Oral Health as a Community Public Health Problem in the U.S.

Introduction

Oral health remains a serious public health issue in the U.S., as it has a significant effect on the overall health and well-being of people (Kaylor, Polivka, Chaudry, Salsberry, & Wee, 2011). Oral health has been a public health and government concern since the 1970s, with efforts geared toward increasing the proportion of persons who use oral health services. The U.S. Department of Health and Human Services (2000) sought to reduce the proportion of American families experiencing difficulties and delays in receiving healthcare, as well as those who do not receive healthcare at all. This paper explores the challenges and problems of oral health in the U.S. community health sector, supported by evidence from a review of literature on oral health as a public health issue, the effect of the Affordable Care Act on oral health care and insurance, and proposed solutions to those challenges.

Challenges and Problems Associated with Oral Health

Oral health has been a major public health concern in the U.S. since the 1960s, following the identification of disparities in the use of dental healthcare among population groups — as illustrated by studies such as that of Okada and Wan (1979). These disparities manifest in differences across racial and income groups, creating serious healthcare delivery problems. Historically, a gap existed in the utilization of dental healthcare between white and Black Americans, and between poor and non-poor people. These inequalities were attributed to the lack of access to quality or affordable dental care. Over the decades, however, oral health status in the U.S. population has improved considerably, especially over the last 30 years — despite a profound and growing disparity among certain populations, particularly people of color, the working class, and those with disabilities and chronic illnesses (Zabos et al., 2008). These disparities have created a need for new community health efforts to eliminate poor oral health outcomes and oral disease in the population.

According to Kaylor et al. (2011), poor oral health contributes to conditions such as cardiovascular disease, poor blood sugar control in diabetes, and cerebral ischemia. Poor oral health also reduces quality of life by lowering self-esteem, impairing speech, and making it difficult to chew. Pain disrupts speech and chewing ability, while associated foul odor prevents individuals from speaking comfortably in public. Poor oral health is a particularly serious concern for women, especially during pregnancy, because it negatively affects fetal development and leads to poor birth outcomes (Kaylor et al., 2011). Specifically, poor oral health is associated with periodontitis, which is linked to preeclampsia, low birth weight, and preterm birth (Kaylor et al., 2011, p. 214).

Another population group disproportionately affected by poor oral health is people of color and those with chronic illnesses and disabilities. For example, research by Zabos et al. (2008) finds that adults — particularly adults of color in Harlem — suffer the highest mortality and morbidity rates due to the impact of oral disease in New York's population. Oral health disparities of this kind are associated with differences in the use of oral health services and access to primary healthcare across population groups.

Oral health is also considered a major public health concern because poor or untreated oral disease affects every part of the U.S. According to Krisberg (2004), certain populations experience disproportionately high rates of untreated and severe oral health disease, which are often left unaddressed and create lifelong problems. This is especially common in rural America, where access to critical oral healthcare is limited or nonexistent. Data from the National Rural Health Association cited by Krisberg (2004) indicate that 11% of rural Americans have never visited a dentist. Rural adults are more likely to have untreated tooth decay than their non-rural counterparts (Krisberg, 2004, p. 11), and rural young people between the ages of 18 and 24 are twice as likely as their non-rural adult peers to have lost all their teeth. Krisberg (2004) further notes that dental caries — the most common chronic tooth disease among American children — are more prevalent among children in rural areas.

Oral health is also an important community health issue because primary healthcare providers such as nurses and registered nurses, who are present in local and rural communities, are well positioned to educate the public on basic oral hygiene. According to Krisberg (2004), a shortage of dentists exacerbates the problem: in rural areas, only about 30 dentists are available per 100,000 people, compared with approximately 60 per 100,000 in urban areas. An additional challenge in providing oral health services in rural and low-income communities — such as Harlem in New York — is that many dentists will not treat patients without Medicaid or other state assistance.

Review of Community Health Literature

Dental healthcare was historically not treated as a community healthcare priority in the way reproductive health or mental health were. However, dental healthcare has received federal support through its inclusion in the Affordable Care Act (ACA), commonly referred to as Obamacare. This represents a significant step toward providing accessible and affordable healthcare at the community level. The inclusion of dental health in the ACA is notable because traditional government and commercial insurance had long focused primarily on medical and major medical care. Under the healthcare law, dental care is included as one of ten essential health benefits required in insurance plans as of 2014, recognizing dental health as crucial to keeping Americans healthy and placing it in the same category as pediatric care, maternity care, hospitalization, and vision care.

A review of literature provides strong evidence for the need to include dental health as a core community health concern and an essential component of healthcare reform. The goal of such inclusion is to reduce the disparities that leave certain populations with little or no access to dental care. A population-based survey of adults in Central Harlem conducted by Zabos et al. (2008) between 1992 and 1994 revealed a high prevalence of oral health complaints among residents. The study found that prevalence was associated with social factors such as social class and access to oral healthcare. Results indicated that 36% of respondents with an annual household income of less than $9,000 were more likely to report oral health issues. Among those surveyed, 34% were unemployed and 34% lacked health insurance; those with private insurance were twice as likely to have visited a dentist or to have a regular dentist compared with the uninsured (87% vs. 48%) (Zabos et al., 2008). These results confirmed previous findings on the existence of disparities in oral health provision in America and reinforced the need for urgent oral health services, recommending the integration of oral health with comprehensive primary care.

Research by Kaylor et al. (2011), which investigated dental health and insurance among American women of childbearing age, similarly identified a need for dental healthcare in community and primary care settings. The study conducted a secondary analysis of data from 1,071 women in America and found that 40% did not have dental health insurance. Women with less education, demonstrable dental need, and lower incomes were less likely to carry dental insurance. Dental health insurance coverage was also lower among racial and ethnic minority groups, reflecting the disparities identified in prior studies.

Conclusion

Krisberg, K. (2004). Prevention key to rural oral health outreach programs. Nation's Health, 34(4), 11–12.

Zabos, G. P., Northridge, M. E., Ro, M. J., Trinh, C., Vaughan, R., Howard, J., & Cohall, A. T. (2008). Lack of oral health care for adults in Harlem: A hidden crisis. American Journal of Public Health, 98, S102–S105.