Improving the Oral Health of At-Risk Children

132 Presentation IMPROVING THE ORAL HEALTH OF AT-RISK CHILDREN ELICAPILOUTO, D.M.D., ScD., M.P.H. Department of Community and Public Health Dentistry University of Alabama School of Dentistry UAB Station Birmingham, Alabama 35294 THE past 30 years have been marked by a considerable decline in dental disease among American children. These improvements in oral health of the general population are rooted in a variety of factors, including advancements in the use of professional services; reductions in the consumption of decay-producing foods; greater use of home prevention regimens (brushing and flossing); and increases in exposure to fluoride through community water and toothpaste, home rinses, and school-based programs. As shown in Figure 1, the average number of decayed, missing, and filled tooth surfaces (DMFS), a benchmark for dental disease, has fallen by as much as 50 percent since the early 1970s. As a result of these trends, many of today's adults, and more of tomorrow's, will dodge the psychological, social, and physical aftermath of early dental disease. The result will mean substantial savings. Last year, U.S. Health and Human Services Secretary Louis Sullivan, M.D., noted that over the past 10 to 15 years, these declines have lowered our nation's annual dental bill by as much as $2 to 3 billion.1 Despite these advancements, epidemiologic evidence indicates that certain groups of children are still at substantial risk of dental disease. This paper examines the following topics: Who are the children at risk of dental disease? Do at-risk children have adequate access to dental health care services, and do they use these services? What policies would reduce high-risk status? Before addressing these issues, it is necessary to draw boundaries around which oral diseases will be included in this discussion and to define our criteria for "risk." In terms of oral diseases, the focus will be on dental caries or tooth decay, still one of the nation's most prevalent diseases.2 This focus is not meant Journal of Health Care for the Poor and Underserved, Vol. 2, No. 1, Summer 1991 Capilouto 133 HGURE1 MEAN DMFS IN THREE NATIONAL U.S. SURVEYS Source: National Institute of Dental Research. Oral health of United States children. Bethesda,MD: U.S. Public Health Service, 1989. (DHHS Pub. No. (NIH) 89-2247.) to dismiss the importance of periodontal disease, a condition that is highly prevalent but whose destructive forms are relatively uncommon in children. Nor should rare but lethal diseases such as oral cancer be forgotten, especially as susceptible young adults increasingly become the targets of marketing campaigns for tobacco products.* As a consequence of the limited scope of this discussion, the remainder of this manuscript will target dental caries as an indicator for determining the oral health of children. Clearly, almost everyone is at risk of tooth decay. According to recent National Institute of Dental Research (NIDR) surveys, only 16 percent of the * For those interested in a review of non-caries disease, the following references are recommended : The health consequences of using smokeless tobacco: A report of the Advisory Committee to the Surgeon General. Bethesda, MD: U.S. Public Health Service, 1989. (DHHS Pub. No. (NIH) 892247 .) Cutress TW. Periodontal health and periodontal disease in young people: Global epidemiology . Int Dental J 1986;36:146-52. 134 Improving Oral Health nation's 17-year-olds and two percent of the adults were caries-free.3-4 Nevertheless , there were sociodemographic groups in which the amount of dental decay was disproportionately skewed. This paper defines "at-risk" to mean those groups which, in comparison to others, have an inordinate amount of the disease. Of course, determination of risk at the individual level would be advantageous, but dental science, despite much progress, has yet to develop highly reliable tests to identify caries susceptibility in individual children.5-7 Until mechanisms are available to accurately screen for and predict dental decay, and moreover to disentangle the complex host/environment/microbial interactions in this disease process, it is necessary to rely upon crude group-level characteristics to identify at-risk populations. Identification of at-risk groups does have certain advantages because it lends itself to the development...