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.

Milestones in oral health services in the Republic of Ireland.

With the many changes occurring in Ireland it would seem an opportune time to review the body of research conducted and policy enacted in the Republic of Ireland on oral health services and oral health. The dental health of the nation prior to water fluoridation, the legislation and policy decisions impacting on oral health up to budgetary changes, and the production of evidence-based guidelines will be discussed. The first national survey of dental health was conducted in Ireland in 1952 - 'Dental Caries in Ireland'. In the intervening 60 years, further surveys of the oral health of people in Ireland have been carried out. Legislation, surveys and policy documents that have shaped dentistry and the oral health of the population are set out in Tables 1 and 2. A more comprehensive description of the policies can be found in the thesis submitted in fulfilment of Masters in Dental Public Health (MDPH) by the lead author.

Development of gold standard ion-selective electrode-based methods for fluoride analysis.

BACKGROUND/AIMS: Currently available techniques for fluoride analysis are not standardized. Therefore, this study was designed to develop standardized methods for analyzing fluoride in biological and nonbiological samples used for dental research. METHODS: A group of nine laboratories analyzed a set of standardized samples for fluoride concentration using their own methods. The group then reviewed existing analytical techniques for fluoride analysis, identified inconsistencies in the use of these techniques and conducted testing to resolve differences. Based on the results of the testing undertaken to define the best approaches for the analysis, the group developed recommendations for direct and microdiffusion methods using the fluoride ion-selective electrode. RESULTS: Initial results demonstrated that there was no consensus regarding the choice of analytical techniques for different types of samples. Although for several types of samples, the results of the fluoride analyses were similar among some laboratories, greater differences were observed for saliva, food and beverage samples. In spite of these initial differences, precise and true values of fluoride concentration, as well as smaller differences between laboratories, were obtained once the standardized methodologies were used. Intraclass correlation coefficients ranged from 0.90 to 0.93, for the analysis of a certified reference material, using the standardized methodologies. CONCLUSION: The results of this study demonstrate that the development and use of standardized protocols for F analysis significantly decreased differences among laboratories and resulted in more precise and true values.

Is the shortened dental arch an underused treatment strategy in the Republic of Ireland?

OBJECTIVES: To determine the proportion of Republic of Ireland 35-44 and 65+ year-olds currently satisfying the criteria for a classic shortened dental arch (SDA) of 20 anterior teeth. RESEARCH DESIGN: Secondary analysis of data collected in the 2000/02 epidemiological survey of the oral health of Irish adults. CLINICAL SETTING: Participants underwent a clinical oral examination in health board dental clinics and completed a detailed interview pertaining to dental and general health. PARTICIPANTS: The analysis is based on a random sample of adults, aged 35 to 44 years (n = 978), and 65 years and older (n = 714). MAIN OUTCOME MEASURES: The SDA was measured as 20 teeth in the mouth in the positions normally described as from the left second premolar to the right second premolar in each arch. RESULTS: Only one of the 35-44 year-olds and none of the 65+ year-olds had teeth in their mouths in positions normally described as a classic SDA. However, of the 35-44 year old age group only five patients who had at least a premolar dentition of 20 contiguous teeth had been provided with a removable denture compared to one patient from the 65+ years group. CONCLUSIONS: Very few older patients in the Republic of Ireland have a SDA based on the measure used. However, very few have been provided with removable dentures where they already possess at least a premolar dentition of 20 contiguous teeth. Suggested reasons for this may include limitations of the data recorded, patient preferences and economic factors.

Impact of Reducing Water Fluoride on Dental Caries and Fluorosis.

Guidance intended to reduce fluoride toothpaste ingestion in early childhood was introduced in Ireland in 2002. In 2007, water fluoride concentration was adjusted from 0.8-1.0 to 0.6-0.8 ppm. The objective of this study was to determine the difference in caries and fluorosis levels following introduction of these 2 policy measures. A before-and-after study compared caries and fluorosis in random samples of 8-y-olds in Dublin (n = 707) and Cork-Kerry (n = 1148) in 2017 with 8-y-olds in Dublin (n = 679) and Cork-Kerry (n = 565) in 2002. Dentinal caries experience (primary teeth, d3vcmft(cde)) and fluorosis (permanent teeth, Dean's index of very mild or higher) were clinically measured. Lifetime exposure to community water fluoridation (CWF) was classified as "full CWF"/"no CWF." Effect of examination year on caries prevalence and severity and fluorosis prevalence was assessed using multivariate regression adjusting for other explanatory variables. There was little change in commencement of fluoride toothpaste use at ≤24 mo following introduction of toothbrushing guidance. Among children with full CWF, there was no statistically significant difference in caries prevalence or severity between 2017 and 2002. In 2017, caries prevalence was 55% in Dublin (full CWF) and 56% in Cork-Kerry (full CWF), and mean d3vcmft(cde) among children with caries was 3.4 and 3.7, respectively. Caries severity was less in 2017 (mean 4.2) than 2002 (mean 4.9) among children with no CWF (P = 0.039). The difference in caries severity between children with full CWF and no CWF was less in 2017 than in 2002 (interaction P = 0.013), suggesting a reduced benefit for CWF in 2017. In 2017, fluorosis prevalence was 18% in Dublin (full CWF) and 12% in Cork-Kerry (full CWF). Fluorosis was predominantly "very mild" with no statistically significant difference between 2017 and 2002. CWF at 0.6 to 0.8 ppm is an effective caries-preventive measure. Results suggested low uptake of toothbrushing guidance, a reduced caries-preventive effect for CWF in primary teeth, and no reduction in fluorosis following introduction of the policy measures.

Is tooth wear in the primary dentition predictive of tooth wear in the permanent dentition? Report from a longitudinal study.

OBJECTIVES: To determine the prevalence of tooth wear in the permanent dentition of a sample of 12-year-old school children and establish whether an association exists between tooth wear recorded now and tooth wear recorded in their primary dentition at age five. DESIGN: A prospective cohort study. METHODS: At follow-up to a previous study complete data were available for 123 children; fieldwork was conducted in the child's primary school. Measurement of tooth wear used a scoring system modified from the Smith and Knight Tooth Wear Index (TWI). Tooth wear which had progressed to dentine was assessed on the occlusal surfaces of the four first permanent molars, the labial, lingual/palatal and incisal surfaces of the six upper and six lower anterior teeth; a total of 40 scoreable surfaces. Demographic data were collected from the parents, and a questionnaire on oral hygiene habits, diet and behaviours was completed by each child. RESULTS: In total 38% (n = 47) of subjects had tooth wear, if incisor teeth only were included, 33% (n = 40) had tooth wear and similarly if the occlusal surfaces of molar teeth only were included 10% (n = 12) had signs of tooth wear. Gender was significantly associated with tooth wear: males had more tooth wear. The presence of tooth wear with dentine exposed in the primary dentition was significantly associated with tooth wear on the occlusal surfaces of the first permanent molars. CONCLUSION: Males had more tooth wear than females. An association existed between tooth wear recorded at age 5 and molar tooth wear recorded at age 12. Tooth wear is a lifelong cumulative process and should be recorded in both the primary and permanent dentitions.

Dental caries and enamel fluorosis among the fluoridated population in the Republic of Ireland and non fluoridated population in Northern Ireland in 2002.

BACKGROUND: An all Ireland/North South survey of Oral Health was carried out in 2001/2002. AIMS: To compare levels of dental caries and enamel fluorosis among children and adolescents in the fluoridated Republic of Ireland (RoI) with those in the non fluoridated North of Ireland (NI). METHODOLOGY: Cross sectional oral health survey of a representative, random, stratified sample of 5-, 8-, 12- and 15-year-olds in Rol and in NI (N = 19,950). WHO examination criteria with the addition of visible, non cavitated dentine caries were used for recording caries. Fluorosis was measured using Dean's Index. RESULTS: In the RoI, the mean d(3c)mft / D(3c)MFT for 5-, 8-, 12-, and 15-year-olds with full domestic water fluoridation (n = 9,975), was 1.0, 0.3, 1.1 and 2.1 respectively. The corresponding means in non fluoridated NI (n = 1,475) were 1.8, 0.3, 1.5 and 3.6 respectively. (p < 0.0001, NS, p < 0.0005 and p < 0.0001). The prevalence of enamel fluorosis has increased in RoI since 1984, 23% and 36% of 8- and 15-year olds respectively in fluoridated areas had Dean's Index scores at the questionable or greater level in 2002 compared with 6% and 5% respectively in 1984. CONCLUSIONS: In 2002 apart from 8-year-olds, caries levels were lower amongst children resident in fluoridated communities in RoI than amongst corresponding age groups in non-fluoridated NI. Caries has declined in fluoridated and non fluoridated groups in both jurisdictions since the early 1960s. In RoI fluorosis levels were higher amongst lifetime residents of fluoridated communities and have increased since 1984.

Attitudes of general dental practitioners in Europe to the microbial risk associated with dental unit water systems.

UNLABELLED: Dental Unit Water Systems (DUWS) are used in dental practices to provide water for cooling of dental equipment and irrigation of the oral cavity. However, they have been demonstrated to be contaminated with micro-organisms. There are currently no European Union (EU) Commission guidelines for the microbial quality of water discharged by DUWS. This study was part of an EU research programme to investigate the microbial contamination of DUWS in general dental practice (GDP) in the UK, Denmark, Germany, The Netherlands, Ireland, Greece and Spain. OBJECTIVE: To undertake a questionnaire survey on the type of DUWS in use and determine the attitude of GDPs to the risk of microbial infection from DUWS. MATERIALS AND METHODS: The questionnaire was written and translated into the language of each country before being posted to each participating dentist. Dentists were asked to complete the questionnaire survey and return it by post. RESULTS AND CONCLUSIONS: The major findings were that the majority of dentists did not clean, disinfect or determine the microbial load of their DUWS, and that dentists would welcome regular monitoring and advice on maintaining their DUWS; the introduction of guidelines; and recommendations on controlling the microbial load of DUWS.

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.

Use of dental service data to inform research and policy.

Data collected routinely in dental care delivery systems could be used to inform research and policy. Projects in which data were collected with the help of general dental practitioners are outlined. In an EU-funded project, six partners collaborated to develop a methodology designed to establish links between characteristics of a health care system and health outcome, and to determine the characteristics of oral health care systems which promote oral health and those which are detrimental to oral health. The results indicated that the data collected in the different systems investigated varied enormously, and they could not be easily adapted to help in developing policy. A theoretical model was developed in which the production of oral health care was considered separately from the production of oral health. In the second example, the longevity of the restorations in a dental care delivery system in Ireland was investigated by routine service data.

Primary tooth fluorosis in 5-year-old schoolchildren in Ireland.

AIM: This was to determine the prevalence of primary tooth fluorosis in the dentitions of 5-year-old schoolchildren. A subsidiary aim was to investigate whether an association existed between the presence of primary tooth fluorosis, fluoridation status, infant feeding practices or the oral hygiene practices of the child. STUDY DESIGN: A cross-sectional and stratified by fluoridation status study. METHODS: Fluorosis was recorded using a modification of the Tooth Surface Index of Fluorosis (TSIF). Demographic data, information on infant feeding practices and oral hygiene practices were collected via a parental questionnaire. STATISTICS: Stepwise logistic regression analysis. RESULTS: Fluorosis prevalence in the fluoridated group (n=208) was 32%; 29.3% (n=61) had a modified TSIF score of 1; 2.4% (n=5) had a modified TSIF score of 2; and 1% (n=1) had a modified TSIF score of 5. In the non-fluoridated group (n=86) one child had a modified TSIF score of 1. Primary tooth prevalence of fluorosis in the entire sample (n=294) was 23%. Factors that were associated with primary tooth fluorosis were: fluoridation status (p= 0.0003, 95% CI = 5-281) and the age at which toothbrushing with toothpaste commenced (p = 0.016, 95% C.I. 1.1 - 3.8). No association with infant feeding practices was identified. CONCLUSION: The overall prevalence of primary tooth fluorosis was 23%. Lifetime residence in a fluoridated area and commencement of toothbrushing with toothpaste between 12 and 18 months of age were associated with primary tooth fluorosis. No association with infant feeding practices was identified.

Attitudes of Irish and European dentists to water quality of dental unit water systems.

BACKGROUND: Dental unit water systems (DUWS) are used in dental practices to provide water to irrigate the oral cavity. Dental surgeries across the European Union (EU) use DUWS that may be prone to microbial contamination. OBJECTIVES: To determine Irish dental practitioners' attitudes to perceived risk from working with DUWS and their protocols for the management of biofilm in their DUWS and compare these with other European dentists. DESIGN: A questionnaire was used to determine DUWS types in use, practitioners' attitudes to risks associated with using DUWS and their DUWS management protocols. RESULTS: There were six different types of DUWS, 40 per cent of which were > 5 years old, 42 per cent of DUWS were fed by purified or distilled water. Only four per cent of practitioners carried out microbiological analysis on their water, but 38 per cent indicated that they cleaned or disinfected their DUWS. One-hundred per cent of practitioners were not aware of national/international guidelines for microbial contamination of DUWS but 77 per cent were concerned about DUWS water quality. CONCLUSIONS: The majority of practitioners were working with equipment that is < 5 years old. The majority of DUWS were not treated but practitioners were concerned about dental unit water quality and would welcome regular microbiological water tests and clear advice on cleaning/disinfection of the water supply in their dental units. Practitioner attitudes and behaviours were broadly similar in the other European countries studied.

Parents' preference as to whether they would like to accompany their child when receiving dental treatment--results from a national survey.

BACKGROUND AND DESIGN: parental accompaniment of children during dental treatment has always been a contentious issue. One of the factors that should be considered is the preference of the parents. The aim of this paper is to report the preference of parents of eight-year-old schoolchildren in Ireland in relation to accompanying their child during dental procedures and is part of the National Survey of Children's Dental Health in Ireland, which was conducted between October 2001 and June 2002. The survey had a cross sectional design and parents of children (average age 8.4 years) selected for dental examination were asked to complete a questionnaire. RESULTS: 3629 completed questionnaires were obtained from parents of eight-year-old children giving a response rate of 68 per cent. Sixty-seven per cent of parents expressed a preference to accompany their child during dental treatment, while nine per cent expressed a preference not to accompany their child. The sex of the child (p = 0.33) or the fact that the parents were holders of a medical card (surrogate for disadvantage) (p = 0.08) did not affect parents' preference. However, parents of a single child had a higher preference (78 per cent) for accompanying their child than did parents with greater than one child in the family unit (66 per cent) (p = 0.0009). CONCLUSION: If given the choice, the majority of parents would prefer to accompany their child when receiving dental treatment.

Microbial contamination of dental unit water systems.

INTRODUCTION: Dental unit water systems (DUWS) may serve as a reservoir for biofilms that contribute to high numbers of bacteria in the water used during dental treatment. These microbes are predominantly harmless but potentially pathogenic organisms can also be present in the biofilm. This may pose a potential health risk for patients and dental personnel. AIM: to determine the microbial levels of DUWS in dental practices. MATERIALS AND METHOD: A cross-sectional study of water and tubing samples from 30 general dental practices (15 health board and 15 private surgeries) was undertaken as part of a pan-European investigation of the microbial qualitative and quantitative aspects of DUWS. RESULTS: Microbial loads ranged from 100 to 104 cfu ml-1 and exceeded the European guidelines for drinking water in many cases. The available evidence suggested the presence of isolates most likely belonging to families of aquatic and soil bacteria. It was not possible to draw distinct conclusions correlating microbial loads with dental unit parameters, including age of the unit, water source and chemistry and presence or absence of anti-retraction devices. Opportunistic or true pathogens were not detected. Yeasts were observed in samples from three units although further analysis confirmed that these were not Candida albicans. A decontamination strategy applied to one of the units eliminated the yeasts completely. CONCLUSIONS: Dental practitioners must be knowledgeable regarding microbial contamination and biofilm formation in dental unit waterlines. There is a need for development of European evidence-based guidelines and reliable control regimes for microbial contamination of DUWS.

New agents in the chemical control of plaque and gingivitis: reaction paper.

The inadequacy of traditional methods in controlling plaque and gingivitis has led to an increasing interest in the chemical approach, especially using toothpastes and mouthrinses. Various agents have been tested by a variety of experimental designs. Further work in this field should include monitoring the effect of long-term use on the oral ecology and an appraisal of the experimental designs used in longitudinal studies of antiplaque and antigingivitis agents.

The future of water fluoridation.

Recently, questions have been raised about the possible reduced effectiveness and cost-effectiveness of water fluoridation in the prevention of dental caries in developed countries. The increase in environmental fluorides since water fluoridation was first introduced in 1945 (particularly from fluoride toothpastes, mouthrinses, and from foods and drinks) generally provided the basis for these questions. A related phenomenon which might decrease the efficiency of water fluoridation is the reduced caries levels in many developed countries. It has also been suggested that excessive fluoride intake, especially in fluoridated communities where there is widespread use of fluoride toothpastes, is likely to manifest itself in an increased dental fluorosis prevalence. In this paper, recent data from Ireland which are similar to those recorded in many developed countries are used to answer these questions in part. It is concluded that water fluoridation continues to be an effective and cost-effective strategy for caries prevention in areas where the overall caries level has declined and where the cost of water fluoridation implementation has increased. Also, there is no evidence of excessive fluoride intake in fluoridated communities where fluoride toothpastes are widely used.

A modified DDE Index for use in epidemiological studies of enamel defects.

The aim of this study was to investigate possible modifications to the DDE Index to make it simpler to use and to make the data collected more meaningful and amenable to analyses and interpretation. After the use of the DDE Index in a National Study in Ireland, initial alterations to the Index were tested on a group of children with enamel defects, in Ireland and New Zealand. The DDE Index was then modified to allow for the measurement of demarcated, diffuse, and hypoplastic defects and their severity. With the Modified Index, the prevalence of defects both on index teeth and all permanent tooth surfaces of 8- and 15-year-old children in fluoridated Cork City and non-fluoridated areas of Cork County and Manchester, U.K., was measured. The prevalence of enamel defects on one or more index teeth of children in the three areas ranged from 30 to 42% in 8-year-olds and from 31 to 38% in 15-year-olds. The percentage of children affected as seen by full-mouth examination was somewhat higher, ranging from 38 to 51% for 8-year-olds and 58 to 63% for 15-year-olds. The percentage of index teeth affected (7 to 14%) was generally higher than for all teeth (5 to 9%). Demarcated opacities were the most common defect seen. Diffuse opacities were found to be the discriminating factor between the fluoridated and non-fluoridated areas. In all areas, the vast majority of diffuse opacities extended over less than 1/3 of the surface area of the teeth affected.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of sequential analysis in clinical trials of caries prophylactic agents.

Using a sequential t test, the objectives of two 3-year experimental clinical trials were achieved more efficiently by using fewer subjects over a shorter time. The assumption of identical distributions of each batch of data analyzed was not apparent and further work to establish the robustness of sequential t tests is indicated. Identification of subjects with more consistent caries increments during the period of a trial would also help to satisfy this assumption.

Indices of root surface caries.

Despite the increasing international interest in recent years in the epidemiology of root surface caries, there is no agreement on the diagnostic criteria to be used when the condition is recorded. In this paper the different methods used by dental epidemiologists are reviewed. It is shown that the wide variation in the levels of root surface caries recorded among different populations could be due to differences in the diagnostic methods as well as to inherent differences in the prevalence of the condition. It is recommended that an attempt be made to reach a global consensus on the methods of diagnosing root surface caries. Also, it is suggested that in reports of epidemiological studies of root surface caries, a basic set of tables including details of tooth loss be included.