals: Dian Baker, PhD, Barbara Quinn, MSN, and Shannon Munro, PhD have studied the impact of oral hygiene on prevention of non-ventilator associated hospital acquired pneumonia (NV-HAP) and found:
    • Only 30% of patients receive consistent oral care (tooth brushing 2-3 times per day) during their hospital stay.38,39
    • Oral care is a modifiable risk factor for NV-HAP.37,40,41,42
    • The average cost of one case of NV-HAP is $40,000 with mortality rates ranging from 15-30%.38,40,43
    • In the first 19 months, cases of NV-HAP dropped from 105 to 8.3 cases per 1000 patient days at the Salem VA Medical Center pilot site that implemented consistent oral care for its long-term care patients.37,42
    • Consistent oral care reduces the risk of developing NV-HAP, lowers health care costs by avoiding long hospital stays, and improves patient quality of life and health.38,44
    • The authors recommend training nurses and unlicensed staff in all hospitals to assist patients with tooth brushing and denture cleaning to help prevent NV-HAP.42

Routine education on oral health preventive practices for older adults

  • The mission of Apple Tree Dental (Apple Tree) is to improve the oral health of all people, including those with special access needs who face barriers to care. The organization delivers education, prevention, and restorative dental services to vulnerable populations at more than 130 community sites including long-term care and assisted living facilities, group homes, Head Start centers, and schools.

Inclusion in person-centered care planning that includes caregivers of older adults

  • Washington State engages AARP to expand community partnerships that address oral health. The two major components of the program are teleconferences that cover oral health education, and targeted mailers to specific geographic regions.
  • The Washington Dental Service Foundation launched the Mighty Mouth Social Marketing Campaign to Improve Oral Health of Older Adults. The educational campaign uses social media, local media (earned and paid), a website, partnerships, and events to improve the oral health of adults (ages 25 and older). The goals of the campaign are to improve the oral health of older adults and increase awareness about the importance of planning for oral care in retirement (since Medicare does not include dental benefits).
  • The Navajo Area Agency on Aging (NAAA) oversees more than 80 senior centers on the Navajo Nation that target older adults. Most oral health education reaches those who participate in activities and eat meals offered at the senior centers.
  • Illinois, Michigan, Minnesota, Oregon, and Tennessee have implemented the Tooth Wisdom: Get Smart about Your Mouth curriculum, which offers oral health education for individuals and caregivers focusing on older adults who live independently (65 years and older) and participate in programs in senior centers, community centers, churches, and libraries. The program's impact is measured by administering pre- and post-tests at oral health education workshops.

5. Have data to help address disparities and achieve health equity

Particularly vulnerable population groups, not represented in Table 1 above, with a high prevalence of dental caries include American Indian (AI)/Alaska Native (AN) children. By the age of 2, approximately 39% of AI/AN children have experienced dental caries, rising to 76% by the age of 5. In terms of dental caries experience, 86% of AI/AN children have had a cavity in their primary (baby) teeth compared with 56% of the general U.S. population. The disparity in the prevalence of dental caries is also seen in individuals of lower socioeconomic status who bear a disproportionate share of this burden.

For those that do not or are unable to seek or receive treatment due to multiple social-economic barriers, untreated dental caries progress, often leading to the need for larger, more expensive procedures, tooth loss, infection, and, in rare cases, death. As noted above, there are various effective education programs, but what is needed to ensure that, regardless of income, ethnicity, social setting, disability or education, is the inclusion of this Core Oral Health Objective, "increasing the prevalence of individuals across the life span who routinely perform oral health preventive practices – brush with fluoridated toothpaste, floss, drink fluoridated water, chew sugarfree gum, avoid fermentable carbohydrates, and do not smoke." Then, all states, counties, and cities would raise as a priority education of individuals across the lifespan and through multiple education and care settings, on oral health preventive practices.

Conclusion

Members of the Oral Health Alliance listed below urge the Department of Health and Human Services to include a new Core Oral Health 2030 Objective, "increasing the prevalence of individuals who routinely perform oral health preventive practices – brush with fluoridated toothpaste, floss, drink fluoridated water, chew sugar-free gum, avoid fermentable carbohydrates, and do not smoke" in the 2030 Healthy People Objectives. With one out of four children under five years of age, one out of two children ages six to nineteen years of age, and over 90 percent of adults thirty-five years of age and older suffering from decayed, missing, or filled permanent teeth, it is time to add a CORE 2030 Oral Health Objective that ensures that individuals at any age will practice routine oral health preventive practices, even if they cannot get to a dentist regularly, if at all. With the proper education, individuals can adopt the preventive practices that are universally available and affordable for most individuals.

Members of the Oral Health Alliance look forward to working with you through the important process of selecting the 2030 Objectives and would be willing to meet with you and share our insights in oral health prevention.

Sincerely,

Organizational Support

Jeanne Blankenship, MS, RDN
Vice President, Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics

Ann Battrell, MSDH
Chief Executive Officer
American Dental Hygienists' Association

Julie Reeder, PhD, MPH, MS, CHES
Chair, Food and Nutrition Section
American Public Health Association

Scott Tomar, DDS
Former Chair, Oral Health Section
American Public Health Association

Patricia M. D'Antonio, BSPharm, MS, MBA, BCGP
Vice President, Professional Affairs
Gerontological Society of America

Kelly D. Horton, MS, RD
North America Policy Director
Mars, Incorporated

Cheryl Y. Lee, D.D,S.
Chairman of the Board
National Dental Association National Dental Association

Katrina Holt, MPH, MS, RD, FAND
Director
National Maternal and Child Oral Health Resource Center

Gail T. Brown, Esq, MSW
Director
New Hampshire Oral Health Coalition

Beth Truett
President & CEO
Oral Health America

Carole. A. Palmer, EdD., RD, LDN
Professor and Head, Division of Nutrition and Oral Health Promotion
Department of Comprehensive Care, Tufts University School of Dental Medicine

Athena S Papas, DMD, PhD
Head of the Division of Oral Medicine, Tufts University School of Dental Medicine

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