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ASTDD Input on CDC Research Agenda.doc

  1. 1. Improving the Oral Health and Well-being of Americans: Research to Guide State and Community Oral Health Program Development Prepared By: The Association of State and Territorial Dental Directors (ASTDD) March 16, 2005A. IntroductionThe Association of State and Territorial Dental Directors (ASTDD) welcomes the opportunity toprovide input for the development CDC’s agency-wide research agenda to support healthprotection goals and guide public health research.ASTDD is a partner of CDC and has closely worked with CDC’s Division of Oral Health for morethan 15 years. ASTDD’s mission is to provide leadership to: (1) formulate and promote oralhealth policy, (2) increase the awareness of oral health issues, and (3) develop initiatives for theprevention and control of oral diseases. ASTDD members include the state and territorial dentaldirectors of the 50 states, District of Columbia and six U.S. territories. They provide leadershipand partner with stakeholders at the Federal, state and local levels to improve the oral healthand well-being of all Americans.B. ASTDD RecommendationASTDD recommends that a key area for CDC’s public health research should aim toprevent oral diseases and to reduce the disparities of oral health among children, adults,seniors and special needs population.World Health Organization (WHO) recognizes that oral health is part of total health andessential to the quality of life.1 WHO reports that despite great achievements in the oral healthof populations globally, problems still remain in many communities, particularly among under-privileged groups in both developed and developing countries. Dental caries (tooth decay) andperiodontal diseases (“gum” disease) have historically been considered the most importantglobal oral health burdens. The distribution and severity of oral diseases vary among differentparts of the world and within the same country or region. The significant role of socio-behavioraland environmental factors in oral disease and health is evidenced in an extensive number ofepidemiological surveys. Dental caries is a major oral health problem in most industrializedcountries, affecting 60-90% of schoolchildren and the vast majority of adults. It is prevalent inseveral Asian countries and is also high in the Americas.Oral Health in America: A Report of the Surgeon General, released in 2000, called oral diseasesin the U.S. a “silent epidemic” affecting our most vulnerable citizens.2 The report provides anoverall message that "oral health is essential to the general health and well-being of allAmericans and can be achieved." 1
  2. 2. In response to the Surgeon General’s report, a broad coalition of public and privateorganizations and individuals developed A National Call To Action To Promote Oral Health.3This report called for stakeholders to expand plans, activities and programs to promote oralhealth, prevent disease and reduce the health disparities that affect members of racial andethnic groups, poor people and others who are vulnerable because of special health careneeds. The Call to Action established five principal actions that are necessary to assureAmericans achieve optimal oral health.One action is to build the science base and accelerate science transfer. While it isessential to expand clinical studies, especially the study of complex diseases that involve theinteractions of genetic, behavioral and environmental factors, oral health research must alsoexamine the association of chronic oral infections with heart and lung disease, diabetes, andpremature low birth weight babies. Findings from this research will not result in improved healthoutcomes without public health research that includes: (1) Prevention and behavioral science research, especially community-based approaches and ways to change risk behavior. (2) Health services research to guide changes in the structure and function of health care services to optimize health outcomes. (3) Population health and epidemiology research to understand potential associations among diseases and possible risk factors, to establish baseline health data for America’s many subpopulations, and to monitor changing patterns of diseases and their response to interventions across populations.The other four principal actions – change perceptions of oral health, overcome barriers byreplicating effective programs and proven efforts, increase oral health workforce diversity,capacity and flexibility, and increase collaborations – will need public health research to guidethe development and implementation of effective strategies.C. ASTDD’s Vision for the Use of a Science BaseASTDD promotes a vision that public health prevention and intervention are built on scientificprinciples, using the best available scientific evidence to design and implement services andactivities.D. Insufficient EvidenceAt the present time, the scientific evidence is not sufficient to guide community preventive effortswith the exception of just two evidence-based practices for public health prevention andintervention to improve oral health. This conclusion is well demonstrated by two currentinitiatives: The Guide to Community Preventive Services and the ASTDD Best PracticesProject. 2
  3. 3. (1) The Guide to Community Preventive ServicesThe Guide to Community Preventive Services is based on the efforts of a Task Force of non-Federal group of national and regional experts in public health, health care, and healthpromotion. The Guide recommends evidence-based prevention services for diseases andconditions which are a personal and societal burden in our nation and for which preventivemeasures exist.4The Task Force evaluated the evidence of effectiveness of five dental public healthinterventions to prevent or control three oral diseases and conditions that can be painful,disfiguring, or lead to loss of life:  Dental caries: Dental caries (tooth decay) is the most common of chronic childhood diseases, five times more common than asthma. Individuals living in poverty are three times more likely to have untreated tooth decay than those who are not poor.  Oral and pharyngeal cancer: About one person dies every hour due to oral and pharyngeal cancer. Tobacco and alcohol use are estimated to account for 75% to 80% of all oral and pharyngeal cancers. Incidence is almost 40% higher in black males than in white males.  Injuries of the face, mouth and head: It has been estimated that one third of all dental injuries are sports-related.Healthy People 2010 has also set national targets to prevent and control these oral diseasesand conditions and to reduce disparities among population groups.5 Effective oral healthprograms able to impact populations at risk will be essential for accomplishing the HealthyPeople 2010 oral health objectives.Through systematic and methodical review of the best available evidence for the fiveinterventions, the Task Force was only able to strongly recommend two evidence-basedpractices: (1) community water fluoridation and (2) school-based or school-linked dental sealantprograms for caries prevention.The Task Force found insufficient evidence (not be confused with evidence of ineffectiveness)for (1) statewide or community-wide sealant promotion programs, (2) population-basedinterventions for early detection of pre-cancers and cancers, and (3) population-basedinterventions to encourage use of helmets, facemasks, and mouthguards in contact sports. TheTask Force recommendations are similar to those of other reviews of the literature even thoughreview methods varied.The Task Force revealed gaps in knowledge and posed nearly 40 critical questions that shouldbe answered to close this gap. These questions should serve as the basis to enhance aresearch agenda to advance the prevention and control of oral diseases and conditions.A key point made by the Task Force is the need to reorient and redesign future research.Actions at the community level are influenced by health, social service, education, legal,regulatory, and other activities. A service is rarely provided in isolation. The Task Force calls fora framework for future investigations to allow evaluation of a variety of program settings,mixtures of interventions, range of targets for changes, and range of desirable health outcomes. 3
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  5. 5. (2) The ASTDD Best Practices ProjectDiminishing public funding requires wise investment of resources in effective public healthpractices to assure the impact of state, territorial and community oral health programs. Stateand local collaborations want to invest in what works. To that end, ASTDD promotes bestpractices and encourages states and their partners to develop their best practices using publichealth strategies that are effective. The ASTDD Best Practices Project, which is supported by acooperative agreement with CDC, coordinates this initiative.6 The Best Practices Project aimsto build more effective state, territorial and community oral health programs. Through bestpractices, programs will be better able to help achieve the Healthy People 2010 objectives toenhance the oral health of all Americans and reduce oral health disparities.Evidence contributes to the assessment of public health strategies and the development of bestpractices. The Best Practices Project evaluated evidence for these eight public healthstrategies:  State oral health surveillance systems  State oral health coalitions  State oral health plans  State mandate for oral health program  Community water fluoridation  School fluoride mouthrinse and supplement programs  School dental sealant programs  Workforce developmentThe evaluation of the strength of evidence for the eight public health strategies provided severallessons: (1) One lesson is that the strength of the scientific evidence of effectiveness varies across the eight public health strategies. Only two (community water fluoridation and school sealant programs) have strong enough research evidence to be recognized as proven practices according to current standards. Insufficient research evidence was concluded for the other six strategies. (2) Another lesson is that program evaluation needs to be strengthened, for determining successful implementation methods in the field. (3) A third lesson is that there are key gaps in the knowledge base.E. Examples of Research QuestionsThe Guide to Community Preventive Services and the ASTDD Best Practices Project haveidentified research questions to fill knowledge gaps related to dental public health interventionsand strategies. Examples of these questions include: (1) What is the accuracy/precision/reliability of alternative measures of caries and periodontal diseases? 5
  6. 6. (2) How can state oral health coalitions maximize their impact on improving community health status and system changes? (3) Under what conditions do state oral health coalitions increase efficiency in delivering community preventive services and demonstrate measurable outcomes in contributing to the delivery of evidence based community preventive services? (4) What factors contribute to an effective and cost-effective collaborative planning process for statewide or community-based oral health improvement? (5) What is the effectiveness of laws, policies, and incentives on community decisions to start or continue water fluoridation? (6) How effective is community water fluoridation and other preventive methods in reducing dental caries among adults (18 years of age and older)? (7) How do state dental practice laws and regulations affect the use of and costs of sealants in school- or community-based programs? (8) How effective and cost-effective are models of sealant delivery other than school-based (e.g., school-linked, community-based)? (9) What workforce development strategies demonstrate long-term, sustainable benefits? (10)What are effective and efficient implementation approaches for community-based fluoride varnish programs?Studies responding to these research questions will expand the science base that will be criticalfor the development of state, territorial and community oral health programs. The science willguide program efforts to deliver population-based interventions and to expand services forvulnerable populations.F. Knowledge Gaps Reported by State Dental DirectorsA 2004 ASTDD survey7 of state dental directors of the 50 states and District of Columbia asked: What are the 5 most critical knowledge gaps (information needed) that have hampered your state oral health program from developing, implementing and sustaining specific public health strategies and services?A total of thirty-seven (37) state dental directors responded and reported knowledge gapsrelated to an array of public health strategies and services that impact their programdevelopment. The top knowledge gaps reported are listed in Table 1. 6
  7. 7. Table 1. Knowledge Gaps Reported by State Dental Directors Strategies & Services with State Dental Directors Public Health Functions Knowledge Gaps Identifying Gaps Assessment Oral health surveillance systems 15 Oral health surveys 12 Policy Development State oral health improvement plans 14 State oral health coalitions 12 Assurance Workforce development 24 Community water fluoridation 15 Dental sealant programs 14 Fluoride varnish programs 12Survey responses showed that the state dental directors have a strong interest in expanding theknowledge base to help them understand effective dental public health strategies and how tobest implement these strategies. The survey findings also showed a need to improveaccessing, translating and applying scientific information for oral health program development.G. Putting Science to ActionIf the public is to benefit from research, efforts are needed to transfer new oral health knowledgeinto improved means of diagnosis, treatment, and prevention. Having research evidence thatshows which public health strategies are effective, efficient and provide sustainable benefits willguide state oral health programs in developing services and help communities withimplementing successful local solutions.In response to the National Call to Action, ASTDD is making efforts to put science to action.These efforts include use of evidence in assessing promising strategies and promoting bestpractices. In addition, ASTDD is considering how to help state dental directors and otherfrontline dental public health practitioners understand the state of the science for public healthstrategies. Future efforts will include strengthening linkages among dental public healthpractitioners and research investigators and promoting evidence-based decision-making forstate and community oral health program development.H. Final StatementTo achieve the nations objectives to prevent oral diseases and reduce oral health disparities,we need to build the science base to guide future efforts and to ensure these efforts are moreeffective and efficient. At the present, there is an overall need to complement behavioral andclinical research with health services research, population-based research, and community-based demonstration research to improve the oral health of children, adults, seniors and specialneeds population. Research is needed to identify effective strategies and expand the 7
  8. 8. knowledge of implementation methods for state and community dental public healthinterventions in order to achieve optimal oral health outcomes for all Americans.References:1. World Health Organization. Objectives of the WHO Global Oral Health Programme. U.S. Department of Health and Human services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000. U.S. Department of health and Human services. National Call to Action to Promote Oral Health. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, National Institute of Dental and Craniofacial Research, NIH Publication No. 03-5303, Spring 2003. Task Force on Community Preventive Services. The guide to community preventive services: oral health. Am J Prev Med 2002. 23 suppl 1:1-2. U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington, DC: U.S. Government Printing Office, November 2000. Association of State and Territorial Dental Directors. Best Practices Project. http://www.astdd.org7. Association of State and Territorial Dental Directors. A Survey of State Dental Directors on Knowledge Gaps. Unpublished results, 2004. 8