A Public Health Perspective on Oral Health in America: Advances and Challenges

Scott L. Tomar, DMD, MPH, DrPH, FACD

Inequities Persist in Oral Health Status, Utilization, and Access to Care.

The population of the United States changed substantially between the publication of the Surgeon General’s Report on Oral Health in 20001 and the 2021 Report on Oral Health in America.2 The nation is now more diverse than ever in terms of race, ethnicity, religion, and other characteristics that describe us socially and culturally. The United States is also an aging nation. By 2035, there will be more adults aged 65-years or older than there will be youth,3 and the health care needs of older adults are quite different from those of younger people.

Although there have been improvements in population oral health during recent decades, many people in the United States still suffer from chronic oral conditions and lack of access to needed oral health care. The incidence of oral diseases and conditions, like many other chronic conditions, is socially patterned, with the largest burden of disease occurring among people living in poverty, racial and ethnic minorities, frail elderly, immigrant populations, persons with physical and intellectual disabilities, and other socially marginalized groups. In fact, the magnitude of disparities in dental caries experienced has increased during the past 20 years among groups defined by household income and race or ethnicity.4 Not only do these groups suffer the highest burden of oral disease, they also face the greatest barriers to accessing routine preventive and other oral health care services.5 to an individual’s biology and behavior. For example, individuals’ choices around diet, tobacco use, and oral hygiene all have clear links to their oral health. However, individuals’ behaviors are strongly influenced by the broader environmental context in which they live, which encompasses the structural and intermediate determinants of health. Structural determinants of health include the socioeconomic, political, and environmental context in which people live, such as policies regarding economics, social welfare, trade, housing, and advertising. Intermediate determinants of health encompass factors related to social position and circumstances such as gender, ethnicity, and neighborhood resources. Determinants at the structural and intermediate levels generally are not under an individual’s direct control, but they play an important role in influencing health status. Collectively, these structural and intermediate determinants are referred to as the social determinants of health.

Identifying the factors that contribute to poor oral health among vulnerable groups may provide guidance for developing and targeting oral health promotion strategies and reducing inequities. To that end, models of oral disease development have been created that bring attention to the multilevel factors now known to contribute to oral health status. The determinants of oral health arise from the level of the individual, the family, the community, and the nation. Factors known to influence oral health status are classified into three levels, labeled as the structural, intermediate, and proximal determinants of oral health.6 Proximal determinants are related

The World Health Organization defines social determinants of health as those with which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.7 Those circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels, and a largely responsible for health inequities—the unfair and avoidable differences in health status seen within and between social groups. Social determinants of health also include and are influenced by commercial determinants of health, which are the “strategies and approaches used by the private sector to promote products and choices that are detrimental to health.” 8 Examples of such products include foods, beverages, and substances such as tobacco products that cause or promote oral disease. Commercial determinants of health also include corporate strategies to influence public policy, oppose regulation, and increase consumption of products that are detrimental to overall health. Perhaps not surprisingly, social and commercial determinants that are most damaging to oral health also are deleterious to overall health.9 That “common risk factor” perspective strongly suggests that dentistry needs to be part of broader societal approaches to address social and commercial determinants of health.