Report details 20 years of advances and challenges of Americans’ oral health

NIH’s new report, Oral Health in America: Advances and Challenges, provides a road map on how to improve the nation’s oral health. NIDCR

Despite important advances in the understanding and treatment of oral diseases and conditions, many people in the U.S. still have chronic oral health problems and lack of access to care, according to a report by the National Institutes of Health. Oral Health in America: Advances and Challenges, is a follow-up to the seminal 2000 Oral Health in America: A Report of the Surgeon General. The new report, which is intended to provide a road map on how to improve the nation’s oral health, draws primarily on information from public research and evidence-based practices and was compiled and reviewed by NIH’s National Institute of Dental and Craniofacial Research (NIDCR) and a large, diverse, multi-disciplinary team of more than 400 experts.

The report updates the findings of the 2000 publication and highlights the national importance of oral health and its relationship to overall health. It also focuses on new scientific and technological knowledge – as well as innovations in health care delivery – that offer promising new directions for improving oral health care and creating greater equity in oral health across communities. Achieving that equity is an ongoing challenge for many who struggle to obtain dental insurance and access to affordable care.

“This is a very significant report,” said NIH Acting Director Lawrence A. Tabak, D.D.S., Ph.D. “It is the most comprehensive assessment of oral health currently available in the United States and it shows, unequivocally, that oral health plays a central role in overall health. Yet millions of Americans still do not have access to routine and preventative oral care.”

The newly issued report provides a comprehensive snapshot of oral health in America, including an examination of oral health across the lifespan and a look at the impact the issue has on communities and the economy. Major take-aways from the report include:

• Healthy behaviors can improve and maintain an individual’s oral health, but these behaviors are also shaped by social and economic conditions.
• Oral and medical conditions often share common risk factors, and just as medical conditions and their treatments can influence oral health, so can oral conditions and their treatments affect other health issues.
• Substance misuse and mental health conditions negatively affect the oral health of many.
• Group disparities around oral health, identified 20 years ago, have not been adequately addressed, and greater efforts are needed to tackle both the social and commercial determinants that create these inequities and the systemic biases that perpetuate them.

“This is an in-depth review of the scientific knowledge surrounding oral health that has accumulated over the last two decades,” said Rena D’Souza D.D.S., Ph.D., director of NIDCR, which oversaw and funded the project’s three-year research program. “It provides an important window into how many societal factors intersect to create advantages and disadvantages with respect to oral health, and, critically, overall health.”

The COVID-19 pandemic emerged while the report was being written. The science around SARS-CoV-2 continues to come into focus in real-time, and, although data were only starting to surface about the oral implications of the disease, the authors included a preliminary analysis of it to assess initial impacts.

The authors make several recommendations to improve oral health in America, which include the need for health care professionals to work together to provide integrated oral, medical, and behavioral health care in schools, community health centers, nursing homes, and medical care settings, as well as dental clinics. They also identify the need to improve access to care by developing a more diverse oral health care workforce, addressing the rising cost of dental education, expanding insurance coverage, and improving the overall affordability of care.

“Although there are challenges ahead, the report gives us a starting point and some clear goals that offer reasons to be hopeful, despite those challenges,” added D’Souza. “It imagines a future, as I do, in which systemic inequities that affect oral health and access to care are more fully addressed, and one in which dental and medical professionals work together to provide integrated care for all.”

Scientists and public health professionals will use the report to identify areas of scientific inquiry and research as well as develop and implement programs that ultimately will improve the oral health of individuals, communities, and the nation.

To view or download the report, please visit the NIDCR website at https://www.nidcr.nih.gov/oralhealthinamerica.

Questions about the report? Email OralHealthReport@nih.gov(link sends e-mail) or call NIDCR at 1-866-232-4528.

About the National Institute of Dental and Craniofacial Research: NIDCR is the nation’s leading funder of research on oral, dental, and craniofacial health.

About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.

Gum disease increases risk of other illness such as mental health and heart conditions

A University of Birmingham-led study shows an increased risk of patients developing illnesses including mental ill-health and heart conditions if they have a GP-inputted medical history of periodontal (gum) disease

Experts carried out a first of its kind study of the GP records of 64,379 patients who had a GP-inputted recorded history of periodontal disease, including gingivitis and periodontitis (the condition that occurs if gum disease is left untreated and can lead to tooth loss).  Of these, 60,995 had gingivitis and 3,384 had periodontitis. These patients’ records were compared to those of 251,161 patients who had no record of periodontal disease. Across the cohorts, the average age was 44 years and 43% were male, while 30% were smokers. Body Mass Index (BMI), ethnicity and deprivation levels were also similar across the groups.

The researchers examined the data to establish how many of the patients with and without periodontal disease go on to develop cardiovascular disease (e.g., heart failure, stroke, vascular dementia), cardiometabolic disorders (e.g., high blood pressure, Type 2 diabetes), autoimmune conditions (e.g., arthritis, Type 1 diabetes, psoriasis), and mental ill-health (e.g., depression, anxiety and serious mental illness) over an average follow-up of around three years.

From the research, published today in journal BMJ Open, the team discovered that those patients with a recorded history of periodontal disease at the start of the study were more likely to go on and be diagnosed with one of these additional conditions over an average of three years, compared to those in the cohort without periodontal disease at the beginning of the research.  The results of the study showed, in patients with a recorded history of periodontal disease at the start of the study, the increased risk of developing mental ill-health was 37%, while the risk of developing autoimmune disease was increased by 33%, and the risk of developing cardiovascular disease was raised by 18%, while the risk of having a cardiometabolic disorder was increased by 7% (with the increased risk much higher for Type 2 diabetes at 26%).

Co-first author, Dr Joht Singh Chandan, of the University of Birmingham’s Institute of Applied Health Research, said: “Poor oral health is extremely common, both here in the UK and globally.  When oral ill-health progresses, it can lead to a substantially reduced quality of life.  However, until now, not much has been known about the association of poor oral health and many chronic diseases, particularly mental ill-health.  Therefore, we conducted one of the largest epidemiological studies of its kind to date, using UK primary care data to explore the association between periodontal disease and several chronic conditions.  We found evidence that periodontal disease appears to be associated with an increased risk of developing these associated chronic diseases. As periodontal diseases are very common, an increased risk of other chronic diseases may represent a substantial public health burden.”

Co-first author, Dr Dawit Zemedikun, of the University of Birmingham’s Institute of Applied Health Research, said: “Our study was the most comprehensive study of its kind and the results provided vital confirmation of evidence which has previously either been lacking in strength or has had gaps – particularly the association between oral ill-health and mental ill-health.”

Co-senior author, Professor Krish Nirantharakumar, also of the University of Birmingham’s Institute of Applied Health Research, said:  “An important implication of our findings is the need for effective communication between dental and other healthcare professionals to ensure patients obtain an effective treatment plan targeting both oral and wider health to improve their existing overall health and reduce the risk of future illness.”

Periodontal specialist, Dr Devan Raindi, of the University of Birmingham’s School of Dentistry, said: “This study strengthens the continually evolving research associating periodontal disease, in particular periodontitis, and various general health conditions. It reinforces the importance of prevention, early identification and treatment of periodontitis and the need for members of the public to attend regular oral health checks with a dentist or dental care professional.”

The research was partly funded by Versus Arthritis’s Centre for Musculoskeletal Ageing Research based at the University of Birmingham, and supported by the National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre.

Caroline Aylott, Head of Research Delivery at Versus Arthritis, said: “Some of the biggest challenges of arthritis, especially auto-immune conditions like rheumatoid arthritis (RA) which affects 400,000 people in the UK, is being able to know who is more at risk of developing it, and finding ways to prevent it. Previous studies have shown that people with RA were four times more likely to have gum disease than their RA-free counterparts and it tended to be more severe. This research provides further clear evidence why healthcare professionals need to be vigilant for early signs of gum disease and how it can have wide-reaching implications for a person’s health, reinforcing the importance of taking a holistic approach when treating people.”

“Good job brushing your teeth!”

 

Study Shows Parent Praise Might Encourage Children’s Persistence

To become healthy and successful adults, children need to persist on tasks that they might not necessarily consider easy or fun, like studying, exercising, or brushing one’s teeth. Throughout childhood, persistence behavior changes daily, but the factors that shape this variability in persistence are understudied. A new study published in Child Development by researchers at the University of Pennsylvania, Yale University and the Sante Fe Institute, analyzed daily toothbrushing behaviors in three-year-olds and examined the relationship between their persistence on the task and parental praise.

“Our work is the first to show that fluctuations in parent praise relate to fluctuations in child persistence,” said Allyson Mackey, assistant professor of psychology at the University of Pennsylvania. “We examined how variations in parent talk and stress, and child mood and sleep, separately impacted fluctuations in brushing time. Surprisingly, parents were not able to accurately predict which variables shaped brushing in their own children.”

The study included eight-one three-year-olds learning to brush their own teeth. The sample was 80% White, 14% Multiracial, 10% Hispanic or Latinx, 2% Asian, 1% Black and 1% preferred not to answer. Data was collected from families in Pennsylvania (94%) with the remaining in New Jersey, Delaware, Massachusetts, Maryland, and Florida. Parental education averaged from 12 to 20 years and the annual income ranged from $14,000 to $200,000. Data were collected throughout a 16-day period in two waves: January-June 2019 and March-May 2020 (during the COVID-19 pandemic). Families were recruited through partnerships with local preschools and through social media.

Parents submitted videos of nightly toothbrushing over 16 days, capturing both children’s persistence and parent talk. Parents were instructed to start recording the video before the toothbrush was in their child’s mouth and to stop recording when they took the toothbrush back from their child. Parents were asked to let their child brush their teeth by themselves for as long as they could before the parent stepped in to help. (If children did not brush their teeth for a night, resulting in no video, parents were instructed to let the researchers know). The videos also included parents talking to their child throughout the toothbrushing and “praise” used by parents throughout the nightly ritual. Praise was broken into categories including “process praise” (e.g., “good job”), “person praise” (e.g., “good girl”), and “other praise” (e.g., “very good” or “nice”). Other utterances from parents included “distraction” (e.g., singing, reading a book, invoking pretend play), and using expressions such as “brush the backs” and “keep brushing” as instruction.

Parents also completed daily surveys about the following:

• Parental nightly stress level: ranging from a scale of 0 (not stressed at all) to 10 (extremely stressed)
• Child’s mood: ranging from a scale of 0 (extremely bad) to 10 (extremely good)
• Sleep duration: daytime nap (if any) and length, nightly bedtime and morning wake up, periods of awake time during the night

The findings showed that children’s persistence fluctuates from day to day and is related to parent talk. Children brushed longer on days when their parents used more praise and less instruction. Parent praise during toothbrushing mostly consisted of generic praise and process (e.g., “nice” and “great job”), with few instances of person praise (e.g., “good girl”). Children varied in their sensitivity to mood, sleep, and parent stress.

“Our work provides a path towards identifying the specific factors that impact individual children’s persistence to design targeted interventions, some of which parents may not find obvious,” said Julia Leonard, assistant professor of psychology at Yale University. “Our work also demonstrates a new approach to studying children’s healthy development - instead of focusing on what factors make one group of children different from another, our study asked which factors make individual children more like the best version of themselves.”

The authors acknowledge several limitations of the study. The exact set of skills involved in toothbrushing are not yet known, the sample was skewed toward higher-income families within a Western, Educated, Industrialized, Rich, and Democratic (WEIRD) cultural context, potential bias in parental reporting and modifications in their behavior, lack of data on the quality of children’s sleep and morning toothbrushing. In addition, this study does not tell us whether parent praise causes positive changes in children’s behavior. To determine this, intervention studies are needed. Future research should consider a larger sample, whether results will differ beyond the pandemic and whether variables such as a good night sleep make an impact in the response to children’s social input. Toothbrushing was selected as the task in this study as it is an everyday, naturalistic task that is not particularly interesting or fun for children but is important for children’s health However, future work should test whether these findings could be used to translate children’s daily fluctuations on other tasks that require persistence including those with more immediate and delayed rewards.

USPSTF recommendation statement on screening, interventions to prevent cavities in children

 The U.S. Preventive Services Task Force (USPSTF) recommends that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride and apply fluoride varnish to the primary teeth of all children starting at the age of primary tooth eruption. The USPSTF concludes that the current evidence is insufficient to make a recommendation on primary care clinicians performing routine screening exams for cavities in children younger than 5. Dental caries (cavities) is the most common chronic disease in children in the United States. The USPSTF routinely makes recommendations about the effectiveness of preventive care services and this statement is consistent with its 2014 recommendation.

Full report

Dental device for snoring may slow onset of Alzheimer’s disease

A multidisciplinary team of researchers discovered that an oral appliance not only improves breathing rate during sleep, but also appears to reverse cognitive impairment.

A good night’s sleep plays an essential role in regulating brain health by removing the waste material and toxins that accumulate. Although many things can disturb sleep, one of the most common causes is snoring or other breathing issues that cause obstructive sleep apnea. A team of researchers from Center for BrainHealth® at The University of Texas at Dallas and Texas A&M University sought to understand the relationship between breathing rate during sleep and cognitive function, and how a snoring intervention affects brain health.

 

The findings were published recently in Geriatrics by the team that included BrainHealth researchers Sandra Bond Chapman, PhD, chief director; Namrata Das, PhD, MD, MPH, a research neuroscientist in Alzheimer's disease; and Jeffrey Spence, PhD, director of biostatistics. Lead researcher Preetam Schramm, PhD, a Visiting Scholar at Texas A&M University, designed the interventional study and provided the sleep science expertise.

 

The team discovered that maximum breathing rate can be used to distinguish healthy individuals from people with mild cognitive impairment and those with Alzheimer’s disease. The researchers also found that a dental device to reduce snoring improves cognitive function in individuals who suffer from mild cognitive impairment.

 

The team’s pilot study included 18 individuals aged 55-85 with a history of snoring. About one third of participants had mild cognitive impairment and another third had Alzheimer’s disease. To examine how breathing rate relates to an individual’s cognitive function, participants slept at home while portable recorders collected data on their breathing rate, heart rate and snoring. Clinicians from Center for BrainHealth assessed the participants’ memory, executive function, and attention. 

 

The team found that the maximum breathing rate during uninterrupted periods of sleep can differentiate healthy individuals from individuals with either Alzheimer’s disease or mild cognitive impairment. “We saw three distinct patterns amongst the groups of people, meaning we can look for a breathing pattern that might predispose individuals to having dementia,” said Emet Schneiderman, PhD, a co-author on the study and Professor in the Department of Biomedical Sciences at Texas A&M University College of Dentistry. Determining breathing rate is cheaper and faster than other existing assessments for measuring an individual’s cognitive function and could be an effective testing alternative.

 

The researchers also looked at whether the myTAP oral appliance, which snaps into the mouth at night to prevent snoring, affects breathing rate and cognitive function. For four weeks, participants wore the device at night and snoring decreased. After the intervention period, cognitive function – especially in the domain of memory – no longer differed between healthy individuals and individuals with mild cognitive impairment. This suggests better sleep improves cognition in individuals with mild cognitive impairment. “If we can make significant changes for individuals with mild cognitive impairment, we can slow the onset of Alzheimer’s disease,” said Das, now a postdoctoral fellow at McLean Hospital, Harvard Medical School.

 

Though the team did not notice an overall difference in the cognitive function of participants with Alzheimer’s disease, researchers are hopeful that the intervention could work. On the individual level, half of the participants with Alzheimer’s disease saw improvements in their cognitive function. “Brain neurogenesis is a slow process, so perhaps these individuals may need a longer time period with the intervention to see any significant cognitive changes,” noted Das.

 

Alternatives to medicine for treating snoring, like dental appliances, could help individuals sleep better and improve their cognitive function. Sleep medications give individuals the impression that they’ve slept well, when in reality the brain never enters a deep phase of the sleep essential for the housekeeping process to rid the body of toxins.

 

And it now appears that alternative treatments, like this dental appliance, might produce meaningful changes in cognition before mild cognitive impairment progresses to Alzheimer’s disease. “Oral appliances could have a wide range of applications since sleep is affected by many different things across many different age groups,” said Das. “Maybe appliances could help individuals sleep better, reducing mental health symptoms caused by poor sleep before they get serious decline in neurocognitive symptoms.”