Oral hygiene and educational programs for caries prevention.

Caries Res. 12 (Suppl. 1): 83-93 (1978)

Oral Hygiene and Educational Programs for Caries Prevention L. A . Hel0e and K. G. König Institute of Community Dentistry, University of Oslo, Oslo and Institute of Preventive and Community Dentistry, University of Nijmegen, Nijmegen

Objectives and Evaluation of Programs

Although a number of oral health pro grams are being carried out, only a few of them have been evaluated. Evaluation is usually defined as ‘ascertaining the value or amount of something or comparing accom plishment with some standard’. Baseline data are obtained before the start of the program. If possible, control groups should be available when assessing the results. Ide ally, the actual status at the time of the eval uation should be compared with the status that would have existed had there been no program [Deniston and Rosenstock, 1970]. Objectives A key point is the relation between the results and the objectives of the program since defined objectives make systematic as sessment possible. At times, it is, however, necessary to consider or reconsider the aims of a dental service and the strategy suitable to achieve these aims [Lennon, 1976]. There might also be special goals such as equal access, moderation of costs and assur ance of quality [Barenthin, 1975], which are explicitly stated or implied in the social leg islation.

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Controlling microbial plaque and limit ing supply of substrate for formation of pathogenic metabolic products are basically the most important requirements for the maintenance of dental and periodontal health. Dental health in addition primarily depends on an adequate fluoride intake. Kegeles [1974] regarded as preventive dental behaviour one or more of the fol lowing: (1) visits to dentists periodically on a routine basis; (2) brushing at appropriate times and intervals; (3) control of plaque through use of other mechanical proce dures, and (4) maintenance of low cariogenic diets either through avoiding certain foods or increasing consumption of others. In order to adopt such favourable habits an individual conceivably needs adequate information and technical skill, a positive attitude towards applying them, and an abil ity to develop patterns of behaviour to make them a daily routine. In genera! the required information, atti tude and behaviour are not conveyed to the individual during childhood from the family and the larger social environment. The chal lenge is therefore to create general approval and appreciation of preventive dental health practices in the population.

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Relationship between Health Knowledge, Attitudes and Behaviour

The mechanisms of adopting dental health habits and the diffusion of dental health knowledge are seemingly manifold and confusing. The validity of the estab lished model: knowledge -* belief -> tempo rary actions -*■ habit has been doubted in a number of papers during recent years [for reviews, see Young, 1971; Rayner and Co hen, 1971; Richards, 19751. Richards argues that there are limitations to eductional ap proaches which intend merely to improve knowledge and change attitudes, ‘since (1) attitudes may have no counterpart in behav iour; (2) it is just as reasonable to conclude that behaviour causes beliefs rather than vice versa, and (3) it is important to have a measure of the consistency, persistency and reality of attitudes’. Treatment patterns and oral health habits of parents, which in turn are related to social background, presumably

have an early and distinct influence on the dental health of children [Rayner, 1970; Toverud and Hel0e, 1976], and even the denial habits of teenagers are influenced by those of their parents [Kriesberg and Trieman, 1962]. Regular school dental treatment is found to be the best predictor of treatment attendance in later youth, which presumably reflects the effect of childhood experience and adapted behaviour [Hel0e and Tronstad, 1975], It is, however, doubtful whether conservative treatment of schoolchildren without regular prevention will result in less caries [Ainamo and Holmberg, 1973], while systematic preventive measures offered dur ing the first 3 years of life will change the dental situation in 3-year-olds as drastically as the dental health status is changed at the age of 7 by systematic preschool dental care from 3 to 7 years of age [Kisling et al., 1977]. The extent of research on modifying health beliefs is limited [Kirscht, 1974], while the evidence is substantial regarding the impact made by cultural and situational, primarily socioeconomic factors upon den tal attitudes and habits [Young, 1971; Ri chards, 1975]. It seems justified to suggest that the model given above should be supple mented by two other simplified models to illustrate the complexity of the relationship between knowledge, attitudes and behaviour. It may thus be maintained that dental attitu des and levels of knowledge proceed from behaviour rather than the contrary. Hypo thetically, the relationship between the latter three may even be spurious, in that they all vary with situational factors, such as differ ent programs. Behaviour Knowledge

Attitudes


Cost-Benefit Analyses Since resources are limited in any field of public health services, choices must be made between alternative policies and strate gies. Cost-benefit analyses are an important part of a study and consist in assessing the relation between the investments and the health improvement afforded by the various programs. For instance, in a comprehensive publication for the WHO, Davies [1974] re viewed ‘Cost and benefit of fluoride in the prevention of dental caries’. The benefit of health programs cannot merely be expressed in monetary terms since expressing it in such a form is simply a way of stating their importance relative to other human objec tives.

Oral Hygiene and Educational Programs for Caries Prevention

Situational factors Knowledge

Attitudes

Behaviour

In conclusion, dental health educational programs should not be based merely upon one of the suggested theoretical parameters and models; they probably all contain some thing of value. Mass media coverage of fluoridation, for instance, which must be ca tegorized under the first model, has been found to increase public knowledge and awareness of the issue, and to increase its acceptance [Wallace et al., 1976]. Whether it is possible to get people motivated to im prove their oral hygiene merely by acting on

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levels of knowledge and dental attitudes, is dubious. This key problem of public health education will be elucidated and commented on in the following.

The Message

The value of traditional doctrines on toothbrushing has often been questionned during the last decade, and there are a num ber of conflicting reports [for reviews, see Bibby, 1966; Sutton and Sheiham, 1974; Braune and Ericsson, 1977]. Table I which is derived from Braune and Ericsson sum-

Table I. Caries status according to oral hygiene [from Braune and Ericsson, 1977] Number of subjects

Age, years Oral hygiene

Hein, 1954

207

21-28

Mansbridge, 1960

146 118 115 264 357 397

12-14

Miller, 1961

Trubman, 1961

Smith and Striffler, 1963

12 12-14

1043

18-44

Dale, 1969

730

17-29

Ainamo, 1971

161

18-26

Sutcliffe, 1973

Andlaw and Tucker, 1975

86

11-13

63

11-13

approx. 400 12

Measure of caries status

1, 2, 3 or 4 times daily > times daily good 15.3 DMFS neglected 17.6 DMFS regular 5.8 DMF irregular 5.0 DMF none 5.0 DMF OHI 0-1 16 DMFS OH1 1-2 14 DMFS OHI > 2 14 DMFS ‘twice yesterday’ 27.3 DMFT ‘once yesterday’ 22.8 DMFT ‘not yesterday’ 19.5 DMFT 3 times daily 17.29 DMFT < once daily 18.69 DMFT 37.58 DMFS > once daily 37.03 DMFS once daily 37.41 DMFS < once daily 3.0 new surfaces good poor 3.17 new surfaces 4.21 new surfaces good poor 4.52 new surfaces good 8.29 new surfaces poor 9.43 new surfaces

Difference of caries status by improved oral hygiene 1, 2, 3, 4: alike > 4: lower caries 13% reduction

16% increase

14% increase 40% increase in group “twice yesterday” 7% reduction

alike 13% reduction, boys 7% reduction, girls 12% reduction


Authors

marizes several investigations. A WHO scientific group concluded that the efficacy of toothbrushing as a public measure to pre vent caries should not be overemphasized [WHO, 1972], It should be stressed, howev er, that proper toothbrushing has definitely been shown to prevent gingivitis and reduce the severity of periodontal disease [for a re view see Bergenholtz, 1972]. Recently completed clinical studies by Silverslein et al. [1977], Horowitz et al. [1977] and Wright et al. [1977], in which fluoride application was excluded, have confirmed that gingivitis reacts more promptly to brushing and flossing than car ies activity (table II). Obviously, this is not because plaque does not play an etiologic role in caries, but because it is very difficult technically to remove plaque quantitatively. This is true not only for small children, but for older ones, up to 13 and 14 years as well [Silverstein et al., 1977; Horowitz et al., 1977] (table II). There is also ample evi dence that in general adults do not clean their teeth more effectively [Bibby, 1966]. Therefore, the disclosing of plaque with a food dye seems to be very important for im proving oral hygiene. The second conclu sion must be that in the prevention of multi factorial diseases like gingivitis and caries we must never rely on elimination of only one factor; in addition to the (partial) me chanical removal of bacterial plaque the metabolism of any residual plaque should be reduced by dietary measures (substrate less frequently) and daily fluoride applica tion. Sutton and Sheiham [1974] conclude their review of the literature by the follow ing rules which may be used as messages in health education programs: (1) Brush your teeth at least once a day

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using a fluoridated toothpaste. It does not matter how you brush as long as you get your teeth clean. A red food dye dissolved in water (or a disclosing tablet from the che mist) will stain the dirty areas red. Use this as a check on your toothbrushing. (2) At least once a year have fluoride ap plied to your teeth and tartar removed from them. (3) Try to eat less sweets and sticky foods; it is less harmful to the teeth to eat much at one time than little spread over a long period. The question may be raised whether the message should include recommendations concerning the use of other fluoride vehi cles, flossing and regular supervised oral hy giene instruction [Birkeland and Axelsson, 1976; Attstrom et al., 1976], In this connec tion one should consider the target group. Messages directed to children should be worded differently from those intended for the adult patient.

Experiences Gained from Various Preventive Programs for Children

Various school dental programs com prise the majority of the organized activities since school children are easy to reach, and since programs are convenient to arrange and carry out in a school setting. Generally, the effect of dental health ed ucation upon large adult population groups appears to be discouraging. Efforts to affect the habits of children and their parents si multaneously have been more successful [for reviews, see Rayner and Cohen, 1971; Young, 1971; Slack, 1974; Richards, 1975]. It must, however, be added that mass media and commercial product messages focussing


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dental health services [Marthaler, 1972; Forsman, 1974; Birkeland and Jorkjend, 1975]. But it is uncertain whether super vised brushing has a better effect than rin sing programs [Birkeland and Jorkjend, 1975], In Norway, there is substantial evi dence for a decrease in caries incidence over the last few years [Baerum, 1976], Fig ure 1 is based upon data on the mean num ber of filled surfaces among children in Harstad, a town of 22,000 inhabitants with regular dental care for the 6- to 17-yearolds since 1960, including fluoride rinsing and/or brushing since 1964. The trend ap pearing in figure 1 is found almost all over the country. Most likely, this improvement must be ascribed to the widespread use of organized programs with fluoride rinsing or brushing. Moreover, 60-70°/o of the tooth paste used in Norway is fluoridated. It seems that information on dental health of children is disseminated rather rapidly as result of collective measures in the school dental clinics, baby health clinics and ma ternity centers [Kjaerheim et al., 1977]. A systematic combination of education of mothers at maternity centers and care for

Fig. 1. Mean number of filled surfaces in the years 1971-1976 in 3,200 children aged 6-17, re siding in Harstad, Norway.


for example on fluoridated toothpastes also seem indirectly to have influenced the den tal health habits and dental status. In the following, a few programs will be described and discussed. The so-called Karlstad model [Lindhe and Axelsson, 1973] for reducing caries in cidence among school children has recently attracted attention. By oral hygiene instruc tion and frequently repeated professional tooth cleaning it was possible to prevent caries and also to reduce substantially the frequency of gingivitis. When this treatment was used, mouthrinsing with 2°/o monofluorophosphate had no additional effect on caries [Axelsson et al., 1976]. In the light of the results summarised in table II this seems to have been due to the impact of frequent perfect professional cleaning. However, the lack of additional effect from monofluorophosphate mouthrinsing may in part be due to the fact that all children had taken fluoride for a fairly long period of time with a probable carry-over effect into the study period. A number of studies have shown the an ticaries effect of fluoride programs in public

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small children has given promising results in Sweden [Forsman, 1974],

Health Information and Education Programs for Children

The main limitations of an approach via general practitioners and school dental sur geons are their inherent restriction to dental problems and lack of continuity. According to the literature compiled by Bay [1972] it may be assumed that the oral hygiene in structions and advice usually do not, unless supervised, result in sufficient active healthpromoting behaviour of the children in volved to yield a demonstrable effect. In a 2-ycar information-motivation clini cal trial on nearly 1,000 children [Plasschaert and König, 1974], repeated careful instruction on toothbrushing and dietary lessons were given. Although the children were contracted up to six times a year, there was no effect of information and motivation after 2 years, whereas those children in the study who in the same period had been giv en fluoride tablets showed a nearly 60% caries reduction on buccal and lingual smooth surfaces, and between 40 and 20% on approximal smooth surfaces, occlusal fis sures and pits. In another clinical investiga tion in The Hague, the effect on the denti tion of a kindergarten and school program consisting of lessons on nutrition and oral hygiene was studied by cross-sectional ex aminations. It was found that there was nearly no improvement after the first 3 years, whereas significant caries reduction was observed 6 years after the programs had been introduced. However, the changes over 6 years, although statistically signifi cant, were much smaller than the differ

ences that were always present between lower-middle-class children and higher-mid dle-class children whose DMFS indices were less than half those of the lower-mid dle-class children [Plasschaert et al., 1977]. Obviously, the influence of educated and motivated parents was very strong here; for instance in the higher-middle-class group twice as many children received fluoride tablets at home as lower-middle-class chil dren. From an analysis of the results of these studies, it was concluded that an improve ment of oral health can hardly be expected from information given incidentally; more over the observations in the program in The Hague with its broader scope suggested that more success might be expected by present ing oral health education in conjunction with other important fields within general health education. The initiators of the School Health Education Study in the US [SHES, 1967] had already postulated that ‘a new approach for the health education curricu lum should not be a “piecemeal” and frag mentary process’, and that ‘the unity of health, its integrated nature, and the inter dependence and interrelatedness of health problems should be reflected in the compo nents of the framework’. The SHES authors also stressed that ‘the essential skills which education seeks to develop’ are ‘critical thinking, student involvement and discovery, concern for value development, and con ceptual thinking, rather than rote memoriza tion of facts’. In an overview scrutinizing methods and means in motivation, Bay [1972] came to the same conclusion that ac tive participation by the children in a pro gram and the practising of two-way commu nication are most important elements of an effective program.


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General (including dental) health education programs starting in early life are ideally characterised by continuity, objectives in logical and chronological order, broad mul tidisciplinary scope, and professional as well as didactic competence. In addition to teachers, an important mediator group for health education is the health personnel, especially those who play a key role in the health of the expectant mother and the baby. And first of all, the success of efforts to promote oral health is dependent upon enthusiastic and preventionoriented dentists with all their collabora tors, their attitudes towards teamwork and eventually their ability to adapt to new chal lenges brought forth by the decline of oral disease [Birkeland and Axelsson, 1976].

Benefits of Oral Hygiene and Health Education Programs

In contrast to the evaluation of defined isolated measures such as the administration of fluoride tablets to school children with a consistent and repeatedly reported benefit of a 40-50% caries reduction [Plasschaert and König, 1974], many methodological problems impede quantitation of the benefits from oral health instruction, information and education programs. The main reason is that few programs are restricted to instruc tion and information. The three examples cited in table II are exceptions indicating that the effects vary according to the time and professional guid ance invested. Programs with a combination of supple mentary methods like the Karlstad-model [Lindlie and Axelsson, 1973] or the Zürich model [Marthaler, 1975] may result in a


In 1967 Bay tended to assume that the pain-inflicting dentist and his team were more likely to motivate children against doing what they recommended; in 1972 she came to the conclusion that ‘it is not clear whether children are best motivated by their teachers, by dentists, or by dental hygien ists’. Most assessors of the literature will probably agree with this statement. Al though Williford et al. [1967] ascribed the failure of school teachers to provide good instruction on oral hygiene to their lack of professional knowledge and authority, it is obvious that a conclusion from this particu lar study must not be generalized. There arc in fact some arguments for ad vocating the teacher as health educator provided that he/she possesses the knowl edge and material enabling him/her to con vey a health education program to his/her class. At the University of Nijmegen, these considerations have resulted in the develop ment of a kindergarten and school health education program mediated by teachers us ing textbooks composed by behavioural sci entists and teachers in collaboration [Cramwinckel, 1974], Eight topics of significance in health education for 4- to 12-year-old children were selected. The program con sists of course in nutrition; physical activity; personal health care; dental health; safety in traffic; safety at home and at school; making use of health information, products and services, and environmental pollution. In addition to this program, which is de signed for children, there are the wellknown ways of instructing and motivating adults (and children, incidentally) (1) in the office of the general practitioner, (2) in school dental services by the dentist and his team, and (3) by advertising campaigns.

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Table II. Results of three clinical trials on the effect of daily efforts to remove plaque Horowitz et al., 1977

Authors

Silverstein et al., 1977

Number of subjects Age at start Cleaning methods Frequency of cleaning

389 480 13 years 11-14 brushing, flossing, disclosing brushing and flossing (after 10 instructions) each school day each school day

Cleaning performed by Cleaning supervised by Final examination after Piaque reduction Reduction of gingivitis Caries reduction

children themselves ‘dental health educator’ 29 months 19% 25-33% not significant

children themselves ‘trained personnel’ 32 months 18% 29% 15%, not significant

Wright et al., 1977 881 6 flossing each school day for twice 8 months ‘research assistants' no supervision 20 months not reported not reported 52-55%,significant (p < 0.05)

nearly complete caries inhibition, but it is difficult to say how much of the effect is due to fluoride, and how much to oral health in formation and changes in habits for improv ing oral health. Long-term general and dental health ed ucation programs are under investigation, however, it may take decades before the ef fects of such programs can be judged con clusively.

Preventive Dental Behaviour among Adults

These perceptual factors are essential in motivating adults to seek preventive care: (1) belief in one’s susceptibility to dental problems; (2) belief in the importance of dental problems, and (3) belief in the effec tiveness of the activities to be carried out. [Kegeles, 1974]. On the other hand, factors which predispose people to neglect preven tive care have been categorized into (1)

negative appraisal of dentists, (2) fear of pain and anxiety about treatment and (3) cost of care. Different negative or positive orienta tions are commonly clustered, also with re gard to other health practices. This cir cumstance should be taken into considera tion when planning educational programs. Differences among individuals and groups prevent the use of only one or a few tech niques, and periodic reinforcement of the message seems to be necessary [Attstrom et al., 1976]. In this connection, the distribu tion of the patients’ problems, symptoms and complaints (’subjective’ or self-per ceived needs) should be given greater em phasis. ‘Health education is not forcing peo ple to act positively - rather it is persuading them along certain lines to do what they ac tually want to do for themselves’ [Richards, 1975]. Regular treatment attendance represents in itself no guarantee against the occurrence


1 The smallest independent experimental units in this split-mouth study were not children, but 374 contra lateral pairs of caries-free contacting approximal tooth surfaces; the test surfaces were flossed whereas the contralateral control surfaces were not.


Conclusions

Within the current dental care systems, the most appropriate way for providing ad vice on dental health appears to be chairside communication. However, inter-office coop eration in a health team should also be de veloped. Oral health is part of general health; for instance, the aim of dietary coun selling should not only be to diminish the risks for the teeth but also for coronary ar teries and all other parts and organs of the body. On the other hand, dentists and doc tors may not be the most ideal educators, and health education should also be given outside the current office system of deliver ing dental and medical care. Systematic, continuous (dental) health education should be integrated in the school curriculum and may thus be dispensed by teachers. At present, the systematic prevention programs including fluoride administration and oral health instruction, which are widely applied, e.g. in Scandinavian, Swiss and Ame rican schools, are practical examples of how organized activities can result in approach ing good dental health as an objective.

There have been two inconspicuous, but major advances of caries research in the last 25 years which are important in this con text: the clarification of the etiology of car ies as the basis of prevention, and proofs that organized prevention programs can be successful.

References Ainamo, J. and Holmberg, S. V.: A retrospective longitudinal study of caries prevalence during and 7 years after free dental care at school in Finland. Community Dent, oral Epidemiol. 1: 30-36 (1973). Attström, R.; Egelberg, J., and Fehr, F. v.d.: Oralhygiene instruction of the adult patient; in Frandsen, Preventive dentistry in practice (Munksgaard, Copenhagen 1976). Axelsson, P.; Lindhe, J., and Wäseby, J.: The ef fect of various plaque control measures on gingivitis and caries in schoolchildren. Com munity Dent, oral Epidemiol. 4: 232-239 (1976). Baerum, P.: Dental health services in Norway (Helsedirektoratet, Oslo 1976). Barenthin, 1.: A review and discussion of goals in community dentistry. Community Dent, oral Epidemiol. 3: 45-51 (1975). Bay, I.: Methods and means in motivation; in Frandsen, Oral hygiene, pp. 89-103 (Copen hagen, Munksgaard 1972). Bergenholtz, A.: Mechanical cleaning in oral hy giene; in Frandsen, Oral hygiene, pp. 27-66 (Munksgaard, Copenhagen 1971). Bibby, B. G.: Do we tell the truth about prevent ing caries? J. Dent. Child. 33: 269-279 (1966). Birkeland, J. M. and Axelsson, P.: Preventive pro grams for children and teenagers with special reference to oral hygiene; in Frandsen, Preven tive dentistry in practice (Munksgaard, Copen hagen 1975). Birkeland, J. M. and Jorkjend, L.: Effect of mouth rinsing and toothbrushing with fluoride solutions on caries among Norwegian schoolchildren. Community Dent, oral Epidemiol. 3: 201-207 (1976).


of dental disease. A restorative approach to the provision of routine care has proved to be ineffective [Ainamo and Holmberg, 1973; Sheiham, 1973; Björn, 1974; Hollo way, 1975], unless accompanied by preven tive services, such as the application of topi cal fluorides, prophylaxis and oral hygiene instruction. This in a way relativates the ne cessity of motivating the patient population to seek preventive care: dentists should be come active and through them prevention should be accorded a priority equal to or greater than curative treatment.

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Björn, A. L.: Dental health in relation to age and dental care. Odont. Revy 25: suppl. 29 (1974). Braune, K. and Ericsson, Y.: Munhygien och karies. Tandläkartidningen 69: 663-667 (1977). Cramwinckel, A. B.: Development of a curricu lum on health education for schoolchildren in the Netherlands. Voeding 35: 471-473 (1974). Davies, G. N.: Cost and benefit of fluoride in the prevention of dental caries (World Health Organization, Geneva 1974). Deniston, O. L. and Rosenstock, I. M.: Evaluating health programs. Publ. Hlth Rep., Wash. 85: 835-840 (1970). Foreman, B.: Fluorides and dental health. Investi gations in Swedish children; thesis Stockholm (1974) . Hel0e, L. A. and Tronstad, L.: The use of dental services among Norwegian adults in 1973. Community Dent, oral Epidemiol. 3: 120-125 (1975) . Holloway, P. J.: The success of restorative dentist ry? Int. dent. J., Lond. 25: 25-30 (1975). Horowitz, A. M.; Suomi, J. D.; Peterson, J. K., and Lyman, B. A.: Effect of supervised daily plaque removal by children: results after third and final year. Abstract No. 170. J. dent. Res. 56: suppl. A (1977). Kegeles, S. S.: Current status of preventive dental health behavior in the population. Hlth Educ. Monogr. 2: 197-200 (1974). Kirscht, J. P.: Research related to the modifica tion of health beliefs. Hlth Educ. Monogr. 2: 455-469 (1974). Kisling, E.; Kjer, H., and Krebs, G.: Effekten af systematisk smab0rnstandpleje p i behandlingssituationen hos b0rn i 1. klasse. Tandlaegebladet 81: 257-261 (1977). Kjaerheim, V.; Fehr, F. R. von der, and Hel0e, L. A.: Preventive practice in schoolchildren in Oppegärd, Norway, related to some back ground factors. Scand. J. dent. Res. 85: 46-50 (1977). Kriesberg, L. and Treiman, B. R.: Preventive utili zation of dentists’ services among teenagers. J. Am. Coll. Dent. 29: 28-45 (1962). Lennon, M. A.: An evaluation of the adequacy of the general dental service. Br. dent. J. 141: 223-225 (1976). Lindhe, J. and Axelsson, P.: The effect of con trolled oral hygiene on topical fluoride appli

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cation on caries and gingivitis in Swedish schoolchildren. Community Dent, oral Epide miol. 1: 9-16 (1973). Marthaler, T. M.: Reduction of caries, gingivitis and calculus after eight years of preventive measures. Observations in seven communities. Helv. odont. Acta 16: 69-83 (1972). Marthaler, T. M.: Selektive Intensivprophylaxe zur weitgehenden Verhütung von Zahnkaries, Gingivitis und Parodontitis beim Schulkind. Schweiz. Mschr. Zahnheilk. 85: 1227-1240 (1975). Plasschaert, A. J. M. and König, K. G.: The effect of information and motivation towards dental health, and of fluoride tablets on caries in schoolchildren. 1. Increment over the initial 2-year experimental period. Int. dent. J., Lond. 24: 50-65 (1974). Plasschaert, A. 1. M.; Truin, G. J.; König, K. G., and Vogels, A. L. M.: Tandcariës bij 5-, 7-, 9en 11-jarige Haagse kinderen. II. Resultaten van onderzoek in 1975 en vergelijking met gegevens uit 1969 cn 1972. Ned. Tijdschr. Tandheelk. 84: 14-20 (1977). Rayner, J. F.: Socioeconomic status and factors influencing the dental health practice of mothers. Am. J. pub. Hlth 60: 1250-1258 (1970). Rayner, J. F. and Cohen, L. K.: School dental health education; in Richards and Cohen, So cial sciences and dentistry (Fédération dentaire internationale, 1971). Richards, N. D.: Methods and effectiveness of health education: the past, present and future of social scientific involvement. Soc. Sei. Med. 9: 141 156 (1975). Sheiham, A.: An evaluation of the success of den tal care in the United Kingdom. Br. dent. J. 135:271-279 (1973). SHES: Health education. A conceptual approach to curriculum design, grades kindergarten through twelve (3M Education Press, Washing ton 1967). Silverstein, S.; Gold, S.; Heilbron, D.; Nelms, D., and Wycoff, S.: Effect of supervised deplaquing on dental caries, gingivitis, and plaque. Ab stract No. 169. J. dent. Res. 56: suppl. A (1977). Slack, G. L.: Dental public health (Wright, Bristol 1974).


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tific group. Tech. Rep. Ser. Wld Hlth Org., No. 494 (1972). Wright, G. Z.; Banting, D. W., and Feasby, W. H.: A cross-validated study of the caries-pre ventive effect of dental flossing. Abstract No. 168. J. dent. Res. 56: suppl. A (1977). Young, M. A. C.: Dental health education of adults; in Richards and Cohen, Social sciences and dentistry (Federation dentaire intemationale, 1971).

Dr. L. A. Hel0e, Dental Faculty, University of Oslo, Geitmyrsveien 71, Oslo 4 (Norway)


Sutton, R. and Sheiham, A.: The factual basis of dental health education. Hlth Educ. J. 33: 49-55 (1974). Toverud, J. F. and Hel0e, L. A.: Eplet faller ikke langt fra stammen. Norske Tannlaegeforen. Tid. 86: 464-469 (1976). Wallace, C. J.; Legett, B. J., and Retz, P. A.: The influence of mass media on the public’s atti tude toward fluoridation of drinking water in New Orleans. J. publ. Hlth Dent. 35: 40-46 (1976). Williford, J. W.; Muhler, J. C„ and Stookey, G. K.: Study demonstrating improved oral health through education. J. Am. dent. Ass. 75: 896-902 (1967). World Health Organization: Etiology and preven tion of dental caries: report of a WHO scien

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