Five Ways to Help Your Children Brush Better

Poor and infrequent brushing may be some of the biggest obstacles preventing children in the United States from having good oral health. That’s one of the key findings from a recent survey1 of American children’s oral health, conducted on behalf of Delta Dental Plans Association, the nation’s leading dental benefits provider.

While nearly two out of five Americans (37 percent) report that their child’s overall oral health is excellent, more than a third of survey respondents (35 percent) admit their child brushes his or her teeth less than twice a day.

Among those who rate their child’s oral health as less than excellent, only 56 percent say their child brushes his or her teeth for at least 2 minutes, which is the amount of time dentists typically recommend spending on each brushing.

While the American Association of Pediatric Dentistry recommends daily flossing, nearly half (48 percent) of the survey respondents whose children have teeth say they have never been flossed; only 22 percent report their child’s teeth are flossed daily.

Getting small children to brush properly can be a challenge, but here are some ideas that can help:

• Trade places: Tired of prying your way in whenever it’s time to brush those little teeth? Why not reverse roles and let the child brush your teeth? It’s fun for them and shows them the right way to brush. Just don’t share a toothbrush. According to the American Dental Association, sharing a toothbrush may result in an exchange of microorganisms and an increased risk of infections.

• Fun Toothbrush Holder/Toothbrush: Another way to get children brushing is by utilizing oral health gifts like robot, tree or animal-shaped toothbrush holders that stick to walls. Kids like the characters and the holder provides a sanitary storage spot for their toothbrushes and toothpaste. Remember to apply just a small dab of toothpaste to the brush since the amount of fluoride in children’s toothpaste is still adult strength.

• Take turns: Set a timer and have the child brush his or her teeth for one minute. Then reset the timer and brush their teeth for the final minute.

• Call in reinforcements: If children stubbornly neglect to brush or floss, maybe it’s time to change the messenger. Call the dental office before the next checkup and let them know what’s going on. The same motivational message might be heeded if it comes from a third party, especially the dentist.

1 Morpace Inc. conducted the 2011 Delta Dental Children’s Oral Health Survey. Interviews were conducted by email nationally with 907 primary caregivers of children from birth to age 11. For results based on the total sample of national adults, the margin of error is ±3.25 percentage points at a 95 percent confidence level.

Before Your Due Date, Schedule a Date With a Dentist’s Office

Most pregnant women recognize how important their own overall health is for their baby’s health, but may ignore a critical component – their oral health. In fact, a survey of American children’s oral health conducted on behalf of Delta Dental found that nearly 4 out of 10 American mothers neglect to visit a dentist during pregnancy, which is significant to helping prevent harmful oral and overall health problems for themselves and their babies. Dentists can identify and treat teeth and gum problems, lowering the risk for more serious, ongoing health problems for both a mother and her baby.

While having a healthy mouth is always important, pregnancy can intensify dental problems. Hormonal changes during pregnancy can exaggerate the way gum tissue reacts to plaque, increasing the risk for gingivitis, the first stage of periodontal (gum) disease. Some studies have suggested that pregnant women with moderate-to-severe gum disease may be more at risk to give birth to low-weight or pre-term babies, who are at risk for many serious diseases.

Dental hygiene habits are controllable, but some pregnancy side effects may wreak havoc on a woman’s oral health. For instance, nausea and vomiting affect 80 percent of all pregnant women.2 The stomach acid from vomiting can erode tooth enamel – making teeth sensitive and more vulnerable to decay. A woman may also feel less willing to follow her usual pattern of regular brushing and flossing.

Most moms-to-be also experience cravings. The additional snacking can lead to increased tooth decay. Giving into cravings for sugary foods can be worse for expectant mothers’ teeth, since sugar is a major cause of tooth decay.

Along with visiting the dentist, Delta Dental offers the following tips to help prevent oral health complications during pregnancy:

• Brush your teeth twice daily with fluoride toothpaste and floss once daily.
• Limit foods containing sugar to mealtime only. If you do indulge one of those cravings, drink a glass of water while snacking and brush your teeth once you’re done.
• Choose water or low-fat milk to drink and avoid carbonated beverages.
• Opt for fruit rather than fruit juice to meet the recommended daily fruit intake.
• If you suffer from “morning sickness,” rinse your mouth out with water and baking soda solution afterward. The combination will neutralize the acid. Also brush your teeth gently and if you chew gum, use the kind with xylitol as the main sweetener.

1 Morpace Inc. conducted the 2011 Delta Dental Children’s Oral Health Survey. Interviews were conducted by email nationally with 907 primary caregivers of children from birth to age 11. For results based on the total sample of national adults, the margin of error is ±3.25 percentage points at a 95 percent confidence level.

2 American Academy of Family Physicians, Nausea and Vomiting of Pregnancy, 2003.

Delta Dental Encourages Major League Baseball to Quit the Spit (Tobacco)

While smokeless tobacco has not been completely banished from baseball, Delta Dental applauds Major League Baseball (MLB) and the Major League Baseball Players Association (MLBPA) during Oral, Head and Neck Cancer Awareness Week for making a positive step toward completely eliminating tobacco’s visibility from impressionable young fans. Under a recent agreement, MLB players, managers and coaches will no longer be able to carry a smokeless tobacco tin or package in their uniforms during games or when fans are in stadiums. Additionally, they will be prohibited from “chewing” during televised interviews, at autograph signings and other fan events.

Smokeless tobacco has been banned from Minor League Baseball since 1993 and from collegiate athletics since 1994. The surge of support for an outright ban on smokeless tobacco has a website, and players like Boston Red Sox outfielder Adrian Gonzalez and Chicago White Sox pitcher John Danks have recorded public service announcements speaking out against smokeless tobacco. Joe Garagiola, an 84-year-old former tobacco chewing-MLB catcher and current broadcaster, is the chairman of NSTEP, the National Spit Tobacco Education Program. NSTEP is a 17-year-old program operated by Oral Health America that educates baseball players of all ages about the dangers of chewing or “spit” tobacco.

The American Cancer Society estimated that more than 39,000 people were diagnosed with oral cancer and nearly 8,000 people died of the disease in 2011, and that men are twice as likely as women to be diagnosed.Tobacco use is considered a major risk factor for the development of oral cancers. Whether they like it or not, athletes serve as role models for impressionable children and teens. The Centers for Disease Control and Prevention (CDC)’s 2009 Behavioral Risk Factor Surveillance Study found that more than 11 percent of male high school students and four percent of male middle school students were current smokeless tobacco users.2 Though smokeless tobacco has been banned in all venues by the NCAA and MILB, a significant number of young players get hooked on the habit earlier in life.

Delta Dental puts its support and resources behind this message. Delta Dental of Tennessee, for instance, leveraged their sponsorship with the Memphis Redbirds (Triple-A affiliate of the St. Louis Cardinals) to present Oral Cancer Awareness Night at AutoZone Park. The event included oral cancer screenings performed by teachers from the University of Tennessee Health Science Center’s College of Dentistry.

Delta Dental wants the professional baseball community to be aware of the inherent risks and dangers of smokeless tobacco use, and the influence that the actions of professional baseball players have on their youthful fans. We ask that – for their own health and that of their young fans – players pause next time before throwing in a dip. We applaud the progress that MLB has made in limiting tobacco use in the sport but would support a complete ban on smokeless tobacco during games when so many young fans are watching attentively.

Below is a video in which Dr. Kohn explores the relationship between smokeless tobacco use and oral cancer.

1 American Cancer Society. Oral Cancer Fact Sheet. Accessed February 2012. http://www.cancer.org/acs/groups/content/@nho/documents/document/oralcancerpdf.pdf

2 Centers for Disease Control and Prevention. Tobacco Use Among Middle and High School Students—United States, 2000–2009. Morbidity and Mortality Weekly Report 2010;59(33):1063–8

You Booze, You Lose: Excessive Drinking Harms Oral Health

People most often associate the health risks of excessive alcohol drinking with damage to the liver or stomach lining. But during Alcohol Awareness Month, Delta Dental warns that alcohol abuse can also prove harmful to oral health.

It is estimated that each year in the United States there will be more than 30,000 new cases of oral cancer diagnosed and about one person every hour will die from this disease.1  Heavy alcohol consumption is a risk factor for oral cancer.* According to the American Cancer Society, about 70 percent of oral cancer patients consume alcohol frequently.Tobacco smoking (i.e., cigarette, pipe or cigar smoking), particularly when combined with heavy alcohol consumption, has been identified as the primary risk factor for approximately 75 percent of oral cancers in the U.S. Using tobacco with alcohol poses a much greater risk than ingesting either substance alone. According to the National Institute on Alcohol Abuse and Alcoholism, there are approximately 17.6 million adults who are alcoholics or have alcohol problems.3 

People with alcohol problems also tend to neglect other healthy habits like eating properly or taking care of daily hygiene. A small 2003 study conducted at an alcohol rehabilitation center found that residents had a higher incidence of periodontal (gum) disease and cavities.4

Drinking, like most other things, is best done in moderation for both your oral and overall health and well-being. Some epidemiological studies suggest a heart protective association for low-to-moderate average alcohol consumption.5  Indeed, sipping alcoholic beverages like red wine (which contain heart-healthy antioxidants like resveratrol) may be beneficial for lowering LDL cholesterol and helping prevent clogging of arteries.6

*According to the Centers for Disease Control and Prevention (CDC), heavy drinking for men is typically defined as consuming an average of more than two drinks per day. For women, heavy drinking is typically defined as consuming an average of more than one drink per day.

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1 National Institutes of Health. NIH Fact Sheets. Oral Cancer – updated February 14, 2011. Accessed March 30, 2012. 

Blot WJ, McLaughlin JK, Winn DM, et al. Smoking and drinking in relation to oral and pharyngeal cancer. Cancer Res 1988;48:3282-7.

3 Medline Plus – Alcoholism http://www.nlm.nih.gov/medlineplus/alcoholism.html. Accessed March 30, 2012.

4 Araujo MW, Dermen K, Connors G, Ciancio S. Oral and dental health among inpatients in treatment for alcohol use disorders: a pilot study. J Int Acad Periodontol. 2004 Oct;6(4):125-30.

5 Di Minno MN, Franchini M, Russolillo A, Lupoli R, Iervolino S, Di Minno G. Alcohol dosing and the heart: updating clinical evidence. Semin Thromb Hemost. 2011 Nov;37(8):875-84. Epub 2011 Dec 23.

6 Wu JM, Hsieh TC. Resveratrol: a cardioprotective substance. Ann N Y Acad Sci. 2011 Jan;1215:16-21.

H2O: Oral Health Opportunity

In 1931, Dr. Frederick McKay concluded his 30-year investigation into why some children in Colorado had brown stained teeth but very little tooth decay. He discovered that water supplies with high levels of fluoride – a water-born mineral found in rocks and soil – caused the discoloration of tooth enamel and prevented tooth decay. [1] However exciting that moment of eureka must have been for Dr. McKay, it’s doubtful he ever imagined that adding fluoride to drinking water would eventually be named “one of 10 great public health achievements of the 20th century” by the Centers for Disease Control and Prevention (CDC).

During National Public Health Week, Delta Dental encourages community leaders to support the fluoridation of their local water systems. Dr. McKay’s discovery was a boon for preventive health. It’s one of the easiest, most reliable ways to bolster the oral health of an entire community. Research studies have demonstrated how fluoride helps strengthen tooth enamel and remineralize teeth that have already been damaged by the early effects of tooth decay.

Although most community water supplies had naturally-occurring fluoride in their water, it was usually at too low a level to help prevent tooth decay, and sometimes at such a high level that it would damage the tooth surface and cause staining and pitting. It took scientists almost two decades after McKay’s discovery to determine the right balance between decay prevention and tooth staining. In 1945, Grand Rapids, Mich., became the first U.S. city to add fluoride to their water supply to prevent tooth decay in the population. The results were so dramatic – a sixty percent drop in tooth decay rates in the children – that other communities began adopting the practice. Today, almost 75 percent of the U.S. population using public water systems – nearly 200 million people – has access to fluoridated water.

Fluoride has not been without its detractors, however, as some people object to any additives to drinking water even when the effects are beneficial. Others proclaim that fluoride has harmful effects, although a large body of scientific studies over the years has not supported those concerns. It is widely known that fluoride can protect teeth across an entire lifetime. The brown staining noticed by McKay – now called severe fluorosis – only occurs when the teeth are developing below the gumline during early childhood. That is why early researchers looked for the proper balance of fluoride to put in water that would both help prevent tooth decay and eliminate risk for severe fluorosis among children.

With the economy struggling, many communities are unable or unwilling to fund community water fluoridation projects. In response, several Delta Dental member companies have helped provide funding for community fluoridation projects. It’s an important dental initiative that Delta Dental is proud to support in the interest of improving public oral health.

To see a video for additional information on this important public health subject, please click here.

[1]The Story of Fluoridation by the NIDCR.  http://www.nidcr.nih.gov/oralhealth/topics/fluoride/thestoryoffluoridation.htm. Accessed February 2012.

The Toothbrush: From Horsehair to Heroes

Even our ancient ancestors – primitive though they were – recognized the need for good dental hygiene. At least that’s what archeologists believe the chewed frayed ends of aromatic twigs from early times indicate.1

The first bristled toothbrushes didn’t appear until around the year 1,000 in China, when people fashioned together a crude tool using an ivory handle with tufts of horsehair. Five hundred years later, the Chinese introduced a bone or bamboo-handle with bristles from the back of a boar’s neck. 2 The “modern” toothbrush debuted in 1938, when a Frenchman named Dupont de Nemours introduced a nylon bristle called Doctor West’s Miracle Toothbrush. 2 The National Museum of Dentistry in Baltimore has amassed quite a collection of such old-school devices and other dental memorabilia.

Of course, dental hygiene’s main tool has come a long way since the Ming Dynasty. These days, toothbrushes have smooth, polished, soft-ended and flexible nylon bristles in various configurations designed to get under the gums and between the teeth. Some offer streamlined plastic handles with rubberized gripping surfaces, action character handles for kids, timers to help you brush an appropriate length of time, LCD screens with smiley faces to encourage optimal brushing, and even tiny speakers to play music. Battery-powered toothbrushes have also evolved and may offer ultrasonic and ionic abilities, as well as oscillating and rotating brushes to mimic the best brushing technique.

Replace your toothbrush every three to six months or even earlier if the bristles start to look bent and splayed apart. Children or adults who scrub too aggressively or chew on the bristles will need to replace their brush more often. The more expensive powered models usually have replacement heads for purchase whereas the cheaper models may not.  Clean your toothbrush thoroughly under running tap water after each use, and store upright and away from other brushes so it dries out between uses.

Golfers often say “it is more the golfer than the club” that determines how good the score is. It’s the same in toothbrushing – it’s more the brusher than the brush itself that determines how well the job is done and if disease is prevented. Even the most basic manual toothbrush will work well if it is picked up and used properly.

Whether you are using a manual or battery-powered toothbrush, the most important thing is that people brush their teeth twice daily (morning and night), taking proper time (about two minutes) to cover the entire surface of every tooth. Brush gently but thoroughly and make sure to reach below the gumline and between the teeth. Take your time. Brushing harder or more aggressively for a shorter period of time doesn’t help and may actually damage the gums or tooth surface.1  Finally, always remember that for most people brushing alone isn’t adequate to prevent tooth decay caused by the sticky, bacteria-laden, acid-producing plaque that is constantly forming on the teeth. Fluoride is currently our best tool for preventing tooth decay, so always use a fluoride containing toothpaste.

Whether manual or battery-powered, the toothbrush is the best vehicle to both remove plaque and deliver fluoride to the teeth at least twice a day. So pick up that toothbrush! One of the keys to good oral health is in your hands.

1 Dental Health for Adults: A Guide to Protecting Your Teeth and Gums. Copyright © by Harvard University. All rights reserved.

2 Mandel ID The Plaque Fighters: Choosing a Weapon. Journal of the American Dental Association 1993; April 124(4); pages 71-74

3 Library of Congress http://www.loc.gov/rr/scitech/mysteries/tooth.html. Accessed Feb. 2012.

Top 5 Reasons Why Early Dental Visits are Important

Most American children don’t see their family dentist until they are over 3 years old, far later than is recommended by both dental and medical professionals.

That’s one of the key findings from a survey of American children’s oral health, [1] conducted on behalf of Delta Dental Plans Association (DDPA), the nation’s leading dental benefits provider.

The survey revealed that for those children ages 1 to 11 that had seen a dentist, the average age at the initial visit was 3.1 years.  The American Academy of Pediatric Dentistry recommends that a child go to the dentist by age 1 or within six months after the first tooth erupts. [2] Almost half of children under age 3 in this survey had never been to the dentist.

Tooth decay is nearly 100 percent preventable. So it’s important to begin good oral health habits, like visiting the dentist, at a young age. Studies show that early preventive dental care such as check-ups and cleanings can save in future dental treatment costs.

Among children who have never visited the dentist or who have not seen a dentist in the past 12 months, the most mentioned reason (52 percent) was that “the child is too young” or “doesn’t have enough teeth yet.” Lack of insurance coverage was cited by 16 percent of the caregivers.

What to Expect at Your Child’s First Visit

During a typical first visit, the dentist will:

  • Examine your child’s teeth for early signs of decay, but will also look for problems with the baby’s head, neck, jaws, skin and soft tissues in and around the mouth like the tongue, cheeks and lips. Your child’s bite, facial growth and development will also be assessed.
  • Demonstrate various tooth brushing and flossing techniques and positions to help parents care for their baby’s teeth properly.
  • Discuss diet and feeding/snacking practices that may put the child at risk for decay.
  • Address the use of topical fluoride.
  • Provide information about trauma prevention.

[1] Morpace Inc. conducted the 2011 Delta Dental Children’s Oral Health Survey. Interviews were conducted by email nationally with 907 primary caregivers of children from birth to age 11. For results based on the total sample of national adults, the margin of error is ±3.25 percentage points at a 95 percent confidence level.

[2] American Academy of Pediatric Dentistry – Policy on the Dental Home. http://www.aapd.org/media/Policies_Guidelines/P_DentalHome.pdf

Take it to Heart: Oral Health is Important

Heart disease has been the leading cause of death in the U.S. since 1921, according to the Centers for Disease Control and Prevention (CDC), which estimated that nearly 1.24 million people – or 141 every hour  and 2.35 every minute – suffered a new or recurrent heart attack in 2010.1 Valentine’s Day – a holiday commonly associated with the heart – seems like the perfect time to point out the connection between oral health and heart health.

Researchers continue to find associations between periodontal (gum) disease and other chronic health conditions including heart disease. Persons with periodontal disease and heart disease share common risk factors such as smoking, older age, low-income status and obesity. Ongoing studies are attempting to determine questions such as if you treat the gum disease will you lower the likelihood of developing or worsening heart disease?

A mix of conditions, behaviors and genetics including high cholesterol and blood pressure, diabetes, smoking and a combination of poor diet and insufficient exercise leading to obesity have helped keep coronary ailments king. Genetics likely has some role in high blood pressure, high cholesterol and other heart disease factors. Odds are that an individual you know and love has dealt with some kind of heart ailment in their lifetime.

Studies show that people with periodontal (gum) disease may be at a higher risk for coronary artery disease (CAD), the most common type of heart disease, than those without it. Researchers are now trying to determine if bacteria and inflammation in the gum tissues as a result of periodontal disease contribute to the clogging of arteries and lead to CAD. 2 

So, for your heart’s sake practice sound dental hygiene habits like brushing and flossing teeth twice daily and eating healthfully. In particular, don’t smoke cigarettes or use other tobacco products. Finally, make time for regular dental check-ups. It is an oft-neglected, but vital aspect of maintaining good oral health. Like most diseases, periodontal disease is much easier to treat and control if discovered early.

Your dentist and hygienist play a major role in detecting and treating any gum problems. Based on what they see in your mouth, they may also suggest you see your physician to evaluate you for other important health problems including cardiovascular disease and diabetes.

1Centers for Disease Control and Prevention. Roger V, Go, A, Lloyd-Jones, D, et al. Heart disease and stroke statistics—2011 update. a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee Circulation 2011;123:e1-e192.

2“Gum Disease Links to Heart Disease and Stroke.”American Academy of Periodontology, May 8, 2008. www.perio.org/consumer/mbc.heart.htm Accessed 2010.

Top 7 Reasons Why a Baby’s Oral Health Care Should Begin at Birth

Most American caregivers don’t realize that cavities are nearly 100 percent preventable, according to a survey of American children’s oral health by Delta Dental Plans Association (DDPA).1 Tooth decay can develop any time after the teeth erupt into the mouth starting at about 6 months of age. So, it’s important to establish good oral health habits from birth to ward off cavity-causing bacteria.

Caregivers might think that caring for their child’s baby teeth is unimportant because they will eventually fall out. But baby teeth help children chew and speak properly, and hold space for permanent teeth. If a child has healthy baby teeth, chances are he or she will have healthy adult teeth, too.

Before the first tooth erupts, caregivers should wipe their baby’s gums with a damp washcloth or soft infant toothbrush after meals to help keep bacteria levels low and maintain a clean home for new teeth. According to the survey, while almost three-quarters of Americans (72 percent) knew that it’s important to clean a baby’s gums with a soft cloth before the teeth surface, 28 percent reported never actually cleaning their baby’s gums.

Nearly one out of five caregivers (17 percent) with a child 4 years old or younger report that he or she goes to bed every night with a bottle or sippy cup containing milk or juice. It’s a mistake to put a child to bed with a bottle of milk, juice, sweetened water or soda, however, because the frequent exposure to sugar can lead to severe tooth decay – often called baby bottle decay. Instead, caregivers should fill the bottle with water.

Here are some additional steps you can take to ensure your little one has a healthy smile through childhood and into adulthood.

  • Avoid sharing toothbrushes, bottles, spoons and straws to protect your baby from the transfer of cavity-causing bacteria.
  • As soon as the first tooth erupts, begin brushing with a small, soft-bristled toothbrush and water at least once a day, preferably before bedtime. Once any two of your child’s teeth are touching, it’s time to start flossing once a day.
  • Within six months of getting the first tooth – and no later than the first birthday – your baby should have his or her first dental visit.
  • By the time your child is 2 (or by the time he or she can spit), start using a pea-sized dab of fluoride toothpaste. Train your child to spit out the toothpaste and rinse afterward and help your child brush properly twice a day.
  • You should help brush and floss (or at least supervise) until age 7 or 8 or until your child can properly care for his or her teeth alone.

 1Morpace Inc. conducted the 2011 Delta Dental Children’s Oral Health Survey. Interviews were conducted by email nationally with 907 primary caregivers of children from birth to age 11. For results based on the total sample of national adults, the margin of error is ±3.25 percentage points at a 95 percent confidence level.

Resolve to Kick Butts in 2012

Of the nearly 8,000 deaths in the United States attributed to oral and pharyngeal cancer annually,1 about 75 percent are due to tobacco and heavy alcohol use.2   Resolving to quit smoking may be one of the most difficult challenges to undertake in 2012, but it also comes with some of the best life- and mouth-saving benefits.

A lifestyle factor that the Surgeon General calls “the single greatest avoidable cause of death,”3 smoking also drastically affects periodontal (gum) health.4-5 According to the Centers for Disease Control and Prevention (CDC), half of the cases of severe gum disease in U.S adults can be attributed to cigarette smoking and the prevalence of gum disease is three times higher among smokers than nonsmokers.6

Smoking is the leading cause of oral and pharyngeal cancer and using tobacco in any form – including dipping snuff 7 or chewing – increases the risk of developing an oral cancer.8 Even if you’ve smoked for decades, you can reap nearly immediate benefits by quitting.9-11 Within 20 minutes, your heart rate drops, and within 12 hours, the carbon monoxide level in your blood returns to normal. Within one year, your added risk for coronary heart disease will fall to half that of a smoker’s, and within 15 years, your risk is that of a nonsmoker’s.10 Quitting reduces many of the cosmetic effects of smoking and can even improve sensitivity to smell and taste.

There are many reasons why smoking is a health risk, but here are the top five ways that kicking butts can immediately improve your oral health:

  1. It significantly reduces your risk of developing oral and pharyngeal cancer
  2. It reduces your risk of developing periodontal disease
  3. It improves the color of your teeth
  4. It can help eliminate halitosis (bad breath)
  5. It can help reduce dental decay12

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1 National Cancer Institute, National Institutes of Health – Oral Cancer http://www.cancer.gov/cancertopics/types/oral

2 Blot WJ, McLaughlin JK, Winn DM, et al. Smoking and drinking in relation to oral and pharyngeal cancer. Cancer Research 1988; 48(11):3282–3287

3 U.S. Dept. of Health and Human Services. The health conse­quences of smoking: A report of the Surgeon General. U.S. Dept. of Health and Human Services, CDC, National Center of Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. Available at: “http://www.surgeongeneral.gov/library/smokingconsequences/”. Accessed June 29, 2010.

4 Tomar SL, Asma S. Smoking-attributable periodontitis in the United States: findings from NHANES III. National Health and Nutrition Examination Survey. . J Periodontol. 2000 May;71(5):743-51

5 “Longitudinal Study of the Association Between Smoking as a Periodontitis Risk and Salivary Biomarkers Related to Periodontitis.” M. Kibayashi. Journal of Periodontology. 2007, vol. 78, no. 5, pages 859–867.

6 Preventing Cavities, Gum Disease, Tooth Loss, and Oral Cancer – 2011 At A Glance. http://www.cdc.gov/chronicdisease/resources/publications/AAG/doh.htm. Accessed 2012.

7 Oral Cancer.” National Institutes of Health. July 2007. http://report.nih.gov/NIHfactsheets/ViewFactSheet.aspx?csid=106&key=O#O

8 “Oral Health Topics A-Z: Smoking (Tobacco) Cessation.” American Dental Association. http://www.ada.org/public/topics/smoking_tobacco_faq.asp. Accessed 2009.

9 “Quitting Smoking: Why to Quit and How to Get Help.” National Cancer Institute, August 17, 2007. www.cancer.gov/cancertopics/factsheet/Tobacco/cessation Accessed 2010.

10 “Guide to Quitting Smoking.” American Cancer Society, August 7, 2008. www.cancer.org/docroot/PED/content/PED_10_13X_Guide_for_Quitting_Smoking.asp Accessed 2008.

11 “Women and Smoking: Questions and Answers. ” National Cancer Institute, February 27, 2008. www.cancer.gov/cancertopics/factsheet/Tobacco/women Accessed 2010.

12  Rooban T, Vidya K, Joshua E, et.al. Tooth decay in alcohol and tobacco abusers. J Oral Maxillofac Pathol. 2011 Jan;15(1):14-21.