Appalachian Health and Well-Being

13. Oral Health

275 13 Oral Health Daniel W. McNeil, Richard J. Crout, and Mary L. Marazita Oral health is a sentinel marker of overall health status. In Appalachia, it serves as a mirror reflecting health and well-being in the region. Whereas dental health involves a singular focus on dentition (teeth), oral health is a more comprehensive concept that includes the well-being of the oral cavity and areas of the head and neck, including aspects of function and appearance . Important health factors related to oral health but not typically considered part of dental health include diet, tobacco use, psychological functioning, pregnancy, cardiovascular disease, and head and neck cancer. Like other areas of health, oral health is not simply the absence of disease1 ; given the importance of the mouth in various consumptive and social arenas , oral health implies functioning that allows a high quality of life. Social aspects such as the smile and the facial structure are included in oral health, as is psychosocial development2 ; the enjoyment of foods that require biting and chewing, such as raw fruits and vegetables; and ongoing self-care behaviors that prevent disease, such as toothbrushing and flossing. Stereotypical views of Appalachians include images of people with broken teeth, missing teeth resulting in gaping holes in the dentition, or completely absent teeth.3 Although some scientific data support the extent of edentulism (toothlessness) in Appalachian states,4 the understanding of the antecedents of and solutions to oral health problems is in its infancy. There is a growing public awareness of oral health problems in Appalachia, as evidenced by reports in the popular press, such as the comprehensive newspaper series “The State of Decay” in West Virginia.5 In an attempt to transcend stereotypes about toothlessness and “fatalism,” this chapter broadly examines oral health in Appalachia, presents findings 276 McNeil, Crout, and Marazita from research conducted at the Center for Oral Health Research in Appalachia , and discusses research and policy needs to promote better oral health among Appalachians. Oral Health and Disease Many of the environmental and behavioral factors associated with oral health in Appalachia are observed in other rural areas as well. The determinants of oral health vary across the region, given that Appalachia spans thirteen states, each of which has its own policies, laws, and social and environmental influences. Among other factors, including psychosocial ones,6 state laws governing dentistry and dental hygiene differ considerably , as does the public funding of dental services for low-income residents through Medicaid. Although caries (cavities) is the most common chronic disease in childhood,1 numerous other oral conditions are important to health status throughout life. Consideration of the complete range of diseases is beyond the scope of this chapter, but the most common disorders are addressed in terms of their relation to Appalachia. Edentulism. Edentulism in the adult population is a major problem in the region. Adults in some parts of Appalachia (e.g., West Virginia and eastern Kentucky) have lost more teeth than their peers in other states,4 and more West Virginians over age 65 have lost six or more teeth (66 percent ) than their counterparts in any other state or jurisdiction. Complete tooth loss in West Virginia is the highest in the nation for those older than 65 (38 percent) and is twice the national average.4 Tooth loss may be considered the unfortunate end point of progressive oral disease so extreme that there is no proper foundation for the teeth. Tooth loss, however, may also occur through extraction due to caries so extensive that a tooth is no longer vital, or it may be caused by trauma related to accidents or injuries. In some population groups in Appalachia and elsewhere, extracting natural teeth is regarded as a viable health choice because of the belief that it will prevent future pain or other dental problems .7 Although lore suggests that having a tooth extracted (or the complete absence of teeth) is preferable to keeping a tooth (or teeth), missing teeth actually set the stage for other oral problems. Historically, marital dowries were sometimes given to couples for full mouth extractions and Oral Health 277 the construction and fitting of upper and lower dentures.8 Even today, patients at dental clinics sometimes choose extraction even when the natural tooth could be saved, or they request the extraction of other teeth near a diseased tooth. The idea is that once the mouth is...