Moving Beyond the Cheshire Cat: Research in Oral Health Behavior

In Lewis Carroll’s classic story Alice in Wonderland, the Cheshire Cat appears and disappears at will, often showing up as a disembodied, grinning mouth full of teeth. This prompts Alice to say, “…a grin without a cat! It’s the most curious thing I ever saw in my life!” One might say the same of studying oral health in isolation from general health, and in fact, many are speaking out about the importance of studying the cat as well as the grin.

In 2000, the U.S. Surgeon General issued a report on oral health in America, meant to highlight to the nation the connection between oral health and general health and well-being. A major theme of this report is that oral health means much more than healthy teeth. The report emphasizes the importance of taking a systems view of oral health, viewing it as integral to overall health, and acknowledging the roles of biological, behavioral, and social factors in determining oral health.

The National Institute of Dental and Craniofacial Research (NIDCR) views oral health through the same lens. In addition to healthy teeth, the NIDCR recognizes that freedom from oral-facial pain, head and neck cancers, birth defects such as cleft lip and palate, craniofacial injuries, and other diseases that affect the craniofacial complex are important indicators of oral health. Most of these diseases and conditions are complex in nature, in that they result from an interplay between and among genes, infectious agents, diet and nutrition, behavior, society, and probably other factors as well. The research grants and contracts, training programs, and dissemination of health information supported by the NIDCR reflect its commitment to tackling these complex problems with every available scientific tool.

Particularly relevant to the members and friends of the Association for Psychological Science are the tools of the behavioral and social sciences. Similar to other areas of health, behavioral and social factors are key determinants of oral health. Engaging in preventive health behaviors, living a healthy lifestyle, seeking preventive care and treatment, and following the recommendations of health care professionals are all aspects of behavior that contribute to oral health. Social relationships, community characteristics, access to preventive care and treatment, and organization of health care systems also are key aspects of the social context that contribute to oral health.

Oral health researchers have made tremendous strides in identifying behavioral and social processes related to oral health and in developing effective interventions to improve some aspects of oral health. In partnership with biological and materials scientists, educators, health professionals, communities, private industry, funding agencies, and policy makers, these researchers have contributed to sparing millions of American adults from complete tooth loss, increasing the proportion of school children without cavities, and many other successes. Despite these successes, many Americans still do not enjoy optimal oral health, and more work is needed. In addition to the continued good work of those in the oral health field, collaborations with scientists and others from outside the field may help to make advances and discoveries that transform oral health in America.

For those studying other areas of health, it may not be intuitive how to incorporate oral health into an existing research program — or perhaps more importantly, why to do so. Regarding the “how,” I’d like to suggest three possible paradigms: 1) Using oral health as an accessible and non-invasive indicator of general health, 2) Applying models and methods from other areas of health research to oral health, and 3) Expanding the focus of research on vulnerable populations to include oral health.

Many health professionals understand that the mouth is a mirror of the body, with systemic and remote processes reflected in the relatively visible tissues of the oral cavity. A few examples may help to illustrate some of the ways in which oral health can be integrated with other areas of health research, as well as the importance of such integration. A thorough oral examination can provide physiological indicators of complex biopsychosocial processes, like self-care, drug addiction, risk taking, family violence, the experience of stress, effective management of chronic illness, etc.  Because of their readily accessible location, salivary glands, which perform both endocrine and exocrine functions, can serve as a study model for other less accessible secretory organs. As a final example, orofacial pain, oral inflammation, and infection reflect systemic nervous and immune processes.

Some areas of health research have developed models and methods of health behavior that could jump-start the understanding of similar topical areas within oral health. For instance, several decades of research on coping with adversity and on family therapy could inform the development and testing of interventions to improve management of craniofacial birth defects, such as cleft lip and palate. Clinical and health services research studying optimal organizational structures for screening, brief intervention, and referral to specialty treatment for psychiatric disorders could inform new oral health care delivery structures. Like primary care clinics, oral health clinics may be an entryway to treatment for drug addiction, nutrition deficits, eating disorders, interpersonal violence, cancer, immune dysfunction, diabetes, and other conditions reflected in the oral cavity.

Unfortunately, the same populations vulnerable to other health disparities also tend to experience disparities in oral health. These include people who are socio-economically disadvantaged, the elderly, and those with developmental or acquired disabilities. In all areas of health, ethnic and racial minority populations experience the greatest disparities. Thus, oral health is important in research addressing the needs and care of vulnerable populations — the homeless, those addicted to substances, individuals with psychiatric disorders, those living in institutions, and others.

Returning to the Cheshire Cat and to the question of why to study the cat as well as the grin, broadening the research focus helps us to get a clearer picture of health and disease and to predict, explain, and intervene more effectively. The many connections between oral health and other aspects of health and functioning have been established. The next steps are to recognize these connections in research on health and oral health and to bring together scientists working in various fields of health to generate novel, integrative, effective approaches to oral health.

To support these next steps, NIDCR is planning an initiative for Fiscal Year 2008 to develop complex models of oral health behavior. The initiative encourages research developing and testing explanatory models that capture the complex nature of oral health. Researchers are encouraged to visit the NIDCR website or to contact program staff for more information. General information can be found on the home page at www.nidcr.nih.gov; for a detailed description of the planned initiative, please see http://www.nidcr.nih.gov/Funding/CurrentFundingOpportunities/RecentlyCleared/Oralhealthbehavior.htm. For more information about NIDCR’s programs on behavioral and social sciences research, contact Melissa Riddle, chief of the Behavioral and Social Sciences Research Branch, by phone at (301) 451-3888 or by email at [email protected].