DISCOVERY!
J.L. Ebersole1*, R. D’Souza2,
S. Gordon3, and C.H. Fox4
1
College of Dentistry, University of Kentucky, Lexington, KY
40536-0297, USA; 2Baylor College of Dentistry of Texas
A&M University, Dallas, TX, USA; 3School of Dental
Medicine, University of Maryland, Baltimore, MD, USA; and
4
American Association for Dental Research, Alexandria, VA
22314, USA; *corresponding author, jleber2@uky.edu
J Dent Res 91(11):997-1002, 2012
Abstract
The 4th Annual AADR Fall Focused Symposium
(FFS), “Oral Health Disparities Research and the
Future Face of America”, took place on November
3-4, 2011 in Washington, DC. The FFS strategy
was developed by the AADR to help provide addi-
tional opportunities for members to engage in
research discussions during the year by identifying
specific research topics of interest among the 21
Scientific Groups and 4 Networks of the IADR
and targeting a focused topic area for the FFS. The
conference attracted an international group of
approximately 120 registrants, including partici-
pants from Canada, India, Mexico, and China; 4
oral sessions and 32 poster presentations were
offered.
KEY WORDS: access to care, caries detection/
diagnosis/prevention, community dentistry, dental
public health, economic evaluation, geriatric den-
tistry.
DOI: 10.1177/0022034512462034
Received April 6, 2012; Last revision August 30, 2012;
Accepted August 31, 2012
© International & American Associations for Dental Research
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© 2012 International & American Associations for Dental Research
Oral Health Disparities and the
Future Face of America
Introduction
A s has been reported, oral diseases in America can be considered a “silent
epidemic” (Evans and Kleinman, 2000). Tooth decay affects 78% of the
population by age 17 and 98% by age 44. Nearly 25% of adults aged 35 through
44 yrs have destructive periodontal disease. Of note, the prevalence of chronic
oral diseases such as periodontal disease and their associated adverse out-
comes increases with age, affecting approximately 45% of adults over 50 yrs
of age in the US, and these diseases are disproportionately borne by persons
with low socio-economic status (Dye and Thornton-Evans, 2007; Demmer
et al., 2008; Sabbah et al., 2008; Fernandes et al., 2009; Jin et al., 2011). Oral
health means much more than healthy teeth. In adults and children, a lack of
dental care often results in severe or persistent pain, inability to eat, swollen
faces, and increased susceptibility to other medical conditions. Self-reported
impacts of oral conditions on social function include limitations in verbal and
non-verbal communication, social interaction, and intimacy. The major mes-
sage of the Surgeon General’s report on Oral Health in America (USDHHS,
2000) is that “oral health is essential to the general health and well-being of all
Americans and can be achieved by all Americans.” Dental disease or visits for
treatment result in annual loss of more than 164 million hours of work among
adults and more than 51 million school hours among children (US Department
of Health and Human Services, 2000). For example, only approximately 68%
of adults 18 yrs or older have visited the dentist in the preceding 12 mos
(Centers for Disease Control and Prevention, 2010), with both Healthy People
2010 and 2020 metrics targeting increasing this proportion to emphasize that
dental care improves oral health. Poor adults are much more likely to have
lost 6 or more teeth to decay and gum disease than are higher income adults
(Kenney et al., 2000). National surveys have shown little improvement in
the use of dental care services among low-income populations over the past
2 decades, which suggests that barriers other than access to insurance cover-
age contribute to the problems faced by low-income populations. Oral health
disparities are unacceptable, although, national, state, and regional data are lim-
ited or non-existent for many oral and craniofacial diseases/conditions within
specific population groups, including rural, agrarian areas (Chattopadhyay,
2008). Importantly, progress must be made in moving from national, state, and
regional surveillance data toward research studies that are designed to identify
the factors that are the underlying causes of oral health disparities, as reported
at this conference.
More broadly, oral diseases constitute a major health burden on a global
scale, and the health community recognizes the importance of addressing the
global burden of non-communicable diseases, including periodontal disease.
Furthermore, non-communicable diseases can arise from exposures throughout
the lifespan, starting in utero (Williams, 2011). As reported by Beaglehole et al.
997
998  Ebersole et al. J Dent Res 91(11) 2012

Figure 1.  Life-course effects and influences on oral health and health disparities. Adapted from Patrick et al. (2006) and Schulz and Northridge
(2004).

(2009), the World Health Organization estimates that, in global
terms, oral diseases are the fourth most expensive to treat, with
estimates for dental services accounting for 3 to 12.5% of overall
health expenditures in industrialized countries. In some industrial-
ized countries, the mouth is the most expensive part of the body
to treat (Williams, 2011). The burden of oral disease for individu-
als in terms of pain and suffering, school attendance, and work
absence is considerable, but the economic impact of oral disease
on governments is enormous (Casamassimo et al., 2009).
Expenditures on dental services in the US in 2010 were $104.8
billion, which represents 4.0% of total health care expenses
(Centers for Medicare & Medicaid Services, 2009). Research is
needed to influence care utilization, focusing on broad access to
preventive care that will substantively affect overall health expen-
ditures in the US. This change can be accomplished only by
changing community oral health norms and expanding community-
based prevention efforts that lower barriers to personal oral health
care for disadvantaged populations.
The Institute of Medicine (IOM) report, Improving Access to
Oral Health Care for Vulnerable and Underserved Populations
(IOM and NRC, 2011), represents a product of a 2009 request
from the Health Resources Services Administration (HRSA) for
the IOM to assess the current oral health care system and to
recommend strategic actions for Department of Health and
Human Services (HHS) agencies to improve oral health and oral
health care in America, to develop a vision for how to improve
oral health care for these populations, and to recommend ways
to achieve this vision. The report conveyed a range of crucial
issues that need to be addressed to improve oral health in these
vulnerable populations:
(1) “Access to oral health care across the life cycle is critical to
overall health, and it will take flexibility and ingenuity
among multiple stakeholders—including government lead-
ers, oral health professionals, and others—to make this
access available.”
(2) “Good health requires good oral health, yet millions of
Americans lack access to basic oral health care. Various
factors create barriers, preventing access to care for vulner-
able and underserved populations, such as children and
Medicaid beneficiaries.”
(3) “To improve provider participation in public programs,
states should increase Medicaid and Children’s Health
Insurance Program reimbursement rates.”

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© 2012 International & American Associations for Dental Research

J Dent Res 91(11) 2012 Discovery!  999

(4) “With proper training, nondental

health care professionals can
acquire the skills to perform oral
disease screenings and provide
other preventive services.”
(5) “Dental schools should expand
opportunities for dental students to
care for patients with complex oral
health care needs in community-
based settings in order to improve
the students’ comfort levels in car-
ing for vulnerable and underserved
populations.”
(6) “. . .states should examine and
amend state practice laws to allow
healthcare professionals to practice
to their highest level of compe-
tence.”

This roadmap, provided by the IOM’s

deliberations and review of the “state of
the nation” with regard to oral health in Figure 2.  Diagram of conceptual framework of children’s oral health over time. Adapted from
the population, delivers a range of Fisher-Owens et al. (2007).
“important and necessary next steps to
improve access to oral health care,
reduce oral health disparities, and improve the oral health of the
nation’s vulnerable and underserved populations.”
This was preceded by another IOM report, Advancing Oral
Health in America (IOM, 2011). This report noted that “tooth
decay is a common chronic disease in the United States and one
of the most common diseases worldwide. Evidence shows that
decay and other oral health complications may be associated
with adverse pregnancy outcomes, respiratory disease, cardio-
vascular disease, and diabetes. While tooth decay is a highly
preventable disease, individuals and many healthcare profes-
sionals remain unaware of the risk factors and preventive
approaches for many oral diseases, and they do not fully appre-
ciate how oral health affects overall health and well-being.”
Furthermore, the IOM recommended that HHS design an oral
health initiative focusing on the areas in greatest need of atten-
tion and on the approaches that have the most potential for creat-
ing improvements. The report also stressed “three key areas
needed for successfully maintaining oral health as a priority
issue: strong leadership, sustained interest, and the involvement
of multiple stakeholders.”
In the context of these national and global considerations,
this AADR FFS conference was organized to bring together the
range of constituencies addressing oral health disparities, both
in the US and internationally, to share concepts on experimental
designs, infrastructure needs, partnership requirements, and
some lessons learned.
Session I: Overview of Health Disparities Research Initiatives
was designed to provide an immediate interface between the
funding stakeholders and the AADR researchers engaged in oral
health disparities research. This session was stratified into 3
emphasis areas. Dr. Joyce A. Hunter, Deputy Director, National
Institute on Minority Health and Health Disparities, National
Institutes of Health, provided a presentation, “Perspectives from
the NIMHHD”. Dr. Martha Somerman, recently appointed the
8th Director of the National Institute of Dental and Craniofacial
Research (NIDCR), provided a presentation titled “Perspectives
from the NIDCR Health Disparities Research Program.” These
presenters emphasized the expanding recognition of the impor-
tance of oral health for the population, as reflected by commit-
ments of the HHS program. Additionally, they described the
broad list of opportunities available from the NIH for investiga-
tors focusing on oral health inequalities, particularly in mothers
and children, as well as numerous programs targeted toward the
training and development of young faculty, and students at all
levels. Also described was the wide array of FOAs in disparities
research that remains a focus of the NIDCR, providing opportu-
nities to move forward in these health challenges. The second
emphasis area integrated presentations from Drs. Melissa W.
Riddle (Chief) and David B. Clark, from the Behavioral and
Social Sciences Research Branch, NIDCR/NIH, who presented
a talk on “Building Programs of Behavioral and Social Research
with the NIDCR” and Dr. Ruth Nowjack-Raymer (Director,
Health Disparities Research Program, Center for Clinical
Research, NIDCR). These presentations emphasized the need to
move research in the behavioral and social sciences of oral
health away from observational studies to those critically evalu-
ating models of health change. They presented the context of a
recent supplement to the Journal of Public Health Dentistry
(Riddle and Clark, 2011), which they co-edited, that presented a
range of invited papers focusing on model constructs for studies
of behavioral and social science strategies to effect changes in
oral health norms for the population. Dr. Nowjack-Raymer pro-
vided some insights into some of these models, including the
“Life Course Theory” (http://mchb.hrsa.gov/lifecourseapproach

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© 2012 International & American Associations for Dental Research

1000  Ebersole et al. J Dent Res 91(11) 2012
.html; see Fig. 1), focusing on the health of mothers and children
and recognizing that the interplay of risk and protective factors,
such as socio-economic status, toxic environmental exposures,
health behaviors, stress, and nutrition, influences health
throughout one’s lifetime. She also referenced a paper by
Fisher-Owens and colleagues (Fisher-Owens et al., 2007),
delineating a conceptual model to influence children’s oral
health (Fig 2.). This model emphasizes multilevel, holistic
approaches to analyses of the complex and interactive causes of
children’s health problems, by including a broad array of
genetic, social, and environmental risk factors and the complex
of interactions among these. The last area was presented by Dr.
Glen P. Mays (F. Douglas Scutchfield Endowed Professor in
Public Health Services and Systems Research, University of
Kentucky College of Public Health), who spoke on the topic of
“Disparities Research in Public Health PBRNs”. This exciting
presentation provided an overview of strategies that are evolv-
ing in the effective use of the various programs and systems
within public health departments and community health centers
to implement practice-based network research activities that do
target vulnerable populations that may not generally be included
in classic private-practice-based research networks in dentistry
and medicine.
Session II: Oral Health Disparities: Programmatic Targets
focused attention on the range of existing disparities center pro-
grams funded by the NIDCR. A goal was to highlight similari-
ties and unique features of the programs, as well as to provide a
venue for sharing in the identification of barriers across popula-
tions and delivery of information on “best practices” that may
have been determined through the successes of these various
programs. Dr. Raul I. Garcia (Boston University, Northeast
Center for Research to Evaluate and Eliminate Dental
Disparities) spoke on “Community Engagement and Oral Health
Disparities Research”, Dr. Stuart A. Gansky (UCSF) summa-
rized the history and activities of the “Center to Address
Disparities in Children’s Oral Health: CAN DO” project, and
Dr. Judith Albino [President Emerita/Interim Dean/Clinical
Professor, Colorado School of Public Health/Centers for
American Indian and Alaska Native Health (CAIANH)] deliv-
ered a presentation on "Disparities Research in Indian Country:
Challenges and Rewards". Dr. Donald Chi (University of
Washington Northwest Center to Reduce Oral Health Disparities)
delivered an impassioned address describing the Center’s activ-
ities and focusing on “A Multi-disciplinary Approach to Reduce
Children’s Oral Health Disparities”. Dr. Woosung Sohn (former
Deputy Director, Detroit Center for Research on Oral Health
Disparities, University of Michigan) spoke on “Oral Health
Disparities Research in an Inner-city African American
Population”, and Dr. Henrietta Logan (Southeast Center for
Research to Reduce Disparities in Oral Health) provided a pre-
sentation on “Theoretically Grounded Community-based
Research”, which helped to provide a bit of historical perspec-
tive and a current roadmap of these programs across the US.
Some central themes of these presentations included: (i) the
need to transition from “observation to intervention” and the
various challenges associated with this process through com-
munity participatory research; (ii) opportunities for oral health
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© 2012 International & American Associations for Dental Research
promotion and disease prevention that are delivered in “non-
dental care” settings; (iii) the importance of clearly enunciating
the “rules of engagement” when committed community partici-
pation is needed to accomplish the goals of research and service;
(iv) methods and models such as “Elaboration Likelihood
Model”, “Theory of Planned Behavior”, and “Extended Parallel
Process Model (EPPM)” to understand and prevent oral disease,
and provide evidence for health policy changes; (v) the stark
realities of both oral and general health needs in minority popu-
lations and the challenges of developing and nurturing trusting
relationships with target communities to help them successfully
change oral health expectations for these populations; (vi) the
crucial need to clarify social determinants of health with a goal
of illuminating causal pathways in health disparities in these
populations; (vii) an understanding of how far we have fallen
behind in attaining US Department of Health and Human
Services goals as outlined in “Healthy People 2010” (http://
www.cdc.gov/nchs/data/hpdata2010/hp2010_final_review.pdf);
(viii) the need for broad conceptual models of influences on oral
health and oral health disparities that include community, inter-
personal, individual, and population requirements to improve
oral health, all of which require a multidisciplinary approach;
and (ix) the importance of supporting interventional research
that would have a clinically meaningful impact, and influence
clinical practice, health policy, and community and/or individ-
ual actions to eliminate disparities in vulnerable subgroups.
Session III: Oral Health Disparities: Focused Approaches
attempted initially to identify disparities research activities more
broadly and included individual investigators who targeted
specific topics and strategies to alter oral health disparities.
Dr. Jessica Y. Lee (University of North Carolina) reported on the
“Contribution of Oral Health Literacy to Disparities in Oral
Health Status and Health Behaviors”. She provided a construct
put forward by Kilbourne et al. (2006) that addressed phases of
disparities research and attempted to identify a range of key
determinants for the origins of health care disparities. Her proj-
ect assessed oral health literacy levels in low-income, high-risk
populations, examined caregivers’ roles in oral health literacy
related to both health behaviors and children’s health status, and
determined the relationship between oral health literacy and
cumulative treatment and costs of Medicaid dental services.
Dr. Robert J. Weyant (University of Pittsburgh) presented
“Genetic Factors Contributing to Oral Health Disparities in
Appalachia: Focus on Dental Caries”. This report described the
COHRA study (Center for Oral Health Research in Appalachia)
focusing on overwhelming oral health disparities in Northern
Appalachia. This talk focused on Genome Wide Association
Studies (GWAS) to identify heritability estimates of caries. The
results described several genes related to caries susceptibility/
resistance and included genes for tooth development and resis-
tance to infectious agents, supporting the likely importance of
environment-gene interactions in dental caries severity. Dr. Sara
A. Quandt (Wake Forest School of Medicine) delivered a pre-
sentation on “Oral Health Disparities among Older Rural Adults:
Implications for Dietary Quality”. She first emphasized that this
was the first generation of older adults retaining their teeth
into old age, although their condition reflects both life-course
J Dent Res 91(11) 2012 Discovery!  1001
experience and access to dental and medical care. Her research
design focused on the concept that “elderly well-being depends
on location, location, location” with regard to general demo-
graphics and overall health. Dr. Ralph V. Katz (New York
University) provided his views on “Oral Cancer: Health
Disparities Findings and Future Issues in the US and Globally”.
His presentation initially summarized the results from the NYU
Oral Cancer RAAHP (Research on Adolescent and Adult Health
Promotion) Center. One major finding from these studies sup-
ported the contention that African American individuals are just
as willing to participate in research studies, but are less trusting,
thus establishing one basis for greater difficulty in enlisting
minorities into research studies. He finished his presentation by
“crystal ball gazing” for the future of oral cancer research, and,
as an epidemiologist, suggested that epi-genetic, epi-behavioral,
and health services research should be a major part of the future
of this field.
The final three speakers for this session described and dis-
cussed issues on the infrastructure that is required to conduct
and sustain an effective program in disparities research and care.
Dr. Susan Reisine (University of Connecticut) described her
group’s activities in “Building Collaborative Research
Infrastructure to Reduce Oral Health Disparities among Older
Urban Adults”. She emphasized the importance of oral health
disparities as individuals age, and described a multilevel
approach to building research infrastructure to conduct collab-
orative research and fostering their project to change oral health
norms and practices among vulnerable older adults. Dr. Mary
McNally (Dalhousie University) presented “Oral Care in
Continuing Care Settings: Collaborating to Improve Policies &
Practices”. The emphasis of this project was oral health for nurs-
ing home elderly. The design and questions asked were how to
integrate oral health care for frail and dependent older adults in
rural continuing-care settings. She emphasized the range of
programmatic strategies and organizational culture that was
required to fully engage all of the stakeholders in these venues.
The importance of this challenge was a continuous theme
throughout the conference. Last, Dr. Gary Slade (UNC) reviewed
some underlying assumptions on oral health disparities in a
presentation titled “Is It Low-income or High-income Inequality
that Contributes to Poor Oral Health?: Evidence from National
Surveys”. He presented concepts relating income inequality to
both health and oral health in these populations. In summarizing
the implications of the county, state, and country data derived
from these studies, he suggested that income inequality is a
lower hazard for tooth loss than is low household income, and
that state-level and not county-level income inequality is associ-
ated with tooth loss. With regard to his data and the International
Association for Dental Research program to address global oral
health inequalities, he emphasized the need to “Think globally.
. .act locally.”
Session IV: Lessons Learned and Wrap-up closed with
Dr. David Williams (University of London), a Past President of the
IADR, providing an update on “Global Oral Health Inequalities:
the Research Agenda (GOHI:RA) – an IADR Initiative”. This
provided a direct link between the primarily US-oriented topics
and the recognition of similar broader global problems and
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© 2012 International & American Associations for Dental Research
goals. His presentation focused on the major oral health mala-
dies of mankind and provided summary data regarding the cost
of dental care globally, as well as the relationship of health care
costs for dental disease vs. other major diseases in the popula-
tion. His presentation continued by describing concepts of the
social determinants of health and how the economic and social
conditions provide certain societal risk conditions coupled with
individual risk factors to alter disease expression, prevalence,
and severity. Dr. Williams emphasized that the GOHI:RA
agenda is attempting to advocate for global oral health and oral
health equity, which should be everyone’s business.
Summary
In summary, the 2011 FFS engaged a broad array of individuals
from within the dental research and service sectors to provide a
substantive overview of the range of activities that are occurring,
nationally and globally, to address oral health disparities and
inequalities. It is clear that the NIDCR is committed to this effort
and continues to identify creative ways to use limited resources
to extend this aspect of its research portfolio. The Institute
remains engaged with a collection of researchers at multiple
institutions fostering community-based studies to improve oral
health in children, adults, and the elderly. The overall emphasis
of the panel of presenters and participants focused on the magni-
tude of oral health disparities in the US population across the
lifespan, and the disproportionate impact on minorities and other
historically vulnerable populations (e.g., rural, elderly). An addi-
tional common theme of the presenters was the absolute require-
ment for the community to be fully engaged as a true partner in
the development, implementation, and assessment of any inter-
ventions to improve oral health. Last, a take-home message was
the sometimes-daunting challenge of coordinating these studies
to affect the targeted populations and the existing limitations of
current funding and study implementation to small segments of
the disadvantaged child and adult populations relative to the total
oral health improvement needs of the nation. This FFS represents
the AADR’s, as part of the IADR, mission to help improve global
oral health through supporting our dental research community,
providing opportunities for scientific discourse and communica-
tion, and advocating at all levels for the importance of oral health
for the population.
Acknowledgments
We gratefully acknowledge the Procter & Gamble Co., the Oral
Health Institute, and the American Association for Dental
Research for support of this conference. Importantly, this docu-
ment and the success of the conference would not have been
possible without the crucial contributions and time provided by
the presenters. We thank Drs. Hunter, Riddle, Clark, Nowjack-
Raymer, Somerman, Mays, Garcia, Gansky, Albino, Chi, Sohn,
Logan, Lee, Weyant, Quandt, Katz, Reisine, McNally, Slade,
and Williams for providing their insights into helping to effect
change in oral health disparities for the future. Dr. Christopher
Fox serves as Executive Director of the AADR. The authors
received no financial support and declare no potential conflicts
1002  Ebersole et al. J Dent Res 91(11) 2012
of interest with respect to the authorship and/or publication of
this article.
References
Beaglehole R, Benzian H, Crail J, Mackay J (2009). The Oral Health Atlas.
Mapping a neglected global health issue. Geneva: FDI World Dental
Foundation.
Casamassimo PS, Thikkurissy S, Edelstein BL, Maiorini E (2009). Beyond
the dmft: the human and economic cost of early childhood caries. J Am
Dent Assoc 140:650-657.
Centers for Disease Control and Prevention (2010). URL accessed on 4/4/2012
at: http://apps.nccd.cdc.gov/nohss/ListV.asp?qkey=5&DataSet=2
Centers for Medicare & Medicaid Services (2009). URL accessed on
9/4/2012 at: http://www.cms.gov/site-search/search-results.html?q=
http%3A%2F%2Fwwwcmsgov%2FNationalHealthExpendData%2F
downloads%2Ftablespdf.
Chattopadhyay A, editor (2008). Oral Health Disparities in the United
States. New York: Elsevier.
Demmer RT, Kocher T, Schwahn C, Volzke H, Jacobs DR Jr, Desvarieux M
(2008). Refining exposure definitions for studies of periodontal disease
and systemic disease associations. Community Dent Oral Epidemiol
36:493-502.
Dye BA, Thornton-Evans G (2007). A brief history of national surveillance
efforts for periodontal disease in the United States. J Periodontol 78(7
Suppl):1373S-1379S.
Evans CA, Kleinman DV (2000). The Surgeon General’s report on America’s
oral health: opportunities for the dental profession. J Am Dent Assoc
131:1721-1728.
Fernandes JK, Wiegand RE, Salinas CF, Grossi SG, Sanders JJ, Lopes-Virella
MF, et al. (2009). Periodontal disease status in Gullah African Americans
with type 2 diabetes living in South Carolina. J Periodontol 80:1062-1068.
Fisher-Owens SA, Gansky SA, Platt LJ, Weintraub JA, Soobader MJ,
Bramlett MD, et al. (2007). Influences on children’s oral health: a con-
ceptual model. Pediatrics 120:e510-e520.
Downloaded from jdr.sagepub.com at Stockholm University Library on May 25, 2015 For personal use only. No other uses without permission.
© 2012 International & American Associations for Dental Research
IOM (Institute of Medicine) (2011). Advancing oral health in America.
Washington, DC: The National Academies Press.
IOM (Institute of Medicine) and NRC (National Research Council) (2011).
Improving access to oral health care for vulnerable and underserved
populations. Washington, DC: The National Academies Press.
Jin LJ, Armitage GC, Klinge B, Lang NP, Tonetti M, Williams RC (2011).
Global oral health inequalities: task group—periodontal disease. Adv
Dent Res 23:221-226.
Kenney G, Ko G, Ormond B (2000). New Federalism: national survey of
America’s families. Washington, DC: The Urban Institute.
Kilbourne AM, Switzer G, Hyman K, Crowley-Matoka M, Fine MJ (2006).
Advancing health disparities research within the health care system: a
conceptual framework. Am J Public Health 96:2113-2121.
Patrick DL, Lee RS, Nucci M, Grembowski D, Jolles CZ, Milgrom P
(2006). Reducing oral health disparities: a focus on social and cultural
determinants. BMC Oral Health 6(Suppl 1):4.
Riddle M, Clark D (2011). Special Issue: Behavioral and social internven-
tion research essentials. J Public Health Dent 71(Suppl 1):1-129.
Sabbah W, Watt RG, Sheiham A, Tsakos G (2008). Effects of allostatic load
on the social gradient in ischaemic heart disease and periodontal dis-
ease: evidence from the Third National Health and Nutrition
Examination Survey. J Epidemiol Community Health 62:415-420.
Schulz A, Northridge ME (2004). Social determinants of health: implica-
tions for environmental health promotion. Health Educ Behav 31:
455-471.
US Department of Health and Human Services (2000). Oral health in America:
A report of the Surgeon General–executive summary. Rockville, MD: US
Department of Health and Human Services, National Institute of Dental
and Craniofacial Research, National Institutes of Health. URL accessed on
5/15/2012 at http://www.nidcr.nih.gov/datastatistics/surgeongeneral/report/
executivesummary.htm
USDHHS (2000). Oral Health in America: A Report of the Surgeon General.
Rockville, MD: US Department of Health and Human Services,
National Institute of Dental and Craniofacial Research, National
Institutes of Health.
Williams DM (2011). Global oral health inequalities: the research agenda.
Adv Dent Res 23:198-200.