Oral Health in America, 2000 to Present: Progress made, but Challenges Remain

On May 25, 2000, Surgeon General David Satcher issued Oral Health in America: A Report of the Surgeon General.¹ The release of this first-ever report on the oral health of Americans brought attention to the oral health needs in our country and affirmed their importance to general health and well-being. The report emphasized that good oral health is more than just preserving one's smile.² Aside from causing dental pain, diminished function, and reduced quality of life, oral disease and related conditions can affect overall physical, psychological, social, and economic well-being.¹

In the 15 years since its release, the report has proven a catalyst for dialogue on the oral health of Americans and a fulcrum for developing the partnerships needed for improvement.³ We have seen progress. Findings from Healthy People 2010 showed that more adults were retaining their natural teeth, fewer adolescents were experiencing tooth decay, and more school-aged children were receiving the dental sealants needed to help prevent dental caries. Additionally, more Americans were being served by optimally fluoridated community water systems, and more adults were receiving examinations for oral and pharyngeal cancer.⁴ In the past 15 years, research has suggested stronger relationships between oral health and a variety of conditions, such as cardiovascular disease, adverse birth outcomes, and diabetes, and new science links oral human papillomavirus infection and oropharyngeal cancer.⁵

Despite this progress, many challenges remain. Poor oral health continues to disproportionately affect low-income individuals, the frail and vulnerable, and the traditionally underserved. One-quarter of preschool-aged children living in households below the federal poverty level have untreated tooth decay, compared with about one in 10 children living above the federal poverty level.⁶ As of 2012, more than 29% of non-Hispanic black adults aged 65 years and older had complete tooth loss compared with fewer than 19% of the overall U.S. population of the same age.⁷ Access to dental services continues to be a challenge for many Americans, because receipt of dental care is often closely related to insurance coverage, and an estimated 126 million Americans do not have dental insurance.⁸

In his Surgeon General's report, Dr. Satcher recalled how helping families with limited means obtain dental care has been a longstanding and important goal for improving oral health in America. He called for “the removal of known barriers between people and oral health services.”³ Fortunately, in the ensuing years, we have made progress in minimizing some of these barriers. The Children's Health Insurance Program (CHIP) has helped many uninsured children in families with incomes near the federal poverty level but too high for Medicaid eligibility to become eligible for dental care. With the 2009 CHIP reauthorization, coverage was expanded to cover more children and pregnant women.⁹ However, the ability of public health insurance programs to provide dental coverage for adults is limited, leading many of the uninsured to seek dental treatment in the nation's emergency departments.¹⁰ Today, the possibility of more uninsured and underinsured adults receiving dental coverage is rising as the Patient Protection and Affordable Care Act matures and more dental plans become available.¹¹

In 2009, the U.S. Department of Health and Human Services (HHS) commissioned the Institute of -Medicine (IOM) to convene a panel of experts to examine oral health progress since 2000, and to recommend actions HHS could take to improve the state of oral health in America. As a result of this commission, two IOM reports, Advancing Oral Health in America and Improving Access to Oral Health Care for Vulnerable and Underserved Populations, were issued in 2011.^12,13 The first report resulted in seven recommendations for HHS to consider for action. A key recommendation called for the integration of oral health into the planning, programming, policies, and research that occurs across all of HHS. Based on this recommendation, a strategic process was initiated by the Oral Health Coordinating Committee, representing agencies and operational divisions within HHS as well as several non-HHS agencies. With help from all HHS stakeholders and other federal partners, and with input from oral health stakeholders, the Oral Health Strategic Framework, 2014–2017 (hereinafter, Framework), was developed and appears in this issue of Public Health Reports.¹⁴

The Framework outlines two linked courses of action: (1) the development of a comprehensive action plan that outlines specific goals and strategies to more effectively target federal resources to advance oral health and (2) the alignment of relevant federal activities across HHS. The implementation of goal-driven strategies and activities outlined in the Framework will strengthen cross-agency collaboration and provide new avenues for private-public partnerships to improve our nation's oral health. The Framework has five overarching goals, which are foundational to the document and can be used as a platform for leveraging action:

1. Integrate oral health and primary health care.

2. Prevent disease and promote oral health.

3. Increase access to oral health care and eliminate disparities.

4. Increase the dissemination of oral health information and improve health literacy.

5. Advance oral health in public policy and research.

The Framework is a commitment by HHS and federal partners to a collaborative call for action, with strategic and performance-based goals, actions, and defined roles and responsibilities by which federal agencies, programs, and stakeholders can measure success. It is evident throughout the Framework that many strategies and actions to meet these goals are underway or planned.¹⁵ As we look to the future, the Framework is a component piece that parallels non-federal efforts within the oral health community. It is not a static document. Rather, it represents strategic efforts that will continue to be monitored and modified by participating federal agencies and HHS. Input from external stakeholders, researchers, and public health advocates will be crucial as we collectively strive to improve the oral health of all Americans.

Vivek H. Murthy, MD, MBA VADM, U.S. Public Health Service Surgeon General