268
Journal of Public Health Dentistry
A Comparison of Available Strategies to Affect Children’s Dental Health: Primary Preventive Procedures for Use in School-based Dental Programs Alice M. Horowitz, R D H , MA* Although there may be various interpretations of the meaning of the term “primary prevention,” in this paper it means that a given procedure or course of action prevents the onset of disease. In contrast, secondary prevention is a procedure that arrests or treats the disease. Thus, a proven fluoride regimen is a primary preventive procedure whereas an amalgam restoration is a secondary one. Also target populations are defined in school dental programs as including all ages from preschool (three to five year olds) through 12th graders, although children in grades kindergarten through six are most routinely addressed in school dental programs. 8 As a permanent community structure, schools provide excellent settings for preventive dental programs. N o other community setting comes close to supplying comparable numbers of children and adults-approximately 45 million students and over two million teachers in 106,000 schools. I n addition, more than 40 percent of children aged three-to-five in the United States are enrolled in early childhood educational programs. Thus, the school is the prominent locus for reaching children with primary preventive measures. Of course, conducting health programs in schools is not a new concept. Dental Health Education and Mechanical Plaque Removal For decades the customary school dental program has consisted of dental health education in the classroom. The traditional approach described the anatomy of teeth and their function as cutters or grinders and admonished children to forego sweets, to brush their teeth (or swish and swallow), and to see their dentists every six months. Today, however, school-based programs for dental health education show signs of increasing sophistication in educational methods. Modern education no longer requires that students only look, listen, and perhaps demonstrate their knowledge of facts. Students are now taking part in the educational process by demonstrating their understanding of health information and by performing specific oral hygiene practices. Some aspects of prevention are increasingly stressed, particularly plaque removal through toothbrushing and flossing in order t o control dental caries and gingivitis. Industry and various agencies and organizations have devised a multitude of programs, teaching aids and gadgets for classroom use-expensive aids and gadgets, one might add. Plaque control has been and still is big business. The “Toothkeeper Program” once touted as a cure-all for preventing dental disease in schoolchildren has been followed by “Toothtown,” “THETA,” “Tattle Tooth,” “The Dental Bear,” and others. Although these efforts may qualify as public relations activities, ultimate benefits to the participants are questionable. Have these programs affected the oral
*Public Health Educator, National Caries Program, National Institute of Dental Research, N I H, Bethesda. MD. 20205.
Vol. 39, No. 4-Fall,
269
1979
health of students; that is, have they prevented dental disease? There is little evidence to show that they do. Yet these kinds of programs persist. Recently, two studies were made to learn the effect of dental caries and gingival inflammation of removing dental plaque. Toothbrushing and flossing were supervised daily 1-2 in school for three academic years. One study with children who were initially in grades five through eight, was done in rural East Hampton, Connecticut, where the concentration of fluoride in the water supply is negligible. N o other preventive dental program was conducted concurrently in the community. After sessions of instruction in plaque removal, a test group practiced daily plaque removal under close supervision by trained personnel. The daily regimen consisted of the use of a disclosing agent, dental floss, a toothbrush and a nonfluoridated dentrifice. The control group was not instructed in procedures to remove plaque nor did they practice oral hygiene procedures in school. Results after 32 months were that mean incremental D M F T and DMFS scores after 32 months were 14 and 15 percent lower, respectively, than the controls . The differences between groups were not statistically significant. Girls in the treatment group showed a 27 percent reduction in mean plaque score whereas the score for boys was reduced by only nine percent (18 percent overall). At the final examination, girls in the treatment group showed a reduction in gingivitis of 40 percent and the boys' mean score was reduced by 17 percent (about 29 percent reduction overall). Although these changes in the treatment group were statistically significant when compared with controls, the changes from a practical standpoint were relatively small. Moreover, differences in plaque and gingivitis scores between groups virtually disappeared during the summer vacation. In a similar study conducted in two schools in Oakland, California, examinations after 29 months showed that the mean plaque and gingivitis scores were lower in the treatment group than in the control group in one school but in the other school only the mean gingivitis score in the treatment group was lower than the control group. There was no reduction of dental caries increments at either school. Inasmuch as the children in both of these studies used thorough and rigorously supervised oral hygiene procedures to remove plaque in school, the findings suggest that one can realistically expect only modest benefits from other school programs for controlling plaque by mechanical methods. It is not suggested that oral hygiene instruction in schools be dropped. It is suggested that such activities should not be the major effort in school-based dental programs. The concepts of increasing the use of a toothbrush and decreasing the consumption of sucrose are not new ideas. Almost everyone beyond age three has heard: "You should brush your teeth" and "You should not eat sweets between meals." All ought to know these dicta; they have been given this information long enough. However, toothbrushing is not synonymous with thorough plaque removal, and both regular and thorough removal of plaque are necessary to improve an individual's oral health. If oral hygiene procedures are to be introduced in schools, they should be valued for their ability to I
synonymous with fhorough pfaque removal, and both regular and thorough removal of plaque are necessary to improve an individual's oral health. If oral hygiene procedures are to be introduced in schools, they should be valued for their ability to reduce gingivitis, and that will happen on/v when the children are adequately trained
_" -..:-.---..---=--... ~ . - ~-,., u d . .,_.____.~ .- .>=--.-.. __.__.~...._ __ -_.-- .-_ -...--..-._ _--_..^ _ _ _-_. g_._-_ .___ ~ ....._. ~ ..-...~ .....~.. -_C._._... .... -_ -.-.....-. ..-____, _-__ ..-_ .-. ______. sup,,,;sed.
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270
Journal of Public Health Dentistry
Reduction of Sugar Consumption Teaching students in today’s society about the deleterious effects of sugar on teeth has about as much chance of preventing dental caries as trying t o get them to remove dental plaque thoroughly each day. Efforts t o control the overconsumption of sucrose, although admirable, may be unrealistic because they compete with the goals of segments of the food industry whose financial resources for advertising are huge. The students one attempts t o educate about the evils of sugar have long been exposed t o countless commercials that extol the “goodness” of sugared products. Conflicting messages abound. How many modern moms can counter the authoritative, knowledgeable actress-mother in a certain T V commercial who states that when she decides her children will have a snack you can be sure it will be a “cream-filled, sugared treat”-that is a satisfying, fortified (and, therefore, healthful) snack that all knowledgeable moms provide? Sugar-laden edibles are given as tokens of love and affection and as rewardseven in some remeiliial reading programs in school. Some health agencies sell candy t o raise funds t o help eliminate another health problem. Moreover, sugar is routinely identified as “the energy-producing food.” N o wonder that moms and their families have Twinkie mentalities and corresponding diets. It is foolish t o try t o teach “good snack habits” t o children when down the school hallway a vending machine filled with sugared products is available. Moreover, these same items are frequently sold at the school lunch counter. It is not uncommon t o find that these items are sold to raise funds for school activities or equipment. Without changes in current practices of advertising edibles laced with sugar and without effective percentage-labeling of the ingredients of all foods, efforts t o reduce consumption of sugared items are undoubtedly exercises in futility. Little research has been conducted into the effect on dental caries of restricting the availability of sweets in school. In Australia, Roder’ demonstrated a modest caries reduction in children who attended a school that severely restricted sweets. However, just how long students will conform with being “sweetless” at school remains t o be seen. Removing the sale of and reducing the excessive serving of sweets in schools should be accomplished. However, it should be done in conjunction with and nor in lieu of primary preventive procedures such as school-based fluoride regimens. T H E USE O F F L U O R I D E S Although the ability t o prvent dental caries is imperfect, tested preventive measures that provide significant protection against this nearly ubiquitous disease are available.d-’ These methods can greatly reduce caries, yet a large portion of the public is neglected. When proven methods are available, the failure t o protect the public from dental caries, particularly the young, is a national disgrace. If improved oral health of children is truly desired, an effective method of fluoride application should be a fundamental part of every school dental program. T h e use of fluorides is the intelligent alternative t o dental caries and costly restorations. A brief review of the various methods of utilizing fluorides is in order.
Communiij! Water Fluoridation Fluoridation is the adjustment of the fluoride content of a community’s water supply to a n optimal concentration (0.7 t o 1.2 ppm) for the prevention of tooth
Vol. 39, No. 4-Fall,
1979
27 1
decay. Water fluoridation is the foundation upon which any local, state, or national program for preventing dental caries should be based. Fluoridation is inexpensive and the entire community benefits regardless of economic or educational level, individual motivation or the availability of dental manpower. No direct action is required of the individual, yet dental caries is reduced by 50-65 percent among children who consume optimally fluoridated water from birth. The major shortcoming of community fluoridation is that it is limited to areas served by central water supplies. About one sixth (17 percent) of the U.S. population cannot benefit from the procedure because they live in areas that lack central water systems. Another one third of the population (33 percent) have not implemented fluoridation of their central water systems. School Water Fluoridation
An effective method of providing the benefits of systemic fluoride in geographic areas that lack central water systems is the fluoridation of school water supplies. Rural schools frequently have an independent water supply that can be fluoridated. Several states have such school fluoridation programs. Both North Carolina and Kentucky have more than 100 schools that are fluoridating their water supplies. School fluoridation effectively reduces tooth decay by about 40 percent. Disadvantages of school fluoridation are that exposure is limited to school-age children during school hours, and use is restricted to areas in which both the school water and the home water supplies of all students have low levels of naturally occurring flu0 ride. Professional Applications of Topical Fluorides
Fluoride can also be applied topically to the teeth by a dentist or a dental hygienist. This method requires (as far as is now known) thorough cleaning of the teeth before the fluoride is applied. Fluoride solutions or gels are then either painted on the teeth or applied in mouth trays. To be effective, the procedure should be done at least annually and preferably every six months for caries-active children. Although professionally applied fluorides will reduce tooth decay by 30-to40 percent, it is an expensive method both from the standpoint of dental manpower and cost compared with other approaches. Programs of professional application of topical fluorides are more suitable in communities or states with an abundance of professional personnel. Self- Applied Fluorides
For the past two decades, considerable research has been conducted on the use of fluoride tablets and/ or fluoride mouthrinses in schools. Because most children attend school regularly, and because schools operate on a more rigid schedule than d o individual families, schools are logical places for administering self-applied fluorides to children. Research has shown that dental caries can be reduced 20 to 40 percent by the daily use of a fluoride tablet in school and 20 to 50 percent by once-a-week fluoride mouthrinsing. These results follow the use of the respective agent on school days only. These two school programs for self-applied fluoride have the following advantages compared with other methods of fluoride application:
272
Journal of Public Health Dentistry
1. The procedures have proved effective in reducing tooth decay. 2. They require little time. 3. The technics of using tablets or rinsing are easy to learn. 4. Few materials and supplies are required, thus these programs are inexpensive. 5. Nondental personnel with minimal training can easily supervise the procedures. 6 . Administration of the procedures is easy and interrupts a school's academic program for only a few minutes. The differences between the two agents are of special interest. When fluoride tablets are given in nonfluoridated communities, children receive systemic as well as topical benefits. Also, tablets are suitable for use with preschool children; mouthrinsing is not. Moreover, weekly mouthrinsing appears t o provide protection against dental caries only as long as the procedure is continued whereas fluoride tablets confer retained benefits. Finally, there are no waste products to dispose of with fluoride tablets anQ the procedure can be less expensive than fluoride rinse programs. Today it is estimated that over eight million children in this country are using either a fluoride mouthrinse once a week, a fluoride tablet once a day in school, or both. Some school programs use both procedures if conditions are appropriate; that is, if only trace amounts of fluoride are in the drinking water. Although the present number of children participating in these programs is a good beginning, there is a long way to go to reach all children who could benefit from these preventive regimens. School dental programs can be exciting opportunities to provide primary preventive procedures. Such self-applied fluoride methods are easy to carry out in school settings. Dentists, dental hygienists and other health personnel can be instrumental in implementing these programs by working with school superintendents, school boards, health departments, health societies, and the public media. In addition t o implementing self-applied fluoride regimens in schools, it is also important to convey the fluoride message clearly to parents, students, faculty, and administrators. They need t o know what fluoride is, what it does to protect teeth from the ravages of dental caries, and what options are available for obtaining maximum benefits from its use. It is incorrect t o assume that adults, not to mention children, know what fluoride is, even if they live in communities with fluoridated water. Some communities have discontinued fluoridation after having benefited from the procedure for years, partly because there were not enough informed citizens to protect the program. Many voters simply d o not know what fluoridation is and what it does because each new generation has not been educated. In a national survey conducted by the National Opinion Research Center in 1972, which investigated knowledge about dental health, 70 percent of the respondents indicated that they had heard of or read about fluoridation, but only one half of these persons knew that fluoridation prevented tooth decay. A similar survey conducted by Gallup earlier this year indicated that the population has nor increased its knowledge about fluoridation.8 Is it any wonder, then, that community fluoridation has not been implemented in more communities? O r that some communities have decided to discontinue it? Probably even fewer persons know of self-applied fluorides. This ignorance is unfortunate, but can be alleviated. Just implementing a fluoride regimen in schools is
Vol. 39, No. 4-Fall,
1979
273
not enough. Each program should include a n educational component t o helt, ensure that all those involved know what they are doing and why. Rinsing by vote will reduce dental caries but alone it will not necessarily make a more informed voter or consumer. Ultimately, both understanding and self-protection must be achieved. SEALANTS Although controlled clinical trials have shown that pit-and-fissure sealants effectively reduce the incidence of dental carries in permanent teeth, few public health programs have made use of them. The major reason is probably the cost. Costs for applying sealants depend upon I ) the type of personnel used, 2) the number of teeth sealed per visit, and 3 ) the type of material used. Interestingly enough, one innovative state is starting a sealant for 6,000 children.9 This sealant program is being used in conjunction with a fluoride mouthrinse program which, of course, is a logical combination of preventive methods. It would be foolish to have a sealant program t o save occlusal surfaces without a n accompanying regimen of fluorides t o protect the smooth surfaces. The director of the program has determined that a tooth surface can be sealed for slightly over one dollar by contracting with local dentists. The practicality of using sealants in public programs may depend ( 1 ) upon dentists who are willing t o contract their services for less than the usual and customary fees in private practice or (2) upon the use of dental auxiliaries. The latter approach, of course, will require chances in many states’ dental practice acts. CONCLUDiNG C O M M E N T S
If the intention in school dental programs is t o lower the incidence of oral diseases, efforts must include primary preventive procedures. Only programs that are effective should be conducted. There is no longer the pre-Proposition 13 luxury of waving a toothbrush in the air and claiming it will reduce dental diseases. Teachers and school administrators are increasingly being asked t o explain M ~ J students . are not learning more. Parents are demanding that their taxes for education produce a better end product. Classroom time is at a premium. In addition, teachers and school administrators must contend with increased classroom disorderliness and violence.“) Faced with these realities, there is but one choice: a sound regimen of primary prevention is mandatory for school dental programs, if dental public health is t o be accountable. School fluoridation, fluoride tablets, or fluoride mouthrinsing must be implemented in order t o reduce dental caries and thus affect the oral health of our children. Only then should additional efforts and monies be expended to include a course of action t o reduce the consumption of sugar and to increase the mechanical removal of dental plaque. Back t o the question posed in the title of this session, “Do School Dental Programs Affect the Dental Health Status of Children?” If the programs include a recommended regimen of fluoride, then the answer is yes. If not, then the value of these programs is highly questionable.
References I . H o r o w i t ~ ,A. M . , et al. Effect of supervised daily plaque removal by children: result, after third and final year. IADR Abstr. J. Dent. Res. 56: Spec. Issue A: 85. Feb. 1977. 2. Silverstein. S.. et al. Effect of supervised deplaquing on dental caries, gingivitis and plaque. IADR Abstr. J. Dent. Res., 56, Spec. Issue A: 85. Feb. 1977.
274
Journal of Public Health Dentistry
3. Roder, D. M. The association between dental caries and the availability of sweets in South Australian school canteens. Aust. Dent. J., 18: 174-82. June, 1973. 4. Driscoll, W. S. The use of dietary fluoride supplements for the prevention of dental caries. presented at the International Workshop on Fluorides and Dental Caries, Reductions. April 28-May I . 1974. 5. Horowitz, H. S. The prevention of dental caries by mouthrinsing with solutions of neutral sodium fluoride. Int. Dent. J., 23:585, Dec. 1973. 6. Leske, Gary S. and Ripa, Louis W. Guidelines for establishing a fluoride mouthrinsing caries prevention program for school children. Pub. Health Rep., 92: 240-4. May-June 1977. 7. National Institute of Dental Research, National Caries Program. Preventing tooth decay. A guide for implementing self-applied fluoride in schools. DHEW Pub. No. (NIH)77-I 196, 1977. 8. Corum, James T., Personal communication September 1978. 9. Tuckman, Edward H.. Personal communication October 1978. 10. Cornlay, C. Blackboard jungle updated. TWA Ambassador. Sept. 1978.
The First 50 Years The Journal of the American Dental Association paid tribute, in 1950, to members of the dental and allied professions who had contributed significantly to the progress of dentistry during the first half of the 20th century. In this series, we present to today's dentists those men who were singled out a generation ago by their constitutent societies for special recognition. Clinton T. Messner was the first dentist to be commissioned in the Regular Corps of the U S Public Health Service. He received his commission in July 1930 and built a solid foundation for dentistry in the Public Health Service before his untimely death in 1936. Dr. Messner was a graduate of the School of Dentistry, Indiana University. After practicing in Oxford, Ind., he went, in 191 1, to Portland, Ore., where he taught in the dental school for two years. Subsequently he resumed private practice in Oxford until he was called to active duty in the army in 1917. Dr. Messner entered the U. S. Public Health Service in 1919 and was placed in charge of the Ninth District dental activities at St. Louis. In 1921, he was transferred to Washington, D.C., and in 1924 he became chief of the Dental Service. The establishment of public health dentistry as a part of the dental school curriculum was the result of Dr. Messner's encouragement. He was responsible for establishing the first chair of public health in the School of Dentistry at Indiana University. He was active in organized dentistry and was interested in international dental health work. Dr. Messner died in 1936. -from
Dent. Abstracts
01June
1979
Journal of Public Health Dentistry
A Comparison of Available Strategies to Affect Children’s Dental Health: Primary Preventive Procedures for Use in School-based Dental Programs Alice M. Horowitz, R D H , MA* Although there may be various interpretations of the meaning of the term “primary prevention,” in this paper it means that a given procedure or course of action prevents the onset of disease. In contrast, secondary prevention is a procedure that arrests or treats the disease. Thus, a proven fluoride regimen is a primary preventive procedure whereas an amalgam restoration is a secondary one. Also target populations are defined in school dental programs as including all ages from preschool (three to five year olds) through 12th graders, although children in grades kindergarten through six are most routinely addressed in school dental programs. 8 As a permanent community structure, schools provide excellent settings for preventive dental programs. N o other community setting comes close to supplying comparable numbers of children and adults-approximately 45 million students and over two million teachers in 106,000 schools. I n addition, more than 40 percent of children aged three-to-five in the United States are enrolled in early childhood educational programs. Thus, the school is the prominent locus for reaching children with primary preventive measures. Of course, conducting health programs in schools is not a new concept. Dental Health Education and Mechanical Plaque Removal For decades the customary school dental program has consisted of dental health education in the classroom. The traditional approach described the anatomy of teeth and their function as cutters or grinders and admonished children to forego sweets, to brush their teeth (or swish and swallow), and to see their dentists every six months. Today, however, school-based programs for dental health education show signs of increasing sophistication in educational methods. Modern education no longer requires that students only look, listen, and perhaps demonstrate their knowledge of facts. Students are now taking part in the educational process by demonstrating their understanding of health information and by performing specific oral hygiene practices. Some aspects of prevention are increasingly stressed, particularly plaque removal through toothbrushing and flossing in order t o control dental caries and gingivitis. Industry and various agencies and organizations have devised a multitude of programs, teaching aids and gadgets for classroom use-expensive aids and gadgets, one might add. Plaque control has been and still is big business. The “Toothkeeper Program” once touted as a cure-all for preventing dental disease in schoolchildren has been followed by “Toothtown,” “THETA,” “Tattle Tooth,” “The Dental Bear,” and others. Although these efforts may qualify as public relations activities, ultimate benefits to the participants are questionable. Have these programs affected the oral
*Public Health Educator, National Caries Program, National Institute of Dental Research, N I H, Bethesda. MD. 20205.
Vol. 39, No. 4-Fall,
269
1979
health of students; that is, have they prevented dental disease? There is little evidence to show that they do. Yet these kinds of programs persist. Recently, two studies were made to learn the effect of dental caries and gingival inflammation of removing dental plaque. Toothbrushing and flossing were supervised daily 1-2 in school for three academic years. One study with children who were initially in grades five through eight, was done in rural East Hampton, Connecticut, where the concentration of fluoride in the water supply is negligible. N o other preventive dental program was conducted concurrently in the community. After sessions of instruction in plaque removal, a test group practiced daily plaque removal under close supervision by trained personnel. The daily regimen consisted of the use of a disclosing agent, dental floss, a toothbrush and a nonfluoridated dentrifice. The control group was not instructed in procedures to remove plaque nor did they practice oral hygiene procedures in school. Results after 32 months were that mean incremental D M F T and DMFS scores after 32 months were 14 and 15 percent lower, respectively, than the controls . The differences between groups were not statistically significant. Girls in the treatment group showed a 27 percent reduction in mean plaque score whereas the score for boys was reduced by only nine percent (18 percent overall). At the final examination, girls in the treatment group showed a reduction in gingivitis of 40 percent and the boys' mean score was reduced by 17 percent (about 29 percent reduction overall). Although these changes in the treatment group were statistically significant when compared with controls, the changes from a practical standpoint were relatively small. Moreover, differences in plaque and gingivitis scores between groups virtually disappeared during the summer vacation. In a similar study conducted in two schools in Oakland, California, examinations after 29 months showed that the mean plaque and gingivitis scores were lower in the treatment group than in the control group in one school but in the other school only the mean gingivitis score in the treatment group was lower than the control group. There was no reduction of dental caries increments at either school. Inasmuch as the children in both of these studies used thorough and rigorously supervised oral hygiene procedures to remove plaque in school, the findings suggest that one can realistically expect only modest benefits from other school programs for controlling plaque by mechanical methods. It is not suggested that oral hygiene instruction in schools be dropped. It is suggested that such activities should not be the major effort in school-based dental programs. The concepts of increasing the use of a toothbrush and decreasing the consumption of sucrose are not new ideas. Almost everyone beyond age three has heard: "You should brush your teeth" and "You should not eat sweets between meals." All ought to know these dicta; they have been given this information long enough. However, toothbrushing is not synonymous with thorough plaque removal, and both regular and thorough removal of plaque are necessary to improve an individual's oral health. If oral hygiene procedures are to be introduced in schools, they should be valued for their ability to I
synonymous with fhorough pfaque removal, and both regular and thorough removal of plaque are necessary to improve an individual's oral health. If oral hygiene procedures are to be introduced in schools, they should be valued for their ability to reduce gingivitis, and that will happen on/v when the children are adequately trained
_" -..:-.---..---=--... ~ . - ~-,., u d . .,_.____.~ .- .>=--.-.. __.__.~...._ __ -_.-- .-_ -...--..-._ _--_..^ _ _ _-_. g_._-_ .___ ~ ....._. ~ ..-...~ .....~.. -_C._._... .... -_ -.-.....-. ..-____, _-__ ..-_ .-. ______. sup,,,;sed.
The
_55
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270
Journal of Public Health Dentistry
Reduction of Sugar Consumption Teaching students in today’s society about the deleterious effects of sugar on teeth has about as much chance of preventing dental caries as trying t o get them to remove dental plaque thoroughly each day. Efforts t o control the overconsumption of sucrose, although admirable, may be unrealistic because they compete with the goals of segments of the food industry whose financial resources for advertising are huge. The students one attempts t o educate about the evils of sugar have long been exposed t o countless commercials that extol the “goodness” of sugared products. Conflicting messages abound. How many modern moms can counter the authoritative, knowledgeable actress-mother in a certain T V commercial who states that when she decides her children will have a snack you can be sure it will be a “cream-filled, sugared treat”-that is a satisfying, fortified (and, therefore, healthful) snack that all knowledgeable moms provide? Sugar-laden edibles are given as tokens of love and affection and as rewardseven in some remeiliial reading programs in school. Some health agencies sell candy t o raise funds t o help eliminate another health problem. Moreover, sugar is routinely identified as “the energy-producing food.” N o wonder that moms and their families have Twinkie mentalities and corresponding diets. It is foolish t o try t o teach “good snack habits” t o children when down the school hallway a vending machine filled with sugared products is available. Moreover, these same items are frequently sold at the school lunch counter. It is not uncommon t o find that these items are sold to raise funds for school activities or equipment. Without changes in current practices of advertising edibles laced with sugar and without effective percentage-labeling of the ingredients of all foods, efforts t o reduce consumption of sugared items are undoubtedly exercises in futility. Little research has been conducted into the effect on dental caries of restricting the availability of sweets in school. In Australia, Roder’ demonstrated a modest caries reduction in children who attended a school that severely restricted sweets. However, just how long students will conform with being “sweetless” at school remains t o be seen. Removing the sale of and reducing the excessive serving of sweets in schools should be accomplished. However, it should be done in conjunction with and nor in lieu of primary preventive procedures such as school-based fluoride regimens. T H E USE O F F L U O R I D E S Although the ability t o prvent dental caries is imperfect, tested preventive measures that provide significant protection against this nearly ubiquitous disease are available.d-’ These methods can greatly reduce caries, yet a large portion of the public is neglected. When proven methods are available, the failure t o protect the public from dental caries, particularly the young, is a national disgrace. If improved oral health of children is truly desired, an effective method of fluoride application should be a fundamental part of every school dental program. T h e use of fluorides is the intelligent alternative t o dental caries and costly restorations. A brief review of the various methods of utilizing fluorides is in order.
Communiij! Water Fluoridation Fluoridation is the adjustment of the fluoride content of a community’s water supply to a n optimal concentration (0.7 t o 1.2 ppm) for the prevention of tooth
Vol. 39, No. 4-Fall,
1979
27 1
decay. Water fluoridation is the foundation upon which any local, state, or national program for preventing dental caries should be based. Fluoridation is inexpensive and the entire community benefits regardless of economic or educational level, individual motivation or the availability of dental manpower. No direct action is required of the individual, yet dental caries is reduced by 50-65 percent among children who consume optimally fluoridated water from birth. The major shortcoming of community fluoridation is that it is limited to areas served by central water supplies. About one sixth (17 percent) of the U.S. population cannot benefit from the procedure because they live in areas that lack central water systems. Another one third of the population (33 percent) have not implemented fluoridation of their central water systems. School Water Fluoridation
An effective method of providing the benefits of systemic fluoride in geographic areas that lack central water systems is the fluoridation of school water supplies. Rural schools frequently have an independent water supply that can be fluoridated. Several states have such school fluoridation programs. Both North Carolina and Kentucky have more than 100 schools that are fluoridating their water supplies. School fluoridation effectively reduces tooth decay by about 40 percent. Disadvantages of school fluoridation are that exposure is limited to school-age children during school hours, and use is restricted to areas in which both the school water and the home water supplies of all students have low levels of naturally occurring flu0 ride. Professional Applications of Topical Fluorides
Fluoride can also be applied topically to the teeth by a dentist or a dental hygienist. This method requires (as far as is now known) thorough cleaning of the teeth before the fluoride is applied. Fluoride solutions or gels are then either painted on the teeth or applied in mouth trays. To be effective, the procedure should be done at least annually and preferably every six months for caries-active children. Although professionally applied fluorides will reduce tooth decay by 30-to40 percent, it is an expensive method both from the standpoint of dental manpower and cost compared with other approaches. Programs of professional application of topical fluorides are more suitable in communities or states with an abundance of professional personnel. Self- Applied Fluorides
For the past two decades, considerable research has been conducted on the use of fluoride tablets and/ or fluoride mouthrinses in schools. Because most children attend school regularly, and because schools operate on a more rigid schedule than d o individual families, schools are logical places for administering self-applied fluorides to children. Research has shown that dental caries can be reduced 20 to 40 percent by the daily use of a fluoride tablet in school and 20 to 50 percent by once-a-week fluoride mouthrinsing. These results follow the use of the respective agent on school days only. These two school programs for self-applied fluoride have the following advantages compared with other methods of fluoride application:
272
Journal of Public Health Dentistry
1. The procedures have proved effective in reducing tooth decay. 2. They require little time. 3. The technics of using tablets or rinsing are easy to learn. 4. Few materials and supplies are required, thus these programs are inexpensive. 5. Nondental personnel with minimal training can easily supervise the procedures. 6 . Administration of the procedures is easy and interrupts a school's academic program for only a few minutes. The differences between the two agents are of special interest. When fluoride tablets are given in nonfluoridated communities, children receive systemic as well as topical benefits. Also, tablets are suitable for use with preschool children; mouthrinsing is not. Moreover, weekly mouthrinsing appears t o provide protection against dental caries only as long as the procedure is continued whereas fluoride tablets confer retained benefits. Finally, there are no waste products to dispose of with fluoride tablets anQ the procedure can be less expensive than fluoride rinse programs. Today it is estimated that over eight million children in this country are using either a fluoride mouthrinse once a week, a fluoride tablet once a day in school, or both. Some school programs use both procedures if conditions are appropriate; that is, if only trace amounts of fluoride are in the drinking water. Although the present number of children participating in these programs is a good beginning, there is a long way to go to reach all children who could benefit from these preventive regimens. School dental programs can be exciting opportunities to provide primary preventive procedures. Such self-applied fluoride methods are easy to carry out in school settings. Dentists, dental hygienists and other health personnel can be instrumental in implementing these programs by working with school superintendents, school boards, health departments, health societies, and the public media. In addition t o implementing self-applied fluoride regimens in schools, it is also important to convey the fluoride message clearly to parents, students, faculty, and administrators. They need t o know what fluoride is, what it does to protect teeth from the ravages of dental caries, and what options are available for obtaining maximum benefits from its use. It is incorrect t o assume that adults, not to mention children, know what fluoride is, even if they live in communities with fluoridated water. Some communities have discontinued fluoridation after having benefited from the procedure for years, partly because there were not enough informed citizens to protect the program. Many voters simply d o not know what fluoridation is and what it does because each new generation has not been educated. In a national survey conducted by the National Opinion Research Center in 1972, which investigated knowledge about dental health, 70 percent of the respondents indicated that they had heard of or read about fluoridation, but only one half of these persons knew that fluoridation prevented tooth decay. A similar survey conducted by Gallup earlier this year indicated that the population has nor increased its knowledge about fluoridation.8 Is it any wonder, then, that community fluoridation has not been implemented in more communities? O r that some communities have decided to discontinue it? Probably even fewer persons know of self-applied fluorides. This ignorance is unfortunate, but can be alleviated. Just implementing a fluoride regimen in schools is
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not enough. Each program should include a n educational component t o helt, ensure that all those involved know what they are doing and why. Rinsing by vote will reduce dental caries but alone it will not necessarily make a more informed voter or consumer. Ultimately, both understanding and self-protection must be achieved. SEALANTS Although controlled clinical trials have shown that pit-and-fissure sealants effectively reduce the incidence of dental carries in permanent teeth, few public health programs have made use of them. The major reason is probably the cost. Costs for applying sealants depend upon I ) the type of personnel used, 2) the number of teeth sealed per visit, and 3 ) the type of material used. Interestingly enough, one innovative state is starting a sealant for 6,000 children.9 This sealant program is being used in conjunction with a fluoride mouthrinse program which, of course, is a logical combination of preventive methods. It would be foolish to have a sealant program t o save occlusal surfaces without a n accompanying regimen of fluorides t o protect the smooth surfaces. The director of the program has determined that a tooth surface can be sealed for slightly over one dollar by contracting with local dentists. The practicality of using sealants in public programs may depend ( 1 ) upon dentists who are willing t o contract their services for less than the usual and customary fees in private practice or (2) upon the use of dental auxiliaries. The latter approach, of course, will require chances in many states’ dental practice acts. CONCLUDiNG C O M M E N T S
If the intention in school dental programs is t o lower the incidence of oral diseases, efforts must include primary preventive procedures. Only programs that are effective should be conducted. There is no longer the pre-Proposition 13 luxury of waving a toothbrush in the air and claiming it will reduce dental diseases. Teachers and school administrators are increasingly being asked t o explain M ~ J students . are not learning more. Parents are demanding that their taxes for education produce a better end product. Classroom time is at a premium. In addition, teachers and school administrators must contend with increased classroom disorderliness and violence.“) Faced with these realities, there is but one choice: a sound regimen of primary prevention is mandatory for school dental programs, if dental public health is t o be accountable. School fluoridation, fluoride tablets, or fluoride mouthrinsing must be implemented in order t o reduce dental caries and thus affect the oral health of our children. Only then should additional efforts and monies be expended to include a course of action t o reduce the consumption of sugar and to increase the mechanical removal of dental plaque. Back t o the question posed in the title of this session, “Do School Dental Programs Affect the Dental Health Status of Children?” If the programs include a recommended regimen of fluoride, then the answer is yes. If not, then the value of these programs is highly questionable.
References I . H o r o w i t ~ ,A. M . , et al. Effect of supervised daily plaque removal by children: result, after third and final year. IADR Abstr. J. Dent. Res. 56: Spec. Issue A: 85. Feb. 1977. 2. Silverstein. S.. et al. Effect of supervised deplaquing on dental caries, gingivitis and plaque. IADR Abstr. J. Dent. Res., 56, Spec. Issue A: 85. Feb. 1977.
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3. Roder, D. M. The association between dental caries and the availability of sweets in South Australian school canteens. Aust. Dent. J., 18: 174-82. June, 1973. 4. Driscoll, W. S. The use of dietary fluoride supplements for the prevention of dental caries. presented at the International Workshop on Fluorides and Dental Caries, Reductions. April 28-May I . 1974. 5. Horowitz, H. S. The prevention of dental caries by mouthrinsing with solutions of neutral sodium fluoride. Int. Dent. J., 23:585, Dec. 1973. 6. Leske, Gary S. and Ripa, Louis W. Guidelines for establishing a fluoride mouthrinsing caries prevention program for school children. Pub. Health Rep., 92: 240-4. May-June 1977. 7. National Institute of Dental Research, National Caries Program. Preventing tooth decay. A guide for implementing self-applied fluoride in schools. DHEW Pub. No. (NIH)77-I 196, 1977. 8. Corum, James T., Personal communication September 1978. 9. Tuckman, Edward H.. Personal communication October 1978. 10. Cornlay, C. Blackboard jungle updated. TWA Ambassador. Sept. 1978.
The First 50 Years The Journal of the American Dental Association paid tribute, in 1950, to members of the dental and allied professions who had contributed significantly to the progress of dentistry during the first half of the 20th century. In this series, we present to today's dentists those men who were singled out a generation ago by their constitutent societies for special recognition. Clinton T. Messner was the first dentist to be commissioned in the Regular Corps of the U S Public Health Service. He received his commission in July 1930 and built a solid foundation for dentistry in the Public Health Service before his untimely death in 1936. Dr. Messner was a graduate of the School of Dentistry, Indiana University. After practicing in Oxford, Ind., he went, in 191 1, to Portland, Ore., where he taught in the dental school for two years. Subsequently he resumed private practice in Oxford until he was called to active duty in the army in 1917. Dr. Messner entered the U. S. Public Health Service in 1919 and was placed in charge of the Ninth District dental activities at St. Louis. In 1921, he was transferred to Washington, D.C., and in 1924 he became chief of the Dental Service. The establishment of public health dentistry as a part of the dental school curriculum was the result of Dr. Messner's encouragement. He was responsible for establishing the first chair of public health in the School of Dentistry at Indiana University. He was active in organized dentistry and was interested in international dental health work. Dr. Messner died in 1936. -from
Dent. Abstracts
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1979
