Dr. Carolyn Marshall's Presentation
PERSPECTIVES ON THE STATUS OF ORAL HEALTH
AND ACCESS ISSUES FOR ADULTS
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
RISK FACTOR REPORT
ORAL HEALTH IN TEXAS - 1995 SURVEY DATA
Behavioral Risk Factor Surveillance System
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
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
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
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.
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.
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 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
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 Childrens
Health, thereby creating a barrier for targeting
programs to adults.
Health professions education curricula should
include oral cancer education and intraoral
Clinical health care professionals should
assess oral cancer risk behaviors for their
patients and provide oral cavity examinations
Public awareness and education efforts should
be increased with emphasis on the oral cancer
risks associated with tobacco and alcohol
Although oral cancer typically strikes older
adults, interventions targeting younger persons
may discourage long-term alcohol and tobacco
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