Four decades ago, the U.S. Surgeon General released a landmark report on the dangers of smoking, leading to societal changes that continue to occur today. Soon, the Surgeon General will release the first-ever report on oral health. Will the new report have a similar impact? Possibly.

"That will depend on how child advocates and the media frame the report—how they communicate it to the public," says Susan Bales, a longtime child advocate and president of FrameWorks Institute, a Washington, DC-based think-tank focused on communications and social issues. "It will be crucial that children's advocates do a better job of explaining this issue to both the public and legislators."

Bales believes advocates should work to shift the discussion from the standard images and topics associated with dental health—keeping smiles bright, avoiding cavities, fearing the dentist's chair—toward the larger health implications for both individuals and the public. Advocates should also connect oral health to gaps in health insurance for children and families.

"The beauty of this issue has been that, unlike issues we normally deal with connected with children, oral health is invisible with the public," says Bales. "It doesn't have any politics associated with it—yet. If you're going to wade into welfare, you have 40 years of baggage that you'll have to deal with. Oral health is a blank slate. Moreover, there are specific ways to solve oral health problems. Here's a really important problem that we can solve easily."

Indeed, oral health involves a lot more than cavities. The General Accounting Office reports that dental disease is one of the most prevalent chronic illnesses affecting children's overall health.

Untended oral infections and disease can have a serious impact. Children with untreated oral disease may end up eating and sleeping badly. Their ability to pay attention to their teachers and their parents can suffer. And the problem is most severe in low-income families, where access to affordable dental care is limited. The Urban Institute reports that tooth decay is responsible for children missing 52 million hours of school each year, especially low-income children who have poor access to preventive dental care.

The Surgeon General's report will amplify previous public statements by government agencies and healthcare associations regarding the importance of a new approach to children's oral health.

For example, in April the American Academy of Pediatrics, the March of Dimes, the National Education Association and more than twenty other national organizations underscored their support for greater funding for the National Institute of Dental and Craniofacial Research (NIDCR) and for the Oral Health Initiative of the Health Resources and Services Administration. In congressional testimony, Stan Peck, executive director of the American Dental Hygienists' Association, said, "Despite recent advances, oral diseases are still among the most common chronic health problems in the United States. Indeed, tooth decay—or dental caries—is the nation's most pervasive childhood disease." Obstacles to progress
The Institute of Medicine estimates that half of Americans do not receive regular oral health care. This is despite the fact that tooth decay is an infectious, transmissible disease; and the three most common oral diseases—dental caries (tooth decay), gingivitis (gum disease) and periodontitis (advanced gum and bone disease)—are proven to be preventable with regular oral health care. Moreover, the impact of oral disease on overall health is profound.

"Research is increasingly demonstrating that the presence of periodontal or gum disease is linked to such life threatening conditions as cardiovascular disease, stroke, and pre-term deliveries," according to Peck. "For example, pregnant women with periodontal disease are seven times more likely to deliver pre-term low birthweight infants. This is because periodontitis is a bacterial infection and bacterial infection accelerates the production of labor inducing fluids, leading to the premature onset of labor."

Though the prevalence of tooth decay has been reduced in recent decades, the disease still affects more than half of all children by second grade, and is disproportionately distributed: 80 percent of cavities occur in only 25 percent of children, mainly among low-income and minority children.

This is one reason that Bales and others argue that the oral health issue must become part of the national debate about health insurance. "We've allowed insurance companies to fragment coverage so that arms and legs are insured, but our eyes and mouths are not," says Bales. "That's a crazy approach to health care, and one that works to save money for big insurers while passing the buck to Medicare and Medicaid."

"We must take children's oral health screening into the schools," adds Bales. "We must reverse the current trends toward less and less dependent coverage for workers, and we must get children's oral health into these benefit packages."

Medicaid alone is clearly not meeting the need. A 1996 HHS report on Children's Dental Services under Medicaid indicated that, despite the provision for oral health benefits under the Early and Periodic Screening, Diagnostic and Treatment Program (enacted by Congress thirty years ago), only one in five (4.2 million out of 21.2 million) eligible children on Medicaid actually received preventive oral health services in 1993. According to Peck, community demand for oral health care is three times the supply. He points out that one major element in the supply—the National Health Service Corps' 2,500 clinicians—can only meet 6 percent of the need for oral health care.

Public health approaches also lag behind. For decades, public health officials have designated fluoridated drinking water as one of the best ways to improve the public's dental health. Fluoride makes tooth enamel stronger, reduces plaque's ability to create acid that breaks down teeth, and promotes natural repair processes. Nonetheless, many cities and regions continue to resist fluoridation. San Diego, sixth largest city in the nation, still has not implemented this basic health measure. A 1954 initiative making it illegal to add fluoride to the water supply remains on the books. As The San Diego Union-Tribune reported on April 11, "Since that time, however, thousands of additional scientific studies?have found fluoridation to be safe and effective."

Nationally, the problem is made worse by an unexpected trend: the switch to drinking bottled water or using tap filters. Dr. Robert Ophaug, a professor of oral health at the University of Minnesota School of Dentistry, says that the public is largely unaware that "this is a real problem" for children, or that fluoride drops and tablets, available by prescription, can easily correct it. People also need to know that their choice of a filter system matters. Most carbon-based filters, for instance, do not remove fluoride from water.

While oral health may not carry as much political baggage as welfare, the debate must overcome public misperceptions about its importance—or lack of importance. Heather Munro Prescott, Ph.D, associate professor and chair of the department of history at Central Connecticut State University, has studied the messages about children's oral health transmitted to the American public since the early twentieth century.

"Like other areas of public health education, dental health advocates were strongly influenced by the advertising and entertainment industries," she writes, in a summary of her paper, "From Oral Health to Perfect Smiles: Advertising and Children's Oral Health." During the early twentieth century, toothpaste advertisements reinforced the dental profession's claim that good oral hygiene was essential to good overall health. But, during the 1920s, "the link between oral health and the health of the rest of the body gradually disappeared from public health messages?and was replaced by a growing emphasis on creating 'perfect smiles.'"

This new approach, argues Prescott, was double-edged. "On the one hand, this message helped 'sell' dental hygiene to a middle-class audience who believed that beauty was essential to personal and professional success. On the other hand, the emphasis on appearance made dental health appear to be a 'luxury' that did not need to be covered by private or public health insurance, nor did it need to be a priority for those concerned with bettering the public health."

Re-framing the message
Advocates must change public misperceptions by re-framing the issues, emphasizes Bales. "The public demonstrates little understanding of the consequences of ignoring children's oral health. This is a very large obstacle to public discussion and prioritization," she says. Based on her own research, and on a study by cognitive linguist Pamela Morgan of the conceptual frameworks that ordinary people use to reason about children's oral health, and a later analysis of news coverage and professional material used by children's oral health professionals, Bales presents an analysis of just how child advocates, health professionals and policy makers could successfully reframe the issues.

Some of her main points:

• Many Americans view children's oral health as a cosmetic issue. Therefore oral health must be framed in terms of illness or disease, and not only gum disease.
• Short term fear-based approaches ("plaque attack") are relatively ineffective compared to an emphasis on the long-term health consequences resulting from lack of care.
• The public believes that the primary responsibility for children's oral health lies solely with parents.

This last point is crucial in developing an advocacy approach, says Bales. "This, of course, is the biggest stumbling block for children's oral health advocates. The literature of children's issues is redolent with this theme, and to the extent that it goes unchecked, it undermines support for public policies," she argues. Americans have been given few alternatives to the parent responsibility model, because of the episodic nature of news coverage, which tends to reinforce individual responsibility, and the confinement of this issue to the literature of parent education.

Pamela Morgan argues that "the best way to change these attitudes is not to take them on directly. In general, the best way to counter a cognitive model is to find a part of the model that is applicable and message-compatible, and emphasize that."

The goal: acknowledge the parents' role but "bridge to the role of the community, government and business in helping parents do their job in setting the child on a path to health and achievement," says Bales. "All the other participants in the frame—dental professionals and professional organizations—must therefore be presented as acting in a supplementary and assisting role, not in a primary one."

One factor that can work in favor of children's oral health advocates is that the public does expect schools to be involved. "The fact that education has displaced crime as the number one concern on the minds of Americans going into this presidential election can only help children's oral health advocates if they use this model correctly," says Bales. In addition, schools are already involved in children's health, through required vision screening and immunization programs. (Some school jurisdictions already require children undergo dental exams each year.) Bales says advocates can "take advantage of these success stories to make the schools the locus for identifying children with dental disease."

She cautions, however, that if the education frame is overused, advocates "run the risk of creating demand for services that are in short supply." Therefore the central message must emphasize that children's oral health is part of a larger health picture.

As Bales points out, the metaphor is the message. One metaphor that works: "These problems begin very early—as the seed is sown, so grows the tree." Advocates should avoid using such symbols and visuals as cavities and toothbrushes, parents and children. Instead, they should emphasize scientific authority in health settings—and the public nature of the problem, through children's hospitals, schools, senior centers.

Finally, who should deliver this message? Surprisingly, it's not dentists, at least according to Morgan's research. "It is in this category that Morgan's research has perhaps the most startling and compelling implications," says Bales. "It is clear from the research that dentists suffer from public stereotypes that both ridicule and demonize them?It would be a mistake to detract from the policy goals of the Surgeon General's Report by deploying spokespersons who evoke negative reactions."

The overall public health message—which affects far more than teeth and gums—can best be delivered by school nurses, doctors/pediatricians, and seniors, argues Bales.

Indeed, seniors could be an interesting and unlikely group of allies and spokespersons. Morgan points out that seniors are networked to powerful voting groups, and "as 'village elders,' they represent community responsibility and social interdependence." Bales suggests that an AARP chapter president or Grey Panthers leader might say something like: "How can I be for expanding drug coverage under Medicare and be against better access to oral health coverage for children?"

And how can the rest of us be for a variety of other public health initiatives, if a child's untended and insidious oral disease—something so easily remedied—undermines those efforts?

• To secure a copy of the original FrameWorks Message Memo on Children's Oral Health or to add your name to a mailing list for future information on communications research related to children's oral health, write the FrameWorks Institute, 1001 Connecticut Avenue, NW, Suite 901, Washington, DC 20036 or e-mail Susan Bales.
• More information is available on fluoride supplements from the American Dental Association.