Valedictory Editorial: The past six years.

Fifty years ago this month I graduated from the University of Liverpool. A few months earlier, along with three friends, I had driven overland to attend the International Dental Students Congress held that year in Israel. On the way we drove the spectacular road from Beirut up to Damascus, visited Petra in the Southern Jordanian desert, at that time devoid of tourists, viewed the Chagall windows in the synagogue on the Hadassah University Medical campus, and listened to the world cup final with a group of German students in a youth hostel overlooking the Mandelbaum Gate. Little did we know that within twelve months these beautiful countries and their kind people would be plunged into war and that this conflict and chaos would continue to haunt this region, almost unabated, for the next fifty years.

Public attitudes to water fluoridation in the North East of England.

Introduction Local authorities in the North East of England plan to conduct a public consultation on community water fluoridation. Monitoring public opinion is an important consideration.Aims To measure public attitudes in five areas in the North East of England, to determine respondents' sources of information and their awareness of the current fluoridation status of their local water supply.Methods A face-to-face quota sample with quotas set for age, gender and district using six closed questions plus demographics. The questions and sample size were based on earlier similar studies.Results Just over one-third of respondents (283/761, 37%) had read or heard about fluoridation over the previous 12 months. Their main sources of information were local newspapers followed by dental practices. A substantial minority believed, incorrectly, that their water supply was already fluoridated. Sixty percent of respondents were in favour of adding fluoride to the water supply to prevent dental decay while 16% were opposed.Conclusion and recommendation Public opinion in the North East of England remains favourable to community water fluoridation. Monitoring public opinion should be conducted on a regular basis.

A randomized controlled trial of outreach placement's effect on dental students' clinical confidence.

This randomized controlled trial compared the effects of outreach placement with traditional, exclusively dental school-based clinical experience on students' confidence in providing treatment for patients presenting with common dental problems. Senior dental students (n=49) were allocated at random to existing dental school-based clinics or placement in primary care clinics to work supervised by local dentists. At baseline, students self-rated their global confidence on a five-point scale. These measures were repeated at follow-up, augmented by a transition judgment and a then-test of confidence (asking students to look back and re-rate their pre-placement confidence). Groups were comparable at baseline. Follow-up scores for global confidence were similar between groups. The outreach group scored higher in the transition judgment (mean 3.7, SD 0.9) than the control group (mean 3.1, SD 1.1, P=0.05). In the then-test, on reflection, the outreach group considered their baseline ratings of confidence were overoptimistic (mean then-test scores 3.2, SD 0.9 and baseline 3.7, SD 0.5) while the control group thought theirs were accurate (mean then-test scores 3.8, SD 0.7 and baseline 3.6, SD 0.8, P=0.01). The findings suggest dental outreach training in primary care settings is more effective than dental school training alone in improving students' confidence in tackling clinical situations. The measurement of change in confidence is complicated by shifts in students' internal scales arising from insights gained on outreach.

Effective use of fluorides for the prevention of dental caries in the 21st century: the WHO approach.

Despite great improvements in the oral health of populations across the world, problems still persist particularly among poor and disadvantaged groups in both developed and developing countries. According to the World Oral Health Report 2003, dental caries remains a major public health problem in most industrialized countries, affecting 60-90% of schoolchildren and the vast majority of adults. Although it appears that dental caries is less common and less severe in developing countries of Africa, it is anticipated that the incidence of caries will increase in several countries of that continent, due to changing living conditions and dietary habits, and inadequate exposure to fluorides. Research on the oral health effects of fluoride started around 100 years ago; the focus has been on the link between water and fluorides and dental caries and fluorosis, topical fluoride applications, fluoride toothpastes, and salt and milk fluoridation. Most recently, efforts have been made to summarize the extensive database through systematic reviews. Such reviews concluded that water fluoridation and use of fluoride toothpastes and mouthrinses significantly reduce the prevalence of dental caries. WHO recommends for public health that every effort must be made to develop affordable fluoridated toothpastes for use in developing countries. Water fluoridation, where technically feasible and culturally acceptable, has substantial advantages in public health; alternatively, fluoridation of salt and milk fluoridation schemes may be considered for prevention of dental caries.

Parental perception of fluorosis among 8-year-old children living in three communities in Iceland, Ireland and England.

OBJECTIVES: To assess the impact of enamel fluorosis in three of the communities examined in 'Project FLINT', it was decided to conduct a structured telephone interview with the parents of some of the children who took part in the study. METHODS: Three communities involved in this project were able to conduct this investigation: Reykjavik (Iceland), Cork (Ireland) and Knowsley (England). The aim was to interview the parents of children with a range of Thylstrup and Fejerskov (TF) index grades selected from each participating centre with respect to the appearance of their child's permanent maxillary central incisors. Interviewers were blinded as to the TF grade of the subject. RESULTS: Interviews were conducted with parents of 215 children: 69 with TF grade 0; 70 with TF grade 1; 60 with TF grade 2 and 16 with TF grade 3 or greater. There was a trend towards more parents being unhappy with the appearance of their child's teeth with increasing TF grade. However, the main reasons given by parents for being unhappy with the appearance of their child's teeth was tooth alignment followed by the more yellow colour of permanent compared with primary teeth. Only with a TF grade of 3 was any appreciable concern expressed about fluorosis. CONCLUSION: It would appear that there is a public awareness of both developmental defects and enamel fluorosis although this is not always expressed as dissatisfaction. Further research is required into the clinical impact of both fluorosis and other developmental defects of enamel.

Urinary fluoride excretion of young children exposed to different fluoride regimes.

AIMS: To compare 24-hour urinary fluoride excretion in young children exposed to different fluoride regimes. DESIGN: Twenty-four-hour urine samples were collected from children aged between 1.8 and 5.2 years. Samples were collected from Cork, Ireland (n=19) where the water is fluoridated to a concentration between 0.8 and 1.0 mg/l; Knowsley, UK, where the water fluoride concentration is <0.1 mg/l (n=22); and from children in Knowsley drinking milk containing 0.5 mg fluoride in nursery school each day (n=16). The volume of the samples was measured, they were analysed for fluoride concentration and the 24-hour urinary fluoride excretion was calculated. RESULTS: It was found that the mean fluoride excretion in response to usual conditions of fluoride intake in these children was 0.21 mg (SD=0.14) in non-fluoridated Knowsley; 0.36 mg (SD=0.11) in fluoridated Cork and 0.30 mg (SD=0.10) in the children drinking fluoridated school milk. CONCLUSIONS: The daily fluoride excretion in these children, corrected for age and fluoride ingested from toothpaste, appeared to indicate that the fluoride intake in the children drinking fluoridated school milk was somewhere between those living in an optimally fluoridated area and those in a low fluoride area.

The effective use of fluorides in public health.

Dental caries remain a public health problem for many developing countries and for underprivileged populations in developed countries. This paper outlines the historical development of public health approaches to the use of fluoride and comments on their effectiveness. Early research and development was concerned with waterborne fluorides, both naturally occurring and added, and their effects on the prevalence and incidence of dental caries and dental fluorosis. In the latter half of the 20th century, the focus of research was on fluoride toothpastes and mouth rinses. More recently, systematic reviews summarizing these extensive databases have indicated that water fluoridation and fluoride toothpastes both substantially reduce the prevalence and incidence of dental caries. We present four case studies that illustrate the use of fluoride in modern public health practice, focusing on: recent water fluoridation schemes in California, USA; salt fluoridation in Jamaica; milk fluoridation in Chile; and the development of "affordable" fluoride toothpastes in Indonesia. Common themes are the concern to reduce demands for compliance with fluoride regimes that rely upon action by individuals and their families, and the issue of cost. We recommend that a community should use no more than one systemic fluoride (i.e. water or salt or milk fluoridation) combined with the use of fluoride toothpastes, and that the prevalence of dental fluorosis should be monitored in order to detect increases in or higher-than-acceptable levels.