The Common Risk Factor Approach (CRFA)
to Oral Health Promotion
Carol Chapman, CDA, RDH, MS
Continuing Education Units: 2 hours
Online Course: www.dentalcare.com/en-US/dental-education/continuing-education/ce435/ce435.aspx
Disclaimer: Participants must always be aware of the hazards of using limited knowledge in integrating new techniques or
procedures into their practice. Only sound evidence-based dentistry should be used in patient therapy.
The subsequent information will provide a synopsis and description of the major modifiable behavioral
risk factors for chronic and oral disease and how these risk factors can be addressed in a cohesive health
promotion program. Upon the completion of this course, dental professionals will be able to create an oral
health promotion program using the CRFA.
Conflict of Interest Disclosure Statement
•
Ms. Chapman reports no conflicts of interest associated with this work.
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Overview
The Common Risk Factor Approach (CRFA) is a method used to create cross-disciplinary health promotion
programs sharing common risk factors for disease. Many of the behavioral risk factors negatively impacting
oral health also have a detrimental effect on overall health. Addressing risk factors in a collaborative health
promotion program is not only an efficacious approach to health; it highlights the important mouth-body
connection. The subsequent information will provide a synopsis and description of the major modifiable
behavioral risk factors for chronic and oral disease and how these risk factors can be addressed in a
cohesive health promotion program.
Learning Objectives
Upon completion of this course, the dental professional should be able to:
• Define the Common Risk Factor Approach (CRFA).
• Identify common risk factors for chronic and oral disease.
• Explain how social determinants affect disease onset and progression.
• Describe the levels of disease prevention.
• Explain the role of oral bacterial plaque in the mouth-body connection.
• Describe the affect of modifiable behaviors on oral disease.
• Provide a rationale for using the CRFA.
• Give examples of CRFA in practice.
• Create an oral health promotion program using the CFRA.
Course Contents
Introdcution
• Introduction
• Risk Factors and the Common Risk Factor
Approach (CRFA) to Disease
• History of the Common Risk Factors for
Chronic Diseases
Framingham Heart Study
• Determinants of Health
Explanation of the Impact of Social
Determinants on Risk Factors for Disease
• Levels of Prevention
Identification and Comparison of "Upstream"
and “Downstream” Health Interventions
• The Mouth-Body Connection
• The Four Major Modifiable Behavioral Risk
Factors
Tobacco Use, Harmful Alcohol Use and an
Unhealthy Diet as Risk Factors for Oral and
Systemic Disease
Oral Biofilm as a Risk Factor for Cancers,
Cardiovascular Diseases, Diabetes and
Respiratory Disease
• CRFA in Action
Examples of CRFA in Practice
•Conclusion
• Course Test Preview
• References
• About the Author
The United States is an aging society. In 2009,
the number of people 65 years of age or older
numbered 39.6 million. By 2030, there will be
approximately 72.1 million older Americans.1 With
the aging population comes an increase in chronic
and degenerative diseases. Chronic diseases
often emerge later in life as a result of years of
exposure to detrimental behavioral risk factors.
Addressing these detrimental modifiable behaviors
at any stage in life will greatly reduce the burden
chronic and degenerative diseases have on our
society.
Risk Factors and the Common Risk
Factor Approach (CRFA) to Disease
Definition of a Risk Factor
The World Health Organization (WHO) describes
a risk factor as “any attribute, characteristic or
exposure of an individual that increases the
likelihood of developing a disease or injury.”2
Identification of Common Risk Factors for
Chronic Non-communicable Diseases (NCDs)
and Oral Disease
According to the WHO, use of tobacco, harmful
alcohol use, an unhealthy diet, and poor oral
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Figure 1. The Four Major Chronic Noncommunicable Diseases (NCDs).
Figure 2. Framingham Heart Study.
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hygiene are risk factors for oral diseases.3 These
factors are also linked to cancers, cardiovascular
diseases, diabetes and respiratory diseases, the
four major chronic non-communicable diseases
(NCDs). Annually, NCDs account for almost twothirds of deaths worldwide and are the number
one cause of disability.4 NCDs are long-lasting
conditions that cannot be cured but can be
controlled.
diseases. Mid twentieth century, with the
emergence and utilization of vaccines and
antibiotics, infectious diseases came under control
and were replaced by an upsurge in chronic
and degenerative diseases. Researchers were
discovering a substantial increase in the number of
men diagnosed with cardiovascular disease (CVD).6
This upsurge shifted the focus of epidemiologic
studies to the little known etiologic factors related
to emerging chronic and degenerative diseases.
Description of the CRFA
Designing health promotion programs with
common risk factors for disease, such as NCDs
and oral diseases, is the focus of applying the
Common Risk Factor Approach (CRFA) to oral
health promotion. ‘Killing two birds with one
stone’ is an apt idiom for the efficacious method
of CRFA.
Framingham Heart Study
One of the most famous studies of the time, the
Framingham Heart Study, was a longitudinal cohort
study undertaken in Framingham, MA. It began
in 1948 and continues today. This unique study
examined the health determinants, also known as
the risk factors, associated with chronic disease.
History of the Common Risk Factors for
Chronic Diseases
Researchers recruited 5,209 male and female
volunteers from 28 to 62 years of age to assess
common factors associated with the development
of CVD.7 Information from physical examinations
Until the 1950s, epidemiologic research
concentrated on the eradication of infectious
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Figure 3. Dahlgren and Whitehead's Model of the Social Determinants of
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Health.
and lifestyle interviews were analyzed using
multivariate regression models. These models
were able to identify specific risk factors
contributing to the overall risk of CVD. Since
1948, surviving subjects have returned every two
years for physical examinations and laboratory
tests. The second generation, the children
and their spouses of the original cohorts, were
enrolled in 1971. In 2002 a third generation, the
grandchildren of the original cohort were enlisted.
This first of a kind study enlightened the medical
community to the multifactorial features of chronic
and degenerative diseases. Prior to this study
many CVDs, such as arthrosclerosis, were seen
as a natural part of the aging process.
“circumstances in which people are born; grow
up, live, work, and age, as well as the systems
put in place to deal with illness.”10 Described as
“the causes of the causes,”11 these determinants
affect the ability of an individual to attain and
maintain health. The wider arches involve issues
such as health policies, access to care, and
conditions under which people live and work.
Explanation of the Impact of Social
Determinants on Risk Factors for Disease
Determinants of health can be addressed at
an individual level or at a community level. In
dentistry, most health promotion is addressed at
an individual level in hopes of changing individual
lifestyle factors. For health promotion, including
dental health promotion, to have a more farreaching affect it should be directed at the wider
sphere of determinants, such as the social and
community networks. To reduce the negative
impact of detrimental modifiable behavioral risk
factors, more emphasis needs to be placed on
the social environments in which these negative
behaviors arise.
Determinants of Health
Description and Identification of the Social
Determinants for Disease
Health is an amalgamation of many factors.
The Dahlgren and Whitehead's model (1991)
depicted in Figure 3 shows a core of individuals
grouped together with some of the non-modifiable
risk factors for disease such as age, gender
and heredity.9 Radiating from the center are
concentric arches of the determinants, the
risk factors, affecting health. Dahlgren and
Whitehead described these layers as the “policy
rainbow.” These determinants not only interact
with the individual but interact with each other
in a complex relationship. The wider bands
of determinants, those outside the social and
community networks, are characterized as the
Levels of Prevention
Identification and Description of the Levels of
Prevention
Primary, secondary and tertiary are the three
levels of prevention used to avert and control
diseases in populations. Primary prevention is
targeted at reducing the incidence of disease.
It focuses on curtailing risk factors. Primary
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Figure 4. The Natural History Disease Model.
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Figure 5. Upstream Downstream Dental Healthcare.
prevention is the most effective and efficient form
of healthcare. Health promotion plays a key
role in primary prevention by “enabling people to
increase control over the determinants of health
and thereby improve their health.”12 Secondary
prevention is directed at the presymptomatic or
early stage of disease, decreasing the number of
existing cases of disease. Secondary prevention
reduces the prevalence of disease. Limiting
disability and improving function following
disease or its complications is the goal of tertiary
prevention.
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in the river upstream? Health promotion is an
upstream approach aimed at limiting the need for
downstream, or secondary and tertiary prevention.
The Mouth-Body Connection
The mouth and body are viewed as separate
biologic entities by many Americans. Traditionally
medicine and dentistry have been seen as fields
unrelated to each other. Medicine and dentistry
are studied in different schools and have separate
professional associations but both professions are
related by human anatomy. Published in 2000,
Oral Health in America: A Report of the Surgeon
General was the first time a Surgeon General
addressed the important connection between oral
health and general health.15 The report stated that
“oral health is a critical component of overall health
and must be included in the provision of health
care and the design of community programs.”
David Satcher, the former Surgeon General, in
the preface of Oral Health in America advocated
for the construction of a “framework for action that
integrates oral health into overall health.”16
Identification and Comparison of “Upstream”
and “Downstream” Health Interventions
Primary prevention has been referred to as
treating people ‘upstream.’ It is a term attributed
to John McKinlay, a medical sociologist. He tells
a tale of a man standing by a swiftly running river
when a drowning person floats past. The man
jumps in the river and rescues the individual.
No sooner had he rescued that person when
another drowning individual comes floating
by. Repeatedly the man rescues and revives
drowning people. The man becomes so involved
in rescuing drowning people that he overlooks
the most important factor, who is pushing people
The WHO declares, “Oral health promotion and
oral disease prevention should embrace what is
termed ‘the common risk factor approach,’ leading
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to the integration of oral health promotion into
broader health promotion.”17 International and
national organizations agree the CRFA framework
is the most effective method for health promotion.
disorders, especially cervical caries.24 When
smoking is accompanied by alcohol consumption,
it produces an even greater negative effect.
People who smoke and also drink alcohol have a
risk of oral cancer greater than the risk of those
who only smoke or those who only drink alcohol.25
The Four Major Modifiable Behavioral
Risk Factors
Healthy People is a nationwide disease prevention
and health promotion plan created by the United
States Department of Health and Human Services
(DHHS).26 Every ten years Healthy People sets
out goals and objectives aimed at attaining health
for Americans for the decade to come. There
are 42 topic areas in Healthy People 2020. One
of these areas addresses tobacco use. Of the
20 objectives directed at tobacco use, objective
TU-10 seeks to “Increase tobacco cessation
counseling in health care settings.”27 More
specifically, TU-10.3 speaks to dentistry and the
obligation dental professionals have to address
tobacco use. The intention of the objective is to,
“Increase tobacco cessation counseling in dental
care settings.” Healthy People realizes dental
health care providers are in an ideal position to
help current tobacco users to quit and to provide
incentives to prevent the onset of tobacco use.
It is well-documented tobacco use, harmful
alcohol use, and an unhealthy diet are risk
factors for cancers, CVDs, respiratory diseases
and diabetes.18 The role oral biofilm plays in
the development of NCDs is a recently studied
relationship.19 Attaching a specific risk factor to a
specific NCD is an impossible task. First, there
is often a lag time between exposure to a risk
factor and the development of a health condition.
Secondly, there is usually more than one risk
factor associated with a health condition, and
thirdly, the exposure to risk factors is often linked
to more than one health condition. Risk factors
act synergistically to accelerate the onset or
worsen already existing NCDs.
Tobacco Use, Harmful Alcohol Use and an
Unhealthy Diet as Risk Factors for Oral and
Systemic Disease
Tobacco Use
All forms of tobacco use pose a threat to oral
health as well as general well-being. The Centers
for Disease Control and Prevention (CDC) affirms
“tobacco use is the leading preventable cause of
disease, disability and death”20 and is the number
one risk factor for NCDs. The CDC points to
cigarette smoking as being responsible for “more
than 480,000 deaths per year in the United
States, including an estimated 41,000 deaths
resulting from secondhand smoke exposure. For
every person who dies from a smoking-related
disease, about 30 more people experience
at least one serious illness from smoking.”21
Statistics from the WHO project “tobacco use
will kill 1 billion people worldwide in the 21st
century.”22
Harmful Alcohol Use
Like tobacco, excessive intake of alcohol is also
a risk factor for NCDs. Harmful alcohol use, as
defined by the National Institute of Alcohol Abuse
and Alcoholism is, “Failure to fulfill major role
obligations at work, school, or home, continued
drinking even in situations where it is physically
hazardous, recurrent alcohol–related legal
problems and continued drinking despite persistent
or recurrent social or interpersonal problems it
may cause.”28 The CDC states, “Excessive alcohol
use includes binge drinking, heavy drinking, any
alcohol use by people under the minimum legal
drinking age, and any alcohol use by pregnant
women.”29 The CDC goes on to say “heavy
drinking for men is defined as consuming 15
drinks or more per week. For women, heavy
drinking is defined as consuming 8 drinks or more
per week.”
Related to oral health, tobacco use is associated
with stained teeth, reduction of taste, periodontal
disease, oral cancer, decreased wound healing
and a decrease in the body’s immune response
to infection.23 In addition, long-term smoking
is associated with reduced salivary flow rate
(SFR) leading to an increase in oral and dental
Alcohol abusers have a much higher rate
of periodontal disease, decayed teeth, and
precancerous lesions.30 Alcohol abuse also delays
the healing process and negatively effects blood
clotting factors. Tooth decay is related to the high
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sugar and acid content in many alcoholic drinks.
Alcohol abuse can also inhibit proper oral hygiene
measures. Failing to brush and floss teeth
regularly can result in tooth decay and periodontal
disease. The Oral Cancer Foundation states,
“The dehydrating effect of alcohol on cell walls
enhances the ability of tobacco carcinogens
to permeate mouth tissues.”31 In addition,
“nutritional deficiencies associated with heavy
drinking can lower the body’s natural ability to use
antioxidants to prevent the formation of cancers.”
Lastly, the Oral Cancer Foundation suggests
cirrhosis of the liver leads to a change in texture
of throat and esophagus tissue that may increase
the likelihood of developing oral cancer.
The body needs the right kind of fat, mainly
monounsaturated and polyunsaturated fatty
acids and very limited amounts of saturated
fats. Poultry, olive and canola oil and plant foods
like nuts and avocados are examples of foods
containing monounsaturated fats. Fatty fish
such as salmon and mackerel, as well as corn
and soybean oils contain polyunsaturated fats.
Saturated fats found in meat and dairy products
such as cheese, butter, and milk should be
limited. Too much saturated fat may elevate blood
cholesterol thereby increasing the risk for CVDs
as well as some cancers. The American Heart
Association (AHA) recommends less than 30% of
total calories for the day come from fat and only
10% of the 30% should come from saturated fat.37
Unhealthy Diet
Unhealthy diets are those that have increased
fat, sugar and sodium and are low in the intake
of fruit and vegetables.32 Dietary excess, termed
overnutrition, are the intake of excessive amounts
of nutrients and are a form of malnutrition.
Overnutrition can result in obesity and contribute
to the NCDs of cancer, CVD, and diabetes as
well as dental caries.33 Limiting the intake of
foods that have refined grains, saturated fats,
and added sodium and sugars is the healthiest
choice. Following the Dietary Guidelines for
Americans, developed by the U.S. Department
of Agriculture (USDA) is the soundest choice
for overall nutrition.34 ChooseMyPlate.gov,
established by the USDA in conjunction with
the DHHS, is an excellent website to evaluate a
patient’s diet for nutritional counseling. It is also
a resource for nutritional information to use in a
health promotion program.
Sugar
Sugar is a carbohydrate. The body uses
carbohydrates to make glucose, the fuel for the
body’s cells.38 Glucose is blood sugar converted
from glycogen stored in the liver and muscles;
when released into the bloodstream, it provides
energy for the cells. Insulin from the pancreas
helps control the amount of glucose in the body.
There are varying amounts of carbohydrates
in food products. The glycemic index is used
to measure the effect of foods containing
carbohydrates on blood glucose level. The
lower the glycemic index the slower the digestion
process. This results in a gradual release of
glucose into the bloodstream. A food with a high
glycemic index causes the hormone insulin to be
released to reduce the glucose level. Less than
100 mg/dL when fasting and less than 140 mg/
dL two hours after eating is considered a normal
sugar level.39 The more glucose in the body, the
more insulin is released into the bloodstream. A
consistently elevated glucose level puts individuals
at risk for insulin resistant type 2 diabetes and
CVD.
Fat
Some intake of fat is needed in the diet. Fats are
required for many important functions in the body.
Fats insulate our body, protect vital organs, act
as messengers, help proteins do their jobs, and
start chemical reactions that help control growth,
immune function, reproduction and other aspects
of basic metabolism.35 Problems arise when
excessive amounts of fat, especially saturated
fats, are consumed. Fat contains 9 calories per
gram, compared to protein and carbohydrates
containing only 4 calories per gram.36 This means
smaller amounts of energy-dense fats should be
eaten.
“There is convincing evidence, collectively from
human intervention studies, epidemiological
studies, animal studies and experimental
studies, for an association between the amount
and frequency of free sugars intake and dental
caries.”40 Added sugar is found in many processed
foods. There is no nutritional benefit from eating
foods with added sugar. Research shows the
average American consumes 22 teaspoons of
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added sugar a day.41 The AHA recommends
limiting sugar intake to no more than 100 calories
per day (about 6 teaspoons) for women and
no more than 150 calories per day (about 9
teaspoons) for men. One regular 12-ounce
soda contains 9 teaspoons of sugar. Drinking
one regular soda a day would put most men and
all women over the recommended daily limit.
Products that list any type of sugar as the first or
second ingredient should be avoided.
National Cancer Institute, there are more than
100 different types of cancer. Worldwide, deaths
from cancer are estimated to reach 13.1 million
by 2030 with about 30% of cancers attributable to
modifiable behavioral risk factors.
Cancer is the result of cell mutation. The
determined life span of cells is regulated by
messages received from the genes inside the
cell. Certain genes tell the cell how to make
different proteins. Some proteins signal the
cell to multiply; others encourage the cell to
stop multiplying. Mutated cells send incorrect
messages leading to an increased production of
proteins that signal abnormal cell proliferation,
diminished cell differentiation, and inhibition of
cell death. The result is a tumorous growth.
Sodium
Many Americans are unaware of how much
dietary sodium they are eating. Excessive intake
of sodium increases the risk for hypertension,
a major contributor to CVD.42 Seventy-five
percent of sodium Americans consume comes
from processed and restaurant foods.43 The
USDA recommendation for daily sodium intake
is 2,400 mg. For persons 51 years of age
and older and for persons of any age who are
African American or have hypertension, diabetes,
or chronic kidney disease the recommended
daily intake is 1,500 mg. About half of the U.S.
population, including children, and the majority of
adults, should not exceed 1,500 mg of sodium a
day.
Close to 43,250 Americans will be diagnosed with
oral or pharyngeal cancer this year. It will cause
over 8,000 deaths, killing roughly 1 person per
hour, 24 hours per day. Of those 43,250 newly
diagnosed individuals, only slightly more than
half will be alive in 5 years.”46 Poor oral hygiene
has been recognized as a possible risk factor
for oral and pharyngeal cancer.47 One theory
suggests chronic infection, such as periodontitis,
may promote normal cells to mutate. The
inflammatory process signals cells to proliferate.
The more proliferation that occurs, the more
chance there is for mutation. The mutation of
cells takes a long time to occur so eliminating risk
factors, such as poor oral hygiene, can halt the
process.
Oral Biofilm as a Risk Factor for Cancers,
Cardiovascular Diseases, Diabetes and
Respiratory Disease
Oral Biofilm
In 2000, the Oral Health in America: A report
of the Surgeon General reported, “You are
not healthy without good oral health.”16 The
connection between oral health and general health
is a recently studied association. Oral biofilm
begins with the formation of the pellicle and ends
with the complex formation of mature biofilm.
Recent research suggests the host response to
pathogenic organisms contained in oral biofilm
may be a risk factor for the four major NCDs,
cancer, CVDs, respiratory diseases and diabetes.44
A new association between oral cancer and oral
hygiene was addressed in a recently published
study in the Cancer Prevention Research, a
journal of the American Association for Cancer.48
Researchers found inadequate oral health to
be correlated with oral human papillomavirus
(HPV) infection. The study controlled for the
number of oral sex partners and smoking and still
discovered that inadequate oral health was an
independent risk for oral HPV infection. Results
showed HPV infection was 55% higher among
those self-reporting poor to fair oral health.
According to one of the researchers, Dr. Thanh
Cong Bui, “Poor oral health is a new independent
risk factor for oral HPV infection. The good news
is, this risk factor is modifiable by maintaining
good oral hygiene and good oral health, and one
Cancer
As defined by the National Cancer Institute,
“cancer is a term used for diseases in which
abnormal cells divide without control and are
able to invade other tissues.”45 Cancer is not
just one disease but various diseases named
according to the site of origin. According to the
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can prevent HPV infection and subsequent HPVrelated cancers.”
respiratory infection whereas COPD is a longstanding chronic infection. These infections can
be severely debilitating and are a major cause of
death. Chronic lower respiratory disease is the
third leading cause of death in the United States.52
Cardiovascular Disease
When oral hygiene is inadequate, undisturbed
bacterial plaque produces harmful toxins that
stimulate an acute inflammatory response
known as gingivitis. This inflammatory reaction
requires constant stimulation to remain active.
If the bacterial plaque is removed, the gingivitis
subsides. If it is not removed, gingivitis can
develop into a chronic inflammatory response,
periodontitis. Not only are the teeth’s supporting
structures destroyed in the presence of chronic
inflammation but research suggests that CVDs
may be associated with the inflammatory
response.
The two most common types of pneumonia
are community-acquired pneumonia (CAP) and
nosocomial, also known as hospital-acquired,
pneumonia. CAP is not usually associated
with oral microorganisms but nosocomial
pneumonia is linked to microorganisms found
in the oral cavity. Patients at the highest risk
for nosocomial pneumonia are patients who are
unable to perform self-oral care such as medically
compromised, institutionalized or hospitalized
patients.
Inflammation is a complex defense mechanism
producing a variety of cellular and chemical
reactions. Bacteremia occurs when bacteria from
the mouth enter the bloodstream via epithelial
tissue. The more inflammation present, the more
permeable the epithelial tissue becomes. Several
species of bacteria related to periodontitis,
in particular Porphyromonas gingivalis, have
been found in the atheromatous plaque in the
arteries of the heart.50 Atheromatous plaque
is the yellow coating on the innermost surface
of an artery produced by lipid deposits. These
deposits cause arteries to narrow, reducing
blood flow, and may result in a heart attack or
stroke. Inflammatory mediators, the cytokines
interleukin-1 beta (IL‑1), interleukin-6 beta (IL-6)
and tumor necrosis factor (TNF), are produced by
a broad range of cells and can enter circulating
blood, attach to the atheromatous plaque in
the arteries, and be a factor in clot formation.
These proteins are also thought to interact with
the vessel wall, contributing to the swelling
and narrowing of the heart’s arteries. The
inflammation in the atheromatous plaque is also
promoted by C-reactive protein (CRP), a marker
for heart disease, as well as the protein fibrinogen
produced in the liver. Fibrinogen and CRP are
also associated with blood clots formation.
COPD is a pulmonary disease affecting airflow.53
People with COPD often have compromised
protective systems in their lungs making it difficult
to eliminate inhaled oral pathogens. If oral
pathogens are not expelled from the lungs, the
result may be proliferation of the bacteria resulting
in lung infections or worsening already existing
lung condition.
The host response to periodontal infection has
four mechanisms associated with the origination
and development of respiratory disease. First,
the protective mechanisms of the lungs usually
prevent colonization of inhaled oral pathogens.
But if a large number of microorganisms are
inspired, a particularly virulent pathogen is
inhaled or the host has a suppressed immune
system, infection can occur. Second, enzymes
in saliva associated periodontal disease may
alter the lungs mucosal surfaces promoting the
adhesion and proliferation of inspired bacteria.
Third, enzymes may break down salivary
pellicles on pathogens and deter their clearance
from the lungs. Lastly, cytokines derived from
periodontal tissues may alter the epithelium in
the lungs encouraging infection from inhaled
pathogens. Appropriate oral hygiene is essential
for susceptible populations such as individuals
with compromised respiratory function and
immunocompromised individuals.
Respiratory Disease
Research studies suggest periodontal disease
is a risk factor for respiratory diseases such as
pneumonia and chronic obstructive pulmonary
disease (COPD).51 Pneumonia is an acute
Diabetes
Diabetes mellitus is a metabolic disorder
associated with the body’s inability to produce
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CRFA in Action
insulin or to produce enough insulin.54 Either
situation results in elevated levels of blood
glucose. Type 1, Type 2 and gestational diabetes
are the three major categories of diabetes.
Gestational diabetes, by definition, is diabetes
diagnosed during pregnancy. Gestational
diabetes usually subsides following delivery but
women identified with gestational diabetes are at
an increased risk of developing type 2 diabetes
later in life. Type 1 diabetes is an autoimmune
disease where the immune system attacks and
destroys the insulin-producing beta cells in the
pancreas. By far, approximately 95% of persons
in the U.S. with diabetes, have type 2 diabetes.
In the past, type 2 diabetes was referred to as
adult-onset diabetes. This term is no longer
applicable due to the dramatic increase in
adolescents and children being diagnosed with
type 2 diabetes.55 The root cause of this increase
is a sedentary lifestyle in combination with an
unhealthy diet.
The Rationale for Using the CRFA to Promote
Oral Health
The common risk factors between general and
oral health provide a rationale for dental health
professionals to partner with community members
to develop health promotion programs that will
benefit a multitude of individuals. Dental health
professionals provide oral care instruction and
education to patients all the time. Although
providing this information on a one-to-one basis
is certainly beneficial, the challenge is to take
that information to a wider community audience.
A community health promotion program is a
win-win for dental health providers as well as
the recipients of the program. Dental health
professionals have an opportunity to promote
dentistry and the important position dentistry
holds in the community, and the recipients are
the beneficiaries of a wealth of health care
information.
Diabetes affects and is affected by several oral
conditions and diseases. Xerostomia is often a
symptom of undetected diabetes. Burning mouth
syndrome, taste disorders, infections, such as
candidiasis, and dental decay are all related to
xerostomia. Diabetes can also lower systemic
resistance to infection and make already existing
oral health problems more severe.
Examples of CRFA in Practice
Women, Infants, and Children (WIC) Program
Dental health professionals can partner with
a local Women, Infants, and Children (WIC)
program. WIC is a special federal supplemental
nutrition program. It serves low-income women,
infants and children up to age five who are at
nutritional risk.58 Dental health intervention can be
as simple as providing pamphlets to a center on
oral care for infants and children as well as oral
care during pregnancy. Participants in the WIC
program are individuals with some of the greatest
need for information on nutrition and oral care.
Children from families with a lower socioeconomic
status are at the highest risk for dental decay.
Pamphlets should be culturally sensitive and
provided in several languages to meet the needs
of the population being served. A step further
would be to set up a booth at the WIC center a
day or two a month for several hours to interact
with the WIC participants. Dental assisting,
dental hygiene, or dental students could use this
opportunity to fulfill community service hours
mandated by their educational programs. Being
present at the facility allows time for students to
demonstrate with typodonts the correct brushing
and flossing techniques and to answer questions
WIC participants may have about dental issues.
According to the CDC periodontal disease
is more common in people diagnosed with
diabetes. Adults, aged 45 years or older, with
poorly controlled diabetes, were 2.9 times more
likely to have severe periodontitis than those
without diabetes.56 The likelihood increases to
4.6 times among individuals who smoke and
have poorly controlled diabetes. Many studies
suggest that oral bacteria and the inflammation
associated with periodontitis play a role in the
ability to control blood sugar levels. Conversely,
poor glycemic control is related to elevated
levels of inflammatory mediators. Research
suggests reduction of oral inflammation may
have a positive effect on the diabetic condition.57
Individuals with diabetes and periodontal disease
have two chronic conditions, each of which may
affect the other. The solution to control of both is
daily brushing and flossing, frequent professional
re-care appointments, and educational
reinforcement.
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Depending on the regulations of the center,
fluoride varnish could be applied to the children
attending with their mothers.
revisited. The newest trend is e-cigarettes. The
risks of using this type of device are not wellknown but the addictive potential of nicotine is
very well-documented. The nicotine cartridges
used in the e-cigarettes are flavored and appear
to be harmless to young adults. Intervention
by a dental health professional on the risks of
e-cigarettes would be beneficial. See dentalcare.
com course Electronic Cigarettes the Past,
Present and Future.
Diabetes
Many communities sponsor Juvenile Diabetes
Research Foundation (JDRF) walks throughout
the year to raise money and awareness for what
was formerly termed juvenile diabetes. Juvenile
diabetes is now known as type 1 diabetes.
Although the etiology of type 1 and type 2
diabetes differs, the oral conditions suffered
by persons with either type of diabetes are
the same. Dental health professionals could
distribute information on oral care and the risk
factors associated with diabetes and oral disease.
Information on JDRF walks can be found at
http://www2.jdrf.org/site/
PageServer?pagename=walk_homepage.
The CDC has developed a model entitled, “the
Coordinated School Health Program (CSHP).”
This model serves as a guide to meet the
health and safety needs of K-12 students. The
CSHP model has eight components designed
to encourage health and learning. Improving the
oral health of school children can be integrated
into each of the eight components of the CSHP
model. A more detailed description of how this
can be accomplished is provided at http://www.
astdd.org/docs/BPA2attachmentschoolcshpB.pdf.
Schools
Although volunteering is not a solution to the lack
of access to dental care that many children in the
U.S. experience, volunteering during February,
Children’s Dental Health Month, at a local
elementary school to give a presentation on oral
health benefits the children. Covering several
topics such as nutrition, brushing and flossing,
and visiting the dental office is an introduction
for many children to basic oral care. Make it a
fun interactive experience. Dental professionals
can dress in costumes; create a nutrition game
or make-up a brushing song. There are also
many other times during the year a school would
accommodate a presentation and work with the
dental health professionals.
Special Programs
Your community may have an adult center where
individuals with learning disabilities or special
needs attend a daytime program. Presenting a
program to these persons is always welcomed.
Mentally and physically challenged adults are
often in the greatest need of instruction. If
caregivers provide oral care for the adult, if
possible, instruction and written information
should also be given to the caregivers.
The Parent Teacher Association (PTA) may be
the place to promote the very controversial topic
of HPV vaccines. According to the CDC, the
HPV vaccines are given as a series of three
shots over six months.60 Cervarix and Gardasil
are vaccines that protect against cervical cancers
in women. Only one vaccine, Gardasil, is offered
for males. For the best protection, all three
doses have to be given and have to have time to
create an immune response before being sexually
active with another person. The vaccination is
recommended for preteens at about age 11 or
12 years. The same types of HPV that infect
the genital areas can infect the mouth and throat
causing cancers of the head and neck area.
Recent studies have associated HPV with a high
risk of tonsilar cancer.61
There are also special needs schools and
programs that often get overlooked during
Children’s Dental Health Month. Whether your
community has schools with special needs
classes or there is a separate school for special
needs students, it is always appreciated by
the school staff when someone takes the time
to cater to the needs of the students in those
programs.
Middle and high school presentations could focus
on tobacco use. The dangers of smoking and
using chew tobacco have been emphasized for
many years but as each new generation reaches
middle and high school age the topics need to be
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Figure 6. Integrating Oral Health into the Coordinated school Health Program Model.
Celebrations
Halloween is a time of year when children receive
a large supply of candy. A dental office could
have a candy exchange. The office could set up
a program where candy could be exchanged for
a small monetary reward or gift. The exchange
could be by the pound or by a designated
number of pieces of candy. The candy could
then be donated to our military troops overseas.
Organizations such as Operation Gratitude
gladly accept donations. Information about
Operation Gratitude can be found at http://www.
operationgratitude.com/.
59
When children come to the office for the
exchange, they could receive a toothbrush, floss
and information on oral care. This information
can also be shared with the accompanying adult.
The staff might also give a tour of the office. A
candy exchange promotes good nutrition, proper
oral hygiene and also promotes the office.
Conclusion
For the most part, dental health promotion
has been isolated from other health promotion
initiatives. Clinical dental preventive and
educational approaches alone can only achieve
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limited results. The dental profession needs to
adopt an integrated common risk factor approach
with groups concerned about reducing NCDs.
Dental health professionals are in a position to
couple with community stakeholders to address
modifiable behavioral risk factors with appropriate
health promotion information. Taking this
combined approach can greatly reducing the
morbidity and mortality from chronic diseases
and decrease the incidence of oral diseases.
Although many of the suggestions for coupling
with community stakeholders are volunteer
initiatives, for real change to occur changes
should be long-term sustainable programs.
Dental health professionals can work within and
between their professional organizations to find
enduring solutions.
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Course Test Preview
To receive Continuing Education credit for this course, you must complete the online test. Please go to:
www.dentalcare.com/en-US/dental-education/continuing-education/ce435/ce435-test.aspx
1.
Which statement best describes a risk factor?
2.
Chronic non-communicable diseases can be cured. Worldwide, the number one cause of
disability is chronic non-communicable diseases.
a.
b.
c.
d.
a.
b.
c.
d.
The etiology of a disease.
A feature that predicts the course of a disease.
An attribute that increases the probability of disease
The intervention to cease the worsening of a disease.
Both statements are true.
Both statements are false.
The first statement is true and the second statement is false.
The second statement is true and the first statement is false.
3.
Which type of research study is the Framingham Heart Study?
4.
Risk factors are also known as __________ of health.
5.
Which risk factor is modifiable?
6.
Which type of prevention is directed at the presymptomatic or early stage of disease?
7.
Tertiary prevention reduces the negative impact of an already established disease by
restoring function and reducing disease-related complications. Tertiary prevention is the
most effective and efficient form of healthcare
a.Cross-sectional.
b. Longitudinal cohort.
c. Retrospective case-control.
d. Randomized controlled trial.
a.rates
b.agents
c.values
d.determinants
a.Age
b.Gender
c.Heredity
d. Oral biofilm
a.Primary
b.Secondary
c.Tertiary
d.Quaternary
a.
b.
c.
d.
Both statements are true
Both statements are false
The first statement is true; second statement is false
The first statement is false; second statement is true
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Crest + Oral-B at dentalcare.com Continuing Education Course, November 1, 2014
8.
Which was the first to address the important connection between oral health and general
health?
a.
b.
c.
d.
9.
Healthy People 2020
World Health Organization
The Framingham Heart Study
Oral Health in America: A Report of the Surgeon General
According to the CDC, which is the number one risk factor for NCDs?
a.
b.
c.
d.
Tobacco use
Poor oral hygiene
An unhealthy diet
Harmful alcohol use
10. Which entity provides 10-year national objectives for improving the health of all Americans?
a.
b.
c.
d.
Healthy People
Institute of Medicine
World Health Organization
Centers for Disease Control and Prevention
11. All of the following have increased rates of occurrence due to harmful alcohol use except
one. Which one is the exception?
a.Malocclusion
b. Decayed teeth
c. Periodontal disease
d. Precancerous lesions
12. Saturated fats are found in fatty fish such as salmon. Polyunsaturated fats are founds in
dairy products such as cheese.
a.
b.
c.
d.
Both statements are true
Both statements are false
The first statement is true and the second statement is false
The second statement is true and the first statement is false
13. The American Heart Association (AHA) recommends limiting sugar intake to no more than
__________ calories per day for women.
a.50
b.100
c.150
d.500
14. According to the USDA, which is the recommended daily amount of sodium for an individual
with hypertension?
a.
b.
c.
d.
1,000
1,500
2,000
2,400
mg
mg
mg
mg
15. Which acute respiratory disease is associated with the inhalation of oral pathogens?
a.Asthma
b.COPD
c.Tuberculosis
d. Nosocomial pneumonia
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Crest + Oral-B at dentalcare.com Continuing Education Course, November 1, 2014
16. Which type of cell is destroyed in type 1 diabetes?
a.Beta
b.Delta
c.Alpha
d.Langerhans
17. Which undertaking utilizes a community approach to oral health promotion?
a.
b.
c.
d.
Application of fluoride varnish at a WIC center
Instructing a patient in the correct flossing technique
Providing oral care pamphlets in the dental office reception area
Performing an oral cancer screening during a recall prophylaxis appointment
18. Which HPV vaccine is offered to males?
a.Gardasil
b.Cervarix
c.Heptavax
d.Menomune
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Crest + Oral-B at dentalcare.com Continuing Education Course, November 1, 2014
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About the Author
Carol Chapman, CDA, RDH, MS
Carol Chapman, CDA, RDH, MS instructs first and second year students in the dental
hygiene program at Florida SouthWestern State College (formerly Edison State
College) in Fort Myers, FL. Her didactic instruction includes courses in patients with
special needs and community dental health. Additionally, Carol is a contracted writer
with Elsevier. Prior to employment at Florida Southwestern State College, Carol
worked in private practice for 23 years as a dental hygienist and also has experience
in dental assisting.
Email: cchapman@fsw.edu
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