Dr. Carolyn Marshall's Presentation


Carolyn E. Marshall, MPH, PhD
Clinical Associate Professor
Department of Dental Diagnostic Science
Division of Geriatrics and Gerontology
University of Texas Health Science Center at San Antonio

Behavioral Risk Factor Surveillance System (BRFSS)
Approximately 8.5 million (64%) non-institutionalized adult Texans reported a past year dental visit.

However, about 1.5 million (5%) have not seen a dentist in 5+ years.

It is estimated that 50% to 77% of elderly in long-term care facilities have lost all of their natural teeth.

Approximately 500 thousand (26%) adults Texans (65+) have lost all of their teeth due to oral disease.

Almost half of Texans surveyed were without any kind of dental insurance.

The majority of Texas adults who had not visited a dentist during the past year indicated “no perceived need to visit a dentist” and, secondly, “cost” as their reason.

Approximately 1.3 million Texans reported cost as the main reason for not seeing a dentist in the past year.

Overall, uninsured adults were three times more likely to cite cost as the main reason for not having a past-year visit.

Infrequent use of dental services is associated with poor oral health among adults with lower income and education levels.

Such persons have more decayed teeth requiring treatment, more severe periodontal disease, and are more likely to be edentate than adults with more education and higher incomes.

Regardless of insurance status, almost half of the adults who did not have a past-year dental visit did not perceive the need for one.

This finding was particularly evident among edentate adults and is of concern to us because adults without teeth are older, and the incidence of oral cancers that could be detected during an oral examination is higher among older adults.
Between 1991 and 1999, The Texas Agricultural Extension Service at Texas A&M University conducted a study, Community-Determined Health Related Issues, supported by HRSA through sub-contracts to the Health Education Training Centers Alliance of Texas (HETCAT).

The study involved thousands of community leaders in Texas'254 counties who worked with local citizen study groups to identify health issues of importance to them. Oral Health or Dental Service were not identified as perceived needs in any of their reports.
Overall, approximately 46% of Texas adults reported that they did not have dental insurance. Starting at age 25, the percentage of Texans with dental insurance begins a steady decline. For older respondents, 65 years and older, approximately 70% are without dental insurance.

Insured respondents had a past year dental visit prevalence of 74% versus 54% for those without dental health coverage.

It comes as no surprise that the highest proportion of those with dental insurance are also in the higher income groups.

In July 2000, the Urban Institute published the results of their survey Health Insurance Coverage of the Near Elderly. The survey included a report of the variation across states for those aged 55 to 64.

Considerable variation exists in the proportion of this age group who were uninsured --- from a low of 5% in Michigan, Minnesota, and Wisconsin - to a high of 26% in Texas.
The Texas Risk Factor Report of 1997 featured Oral Cancer Risk Behaviors - cigarette smoking, smokeless tobacco use, and risky alcohol behaviors.

It is estimated that one million adult Texans with at least one oral cancer risk behavior had no dental or routine medical visit in the past year where they might have received oral cancer preventive services.

Smokeless tobacco users were more likely than non-users to report no past year dental or routine medical visits that may have provided an oral cancer examination.

The bulk of smokeless tobacco use was reported by those men in the lowest and highest income groups. This may suggest a rising trend among those in higher income groups.

In 1999, the Association of State and Territorial Dental Directors (ASTDD) prepared their Final Report, Review of The Texas Oral Health Program. Some of their findings relating to adults follow.

The Texas State Division of Oral Health, under the leadership of Dr. Jerry Felkner operates on sound principles of Public Health Dentistry.

Fluoridation of San Antonio's water.

The Division of Oral Health should consider establishing and strengthening formal relationships and communication with the diverse stake holder communities in the state.

The Division of Oral Health should consider affording the Oral Health Services Advisory Committee increased status in order to make policy change recommendations and improvements in the state oral health program.

The Texas Department of Health should consider consolidating oral health activities within the Department to the Division of Oral Health with appropriate organizational status for the Director.

The Division of Oral Health should strengthen in leadership role in providing core public health functions at the state level and supporting local dental public health programs.

Assessment of identifiable population groups other than indigent children, including but not limited to, all children, adults, geriatric, migrant/seasonal farm-workers is lacking.

Under the heading of Policy Development, two areas of shortcomings noted are of particular interest:

Oral health activities are decentralized, existing within several different programs of the TDH, creating a lack of focus

The organizational structure locates the Division of Oral Health within the Bureau of Children’s Health, thereby creating a barrier for targeting programs to adults.


Health professions education curricula should include oral cancer education and intraoral examination techniques.

Clinical health care professionals should assess oral cancer risk behaviors for their patients and provide oral cavity examinations as recommended.

Public awareness and education efforts should be increased with emphasis on the oral cancer risks associated with tobacco and alcohol use.

Although oral cancer typically strikes older adults, interventions targeting younger persons may discourage long-term alcohol and tobacco exposure
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