E D I T O R I A L

Moving the Public’s Oral Health Forward through ResearchHelen C. Gift, PhD

In December 2006, the NIDCRsponsored a symposium to honorthe lifetime contributions of Lois K.Cohen, PhD. Dr. Cohen’s areas ofleadership and mentorship are many,but largely fall under the umbrella ofresearch in global behavioral andsocial sciences and public health.The symposium was a composite ofcritical scientific areas presented byexperts from around the world(http://www.nidcr.nih.gov/NewsAndReports / ReportsPresentation / LoisCohenSymposium.htm). Followingthe symposium, speakers and NIDCRstaff1 met to deliberate research op-portunities and issues for behavioraland social sciences research.

The charge to the group was to becreative by identifying emergingareas that have not yet been appliedto oral health issues, that have notyet been integrated into oral healthresearch, or that are in the earlystages of investigation but mayrequire new approaches for theirdevelopment. The participants iden-tified many research opportunitiesand grouped them under four maintopics: Developmental Approaches;Information Dissemination Scienceand Health Literacy; Social Policiesand Systems; and Behavioral andSocial Aspects of Oral Health andDiseases. In addition, the participantsaddressed workforce needs as wellas policy and system issues.

Within these deliberations, thereappears to be a charge to publichealth professionals to continue towork with behavioral and social sci-entists to sustain progress withinthese research opportunities so thatthe oral health of the public can con-tinue to improve. In the interest of

focus and space, I am briefly summa-rizing those areas of most pertinenceto the dental public health audience.

Developmental ApproachesResearch investigations across the

life span are needed a) to under-stand the developmental trajectoriesderived from oral health and diseaseexperience and behaviors that affectfuture health outcomes and b) todevelop interventions that enhancean individual’s capacity and compe-tence for oral health throughout life.Early health behavior, either positiveor negative, has implications forsubsequent health behaviors over alifetime. The pathways set in placein early childhood reflect individualexperiences, and the interactionsamong genetic and environmental(social, cultural, economic) condi-tions need examination through lon-gitudinal studies.

We need to enhance the capacityand competence of individuals andgroups to maintain and improve theiroral health. For example, by under-standing the intersections and inter-actions among patients and families,consumers and communities, andoral health care providers, and bydeveloping interventions to fosternormative oral health behaviors inter-acting with general health behaviors,we should be able to foster improvedoral health for a lifetime.

Specifically, research and demon-stration would be improved with afoundation in developmental theory.What are the events that affect futureoral health and general health out-comes? Can individuals developcapacity and competence for oralhealth throughout life with proactive

skill building, emphasis on self-care,and a focus on the interaction andengagement between oral health con-sumers and providers?

Information Dissemination andHealth Literacy

Health literacy is a newly devel-oping field of research. As yet, thereare no fully accepted instruments ormeasures for assessing health literacyamong health consumers, health careproviders, and/or policymakers. Thespecific meaning of oral health lit-eracy, the measurement of literacy,and the potential use of researchfindings are not clear. It is not yetknown, for example, whether healthliteracy can be changed or is only alabel or variable in understandingpatient interactions with the healthsystem. That is, if health literacy isdetermined to be important, whointervenes to change it? Research isneeded to clarify and focus the use-fulness of oral health literacy as aconcept in public health.

Basic research is needed to clarifythe meaning and measurement ofkey concepts, notably oral health lit-eracy in health care, so that researchfindings can have more potentialuse. Interdisciplinary/multifacetedap-proaches are critically needed in allareas of behavioral and social sci-ences, specifically, in this case, toimprove health literacy among indi-viduals (particularly children) andfamilies, providers, communities,organizations, and policymakers.

Social Policies and SystemsBehavioral and social scientists

need to learn more about socialstructures and systems and healthand social policies that affect a

1 This editorial is largely drawn from a summary report of the group deliberations with liberties taken based on personal perspective andinterpretation. The ideas are not exclusive to me but represent the exchange and consensus of the group convened by NIDCR in December 2006,to discuss behavioral and social science research issues for the 21st century. Acknowledgments are extended to David B. Abrams, Judith E. N.Albino, Ronald M. Andersen, Norman S. Braveman, María Teresa Canto, Lois K. Cohen, Peter Davis, Samuel F. Dworkin, Helen C. Gift, Alice M.Horowitz, H. Asuman Kiyak, Dushanka V. Kleinman, Ruth E. Nowjack-Raymer, Jeffrey M. Ortiz, Debra L. Roter, and Richard G. Watt.

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©2007, American Association of Public Health DentistryDOI: 10.1111/j.1752-7325.2007.00044.x

population’s oral health as well asdetermine the most efficient, macro-level ways of effecting behavioralchanges to improve the oral health ofpopulations. Evidence demonstratesthe value of population-wide inter-ventions e.g., antismoking cam-paigns, water fluoridation, but moreresearch is needed to demonstratenew and valuable approaches. Ex-amination of macrolevel (e.g., socialstructures, systems, policies) andorganizational level (e.g., schools,community health clinics, provisionof medical/dental services) that affectoral health, as well as identification ofcost-efficient ways for promoting oralhealth across populations, are neededto test and evaluate interventionsusing appropriate methodologies.

The delivery and organization oforal health care in relation to accessissues remain as enigmas. Despitemany studies over decades, a lack ofunderstanding persists. As recently asthe 2007 report from NHANES, wesee challenges represented by thedental visit variable. The agenda forhealth services research is scattered,making the examination of the com-plexity of this multidimensional topica continuing challenge.

Behavioral and social science andhealth services research is specificallyneeded to study health care deliverysystems to better understand andimprove a) the translation of researchfindings into clinical and communityapplications and b) the consistenciesin oral health care between poorand nonpoor populations. Focus isneeded on basic research to under-stand the functional processes andmechanisms that impede or facilitatedissemination of research findings aswell as on demonstration research toshow the potential for research out-comes that would initiate or changehealth care policies. We need to applydetailed methodologies to elucidatethe direct and indirect pathwaysby which community and societylink with oral health in order to usethis understanding to foster policiesand interventions to enhance thehealth of communities and popula-tions. Further, exploration is neededof the potential role of the health careproviders as change agents to monitor

individuals’ health behaviors, preventhealth risks (e.g., tobacco use, obe-sity), and detect the oral manifesta-tions of systemic diseases.

Behavioral and Social Aspects ofOral Health and Diseases

The group also addressed theimportance of expanding our knowl-edge to understand the behavioral,psychological, social, and culturalaspects of “oral–systemic” connec-tions to diseases. This discussion wasextensive, but cannot be done justicein this editorial. At the bottom line,there are two relatively simple ques-tions: If there is a behavioral bridge toa specified disease, what is it? Howcan scientists understand this contri-bution and use this understanding toinfluence the disease process? Direc-tions require integration across dis-ciplines in planning, implementing,and evaluating research. Understand-ing the oral–systemic interface is sup-portive of the earlier opportunitiesdiscussed. For example, researchinvolving Native Americans stronglysuggests that their medical conditionsreflect involvement of macroleveldeterminants (e.g., socioeconomicstatus, access to health care) as well asindividual determinants (e.g., physi-cal activity, health behaviors, pro-vider skills), both of which relate tobehaviors in families, neighborhoods,and communities, and all of whichaffect oral health outcomes. Similarly,behavioral and social sciences re-search is critical to research on obe-sity and nutrition and to studies ofquality of life.

Overall, a prevailing focus of thediscussion was the breadth of studiesneeded. A systems approach isnecessary to improve the researchagenda for the public’s oral health.For example, we need to elaboratethe behavioral, psychological, social,and cultural dimensions of diseasescharacterized by oral–systemic con-nections and study the layering ofthese associations to identify anddescribe the cause(s) of disease. Thedimensions to consider includemacrolevel and individual determi-nants of disease, behaviors and riskof disease, and comorbidities. Also,we need to pursue systems

approaches focusing at common riskfactors between oral and medicalconditions. Areas of obvious overlapfor behavioral and social sciencesresearch include, for example, com-monalities in understanding andmonitoring self-care, the socialcontext of nutrition and obesity,assurance of quality of life (vis-à-visactivities of daily living), and assess-ment of burden of disease (e.g.,disability-adjusted life years).

Interdisciplinary research, in andof itself, is not the answer. It would bemore productive to adopt a systemsapproach which would serve to frameresearch and, at the same time,remain open to new opportunitiesand directions. Research needs tomove away from descriptive, repeti-tive studies and embrace systemstheory, develop hypotheses and indi-cators, and apply comprehensive,theoretical designs to studies. Scien-tists should use statistical models/approaches and comparative me-thods appropriately to examine theo-ries and apply them in interventionresearch to identify factors that con-tribute the most risk for diseases.Positive and negative, as well as un-expected research, outcomes need tobe critically reviewed in order toreturn to examine the originatingtheories and systems approachesmore thoroughly.

Development of the workforce inoral health to address these researchand implementation needs is a majorconcern. Two possibilities are a) todevelop this workforce within den-tistry and oral health researchersand b) to piggyback onto other areasof research by introducing/enticinginvestigators into oral health. Thesemanpower issues are similar to thosediscussed within AAPHD regardingteachers and practitioners of publichealth dentistry. The challenge ofgrowing the next generation of re-searchers, teachers and practitionersof public health, behavioral andsocial scientists, and health serviceresearchers is mammoth. We, inthese professions, need to encouragefunding and action by supporting theorganizations positioned strategicallyto achieve the public’s oral health inthe 21st century.

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