Microbiota-immune-brain interactions: A new vision in the understanding of periodontal health and disease.

This review highlights the significance of interactions between the microbiota, immune system, nervous and hormonal systems, and the brain on periodontal health and disease. Microorganisms in the microbiota, immune cells, and neurons communicate via homeostatic nervous and hormonal systems, regulating vital body functions. By modulating pro-inflammatory and anti-inflammatory adaptive immune responses, these systems control the composition and number of microorganisms in the microbiota. The strength of these brain-controlled responses is genetically determined but is sensitive to early childhood stressors, which can permanently alter their responsiveness via epigenetic mechanisms, and to adult stressors, causing temporary changes. Clinical evidence and research with humans and animal models indicate that factors linked to severe periodontitis enhance the responsiveness of these homeostatic systems, leading to persistent hyperactivation. This weakens the immune defense against invasive symbiotic microorganisms (pathobionts) while strengthening the defense against non-invasive symbionts at the gingival margin. The result is an increased gingival tissue load of pathobionts, including Gram-negative bacteria, followed by an excessive innate immune response, which prevents infection but simultaneously destroys gingival and periodontal tissues. Thus, the balance between pro-inflammatory and anti-inflammatory adaptive immunity is crucial in controlling the microbiota, and the responsiveness of brain-controlled homeostatic systems determines periodontal health.

Dental caries and associated factors in a group of Swedish snus users.

The aim of this study was to investigate the effects of the Swedish moist powder tobacco product known as "snus" on dental caries and to measure the pH fall in dental plaque. The subjects comprised male and female adults between 26 and 62 years of age (n = 102), all habitual snus users for ≥ 10 years. The control group (n = 101) consisted of similar individuals in terms of gender, age and educational level but with no tobacco use for ≥ 10 years. A clinical and radiographic examination and a questionnaire were completed. The pH fall after a sucrose rinse was estimated in situ in 10 randomly selected subjects per group. The salivary secretion rate was higher in snus users than non-users (2.5 vs 2.2 ml/min, p = 0.005).There was no statistically significant difference regarding salivary buffer capacity. No differences were found between the two groups in terms of the plaque index, primary or secondary enamel and dentine caries, DFS and salivary counts of mutans streptococci or lactobacilli. The pH fall was somewhat more pronounced among non-users compared with snus users (NS). Snus users had a lower intake of snacks between meals and a less frequent intake of cookies (p = 0.000). Furthermore, snus users had a mean gingival index (± SD) for the whole dentition of 20.4 ± 18.2, while the index for non-users was 14.4 ± 13.9 (p = 0.09); the corresponding values for teeth 13-23 were 14.9 ± 20.6 and 7.7 ± 11.9 respectively (p = 0.003). To conclude, this clinical study revealed no statistically significant differences in caries prevalence between snus users and non-users and only minor differences regarding different caries associated factors.

Oral health-related quality of life and its relationship to self-reported oral discomfort and clinical status.

The impact of oral health on quality of life is one aspect when it comes to understanding the significance of oral health. The aim of this study was to analyse the self-reported oral discomfort and clinical status of individuals reporting oral problems never/very seldom affecting quality of life during the last year and compare them with individuals who reported oral problems hardly ever/occasionally or often/very often during the the same period. The study comprised a stratified random sample of 515 individuals who lived in four parishes in the City of Jonköping, Sweden, and turned 20, 30, 40, 50, 60, 70 and 80 years of age in 2003. The impact of oral health on quality of life was examined using the OHIP-14 questionnaire. The individuals were also examined clinically and radiographically. Of the participants, 21% reported no experience of impaired quality of life and 20% of the individuals reported that they had experienced impaired quality of life often or very often during the last year. The highest frequency of oral problems was found among individuals aged 20 and 80 years. Subjective symptoms, such as grinding/clenching and headache, were found among 20- and 30-year-olds. Edentulous individuals and individuals with many missing teeth, individuals with severe periodontal disease or subjective dry mouth answered that they experienced problems according to the OHIP-14 often or very often. A number of individuals, young and old, had thus experienced subjective or clinically verified oral conditions associated with a negative experience of quality of life. This complementary information will provide a deeper understanding of the importance of oral health in the population.

Clinical signs indicative of temporomandibular disorders in adults: time trends and associated factors.

The study aimed to examine possible time trends in the prevalence of clinical signs indicative of temporomandibular disorder (TMD) in an adult population, to analyse possible associations between TMD signs and associated factors and to estimate the need for TMD treatment. Three independent, stratified and randomly selected samples of around 100 individuals in the age groups of 20, 30, 40, 50, 60 and 70 years participated in the Jönköping studies in 1983,1993 and 2003. The study material consisted of 1,693 subjects who, after answering a questionnaire and being interviewed about the presence of TMD symptoms, were clinically examined in terms of the presence of TMD signs according to the Clinical Dysfunction Index (Di) by Helkimo. Associations between clinical signs and the Di as dependent variables and each of the independent variables of age group, gender, reported bruxism, trauma, self-perceived healthiness and the year of investigation were analysed in binary logistic regression models. Estimates of the need for TMD treatment were based on the presence of a combination of severe symptoms and clinical signs. The prevalence of severely impaired jaw movement capacity, relating to horizontal movements, had increased in 2003. The prevalence of muscle pain and temporomandibular joint pain upon posterior palpation was found to vary statistically significantly between 1993 and 2003. Gender differences were noted in these changes overtime. Female gender, advancing age, awareness of bruxism, self-perceived health impairment and the wearing of complete dentures were associated with TMD signs and a higher degree of clinical dysfunction. The estimated need for TMD treatment increased from 5% in 1983 to 8% in 2003 and was higher in women than in men. In conclusion, the results indicate that the prevalence of some TMD signs and of estimated treatment need increased during the period 1983-2003.

Dental caries in relation to smoking and the use of Swedish snus: epidemiological studies covering 20 years (1983-2003).

OBJECTIVE: The aim of this study was to evaluate some intra-oral caries-associated variables and tobacco use on dental caries. MATERIALS AND METHODS: The participants were randomly recruited from three cross-sectional studies in Jönköping, Sweden, in 1983, 1993 and 2003. Each study consisted of 130 individuals in each of the 20, 30, 40, 50, 60 and 70-year age groups. Of these, 550, 552 and 523 dentate individuals attended respective year of examination. They were all examined both clinically and radiographically. A questionnaire was completed in conjunction with the examination. In the studies, 345 were smokers, 104 snus users and 1142 non-tobacco users, in total 1591 individuals. RESULTS: In 1983 and 1993, there were no significant differences in mean DFS between non-users and smokers, but a statistically significantly higher mean DFS in comparison with snus users. In 2003, there was no statistically significant difference in mean DFS between the groups. Multiple regressions showed that, after adjusting for age, gender and socio-demographic variables, there was a statistically significant association between DFS and smoking in 1983 (smoking excluded in favour of lactobacilli when further analysed) and DFS and plaque index (PLI) in 1993. In 2003, there was no association, apart from buffer capacity (Power rising) between DFS and the examined intra-oral caries-associated variables and tobacco use. CONCLUSIONS: The results of these epidemiological studies, performed in 1993 and 2003, indicate that daily smoking or snus use does not increase the risk of dental caries.

Prevalence of symptoms indicative of temporomandibular disorders in adults: cross-sectional epidemiological investigations covering two decades.

OBJECTIVES: The aims were (1) to study possible secular trends in the prevalence of temporomandibular disorder (TMD) symptoms in adults and (2) to analyse possible associations between TMD symptoms and background factors. MATERIALS AND METHODS: The investigation has a repeated cross-sectional design. Three independent, randomly selected samples of ∼100 individuals in the age groups of 20, 30, 40, 50, 60 and 70 years, a total of 1704 subjects, participated in the Jönköping studies in 1983, 1993 and 2003. All the subjects were evaluated using a questionnaire and a structured interview relating to the presence of TMD symptoms. Associations between symptoms and the Anamnestic Dysfunction Index (Ai) as dependent variables and each of the independent variables, age group, gender, reported bruxism, trauma (1983), self-perceived health impairment and the year of investigation were analysed in binary logistic regression models. RESULTS: The prevalence of the separate symptoms, apart from for TMJ clicking, did not vary to any statistically significant degree between the different examination years. However, the prevalence of recurrent headache in 20-year-old subjects rose remarkably in 2003 and an increase in the Ai I and Ai II for the whole population was observed during the 20-year period. Reported bruxism, which increased during the study period, and self-perceived health impairment were associated with most of the TMD symptoms and the Ai. CONCLUSIONS: An increase in the prevalence of TMD symptoms expressed as Anamnestic Dysfunction Index I and II has been noted over a 20-year period.

Effect of nicotine-free and nicotine-containing snus on plaque pH in vivo.

The aim was to investigate pH changes in plaque in vivo during the use of nicotine-free and nicotine-containing snus. The carbohydrate content of the products was also analysed. Ten subjects, all regular snus users, participated in an experimental crossover study, on eleven occasions with an interval of one week. Six nicotine-free and four nicotine-containing products, which are sold on the Swedish market, were included and a sucrose solution was used as a control. The subjects did not brush their teeth for three days before coming to the laboratory, without eating, drinking or using snus/smoking for two hours prior to the test. pH was measured at three approximal sites up to 45 min with the test product placed under the upper lip. The carbohydrate analysis showed that the nicotine-containing products contained only traces of glucose, fructose and sucrose (0.5-1%) and starch (approximately 1.5%). Some of the nicotine-free products contained up to 6.5% low-molecular-weight carbohydrates and 26.0% starch. The intraoral pH measurements showed that four nicotine-containing products increased the plaque pH, in contrast to three of the six nicotine-free products, which lowered the pH. These pH changes may have an effect on the caries risk, both positively and negatively, depending on which product is used.

Periodontal disease in relation to smoking and the use of Swedish snus: epidemiological studies covering 20 years (1983-2003).

AIM: The aim of the present study was to examine how deleterious current smoking and the use of Swedish moist snuff (snus) is for periodontal health compared with non-tobacco users. MATERIALS AND METHODS: The studies comprised three epidemiological cross-sectional studies, in 1983, 1993 and 2003, of stratified random samples aged 20, 30, 40, 50, 60 and 70 years. The numbers of dentate participants were 550, 552 and 523, respectively. The participants were examined clinically and radiographically. Diagnostic criteria were the number of teeth, plaque, gingival status, probing pocket depth (PPD) ≥ 4 mm, height of the alveolar bone level and classification by periodontal disease experience. In addition, participants were asked about their tobacco habits. RESULTS: Multiple logistic regression shows, after adjusting for age, gender and sociodemographic variables, that relative to non-tobacco users, cigarette smokers had statistically significant less gingivitis, a higher frequency of PPD ≥ 4 mm and a higher incidence of severe periodontitis. There was no significant association between gingivitis, frequency of PPD ≥ 4 mm and periodontal disease experience and snus use. CONCLUSIONS: Cigarette smokers were found to have a statistically significant higher risk of severe periodontitis than non-tobacco users and users of snus. Using snus did not seem to be a risk factor for periodontitis.

Sense of coherence and oral health status in an adult Swedish population.

OBJECTIVE: To investigate sense of coherence in relation to oral health status in an adult Swedish population in order to better understand the determinants of positive oral health-promoting behavior and differences in oral health. MATERIAL AND METHODS: A stratified random sample of 910 individuals from Jönköping, Sweden aged 20, 30, 40, 50, 60, 70 and 80 years was obtained. The investigation used the Swedish short version of the Sense of Coherence (SOC) questionnaire comprising 13 items and a self-report questionnaire to elicit demographic information. In addition, a clinical and radiographic oral examination was performed. RESULTS: A total of 525 individuals, 261 men and 264 women, consented to participate in the study. Bivariate analysis revealed that higher mean SOC scores were statistically significantly associated with more decayed and filled surfaces (DFS) and filled surfaces (FS), fewer decayed surfaces (DS), fewer teeth with calculus and periodontal health. Multivariate analysis showed that higher SOC scores represented a predictor of fewer occurrences of a periodontal probing pocket depth of ≥4 mm and a lower risk of plaque in different regression models. CONCLUSIONS: Higher SOC scores may be a protective determinant of plaque and periodontal disease, indicating an association between SOC and oral health.

Root-filled teeth and recurrent caries-a study of three repeated cross-sectional samples from the city of Jönköping, Sweden.

OBJECTIVE: The aim of the study was to test the hypothesis that root-filled teeth are at a higher caries risk than non-root-filled teeth. MATERIALS AND METHODS: Two sub-samples from epidemiologically obtained data collected in 1983, 1993 and 2003 in the city of Jönköping, Sweden, were analysed. All the participants were examined clinically and radiographically and the type of filling and the presence or absence of caries were recorded. Sub-sample 1 comprised 832 individuals (9202 teeth) aged 20-70 years with at least eight premolars/molars. In sub-sample 2, 163 subjects (577 teeth) with only one or two decayed tooth surfaces and at least one tooth with full crown coverage were analysed. RESULTS: Logistic regression analysis found that root-filled teeth were predictive of recurrent caries when controlling for the type of restoration in sub-sample 1 (OR = 1.68; 1.41-2.0; CI 95%) and sub-sample 2 (OR = 2.20; 1.07-4.52; CI 95%). CONCLUSION: In support of the suggested hypothesis, the data revealed a significant association between root-filled teeth and recurrent caries.

The distribution of ''sense of coherence'' among Swedish adults: a quantitative cross-sectional population study.

BACKGROUND: Antonovsky's concept of ''sense of coherence'' (SOC) has been shown to be related to health. The aim of this study was to describe the distribution of SOC scores and their components in an adult Swedish population aged 20-80 years. METHODS: A random sample of 910 individuals from Jönköping, Sweden, aged 20, 30, 40, 50, 60, 70 and 80 years, of which 589 agreed to participate in an oral health examination. The participants answered Antonovsky's 13-item version of ''the life orientation questionnaire scale''. The response to the items and the distribution of the three components of comprehensibility, manageability and meaningfulness were analyzed for different age groups and genders using mean values and standard deviations, Student's t-test and ANOVA. RESULTS: A total of 526 individuals, 263 men and 263 women, answered all 13 questions and constituted the final material for the study (response rate 89%). The individual SOC score increased with age. The 20 year olds had a statistically significantly lower SOC score compared with the other age groups and 55% of them had a low SOC (< or = 66 points) compared with 17% of the 80 year olds. Men in the 60 and 70 year age groups had a statistically significantly higher SOC score compared with women of the same age. CONCLUSIONS: The individual distribution of SOC varied with age and gender. Twenty year olds had a significantly lower SOC score compared with elderly age groups. Elderly men had a statistically significantly higher SOC score compared with women of the same age.

Dental care utilization in a Swedish county in 1993 and 2003.

The aim of the present study is to analyse factors influencing the patterns of utilization of dental care in an adult urban Swedish population aged between 30 and 80 in the years 1993 and 2003. This study is part of two large epidemiological dental studies of randomly selected individuals, performed in 1993 and 2003. It comprises clinical and questionnaire data from 555 and 505 individuals in the two studyyears. In 1993, more patients visited the private dental care system more often than the public system. This difference still existed in 2003, but to a 50% lower extent. All age groups had less utilization of dental care in 2003 than in 1993. The largest change was seen in the 30-year age group in utilization patterns of dental care between the two study years. A hierarchical block regression method was performed in four steps, analysing utilization for the two study years separately. The dental service system influenced the utilization patterns significantly for both years. The health factors strengthened this main result. Irrespective of dental health, patients were predicted to visit the private dental care service system more often in both 1993 and 2003. The socio-economic differences between people in Sweden were of no consequence for dental care utilization. As to age and attitude towards treatment costs, a substantial change was observed and might reflect a change in social patterns with greater inequalities, but the overall picture of equal access in dental care in Sweden remains.

Oral health impact on quality of life in an adult Swedish population.

OBJECTIVES: Oral health has a major impact on general quality of life. The aspects of oral health that are most important for each individual vary, and quality of life is a construct and not a measurable variable. The aim of this study was to describe the impact of oral health on quality of life in an adult Swedish population. MATERIAL AND METHODS: The study comprised a stratified random sample of 519 individuals. The OHIP-14 questionnaire was used and the answers were rated on a scale of 0-4. RESULTS: Twenty-one percent of the respondents stated that they had no oral problems related to well-being, and 79% had some form of problem related to quality of life. The mean value for the entire population was 6.4 (SD = 7.1); 5.9 (SD = 7.1) for men and 6.8 (SD = 7.2) for women. Of individuals who stated that they had oral problems, the majority were women aged 20 years. Nineteen percent of 30-year-old men and 53% of 70-year-old women stated that they had had problems that had made life less satisfactory. Individuals who frequently experienced problems related to oral health, with scores of 16-41 points, accounted for 10%. CONCLUSION: In this Swedish population, a number of individuals, young and old, experienced oral problems that had an impact on their well-being.

The meaning of oral health-related quality of life for elderly persons with dementia.

OBJECTIVE: Studies of oral health developments increasingly include self-reported assessments of how oral health affects quality of life (QoL), referred to as "oral health-related QoL". People with dementia are often excluded in studies of oral health-related QoL and thus our aim in this study was to explore this area in elderly persons with dementia. MATERIAL AND METHODS: Eighteen elderly individuals (aged between 78 and 94 years) with dementia of varying degrees of severity were interviewed with the aid of an interview guide; pictures and objects were used as stimulus material (triggers). The material was analyzed using grounded theory as point of departure, and a professional assessment of the oral health of the participants was used as reference. RESULT: Four categories were identified: the ability to chew and eat, independence, oral problems, and teeth are important. These factors are largely consistent with those that have emerged in earlier studies of the elderly, but in some cases less pronounced in persons with dementia. CONCLUSION: The use of triggers is a positive way to communicate oral health-related QoL among persons suffering from dementia, although the material used in this study needs further evaluation and development.

The importance of psychological factors in the maintenance of oral health: a study of Swedish university students.

PURPOSE: The aim of this study was to investigate the predictive value of the traditional multidimensional health locus of control (MHLC) scale, a corresponding dental health locus of control (DHLC) scale and dental health values (DHVs) regarding students' dental health before and after a video programme that presented information about dental diseases and instructions on oral hygiene. MATERIALS AND METHODS: A group of 217 university students participated in this study. Before the video programme was presented, assessments were made of MHLC, DHLC and DHVs. Plaque and gingival indices were obtained in a clinical examination conducted before (plaque index [PLI] 1 and gingival index [GI] 1) and 10 weeks after (PLI 2 and GI 2) the presentation of the programme. RESULTS: The percentage of tooth surfaces exhibiting plaque and of sites involving gingivitis decreased and was statistically significant between baseline and re-examination for both males and females. The females exhibited statistically significant better PLI 1 and GI 1 values and stronger DHVs than males. Also, better GI 1 values were found to be statistically significant and related to stronger DHVs for females. A stronger trust in the dental health personnel regarding the dental health was related to more gingivitis at the initial examination (GI 1). For males, stronger internal DHLC was related to more plaque at the final examination (PLI 2). CONCLUSION: The only psychological scales that showed some relationship to the measures of dental health were DHLC and DHVs. Gender was the strongest related variable to dental health.

Has the prevalence of periodontitis changed during the last 30 years?

AIM: This paper reviews global trends in the change in prevalence of periodontitis over the last 30 years. MATERIAL AND METHODS: The epidemiology of periodontal disease is briefly reviewed together with the current classification system and the clinical and radiographic diagnostic methodology in periodontal disease. RESULTS: This review identifies the very limited number of studies that provide prevalence data over time, and this data is discussed in comparison with those stemming from a few corresponding studies from countries outside Europe. CONCLUSIONS: The data indicate a possible trend of a lower prevalence of periodontitis in recent years.

Trends over 30 years, 1973-2003, in the prevalence and severity of periodontal disease.

AIM: The present investigation presents findings of the prevalence and distribution of gingivitis and periodontitis in a Swedish population over the 30 years 1973-2003. MATERIAL AND METHODS: Four cross-sectional epidemiological studies in 1973, 1983, 1993, and 2003 were performed in Jönköping, Sweden. Random samples of individuals aged 20, 30, 40, 50, 60, 70, and 80 years were examined clinically and radiographically. Diagnostic criteria were edentulousness, number of teeth, plaque, gingival status, probing pocket depth, gingival recession, alveolar bone level, and classification according to periodontal disease status. RESULTS: In all age groups, the number of edentulous individuals decreased dramatically and the number of teeth increased. Oral hygiene improved considerably. Over the 30 years, the proportion of periodontally healthy individuals increased from 8% in 1973 to 44% in 2003 and the proportion of individuals with gingivitis and moderate periodontitis decreased. There was a non-significant trend for the proportion of individuals with severe periodontal disease experience (Group 4) to decrease, while the proportion of individuals with advanced periodontitis (Group 5) remained unchanged. CONCLUSION: Oral hygiene and periodontal health improved significantly in the 20-80-year age groups over the 30 years 1973-2003.

Thirty year trends in the prevalence and distribution of dental caries in Swedish adults (1973-2003).

The aim of the present investigation is to report on the trends in the prevalence and severity of dental caries and dental status in an adult Swedish population over a 30-year period (1973-2003). Four cross-sectional epidemiological studies in 1973, 1983, 1993, and 2003 were performed in Jönköping, Sweden.A random sample of individuals aged 20, 30, 40, 50, 60, 70, and 80 years were examined clinically and radiographically, a total of 2521 individals. Diagnostic variables were edentulousness, number of teeth, initial and manifest caries lesions, restorations, fissure sealants, and quality of restorations (secondary caries and overhangs). The percentage of edentulous 40- to 70-year-old individuals decreased during the 30-year period from 16% to 1%. The distribution of individuals by DFS in the age groups 20-50 years showed a gradual shift towards a positively skewed distribution between the years 1973 to 2003. There was a steady decrease in mean number of DFS in the age groups 20-50 years. In the 20-year-olds the mean number of DFS decreased by 72% and for 50-year-olds, by 37%. In conclusion there has been a marked decrease in DFS in adults up to middle age and a marked reduction in edentulousness over a thirty year period. This shows that the decrease in caries levels in children and adolescents is also occurring among adults.

Effects of snuff on the oral health status of adolescent males: a comparative study.

PURPOSE: The purpose of this study was to investigate effects of snuff on the oral health status of adolescent males. MATERIALS AND METHODS: The participants consisted of 80 adolescent males between 16-25 years, 40 snuff users and 40 non-users. The snuff users and non-users were matched with reference to their age. Data were collected using a questionnaire containing questions on general and oral health, daily oral hygiene and tobacco habits. The clinical examination was carried out in a dental office by two experienced dental hygienists. Snuff lesions were clinically classified on a four-point scale and documented on colour slides. The examination also assessed the number of teeth, restored tooth surfaces, plaque index and gingival index, probing pocket depth and gingival recessions. RESULTS: Out of 40 snuff users, 35 showed snuff incluced lesions. The clinical diagnosis of snuff users' mucosa showed snuff lesions of different severity clinically classified as degree 1, 2 and 3. When explaining snuff lesions of degree 2 and 3, hours of daily snuff use and package form (portion-bag snuff versus loose snuff) was statistically significant. There were no statistical differences between snuff users and non-users regarding restored tooth surfaces, presence of plaque, gingival inflammation and probing pocket depth. Seventeen percent of the cases showed loss of periodontal attachment as gingival recessions. CONCLUSION: In spite of mucosal lesions caused by snuff there were no statistical differences in prevalence in plaque and gingivitis between snuff users and non-users. However, some cases showed loss of periodontal attachment as gingival recessions.

Oral health of individuals aged 3-80 years in Jönköping, Sweden during 30 years (1973-2003). I. Review of findings on dental care habits and knowledge of oral health.

The aim of the present study was to compare data on dental care habits and knowledge of oral health in four cross-sectional epidemiological studies carried out in 1973,1983,1993, and 2003. The 1973 study constituted a random sample of 1,000 individuals evenly distributed in the age groups 3, 5, 10, 15, 20, 30, 40, 50, 60, and 70 years. The same age groups with addition of a group of 80-year-olds were included in the 1983, 1993 and 2003 studies, which comprised 1,104, 1,078, and 987 individuals, respectively. A questionnaire about dental care habits and knowledge of oral health was used in connection with a clinical and radiographic examination. The same questions were used in all the four studies. An addition to the 1993 and 2003 investigations were questions concerning ethnic background. In 2003 approximately 90-95 per cent of all individuals were visiting the dentist on a regular basis every or every second year. The 30- and 40-yea r-olds, however, did not visit a dentist as regularly in 2003 as in 1993. In these age groups 21-24 per cent of the individuals, respectively, reported that they had not visited a dentist in the last 2 years. Almost all children 3-15 years old received their dental care within the Public Dental Service (PDS). During the period 1973-2003 an increase in percentage of individuals aged 20-50 years treated by the PDS was seen compared to private practice, while among 60-80 year-olds there were only minor changes. Most so-year-olds and older received their dental care by private practitioners. About 70-80 per cent of all adults in 2003 were enrolled in a recall system on the dentist's initiative while in 1973 most appointments were based on the patient's own initiative. The number of individuals who were frightened, 5-17 per cent, or felt discomfort at the prospect of an appointment with the dentist was more or less the same during the whole period. The knowledge of the etiology of dental diseases did not changed much between 1973 and 2003. The frequency of toothbrushing increased since 1973 and in 2003 more than 90 per cent of all individuals brushed their teeth twice or once a day. The use of dental floss and toothpicks decreased in 2003 compared to 1983 and 1993. Almost all individuals in 2003 used fluoride toothpaste. It was obvious that the dental team constituted the main source of dental health information. For the age groups 20 and 30 years information from friends and relatives was also important. In the age groups 3-20 years up to 45 per cent of the individuals were consuming soft drinks every day or several times a week.