Fluoride and Oral Health.

The discovery during the first half of the 20th century of the link between natural fluoride, adjusted fluoride levels in drinking water and reduced dental caries prevalence proved to be a stimulus for worldwide on-going research into the role of fluoride in improving oral health. Epidemiological studies of fluoridation programmes have confirmed their safety and their effectiveness in controlling dental caries. Major advances in our knowledge of how fluoride impacts the caries process have led to the development, assessment of effectiveness and promotion of other fluoride vehicles including salt, milk, tablets, toothpaste, gels and varnishes. In 1993, the World Health Organization convened an Expert Committee to provide authoritative information on the role of fluorides in the promotion of oral health throughout the world (WHO TRS 846, 1994). This present publication is a revision of the original 1994 document, again using the expertise of researchers from the extensive fields of knowledge required to successfully implement complex interventions such as the use of fluorides to improve dental and oral health. Financial support for research into the development of these new fluoride strategies has come from many sources including government health departments as well as international and national grant agencies. In addition, the unique role which industry has played in the development, formulation, assessment of effectiveness and promotion of the various fluoride vehicles and strategies is noteworthy. This updated version of 'Fluoride and Oral Health' has adopted an evidence-based approach to its commentary on the different fluoride vehicles and strategies and also to its recommendations. In this regard, full account is taken of the many recent systematic reviews published in peer reviewed literature.

Community-oriented administration of fluoride for the prevention of dental caries: a summary of the current situation in Asia.

Dental caries is the most prevalent chronic disease affecting human populations around the world. It is recognized that fluoride plays a significant role in dental caries reduction. Meanwhile, several low- and middle-income countries of Asia have not yet implemented systematic fluoride programs; contributing factors relate to misconceptions about the mechanisms of fluoride, low priority given to oral health in national health policy and strategic plans, and lack of interest among public health administrators. A workshop on the effective use of fluoride in Asia took place in Phang-Nga, Thailand, in 2011. A series of country presentations addressed some of the topics mentioned above; in addition, speakers from countries of the region provided examples of successful fluoride interventions and discussed program limitations, barriers encountered, and solutions, as well as possibilities for expanding coverage. Participants acknowledged that automatic fluoridation through water, salt, and milk is the most effective and equitable strategy for the prevention of dental caries. Concerns were expressed that government-subsidized community fluoride prevention programs may face privatization. In addition, the use of affordable fluoride-containing toothpastes should be encouraged. The workshop identified: strengths and weaknesses of ongoing community-based fluoride programs, as well as the interest of countries in a particular method; the requirement for World Health Organization (WHO) technical assistance on various aspects, including fluoridation process, feasibility studies, and implementation of effective epidemiological surveillance of the program; exchange of information; and the need for inter-country collaboration. It was acknowledged that program process and evaluation at the local and country levels need further dissemination. The meeting was co-sponsored by the World Health Organization, the International Association for Dental Research, and the World Dental Federation.

Students' clinical experience on outreach placements.

UNLABELLED: Primary care outreach placements increasingly feature in UK undergraduate dental curricula. The profile of clinical work undertaken on placement may differ from traditional hospital-based programmes and between outreach settings. An appreciation of any differences could inform curriculum development. OBJECTIVE: To compare the profiles of clinical work experienced on a traditional hospital-based programme and outreach placements in different settings. SETTING: One dental hospital and eight existing primary care block placements in England. SUBJECTS AND METHODS: Subjects were four cohorts of senior dental students in one UK dental school. Departmental records provided data on students' clinical experience in different settings and their achievement of placement learning objectives. Descriptive statistics for groups were compared. MAIN OUTCOME MEASURES: (1) Counts of patients encountered and of clinical procedures completed in the following categories: simple plastic restorations, endodontics, cast restorations, dentures, extractions and children's dentistry. (2) Student perceptions of placement learning reported via Likert scales. RESULTS: Outreach students encountered twice as many patients and typically completed about three times as much clinical work as students in the hospital, e.g. 44 cf 16 simple plastic restorations, seven cf two endodontic procedures. There were variations in profiles by setting. For example, amalgam being more likely to be used on outreach especially in the General Dental Service; more children's dentistry in community services and more extractions in Dental Access Centres. Students reported learning outcomes generally being achieved (average 94%) although with some variation by setting. CONCLUSION: Dental outreach training greatly increases the quantity of students' clinical experience in everyday dentistry compared to a hospital-based programme. Placements also increase awareness of service delivery and develop clinical skills. There are appreciable variations between outreach settings possibly reflecting their purposes. Multiple contrasting outreach placements for each student might increase the uniformity of learning experiences.

RCT of the effects of block absence for outreach placements on dental students' finals grades.

UNLABELLED: Undergraduate dental curricula are being supplemented with primary care placements requiring periods away from the dental school. These absences may impact negatively on students' other studies. OBJECTIVE: To compare the effect of outreach placement and traditional hospital-based training alone on students' final examination scores. Existing primary care placements in northern England about one year from students' qualification. SUBJECTS AND METHODS: Analysis of secondary outcomes in a randomised controlled trial with students' final examination marks being compared on qualification. To reduce Type I error only 4 of 24 available scores were considered and multiple testing correction applied. Five-week block outreach placements for 25 of 49 students. Honours awarded and examination scores for children's dentistry, overall clinical work and theory. RESULTS: Groups' final exam scores were similar: children's dentistry - outreach 64.9 (SD 2.1), hospital-based 65.0 (3.0); overall clinical work 58.3 (3.4) cf 60.7 (4.8) and theory 54.6 (3.5) cf 56.5 (4.0). The numbers of students awarded honours (outreach 1, hospital 4) showed no significant difference (Fisher's exact text P = 0.19). CONCLUSION: Dental outreach training involving several weeks' absence from the school had no negative impact on students' finals scores.

A randomised controlled trial of the effect of outreach placement on treatment planning by dental students.

UNLABELLED: Undergraduate dental students' curricula are being supplemented with primary care placements. OBJECTIVE: To compare the effect of outreach placement and traditional hospital-based training alone on students' treatment planning ability. DESIGN: Randomised controlled trial.Setting Four existing primary care placements in England during 2004. SUBJECTS AND METHODS: At follow-up the fourth-year students took a history from a standard 'patient' then recorded a treatment plan. Interview skill was scored. The history and plan were assessed by clinicians blind to the intervention. INTERVENTION: Five-week block outreach placements for 25 of 49 students. MAIN OUTCOME MEASURES: Interviewing skill, quality of dental and social histories, the appropriateness of planned treatments and the consideration of wider issues. RESULTS: The two groups were similar in the scores for interviewing and taking a dental history. The outreach group scored higher for capturing a social history (outreach mean 4.4, SD = 2.1, n = 22 and hospital 2.8, SD = 1.9, n = 23; p = 0.01) and for developing an appropriate treatment plan (5.6 [SD = 2.1] and 3.9 [SD = 2.3]; p = 0.01). There were no differences in scores relating to the wider issues. CONCLUSION: Dental outreach training was significantly more effective than traditional training alone in improving students' ability to capture relevant points of social history from a patient and to consider them when planning treatment.

Critique of the review of 'Water fluoridation for the prevention of dental caries' published by the Cochrane Collaboration in 2015.

The Cochrane Review on water fluoridation for the prevention of dental caries was published in 2015 and attracted considerable interest and comment, especially in countries with extensive water fluoridation programmes. The Review had two objectives: (i) to evaluate the effects of water fluoridation (artificial or natural) on the prevention of dental caries, and (ii) to evaluate the effects of water fluoridation (artificial or natural) on dental fluorosis. The authors concluded, inter alia, that there was very little contemporary evidence, meeting the Review's inclusion criteria, that evaluated the effectiveness of water fluoridation for the prevention of dental caries. The purpose of this critique is to examine the conduct of the above Review, and to put it into context in the wider body of evidence regarding the effectiveness of water fluoridation. While the overall conclusion that water fluoridation is effective in caries prevention agrees with previous reviews, many important public health questions could not be answered by the Review because of the restrictive criteria used to judge adequacy of study design and risk of bias. The potential benefits of using wider criteria in order to achieve a fuller understanding of the effectiveness of water fluoridation are discussed.

The effect of water fluoridation and social inequalities on dental caries in 5-year-old children.

BACKGROUND: Many studies have shown that water fluoridation dramatically reduces dental caries, but the effect that water fluoridation has upon reducing dental health inequalities is less clear. The aim of this study is to describe the effect that water fluoridation has upon the association between material deprivation and dental caries experience in 5-year-old children. METHODS: It is an ecological descriptive study of dental caries experience using previously obtained data from the British Association for the Study of Community Dentistry's biennial surveys of 5-year-old children. This study examined the following data from seven fluoridated districts and seven comparable non-fluoridated districts in England: 1) dental caries experience using the dmft (decayed, missing, filled teeth) index; 2) the Townsend Deprivation Index of the electoral ward in which the child lived; 3) whether fluoride was present at an optimal concentration in the drinking water or not. RESULTS: A statistically significant interaction was observed between material deprivation (measured by the Townsend Deprivation Index) and water fluoridation (P < 0.001). This means that the social class gradient between material deprivation and dental caries experience is much flatter in fluoridated areas. CONCLUSION: Water fluoridation reduces dental caries experience more in materially deprived wards than in affluent wards and the introduction of water fluoridation would substantially reduce inequalities in dental health.

Enamel defects in the deciduous dentition as a potential predictor of defects in the permanent dentition of 8- and 9-year-old children in fluoridated Cheshire, England.

It is claimed that dental fluorosis in both deciduous and permanent teeth is increasing in fluoridated and non-fluoridated communities. What is unclear is whether fluoride-induced enamel opacities in the deciduous dentition are associated with the subsequent appearance of enamel defects in the permanent dentition. The aim of this study was to establish whether a relationship existed between the presence of diffuse enamel defects on the deciduous molars and permanent incisors of schoolchildren who were lifetime residents in an optimally fluoridated community in Cheshire, England. The dentitions of eight-and nine-year-old children were examined by two examiners, each unaware of the findings of the other. There was a significant increased risk of diffuse enamel defects in the permanent incisors for those children who presented with diffuse defects on their first deciduous molars (Relative Risk, 1.45; 95% confidence interval, 1.05 to 2.0) or second deciduous molars (Relative Risk, 1.86; 95% confidence interval, 1.36 to 2.54). In light of these findings, it is worth considering the potential of the presence of enamel defects in deciduous molars in children aged 1 to 3 years as a predictor of the future appearance of similar lesions in their permanent incisors.

Reducing patients' state anxiety in general dental practice: a randomized controlled trial.

Anxiety assessment by questionnaire provides information for the dentist and may also confer a psychological benefit on patients. This study tested the hypothesis that informing dentists about patients' dental anxiety prior to commencement of treatment reduces patients' state anxiety. A randomized controlled trial was conducted involving eight General Dental Practitioners in North Wales. Participants included patients attending their first session of dental treatment, and accumulating a score of 19 or above, or scoring 5 on any one question, of the Modified Dental Anxiety Scale (MDAS). Patients (n = 119) completed Spielberger's state anxiety inventory (STAI-S) pre- and post-treatment and were randomly allocated to intervention (dentist informed of MDAS score) and control (dentist not informed) groups. Intervention patients showed greater reduction in mean change STAI-S scores (F[1,119] = 8.74, P < 0.0001). Providing the dentist with information of the high level of a patient's dental anxiety prior to treatment, and involving the patient in this, reduced the patient's state anxiety.

A method for defining the level of periodontal treatment need in a population of 15-year-old schoolchildren.

In a public dental service with scarce resources, the presence of gingivitis in teenage children cannot necessarily be considered as indicating treatment need. However, it is suggested that early bone loss may be an important indication for treatment in teenage children and the aim of the present study was to determine whether the presence of early bone loss in 622 15-year-old children assessed by the measurement of loss of attachment could be predicted from more readily identifiable factors such as gingival bleeding or subgingival calculus. However, such screening tests will make errors by including "healthy subjects" or excluding "diseased "subjects. The acceptable balance of these two kinds of error is a public health decision, a decision which may be affected by a number of variables, including the public's and profession's attitudes to the disease, the effectiveness of available treatments and the resources available.

Promoting water fluoridation.

The Department of Health published two reports in 1962 and 1969 confirming the effectiveness of water fluoridation in demonstration studies in Watford, Anglesey and Kilmarnock. By 1988, approximately 6 million consumers (12 per cent of the population of England and Wales) were receiving artificially fluoridated water, although much of that progress was the result of decisions taken by local authorities prior to the reorganisation of local government and the health service in 1973-74. The Water Fluoridation Act (1985) established a clear process for decision making which incorporated requirements for local consultation. National opinion surveys indicate that public support for fluoridation has increased from 66 per cent in 1980 to 79 per cent in 1992. Regional Fluoridation Publicity Action Groups will need to convince local decision makers of the extent of this public support.

The effect of school dental screening on dental attendance. The results of a randomised controlled trial.

The aim of this study was to determine the effectiveness of a school dental screening in encouraging school children aged 4 to 6 years to visit a dentist. One thousand five hundred and sixty-two children attending the 13 primary schools in Wallasey. Merseyside, were examined by a single trained examiner; those with urgent treatment needs or evidence of recent treatment were excluded. The remaining 528 children with signs of dental caries were entered into the study. Children within each school were stratified by age, sex and number of carious teeth and then allocated at random to test and control groups. Parents of children in the test group were advised by letter that their child would benefit from a more detailed clinical examination. A reply slip was attached to the letter and non-responders were carefully followed up. The control group received no such interventions. After 4 months, data on dental visits by both test and control group children were extracted from clinical records. Attendance data were obtained for 262 children (97 per cent) in the test group and 243 children (94 per cent) in the control group. Seventy-three per cent of the test group and 42 per cent of the control group visited the dentist over the review period; the difference of 31 per cent favour of the test group was statistically significant. Attendances at both general dental practitioners and community dental clinics were increased. The effect of the screening procedure was seen particularly in areas of lower socio-economic status.(ABSTRACT TRUNCATED AT 250 WORDS)

Dental attendance patterns among mothers and their children in an area of social deprivation.

Dental attendance behaviour was recorded for 358 children aged 5-6 and 10-11 years and their mothers living in a socially deprived area of south Manchester. Information obtained by questionnaire was verified by the local dentists concerned. Forty-four per cent of mothers and 61 per cent of children had attended a dentist in the previous 12 months. The mothers' attendance was a good predictor of children's attendance, although a substantial proportion of mothers who did not attend the dentist themselves did ensure the attendance of their children.

Sugar consumption in 5 and 12-year-old school children in Ondo State, Nigeria in 1985.

In a previous study (Olojugba & Lennon, 1987) of 5 and 12-year-old children residing in Ondo State, Nigeria, it was shown that caries had increased (1977 to 1983) in children of both age groups in higher social class families; caries had also increased in the 12-year-old children but not in those aged 5 year olds among lower social class families. The object of the present study was to examine sugar consumption in samples of children of the same age groups drawn from the same population. One hundred families with siblings in both age groups were selected. 24-hour dietary records were obtained for each child; an inventory was also made of all food and drink stored within the home. The 5-year-old children from the higher social class families had 5.9 sugar intakes, as against 1.5 intakes among their lower social class urban counterparts. All the sugar-containing items were consumed by the 5-year-old children at home. The difference in the frequency of intake among those aged 12 years was much less obvious, 4.9 and 4.2 intakes respectively. Sixty-eight per cent of the intakes among the lower social class 12-year-old children was in the form of cheap sugar-containing drinks, ice lollies and sweets which they bought themselves and consumed away from home. These cheap sources of sugar were not available to their younger siblings. It was concluded that the sugar consumption patterns recorded in the children, and confirmed by the household food inventory, provided a plausible explanation of the previously reported changes in caries severity.

The prevalence of tooth wear in 14-year-old school children in Liverpool.

The prevalence of tooth wear was assessed in a random sample of 14 year old school children in Liverpool. A total of 1035 children were examined in 10 schools of whom 526 (50.8 per cent) were male and 509 (49.2 per cent) were female. Three hundred and seven children (30 per cent) had exposed dentine, mainly incisally, and this occurred significantly more often in males than females (P < 0.01). Of these children, 80 (8 per cent) also exhibited exposed dentine on occlusal and/or lingual surfaces. This occurred mainly on the occlusal surfaces of the first mandibular molars and the lingual aspects of the upper incisors. A slight positive association was found between tooth wear and the level of social deprivation in the electoral ward in which the school was located.

Risk factors associated with tooth wear in teenagers: a case control study.

OBJECTIVE: To measure the association of various aetiological risk factors with tooth wear in 15-year-old school children. BASIC RESEARCH DESIGN: A case control study conducted one year after a prevalence study (Milosevic et al., 1994). The 80 children, identified from the prevalence study with palatally and/or occlusally exposed dentine, acted as cases. The control group were systematically selected from every tenth name on year registers. The only matching criteria were age, gender and school. All children answered a questionnaire detailing the risk factors and the tooth wear was further scored by one examiner (AM). SETTING: Ten randomly selected schools in Liverpool. PARTICIPANTS: 102 children participated out of a possible 160, an overall response rate of 64 per cent. Of the 54 controls, six had developed tooth wear into dentine during the 12-month interval following the prevalence study and were therefore excluded from the analysis. RESULTS: The odds ratio on 37 matched pairs was 1.7 (95% CI 0.72, 3.87) for grinding and clenching teeth and 2.6 (95% CI 0.91, 7.45) for carbonated drink consumption. Eating pickled food other than pickled onions was significantly more frequent in cases than in controls. Other potential aetiological factors which were not significantly associated with tooth wear in this group of children included stomach upsets, frequency of tooth brushing, weight/body shape and drinking fruit juice or using ketchup/sauces. Conditional logistic regression analysis of the paired data showed that carbonated beverage consumption was on the borderline of significance (P = 0.055) as a predictor for tooth wear in teenagers either on its own or allowing for the effect of tooth grinding. CONCLUSIONS: The frequent consumption of carbonated beverages is probably related to tooth wear. Future case control studies should seek to incorporate around 100 to 160 cases.

A national calibration exercise for the British Association for the Study of Community Dentistry regional examiners.

Representative examiners from all regions in England and examiners from Wales and Scotland took part in a national calibration exercise conducted in Manchester for The British Association for the Study of Community Dentistry (BASCD). Each dentist examined the same group of thirty-three 5-year-old and thirty 14-year-old children independently, and they were asked to examine the children by the same method as that used within that Region when conducting the annual BASCD surveys. Comparisons of inter-examiner differences revealed that in the examination of 5-year-old children diagnoses were not significantly different for 14 out of the 16 Regional examiners. Differences in the conventions applied in the case of missing teeth and 'arrested caries' were found and are discussed. There were no significant differences in the diagnoses for the DMFT for the 14-year-old children amongst all 16 Regional examiners. The calibration exercise allowed a close examination of the application of the BASCD criteria in the field.

A dental care programme for occasional dental attenders.

This study investigated the provision of dental care to primary schools in which many children were irregular or occasional dental attenders. The dental care programme was targeted at 9- to 11-year-old children in the two test schools, and comprised a series of dental health education lessons, followed by the offer of dental treatment within the school. This treatment was carried out using portable equipment set up in the medical room or spare classroom. Children in the control schools received a traditional school dental inspection and the offer of clinic-based treatment. The results showed that simple operative treatment could be satisfactorily provided on school premises, and by removing many barriers to dental care, could be considered appropriate in circumstances where there is a 'core, of children not receiving this care.

The use of school milk as a vehicle for fluoride in Knowsley, UK; an evaluation of effectiveness.

OBJECTIVE: To compare caries in children initially aged 3 to 5 years who had participated for four years in a fluoridated school milk programme with a group of children in a similar community drinking non-fluoridated milk. STUDY DESIGN: A four-year longitudinal study measuring caries experience and caries increment in primary molars and caries experience in permanent molars and incisors. METHOD: 478 children in Knowsley (test group) and 396 in Skelmersdale (comparison group) were examined for caries (dmft/dfs) at baseline in 1997. Of these, 318 in Knowsley and 233 in Skelmersdale were re-examined at follow-up (dmft/dfs and DMFT/DFS) in 2001. RESULTS: The mean ages at baseline of the children from the test and comparison groups were 4.7 and 4.8 years respectively. The baseline dmft/dfs was 1.73/2.51 in the test group and 1.29/2.15 in the comparison group. The 4-year dmft/dfs mean increments were 2.28/4.49 and 1.96/4.12 in test and comparison groups respectively. The DMFT/DFS at age 7-9 years in the test and comparison groups were 0.40/0.45 and 0.40/0.55 respectively. CONCLUSION: The fluoridated school milk scheme, as configured in Knowsley. Merseyside, did not reduce caries within the primary dentition and, at best, had a small clinical impact on the permanent dentition up to 8 years of age.