Primary Preventive Dentistry, Sixth Edition - Norman O. Harris, Franklin Garcia-Godoy

Primary Preventive Dentistry - 6th Ed.
(2004 (

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PRIMARY PREVENTIVE DENTISTRY - 6th Ed. (2004 (
Front Matter
TITLE PAGE
Norman O. Harris, DDS, MSD, FACD
Professor (Retired), Department of Community Dentistry
University of Texas Health Science Center at San notnio
San ntonio, Texas
Franklin Garcia-Godoy, DDS, MS, FICD
!ditor, merican "ournal of Dentistry ,
Professor and ssociate Dean for Research ,
Director, Clinical Research Center ,
Director, #ioscience Research Center ,
Colle$e of Dental %edicine
&ova Southeastern University
'ort (auderdale, 'lorida
Uer Saddle !i"er, New #ersey $%&'(
COPYRIGHT
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CONTENTS
)re+ace "ii
Acknowled*ments i0
Contri-/tors 0i
: Introd/ction to )rimary )re"enti"e Dentistry :
&orman +, Harris
> 5,e De"eloment and Str/ct/re o+ Dental )la?/e 7A 1acterial 1io+ilm8, Calc/l/s,
and ot,er 5oot,-Ad,erent Or*anic Materials >=
%ax , (ist$arten
"onathan )orostoff
= 5,e De"eloin* Cario/s .esion &'
&orman +, Harris
driana Se$ura
& 5,e !ole o+ Dental )la?/e in t,e 3tiolo*y and )ro*ress o+ )eriodontal
Disease %=
Donald !, -illmann
&orman +, Harris
' 5oot,-r/s,es and 5oot,-r/s,in* Met,ods ;=
Samuel (, .an*ell
Ulrich P, Saxer
< Denti+rices, Mo/t,rinses, and C,ewin* G/ms ::;
Stuart (, 'ischman
Samuel (, .an*ell
% Oral-Healt, Sel+-Care S/lemental Meas/res to Comlement 5oot,-r/s,in*
:&'
Terri S,/, Tilliss
"anis 0, )eatin$
( 4ater Fl/oridation :(:
!laine %, &eenan
%ichael -, !asley
%ichael Rui1, Research ssistant
; 5oical Fl/oride 5,eray >&:
)evin ", Donly
0eor$e ), Stoo*ey
:$ )it-and-Fiss/re Sealants >('
'ran*lin 0arcia20odoy
&orman +, Harris
Denise %uesch Helm
:: Oral 1iolo*ic De+enses in 5oot, Deminerali@ation and !eminerali@ation =:;
&orman +, Harris
"ohn Hic*s
:> Caries !isk Assessment and Caries Acti"ity 5estin* ==%
Svante T3etman
:= )eriodontal Disease )re"ention9 Facts, !isk Assessment, and 3"al/ation =<%
&orman +, Harris
Donald !, -illmann
:& S/*ar and Ot,er Sweeteners =;;
Peter !, Cleaton2"ones
Connie %o4ley
:' N/trition, Diet, and Oral Conditions &:;
Carole , Palmer
(inda D, #oyd
:< Understandin* H/man Moti"ation +or 1e,a"ior C,an*e &&;
%ary )aye Sa3yer2%orse
lexandra !vans
:% Dental )/-lic-Healt, )ro*rams &<%
%ar* D, %ace*
Harold S, 0oodman
:( )re"enti"e Oral-Healt, in 3arly C,ild,ood '$:
Stephen ", 0oepferd
:; Oral-Healt, )romotion in Sc,ools '>:
lice %, Horo3it1
&orman +, Harris
>$ )re"enti"e Oral-Healt, Care +or Comromised Indi"id/als '';
Roseann %ulli$an
Stephen So4el
>: Geriatric Dental Care '(;
"anet , .ello3it1
%ichael S, Strayer
>> )rimary )re"enti"e Dentistry in a Hosital Settin* <$'
&orman +, Harris
"effery (, Hic*s
>= !ationale, G/idelines, and )roced/res +or )re"ention o+ t,e )la?/e Diseases <&'
&orman +, Harris
%arsha , Cunnin$ham2'ord
Glossary <('
Inde0 <;'
PREFACE
5,is is t,e si0t, edition o+ t,e te0t, Primary Preventive Dentistry. 5,e s/ccessi"e
editions since :;(> ,a"e ro"ided an e0cellent e0amle o+ t,e +act t,at t,e /se+/l
li+etime o+ m/c, knowled*e is +inite. At t,e time o+ t,e +irst edition e"en s/c, dental
essentials as mec,anical and c,emical la?/e control, access to dental care and dental
ins/rance were only -ein* slowly acceted. Now, a new wa"e o+ dental "isionaries is
comin* on t,e world sta*e to seak wit, con+idence a-o/t +/t/re "accines, *enetic
en*ineerin* and t,erae/tic stem cells. 5,ese are e0ceedin*ly imortant -asic science
s/-Aects to all ,ealt, ro+essions and are only now creein* into t,e *eneral dental
le0icon and alication .
.ike in ast editions, t,e in+ormation in t,e te0t and s/ortin* re+erences ,as -een
*reatly /*raded, alt,o/*, e"ery e++ort ,as -een made to retain ori*inal citations +rom
ast landmark researc,. An increased em,asis ,as -een *i"en to sc,ool ro*rams
-eca/se o+ t,e increasin* n/m-er o+ sc,ool -ased ,ealt, clinics 7S1HC8 t,at are
-ein* de"eloed to care +or c,ildren. !isk assessment is ,i*,li*,ted in t,e te0t as a
necessity +or determinin* at t,e time o+ an initialBann/al clinical e0amination w,et,er
a atientCs treatment is to -e re"enti"e or restorati"e. !eminerali@ation o+ inciient
caries, an old idea, -/t a relati"ely new weaon in t,e dentistsC arsenal, o++ers a new
re"enti"e strate*y +or t,ose seekin* to maintain intact teet, +or a li+etime .
5,ro/*,o/t t,is aro0imate last ?/arter-cent/ry o+ metamor,osis, t,e +ormat o+ t,e
-ook ,as remained constant. It is written in a style t,at is /ser-+riendly, w,et,er t,e
/ser is a dental or dental-,y*ienist st/dent, a dental assistant, a ri"ate- or /-lic-
,ealt, ractitioner, a ,ealt, ed/cator, or a sc,ool n/rse. 5,e -ook and s/**ested
learnin* strate*ies ,a"e -een s/ccess+/lly /sed +or class-aced st/dyD t,ey ,a"e -een
/sed +or remedial ro*ramsD and t,ey ,a"e -een /sed +or remote sel+-aced learnin*
as well as +or sc,ed/led contin/in* ed/cation co/rses .
3ac, c,ater commences wit, a series o+ o-Aecti"ess/-Aect matter t,at t,e a/t,ors
consider essential. 2ey words and concets are italici1ed in eac, c,ater to ,el +oc/s
on in+ormation deemed imortant. 5,ro/*,o/t t,e te0t, t,ere are em-edded cl/sters
o+ tr/e-and-+alse ?/estions, as well as answers and +ill-in-t,e--lank ?/estions at t,e
end o+ t,e c,ater. 5,ese are incl/ded +or st/dent sel+-e"al/ation .
Followin* t,e class resentation o+ t,e s/-Aect matter it is recommended t,at a-o/t an
,o/r-or-so s,o/ld -e sent o/tside t,e classroom to re"iew t,e c,ater. As eac,
?/estion is enco/ntered +or w,ic, t,e answer is not comletely /nderstood, a c,eck
mark s,o/ld -e made -e+ore readin* on. At t,e end o+ t,e c,ater, t,e marked
?/estions s,o/ld -e a*ain re"iewed and t,e answers learned at t,e :$$E le"elnot
A/st memori@ed .
)rentice Hall ,as, wit, t,is si0t, edition, esta-lis,ed a we-site +or t,e -ook t,at
ermits a st/dent to take a Fmock e0aminationF at t,e end o+ eac, c,ater. A ersonal
or instit/tional com/ter is a re?/isite +or )rentice Hall to resond to new tr/e-or-
+alse, essay, and to +ill-in-t,e--lank tye o+ ?/estions. 5,e tr/e-or-+alse ?/estions will
-e com/ter marked and ret/rned immediately to t,e st/dents e-mail address. 5,e
essay and +ill-in-t,e -lank ?/estions will not -e marked -eca/se o+ t,e "ariety o+
ossi-le correct answers s/-mitted, -/t will -e immediately ret/rned to t,e st/dent
alon* wit, t,e Fsc,ool answersF +or comarison. 5,is e0c,an*e -etween t,e st/dent
and t,e )rentice Hall we-site is strictly -etween two com/ters. No student records
will be kept at the website. 5,e *oal o+ t,e ro*ram is to ro"ide t,e learner wit, a
means o+ sel+-e"al/ation o+ ,isB,er le"el o+ attainment. St/dent articiation in t,is
"ol/ntary, non-Aeoardi@in*, we-site ro*ram can res/lt in a ,/*e ste towards
ac,ie"in* lon*-term mastery learnin*. 5,e ?/estions in t,e ?/estion -ank are also
a"aila-le to teac,ers w,o mi*,t desire to /se t,em +or t,eir own /roses
Since c/rric/l/m time allocations "ary +rom instit/tion-to-instit/tion, t,e c,aters do
not need to -e sc,ed/led in a *i"en se?/ence, -ein* +ree standin* +or t,e inde0ed
s/-Aect matter. 5,e >= c,aters incl/de t,e t,eory and ractice o+ re"enti"e dentistry
in ri"ate and /-lic ,ealt, en"ironments. One c,ater disc/sses la?/e +ormation,
w,ile two c,aters eac, em,asi@e t,e imortance o+ caries and eriodontal disease
and disease re"ention. 5o aid in com-atin* t,ese two la?/e diseases, t,ere are
c,aters on denti+rices, toot,-r/s,in* and a/0iliary toot, cleanin* de"ices /sed in
accomlis,in* mec,anical and c,emical la?/e control. S/*ars, diets, and ,/man
moti"ation are incl/ded to +acilitate -etter co/nselin* o+ atients. A c,ater is de"oted
to t,e /se o+ it-and-+iss/re sealants. C,aters on /-lic ,ealt, oint o/t t,e
resonsi-ilities o+ a /-lic ,ealt, dentist, as well as two c,aters on t,e oral ,ealt,
ad"anta*es o+ +l/oridewater +l/oridation, and toical alications-ot, o+ w,ic,
are rime re"enti"e tools o+ a /-lic ,ealt, dentist as well as +or t,e ri"ate
ractitioner. Di++erent a*e and ,ealt, stat/s *ro/s are also considered in searate
c,atersedodontic, *eriodontic, ,andicaed, and ,ositali@ed indi"id/als.
Finally, t,ere is a c,ater on ,ow to /se risk assessment to inte*rate re"ention into
t,e total treatment lan .
In s/mmary, t,e a/t,ors ,a"e contri-/ted t,e c,aters o+ /dated in+ormation, t,e
editors ,a"e esta-lis,ed t,e learnin* system, w,ile )rentice Hall ,as ro"ided a
we-site +or worldwide /ser sel+-e"al/ation .
ACKNOWLEDGMENTS
For a m/ltia/t,ored and m/lti-edition -ook te0t, t,ere is a need +or a lot o+ credit to
*o aro/nd. .est we +or*et, t,e a/t,ors o+ t,e +irst edition esta-lis,ed t,e +o/ndation,
+rom w,ic, t,e se"eral later editions in re"enti"e dentistry ,a"e -een /*raded.
Aro0imately <$ a/t,ors and a/t,oresses ,a"e contri-/ted o+ t,eir knowled*e and
time t,ro/*, t,eir writin*s +rom t,e +irst to t,e resent si0t, edition. 5,ese a/t,ors
and a/t,oresses ,a"e come +rom researc, la-oratories, state and national /-lic ,ealt,
a*encies and teac,in* instit/tions in t,e United States and o"erseas. A/t,ors +rom
Canada, 2orea, 3n*land, So/t, A+rica, Swit@erland and Sweden are reresented in
t,e latter *ro/. A sin-o++ Sanis, edition o+ t,e +i+t, edition o+ t,e te0t ,as -een
/-lis,ed re+lectin* t,is m/ltinational aroac, to t,e -ook. Man/+act/rers and
dental-s/ly ,o/ses ,a"e contri-/ted ,otos and in+ormation on t,eir rod/cts,
w,ile Ao/rnal /-lis,ers ,a"e *i"en ermission +or /se o+ coyri*,t material.
5eac,ers /sin* t,e -ook, and st/dents learnin* +rom t,e -ook, ,a"e -ot, made
s/**estions t,at ,a"e en,anced t,e "al/e o+ t,e te0ts .
6ery +ew te0ts wo/ld -e /-lis,ed wit,o/t t,e ,el o+ a /-lis,er. For t,is
/-lication -y )rentice Hall, t,ere is Melissa 2erian w,o ket /s on sc,ed/le, Amy
)eltier w,o ,as lent ,er com/ter e0ertise, and Mark Co,en, t,e -ook editor, w,o
,armonio/sly ket e"eryone stayin* t,e co/rse. 5o t,ose many ot,er known and
/nknown indi"id/als w,o ,eled de"elo t,is edition o+ t,e rimary dental
re"ention te0t, t,e editors desire to "oice ,eart+elt areciation. O+ a more ersonal
nat/re, -ot, editors wis, to t,ank t,eir wi"es, 2at,erine Garcia-Godoy and Grace
Harris +or t,eir contin/in* s/ort and enco/ra*ement .
Norman O. Harris
DDS, MSD, FACD

www.allislam.net
Franklin Garcia-Godoy
DDS MS, FICD
CONTRIBUTORS
Linda D. Boyd, MS, RDH, R
Assistant )ro+essor
Deartment o+ )eriodontolo*y
Ore*on Healt, Sciences Uni"ersity
Sc,ool o+ Dentistry
)ortland, O!
Peter E. Cleaton-1ones, BDS, MB, BCH
)ro+essor o+ 30erimental Odontolo*y
Director, Dental !esearc, Instit/te
Director, Medical !esearc, Co/ncil
Uni"ersity o+ 4itwatersrand
4itwatersrand, So/t, A+rica
Marsha A Cunningham-Ford, RDH, BS, MS
Associate )ro+essor
Deartment o+ )re"enti"e Dentistry and Comm/nity Dentistry
Uni"ersity o+ Iowa ,
Iowa City, IA
Kevin 1. Donly, DDS, MS
)ro+essor
Director )ostdoctoral )ediatric Dentistry
Deartment o+ )ediatric Dentistry
Uni"ersity o+ 5e0as Dental Sc,ool at San Antonio
San Antonio, 5G
Michael Easley, DDS, MPH, FACD
Associate )ro+essor
Deartment o+ Healt, )romotion and Administration
3astern 2ent/cky Uni"ersity
!ic,mond, 2H
Alexandra E. Evans, PHD
Assistant )ro+essor
Deartment o+ Healt, )romotion, 3d/cation and 1e,a"ior
Uni"ersity o+ So/t, Col/m-ia, SC
Stuart Fischman, DMD, FACD, FICD
)ro+essor 3merit/s
Sc,ool o+ Dental Medicine
State Uni"ersity o+ New Hork at 1/++alo
1/++alo, NH
Franklin Garcia-Godoy, DDS, MS, FICD
Associate Dean +or !esearc,
)ro+essor o+ !estorati"e Dentistry
)ro+essor o+ )ediatric Dentistry
No"a So/t,eastern Uni"ersity
Fort .a/derdale, F.
Stephen 1 Goepferd. DDS, MS
)ro+essor
Colle*e o+ Dentistry
Uni"ersity o+ Iowa
Iowa City, IA
Harold S. Goodman, DMD, MPH
Associate )ro+essor
1altimore Colle*e o+ Dental S/r*ery, Dental Sc,ool
Uni"ersity o+ Maryland
1altimore, MD
Norman O. Harris, DDS, MSD, FACD
)ro+essor 7!etired 7
Deartment o+ Comm/nity Dentistry
Deartment o+ Dental Hy*iene
San Antonio, 5G
Denise M/esc, Helm, !DH MA
Assistant )ro+essor
Nort,ern Ari@ona Uni"ersity
Fla*sta++, AI
1effery L. Hicks, DDS
Associate )ro+essor
General Dentistry
San Antonio, 5G
M. 1ohn Hicks, DDS, MS, PhD, MD
Associate )ro+essor o+ )at,olo*y and Director o+ S/r*ical and Ultrastr/ct/re
)at,olo*y
Deartment o+ )at,olo*y
5e0as C,ildrenCs Hosital Ho/ston and 1aylor Colle*e o+ Medicine
Ho/ston, 5G
Alice M. Horowitz, PhD
Senior Scientist
National Instit/te o+ Dental and Cranio+acial !esearc,
National Instit/tes o+ Healt,
1et,esda, MD
1anis G. Keating, RDH
)ro+essional 3d/cator
),illis Oral Healt,care, Inc .
.ittleton, CO
1onathan Korostoff, DMD, PhD
Assistant )ro+essor
Deartment o+ )eriodontics
Uni"ersity o+ )ennsyl"ania
),iladel,ia, )A
Max A. Listgarten, DDS
)ro+essor 3merit/s
Uni"ersity o+ )ennsyl"ania ,
),iladel,ia, )A
6isitin* )ro+essor, Uni"ersity o+ Cali+ornia in San Francisco
Foster City, CA
Mark D. Macek, DDS, DrPH
Assistant )ro+essor
Deartment o+ Oral Healt, Care Deli"ery and Director o+ Comm/nity )ro*rams
1altimore, MD
Connie Mobley, PhD
Associate )ro+essor
Deartment o+ Comm/nity Dentistry
San Antonio, 5G
Mary Kaye Sawyer-Morse, PhD
Associate )ro+essor, N/trition
Uni"ersity o+ t,e Incarnate 4ord
San Antonio, 5G
Roseann Mulligan, DDS, MS
Associate )ro+essor and C,airman
Deartment o+ Dental Medicine and )/-lic Healt,
Section o+ Geriatric and Secial Care Dentistry
Sc,ool o+ Dentistry
Uni"ersity o+ So/t,ern Cali+ornia
.os An*eles, CA
Elaine M. Neenan, MS, DDS, MPH
Associate Dean, 30ternal A++airs
Sc,ool o+ Dentistry
Uni"ersity o+ 5e0as Dental Sc,ool
San Antonio, 5G
Carole A. Palmer, EdD, RD
)ro+essor and Head
Di"ision o+ N/trition and Oral Healt, )romotion
Deartment o+ General Dentistry
5/+ts Uni"ersity
1oston, MA
Ulrich P. Saxer, DDS, PhD
)ro+essor and Head o+ )ro,yla0is Sc,ool
.ect/rer in )eriodontolo*y
Uni"ersity o+ I/rick
I/rick, Swit@erland
Adriana Segura Donly, DDS, MS
Associate )ro+essor
San Antonio, 5G
Stephen Sobel, DDS
Associate )ro+essor o+ Clinical Dentistry
Sc,ool o+ Dentistry
Uni"ersity o+ So/t,ern Cali+ornia
.os An*eles, CA
George K. Stookey, MSD, PhD
Distin*/is,ed )ro+essor
Indiana Uni"ersity Sc,ool o+ Dentistry
Indianaolis, IN
Michael S. Strayer
Associate )ro+essor
Section o+ )rimary Care
Colle*e o+ Dentisitry
O,io State Uni"ersity
Col/m-/s, OH
Terri S. I. Tillis, RDH, MS, MA
)ro+essor
Dental Hy*iene Deartment
Sc,ool o+ Dentistry
Uni"ersity o+ Colorado Healt, Science Center
Den"er, CO
Svante Twetman, DDS, PhD, Odont Dr
)ro+essor
Fac/lty o+ Odontolo*y
Uni"ersity o+ ./nd
Malmo, Sweden
Donald E. Willmann, DDS, MS
Associate )ro+essor
Deartment o+ )eriodontics
Dental Sc,ool
San Antonio, 5G
Dr. Samuel L. Yankell, PhD, RDH
!esearc, )ro+essor in )eriodontics
Uni"ersity o+ )ennsyl"ania
),iladel,ia, )A
1anet A. Yellowitz, DMD, MPH
Associate )ro+essor
Deartment o+ Oral Healt, Care Deli"ery
1altimore, MD
REVIEWERS
Chris French Beatty, RDH, Ph.D .
Associate )ro+essor
5e0as 4omanCs Uni"ersity
Denton, 5G
Margaret Bloy, CDA, RDH, MS
Coordinator
Dental Assistin* )ro*ram
Middlese0 Comm/nity Colle*e
.owell, MA
1anet Hillis, RDH, MA
C,air
Dental Hy*iene
Iowa 4estern Comm/nity Colle*e
Co/ncil 1l/++s, IA

www.allislam.net
William 1ohnson, DMD, MPH
Director
Dental A/0iliary )ro*rams
C,attanoo*a State 5ec,nical Comm/nity Colle*e
C,attanoo*a, 5N
Vickie 1ones, RDH
Instr/ctor
Nort,east Mississii Comm/nity Colle*e
1oone"ille, MS
Shawn Moeller, RDH
Associate )ro+essor
Dental Hy*iene
Salt .ake Comm/nity Colle*e
Salt .ake City, U5
Barbara Ringle, RDH, M.Ed.
Assistant )ro+essor
Dental Hy*iene )ro*ram
C/ya,o*a Comm/nity Colle*e
Cle"eland, OH
Katharine R. Stilley, RDH, MS
Assistant )ro+essor
Uni"ersity o+ Mississii Medical Center
#ackson, MS
Pamela Wade, RDH, BS, MS, CFCS
Instr/ctor
5yler #/nior Colle*e
5yler, 5G
Coyri*,t J >$$& -y )earson 3d/cation, Inc., )earson )rentice Hall. All ri*,ts
reser"ed.
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Chapter 1. Introduction to Primary Preventive Dentistry - &orman +, Harris
Objectives
t the end of this chapter, it 3ill 4e possi4le to
:. De+ine t,e +ollowin* key terms9 ,ealt,, rimary re"ention, secondary re"ention,
and tertiary re"ention. Also, ro"ide one seci+ic e0amle o+ eac,.
>. Name t,ree con"enient cate*ories t,at aid in classi+yin* dental disease and in
lannin* oral-disease re"ention and treatment ro*rams.
=. Name +o/r strate*ies and two administrati"e means +or red/cin* t,e re"alence o+
dental caries andBor eriodontal disease.
&. Cite two early actions t,at are essential +or arrestin* t,e ro*ression o+ t,e la?/e
diseases once rimary re"enti"e meas/res ,a"e +ailed.
'. 30lain w,y t,e lanned alication o+ re"enti"e-dentistry concets and
ractices, incl/din* /se o+ sealants and +l/oride t,eray, w,en co/led wit, early
detection and immediate treatment o+ t,e la?/e diseases, can res/lt in a @ero or near-
@ero ann/al e0traction rate.
Introduction
In t,e year >$$$, in t,e 30ec/ti"e S/mmary o+ t,e S/r*eon Generals !eort
a
on t,e
FOral Healt, in America,F some o+ t,e maAor c,allen*es +acin* American dentistry
were listed.
:,>
It is aroriate to a-stract a n/m-er o+ t,ese ro-lem areas in order to
-etter /nderstand t,e role t,at re"ention can lay in t,eir sol/tion.
:. 5o-acco9 5,is is a maAor societal ,ealt, ro-lem wit, "ery stron* relations,is to
dentistry. Smokin* ,as a "ery de"astatin* relations,i to eriodontal disease and oral
and ,aryn*eal cancer, w,ile t,e /se o+ c,ewin* to-acco is associated wit, oral
cancer as well as root decay 7see C,ater >=8.
>. 5,e statistics o+ dental need9
Children
a. Dental caries is t,e most common c,ronic c,ild,ood disease.
-. O"er '$E o+ '- to ;-year-olds ,a"e at least one ca"ity or +illin*D -y a*e :%, t,e
ercenta*e ,as increased to %(E.
c. As a art o+ c,ild,ood, c,ildren ,a"e many inA/ries to t,e ,ead, +ace, and neck.
d. 5wenty-+i"e E o+ t,e c,ildren ,a"e not seen a dentist -e+ore enterin* kinder*arten.
e. More t,an ': million sc,ool ,o/rs are lost eac, year to dental-related illness.
Adults
a. Most ad/lts s,ow si*ns o+ eriodontal or *in*i"al diseases. Se"ere eriodontal
disease cmeas/red as < millimeters o+ eriodontal attac,ment loss 7ockets8d a++ects
a-o/t :&E o+ ad/lts a*ed &' to '&.
-. 3mloyed ad/lts lose more t,an :<& million ,o/rs o+ work eac, year -eca/se o+
dental disease and dental "isits.
c. A little less t,an two-t,irds o+ ad/lts reort ,a"in* "isited a dentist in t,e ast :>
mont,s.
Older adults
a. 5wenty-t,ree E o+ <'- to %&-year-olds ,a"e se"ere eriodontal disease
7c,aracteri@ed -y < millimeters or more o+ eriodontal attac,ment loss8. At all a*es,
men are more likely t,an women to ,a"e more se"ere disease.
-. A-o/t =$E o+ ad/lts <' years and older are edent/lo/s, comared to &<E >$ years
a*o.
c. Oral and ,aryn*eal cancers are dia*nosed in a-o/t =$,$$$ Americans ann/ally.
Nine t,o/sand die +rom t,ese diseases eac, year. )ro*nosis is oor.
d. At any *i"en time, 'E o+ Americans a*ed <' and older 7c/rrently some :.<'
million eole8 are li"in* in lon*-term care +acilities w,ere dental care is ro-lematic.
a
United States )/-lic Healt, Ser"ice.
5,ro/*,o/t t,e entire S/r*eon GeneralCs reort, t,ere is maAor em,asis on t,e *reat
disarity 4et3een those 3ho $et dental care and those that do not ,a"e access to a
dental +acility.
=,&
5,ese are t,e eole w,o are oor,
',<
are mentally ,andicaed,
%

t,ose t,at are disa-led,
(
c,ildren,
;-:>
t,e a*ed,
:=
and t,ose wit,o/t dental ins/rance.
5,ere are ot,ers li"in* in /nderser"ed *eo*ra,ical areas,
:&
and still ot,ers w,o do
not ,a"e access to dental care -eca/se o+ disease,
:'
c/lt/re, or race.
:<
5o address t,ese
ro-lems a national ro*ram and */idelines o+ dental care is needed t,at will incl/de
t,ese dentally ne*lected *ro/s. 5,e ?/estions t,en -ecome, F4,at kind o+ a national
ro*ram s,o/ld it -ee Is it ossi-le to take care o+ so many eole wit, so fe3 dental
,ealt, ro+essionalseF
It is t,e *oal o+ t,e dental ro+ession to ,el indi"id/als ac,ie"e and maintain
ma0im/m oral ,ealt, t,ro/*,o/t t,eir li"es. S/ccess in attainin* t,is o-Aecti"e is
,i*,li*,ted -y t,e decline o+ caries t,ro/*,o/t t,e 4estern world,
:%
and t,e dramatic
red/ction o+ toot, loss amon* ad/lts in t,e United States. 5,is ro*ress ,as -een
mainly attri-/ted to t,e /se o+ 3ater fluoridation and fluoride2containin$
productstoot,astes and mo/t,rinsesand t,e *rowin* accetance and ractice o+
rimary re"enti"e care.
:(
Het, dental caries remains a maAor /-lic-,ealt, ro-lem.
Untold millions o+ researc, ,o/rs and money ,a"e -een in"ested in reac,in* o/r
resent caa-ility to control t,e ra"a*es o+ t,e pla5ue diseases. 3++ecti"e strate*ies
t,at can markedly red/ce t,e n/m-er o+ cario/s teet, and -etter control o+ eriodontal
disease are now a"aila-le. They only need to 4e used.
All ,ealt, ro+essions em,asi@e t,at atients s,o/ld seek entry into well-lanned
re"enti"e ro*rams. For dentistry, lack o+ re"ention res/lts in more restorations,
eriodontal treatment, e0tractions, and dent/res. 5,e c,an*eo"er in riority +rom
treatment to re"ention will re?/ire acti"e leaders,i and ,ealt, romotion -y t,e
dental ro+ession, cons/mer ad"ocates, /-lic ,ealt, ed/cators, and ,ealt,-olicy
lanners. )/-lic-,ealt, deli"ery systems, s/c, as t,e military, national and state
/-lic-,ealt, ser"ices, and ind/strial or*ani@ations t,at ro"ide -ene+its to t,eir
ersonnel, ,a"e /s/ally -een in t,e +ore+ront o+ s/c, c,an*e -eca/se o+ t,e economic
ad"anta*es accr/in* to t,e ro"ider and ,ealt, -ene+its to t,e reciients. For e0amle,
in :;(;, a reort -y Mal"it@ and 1roderick
:;
reco/nted t,e res/lts +ollowin* t,e
c,an*e o+ +oc/s toward a ma0im/m em,asis on re"ention +or dental ser"ices -y t,e
Indian Healt, Ser"ice in t,e Okla,oma City area. 5,e total n/m-er o+ "isits increased
-y :$E, yet t,e n/m-er o+ dental ersonnel remained constant. 5,e ercenta*e o+
preventive services increased, alon* wit, a decrease o+ restorati"e roced/res.
Benefits of Primary Preventive Dentistry to the Patient
For t,e atient w,o t,inks in terms o+ economic -ene+its and enAoyment o+ li+e,
re"ention ays. Many st/dies doc/ment t,e prevalence o+ dental disease, -/t -e,ind
t,ese n/m-ers t,ere is little mention o+ t,e ad"erse a++ects on ,/mans ca/sed -y
dental ne*lect. One st/dy oints o/t t,at ':E o+ dentate atients ,a"e -een a++ected in
some way -y t,eir oral ,ealt,, and in (E o+ t,e cases, t,e imact was s/++icient to
,a"e red/ced t,eir ?/ality o+ li+e.
>$
I+ re"enti"e ro*rams are started early -y t,e
atient 7or, re+era-ly, -y t,e arents o+ yo/n* c,ildren8 lon*-ran*e +reedom +rom t,e
la?/e diseases is ossi-lea so/nd cost--ene+it in"estment. A+ter all, t,e teet, are
needed o"er a li+etime +or eatin*. Seec, is *reatly imro"ed -y t,e resence o+ teet,.
A leasant smile en,ances ersonality e0ression. 5eet, also contri-/te to *ood
n/trition +or all a*es. At rare times, teet, ,a"e e"en ro"ided a means o+ sel+-de+ense.
On t,e ot,er ,and, t,e a4sence o+ teet, or resence o+ -roken-down teet, o+ten res/lts
in a loss o+ sel+-esteem, minimi@es emloyment ossi-ilities and o+ten c/rtails social
interaction.
Benefits to the Dentist
)ossi-ly t,e +irst -ene+it o+ re"enti"e dentistry is t,e +/l+illment o+ t,e moral
commitment to t,e Hiocratic Oat, t,at was taken -y ,ealt, ro+essionals at
*rad/ation Fto render ,el to t,ose in need, and to do no ,arm.F 5,ro/*, et,ics and
trainin*, t,e dentist s,o/ld deri"e a dee sense o+ satis+action -y ,elin* eole
maintain t,eir oral str/ct/res in a state o+ ma0im/m +/nction, com+ort, and aest,etics.
A well--alanced ractice t,at acti"ely seeks to re"ent disease -/t is also a-le to care
+or t,ose indi"id/als w,ere re"ention ,as +ailed s,o/ld roser. )atients can -e
o/tstandin* /-lic relations ad"ocates i+ t,ey are con"inced t,at t,eir dentist and sta++
are tr/ly interested in re"entin* disease.
I+ +or no ot,er reason, a dentist s,o/ld consider re"ention to a"oid ossi-le le$al
pro4lems. A now stron*ly s/orted law +or medicine, -/t to a lesser e0tent +or
dentistry, re?/ires t,at rior to treatment, all otionsre"enti"e as well as
treatments,o/ld -e e0lained to sec/re informed patient consent. 5,is disc/ssion
s,o/ld incl/de a comarison o+ ,ealt, -ene+its and ,a@ards, as well as t,e economic
and t,e oral-,ealt, -ene+its o+ re"ention. .on*-term atients, t,e lawyers and t,e
co/rt system are takin* a more /nsymat,etic attit/de toward ractitioners w,o ,a"e
ermitted a disease to ro*ress o"er many years wit,o/t ,a"in* taken some acceted
rimary re"enti"e actions to ,a"e slowed, or ,alted its ro*ress. )atients no lon*er
tolerate s/er"ised ro+essional ne*lect.
>:
What is Primary Prevention?
4,en disc/ssin* rimary re"ention, we m/st +irst de+ine a +ew key words. Healt, is
w,at we want to reser"e, and it is de+ined as a state of complete physical, mental,
and social 3ell24ein$, and not merely the a4sence of disease or infirmity. For
instance, some indi"id/als may act/ally -e in e0cellent ,ealt, -/t -elie"e, +or some
reason lo*ical to t,em, t,at t,ey ,a"e oral cancer. S/c, indi"id/als do not ,a"e an
otim/m mental well--ein* and will contin/e to worry /ntil t,ey are some,ow
con"inced ot,erwise t,at t,ey are indeed ,ealt,y. Anot,er erson may -e +/nctionally
,ealt,y, alt,o/*, +acially dis+i*/red, and as s/c, -e socially s,/nned t,ro/*,o/t
li+e.
>>
5,/s, ,ealt, can at times -e w,at t,e atient t,inks and not t,e act/al condition
o+ t,e -ody. 3"en t,e terminolo*y Fre"enti"e dentistryF ,as di++erent connotations
to di++erent eole. As a res/lt, re"enti"e dentistry can -e ar-itrarily classi+ied into
t,ree di++erent le"els.
:. Primary re"ention emloys strate*ies and a*ents to forestall t,e onset o+ disease,
to reverse t,e ro*ress o+ t,e disease, or to arrest t,e disease rocess -e+ore
secondary re"enti"e treatment -ecomes necessary.
>. Secondary prevention emloys ro/tine treatment met,ods to terminate a disease
rocess andBor to restore tiss/es to as near normal as ossi-le.
=. Tertiary prevention emloys meas/res necessary to replace lost tiss/es and to
reha4ilitate atients to t,e oint t,at ,ysical caa-ilities andBor mental attit/des are
as near normal as ossi-le a+ter t,e +ail/re o+ secondary re"ention 7Fi*/re :-:8.
Fi*/re :-: From nat/ral teet, to dent/re teet, in t,ree not-so-easy sta*es.
7Source6 Dr. Norman O. Harris, Uni"ersity o+ 5e0as Dental Sc,ool at San
Antonio.8
Question 1
4,ic, o+ t,e +ollowin* statements, i+ any, are correcte
A. 5,e a-sence o+ a disease or in+irmity is a *ood si*n o+ ,ysical ,ealt, -/t not
necessarily o+ mental and social well--ein*.
1. A ro+essional +oot-all layer w,o looks well, ,as no ,ysical in+irmities, -/t
contin/ally worries a-o/t ,is f:$ million contract, can -e considered in e0cellent
,ealt,.
C. An amal*am restoration t,at is laced in a cario/s occl/sal it o+ a molar is an
e0cellent e0amle o+ tertiary re"ention.
D. 5,e a"oidance o+ an etiolo*ic +actor +or a seci+ic diseases/crose +or instance to
red/ce cariesis an e0amle o+ rimary re"ention.
3. )re"enti"e dentistry, in its -roadest sense, em-odies rimary, secondary, and
tertiary re"ention.
In *oin* +rom rimary to tertiary re"ention, t,e cost o+ ,ealt, care increases
e0onentially, and atient satis+action decreases roortionately. An e0cellent
e0amle o+ t,e comarati"e cost o+ t,ese two le"els o+ care was t,e treatment o+ an
indi"id/al wit, oliomyelitis. It ,as only -een a +ew years a*o t,at t,e cost o+ t,e
olio "accine was only a +ew dollars. 5,e /se o+ t,e olio "accine to re"ent t,e onset
o+ t,e disease was hi$hly e++ecti"e. 1/t, +or someone not ade?/ately imm/ni@ed, t,e
cost o+ treatment +or oliomyelitis and s/-se?/ent re,a-ilitation aro0imated
f'$,$$$ or more +or t,e +irst % weeks o+ ,ositali@ation and o/tatient care.
>=
Het, t,e
indi"id/al recei"in* t,e f'$,$$$ wort, o+ tertiary re"enti"e treatment and t,e
attendant disa-ility was certainly not as ,ay as t,e one w,o -ene+ited +rom only a
+ew dollarsC wort, o+ rimary re"enti"e care. 5,e ayo++ o+ t,e worldwide dri"e to
eliminate olio romises to ,a"e t,is disease +ollow smallo0 into o-li"ion. Anot,er
aroriate e0amle is t,e +l/oridation o+ drinkin* water. 5,is costs aro0imately
f$.'$ er year er indi"id/al, yet it red/ces t,e incidence o+ dental caries in t,e
comm/nity -y >$ to &$E. I+ t,is rimary-re"enti"e meas/re is not a"aila-le, t,e
necessary restorati"e dentistry 7secondary re"ention8 can cost aro0imately :$$
times more, or a-o/t f'$.$$ er restoration.
:(
Finally, i+ restorati"e dentistry +ails, as
it o+ten does, rost,etic de"ices m/st -e constr/cted at an e"en *reater cost. 5,is *reat
disarity -etween t,e lower cost o+ re"ention and t,e m/c, ,i*,er cost o+ treatment
m/st -e serio/sly considered if t,e United States is to de"elo an a++orda-le national
,ealt, ro*ram in w,ic, dentistry is reresented.
5,is te0t em,asi@es rimary re"ention, and seci+ically +oc/ses on rimary
re"ention as it alies to t,e control o+ dental caries and eriodontal disease. On t,e
ot,er ,and, it m/st -e reco*ni@ed t,at rimary re"ention o+ten +ails +or many
reasons. 4,en s/c, +ail/re occ/rs, t3o actions are essential to contain t,e dama*e9
7:8 early identification o+ t,e disease 7dia*nosis8 and 7>8 immediate treatment o+ t,e
disease.
Categories of Oral Disease
For lannin* /roses, dental diseases and a-normalities can -e con"eniently *ro/ed
into t,ree cate*ories9 7:8 dental caries and eriodontal disease, 4oth o+ w,ic, are
ac?/ired conditions, 7>8 ac?/ired oral conditions other than dental caries and
eriodontal disease 7oort/nistic in+ections, oral cancer, HI6BAIDS8, and 7=8
cranio+acial disorders w,ic, wo/ld incl/de a wide "ariety o+ conditions ran*in* +rom
,eredity to accidents.
>&,>'
For instance, t,e ordinary seat -elt and t,e air -a*s in a car
e0emli+y ,ow a simle re"enti"e meas/re can *reatly red/ce t,e +acial inA/ries o+
car accidents. .oomin* in t,e not-too-+ar distant +/t/re is t,e "ery real ossi-ility t,at
many ac?/ired ,ealt, ro-lems will -e corrected or ameliorated +or total o/lations
-y /se o+ "accines, *enetic en*ineerin*, or seci+ically tar*eted dr/*s 7Fma*ic
-/lletsF8.
5,e treatment o+ caries and eriodontal disease 7and t,eir se?/elae8 acco/nts +or most
o+ t,e estimated f<$ -illion U.S. dental -ill +or t,e year >$$$.
><
#oth caries and
eriodontal disease are ca/sed -y t,e resence o+ a at,o*enic dental la?/e on t,e
s/r+aces o+ t,e teet, and ,ence are known as t,e pla5ue diseases. Any maAor
red/ction in t,e incidence o+ caries and eriodontal disease will release reso/rces +or
t,e in"esti*ation and treatment o+ conditions incl/ded in t,e ac?/ired and cranio+acial
cate*ory.
5,e ideal, or lon$2ran$e lannin* o-Aecti"es +or coin* wit, -ot, dental caries and
eriodontal disease s,o/ld -e t,e de"eloment o+ a re"enti"e deli"ery system and
met,ods to e"ent/ally attain a @ero or near-@ero disease incidence +or t,e tar*et
o/lation. Howe"er, a more realistic and +easi-le shorter2term $oal is t,e attainment
o+ a @ero or near-@ero rate o+ tooth loss +rom t,ese diseases -y inte*rated re"enti"e
and treatment roced/res. 1eca/se o+ t,e "aried etiolo*y o+ t,e second and t,ird
cate*ories, t,at is, ot,er ac?/ired conditions and cranio+acial mal+ormations and
diseases, t,e lannin* +or t,e control o+ eac, o+ t,ese ro-lem areas m/st -e
indi"id/ally addressed and laced wit,in t,e riorities o+ any o"erall ,ealt, lan.
Question 2
A. A dis+i*/rin* +acial de+ormity res/ltin* +rom an a/tomo-ile accident can -e
considered an ac?/ired cranio+acial ro-lem.
1. 5,e -road concet o+ re"enti"e dentistry laces maAor em,asis on rimary
re"enti"e care -/t also considers t,e e?/al need +or secondary and tertiary re"enti"e
care.
C. 1eca/se dental caries and eriodontal disease are in+ectio/s diseases 7tr/e8, t,ey
are ac?/ired conditions.
D. 5,e ideal or lon*-ran*e o-Aecti"e +or dentistry is an e"ent/al @ero ann/al
e0traction rateD t,e more realistic, and m/c, more encomassin* short2ran$e
o47ective is to totally re"ent t,e onset o+ any at,olo*y re?/irin* e0traction.
3. Ac?/ired conditions 7other than caries or eriodontal disease8 and ,ereditary
diseases acco/nt +or t,e *reat roortion o+ income deri"ed -y t,e dental ro+ession.
Strategies to Prevent the Plaque Diseases
1e+ore ro"idin* an o"er"iew o+ met,ods /sed to imlement rimary re"ention
ro*rams, it is imortant to oint o/t t,at -ot, dental caries and eriodontal disease
are transmissi4le diseases. I+ a c,ild is considered at ,i*, risk +or caries, one o+ t,e
arents
>%
/s/ally t,e mot,ercan /s/ally -e identi+ied as ,i*, riskD i+ a c,ild ,as
eriodontal ro-lems, /s/ally one o+ t,e arents is also a++licted. Any in+ectio/s
7ac?/ired8 disease can only -e*in i+ t,e c,allen*e or*anisms are in s/++icient n/m-ers
to o"erw,elm t,e com-ined manmade and -ody de+enses and reair caa-ilities. For
t,is reason, all strate*ies to re"ent, arrest, or re"erse t,e ra"a*es o+ t,e la?/e
diseases are -ased on 7:8 red/cin* t,e n/m-er o+ c,allen*in* oral at,o*ens, 7>8
-/ildin* / t,e toot, resistance and maintainin* a ,ealt,y *in*i"a, and 7=8 en,ancin*
t,e reair rocesses.
In *eneral, eriodontal disease is a disease t,at in"ol"es t,e so+t tiss/e and -one
s/rro/ndin* t,e a++ected teet,. Caries in"ol"es t,e deminerali@ation and e"ent/al
cavitation o+ t,e enamel and o+ten o+ t,e root s/r+ace. I+ t,e incipient lesions 7earliest
visi4le si*n o+ disease8 o+ caries and eriodontal disease are reco*ni@ed at t,e time o+
t,e initialBann/al dental e0amination, t,ey can o+ten -e re"ersed wit, rimary
re"enti"e strate*ies. For caries, t,e visi4le inciient lesion is a 3hite spot, w,ic,
aears on t,e s/r+ace o+ t,e enamel as a res/lt o+ s/-s/r+ace acid-ind/ced
deminerali@ation. For eriodontal disease, t,e visi4le inciient lesion is $in$ivitisan
in+lammation o+ t,e *in*i"a t,at is in contact wit, t,e -acterial la?/e. Not all Fw,ite
sotsF *o on to -ecome caries, nor do all cases o+ *in*i"itis *o on to -ecome
eriodontal disease. In -ot, cases, i.e., caries and eriodontal disease, it s,o/ld -e
noted that if dental pla5ue did not exist, or if the adverse effects of its micro4ial
inha4itants could 4e ne$ated, the decrease in the incidence of the pla5ue diseases
3ould 4e very dramatic, #ased on these facts, it is understanda4le 3hy pla5ue
control is so important in any oral2health pro$ram.
5o control t,e pla5ue diseases wit, availa4le met,ods and tec,ni?/es, stron*
em,asis ,as -een directed to +o/r *eneral strate*ies to red/ce caries and two
administrati"e re?/irements9
General Strategies
:. Mec,anical 7toot,-r/s,, dental +loss, irri*ator, or rinse8
>. C,emical la?/e control. Use o+ fluorides to in,i-it deminerali1ation and to
en,ance reminerali1ation8 /se o+ antimicro-ial a*ents to s/ress cario*enic -acteria.
=. S/*ar disciline.
&. Use o+ it and +iss/re sealants, w,en indicated, on osterior occl/sal s/r+aces.
Administrative
'. 3d/cation and ,ealt, romotion.
<. 3sta-lis, access to dental +acilities w,ere dia*nostic, restorati"e, and re"enti"e
ser"ices are rendered, and w,ere lanned recalls -ased on risk are ro/tine.
A -rie+ s/mmary o+ eac, o+ t,ese rimary re"enti"e roced/res will ser"e as an
introd/ction +or t,e more detailed in+ormation resented in later c,aters.
)la?/e Control
Dental la?/e is comosed o+ salivary proteins t,at ad,ere to t,e teet,, l/s 4acteria
and end2products o+ -acterial meta-olism. 1ot, cario*enic and eriodontoat,o*ens
acc/m/late in t,e la?/e located alon* t,e *in*i"al mar*in, interro0imally, and in
t,e its and +iss/res. )la?/e collects more ro+/sely in t,ese seci+ic areas -eca/se
none o+ t,ese locations is otimally e0osed to t,e normal sel+-cleansin* action o+ t,e
sali"a, t,e a-rasi"e action o+ +oods, nor t,e m/sc/lar action o+ t,e c,eeks and ton*/e.
)la?/e decreases in t,ickness as t,e incisal or occl/sal s/r+ace is aroac,ed. .ittle
la?/e is +o/nd on t,e occl/sal s/r+ace e0cet in t,e its and +iss/res. As wo/ld -e
e0ected, la?/e +orms more ro+/sely on malosed teet, or on teet, wit, ort,odontic
aliances, w,ere access +or cleanin* is o+ten di++ic/lt.
In t,e $in$ival sulcus -etween t,e *in*i"a and t,e toot,, little or no la?/e normally
acc/m/lates until *in*i"al in+lammation -e*ins, at w,ic, time t,e -acterial
o/lation increases in ?/antity and comle0ity. 5,is is t,e -e*innin* o+ $in$ivitis
t,at, i+ contin/ed, may e"ent/ally res/lt in an irreversi4le periodontitis.
It is imortant to di++erentiate -etween t,e supra*in*i"al and t,e su4*in*i"al la?/es.
5,e supra*in*i"al la?/e can -e seen a-o"e t,e *in*i"al mar*in on all toot, s/r+acesD
t,e su4*in*i"al la?/e is +o/nd in t,e s/lc/s and ocket -elow t,e *in*i"al mar*in,
w,ere it is not "isi-le. 5,e s/ra*in*i"al la?/e ,ar-ors seci+ic -acteria t,at can
ca/se s/ra*in*i"al 7coronal8 caries. 5,e s/-*in*i"al la?/e micro-iota is mainly
resonsi-le +or eriodontal ro-lems. 5,e -acterial o/lations o+ eac, o+ t,ese
la?/es di++er ?/alitati"ely and ?/antitati"ely in ,ealt, and disease.
>(
5,e
at,o*enicity o+ eac, o+ t,e la?/es can "ary indeendently o+ t,e ot,er. For
e0amle, it is ossi-le to ,a"e eriodontal disease wit, or wit,o/t caries, to ,a"e
neit,er, or to ,a"e a s,i+tin* stat/s o+ caries or eriodontal disease, or -ot,.
5,e at,o*enicity o+ t,e s/-*in*i"al la?/e is -ecomin* an increasin* concern. Not
only does it ca/se eriodontal disease, w,ic, is a li+elon* de-ilitatin* disease o+ t,e
toot, s/ortin* tiss/es, -/t it is now -elie"ed t,at t,ere is a ca/sal relations,i
-etween eriodontitis
>;
and s/c, di"erse conditions as, cardio"asc/lar disease,
=$

dia-etis mellit/s,
=:
c,ronic resiratory disease,
=>
and imm/ne +/nction.
==
5,ere is also
t,e ossi-ility in some cases t,at t,is is a -i-directional association w,ere t,e oral
ro-lem -e*ins wit, a systemic condition, instead o+ "ice "ersa.
In many cases, la?/e is di++ic/lt +or a atient to identi+y. 5,is ro-lem can -e
o"ercome, at least in t,e case o+ t,e s/ra*in*i"al la?/e, -y t,e /se o+ disclosin$
a*ents, w,ic, are ,armless dyes s/c, as t,e red-stainin* a*ent, FDgC !ed. 5,e dyes
may -e in sol/tion and ainted on t,e teet, wit, a cotton alicator, or t,ey may -e
ta-lets w,ic, are c,ewed, swis,ed aro/nd t,e mo/t,, and t,en e0ectorated. Once
disclosed, most o+ t,e s/ra*in*i"al la?/e and +ood de-ris can -e easily remo"ed -y
t,e daily /se o+ a toot,-r/s,, +loss, and an irri$ator 7Fi*/re :->8. )la?/e can also -e
remo"ed at lanned inter"als -y t,e dental ,y*ienist or a dentist as art o+ an oral
prophylaxis. 5,is is a roced/re t,at ,as as its o-Aecti"e t,e mec,anical remo"al o+ all
so+t and ,ard deosits, +ollowed -y a olis,in* o+ t,e toot, s/r+aces. Howe"er,
-eca/se daily remo"al o+ t,e la?/e is more e++ecti"e, it is the individualnot t,e
,y*ienist or t,e dentistw,o is "ital +or reser"in* li+elon* intact teet,.
One site w,ere neit,er t,e dentist nor an indi"id/al can s/ccess+/lly remo"e la?/e is
in t,e det, o+ its and +iss/res o+ occlusal s/r+aces w,ere t,e ori+ices are too small
+or t,e toot,-r/s, -ristle to enetrate 7see C,ater :$8. 5,e +low o+ sali"a or t,e
m/sc/lar action o+ t,e c,eeks and ton*/e also ,a"e little in+l/ence o"er t,e e"ent/al
de"eloment o+ caries in t,ese areas. Not coincidentally, t,e occl/sal s/r+ace is w,ere
t,e $reatest percenta$e o+ caries lesions occ/r. 'or this reason, it is recommended
that all occlusal surfaces 3ith deep convoluted fissures 4e sealed 3ith a pit2and2
fissure sealant.
As soon as t,e la?/e is remo"ed +rom any s/r+ace o+ t,e toot,, it immediately -e*ins
to re+orm. 5,is s,o/ld not -e /ne0ected, since -y de+inition, dental la?/e is
comosed o+ sali"ary resid/e, -acteria, and t,eir end-rod/cts, all o+ w,ic, are
always resent in t,e mo/t,. 5,/s, a *ood la?/e-control ro*ram m/st -e
contin/o/s. It m/st -e a daily commitment o"er a li+etime.
Fi*/re :-> A. Flossin* *ets down /nder t,e *in*i"a and B.Flossin* cleans t,e
sace -etween t,e teet, as well. 7Source6 Dr. Norman O. Harris, Uni"ersity o+
5e0as Dental Sc,ool at San Antonio.8
Question 3
A. Fo/r *eneral areas t,at +orm t,e -asis +or strate*ies +or t,e rimary re"ention o+
dental diseases are 7:8 la?/e control, 7>8 +l/oride /se, 7=8 sealants, and 7&8
restorations.
1. )la?/e is +o/nd only on t,e smoot, enamel s/r+aces o+ t,e toot,.
C. )la?/e remo"al re?/ires t,e /se o+ instr/mentation -y a dentist or a dental
,y*ienist.
D. Good +lossin* and toot,-r/s,in* tec,ni?/es can comletely remo"e t,e
s/ra*in*i"al la?/e +rom all +i"e toot, s/r+aces.
3. 5,e daily sel+-care remo"al o+ la?/e -y an indi"id/al is more rod/cti"e t,an a
semiann/al remo"al -y t,e dental ,y*ienist.
Not only does t,e daily remo"al o+ dental la?/e red/ce t,e ro-a-ility o+ dental
cariesD e?/ally imortant, it also red/ces t,e ossi-ility o+ t,e onset o+ *in*i"itis. 5,is
occ/rs w,en t,e meta-olic end-rod/cts o+ t,e periodontopatho2$ens t,at are
contained in t,e la?/e irritate t,e adAacent *in*i"al tiss/es, rod/cin* an
in+lammation 7i.e., *in*i"itis8. I+ t,e in+lammation contin/es, -leedin* 7,emorr,a*e8
can -e e0ected +ollowin* e"en minimal ress/re 7Fink toot,-r/s,F8. 5,is *in*i"itis
can -e arrested and re"ersed 7c/red8 in t,e early sta*es -y roer -r/s,in*, +lossin*,
and irri*ation, esecially i+ accomanied wit, ro+essional */idance.
)la?/e concentrates minerali@in* ions s/c, as calci/m, ,os,ate, ma*nesi/m,
+l/oride and car-onates +rom t,e sali"a to ro"ide t,e c,emical en"ironment +or t,e
reciitation and +ormation o+ calculus, a concretion t,at ad,eres +irmly to t,e teet,.
I+ t,e la?/e is not remo"ed -y +lossin* and -r/s,in* -e+ore t,e calc/l/s -e*ins to
+orm, t,e res/ltant minerali@ed mass ro"ides a *reater s/r+ace area +or an e"en more
dama*in* la?/e acc/m/lation. 5,is additional mass o+ periodontopathic la?/e
co"erin* t,e ro/*, oro/s s/r+ace ca/ses t,e sta*nation o+ e"en more -acteria and is
resonsi-le +or t,e dama*e to t,e eriodontal tiss/es. Also, t,e ,ard, irre*/lar
calc/l/s deosits ressin* a*ainst t,e so+t tiss/es ser"es to exacer4ate t,e
in+lammation ca/sed -y t,e -acteria alone. 5,e daily remo"al o+ la?/e can
s/ccess+/lly a-ort or markedly retard t,e -/ild-/ o+ calc/l/s. Once t,e calc/l/s
+orms, t,e -r/s,in* and +lossin* /s/ally /sed +or la?/e control does not remo"e t,e
deosits. At t,is time, t,e dental ,y*ienist or dentist m/st intercede to remo"e t,e
calc/l/s -y instr/mentation.
5o t,is oint, only mec,anical la?/e control 7i.e., /se o+ a toot,-r/s,, dental +loss,
and an irri*ator8 ,as -een ,i*,li*,ted. !aidly *rowin* in imortance as a
s/lement to mec,anical la?/e control 7-/t not as a relacement8, is chemical
pla5ue control. 5,is aroac, /tili@es mo/t,rinses containin* antimicro-ial a*ents
t,at e++ecti"ely ,el control t,e la?/e -acteria in"ol"ed in ca/sin* 4oth caries and
*in*i"itis. For ,elin* to control *in*i"itis, a o/lar and economical o"er-t,e-
co/nter rod/ct is .isterineD t,e most e++ecti"e prescription rinse is chlorhexidine.
Many st/dies indicate t,at c,lor,e0idine is as e++ecti"e in s/ressin* cario*enic
or*anisms as it is e++ecti"e in controllin* *in*i"itis and eriodontitis.
=&,='
Fl/orides
5,e /se o+ +l/orides ,as ro"ided e0cetionally meanin*+/l red/ctions in t,e
incidence o+ dental caries. 1eca/se o+ water +l/oridation, +l/oride denti+rices, and
mo/t,rinses, dental caries is declinin* t,ro/*,o/t t,e ind/striali@ed world.
Historically, t,e inAection o+ +l/oride into water s/lies in t,e mid->$t, cent/ry
res/lted in a decrement o+ aro0imately <$ to %$E in caries. Since t,at time, +l/oride
,as -een introd/ced into rorietary rod/cts s/c, as denti+rices and mo/t,rinses. As
a res/lt, t,e caries decrement directly attri4uta4le to water +l/oride o"er t,e ast years
,as declined. Het, t,e lacement o+ +l/oride into comm/nal water s/lies still res/lts
in an estimated >$ to &$E red/ction in coronal caries, and a similar >$ to &$E
decrease in root caries
=<
7Fi*/re :-=8.
Aro0imately :>< million indi"id/als in t,e United States cons/me +l/oridated
water t,ro/*, communal 3ater s/lies and anot,er ; million are drinkin* naturally
+l/oridated water. It is estimated t,at <'E o+ t,e U.S. o/lation, t,ere+ore, is
recei"in* +l/oride t,ro/*, drinkin* water.
=%
Many times d/rin* t,e ast years, it ,as
not -een ossi-le to +l/oridate city water s/lies -eca/se o+ olitical, tec,nical, or
+inancial considerations. In s/c, cases, it is still ossi-le to recei"e t,e systemic
-ene+its o+ +l/oride -y /sin* dietary supplements in t,e +orm o+ +l/oride ta-lets,
dros, lo@en*es, and "itamin rearations. Some co/ntries ermit +l/orides to -e
added to ta-le salt.
=(
3lsew,ere, on*oin* researc, st/dies are -ein* cond/cted to
determine t,e anticario*enic e++ect o+ +l/oride w,en laced in milk,
=;,&$
and e"en
s/*ar.
&:
It is also ossi-le to aly +l/oride directly to the surface o+ t,e teet, -y /se o+ cotton
led*ets, andBor -y /se o+ +l/oride-containin* denti+rices, *els, "arnis,es or mo/t,
rinses. S/c, alications to t,e s/r+ace o+ t,e teet, are re+erred to as topical
applications. 5,e e0tent o+ caries control ac,ie"ed t,ro/*, toical alications is
directly related to t,e n/m-er o+ times t,e +l/oride is alied and t,e len*t, o+ time
t,e +l/oride is maintained in contact wit, t,e teet,. !esearc, data also indicate t,at it
is -etter to aly lo3er concentrations o+ +l/oride to t,e teet, more often t,an to aly
,i*,er concentrations at lon*er inter"als.
Fl/orides and c,lor,e0idine are t,e most e++ecti"e a*ents /sed -y t,e ro+ession to
com-at t,e la?/e diseases. 5,e +l/orides ,el re"ent deminerali@ation and en,ance
reminerali@ation, w,ile c,lor,e0idine se"erely s/resses t,e m/tans stretococci t,at
ca/se t,e deminerali@ation. C,lor,e0idine also ,els s/ress -acteria ca/sin* t,e
in+lammation o+ eriodontal disease.
Fi*/re :-= 4ater +l/oridation red/ces ca"ities in t,e o/lation -y >$ to &$E.
7Source6 Dr. Norman O. Harris, Uni"ersity o+ 5e0as Dental Sc,ool at San
Antonio.8
Question 4
A. )ro,yla0es and c,lor,e0idine are e++ecti"e in t,e artial control o+ 4oth caries and
*in*i"itis.
1. 3"en a+ter calc/l/s -ecomes attac,ed to t,e toot,, it can still -e remo"ed -y *ood
,ome sel+-care la?/e control ro*rams.
C. 5,e addition o+ +l/oride to comm/nal water s/lies is now accomanied -y a >$
to &$E decrease in caries incidence.
D. 5,e toical alication o+ ,i*,er concentrations o+ +l/oride at lon*er time inter"als
is more e++ecti"e t,an lower concentrations o+ +l/oride at s,orter inter"als.
3. 5,e toical alication o+ +l/oride can only -e accomlis,ed -y a dentist or a
dental ,y*ienist.
Neit,er t,e action o+ toically alied nor o+ systemic 7in*ested8 +l/oride in
re"entin* dental caries is comletely /nderstood. It is -elie"ed t,at +l/oride ,as
se"eral key actions9 7:8 it may enter t,e dental la?/e and a++ect t,e -acteria -y
deressin* t,eir rod/ction o+ acid and t,/s red/ce t,e ossi-ility o+ deminerali@ation
o+ t,e teet,D 7>8 it reacts wit, t,e mineral elements on t,e s/r+ace o+ t,e toot, to make
t,e enamel less sol/-le to t,e acid end-rod/cts o+ -acterial meta-olismD and 7=8 it
+acilitates t,e reminerali@ation 7reair8 o+ teet, t,at ,a"e -een deminerali@ed -y acid
end-rod/cts. 5,e latter is ro-a-ly t,e most imortant o+ t,ese t,ree e++ects.
5,e nat/ral so/rce o+ minerals s/c, as calci/m and ,os,ate, +l/oride and ot,ers
needed +or t,is reminerali@ation is t,e saliva.
S/*ar and Diet
5,e de"eloment o+ dental caries deends on +o/r interrelated +actors9 7:8 diet, 7>8
in,erent +actors o+ ,ost resistance, 7=8 t,e n/m-er o+ c,allen*e -acteria located in t,e
dental la?/e, and 7&8 time 7Fi*/re :-&8. 4it,o/t -acteria, no caries can de"elo. For
t,e -acteria in t,e la?/e to li"e, t,ey m/st ,a"e t,e same amino acids, car-o,ydrates,
+atty acids, "itamins, and minerals t,at are re?/ired +or all li"in* or*anisms. 1eca/se
t,ese n/trients are also re?/ired -y t,e cells o+ t,e -ody, t,e +ood t,at is in*ested -y
t,e ,ost or t,at w,ic, later aears in t,e sali"a in a meta-oli@ed +orm, ro"ides
ade?/ate n/trients +or -acterial s/r"i"al and rerod/ction. 4it, t,ree 3ell24alanced
meals er day, ,owe"er, t,e /s/al la?/e -acteria ro-a-ly wo/ld not release a
s/++icient ?/antity o+ meta-olic acids to ca/se caries de"eloment 7Fi*/re :-'A8. 1/t,
as soon as su$ar and su$ar products are incl/ded in t,e diet o+ t,e ,ost, -acterial acid
rod/ction markedly increases in t,e la?/e. 5,is release o+ acid end-rod/cts is t,e
maAor ca/se o+ t,e initiation and ro*ression o+ caries.
&>
O+ e"en *reater imortance
than t,e total inta*e o+ re+ined car-o,ydrates is t,e fre5uency o+ intake and t,e
consistency o+ t,e s/*ar-containin* +oods.
&=
5,e contin/o/s snackin* o+ re+ined
car-o,ydrates t,at c,aracteri@es modern li"in* res/lts in t,e teet, -ein* constantly
e0osed to -acterial acids 7Fi*/re :-'18. For e0amle, t,e rolon*ed ad,erence o+
s/*ar rod/cts to t,e teet,, s/c, as t,at e0erienced a+ter eatin* taffies and hard
candies, res/lts in rolon*ed rod/ction o+ t,e la?/e acids t,at are in direct contact
wit, t,e toot, s/r+ace. 5,/s, i+ caries incidence is to -e red/ced, all t,ree
+actorstotal inta*e o+ s/*ar, consistency o+ t,e cario*enic +oods, and esecially
fre5uency o+ intake s,o/ld -e considered.
)ossi-ly one o+ t,e most romisin* means o+ red/cin* caries incidence in t,e United
States ,as -een t,e wide-scale accetance o+ s/*ar s/-stit/tes s/c, as N/traSweet,
SweetCn .ow, and Slenda. In t,e Nordic co/ntries, t,ere is considera-le ent,/siasm
+or /se o+ 0ylitola s/*ar alco,ol. Gylitol ,as -een +o/nd to in,i-it decay, red/ce t,e
amo/nt o+ la?/e and la?/e acid, in,i-it *rowt, and meta-olism o+ stretococci,
&&

red/ce decay in animal st/dies, and contri-/te to reminerali@ation. It is considered
noncario*enic and cariostatic.
&'
All t,e Nordic dental associations recommend its /se.
Since t,e :;%$s, one o+ t,e +a"orite ways to take ad"anta*e o+ 0ylitols /ni?/e
anticaries roerty, ,as -een to /se it to sweeten c,ewin* */m, a rod/ct t,at is a
o/lar item amon* sc,ool c,ildren.
&<
5wo ot,er dental /ses o+ 0ylitol c,ewin* */m ,a"e come o/t in Scandina"ia9
:. C,lor,e0idine can dramatically s/ress t,e n/m-er o+ m/tans stretococc/s in t,e
sali"a. Howe"er, a+ter discontin/in* /se o+ t,e rod/ct, t,ere is a raid reo/lation
o+ t,e -acteria. 5,is reo/lation can -e arrested or *reatly slowed -y t,e /se o+
0ylitol c,ewin* */m.
&%
>. )re"io/sly it was mentioned t,at a c,ildCs +lora o+ten re+lected t,at o+ t,e mot,er.
5o ,el minimi@e t,is mot,er-c,ild transmission o+ cario*enic -acteria, mot,ers ,a"e
-een /r*ed to c,ew 0ylitol */m.
&(
5,is credita-le -ack*ro/nd o+ 0ylitol ,as romted Anasa"ice to ask, FAre
c,lor,e0idine, +l/oride, +l/oride "arnis,es, and 0ylitol c,ewin* */m /nder /stili@ed
re"enti"e t,eraieseF
&;
)it and Fiss/re Sealants
Aro0imately ;$E o+ all t,e cario/s lesions in t,e mo/t, occ/r on t,e occl/sal
s/r+aces o+ t,e osterior teet,.
'$
5,ese s/r+aces reresent only :>E o+ t,e total
n/m-er o+ toot, s/r+aces, so t,at occl/sal s/r+aces wit, t,eir dee its and +iss/res are
aro0imately ei$ht times as vulnera4le as all t,e ot,er smoot, s/r+aces. 5,e
a"aila-ility o+ sealants o++ers an alternati"e to a restoration. 4it, t,e /se o+ sealants, a
t,in layer o+ a lastic, called 1is-GMA, is +lowed into t,e dee occl/sal its and
+iss/res o+ teet, not ,a"in* oen cario/s lesions. 5,is action e++ecti"ely isolates t,ese
areas +rom t,e oral en"ironment 7Fi*/re :-<8. Since no ca"ity rearation is
necessary, no ain or discom+ort accomanies sealant lacement. Followin* t,e
lacement o+ t,e sealant in t,e dee +iss/res, t,e newly created +ossae can -e
e++ecti"ely cleaned wit, a toot,-r/s,.
As lon* as t,e sealants are retained, no -acteria or -acterial acids can a++ect t,e sealed
areas. I+ t,ey are not retained, no dama*e to t,e teet, res/lts +rom a retreatment. 5,e
lost sealant can -e easily relaced. One :$-year st/dy demonstrated a '%E retention
o+ t,e ori*inal sealants.
':
In anot,er st/dy, aro0imately ;'E retention occ/rred o"er
> years.
'>
4it, t,ese er+ormances, t,e a"era*e li+e o+ t,e sealant aro0imates t,e :$
years roAected +or an amal*am.
'=
It s,o/ld -e em,asi@ed t,at sealant lacement
s,o/ld -e +ollowed -y a toical +l/oride alication to t,e teet,, -eca/se fluorides are
most effective in protectin$ the smooth surfaces and least effective on the occlusal
surfaces, a situation that is the reverse of the results expected of the sealants.
Fi*/re :-& Caries is a multifactorial disease ca/sed -y -acteria, a s/ortin*
,ost diet o+ re+ined car-o,ydrates, decreased ,ost resistance, and time +or t,e
ca"ity to de"elo. 7Source6 Dr. Norman O. Harris, Uni"ersity o+ 5e0as Dental
Sc,ool at San Antonio.8
Fi*/re :-' A. 5,is -alanced meal does not ro"ide t,e -acteria wit, eno/*,
ener*y to rod/ce acids.
Fi*/re :-' B. Snacks s/c, as t,is e0ose teet, to -acterial acids.
Fi*/re :-< Molar A. wit,o/t and B. wit, a clear lastic sealant to rotect t,e
dee occl/sal +iss/res. 7Source6 Dr. Norman O. Harris, Uni"ersity o+ 5e0as
Dental Sc,ool at San Antonio.8
Question 5
A. Usin* +l/oride to reminerali@e inciient lesions, one can e0ect t,e reminerli@ed
lesion to -e more resistant to +/t/re deminerali@ation t,an inciient lesions -e+ore
reminerali@ation.
1. 5,e calci/m and ,os,ate t,at is lost +rom t,e toot, in deminerali@ation can -e
relaced d/rin* reminerali@ation.
C. 5,e de"eloment o+ dental caries deends on +o/r essential +actors9 7:8 dietD 7>8
in,erent +actors o+ ,ost resistanceD 7=8 -acteriaD and 7&8 time.
D. !e+ined car-o,ydrates alone ro"ide s/++icient n/trition +or cario*enic -acteria.
3. Sealant lon*e"ity closely coincides wit, t,e lon*e"ity o+ amal*am restorations.
)/-lic Dental Healt, 3d/cation
I+ t,e ro+ession o+ dentistry can control caries e++ecti"ely t,ro/*, la?/e control,
systemic 7in*ested8 and toical 7local alication8 /se o+ +l/orides, dietary control,
and t,e /se o+ lastic sealants, two imortant ?/estions need to -e asked.
:. 4,y do we not ,a"e a more e++ecti"e dental caries-control ro*ram in t,e United
Statese
>. I+ daily toot,-r/s,in*, +lossin* o+ teet,, and irri*ation remo"es la?/e and +ood
resid/e, w,y are t,ese simle roced/res not /sed e++ecti"ely to control -ot, caries
and eriodontal diseasee
)ro-a-ly t,e -est answer to t,ese ?/estions is t,at eole m/st +irst *no3 w,at t,ey
need to do as well as ho3 it is to -e done. Un+ort/nately, t,e /-lic ,as relati"ely
little in+ormation a-o/t t,e tremendo/s otential o+ rimary re"enti"e dentistry +or
red/cin* t,eir ad"erse e0os/res to t,e la?/e diseases. 4it,o/t t,is in+ormation, it is
difficult to convince people that they can $reatly control their o3n dental destiny.
Many indi"id/als t,ink o+ dentistry as a treatment-oriented ro+ession t,at
seciali@es in eriodontal treatment, restorations, endodontics, e0odontics, and
rost,etics. An e0anded /-lic ed/cation and romotion ro*ram is essential to
ens/re t,e s/ccess o+ any re"enti"e dentistry ro*ram in w,ic, an indi"id/al or a
comm/nity is asked to articiate.
In dentistry, a one-on-one relations,i -etween t,e atient and t,e ,ealt,
ro+essional is still a -asic aroac, to atient ed/cation and moti"ation. 5,is
aroac, makes t,e task imossi-le -eca/se t,ere are >'$ million eole in t,e
United States and only aro0imately :<',$$$ racticin* dentists, l/s :>$,$$$ dental
,y*ienists and :%',$$$ assistants.
'&,''
5,e main t,r/st o+ /-lic dental-,ealt,
ed/cation and oral-,ealt, romotion is ro"ided -y t,e "ario/s dentri+ice
man/+act/rers ad"ocatin* t,e daily toot,-r/s,in* ro/tine and -iann/al "isits to t,e
dentist +or a c,eck/. 5,e e++ecti"eness o+ t,is aroac, was /nderlined -y t,e lon*-
r/nnin* ad"ertisement +or t,e +irst marketed, stanno/s +l/oride containin*, Crest
toot,aste, F.ook Mom, no ca"ities.F
2nowin* +acts and alyin* t,e in+ormation are two searate rocesses. 5,e
alication o+ knowled*e -y an indi"id/al re?/ires a ersonal commitmentD it is at
t,is oint o+ ersonal commitment t,at most rimary re"enti"e-dentistry ro*rams
+ail. /f eole em-raced t,e daily /se o+ mec,anical and c,emical la?/e control
re*imens, t,e risk o+ caries and *in*i"itis wo/ld -e minimi@ed. /f eole wo/ld
e0ercise reasona-le s/*ar disciline t,e ossi-ility o+ caries de"eloment wo/ld -e
+/rt,er red/ced. /f indi"id/als reAected t,e /se o+ ci*arettes as well as smokeless
7FsitF8 to-acco, oral and ,aryn*eal cancer and eriodontitis wo/ld -e m/c, less
re"alent. Clearly, ed/cation, moti"ation, and -e,a"ior modi+ication are a necessary
art o+ enAoyin* *ood oral and *eneral ,ealt,.
A so/nd, well-lanned ro*ram o+ dental-,ealt, ed/cation and romotion is lackin*
in t,e c/rric/l/m o+ t,e *reat maAority o+ rimary and secondary sc,ools. Few eole
can disc/ss t,e ad"anta*es and disad"anta*es o+ water +l/oridation and t,e toical
alication o+ +l/orides. Few ,a"e any detailed in+ormation a-o/t t,e dental la?/e
and t,e disease-ind/cin* otentialities o+ t,is -acterial +ilm.
-
Few eole know w,y
s/*ar is cario*enic. 3"en +ewer eole know t,at *in*i"itis can -e cured, -/t t,at i+
allowed to ro*ress, t,ere is t,e ossi-ility o+ a li+e lon* +/t/re o+ eriodontal disease
treatment and maintenance. Finally, t,e /-lic ,as not -een ade?/ately in+ormed t,at
t,e timely /se o+ sealants and reminerali@ation t,eray ro"ides a ,oe o+ ossessin*
a +/ll intact dentition +or li+e. 3"en t,o/*, t,e Internet ,as *reatly e0anded t,e
deli"ery o+ ,ealt, ed/cation, t,ere is always t,e ?/estion o+ t,e ?/ality o+ in+ormation
7or misin+ormation8 t,at is disseminated.
'<
Ideally, sc,ool--ased and /-lic-ed/cation ro*rams s,o/ld e0ist to ,el eole to
help themselves in alyin* rimary re"enti"e roced/res. 5,e same ro*rams
s,o/ld also teac, all indi"id/als to reco$ni1e the presence of oral disease. 4it,
roer instr/ction t,at can -e ro"ided -y schoolteachers. 5,e *eneral /-lic can -e
ta/*,t to /nderstand t,at t,ey m/st ass/me maAor resonsi-ility +or t,eir own oral
,ealt, 7see C,ater :;8. Only t,e indi"id/al can seek immediate treatment w,en ain
or disease occ/rs. )/-lic dental-,ealt, ed/cation mi*,t -ene+it i+ t,ere was a
cons/mer or*ani@ation s/c, as an American Oral Healt, Association t,at co/ld
romote oral ,ealt, ed/cation, m/c, like t,e American Cancer Society and t,e
American Heart Association.
-
1io+ilm h A collection 7+ilm8 o+ li"in* or*anisms attac,ed to a solid -ase, s/c, as
al*ae to t,e -ottom o+ a swimmin* ool, or dental la?/e to a toot,. 1ot, terms are
/sed in t,e -ook, -/t dental la?/e is re+erred -eca/se o+ /-lic +amiliarity and
/nderstandin* o+ Fdental la?/e.F
Access to Comre,ensi"e Dental Care
5,is +actor is ro-a-ly t,e most imortant o+ all re"enti"e otions. 4it,o/t t,e
-ene+it o+ a ro/tine eriodic dental e0amination, it is di++ic/lt +or indi"id/als to reali@e
t,at t,ey are "/lnera-le to oral disease. 5,e +irst indication o+ a dental ro-lem is
ain, w,ic, is t,e wron* startin* oint +or re"ention. An e0amle o+ t,e -ene+its o+
com-inin* re"ention wit, t,e ad"anta*es o+ early identi+ication, re"ention and
treatment is seen in t,e New Iealand sc,ool-dental-n/rse ro*ram. In t,e New
Iealand Sc,ool Dental Ser"ice, a dental n/rse "isits e"ery rimary and secondary
sc,ool in t,e co/ntry at aro0imately <-mont, inter"als. At t,at time, all c,ildren
recei"e a dental e0amination. I+ necessary, t,e dental n/rse alies +l/oride "arnis, to
ac,ie"e reminerali@ation o+ inciient caries, remo"es "isi-le calc/l/s, or w,en
indicated, re+ers t,e c,ild to a dentist +or more comle0 treatment re?/irements.
'%
As a res/lt o+ t,is ro*ram, t,e a"era*e rate o+ e0tractions droed +rom :; er :$$
st/dents in :;<$, to > er :,$$$ in :;%;. From :;%= /ntil :;;>, t,e a"era*e decayed,
missin*, or +illed ermanent teet, 7DMF58 +or :>- to :&-year-old c,ildren l/mmeted
+rom :$.% to :.(( er c,ild. Aro0imately ;<E o+ all New Iealand sc,oolc,ildren
are enrolled in t,is ro*ram. Un+ort/nately, relati"ely +ew comre,ensi"e rimary-
re"enti"e dentistry sc,ool ro*rams are -ein* cond/cted in t,e United States sc,ool
systems. Howe"er, t,ere are more t,an :,&$$ Sc,ool 1ased Dental Healt, Clinics
7S1DHC8 now in oeration in t,e United States 7see C,ater :;8.
Prognostic and Diagnostic Tests
Se"eral met,ods +or re"entin* t,e onset or ro*ress o+ caries and eriodontal disease
,a"e -een disc/ssed. 1eca/se it is imossi-le to aly "i*oro/sly all t,e re"enti"e
roced/res to all t,e eole all t,e time, it wo/ld -e desira-le to ,a"e some tests to
indicate t,e e0tent o+ caries and eriodontal disease ris* o+ an indi"id/al at any *i"en
time. 5,is need is ,i*,li*,ted -y t,e +act t,at an estimated 9:; o+ all cario/s lesions
in sc,oolc,ildren occur in <:; o+ t,e st/-dents.
'(
It wo/ld sa"e m/c, time to -e a-le
to identi+y t,is >$E *ro/ o+ ,i*,-risk st/dents wit,o/t ,a"in* to e0amine an entire
sc,ool o/lation. Alt,o/*, no tests are :$$E correlated wit, t,e e0tent o+ caries
acti"ity or eriodontal disease, se"eral test roced/res are s/++iciently well correlated
wit, eit,er condition to -e o+ interest. 5o -e s/ccess+/l, s/c, screenin* tests s,o/ld -e
simle to accomlis,, "alid, economical, re?/ire a minim/m o+ e?/iment, -e easy to
e"al/ate, and -e comati-le wit, mass-,andlin* tec,ni?/es.
.a-oratory met,ods e0ist +or co/ntin* t,e n/m-er o+ -acteria in t,e sali"a. I+ t,e
caries-ca/sin* m/tans stretococci or lacto-acilli co/nts are ,i*,, t,e indi"id/al +rom
w,om t,e samle was deri"ed can -e res/med to ,a"e a ,i*,er risk +or dental caries,
w,ereas a low co/nt ermits t,e oosite ass/mtion.
';
A second *eneral met,od +or
estimatin* caries s/sceti-ility is -y /se o+ a re+ined-car-o,ydrate dietary analysis to
7:8 e"al/ate t,e atientCs o"erall diet wit, secial attention to +ood re+erences and
amo/nts cons/med and 7>8 to determine i+ t,e intake o+ re+ined car-o,ydrates is
e0cessi"e in ?/antity or +re?/ency 7see Aendi0 >=->8. A well--alanced diet is
ass/med to raise host resistance to all disease rocesses, w,ereas a +re?/ent and
e0cessi"e intake o+ re+ined car-o,ydrates 7i.e., s/*ar8 ,as -een associated wit, a ,i*,
risk o+ caries de"eloment. 5,e dietary analysis is "ery e++ecti"e w,en /sed as a */ide
+or atient ed/cation.
5,e onset o+ $in$ivitis is m/c, more "isi-le t,an t,e early deminerali@ation t,at
occ/rs in caries. 5,e si*n o+ imendin* eriodontal disease is an in+lammation o+ t,e
*in*i"a t,at can -e locali@ed at one site, or *enerali@ed aro/nd all t,e teet,. !ed,
-leedin*, swollen, and a sore *in*i"a are readily aarent to dentist and atient alike.
Remineralization of Teeth
1ot, deminerali@ation and reminerali@ation occ/r daily +ollowin* t,e cyclic e---and-
+low o+ t,e caries rocess d/rin* and a+ter eatin* meals and snacks. An e"ent/al
caries lesion de"elos over a period of time w,en t,e rate o+ acid-ind/ced
deminerali@ation o+ teet, e0ceeds t,e caa-ility o+ t,e sali"a to reminerali@e t,e
dama*ed enamel comonents. A ne*ati"e mineral -alance at t,e enamel-la?/e
inter+ace, i+ contin/ally reeated, res/lts in an inciient lesion t,at e"ent/ally can
-ecome an o"ert lesion. It o+ten re?/ires mont,s, or e"en years, +or t,e o"ert lesion to
de"elo.
<$,<:
D/rin* t,is time, /nder roer conditions, reminerali@ation can re"erse
t,e ro*ress o+ t,e caries +ront, wit, t,e mineral comonents comin* +rom t,e sali"a.
5,ere is a ,ysiolo*ical recedent +or s/c, a minerali@ation. Immediately a+ter
er/tion o+ t,e teet, t,e o/ter layer o+ t,e enamel is not comletely minerali@edD t,e
mat/ration 7minerali@ation8 o+ t,is o/ter layer re?/ires aro0imately : year, d/rin*
w,ic, time t,e toot, is contin/o/sly -at,ed in t,e sali"a.
5,e oint at w,ic, a de"eloin* caries lesion is no lon*er re"ersi-le is considered to
-e w,en cavitation occ/rsD clinical e0erience indicates t,at as lon* as t,e lesion is
inciient 7i.e., wit, no ca"itation8, reminerali@ation is ossi-le.
<>
5,e need to e0loit
t,is ossi-ility to t,e -ene+it o+ all atients was em,asi@ed -y 2o/lo/ridesCs
statement many years a*o t,at Ft,ere is a wide *a -etween c/rrent ractices o+ many
dental clinicians and t,e otential alication o+ resent scienti+ic knowled*e to arrest
and re"erse inciient cario/s lesions.F
<=
5,e o/tstandin* electron microscoe researc, contri-/tions o+ Sil"erstone se"eral
decades a*o clearly demonstrated t,at deminerali@ed toot, str/ct/re co/ld -e
reminerali@ed.
<&
No lon*er was a simle interro0imal 0-ray radiol/cency a si*nal to
lace an interro0imal restoration. Se"eral reorts +rom Scandina"ia now indicate t,at
e"en w,en t,e caries +ront o+ an inciient lesion e0tends past t,e dentino-enamel
A/nction, it can -e reminerali@ed. Foster 73n*land8 ,as recommended F t,at
oerati"e inter"ention 7-e8 considered +or aro0imal lesions w,ic, e0tend deeper
t,at $.' mm into t,e dentine, w,ile preventive treatment and re2assessment may -e
considered +or shallo3er lesions.F
<'
Missin* at t,e resent time is an acc/rate
redicti"e test +or caries t,at wo/ld ermit t,e tar*etin* o+ indi"id/als w,o wo/ld -e
candidates +or reminerali@ation t,eray 7see C,ater >=8.
5,e conditions +or otim/m reminerali@ation are t,e same as +or re"entin* t,e
initiation o+ a lesion9 7:8 la?/e control to red/ce t,e n/m-er o+ cario*enic -acteria,
7>8 a strict sel+-imosed s/*ar disciline to minimi@e t,e n/m-er o+ acido*enic
eisodes, 7=8 t,e /se o+ sealants to interdict -acterial entry into dee its and +iss/res,
and 7&8 t,e /se o+ toical andBor systemic +l/oride to in,i-it deminerali@ation and to
otentiate t,e reminerali@ation rocess. 5,/s, wit, t,e same rimary re"enti"e
dentistry ro/tines /sin* +l/oride, an indi"id/al can simultaneously rotect t,e toot,
into t,e +/t/re -y re"ention, as well as to comensate +or limited ast dama*e
t,ro/*, re"ersal strate*ies.
Question 6
A. Sealants are most e++ecti"e in re"entin* smoot,-s/r+ace caries, w,ereas +l/orides
are most e++ecti"e in re"entin* caries in t,e dee occl/sal its and +iss/res.
1. 5,ere are eno/*, dentists and dental a/0iliaries in t,e United States to ro"ide
aro0imately : ,o/r er year o+ ed/cational lect/res to eac, o+ t,e >'$ million
citi@ens o+ t,e United States.
C. Caries acti"ity indicators 7tests8 are indicati"e o+ a atientCs "/lnera-ility at t,e
time o+ t,e test.
D. )la?/e control, s/*ar restriction, and toical-+l/oride t,eray not only are e++ecti"e
in re"entin* deminerali@ation, -/t t,ey also can en,ance reminerali@ation.
3. 5,e rocess o+ nat/ral minerali@ation 7mat/ration8 o+ enamel d/rin* t,e +irst year
a+ter er/tion is a recedent +or man-initiated reminerali@ation 7reair8 o+ inciient
lesions.
Summary
3ac, year more t,an f<$ -illion is sent in t,e United States +or dental care, mainly
+or t,e treatment o+ dental caries and eriodontal disease or t,eir se?/elae. Het,
strate*ies now e0ist t,at wit, atient knowled*e and cooeration, co/ld *reatly aid in
re"entin*, arrestin*, or re"ersin* t,e onset o+ caries or eriodontal disease. 5,e si0
*eneral aroac,es to t,e control o+ -ot, caries and eriodontal disease in"ol"e 7:8
la?/e control, 7>8 water +l/oridation and /se o+ +l/oride rod/cts +or sel+-care and +or
ro+essionally initiated reminerali@ation roced/res, 7=8 lacement, w,en indicated, o+
it and +iss/re sealants, and 7&8 s/*ar disciline. S/ortin* t,ese meas/res are 7'8
/-lic and ri"ate enterrise +inanced media distri-/ted ro*rams e0tollin* t,e
-ene+its o+ oral ,ealt, and rorietory rod/cts +or +amily re"entionD and 7<8 access
to a dental +acility w,ere dia*nosis, comre,ensi"e re"enti"e, restorati"e treatment,
and lanned recall and maintenance
c
ro*rams are a"aila-le. 5,e @eal and
t,oro/*,ness wit, w,ic, t,ese re"enti"e meas/res s,o/ld -e rescri-ed and /sed are
indicated -y t,e in+ormation o-tained +rom t,e clinical and roent*eno*ra,ic oral
e0amination, dietary analysis, atient ,istory, and la-oratory tests.
I+ at t,e time o+ t,e clinical and roent*eno*ra,ic e0aminations, em,asis was laced
on searc,in* o/t t,e inciient lesions 7Fw,ite sotsF8 and early eriodontal disease
7*in*i"itis8, re"enti"e strate*ies co/ld -e alied t,at wo/ld res/lt in a re"ersal or
control o+ eit,erBor -ot, o+ t,e la?/e diseases. It is essential t,at -ot, t,e ro+ession
and t,e /-lic reali@e t,at -iolo*ic FreairF o+ inciient lesions, and Fc/reF o+
*in*i"itis is a re+erred alternati"e to restorations or eriodontal treatment.
3"en i+ t,ese rimary re"enti"e dentistry roced/res +ail, toot, loss can still -e
a"oided. In ractice, t,e early identi+ication and e0editio/s treatment o+ caries and
eriodontal disease *reatly minimi@es t,e loss o+ teet,. 4,en s/c, ro/tine dia*nostic
and treatment ser"ices are linked wit, a dynamic re"enti"e-dentistry ro*ram t,at
incl/des an ann/al dental e0amination and recall ro*ram -ased on risk assessment,
toot, loss can realistically -e e0ected to -e red/ced to @ero or near-@ero.
5,is introd/ctory c,ater ,as -rie+ly ointed o/t some o+ t,e ro-lems o+ dentistry
and t,e means -y w,ic, t,e dental ro+ession can make rimary re"enti"e dentistry
its ,allmark. 5,e remainin* c,aters ro"ide t,e detailed -ack*ro/nd t,at can make
t,is c,allen*e -ecome a reality.
c
5,ere is a trend to consolidate t,e two terms, FrecallF and FmaintenanceF, into t,e
word, FrecareF.
Answers and Explanations
:. A, D, and 3correct.
1incorrect. 4it, salaries now escalatin*, may-e t,e oor +ellow ,as somet,in* to
worry a-o/tD t,e tr/e answer is t,at contin/ed worry is not ,ealt,y.
Cincorrect. An amal*am restoration is an e0cellent e0amle o+ secondary
re"ention, not tertiary.
>. A, 1, and Ccorrect.
Dincorrect. It is easier to red/ce t,e e0traction rate to @ero or near-@ero -y t,e
com-ined alication o+ treatment and re"enti"e roced/res, t,an to red/ce t,e
incidence o+ disease -y re"enti"e roced/res alone.
3incorrect. 5,e maAor income o+ a dentist is deri"ed +rom treatment o+ t,e la?/e
diseases and t,eir se?/elae.
=. 3correct.
Aincorrect. !estorations are not a rimary re"enti"e-dentistry otionD rat,er t,ey
are t,e mainstay o+ secondary re"ention.
1incorrect. )la?/e is +o/nd in t,e its and +iss/res o+ t,e occl/sal s/r+aces.
Cincorrect. )la?/e can -e remo"ed -y /se o+ toot,-r/s, and +lossD it is calc/l/s
remo"al t,at re?/ires instr/mentation.
Dincorrect. It is not ossi-le to remo"e oral de-ris +rom dee its and +iss/res.
&. A and Ccorrect.
1incorrect. Once calc/l/s ,as +ormed, ro+essional inter"ention is re?/ired +or its
remo"al.
Dincorrect. It is "ice "ersat,e more o+ten t,at +l/oride is alied toically
7denti+rices8, t,e more e++ecti"e it is.
3incorrect. !emem-er, -r/s,in* wit, a +l/oride denti+rice constit/tes a toical
alication.
'. A, 1, C, and 3correct.
Dincorrect. 1acteria re?/ire car-o,ydrates, +ats, roteins, minerals, and water to
e0istD t,ey need t,e car-o,ydrates +or t,eir ener*y needs, w,ic,, in t/rn, res/lts in
t,eir acid rod/ction and cario*enicity.
<. C, D, and 3correct.
Aincorrect. #/st t,e oosite. 5,e sealants are /sed to seal o++ t,e con"ol/ted its
and +iss/res o+ t,e occl/sal s/r+aces.
1incorrect. 5,e only means to romote re"enti"e dentistry to a total o/lation is
-y t,e /se o+ t,e sc,ools and t,e o/lar media.
Self-evaluation Questions
:. Healt, is de+ined as
iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii.
>. I+ rimary re"ention +ails, t,e two se?/ential actions necessary to minimi@e
ro*ression o+ a disease rocess are iiiiiii and iiiiiii.
=. For lannin* /roses, oral diseases and a-normalities can -e *ro/ed into t,ree
*eneral cate*ories9 7:8 iiiiiii, 7>8 iiiiiii, and 7=8 iiiiiii.
&. Fi"e strate*ies /sed to attain rimary re"ention in caries control are9 7:8 iiiiiii
7>8 iiiiiii, 7=8 iiiiiii, 7&8 iiiiiii, and 7'8 iiiiiii.
'. O+ t,e si0 *eneral met,ods +or caries control, t,e two t,at are also "al/a-le in
eriodontal disease control are 7:8 iiiiiii and 7>8 iiiiiii.
<. )la?/e control in a ,ome en"ironment re?/ires essential items or de"ices9 7:8
iiiiiii and 7>8 iiiiiii and 7=8 an irri*ator.
%. Caries de"eloment deends on +o/r interrelated +actors9 7:8 iiiiiii, 7>8 iiiiiii,
7=8 iiiiiii and 7&8 time.
(. Fl/oride is most e++ecti"e in re"entin* caries on 7smoot,87occl/sal8 s/r+aces o+ t,e
teet,, w,ereas lastic sealants are most e++ecti"e in re"entin* caries on 7smoot,8
7occl/sal8 s/r+aces o+ t,e teet,.
;. F1iolo*ic reairF o+ a toot, res/lts +rom a ositi"e mineral -alance at t,e enamel
s/r+aceD t,e rocess o+ relacin* t,e ions lost in deminerali@ation is known as
iiiiiii.
:$. Name t,ree American s/*ar s/-stit/tes and one +orei*n anticario*enic s/*ar
alco,ol /sed +or sweetenin*9 iiiiiii, iiiiiii, iiiiiii and iiiiiii.
References
:. U.S. S/r*eon GeneralCs !eort9 )art II. 7>$$$8. 4,at is t,e stat/s o+ oral ,ealt, in
America, ='-=;.
>. 3"ans, C. A., g 2leinman, D. 6. 7>$$$8. 5,e S/r*eon GeneralCs reort on
AmericaCs oral ,ealt,9 Oort/nities +or t,e dental ro+ession. "D, =:9:%>:->(.
=. Mil*rom )., g !eisine, S. 7>$$$8. Oral ,ealt, in t,e United States9 5,e ost-
+l/oride *eneration. nnu Rev Pu4lic Health, >:9&$=-=<.
&. 4att, !., g S,ei,am, A. 7:;;;8. Ine?/alities in oral ,ealt,9 A re"iew o+ t,e
e"idence and recommendations +or action. #r Dent " , :(%9<-:>.
'. .ocker, D. 7>$$$8. Deri"ation and oral ,ealt,. Community Dent +ral
!pidemiolo$y , >(9:<:-;.
<. Marcias, 3. )., g Morales, .. S. 7>$$:8. Crossin* t,e -order +or ,ealt, care. "
Health Care Poor Underserved , :>9%%-(%.
%. 4aldman, H. 1., g )erma,, S. ). 7>$$:8. Comm/nity--ased dental ser"ices +or
atients wit, secial needs. &. State Dent " , <%9=;-&>.
(. 4aldman, H. 1., g )erlman, S. ). 7>$$$8. )ro"idin* *eneral dentistry +or eole
wit, disa-ilitiesD a demo*ra,ic re"iew. 0en Dent , &(9'<<-;.
;. C,o, I. 7>$$$8. Disarity in o/r nationCs ,ealt,9 Imro"ed access to oral ,ealt, care
+or c,ildren. &. State Dent " , <<9=&-%
:$. Mo/radian, 4. 3., 4e,r, 3., g Crall, #. #. 7>$$$8. Disarities in c,ildrenCs oral
,ealt, and access to dental care. "% , >(&9><>'.
::. Gilcrist, #. A., 1r/mley, D. 3., g 1lack+ord, #. U. 7>$$:8. Comm/nity stat/s and
c,ildrenCs dental ,ealt,. "D , :=>9>:<->>.
:>. Newac,eck, ). 4., H/*,es, D. C., H/n*, 4. !., 4on*, S., g Stoddard, #. #.
7>$$$8. 5,e /nmet needs o+ AmericaCs c,ildren. Pediatrics , :$'9;(;-;%.
:=. 4arren, #. #., Cowen, H. #., 4atkins, C. M., g Hand, #. S. 7>$$$8. Dental caries
re"alence and dental care /tili@ation amon* t,e "ery old. "D , :=:9:'%:-;.
:&. Stearns, S. C., Sli+kin, !. 5., g 3din, H. M. 7>$$$8. Access to care +or r/ral
Medicare -ene+iciaries. " Rural Health, :<9:=:-&>.
:'. Hicks, M. #., Flait@, C. M., Carter, A. 1., Cron, S. G., !ossman, S. N., Simon, C.
.., Demmler, G. #., g 2line, M. 4. 7>$$$8. Dental caries in HI6-in+ected c,ildren9 a
lon*it/dinal st/dy. Pediatr Dent , >>9=';-<&.
:<. Gil-ert, G. H., Foerster, U., Dolan, 5. A., D/ncan, !. )., g !in*el-/r*, M. ..
7>$$$8. 5wenty-+o/r mont, coronal caries incidence9 5,e role o+ dental care and race.
Car Res, =&9=<%-%;.
:%. !eort o+ t,e Ad Hoc S/-committee to Coordinate 3n"ironmental Healt, and
!elated )ro*rams. !e"iew o+ Fl/oride 1ene+its and !isks. 4as,in*ton DC9 U.S.
Deartment o+ Healt, and H/man Ser"ices, U.S. )/-lic Healt, Ser"ice9 :;;:.
:(. 1lair, 2. ). 7:;;>8. Fl/oridation in t,e :;;$s. " m Coll Dent , ';9=.
:;. Mal"it@, D. M., g 1roderick, 3. 1. 7:;(;8. Assessment o+ a dental disease
re"ention ro*ram a+ter t,ree years. " Pu4l Health Dent , &;9'&-'%.
>$. N/ttal, N. M., Steele, #. G., )ine, C. M., 4,ite, D., g )itts, N. 1. 7>$$:8. 5,e
imact o+ oral ,ealt, on eole in t,e U2 in :;;(. #rit Dent " , :;$9:>:-<.
>:. S+ikas, ). M. 7:;;(8. In+ormed consent and t,e law. "D , :>;9:&%:-%=.
>>. Clarke, A., g Cooer, C. 7>$$:8. )syc,olo*ical re,a-ilitation a+ter dis+i*/rin*
inA/ry or diseaseD in"esti*atin* t,e trainin* needs o+ secialist n/rses. " dv &urs,
:9:(-><.
>=. )ersonal comm/nication, 3aster Seal Fo/ndation. San Antonio, 5GD :;;%.
>&. Mo/radian, 4. 3. 7:;;'8. 4,o decidese )atients, arents or *atekeeer9 )ediatric
decisions in t,e cranio+acial settin*. Cleft Palate Craniofac " , =>9':$-:&.
>'. Ha/*, !. H., g Foss #. 7>$$$8. Ma0illo+acial inA/ries in t,e ediatric atient. +ral
Sur$ +ral %ed +ral Path and +ral Radiol !ndod , ;$9:><-=&.
><. Healt, Care Financin* Administration 7HCFA8, National Healt, 30endit/res
)roAections9 :;;(->$$$. O++ice o+ t,e Act/ary. ,ttBBwww.,e+a.*o"BstatsBNH3-)roA,
Aril >'.
>%. Ca/+ield, ). 4., g Gri++en, A. .. 7>$$$8. Dental caries9 An in+ection and
transmissi-le disease. Pediatr Cln &orth m , &%9:$$:-:;.
>(. Gimene@-Fr"ie, .. A., Ho++a*ee, A. D., g Socransky, S. S. 7>$$$8 Comarison o+
t,e micro-iota o+ s/ra- and s/-*in*i"al la?/e in ,ealt, and eriodontitis. " Clin
Peridonol >%9<&(-'%.
>;. Fowler, 3. D., 1rea/lt, .. G., g C/enin, M. F. 7>$$:8. )eriodontal disease and its
associations wit, systemic disease. %il %ed :<<9('-(;.
=$. cNo a/t,or listedd 7>$$$8. )arameter on systemic conditions a++ected -y
eriodontal disease. ", Periodontol, >:9(($-=.
=:. 5omar, S. .., g .ester, A. 7>$$$8. Dental and ot,er ,ealt, care "isits amon* U.S.
ad/lts wit, dia-etes. Dia4etes Care, >>=9:'$'-:$.
=>. Scannaeco, F. A., HO, F. 4. 7>$$:8. )otential association -etween c,ronic
resiratory diseaseD analysis o+ National Healt, and N/trition 30amination S/r"ey III.
" Periodontol, ;>9:(=-(;.
==. MacFarlane, G. D., Her@-er*, M. C. 4ol++, .. F., g Hardie, N. A. 7:;;>8.
!e+ractory eriodontitis associated wit, a-normal le/cocyte ,a*ocytosis and
ci*arette smokin*. ", Periodontol , <=9;$(-:=.
=&. ./oma, H. 7:;;>8. C,lor,e0idine sol/tions, *els and "arnis,es in caries
re"ention. Proc 'inn Dent Soc , ((9:&%-'=.
='. 5wetman, S., g )etersson, .. G. 7:;;;8. Interdental caries incidence and
ro*ression in relation to m/tans stretococci s/ression a+ter c,lor,e0idine-t,ymol
"arnis, treatment in sc,ool c,ildren. cta +dontol Scand , '%9:&&-(.
=<. New-r/n, 3. 7:;;>8. C/rrent re*/lations and recommendations concernin* water
+l/oridation, +l/oride s/lements and toical +l/oride a*ents. " Dent Res, <%9:>''-
:><'.
=%. .etter9 F.-:=;, May :;;>. Deartment o+ Healt, and H/man Ser"ices. U.S.
)/-lic Healt, Ser"ice, Centers +or Disease Control and )re"ention9 May :;;>.
=(. Fa-ian, 6., O-ry-M/sset, A. M., Meddin, G., g Co,en, ). M. 7:;;<8. Caries
re"alence and salt +l/oridion amon* ;-year-old sc,ool c,ildren in Stras-o/r*,
France. Community Dent +ral !pidemiol , >&9&$(-::,
=;. 5wetman, S., Neder+ors, 5., g )etersson, .. C. 7:;;(8. Fl/oride concentrations in
w,ole sali"a and searate *land secretions in sc,ool c,ildren a+ter intake o+
+l/oridated milk. Car Res , =>9&:>-:<.
&$. Marino, !. 7:;;'8. S,o/ld we /se milk +l/oridatione A re"iew. #ull Pan m
Health +r$an , >;9>(%-;(.
&:. 1ratt,all, D., g 1arnes, D. 3. 7:;;'8. Addin* +l/oride to s/*ara new a"en/e to
red/ce dental caries, or a Fdead endFe dv Dent Res , ;9=-'.
&>. !osan, 1., g .amont, !. #. 7>$$$8. Dental la?/e +ormation. %icro4es /nfect ,
>9:';;-<$'.
&=. G/sta+sson, 1. 3., jensel, C. 3., .anke, .. S., ./n?rist, D., Gra,nen, H., 1onow,
1. 3., g 2rasse, 1. 7:;'&8. 5,e 6ie,old dental caries st/dy. cta +dont Scand,
::9>=>-><&.
&&. Sc,eie, A. A., g FeAersko", O. 1. 7:;;(8. Gylitol in caries re"ention9 w,at is t,e
e"idence +or clinical e++icacy. +ral Dis , &9>><-=$.
&'. 5an@er, #. M. 7:;;'8. Gylitol c,ewin* +/ms and dental caries. /nternat Dent " ,
&'9<'-(<.
&<. Honkala, S., Honkala, 3., 5ynAala, 2., g 2anas, .. 7:;;;8. 5,e /se o+ 0ylitol
c,ewin* */m amon* Finnis, sc,oolc,ildren. cta +dontolo$ Scand, '%9=$<-;.
&%. Hilde-randt, G. H., g Sarks, 1. S. 7>$$$8. Maintainin* m/tans stretococci
s/ression wit, 0ylitol c,ewin* */m. "D , :=:9;$;-:<.
&(. Isokan*es, )., Soderlin*, 3., )ieni,ekkinen, 2., g Alanen, ). 7>$$$8. Occ/rrence
o+ dental decay in c,ildren a+ter maternal cons/mtion o+ 0ylitol c,ewin* */m, a
+ollow-/ +rom $ to ' years o+ a*e. " Dent Res, >;9:(('-;.
&;. Anasa"ice, 2. #. 7:;;(8. C,lor,e0idine, +l/oride "arnis,, and 0ylitol c,ewin*
*/m9 /nder/tili@ed re"enti"e t,eraiese 0en Dent, :9=&-(, &$.
'$. Mert@-Fair,/rst, 3. #. 7:;;>8. )it and +iss/re sealantsD a *lo-al lack o+ scienti+ic
trans+ere c3ditorial ind " Dent Res , %:9:'&=-&.
':. Simonson, !. #. !etention and e++ecti"eness o+ a sin*le alication o+ w,ite
sealant a+ter :$ years 7:;(%8. "D , ::'9=:-<.
'>. Mert@-Fair,/rst, 3. #., S,/ster, G. S., g Fair,/rst, C. 4. 7:;(<8. Arrestin* caries
wit, sealants9 res/lts o+ a clinical st/dy. "D , ::>9:;&-=>=.
'=. j"ist, #., j"ist, 6., g MAor, I. A. 7:;;$8. )lacement and lon*e"ity o+ amal*am
restorations in Denmark. " Dent Res cSec Iss/ed, <;9>=% 7A-st. :$:(8.
'&. )ersonal comm/nication, American Dental Association, C,ica*o, :;;%.
''. )ersonal comm/nication, American Dental Hy*ienists Association, C,ica*o :;;%.
'<. 1est, H. A., g 1edi, !. 7>$$:8. Is t,e c/rrent access to ,ealt, care in+ormation
,elin* or ,inderin* e++ecti"e decision-makin* +or dentists and atientse G/idelines
+or dental ractice. Prim Dental Care , (9%%-($.
'%. Mac2en@ie, F. M., g )eterson, M. 7:;;&8. 5,e New Iealand Sc,ool Dental
Ser"ice. In Harris, N. O., g C,risten, A. G., 3ds. Primary preventive dentistry, 7&t,
ed.8 Norwalk, C59 Aleton g .an*e, <$:-'.
'(. Miller, A. #., g 1r/nelle, #. 7:;(=8. A s/mmary o+ t,e NID! Comm/nity Caries
)re"ention Demonstration )ro*ram. "D , :$%9><'-;.
';. 2rasse, 1. 7:;(&8. Can micro-iolo*ical knowled*e -e alied in dental ractice
+or t,e treatment and re"ention o+ dental cariese " Can Dent ssoc , '$9>>:->=.
<$. 1acker-Dirks, O. 7:;<:8. .on*it/dinal dental caries st/dy in c,ildren ;-:' years
o+ a*e. rch +ral #iol (Supp,), 99;&D:$(->%.
<:. Foster, .. H. 7:;;(8. 5,ree years in "i"o in"esti*atin* to determine t,e
ro*ression o+ aro0imal rimary cario/s lesions e0tendin* into dentine. #r Dent ",
:('9='=-%.
<>. 3lderton, !. #. 7:;;=8. O"ertreatment wit, restorati"e dentistry9 w,en to
inter"ene. " /nternat Dent, &=9>$-&.
<=. 2o/lo/rides, 5. I. 7:;%%8. 5o w,at e0tent is t,e inciient lesion o+ dental caries
re"ersi-lee In !owe N. H., 3d. )roceedin*s o+ Symosi/m on Inciient .esions in
3namel. Ann Ar-or, MID Uni"ersity o+ Mic,i*an Sc,ool o+ DentistryD No"em-er ::-
:>9':-<(.
<&. Sil"erstone, .. M. 7:;(&8. Si*ni+icance o+ reminerali@tion in caries re"ention. "
Can Dent ssoc, '$9:'<-:<<.
<'. Foster, .. 6. 7:;;(8. 5,ree year in "i"o in"esti*ation to determine t,e ro*ression
o+ aro0imal rimary cario/s lesions e0tendin* into dentine. #r Dent ", :('9='=-'%.
reser"ed.
Chapter 2. The Development and Structure of Dental Plaque (A Bacterial
Biofilm), Calculus, and Other Tooth-adherent Organic Materials - %ax ,
(ist$arten "onathan )orostoff
Objectives
t the end of this chapter it 3ill 4e possi4le to
:. Di++erentiate -etween or*anic coatin*s o+ endo$enous and exo$enous (ac5uired)
ori*in.
>. 30lain w,y dental la?/e is not /ni?/e amon* nat/rally occ/rrin* micro-ial
layers.
=. Disc/ss some o+ t,e mec,anisms roosed to e0lain 4acterial adhesion to t,e
ac5uired pellicle,
&. Distin*/is, -etween primary and secondary -acterial coloni@ers in dental la?/e,
and cite e0amles o+ eac,.
'. Identi+y t,e rime sites o+ calc/l/s +ormation, e0lain ,ow calc/l/s +orms, and
detail t,e di++erences -etween supra$in$ival and su4$in$ival calc/l/s.
<. 30lain t,e -asis +or t,e in"ol"ement o+ t,e ac?/ired ellicle, -acterial dental
la?/e, and dental calc/l/s in caries and t,e in+lammatory eriodontal diseases.
Introduction
5,e dental ro+ession ,as to deal wit, two o+ t,e most widesread o+ all ,/man
maladies, dental caries 7toot, decay8, and in+lammatory diseases o+ t,e eriodonti/m
7i.e., t,e s/ortin* tiss/es o+ t,e teet,8, *in*i"itis, and eriodontitis 7Fi*/re >-:8.
5,ese conditions are known to ,a"e a -acterial etiolo*y. Unlike some ot,er in+ectio/s
diseases, t,ese diseases are not ca/sed -y a sin*le at,o*enic microor*anism. Dental
caries and in+lammatory eriodontal diseases res/lt +rom t,e acc/m/lation o+ many
di++erent -acteria t,at +orm dental pla5ue,
:,>
a nat/rally ac?/ired -acterial -io+ilm t,at
de"elos on t,e teet, 7Fi*/re >->8. Some -acterial secies in dental la?/e may -e o+
*reater rele"ance to caries and eriodontal diseases t,an ot,ers. Dental la?/e cannot
-e remo"ed -y rinsin* alone -/t can -e remo"ed -y mec,anical de-ridement. 5,e
proportions o+ di++erent -acteria in la?/e +rom a ,ealt,y mo/t, are di++erent +rom
t,ose in la?/e associated wit, caries, and -ot, are di++erent +rom t,e dental la?/e o+
an indi"id/al wit, in+lammatory eriodontal disease.
=,&
I+ t,e role o+ dental la?/e in caries and in+lammatory eriodontal diseases is to -e
/nderstood,
',<
t,e lo*ical lace to start is -y e0aminin* ,ow dental la?/e +orms and,
as will -e disc/ssed in later c,aters, ,ow c,an*es in t,e roortions o+ di++erent
la?/e -acteria lead to oral disease.
Fi*/re >-: A :=-year-old +emale wit, dental caries on +acial s/r+ace o+ t,e
ma0illary incisors and swollen, discolored *in*i"al tiss/es aro/nd t,e
mandi-/lar incisors, c,aracteristic o+ c,ronic *in*i"itis.
7Co/rtesy o+ Dr. 42 Gri*s-y, Uni"ersity o+ Iowa Colle*e o+ Dentistry.8
Fi*/re >-> 5,e dental la?/e on t,ese teet, ,as -een stained wit, a discolorin*
sol/tion and rinsed. Note t,e resence o+ la?/e interro0imally and adAacent to
t,e *in*i"a, -/t relati"ely a-sent closer to t,e incisal ed*e. 7Co/rtesy o+ Dr. 42
Gri*s-y, Uni"ersity o+ Iowa Colle*e o+ Dentistry.8
Dental Plaque as One of Many Microbial Biofilms
Most nat/ral s/r+aces ,a"e t,eir own coatin* o+ microor*anisms or -io+ilm adated to
its indi"id/al ,a-itat. 5,e +eat/res o+ dental la?/e +ormation are -y no means /ni?/e
and merely re+lect a sin*le instance o+ a widesread and ancient nat/ral ,enomenon.
One o+ t,e +irst known e0amles o+ li+e are minerali@ed -acteria or al*ae
%,(
+o/nd on
rocks +rom t,e )recam-rian era. 5,ese are ?/ite similar to dental calc/l/s. 5,e
,ysicoc,emical and -ioc,emical interactions t,at /nderlie -acterial ad,esion
elsew,ere in nat/re are t,e same as t,ose o-ser"ed in la?/e +ormation.
;-::
For
e0amle, all li"in* cells, incl/din* -acterial cells, ,a"e a net ne$ative surface char$e,
5,e cells can, t,ere+ore, -e attracted to oositely c,ar*ed s/r+aces on s/c, items as
rocks in a stream, skin, or teet,. As wit, la?/e -acteria, or*anisms in ot,er
en"ironments can rod/ce e0tracell/lar coatin*s or slime layers, or a "ariety o+
s/r+ace +i-rils or aenda*es e0tendin* +rom t,eir cell walls t,at mediate t,eir
attac,ment to t,e s/-strate.
;,:>
In resonse to en"ironmental conditions and interactions wit, ot,er mem-ers o+ t,e
micro-ial comm/nity, -io+ilm -acteria -e,a"e di++erently +rom lanktonic 7li?/id-
,ase8 cells. 5,is ,as si*ni+icant clinical imlications. C/rrent researc, indicates t,at
-acteria *rowin* in -io+ilms are more resistant to t,e e++ects o+ ,ost de+ense
mec,anisms and e0o*eno/s antimicro-ial a*ents w,en comared to t,e same cells in
a li?/id s/sension.
:=,:&,:'
5,/s, it -ecomes o+ aramo/nt imortance to mec,anically
dist/r- t,e -io+ilm w,en /tili@in* antimicro-ial t,eray.
Bacterial Colonization of the Mouth
Microor*anisms initially coloni@e t,e mo/t, d/rin* -irt,, -ein* nat/rally ac?/ired
+rom t,e mother, 5,erea+ter, -acteria are ac?/ired +rom t,e atmos,ere, +ood, ,/man
contact, and e"en +rom animal contacts 7e.*., ets8. 5,e -acteria s/-se?/ently
coloni@e inter+aces -etween sali"a and -ot, oral so+t 7e.*., *in*i"a, ton*/e, c,eeks,
and alimentary tract8 and ,ard tiss/es 7e.*., er/ted teet,8. M/cosal s/r+aces o+ t,e
ton*/e and tonsils may ser"e as reser"oirs +or dental la?/e-+ormin* or*anisms,
incl/din* t,ose related to disease.
:<
4it, increasin* a*e and imroer toot,-r/s,in*, *in*i"al recession may occ/r and
res/lt in t,e e0os/re o+ root cement/m and dentin. 5,ese s/r+aces, like enamel, may
-ecome coloni@ed -y oral -acteria t,at can tri**er dental caries.
)rior to er/tion, t,e enamel is lined -y remnants o+ t,e enamel-+ormin* or*an,
namely t,e reduced enamel epithelium and the 4asal lamina t,at connects it to t,e
enamel s/r+ace. 5,e -asal lamina is also contin/o/s wit, or*anic material t,at +ills t,e
microscoic "oids in t,e s/er+icial enamel. 5,is s/-s/r+ace material aears as a
+rin*e attac,ed to t,e -asal lamina and is comosed o+ resid/al enamel matri0
roteins 7Fi*/res >-=, >-&8. It is re+erred to as a su4surface pellicle, 1eca/se it
ori*inates +rom local cells d/rin* toot, +ormation, it is considered to -e o+
endo$enous ori*in. 4,en t,e toot, emer*es into t,e oral ca"ity, t,e remnants o+ t,e
red/ced enamel eit,eli/m are worn o++ or di*ested -y sali"ary and -acterial
en@ymes. 5,e /nderlyin* enamel -ecomes e0osed to sali"a and t,e oral micro-iota.
Sali"ary comonents -ecome adsor-ed to e0osed enamel 3ithin seconds, +ormin* a
microscoic coatin* o"er t,e e0osed toot, s/r+ace. 5,is t,in coatin* can
s/-se?/ently -ecome coloni@ed -y oral -acteria. 1eca/se t,is coatin* ori*inates +rom
sali"ary roteins rat,er t,an t,e dental or*an, it is considered to -e o+ exo$enous
ori*in. 5,/s, t,e toot, s/r+ace is almost always coated -y a "ariety o+ str/ct/res t,at
are eit,er o+ endo*eno/s ori*in 7i.e., deri"ed +rom cells o+ t,e dental or*an8 or o+
e0o*eno/s ori*in 7i.e., ac?/ired +ollowin* er/tion o+ t,e teet, into t,e oral ca"ity8.
:%
Fi*/re >-= 5,is transmission electron micro*ra, demonstrates remnants o+ t,e
s/-s/r+ace ellicle 7SS)8 and t,e ac?/ired ellicle 7A)8 -etween t,e enamel
73S8 s/r+ace and t,e -acterial cells 718 o+ t,e dental la?/e. 7Co/rtesy o+ Dr.
MA .ist*arten, Uni"ersity o+ )ennsyl"ania Sc,ool o+ Dental Medicine.8
Fi*/re >-& #/nction o+ red/ced enamel eit,eli/m and enamel. 5,e red/ced
amelo-lasts 7!A8 are attac,ed to t,e enamel -y ,emidesmosomes 7HD8 and a
-asal lamina 71.8. 3M, enamel matri0 remnants +orm a s/-s/r+ace ellicleD 3S,
enamel sace. &',$$$. 7Co/rtesy o+ Dr. MA .ist*arten, Uni"ersity o+
)ennsyl"ania Sc,ool o+ Dental Medicine.8
The Acquired Pellicle
5,e coatin* o+ sali"ary ori*in t,at +orms on e0osed toot, s/r+aces is called t,e
ac5uired pellicle,
:(,:;
It is acell/lar and consists rimarily o+ *lycoroteins
a
deri"ed
+rom sali"a 7Fi*/re >-=8. 5,e ellicle also occ/ies t,e millions o+ microscoic "oids
in t,e er/ted toot, ca/sed -y c,emical and mec,anical interactions o+ t,e toot,
s/r+ace wit, t,e oral en"ironment. Collecti"ely t,ese or*anic +rin*e-like roAections
+orm a su4surface pellicle, w,ic, is o+ exo$enous or ac?/ired ori*in. Oral +l/ids and
small molec/les can slowly di++/se t,ro/*, t,e ac?/ired ellicle into t,e s/er+icial
enamel. I+ t,e ellicle is dislaced, +or e0amle -y a ro,yla0is, it -e*ins to re+orm
immediately.
>$,>:
It takes a-o/t a week +or t,e ellicle to de"elo its condensed,
mat/re str/ct/re w,ic, may also incororate -acterial rod/cts.
>>->&
An ac?/ired ellicle also +orms on arti+icial s/r+aces, incl/din* dental restorations and
dent/res. 5,ese or*anic coatin*s are similar to t,e ellicles on nat/ral teet, and may
-e coloni@ed -y -acteria.
>'->%
Coloni@ation o+ t,e ac?/ired ellicle can -e -ene+icial
+or t,e -acteria -eca/se t,e ellicle comonents can ser"e as n/trients.
>(
For e0amle,
roline-ric, sali"ary roteins may -e de*raded -y -acterial colla*enases,
>;
releasin*
etides, +ree amino acids, and sali"ary m/cins t,at may en,ance t,e *rowt, o+ dental
la?/e or*anisms, s/c, as actinomycetes and siroc,etes.
=$
5,e car-o,ydrate comonents o+ certain ellicle *lycoroteins may ser"e as recetors
+or -acterial--indin* roteins s/c, as adhesins, t,ere-y contri-/tin* to -acterial
ad,esion to t,e toot,.
=:-==
5,ere is cometition +or t,e -indin* sites on t,e ellicle, not
only -y recetors on -acteria, -/t also +rom host proteins, incl/din* imm/no*lo-/lins
7i.e., anti-odies8, roteins o+ t,e comlement system, and t,e en@yme lyso1yme, 5,ese
,ost roteins ori*inate +rom sali"a and *in*i"al s/lc/s +l/id.
=&,='
Once a ellicle site is
occ/ied -y one o+ t,e cometin* entities, occ/ancy -y anot,er is in,i-ited.
=<
Not
only does cometition arise +or occ/ancy o+ -indin* sites, -/t an anta*onistic
relations,i o+ten e0ists -etween di++erent tyes o+ -acteria cometin* +or t,e -indin*
sites. For e0amle, it ,as -een s,own t,at some stretococci synt,esi@e and release
4acteriocins, w,ic, can in,i-it some strains o+ ctinomyces
=%
and ctino4acillus
secies.
=(
a
A *lycorotein is a rotein molec/le t,at incl/des an attac,ed car-o,ydrate
comonent.
Dental Plaque Formation
All -acteria t,at initiate la?/e +ormation come in contact wit, t,e or*anically coated
toot, s/r+ace +ort/ito/sly. Forces e0ist t,at tend to allow -acteria to acc/m/late on
teet, or to remo"e t,em. S,i+ts in t,ese +orces determine w,et,er more or less la?/e
acc/m/lates at a *i"en site on a toot,. Many +actors in+l/ence t,e -/ild-/ o+
la?/e,
=;
ran*in* +rom simle +actors, s/c, as mec,anical dislacement, sta*nation
7i.e., coloni@ation in a s,eltered or /ndist/r-ed en"ironment8, and a"aila-ility o+
n/trients, to comle0 +actors, incl/din* interactions -etween t,e micro-es and t,e
,ostCs in+lammatory-imm/ne systems. 1acteria tend to -e remo"ed +rom t,e teet,
d/rin* mastication o+ +oods, -y t,e ton*/e, toot,-r/s,in*, and ot,er oral-,y*iene
acti"ities. For t,is reason, -acteria tend to acc/m/late on teet, in s,eltered,
/ndist/r-ed en"ironments 7sites at risk8, s/c, as t,e occl/sal +iss/res, t,e s/r+aces
aical to t,e contact -etween adAacent teet,, and in t,e *in*i"al s/lc/s.
Question 1
4,ic, o+ t,e +ollowin* statements, i+ any, are tr/ee
A. 5,e ac?/ired ellicle is a layer o+ cells on t,e external surface o+ t,e clinical
crown o+ t,e toot,.
1. Sali"ary *lycoroteins are a maAor so/rce o+ or*anic materials in t,e ac?/ired
ellicle.
C. 1acteria rod/ce en@ymes t,at may de*rade some o+ t,e ac?/ired ellicle
comonents s/c, as roteins.
D. It /s/ally takes several days -e+ore t,e ac?/ired ellicle is re+ormed a+ter a
ro,yla0is.
3. 5,e resence o+ imm/no*lo-/lins in t,e ac?/ired ellicle */arantees t,at t,e
ac?/ired ellicle will remain +ree +rom -acterial coloni@ation.
5,ere+ore, it is no coincidence t,at t,e maAor la?/e--ased diseases, caries and
in+lammatory eriodontal diseases, arise at t,ese sites w,ere la?/e is most a-/ndant
and sta*nant. Initial la?/e +ormation may take as lon* as > ,o/rs.
&$
1indin* sites and
indi"id/al strain a++inity +or a *i"en s/r+ace "ary considera-ly.
&:,&>
Coloni@ation
-e*ins as a series o+ isolated colonies, o+ten con+ined to microscoic toot, s/r+ace
irre*/larities.
>=
4it, t,e aid o+ n/trients +rom sali"a and ,ost +ood, t,e coloni@in*
-acteria -e*in to m/ltily. A-o/t > days are t,en re?/ired +or t,e la?/e to do/-le in
mass, d/rin* w,ic, time, t,e -acterial colonies ,a"e -een coalescin*.
&=
5,e most
dramatic c,an*e in -acterial n/m-ers occ/rs d/rin* t,e +irst & or ' days o+ la?/e
+ormation.
&&,&'
A+ter aro0imately >: days, -acterial relication slows so t,at la?/e
acc/m/lation -ecomes relati"ely sta-le.
&<
5,e increasin* t,ickness o+ t,e la?/e
limits t,e di++/sion o+ o0y*en to t,e entraed ori*inal, o0y*en-tolerant o/lations.
As a res/lt, t,e or*anisms t,at s/r"i"e in t,e deeer asects o+ t,e de"eloin* la?/e
are eit,er facultative or o4li$ate anaero4es,
-
5,e +ormin* -acterial colonies are raidly co"ered -y sali"a.
&%
4,en seen wit, t,e
scannin* electron microscoe, *rowin* colonies rotr/de +rom t,e s/r+ace o+ t,e
la?/e as domes, *i"in* t,e aearance o+ a cl/ster o+ i*loos -eneat, newly +allen
snow 7Fi*/re >-'8. In indi"id/als wit, oor oral ,y*iene, s/er+icial dental la?/e
may incororate +ood de-ris and mammalian cells s/c, as des?/amated eit,elial
cells and le/kocytes. 5,is de-ris is called materia al4a 7literally, Fw,ite matterF8.
Unlike la?/e, it is /s/ally remo"ed easily -y rinsin* wit, water.
:(
At times, t,e
la?/e demonstrates stainin*, wit, t,e discoloration -ein* ca/sed -y so/rces
incl/din* tea, ,ea"y metal salts, dr/*s, and c,romo*enic -acteria.
-
Fac/ltati"e anaero-es can e0ist in an en"ironment wit, or wit,o/t o0y*enD o-li*ate
anaero-es cannot e0ist in an en"ironment wit, o0y*en.
Fi*/re >-' Scannin* electronmicro*ra, o+ dome +ormation in t,e la?/e.
7From 1rady, #. M. " Periodontol, :;%=, &&9&:<-&>(.8
Molecular Mechanisms of Bacterial Adhesion
5,e initial -acterial attac,ment to t,e ac?/ired ellicle 7Fi*/re >-< A8 is t,o/*,t to
in"ol"e ,ysicoc,emical interactions 7e.*., electrostatic +orces and ,ydro,o-ic
-ondin*8
&(-':
-etween molec/les or ortions o+ molec/les, s/c, as t,e side c,ains o+
t,e amino acids ,enylalanine and le/cine. It ,as -een s/**ested t,at t,e
,ydro,o-icity o+ some stretococci, a maAor la?/e *ro/, is ca/sed -y cell wall-
associated molec/les incl/din* $lucosyltransferase, an en@yme t,at con"erts t,e
*l/cose ortion o+ t,e s/*ar, s/crose, into e0tracell/lar olysacc,aride. Some
*l/cosyltrans+erases ,a"e -een desi*nated as hydropho4ins,
'>
Anot,er molec/lar mec,anism o+ -acterial ad,esion is calcium 4rid$in$
'=-''
w,ic,
links ne$atively c,ar*ed -acterial cell s/r+aces to t,e ne$atively c,ar*ed ac?/ired
ellicle 7Fi*/re >-< 18 "ia interosed ositi"ely c,ar*ed, di"alent calci/m ions +rom
t,e sali"a. Calci/m -rid*in* may only -e imortant in early la?/e +ormation,
-eca/se recently +ormed la?/e is readily disr/ted -y e0os/re to a calci/m-
comle0in* 7chelatin$8 a*ent, s/c, as et,ylenediaminetetraacetic acid 73D5A8.
'<
Some o+ t,e stretococci in la?/e /se t,e en@yme *l/cosyltrans+erase to synt,esi@e
e0tracell/lar olysacc,arides 73C)8. Amon* t,ese are FstickyF $lucans t,at, t,ro/*,
,ydro*en -ondin*, are t,o/*,t to contri-/te to t,e mediation o+ -acterial ad,esion
7Fi*/re >-< C8.
'%
Once t,e -acteria ad,ere, t,ey are o+ten Fentom-edF as additional
*l/can is rod/ced.
'(
1acteria also e0,i-it e0ternal cell s/r+ace roteins termed adhesins,
==,';
t,at ,a"e
lectin-like
c
acti"ity as t,ey can -ind to car-o,ydrate comonents o+ *lycoroteins.
=>,<$

5,ese molec/les, w,ic, some researc,ers ,a"e s/**ested may -e located on -acterial
s/r+ace aenda*es, s/c, as +im-riae
<:
7Fi*/r e >-< D8, are -elie"ed to +acilitate
coloni@ation o+ t,e ac?/ired ellicle.
<>
Fim-ria-associated ad,esins ro-a-ly mediate
-acterial ad,esion "ia ionic or ,ydro*en--ondin* interactions. Ad,esins and +im-riae
may +/nction to*et,er to romote -acterial attac,ment to ellicle-coated s/r+aces.
<=

For e0amle, pilin, a str/ct/ral rotein t,at constit/tes t,e -/lk o+ some +im-riae, is
,ydro,o-ic -eca/se o+ its amino-acid content.
<&
5,ese +i-rillar s/r+ace aenda*es
e0tend +rom t,e -acterial s/r+ace and may reduce or mas* t,e reellin* e++ect o+ t,e
net ne*ati"e s/r+ace c,ar*es. Car-o,ydrate--indin* ad,esins ,a"e -een s,own to link
actinomycetes to stretococci in early dental-la?/e +ormation.
<',<<
4,ile some or all o+ t,e a-o"e-descri-ed mec,anisms may lay a role in t,e
attac,ment o+ -acteria to one anot,er and to t,e toot, s/r+ace, t,e nat/re o+ t,e act/al
linkin* molec/les in la?/e, or -etween la?/e and toot, s/r+ace coatin*s is not
known.
c
.ectins are lant roteins wit, recetor sites t,at -ind seci+ic s/*ars.
Fi*/re >-< 5,is dia*ram ill/strates some o+ t,e ossi-le molec/lar mec,anisms
mediatin* -acterial attac,ment to teet, d/rin* dental la?/e +ormation. A. A side
c,ain o+ a ,enylalanine comonent o+ a -acterial rotein interacts "ia
,ydro,o-ic -ondin* wit, a side c,ain o+ a le/cine comonent o+ a sali"ary
*lycorotein in t,e ac?/ired ellicle. B. 5,e ne*ati"ely c,ar*ed car-o0yl *ro/
o+ a -acterial rotein is attracted to a ositi"ely c,ar*ed calci/m ion 7i.e.,
electrostatic attraction8, w,ic, in t/rn is attracted to a ne*ati"ely c,ar*ed
,os,ate *ro/ o+ a sali"ary ,os,orotein in t,e ac?/ired ellicle. C. 5,e
,ostCs dietary s/crose is con"erted -y t,e -acterial en@yme, *l/cosyltrans+erase,
to t,e e0tracell/lar olysacc,aride, *l/can, w,ic, ,as many ,ydro,o-ic *ro/s
and can interact wit, amino acid side-c,ain *ro/s, s/c, as serine, tyrosine, and
t,reonine. D. 5,e +im-rial s/r+ace aenda*e e0tends +rom t,e -acterial cell to
ermit t,e terminal ad,esin ortion to -ind to a s/*ar comonent o+ a sali"ary
*lycorotein in t,e ac?/ired ellicle.
Bacteria in the Dental Plaque
)la?/e -acteria "ary in n/m-er and roortions +rom time to time and +rom site to site
wit,in t,e mo/t, o+ any one indi"id/al. 5,e di"ersity is e"en *reater -etween
indi"id/als,
<%
-etween races,
<(
and -etween s/ra- and s/-*in*i"al la?/es.
<;
5,e only
a-/ndant -acteria +o/nd almost /ni"ersally in t,e mo/t,s o+ ,/mans and animals are
stretococci and actinomycetes.
5,e -acteria coloni@e t,e teet, in a reasona-ly predicta4le se?/ence. 5,e +irst to
ad,ere are primary coloni1ers, sometimes re+erred to as ioneer secies. 5,ese are
microor$anisms t,at are a-le to stick directly to t,e ac?/ired ellicle. 5,ose t,at
arri"e later are secondary coloni1ers, 5,ey may -e a-le to coloni@e an e0istin*
-acterial layer, -/t t,ey are /na-le to act as rimary coloni@ers. Generally seakin*,
t,e rimary coloni@ers are not at,o*enic. I+ t,e la?/e is allowed to remain
/ndist/r-ed, it e"ent/ally -ecomes o/lated wit, secondary coloni@ers t,at are t,e
likely etiolo*ic a*ents o+ caries, *in*i"itis, and eriodontitis, t,e destr/cti"e +orm o+
in+lammatory eriodontal disease.
5,e earliest coloni@ers are o"erw,elmin*ly cocci 7i.e., s,erical cells8,
:,<;,%$
esecially
stretococci, w,ic, constit/te &% to ('E o+ t,e c/lti"a-le cells +o/nd d/rin* t,e +irst
& ,o/rs a+ter ro+essional toot, cleanin*.
%:
5,ese tend to -e +ollowed -y s,ort rods
and +ilamento/s -acteria. 1eca/se o+ sta*nation, t,e most a-/ndant coloni@ation is on
t,e ro0imal s/r+aces, in t,e +iss/res o+ teet,, and in t,e *in*i"al s/lc/s re*ion.
%>
Cocci are ro-a-ly t,e +irst to ad,ere -eca/se t,ey are small and ro/nd and, t,ere+ore,
,a"e a smaller ener*y -arrier to o"ercome t,an ot,er -acterial +orms.
%=
5,e +irst or
rimary coloni@ers tend to -e aero4ic 7i.e., o0y*en-tolerant8 -acteria incl/din*
&eisseria and Rothia, 5,e stretococci, t,e Gram-ositi"e +ac/ltati"e rods, and t,e
actinomycetes are t,e main or*anisms in -ot, early +iss/re and aro0imal la?/e.
%=-%'
As la?/e o0y*en le"els +all, t,e roortions o+ Gram-ne*ati"e rods, +or e0amle
+/so-acteria, and Gram-ne*ati"e cocci s/c, as =eillonella tend to increase.
O+ t,e early coloni@ers, Streptococcus san$uis o+ten aears +irst,
%<
+ollowed -y S,
mutans, 1ot, deend on a s,eltered en"ironment +or *rowt, and t,e resence o+
e0tracell/lar car-o,ydrate 7e.*., s/crose8. S/crose is /sed to synt,esi@e intracellular
olysacc,arides t,at ser"e as an internal so/rce o+ ener*y, as well as e0ternal
olysacc,aride coats.
%%,%(
5,e olysacc,aride coatin* ,els rotect t,e cell +rom t,e
osmotic e++ects o+ s/crose. In addition, it red/ces t,e in,i-itory e++ect o+ to0ic
meta-olic end products, s/c, as lactic acid, on -acterial s/r"i"al.
4,ereas nonmotile cells, incl/din* stretococci and actinomycetes, come into contact
wit, t,e toot, randomly, motile cells s/c, as t,e siroc,etes are likely to -e attracted
-y chemotactic +actors 7e.*., n/trients8. S/r+ace recetors ro-a-ly ro"ide a means o+
attac,ment +or secondary coloni@ers onto the initial 4acterial layer,
%;
1acteria t,at
cannot ad,ere easily to t,e toot, initially "ia or*anic coatin*s can ro-a-ly attac, -y
stron* lectin-like, cell-to-cell interactions wit, similar or dissimilar 4acteria t,at are
already attac,ed 7i.e., t,e rimary coloni@ers8.
==,($,(:
Gram-ne*ati"e, anaero4ic 7e.*., o0y*en-intolerant8 secies redominate in t,e
su4$in$ival la?/e d/rin* t,e later ,ases o+ la?/e de"eloment,
(>
-/t t,ey may also
-e resent in early la?/e, +or e0amle, Treponema, Porphyromonas, Prevotella, and
'uso4acterium secies. 5,ere is e"idence t,at o0y*en does not enetrate more t,an
$.: mm into t,e dental la?/e,
(=,(&
a +act t,at may e0lain t,e resence o+ anaero-ic
-acteria in early la?/e.
Question 2
4,ic, o+ t,e +ollowin* statements, if any, are correcte
A. An imortant criterion +or s/ccess+/l -acterial coloni@ation o+ teet, is t,e
a"aila-ility o+ an /nocc/ied -indin* site.
1. Sites on teet, at risk +or dental la?/e +ormation incl/de t,e occl/sal +iss/res,
aro0imal s/r+aces apical to t,e contact oint -etween adAacent teet,, and t,e
*in*i"al s/lc/s re*ion.
C. An oerational de+inition +or materia al-a is Ft,e ad,erent material on toot,
s/r+aces t,at can -e remo"ed -y rinsin$,F
D. D/rin* initial +ormation o+ dental la?/e, ne*ati"e c,ar*es on -acterial cells are
attracted to t,e ne*ati"e c,ar*es o+ t,e ac?/ired ellicle.
3. 5,e o-ser"ation t,at calci/m-comle0in* a*ents release recently +ormed dental
la?/e +rom t,e teet, s/orts t,e ar*/ment +or calcium 4rid$in$,
Dental-Plaque Matrix
A *reat "ariety o+ +actors a++ect t,e coloni@ation o+ t,e teet, -y -acteria. Dental
la?/e consists o+ di++erent secies o+ -acteria t,at are not /ni+ormly distri-/ted, since
di++erent secies coloni@e t,e toot, s/r+ace at di++erent times and /nder di++erent
circ/mstances. 5,e newly +ormed s/ra*in*i"al -io+ilm +re?/ently e0,i-its
FalisadesF 7i.e., col/mnar microcolonies o+ cells8 o+ +irmly attac,ed cocci, rods, or
+ilaments. 5,e or*anisms are ositioned erendic/lar to t,e toot, s/r+ace,
:,<;,('
t,e
res/lt o+ cometiti"e coloni@ation. 5,e -acterial cells in t,e -io+ilm are s/rro/nded -y
an intercellular pla5ue matrix 7Fi*/re >-%8.
'<
5,e matri0 is comosed o+ -ot, or*anic
and inor*anic comonents t,at ori$inate primarily from the 4acteria, )olysacc,arides
deri"ed +rom -acterial meta-olism o+ car-o,ydrates are a maAor constit/ent o+ t,e
matri0 w,ile sali"ary and ser/m roteinsB*lycoroteins reresent minor comonents.
5,e -acteria in t,e s/-*in*i"al -io+ilm consist o+ se"eral motile secies t,at do not
+orm distincti"e microcolonies. 5,ey tend to -e located on t,e s/r+ace o+ t,e ad,erent
-acterial layer and are searated -y an a-/ndant intercell/lar matri0. Some -acteria
on t,e s/r+ace o+ t,e -io+ilm a**re*ate into distincti"e str/ct/res t,at incl/de
arran*ements o+ cocci 7Fcorn-co-F con+i*/rations8 and rods 7Ftest-t/-e -r/s,F
con+i*/rations8
:,>,<;,(<
radially arran*ed aro/nd a central +ilament 7Fi*/re >-(8.
Fi*/re >-% An electron micro*ra, s,owin* alisades 7)8 o+ -acteria
erendic/lar to t,e enamel s/r+ace 73S8, -acterial cells t,at are ro-a-ly
secondary coloni@ers 7SC8, t,e intercell/lar la?/e matri0 7I)M8, and t,e
ac?/ired ellicle 7A)8. 7Co/rtesy o+ Dr. MA .ist*arten, Uni"ersity o+
Fi*/re >-( A. Cross section o+ Fcorn co-F +rom >-mont,-old la?/e. A coarse
+i-rillar material attac,es t,e cocci 7C8 to t,e central +ilament 7CF8. Ori*inal
ma*ni+ication >>,'$$. 7From .ist?arten, M. A., Mayo, H. 3., 5rem-lay, !. "
Periodontol, :;%'D &<9:$-><.8 B. Coarse Ftest-t/-e -r/s,F +ormations consistin*
o+ central +ilament 7CF8 s/rro/nded -y lar*e, eritric,o/sly +la*ellated
+ilamento/s -acteria 7.F8. 1ack*ro/nd consists o+ a siroc,ete-ric, micro-iota
7S8. Ori*inal ma*ni+ication &,=$$. 7From .ist*arten M. A. " Periodontol,
:;%<D &%, :-:(.8
Dental-Plaque Metabolism
For meta-olism to occ/r, a so/rce o+ ener*y is re?/ired. For t,e caries-related S,
mutans and many ot,er acid-+ormin* or*anisms, t,is ener*y so/rce can -e sucrose,
(%

Almost immediately +ollowin* e0os/re o+ t,ese microor*anisms to s/crose, t,ey
rod/ce 7:8 acid, 7>8 intracell/lar olysacc,arides 7IC)8, t,at ro"ide a reser"e so/rce
o+ ener*y +or eac, -acteri/m, m/c, like *lyco*en does +or ,/man cells,
((
and 7=8
e0tracell/lar olysacc,arides incl/din* *l/cans 7de0tran8
(;
and +r/ctans 7le"an8.
;$

Gl/cans can -e "iscid s/-stances t,at ,el anc,or t,e -acteria to t,e ellicle, as well
as sta-ili@e t,e la?/e mass. Fr/ctans can act as an ener*y so/rce +or any -acteria
,a"in* t,e en@yme le"anase.
;:,;>
j/antitati"ely, t,e *l/cans constit/te / to
aro0imately >$E o+ la?/e dry wei*,t, le"ans a-o/t :$E, and -acteria t,e
remainin* %$ to ($E. As mentioned re"io/sly, t,e *l/cans and +r/ctans are maAor
contri-/tors to t,e intercellular pla5ue matrix,
;>
)la?/e or*anisms *row /nder ad"erse en"ironmental conditions. 5,ese incl/de H,
temerat/re, ionic stren*t,, o0y*en tension, n/trient le"els, and anta*onistic elements,
s/c, as cometin* or*anisms and t,e ,ost in+lammatory-imm/ne resonse. 5o coe
wit, t,is ,ostile en"ironment, t,e la?/e or*anisms m/st +ind a sa+e ,a"en in relation
to t,eir nei*,-ors and t,e oral en"ironment. S/c, a +a"ora-le location is termed an
ecolo$ic niche,
'
Normally, once t,e nic,es are esta-lis,ed, t,e -acteria o+ t,e resident
micro-iota coe0ist wit, t,e ,ost and t,e s/rro/ndin* microcosm. 5,is sym-iosis
res/lts in a resistance to coloni@ation -y s/-se?/ent nonindi$enous or*anisms. In t,is
manner, t,e resident micro-iota can rotect t,e ,ost a*ainst in+ection -y maAor
rimary at,o*ens, e.*., Coryne4acterium diphtheria and Streptococcus pyo$enes,
4it, dietary s/*ars enterin* t,e la?/e, anaero4ic $lycolysis res/lts in acid
rod/ction 7acido$enesis8 and acc/m/lation o+ acid in t,e la?/e.
'
I+ no acid-
cons/min* or*anisms 7e.*., =eillonella) are a"aila-le to /tili@e t,e acids, t,e la?/e
H dros raidly +rom %.$ to -elow &.'. 5,is dro is imortant -eca/se enamel
4e$ins to deminerali1e 4et3een pH >,: and >,>, One ossi-le o/tcome o+ t,e dro in
H may -e t,e dissol/tion o+ t,e minerali@ed toot, s/r+ace adAacent to t,e la?/e,
res/ltin* in cario/s cavitation o+ t,e toot,.
%%
5,is rocess ro"ides t,e -acteria access
to t,e inor*anic elements 7e.*., calci/m and ,os,ate8 needed +or t,eir n/tritional
re?/irements. 1y ad,erin* to t,e toot, s/r+ace "ia an or*anic layer o+ sali"ary ori*in,
dental la?/e -acteria can *ain access to a s/ly o+ or*anic n/trients, a widesread
,enomenon.
&%
5,e same searc, +or n/trients may e0lain t,e e0tension o+ -acteria
+rom t,e s/ra*in*i"al la?/e into t,e *in*i"al s/lc/s.
;=,;&
5o re"ent or red/ce
s/-*in*i"al coloni@ation, t,e ,ost tiss/es de+end a*ainst t,e -acterial c,allen*e wit,
anti-acterial strate*ies, s/c, as t,e assa*e o+ anti-odies and t,e emi*ration o+
olymor,on/clear ne/tro,ils +rom t,e adAacent connecti"e tiss/e into t,e *in*i"al
s/lc/s. 5,e contin/ed meta-olic acti"ity o+ la?/e in t,e s/-*in*i"al en"ironment
initiates t,e in+lammatory resonse o+ t,e *in*i"al tiss/es 7*in*i"itis8
;'
and also may
e"ent/ally lead to ro*ressi"e destr/ction o+ t,e eriodonti/m 7eriodontitis8
;<
.
Until s/ra*in*i"al la?/e minerali@es as dental calc/l/s, it can -e remo"ed -y
toot,-r/s,in* and +lossin*.
;%
As t,e la?/e mat/res, it -ecomes more resistant to
remo"al wit, a toot,-r/s,. In one st/dy, at >&, &(, and %> ,o/rs a+ter +ormation, '.',
%.(, and :&.$ *Bcm
>
o+ ress/re, resecti"ely, were re?/ired to dislod*e t,e
la?/ealmost t,ree times as m/c, ress/re to remo"e it on t,e t,ird day as on t,e
+irst.
;(
Once dental calc/l/s is +ormed, ro+essional instr/mentation is necessary +or
its remo"al.
Question 3
A. Dental la?/es tyically e0,i-it /ni+orm str/ct/res, comosition, and roerties.
1. 5,e intercell/lar dental la?/e matri0 is ro-a-ly +ormed -y a com-ination o+ ,ost
materials, s/c, as sali"ary roteins, and -acterial meta-olites.
C. 5,e term Fcorn-co-F con+i*/ration, descri-es one o+ se"eral ossi-le a**re*ates
-etween di++erent kinds o+ -acterial cells in t,e dental la?/e matri0.
D. 5,e acid dissol/tion o+ toot, mineral s/lies calci/m +or -ot, -acterial n/trition
and +or calci/m -indin*.
3. Gin*i"al in+lammation is *enerally ca/sed -y -acteria t,at reside in dental la?/e
adAacent to t,e toot,.
Dental Calculus
A last sta*e in t,e mat/ration o+ some dental la?/es is c,aracteri@ed -y t,e
aearance o+ minerali@ation in t,e deeer ortions o+ t,e la?/e to +orm dental
calc/l/s
;;
. 5,e term calculus is deri"ed +rom t,e .atin word meanin* e--le or stone.
5,e lay term, tartar, re+ers to an acc/m/lated sediment or cr/st on t,e sides o+ a wine
cask. Some eole do not +orm calc/l/s, ot,ers +orm only moderate amo/nts, and still
ot,ers +orm ,ea"y amo/nts.
Calc/l/s itsel+ is not ,arm+/l. Howe"er, a layer o+ /nminerali@ed, "ia-le,
meta-olically acti"e -acteria t,at are closely associated wit, t,e e0ternal calc/l/s
s/r+ace is otentially at,o*enic. Calc/l/s cannot -e remo"ed -y -r/s,in* or
+lossin*. It is o+ten di++ic/lt to remo"e all t,e calc/l/s, e"en ro+essionally, wit,o/t
dama*in* t,e toot,, esecially t,e so+ter root cement/m. Howe"er, calc/l/s needs to
-e remo"ed -eca/se its resence makes ro/tine oral ,y*iene more di++ic/lt or e"en
imossi-le -y +ormin* calc/l/s spurs 7Fi*/re >-;8. 5,ese str/ct/res may contri-/te to
la?/e acc/m/lation and sta*nation. Calc/l/s remo"al is also a rere?/isite to
re*enerate lost or dama*ed eriodontal tiss/es +ollowin* treatment.
In addition to local +actors, -e,a"ioral and systemic conditions may a++ect calc/l/s
+ormation. For e0amle, smokin* ca/ses an accelerated +ormation o+ calc/l/s.
:$$

C,ildren a++licted wit, ast,ma or cystic +i-rosis +orm calc/l/s at aro0imately twice
t,e rate o+ ot,er c,ildren.
:$:
Similarly, non-am-/latory, mentally ,andicaed
indi"id/als, t/-e-+ed o"er lon* eriods, may de"elo ,ea"y calc/l/s wit,in =$ days,
desite t,e +act t,at no +ood asses t,ro/*, t,e mo/t,.
:$>
Con"ersely, medications
s/c, as -eta--lockers, di/retics, and antic,oliner*ics can res/lt in si*ni+icantly
red/ced le"els o+ calc/l/s. 5,e a/t,ors o+ t,e latter st/dy concl/ded t,at eit,er t,e
medications were e0creted directly into t,e sali"a, a++ectin* t,e rate o+ crystalli@ation,
or altered t,e comosition o+ t,e sali"a and t,/s indirectly a++ected calc/l/s
+ormation.
:$=
Calc/l/s +ormation is related to t,e +act t,at sali"a is sat/rated wit, resect to calci/m
and ,os,ate ions.
:$&
)reciitation o+ t,ese elements leads to minerali@ation o+ dental
la?/e *i"in* rise to calc/l/s. 5,e crystals in calc/l/s incl/de ,ydro0yaatite,
-r/s,ite, and w,itlockite, all o+ w,ic, ,a"e di++erent roortions o+ calci/m and
,os,ate in com-ination wit, ot,er ions, s/c, as ma*nesi/m, @inc, +l/oride, and
car-onate. Supra$in$ival calculus +orms on t,e toot, coronal to t,e *in*i"al mar*in,
and +re?/ently de"elos oosite t,e d/ct ori+ices o+ t,e maAor sali"ary *lands. It is
o+ten +o/nd w,ere sali"a ools on t,e lin*/al s/r+aces o+ t,e mandi-/lar incisors
7Fi*/re >-:$8, and can +orm in t,e +iss/res o+ teet,. S/-*in*i"al calc/l/s +orms +rom
calci/m ,os,ate and or*anic materials deri"ed +rom ser/m, w,ic, contri-/te to
minerali@ation o+ s/-*in*i"al la?/e.
One o+ t,e means -y w,ic, +ormation and *rowt, o+ calc/l/s may -e st/died is -y
li*atin* t,in lastic stris aro/nd t,e teet, and t,en remo"in* t,e stris at "ario/s
inter"als.
:$'
4it,in :> ,o/rs a+ter lacement, 0-ray di++raction st/dies demonstrate
mineral elements in t,e +ormin* la?/e. 1y = to & days, t,e concentration o+ calci/m
and ,os,ate is si*ni+icantly ,i*,er in t,e la?/e o+ t,ose wit, ,ea"y calc/l/s
+ormation t,an in t,e la?/e o+ t,ose wit, no calc/l/s +ormation.
S/-*in*i"al calc/l/s is a-o/t <$E minerali@ed, w,ereas s/ra*in*i"al calc/l/s is
only a-o/t =$E minerali@ed.
:$<
1eca/se it is ,arder, t,inner, and more closely adated
to toot, s/r+ace imer+ections, s/-*in*i"al calc/l/s can -e more di++ic/lt to remo"e
t,an s/ra*in*i"al calc/l/s. 5,e two tyes o+ calc/l/s may di++er in color.
S/ra*in*i"al calc/l/s, w,ic, deri"es its mineral content +rom sali"a, /s/ally aears
as a yellow to w,ite mass wit, a c,alky consistency. S/-*in*i"al calc/l/s, w,ic,
deri"es its mineral +rom t,e in+lammatory e0/date in t,e s/lc/s and eriodontal
ocket, aears *ray to -lack in color and ,as a +lint-like consistency. 5,e dark
coloration may -e ca/sed -y -acterial de*radation o+ comonents o+ t,e ,emorr,a*ic
e0/date t,at accomanies *in*i"al in+lammation.
Alkaline conditions in dental la?/e may -e an imortant redisosin* +actor +or
calc/l/s +ormation.
:$%
Calc/l/s +ormation is not restricted to one -acterial secies, or
e"en to t,ose *rowin* at ne/tral or sli*,tly acidic Hs. 5,is is e"idenced -y t,e +act
t,at caries-related stretococci may minerali@e.
:$(
Not all la?/es minerali@e, -/t a
la?/e t,at is destined to minerali@e -e*ins to do so wit,in a +ew days o+ its initial
+ormation, e"en t,o/*, t,is early c,an*e is not detecta-le at a clinical le"el.
Minerali@ation /s/ally -e*ins in t,e intercellular pla5ue matrix -/t e"ent/ally occ/rs
3ithin t,e -acterial cells 7Fi*/re >-::8. 1acterial ,os,oliids and ot,er cell-wall
constit/ents may act as initiators o+ minerali@ation,
:$;
in w,ic, case minerali@ation
may -e*in in the cell 3all and s/-se?/ently e0tend to t,e rest o+ t,e cell and into t,e
s/rro/ndin* matri0 7Fi*/re >-:>8. Calc/l/s may also +orm on t,e toot, s/r+aces o+
*erm+ree animals.
::$
5,is tye o+ calc/l/s consists o+ an or*anic matri0 o+
nonmicro-ial ori*in w,ic, -ecomes minerali@ed.
Attac,ment o+ Calc/l/s to t,e 5eet,
At t,e toot, inter+ace wit, calc/l/s, t,e enamel or root cement/m are ne"er er+ectly
smoot, and in"aria-ly contain a "ariety o+ s/r+ace imer+ections. 5,ese normal
irre*/larities s/c, as t,e peri*ymata
d
and t,e oint o+ ori*in o+ Sharpey?s fi4ers
e
on
t,e cement/m aear to aid calc/l/s attac,ment. Ot,er de+ects in t,e enamel and
cement/m, incl/din* areas o+ deminerali@ation and cemental tears,
:::
may also
contri-/te to a stron*er calc/l/s attac,ment to t,e toot,. 3lectron micro*ra,s
indicate a "ery close relations,i -etween t,e matri0 o+ t,e toot, s/r+ace and t,e
matri0 o+ calc/l/sD t,e crystalline str/ct/res o+ -ot, are also "ery similar.
::>
d
)erikymata are t,e n/mero/s, small, trans"erse rid*es on t,e e0osed s/r+ace o+ t,e
enamel o+ t,e ermanent teet,.
e
5,e toot, is anc,ored -y connecti"e tiss/e +i-ers t,at e0tend -etween t,e cement/m
and t,e -oneD t,e ends em-edded in t,e cement/m and -one are known as S,areyCs
+i-ers.
In,i-itin* Calc/l/s Formation
Se"eral a*ents are c/rrently a"aila-le to red/ce calc/l/s +ormation, incl/din*
denti+rices t,at contain yro,os,ate, or metal ions s/c, as @inc.
::=,::&
One denti+rice
contains two sol/-le ,os,ates, tetrasodium pyrophosphate and disodium
dihydro$en pyrophosphate, in addition to +l/oride.
::&,::'
5,e yro,os,ate ion not
only ser"es as a str/ct/ral analo* o+ t,e ort,o,os,ate ion, disr/tin* t,e +ormation
o+ calci/m ,os,ate crystals, -/t also in,i-its some -acterial *rowt, at
concentrations si*ni+icantly lower t,an t,e le"els +o/nd in denti+rices.
Fi*/re >-; !adio*ra, demonstratin* a Fs/rF- s,aed deosit o+ calc/l/s 7C8
on t,e distal side o+ t,e ma0illary le+t +irst molar aical to t,e o"er,an*in*
metallic restoration 7!8. 5,e arrow 7G8 marks t,e coronal le"el o+ t,e *in*i"al
tiss/es indicatin* t,at t,is is a s/-*in*i"al deosit o+ calc/l/s. 7Co/rtesy o+ Dr.
42 Gri*s-y Uni"ersity o+ Iowa Colle*e o+ Dentistry.8
Fi*/re >-:$ Deosits o+ s/ra*in*i"al calc/l/s on t,e lin*/al s/r+ace o+ incisors
and canines t,at co/ld not -e remo"ed -y -r/s,in*. 7Co/rtesy o+ Dr. 42
Gri*s-y, Uni"ersity o+ Iowa Colle*e o+ Dentistry.8
Fi*/re >-:: 5yical attern o+ dental la?/e minerali@ation in w,ic, t,e initial
minerali@ation occ/rs in t,e inter-acterial la?/e matri0 7M8, wit, -acterial cells
718 -ecomin* minerali@ed secondarily, &$,$$$. 7Co/rtesy o+ Dr. MA
.ist*arten, Uni"ersity o+ )ennsyl"ania Sc,ool o+ Dental Medicine.8
Fi*/re >-:> Atyical attern o+ dental la?/e minerali@ation in w,ic, -acterial
cells 718 act as +oci o+ initial minerali@ation, wit, t,e matri0 7NM8, -ecomin*
minerali@ed secondarily, >',$$$. 7Co/rtesy o+ Dr. MA .ist*arten, Uni"ersity o+
Question 4
A. Intracell/lar olysacc,arides are a so/rce o+ ener*y a"aila-le to -acteria, -/t
le"ans are a"aila-le only to t,e synt,esi@in* -acteria.
1. An oerational de+inition o+ calc/l/s mi*,t -e t,at it is Fa minerali@ed dental
la?/e t,at cannot -e remo"ed +rom t,e toot, -y -r/s,in* or +lossin*.F
C. 5,e +low o+ sali"a o"er t,e toot, s/r+aces near t,e maAor sali"ary *land d/cts kees
t,ose teet, +ree o+ calc/l/s deosits.
D. S/-*in*i"al calc/l/s is /s/ally more densely minerali@ed t,an s/ra*in*i"al
calc/l/s.
3. Calc/l/s +ormation /s/ally -e*ins in t,e -acterial cell wall and e0tends to t,e
intercell/lar matri0.
Summary
1acteria in dental la?/e are t,e direct ca/se o+ t,e most widesread o+ all ,/man
diseasesdental caries and in+lammatory eriodontal diseases. 5,ese diseases,
,owe"er, are not classical in+ections. 5,ey arise -eca/se o+ comle0 c,an*es in
la?/e ecolo*y and are a++ected -y many +actors in t,e ,ostCs rotecti"e resonses. 5o
/nderstand t,e role o+ dental la?/e in disease and ,ow to re"ent or control t,e
la?/e-associated diseases, it is essential to /nderstand t,e nat/re o+ dental la?/e.
)la?/e +orms initially on t,e or*anic layer coatin* t,e er/ted toot,. 5,is or*anic
layer ori*inates +rom sali"ary rod/cts t,at are deosited on t,e teet,, +ormin* an
ac?/ired ellicle to w,ic, -acteria ad,ere. Ad,esion is mediated -y a "ariety o+
-ondin* mec,anisms, incl/din* ,ysicoc,emical and electrostatic interactions, and
stereo-c,emical interactions -etween -acterial ad,esins and recetors in t,e ac?/ired
ellicle and -acterial s/r+aces. 5,e earliest o+ t,e rimary -acterial coloni@ers are
mainly Gram-ositi"e +ac/ltati"e cocci. 5,ey are +ollowed -y a "ariety o+ Gram-
ositi"e and Gram-ne*ati"e seciest,e secondary coloni@ers. Caries-related
-acterial secies ,a"e a *reater a-ility t,an ot,ers to adat to e0cess s/*ars and t,eir
meta-olites. S/ra*in*i"al la?/e is associated wit, caries and *in*i"itis, w,ereas
s/-*in*i"al la?/e is associated wit, *in*i"itis and eriodontitis. 4it, ,i*,er H
7i.e., less acidity8, some la?/es minerali@e to +orm s/ra- and s/-*in*i"al dental
calc/l/s. In calc/l/s +ormation, minerali@ation o+ dental la?/e *enerally -e*ins in
t,e e0tracell/lar matri0 and e"ent/ally sreads to incl/de t,e -acteria. !arely,
minerali@ation may -e*in wit,in t,e walls o+ -acterial cells and sread to t,e
e0tracell/lar matri0. Calc/l/s is *enerally co"ered -y acti"ely meta-oli@in* -acteria,
w,ic, can ca/se caries, *in*i"itis, and eriodontitis. !e*/lar toot,-r/s,in* and
+lossin* can remo"e dental la?/e and control its +ormation. Once dental la?/e
minerali@es to +orm calc/l/s, ro+essional instr/mentation is necessary +or its
remo"al. Notwit,standin* t,e contri-/tion o+ calc/l/s to in+lammatory eriodontal
diseases, it is sta*nation o+ at,o*enic -acteria at critical sites t,at leads to -ot, dental
caries and eriodontal diseases. .ater c,aters deal wit, t,e wide ran*e o+ met,ods,
mec,anical and c,emical, increasin*ly /sed to control la?/e and calc/l/s +ormation.
All o+ t,ese met,ods ,a"e t,e aim o+ re"entin*, arrestin*, or re"ersin* t,e
ro*ression o+ dental caries and eriodontal tiss/e in+lammation.
:. 1 and Ccorrect.
AIncorrect. 5,e ac?/ired ellicle is Facell/lar,F i.e., cell-+ree.
DIncorrect. 5,e ac?/ired ellicle -e*ins to re+orm immediately and is reesta-lis,ed
wit,in se"eral ,o/rs.
3Incorrect. 3"en t,o/*, some -indin* sites are occ/ied -y imm/no*lo-/lins,
many more are occ/ied -y -acteria.
>. A, 1, D, and 3correct.
CIncorrect. .ike c,ar*es 7i.e., ne*ati"e to ne*ati"e or ositi"e to ositi"e8 reelD
/nlike c,ar*es attract.
=. 1, C, D, and 3correct.
AIncorrect. So many +actors a++ect la?/e +ormation t,at comosition, str/ct/re,
and roerties are *reatly "aried.
&. 1 and Dcorrect.
AIncorrect. It s,o/ld -e t,e re"erse, wit, intracell/lar olysacc,arides a"aila-le to
t,e synt,esi@in* -acteria, and le"ans to t,e s/rro/ndin* -acteria wit, t,e en@yme
le"anase.
CIncorrect. 5,e resence o+ ,i*, concentrations o+ calci/m and ,os,ate ions at
t,e d/ct oenin*s res/lts in more, not less, calc/l/s +ormation.
3Incorrect. Calc/l/s usually -e*ins in t,e intercell/lar matri0, and sreads to
en*/l+ t,e cells.
:. 5,e resence o+ a reonderance o+ cocci is a si*n o+ 7early87late8 la?/e
+ormation.
>. Followin* ro,yla0is, it takes a-o/t iiiii 7,o/rs87days8 +or t,e ac?/ired ellicle
to comletely re+orm.
=. 5wo o+ t,e ,ostCs defensive proteins that comete wit, -acteria +or recetor sites on
t,e ac?/ired ellicle are iiiiiiii and iiiiiiii.
&. It takes aro0imately iiiii 7,o/rs8 7days8 +or t,e initial la?/e to +orm and a-o/t
iiiii days to do/-le in mass. Once +ormed, t,e *rowt, is raid +or a-o/t iiiii days
and +inally sta-ili@es in mass aro/nd t,e iiiii day.
'. Gi"en t,e c,oice o+ 7water87a toot,-r/s,8 or a 7ro,yla0is8D w,ic, one is re?/ired
to remo"e eac, o+ t,e +ollowin*9 7:8 materia al-a, 7>8 la?/e, or 7=8 calc/l/se
<. 1acteria can attac, to t,e ac?/ired ellicle "ia iiiiiiiii -ondin*, -y calci/m
iiiiiiiii, "ia attac,ment to t,e sticky iiiiiiiii, and -y s/r+ace roteins called
iiiiiiiii.
%. 5,e t,ree laces on t,e teet, w,ere -acterial coloni@ation is most a-/ndant are
iiiiiiiii, iiiiiiiii, and iiiiiiiii.
(. FCorn-co-F con+i*/rations are ca/sed -y 7cocci8 7rods8 radially attac,ed to a central
rod, w,ereas t,e FiiiiiiiiiiiF con+i*/ration is ca/sed -y rods radially attac,ed to a
central rod.
;. 1etween t,e cells o+ t,e la?/e is t,e 7e0tracell/lar olysacc,aride87intracell/lar
olysacc,aride8 containin* iiiiiiiii and le"ans t,at ser"e as ener*y so/rces +or t,e
-acteria.
:$. 5,e Fsa+e ,a"enF w,ere a -acterial colony can e0ist in t,e la?/e en"ironment is
known as a7n8 iiiiiiiii.
::. Calc/l/s is mainly made / o+ calci+ied iiiiiiii.
:>. One condition ca/sin* accelerated calc/l/s +ormation is iiiiiiiiiii. !ed/ced
+ormation is seen a+ter /se o+ iiiiiiiii 7dr/*s8.
:=. Supra$in$ival calc/l/s deri"es its minerals +rom t,e iiiiiiiiiiD w,ereas
su4$in$ival calc/l/s deri"es t,em +rom t,e iiiiiiiiii.
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>:. May,all, C. 4. 7:;%$8. Concernin* t,e comosition and so/rce o+ t,e ac?/ired
enamel ellicle on ,/man teet,. rch +ral #iol, :'9:=>%-&:.
>>. Hardie, #. M., g 1owden, G. H. 7:;%<8. 5,e micro-ial +lora o+ dental la?/e9
1acterial s/ccession and isolation considerations. In Stiles, H. M., .oesc,e, 4. #., g
OC1rien, 5. C., 3ds. Proceedin$s %icro4ial spects of Dental Caries, %icro4iol
4str, : 7Sec S/l89<=-(%.
>=. .ie, 5., g G/s-erti, F. 7:;%;8. !elica st/dy o+ la?/e +ormation on ,/man toot,
s/r+aces. cta +dontol Scand, %;9<'-%>.
>&. 1aier, !. 3. 7:;%%8. On t,e +ormation o+ -iolo*ical +ilms. S3ed Dent ", :9><:-%:.
>'. 5/ll-er*, A. 7:;(<8. An e0erimental st/dy o+ t,e ad,esion o+ -acterial layers to
some restorati"e dental materials. Scand " Dent Res, ;&9:<&-%=.
><. 2awai, 2., Urano. 7>$$:8. Ad,erence o+ la?/e comonents to di++erent
restorati"e materials. +perative Dentistry , ><9=;<-&$$.
>%. j/irynen, M., De Soete, g "an Steen-er*,e, D. 7>$$>8. In+ectio/s risks +or oral
imlants9 A re"iew o+ t,e literat/re. Clin +ral /mplant Res, :=9:-:;.
>(. .eac,, S. A., g Critc,ley, ). 7:;<<8. 1acterial de*radation o+ *lycorotein s/*ars
in ,/man sali"a. &ature, >$;9'$<.
>;. Hay, D. I., g Oen,eim, I. G. 7:;%&8. 5,e isolation +rom ,/man arotid sali"a o+
a +/rt,er *ro/ o+ roline-ric, roteins. rch +ral #iol, :;9<>%-=>.
=$. Glenister, D. A., Salamon, 2. 3., g Smit,, 2. et al. 3n,anced *rowt, o+ comle0
comm/nities o+ dental la?/e -acteria in m/cin-limited contin/o/s c/lt/re. %icro4iol
!col Hlth Dis, :9=:-=(.
=:. Gi--ons, !. #., g "an Ho/te, #. 7:;%'8. 1acterial ad,erence in oral micro-ial
ecolo*y. nn Rev %icro4iol, >;9:;-&&.
=>. 4eerkam, A. H., "an der Mei, H. C., 3n*elen, D. )., et al. 7:;(&8. Ad,esion
recetors 7ad,esins8 o+ oral stretococci. In ten Cate, #. M., .eac,, S. A., g Arends,
#., 3ds. #acterial adhesion and preventive dentistry, O0+ord9 I!. )ress, ('-;%.
==. !osan, 1. !., g .amont, !. #. 7>$$$8. Dental la?/e +ormation. %icro4es and
/nfection, >9:';;-:<$%.
=&. 2ra/s, F. 4., Orsta"ik, D., H/rst, D. C., g Cook, C. H. 7:;%=8. 5,e ac?/ired
ellicle9 6aria-ility and s/-Aect deendence o+ seci+ic roteins. " +ral Pathol %ed,
>9:<'-:%=.
='. Orsta"ik, D., g 2ra/s, F. 4. 7:;%=8. 5,e ac?/ired ellicle9 Imm/no+l/orescent
demonstration o+ seci+ic roteins. " +ral Pathol %ed, >9<(-%<.
=<. 4illiams, !. C., g Gi--ons, !. #. 7:;%'8. In,i-ition o+ stretococcal attac,ment to
recetors or ,/man -/ccal eit,elial cells -y anti*enically similar sali"ary
*lycoroteins. /nfect /mmun, ::9%::-:(.
=%. !o*ers, A. H., "an der Hoe"en, #. S., g Mik0, F. 7:;%(8. In,i-ition o+
ctinomyces viscosus -y -acteriocin rod/cin* strains o+ Streptococcus mutans in t,e
dental la?/e o+ *noto-iotic rats. rch +ral #iol, >=9&%%-(=.
=(. Hammond, 1. F., .illard, S. 3., g Ste"ens, !. H. 7:;(%8. A -acteriocin o+
ctino4acillus actino2mycetemcomitans, /nfect /mmun, ''9<(<-;:.
=;. C,ristersson, .. A., Grossi, S. G., D/n+ord, !. G., Nac,tei, 3. 3., g Genco, !. #.
7:;;>8. Dental la?/e and calc/l/s9 !isk indicators +or t,eir +ormation. " Dent Res,
%:9:&>'-=$.
&$. 1aier, !. 3., g Glant@, )-$. 7:;%;8. C,aracteri@ation o+ oral in vivo +ilm +ormed
on di++erent tyes o+ solid s/r+aces. cta +dontol Scand, =<9>(;-=$:.
&:. .ilAemark, 4. F., g Sc,a/er, S. 6. 7:;%%8. Cometiti"e -indin* amon* oral
stretococci to ,ydro0yaatite. " Dent Res, '<9:'<-<'.
&>. 2/ramits/, H., g In*ersoll, .. 7:;%%8. Molec/lar -asis +or t,e di++erent s/crose-
deendent ad,erence roerties o+ Streptococcus mutans and Streptococcus san$uis,
/nfect /mmun, :%9==$-=%.
&=. 5an@er, #. M., g #o,nson, M. C. 7:;%<8. Gradients +or *rowt, wit,in intact
Streptococcus mutans la?/e in vitro demonstrated -y a/toradio*ra,y. rch +ral
#iol, >:9'''-';.
&&. 1Aorn, H., g Carlsson, #. 7:;<&8. O-ser"ations on a dental la?/e mor,o*enesis.
+dontol Rev, :'9>=->(.
&'. F/r/ic,i, H., .ind,e, #., !am-er*, )., g 6ole, A. !. 7:;;>8. )atterns o+ de no"o
la?/e +ormation in t,e ,/man dentition. " Clin Periodontol, :;9&>=-==.
&<. Howell, A. #r., !isso, A., g )a/l, F. 7:;<'8. C/lti"a-le -acteria in de"eloin* and
mat/re ,/man dental calc/l/s. rch +ral #iol, :$9=$%-=:=.
&%. !/dney, #. D. 7>$$$8. Sali"a and dental la?/e. dv Dent Res, :&9>;-=;.
&(. Newman, H. N. 7:;%&8. Diet, attrition, la?/e and dental disease. #r Dent ",
:=<9&;:-;%.
&;. .eac,, S. A. 7:;%;8. On t,e nat/re o+ interactions associated wit, a**re*ation
,enomena in t,e mo/t,. " Dent, %9:&;-<$.
'$. !osen-er*, M., #/des, H., g 4eiss, 3. 7:;(=8. Cell s/r+ace ,ydro,o-icity o+
dental la?/e microor*anisms. /nfect /mmun, &>9(=:-=&.
':. 1/ssc,er, H. #., g "an der Mei, H. C. 7:;;%8. ),ysico-c,emical interactions in
initial micro-ial ad,esion and rele"ance +or -io+ilm +ormation. dv Dent Res, ::9>&-
=>.
'>. Doyle, !. #., !osen-er*, M., g Drake, D. 7:;;$8. Hydro,o-icity o+ oral -acteria.
In Doyle, !. #., !osen-er*, M., 3ds. %icro4ial Cell Surface Hydropho4icity,
4as,in*ton, DC9 American Society +or Micro-iolo*y, =(%-&:;.
'=. 3d*ar, 4. M. 7:;%;8. St/dies o+ t,e role o+ calci/m in la?/e +ormation and
co,esion. " Dent, %9:%&-%;.
'&. Mats/k/-o, 5., 2atow, 5., g 5aka@oe. 7:;%(8. Si*ni+icance o+ Ca--indin* acti"ity
o+ early la?/e -acteria. #ull To*yo Dent Coll, :;9'=-'%.
''. !ose, !. 2., Di-din, G. H., g S,ellis, !. ). 7:;;=8. A ?/antitati"e st/dy o+
calci/m -indin* and a**re*ation in selected oral -acteria. " Dent Res, %>9%(-(&.
'<. Newman, M. N., g 1ritton, A. 1. 7:;%&8. Dental la?/e /ltrastr/ct/re as re"ealed
-y +ree@e-etc,in*. " Periodontol, &'9&%(-((.
'%. Germaine, G. !., Harlander, S. 2., .e/n*, 4-..S., g Sc,ac,tele, C. F. 7:;%%8.
Streptococcus mutans de0tran-s/crase9 F/nctionin* o+ rimer de0tran and endo*eno/s
de0trans/crase in water-sol/-le and water-insol/-le *l/can synt,esis. /nfect /mmun,
:<9<=%-&(.
'(. Gi--ons, !. #., g "an Ho/te, #. 7:;($8. 1acterial ad,erence and t,e +ormation o+
dental la?/e. !ecetors and reco*nition. In 1eac,ey, 3. H., 3d. #acterial adherence,
.ondon. C,aman and Hall, .td., <9<=-:$&.
';. O+ek, I., g )erry, A. 7:;('8. Molec/lar -asis o+ -acterial ad,erence to tiss/es. In
Mer*en,a*en, S. 3., g !osan, 1., 3ds. %olecular 4asis of oral micro4ial adhesion,
4as,in*ton, DC9 American Society +or Micro-iolo*y, %-:=.
<$. Gi--ons, !. #. 7:;(&8. Ad,erent interactions w,ic, may a++ect micro-ial ecolo*y
in t,e mo/t,. " Dent Res, <=9=%(-('.
<:. Clark, 4. 1., 4,eeler, 5. 5., .ane, M. D., g Cisar, #. O. 7:;(<8. Actinomyces
adsortion mediated -y tye-I +im-riae. " Dent Res, <'9::<<-<(.
<>. 2olen-rander, ). 3., g .ondon, #. 7:;;>8. 3colo*ical si*ni+icance o+
coa**re*ation amon* oral -acteria. dv %icro4 !col, :>9:(=->:%.
<=. Handley, ). S., McNa-, !., g #enkinson, H. F. 7:;;;8. Ad,esi"e s/r+ace
str/ct/res on oral -acteria. In Newman, H. N., g 4ilson, M., 3ds. Dental pla5ue
revisitedoral 4iofilms in health and disease, Cardi++9 1io.ine, :&'-%$.
<&. Irwin, !. 5. 7:;;$8. Hydro,o-icity o+ roteins and -acterial +im-riae. In Doyle,
!. #., g !osen-er*, M., 3ds. %icro4ial cell surface hydropho4icity, 4as,in*ton, DC9
American Society o+ Micro-iolo*y, :=%-%%.
<'. Cisar, #. O., 1rennan, M. #., g Sand-er*, A. .. 7:;('8. .ectin-seci+ic interaction
o+ ctinomyces +im-riae wit, oral stretococci. In Mer*en,a*en, S. 3., g !osan, 1.,
3ds. %olecular 4asis of oral micro4ial adhesion, 4as,in*ton, DC9 American Society
+or Micro-iolo*y, :';-<=.
<<. 2olen-rander, ). 3., g Andersen, !. N. 7:;('8. Use o+ co-a**re*ation-de+ecti"e
m/tants to st/dy t,e relations,i o+ cell-to-cell interactions and oral micro-ial
ecolo*y. In Mer*en,a*en, S. 3., g !osan, 1., 3ds. %olecular 4asis of oral micro4ial
adhesion, 4as,in*ton, DC9 American Society +or Micro-iolo*y, :<&-<<.
<%. !osen-er*, 3. S., 3"ian, C. I., g .ist*arten, M. A. 7:;(:8. 5,e comosition o+ t,e
s/-*in*i"al micro-iota a+ter eriodontal t,eray. " Periodontol, '>9&='-&:.
<(. Cao, C. F., Aeli, D. M., .ilAemark, 4. F., 1loom?/ist, C. G., 1randt, C. .., g
4ol++, .. F. 7:;;$8. Comarison o+ la?/e micro+lora -etween C,inese and
Ca/casian o/lation *ro/s. " Clin Periodontol, :%9::'-:(.
<;. .ist*arten, M. A., Mayo, H. 3., g 5rem-lay, !. 7:;%'8. De"eloment o+ dental
la?/e on eo0y resin crowns in man. A li*,t and electron microscoic st/dy. "
Periodontol, &<9:$-><.
%$. .ie, 5. 7:;%(8. Ultrastr/ct/ral st/dy o+ early la?/e +ormation. " Periodont Res,
:=9=;:-&$;.
%:. 2olen-rander, ). 3., g .ondon, #. 7:;;=8. Ad,ere today, ,ere tomorrow9 Oral
-acterial ad,erence. " #acteriol, :%'9=>&%-'>.
%>. 5,eilade, #., FeAersko", O., Horsted, M. 7:;%<8. A transmission electron
microscoic st/dy o+ %-day-old -acterial la?/e in ,/man toot, +iss/res. rch +ral
#iol, >:9'(%-;(.
%=. Newman, H. N. 7:;($8. !etention o+ -acteria on oral s/r+aces. In 1itton, G., g
Mars,all, 2. C., 3ds. dsorption of %icroor$anisms to Surfaces, New Hork9 4iley-
Intersciences, >$%-':.
%&. Hardie, #. M., g 1owden, G. H. 7:;%&8. 5,e normal micro-ial +lora o+ t,e mo/t,.
In Skinner, F. A., g Carr, #. G., 3ds. The normal micro4ial flora of man, .ondon9
Academic )ress, &%-(=.
%'. Socransky, S. S. 7:;%%8. Micro-iolo*y o+ eriodontal diseaseresent stat/s and
+/t/re considerations. " Periodontol, &(9&;%-'$&.
%<. "an Ho/te, #., Gi--ons, !. #., g 1an*,art, S. 1. 7:;%$8. Ad,erence as a
determinant o+ t,e resence o+ Streptococcus salivarius and Streptococcus san$uis on
t,e ,/man toot, s/r+ace. rch +ral #iol, :'9:$>'-=&.
%%. Dono*,/e, H. D., g Newman, H. N. 7:;%<8. 3++ect o+ *l/cose and s/crose on
s/r"i"al in -atc, c/lt/re o+ Streptococcus mutans C<%-: and a non-cario*enic m/tant,
C<%->'. /nfect /mmun, :=9:<->:.
%(. 2ilian, M., g !olla, G. 7:;%<8. Initial coloni@ation o+ teet, in monkeys as related
to diet. /nfect /mmun, :&9:$>>->%.
%;. 4eerkam, A. H. 7:;('8. Coa**re*ation o+ Streptococcus salivarius wit, Gram-
ne*ati"e oral -acteria9 Mec,anism and ecolo*ical si*ni+icance. In Mer*en,a*en, S.
3., g !osan, 1., 3ds. %olecular 4asis of oral micro4ial adhesion, 4as,in*ton, DC9
American Society +or Micro-iolo*y, :%%-(=.
($. Ciardi, #. 3., McCray, G. F. A., 2olen-rander, ). 3., g .a/, A. 7:;(%8. Cell-to-
cell interaction o+ Streptococcus san$uis and Propioni4acterium acnes on sali"a-
coated ,ydro0yaatite. /nfect /mmun, ''9:&&:-&<.
(:. .amont, !. #., g !osan, 1. 7:;;$8. Ad,erence o+ m/tans stretococci to ot,er oral
-acteria. /nfect /mmun, '(9:%=(-&=.
(>. S,a,, H. N., g G,ar-ia, S. 3. 7:;;:8. Micro-ial +actors in t,e aetiolo*y o+ c,ronic
in+lammatory eriodontal disease. In Newman, H. N., g 4illiams, D. N., 3ds.
/nflammation and immunolo$y in chronic inflammatory periodontal disease,
Nort,wood, 3n*land9 Science !e"iews .imited, :-=>.
(=. 6an der Hoe"en, #. S., de #on*, M. H., g 2olen-rander, ). D. 7:;('8. /n vivo
st/dies o+ micro-ial ad,erence in dental la?/e. In Mer*en,a*en, S. 3., g !osan, 1.,
3ds. %olecular 4asis of oral micro4ial adhesion, 4as,in*ton, DC9 American Society
+or Micro-iolo*y, >>$->%.
(&. Glo-erman, D. H., g 2lein-er*, I. 7:;%;8. Intra-oral O
>
and its relation to
-acterial acc/m/lation on t,e oral tiss/es. In 2lein-er*, I., 3llison, S. A., Mandel, I.
D., 3ds. Proceedin$s6 Saliva and dental caries 7A secial s/lement +or %icro4iol
4st8. New Hork9 In+ormation !etrie"al, >%'-;>.
('. Newman, H. N. 7:;%=8. 5,e or*anic +ilms on enamel s/r+aces. >. 5,e dental
la?/e. #r Dent ", :='9:$<-::.
(<. 2olen-rander, ). 3. 7:;;:8. Coa**re*ation9 Ad,erence in t,e ,/man oral
micro-ial ecosystem. In Dworkin, M., 3d. %icro4ial cell2cell interactions,
4as,in*ton, DC9 American Society +or Micro-iolo*y, =:<.
(%. Simmonds, !. S., 5omkins, G. !., g Goer*e, !. #. 7>$$$8. Dental caries and t,e
micro-ial ecolo*y o+ dental la?/e9 a re"iew o+ recent ad"ances. &e3 @ealand Dent
", ;<9&&-&;
((. Mattin*ly, S. #., Daneo-Moor, .., g S,ockman, G. D. 7:;%%8. Factors re*/latin*
cell wall t,ickenin* and intracell/lar iodo,ilic olysacc,aride stora*e in
Streptococcus mutans, /nfect /mmun, :<9;<%-%=.
(;. Critc,ley, )., 4ood, #. M., Sa0ton, C. A., g .eac,, S. A. 7:;<%8. 5,e
olymeri@ation o+ dietary s/*ars -y dental la?/e. Caries Res, ::>->;.
;$. McDo/*all, 4. F. 7:;<&8. St/dies on t,e dental la?/e. I6. .e"ans and t,e dental
la?/e. ust Dent ", ;9:-'.
;:. Da Costa, 5., g Gi--ons, !. #. Hydrolysis o+ le"an -y ,/man la?/e stretococci.
rch +ral #iol, :=9<$;-:%.
;>. Manly, !. S., g !ic,ardson, D. 5. 7:;<(8. Meta-olism o+ le"an -y oral samles. "
Dent Res, &%9:$($-(<.
;=. Newman, H. N. 7:;%>8. Str/ct/re o+ aro0imal ,/man dental la?/e as o-ser"ed
-y scannin* electron microscoy. rch +ral #iol, :%9:&&'-'=.
;&. Soames, #. 6., g Da"ies, !. M. 7:;%'8. 5,e str/ct/re o+ s/-*in*i"al la?/e in a
-ea*le do*. " Periodont Res, ;9===-&:.
;'. .oe, H., 5,eilade, 3., g #ensen, S. 1. 7:;<'8. 30erimental *in*i"itis in man. "
Periodontol, =<9:%%-(%.
;<. 2inane, D. F. 7>$$:8. Ca/sation and at,o*enesis o+ eriodontal disease.
Periodontol <:::, >'9(->$.
;%. )etersilka, G. #., 3,mke, 1., g Flemmi*, 5. F. 7>$$>8. Antimicro-ial e++ects o+
mec,anical De-ridement. Periodontol <:::, >(9'<-%:.
;(. Me,rotra, 2. 2., 2aoor, 2. 2., )rad,an, 1. )., g 1,/s,an, A. 7:;(=8.
Assessment o+ la?/e tenacity on enamel s/r+ace. " Periodont Res, :(9=(<-;>.
;;. 4,ite, D. #. 7:;;%8. Dental calc/l/s9 !ecent insi*,ts into occ/rrence, +ormation,
re"ention, remo"al and oral ,ealt, e++ects o+ s/ra*in*i"al and s/-*in*i"al deosits.
!ur " +ral Sci, :$'9'$(->>.
:$$. Feldman, !. S., 1ra"acos, #. S., g !ose, C. .. 7:;(=8. Association -etween
smokin* di++erent to-acco rod/cts and eriodontal disease inde0es. " Periodontol,
'&9&(:-((.
:$:. 4otman, S., Mercadante, #., Mandel, I. D., Goldman, !. S., g Dennin*, C.
7:;%=8. 5,e occ/rrence o+ calc/l/s in normal c,ildren, c,ildren wit, cystic +i-rosis,
and c,ildren wit, ast,ma. " Periodontol, &&9>%(-($.
:$>. 2lein, F. 2., g Dicks, #. .. 7:;(&8. 3"al/ation o+ acc/m/lation o+ calc/l/s in
t/-e-+ed mentally ,andicaed atients. " m Dent ssoc, :$(9='>-'&.
:$=. 5/resky, S., 1re/r, M., g Co++man, G. 7:;;>8. 5,e e++ect o+ certain systemic
medications on oral calc/l/s +ormation. " Periodontol, <=9(%:-%'.
:$&. 5en Cate, #. M. 7:;((8. Recent advances in the study of dental calculus, O0+ord9
I!. )ress, :&=->';.
:$'. McDo/*all, 4. A. 7:;('8. Analytical transmission electron microscoy o+ t,e
distri-/tion o+ elements in ,/man s/ra*in*i"al dental calc/l/s. rch +ral #iol,
=$9<$=-<$(.
:$<. Galil, 2. A., g Gwinnett, A. #. 7:;%'8. H/man toot,-+iss/re contents and t,eir
ro*ressi"e minerali@ation. rch +ral #iol, >9'';-<>.
:$%. 5/resky, S., !enstr/, G., g Glickman, I. 7:;<:8. Histolo*ic and ,istoc,emical
o-ser"ations re*ardin* early calc/l/s +ormation in c,ildren and ad/lts. " Periodontol,
=>9%-:&, <;-:$$.
:$(. S/nd-er*, M., g Frisko, #. 7:;('8. Crystallo*ra, o+ s/ra*in*i"al ,/man
dental calc/l/s. Scand " Dent Res, ;=9=$-=(.
:$;. Sc,roeder, H. 3. 7:;<;8. 'ormation and inhi4ition of dental calculus, 1ern,
Swit@erland9 Hans H/-er )/-lis,ers, '';-<>.
::$. .ist*arten, M. A., g Hene*,an, #. 1. 7:;%=8. O-ser"ations on t,e eriodonti/m
and ac?/ired ellicle o+ ad/lt *ern+ree do*s. " Periodontol, &&9('-;:.
:::. Moskow, 1. S. 7:;<;8. Calc/l/s attac,ment in cemental searations. "
Periodontol, &9::>'-:=$.
::>. Sel"i*, 2. A. 7:;%$8. Attac,ment o+ la?/e and calc/l/s to toot, s/r+aces. "
Periodontol Res, '9(-:(.
::=. Iac,erl, 4. A., )+ei++er, H. #., g Swancar, #. !. 7:;('8. 5,e e++ect o+ sol/-le
yro,os,ates on dental calc/l/s in ad/lts. " m Dent ssoc, ::$9%=%-=(.
::&. Ciancio, S. G. 7:;;'8. C,emical a*ents9 )la?/e control, calc/l/s red/ction and
treatment o+ dentinal ,yersensiti"ity. Periodontol <:::, (9%'-(<.
::'. Drake, D. !., C,/n*, #., Gri*s-y, 4., g 4/-H/an, C. 7:;;>8. Syner*istic e++ect
o+ yro,os,ate and sodi/m dodecyl s/l+ate on eriodontal at,o*ens. "
Periodontol, <=9<;<-%$$.
reser"ed.
Chapter 3. The Developing Carious Lesion - &orman +, Harris driana Se$ura
Objectives
:. Name t,e +o/r *eneral tyes o+ cario/s lesions t,at are +o/nd on t,e di++erent
s/r+aces o+ t,e teet,.
>. Descri-e t,e ,istolo*ic c,aracteristics o+ enamel and dentin t,at +acilitate +l/id +low
t,ro/*,o/t a toot,.
=. Descri-e t,e +o/r @ones o+ an inciient caries lesion.
&. Descri-e t,e cond/its 7ores8 t,at directly cond/ct acid +rom t,e -acterial la?/e to
t,e -ody o+ t,e lesion.
'. Name t,e two -acteria most o+ten imlicated in t,e caries rocess, and indicate
w,en eac, is resent in t,e *reatest n/m-ers d/rin* t,e caries rocess.
<. Descri-e t,e series o+ e"ents in a cario*enic la?/e and s/-s/r+ace lesion +rom t,e
time o+ -acterial e0os/re to s/*ar /ntil t,e H ret/rns to a restin* state.
%. Disc/ss t,e c,aracteristics o+ root caries and e0lain t,e di++erences and similarities
to coronal caries.
(. .ist meas/res to re"ent and to reminerali@e root and coronal caries.
;. 30lain w,y so m/c, time is taken -y t,e ro+ession in treatin* secondary caries.
:$. 30lain t,e relations,i -etween H and calci/m and ,os,or/s sat/ration in
caries de"eloment.
::. Disc/ss t,e rotecti"e relations,i o+ calci/m +l/oride to ,ydro0yaatite and
+l/or,ydro0yaatite d/rin* an acido*enic attack.
Introduction
Understanding Caries: Concepts
3"ery day t,ere is a normal, 4ut minute, deminerali1ation o+ t,e ,ard toot, str/ct/res
ca/sed -y -acterial acid rod/ction, as well as cons/min* acid +oods s/c, as +r/it
A/ices, "ine*ar, and so+t drinkse"en +rom t,e a-rasion o+ toot,-r/s,in*.
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So lon*
as t,e deminerali@ation is limited, t,e -odyCs reminerali1ation caa-ilities can relace
t,e lost minerals +rom elements s/c, as calci/m, ,os,ate, +l/oride and ot,er
elements t,at are +o/nd in t,e sali"a. 5,e physiolo$ic deminerali1ation does not
-ecome at,olo*ic /ntil t,e deminerali@ation o/tstris t,e reminerali@ation o"er an
inde+inite eriod o+ time t,at leads to t,e onset o+ cavitation. A +a"ora-le -alance
-etween de- and reminerali@ation is necessary to maintain t,e ,omeostasis needed +or
a li+etime o+ intact toot, retention.
4,en a ca"ity occ/rs, it can -e de+ined as a locali@ed, ost-er/ti"e at,olo*ical
rocess in"ol"in* -acterial acid deminerali@ation o+ ,ard toot, tiss/e, w,ic, i+
contin/ed wit,o/t a comensatory reminerali@ation, res/lts in t,e +ormation o+ a
ca"ity.
5,e ,istory o+ dental caries is as lon* as ,istory itsel+. )ro-a-ly one o+ t,e oldest and
most w,imsical t,eories o+ caries and toot,ac,e was t,at o+ t,e tooth 3orm w,ic,
alle*edly li"ed in t,e center o+ t,e toot,.
=
Many early -ar-er-s/r*eons reorted
si*,tin* t,e Fworm,F -/t none seemed to -e a-le to cat/re t,e creat/re, nor co/ld
e0lain ,ow it *ot into t,e toot, in t,e +irst lace. In t,e late :%$$s t,e worm t,eory
was lar*ely relaced -y t,e vital theory, a t,eory t,at ost/lated t,at in+lammation
arisin* +rom 3ithin a de+ecti"e toot, e"ent/ally ca/sed a s/r+ace lesion. !o-ertson in
:(='-3n*land, and ro-a-ly one o+ t,e +irst re"enti"e-oriented dentists -elie"ed and
/-lis,ed, t,at +ood imaction and +ermentation mi*,t -e t,e ca/se.
&
1y t,e end o+
t,e :;t, cent/ry, ot,ers in 3/roe -e*an to indict -acteria as t,e c/lrit.
In :(;$ 4. D. Miller, an American dentist teac,in* in Germany, /-lis,ed ,is
chemicoparasitic theory o+ caries w,ic, 7wit, many modi+ications8 is still acceted in
concet today.
'
As a res/lt o+ ,is e0erimentation, Miller -elie"ed t,at t,e e0traction
o+ t,e Flime saltsF +rom t,e teet, was a res/lt o+ -acterial acido*enesis and was t,e
+irst ste in dental decay. MillerCs work ,owe"er, +ailed to identi+y dental la?/e as
t,e so/rce o+ t,e -acteria and t,e -acterial acids. 5,e c,emicoarasitic t,eory -ecame
more co*ent w,en taken in conA/nction wit, t,e +indin* o+ ot,er contemorary dental
researc,ers, incl/din* G. 6. 1lack 7t,e FGrand Old Man o+ DentistryF8 w,o
descri-ed t,e F*elatino/s micro-ic la?/eF as t,e so/rce o+ t,e acids.
<
Caries lesions occ/r in +o/r *eneral areas o+ t,e toot,9 7:8 pit and fissure caries, w,ic,
are +o/nd mainly on t,e occl/sal s/r+aces o+ osterior teet, as well as in lin*/al its
o+ t,e ma0illary incisors and -/ccal s/r+aces o+ lower molarsD 7>8 smooth2surface
caries, t,at arise on intact smoot, enamel s/r+aces ot,er t,an at t,e location o+ t,e its
and +iss/resD 7=8 root2surface caries, w,ic, mi*,t in"ol"e any s/r+ace o+ t,e rootD and
7&8 secondary or recurrent caries t,at occ/r on t,e toot, s/r+ace adAacent to an
e0istin* restoration. Smoot,-s/r+ace caries can -e +/rt,er di"ided into caries a++ectin*
t,e 4uccal and lin$ual toot, s/r+aces, and approximal caries, a++ectin* t,e contact
area o+ adAoinin* toot, s/r+aces 7i.e., mesial or distal s/r+aces8.
Dental caries is a multifactorial disease rocess, o+ten reresented -y t,e t,ree
interlockin* circles and an arrow deictin* t,e assa*e o+ time 7C,ater :, Fi*/re :-
&8. For caries to de"elo, t,ree conditions m/st occ/r sim/ltaneo/sly9 7:8 t,ere m/st
-e a s/sceti-le toot, and ,ostD 7>8 cario*enic microor*anisms m/st -e resent in
?/antityD and 7=8 t,ere m/st -e e0cessi"e cons/mtion o+ re+ined car-o,ydrates.
4,en e0osed to a s/ita-le s/-strate 7/s/ally su$ar or su$ar2laden snac*s or
desserts), cario*enic -acteria resent in t,e la?/e rod/ce acid. I+ t,is occ/rs o"er a
s/++iciently lon* eriod o+ time, a caries lesion de"elos. 3ac, o+ t,ese main +actors
incl/des a n/m-er o+ secondary +actors and can -e introd/ced to eit,er rotect or
+/rt,er dama*e t,e toot,. For e0amle, +l/oride incororated into dental enamel
increases toot, resistance 7see C,ater ( and ;8. Con"ersely, a red/ction in t,e sali"a
+low 7xerostomia8 *reatly increases t,e caries risk.
Fi*/re :-& Caries is a multifactorial disease ca/sed -y -acteria, a s/ortin*
,ost diet o+ re+ined car-o,ydrates, decreased ,ost resistance, and time +or t,e
ca"ity to de"elo. 7Source6 Dr. Norman O. Harris, Uni"ersity o+ 5e0as Dental
Sc,ool at San Antonio.8
Embryology and Histology of Enamel
1e+ore disc/ssin* t,e cario/s rocess +/rt,er, it is necessary to -rie+ly re"iew t,e
em-ryolo*y and ,istolo*y o+ enamel. 4it,o/t t,is re"iew it is "ery di++ic/lt to
/nderstand ,ow de- and reminerali@ation can occ/r in s/c, a ,i*,ly minerali@ed tiss/e
as enamel.
5,e enamel is made / o+ -illions o+ crystals t,at in t/rn make / millions o+
indi"id/al rods. 5,e enamel rods, w,en "iewed in cross section wit, an electron
microscoe, aear not as rods, -/t as *eyhole2shaped structures, aro0imately < to
( microns in diameter, wit, t,e enlar*ed ortion o+ t,e key,ole called t,e head and
t,e narrow ortion t,e tail. 4it, t,is con+i*/ration, eac, ,ead +its -etween two tails.
5,e tail is al3ays ositioned toward t,e apex. In t,e ,ead o+ t,e rod t,e lon* a0es o+
t,e crystals, called t,e C axis, are arallel to t,e enamel rod. Howe"er, as t,e
eri,ery o+ t,e rod is aroac,ed, t,e crystals ass/me an an*le to t,e more central
crystalsD in +act, in t,e tail t,is an*le may -e aro/nd =$. 7Fi*/re =-:8.
3ac, rod t,at e0tends +rom t,e dentoenamel A/nction 7D3#8 to t,e toot, s/r+ace is
comleted start-to-+inis, -y one amelo-last. 5,e +inal enamel is aro0imately ;'E
inor*anic, and 'E or*anic material and water. 5,is 'E orosity +orms a network o+
c,annels +or +l/id di++/sion o+ ions and small molec/les t,at are disersed t,ro/*,o/t
t,e entire enamel cap.
a
5,e sace a"aila-le +or t,is di++/sion is +o/nd -etween t,e
rods and e"en -etween t,e crystals. 5o +/rt,er e0tend t,is intra enamel network
t,ro/*,o/t t,e enamel, t,ere are mor,olo*ic str/ct/res in t,e enamel wit, a ,i*,
rotein content, s/c, as t,e striae o+ !et@i/s, enamel lamellae, enamel t/+ts, ores,
and enamel sindles. 5,ese se"eral di++/sion c,annels ro-a-ly ser"e two "ery
imortant /roses in reser"in* t,e teet,9 7:8 t,eir teleolo*ical /rose was ossi-ly
to permit physiolo$ical reminerali1ation t,ro/*,o/t li+e, and 7>8 t,e "oids and rotein
content in t,e enamel ro-a-ly cushion intense 4itin$ pressures to ,el re"ent
+ract/res. Un+ort/nately, t,ese same c,annels o+ di++/sion also ser"e anot,er /rose,
"i@., t,e cond/ctin* o+ la?/e acids into t,e enamel interior to cause
deminerali1ation.
5,is -rie+ s/mmary also oints o/t t,e ex5uisite $enetic control e0ercised o"er t,e
raidly c,an*in* and comle0 tiss/e -/ildin* t,at marks t,e de"eloment o+ enamel.
5,e +ollowin* re"iew -e*ins at t,e time w,en odonto-lasts and amelo-lasts are lined
/ oosite eac, ot,er alon* t,e future dentino-enamel A/nction.
5,e initial e"ent o+ t,e secretory sta*e occ/rs wit, an odonto-lastic deosition o+ t,e
+irst +ew microns o+ predentin. 5,is is +ollowed -y t,e initiation o+ t,e secretory ,ase
o+ t,e amelo-last. 5,e +irst secreted enamel roteins do not acc/m/late as a layer, -/t
instead, enetrates into t,e de"eloin* redentin and s/-Aacent odonto-lasts.
%
5,e
microen"ironment o+ t,e amelo-last at t,is time, is mainly one o+ roteins and water.
(
As t,e amelo-last retreats towards t,e +/t/re s/r+ace o+ t,e toot,, it /ses t,ese
roteins to +orm an acell/lar and a"asc/lar matri0 temlate /on w,ic, t,e +/t/re
,ydro0yaatite crystals are to -e ositioned.
;,:$
5,is re?/ires a "ery ri*id $enetic
control o"er t,e se?/ence o+ e"ents t,at will e0tend t,ro/*, matri0 +ormation, crystal
n/cleation, and crystal *rowt,D as well as rod +ormation 7elon*ation, widenin*, and
mat/ration8.
5,e matri0 is ,i*,ly ,etero*eno/s -eca/se o+ t,e in"ol"ement o+ rotein
contri-/tions +rom many di++erent *enesamelo*ens, enamelin, amelo-lastin,
t/+telin, and "ario/s en@ymes.
-
)ossi-le +/nctions o+ t,ese roteins are n/cleation
7t/+telin8, mineral ion -indin*, 7amelo*enin, enamelin8, and crystal *rowt,
7amelo*enin, enamelin*, amelo-lastin8.
::
I+ t,ere is a +ail/re o+ initiation or
inte*ration o+ action o+ any o+ t,ese roteins, a dyslastic tiss/e can res/lt, +or
e0amle, amelo*enesis imer+ecta t,at is ca/sed -y a de+ect in t,e amelo*en *ene.
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It
s,o/ld -e em,asi@ed t,at t,e amelo-last does not comlete t,e matri0 temlate +rom
t,e dentino-enamel A/nction to t,e e0terior o+ t,e toot, -e+ore enamel +ormation
-e*ins. Instead, w,ile t,e amelo-last is matrix24uildin$ on t,e lateral sides, at t,e
same time t,e 5omes rocess at t,e 4asal end o+ t,e cell is mod/latin* t,e enamel-
-/ildin* +rom t,e time o+ initial secretion to t,e re-er/tion mat/ration sta*es.
:=
5,is
is a contin/o/s rocess as t,e amelo-last mo"es o/tward. In an early supersaturated
en"ironment o+ ,i*, calci/m and ,os,or/s initiated -y t,e amelo-last, octacalcium
phosphate is laid down as a precursor to t,e hydroxyapatite crystal.
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5,e early
,ydro0yaatite crystals are small and o+ oor crystalinity. As t,e amelo-last mo"es
o/tward, t,e rod increases in len*t, and t,ickness. 5owards t,e end o+ t,e secretory
sta*e, t,e matri0 is almost comletely de$raded. Accomanyin* t,is e"ent, t,ere is a
massi"e crystal *rowt,.
:'
5,e mat/rin* enamel *rowt, is now aroac,in* t,e re-
er/ti"e state. 5,e ,ydro0yaatite crystals are /n/s/ally lar*e, /ni+orm in si@e, and
re*/larity ositioned.
::
5,e enamel t,at was ori*inally a so+t rod/ct is now t,e
,ardest and most d/ra-le rod/ced in t,e ,/man -ody.
5,ere are still a +ew more oints a-o/t t,e li+e san o+ t,e ama@in* amelo-last. As t,e
toot, aroac,es er/tion, t,e col/mnar con+i*/ration o+ t,e amelo-lasts +lattens to
+orm t,e reduced enamel epithelium t,at co"ers 7and rotects8 t,e yet immat/re
enamel. A+ter er/tion, t,e red/ced enamel eit,eli/m disaears and is s/cceeded -y
t,e ac5uired (also called salivary) pellicle t,at, in t/rn, is co"ered -y t,e dental
pla5ue 7C,ater >8. 3"en at t,is time, t,e crystals o+ t,e rod are not yet +/lly
minerali@ed. For t,e +irst year a+ter er/tion into t,e mo/t,, t,e rods /nder*o a ost-
er/ti"e mat/ration, wit, t,e additional toot, minerals -ein* deri"ed +rom t,e sali"a.
5,is temorary ,yominerali@ation o+ t,e enamel wit, its *reater orosity, in art
e0lains w,y newly er/ted teet, are more s/sceti-le to caries t,an teet, t,at ,a"e
-een resent in t,e mo/t, +or some time.
a
I+ an intact toot, was stried o+ its /l c,am-er, dentin and cement/m, t,e only
remainin* str/ct/re is t,e enamel ca.
-
At t,is oint in time, it is not necessary to memori@e t,e names and +/nctions o+
*enes. #/st remem-er t,at t,e toot, mor,olo*y deends on *enetic */idance.
Fi*/re =-: 3namel str/ct/re. A. 5,e orientation o+ t,e enamel rods +rom t,e
dentoenamel A/nction to t,e toot, s/r+ace. B. An arcade o+ rods seen at t,e
section indicated -y t,e line in A. C. 5,e key,ole mor,olo*y o+ t,e rods.
S,adin* di++erences reresent di++erent orientations o+ t,e crystals. 7Co/rtesy o+
M4# Dodds, Uni"ersity o+ 5e0as Dental Sc,ool, San Antonio.8
Physical and Microscopic Features of Incipient Caries
5,e de"eloment o+ a cario/s lesion occ/rs in t,ree distinct sta*es. 5,e earliest sta*e
is t,e incipient lesion, w,ic, is accomanied -y ,istolo*ic c,an*es o+ t,e enamelD t,e
second sta*e incl/des t,e ro*ress o+ t,e deminerali@ation +ront toward t,e dentino-
enamel A/nction andBor into t,e dentinD w,ile t,e +inal ,ase o+ caries de"eloment is
t,e de"eloment o+ t,e overt, or fran*, lesion, w,ic, is c,aracteri@ed -y act/al
cavitation. I+ t,e time -etween t,e onset o+ t,e inciient lesion in one or more teet,,
and t,e de"eloment o+ ca"itation is raid and e0tensi"e, t,e condition is re+erred to
as rampant dental caries. Us/ally ramant caries occ/rs +ollowin* eit,er t,e e0cessi"e
and +re?/ent intake o+ s/crose, or t,e resence o+ a se"ere xerostomia 7i.e., dry
mo/t,8 or -ot,. From a re"enti"e dentistry standoint, t,e early identi+ication o+ t,e
inciient lesion is e0tremely imortant, -eca/se it is d/rin* t,is sta*e t,at t,e cario/s
rocess can 4e arrested or reversed. 5,e o"ert lesion can only -e treated -y oerati"e
inter"ention.
Clinically, it is o+ten di++ic/lt to reco*ni@e and dia*nose t,e early lesion, and +or t,is
reason it is imortant to -e +amiliar wit, its +eat/res +rom etiolo*ic and ,istolo*ic
standoints.
:%
5,e inciient lesion is macroscoically e"idenced on t,e toot, s/r+ace
-y t,e aearance o+ an area o+ opacityt,e 3hite spot lesion. At t,is earliest
clinically "isi-le sta*e, t,e s/-s/r+ace deminerali@ation at t,e microscoic le"el is
well esta-lis,ed wit, a n/m-er o+ reco*ni@a-le @ones. )ro-a-ly a most imortant +act
is t,at t,e s/r+ace o+ t,e enamel aears relati"ely intact 7alt,o/*, t,e electron
microscoe s,ows a s/r+ace t,at is more oro/s t,an so/nd enamel8. On t,e -/ccal
and lin*/al s/r+ace o+ a toot,, t,e w,ite sot may -e locali@ed, or it can e0tend alon*
t,e entire *in*i"al area o+ t,e toot,, or m/ltile teet, w,ere +ood tends to lod*e.
/nterproximally, t,e inciient lesion is /s/ally +irst detected on a 4ite 3in$ x2ray. It
/s/ally starts as a small l/cency immediately $in$ival to t,e contact point and t,en
*rad/ally e0ands to a small kidney s,ae, wit, t,e indentation o+ t,e kidney conto/r
directed coronally.
:(
In +iss/re caries, t,e initial lesion comara-le to t,e Fw,ite sot,F
/s/ally occ/rs 4ilaterally on t,e two s/r+aces at the orifice o+ t,e +iss/re and
e"ent/ally coalesces at t,e -ase
:;
7Fi*/re =->8. Occasionally lesion +ormation -e*ins
alon* t,e wall o+ t,e +iss/re or at t,e -ase, eit,er /nilaterally or -ilaterally.
>$
D/rin* t,e early sta*es t,e inciient lesion is not a s/r+ace lesion in w,ic, loss o+
o/ter enamel can -e detected. Instead, t,e mat/re s/r+ace layer o+ :$ to :$$ microns
remains intact. I+ an e0lorer is /sed, t,e s/r+ace enamel +eels ,ard and ro"ides no
indication o+ deminerali@ation. Howe"er, microscoic ores e0tend t,ro/*, t,e
mat/re s/r+ace layer to t,e oint w,ere s/-s/r+ace deminerali@ation occ/rsD t,e main
-ody o+ t,e lesion is located and enlar*es +rom t,is oint.
5,e inciient lesion ,as -een e0tensi"ely st/died and -est descri-ed -y Sil"erstone.
:(

Many o+ t,e o-ser"ations o+ t,e inciient lesion ,a"e -een -ased on t,e /se o+ a
olari@in* microscoe, w,ic, ermits recise meas/rements o+ t,e amo/nt o+
sacecalled pore spacet,at e0ists in normal enamel and to a *reater e0tent in
enamel de+ects. 5,/s as deminerali@ation ro*resses, more ore sace occ/rsD
con"ersely, as reminerali@ation occ/rs, less ore sace is resent.
In t,e inciient lesion as descri-ed -y Sil"erstone, +o/r @ones are usually resent.
Startin* from the tooth surface, t,e +o/r @ones are t,e 7:8 surface @one, 7>8 4ody of the
lesion, 7=8 dar* 1one, and 7&8 t,e translucent @one. 7Fi*/re =-=8
)ore Saces o+ t,e Di++erent Iones
5,e transl/cent @one, t,e deepest @one is seen in aro0imately '$E o+ t,e cario/s
lesions e0amined.
:(
In t,is @one, w,ic, is t,e advancin$ front o+ t,e lesion, sli*,t
deminerali@ation occ/rs, wit, a :E ore sace, comared wit, $.:E +or intact
enamel. In contrast, t,e dark @one occ/rs in aro0imately ;'E o+ cario/s lesions and
,as a ore "ol/me o+ > to &E. 4,en teet, s,owin* no dark @one are laced in a
reminerali@in* sol/tion, t,e dark @one -ecomes "isi-le in its e0ected osition
-etween t,e transl/cent @one and t,e -ody o+ t,e lesion.
>:
On t,e -asis o+ t,is
,enomenon, it is s/**ested t,at this dar* 1one is the site 3here reminerali1ation can
occur and t,at a wider dark @one indicates a *reater amo/nt, or a lon*er eriod, o+
reminerali@ation.
)eri,eral to t,e dark @one lies t,e main -ody o+ t,e lesion. In t,is @one, ore "ol/me
ran*es +rom aro0imately 'E on t,e +rin*es o+ t,e lesion to a-o/t >'E in t,e
center.
:(
Desite t,is considera-le amo/nt o+ deminerali@ation, t,e remainin* crystals
still maintain t,eir -asic orientation on t,e rotein matri0. Finally, t,e s/r+ace @one
,as a near-normal ore sace o+ aro0imately :E. It is t,e s/r+ace @one and t,e dark
@one t,at are t,e reminerali@ation @ones o+ t,e inciient lesion.
Direct Connection o+ t,e 1acterial )la?/e to t,e 1ody o+ t,e .esion
Deminerali@ation o+ t,e s/r+ace enamel rod/ces a ra**ed ro+ile w,en seen wit, t,e
electron microscoe 7Fi*/re =-&8. Small ores, or microc,annels, ,a"e -een o-ser"ed
-y electron microscoy in t,e surface 1one o+ inciient lesions. 5,e initial attack may
-e on t,e rod ends, -etween t,e rods, or -ot,.
>>
5,ere is a 3idenin$ o+ t,e areas
-etween adAacent rods.
>=
4,en conditions are otim/m, t,is ra**ed inter+ace -etween
s/r+ace and s/-s/r+ace can -e reminerali@ed 7reaired8, eit,er -y t,e -ody de+enses
7calci/m and ,os,ate and ot,er ions +rom t,e sali"a8, or -y man-made strate*ies
7+l/oride t,eray and s/*ar disciline8.
'i$ure A2B is an outstandin$ electron micro$raph to aid in visually understandin$
caries initiation and pro$ression 4eyond the details provided 4y Silverstone. For
orientation, in t,e /er-le+t corner o+ t,e ill/stration, t,ere is t,e -acterial la?/e 718D
immediately -elow is t,e sali"ary ellicle 7S)8, +ollowed -y t,e enamel 73N8. 5,e
li*,ter area la-eled CM leads directly +rom t,e -acterial la?/e to t,e area t,at is, or
will -e, t,e e0andin* -ody o+ t,e lesion. In t/rn, t,e -ody o+ t,e lesion oens into
many interrod saces t,at contin/e /ninterr/ted to t,e dentino-enamel A/nction
7D3#8. It is alon* t,ese inter-rod saces t,at t,e -acterial la?/e +l/ids di++/se
7Fi*/res =-' A and 18.
3n ro/te to t,e D3#, t,e stria o+ !et@i/s allows lateral acid access o/t o+ t,e inter-rod
sace into t,e center o+ t,e intact or dama*ed rods and crystals. Once at t,e D3#, any
+l/id +low w,et,er ca/sin* de- or reminerali@ation, can tric,otomi@e
c
eit,er alon* t,e
,yominerali@ed D3#, or into t,e dentinal t/-/les to t,e /l c,am-er 7Fi*/re =-<8.
5,e seed o+ ro*ression o+ t,e caries +ront deends on s/c, +actors as ion
concentration, H, sali"a +low, and -/++erin* actionsall o+ w,ic, are contin/ally
c,an*in*. In s/mmari@in*, t,ere is a trail o+ interconnectin* c,annels +or di++/sion o+
+l/ids transitin* +rom t,e -acterial la?/e to t,e /l c,am-er. Any c,emical c,an*es
in t,e pla5ue can -e soon re+lected throu$hout t,e enamel and dentin as art o+ t,e
inciient lesion.
5,ese /ltrastr/ct/ral enamel de+ectst,e oresallow t,e e0it o+ la?/e acids direct
to t,e s/-s/r+ace re*ion. 5,e initial acid attack re+erentially dissol"es t,e
ma*nesi/m and car-onate ions and is later +ollowed -y a remo"al o+ t,e less sol/-le
calci/m, ,os,ate, and ot,er ions t,at are art o+ t,e crystal.
3"ent/ally t,e /ndermined s/r+ace @one collases. Conc/rrent wit, t,is c,an*e, t,e
more sol/-le roteins are lost +rom t,e s/-s/r+ace matri0. Once ca"itation occ/rs, t,e
@ones o+ t,e inciient lesion -ecome less clearly de+ined -eca/se o+ mineral loss and
t,e resence o+ -acteria, -acterial end rod/cts, la?/e, and resid/al s/-strate, w,ic,
may s/ort +/rt,er lesion de"eloment. 5,e lesion is no lon$er an inciient lesionD it
is now an overt caries lesion re?/irin* oerati"e inter"ention.
c
tric,otomi@e h *o in one o+ t,ree directionsalon* t,e D3# in eit,er direction, or
into t,e dentinal t/-/les.
Fi*/re =-> Inciient caries in an occl/sal +iss/re. 5,e -ilaterality o+ t,e lesion is
e"ident in t,e microradio*ra,. 7Co/rtesy o+ #S 4e+el, Uni"ersity o+ Iowa
Colle*e o+ Dentistry.8
Fi*/re =-= A and B. 5,e -ilaterality o+ caries de"eloment. Note coalescence o+
two lateral cario/s areas at -ase o+ +iss/re. 7From 2oni*, 2.G. Dental
mor,olo*y in relation to caries resistance wit, secial re+erence to +iss/res as
s/sceti-le areas. " Dent Res, :;<=. &>9&<:-&%<.8
Fi*/re =-& From a mesial -rown sot on a lower second molar. An $.( /m
de+ect +illed wit, or*anic material 7CM8 e0tends +rom t,e la*/e 7/er le+t, 18,
t,ro/*, t,e enamel 73N8 as t,e s/r+ace @one, and contin/es into t,e lar*er area
o+ t,e deminerali@ed s/-s/r+ace -ody o+ t,e lesion. On eit,er side o+ t,e -ody o+
t,e lesion are areas wit, disoriented crystals t,at constit/te t,e 7deminerali@in*8
transl/cent @ones. 7From Frank !M, 1rendel A. Ultrastr/ct/re o+ t,e aro0imal
dental la?/e and t,e /nderlyin* normal and cario/s enamel. Arc,Oral 1iol.
:;;<9::9;$;. )ermission *ranted -y )er*aron )ress, .td., O0+ord, 3n*land.8
5eac,in* comment9 5,is electron micro*ra, is "ery imortant to /nderstandin*
t,e ro/te o+ ions +rom t,e la?/e o+ t,e toot, to t,e interior and "ice "ersa, in de-
and reminerali@ation, resecti"ely o+ an inciient lesion.
Fi*/re =-' A. 3lectron micro*ra, o+ rod c/t erendic/lar to lon* a0is,
s,owin* ,ead 7H8 and tail 758 relations,i. B. 3lectron micro*ra, o+ arallel to
lon* a0is s,owin* two rods 7!8 and interrod area 7I8. Ori*inal ma*ni+ication
'$$$. 7From Meckel AH, Grie-stein 4#, Neal !#. Str/ct/re o+ mat/re ,/man
dental enamel as o-ser"ed -y electron microscoy. rch +ral #iol, :;<'D
:$9%%'-%(=.8
Fi*/re =-< Dia*ram o+ a tric,otomi@ed lesion, d/e to di++/sion o+ acids in -ot,
directions /nder t,e enamel, and directly into t,e -ody o+ t,e lesion in t,e dentin.
5 h transl/cent @one, 1 h -ody o+ t,e lesion, ! h reactionary dentin, ) h /l.
7Sil"erstone .M, Hicks M#. 5,e str/ct/re and /ltrastr/ct/re o+ t,e cario/s lesion
in ,/man dentin. 0erodontics, :;(', :9:('-;=.8
Question 1
A. All t,e +ollowin* str/ct/res are in"ol"ed in t,e assa*e o+ +l/ids in t,e enamel9
interrod sace, intercrystalline matri0, ores, and striae o+ !et@i/s.
1. 5,e ,ead o+ t,e enamel rod is always oriented toward t,e incisal or occl/sal
s/r+aces in -ot, t,e ma0illary and mandi-/lar teet,.
C. A ramant caries attack imlies a re"io/s inciient lesion +or eac, o"ert lesion
t,at de"elos.
D. 5,e inciient lesion /s/ally starts incisal to t,e contact oint in interro0imal
caries and at t,e -ase o+ t,e +iss/re in occl/sal caries.
3. 5,e dark and t,e transl/cent @ones are t,e centers o+ reminerali@ation w,en
F-iolo*ic reairF o+ t,e toot, is occ/rrin*.
Know your Enemy, the Cariogenic Bacteria
Followin* MillerCs works in t,e :(;$s, it was not /ntil :;'& t,at +/ndamental
experimental evidence proved t,at -acteria were t,e a*ents o+ acid rod/ction. Orland
and collea*/es
>&
demonstrated t,at $noto4iotic
d
rats did not de"elo caries w,en +ed a
cario*enic dietD t,ey did de"elo caries w,en acido*enic -acteria, l/s a cario$enic
diet 3ere introduced into t,e re"io/s *erm-+ree en"ironment. 5,e transmissi4le
nat/re o+ caries in animals was later demonstrated -y t,e e0eriments o+ 2eyes
>'
w,o
s,owed t,at re"io/sly *noto-iotic, caries-inacti"e ,amsters de"eloed caries a+ter
contact wit, caries-acti"e animals.
d
Gnoto-iotic h *erm-+ree en"ironments
M/tans Stretococci and Caries
For caries to de"elo, acido*enic 7acid-rod/cin*8 -acteria must -e resent, and a
means must e0ist to re"ent t,e acid +rom -ein* was,ed away +rom t,e oint w,ere
caries is to de"elo. Dental la?/e +/l+ills -ot, o+ t,ese +/nctions. It ,els rotect t,e
-acterial colonies in a cocoon o+ 7a *el-like8 $lucan +rom -ein* +l/s,ed, ne/trali@ed,
or e++ected -y antimicro-ials in t,e sali"a or introd/ced -y ,/mans.
O+ t,e =$$-or-more secies o+ microor*anisms in,a-itin* t,e la?/e, t,e *reat
maAority are not directly in"ol"ed in t,e caries rocess. 5wo -acterial *enera are o+
secial interest in cario*enesis9 7:8 t,e mutans streptococci
e
and 7>8 t,e
lacto4acillti.
><,>%
5,e m/tans stretococci 7MS8 are a *ro/ o+ -acterial secies
re"io/sly considered to -e serotyes o+ t,e sin*le secies, Streptococcus mutans.
><

5,ese -acteria are c,aracteri@ed -y t,eir a-ility to rod/ce extracellular $lucans +rom
s/crose and -y t,eir acid rod/ction in animal and ,/man st/dies. Streptococcus
mutans recei"ed its name in :;>& w,en #. 2. Clarke in 3n*land isolated or*anisms
+rom ,/man cario/s lesions. He noted t,at t,ey were more o"al t,an ro/nd and
ass/med t,em to -e a m/tant +orm o+ a stretococc/s.
>(
M/tans stretococci are now considered to -e t,e maAor at,o*enic -acterial secies
in"ol"ed in t,e caries rocess. Inn/mera-le s/r"eys ,a"e indicated an association
-etween t,e n/m-er o+ S, mutans and dental caries.
>;-=:
5,e co/nts ,a"e -een reeated
worldwide +or o"er more t,an +i"e decades +or all a*esin t,e United States,
=>

Sweden,
==
.at"ia,
=&
Finland,
='
and C,ina
=<
wit, ,i*, MS -acterial co/nts -ein*
o"erw,elmin*ly correlated to t,e n/m-er o+ teet, wit, caries or restorations.
M/tans stretococci are /s/ally +o/nd in relati"ely lar*e n/m-ers in t,e la?/e
occ/rrin* immediately o"er de"eloin* smoot,-s/r+ace lesions. In one lon*it/dinal
st/dy, seci+ic sites were eriodically samled +or t,e resence o+ MS, and t,e teet,
later e0amined +or caries. 5eet, destined to -ecome cario/s e0,i-ited a si*ni+icant
increase in t,e roortions o+ MS +rom < to >& mont,s 4efore t,e e"ent/al dia*nosis
o+ caries.
=%
Similarly, dental la?/es isolated +rom sites o"erlyin* w,ite sot lesions
were c,aracteri@ed -y a si*ni+icantly ,i*,er roortion o+ MS t,an la?/es samled
+rom so/nd enamel sites.
=(
Increased n/m-ers o+ MS in t,e sali"a also arallel t,e
de"eloment o+ t,e smoot,-s/r+ace lesion. In anot,er st/dy, MS co/nts +rom t,e
sali"a o+ >$$ c,ildren indicated t,at ;=E wit, detecta-le caries were ositi"e +or MS,
w,ereas /nin+ected c,ildren were almost always caries-+ree.
=;
Certain ,ysiolo*ical c,aracteristics o+ t,e MS +a"or t,eir re/tation as a rime a*ent
in caries. 5,ese traits incl/de t,e a-ility to adhere to toot, s/r+aces, rod/ction o+
a-/ndant insol/-le extracellular olysacc,arides 7*l/can8 +rom s/crose, rapid
rod/ction o+ lactic acid +rom a n/m-er o+ s/*ar s/-strates, acid tolerance, and t,e
rod/ction o+ intracellular olysacc,aride 7ener*y8 stores. 5,ese +eat/res ,el t,e
MS s/r"i"e in an /n+riendly en"ironment d/e to eriods o+ "ery low a"aila-ility o+
s/-strate 7i.e., -etween meals and snacks8. As a *eneral r/le, t,e cario*enic -acteria
meta-oli@e s/*ars to rod/ce t,e ener*y re?/ired +or t,eir *rowt, and rerod/ction.
5,e -y-rod/cts o+ t,is meta-olism are acids, w,ic, are released into t,e la?/e +l/id.
5,e dama*e ca/sed -y MS is mainly ca/sed -y lactic acid, alt,o/*, ot,er acids, s/c,
as -/tyric and roionic, are resent wit,in t,e la?/e.
&$
e
Ori*inally, it was -elie"ed t,at Stretococci m/tans was t,e only secies o+
stretococci t,at ca/sed cariesD ,owe"er, w,en it was +o/nd t,at ot,er stretococci
were also in"ol"ed, t,ey were all *ro/ed /nder t,e /m-rella desi*nation o+ m/tans
stretococci. In t,e older re+erences, t,e ori*inal terminolo*y will -e maintained.
.acto-acilli and Caries
.acto-acilli 7.18 are cario*enic, acido*enic, and acid/ric. Indeed, +rom t,e early
:;>$s /ntil t,e :;'$s, .1 was considered the essential -acteria ca/sin* caries. It was
not /ntil :;'& w,en t,e *noto-iotic
+
st/dies o+ Orland demonstrated t,at i+ rodents
li"in* in a *erm-+ree en"ironment were in+ected wit, a lactic acid-rod/cin*
enterococci 7-/t no .18, t,ey still de"eloed caries.
>&
5,is was t,e +irst time t,at it
was *no3n t,at .1 were not re?/isite +or caries de"eloment. O+ten, t,e n/m-er o+
lacto-acilli isolated +rom eit,er sali"a or la?/e was too low in n/m-er to -e
considered caa-le o+ rod/cin* t,e ran*e o+ H "al/es re?/ired +or caries initiation.
&:
Howe"er, once a caries lesion de"elos, t,e sta-ility o+ t,e immediate la?/e
o/lation c,an*es raidly. 5,e low H en"ironment o+ .1 o+ten eliminates, or at
least s/resses t,e contin/ity o+ coloni@ation o+ MS.
&>
5,is, desite t,e +act t,at
some or*anisms s/c, as MS ro-a-ly ,a"e *enetic de+ensi"e mec,anisms to
minimi@e t,e e++ects o+ a low H.
&=
5,is ,enomenon o+ a lowerin* H res/ltin* in MS -ein* dislaced -y .1, is seen
+ollowin* irradiation +or ,ead and neck cancer, w,en e0tensi"e, m/ltile, caries
lesions de"elo raidly -eca/se o+ t,e destr/ction o+ t,e sali"ary *lands.
&&
D/rin* t,e
initial ,ases o+ t,e de"eloin* cario/s lesions, lar*e n/m-ers o+ %S are in"ol"ed,
only to decrease later in n/m-er as t,e .1 o/lation increases. 5,is is -elie"ed to
-e ca/sed -y .1 creatin* a s/++iciently low H to esta-lis, a monooly o+ t,e
en"ironment.
+
Gnoto-iotic h In t,is /se, t,e animals were raised in a sterile en"ironment.
Adherence
Contin/o/s adherence to t,e solid toot, s/r+ace -y S, mutans is necessary -ot, -e+ore
and a+ter initial coloni@ation. 5,e +irst -acteria m/st esta-lis, a +oot,old on t,e toot,
s/r+ace 7ac?/ired ellicle8 and t,en maintain t,eir ositions w,ile ot,er -acteria
contin/e to coloni@e in ot,er rotected areas o++ered -y t,e interro0imal saces,
alon* t,e *in*i"a, or in t,e its and +iss/res. Ot,erwise t,ey wo/ld -e swet away -y
t,e sali"a.
M/tans stretococci are a-le to attac, to t,e toot, s/r+ace -y eit,er o+ two
mec,anisms9
><,>%,&'
7:8 attac,ment to t,e ac?/ired ellicle t,ro/*, e0tracell/lar
roteins 7adhesins8 located on t,e +im-riae 7+/@@y coat8 o+ t,ese or*anismsD and 7>8
s/crose-dependent mec,anisms, in w,ic, -acteria re5uire t,e resence o+ s/crose to
rod/ce sticky extracellular polysaccharides 7$lucans8, t,at allows attac,ment and
acc/m/lation o+ additional wa"es o+ -acterial coloni@ation.
&<
S/crose is a disacc,aride, consistin* o+ one *l/cose and one +r/ctose /nit 7moieties8.
One o+ t,e key en@ymes in t,e con"ersion o+ t,e *l/cose moiety o+ s/crose to *l/can
is $lucosyltransferase. At times t,e en@yme may -e altered, res/ltin* in t,e
rod/ction o+ a solu4le *l/can t,at does not s/ort ad,erence. 5,ese m/tant strains
t,at +orm solu4le *l/can are /s/ally noncario*enic.
&%
5,e e++ect o+ s/crose restriction on *l/can rod/ction is seen in se"eral clinical
sit/ations. C,ildren w,o cons/me little or no s/crose -eca/se o+ s/crase or +r/ctase
en@yme de+iciencies ,a"e a less cario*enic la?/e. Similarly, atients recei"in* lon*-
term no/ris,ment "ia stomac, t/-e ,a"e less la?/e and +ewer MS.
&(
Indi"id/als
restrictin* t,eir s/crose intake ,a"e a decreased roortion o+ MS in t,eir la?/e, -/t
t,e MS increases w,en s/crose is reintrod/ced into t,e diet.
&;
Dietary restriction o+
s/*ar ,as also -een s,own to red/ce t,e acido*enicity o+ dental la?/e.
'$,':
Ecology of Caries Development
Se"eral st/dies s/ort t,e ossi-ility t,at t,e initial coloni@ers can ,el to determine
t,e e"ent/al at,o*enicity o+ t,e la?/e.
=%
Once a secies o+ -acteria ,as esta-lis,ed
its ecolo$ic niche,
*
ot,er -acteria introd/ced at a later date aear to ,a"e a more
di++ic/lt task in coloni@in*. Once esta-lis,ed, a nic,e can -e lon*-lastin*. For
instance, c,ildren wit, t,e ,i*,est n/m-er o+ MS +or decid/o/s teet, /s/ally
e0erience a ,i*,er attack rate +or t,e later ermanent teet,.
'>
M/tans stretcoccoi re?/ire a solid surfacet,e toot, s/r+ace+or s/ccess+/l
coloni@ation. D/rin* t,e +irst year o+ li+e 4efore er/tion o+ t,e rimary teet,, "ery
+ew MS are +o/nd in t,e mo/t,.
'=
4,en teet,in* -e*ins at aro0imately ( mont,s,
MS o+ten raidly coloni@es t,e la?/e o+ newly er/tin* teet,.
'&
It ,as -een s,own
t,at an imortant so/rce o+ in+ection o+ in+ants -y MS is +rom t,e care$ivers (usually
the mother) -y t,e mo/t,-to-mo/t, transmission, s/c, as "ia kissin*, or -y s,arin* a
soon d/rin* +eedin*.
''
Mot,ers wit, t,e ,i*,est MS co/nts o+ten ,a"e in+ants wit,
similarly ,i*, caries lesion co/nts.
'<
Since early in+ection -y MS is associated wit,
,i*, decay rates,
'%
it ,as -een stron*ly s/**ested t,at an e++ecti"e means o+
re"entin* caries in yo/n* c,ildren wo/ld -e to red/ce t,e n/m-er o+ MS in t,e
arentsC and si-lin*sC mo/t,s -e+ore a c,ildCs -irt,.
1eca/se no entrenc,ed cometition +rom ot,er or*anisms occ/rs on er/tion, t,e +irst
-acterial coloni@ers ro-a-ly ,a"e little di++ic/lty in esta-lis,in* t,eir ecolo*ic nic,es
on t,e ac?/ired ellicle and in t,e sali"a. Once t,e teet, er/t, many o+ t,ese oral
reser"oirs o+ -acteria articiate in t,e +ormation o+ t,e la?/e. 3ac, +irmly
esta-lis,ed nic,e can act as a Fseedin*F area +or ot,er areas o+ t,e mo/t,. M/tans
stretcoocci decrease in n/m-er as teet, are lost t,ro/*,o/t li+e and ractically
disaear +ollowin* +/ll-mo/t, e0traction.
'(
A+ter dent/res are inserted, S, mutans
reaear, only to disaear a*ain w,en t,e dent/res are remo"ed +or an e0tended
eriod.
*
An area in t,e la?/e w,ere seci+ic secies o+ -acteria are relati"ely sa+e +rom ,ost
rotecti"e +/nction o+ sali"a and +rom ot,er anta*onistic -acteria.
Question 2
A. Stretococc/s m/tans can -e e0ected in increased n/m-ers at t,e site o+ an
inciient lesion.
1. .acto-acilli are /s/ally +o/nd e"en earlier t,an m/tans stretococci at t,e inciient
lesion site.
C. Sol/-le *l/cans +oster -etter -acterial ad,erence t,an insol/-le *l/cans.
D. Care*i"ers can -e a c,ildCs worst dental +riend.
3. 5,e m/tans stretococci re?/ire a solid s/r+ace on w,ic, to coloni@e.
Coronal Dentin Caries
It is now desira-le to re"isit t,e em-ryolo*y o+ t,e toot,,
';
startin* at t,e dentoenamel
A/nction 7D3#8 w,en t,e amelo-lasts and t,e odonto-lasts were lined / at t,e +/t/re
D3#. 5,e o-Aecti"e o+ t,e amelo-lasts was t,e +/t/re s/r+ace o+ t,e toot,, w,ile t,e
o-Aecti"e o+ t,e odonto-lasts was t,e +/t/re -order o+ t,e dental /l. D/rin* t,e
eriod o+ toot, +ormation, eac, day t,e odonto-last laid down a trailin* odonto-lastic
rocess and a concentric increment layer o+ predentin. 3ac, s/cceedin* day t,e
redentin -ecame a calci+ied layer o+ dentin +ormin* a t/-/le aro/nd t,e odonto-lastic
rocess, t,e linin* o+ w,ic, is a hypercalci+ied layer called t,e peritu4ular dentin.
5,ese t/-/les e0tended +rom t,e D3# to t,e dental /l, in +act a +ew e0tended into
t,e enamel as enamel spindles.
1etween t,e t/-/les t,ere is intertu4ular dentin 7also called mantle dentin8.
<$
5,e
t/-/les contain +l/id t,at ori*inates +rom t,e /l c,am-er. 5,ere is intert/-/lar
comm/nication and +l/id transort, "ia secondary tu4ules and smaller si@ed
canaliculi. All t/-/les act as c,annels +or t,e convection
,
+low o+ +l/ids t,at +low
outward +rom t,e /l.
<:
Dentinal +l/id is constantly /med into t/-/les -y t,e
+orces o+ mastication, wit, a ret/rn o+ t,e +l/id to t,e /l /on release o+ t,e
ress/re.
<>
4,en t,ere are in+ection rod/cts 7caries8 arri"in* in t,e t/-/les, more
+l/id is +orced into t,e t/-/le.
<=,<&
5,e /l +l/id also contains imortant calci/m,
,os,ate and secretory imm/no*lo-/lin A.
<&,<'
Uon t,e aroac, o+ enamel caries to t,e D3#, many o+ t,e odonto-lastic rocesses
/nderlyin* t,e cario/s enamel interrod areas o+ t,e enamel will lose t,eir "itality.
5,ese t/-/les -ecome dead tracts and may -e*in to artially or w,olly calci+y 5,e
comlete calci+ication res/lts in a ,ard calci+ied *ro/ o+ t/-/les, called sclerotic
dentin t,at acts as a rotecti"e -arrier to t,e ad"ancin* caries. At t,e same time, t,e
odonto-lasts located on t,e eri,ery o+ t,e /l are tri**ered to -e*in layin* down
increments o+ amor,o/s reparative dentin to +/rt,er rotect t,e /l.
In s/mmary, t,e millions o+ di++/sion and con"enction c,annels in t,e enamel and
dentin resecti"ely, ermit a mo"ement o+ +l/id +rom t,e toot, s/r+ace to t,e /l.
<<,<%

5,e intert/-/lar secondary canals and t,e canalic/li ro"ide ermea-ility wit,in t,e
dentin, w,ilst t,e D3# ro"ides t,e same lateral +l/id 7acid8 mo-ility t,at can
/ndermine t,e enamel and aid in its collase to +orm an o"ert caries lesion. It s,o/ld
-e ointed o/t t,at e"en wit, a "isi-le 0-ray l/cency t,at e0tends into t,e dentin, i+
t,e ori*inatin* s/r+ace @one ,as not -roken down into an o"ert ca"ity, t,e entire re-
caries lesion, e"en in dee dentin can on t,e -asis o+ in "itro st/dies, t,eoretically
7and slowly8, -e reminerali@ed.
<(
,
5,e +l/id enterin* t,e toot, +rom t,e s/r+ace is said to diffuse inwardD +l/ids arisin*
+rom t,e /l are said to -e convection fluids.
!oot Caries
A *eneral demo*ra,ic s,i+t is contin/ally occ/rrin* in America, wit, eac,
s/ccessi"e *eneration li"in* lon*er. 5,is ro"ides a lon*er time +or more *in*i"al
recession and more root caries. In addition, Seniors are cons/min* an increasin*
n/m-er o+ medicines t,at are known to red/ce sali"a and ca/se root caries.
<;
2at@ and
collea*/es estimated t,at indi"id/als *oin* into t,eir =$s ,a"e a-o/t : o/t o+ :$$
s/r+aces wit, recession and root cariesD w,en t,ey lea"e t,eir '$s, a-o/t : o/t o+ '
e0osed s/r+aces is in"ol"ed. 5,e roots o+ t,e mandi-/lar molars and t,e mandi-/lar
incisors are at t,e *reatest, and t,e least risk, resecti"ely.
%$
5,e 5,ird National Healt, and N/trition 30amination S/r"ey +o/nd t,at t,e
ercenta*e o+ ersons wit, at least one decayed or +illed root s/r+ace increased +rom
>$.(E in t,e ='- to &&-year a*e *ro/, to ''.;E in t,ose a*ed %' years and older.
%:
A
Canadian st/dy concl/ded t,at Ft,e increase in t,e re"alence o+ root decay wit, a*e
may not -e d/e to a*in* er se, -/t instead, may -e t,e res/lt o+ ne*lect o+ oral ,ealt,
d/rin* t,e years o+ *rowin* older.F Older ad/lts wit, contin/al *ood oral ,ealt, still
,ad low rates o+ root decay.
%>
In a st/dy o+ '$$$ s/-Aects in Finland, it was +o/nd t,at
men ,ad +rom :.: to >.' times more root caries t,an women. 5,e *reatest di++erence
was in t,e *ro/ <$ to <; years o+ a*e.
%=
A n/m-er o+ risk +actors ,a"e -een de+ined +or root caries de"eloment, incl/din*
a*e, *ender, +l/oride e0os/re, systemic illness, medications, oral ,y*iene, and diet.
%&

In terms o+ t,e micro-iolo*y o+ root caries, desite early indications o+ a stron*
association -etween Actinomyces secies and ro*ressi"e root lesions,
%',%<
more
recent st/dies indicate t,at la?/e and sali"ary concentrations o+ t,e m/tans
stretococci are correlated ositi"ely wit, t,e resence o+ root s/r+ace caries.
%%,%(
!oot caries di++ers +rom coronal caries in se"eral asects. A critical di++erence is t,at
t,e tiss/es a++ectedenamel "s. cement/mare +/ndamentally dissimilar. 3namel is
m/c, more ,i*,ly minerali@ed t,an cement/m or dentin. 1eca/se o+ t,e lo3er
mineral content and hi$her or$anic content o+ t,e cement/m-dentin comle0, root
caries may ro*ress 4oth -y acid deminerali1ation of the inor$anic structure and -y
proteolysis of the or$anic component.
%;
5,ese tiss/e "ariations determine t,e
di++erences in t,e rate o+ lesion +ormation, ,istolo*ic and "is/al aearance, as well as
in t,e otential +or and rate o+ reminerali@ation.
($
Clinically, t,e lesion is initially
nonca"itated. 5,e cario/s material is so+t and ,as a yellowis,--rown coloration. 5,e
lesion can e"ent/ally ass/me any o/tline and may in"ol"e m/ltile root s/r+aces
7Fi*/re =-(8. 4,en ca"itation is e"ident, lesions tend to sread laterally, ,a"e a det,
o+ aro0imately $.' to :.$ mm, and are o+ a dark--rown aearance.
(:
5,e lesions
aear immediately 4elo3 t,e cemento-enamel A/nction, /nderminin* -/t not
in"ol"in* t,e enamel 7Fi*/re =-(8.
!oot caries di++er +rom coronal caries in t,at 4acterial invasion o+ cement/m and
dentin occ/rs early. At times, t,e in"asion +eat/res col/mns o+ or*anisms -etween
sikes o+ relati"ely intact cement/m. At ot,er times, a comlete loss o+ cement/m
e0oses t,e dentin. .ike enamel caries, root caries is amena-le to reminerali@ation
andBor arrest.
($
Arrested root caries lesions demonstrate t,ree ,ysical c,aracteristics9
7:8 an outer -arrier o+ ,yerminerali@ed s/r+ace dentinD 7>8 a sclerotic inner -arrier
-etween cario/s and so/nd dentinD and 7=8 minerali@ation occ/rrin* 3ithin t,e
dentinal t/-/les.
(>
Clinically, s/c, reminerali@ed lesions may aear dark and ,ardD
/nder tactile e0amination -y t,e e0lorer, arrested lesions are easily distin*/is,ed
+rom acti"e lesions -y t,eir smoot,, ,ard, and *lassy +eel comared to t,e leat,ery
+eel o+ acti"e root caries.
)re"ention o+ !oot Caries
5,e -est re"ention +or root caries in t,e elderly o/lation is the prevention of
periodontal disease in middle2a$e or earlier. Howe"er, since e0 ost +acto
i
remedial
treatment is not ossi-le, earlier re"enti"e dentistry care needs to -e racticed. 5,e
strate*ies incl/de9 7:8 daily mechanical and chemical pla5ue control 7>8 severe
restriction of refined car4ohydratesD and 7=8 ro/tine ro+essional dental attendance +or
re"enti"e o++ice identi+ication o+ risks and co/nselin* on sel+-care needs. For
instance, +or t,ose at ,i*, risk, a prescription denti+rice wit, a ,i*,-+l/oride content,
)re"ident, wit, ',$$$ arts +l/oride er million, ,as -een +o/nd to si*ni+icantly
increase t,e electrical resistance
A
o+ a toot, s/r+ace.
(=
Fre?/ent ro+essional
e0aminations -ased on an indi"id/alCs risk s,o/ld -e ro/tine. All e0tensi"e
eriodontal s/r*ery +or ocket elimination s,o/ld lace an indi"id/al in a ,i*,er root
caries risk cate*ory +or li+e.
(&,('
In later c,aters, t,e /se o+ t,e antimicro-ial mo/t,
rinse, chlorhexidine, will -e introd/ced as a "ery e++ecti"e m/tans stretococci control
a*ent. 4it, ro+essional */idance and atient cooeration, -iolo*ical reair o+ a root
caries lesion can -e ac,ie"ed in many casesa desira-le otion in "iew o+ t,e
di++ic/lty and lack o+ s/ccess in restorin* root caries "ia oerati"e roced/res.
i
30 ost +acto h A+ter t,e +act, meanin* t,e it is not ossi-le to correct some e"ents o+
t,e ast.
A
Se"eral de"ices are on t,e market t,at are modi+ied "ersions o+ t,e common "olt-o,m
meter. 5,e atient ,olds one electrode, w,ile t,e e0lorer ser"es as t,e second
electrode. 4,en t,e e0lorer is laced on t,e s/sect area, t,e resistance o+ t,e toot,
is meas/red. A ,i*, resistance is associated wit, no caries, and little resistance is
associated wit, caries ro-a-ility.
Secondary, or Recurrent, Caries
Secondary caries start wit, small imer+ections or restoration o"er,an*s t,at e0ist
-etween t,e toot, and t,e mar*ins o+ a restoration.
(<
Also, some toot,-colored +illin*s
,a"e a ,i*,er a++inity +or la?/e.
(%
1acteria are a-le to coloni@e and m/ltily at t,ese
"/lnera-le sites, s,eltered +rom t,e rotecti"e e++ects o+ sali"a and sel+-care e++orts.
3"ent/ally, a lesion de"elos -etween t,e ca"ity mar*in and t,e restoration.
5,e dia*nosis o+ t,ese lesions is di++ic/lt.
((
In one st/dy, e0tracted teet, were c/t so
t,at t,e section incl/ded -ot, a clinically sound amal$am mar$in and one de+ined as
Fditched.F 5,e re"alence o+ rec/rrent lesions in -ot, so/nd and ditc,ed restorations
was close to '$E, alt,o/*, it is /nknown w,et,er t,ese lesions were tr/ly rec/rrent
or d/e to resid/al caries le+t d/rin* a re"io/s ca"ity rearation.
(;
5,e ma*nit/de o+
t,e ro-lem o+ secondary decay is ill/strated -y st/dies indicatin* t,at t,e median
s/r"i"al time o+ restorations ran*es +rom > to C: years.
;$
!elacement o+ de+ecti"e
restorations acco/nt +or insertin* se"eral-times-more t,an needed restorations o"er a
li+e time.
;:
!ed/cin* t,is ro-lem can -est come +rom re"entin* t,e n/m-er o+
rimary lesions 7rimary re"ention8. Some +/t/re relie+ may -e +ort,comin* +rom t,e
/se o+ materials t,at -ond directly to t,e toot, tiss/e, eliminatin* t,e *a -etween
toot, and +illin*, or +rom restorati"e materials t,at slowly release +l/oride, s/c, as
*lass ionomers and newer +l/oride-releasin* comosites and amal*ams.
;>,;=
Fi*/re =-( !oot caries. 5,e darker stainin* o+ t,e coronal ,al+ o+ t,e root
indicates considera-le *in*i"al recession, w,ic, is a rere?/isite to lesion
de"eloment.
Question 3
A. 5,e critical H +or enamel deminerali@ation ran*es -etween <.$ to '.'.
1. 5,ere cannot -e secondary caries, wit,o/t ,a"in* ,ad a re"io/s inciient lesion at
t,e same site.
C. Once t,e inciient lesions -ecome o"ert, all t,e lesion @ones disaear.
D. !oot caries is not necessarily a art o+ t,e a*in* rocess -/t is /s/ally a si*n o+
eriodontal disease andBor re"io/s eriodontal ne*lect.
3. A dentist /s/ally inserts more restorations as a res/lt o+ secondary caries t,an +or
rimary caries.
%easurin$ Pla5ue pH, the Stephan Curve
3"ery time a erson eats a +ood, t,ere is a contin/o/s H c,an*e in t,e la?/e. In
many st/dies, H microelectrodes ,a"e -een inserted in -rid*es and telemonitored to
determine t,ese c,an*es. For s/*ar and s/*ary snacks, an almost immediate dro in
H occ/rs, +ollowed -y a lon*er reco"ery eriod. 5,is dro and reco"ery c/r"e ,as
-een termed t,e Stephan Curve a+ter Dr. !o-ert Ste,an, an o++icer in t,e United
States )/-lic Healt, Ser"ice w,o +irst reorted on t,e contin/o/s c,an*es in H t,at
+ollowed eatin* and drinkin* di++erent +oods and drinkin* di++erent -e"era*es.
;&

)la?/e H resonses to simle s/*ar rinses -y caries-+ree and caries acti"e indi"id/als
e0,i-ited di++erent dros in H and di++erent len*t,s o+ time to ret/rn to normal. 5,/s,
di++erent indi"id/als ,a"e di++erent caa-ilities to -/++er acid rod/ction. 7Fi*/re =-;8.
Similar H st/dies ,a"e -een accomlis,ed t,at identi+y +oods t,at are not ,a@ardo/s
to t,e teet,, and "ice "ersa, t,ose t,at are accomanied -y a dro ast t,e Fcritical
HF o+ H '.' to '.$. 5,ese lists are o+ considera-le "al/e w,en co/nselin* atients.
;'
The Relationship of Saturation to pH
5,e concentration o+ calci/m and ,os,ate ions in t,e pla5ue fluid -at,in* t,e toot,
at t,e la?/e-toot, inter+ace is e0tremely imortant, -eca/se t,ese are t,e same
elements t,at comose t,e ,ydro0yaatite crystal. /f the fluid ad7acent to the tooth is
supersaturated 3ith calcium and phosphate ions at a $iven pH, the enamel cannot
under$o deminerali1ation.
5,e sali"a in contact wit, t,e teet, is normally s/ersat/rated wit, resect to t,e
calci/m and ,os,ate in enamel.
:'
5,e -acterial la?/e can concentrate t,ese ions to
an e"en *reater e0tent. For instance, -ot, calci/m and ,os,ate are t,ree+old times
*reater t,an in t,e sali"a.
;<
5,is increased concentration is o+ ractical imortance
-eca/se calci/m and ,os,ate le"els tend to -e in"ersely related to t,e caries score.
&%
It is also o+ *reat imortance -eca/se it is t,e pla5ue fluid that determines the
eventual caries status.
As t,e H dros in an acid attack, t,e le"el o+ s/ersat/ration also dros, and t,e risk
o+ deminerali@ation increases. 5,ere is no e0act H at w,ic, t,e deminerali@ation
-e*ins, only a *eneral ran*e o+ '.' to '.$. 5,e ran*e is rat,er lar*e -eca/se
deminerali@ation is a +/nction o+ -ot, H and d/ration o+ e0os/re o+ t,e enamel
s/r+ace to t,e acid en"ironment. Di++erent la?/es ,a"e di++erent initial Hs, -/++erin*
otentials, and concentrations o+ calci/m and ,os,ate in di++erent arts o+ t,e
mo/t,. A c,an*e in any o+ t,ese "aria-les res/lts in a di++erent le"el o+
s/ersat/ration in t,e toot, en"ironment.
De2 and Reminerali1ation of Teeth, Principles
5,ro/*,o/t t,is -ook, t,ere will contin/e to -e many re+erences to de- and
reminerali@ation o+ teet,, -ot, as a at,olo*ic and as a t,erae/tic rocess. 5,e
deminerali@ation is ca/sed -y pla5ue acids ca/sin* t,e dissol/tion o+ t,e toot,
minerals makin* / t,e -asic calci/m, ,os,ate, and ,ydro0yl crystals o+ t,e
enamel, dentin and cement/m. !eminerali@ation on t,e ot,er ,and, re?/ires t,e
availa4ility of the same ions, prefera4ly 3ith fluoride as a catalyst to reconstr/ct t,e
missin* or dama*ed rodsa rocess t,at ten Cate atly calls, non2restorative repair.
;%
5,ere are many calci/m and ,os,ate como/nds in t,e -ody t,at "ary in +orm/lae
and wit, c,an*es in H. Howe"er, at t,is time, +or t,e sake o+ simlicity, t,e crystals
and +l/oride como/nd o+ most dental interest in t,e de- and reminerali@ation rocess
are ,ydro0yaatite 7HA)8, +l/or,ydro0yaatite 7FHA8, and calci/m +l/oride 7CaF
>
8.
5,e lon*-term e0os/re o+ teet, to lo3 concentrations o+ +l/oride 7as +o/nd in
+l/oridated water8 res/lts in t,e *rad/al incororation o+ +l/oride into t,e e0istin*
,ydro0yaatite 7HA)8 crystals to +orm +l/or,ydro0yaatite 7FHA8 t,at is more
resistant to acid dama*e. Con"ersely, a hi$her concentration o+ +l/oride 7as occ/rs in
toical alications, /se o+ +l/oride denti+rices, *els, and "arnis,es, etc.8, res/lts in t,e
+ormation o+ surface $lo4ules o+ calci/m +l/oride 7as seen in electron microscoe
ima*es8. A s/-se?/ent coatin* o+ t,ese *lo-/les -y ,os,ates and roteins o+ t,e
sali"a renders t,ese *lo-/les more insol/-le.
;(
As a matter o+ terminolo*y, w,en t,e
+l/oride is incororated into HA) to +orm FHA, it is said to -e +irmly -o/ndD w,ereas,
loosely -o/nd +l/oride is in t,e +orm o+ calci/m +l/oride t,at is adsor4ed onto t,e
s/r+ace o+ HA) and FHA crystals.
;;
See Fi*/re =-:$.
5,e !elations,i 1etween HA), FHA and CaF
>
Followin* an attack -y la?/e acid7s8, t,e CaF
>
dissol"es +irst, +ollowed in se?/ence
-y t,e HA), and +inally, t,e FHA 7wit, its +l/oride s/-stit/tions8. As t,e attack
contin/es, t,e dissociated ions increase the saturation level of the immediate fluid
sufficiently to slo3 crystal dissolution, and eventually arrest +/rt,er sol/tion o+ t,e
crystals. As t,e H -e*ins to ret/rn to normal, crystals -e*in to re2form +rom t,e
comle0 pool o+ dissol"ed ionssome as HA), some as FHA 7wit, many o+ t,e
+l/oride ions comin* +rom t,e re"io/s CaF
>
, and +inally t,e reciitation o+ newly
adsor-ed CaF
>
. Any de+iciencies are s/-se?/ently relaced in time -y calci/m,
,os,ate, and +l/oride +rom so/rces s/c, as t,e sali"a, water, and toot,astes. In
o-ser"in* t,e a-o"e rocess, one m/st mar"el at t,e -ody de+ense system t,at in t,e
a-sence o+ a cell/lar or ,/meral s/r"eillance o+ t,e enamel, can /se a c,emical
system to maintain ,omeostasisone in w,ic, Ca'
<
provides a reservoir for fluoride
that is immediately availa4le 3hen and 3here it is needed.
:$$
5,e only time t,e
system -reaks down is w,en t,e attacks are too +re?/ent and too rolon*ed.
Depth of Reminerali1ation
5,ere is little contro"ersy a-o/t t,e s/ccess o+ s/r+ace reminerali@ation roced/res
in"ol"in* toical roced/res, and o+ /sin* commercial +l/oride rod/cts s/c, a
denti+rices, *els, and "arnis, to comensate +or t,e daily wear and tear o+
deminerali@ation 7C,ater ;8. In t,e New Iealand Sc,ool System, t,ey consider 0-ray
l/cencies o+ inciient lesions t,at e0tend midway t,ro/*, t,e enamel as candidates
+or reminerali@ation. ten Cate, in an in vitro st/dy, +o/nd t,at -ot, t,e inner enamel
and dentin co/ld -e reminerali@ed, -/t "ery slow. Only t,e outer part o+ t,e enamel
aeared to -e resonsi"e to +l/oride di++/sion and reminerali@ation.
;%
At deeer
le"els, reminerali@ation co/ld -e ac,ie"ed, -/t only "ery slowly. In Scandina"ia, t,e
literat/re re+lects t,e -elie+ t,at reminerali@ation is a reasona-le o-Aecti"e e"en +or
lesions reac,in* to t,e dentin. 5,e test +or reminerali@ation in t,ese cases is t,at t,ere
is no demonstra-le caries ro*ress +or > to = years. Howe"er, t,e imortant +act is t,at
t,ere are no reorted st/dies t,at indicate w,et,er dee reminerali@ation is or is not
s/ccess+/l.
%ethods of =arnish pplication
In t,e United States, toical administration o+ +l/orides is /s/ally "ia cotton
alicators, *el trays, and less +re?/ently -y /sin* "arnis,. 7C,ater ;8. In 3/roe,
"arnis,es aear re+era-le -eca/se o+ t,e lon*er e0os/re to +l/oride +ollowin*
alication. Since "arnis,es do seal dental t/-/les in"ol"ed in ,yersensiti"ity,
:$:

t,ere is a ossi-ility t,at t,ey also temorarily seal ores as seen in Fi*/res =-%A and
=-%1. Once sealed, t,ere co/ld -e little or no acid enetration into t,e Fw,ite sot.F
At least t,ree commercial "arnis,es are a"aila-le in Nort, AmericaD/ra,at
7Col*ate-)almoli"e, NH8, D/ra+lor 7),armascience, Montreal8, and Fl/or )rotector
7I"oclar, 6iyadent, Am,erst, NH8. 5,e U.S. Food and Dr/* Administration 7FDA8
,as cleared "arnis,es +or alyin* +l/oride "arnis,-/t only as medical de"ices to -e
/sed as ca"ity liners and desensiti@in* a*ents, not +or caries control. Semiann/al
alications are t,e most acceted time inter"al.
:$>
S/ortin* t,is time inter"al was
SeaCs st/dy in Finland w,ere increasin* t,e alication inter"al +rom two, to +o/r
times er year did not increase t,e e++ecti"eness o+ D/ra,at, e"en in ,i*,-risk
c,ildren.
:$=
6arnis,es ,a"e ro"ed to -e e++ecti"e. One st/dy o+ :&> >- to =-year-old c,ildren was
cond/cted to determine t,e anticaries e++ecti"eness o+ D/ra,at. At t,e end o+ ;
mont,s, =%.(E o+ t,e ori*inally acti"e occl/sal, lin*/al, and -/ccal lesions o+ t,e
control *ro/ -ecame inacti"e, =.<E ,ad ro*ressed, and =<.;E did not c,an*e. For
t,e Duraphat $roup, (:.>E -ecame inacti"e, >.&E ro*ressed, and (.>E did c,an*e
7) >. $$$:8. 5,e a/t,or concl/ded t,at t,e /se o+ "arnis, was easy, sa+e and e++icientD
t,at it was ossi-ly a non-in"asi"e alternati"e +or t,e treatment o+ decay in c,ildren.
:$&
5,e alication o+ t,e "arnis, is receded -y a ro,yla0is, +l/s,in*, isolatin* t,e
tar*et teet,, dryin*, and alyin* t,e "arnis, wit, a small -r/s,tec,ni?/es t,at are
well known and racticed -y t,e dental hy$ienist.
Fi*/re =-% A Scannin* electron micro*ra, o+ dentinal t/-/les. 5,e t/-/les are
aro0imately :.' /m in diameter and s/rro/nded -y a ,i*,ly minerali@ed collar
o+ erit/-/lar dentin. 5,e matri0 -etween t,e t/-/les and erit/-/lar dendentin
is t,e intert/-/lar matri0 and consists o+ -/ndles o+ colla*en +i-rils r/nnin* in a
lane at ri*,t-an*les to t,e lon* a0is o+ t,e t/-/les. Mineral crystals are also
+o/nd ali*ned alon* t,e colla*en +i-ril. 7Sil"erstone, .. M. g Hicks, M. #. 5,e
str/ct/re and /ltrastr/ct/re o+ t,e cario/s lesion in t,e ,/man dentin.
0erodontics :;('D:9:('-;=.8
Fi*/re =-% B Scannin* electron micro*ra, s,owin* t,e @one o+
deminerali@ation in t,e -ody o+ a lesion in dentin caries. 5,is re*ion is -acteria-
+ree and s,ows e"idence o+ acid dissol/tion, esecially in t,e erit/-/lar denin.
5,e sclerosed t/-/lar contents o+ t,e transl/cent @one ,a"e also -een lost as a
res/lt o+ dissol/tion. 7Sil"erstone, .. M. g Hicks, M. #. 5,e str/ct/re and
/ltrastr/ct/re o+ t,e cario/s lesion in ,/man dentin. 0erodontics :;('9:9:('-
;=.8
Fi*/re =-; Ste,an c/r"es. 5,ese c/r"es s,ow t,e tyical la?/e H resonse to
an oral *l/cose rinse 7indicated -y t,e screened area8. 5,ere is an immediate +all
in t,e H, +ollowed -y a *rad/al ret/rn to restin* "al/es a+ter a-o/t &$ min/tes.
3ac, c/r"e reresents t,e mean o+ :> s/-AectsD t,e H was meas/red -y
samlin* met,od 7see C,a. :'8 and t,ere+ore is an a"era*e "al/e +or t,e w,ole
mo/t, la?/e H. In indi"id/al sites away +rom t,e sali"ary -/++ers, t,e H
"al/es may +all close to &.$. 5,e /er c/r"e was o-tained +rom reconstit/ted
skim milk and t,e lower one +rom an ale-+la"ored drink, s,owin* a lar*e
di++erence in t,e acido*enicity o+ t,ese two drinks. 7Co/rtesy o+ M4# Dodds,
Uni"ersity o+ 5e0as Dental Sc,ool, San Antonio.8
Fi*/re =-:$ 3lectron micro*ra,. .oosely -o/nd calci/m +lo/ride *lo-/les on
t,e s/r+ace o+ t,e enamel +ollowin* an alication o+ sodi/m +lo/ride. 5,ese
reaction rod/cts +ollowin* t,e +lo/ride alication will -e dissol"ed in two or
t,ree weeks into t,e sali"a. 3ac, time an alication o+ +lo/ride denti+rice or
mo/t, rinse occ/rs, t,is attern o+ *lo-/le distri-/tion is reeated, wit, t,e
e0tent deendin* on t,e seci+ic +lo/ride and concentration. 7Co/rtesy, Dr. M.#.
Hicks, 5e0as C,ildrens Hosital, Ho/ston, 5G. Ma*ni+ication '$$$G8
Question 4
4,ic, o+ t,e +ollowin* ?/estions, i+ any, are correcte
A. A+ter e0aminin* t,e Ste,an C/r"e recorded +or se"eral +oods, it is ossi-le to
determine w,ic, +oods and snacks are ,a@ardo/s to toot, ,ealt,.
1. As t,e H o+ t,e la?/e +l/id +alls, it is necessary to ,a"e an increasin* amo/nt
7sat/ration8 o+ calci/m and ,os,ate in t,e la?/e +l/id to re"ent t,e dissol/tion o+
t,e toot, mineral.
C. As t,e H dros ast t,e critical H +or enamel dissol/tion, t,e dissol"in* crystals
*rad/ally increase t,e immediate concentration 7sat/ration8 o+ toot, minerals t,at
*rad/ally slow, and ossi-ly arrest t,e +/rt,er sol/tion o+ t,e rod crystals.
D. It re?/ires a lower critical H to dissol"e a crystal t,at is in t,e +l/id en"ironment
o+ dissol"in* CaF
>
.
3. 5,e many st/dies o+ Fdee reminerali@ationF ro"ide ade?/ate scienti+ic 7e"idence
-ased8 "eri+ication t,at it is a "alid means to mana*e inciient lesions w,ere t,e -ody
o+ t,e lesion ,as ro*ressed ast t,e mid oint in t,e enamel.
Summary
Dental caries is a m/lti+actorial disease in"ol"in* an interaction o+ -acteria, diet, ,ost
resistance, and time. Ca"itation can only occ/r w,en deminerali@ation o/tstris t,e
-odyCs de+ensi"e caa-ility +or reminerali@ations o"er a eriod o+ time. 5,e
em-ryolo*y and ,istolo*y o+ t,e enamel are +a"ora-le +or eit,er t,e de- or t,e
reminerali@ation o+ t,e enamel. 5,e resid/al matri0 and sacial relations,is o+ rod-
to-rod and crystalite-to-crystalite, as well as t,e less-calci+ied str/ct/res as t,e
incremental lines o+ !et@i/s, lamellae, and t/+ts, allow +l/ids to di++/se t,ro/*,o/t t,e
enamel. .ike t,e wick o+ an oil lam, t,is network is a"aila-le +or t,e in-and-o/t
mo"ement o+ toot,-mineral ions and la?/e acids. 3"en w,en t,ere ,as -een a
enetration o+ t,e enamel ca -y an inciient lesion, t,is is a re-caries lesion t,at can
o+ten -e reminerali@ed wit,o/t t,e need +or a restoration. )ossi-ly mont,s or years
will elase -e+ore ca"itation, or t,ere may e"en -e a nat/ral reminerali@ation t,at
entirely re"erses t,e caries ro*ression. 5,ere are se"eral acido*enic -acteria t,at are
ca/sal +or caries rod/ction, wit, m/tans stretococci and lacto-acilli -ein* t,e most
st/died. Sil"erstone oened / t,e ossi-ility o+ a new nonrestorati"e reair era w,en
,e descri-ed t,e de- and reminerali@in* @ones o+ an inciient lesion. I+ t,ose in t,e
dental care ro+ession and researc, can -rin* reminerali@ation to +r/ition, millions o+
teet, can -e sa"ed +rom t,e dentistCs drill. 5,e olari@in* and t,e electron
microscoes allow /s to see t,e details o+ ,ow t,e la?/e acids can easily +low into
t,e -ody o+ t,e lesion and -eyond. 5o increase toot, resistance and, at t,e same time,
t,e ro-a-ility o+ reminerali@in* any known or /nknown inciient lesions, mec,anical
la?/e control strate*ies consistin* o+ toot, -r/s,in*, +lossin*, and irri*ation are /sed
to remo"e t,e la?/e. C,emical la?/e control strata*ems in"ol"e t,e /se o+
antimicro-ials to kill or s/ress t,e cario*enic -acteriaD and +l/oride in t,e +orms o+
water +l/oridation, o++ice toical alications, or t,e /se o+ +l/oride rinses or
denti+rices are /sed to imro"e toot, resistance. 5,ere are now t,e means to *reatly
red/ce t,e toll o+ dental cariesD yet needed is access to e0amination and treatment
systems -ased on early identi+ication and treatment o+ risk +actors -e+ore t,ey -ecome
treatment re?/irements. 5,ro/*,o/t t,is -ook, em,asis will -e laced on t,e "ario/s
strate*ies now a"aila-le +or re"entin* or limitin* deminerali@ation, or o+ en,ancin*
reminerali@ation.
:. A, 1, and Ccorrect.
Dincorrect. 5,e interro0imal startin* oint is aical to t,e contact ointD +or t,e
it-and-+iss/re lesion, it /s/ally -e*ins -ilaterally at t,e ori+ice o+ t,e +iss/re.
3incorrect. 5,e dark and t,e s/r+ace @ones are t,e centers +or reminerali@ationD t,e
-ody o+ t,e lesion and t,e transl/cent @ones are centers +or deminerali@ation.
>. A, D, and 3correct.
1incorrect. 5,e MS /s/ally recede t,e lacto-acilli.
Cincorrect. 5,e -acteria-rod/cin* sol/-le *l/cans o+ten are noncario*enic
-eca/se o+ ad,erence ro-lemsD t,e insol/-le *l/cans are /s/ally rod/ced -y t,e
cario*enic -acteria and +acilitate ad,erence.
=. 1, D, and 3correct.
Aincorrect. 5,e critical H +or enamel deminerali@ation is +rom '.' to '.$.
Cincorrect. 5,e same @ones are resent -/t are less clearly de+ined -eca/se o+ t,e
resence o+ -acteria, la?/e, and de-ris.
&. A, 1, C and Dcorrect.
3incorrect. No st/dies to date indicate t,at Fdee reminerali@ationF -y /se o+
+l/oride t,eray is or is not an aroriate met,od o+ caries control. 5,ere is a
t,eoretical -asis, m/c, researc,, and a let,ora o+ ,oe and ent,/siasm +or t,is
aroac, to nonrestorati"e FreairF o+ teet,. 74,at s/*ar ,at, rendered as/nder,
,/mankind is now la-orin* to correctk8
:. In :(;$, Miller roosed t,e iiiiiiiiiiiiiiiiiiiiiiii t,eory +or caries, w,ic,
is still 7wit, many modi+ications8 a -asis +or o/r resent concet o+ t,e dental caries.
>. 5,e -e*innin* and end-oints o+ a cario/s lesion are t,e iiiiiiiiiiiii 7initial8
lesion, w,ic, can -e arrested or re"ersed -y reminerali@ation t,eray, and t,e
iiiiiiiiiiiii 7end oint8 lesion, w,ic, m/st -e restored.
=. 5,e +o/r @ones o+ an inciient lesion seen wit, t,e olari@in* microscoe 7startin*
+rom t,e toot, s/r+ace8 are t,e iiiiiiiiiiiii, iiiiiiiiiiiii, iiiiiiiiiiiii,
and t,e iiiiiiiiiiiii @ones.
&. 5,e @one o+ t,e inciient lesion t,at is t,e -est indicator o+ reminerali@ation is t,e
iiiiiiiiiiiii @oneD t,e two @ones o+ deminerali@ation are t,e iiiiiiiiiiiii and
t,e iiiiiiiiiiiii @ones.
'. As t,e H dros in t,e en"ironment o+ t,e HA), t,e sa iiiiiiiiiiiiin o+
calci/m and ,os,ate in t,e en"ironment m/st increase in order to rotect t,e
crystals. 5,e resence o+ iiiiiiiiiiiii 7element8 will also ,el to rotect t,e
crystal at a lower H.
<. 5,e critical H +or enamel deminerali@ation is wit,in t,e *enerally acceted ran*e
o+ H iiiii to iiiii.
%. 5,e dia*rammin* o+ t,e dro and reco"ery o+ H on a *ra, is o+ten re+erred to as
t,e iiiiiiiiii c/r"e +or t,e in"esti*ator w,o +irst /-lis,ed on t,e ,enomenon.
(. 5wo ossi-le so/rces o+ t,e calci/m and ,os,ate acco/ntin* +or t,e
,yerminerali@ed s/r+ace o+ root caries are iiiiiiiiiiiii and iiiiiiiiiiiii.
;. 5,e +o/r maAor tyes 7location8 o+ caries are9 iiiiiiiiiiiii, iiiiiiiiiiiii,
iiiiiiiiiiiii, and iiiiiiiiiiiii.
:$. 5wo ca/ses +or ramant caries are iiiiiiiiiiiii 7dietary F+oodF8 and
iiiiiiiiiiiii 7dry mo/t,8.
::. 5,e ore sace in -ot, t,e transl/cent and s/r+ace @ones is : ercentD dark @one
aro0imately iiii ercent, and t,e -ody o+ t,e lesion ran*es / to iiii ercent.
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%'. #ordan, H. 6., g Hammond, 1. F. 7:;%>8. Filamento/s -acteria isolated +rom
,/man root s/r+ace caries. rch +ral #iol , :%9:===-&>.
%<. S/mney, D., g #ordan, H. 7:;%&8. C,aracteri@ation o+ -acteria isolated +rom
,/man root s/r+ace cario/s lesions. " Dent Res, <=9=&=-':.
%%. 6an Ho/te, #., #ordan, H. 6., .araway, !., 2ent, !., Soark, ). M., g De)a/la ).
F. 7:;;$8. Association o+ t,e micro-ial +lora o+ dental la?/e and sali"a wit, ,/man
root-s/r+ace caries. " Dent Res , <;9:&<=-<(.
%(. 1owden, G. H. 4. 7:;;$8. Micro-iolo*y o+ root s/r+ace caries in ,/mans. " Dent
Res , <;9:>$'-:$.
%;. D/n*, S. I. 7:;;;8. 3++ects o+ m/tans stretococci, Actinomyces secies and
)or,yromona *in*i"alis on colla*en de*enerations. Chun$ Hua /, Hsueh Tsa Chihi
75aiai8. <>9%<&-%&.
($. Mell-er*, #. !. 7:;(<8. Deminerali@ation and reminerali@ation o+ root s/r+ace
caries. 0erodontolo$y , '9>'-=:.
(:. Ny"ad, 1., g FeAersko", O. 7:;(<8. Acti"e root s/r+ace caries con"erted into
inacti"e caries as a resonse to oral ,y*iene. Scand " Dent Res , ;&9>(:-(&.
(>. Sc,/-ac,, )., ./t@, F., g G/**en,eim, 1. 7:;;>8. H/man root caries9
Histoat,olo*y o+ arrested lesions. Caries Res , ><9:'=-<&.
(=. 1aysan, A., .ync,, 3., 3llwood, !., )etterson, .., g 1ors-oom, ). 7>$$:8
!e"ersal o+ rimary root caries /sin* denti+rices containin* ',$$$ and :,:$$ m.
Fl/oride. Caries Res , ='9&:-&<.
(&. 6an der !eiAden, 4. A., DelemiAn-2i/w, N., StiAne-"an Nes, A. M., deSoet, #.
#., g "an 6inkel,o++, A. #. 7>$$:8. M/tans stretococci in s/-*in*i"al la?/e o+
treated and /ntreated atients wit, eriodontitis. " Clin Periodontol >(9<(<-;:.
('. !eikeer, #., "an der 6elden, U., 1arende?t, D. S., g .oos, 1. G. 7>$$$8. !oot
caries in atient wit, eriodontal +ollow-/ care. )re"alence and risk +actors. &ed
Ti7schr Tandheel*d, :$%9&$>-'.
(<. 4allman, C., g 2rasse, 1. 7:;;>8. M/tans stretococci on mar*ins o+ +illin*s and
crowns. " Dent , >$9:<=-<<.
(%. .ind?/ist, 1., g 3mlson, C. G. 7:;;$8. Distri-/tion and re"alence o+ m/tans
stretococci in t,e ,/man dentition. " Dent Res , <;9::<$-<<.
((. 2idd, 3. A. M. 7:;;$8. Caries dia*nosis wit,in restored teet,. dv Dent Res , &9:$-
:=.
(;. 2idd, 3. A. M., g OCHara, #. 4. 7:;;$8. 5,e caries stat/s o+ occl/sal amal*am
restorations wit, mar*inal de+ects. " Dent Res , <;9:>%'-%%.
;$. 3lderton, !. #. 7:;(=8. .on*it/dinal st/dy o+ dental treatment in t,e General
Dental Ser"ice in Scotland. #r Dent ", :''9;:-;<.
;:. 3lderton, !. #. 7:;;$8. Clinical st/dies concernin* re-restoration o+ teet,. dv
Dent Res , &9&-;.
;>. Skart"eit, .., 4e+el, #. S., g 3kstrand, #. 7:;;:8. 3++ect o+ +l/oride amal*ams on
arti+icial rec/rrent enamel and root caries. Scand " Dent Res , ;;9>(%-;&.
;=. DiAkman, G. 3. H. M., de 6ries, #., .oddin*, A., g Arenda, #. 7:;;=8. .on*-term
+l/oride release o+ "isi-le li*,t-acti"ated comosites in vitro9 A correlation wit, in
sit/ deminerali@ation data. Caries Res , >%9::%->=.
;&. Ste,an, !. M. 7:;:$8. C,an*es in ,ydro*en-ion concentration on toot, s/r+aces
and in cario/s lesions. "D, >%9%:(->=.
;'. Dodds, M. 4. #., g 3d*ar, 4. M. 7:;;(8. 5,e relations,i -etween la?/e H,
la?/e acid anion ro+iles and oral car-o,ydrate retention a+ter in*estion o+ se"eral
Cre+erence +oodsC -y ,/man s/-Aects. " Dent Res, <%9(<:-<'.
;<. ten Cate, #. M. 7:;;>8. Sali"a a ,ysiolo*ical medi/m. &ed Ti7dschr Tandheel*r ,
;;9(>-&.
;%. ten Cate, #. M. 7>$$:8. !eminerali@ation o+ caries lesions e0tendin* into dentin. "
Dent Res , ($9:&$%-::.
;(. O*aard, 1. 7:;;;8. 5,e cariostatic mec,anism o+ +l/oride. Comp Contin !duc
Dent , >$ 7: S/l89:$-:%.
;;. ten Cate, #. M., g .o"eren, "an Cor 7:;;;8. Fl/oride mec,anisms. Dent Clinics
&or mer , &=9%:=-&>.
:$$. !osin-Gr*et, 2., g .incir, #. 7>$$:8. C/rrent concet on t,e anticaries +l/oride
mec,anism o+ t,e action. Coll ntropol , >'9%$=-:>.
:$:. Ga++ar, A. 7:;;(8. 5reatin* ,yersensiti"ity wit, +l/oride "arnis,es. Comp Cont
!du Dent , :;9:$((-;$.
:$>. 1eltran-A*/ilar, 3. D., Goldstein, #. 4., g .ockwood, S. A. 7>$$$8. Fl/oride
"arnis,es. A re"iew o+ t,eir clinical /se, cariostatic mec,anisms, e++icacy and sa+ety.
"D , :=:9'(;-;<.
:$=. Sea, .. 7:;;:8. St/dies o+ +l/oride "arnis,es in Finland. Proc 'inn Dent Soc ,
(%9'&:-&%.
:$&. A/tio-Gold, #. 5., g Co/rts, F. 7>$$$8. Assessin* t,e e++ect o+ +l/oride "arnis,
on early enamel cario/s lesions in t,e rimary dentition. "D, :=>9:>&%-'=.
reser"ed.
Chapter 5. Toothbrushes and Toothbrushing Methods - Samuel (, .an*ell Ulrich
P, Saxer
Objectives
t the end of this chapter it 3ill 4e possi4le to6
:. Gi"e a -rie+ ,istory o+ t,e toot,-r/s,, descri-e its arts in detail, and e0lain w,y
t,ere is no one FidealF -r/s,.
>. Comare nat/ral and nylon -ristles +or t,eir /ni+ormity o+ len*t,, diameter, and
d/ra-ility.
=. Disc/ss t,e wide ran*e o+ ,ead and ,andle desi*ns and e0lain w,y t,ere are many
FnewF man/al and owered toot,-r/s, rod/cts -ein* marketed.
&. Comare and contrast la-oratory and clinical e"al/ations o+ toot,-r/s,
e++ecti"eness.
'. Comare man/al and owered toot,-r/s,es +or e++ecti"eness and sa+ety.
<. Comare t,e ADA rocess +or e"al/atin* FstandardF and FnewF man/al
toot,-r/s,es.
%. Disc/ss modi+ications o+ toot,-r/s,in* met,ods alica-le to secial atient care,
atients /sin* rost,eses, and t,ose /nder ort,odontic care.
(. Disc/ss interro0imal access o+ di++erent toot,-r/s,es and t,eir ossi-le role in
oral-disease treatment and re"ention.
Introduction
A+ter teet, ,a"e -een comletely cleaned -y t,e dental ro+essional or -y t,e
indi"id/al, so+t micro-ial dental la?/e contin/ally re+orms on t,e toot, s/r+aces.
4it, time, la?/e is t,e rimary a*ent in t,e de"eloment o+ caries, eriodontal
disease, and calc/l/st,e t,ree conditions +or w,ic, indi"id/als most o+ten seek
ro+essional ser"ices. I+ la?/e, artic/larly at interro0imal and *in*i"al areas, is
comletely remo"ed wit, ,ome-care roced/res, t,ese dental-disease conditions can
-e re"ented. Un+ort/nately, t,e maAority o+ t,e o/lation is /na-le, /ninstr/cted, or
/nwillin* or does not reali@e t,e need to send t,e time to remo"e la?/e +rom all
toot, s/r+aces, andBor t,e rod/ct7s8 /sed are not ade?/ate to remo"e la?/e at critical
sites. )la?/e deosits can -e remo"ed eit,er mec,anically or c,emically. 5,e +oc/s o+
t,is c,ater is t,e mec,anical remo"al o+ la?/e, /sin* toot,-r/s,es and
toot,-r/s,in* tec,ni?/es. 5,e +ollowin* two c,aters em,asi@e t,e /se o+ rod/cts
and a/0iliary aids wit, toot,-r/s,es in remo"in* la?/e and t,e maintenance o+
,ealt,y teet, and *in*i"al tiss/es.
The Manual Toothbrush
History
Hirsc,+eld, in ,is :;=; landmark te0t-ook on t,e toot,-r/s, and oral care, incl/ded
an in-det, re"iew o+ t,e ,istory o+ toot,-r/s,in*.
:
5,e e0act ori*in o+ mec,anical
de"ices +or cleanin* teet, is /nknown. Ancient eoles c,ewed twi*s +rom lants
wit, ,i*, aromatic roerties. C,ewin* t,ese twi*s +res,ened t,e -reat, and sread
o/t +i-ers at t,e tis o+ t,e twi* +or cleanin* t,e toot, and */m s/r+aces. 5,e Ara-s
-e+ore Islam /sed a iece o+ t,e root o+ t,e arak tree -eca/se its +i-ers stood o/t like
-ristlesD t,is de"ice was called a siwak. A+ter se"eral /ses, t,e -ristle +i-ers -ecame
so+t, and a new F-r/s,F was created -y striin* o++ t,e end and makin* new -ristle
+i-ers. In t,e se"ent,-cent/ry, Mo,ammed made r/les +or oral ,y*iene, and so it
-ecame a reli*io/s o-li*ation. 5o t,is day t,e siwak, comosed +rom aromatic tyes
o+ wood, is still /sed. C,ew sticks not only ,el to ,ysically clean teet, -/t also,
-eca/se t,ey contain anti-acterial oils and tannins, may ,el re"ent or remo"e
la?/e.
>
5,e C,inese are credited +or in"entin* t,e toot,-r/s, comrisin* a ,andle wit,
-ristles d/rin* t,e 5an* dynasty 7<:(-;$% A.D.8. 5,ey /sed ,o* -ristles similar to
t,ose in some contemorary models. In :%($, in 3n*land, 4illiam Addis
man/+act/red w,at was termed Ft,e +irst modern toot,-r/s,.F
=,&
5,is instr/ment ,ad a
-one ,andle and ,oles +or lacement o+ nat/ral ,o* -ristles, w,ic, were ,eld in lace
-y wire. In t,e early :;$$s, cell/loid -e*an to relace t,e -one ,andle, a c,an*eo"er
t,at was ,astened -y 4orld 4ar I w,en -one and ,o* -ristles were in s,ort s/ly.
As a res/lt o+ t,e -lockade o+ ,i*,-?/ality nat/ral ,o* -ristles +rom C,ina and !/ssia
d/rin* 4orld 4ar II, nylon -ristles were /sed instead. Initially, nylon -ristles were
coies o+ nat/ral -ristles in len*t, and t,ickness. 5,ey were sti++er t,an nat/ral
-ristles o+ similar diameter. 5,ey did not ,a"e t,e ,ollow stem o+ nat/ral -ristles and,
accordin*ly, did not a-sor- water. Comared to nat/ral -ristles, nylon +ilaments ,a"e
t,e additional ad"anta*es t,at t,ey can -e reared in "ario/s /ni+orm diameters and
s,aes, and can -e end-ro/nded to -e more *entle on *in*i"al tiss/es d/rin* t,e
-r/s,in* roced/re. In :;>&, an American dentist reorted on =% di++erent man/al
toot,-r/s,es wit, re*ard to ,andle s,ae, ,ead desi*n, -ristle tye, len*t,, and widt,.
Indi"id/al dentists disa*reed t,en, and still do today, on w,at tye o+ toot,-r/s, was
-est. 5,e rimary toot,-r/s, s,aes marketed in t,e :;&$s t,ro/*, :;($s in t,e
United States ,ad +lat, m/ltit/+ted toot,-r/s,-,ead s,aes. Since t,e :;;$s new
man/al toot,-r/s,es ,a"e -een introd/ced wit, new s,aes, si@es, colors, and
claimed ad"anta*es. 1y "aryin* t,e len*t, and t,e an*le o+ t,e +ilaments in t,e -r/s,
,ead, -r/s,in* wit, t,ese newly desi*ned rod/cts ,as -een doc/mented to imro"e
la?/e remo"al since t,e -ristle +ilaments can -e directed into t,e s/lc/s or
interro0imal areas.
=-:>
New /ncon"entional toot,-r/s,es wit, two or more ,eads or
se*ments o+ +ilaments in an*/lar relation- s,i ,a"e s,own imro"ed la?/e remo"al.
One new -r/s, wit, t,ree ,eads can -e /sed to sim/ltaneo/sly clean t,e -/ccal,
occl/sal, and lin*/al s/r+aces.
:=-:'
5,e roli+eration o+ -r/s,es can -e attri-/ted, in
art, to ad"ances in man/+act/rin*, +or e0amle, t,e attac,ment o+ -ristles into t,e
,andle /sin* moldin* tec,ni?/es rat,er t,an stalin* to allow a wider +le0i-ility in
toot,-r/s, desi*ns and -ristle an*/lations. In addition, toot,-r/s, -ristles are now
a"aila-le in a "ariety o+ colors, te0t/res and s,aes.
5,ere also ,as -een an increase in -ot, t,e ?/ality and n/m-er o+ la-oratory and
clinical researc, st/dies on toot,-r/s,es. 5,e International Association o+ Dental
!esearc, and American Association o+ Dental !esearc, are maAor meetin*s +or -ot,
academic and ind/stry scientists to resent t,eir latest researc,. In t,e :;;: and :;;>
key-word inde0es o+ t,e a-stracts acceted +or resentation at t,ese meetin*s,
toot,-r/s,es were not incl/ded as a toic. In :;;= t,e n/m-er o+ a-stracts were
ranked as denti+rices > mo/t,rinses > toot,-r/s,es. Since t,en, t,ro/*, >$$:, t,e
n/m-er o+ denti+rice a-stracts ,as s,own marked increases or decreases, wit, a eak
o+ o"er ;$ a-stracts in :;;(. Mo/t,rinse a-stracts ,a"e s,own essentially a le"elin*-
o++ or a sli*,t decrease in n/m-er since :;;:. 5oot,-r/s, a-stracts ,a"e contin/ed to
demonstrate a consistent increase, and at t,e >$$: AAD! meetin*, e0ceeded
denti+rices and mo/t,rinses.
4it, t,e scienti+ic reorts a-o/t toot,-r/s, contamination a+ter oral or medical
-acterialB "iral in+ections, dental ro+essionals recommend relacin* toot,-r/s,es at
=- to &-mont, inter"als, so reeat /rc,asin* o+ toot,-r/s, rod/cts is done more
+re?/ently. 5,e increase in toot,-r/s, sales may -e an additional dri"in* +orce +or t,e
marketin* o+ new desi*ns and "ariety o+ toot,-r/s,es. 5oot,-r/s, ricin* ,as reac,ed
new ,i*,s wit, t,e introd/ction o+ F,i*,-tec,F man/al toot,-r/s, desi*ns and
stron*er claims, yet t,e cost er indi"id/al rod/ct is *enerally less t,an t,e cost +or a
F+amily-si@eF t/-e o+ toot,aste or mo/t,rinse. 5oot,-r/s, s,iin* costs are less,
-reaka*e is minimal and t,e s,el+-li+e 7sta-ility8 is lon*er t,an +or ot,er rod/ct
cate*ories t,/s, t,e otential ro+ita-ility o+ toot,-r/s,es to t,e man/+act/rers may -e
*reater t,an +or denti+rice or mo/t,rinse rod/cts.
Question 1
A. 5,e toot,-r/s, -ecame commercially a"aila-le in t,e United States A/st -e+ore t,e
Ci"il 4arD t,e cell/loid ,andle -ecame o/lar d/rin* 4orld 4ar ID and nylon
-ristles aeared A/st -e+ore 4orld 4ar I.
1. 4,ile toot,-r/s,-,ead desi*ns ,a"e c,an*ed considera-ly in t,e ast decade,
toot,-r/s, -ristles s,aes ,a"e remained essentially t,e same.
C. 5,e cross section o+ t,e a"era*e toot,-r/s, in t,e United States, rior to t,e :;;$s,
,ad a +lat ,ead and a +lat -ristle ro+ile.
D. Nylon -ristles are more +irm or sti++er t,an nat/ral -ristles wit, t,e same diameter.
3. In t,e :;;$s toot,-r/s,es ,a"e -een t,e s/-Aect o+ a steadily increasin* n/m-er o+
la-oratory and clinical researc, st/dies.
Man/al 5oot,-r/s, Desi*ns
Man/al toot,-r/s,es "ary in si@e, s,ae, te0t/re, and desi*n more t,an any ot,er
cate*ory o+ dental rod/cts.
'
A man/al toot,-r/s, consists o+ a ,ead wit, -ristles and
a ,andle 7Fi*/re '-:8. 4,en t,e -ristles are -/nc,ed to*et,er, t,ey are known as
t/+ts. 5,e ,ead is ar-itrarily di"ided into t,e toe, w,ic, is at t,e e0treme end o+ t,e
,ead, and t,e ,eel, w,ic, is closest to t,e ,andle. A constriction, termed t,e s,ank,
/s/ally occ/rs -etween t,e ,andle and t,e ,ead. Many toot,-r/s,es are man/+act/red
in di++erent si@eslar*e, medi/m, and small 7or comact8to adat -etter to t,e oral
anatomy o+ di++erent indi"id/als.
',%
5oot,-r/s,es also di++er in t,eir de+ined ,ardness
or te0t/re, /s/ally -ein* classi+ied as ,ard, medi/m, so+t or e0tra so+t. Descritions
and meas/rements o+ selected U.S. toot,-r/s,es are s,own in 5a-le '-:.
M/c, o+ t,e early data comarin* t,e e++icacy o+ "ario/s toot,-r/s, desi*ns is
contradictory -eca/se o+ 7:8 t,e lack o+ ?/antitati"e met,ods /sed to meas/re
cleanin* 7la?/e remo"al8, 7>8 t,e many si@es and s,aes o+ toot,-r/s,es /sed, and
7=8 t,e lack o+ standardi@ed toot,-r/s,in* roced/res /sed in t,e st/dies. More
recently, toot,-r/s, ,eads ,a"e -een altered to "ary -ristle len*t,s and lacement in
attemts to -etter reac, interro0imal areas. Handles ,a"e also -een er*onomically
desi*ned to accommodate m/ltile de0terity le"els. As descri-ed in t,e introd/ction,
t,e c,an*e +rom t,e old +lat toot,-r/s, to m/ltile"el desi*ns was ossi-le -eca/se o+
new -ristle tec,nolo*y and man/+act/rin* roced/res.
)ro+iles
4,en "iewed +rom t,e side, toot,-r/s,es ,a"e +o/r -asic lateral ro+iles9 conca"e,
con"e0, +lat, and m/ltile"eled 7riled or scalloed8. 5,e conca"e s,ae can -e /se+/l
+or imro"ed cleanin* o+ +acial s/r+aces, w,ereas con"e0 s,aes aear more /se+/l
+or imro"ed cleanin* o+ lin*/al s/r+aces.
'
.ateral and cross-section ro+iles and t,e
o"er,ead aearance o+ selected toot,-r/s,es commercially a"aila-le in t,e United
States are s,own in Fi*/res '->, '-=, and '-&. In la-oratory and clinical st/dies,
toot,-r/s,es wit, m/ltile"el ro+iles were consistently more e++ecti"e t,an +lat
toot,-r/s,es, esecially w,en interro0imal e++icacy was monitored.
<,(,::,:<,:%
1ristle S,aes
!ecently, new toot,-r/s, -ristle s,aes and te0t/res ,a"e -een +a-ricated, as s,own
in Fi*/re '-'. 5oot,-r/s, rod/cts /tili@in* t,ese -ristles in m/ltile diameters,
te0t/res, and -ristle trims ,a"e -een de"eloed, and la-oratory st/dies ,a"e
doc/mented imro"ed e++icacy o+ toot,-r/s,es wit, taered, +eat,ered and diamond-
s,aed -ristles, comared to toot,-r/s,es wit, standard ro/nd -ristles.
:(->$
!nd2roundin$
Ori*inally, indi"id/al toot,-r/s, -ristles were c/t -l/ntly and o+ten ,ad s,ar end
con+i*/rations. In :;&(, 1ass reorted t,at t,ese -ristle tis co/ld dama*e t,e so+t
tiss/es and t,at ro/nded, taered, or smoot, -ristle tis were less a-rasi"e.
>:
Alt,o/*,
1assCs researc, was not er+ormed accordin* to strict researc, rotocol, ,is +indin*s
,a"e remained /ndis/ted +or more t,an &$ years. Indeed, ad"ertisers still recommend
end-ro/nded tis +or sa+ety and to romote toot,-r/s, sales. 4,en toot,-r/s,es are
e0amined /nder low ma*ni+ication, most -ristles la-eled as Fro/ndedF do in +act
aear smoot, or end-ro/nded. Howe"er, at ,i*,er ma*ni+ication, as s,own in Fi*/re
'-<, many o+ t,ese Fro/ndedF -ristles take on di++erent con+i*/rations.
'
D/rin* /se,
-ristles -ecome smoot,er and more end-ro/nded. 4it, contin/ed /se, t,e -ristles o+
t,e t/+t e0and and sread o/t.
>>
1ristle wear ,as -een s,own to "ary directly wit, t,e
toot,-r/s,in* load and amo/nt o+ denti+rice and in"ersely wit, -ristle diameter.
>=
In a
recent st/dy, t,ere were no si*ni+icant di++erences in la?/e or *in*i"itis indices in a
*ro/ in w,ic, toot,-r/s,es were relaced on a mont,ly -asis comared to t,e
second *ro/ /sin* t,eir same toot,-r/s, o"er t,e = mont, eriod. 5,e toot,-r/s,es
/sed +or = mont,s e0,i-ited a si*ni+icant increase in t,e wear inde0 comared to t,e
-aseline "al/es.
>&
A :;(( scannin*-electron microscoe st/dy
>'
comared end-
ro/ndin* o+ -ristles +rom ei*,t marketed tyes. 1ased on statistical analysis o+ =$
toot,-r/s,es o+ eac, tye, acceta-ility "aried +rom >> to ((E, indicatin* to t,ese
a/t,ors t,at some -r/s,es are not s/++iciently ro/nded and are likely to rod/ce
*in*i"al dama*e. In addition, t,ey ,a"e a-rasi"e otential on dentin and cement/m.
A :;;> st/dy
><
comared a rile desi*n wit, a +lat-ro+ile -r/s, /sin* a stereoscoic
microscoe wit, +i-erotic li*,tin*. Close to ;$E o+ t,e -ristles o+ t,e rile -r/s,
were end-ro/nded, w,ereas t,e +lat -r/s, ,ad an a"era*e o+ '>E ro/nded -ristles.
Aarently, t,e de*ree o+ end-ro/ndin* deends on a man/+act/rerCs seci+ications
and not on toot,-r/s, desi*n.
In a st/dy cond/cted in >$$: on =: di++erent toot,-r/s,es, only & rod/cts ,ad more
t,an '$E o+ t,e +ilaments ro/ndedD in :; rod/cts, end-ro/ndin* was :> to &$E and
only $ to %E in ( -rands. 5,e a/t,ors concl/ded t,at a lar*e ercenta*e o+ marketed
toot,-r/s,es do not meet acceta-le end-ro/ndin* criteria.
>%
I+ -ristles are c/t, +rayed,
or are ,ollow t,ey can ,ar-or -acteria, "ir/ses, and ot,er otential erioat,o*ens,
esecially i+ no denti+rice is /sed, and t,ey can trans+er t,ese into and aro/nd t,e
mo/t,.
>(
Handle Desi*ns
Many o+ t,e new toot,-r/s,es in t,e United States ,a"e a styled-,andle desi*n.
Modi+ications, s/c, as trian*/lar e0tr/sions or indentations alon* t,e sides +or a -etter
*ras, a Ft,/m- ositionF on t,e -ack o+ t,e ,andle +or more com+ort, and "ario/s
an*le -ends to ermit -etter access into and aro/nd t,e mo/t,, ,a"e -een introd/ced.
Fo/r toot,-r/s,-,andle desi*ns are s,own in Fi*/re '-%. Se"eral -r/s,es ,a"e
recently -een marketed wit, an Fan*ledF desi*n, stated to -e like a dental instr/ment.
As s,own in Fi*/re '-(, t,ese toot,-r/s,es are similar to a dental ro+essionalCs
mirror. 1r/s,es are also a"aila-le, as deicted in Fi*/re '-;, wit, a ,andle on t,e
same lane as t,e -ristle tis, as are dental instr/ments /sed +or caries e"al/ations and
ro,yla0es. 4it, -ot, t,e o++set and an*led-o++set desi*ns, oints o+ -ristle contact
are in line wit, t,e lon*it/dinal a0is o+ t,e ,andle d/rin* -r/s,in*. Handle desi*n and
len*t, may ro"ide com+ort and comliance d/rin* toot,-r/s, /se and t,ese +actors
,a"e recently -een doc/mented to imro"e t,e ?/ality o+ toot, -r/s,in*. 5,is is
artic/larly tr/e o+ toot,-r/s,es +or c,ildren, w,ose de0terity may not -e ,i*,ly
de"eloed.
(,;
5e0t/re
Nylon -ristles ,a"e a /ni+orm diameter and a wide ran*e o+ redicta-le te0t/res.
5e0t/re is de+ined as -ristle resistance to ress/re and is also re+erred to as +irmness,
sti++ness, and ,ardness. 5,e +irmness or te0t/re o+ a -ristle is related to its 7:8
comosition, 7>8 diameter, 7=8 len*t,, and 7&8 n/m-er o+ indi"id/al -ristles er t/+t. In
t,e man/+act/rin* rocess, t,e diameter o+ nylon -ristles can -e well controlled.
1eca/se t,e maAority o+ toot,-r/s,es contain -ristles :$- to :>-millimeters lon*, t,e
diameter o+ t,e -ristle -ecomes t,e critical determinant o+ te0t/re. 5,e /s/al ran*e o+
diameters +or ad/lt toot,-r/s, -ristles is +rom $.$$% to $.$:' inc,es. Factors s/c, as
temerat/re, /take o+ water 7,ydration8, and toot,-r/s,-/se +re?/ency a++ect te0t/re.
5e0t/re la-elin* is not standardi@ed. Indi"id/al man/+act/rers la-el t,eir -r/s,es
accordin* to t,eir testin* criteria. 5,/s one man/+act/rerCs Fso+tF *rade may -e sti++er
t,an anot,er man/+act/rerCs Fmedi/mF *rade. 5,e International Or*ani@ation +or
Standardi@ation 7ISO8 ,as +orm/lated testin* roced/res t,at ermit man/+act/rers to
la-el t,eir -r/s,es in a consistent manner.
>;
5,e American Dental Association is a
mem-er o+ ISO.
Nylon 6ers/s Nat/ral 1ristles
5,e nylon -ristle is s/erior to t,e nat/ral 7,o*8 -ristle in se"eral asects. Nylon
-ristles +le0 as many as :$ times more o+ten t,an nat/ral -ristles -e+ore -reakin*D t,ey
do not slit or a-rade and are easier to clean. 5,e con+i*/rations and ,ardness o+
nylon -ristles can -e standardi@ed wit,in seci+ied and rerod/ci-le tolerances.
Nat/ral -ristle diameters, since t,ey are taered, "ary *reatly in eac, +ilament. 5,is
can lead to wide "ariations in t,e res/ltin* te0t/re o+ t,e marketed toot,-r/s,. As a
res/lt o+ t,e ad"anta*es o+ nylon, as well as its ease and economy o+ rod/ction,
relati"ely +ew nat/ral -ristle toot,-r/s,es are marketed.
Actions
1ristle actions ca/sed -y di++erent -r/s,in* motions are ill/strated in a :;;>
/-lication
%
t,at meas/red and ?/anti+ied t,ree-dimensional indi"id/al mo"ements
d/rin* -r/s,in*. Data +rames were +ilmed to create a com/ter-*enerated reanimation
o+ -r/s,in* motions in order to desi*n new toot,-r/s, -ristle con+ormations. 5,ese
a/t,ors concl/ded t,at an indi"id/alCs -r/s,in* tec,ni?/es do not "ary and are
inade?/ateD t,ere+ore -ristle con+i*/rations in newly desi*ned toot,-r/s,es co/ld -e
de"eloed to -e adata-le to any -r/s,in* style
Fi*/re '-: )arts o+ a toot,-r/s,.
Fi*/re '-> .ateral ro+iles o+ selected toot,-r/s,es9 A?/a+res, Fle0D Col*ate
)l/sD Col*ate 5otalD Col*ate 4a"eD Crest ComleteD MentadentD Oral-1
Ad"anta*eD Oral-1 )-&$D !eac, Ad"anced Desi*nD !eac, )la?/e SweeerD
!eac, 5oot, g G/m Care.
Fi*/re '-= Cross-sectional ro+iles o+ +o/r toot,-r/s,es9 1/tler GUMD Col*ate
5otalD Oral-1D !eac,.
Fi*/re '-& O"er,ead aearance o+ selected toot,-r/s,es, +rom le+t to ri*,t9
!eac, Ad"anced Desi*nD A?/a+res,D Col*ate )l/sD Crest ComleteD #ordan 6.
Fi*/re '-' New s,aes and te0t/res o+ 5yne0 nylon toot,-r/s, +ilaments.
7Co/rtesy o+ D/)ont Filaments.8
Fi*/re '-< 5oot,-r/s, -ristle ends as seen wit, t,e scannin* electron
microscoe. A. A coarse-c/t toot,-r/s, -ristle end, ro-a-ly t,e res/lt o+ an
incomlete sin*le--lade c/t d/rin* t,e man/+act/rin* rocess. 5,ese s,ar
roAections can red/ce t,e -ristlesC o"erall cleanin* e++iciency and dama*e oral
tiss/es 7S3M ('8. B. A sli*,tly enlar*ed, -/l-o/s nylon -ristle end, res/ltin*
+rom a do/-le--lade or scissor c/t d/rin* t,e man/+act/rin* rocess 7S3M
:%$8. C. A taered or ro/nd-end nylon -ristle rod/ced -y ,eat or a mec,anical
olis,in* rocess 7S3M :%$8. D. 5,e scr/--in*, mec,anical action o+ a
toot,-r/s, wear mac,ine ,as nicely ro/nded o++ t,is -ristle remo"ed +rom a
-r/s, t,at was ori*inally coarse c/t. 7S3M :%$8. 7Co/rtesy o+ 22 )ark, 1A
Matis, AG C,risten, Indiana Uni"ersity Dental Sc,ool.8
Fi*/re '-% Fo/r -asic s,aes o+ toot,-r/s, ,andles. (" Clin Dent,)
Fi*/re '-( Similarity o+ an*led toot,-r/s,es and a dental mirror.
Fi*/re '-; Similarity o+ two dental instr/ments and a toot,-r/s, wit, t,e ,ead
on t,e same lane as t,e ,andle.
Powered Toothbrushes
Introd/ction
)owered toot,-r/s,es were +irst ad"ertised in Harper?s -ee*ly in Fe-r/ary :((<,
=$

-/t only -ecame a +actor in t,e U.S. marketlace -e*innin* in t,e :;<$s wit, t,e
introd/ction o+ 1ro0adent. 4it, t,e commercial s/ccess o+ t,is rod/ct, -attery-
owered rod/cts were introd/ced wit, t,e ad"anta*e o+ -ein* orta-le and a"aila-le
at a lower cost. Un+ort/nately, ro-lems wit, t,ese -attery-owered rod/cts
incl/ded s,ort Fworkin* timesF and mec,anical -reakdowns. 5,e ent,/siasm +or t,e
owered toot,-r/s, declined and was recommended mainly +or t,e ,andicaed.
In t,e :;($s, t,e cate*ory o+ owered toot,-r/s,es was re"itali@ed wit, t,e
introd/ction o+ t,e Inter)lak rod/ct. 5,is Fsecond *enerationF owered toot,-r/s,
,ad a /ni?/ely rotatin* ,ead and was owered -y lon*-li+eB rec,ar*ea-le -atteries.
Increased e++icacy comared to man/al toot,-r/s,es was consistently demonstrated in
/-lis,ed st/dies.
&,(,;, =:-==
Since t,en, sonic-owered toot,-r/s,es o+ a Ft,irdF *eneration ,a"e -een de"eloed
and s,own to remo"e more la?/e in comarison to man/al toot,-r/s,es, esecially
in lon*-term st/dies. 5wo rimary tyes o+ ,ead desi*ns are now /sed9 t,e rotatin*,
oscillatin* tye wit, a small, ro/nd molar-crown-si@e -r/s, ,ead and t,ree oscillatin*
-r/s,es wit, eit,er "i-ratin* or rotational sonic mo"ements.
=&-=%
)la?/e remo"al -y
t,ese -r/s,es aears e?/ally e++ecti"eD eriodontal t,erae/tic e++ects were
demonstrated in ockets o+ ' mm. FGenerationsF o+ owered toot,-r/s,es are
resented in 5a-le '->.
Most recently, owered toot,-r/s,es ,a"e -een introd/ced t,at are -attery-owered
or disosa-le a+ter Fr/nnin* down,F and are riced, in t,e United States -elow f>$.$$.
)/-lis,ed st/dies ,a"e -een +o/nd on two o+ t,ese -r/s,es.
=(-=;
In most de"eloed co/ntries, t,e n/m-er o+ owered toot,-r/s, rod/cts sold ,as
increased dramatically in recent years. In Swit@erland, t,e re*/lar /se o+ owered
toot,-r/s,es increased +rom :$ to =$E in t,e last decade. In eidemiolo*ical st/dies,
it ,as -een doc/mented t,at o/lations are e0,i-itin* increased *in*i"al a-rasion
and recession. 5,is ,as -een associated wit, t,e increased /se o+ oscillatin* owered
toot,-r/s,es. In comarison to t,ese oscillatin* toot,-r/s,es, sonic toot,-r/s,es ,a"e
-een s,own to do little ,arm to t,e *in*i"a. Also sonic -r/s,es o+ t,is tye can -e
/sed / to < or :> mont,s -eca/se t,e -ristles s,ow minimal o"ert si*ns o+ /se and do
not slay.
&$-&&
1ristleBDesi*ns
5,e ,eads o+ most owered or mec,anical toot,-r/s,es are smaller t,an man/al
toot,-r/s,es and are /s/ally remo"a-le to allow +or relacements 7Fi*/re '-:$8. 5,e
,ead +ollows t,ree -asic atterns w,en t,e motor is started9 7:8 recirocatin*, a -ack-
and-+ort, mo"ementD 7>8 arc/ate, an /-and-down mo"ementD and 7=8 ellitical, a
com-ination o+ t,e recirocatin* and arc/ate motions. )owered toot,-r/s,es are
consistently s/erior to man/al toot,-r/s,es in la?/e remo"al and *in*i"itis
e++icacy.
;,=:,&'
Di++erences are most si*ni+icant w,en tested a*ainst man/al
toot,-r/s,es.
Moti"ation
Moti"ation to imro"e oral ,y*iene aears to -e a key +actor +or atients to /rc,ase
owered toot,-r/s,es.
=:,&<
In a s/r"ey -y t,e ADA, o+ t,e :=; resondents w,o
owned owered toot,-r/s,es, >:.<E /sed t,em re*/larly, and >'.>E /sed t,em
occasionally.
&%
5,is s/r"ey does not indicate t,e toot,-r/s,in* +re?/ency o+ t,e
remainin* '=E. A /-lis,ed st/dy on t,e /se o+ owered toot,-r/s,es +o/nd t,at
w,en cons/mers +irst /rc,ased t,e electric -r/s, t,ey increased t,eir +re?/ency o+
-r/s,in*. 5,e e++ecti"eness is esecially imro"ed w,en t,e /sers are *i"en
instr/ctions and controlled d/rin* t,e +irst <-mont, eriod. More recently,
&(
a s/r"ey
cond/cted < mont,s a+ter s/-Aects comleted a clinical e++icacy st/dy indicated t,at
most s/-Aects were not /sin* t,eir owered de"ice twice a day. 4it, t,e de"eloment
o+ t,e second and t,ird *eneration o+ owered toot,-r/s,es, it aears t,at lon*-term
/se is increasin*D ,owe"er, recent /-lications on t,is ,a"e not -een de+initi"e.
4einstein et al.
&;
analy@ed t,e +ail/res o+ moti"ation. One o+ t,e imortant asects is
to accet eac, atient as an indi"id/al, and t,e dental ,y*ienist and dentist s,o/ld -e
a-le to listen to t,e atient. Oral ,y*iene can -e instr/cted only w,en we are in+ormed
a-o/t a atientCs attit/des, and ,e or s,e ,as to demonstrate t,eir oral ,y*iene. 5,e
roced/re in -r/s,in* +or any met,od /sed s,o/ld ,a"e a de+inite se?/ence. Healt,
ro+essionals s,o/ld take time and not e0ect t,e atient to c,an*e more t,an one
t,in* +rom session to session. It is imortant to ,a"e a re"enti"e ro*ram +or eac,
atient, and t,is starts wit, t,e c,artin*. A+ter t,e +irst stes we s,o/ld +ollow t,e
ro*ram to o-tain t,e *oals wit, t,e atient. 5,e atientsC ro*ress s,o/ld -e
e"al/ated +rom session to session and +rom year to year. Dental ro+essionals s,o/ld
also accet +ail/res and ,a"e an alternati"e lan to imlement in case o+ +ail/re.
Fi*/re '-:$ 5oot,-r/s, ,eads +rom +o/r owered toot,-r/s,es9 1ra/nD
InterlakD SonicareD !ota-dent.
Efficiency / Safety Evaluations
5oot,-r/s,in* de"ices ,a"e -een de"eloed t,at acc/rately standardi@e all o+ t,e
a-o"e +actors, in addition to len*t, and n/m-er o+ toot,-r/s,in* strokes o"er
sim/lated anterior or osterior teet,. )/-lis,ed testin* met,ods are now a"aila-le to
e"al/ate -ot, sa+ety and e++icacy o+ man/al and owered toot,-r/s,es 75a-le '-=8.
Di++erences -etween rod/cts can -e determined and, in se"eral areas, are redicti"e
o+ clinical res/lts. For e0amle, t,ree la-oratory met,ods ,a"e -een redicti"e o+
clinical la?/e remo"al w,en la?/e assessments +oc/sin* on interro0imal areas
were /sed. Si*ni+icant clinical di++erences -etween toot,-r/s, desi*ns ,a"e also -een
doc/mented.
(,;,:%
Interro0imal access e++icacy ,as -een directly related to increasin*
-r/s,in* ress/res and in"ersely correlated wit, -ristle te0t/re 7t,e Fso+terF t,e
te0t/re, t,e ,i*,er t,e interro0imal e++icacy8.
'$,':
Clinical ad"anta*es o+ "ario/s toot,-r/s,-,ead con+i*/rations +or remo"in* dental
la?/e and de-ris 7cleanin* e++icacy8 ,a"e -een di++ic/lt to s/-stantiate. 5,is is
attri-/ted to t,e wide "ariations amon* indi"id/als in toot,-r/s,in* times, motions,
ress/res, and in t,e s,ae and n/m-er o+ teet, resent. )/-lis,ed st/dies on t,e
clinical s/eriority o+ one newly desi*ned man/al or owered toot,-r/s, "ers/s
anot,er ,a"e -een inconsistent. It is clear, ,owe"er, t,at t,ese new rod/cts are more
e++ecti"e t,an standard man/al -r/s,es.
(,;
The American Dental Association (ADA) Acceptance Program
5,e American Dental Association 7ADA8 ,as esta-lis,ed */idelines to ena-le
man/+act/rers to o-tain an acceta-le ratin* and /se t,e ADA Seal o+ Accetance. In
:;;<, t,e Co/ncil on Scienti+ic A++airs o+ t,e American Dental Association roosed
new */idelines +or t,e Seal o+ Accetance.
'>
5,ese */idelines re?/ire la-oratory
doc/mentation o+ acceta-le end-ro/ndedness, *ood man/+act/rin* roced/res
7GM)s8, and e?/i"alency in clinical la?/e and *in*i"itis e++icacy comared wit, a
control toot,-r/s, ro"ided -y t,e ADA.
Man/al toot,-r/s,es wit, a standard desi*n, acceta-le la-oratory data, and GM)s
do not re?/ire clinical testin*. For man/al toot,-r/s,es wit, new desi*ns and +or
mec,anical -r/s,es, t,e */idelines re?/ire only e?/i"alency in la?/e and *in*i"itis
red/ction comared wit, a toot,-r/s, ro"ided -y t,e ADA. 5,e clinical rotocol is
s/mmari@ed in 5a-le '-&. 5,e statement to -e /sed in t,e la-elin* o+ rod/cts
acceted -y t,e ADA is9 F7)rod/ct Name8 is acceted as an e++ecti"e cleansin* de"ice
t,at ,as -een s,own to remo"e la?/e and red/ce *in*i"itis w,en /sed as directed in
a ro*ram o+ *ood oral ,y*iene to s/lement re*/lar ro+essional care.F
As listed on t,e American Dental AssociationCs we-site 7www.ADA.or*8, more t,an
:&$ man/al toot,-r/s,es ,a"e -een awarded t,e ADA Seal o+ Aro"al 7A/*/st
>$$:8.
5,e ADA ,as de"eloed criteria +or accetance o+ owered toot,-r/s,es -ased on
-ot, sa+ety and e++icacy. 5,ese are9 7:8 la-oratory e"idence o+ electric sa+ety, t,at is,
no electric s,ock ,a@ardD 7>8 clinical e"idence o+ -ot, ,ard- and so+t-tiss/e sa+ety
/nder /ns/er"ised conditionsD 7=8 clinical e"idence o+ la?/e and *in*i"itis e++icacy
comared to a toot,-r/s, already acceted and ro"ided -y t,e ADAD and 7&8
e"idence o+ roer la-elin* and ad"ertisin* claims t,at may mention la?/e red/ction
-/t not imro"ement o+ any e0istin* oral disease.
'>
5,e re?/ired statement +or
la-elin* and commercial claims on owered toot,-r/s,es acceted -y t,e ADA is t,e
same as +or man/al toot,-r/s,es. As o+ A/*/st >$$:, :$ owered toot,-r/s,es ,a"e
-een awarded t,e ADA Seal o+ Accetance. Fi"e o+ t,ese rod/cts are distri-/ted -y
4ater )ik 5ec,nolo*ies.
Question 2
A. Usin* la-oratory tests, t,e relati"e e++ecti"eness o+ di++erent toot,-r/s,es can -e
comared and seci+ic -r/s,es identi+ied as e++ecti"e +or remo"al o+ la?/e.
1. Interro0imal access decreases as t,e te0t/res o+ t,e -ristles increases.
C. Interro0imal access is -etter wit, "ertical -r/s,in* roced/res, comared wit, a
,ori@ontal motion o+ t,e -r/s, ,ead.
D. Standard man/al toot,-r/s,es can remo"e la?/e as e++ecti"ely as t,e newly
desi*ned owered toot,-r/s,es.
3. An interro0imal la?/e inde0 is /sed to meas/re interro0imal toot,-r/s,
cleanin* e++iciency.
Toothbrushing Methods
5,e o-Aecti"es o+ toot,-r/s,in* are to 7:8 remo"e la?/e and dist/r- re+ormationD 7>8
clean teet, o+ +ood, de-ris, and stainD 7=8 stim/late t,e *in*i"al tiss/esD and 7&8 aly
denti+rice wit, seci+ic in*redients to address caries, eriodontal disease or
sensiti"ity.
D/rin* t,e last '$ years many toot,-r/s,in* met,ods ,a"e -een introd/ced, and most
are identi+ied -y an indi"id/alCs name, s/c, as 1ass, Stillman, C,arters, or -y a term
indicatin* a rimary action to -e +ollowed, s/c, as roll or scr/-. No one met,od
s,ows consistently -etter res/lts in remo"in* la?/e t,an scr/--in*. Most st/dies
wit, man/al toot,-r/s,es and t,e di++erent instr/cted met,ods s,ow more *in*i"al
a-rasion t,an wit, owered sonic toot,-r/s,es. Most eole -r/s,in* wit, an
instr/cted ro+essional met,od are not aware t,at t,ey are -r/s,in* in a seci+ic way.
5,/s it may -e more e++ecti"e to instr/ct atients to imro"e t,eir own met,od. 5,is
can -e ac,ie"ed -y /sin* a la?/e disclosant to stain la?/e or identi+y areas t,at are
missed d/rin* toot, -r/s,in*. 5,en t,e atient can -e ta/*,t ,ow to clean t,e sites
roerly and on t,e ne0t "isit -e rec,ecked. 5,e roosed adatation ,as to -e
recorded in t,e atientCs c,art and rec,ecked at t,e -e*innin* o+ t,e ne0t session, as
not all atients can remem-er all t,e instr/ctions. Additionally, ro+essionals s,o/ld
ne"er ar*/e wit, a atient -/t instead s,o/ld enco/ra*e and ,el.
6ario/s toot,-r/s,in* met,ods will -e -rie+ly descri-ed ,ere. For more details see
t,e ori*inal aers or t,is c,ater in t,e re"io/s te0t-ook edition. 5,e toot,-r/s,in*
met,ods most em,asi@ed are ,ori@ontal scr/-, Fones, .eonard, Stillman, C,arters,
1ass, rollin* stroke 7ress roll8, and Smit,-1ell. All o+ t,ese tec,ni?/es are alica-le
to t,e cleanin* o+ t,e +acial, lin*/al, and to some e0tent to occl/sal s/r+acesD all are
relati"ely ine++ecti"e in cleanin* interro0imal areasD and only t,e 1ass tec,ni?/e is
e++ecti"e in cleanin* t,e s/lc/s. 5,e -r/s, motions /sed in eac, o+ t,ese tec,ni?/es
are s/mmari@ed in 5a-le '-'.
Nat/ral Met,ods o+ 1r/s,in*
5,e most nat/ral -r/s,in* met,ods /sed -y atients are a recirocatin* ,ori@ontal
scr/- tec,ni?/e,
'=
a rotary motion 7FonesCs tec,ni?/e8,
'&
or a simle /-and-down
motion o"er t,e ma0illary and mandi-/lar teet, 7.eonardCs tec,ni?/e8.
''
)atients
mana*in* e++ecti"e toot,-r/s,in* wit, t,ese met,ods wit,o/t ca/sin* tra/matic
ro-lems or disease s,o/ld not alter t,eir -r/s,in* met,ods A/st +or t,e sake o+
c,an*e.
'<
StillmanCs met,od was ori*inally de"eloed to ro"ide *in*i"al stim/lation.
'%
5,e
toot,-r/s, is ositioned wit, t,e -ristles inclined at a &'-de*ree an*le to t,e ae0 o+
t,e toot,, wit, art o+ t,e -r/s, restin* on t,e *in*i"a and t,e ot,er art on t,e toot,
7Fi*/re '-::8. A "i-ratory motion is /sed wit, a sli*,t ress/re to stim/late t,e
*in*i"a. 5,e -r/s, is li+ted and t,en relaced in t,e same area, and /lsin* is
reeated.
C,arters ad"ocated a ress/re-"i-ratory tec,ni?/e to clean interro0imal areas.
'(
5,e
toot,-r/s, s,o/ld -e laced at a ;$-de*ree an*le to t,e lon* a0is o+ t,e teet, so t,at
t,e -ristles are *ently +orced -etween t,e teet, -/t do not rest on t,e */ms. 5,e -r/s,
is mo"ed in se"eral small rotary motions so t,at t,e sides o+ t,e -ristles are in contact
wit, t,e */m mar*in. A+ter two or t,ree s/c, motions, t,e -r/s, is remo"ed and
relaced in t,e same area and t,e motions are reeated.
It is imortant to note t,at t,e 1ass tec,ni?/e was t,e +irst to +oc/s on t,e remo"al o+
la?/e and de-ris +rom t,e *in*i"al s/lc/s -y t,e com-ined /se o+ a so+t toot,-r/s,
and dental +loss. 5,e met,od is e++ecti"e +or remo"in* la?/e adAacent to and directly
-eneat, t,e *in*i"al mar*ins as art o+ t,e sel+-care re*imen +or controllin*
eriodontal disease and caries. In t,e 1ass tec,ni?/e, t,e toot,-r/s, is ositioned in
t,e *in*i"al s/lc/s at a &'-de*ree an*le to t,e toot, ae0. 5,e -ristles are t,en *ently
ressed to enter t,e s/lc/s. A "i-ratory action, descri-ed as a -ack-and-+ort,
,ori@ontal Ai**le, ca/ses a /lsin* o+ t,e -ristles to clean t,e s/lci
';
7Fi*/re '-:>8. 5en
strokes are ad"ised +or eac, area.
In t,e rollin*-stroke met,od, t,e toot,-r/s, -ristles are ositioned arallel to and
a*ainst t,e attac,ed *in*i"a, wit, t,e toot,-r/s, ,ead le"el wit, t,e occl/sal lane.
5,e wrist is t,en t/rned to +le0 t,e toot,-r/s, -ristles +irst a*ainst t,e *in*i"a and
t,en t,e +acial s/r+ace. A sweein* motion is contin/ed /ntil t,e occl/sal or incisal
s/r+ace is reac,ed 7Fi*/re '-:=8. 5,e toot,-r/s, -ristles are at ri*,t an*les to t,e
toot, s/r+ace as t,e -r/s, asses o"er t,e crown. 5,e ress roll action is reeated at
least +i"e times -e+ore roceedin* to t,e ne0t site.
<$
Modi+ied 1r/s,in* Met,ods
In attemts to en,ance -r/s,in* o+ t,e entire +acial and lin*/al toot, s/r+aces, t,e
ori*inal tec,ni?/es ,a"e -een modi+ied. Some modi+ications like t,e 1ass met,od
may ind/ce a more rono/nced *in*i"al tra/ma wit, standard -r/s,es.
<:
New
toot,-r/s, desi*ns s/c, as m/ltile"el and cross-section -ristles t,at ,a"e -een tested
are not only more e++ecti"e -/t can -e also less ,arm+/l.
<>
5,e +ollowin* considerations are imortant w,en teac,in* atients a artic/lar
toot,-r/s,in* tec,ni?/e9 7:8 t,e atientCs oral ,ealt, stat/s, incl/din* n/m-er o+ teet,,
t,eir ali*nment, atientCs mo/t, si@e, resence o+ remo"a-le rost,eses, ort,odontic
aliances, eriodontal ockets, and *in*i"al conditionD 7>8 t,e atientCs systemic
,ealt, stat/s, incl/din* m/sc/lar and Aoint diseases, and mental retardationD 7=8 t,e
atientCs a*eD 7&8 t,e atientCs interest and moti"ationD 7'8 t,e atientCs man/al
de0terityD and 7<8 t,e ease and e++ecti"eness wit, w,ic, t,e ro+essional can e0lain
and demonstrate roer toot,-r/s,in* roced/res.
!ecommended )owered 5oot,-r/s,in* Met,ods
Most owered toot,-r/s, man/+act/rers do not recommend a seci+ic -r/s,in*
met,od, ,owe"er, t,e electric -r/s,es s,o/ld -e /sed in a seci+ied manner. 5,e
Swiss Dental Society, in >$$: de"eloed an instr/ction man/al.
<=
Instr/ctions +or
-r/s,es wit, a sweein* and Bor oscillatin* rotary motion are as +ollows9
:. 5,e -r/s,es are ositioned on t,e toot, s/r+aces in a &'- or ;$-de*ree an*le to t,e
incisal lane. Only w,en ositioned s,o/ld t,e -r/s, -e switc,ed to Fon.F 5,e mo/t,
s,o/ld -e almost closed.
>. 5,e -r/s, s,o/ld -e mo"ed slowly o"er and aro/nd eac, toot, +or = to ' seconds,
makin* s/re t,at t,e -ristles clean t,e cre"ices -etween t,e teet,.
=. 5,e -r/s, ,ead can -e li+ted distally and mesially into t,e interro0imal areas to
reac, t,e interdental areaD t,e -r/s, always remains on a sin*le toot,.
&. A+ter a eriod o+ aro0imately ' seconds, t,e -r/s, is mo"ed to t,e ne0t toot,
s/r+ace and reositioned.
'. 30erienced indi"id/als can /se t,e -r/s, also in a erendic/lar an*le to t,e teet,
and */ms, -/t t,e alied +orce ,as to -e *entle. In t,is way, eac, toot, in t,e /er
and lower arc, is cleaned on t,e -/ccal and lin*/al s/r+aces.
<. It is -est to di"ide t,e mo/t, into +o/r ?/adrants 7/er-ri*,t, /er-le+t, lower-
ri*,t, and lower-le+t8 and to start -r/s,in* on a toot, in t,e /er rear and t,en clean
one s/r+ace a+ter t,e ot,er "ery systematically.
%. It is an easy way, *i"es *ood control +or t,e indi"id/al, and does not omit any toot,
s/r+ace. 5,is met,od takes more time, -eca/se at a sin*le time inter"al, only one
toot, s/r+ace can -e cleaned.
5oot,-r/s,in* 5ime and Fre?/ency
For many years t,e dental ro+essional ad"ised atients to -r/s, t,eir teet, a+ter e"ery
meal. 5,e ADA ,as modi+ied t,is osition -y /se o+ t,e statement t,at atients s,o/ld
-r/s, Fre*/larly.F !esearc, ,as indicated t,at i+ la?/e is comletely remo"ed e"ery
ot,er day, t,ere will -e no deleterio/s e++ects in t,e oral ca"ity.
<&
On t,e ot,er ,and,
-eca/se +ew indi"id/als comletely remo"e la?/e, daily -r/s,in* is still e0tremely
imortant to ma0imi@e s/lc/lar cleanin* as a eriodontal disease control meas/re, as
well as to a++ord an oort/nity to /se +l/oride denti+rices more o+ten in caries
control. 4,ere eriodontal ockets e0ist, e"en more +re?/ent oral ,y*iene roced/res
are indicated.
St/dies ,a"e -een cond/cted in w,ic, atients were asked to -r/s, e0actly as t,ey did
at ,ome and t,en co"ertly monitored to determine t,e len*t, o+ time o+ -r/s,in*. In
t,e last two decades, t,e a"era*e -r/s,in* time was s,own to ,a"e increased +rom
a-o/t >$ to =$ seconds, to <$ seconds,
<',<<
and to ($ seconds in a :;;' st/dy.
<%
In all
o+ t,ese st/dies, t,e indi"id/als claimed t,at t,ey /s/ally -r/s,ed +or > or = min/tes.
5,ese res/lts demonstrate t,at eole *reatly o"erestimate t,eir e++orts or else are
tellin* t,eir ro+essionals w,at t,e indi"id/als -elie"e or wo/ld like t,e ro+essionals
to ,ear.
5,oro/*, toot,-r/s,in* re?/ires a di++erent amo/nt o+ time +or eac, indi"id/al,
deendin* on s/c, +actors as t,e innate tendency to acc/m/late la?/e and de-risD t,e
syc,omotor skillsD and t,e ade?/acy o+ clearance o+ +oods, -acteria, and de-ris -y
t,e sali"a. Only a+ter atients ,a"e reeatedly -r/s,ed t,eir teet, /nder t,e
s/er"ision o+ a dental ro+essional can t,e ade?/acy o+ cleanin* in a *i"en time -e
determined. O+ten a comromise is made -y s/**estin* ' to :$ strokes in eac, area or
-y ad"ocatin* t,e /se o+ a timer. 5,is amo/nt o+ time, w,ic, mi*,t -e ade?/ate +or
t,e a"era*e erson, may not -e s/++icient +or atients in most need o+ ma0im/m
la?/e-control ro*rams. 5o ens/re contin/ed commitment to a ersonal oral-,y*iene
ro*ram, t,e -ene+its o+ roer oral care m/st -e e0lained and demonstrated to
atients.
;
5oot,-r/s,in* )roced/res
+cclusal Surfaces
5,e occl/sal s/r+aces may -e cleaned -y eit,er 7:8 s,ort "i-ratory strokes, wit,
ress/re -ein* maintained to accomlis, as dee a enetration o+ t,e its and +iss/res
as ossi-leD or 7>8 a raid -ack-and-+ort, "i-ratin* motion to +orce t,e -ristles into t,e
its and +iss/res, +ollowed -y a sweein* motion to e0el t,e dislod*ed de-ris. .on*,
sweein*, ,ori@ontal strokes are contraindicated, -eca/se t,e toot,-r/s, -ristles ,a"e
minim/m contact in t,e deeer and more critical +iss/res 7Fi*/re '-:&8. 5,e ori+ices
o+ t,e its and +iss/res are too narrow +or -ristle enetration and, w,ate"er t,e
tec,ni?/e, are inaccessi-le +or ade?/ate cleanin*. 5,is ,els e0lain w,y more t,an
<$E o+ all cario/s lesions in t,e mo/t, are +o/nd on t,e occl/sal s/r+ace, e"en t,o/*,
most indi"id/als attemt to -r/s, t,is s/r+ace.
The nterior (in$ual reas
Access to t,e lin*/al s/r+aces o+ t,e mandi-le and ma0illa is di++ic/lt. 1r/s,in* in
t,ese areas can -e +acilitated -y c/ttin* o++ all t/+ts on a -r/s,, e0cet t,e +irst +o/r or
+i"e rows in t,e toe. 5,is modi+ied -r/s, ,as /nimeded access to t,e *in*i"al s/lci
and lin*/al +ossae areas 7Fi*/re '-:'8. In t,e lower arc,, t,e ,eel o+ t,e -r/s, can -e
/sed +or t,e same /rose.
#rushin$ Se5uence
A ro/tine -r/s,in* attern s,o/ld -e esta-lis,ed to a"oid e0cl/sion o+ any area. One
systematic attern is to teac, c,ildren to -e*in -y cleanin* t,e occl/sal s/r+aces o+ t,e
ma0illary arc,es, startin* wit, t,e molars, and t,en t,e same on t,e mandi-/lar
arc,es. For c,ildren it is most imortant to -r/s, t,e it and +iss/res. 5,e /se o+ a
t,ree-dimensional -r/s, can -e recommended as lon* as c,ildren are not a-le to -r/s,
t,e more di++ic/lt -/ccal and lin*/al s/r+aces.
<(
S/c, toot,-r/s,es t,at ,/* t,e teet,
and clean t,e -/ccal, lin*/al, and occl/sal s/r+aces sim/ltaneo/sly are easier +or
c,ildren to /se, as t,e -r/s, */ides itsel+ +rom toot, to toot,. St/dies s,ow t,at
c,ildren +a"or s/c, toot,-r/s,es.
Ad/lt atients are ta/*,t to -e*in wit, t,e distal s/r+ace o+ t,e most osterior toot,
and to contin/e -r/s,in* t,e occl/sal and incisal s/r+aces aro/nd t,e arc, /ntil t,e
last molar on t,e ot,er side o+ t,e arc, ,as -een reac,ed. 5,e lower arc, is t,en
-r/s,ed in a similar manner.
)atients tend to aortion more time and e++ort on t,e +acial areas o+ t,e anterior
teet,.
<;
O+ten, ri*,t-,anded eole do not -r/s, t,e ri*,t side o+ t,e arc, as well as
t,e le+t sideD le+t-,anded eole similarly ne*lect t,e le+t side o"er t,e ri*,t side.
Clinical ssessments of Tooth4rushin$
4,ate"er tec,ni?/es are recommended, t,e main /rose o+ toot, -r/s,in* is to
remo"e dental la?/e +rom t,e teet,, incl/din* t,e *in*i"al cre"ice, wit, t,e
minim/m amo/nt o+ dama*e to t,e teet, and s/rro/ndin* str/ct/res. Disclosin*
a*ents ro"ide t,e means o+ e"al/atin* t,e t,oro/*,ness o+ cleanin* t,e teet,.
'<,%$
5,e
most widely marketed red disclosin* rod/cts contain FDgC !ed l>(.
Disclosin* a*ents may -e in eit,er a li?/id or ta-let +orm. 5,e c,ewa-le ta-let or t,e
li?/id disclosant s,o/ld -e swis,ed aro/nd in t,e mo/t, +or :' to =$ seconds and t,en
e0ectorated. Home /se o+ disclosants -y t,e atient s,o/ld -e enco/ra*ed to ermit
sel+-e"al/ation o+ t,e e++ecti"eness o+ la?/e-control ro*rams. Clinical assessments
s,o/ld -e made +or e"idence o+ imroer toot, -r/s,in*. Minor dama*e t,at may -e
noted incl/des a-rasion to t,e so+t tiss/es 7sc/++in*, -r/isin*, and /nctate lesions8 or
dama*e to t,e toot, s/r+ace.
5oot,-r/s, a-rasion, or t,e wearin* away o+ toot, s/-stances, occ/rs +rom t,e /se o+
,i*,ly a-rasi"e denti+ices, too-+irm -r/s, -ristles, incorrect -r/s,in* met,ods, and
e0cessi"e ress/re d/rin* -r/s,in*. Common a-rasion locations are on t,e s/r+aces o+
t,e teet, dislaced +acially and on t,e cer"ical areas o+ e0osed root s/r+aces.
1eca/se enamel is ,arder t,an cement/m, toot, dama*e /s/ally occ/rs as a 6-s,aed,
,ori@ontal notc, immediately aical to t,e cementoenamel A/nction. F/rt,er ro*ress
o+ t,e a-rasion can -e minimi@ed -y /se o+ so+t--ristle -r/s,es, c,an*es in -r/s,
an*/lation, /lsin* instead o+ strokin*, t,e /se o+ less a-rasi"e denti+rices, and less
ress/re d/rin* -r/s,in*.
5oot,-r/s, !elacement
5oot,-r/s, wear 7slayed, -ent, or -roken -ristles8 is in+l/enced more -y -r/s,in*
met,ods t,an -y t,e len*t, o+ time or n/m-er o+ -r/s,in*s er day.
%:
5,e a"era*e
Fli+eF o+ a man/al toot,-r/s, is aro0imately = mont,s. 5,is estimate can "ary
*reatly, ,owe"er, -eca/se o+ di++erences in -r/s,in* ,a-its. It is also so/nd ad"ice +or
atients to ,a"e se"eral toot,-r/s,es and to rotate t,eir daily /se, to ass/re dryin*
-etween -r/s,in*s. I+ toot,-r/s,es need to -e relaced more +re?/ently t,an e"ery
t,ree mont,s, t,e atientCs -r/s,in* tec,ni?/e s,o/ld -e c,ecked. 3"en i+ t,e
-r/s,in* tec,ni?/e is acceta-le or ,as -een corrected, toot,-r/s,es s,o/ld still -e
relaced +re?/ently. Indeed, a+ter e"ery oral or conta*io/s medical illness, it is
imerati"e t,at atients -e made aware o+ t,e imortance o+ ,a"in* a new toot,-r/s,.
Fi*/re '-:: Stillman tec,ni?/e seen dia*rammatically.
Fi*/re '-:> 1ass tec,ni?/e9 A. *ra,icallyD B. ictorially.
Fi*/re '-:= !ollin* stroke tec,ni?/e.
Fi*/re '-:& Occl/sal -r/s,in* dislod*es de-ris in t,e its and +iss/res o+
osterior teet, 7commonest site o+ caries8 as well as in interro0imal incisal
areas.
Fi*/re '-:' 6ertical osition o+ t,e toot,-r/s, +or t,e o+ten constricted lin*/al
area.
Special Needs
5on*/e 1r/s,in*
Malodor +rom t,e mo/t, most o+ten ,as its ori*in on t,e ton*/e. 5,ere+ore, +or
ersons e0irin* mo/t, odor, ton*/e -r/s,in* is imortant. 5on*/e cleanin* is also
indicated +or atients ,ar-orin* a coated ton*/e. A coated ton*/e is a -acterial
reser"oir -/t co/ld also -e a loc/s +or intraoral transmission o+ or*anisms d/rin*
toot,-r/s,in*, t,ro/*, in+ection or rein+ection o+ eriodontally treated ockets. 5,is
is anot,er reason t,at j/irynen et al. introd/ced t,e +/ll-mo/t, disin+ection concet
in eriodontal atients to re"ent recoloni@ation o+ -acteria.
>(
5,e -r/s,in* o+ t,e ton*/e and alate ,els red/ce t,e de-ris, la?/e, and n/m-er o+
oral microor*anisms. 5,e aillae on t,e ton*/e ro"ide an area esecially cond/ci"e
to -acterial and de-ris retention. 5on*/e cleansin* can -e accomlis,ed -y lacin*
t,e side o+ t,e toot,-r/s, near t,e middle o+ t,e ton*/e, wit, t,e -ristles ointed
toward t,e t,roat. 5,e -r/s, is swet +orward, and t,is motion is reeated si0 to ei*,t
times in eac, area. 5,e alate s,o/ld also -e cleansed wit, a sweein* motion. A
denti+rice s,o/ld -e /sed wit, t,is -r/s,in* o+ so+t tiss/es to imro"e cleansin*
action.
%>
A-/tment 5eet, and Ort,odontic Aliances
A-/tment teet,, imlants, +i0ed -rid*ework and +i0ed ort,odontic aliances re?/ire
secial em,asis on s/lc/lar -r/s,in* to re"ent *in*i"itis. 5,oro/*, cleansin*
-etween ort,odontic aliances and *in*i"a will re"ent dental caries. A re-teen or
teena*er, as well as atients wit, e0tensi"e reconstr/ction -rid*ework, are rone to
dental diseases -/t are also more moti"atedD t,ere+ore, a ri*id, re"enti"e ro*ram is
re?/ired. A owered -r/s, and a/0iliary aids are s/**ested.
5,e e++ecti"eness o+ a new toot,-r/s, desi*n in ort,odontic atients ,as -een
doc/mented in di++erent /-lications. At t,e end o+ a &-mont, st/dy, a t,ree-sided
man/al toot,-r/s, si*ni+icantly decreased *in*i"itis and was more e++ecti"e in la?/e
remo"al comared to a +lat m/ltit/+ted toot,-r/s,.
%=
)owered toot,-r/s,es ,a"e -een
doc/mented to ro"ide s/erior e++icacy in ort,odontic atients comared to res/lts in
atients /sin* man/al toot,-r/s,es.
;
Dent/res and !emo"a-le Ort,odontic Aliances
)atients wit, +/ll dent/res can meet t,eir oral ,y*iene needs wit, a so+t nylon -r/s,
+or t,e oral tiss/es and a dent/re -r/s, t,at cleans all areas o+ t,e dent/re. 5,e
dent/re -r/s, wit, a nona-rasi"e cleaner s,o/ld reac, into t,e recessed al"eolar rid*e
area o+ t,e dent/re to ens/re ma0im/m cleansin*. 5,e oral tiss/es s,o/ld -e -r/s,ed
at least once a day /sin* a *entle "i-ration and lon*, strai*,t strokes +rom t,e
osterior to anterior mo/t, re*ions.
%$
)atients wit, remo"a-le artial dent/res and remo"a-le ort,odontic aliances need
at least t,ree toot,-r/s,es, one +or t,e nat/ral teet,, anot,er +or t,e aliance, and a
t,ird +or class. 1r/s,in* class, wires, and ot,er metal arts can wear o/t a re*/lar
toot,-r/s,. A clas -r/s,> or = inc,es lon*, narrow, and taeredcan -e o-tained
as a t,ird -r/s,. Secial care is needed to care+/lly clean all la?/e +rom t,e class as
a re"enti"e meas/re +or t,e s/ortin* teet,.
Handicaed )atients
Some ,andicaed atients are a-le to -r/s, t,eir own teet, and can o+ten do so wit,
s/ort and enco/ra*ement +rom dental ersonnel and t,e /se o+ secial toot,-r/s,es.
A man/al -r/s, wit, an enlar*ed ,andle, elastic c/++, or small stra attac,ed to t,e
-r/s, or a lon*-,andled ,older +or atients w,o cannot raise t,eir arms or do not ,a"e
,ands, ermits t,e atient to -r/s,.
%&
5,e elastic c/++ is +itted aro/nd t,e ,and and
,olds t,e toot,-r/s, in t,e atientCs alm. )atients w,o are /na-le to reac, t,eir
mo/t,s +or -r/s,in* can, at times, attac, t,e -r/s, in a stationary /ri*,t osition -y
/sin* a clam.
%'
5,e atients -end o"er to osition t,e -r/s, in t,e mo/t,. 5,e
National Fo/ndation o+ Dentistry +or t,e Handicaed is de"eloin* a re"enti"e
ro*ram to enco/ra*e toot,-r/s,in* to t,e -eat o+ m/sic. A -r/s, w,eel, w,ic, can
-e /sed in -etween t,e teet, and mo"ed t,ro/*, t,e dentiton wit,o/t /sin* t,e ,ands
mi*,t -e ,el+/l +or tetrale*ics. 5,e res/lts are almost comara-le wit,
,and-r/s,es.
%<,%%
Mentally retarded atients can o+ten -r/s, /sin* a so+t toot,-r/s,
wit, t,e lastic ,andle -ent +or -etter *rasin*. A ,ori@ontal scr/- is o+ten t,e -est
t,at t,ese atients can mana*e. A t,ree-,eaded toot,-r/s, or a owered toot,-r/s,
assisted -y a care*i"er can -e /se+/l.
=%
Secial Uses +or )owered 5oot,-r/s,es
)owered toot,-r/s,es can -e -ene+icial +or arental -r/s,in* o+ c,ildrenCs teet,D +or
c,ildren and ad/lts w,o are ,ysically ,andicaed, mentally retarded, a*ed, art,ritic,
or ot,erwise wit, oor de0terityD and +or t,ose atients w,o are oorly moti"ated.
5,ese -r/s,es are esecially recommended +or atients w,o re?/ire a lar*er ,andle,
-eca/se owered models are easier to *ras.
Question 3
A. A metic/lo/s, once-e"ery-ot,er-day ro*ram may -e as e++ecti"e as daily mornin*
and e"enin* -r/s,in*s.
1. 5,e ,i*, incidence o+ caries t,at occ/rs on t,e occl/sal s/r+ace is /s/ally tracea-le
to inade?/ate -r/s,in*.
C. 5oot,-r/s, relacement e"ery = mont,s is as imortant as roer -r/s,in*
tec,ni?/es.
D. For a erson wit, a artial dent/re, t,e toot,-r/s, /sed +or t,e nat/ral teet, is not
ade?/ate +or cleanin* t,e class.
3. It is necessary +or ,andicaed ersons to ,a"e ot,ers aid in -r/s,in* t,eir teet,.
Summary
5oot,-r/s,in* alone cleans -/ccal and lin*/al toot, s/r+aces. No sin*le
toot,-r/s,in* tec,ni?/e ade?/ately cleans occl/sal its and +iss/res. No
toot,-r/s,in* roced/re remo"es all interro0imal and s/-*in*i"al la?/e, esecially
aro/nd malosed teet, and +i0ed rost,eses. Interro0imal cleanin* aids are necessary
to comlete t,e toot,-cleanin* rocess. No one toot,-r/s, desi*n ,as -een
demonstrated to -e most e++ecti"e +or all atients in lon*-term st/dies. Dental
ro+essionals s,o/ld -e +amiliar wit, "ario/s toot,-r/s, rod/cts, rimarily +rom
t,eir own /se e0erience, and ,a"e e0amles o+ toot,-r/s,es demonstratin* "ario/s
de*rees o+ slayin* or -endin*. 5,ese s,o/ld -e demonstrated w,en re"ention
met,ods are -ein* disc/ssed wit, t,eir atients.
Alt,o/*, man/+act/rers are ad"ertisin* "ariations in -ristle s,ae, -ristle si@e, and
n/m-er o+ +ilaments, no acceted criteria e0ist +or rod/ct la-elin*. 5,e American
Dental Association does not yet consider one toot,-r/s, desi*n s/erior to anot,er
-/t is de"eloin* clinical-testin* */idelines associated wit, -ot, la?/e and *in*i"itis
red/ctions. 5,oro/*,ness and +re?/ency o+ -r/s,in* are ro-a-ly more imortant
t,an a seci+ic toot,-r/s,in* met,od and toot,-r/s,in* rod/cts. Any met,od t,at is
ta/*,t s,o/ld -e e++ecti"e, not dama*in* to t,e ,ard or so+t tiss/es, ro/tinely /sed and
s,o/ld not ca/se e0cessi"e toot, wear. In initiatin* e++ecti"e toot,-r/s,in*, it is
necessary to 7:8 select t,e aroriate toot,-r/s,7es8 s/ita-le +or t,e atientD 7>8 instill
in indi"id/als t,e *oals o+ toot,-r/s,in* and t,e need +or *ood oral ,ysiot,erayD 7=8
teac, a tec,ni?/e or com-ination o+ -r/s,in* met,ods needed to meet secial needsD
and 7&8 assess t,oro/*, and e++ecti"e toot,-r/s,in* as a art o+ t,e total oral ,y*iene
ro*ram
:. A, C, D, and 3correct.
1incorrect. 5oot,-r/s, -ristles ,a"e also /nder*one maAor c,an*es in s,ae and
desi*n.
>. A, 1, C, and 3correct.
Dincorrect. 5,e standard man/al toot,-r/s, is not as e++ecti"e as t,e new owered
toot,-r/s,es.
=. C and Dcorrect.
Aincorrect. It is tr/e t,at one *ood cleanin* wo/ld do t,e Ao-, -/t so +ew eole do
a *ood Ao- t,at se"eral cleanin*s mi*,t -e e?/al to one *ood try. Howe"er, eit,er
answer co/ld -e correct.
1incorrect. No matter ,ow well t,e occl/sal s/r+ace is -r/s,ed, t,e dee its and
+iss/res cannot -e ade?/ately cleaned wit, a -r/s,.
3incorrect. Handicaed ersons can o+ten mana*e -r/s,in* wit, sli*,tly modi+ied
oral-,y*iene aids or wit, secially de"eloed -r/s,in* de"ices.
:. 5,ree *eneral reasons t,at eole do not send ade?/ate time +or ersonal oral-
,ealt, care are iiiiiiii, iiiiiiii, and iiiiiiii.
>. 4adswort, introd/ced t,e toot,-r/s, into t,e United States A/st -e+ore t,e
iiiiiiiiiiiiiiii 4ar.
=. 5,e constricted art o+ t,e toot,-r/s, -etween t,e ,andle and t,e ,ead is t,e
iiiiiiii. 5,e end o+ t,e ,ead is ar-itrarily termed t,e iiiiiiiiD t,e art closest to
t,e ,andle is called t,e iiiiiiii.
&. Fo/r lateral ro+iles o+ -r/s,es sold in t,e United States are iiiiiiii, iiiiiiii,
iiiiiiii, and iiiiiiii.
'. 5,e American Dental Association Co/ncil on iiiiiiiiiiiiiiii 7name8
contin/ally accomlis,es scienti+ic e"al/ations o+ de"ices /sed in dentistry. 5o
s/ort standardi@ation o+ ro+essional de"ices, t,e ADA is a mem-er o+ t,e
International iiiiiiiiii, w,ic, ,as as its o-Aecti"e t,e esta-lis,ment o+ consistency
o+ la-elin*.
<. 5wo synonyms +or ,ardness o+ -ristles and toot,-r/s,es are iiiiiii, and
iiiiiiii. Firmness o+ -ristles is ca/sed -y t,ree *eneral c,aracteristics o+ -ristlesD
t,ey are iiiiiiii, iiiiiiii, and iiiiiiii. A medi/m-te0t/re -ristle ,as a
diameter o+ aro0imately iiiiiiii in.
%. Gin*i"al a-rasion can occ/r wit, man/al toot,-r/s,es -eca/se o+ iiiiiiii,
iiiiiiii, or iiiiiiii.
(. 5,ree -asic motions o+ electric toot,-r/s, ,eads are iiiiii, iiiii, and iiiii.
;. 5,ree *ro/s o+ eole w,o can esecially -ene+it +rom /se o+ electric toot,-r/s,es
are iiiiiiii, iiiiiiii, and iiiiiiii.
:$. Fo/r o-Aecti"es o+ toot,-r/s,in* are iiiiiiii, iiiiiiii, iiiiiiii, and
iiiiiiii. 5,e t,ree nat/ral met,ods o+ toot,-r/s,in* are iiiiiiii,iiiiiiii, and
iiiiiiii. 5,e motion o+ t,e -r/s, in -lank no. : in t,e re"io/s sentence
isiiiiiiiiD in -lank no. > is iiiiiiiiD and in -lank no. = is iiiiiiii.
AC2NO4.3DGM3N5S
5,e a/t,ors e0ress t,eir sincere areciation to #eni+er 1. S,e +or assistance in t,e
translations, ). Heller and ,er sta++ at li-rary o+ t,e Uni"ersity o+ )ennsyl"ania Sc,ool
o+ Dental Medicine +or t,eir "al/a-le cooeration, and to #essica and Claire Hankell
+or t,eir com/ter e0ertise.
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1eein+l/ss/nn* der *in*i"alen "er,altnisse d/rc, den *e-ra/c, einer @a,n-/rste oder
eines ka/radc,ens. Sch3ei1 %onatsschr @ahnmed , ;%9';:-;&.
%%. 2o@lo"sky, A., Dreian*el, A., g )erlm/tter, S. 7:;;:8. 5,e c,ewin* w,eel
de"ice9 la?/e remo"in* e++iciency and /se in oral ,y*iene ro*rams. Euint /nt ,
>>9%>%-=$.
reser"ed.
Chapter 6. Dentifrices, Mouthrinses, and Chewing Gums - Stuart (, 'ischman
Samuel (, .an*ell
Objectives
t the end of this chapter, it 3ill 4e possi4le to6
:. Di++erentiate -etween a cosmetic and a therapeutic denti+rice, mo/t,rinse, or
c,ewin* */m.
>. 30lain t,e t,ree ,ases o+ researc, necessary w,en alyin* to in"esti*ate a new
dr/* 7IND8t,e rocess t,at recedes recei"in* a new dr/* alication 7NDA8,
w,ic, is necessary to market a new rod/ct wit, a t,erae/tic claim.
=. Disc/ss ,ow aro"al or nonaro"al o+ a new rod/ct -y t,e Food and Dr/*
Administration 7FDA8 di++ers +rom accetance or reAection -y t,e American Dental
Association 7ADA8.
&. 30lain t,e "ario/s reasons t,at t,e same a-rasi"e material in toot,aste can ca/se
di++erin* le"els o+ a-rasion on toot, str/ct/re.
'. Name t,e /s/al denti+rice in*redients and t,eir ercenta*es in a denti+rice.
<. Name t,e a*ents /sed in denti+rices to rod/ce anticaries, anticalc/l/s, w,itenin*,
and anti,yersensiti"ity e++ects.
%. Name t,e acti"e in*redients in tyical antila?/e and anti*in*i"itis mo/t, rinses9
one sold o"er t,e co/nter, t,e ot,er as a rescrition item.
Introduction
Denti+rices and mo/t,rinses are t,e maAor rod/cts +or ro/tinely administerin*
e++ecti"e cosmetic and therapeutic a*ents in t,e mo/t,. 5,ese rod/cts are t,e most
widely /sed -y cons/mers, *eneratin* t,e lar*est sales o+ all dental rod/cts.
C,ewin* */ms are a new cate*ory o+ rod/cts wit, cosmetic claims and t,e a-ility to
deli"er t,erae/tic como/nds.
Denti+rices and mo/t,rinses di++er considera-ly. Denti+rices are comle0 and di++ic/lt
to +orm/late. 5remendo/s inno"ations ,a"e occ/rred in t,e ast >$ years in t,e
aearance and acka*in* o+ denti+rices. 5,e contemorary cons/mer is +aced wit,
many alternati"es in appearance 7astes, clear *els, stries8 and pac*a$in$
7con"entional t/-es, stand-/ t/-es, /ms8, as well as rod/cts marketed seci+ically
+or c,ildren. In addition, n/mero/s claims are made +or denti+rices. 5,ey are said to
prevent calc/l/s and caries, to w,iten teet,, to eliminate ,yersensiti"ity, and to
red/ce la?/e and *in*i"itis.
1eca/se t,e /-lic ro/tinely /ses t,em one to t,ree times er day, denti+rices are t,e
most -ene+icial dental rod/cts. Some o+ t,is -ene+it may -e lost i+ a erson rinses
immediately a+ter -r/s,in* -eca/se rinsin* decreases t,e concentration or reser"oir o+
t,e acti"e a*ent7s8 in t,e oral ca"ity.
Mo/t,rinses are a"aila-le in li?/id +orm, t,e traditional met,od +or sta-ili@in* and
deli"erin* many ,armace/tically acti"e a*ents. Mo/t,rinses are considered -y
cons/mers to ,a"e rimarily cosmetic -ene+its 7i.e., -reat, +res,eners8 and are
t,ere+ore not /sed as +re?/ently or ro/tinely as denti+rices in t,e daily oral-,y*iene
re*imen. 5wo cate*ories o+ mo/t,rinses ,a"e -een reco*ni@ed -y t,e American
Dental Association 7ADA8 as e++ecti"e a*ainst pla5ue and $in$ivitis 7see ADA
we-site www.ada.or*8. One cate*ory contains t,e essential oils as t,e acti"e
in*redients. )rod/cts in t,is cate*ory incl/de .isterine and its *eneric e?/i"alents
containin* t,e ori*inal essential oils, 5o date, more t,an >$$ *eneric "ersions ,a"e
-een re"iewed and acceted -y t,e ADA. 5,ese rod/cts are sold o"er t,e co/nter.
5,e ot,er cate*ory o+ rod/cts contains chlorhexidine as t,e acti"e a*ent. C/rrently
marketed rod/cts are )eride0 and )re"ident. 5,e Food and Dr/* Administration
7FDA8, ,as aro"ed c,lor,e0idine-containin* rod/cts only as rescrition rod/cts.
C,ewin* */ms ,a"e t,e otential to -e /sed -y t,e cons/mer +or eriods o+ ' to >$
min/tes se"eral times a day, /ntil t,e +la"or o+ t,e rod/ct dissiates. 5,is wo/ld
ena-le deli"ery o+ a cosmetic or t,erae/tic a*ent +or a lon$er time t,an denti+rices or
mo/t,rinses. In addition to rolon*ed deli"ery o+ an a*ent, c,ewin* */ms stimulate
salivary flo3, w,ic, can ro"ide a -/++er e++ect and also ens/re remo"al o+ de-ris
+rom occl/sal and interro0imal sites. 5o ass/re sa+ety and a"oid ,arm+/l
*astrointestinal e++ects, acti"e a*ents deli"ered -y c,ewin* */ms m/st -e safe for
s3allo3in$ at t,e dose deli"ered in one /se or contained in t,e entire rod/ct sold in
one acka*e.
Monitoring the Safety and Effectiveness of Therapeutic Dental Products
Ca/tion is needed -e+ore introd/cin* a new t,erae/tic rod/ct to t,e market. Some
o+ t,e concerns s/rro/ndin* new rod/cts are9 4ill t,e acti"e a*ent disr/t t,e
FnormalF -acterial -alance o+ t,e mo/t,e S,o/ld t,e searc, +or an ideal a*ent +oc/s
on deressin* or eliminatin* seci+ic disease-related or*anisms or a -road sectr/m
o+ or*anismse S,o/ld a rod/ct -e /sed to reser"e a disease-+ree state w,ile riskin*
t,e ossi-ility o+ de"eloin* dr/* resistancee !e*ardless o+ t,e aarent e++ecti"eness
o+ any new rod/ct in t,e la-oratory or in controlled clinical st/dies, /-lic safety
wit, /ns/er"ised, widesread a"aila-ility and /se -y cons/mers is paramount,
5,e rocess -y w,ic, oral-care a*ents are e"al/ated and re*/lated in t,e United
States ,as -een re"iewed -y 5r/mmel.
:
Sa+ety and e++icacy standards aly not only
to rescrition medications -/t also to o"er-t,e-co/nter 7O5C8 dr/*s. 5,ere are t,ree
le"els o+ re*/lation o+ oral c,emot,erae/tic a*ents. 5,e *o"ernment le"el incl/des
t,e 'ood and Dru$ dministration ('D) and t,e United States Pharmacopoeia
Convention, 5,e professional or voluntary level incl/des t,e Co/ncil on Scienti+ic
A++airs 7CSA8 o+ t,e merican Dental ssociation (D), 5,e third le"el o+ re"iew
incl/des consumer advocacy or$ani1ations, ad"ertisin* standards re"iew anels, and
t,e Federal 5rade Commission. In addition, eac, o+ t,e maAor tele"ision networks ,as
its own in-,o/se re"iew committee.
5,e FDA cond/cts an on*oin* re"iew o+ all O5C rod/cts. One aim o+ re*/lation is
to rotect t,e atient-cons/mer +rom useless or harmful rod/cts. All aro"al or
disaro"al decisions -y t,e FDA ,a"e t,e force of la3,
5,e sta*es o+ FDA aro"al incl/de reclinical researc, and de"eloment 7animal
testin*, la-oratory testin*, and to0icity e"al/ation8 +ollowed -y clinical researc,
cond/cted wit, an aro"ed investi$ational ne3 dru$ (/&D) alication. 5,e IND
/s/ally incl/des three ,ases9 In ,ase :, t,e st/dy is limited in scope and /ses only a
+ew s/-Aects to determine t,e sa+e dose +or ,/mans. For dental rod/cts, t,is /s/ally
in"ol"es in*estion or e0a**erated 7t,ree or +o/r times er day8 toical alications or
-ot,. ),ase > involves more su47ects to demonstrate t,e initial clinical e++icacy o+ t,e
dr/* and de+ine a dose ran*e +or -ot, sa+ety and e++icacy. ),ase = *enerally incl/des
dou4le24lind, controlled trials wit, F+inalF +orm/las to demonstrate lon*-term sa+ety
and e++icacy. 5,ese ran*e +rom = to < mont,s +or la?/e and *in*i"itis st/dies to > or
= years +or caries st/dies. A+ter t,e comany recei"es an approved ne3 dru$
application 7NDA8, marketin* may -e*in, -/t ost-marketin* s/r"eillance o+ t,e
rod/ct is mandatory,
O"er t,e years, t,e FDA ,as re?/ested man/+act/rers o+ O5C rod/cts to s/-mit a
listin$ o+ t,e acti"e and inacti"e in*redients in t,eir rod/cts as a -asis +or ,elin* to
codi+y re*/lations *o"ernin* O5C sales. Amon* t,e many recommendations o+ t,e
FDA ad"isory anel
>
t,at ro"ide +or -etter control o+ O5C oral t,erae/tic rod/cts
is t,e sti/lation t,at all inacti"e in*redients -e listed on t,e la-el -y ?/antity in
descendin* order. Acti"e in*redients, as well as inacti"e a*ents, s,o/ld -e in no
,i*,er concentrations t,an necessary +or t,e intended /rose. 5,e anel also
recommended t,at t,e indicated o-Aecti"e o+ t,e acti"e a*ent7s8 m/st -e on t,e la-el
and t,at t,e incl/sion o+ t,e name o+ an acti"e a*ent7s8 wit,o/t statin* t,e roosed
-ene+its wo/ld -e considered misleadin*. )roo+ m/st e0ist to s/-stantiate any claim
+or a seci+ic t,erae/tic -ene+it. For e0amle, denti+rices t,at ,a"e not -een
s/-Aected to la-oratory or clinical trials and do not ,a"e t,e ADA Seal o+ Accetance,
-/t only list t,e incl/sion o+ Fdecay-+i*,tin* +l/oridesF in t,eir rod/cts, cannot claim
t,at t,e denti+rice is anticario*enic, only t,at it contains +l/oride. It is ossi-le t,at t,e
+l/oride in t,e /ntested denti+rice mi*,t not -e comati-le wit, ot,er denti+rice
in*redients, or t,e +l/oride may not -e released in acti"e ionic +orm and t,ere+ore -e
totally ine++ecti"e.
!ecommendations also aly to pac*a$in$ and la4elin$ */idelines to re*/late
ad"ertisin*. For e0amle, t,e recommendations s/**est t,at all containers +or O5C
t,erae/tic denti+rices, rinses, and *els containin* +l/oride ,a"e a la-el to identi+y t,e
rod/ct, e.*., Fanticaries denti+riceFD its /se, e.*., Faids in t,e re"ention o+ dental
cariesFD a 3arnin$, e.*., FDo not swallow. De"eloin* teet, o+ c,ildren /nder < years
o+ a*e may -ecome ermanently discolored i+ e0cessi"e amo/nts o+ +l/oride are
reeatedly swallowedFD and directions +or /se, e.*., FAd/lts and c,ildren < years o+
a*e or older s,o/ld -r/s, teet, t,oro/*,ly at least twice daily, or as directed -y a
dentist or ,ysician.F
In Aril :;;%, t,e FDA iss/ed a la-elin* re?/irement +or +l/oride toot,aste. 5,is
states, F2ee o/t o+ reac, o+ c,ildren /nder < years o+ a*e. I+ yo/ accidentally
swallow more t,an /sed +or -r/s,in*, seek ro+essional ,el or contact a oison
control center immediately.F 5,is recommendation may -e an e0a**erated resonse,
as most e0erts -elie"e t,at neit,er an ad/lt nor a c,ild co/ld a-sor- eno/*, +l/oride
to ca/se a serio/s ro-lem.
A+ter years o+ i*norin* claims o+ anti*in*i"itis e++icacy +or "ario/s O5C denti+rices
and rinses, in :;(( t,e FDA ad"ised man/+act/rers o+ s/c, rod/cts t,at t,ey m/st
eit,er cease makin* s/c, claims or s/-stantiate t,em. In :;;$, t,e FDA /-lis,ed its
call +or data statin*9
5,e Food and Dr/* Administration is anno/ncin* a call +or data +or in*redients
containin* rod/cts -earin* antila?/e and antila?/e related claims, s/c, as F+or t,e
red/ction or re"ention o+ la?/e, tartar, calc/l/s, +ilm, sticky deosits, -acterial
-/ild/ and *in*i"itis.F 5,e a*ency will re"iew t,e s/-mitted data to determine
w,et,er t,ese rod/cts are *enerally re*arded as sa+e and e++ecti"e and not
mis-randed +or t,e la-el /ses. 5,is notice also descri-es t,e Attorney GeneralCs
en+orcement o+ olicy *o"ernin* t,e marketin* o+ o"er-t,e-co/nter 7O5C8 dr/*
rod/cts -earin* antila?/e and antila?/e related claims d/rin* t,e endency o+ t,is
re"iew. 5,is re?/est is art o+ t,e on*oin* re"iew o+ O5C dr/* rod/cts cond/cted
-y t,e FDA.
=
In addition to t,e FDACs re*/lation o+ O5C rod/cts, t,e American Dental
AssociationCs Co/ncil on Scienti+ic A++airs 7CSA8 contin/ally re"iews dental
rod/cts. 5,e Co/ncil is directed to st/dy, e"al/ate, and disseminate in+ormation wit,
re*ard to dental t,erae/tic a*ents, t,eir adA/ncts, and dental cosmetic a*ents t,at are
o++ered to t,e /-lic or to t,e ro+ession.
:
5,e most imortant acti"ity o+ t,e CSA in
meetin* t,is c,ar*e is its accetance ro*ram. Unlike t,e IND rocess, s/-mission -y
a man/+act/rer to t,e ADA ro*ram is voluntary, Also, /nlike t,e FDA re"iew
rocess, t,e rimary re"iew resonsi-ilities are cond/cted -y cons/ltin* dental
ro+essionals w,o are aointed -y t,e CSA -/t are not emloyees o+ t,e ADA. I+ t,e
rod/ct is safe and effective, t,e Seal of cceptance is *ranted and can 4e used 4y the
manufacturer in marketin* t,e rod/ct. 5,e Seal ro"ides assurance to dental
ro+essionals and to t,e /-lic. In addition to t,e traditional Frint media,F t,is
in+ormation is a"aila-le at t,e ADA we-site, www.ada.or*.
5,e co/ncil reco*ni@ed t,at la?/e control mi*,t -est -e demonstrated -y clinically
si*ni+icant red/ction o+ *in*i"itis. In :;(<, t,e co/ncil iss/ed FG/idelines +or
Accetance o+ C,emot,erae/tic )rod/cts +or t,e Control o+ S/ra*in*i"al Dental
)la?/e and Gin*i"itis.F
&
5,e G/idelines +or Accetance are resented in 5a-le <-:.
5,e /rose o+ t,e searate and indeendent actions o+ t,e FDA and t,e ADA is to
ens/re t,e e++ecti"eness and sa+ety o+ O5C rod/cts and to re"ent misla-elin* and
t,/s misleadin* in+ormation. The D and 'D differ in their acceptance criteria,
3hich places the responsi4ility for selectin$ an effective product on the dental
professional,
Question 1
A. 5,e Food and Dr/* Administration 7FDA8 and t,e American Dental Association
7ADA8 ,a"e -ot, reco*ni@ed essential oils and c,lor,e0idine as
antila?/eBanti*in*i"itis a*ents.
1. 5,e decisions o+ -ot, t,e Food and Dr/* Administration and o+ t,e American
Dental Association to aro"e a rod/ct ,a"e t,e +orce o+ law.
C. 5o recei"e t,e ADACs Seal o+ Accetance an antila?/e rod/ct m/st re"ent or
red/ce t,e se"erity o+ some disease ca/sed -y t,e la?/e.
D. 5,e sales o+ -ot, t,erae/tic and o"er-t,e-co/nter dental rod/cts are re*/lated -y
t,e FDA.
3. A man/+act/rer m/st sec/re t,e ADACs Seal o+ Accetance -e+ore marketin* a
dental rod/ct.
Dentifrices
Accordin* to t,e dictionary, t,e term denti+rice is deri"ed +rom dens 7toot,8 and
+ricare 7to r/-8. A simle, contemorary de+inition o+ a denti+rice is a mi0t/re /sed on
t,e toot, in conA/nction wit, a toot,-r/s,. 5,e ,istoric asects o+ denti+rice /se ,as
-een re"iewed -y Fisc,man.
'
Denti+rices are marketed as toot,owders, toot,astes, and *els. All are sold as eit,er
cosmetic or t,erae/tic rod/cts. I+ t,e /rose o+ a denti+rice is t,erae/tic, it m/st
red/ce some disease-related rocess in t,e mo/t,. Us/ally t,e act/al or alle*ed
t,erae/tic e++ect is to red/ce caries incidence, *in*i"itis, or toot, sensiti"ity. 5,e
sales aeal o+ a rod/ct, ,owe"er, is stron*ly linked to its +la"or and +oamin* action.
In :;%$, t,e denti+rice market amo/nted to an estimated f='' millionD -y :;(( it ,ad
increased to f: -illionD in :;;< to f:.' -illionD in >$$$ to f:.; -illionD and t,e
estimated market +or >$$' is f>.> -illion 7Fi*/re <-:8.
)acka*in*
5,e de"eloment o+ t,e toot,-r/s, in CF>D ro"ided t,e stim/l/s to market
commercial denti+rices. 5oot,owders were o/lar -eca/se -o0es and cans +rom
w,ic, t,ey co/ld -e disensed already e0isted. 5,e +orm/las consisted o+ little more
t,an water, soa, and +la"or.
5oot,astes -e*an to aear on t,e market +ollowin* t,e de"eloment o+ lead t/-es
+or acka*in*. 5,e c,an*e to lastic acka*in* d/rin* 4orld 4ar II sim/ltaneo/sly9
3liminated t,e ossi-ility o+ t,e /ser in*estin* lead,
!ed/ced t,e ossi-ility o+ incomati-ility o+ t,e t/-e and aste comonents,
Aided t,e e0ellin* o+ t,e aste -y s?/ee@in*,
)ermitted an easier and more economic rod/ction o+ t/-es, and
)ro"ided a *ood s/r+ace +or t,e rintin* o+ decorati"e desi*ns and in+ormation.
A draw-ack wit, t,e initial /se o+ lastic t/-es was t,e ermea-ility and s/-se?/ent
loss o+ +la"ors t,o/*, t,e acka*in*. 5,is ,as -een resol"ed wit, t,e /se o+ new
lastic materials and t,e /se o+ laminated or layered acka*in* materials.
In :;(&, Col*ate introd/ced t,e /m disenser to t,e market. Searate color
comartments /sed to disense FstriedF rod/cts were introd/ced in Strie denti+rice
-y .e"er 1rot,ers and are now /sed in A?/a+res, 7Smit,, 2line, 1eec,am8 and
Col*ate 5otal Strie 7Col*ate-)almoli"e Co.8. C,ese-oro/*,-)ondCs introd/ced a
d/al-c,am-er /m disenser to kee t,e ero0ide and -akin* soda comonents o+
t,eir denti+rice, Mentadent, searate /ntil immediately rior to /se w,en t,ey are
deli"ered to*et,er on t,e toot,-r/s,.
Denti+rice In*redients
Denti+rices were ori*inally de"eloed to ro"ide a cosmetic e++ect and deli"er a
leasant taste. 5,ey are e++ecti"e in remo"in* extrinsic stains, t,ose t,at occ/r on t,e
s/r+ace o+ t,e toot,. 5,ese stains, w,ic, are o+ten t,e end-rod/cts o+ -acterial
meta-olism, ran*e in color +rom *reen to yellow to -lack. Stains may also res/lt +rom
+oods, co++ee, tea, cola-containin* drinks, and red wines. O5C denti+rices do not
remo"e intrinsic stains, w,ic, are a res/lt o+ altered amelo*enesis, s/c, as t,e w,ite-
to--rown color c,an*es seen in fluorosis or t,e *rayis,--l/e aearance o+ enamel
+ollowin* administration of tetracycline, Denti+rices, and ot,er O5C rod/cts, are
also ine++ecti"e in alterin* t,e yellowin* color o+ teet, seen wit, physiolo$ic a$in$
and in alterin* t,e ,/es o+ toot, color rod/ced -y di++erin* s,ades o+ dentin.
5,ere+ore, t,ey can only claim to Fmake yo/r teet, t,eir w,itest or -ri*,testFD t,ey
cannot state, FMakes yo/r teet, w,iter or toot, color li*,ter.F
5oot,astes contain se"eral or all o+ t,e in*redients listed in 5a-le <->. Gel
denti+rices are also marketed. Gels contain t,e same comonents as toot,astes,
e0cet t,at *els ,a"e a hi$her proportion o+ t,e t,ickenin* a*ents. 1ot, toot, *els
and toot,astes are e5ually e++ecti"e in la?/e remo"al and in deli"erin* acti"e
in*redients.
A-rasi"es
5,e de*ree o+ denti+rice a-rasi"eness deends on t,e inherent hardness o+ t,e
a-rasi"e, si1e o+ t,e a-rasi"e article, and t,e shape o+ t,e article. Se"eral ot,er
"aria-les can a++ect t,e a-rasi"e otential o+ t,e denti+rice9 t,e -r/s,in* tec,ni?/e, t,e
ress/re on t,e -r/s,, t,e ,ardness o+ t,e -ristles, t,e direction o+ t,e strokes, and t,e
n/m-er o+ strokes. 5,e a-rasi"e tested alone can di++er +rom t,e same a-rasi"e tested
as part o+ a denti+rice +orm/la. 5,e sali"ary c,aracteristics o+ indi"id/als may also
a++ect denti+rice a-rasi"eness.
Calci/m car-onate and calci/m ,os,ates were re"io/sly t,e most common
a-rasi"es /sed. 5,ese a*ents o+ten reacted ad"ersely wit, +l/orides. C,alk 7calci/m
car-onate8 and -akin* soda 7sodi/m -icar-onate8 are also common denti+rice
a-rasi"es. New silicas, silicon o0ides, and al/min/m o0ides are -ein* introd/ced into
denti+rice +orm/las, wit, additional e++icacy claims.
<-;
A-rasi"eness 5estin*
Standard la-oratory testin* /ses a mac,ine wit, se"eral -r/s,es. 5,e len$th o+ t,e
recirocatin* stroke, num4er o+ strokes, and pressure o+ t,e -r/s, can -e adA/sted.
Deendin* on t,e e0erimental o-Aecti"es, enamel, dentin, or cement/m is -r/s,ed,
and t,e amo/nt o+ calci/m or ,os,or/s in t,e res/ltant sl/rry is analy@ed. A more
acc/rate met,od ,as -een de"eloed in w,ic, e0tracted teet, are irradiated to acti"ate
some o+ t,e toot, ,os,or/s to radioactive phosphorus, A+ter -r/s,in* root s/r+aces
o+ so/nd canines and molars, t,e amo/nt o+ radioacti"e ,os,or/s remo"ed may -e
more acc/rately assessed t,an wit, classical c,emical analyses. !es/lts are re+erenced
a*ainst t,e amo/nt o+ toot, s/-stance remo"ed -y t,e /se o+ t,e control-a-rasi"e,
calci/m yro,os,ate.
:$
A-rasi"es /s/ally do not dama*e enamel, -/t t,ey may d/ll t,e toot, l/ster. 5o
comensate +or t,is, polishin$ a$ents are added to t,e denti+rice +orm/lation. 5,ese
olis,in* a*ents are /s/ally small-si@ed articles o+ al/min/m, calci/m, tin,
ma*nesi/m, or @irconi/m como/nds. 5yically, t,e man/+act/rer 4lends the
a4rasives and t,e polishin$ a$ents to +orm an a4rasive system, A*ents, s/c, as c,alk
or silica, may ,a"e -ot, olis,in* and a-rasi"e e++ects. Smaller articles 7: mm8 ,a"e
a olis,in* action, and lar$er articles 7>$ mm8 ,a"e an a-rasi"e action.
::
In selectin* a denti+rice, t,e a-rasi"eness and olis,in* c,aracteristics s,o/ld meet
indi"id/al needs. For instance, / to >$E o+ t,e o/lation does not acc/m/late
"isi-le stain w,en en*a*ed in t,eir own style o+ ersonal oral ,y*iene.
:>
For t,ese
indi"id/als, a denti+rice wit, ,i*, olis,in* and low a-rasion s,o/ld -e
recommended. For t,e a"era*e indi"id/al, an additional amo/nt o+ a-rasi"e is needed
to control acc/m/latin* stain. 5,e stains on ne*lected teet, may -e *reen, oran*e, or
-lack stains o+ c,romo*enic -acterial ori*in, or yellow and -rown stains +rom
smokin*. As t,e a-rasi"e le"el increases, *reater care m/st -e taken to er+ect
-r/s,in* tec,ni?/es t,at do not ca/se self2inflicted in7ury to t,e teet, or so+t tiss/es.
S/c, inA/ries can res/lt +rom e0cessi"e ress/re, ,ard -ristles, and rolon*ed
-r/s,in*.
4,en toot,-r/s,in* is done wit,o/t toot,aste, t,ere is little ossi-ility o+ a-rasion.
4,en dama*e does occ/r, it /s/ally aears as a 6-s,aed notc, in t,e cementum
immediately 4elo3 the cementoenamel 7unction 7Fi*/re <->8. 5,is area is "/lnera-le,
-eca/se enamel is a-o/t <: times harder t,an dentin or cement/m. More serio/s
de+ects /s/ally occ/r in older indi"id/als w,o maintain a "ery ,i*, le"el o+ oral
,y*iene.
H/mectants
5oot,aste consistin* only o+ a toot,owder and water res/lts in a rod/ct wit,
se"eral /ndesira-le roerties. O"er time, t,e solids in t,e aste tend to settle o/t o+
sol/tion and t,e water e"aorates. 5,is may res/lt in cakin* o+ t,e remainin*
denti+rice. Until t,e :;=$s, most toot,aste ,ad a s,ort s,el+-li+e -eca/se o+ t,is
ro-lem. Once t,e t/-e was oened, t,e +irst e0elled aste was too li?/id, -/t t,e
last aste in t,e t/-e was eit,er imossi-le to e0el or too ,ard to /se. 5o sol"e t,is
ro-lem, humectants 3ere added to maintain the moisture, Commonly /sed
,/mectants are sor-itol, mannitol, and roylene *lycol. 5,ese ,/mectants are
nonto0ic, -/t mold or -acterial *rowt, can occ/r in t,eir resence. For t,is reason,
preservatives s/c, as sodi/m -en@oate are added.
H/mectants ,el maintain t,e consistency o+ toot,aste, -/t desite t,eir resence,
t,e solids tend to settle o/t o+ t,e aste. 5o counteract t,is, thic*enin$ or 4indin$
a$ents are added to t,e +orm/la. G/ms, s/c, as */m tra*acant,, were +irst /sed.
5,ese were +ollowed -y colloids deri"ed +rom seaweed, s/c, as carra*eenan. 5,ese,
in t/rn, were relaced -y synt,etic cell/loses. 5,ese cell/loses in lo3 concentrations
are also o+ten /sed as ,/mectantsD in hi$her concentrations t,ey +/nction as *ellin*
a*ents in t,e +orm/lation o+ *el denti+rices. At hi$h concentrations 7> &$E8,
,/mectants also act as reser"ati"es.
Soas and Deter*ents
1eca/se toot,astes were ori*inally man/+act/red to kee t,e teet, clean, soa was
t,e lo*ical cleansin* a*ent. As t,e toot,-r/s, -ristles dislod*e +ood de-ris and
la?/e, t,e +oamin* or s/dsin* action o+ t,e soa aids in t,e remo"al o+ t,e loosened
material. Soas ,a"e se"eral disad"anta*es9 t,ey can -e irritatin* to t,e m/co/s
mem-rane, t,eir +la"or is di++ic/lt to mask and o+ten ca/ses na/sea, and many times
soas are incomati-le wit, ot,er in*redients, s/c, as calci/m.
4,en deter*ents aeared on t,e market, soas lar*ely disaeared +rom denti+rices.
5oday, sodium lauryl sulfate (S(S) is the most 3idely used deter$ent, It is sta4le,
ossesses some anti4acterial roerties, and ,as a lo3 surface tension, w,ic,
+acilitates t,e +low o+ t,e denti+rice o"er t,e teet,. S.S is acti"e at a ne/tral H, ,as a
+la"or t,at is easy to mask, and is comati-le wit, t,e c/rrent denti+rice in*redients.
1ark"oll ,as s/**ested t,at atients w,o s/++er +rom "ario/s oral m/cosal diseases
s,o/ld a"oid t,e /se o+ denti+rices containin* S.S.
:=
.ow S.S denti+rices ,a"e -een
marketed, w,ic, claim to -e associated wit, a lower incidence o+ oral /lcers.
Fla"orin* and Sweetenin* A*ents
'lavor, alon* wit, smell, color, and consistency o+ a rod/ct, are imortant
c,aracteristics t,at lead to pu4lic acceptance of a dentifrice, I+ denti+rices did not
ossess t,ese c,aracteristics, t,ey wo/ld ro-a-ly -e oorly acceted. For taste
accetance, t,e +la"or m/st -e leasant, ro"ide an immediate taste sensation, and -e
relati"ely lon*-lastin*. Us/ally synt,etic +la"ors are -lended to ro"ide t,e desired
taste. Searmint, eermint, winter*reen, cinnamon, and ot,er +la"ors *i"e
toot,aste a leasant taste, aroma, and re+res,in* a+tertaste. Some man/+act/rers /se
essential oils s/c, as t,ymol, ment,ol, etc., w,ic, may ro"ide a FmedicinalF taste to
t,e rod/ct. In addition, t,ese oils may imart anti-acterial e++ects, as will -e
disc/ssed later in t,is c,ater. It is di++ic/lt to +orm/late a +la"or t,at is /ni"ersally
acceta-le, -eca/se eole ,a"e di++erent color and taste re+erences.
Fi*/re <-: S,owin* t,e raid se"en+old increase in toot,aste sales o"er t,e
ast =$ years, and roAected increase till >$$'.
Fi*/re <-> 6-S,aed notc,es in central incisors res/ltin* +rom /se o+ a
denti+rice wit, a ,ars, a-rasi"e system. 7Co/rtesy o+ Dr. 1 1aker, Uni"ersity o+
5e0as Dental Sc,ool, San Antonio.8
Question 2
A. Gel denti+rices are t,e same as re*/lar denti+rices, e0cet t,at t,ey contain a
*reater roortion o+ t,ickenin* a*ent.
1. 5,e a-rasi"eness o+ an a-rasi"e a*ent deends on t,e in,erent ,ardness o+ an
a-rasi"e, t,e si@e o+ t,e a-rasi"e articles, and t,e s,ae o+ t,e a-rasi"e articles.
C. 5,e 6-s,aed dama*e to t,e toot, +rom /sin* an e0cessi"ely a-rasi"e denti+rice
occ/rs aical to t,e cementoenamel A/nction.
D. Synt,etic cell/loses are now /sed as t,ickenin* a*ents +or toot,astes and *els.
3. I+ sodi/m la/ryl s/l+ate is added to t,e denti+rice +orm/la, +oamin* can -e e0ected
w,en -r/s,in*.
Sweetenin* A*ents
In early toot,aste +orm/lations, s/*ar, ,oney, and ot,er sweeteners were /sed.
1eca/se t,ese materials can -e -roken down in t,e mo/t, to rod/ce acids and lower
la?/e H, t,ey may increase caries. 5,ey ,a"e -een relaced wit, sacc,arin,
cyclamate, sor-itol, and mannitol as rimary noncario$enic sweetenin* a*ents.
Sor-itol and mannitol ser"e a dual role as sweetenin* a*ents and ,/mectants.
Glycerin, w,ic, also ser"es as a ,/mectant, adds to t,e sweet taste. A new sweetener
in some denti+rices is xylitol, In la-oratory st/dies, it is not meta-oli@ed -y -acteria to
rod/ce acid. In ,/man st/dies, w,ere it was laced in c,ewin* */ms and +ood,
0ylitol was noncario*enic. In addition, it demonstrated an anticaries caa-ility -y
facilitatin$ t,e reminerali1ation o+ inciient cario/s lesions.
1akin*-Soda Denti+rices
1akin* soda 7sodi/m -icar-onate8 ,as ,ad a lon$ history of use as an oral2hy$iene
aid, C,/rc, and Dwi*,t, a man/+act/rer o+ -akin* soda, and also t,e man/+act/rer o+
t,e ori*inal -akin*-soda toot,aste, ,as stated Ftwo o/t o+ t,ree dentists and
,y*ienists recommend -r/s,in* wit, -akin* soda +or ,ealt,ier teet, and */ms.F In a
series o+ aers /-lis,ed in :;;(, antila?/e, *in*i"itis red/ction, stain-remo"al, and
odor-red/cin* e++icacy were documented +or sodi/m -icar-onate-containin*
denti+rices.
<
Some dentists ,a"e also s/**ested t,e mi0t/re o+ -akin* soda wit, ero0ide as an
alternati"e to t,e /se o+ commercial denti+rices. Anecdotally, many atients attri-/te
-ene+it to t,e ro/tine /se o+ t,ese rod/cts. It was ine"ita-le t,at t,ese rod/cts
wo/ld -e incororated into toot,astes. Selected e0amles o+ c/rrently marketed
-akin* soda denti+rices are resented in Aendi0 <-:. All contain ,ydrated silica t,at
is comati-le wit, +l/oride. No denti+rice containin* -akin* soda as t,e sole acti"e
in*redient ,as recei"ed t,e ADA Seal o+ Accetance. It was only after fluoride was
added to t,e +orm/lations, and a+ter re?/ired la-oratory, animal, and clinical st/dies
were comleted, t,at se"eral -akin* soda-+l/oride denti+rices were acceted as
e++ecti"e in caries control. 5,ese -akin*-soda denti+rices act/ally contain only a small
amo/nt o+ -akin* soda, in addition to t,e standard +l/oride-comati-le a-rasi"es.
3ssential-Oil Denti+rices
5,e essential-oil in*redients +o/nd in .isterine mo/t,rinse 7see -elow8 are also
a"aila-le in a denti+rice +orm/lation. 5,e clinical and la-oratory data s/**est a -ene+it
to *in*i"al ,ealt, and la?/e red/ction.
:&,:'
5,is rod/ct does not carry t,e ADA Seal
o+ Accetance.
5,erae/tic Denti+rices
5,e most commonly /sed t,erae/tic a*ent added to denti+rices is fluoride, w,ic,
aids in t,e control o+ caries. In :;<$, t,e Co/ncil on Dental 5,erae/tics o+ t,e
American Dental Association, -ased on se"eral st/dies t,at indicated its e++ecti"eness,
classi+ied Crest toot,aste wit, stanno/s +l/oride as a caries prophylactic dentifrice,
For t,e +irst time, a t,erae/tic denti+rice was awarded t,e Seal o+ Provisional
Accetance. In :;<&, on t,e -asis o+ +/rt,er new and +a"ora-le data,
:<
t,e
classi+ication was /*raded to full accetance.
5,e ori*inal le"el o+ +l/oride in O5C denti+rices and *els was restricted to :,$$$ to
:,:$$ m +l/oride and a total o+ no more t,an :>$ m* o+ +l/oride in t,e t/-e, wit, a
re?/irement t,at t,e acka*e incl/de a sa+ety clos/re. 5,erae/tic toot,astes,
disensed on rescrition, co/ld contain / to ><$ m* o+ +l/oride in a t/-e.
5,e +ollowin* +l/orides are *enerally reco*ni@ed as e++ecti"e and sa+e +or O5C sales9
$.>>E sodi/m +l/oride 7NaF8 at a le"el o+ :,:$$ m, $.%<E sodi/m
mono+l/oro,os,ate 7MF)8 at a le"el o+ :,$$$ m, and $.&E stanno/s +l/oride
7SnF
>
8 at a le"el o+ :,$$$ m. Fl/oride le"els were increased to :,'$$ m sodi/m
mono+l/oro,os,ate in F30tra Stren*t, Aim,F marketed O5C. In /-lis,ed
st/dies,
:%,:(
t,is rod/ct was :$E more e++ecti"e t,an an :,:$$ m NaF denti+rice. A
recently introd/ced prescription dentifrice, Col*ate )re"ident ',$$$, contains ',$$$-
m +l/oride.
One -akin* soda-ero0ide-+l/oride denti+rice 7Mentadent8 is /ni?/e in its acka*in*.
Mentadent contains a com-ination o+ $.%'E sta-le peroxide $el in conA/nction wit,
4a*in$ soda, and C,C:: ppm sodium fluoride, 5,e materials are acka*ed in a two-
c,am-er /m to ermit t,e -akin* soda and ero0ide comonents to -e mi0ed wit,
t,e +l/oride at t,e time o+ deli"ery. 5,e rod/ct ,as -een demonstrated to -e sa+e,
:;

and t,e low le"el o+ ,ydro*en ero0ide does not resent ro-lems alle*ed to res/lt
+rom ,i*,er le"els o+ ero0ide in early animal st/dies.
>$
M/ltile clinical st/dies o+ +l/oride denti+rices containin* NaF, MF), or SnF
>
in t,e
resence o+ comati-le a-rasi"es and sta-le +orm/lations ,a"e -een s/-mitted to and
-een acceted -y t,e ADA. 5,e Association, t,ere+ore, awards t,e Seal o+
Accetance to +l/oride denti+rices -ased solely on la-oratory data i+ t,ey comly wit,
re"io/sly s/-mitted clinical data.
>:
5,e +l/oride denti+rices c/rrently acceted -y t,e Co/ncil on Scienti+ic A++airs o+ t,e
American Dental Association are a"aila-le at t,e ADA we- site, www.ada.or*. &ot
all fluoride2containin$ dentifrices have demonstrated anticaries activity, 5,e le"el o+
acti"e +l/oride m/st -e ade?/ate and m/st -e maintained o"er t,e s,el+-li+e o+ t,e
denti+rice. 5,e Seal o+ Accetance o+ t,e American Dental Association is one
ass/rance o+ an acti"e rod/ct. Fl/oride denti+rices are disc/ssed more e0tensi"ely in
C,ater ;.
Control o+ )la?/e and Gin*i"itis
Most intri*/in* is t,e concet o+ chemical pla5ue control, in w,ic, c,emical
como/nds are /sed to supplement t,e /s/al -r/s,in*, +lossin*, and /se o+ a/0iliary
aids emloyed in mec,anical la?/e control. Antila?/e a*ents can act directly on t,e
la?/e -acteria or can disr/t di++erent comonents o+ la?/e to ermit easier and
more comlete remo"al d/rin* toot,-r/s,in* and +lossin*. 5,is oort/nity to /se
c,emistry to en,ance oral ,y*iene roced/res is imortant -eca/se man/al la?/e-
control met,ods are di++ic/lt to teac, and monitor, tedio/s to er+orm, time-
cons/min*, imossi-le to accomlis, -y some ,ysically and mentally ,andicaed
ersons, and not /sed -y nonmoti"ated indi"id/als.
5,e resent c,emical la?/e-control a*ents s,o/ld not -e considered a anacea
-eca/se t,ey ,a"e not -een ro"en to -e a total s/-stit/te +or ro/tine oral-,y*iene
meas/res. !xcessive emphasis on chemical control may encoura$e some patients to
deemphasi1e proven oral2hy$iene methods,
At t,e resent time, an a*ent 7or a*ents8 analo*o/s to +l/oride in controllin* caries is
-ein* so/*,t to control la?/e and *in*i"itis and to re"ent eriodontitis. 5,e
roerties o+ an ideal +orm o+ s/c, an a*ent are listed in 5a-le <-=. Alt,o/*, many
O5C rod/cts are -ein* marketed wit, la?/e-*in*i"itis claims, only t3o denti+rices
are c/rrently marketed wit, D2accepted claims 7see ADA we-site, www.ada.or*8.
1ot, contain triclosan and will -e disc/ssed +/rt,er in t,is c,ater.
Stanno/s Salts
Stanno/s +l/oride 7SnF
>
8, seci+ically t,e stanno/s ion, ,as reorted acti"ity a*ainst
caries, la?/e, and *in*i"itis.
>>
4,ile SnF
>
,as a lon* record as an anticaries a*ent,
lon*-term sta-ility in denti+rices and mo/t,rinses ,as -een ?/estioned since clinical
antimicro-ial acti"ity ,as only -een demonstrated in an,ydro/s rod/cts.
>>
5,e
de"eloment and s/-se?/ent la-oratory and clinical e++icacy o+ a sta-ili@ed SnF
>

denti+rice ,as -een reorted.
>=,>&
5,is denti+rice ,as -een marketed in t,e United States
-y )rocter g Gam-le as Crest G/m Care. Clinical st/dies ,a"e -een er+ormed "ers/s
essential-oil mo/t,rinses, -akin*-sodaBero0ide denti+rices, and triclosan-containin*
denti+rices wit, yro,os,ateBcoolymerB@inc citrate. S/erior e++icacy ,as -een
s,own +or Crest G/m Care in antimicro-ial, la?/e acido*enicity, *in*i"itis or
*in*i"al -leedin*, and calc/l/s control.
>',><
Howe"er, lon*-term st/dies wit, t,is SnF
>

denti+rice demonstrated an increase in e0trinsic stain attri-/ted to t,e stanno/s ion.
5riclosan
5riclosan is a -road-sectr/m anti-acterial a*ent, marketed -y its man/+act/rer, Ci-a-
Gei*y, +or /se in oral rod/cts /nder t,e trade name Ir*acare. It is e++ecti"e a*ainst a
wide "ariety o+ -acteria and is widely /sed as an anti-acterial a*ent in O5C cons/mer
rod/cts in t,e United States, incl/din* deodorant soas and anti-acterial skin scr/-s.
It ,as also -een s,own to -e a /se+/l anti-acterial a*ent in oral rod/cts. A re"iew o+
t,e a"aila-le ,armacolo*ical and to0icolo*ical in+ormation concl/ded, F5riclosan
can -e considered sa+e +or /se in denti+rice and mo/t, rinse rod/cts.F
>%
Many denti+rices and mo/t,rinses containin* triclosan are marketed in 3/roe. In t,e
United States, one denti+rice, de"eloed -y Col*ate-)almoli"e, contains triclosan, a
atented coolymer, CGantre@C, and +l/oride. 5,is rod/ct, Col*ate 5otal, ,as
/nder*one e0tensi"e sa+ety
>%
and clinical-e++icacy testin*.
>(,>;,=$
and was aro"ed in
:;;% -y t,e FDA as t,e +irst denti+rice to ,el re"ent $in$ivitis, pla5ue, and caries,
Col*ate 5otal also ,as recei"ed t,e American Dental AssociationCs Seal o+
Accetance as an Fe++ecti"e decay re"enti"e denti+rice, and to ,el re"ent and
red/ce *in*i"itis w,en /sed as directed in a conscientio/sly alied ro*ram o+ oral
,y*iene and re*/lar ro+essional care. It ,as also -een s,own to ,el red/ce t,e
+ormation o+ la?/e and tartar a-o"e t,e */m line. Its e++ect on eriodontitis ,as not
-een determined.F 5wo ot,er FCol*ate 5otalsF ,a"e -een accetedD FFres, StrieF and
a new +orm/la makin* all o+ t,e a-o"e claims l/s w,itenin*. !ecently, a >-year
st/dy on 5otal ,as doc/mented lon*-term anticaries e++icacy.
=:
!esearc, on a
triclosan-yro,os,ate com-ination in a denti+rice ,as demonstrated la?/e
re$ro3th inhi4ition and anticalculus activity,
=>,==
A Unile"er rod/ct containin* @inc citrate and triclosan ,as also recei"ed attention.
Clinical e"al/ation ,as s,own t,is to -e e++ecti"e in red/cin* la?/e +ormation and in
re"entin* *in*i"itis. A s/mmary o+ t,e @inc citrate-triclosan st/dies ,as -een
/-lis,ed.
=&
5,is rod/ct is not c/rrently marketed in t,e United States.
Anticalc/l/s Denti+rices
Calc/l/s-control denti+rice +orm/lations are desi*ned to interrupt the process of
minerali1ation of pla5ue to calculus, )la?/e ,as a -acterial matri0 t,at minerali@es
d/e to t,e super saturation o+ sali"a wit, calci/m and ,os,ate ions. Crystal *rowt,
in,i-itors may -e added to denti+rices to ro"ide a red/ction in calc/l/s +ormation.
In t,e late :;%$s, anticalc/l/s denti+rices -e*an to aear on t,e market wit,o/t any
e"idence o+ e++ecti"eness.
='
In :;(', )rocter g Gam-le s/lemented t,eir e0istent
Crest anticario*enic toot,aste wit, a similar anticaries +orm/la t,at also contained a
com-ination o+ tetra sodium phosphate and disodium dihydro$en pyrophosphate, 5,e
sol/-le yro,os,ates are crystal *rowt, in,i-itors, w,ic, retard t,e +ormation o+
calc/l/s.
=<
5,is com-ination ,as -een demonstrated in clinical st/dies to si*ni+icantly
red/ce t,e amo/nt o+ calc/l/s +ormed, comared wit, a control denti+rice. 5,e
denti+rice is marketed as Crest 5artar Control. 5,e +orm/la recei"ed t,e American
Dental AssociationCs Seal o+ Accetance, -/t only as a caries control rod/ct and only
-eca/se o+ its +l/oride content. Ot,er similar anticalc/l/s rod/cts t,at are now on t,e
market all contain NaF.
A recent addition to t,e list o+ a"aila-le rod/cts is a denti+rice wit, -ot, a w,itenin*
and an anticalc/l/s claim.
=%
5,e rod/ct, FCol*ate 5artar Control )l/s 4,itenin*
Fl/oride 5oot,asteF contains tetrasodi/m yro,os,ate, sodi/m trioly,os,ate, a
coolymer, and NaF.
!olla and Sa0e*aard
=(
,a"e noted t,e ossi-ility o+ Fcrystal oisons,F s/c, as
yro,os,ates and ,os,onates, in,i-itin* reminerali@ation. S/c, in,i-ition mi*,t
ad"ersely a++ect t,e anticaries e++ect o+ t,e +l/oride in t,is tye o+ calc/l/s control
denti+rice. Iinc citrate tri,ydrate is /sed to in,i-it calc/l/s +ormation in t,e tartar
control "ersions o+ -ot, Aim and Close-U. Clinical st/dies
=;
,a"e s,own t,at 1inc
citrate does not affect the caries inhi4ition of fluoride,
Desite +a"ora-le anticalc/l/s data, t,e ADA seal has not 4een a3arded to rod/cts
wit, only an anticalc/l/s claim, -eca/se t,e ADA considers calc/l/s in,i-ition as a
cosmetic, not a t,erae/tic e++ect. 4it, an anticalc/l/s a*ent, two sim/ltaneo/s
-ene+icial e++ectscaries control and calc/l/s in,i-itionare a"aila-le wit, one
-r/s,in* oeration. 5,e c/rrently marketed ADA acceted anticaries rod/cts t,at
also in,i-it calc/l/s +ormation mi*,t -e +o/nd at t,e ADA we- site, www.ada.or*
7see Aendi0 <->8.
Question 3
4,ic, o+ t,e +ollowin* statements, i+ any, are tr/ee
A. 1akin* soda, ero0ide, and +l/oride are incomati-le in a denti+rice.
1. 5,e resent consens/s is t,at c,emical-la?/e control is only a s/lement to
mec,anical-la?/e control.
C. Stanno/s +l/oride is -ot, an anticaries and an anti*in*i"itis a*ent.
D. 5riclosan is an e++ecti"e anti-acterial a*ent.
3. Crest 5artar Control toot,aste ,as recei"ed t,e American Dental AssociationCs
Seal o+ Accetance as a t,erae/tic anticalc/l/s rod/ct.
Anti,yersensiti"ity )rod/cts
Many eole e0erience ain w,en e0osed areas o+ t,e root, esecially at t,e
cemento-enamel A/nction, are su47ected to heat or cold, 5o address t,is iss/e t,e
ADA ,as +ormed t,e Ad Hoc Committee on Dentinal Sensiti"ity. Se"eral O5C
denti+rices ,a"e -een acceted wit, t,e acti"e a*ents s/c, as potassium nitrate,
strontium chloride, and sodium citrate,
&$
C/rrently acceted rod/cts may -e +o/nd
on t,e ADA we- site, www.ada.or* 7see Aendi0 <->8. )otassi/m citrate ,as also
-een acceted -y t,e 1ritis, Deartment o+ Healt,.
5,e American Dental AssociationCs Co/ncil on Dental 5,erae/tics ,as aro"ed a
denti+rice 7Sensodyne F8 wit, a com-ination o+ acti"e in*redients, demonstratin* -ot,
anti,yersensiti"ity and caries-re"enti"e -ene+its. 5,is is anot,er e0amle o+ a
t,erae/tic denti+rice directed sim/ltaneo/sly at sol"in* two ro-lems, caries and
,yersensiti"ity, wit, t,e same -r/s,in* oeration.
4,iteners
Considera-le contro"ersy s/rro/nds t,e /se o+ stain remo"ers and toot, w,iteners.
)rod/cts are -ein* marketed +or ro+essional /se or +or /se -y t,e atient at ,ome.
Many claims +or e++icacy and sa+ety are /nder re"iew -y a*encies and *o"ernment
anels. 5,e ADA we-site s,o/ld -e cons/lted +or a list o+ c/rrently acceted
rod/cts. Cosmetic -ene+its o+ denti+rices remain imortant to atients.
S/r"eys re"eal a *rowin* U.S. market s,are +or denti+rices claimin* Fw,itenin*F or
Fstain control.F 5,ese denti+rices control stain "ia physical methods 7a-rasi"es8 and
chemical mechanisms 7s/r+ace acti"e a*ents or -leac,in*Bo0idi@in* a*ents8. Alt,o/*,
t,e /-lic ercei"es t,ese as more a-rasi"e t,an ordinary toot,astes, t,eir
a-rasi"eness is /s/ally intermediate amon* t,e rod/cts tested.
Denti+rices marketed wit, toot,-w,itener claims are a"aila-le as a toot,aste or *el,
or are /sed in a two- or t,ree-ste treatment Frocess.F 5,ese rod/cts /s/ally contain
hydro$en peroxide or car4amide peroxide as t,eir -leac,in* or w,itenin* in*redient.
Car-amide ero0ide -reaks down to +orm /rea and ,ydro*en ero0ide. Hydro*en
ero0ide, in t/rn, +orms a +ree radical containin* oxy$en, w,ic, is t,e acti"e -leac,in*
molec/le. Home--leac,in* rod/cts may contain ot,er c,emicals to aid in t,e
deli"ery o+ t,e 4leachin$ a*ent. Glycerin or roylene *lycol is commonly added to
t,icken t,e sol/tion and rolon* contact wit, t,e toot, s/r+ace. In t,e two- or t,ree-
ste rod/cts, a*ents can -e deli"ered to teet, "ia a c/stom-made tray or -y
toot,-r/s,in*.
5,ere is concern t,at re*/lar /se o+ t,e ero0ides or t,eir -reakdown rod/cts may
ena-le o"er*rowt, o+ /ndesira-le or*anisms, incl/din* yeasts, ossi-ly leadin* to
F-lack ,airy ton*/e.F In addition, ero0ides may dama*e t,e /l or t,e so+t tiss/es
o+ t,e mo/t,. Delayed wo/nd ,ealin* is also a concern, as is t,e ossi-le m/ta*enic
e++ect o+ stron* o0y*enatin* a*ents. 5,e Food and Dr/* Administration ,as sent a
re*/latory letter to rod/cers o+ t,ose commercial toot,-w,itenin* a*ents containin*
ero0ides to in+orm t,em t,at t,ese rod/cts are classi+ied as dr/*s. 5,e letter asked
+or in+ormation a-o/t ossi-le side e++ects, s/c, as delayed wo/nd ,ealin*,
eriodontal ,arm, and m/ta*enic otential. 5,e American Dental AssociationCs
Co/ncil on Scienti+ic A++airs ,as iss/ed FG/idelines +or t,e Accetance o+ )ero0ide
Containin* Oral Hy*iene )rod/cts.F
&:
A denti+rice 7Crest 30tra 4,itenin*8 ,as -een introd/ced w,ic, /ses a stain seci+ic
so+t tiss/e tec,nolo*y.
&>
5,is rod/ct, w,ic, contains NaF, claims calc/l/s control
acti"ity as well as stain remo"al and an anticaries -ene+it.
Mo/t,rinses
Fres,enin* -ad -reat, ,as -een t,e traditional /rose o+ mo/t,rinses. 5,e :;;>
market +or s/c, rod/cts was estimated at f<=' million. Sales increased to f%=;
million in >$$$. In addition to t,e traditional cosmetic /se, t,erae/tic mo/t,rinses
are now a"aila-le.
5,e claimed acti"e in*redients o+ mo/t,rinses incl/de 5uaternary ammonium
compounds, 4oric and 4en1oic acids, and phenolic compounds, As wit, denti+rices,
commercial sales o+ cosmetic rinses ,a"e -een related to taste, color, smell, and t,e
leasant sensation t,at +ollows /se. 5,e leasant sensation is o+ten en,anced -y t,e
addition o+ astrin*ents. Commonly /sed astrin*ents are al/m, @inc stearate, @inc
citrate, and acetic or citric acids. Iinc s/l+ate ,as -een added to mo/t, rinses as a
claimed antila?/e in*redient.
Alco,ol in mo/t,rinses is /sed as a solvent, a taste enhancer, and an a*ent ro"idin*
an aftertaste, 5,e alco,ol content o+ commercial rinses, ran*in* up to <D;, may
constit/te a dan*er +or c,ildren, esecially t,ose +rom > to = years o+ a*e. Accordin*
to t,e National )oison Center Network, ' to :$ o/nces o+ a mo/t,rinse containin*
alcohol can 4e lethal for a child wei*,in* >< o/nds. 1etween :;(% and :;;:, t,e
nationCs oison-control centers lo**ed more t,an :$,$$$ reorts o+ c,ildren yo/n*er
t,an < years old drinkin* mo/t,rinses containin* alco,olD A died and anot,er &$ ,ad
li+e-t,reatenin* conditions or s/++ered ermanent inA/ries.
&=
5,e American Academy
o+ )ediatrics ,as recommended t,at O5C li?/id rearations -e limited to >;
ethanol, t,at sa+ety clos/res -e re?/ired, and t,at t,e acka*ed "ol/me -e ket to a
Freasona-le minim/m to re"ent t,e otential +or let,al in*estion.F
&&
5,e Co/ncil on Scienti+ic A++airs o+ t,e American Dental Association re?/ires c,ild-
resistant cas on all alco,ol-containin* mo/t, rinses t,at -ear t,e Seal o+
Accetance.
&=
5,e co/ncil also re?/ires man/+act/rers o+ ADA-acceted mo/t,rinses
t,at contain more t,an 'E alco,ol to incl/de t,e +ollowin* statement on t,e la-el9
F4arnin*9 2ee o/t o+ reac, o+ c,ildren. Do not swallow. Contains alco,ol. Use only
as directed.F 5,e attorneys *eneral o+ >; states ,a"e etitioned t,e U.S. Cons/mer
)rod/cts Sa+ety Commission to re?/ire c,ild sa+ety cas on -ottles o+ mo/t,was, t,at
contain more t,an 'E alco,ol.
!esearc, +rom t,e National Cancer Instit/te 7NCI8 ,as lin*ed alco,ol and mo/t,was,
to mouth and throat cancers,
&'
A+ter takin* into acco/nt articiantsC smokin* and
drinkin* ,a-its, it was +o/nd t,at cancer atients were more likely t,an t,e control
*ro/ to ,a"e rinsed re*/larly wit, a ,i*,-alco,ol 7>'E or more8 mo/t,was,. 5,e
researc,ers concl/ded t,at alco,ol may or may not ca/se cancer in and o+ itsel+ -/t
may romote t,e disease -y dissol"in* and disersin* ot,er cancer-ca/sin*
s/-stances wit,in t,e mo/t, and t,roat. 5,e ADA ,as stated, FAccordin* to a
statement +rom t,e NCI, it is remat/re to make recommendations a-o/t any alco,ol-
containin* mo/t,was,es. In t,e meantime, t,e Association s/**ests t,at atients
contin/e to /se t,e t,erae/tic mo/t,rinses acceted -y t,e ADA . . . and
recommended -y t,eir dentists.F
&<
Cosmetic Mo/t,rinses
Halitosis
Oral malodor ,as -een a ne*lected researc, area. Indeed, t,e +irst scienti+ic
symosi/m on ,alitosis researc, was not ,eld /ntil :;;:. F/rt,er researc, and
ed/cation is needed in t,is imortant area -eca/se many racticin* dental
ro+essionals still -elie"e t,at -ad -reat, /s/ally comes +rom t,e stomac,. Identi+yin*
t,e ca/se o+ ,alitosis and de"eloin* an aroriate treatment lan can -e di++ic/lt.
&%

)/-lis,ed st/dies -y So/*e
&(
and -y 5on@etic,
&;
,a"e demonstrated t,at oral
malodor usually derives from the mouth itsel+ and may -e red/ced +ollowin* oral
,y*iene. 5o moti"ate imro"ement in oral ,y*iene, dental ro+essionals s,o/ld ad"ise
atients t,at -ad -reat, mi*,t res/lt +rom micro-ial /tre+action wit,in t,e mo/t,.
!osen-er*
'$
notes, F1ad -reat, is a ca/se o+ concern, em-arrassment, and +r/stration
on t,e art o+ t,e *eneral /-lic. Oral malodor, w,et,er real or ercei"ed, can lead to
social isolation, di"orce roceedin*s, and e"en Ccontemlation o+ s/icide.C F
A -ody o+ science c/rrently e0ists to ermit t,e 5uantitative assessment of 4ad
4reath, w,ic, s,o/ld -e a-le to "eri+y rod/ct claims +or treatin* t,is imortant
symtom. Many rinses ,a"e -reat,-+res,enin* claims. Many claim -reat, +res,enin*,
-/t t,e e++ect is ca/sed -y +la"ors and ,as no e++ect a+ter = to ' ,o/rs. In dia*nosin*
and treatin* comlaints o+ -ad -reat,, t,e clinician s,o/ld consider syc,olo*ical as
well as ,ysical +actors.
':
Gerostomia %outh Rinses
Many eole e0erience dry mo/t, 7xerostomia8 tracea-le to several possi4le causes,
s/c, as dama*e to t,e sali"ary *lands +ollowin* radiation t,eray +or ,ead and neck
cancer, SAo*renCs syndrome, and /se o+ tran?/ili@in* dr/*s, esecially t,e tricyclic
antideressants. In s/c, cases t,e m/co/s mem-rane is contin/ally dry and
/ncom+orta-le. 5o ameliorate t,e dryness, arti+icial sali"as ,a"e -een de"eloed,
w,ic, are /sed ad li4itum -y t,e atient to moisten t,e m/co/s mem-rane.
1eca/se 0erostomia is correlated wit, an increased caries incidence, t,e rinses
/s/ally contain fluoride as well as c,emical como/nds in concentrations t,at closely
arallel t,ose o+ sali"a. 5,e rinses t,at contain +l/oride may, in reality, -e
reminerali1in$ solutions, Se"eral arti+icial sali"as ,a"e -een acceted -y t,e ADAD
amon* w,ic, are Sali"art and Gero-./-e. For a c/rrent listin*, cons/lt t,e ADA
we-site, www.ada.or*. Se"eral moist/ri@in* a*ents are also a"aila-le to 0erostomia
atients.
'>
5,erae/tic Mo/t, !inse A*ents
Chlorhexidine
The 'D has approved prescription pla5ue2control rinses containin$ :,C<;
chlorhexidine, )eride0 7Omni Oral ),armace/ticals8 ,as recei"ed t,e ADA seal and
)re"ident 7Col*ate8 is also marketed. Directions call +or a twice daily, =$-second rinse
wit, : o@ o+ s/c, sol/tions.
C,lor,e0idine ,as ro"ed to -e one o+ t,e most e++ecti"e antila?/e a*ents to date.
'=

C,lor,e0idine is a cationic como/nd t,at -inds to t,e ,ydro0yaatite o+ toot,
enamel, to t,e ellicle, to la?/e -acteria, to t,e e0tracell/lar olysacc,aride o+ t,e
la?/e,
'&
and esecially to t,e m/co/s mem-rane.
''
5,e c,lor,e0idine adsor-ed to t,e
,ydro0yaatite is -elie"ed to in,i-it -acterial coloni@ation.
'<
A+ter -indin*, t,e a*ent
is slo3ly released in active form over C< to <B hours.
'%
5,is a-ility o+ t,e oral tiss/es
to adsor- an acti"e a*ent and to ermit its slow release in acti"e +orm o"er a
rolon*ed eriod is known as su4stantivity, As t,e s/-stanti"ity o+ an antila?/e
a*ent decreases, t,e +re?/ency o+ /se needs to -e increased.
C,lor,e0idine ,as not ro"ed -ene+icial as t,e sole met,od o+ treatin* eriodontitis
wit, dee ockets. Followin* root lanin*, ro,yla0is, or eriodontal s/r*ery,
c,lor,e0idine irri*ation may -e e++ecti"e in ,elin* to control in+lammation and
s/-*in*i"al la?/e.
'(
In some co/ntries, s/c, as t,e United States, c,lor,e0idine rod/cts are a"aila-le
only -y rescrition. In ot,ers, s/c, as t,e United 2in*dom, t,ey are a"aila-le o"er
t,e co/nter. Alt,o/*, c,lor,e0idine is ?/ite e++ecti"e, it is not acti"e a*ainst all
rele"ant anaero-es. A ,i*, minimal concentration is necessary +or e++icacy. Some side
e++ects are associated wit, c,lor,e0idine /se, o+ w,ic, stain is t,e most common.
';

Occasionally altered taste sensation is reorted.
<$
/ncreased calculus +ormation,
<:

superficial des5uamation of tissue, and hypersensitivity ,a"e also -een noted.
<>,<=

C,lor,e0idine is inacti"ated -y most denti+rice s/r+actants and, t,ere+ore it is not
incl/ded in denti+rices. Also, -eca/se o+ t,is inacti"ation, it is critical for dental
professionals to alert atients not to /se c,lor,e0idine mo/t,rinses wit,in =$ min/tes
-e+ore or a+ter re*/lar toot,-r/s,in*.
Alt,o/*, c,lor,e0idine may -e more e++ecti"e t,an any ot,er c/rrent antila?/e
a*ent and ,as a de+inite role in re"enti"e and control dental roced/res, it is not a
Fma*ic -/llet.F Its side effects and inade?/ate acti"ity ran*e somew,at limit its /se.
3ssential Oils
.isterine antisetic was t,e +irst O5C antila?/e and anti*in*i"itis mo/t, rinse to -e
aro"ed -y t,e ADA.
<&
)atients are ad"ised to rinse twice daily wit, >$ m. o+
.isterine +or =$ seconds, in addition to t,eir /s/al oral-,y*iene re*imen. .isterine ,as
-een /sed as a mo/t,rinse +or more t,an ::$ years. 5,e acti"e in*redients are thymol,
menthol, eucalyptol, and methyl salicylate, termed essential oils, 5,e ori*inal +orm/la
contains <9,H; alcohol, A +la"or "ariation o+ t,e rod/ct, Cool Mint .isterine
Antisetic, w,ic, also ,as recei"ed t,e ADA seal, contains >:.<E alco,ol.
Microor*anisms do not de"elo a resistance to t,e anti-acterial e++ects o+ essential
oils, s/c, as clo"e oil 7e/*enol8 and t,yme oil 7t,ymol8.
<'
In lon*-term clinical trials,
.isterine ,as -een s,own to reduce -ot, la?/e acc/m/lation and se"erity o+
*in*i"itis -y / to =&E.
<<
Micro-ial samlin* o+ la?/e in t,ese trials ,as
demonstrated no /ndesira-le s,i+ts in t,e comosition o+ t,e micro-ial +lora.
1ased on la-oratory testin*, more t,an >$$ *eneric "ersions o+ ori*inal .isterine ,a"e
also -een *ranted t,e ADA seal and are marketed /nder n/mero/s trade names. 5,ese
may -e +o/nd at t,e ADA we-site, www.ada.or*.
A recent st/dy e"al/ated t,e comarati"e e++icacy o+ .isterine and an
antila?/eBanti*in*i"itis denti+rice 7Col*ate 5otal8.
<%
4,en /sed in conA/nction wit, a
+l/oride denti+rice and /s/al oral ,y*iene, .isterine was reorted to ro"ide a *reater
-ene+it in red/cin* la?/e t,an did Col*ate 5otal.
As wit, c,lor,e0idine, rinsin* wit, an essential oil mo/t, rinse per se is /nlikely to
-e e++ecti"e in treatin* eriodontitis -eca/se t,e sol/tion does not reac, t,e det,s o+
t,e eriodontal ockets. Irri*ation st/dies, /sin* irri*ator tis desi*ned to deli"er
sol/tions s/-*in*i"ally, s/**est t,at .isterine and )eride0 may ,a"e some "al/e as
adA/ncts to mec,anical t,eray.
For t,e dental ro+essional, it may 4e important +or atients to /se a mo/t,rinse rior
to aerosol-*eneratin* roced/res. Unless an e++ecti"e dry-+ield tec,ni?/e is /sed, t,e
-acterial aerosol *enerated -y a ,i*,-seed t/r-ine in a =$-second eriod is ro/*,ly
e?/i"alent to t,e atient snee@in* in t,e dentistCs +ace.
<(
A st/dy -y 4yler and
coworkers
<;
+o/nd t,at e"en a reliminary water rinse temorarily red/ced t,e
-acterial aerosol o/lation -y <:E, -r/s,in* alone -y ('E, and an anti-acterial
mo/t,rinse -y ;%E. Fine and coworkers,
%$
/sin* a sim/lated o++ice "isit model,
s,owed t,at preprocedural /se o+ an antimicro-ial mo/t, rinse 7.isterine8 res/lted in
a ;=.<E red/ction in t,e n/m-er o+ "ia-le -acteria in a dental aerosol rod/ced -y
/ltrasonic scalin*. 5,e e++ect o+ t,is red/ction on act/al disease transmission ,as not
-een determined.
%:
Fl/oride !inses
5,e acti"e a*ents in o"er-t,e-co/nter +l/oride mo/t,rinse rod/cts are sodi/m
+l/oride 7NaF8 or acid/lated ,os,o+l/orides 7A)F8 at concentrations o+ $.$' and
$.&&E, resecti"ely. 5,e dose directions are :$ ml o+ rod/ct to -e /sed once daily,
)/-lis,ed lon*-term clinical st/dies ,a"e consistently s,own anticaries e++ecti"eness
e5ual or superior to +l/oride denti+rices. 5,e ADA we-site, www.ada.or*, c/rrently
lists se"en nonrescrition +l/oride-containin* mo/t,rinses t,at ,a"e recei"ed t,e
Seal o+ Accetance +or anticaries e++ecti"eness.
Question 4
A. Gersostomia mo/t,rinses are /s/ally +orm/lated to re"ent deminerali@ation and
romote reminerali@ation.
1. 5,e ADA ,as awarded its Seal o+ Accetance to a w,itener-containin* car-amide
ero0ide.
C. 5,e a*ent in cosmetic mo/t,rinses t,at oses t,e *reatest dan*er to >- to &-year-
old c,ildren is alco,ol.
D. C,lor,e0idine mo/t,rinses are most e++ecti"e w,en /sed immediately a+ter
-r/s,in*.
3. Fl/oride-containin* mo/t,rinses are not as e++ecti"e as +l/oride-containin*
denti+rices +or anticaries acti"ity.
Chewing Gum
1eca/se */m c,ewin* is leas/ra-le, eole normally c,ew +or lon*er eriods o+
time t,an t,ey send -r/s,in* t,eir teet,. .ikewise, */m may comlement
toot,-r/s,in* -y reac,in* many o+ t,e toot, s/r+aces commonly missed d/rin*
-r/s,in*. 5,e a"era*e American +ails to contact aro0imately &$E o+ toot, s/r+aces
d/rin* toot,-r/s,in*, esecially t,e osterior teet, and lin*/al s/r+aces. !e*/lar
toot,-r/s,in* remo"es only a-o/t =' to &$E o+ dental la?/e resent on toot,
s/r+aces. In addition, c,ewin* */m is esecially ad"anta*eo/s d/rin* t,e co/rse o+
t,e day w,en toot,-r/s,in* is not ossi-le or con"enient.
1ene+icial e++ects o+ */m c,ewin* incl/de increased saliva rod/ction res/ltin* in t,e
mec,anical remo"al o+ dental la?/e and de-ris. St/dies ,a"e s,own t,at c,ewin*
s/*ared or s/*ar-+ree */m is an e++ecti"e means o+ red/cin* la?/e acc/m/lation and
t,at */m c,ewin* can also e++ecti"ely red/ce esta-lis,ed la?/e on many toot,
s/r+aces 7see Aendi0 <-=8.
Since :;;%, t,ree maAor re"iew articles de"oted solely to c,ewin* */m and otential
oral ,ealt, -ene+its ,a"e -een /-lis,ed.
%>-%&
5,e interest o+ researc,ers in e++ecti"e
*/m additi"es co/led wit, t,e accetance and /se o+ c,ewin*-*/m rod/cts -y t,e
*eneral /-lic makes t,is a new and otentially imortant cate*ory to -e considered
-y dental ro+essionals. In :;;;, t,e worldwide c,ewin*-*/m market was estimated
to -e '<$,$$$ tons er year, or aro0imately ' -illion U.S. dollars.
%&
D/rin* */m c,ewin*, sali"ary +low rates increase, esecially in t,e +irst +ew min/tes,
-eca/se o+ 4oth mechanical and $ustatory stimulation, Increased sali"ary stim/lation
can contin/e +or eriods o+ > to <: minutes, /s/ally /ntil t,e +la"or7s8 in t,e rod/ct
dissiates. Howe"er, e"en wit, /n+la"ored c,ewin* */m, sali"a +low, as e"idenced -y
swallowin* rates, increase o"er -aseline.
%'
5,e -ene+icial e++ects o+ additional sali"a
in t,e mo/t, incl/de increased 4uffer capacity and mineral super saturation, -ot, o+
w,ic, ,el re*/late or increase la?/e H, and increase la?/e calci/m le"els
7Ca8.
%<
In addition, increased sali"a +low can assist in loosenin* and remo"in* de-ris
+rom occl/sal or interro0imal sites, and can -e -ene+icial to 0erostomia atients.
5,e +oc/s o+ c,ewin* */m researc, to date ,as -een on Fs/*ar-+reeF rod/cts,
%%
w,ic,
contain olyol sweeteners s/c, as sor4itol or xylitol, 5,ese sweeteners are not -roken
down -y la?/e or oral microor*anisms to rod/ce acid. )la?/e H st/dies ,a"e
doc/mented red/ction o+ la?/e acidity and maintenance o+ la?/e ne/trality -ot,
d/rin* and, wit, 0ylitol, +or eriods o+ > to = weeks +ollowin*, */m c,ewin*.
%=
In
addition, */ms containin* 0ylitol ,a"e s,own anticaries acti"ity in se"eral lon$2term
studies,
%=
C,ewin* a sor4itol24ased che3in$ $um a+ter meals si*ni+icantly reduced
dental caries incidence in a t,ree-year st/dy.
%(
St/dies
%;
,a"e s,own t,at a commercial c,ewin* */m containin* 'E sodi/m
-icar-onate 7Arm and Hammer Dental Care8 is caa-le o+ remo"in* si*ni+icant
amo/nts o+ la?/e and red/cin* *in*i"itis w,en /sed as an adA/nct to re*/lar
toot,-r/s,in*. Stain remo"al is also o+ interest to t,e cons/mer. St/dies sim/latin* a
realistic sit/ation 7twice-daily -r/s,in* and /ns/er"ised /se o+ a -akin* soda
c,ewin* */m8 demonstrated reduction in stain a+ter +o/r weeks.
%;
Cons/mers ,a"e relied on c,ewin*-*/m rod/cts +or F+res, -reat,.F A recent reort
on red/cin* "olatile s/l+/r como/nds associated wit, oral malodor and or*anoletic
scores indicates t,at t,e rod/cts tested are e++ecti"e rimarily as maskin* a*ents
7+la"or8 and +or t,e mec,anical role in cleanin* toot, s/r+aces. !ed/ced malodor
le"els were o-tained d/rin* initial /se o+ t,e rod/cts, -/t decreased to -aseline le"els
at t,e t,ree-,o/r assessment times.
($
!eynolds
(:
,as roosed t,e introd/ction o+ casein phosphopeptide to c,ewin* */m
as a mec,anism to reminerali1e early cario/s lesions. In sit/ st/dies aear
romisin*.
(>
5rident Ad"anta*e, wit, !ecaldent, makes /se o+ t,is tec,nolo*y.
An o"er"iew o+ selected a*ents added to c,ewin* */ms is resented in Aendi0 <-=.
Como/nds s/c, as c,lor,e0idine and +l/orides wo/ld aear to -e /se+/l w,en
deli"ered /sin* c,ewin* */m as t,e "e,icle, since t,ere wo/ld -e a minim/m o+
otentially inter+erin* a*ents in t,e */m rod/ct 7comared to a-rasi"es in denti+rices
and water and alco,ol "e,icles in mo/t,rinses8, as well as a s/stained time o+ release
and a"aila-ility in t,e oral ca"ity. In addition, t,e acti"e a*ents wo/ld -e a"aila-le at
occl/sal sites, w,ic, are rime areas +or la?/e *rowt, and it and +iss/re decay.
Neit,er o+ t,ese a*ents is a"aila-le in t,e United States. Since c,ewin*-*/m rod/cts
are o+ten in t,e mo/t, se"eral times a day, t,e concentration o+ in*redients released
7esecially +l/oride8 must 4e safe for s3allo3in$,
Question 5
A. Sali"a +low rates increase w,ile /sin* c,ewin* */m.
1. An increased sali"a +low wo/ld ,el dil/te any acids in t,e la?/e.
C. Gylitol and sor-itol +la"orin* o+ c,ewin* */m is ideal -eca/se -ot, are
anticario*enic.
D. A c,ewin* */m wit, 'E sodi/m -icar-onate ,as -een demonstrated to red/ce
stain and red/ce *in*i"itis.
3. Casein ,os,oetide aears to -e a romisin* a*ent in c,ewin* */m +or
en,ancin* reminerali@ation.
Summary
5,e sel+-/se o+ denti+rices and mo/t,rinses is ro"in* to -e an imortant re"enti"e
dentistry meas/re.
Denti+rices, mo/t,rinses, and c,ewin* */ms can -e cate*ori@ed as eit,er cosmetic or
t,erae/tic. Cosmetic rod/cts ,a"e traditionally -een /sed to remo"e de-ris, ro"ide
a leasant Fmo/t, +eel,F and temorarily red/ce ,alitosis. 5o imro"e on t,eir
marketa-ility, +la"ors, stries, srinkles, and colors ,a"e -een added to denti+rices and
mo/t,rinses. !ecently, ot,er in*redients ,a"e also -een added to temorarily deress
t,e oral -acterial o/lation or to re"ent or moderate some disease rocess in t,e
mo/t,.
5,e widesread /se o+ t,erae/tic +l/oride denti+rices and mo/t,rinses is credited
wit, ,elin* to red/ce t,e worldwide re"alence o+ dental decay. All rod/cts
carryin* t,e ADA Seal also contain +l/oride.
Ot,er a*ents are now -ein* /sed to tar*et ot,er oral-,ealt, ro-lems.
5,e Food and Dr/* Administration ,as de"eloed ri*id */idelines +or testin* t,e
sa+ety and e++icacy o+ rod/cts rior to t,eir introd/ction on t,e market. )art o+ t,e
+/nction o+ t,e re*/latory rocess is to di++erentiate -etween rod/cts w,ose otential
risks are s/++iciently low to allow t,em to -e sold o"er t,e co/nter and t,ose w,ose
ossi-le ,a@ards A/sti+y restriction to rescrition /se.
4,ile t,e ADA considers antila?/e, anticalc/l/s, and -reat,-+res,enin* claims as
cosmetic, t,ey will re"iew data and allow man/+act/rers to make t,ese statements, i+
co/led wit, a disease related acti"ity 7e.*., re"ents *in*i"itis or caries8. 5oot,astes
containin* otassi/m nitrate, stronti/m c,loride, and sodi/m citrate ,a"e
anti,yersensiti"ity roertiesD ot,er toot,astes wit, tetrasodi/m ,os,ate and
disodi/m di,ydro*en yro,os,ate retard t,e +ormation o+ calc/l/s. C,lor,e0idine
is a ,i*,ly e++ecti"e antila?/e, anti*in*i"itis a*ent, acceted -y t,e ADA, -/t wit,
si*ni+icant side e++ects and may only -e disensed on rescrition. .isterine,
containin* essential oils, ,as -een o/lar +or o"er a cent/ry, and ,as demonstrated
t,e same roerties -/t wit,o/t t,e side e++ects o+ c,lor,e0idine. More t,an >$$
*eneric "ersions o+ .isterine, containin* essential oils, ,a"e -een acceted -y t,e
ADA +or la?/e and *in*i"itis claims.
C,ewin* */m rod/cts are a new dental cate*ory in w,ic, man/+act/rers are makin*
claims +or cosmetic and t,erae/tic e++ecti"eness. At t,is time, neit,er t,e ADA nor
t,e FDA ,as aro"ed any c,ewin* */m rod/cts +or dental t,erae/tic claims.
:. A, C, and DCorrect
1incorrect. 5,e r/lin*s -y t,e FDA ,a"e t,e +orce o+ lawD t,e r/lin*s -y t,e ADA
are ad"isory to t,e ro+ession and /-lic.
3incorrect. All actions to sec/re t,e Seal o+ Aro"al are "ol/ntary. 5,e
man/+act/rer is not committed to aly +or it, or to /se it in ad"ertisin*. Howe"er, to
/se it +or marketin* /roses is to t,e ad"anta*e o+ any man/+act/rer ,a"in* recei"ed
it.
>. A, 1, C, D, and 3correct.
=. 1, C, and Dcorrect.
Aincorrect. Under some circ/mstances, it is ossi-le t,ey are incomati-le.
Howe"er, t,e +act t,at t,ere is now a denti+rice called Mentadent is roo+ t,at
ero0ide, -akin* soda, and +l/oride can -e comati-le.
3incorrect. !emem-er, t,e ADA awards t,e Seal o+ Accetance +or t,erae/tic
rod/cts, and not +or cosmetic a*ents. Calc/l/s is considered a cosmetic -li*,t.
&. A, Ccorrect.
1incorrect. 5,is is anot,er e0amle o+ t,e ADA olicy o+ not awardin* t,e Seal o+
Accetance +or a cosmetic rod/ct.
Dincorrect. Since c,lor,e0idine is inacti"ated -y most denti+rice s/r+actants, a
eriod o+ a-o/t =$ min/tes s,o/ld elase -etween toot,-r/s,in* and c,lor,e0idine
mo/t,rinsin*.
3incorrect. 5,e +l/oride mo/t,rinses are ro-a-ly -etter t,an +l/oride denti+rices,
ossi-ly -eca/se t,ey allow -etter access to caries-rone interro0imal locations.
'. A, 1, C, D, and 3correct.
:. Name at least +o/r toot, and */m conditions +or w,ic, +orm/las ,a"e -een
de"eloed to ,el re"ent or control9 iiiiiiiiii, iiiiiiiiii, iiiiiiiiii and
iiiiiiiiii.
>. 5,e iiiiiiiiiiii is t,e name o+ t,e award *i"en -y t,e ADA to dental
man/+act/rers w,o ,a"e reared a t,erae/tic rod/ct t,at is sa+e and e++icient.
=. 5,ere are t,ree le"els o+ concern +or t,e sa+ety and e++iciency o+ rescrition and
o"er-t,e-co/nter dental rod/cts. 5,e *o"ernment le"el incl/des t,e Food and Dr/*
administration and t,e iiiiiiiiiiD t,e second le"el is "ol/ntary ro+essional
o"ersi*,t ass/med "ol/ntarily -y t,e iiiiiiiiii, w,ile t,e t,ird le"el is -y
iiiiiiiiii ad"ocates.
&. 5,e two mo/t,rinses *ranted t,e Seal o+ Accetance -y t,e ADA as antila?/e and
anti*in*i"itis are iiiiiiiiii and iiiiiiiiii.
'. 5wo +actors t,at can decrease or en,ance t,e a-rasi"eness o+ a toot,aste are9
iiiiiiiiii and iiiiiiiiii.
<. 5,e di++erence -etween an a-rasi"e and a olis,in* a*ent is iiiiiiiiiiD w,en t,e
two are mi0ed to*et,er, t,ey constit/te an iiiiiiiiii.
%. 5,e t,ree +l/oride como/nds most /sed in +l/oride denti+rices are iiiiiiiiii,
iiiiiiiiii, and iiiiiiiiii.
(. 5,ree roerties o+ a denti+rice or a mo/t,rinse t,at do not contri-/te to t,e
t,erae/tic or cosmetic e++ects, -/t m/st -e considered -eca/se o+ marketin*
necessities are iiiiiiiiii, iiiiiiiiii, and iiiiiiiiii.
;. 5,e a*ent added to a toot,aste +orm/la to reser"e t,e moist/re is called a
iiiiiiiiii.
:$. A toot,aste +orm/la w,ere t,e e++ecti"e a*ent is solely -akin* soda is a
7cosmetic87t,erae/tic8 denti+rice.
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anti-acterial acti"ity o+ c,lor,e0idine adsor-ed to teet,. " Periodontol, &(9<&<-&;.
''. !olla, G., .oe, H., g Sc,iott, C. !. 7:;%$8. 5,e a++inity o+ c,lor,e0idine +or
,ydro0yaatite and sali"ary m/cins. " Periodont Res, '9;$-;'.
'<. Hankell, S. .., Moreno, O. M., Sa++ir, A. #., .owary, !. .., g Gold, 4. 7:;(>8.
3++ects o+ c,lor,e0idine and +o/r antimicro-ial como/nds on la?/e *in*i"itis and
stainin* in -ea*le do*s. " Dent Res, <:9:$(;-;=.
'%. A0elson, )., g .ind,e, #. 7:;(%8. 3++icacy o+ mo/t,rinses in in,i-itin* dental
la?/e and *in*i"itis in man. " Clin Periodontol, :&9>$'-:>.
'(. 4ieder, S. G., Newman, H. N., g Stra,an, #. D. 7:;(=8. Stanno/s +l/oride and
s/-*in*i"al c,lor,e0idine irri*ation in t,e control o+ la?/e and c,ronic eriodontitis.
" Clin Periodontol, :$9:%>-(:.
';. 3riksen, H., g GAermo, ). 7:;%=8. Incidence o+ stained toot, s/r+aces in st/dents
/sin* c,lor,e0idine-containin* denti+rices. Scand " Dent Res, (:9'==-=%.
<$. Flotra, .., GAermo, )., !olla, G., g 4aer,a/*, #. 7:;%:8. Side e++ects o+
c,lor,e0idine mo/t, was,es. Scand " Dent Res, %;9::;->'.
<:. .oe, H., Mandell, M., Derry, A., g Sc,iott, C. 7:;%:8. 5,e e++ect o+ mo/t,rinses
and toical alication o+ c,lor,e0idine on calc/l/s +ormation in man, " Periodontol
Res, <9=:>-:&.
<>. Mo*,adam, 1. 2. H., Drisko, C. .., g Gier !. 3. 7:;;:8. C,lor,e0idine
mo/t,was,-ind/ced +i0ed dr/* er/tion. +ral Sur$, +ral %edicine, +ral Path,
%:9&=:-=&.
<=. Sko*l/nd, .. A., g Holst, 3. 7:;(>8. Des?/amati"e m/cosal reactions d/e to
c,lor,e0idine *l/conate. /nt " +ral Sur$, ::9=($-(>.
<&. American Dental Association 7:;((8. Co/ncil on Dental 5,erae/tics accets
.isterine. "D, ::%9':'-:%.
<'. Meeker, H. G., g .inke, H. A. 1. 7:;((8. 5,e anti-acterial action o+ e/*enol,
t,yme oil, and related essential oils /sed in dentistry. Comp Cont !duc Dent, ;9=>-
&$.
<<. Menaker, .., 4eat,er+ord, 5. 4., )itts, G., !oss, N. M., g .amm, !. 7:;%;8. 5,e
e++ects o+ .isterine antisetic on dental la?/e. la " %ed Sci, :<9%:-%%.
<%. C,arles, C., S,arma, N., Gal/stians, H., McG/ire, A., g 6incent, #. 7>$$:8.
Comarati"e e++icacy o+ an antisetic mo/t,rinse and an antila?/eBanti*in*i"itis
denti+rice, A si0-mont, trial. "D, :=>9<%$-%'.
<(. Miller, !. .., g Micik, !. 3. 7:;%(8. Air oll/tion and its control in t,e dental
o++ice. Dent Clin &orth m, >>9&'=-%<.
<;. 4yler, D., Miller, !., g Micik, !. 7:;;$8. 3++icacy o+ sel+-administered
reoerati"e oral ,y*iene roced/res in red/cin* t,e concentration o+ -acteria in
aerosols *enerated d/rin* dental roced/res. " Dent Res, '$9'$;.
%$. Fine, D., Hi, #., F/r*an*, D., 1arnett, M. .., Ols,an, A. M., g 6incent, #. 7:;;=8.
!ed/cin* -acteria in dental aerosols9 )re-roced/ral /se o+ an antisetic mo/t,rinse.
"D, :>&9'<-'(.
%:. Molinari, #., g Molinari, G. 7:;;>8. Is mo/t,rinsin* -e+ore dental roced/res
wort,w,ilee "D, :>=9%'-($.
%>. Itt,a*ar/n, A., g 4ei, S. H. 7:;;%8. C,ewin* */m and sali"a in oral ,ealt,. "
Clin Dent, (9:';-<>.
%=. 3d*ar, 4. M. 7:;;(8. S/*ar s/-stit/tes, c,ewin* */m and dental cariesa
re"iew. #rit Dent ", :(&9>;-=>.
%&. Im+eld, 5. 7:;;;8. C,ewin* */m+acts and +iction9 a re"iew o+ */m c,ewin* and
oral ,ealt,. Crit Rev +ral #iol %ed, :$9&$'-:;.
%'. Hankell, S. .., g 3mlin*, !. C. 7:;;;8. Clinical e++ects on la?/e H, Ca and
swallowin* rates +rom c,ewin* a +la"ored or /n+la"ored c,ewin* */m. " Clin Dent,
:$9(<-((.
%<. 2oarol, 3., 3rt/*r/l, F., g Sa-a,, 3. 7>$$$8. 3++ect o+ */m c,ewin* on la?/e
acido*enicity. " Clin Pediatric Dent, >&9:>;-=>.
%%. 3d*ar, 4. M. 7:;;;8. FA role +or s/*ar +ree */m in oral ,ealt,.F " Clin Dent,
:$9(;-;=.
%(. 1eiswan*er, 1. 1., 1oneta, A. 3., Ma/, M. S., 2at@, 1. )., )roskin, H. M., g
Stookey, G. 2. 7:;;(8. 5,e e++ect o+ c,ewin* s/*ar-+ree */m a+ter meals on clinical
caries incidence. "D, :>;9:<>=-><.
%;. Compend Contin !duc Dent, Sec Iss %, >$$:, >> no. %-A9:-'>.
($. !ein*ewirt@, H., Gira/lt, O., !ein*ewirt@, N., Sen*er, 1., g 5anen-a/m, H.
7:;;;8. Mec,anical e++ects and "olatile s/l+/r como/nd-red/cin* e++ects o+ c,ewin*
*/ms9 comarison -etween test and -ase */ms and a control *ro/. Euintessence /nt,
=$9=:;->=.
(:. !eynolds, 3. C., 1lack, C. .., Cai, F., Cross, 2. #., 3akins, D., H/?, N. ..,
Mor*an, M. 6., Nowicki, A., )eric,, #. 4., !iley, ). F., S,en, )., 5al-o, G., g
4e--er, F. 7:;;;8. Ad"ances in enamel reminerali@ation9 casein ,os,oetide-
amor,o/s calci/m ,os,ate. " Clin Dent, :$9(<-((.
(>. S,en, )., Cai, F., Nowicki, A., 6incent, #., g !eynolds, 3. C. 7>$$:8.
!eminerali@ation o+ enamel s/-s/r+ace lesions -y s/*ar-+ree c,ewin* */m containin*
casein ,os,oetide-amor,o/s calci/m ,os,ate. Acceted +or /-lication. "
Dent Res, ($9>$<<-%$.
reser"ed.
Chapter 7. Oral Health Self-Care Supplemental Measures to
Complement Toothbrushing - Terri S, /, Tilliss "anis 0, )eatin$
Objectives
:. 30lain t,e reasons w,y s/lemental oral ,ealt, sel+-care is needed to
comlement toot,-r/s,in*.
>. Identi+y +actors, in addition to oral conditions, t,at in+l/ence selection o+
s/lemental oral ,y*iene de"ices and tec,ni?/es.
=. State t,e /roses, indications, contraindications, tec,ni?/es, ad"anta*es, and
limitations o+ t,e +ollowin* oral ,y*iene de"ices9
Dental +loss,
Dental +loss ,older,
Dental +loss t,reader,
4ooden or lastic trian*/lar stick,
5oot,icks and ,older,
Interro0imal -r/s, or de"ices,
5on*/e cleaners,
Ot,ers9 yarn, r/--er or lastic ti, *a/@e, a/tomated interro0imal de"ices.
&. #/sti+y t,e /rose and e0lain tec,ni?/es +or t,e /se o+ mo/t,rinses and oral
irri*ators.
'. Descri-e roer oral ,y*iene sel+-care +or dental imlants.
<. 30lain roer oral ,y*iene sel+-care +or remo"a-le artial and +/ll dent/res.
Introduction
S/lemental la?/e remo"al meas/res -eyond toot,-r/s,in* are necessary in order
to t,oro/*,ly remo"e la?/e.
:,>,=
Alt,o/*, toot,-r/s,in* can -e e++ecti"e at remo"in*
t,e la?/e residin* on -/ccal and lin*/al asects o+ teet,, it is *enerally ine++ecti"e
+or interro0imal s/r+aces.
&,'
5,ere are n/mero/s intraoral sites and conditions -etter
ser"ed -y la?/e remo"al met,ods and de"ices ot,er t,an toot,-r/s,in*. 30amles o+
t,ese sites incl/de, +i0ed rost,eses, crown mar*ins, +/rcations o+ m/ltirooted teet,,
ort,odontic aliances, t,e ton*/e, imlants, and dent/res.
Interro0imal asects o+ teet, are not "ery accessi-le +or t,e remo"al o+ la?/e -y t,e
toot,-r/s,.
:
5,ese sites ,a"e consistently -een s,own to ,ar-or ,i*, amo/nts o+
la?/e.
<-(
!e*/lar interro0imal la?/e remo"al is recommended +or t,e +ollowin*
reasons9
Incomlete la?/e remo"al can increase t,e rate and *rowt, o+ new la?/e.
;
Allowin* la?/e to remain on some toot, s/r+aces can +acilitate de"eloment o+ a
comle0 micro+lora on ot,er cleaned s/r+aces.
:$,::
Indi"id/als w,o clean interro0imally on a daily -asis ,a"e less la?/e and
calc/l/s.
:>
Interro0imal la?/e remo"al is -ene+icial +or re"entin* *in*i"al and eriodontal
in+ections as well as +or red/cin* or eliminatin* diseases in t,ese so+t tiss/es.
:,:=,:&
5,ere is interro0imal site redilection +or *in*i"itis, eriodontitis, and caries.
:,:',:<
)re"ention o+ dental caries can -e +acilitated -y e++ecti"e daily interro0imal la?/e
remo"al.
:%
5,e dentition or eriodontal tiss/es can -e altered as a res/lt o+ disease, reair, or
+rom arc,itect/ral tiss/e c,an*es +ollowin* t,eray. 4,en t,is occ/rs, a de"ice
andBor tec,ni?/e m/st -e introd/ced to accommodate t,ese c,an*es. It ,as -een
s,own t,at s/ra*in*i"al la?/e remo"al in+l/ences s/-*in*i"al la?/e comosition,
,owe"er, la?/e remo"al e++orts s,o/ld e0tend as +ar s/-*in*i"ally as ossi-le.
:$,::,:(
5o determine t,e most aroriate rod/cts and ractices +or interro0imal la?/e
remo"al t,e Process of Care %odel is /se+/l 7Fi*/re %-:8. 5,is treatment model is
descri-ed in detail in t,e te0t-ook, Dental Hy$iene Theory and Practice.
:;
5,e oral
,ealt, ro+essional m/st care+/lly assess n/mero/s oral ,ealt, and disease risk
+actors. 5,ese incl/de c/rrent oral sel+-care ractices, and ast and c/rrent oral ,ealt,
stat/s. 5,e imortance o+ t,is assessment ,ase cannot -e o"erem,asi@ed. D/rin*
t,e dia$nosis and plannin$ ,ases, t,e risk +actors and t,e aroriate oral sel+-care
rod/cts and roced/res to address t,ese risks are Aointly determined wit, t,e
indi"id/al. 5,e oral ,ealt, ro+essional can t,en aly t,eory--ased ed/cational and
moti"ational strate*ies d/rin* t,e implementation ,ase to +acilitate -e,a"ioral
c,an*e. 3ns/rin* t,at s/c, -e,a"ioral c,an*es are consistent wit, t,e li+estyle o+ t,e
indi"id/al will increase t,e otential +or lon*-term comliance o+ oral sel+-care
ractices. 5,e evaluation ,ase +oc/ses /on o/tcomes to determine w,et,er
modi+ications to t,e oral ,y*iene strate*ies are indicated. Contin/ation or c,an*e o+
an oral ,y*iene re*imen is -ased /on t,e e"al/ation o+ tiss/e ,ealt,. 5,e e"al/ation
rocess is contin/o/s o"er t,e li+esan as t,e dentition and so+t tiss/es may -ecome
altered wit, time.
A ersonali@ed oral ,y*iene re*imen will -est meet t,e needs o+ t,e indi"id/al. 4,en
emloyin* an interro0imal cleanin* tec,ni?/e, a systematic aroac, +ollowin*
rescri-ed tec,ni?/es will en,ance la?/e remo"al wit,o/t ca/sin* so+t tiss/e
dama*e. 5,e oral ,y*iene sel+-care recommendations, w,ic, ,a"e -een a*reed /on
-y t,e indi"id/al and t,e oral ,ealt, care ro"ider, are doc/mented in t,e dental c,art
and modi+ied as necessary at s/-se?/ent re-care "isits. 5,is tye o+ doc/mentation
allows +or contin/ity o+ care.
Fi*/re %-: ),ases o+ t,e )rocess o+ Care Model
Oral Health Self-Care
Sel+-care incl/des all acti"ities and decisions o+ an indi"id/al to re"ent, dia*nose, or
treat ersonal ill ,ealt,. 5,is concet as alied to care o+ t,e oral ca"ity is re+erred to
as oral sel+-care or oral ,ealt, sel+-care, relacin* earlier terms s/c, as ersonal
la?/e control, ,ome care, and oral ,ysiot,eray. One rimary /rose o+ oral
,ealt, sel+-care is to re"ent or arrest eriodontal disease and caries -y red/cin*
la?/e acc/m/lation.
'
.ess t,an otimal oral sel+-care is re*arded as a maAor risk
+actor +or eriodontal disease. In order to determine t,e most aroriate sel+-care
ractices +or eac, indi"id/al, a "ariety o+ +actors m/st -e assessed9
)resence o+ *in*i"al in+lammation and -leedin*,
Alterations o+ t,e interdental *in*i"al arc,itect/re ca/sed -y toot, ali*nment,
sacin*, recession, and lack o+ attac,ed tiss/e,
Malali*nment o+ teet, and toot, mor,olo*y,
Con+i*/ration o+ em-ras/re saces,
30tent and location o+ la?/e and calc/l/s acc/m/lation,
Caries e0erience and s/sceti-ility,
3"idence and risk +actors +or eriodontal diseases,
5ra/ma +rom imroer /se o+ oral-,y*iene de"ices,
C/rrent oral sel+-care ractices and le"el o+ man/al de0terityBmental caacity,
Comliance otential, and
)resence, con+i*/ration, and condition o+ restorations.
5,ere is no /ni"ersally acceted oral ,y*iene de"ice. 5,e aroriate oral ,y*iene
re*imen is determined accordin* to t,e dictates o+ t,e oral condition, ersonal
re+erences, de0terity, and li+estyle.
:<
Ade?/ate instr/ction in t,e /se o+ any
recommended de"ice m/st -e ro"ided.
Additional Considerations: Plaque and Caries
Utili@in* an evidence24ased aroac, to /nderstand oral disease, se"eral concl/sions
can -e drawn. .ittle data s/orts t,e t,eory t,at interro0imal la?/e remo"al alone
red/ces t,e incidence o+ caries. One reason +or t,is is t,at t,e /-i?/ito/s /se o+
+l/oride makes it di++ic/lt to searate o/t t,e -ene+its o+ +l/oride +rom t,at o+
interro0imal la?/e remo"al. One st/dy did demonstrate t,at interro0imal caries
co/ld -e re"ented w,en daily interro0imal +lossin* is er+ormed -y an oral ,ealt,
ro+essional.
:%
Howe"er, ot,er st/dies o+ s/er"ised sel+-er+ormed interro0imal
cleanin* were /na-le to demonstrate a caries red/ction.
>$->=
5,ere are se"eral st/dies
doc/mentin* t,e correlation -etween t,e *eneral le"el o+ mec,anical la?/e remo"al
and t,e incidence o+ caries.
>&-><
It aears t,at only a "ery ,i*, le"el o+ ersonal
mec,anical la?/e remo"al imacts t,e caries rate. 5,is le"el is di++ic/lt +or t,e
a"era*e erson to s/stain.
>%
Conse?/ently, +l/orides and dietary car-o,ydrate control
s,o/ld -e em,asi@ed, in addition to interro0imal la?/e remo"al +or otimal e++ect
on t,e caries rate.
Plaque and Gingivitis
It ,as -een s,own t,at remo"in* la?/e once e"ery &( ,o/rs is s/++icient to red/ce
micro-ial la?/e acc/m/lations t,at are mat/re eno/*, to ind/ce *in*i"al
in+lammation.
<,>(
For t,ose wit, e0istin* in+lammation or eriodontitis, e"ery &( ,o/rs
is not +re?/ent eno/*,.
:
Under t,ese conditions it ,as -een s,own t,at coloni@ation
and mat/ration o+ la?/e occ/rs more raidly in t,e resence o+, t,an in t,e a-sence
o+ in+lammation.
&,<,>;,=$
Frequency of Plaque Removal
5,e recedin* in+ormation descri-in* t,e relations,i -etween la?/e and caries and
la?/e and *in*i"itis, s/**ests t,at t,e otimal +re?/ency +or mec,anical la?/e
remo"al is not recisely known. 1ased on t,e one st/dy correlatin* caries wit, daily
+lossin*,
:%
it seems ad"isa-le to remo"e interro0imal la?/e at least once e"ery >&
,o/rs +or caries re"ention. .ikewise, t,e e"idence--ased aroac, s/**ests t,at
t,ose wit, an e0istin* *in*i"itis or eriodontitis s,o/ld remo"e interro0imal la?/e
on a daily -asis. Howe"er, t,ose wit, ,ealt,y *in*i"a may -e a-le to ractice
interro0imal la?/e remo"al only once e"ery &( ,o/rs. 5,ere+ore, wit, more daily
attemts at la?/e remo"al, it is more likely t,at t,e additi"e e++orts will ma0imi@e
t,e remo"al o+ la?/e. Since t,e ideal +re?/ency o+ interro0imal la?/e remo"al ,as
not -een s,own, indi"id/al +actors s/c, as t,e amo/nt o+ in+lammation, caries
s/sceti-ility, la?/e remo"al e++iciency, and acc/m/lation and "ir/lence o+ la?/e
m/st -e considered in t,e recommendation.
Interestin*ly, alt,o/*, ;&E o+ oral ,ealt, ro+essionals and researc,ers attendin* a
symosi/m on mec,anical la?/e remo"al -elie"ed interro0imal cleanin* was an
essential comonent o+ a s/ccess+/l oral sel+-care ro*ram, only ':E -elie"ed it was
needed on a daily -asis. Only %%E ercent +elt t,at interro0imal cleanin* s,o/ld -e
ad"ised +or t,e w,ole dentate o/lation rat,er t,an A/st +or t,ose deemed s/sceti-le
to eriodontal disease and caries.
=:
Determinin* t,e risk +actors t,at increase oneCs
s/sceti-ility to caries and eriodontal diseases co/ld identi+y w,ic, indi"id/als are
in need o+ consistent interro0imal cleanin*, and at w,at +re?/ency.
S/er"ised oral sel+-care ractice sessions romote roer /tili@ation o+ oral ,y*iene
de"ices -y ro"idin* an oort/nity to monitor tec,ni?/e. AdA/stment o+ tec,ni?/e
can ma0imi@e la?/e remo"al w,ile minimi@in* tiss/e dama*e. A+ter s/c, instr/ction
and rein+orcement, s/ccess in oral ,ealt, meas/res /ltimately rests wit, t,e
indi"id/al. )rinciles o+ learnin* and moti"ation s,o/ld -e alied to enco/ra*e
comliance 7see C,ater :<8.
Question 1
A. S/lemental la?/e remo"al is /se+/l +or indi"id/als wit, ort,odontic aliances.
1. )la?/e allowed to remain on interro0imal s/r+aces will not imact la?/e
acc/m/lations on clean s/r+aces.
C. 5,e )rocess o+ Care Model -e*ins wit, t,e e"al/ation ,ase.
D. Sel+-care as it relates to ,ealt, incl/des all acti"ities and decisions indi"id/als
make a-o/t t,eir ,ealt,.
3. A lar*e -ody o+ researc, s/orts t,e t,eory t,at interro0imal la?/e remo"al
alone red/ces t,e incidence o+ caries.
Dental Floss
Dental +loss is -est indicated +or la?/e and de-ris remo"al +rom 5ye I em-ras/res
w,ere t,e ailla +ills t,e interro0imal sace and t,e teet, are in contact. For 5ye II
and III em-ras/res, de"ices ot,er t,an +loss may -e more e++ecti"e in remo"in*
la?/e
=>,==
7Fi*/re %->8. 3++ecti"e /se o+ dental +loss accomlis,es t,e +ollowin*
o-Aecti"es.
:. !emo"es la?/e and de-ris t,at ad,eres to t,e teet,, restorations, ort,odontic
aliances,
=&
+i0ed rost,eses and ontics,
='
*in*i"a in t,e interro0imal em-ras/res,
=<
and aro/nd imlants.
=%,=(
>. Aids t,e clinician in identi+yin* t,e resence o+ interro0imal calc/l/s deosits,
o"er,an*in* restorations, or interro0imal cario/s lesions.
=. May arrest or re"ent interro0imal cario/s lesions.
:%
&. !ed/ces *in*i"al -leedin*.
:,=;
'. May -e /sed as a "e,icle +or t,e alication o+ olis,in* or c,emot,erae/tic
a*ents to interro0imal and s/-*in*i"al areas.
=;
Not all interro0imal contact areas, w,et,er nat/ral or restored, ,a"e t,e same
con+i*/ration. Conse?/ently, se"eral tyes o+ +loss are a"aila-le to accommodate
t,ese di++erences. 5,ese "ary +rom t,in /nwa0ed "arieties, to t,icker wa0ed taes and
incl/de "aria-le t,ickness +loss 7Fi*/re %-=8. Clinical trials ,a"e s,own no si*ni+icant
di++erences in t,e cleansin* a-ility -etween wa0ed and /nwa0ed +loss.
:
4a0 resid/e
,as not -een +o/nd on toot, s/r+aces cleaned wit, wa0ed +loss.
&$
Unwa0ed +loss is +re?/ently recommended -eca/se it is t,in and slis easily t,ro/*,
ti*,t contact areas. Howe"er, /nwa0ed +loss can +ray and tear w,en contactin* rotated
teet,, ,ea"y calc/l/s deosits, or de+ecti"e and o"er,an*in* restorations. Fre?/ent
+loss -reaka*e may disco/ra*e contin/ed /se. For t,ese conditions, wa0ed, li*,tly
wa0ed, or s,red-resistant +loss are recommended.
4a0ed dental tae, /nlike ro/nd dental +loss, is -road and +lat, and may -e e++ecti"e
in an interro0imal sace wit,o/t ti*,t contact oints. Additional tyes o+ +loss, s/c,
as t,ose made o+ olytetra+l/oroet,ylene 7)5F3, te+lon-like8, are stron*er and more
s,red-resistant. 5,ey ,a"e -een s,own to -e re+erred -y t,ose w,o ,a"e ti*,t
contacts or ro/*, ro0imal toot, s/r+aces.
&:
Ot,er "arieties, s/c, as t/+ted +loss
increments alternated wit, standard +loss, and +loss w,ic, stretc,es +or insertion are
alternati"es.
Some -rands o+ dental +loss and tae are colored and +la"ored. In addition to
increased aeal, color ro"ides a "is/al contrast to la?/e and oral de-ris, t,/s
ena-lin* one to see w,at is -ein* remo"ed, ossi-ly increasin* t,e moti"ation to
+loss. One st/dy indicated a /ser re+erence +or wa0ed o"er /nwa0ed +loss and mint-
+la"ored wa0ed +loss o"er lain wa0ed +loss.
&>
Flosses imre*nated wit, a "ariety o+
a*ents ,a"e -een introd/cedD e0amles o+ t,ese incl/de +loss treated wit, -akin*
soda, +l/oride, ,er-al e0tracts, antimicro-ial a*ents, or a-rasi"es +or w,itenin*.
Fl/oride-imre*nated +loss ,as -een mar*eted -/t lacks e++icacy data +or a++ectin* t,e
caries rate.
One tye o+ "aria-le-t,ickness +loss ,as a sti++ end to allow +or t,readin* /nder
-rid*es, -eneat, ti*,t contact areas, /nder ontics, t,ro/*, e0osed +/rcations, and
aro/nd ort,odontic wires 7Fi*/re %-&8. 5,is +loss com-ines a section o+ /nwa0ed +loss
wit, an area o+ t,icker nylon mes,work to clean lar*er s/r+ace areas. 6aria-le
t,ickness +loss may -e recommended +or /se in cleanin* imlant a-/tments, areas
wit, oen contacts, wide em-ras/res, or sites w,ere recession and -one loss ermit
access to +/rcations. It can also -e /sed to remo"e la?/e +rom t,e distal asect o+ t,e
most distal toot, in all ?/adrants.
4,en recommendin* a tye o+ +loss, t,e seci+ic oral conditions, atient re+erence,
and a-ility are all +actors t,at need to -e considered. A limitation o+ +lossin* is t,e
ina-ility to con+orm to a conca"e interro0imal s/r+ace s/c, as t,e mesial o+
ma0illary remolars. Ot,er interro0imal de"ices will clean t,ose s/r+aces more
e++ecti"ely 7Fi*/re %-'8.
Dental Flossin* Met,ods
5wo +re?/ently /sed +lossin* met,ods are t,e sool met,od and t,e circle, or loo,
met,od. 1ot, +acilitate control o+ t,e +loss and ease o+ ,andlin*. 5,e sool met,od is
artic/larly s/ited +or teena*ers and ad/lts w,o ,a"e ac?/ired t,e necessary
ne/rom/sc/lar coordination re?/ired to /se +loss. 5,e loo met,od is s/ited +or
c,ildren as well as ad/lts wit, less nim-le ,ands or ,ysical limitations ca/sed -y
conditions s/c, as oor m/sc/lar coordination or art,ritis. Flossin* is a comle0 skill,
so /ntil c,ildren de"elo ade?/ate de0terity, /s/ally aro/nd t,e a*e o+ :$ to :> years,
an ad/lt s,o/ld er+orm +lossin* on t,e c,ild. Ho/n*er c,ildren w,ose teet, still
e0,i-it rimate saces 7no interro0imal contact8 will not re?/ire +lossin*.
4,en /sin* t,e sool met,od, a iece o+ +loss aro0imately :( inc,es lon* is
/tili@ed. 5,e -/lk o+ t,e +loss is li*,tly wo/nd aro/nd t,e middle +in*er. Sace s,o/ld
-e le+t -etween wras to a"oid imairin* circ/lation to t,e +in*ers 7Fi*/re %-< A8. 5,e
rest o+ t,e +loss is similarly wo/nd aro/nd t,e same +in*er o+ t,e oosite ,and. 5,is
+in*er can wind, or Ftake /,F t,e +loss as it -ecomes soiled or +rayed to ermit access
to an /n/sed ortion. 5,e last t,ree +in*ers are clenc,ed and t,e ,ands are mo"ed
aart, /llin* t,e +loss ta/t, t,/s lea"in* t,e t,/m- and inde0 +in*er o+ eac, ,and +ree
7Fi*/re %-< 18. 5,e +loss is t,en sec/red wit, t,e inde0 +in*er and t,/m- o+ eac,
,and -y *rasin* a section t,ree ?/arters to : inc, lon* -etween t,e ,ands 7Fi*/re %-<
C8.
For t,e loo met,od, t,e ends o+ t,e :(-inc, iece o+ +loss are tied in a knot. All o+
t,e +in*ers, -/t not t,e t,/m-s o+ t,e two ,ands are laced close to one anot,er wit,in
t,e loo 7Fi*/re %-%8. 4,et,er /sin* t,e sool or t,e loo met,od o+ +lossin*, t,e
same -asic roced/res are +ollowed. 5,e t,/m- and inde0 +in*er o+ eac, ,and are
/sed in "ario/s com-inations to */ide t,e +loss -etween t,e teet,.
4,en insertin*, +loss, it is *ently eased -etween t,e teet, wit, a seesaw motion at t,e
contact oint. 5,e *entle seesaw motion +lattens t,e +loss, makin* it ossi-le to ease
t,ro/*, t,e contact oint and re"ent snain* it t,ro/*,, t,/s a"oidin* tra/ma to t,e
s/lc/lar *in*i"a 7Fi*/re %-( A8. Once ast t,e contact oint, t,e +loss is adated to
eac, interro0imal s/r+ace -y creatin* a C-s,ae. 5,e +loss is t,en directed aically
into t,e s/lc/s and -ack to t,e contact area 7/-and-down a*ainst t,e side o+ t,e
toot,8 se"eral times or /ntil t,e toot, s/r+ace is clean 7Fi*/re %-( 18. 5,e roced/re is
reeated on t,e adAacent toot, in t,e ro0imal area, /sin* care to re"ent dama*e to
t,e ailla w,ile readatin* to t,e adAacent toot,. A clean, /n/sed ortion s,o/ld -e
/sed +or eac, interro0imal area.
In *eneral, +lossin* is -est er+ormed -y cleanin* eac, toot, in s/ccession, incl/din*
t,e distal s/r+ace o+ t,e last toot, in eac, ?/adrant. 5,e indi"id/al s,o/ld -e assisted
wit, ro-lem areas and enco/ra*ed to /tili@e w,ic,e"er met,od rod/ces t,e -est
res/lts.
Criteria +or e"al/ation are -ased on t,e e++icacy o+ la?/e remo"al and sa+ety o+ t,e
+lossin* met,od. Incorrect +lossin* can o+ten -e detected t,ro/*, clinical o-ser"ation
o+ t,e *in*i"a and t,e tec,ni?/e 7Fi*/re %-;8. Si*ns t,at s/**est incorrect /se o+
dental +loss incl/de *in*i"al c/ts, so+t tiss/e cle+tin*, and cer"ical wear on
interro0imal root s/r+aces. 7Fi*/res %-:$, %-::8 I+ +lossin* tra/ma is e"ident, +/rt,er
instr/ction s,o/ld -e *i"en /ntil t,e indi"id/al ,as -ecome adet. )roer instr/ction
and ractice allows most moti"ated ad/lts to master eit,er t,e sool or loo met,od o+
+lossin*. In certain circ/mstances, t,e /se o+ a +loss ,older, +loss t,reader, "aria-le-
t,ickness +loss, or re-c/t +loss strands wit, a sti++ end may -e more e++ecti"e.
It is imortant to note t,at a +lossin* ,a-it ,as traditionally -een di++ic/lt +or eole to
em-race. In reality, only a "ery small roortion o+ indi"id/als ractice daily +lossin*.
Findin*s ,a"e ran*ed +rom :$ to >:E o+ o/lation.
&=-&(
Floss may -e s/erior to
ot,er interro0imal cleanin* met,ods, -/t +or t,ose w,o ,a"e not or will not adot a
+lossin* -e,a"ior anot,er interro0imal de"ice may -e more e++ecti"e t,an no
interro0imal cleanin*.
&;
A less e++ecti"e de"ice /sed on a re*/lar -asis is s/erior to
soradic /se o+ a more e++ecti"e de"ice. )articiation o+ t,e indi"id/al in selectin* an
interro0imal cleanin* de"ice and re*imen is cr/cial to imro"in* andBor en,ancin*
comliance. Sometimes indi"id/als a*ree to adot a -e,a"ior -eca/se t,is is w,at t,e
clinician wants to ,ear. A0elsson ,as re+erred to t,is as Fa ,asty a++irmati"e in a
moment o+ s/ddenly insired co/ra*e.F
&=
Dental 'loss Holder
5,e +loss ,older is a de"ice t,at eliminates t,e need +or lacin* +in*ers in t,e mo/t,.
It is recommended +or indi"id/als wit,9
),ysical disa-ilities,
)oor man/al de0terity,
'$
.ar*e ,ands,
.imited mo/t, oenin*,
A stron* *a* re+le0, andBor
.ow moti"ation +or traditional +lossin*.
'$
5,e +loss ,older may also -e ,el+/l w,en one erson is assistin* anot,er wit,
+lossin*. .imited scienti+ic data comarin* +in*er-mani/lated +lossin* to t,e /se o+ a
+loss ,older s,ows no di++erence in la?/e remo"al.
&%
St/dies ,a"e +o/nd t,at, w,en
comared, a si*ni+icant maAority o+ indi"id/als re+erred t,e +loss ,older o"er +in*er-
mani/lated +lossin*.
&%,':,'>
It s,o/ld -e em,asi@ed t,at e++ecti"e initial ed/cation and
rein+orcement are necessary +or roer /se o+ t,e +loss ,older. Use o+ t,e +loss ,older
may aid in de"eloin* a +lossin* ,a-it and s,o/ld -e considered w,en indi"id/als
e0erience di++ic/lty wit, man/al +lossin*.
'=
A "ariety o+ di++erent +loss-,older desi*ns are a"aila-le 7Fi*/re %-:>8. Most
commonly, t,ey consist o+ a yoke-like de"ice wit, a =B&- to :-inc, sace -etween t,e
two ron*s o+ t,e yoke. 5,e +loss is sec/red ti*,tly -etween t,e two ron*s and t,e
,andle is *rased to */ide t,e +loss d/rin* /se. 5,e widt, and len*t, o+ t,e ,andle are
imortant +eat/res to consider w,en recommendin* t,e /se o+ a +loss ,older to t,ose
wit, limited *riin* a-ilities.
'&
Most +loss ,olders re?/ire t,at +loss -e str/n* aro/nd
"ario/s arts o+ t,e ,older rior to eac, /se. 5,is assem-ly mec,anism allows +or re-
t,readin* o+ t,e +loss w,ene"er t,e workin* ortion -ecomes soiled or -e*ins to +ray.
Some de"ices ,a"e a +loss reser"oir in t,e ,andle. 5,is imro"ement allows +or ease
o+ t,readin* and ad"ancin* t,e +loss w,ile maintainin* t,e roer ta/tness. Se"eral
-rands o+ re-t,readed, one-time-/se +loss ,olders are a"aila-leD t,ey re?/ire minimal
de0terity, a +actor t,at may ,el imro"e comliance.
4,en /sin* a ,older, t,e +loss is inserted interro0imally, /sin* t,e same tec,ni?/e
emloyed +or +in*er-mani/lated +lossin*. Once t,ro/*, t,e contact oint, t,e +loss
and ,older are /s,ed distally to clean t,e mesial s/r+ace o+ a toot, or /lled mesially
to clean t,e distal s/r+ace 7Fi*/re %-:=8. 5,is /llin* or /s,in* motion creates
con+ormity to t,e toot, con"e0ities, t,/s allowin* t,e +loss to slide aically into t,e
s/lc/s. 5,e +loss is t,en acti"ated in t,e same manner as wit, +in*er-mani/lated
+lossin*, -y mo"in* t,e +loss in t,e direction o+ t,e lon* a0is o+ t,e toot,.
Strict attention s,o/ld -e *i"en to ac,ie"in* t,e desired +loss tension w,en
assem-lin* t,e +loss ,older. 5o ens/re ta/tness, t,e ron*s can -e +orced to*et,er
w,ile sec/rin* t,e +loss. 5,e most ersistent ro-lems wit, t,e yoke-like de"ices are
t,e di++ic/lties in loadin* and t,readin* t,e +loss, maintainin* tension o+ t,e +loss
-etween t,e ron*s and decreased a-ility to adat t,e +loss into a C-s,ae aro/nd t,e
ro0imal s/r+ace. Any de"ice recommended s,o/ld allow +or ease o+ t,readin*,
maintenance o+ roer ta/tness, and easy mani/lation -y t,e /ser.
A/tomated +loss ,olders ,a"e -een introd/ced -/t ,a"e not s,own an ad"anta*e o"er
man/al +lossin*.
''
Howe"er, t,ose wit, lar*e diameter ,andles may -e esecially
,el+/l +or atients wit, limited man/al de0terity and ina-ility to *ri a smaller
diameter 7Fi*/re %-:&8.
Dental Floss 5,reader
A +loss t,reader is a lastic loo into w,ic, a len*t, o+ +loss is inserted, similar to
t,readin* a needle. 5,e t,reader is /sed to carry t,e +loss interro0imally in t,e
+ollowin* circ/mstances9
5,ro/*, em-ras/re areas /nder contact oints t,at are too ti*,t +or +loss insertion,
1etween t,e ro0imal s/r+ace and *in*i"a o+ a-/tment teet, o+ +i0ed rost,eses,
Under ontics,
Aro/nd ort,odontic aliances, and
Under teet, t,at are slinted to*et,er.
Care s,o/ld -e taken to re"ent tra/ma -y not +orcin* t,e sti++ end o+ t,e +loss
t,reader into t,e *in*i"al tiss/es. 4,en cleanin* /nder a +i0ed artial dent/re, t,e
+loss t,reader is inserted +rom t,e +acial and /lled comletely t,ro/*, to t,e lin*/al
asect /ntil t,e +loss is a*ainst t,e a-/tment or ontic 7Fi*/re %-:' A8. 5,e +loss may
t,en -e disen*a*ed +rom t,e t,reader. 5,e +loss is adated to one a-/tment toot,
s/r+ace in t,e area o+ t,e em-ras/re 7Fi*/re %-:' 18 and mo"ed in t,e direction o+ t,e
lon* a0is o+ t,e toot, to remo"e la?/e +rom t,e ro0imal s/r+ace. It is imortant to
*lide t,e +loss t,ro/*, t,e sace -etween t,e ontic and t,e *in*i"a in order to clean
t,e /nderside o+ t,e ontic 7Fi*/re %-:' C8. A+ter cleanin* t,e /nderside o+ t,e ontic,
it is necessary to slide t,e +loss to t,e oosite ro0imal s/r+ace 7Fi*/re %-:' D8.
!emo"al o+ t,e +loss +rom -etween t,e a-/tment and ontic is accomlis,ed -y
/llin* it o/t +rom t,e +acial asect.
Fi*/re %-> 3m-ras/re 5yes. a. 5ye Iailla +ills interro0imal sace. B.
5ye IIsli*,t to moderate recession o+ ailla. C. 5ye IIIe0tensi"e
recession or comlete loss o+ ailla.
Fi*/re %-= 6arieties o+ Floss. a. Dental tae. B. 4a0ed. C. Unwa0ed. D.
6aria-le t,ickness +loss.
Fi*/re %-& 6aria-le t,ickness +loss wit, sti++ end /sed to clean /nder t,e ontic
and at interro0imals o+ a-/tments o+ a +i0ed artial dent/re. 7Co/rtesy o+ Dr.
.inda S. Sc,eirton, Crei*,ton Uni"ersity, Oma,a, N1.8
Fi*/re %-' Dental +loss is not as e++ecti"e in cleanin* teet, wit, interro0imal
root conca"ities since it does not contact t,e s/r+aces o+ t,e conca"ity. 7Co/rtesy
o+ Dr. .inda S. Sc,eirton, Crei*,ton Uni"ersity, Oma,a, N1.8
Fi*/re %-< Sool met,od +or dental +lossin*. A. Floss is li*,tly wo/nd and
saced aro/nd t,e middle +in*er o+ eac, ,and. B. 5,e last t,ree +in*ers are
clenc,ed, /llin* t,e +loss ta/t and lea"in* t,e inde0 +in*er and t,/m- o+ eac,
,and +ree. C. 5,e +loss is ,eld wit, t,e inde0 +in*er and t,/m- o+ eac, ,and -y
*rasin* a section t,ree ?/arters to : in. lon* -etween t,e ,ands. 7Co/rtesy o+
Dr. .inda S. Sc,eirton, Crei*,ton Uni"ersity, Oma,a, N1.8
Fi*/re %-% .oo met,od o+ dental +lossin*. A. All +in*ers e0cet t,e t,/m-s are
laced wit,in t,e loo +or easy mane/"era-ility. B. For t,e mandi-/lar teet,, t,e
+loss is */ided wit, t,e two inde0 +in*ers. C. For t,e ma0illary teet,, t,e +loss is
*/ided wit, two t,/m-s or one t,/m- and one inde0 +in*er. 7Co/rtesy o+ Dr.
.inda S. Sc,eirton, Crei*,ton Uni"ersity, Oma,a, N1.8
Fi*/re %-( A. 5o insert, t,e +loss is *ently eased -etween t,e teet,, w,ile sawin*
it -ack and +ort, at t,e contact oint. B. t,e +loss is directed into t,e s/lc/s and
-ack to t,e contact area se"eral times or /ntil t,e toot, s/r+ace is clean.
7Co/rtesy o+ #o,n O. 1/tler Co., C,ica*o, I..8
Fi*/re %-; Imroer dental +loss tec,ni?/e wit, otential +or *in*i"al F+loss-
c/ts.F 7Floss s,o/ld adat to interro0imal s/r+ace in a C-s,ae.8
Fi*/re %-:$ Gin*i"al F+loss-c/tsF created -y +ail/re to adat +loss to
interro0imal s/r+ace in a C-s,ae.
Fi*/re %-:: Groo"e created on mesial asect o+ toot, 7arrow8 ca/sed -y
mo"ement o+ +loss in -/cco-lin*/al 7,ori@ontal8 rat,er t,an aical-occl/sal
7"ertical8 direction.
Fi*/re %-:> A "ariety o+ +loss ,olders. 5,e +irst t,ree deicted in ,oto*ra, are
re-t,readed +or one-time /se. 5,e last +loss ,older e0,i-its a +loss-reser"oir in
,andle.
Fi*/re %-:= Correct /se o+ +loss ,older on mesial asect o+ toot,. Note t,at +loss
is ta/t, /lled mesially to adat in C-s,ae, and e0tended s/-*in*i"ally.
Fi*/re %-:& A/tomated +loss ,older. Note lar*e diameter ,andle +or easier
*rasin*.
Fi*/re %-:' Use o+ a dental +loss t,reader. A. Floss t,reader inserted /nder
ontic. B. Floss adation to mesial o+ a-/tment. C. Floss /nderneat, ontic. D.
Floss adation to distal o+ a-/tment. 7Co/rtesy o+ Dr. .inda S. Sc,eirton,
Crei*,ton Uni"ersity, Oma,a, N1.8
Question 2
A. 4a0ed dental +loss is -etter +or remo"in* interro0imal dental la?/e t,an
/nwa0ed.
1. A maAor ro-lem enco/ntered wit, t,e dental +loss ,older is maintainin* ta/tness
o+ t,e +loss.
C. 5,e sool met,od o+ /sin* interdental +loss is t,e re+era-le tec,ni?/e +or
introd/cin* c,ildren to +lossin*.
D. Indi"id/als indicate a re+erence +or t,e +loss ,older, -/t it is not as e++ecti"e as
+lossin* wit, t,e sool or loo met,ods.
3. Only a-o/t %$E 7l/s or min/s 'E8 o+ t,e eole w,o ro/tinely -r/s,, +loss.
4ooden or )lastic 5rian*/lar Sticks
Interro0imal cleanin* can -e +acilitated /sin* sticks made o+ wood or lastic 7Fi*/re
%-:<8. 1alsa and -irc,wood are most common since t,ey are lia-le. A red/ction in
in+lammation and -leedin* sites ,as -een demonstrated /tili@in* wooden or lastic
sticks to red/ce la?/e acc/m/lations.
:&,'<
5,ey can -e /sed +or 5ye I, II, or III
em-ras/res, -/t are -est s/ited w,ere t,e ailla does not comletely +ill t,e
em-ras/re sace.
&=
5,ese sticks are trian*/lar in cross section to slide easily -etween
teet, and to red/ce otential tiss/e tra/ma. 5,e stick is inserted interro0imally +rom
t,e -/ccal asect wit, t,e +lat s/r+ace, t,e -ase o+ t,e trian*le, restin* on t,e *in*i"a.
5,e ti o+ t,e stick is an*led coronally and is mo"ed in a -/cco-lin*/al direction
7Fi*/re %-:%8. 4ooden sticks ,a"e an ad"anta*e o"er lastic in t,at t,e ointed end
can -e so+tened in t,e mo/t, -y moistenin* it wit, sali"a. A so+ter stick can -e more
easily adated to t,e interro0imal s/r+ace. 5,e stick s,o/ld -e discarded i+ t,e wood
-ecomes slayed as slinters co/ld -e +orced into t,e *in*i"al tiss/es. )lastic sticks
can -e t,oro/*,ly was,ed and re/sed.
5rian*/lar wood sticks ,a"e -een s,own to red/ce -leedin* sites and to do so -etter
t,an rinsin* wit, c,lor,e0idine.
'<
In oral ,y*iene st/dies o+ articiants e0,i-itin*
-leedin* aillae, it was +o/nd t,at la?/e remo"al wit, wooden trian*/lar sticks
e++ecti"ely red/ced in+lammation more in t,e coronal re*ions o+ t,e interro0imal
ocket t,an in t,e aical re*ions.
'<
It ,as also -een s/**ested t,at -y deressin* t,e
ailla, wood sticks can e0tend > to = millimeters into t,e s/lc/s, t,/s en,ancin*
s/-*in*i"al la?/e remo"al.
&=
A res/r*ence in t,e o/larity o+ wood sticks ,as
romted recent marketin* o+ desi*n "ariations +rom t,e traditional trian*/lar
woodsticks. One s/c, model is a +a-ric coated or F+lockedF lastic stick 7Fi*/re %-:<8.
5oot,icks
A comre,ensi"e ,istory o+ toot,ick /se s/**ests t,at toot,icks are one o+ t,e
earliest and most ersistent FtoolsF /sed to Fick teet,.F 5,e toot,ick may date -ack
to t,e days o+ t,e ca"eeole, w,o ro-a-ly /sed sticks to ick +ood +rom -etween t,e
teet,.
'%,'(
5,e no-ility and t,e a++l/ent /sed ela-orate toot,ick kits o+ metal, i"ory,
and car"ed woodD t,e less a++l/ent w,ittled sticks +or t,e same /rose.
5oot,icks are /tili@ed alon* t,e s/lc/s and in t,e interro0imal s/r+ace to dislod*e
+ood de-ris and la?/e. Consistent /se o+ t,e toot,ick can res/lt in +irm, resilient
tiss/e. O/tcomes are *enerally similar to trian*/lar wood sticks, alt,o/*, one st/dy
s,owed s/erior -ene+its o+ t,e trian*/lar wood stick.
';
5oot,icks are *enerally
considered easier to mani/late t,an +loss and indeed are /sed more t,an +loss +or oral
,y*iene.
<$
A draw-ack wit, toot,ick /tili@ation is t,e ossi-ility o+ contri-/tin* to
recession, -l/ntin* t,e aillae, or ca/sin* e"en more se"ere dama*e wit, imroer
/se. !ecommended /se o+ t,e toot,ick is descri-ed wit, t,e toot,ick ,older and is
an imortant asect o+ oral ,y*iene sel+-care instr/ction.
5oot,ick Holder
Alt,o/*, a toot,ick may -e mani/lated -y ,and, t,e toot,ick ,older is a ,andle
desi*ned to increase e++ecti"e alication o+ t,e traditional toot,ick -y ,oldin* it
sec/rely at t,e roer an*le. It also ser"es as an e0tension o+ t,e +in*ers in ,ard-to-
reac, areas. In artic/lar, toot,icks in a ,andle ,a"e -een s/**ested +or cleanin* t,e
lin*/al em-ras/res o+ t,e osterior teet,.
<:
)la?/e remo"al is ac,ie"ed -y tracin* t,e *in*i"al mar*in aro/nd eac, toot, or
+/rcation area, and in eac, interro0imal area wit, moderate ress/re.
Interro0imally, t,e toot,ick is mo"ed -ack and +ort, -etween t,e -/ccal and lin*/al
asects to remo"e la?/e and stim/late *in*i"al tiss/es 7Fi*/re %-:(8.
A "ariety o+ toot,ick ,olders are a"aila-le commercially 7Fi*/re %-:;8. 5,e
toot,ick is inserted into an adA/sta-le lastic contra-an*led ,andle, wit, t,e e0cess
wood end -roken o++ -y snain* t,e toot,ick in a downward direction. 5,is lea"es
a stem to re"ent t,e ti +rom disen*a*in* +rom t,e ,older. 5,e toot,ick can -e
ositioned ac/tely on one end to access lin*/al s/r+aces and o-t/sely at t,e ot,er end
to adat to -/ccal s/r+aces. 5,e /se o+ t,e toot,ick ,older is indicated in t,e
+ollowin* circ/mstances9
)la?/e remo"al alon* t,e *in*i"al mar*in and wit,in t,e *in*i"al s/lci or
eriodontal ockets,
Cleanin* o+ conca"e ro0imal s/r+aces 7Fi*/re %-'8,
Cleanin* o+ accessi-le +/rcation areas,
Cleanin* aro/nd ort,odontic aliances and +i0ed rost,eses,
Alication o+ c,emot,erae/tic a*ents 7s/c, as -/rnis,in* +l/oride into t,e toot,
to treat ,yersensiti"ity or deli"erin* c,lor,e0idine into t,e *in*i"al s/lc/s8.
4,en /sin* a toot,ick to remo"e la?/e, it may -e re-moistened wit, sali"a to
so+ten t,e wood, A/st as wit, t,e wood stick. 4,en alied to t,e *in*i"al mar*in, t,e
-l/nt ti is laced erendic/lar to t,e lon* a0is o+ t,e teet,. As re"io/sly
mentioned, care s,o/ld -e taken to a"oid s/-*in*i"al insertion or "i*oro/s
interro0imal /se -eca/se o+ otential dama*e to t,e *in*i"a or teet,.
Interro0imal and Uni-t/+ted 1r/s,es
Small interro0imal -r/s,es w,ic, are attac,ed to a ,andle come in a "ariety o+
desi*ns. Some o+ t,e desi*ns ,a"e a nonrelacea-le -r/s,D t,e entire de"ice is
discarded w,en t,e -r/s, is worn 7Fi*/re %->$8. Interro0imal -r/s,es can -e /tili@ed
to clean saces -etween teet, and aro/nd +/rcations, ort,odontic -ands, and +i0ed
rost,etic aliances wit, saces t,at are lar*e eno/*, to easily recei"e t,e de"ice
7Fi*/res %->:, %->>8. 5,ey may also -e /sed to aly c,emot,erae/tic a*ents into
interro0imal areas as well as +/rcations. Foam tis initially de"eloed +or /se wit,
imlants are an ideal mec,anism +or deli"ery o+ medicaments interro0imally or at
+/rcations. Interro0imal -r/s,es are re+era-le to t,e /se o+ dental +loss +or cleanin*
-etween teet, w,ere t,e ailla does not +ill t,e em-ras/re sace or w,ere root
conca"ities are resent
>,=>
7Fi*/re %-'8. 5,e -r/s,es are taered or cylindrical in s,ae
and are a"aila-le in a "ariety o+ si@es 7Fi*/re %->=8. 5,e core o+ t,e -r/s, t,at ,olds
t,e -ristles is made o+ lastic, wire, or nylon-coated wire.
4,en determinin* t,e aroriate si@e o+ interro0imal -r/s,es, t,e diameter o+ t,e
-ristles s,o/ld -e sli*,tly lar*er t,an t,e sace to -e cleaned. 5,e -r/s, can -e
moistened, and t,en inserted into t,e area at an an*le aro0imatin* t,e normal
*in*i"al conto/r 7Fi*/re %->&8. A -/cco-lin*/al mo"ement is /sed to remo"e la?/e
and de-ris. Ca/tion s,o/ld -e e0ercised to re"ent dama*e to t,e toot, or so+t tiss/es
+rom t,e +irm wire or lastic core o+ t,e -r/s,. Imlant a-/tments are easily cleaned
wit, interdental -r/s,es ,owe"er, e0treme ca/tion s,o/ld -e e0ercised to re"ent
scratc,in* o+ t,e titani/m s/r+ace.
=(
Only plastic coated wires are recommended.
Foam -r/s,es can also -e /tili@ed +or t,is /rose.
5,e /ni-t/+ted -r/s,, also known as t,e sin*le-t/+ted -r/s,, is e++icient +or remo"in*
la?/e in n/mero/s sites 7Fi*/re %->'8. 5,ese incl/de t,e +ollowin*9
Mesial and distal s/r+aces o+ teet, adAacent to edent/lo/s saces, incl/din* t,e distal
o+ t,e last molar in eac, ?/adrant,
F/rcations and +l/ted root s/r+aces 7mesial asect o+ ma0illary +irst remolars and
mandi-/lar +irst molars8 t,at ,a"e -een e0osed -eca/se o+ *in*i"al recession or
eriodontal s/r*ery,
4ide oen em-ras/res w,ere aillae ,a"e -een lost,
Aro/nd dental aliances, incl/din* imlants and ort,odontic wires and -rackets.
One st/dy demonstrated t,e ad"anta*es o+ com-inin* t,e /se o+ t,e /ni-t/+ted -r/s,
wit, t,e toot,ick.
<>
5,e end o+ t,e t/+t is directed into t,e interro0imal area -y
com-inin* a rotatin* motion wit, intermittent ress/re. 5,e /ni-t/+t -r/s, ,as also
-een s/**ested +or alication o+ c,emot,erae/tic a*ents. 1y so+tenin* in "ery ,ot
or -oilin* water, ,andles o+ some /ni-t/+ted -r/s,es can -e -ent in order to allow
easier access to t,e osterior -/ccal and lin*/al interro0imal areas.
Ot,er Interro0imal De"ices
Ru44er or Plastic Tip
5,ese de"ices consist o+ a conical, +le0i-le r/--er or lastic ti attac,ed to a ,andle or
to t,e end o+ a toot,-r/s, 7Fi*/re %-><8. )rimarily /tili@ed +or *in*i"al massa*e, t,ey
can -e /sed to remo"e la?/e and de-ris +rom e0osed +/rcation areas, oen
em-ras/res, and alon* t,e *in*i"al mar*in. In one st/dy, no di++erences were +o/nd in
la?/e or *in*i"al inde0 scores w,en comarin* t,e r/--er ti, dental +loss, and
interro0imal -r/s,es.
<=
Howe"er, ractitioners do not *enerally "iew r/--er or
lastic tis as e++ecti"e la?/e remo"al de"ices. Additional researc, is warranted. 5,e
lack o+ consistent e"idence /nderscores t,e "al/e o+ selectin* a de"ice t,at t,e
ed/cator is ent,/siastic a-o/t in order to en,ance comliance and ,a"e t,e *reatest
likeli,ood o+ s/ccess +or an indi"id/al.
5,e ti is laced at a ;$-de*ree an*le to t,e lon* a0is o+ t,e toot, and traced wit,
moderate ress/re alon* t,e *in*i"al mar*in 7Fi*/re %->%8. In an oen em-ras/re
area, t,e ti is mo"ed in and o/t in a -/cco-lin*/al direction. 5,e /se o+ a ti attac,ed
to an an*led s,ank rat,er t,an a toot,-r/s, ,andle may allow +or *reater ease o+
access and adatation. 5o re"ent dama*e to t,e so+t tiss/es, care s,o/ld -e taken to
a"oid insertin* t,e ti s/-*in*i"ally. Anot,er desi*n is made o+ elastomeric +lan*es
and adds te0t/re to t,e r/--er ti allowin* +or a otential increase in la?/e remo"al
a-ility 7Fi*/re %->(8.
4,en /sed to massa*e t,e *in*i"a t,e r/--er ti stim/lates t,e tiss/e leadin* to
increased keratini@ation.
<&,<'
Howe"er, since t,e keratini@ation occ/rs in t,e oral rat,er
t,an t,e s/lc/lar *in*i"a, imro"ed *in*i"al ,ealt, ro-a-ly res/lts +rom remo"al o+
-acterial la?/e rat,er t,an +rom t,e stim/lation.
<<
Some ractitioners also
recommend t,e r/--er ti +ollowin* eriodontal s/r*ery to aid in tiss/e re-conto/rin*.
)nittin$ .arn
In areas w,ere t,e aillae ,a"e receded and t,e em-ras/re is oen, w,ite knittin*
yarn 7no dyes8 can -e /sed in lace o+ +loss +or ro0imal cleanin*. 4ool yarns s,o/ld
-e a"oided -eca/se o+ t,e ossi-ility o+ tiss/e irritation. 5,e rationale +or /se o+ yarn
is t,at t,e increased t,ickness and te0t/re can en,ance la?/e remo"al. 4,en access
is limited, a +loss t,reader may -e /sed to insert t,e yarn into t,e em-ras/re 7Fi*/re %-
>;8. Once t,e yarn ,as -een drawn t,ro/*, t,e em-ras/re, t,e tec,ni?/e is t,e same
as +or dental +loss, takin* care not to tra/mati@e t,e tiss/e. 5,e incon"enience o+
ac?/irin* yarn, w,ic, is not a common ,o/se,old item, may a++ect comliance.
0au1e Strip
A *a/@e stri can -e /sed +or cleanin* t,e ro0imal s/r+aces o+ teet, adAacent to
edent/lo/s areas, teet, t,at are widely saced, or imlant a-/tments. 5o reare t,e
stri, a >-inc,-wide *a/@e -anda*e is /n+olded and re+olded len*t,wise. 5,e
len*t,wise ed*e o+ t,e *a/@e is ositioned wit, t,e +old toward t,e *in*i"a and t,e
ends +olded inward to a"oid *in*i"al irritation 7Fi*/re %-=$8. 5,e *a/@e is adated -y
wrain* it aro/nd t,e e0osed ro0imal s/r+ace to t,e +acial and lin*/al line an*les
o+ t,e toot,. A -/cco-lin*/al Fs,oes,ineF stroke is /sed to loosen and remo"e la?/e
and de-ris. Ga/@e stris are recommended to clean t,e most distal s/r+ace o+ t,e most
distal toot, in t,e mo/t,. It is artic/larly -ene+icial +or t,e distal a-/tment toot, +or
artial dent/res, an area w,ere la?/e acc/m/lation is +re?/ently a-/ndant and t,ick.
utomated /nterproximal Cleaners
A/tomated interro0imal cleanin* de"ices ,a"e -een de"eloed to ,el imro"e
indi"id/al comliance wit, cleanin* t,e ro0imal s/r+aces o+ teet,. One s/c, de"ice
is a nylon +ilament ti t,at mo"es at :$,$$$ linear strokes er min/te 7Fi*/re %-=:8.
4,en comared to man/al +lossin*, researc, demonstrates t,at t,e de"ice is a-le to
red/ce la?/e le"els and -leedin*, and imro"e *in*i"al arameters e?/al to t,at
ac,ie"ed wit, man/al +lossin*.
<%
Se"eral owered toot,-r/s,es ,a"e attac,ments t,at are desi*ned wit, a small
n/m-er o+ -ristles to remo"e la?/e at t,e interro0imal areas, aro/nd +/rcations,
rost,etic a-/tments, and imlants. One s/c, de"ice /ses a /ni-t/+t o+ micro+ine
+ilaments t,at mo"e in an or-ital motion. Anot,er /ses se"eral -ristle t/+ts t,at are
$.$$< millimeters diameter wit, end-ro/nded -ristles t,at oscillate w,en acti"ated.
One st/dy +o/nd t,is a/tomated oscillatin* interro0imal -r/s, to -e sa+e and
e++ecti"e in remo"in* la?/e +rom t,e interro0imal area.
<(
Fi*/re %-:< 6ariety o+ wooden and lastic trian*/lar sticks. )lastict,ree
sticks deicted at le+t. Note +locked desi*n o+ +irst lastic stick. 4oodent,ree
sticks deicted at ri*,t. Note -alsa wood comosition o+ last wooden stick
7ot,ers are -irc,8.
Fi*/re %-:% )lacement o+ -alsa wood trian*/lar stick interro0imally. 7Note9
-ase o+ trian*/lar stick rests at *in*i"al asect.8
Fi*/re %-:( Use o+ a toot,ick ,older. A. 5i is laced erendic/lar to t,e lon*
a0is o+ t,e toot, to clean alon* *in*i"al mar*ins. B. 5i is laced at less t,an a
&' an*le on t,e toot, to clean alon* mar*inal *in*i"a. Frayed ti is /sed to
-/rnis, or -r/s, t,e toot, s/r+ace. 7Co/rtesy o+ Mar?/is Dental Man/+act/rin*
Comany, A/rora, CO.8
Fi*/re %-:; A "ariety o+ toot,ick ,olders.
Fi*/re %->$ A "ariety o+ interro0imal -r/s, de"ices.
Fi*/re %->: Interro0imal -r/s, mo"ed in a -/cco-lin*/al direction -etween
teet,.
Fi*/re %->> Interro0imal -r/s, directed into +/rcation.
Fi*/re %->= !elacea-le interro0imal -r/s, inserts in = "aryin* si@es.
Fi*/re %->& Interro0imal -r/s, inserted -etween a-/tment and ontic o+ +i0ed
artial dent/re at an*le aro0imatin* t,e *in*i"al conto/r. 1r/s, can -e
inserted /nder ontic i+ sace allows. 7Co/rtesy o+ Dr. .inda S. Sc,eirton,
Crei*,ton Uni"ersary, Oma,a, N1.8
Fi*/re %->' A "ariety o+ /ni-t/+ted -r/s,es.
Fi*/re %->< A "ariety o+ r/--er or lastic ti de"ices.
Fi*/re %->% Use o+ interdental ti stim/lator to remo"e la?/e. 5,e ti is laced
at a ;$ an*le to t,e lon* a0is o+ t,e toot, and traced alon* t,e *in*i"al mar*in
or mo"ed in a -/ccolin*/al direction in an oen em-ras/re area. 7Co/rtesy o+
#o,n O. 1/tler Co., C,ica*o, I..8
Fi*/re %->( !/--er ti de"ice wit, te0t/red elastomeric +lan*es.
Fi*/re %->; Use o+ knittin* yarn in wide oen em-ras/re. A. Harn is looed
t,ro/*, dental +loss and inserted t,ro/*, t,e contact oint. B. Harn is drawn
t,ro/*, t,e em-ras/re. 7Co/rtesy o+ Dr. .inda S. Sc,eirton, Crei*,ton
Uni"ersity, Oma,a, N1.8
Fi*/re %-=$ A <-in. len*t, o+ :-in. *a/@e -anda*e +olded in ,al+ wit, t,e +olded
ed*e adAacent to t,e *in*i"a +or adatation. 7Co/rtesy o+ Dr. .inda S. Sc,eirton,
Crei*,ton Uni"ersity, Oma,a, N1.8
Fi*/re %-=: A/tomated interro0imal cleaner.
Question 3
A. Utili@ation o+ wood or lastic sticks does red/ce la?/e acc/m/lations and does
clear +ood de-ris +rom t,e mo/t,.
1. Incorrect /se o+ a toot,ick may ca/se *in*i"al recession or dama*e to t,e
aillary tiss/es.
C. 5,e diameter o+ an /ni-t/+ted -r/s, s,o/ld -e sli*,tly smaller t,an t,e em-ras/re
sace to -e cleaned.
D. 4,en /tili@in* a *a/@e stri to clean in interro0imal s/r+ace t,e +old s,o/ld -e
ositioned toward t,e *in*i"al mar*in.
3. A r/--er ti aids in remo"in* oral de-ris and la?/e +rom t,e *in*i"al s/lc/s, -/t
t,e keritini@ation it stim/lates, is on t,e oral side o+ t,e *in*i"al mar*in.
Tongue Cleaners
5on*/e cleanin* ,as -een racticed since anti?/ity.
<;
St/dies on ton*/e de-ridement
,a"e renewed interest in t,is s/lemental meas/re to +/rt,er red/ce -acterial la?/e
-eyond toot,-r/s,in* and interro0imal cleanin*.
%$,%:
5,e lar*e aillary s/r+ace area
o+ t,e ton*/e dors/m +a"ors t,e acc/m/lation o+ oral microor*anisms and oral de-ris.
Anatomically, t,e s,orter +/n*i+orm aillae and t,e lon*er +ili+orm aillae create
ele"ations and deressions t,at may entra de-ris and ,ar-or microor*anisms, makin*
t,e ton*/e an ideal location +or -acterial *rowt,. Oral de-ris +rom t,ese sites may
contri-/te to la?/e +ormation in ot,er areas o+ t,e mo/t,.
%>
!ed/ction o+ t,is de-ris
-y mec,anical ton*/e de-ridement can a++ect la?/e acc/m/lation, and oral
malodor.
%=
6ario/s desi*ns o+ ton*/e cleaners are a"aila-le 7Fi*/re %-=>8. A so+t--ristled
toot,-r/s, can also -e /sed a+ter t,e standard toot,-r/s,in* re*imen. 4,en /sin* a
ton*/e cleaner, t,e de"ice is laced on t,e dorsal s/r+ace o+ t,e ton*/e close to t,e
-ase o+ t,e ton*/e and /lled +orward, ressin* li*,tly a*ainst t,e s/r+ace o+ t,e
ton*/e 7Fi*/res %-==, %-=&8. 5,is rocess is reeated to co"er t,e entire s/r+ace area
o+ t,e ton*/e. Smokers or t,ose wit, coated, deely +iss/red ton*/es, or wit,
elon*ated aillae 7,airy ton*/e8 will +ind t,at ton*/e de-ridement is esecially
-ene+icial in red/cin* oral -acteria.
Oral Malodor and t,e 5on*/e
Oral malodor, anot,er term +or -ad -reat, or ,alitosis, can ,a"e a systemic ori*in or
may ori*inate in t,e oral ca"ity. A t,oro/*, ,ysical e0amination can r/le o/t a
systemic disorder. Us/ally odors in t,e oral ca"ity occ/r w,en s/l+/r-containin*
roteins and etides are ,ydroly@ed -y Gram-ne*ati"e -acteria in an alkaline
en"ironment.
%&
Odi+ero/s s/l+/r-containin* end rod/cts created -y t,is rocess
incl/de ,ydro*en s/l+ide, met,ylmercatans, and dimet,yl s/l+ide. A s,i+t +rom a
redominantly *ram ositi"e to a *ram ne*ati"e and anaero-ic -acterial o/lation is
associated wit, odor rod/ction. .ocal +actors s/c, as red/ced sali"ary +low, andBor a
rise in oral H may a++ect t,is s,i+t. Inconsistent or ine++ecti"e interro0imal la?/e
remo"al can ro"ide a nic,e +or *ram ne*ati"e -acteria to de*rade s/l+/r-containin*
amino acids res/ltin* in malodor.
%>
5,e resence o+ eriodontal disease may also -e a
contri-/tin* +actor since t,e in+lammatory rocess creates s/-strates t,at stim/late
-acterial *rowt,.
%'
Also, t,e /tre+action rocess and its concomitant odor occ/rs
more raidly w,en -acterial acc/m/lations on t,e ton*/e are ,i*,. Acti"e eriodontal
disease, e0,i-itin* deeer ockets, contri-/tes to malodor. 5,/s, +or some eole,
mana*ement o+ eriodontal disease is an imortant asect in t,e control o+ malodor.
5reatment considerations can incl/de instr/ction in consistent ton*/e -r/s,in* or
scrain* since t,e dorsoosterior s/r+ace o+ t,e ton*/e seems to -e a common site +or
rod/ction o+ "olatile s/l+/r como/nds. Additionally, t,e intraoral /se o+ c,lorine
dio0ide rinse, w,ic, o0idi@es t,e malodoro/s s/l+ides ,as -een s,own to e++ecti"ely
red/ce malodor.
%>
Fi*/re %-=> A "ariety o+ ton*/e cleaners.
Fi*/re %-== )lastic ton*/e cleanin* de"ice /sed -y ressin* a*ainst ton*/e in an
arc. Note serrations t,at ro"ide a scrain* action.
Fi*/re %-=& )lastic ton*/e cleanin* de"ice /sed -y ressin* in a osterior to
interior direction.
Rinsing
6i*oro/s rinsin* o+ t,e mo/t, will aid in t,e remo"al o+ +ood de-ris and loosely
ad,erent la?/e. Alt,o/*, water rinsin* does not remo"e attac,ed la?/e, it may ,el
ret/rn t,e mo/t, to a ne/tral H +ollowin* t,e acid rod/ction t,at res/lts +rom
in*estin* +ermenta-le car-o,ydrates. !insin* or /se o+ an irri*ator is also ,el+/l +or
indi"id/als wit, ort,odontic aliances.
For ma0im/m e++ecti"eness, a tec,ni?/e s,o/ld -e adoted w,ere-y +l/id is +orced
t,ro/*, t,e interro0imal areas o+ clenc,ed teet, wit, as m/c, ress/re as ossi-le in
order to loosen and clear de-ris. Use o+ t,e li, ton*/e, and c,eek m/scles aids in
+orcin* t,e +l/id -ack and +ort, -etween t,e teet, rior to e0ectoration.
!insin* ,as a limited imact s/ra*in*i"ally and is not e++icient in s/-*in*i"al
enetration. It ,as no imact in red/cin* clinical arameters associated wit, *in*i"al
in+lammation. Howe"er, t,e /se o+ a t,erae/tic a*ent en,ances t,e e++ect o+ rinsin*.
Antimicro-ial rinsin* ,as -een /tili@ed as art o+ a +/ll mo/t, disin+ection aroac,
to imro"e oral tiss/e ,ealt,.
%<,%%
See C,ater < +or a detailed disc/ssion o+ t,e imact
o+ c,emot,erae/tics.
Irrigation Devices
Irri*ation de"ices are a means o+ irri*atin* seci+ic areas o+ t,e mo/t, w,ereas
rinsin* is a means o+ +l/s,in* t,e entire mo/t,. A ,ome-irri*ation de"ice t,at is /sed
+or sel+-care ro"ides a steady or /lsatin* stream o+ +l/id, alt,o/*, t,e /lsatin*
stream is re+era-le 7Fi*/re %-='8. Irri*ation can res/lt in t,e disr/tion o+ loosely
attac,ed or /nattac,ed s/ra- and s/-*in*i"al la?/e. 5,e action is two+old. .oosely
attac,ed micro+lora are disr/ted w,en t,e /lsatin* +l/id makes initial contact. 5,ere
is a secondary +l/s,in* action as t,e irri*ant is de+lected +rom t,e toot, s/r+ace. 5,e
micro+lora is disr/ted -ot, ?/alitati"ely and ?/antitati"ely.
%(
It ,as -een demonstrated t,at irri*ation wit, water or a nont,erae/tic lace-o can
imro"e *in*i"itis or early eriodontitis, w,en com-ined wit, toot,-r/s,in*.
%;-(=

S/ra*in*i"al water irri*ation alone, wit,o/t toot,-r/s,in*, is not e++ecti"e and is
in+erior to toot,-r/s,in*.
(&-(%
Home irri*ation is not indicated +or t,ose w,o -r/s,
e++ecti"ely and ,a"e no *in*i"al in+lammation. Indi"id/als wit, inconsistent or
ine++ecti"e interro0imal cleanin*, +i0ed ort,odontic aliances, crowns, +i0ed artial
dent/res, and imlants ,owe"er, may -ene+it +rom a ,ome irri*ation sel+-care
re*imen.
(<,((
Oral irri*ation may also -e ,el+/l +or indi"id/als w,o ,a"e Aaws
temorarily wired to*et,er +or sta-ili@ation +ollowin* s/r*ery or ,ead and neck
tra/ma. Irri*ation ,as -een s,own to red/ce roin+lammatory cytokines in"ol"ed in
t,e -one destr/cti"e rocess w,en eriodontal diseases are resent.
(;
5,e standard ti is desi*ned +or s/ra*in*i"al /se. 5,e ti is directed erendic/lar to
t,e toot, at or near t,e *in*i"al mar*in. 5,e cann/la-tye ti is directed into t,e
*in*i"al s/lc/s and allows a +oc/sed la"a*e addin* to t,e det, o+ enetration.
;$

!/--er-tied cann/las can -e an*led into t,e s/lc/s a-o/t > millimeters. Home
s/-*in*i"al irri*ation ,as -een /sed to deli"er medicaments +/rt,er into t,e *in*i"al
s/lc/s.
(:,;:
Se"eral st/dies demonstrated additional red/ctions in *in*i"itis and
-leedin* w,en /sin* an antimicro-ial a*ent in an oral irri*ator wit, a cann/la-tye
ti.
(>, ;>-;&
Use o+ t,e cann/la-tye ti s,o/ld -e limited to indi"id/als wit, ade?/ate
skill and de0terity.
Antimicro-ial a*ents /sed as t,e irri*ant ,a"e s,own clinical and micro-iolo*ic
imro"ements in t,ose wit, *in*i"itis.
(=,;',;<
5,e +ail/re to reac, t,e -ase o+ t,e ocket
may e0lain w,y s/ra*in*i"al irri*ation is more e++ecti"e a*ainst *in*i"itis t,an
eriodontitis. In"esti*ations ,a"e comared s/ra*in*i"al irri*ation wit, water to
rinsin* wit, c,lor,e0idine. Some st/dies s,ow no di++erence
;%
w,ile ot,ers +o/nd
c,lor,e0idine rinse more e++ect-i"e in la?/e remo"al t,an water irri*ation alone.
(>,(<
5,e otential +or s/ra*in*i"al irri*ation to ind/ce -acteremias ,as -een st/died, -/t
does not aear ,a@ardo/s to ,ealt,y atients
;(
since toot,-r/s,in*,
;;
creates a similar
le"el o+ -acteremia. Oral irri*ators /sed inaroriately -y t,ose wit, oor oral
,y*iene ,a"e ind/ced -acteremias, -/t t,e relations,i to -acterial endocarditis is
/nclear.
;(
5,ere is less risk o+ -acterial endocarditis +rom irri*ation o+ a ,ealt,y
mo/t, t,an w,en irri*atin* an in+lamed mo/t, -eca/se o+ di++erences in micro-ial
load.
;(, ;;
Fi*/re %-=' Oral irri*ator +or ,ome /se. Note standard ti and additional
,y*iene accessories. 7Co/rtesy o+ 4aterik 5ec,nolo*ies.8
Implant Maintenance
Metic/lo/s oral ,y*iene sel+-care is essential in maintainin* dental imlants. )la?/e
and calc/l/s acc/m/late more raidly, in lar*er amo/nts and ad,ere more easily to
t,e imlant a-/tment t,an to nat/ral teet,.
:$$
5,e eit,elial -arrier and connecti"e
tiss/e attac,ment mec,anism is not as stron* aro/nd an imlant w,en comared to a
nat/ral toot,. 5,is weaker attac,ment allows +or a more raid -acterial in"asion o+ t,e
-iolo*ic seal w,ic, can contri-/te to t,e destr/ction o+ osseo/s inte*ration. 3++ecti"e
la?/e remo"al is a critical +actor in t,e maintenance o+ a ,ealt,y -iolo*ic seal and to
re"ent imlant +ail/re.
:$:
5,ere is a ositi"e correlation -etween t,e amo/nt o+
la?/e and s/-se?/ent *in*i"itis and -one loss aro/nd imlants.
:$>
5,e loss o+ nat/ral teet, res/ltin* in t,e lacement o+ imlants is o+ten ca/sed -y a
,istory o+ oor oral ,y*iene res/ltin* in dental disease. A commitment to metic/lo/s
daily oral ,y*iene sel+-care is critical +or t,ose wit, imlants. Cleanin* t,e a-/tment
osts, -ars, and rost,etic s/erstr/ct/res, resents a c,allen*e t,at can -e e"en more
demandin* t,an cleanin* nat/ral teet,. As wit, nat/ral teet,, a com-ination o+
de"ices is /s/ally needed to remo"e la?/e +rom all s/r+aces. 5,e *oal o+ imlant
maintenance is to re*/larly remo"e so+t deosits wit,o/t alterin* t,e s/r+ace o+ t,e
imlants. Dama*e to titani/m imlants can increase corrosion and a++ect t,e
molec/lar interaction -etween t,e imlant s/r+ace and ,ost tiss/e.
:$=
A scratc,ed
s/r+ace may lead to increased la?/e acc/m/lation.
:$&
5,e s/-se?/ent -acterial
in"asion can ro*ress raidly to eri-imlantitis and otential imlant +ail/re.
An e++ecti"e -r/s,in* tec,ni?/e s,o/ld -e t,e +irst comonent o+ an imlant oral
,y*iene sel+-care re*imen. A so+t, man/al toot,-r/s, can -e /sed. A sonic owered
toot,-r/s, ,as -een s,own to -e -etter t,an a man/al toot,-r/s, in red/cin* la?/e
and -leedin* scores aro/nd imlants.
:$'
Some indi"id/als may re+er a owered rotary
-r/s, wit, a taered -r/s,,ead desi*n. Neit,er tye o+ owered -r/s, was +o/nd to
dama*e t,e imlant s/r+ace and -ot, were e++ecti"e in areas w,ere access is
di++ic/lt.
:$',:$<
4,ate"er -r/s, is /sed, a demonstration o+ t,e adatation o+ t,e -r/s,
to t,e a-/tment osts and ontics s,o/ld -e ro"ided. 5,e denti+rice /sed s,o/ld meet
American Dental Association standards to ens/re t,at it is not a-rasi"e.
5o aid in la?/e remo"al +rom a-/tment osts t,ere are a "ariety o+ ot,er de"ices t,at
can -e /tili@ed 7Fi*/re %-=<8. A taered or cylindrical s,aed interro0imal -r/s, or
/ni-t/+ted -r/s, can -e /sed wit, an in-and-o/t motion to clean t,e a-/tment osts.
7Fi*/re %-=< 1, %-=< C8 5,e interro0imal -r/s, m/st ,a"e a nylon-coated wire rat,er
t,an t,e standard metal wire to re"ent scratc,in* t,e imlant wit, t,e ti o+ t,e
interro0imal -r/s,. Foam tis are an alternati"e c,oice +or cleanin* t,e interro0imal
s/r+ace o+ an imlant. 5o ,el control -acteria, t,e +oam ti, interro0imal -r/s,, or
eit,er o+ t,e owered -r/s,es may -e died into an antimicro-ial sol/tion s/c, as
c,lor,e0idine *l/conate 7$.:>E8. Alternately, a cotton swa- can -e /sed to aly t,e
a*ent.
Any tye o+ +loss, tae, or yarn can -e /sed +or circ/m+erential la?/e remo"al aro/nd
a-/tment osts. In some cases, traditional +loss wit, a +loss t,reader, "aria-le
t,ickness +loss or *a/@e can -e laced in a =<$-de*ree loo aro/nd t,e a-/tment ost
and mo"ed wit, a s,oes,ine motion in t,e direction o+ t,e lon* a0is o+ t,e toot,.
Alternately, +loss rod/cts desi*ned seci+ically +or /se wit, imlants can -e /sed
7Fi*/re %-=< A8. !i--on +loss is a wide, wo"en, sometimes -raided, *a/@e-like
"ersion o+ +loss, w,ic, ro"ides increased te0t/re to en,ance la?/e remo"al. One
rod/ct ,as a ,ook on t,e end o+ t,e +loss ri--on to allow +or wrain* t,e +loss
aro/nd an entire ost -y insertin* +rom t,e +acial asect, t,/s eliminatin* insertion
+rom -ot, +acial and lin*/al s/r+aces. Harn and s,oelaces can also -e /sed. )lacin* a
small amo/nt o+ nona-rasi"e toot,aste on t,e +lossin* rod/ct can olis, t,e osts.
Oral irri*ators can -e /sed +or cleanin* aro/nd a-/tments, ,owe"er, t,e water sray
s,o/ld -e /sed on t,e lowest settin* and s,o/ld not -e directed s/-*in*i"ally. Daily
s/-*in*i"al irri*ation wit, $.$<E c,lor,e0idine ,as s,own -ene+icial e++ects on
*in*i"al, la?/e, -leedin*, and calc/l/s indices w,ile rinsin* wit, $.:>E
c,lor,e0idine a++ected *in*i"al and -leedin* indices only.
:$%
5,e s/-stanti"ity e++ect
is not as stron* +or imlants as +or nat/ral teet, -/t wo/ld -e -etter +acilitated -y
s/-*in*i"al irri*ation t,an rinsin*.
A critical +actor in s/ccess+/l imlant maintenance as wit, all oral ,ealt, sel+-care is
to recommend only t,e minimal n/m-er o+ cleanin* de"ices needed +or e++ecti"e
la?/e remo"al. 4it, roer instr/ction, t,e moti"ated indi"id/al can s/ccess+/lly
maintain imlants.
Fi*/re %-=< Cleanin* imlants9 A. Circ/m+erential lacement o+ )ostcare
-raided nylon cord. B. Interro0imal -r/s,. C. 3nd-t/+t -r/s,. 7Co/rtesy o+ #o,n
O. 1/tler Co., C,ica*o, I..8
Denture Maintenance
Instr/ctions s,o/ld -e ro"ided +or t,e roer care and cleanin* o+ -ot, t,e dent/res
and t,e /nderlyin* tiss/es. Accordin* to one s/r"ey, only &$E o+ dent/res worn -y
t,e elderly are ade?/ately cleaned.
:$(
Care o+ t,e so+t tiss/es on w,ic, a dent/re rests incl/des remo"in* t,e dent/re
o"erni*,t or +or a s/-stantial time eac, day, cleanin* and massa*in* t,e tiss/es /nder
t,e dent/re daily,
:$;,::$
and er+ormin* re*/lar oral sel+-e0aminations to o-ser"e and
reort any irritation or c,ronic c,an*es in aearance o+ t,e tiss/es. Fail/re to remo"e
t,e dent/re may res/lt in oral malodor, e0cessi"e al"eolar rid*e resortion, diseased
or irritated oral tiss/es, or t,e de"eloment o+ e/lis +iss/rat/m.
Cleanin* and massa*in* o+ t,e so+t tiss/es can -e er+ormed sim/ltaneo/sly -y
-r/s,in* wit, a so+t--ristled toot,-r/s, or -y massa*in* wit, t,e t,/m- or +ore+in*er
wraed in a clean +aceclot,. Deosits t,at +orm on dent/res incl/de ellicle, la?/e,
calc/l/s, oral de-ris 7e.*., des?/amated eit,elial cells8, stain and +ood de-ris. 5,e
microscoic oro/s s/r+ace o+ a dent/re attracts dental deosits.
Consistent, e++ecti"e cleanin* o+ dent/res not only ser"es to en,ance t,e sense o+ oral
cleanliness, -/t also ser"es to re"ent oral malodor, dent/re stomatitis, and ot,er
tiss/e irritations. M/cosal irritation may imair eatin*, w,ic, can ,a"e a ne*ati"e
n/tritional imact on a +rail, elderly indi"id/al. 5,e incidence o+ dent/re stomatitis
"aries +rom >$ to &$E o+ t,e dent/re o/lation and occ/rs most commonly in
+emales. Fre?/ently, dent/re wearers are only aware o+ t,e aest,etic -ene+its to -e
deri"ed +rom maintainin* cleanliness. It is inc/m-ent /on t,e oral ,ealt,
ro+essional to stress t,e n/mero/s ,ealt, -ene+its o+ dent/re cleanin*.
1acterial and +/n*al or*anisms can coloni@e t,e oro/s dent/re s/r+ace. For candidial
in+ections t,e dent/re s,o/ld -e soaked in a nystatin anti+/n*al s/sension w,ile
sim/ltaneo/sly treatin* t,e oral tiss/es wit, t,e same medication. Daily t,oro/*,
cleansin* o+ t,e dent/re is recommended -eca/se dent/res ,ar-or t,e -acteria
in"ol"ed in t,e creation o+ t,e "olatile s/l+/r como/nds t,at contri-/te to oral
malodor.
::$,:::
Commonly racticed cleanin* met,ods incl/de immersion, -r/s,in*, or
a com-ination o+ -ot,.
Immersion Cleaners
Immersin* t,e dent/re in a cleanin* sol/tion ,as t,e ad"anta*e o+ reac,in* all arts o+
a dent/re, w,ile wit, -r/s,in*, areas o+ t,e dent/re may -e missed. Conse?/ently a
com-ination may res/lt in a more t,oro/*,ly cleaned dent/re. 4,en selectin* an
immersion cleaner, t,e tye o+ dent/re material m/st -e considered. Alco,ol or
essential oils +o/nd in commercial mo/t,was,es are not comati-le wit, dent/re
acrylic, w,ic, may -ecome dry or lose color +rom rolon*ed contact wit, t,ese
s/-stances.
Hyoc,lorite sol/tions dil/ted :9:$ wit, ta water act as anti+/n*al and anti-acterial
a*ents.
::>
Addin* a teasoon o+ calci/m-c,elatin* dis,was,er deter*ent 7e.*.,
Cal*onite8 may ,el to control calc/l/s or stains. Care m/st -e taken to not
immerse aliances wit, metallic comonents in ,yoc,lorite sol/tions since t,e
metallic s/r+ace may corrode.
::>
It is imerati"e t,at indi"id/als -e instr/cted to
t,oro/*,ly rinse t,e -leac, o++ -e+ore lacement on t,e oral tiss/es. Acetic acid
7"ine*ar8 can -e /sed +or immersion, will kill some or*anisms, and is less ca/stic to
so+t tiss/es i+ not t,oro/*,ly rinsed.
Commercial alkaline ero0ide owders and ta-lets are a"aila-le. 5,ese tyically
contain an alkaline +or o0idi@in*, er-orate or car-onate +or e++er"escin*, and a
c,elatin* a*ent 73D5A8.
:$<
4,en dissol"ed in water, t,ese a*ents decomose and
release o0y*en -/--les, w,ic, mec,anically loosen la?/e de-ris on t,e dent/re
s/r+ace. 5,e alkaline s/-stances and deter*ent en,ance t,e mec,anical e++ect o+ t,e
-/--les. A ;;E -acterial kill ,as -een reorted wit, t,ese commercial rod/cts, and
t,eir e++ects are en,anced at :>> F.
::=
3n@yme roteolytic a*ents ,a"e -een /sed -/t
aear in+erior to alkaline ero0ides.
::&
Cleanin* t,e Dent/re
1r/s,in* in conA/nction wit, an a-rasi"e a*ent or -r/s,in* a dent/re -e+ore and a+ter
it ,as soaked in an immersion cleaner, can -e /tili@ed to aid in t,e remo"al o+
deosits. Incorrect /se o+ an a-rasi"e a*ent 7oor tec,ni?/e andBor too m/c, ress/re8
can dama*e t,e dent/re. A -r/s, wit, medi/m or so+t end-ro/nded -ristles, i+ /sed
roerly, s,o/ld not a-rade dent/re materials. A dent/re -r/s, ro"ides access to all
s/r+aces o+ a dent/re 7Fi*/re %-=%8. 5,e dental ro+essional s,o/ld assess t,e le"el o+
man/al de0terity w,en ro"idin* instr/ction in dent/re -r/s,in*.
Nona-rasi"e a*ents s/c, as soa or -akin* soda, or a commercial denti+rice may -e
sa+ely /sed in conA/nction wit, a -r/s,. Ot,er a*ents may -e ,arm+/l to dent/re
materials. 5,e dent/re deli"ery aointment is an e0cellent time to e0lain and
demonstrate ,ow to care +or t,e new dent/re.
Ultrasonic or sonic de"ices are a"aila-le +or ,ome dent/re cleanin*. 5,ey /tili@e a
cleanin* sol/tion in conA/nction wit, a*itation rod/ced -y /ltrasonic 7ina/di-le,
,i*, +re?/ency8 or sonic 7a/di-le8 so/nd wa"es to remo"e de-ris and stains. St/dies
"eri+y t,e e++icacy o+ t,e /ltrasonic cleanerD t,ey are more e++ecti"e t,an -r/s,in*
wit, water.
::',::<
Use o+ t,ese de"ices may -e artic/larly ,el+/l +or indi"id/als wit,
limited de0terity or +or t,e ersonal-care sta++ at lon*-term care +acilities. 4,ic,e"er
met,od is /sed, t,e dent/re s,o/ld -e t,oro/*,ly rinsed /nder r/nnin*, teid water
-e+ore reinsertion into t,e mo/t, in order to remo"e any s/-stances t,at co/ld irritate
so+t tiss/e.
Instr/ction in t,e recommended met,od o+ sel+-care o+ t,eir dent/re and o+ t,e tiss/es
/on w,ic, it rests is critical to s/ccess+/l dent/re maintenance. It is t,e
resonsi-ility o+ t,e dental ro+essional to ens/re an /nderstandin* o+ -ot, t,e Fw,yF
and F,owF o+ dent/re maintenance and t,e otential conse?/ences o+ oor dent/re
sel+-care. 30lainin* t,e roced/re, demonstratin* t,e correct met,od, and t,en
re?/estin* a ret/rn demonstration are all instr/ctional met,ods to imro"e
comliance. 4ritten instr/ctions and recommendations s,o/ld -e ro"ided +or easy
re+erence and re+erral.
Fi*/re %-=% 1r/s,in* t,e al"eolar s/r+ace o+ a +/ll dent/re wit, a dent/re -r/s,.
Note t,e +irm ,old to re"ent t,e dent/re sliin* o/t o+ t,e ,and.
Question 4
A. Imlants acc/m/late dental la?/e and t,/s can contri-/te to t,e de"eloment o+
eriodontal disease.
1. )la?/e remo"al +rom an imlant can -est -e accomlis,ed wit, a ie cleaner.
C. 5,e stream o+ sol/tion +rom an irri*atin* de"ice s,o/ld -e directed aically to
clean t,e s/lc/s aro/nd imlants.
D. Immersion cleanin* o+ dent/res is /s/ally more e++ecti"e t,an -r/s,in* -eca/se
immersion ens/res t,e cleanin* a*ent reac,es all areas o+ t,e dent/re.
3. A+ter ro"idin* ed/cation on a/0iliary met,ods o+ oral ,y*iene, instr/ctions s,o/ld
-e *i"en on t,e /se o+ se"eral met,ods to sol"e t,e atientCs ro-lem.
Summary
In addition to oral conditions, se"eral +actors a++ect t,e aroriate selection and /se
o+ s/lemental oral ,y*iene de"ices. 5,e de0terity and moti"ation +or er+ormin*
oral ,y*iene roced/res, and t,e re+erences +or seci+ic de"ices s,o/ld -e assessed
w,en recommendin* s/lemental oral ,y*iene de"ices and tec,ni?/es. 4,en a
de"ice is introd/ced, it is essential t,at t,e roer alication in all areas o+ t,e mo/t,
-e demonstrated and t,at t,e otential +or dama*e wit, imroer /se is /nderstood.
Desite ade?/ate de0terity and a-ility, attainment o+ otimal oral ,ealt, re?/ires
moti"ation and daily comliance in er+ormin* oral care. 5o en,ance comliance and
skill de"eloment, t,e n/m-er o+ recommended oral ,y*iene de"ices s,o/ld -e
limited. St/dies e0aminin* comliance and e++ecti"eness indicate t,at de"eloment o+
roer skills and a willin*ness to /se s/lemental oral ,y*iene de"ices is +acilitated
w,en t,e n/m-er o+ de"ices is limited to no more t,an two.
::%,::(
)ersonal re+erences
+or artic/lar oral ,y*iene de"ices s,o/ld also -e considered. Alt,o/*, a seci+ic
de"ice may -e +a"ored -y t,e oral ,ealt, ro+essional, it will -e ine++ecti"e i+ not
/sed. I+ an indi"id/al ,as s,own a re+erence +or a seci+ic de"ice, its /se s,o/ld -e
enco/ra*ed. For e0amle, i+ an indi"id/al /ses a toot,ick -/t resents wit,
inade?/ate oral ,y*iene as e"idenced -y disclosed la?/e andBor tiss/e in+lammation
t,e oral ,ealt, ro+essional mi*,t consider one o+ t,e +ollowin*9
Instr/ction to en,ance t,e e++ecti"eness wit, t,e toot,ick,
Introd/ction o+ a toot,ick ,older to +acilitate access and mani/lation o+ t,e
toot,ick,
Use o+ t,e wooden or trian*/lar interdental stick -eca/se o+ its similarity to t,e
toot,ick.
A wide "ariety o+ interro0imal la?/e remo"al de"ices are a"aila-le. 5,e oral ,ealt,
ro+essional will need to stay in+ormed o+ t,e researc, descri-in* new de"ices, as it
-ecomes a"aila-le. De"ices wit, e"idenced -ased si*ni+icance s,o/ld -e considered.
Clinical e0erience and e0ertise s,o/ld not -e disco/nted, ,owe"er, since t,ese are
also imortant comonents o+ e"idence--ased decision makin*.
::;,:>$
It is inc/m-ent
/on t,e oral ,ealt, ro+essional to consistently in"esti*ate e"idence and aly
clinical A/d*ment.
:. A and Dcorrect.
1incorrect. St/dies s,ow incomlete la?/e remo"al increases rate and *rowt, o+
new la?/e.
Cincorrect. Moti"ational +actors are considered d/rin* t,e lannin* ,ase. 5,e
e"al/ation ,ase +oc/s is on atient o/tcomes and w,et,er t,e oral ,y*iene sel+-care
re*imen needs to -e adA/sted.
3Incorrect. Only w,en ri*oro/s interro0imal cleanin* was er+ormed -y an oral
,y*iene ro+essional was t,ere a red/ction in caries incidenceD t,ere is "ery little
e"idence to s/ort t,at t,eory.
>. 1 and 3correct.
Aincorrect. 4a0ed and /nwa0ed +loss ,a"e -ot, -een s,own to -e e?/ally
e++ecti"e in remo"in* la?/e +rom t,e interro0imal s/r+ace, wit,o/t lea"in* a wa0y
resid/e. 5,ere is no e"idence to indicate t,at one tye o+ +loss is -etter t,an t,e ot,er.
Cincorrect. 5,e circle 7or loo8 met,od is -est +or c,ildren w,o do not yet ,a"e t,e
de0terity needed +or t,e sool met,od.
Dincorrect. 5,ere is no st/dy to date t,at s,ows one met,od is more e++ecti"e t,an
t,e ot,er. )atient re+erence on t,e ot,er ,and, +a"ors t,e /se o+ +loss ,olders.
=. A, 1, D, and 3correct
Cincorrect. It s,o/ld -e sli*,tly lar*er so as to e++ecti"ely scr/- a*ainst t,e s/r+ace
disr/tin* and remo"in* -acterial la?/e.
&. A and Dcorrect.
1incorrect. Circ/m+erential la?/e remo"al +rom an imlant is -est accomlis,ed
wit, a so+t material t,at can -e wraed aro/nd its circ/m+erence9 +loss, tae, or yarn.
Metal wire in a ie cleaner co/ld scratc, t,e imlant.
CIncorrect. 5,e stream o+ sol/tion +rom an irri*atin* de"ice s,o/ld -e at a ri*,t
an*le to t,e lon* a0is o+ t,e toot,D ot,erwise -acteria can -e +orced into t,e -lood
s/ly to t,e area.
3Incorrect. It is -est to restrict t,e recommendation to one or two otions, w,ic,
will en,ance comliance otential.
:. 5,e toot, s/r+ace least accessi-le to t,e toot,-r/s, is t,e 7interro0imal8 7-/ccal8
7lin*/al8 s/r+ace.
>. 5,e 7wa0ed8 7/nwa0ed8 +loss +rays and -reaks more +re?/ently on contact wit,
calc/l/s and restoration o"er,an*s. 5,e sool met,od o+ +lossin* re?/ires 7more8
7less8 syc,omotor coordination t,an is re?/ired +or t,e circle met,od. 4,en /sin*
+loss +or t,e loo met,od, aro0imately iiiiiiiii inc,es are needed, o+ w,ic, only
a-o/t iiiiiiiii inc,7es8 isBare ,eld -etween t,e +in*ers to insert t,e +loss -etween
t,e teet,. A new se*ment o+ +loss 7is8 7is not8 /sed to clean eac, interdental sace. I+
+loss is +orced too deely into t,e s/lc/s, it can ca/se iiiiiiiii in t,e *in*i"a,
w,ereas i+ it is w,isawed -/ccolin*/ally wit, too m/c, +orce, it ca/ses iiiiiiiii
o+ t,e cement/m. I+ a eriodontal condition e0ists, t,ere isBare /s/ally 7one -est8
7se"eral satis+actory8 de"ice7s8 +or la?/e remo"al +rom areas wit, di++ic/lt access.
=. Fo/r indications +or t,e /se o+ a dental +loss ,older in lie/ o+ re*/lar +in*er +lossin*
are iiiiiiiii, iiiiiiiii, iiiiiiiii, and iiiiiiiii.
&. 5,ree indications +or t,e /se o+ a +loss t,reader are iiiiiiiii, iiiiiiiii, and
iiiiiiiii.
'. !esearc, 7,as8 7,as not8 ro"ed t,e "al/e o+ t,e toot,ick in maintainin* oral
,ealt,.
<. Irri*ation de"ices ,a"e -een /sed 7s/ccess+/lly8 7/ns/ccess+/ly8 to deli"er
medicaments +/rt,er into t,e *in*i"al s/lc/s.
%. Scratc,in* t,e titani/m imlant w,ile remo"in* la?/e can ca/se a more raid
-/ild/ o+ iiiiiiiii and ,ence ose a *reater risk o+ *in*i"itis and eriodontitis.
(. 5,e wrain* o+ +loss aro/nd an imlant ost +or la?/e remo"al is accomlis,ed
/sin* a iiiiiiiii iiiiiiiii motion.
;. One st/dy indicates t,at as +ew as iiiiiiiiiE o+ t,e dent/res worn -y t,e elderly
are ade?/ately cleaned. Fail/re to maintain clean dent/res can res/lt in dent/re
iiiiiiiii iiiiiiiii 7o"er*rowt, o+ tiss/e8, a condition w,ic, is seen in <$ to %$E
o+ dent/re wearers.
:$. Fo/r o-Aecti"es t,at may -e attained -y roer /se o+ dental +loss are9 iiiiiiiii,
::. 5wo a/0iliary cleanin* aids t,at can -e /sed to sa+ely and e++ecti"ely clean /nder
a +i0ed artial dent/re are iiiiiiiii and iiiiiiiii.
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alication o+ antimicro-ial a*ents in c,emical la?/e control. " Clin Periodontol ,
(9:%%-((.
(%. .an*, N. )., g !amseir-Grossman, 2. 7:;(:8. Otimal dosa*e o+ c,lor,e0idine
di*l/conate in c,emical la?/e control w,en alied -y an oral irri*ator. " Clin
Periodontol , (9:(;->$>.
((. A@i@-Gando/r, I. A., g Newman, H. N. 7:;(<8. 5,e e++ects o+ a simli+ied oral
,y*iene re*ime l/s s/ra*in*i"al irri*ation wit, c,lor,e0idine or metronida@ole on
c,ronic in+lammatory eriodontal disease. " Clin Periodontol , :=9>>(-=<.
(;. C/tler, C. 4., Stan+ord, 5. 4., A-ra,am, C., Ceder-er*, !. A., 1roadman, 5. #.,
g !oss, C. 7>$$$8. Clinical -ene+its o+ oral irri*ation +or eriodontics are related to
red/ction o+ ro-in+lammatory cytokine le"els and la?/e. " Clin Periodontol ,
>%9:=&-&=.
;$. American Academy o+ )eriodontolo*y, Committee on !esearc, Science and
5,eray 7:;;'8. 5,e role o+ s/ra- and s/-*in*i"al irri*ation in t,e treatment o+
eriodontal diseases. American Academy o+ )eriodontolo*y, ::-==.
;:. .o+t,/s, #. 3., 4aki, M., #olko"sky, D., Otomo-Cor*el, #., Newman, M. G.,
Flemmin*, 5., g Nac,nani, S. 7:;;:8. 1acteremia +ollowin* s/-*in*i"al irri*ation
and scalin* and root lanin*. " Periodontol , <>9<$>-%.
;>. Grossman, 3., Meckel, A. H., Isaacs, 5. I., Ferretti, G. A., St/r@en-er*er, O. ).,
1ollmer, 1. 4., Moore, D. #., .iAana, !. C., g Man,art, M. D. 7:;(;8. A clinical
comarison o+ anti-acterial mo/t,rinses9 3++ects o+ c,lor,e0idine, ,enolics, and
san*/inarine on dental la?/e and *in*i"itis. " Periodontolo$y , <$9&='-&$.
;=. C,a"es, 3. S., 2ornman, 2. S., Manwell, M. A., #ones, A. A., New-old, D. A., g
4ood, !. C. 7:;;&8. Mec,anism o+ irri*ation e++ects on *in*i"itis. " Periodontol ,
<'9:$:<->:.
;&. .yle, D. 7>$$$8. 5,e role o+ ,armacot,erae/tics in t,e red/ction o+ la?/e and
*in*i"itis. " Prac Hy$iene, ;9&<-&;.
;'. )arsons, .. G., 5,omas, .., g So/t,ard, G. 7:;(%8. 3++ect o+ san*/inaria e0tract
on esta-lis,ed la?/e and *in*i"itis w,en s/ra*in*i"ally deli"ered as a man/al rinse
/nder ress/re /nder oral irri*ator. " Clin Periodontol , :&9=(:-('.
;<. 4als,, 5. F., Glenwri*,t, H. D., g H/ll, ). S. 7:;;>8. Clinical e++ects o+ /lsed
oral irri*ation wit, $.>E c,lor,e0idine di*l/conate in atients wit, ad/lt
eriodontitis. " Clin Periodontol , :;9>&'-&(.
;%. Newman, M. G., Flemmi*, 5. F., g Nac,nani, S. 7:;;$8. Irri*ation wit, $.$<E
c,lor,e0idine in nat/rally occ/rrin* *in*i"itis. II. <-mont, micro-iolo*ical
o-ser"ations. " Periodontol , <:9&>%-==.
;(. DaAani, A. S., 5an-ert, 2. A., 4ilson, 4., 1ol*er, A. F., 1ayer, A., Ferrier, ).,
Gewit@, M. A., S,/lman, S. 5., No/ri, S., New-/r*er, #. 4., H/tto, C., )allasc,, 5. #.,
Ga*e, 5. 4., .e"inson, M. 3., )eter, G., g I/ccaro, G. #r. 7:;;%8. )re"ention o+
-acterial endocarditis9 !ecommendations o+ t,e American Heart Association. "% ,
>%%9:%;&-:($:.
;;. )allasc,, 5. #., g Slots, #. 7>$$$8. Anti-iotic ro,yla0is and t,e medically
comromised atient. ",Periodontol, :;;<D:$9:$%-=(.
:$$. 6an Stee-er*,e, D. 7:;;$8. )eriodontal asects o+ osseointe*rated oral imlants
mod/m 1ranemark. Dent Clin &orth mer, =>9=''-%$.
:$:. 1aoo-Mo,amed, 2. 7:;;<8. )ost-insertion eri-imlant tiss/e assessment9 A
lon*it/dinal st/dy. " +ral /mplantol , >>9>>'-=:.
:$>. .ek,olm, !., Adell, !., .ind,e, #., 1ranemark, ). I., 3riksson, 1., !ockler, 1.,
.ind"all, A. M., g Honeyama, 5. 7:;(<8. Mar*inal tiss/e reactions o+ osseointe*rated
titani/m +i0t/res9 A cross-sectional st/dy. /nt " %axillofac Sur$, :'9'=-<:.
:$=. 1aier, !. 3., Meena*,an, M. A., Hartman, .. C., 4irt,, #. 3., Flynn, H. 3.,
Meyer, A. 3., Natiella, #. !., g Carter, #. M. 7:;((8. Imlant s/r+ace c,aracteristics
and tiss/e interaction. " +ral /mplantol , :=9';&.
:$&. Dmytryk, #., Fo0, S., g Moriarty, #. 7:;;$8. 5,e e++ects o+ scalin* titani/m
imlant s/r+aces wit, metal and lastic instr/ments on cell attac,ment. " Periodontol ,
<:9&;:-;<.
:$'. 4ol+, .., 2im, A., N/nn, M., g 1akdas,, 1. 7:;;(8. 3++ecti"eness o+ a sonic
toot,-r/s, in maintenance o+ dental imlants. " Clin Periodontol , >'9(>:->(.
:$<. 5,omson-Neal, D., 3"ans, G., g Me++ert, !. M. 7:;(;8. A S3M e"al/ation o+
"ario/s ro,ylactic modalities on di++erent imlants wit, titani/m-srayed s/r+aces.
/nt " Periodont Restor Dent, ;9=$:-::.
:$%. Felo, A., S,i-ly, O., Cidnero, S. G., .a/ciella, F. !., g Ho, A. 7:;;%8. 3++ects o+
s/-*in*i"al c,lor,e0idine irri*ation on eri-imlant maintenance. mer " Dent ,
:$9:$%-:$.
:$(. Hoad-!eddick, G., Grant, A. A., g Gri++it,, C. S. 7:;;$8. In"esti*ation into t,e
cleanliness o+ dent/res in an elderly o/lation. " Prosthet Dent , <&9&(-'>.
:$;. Iar-, G. A., 1olender, C. .., Hickey, #. C., g Carlsson, G. 3. 7:;;$8. #ouher?s
prosthetic treatment for edentulous patients 7:$t, ed.8 Mos-y, St. .o/is.
::$. S,ay, 2. 7>$$$8. Dent/re ,y*iene9 A re"iew and /date. " Contemp Dent Prac,
:9>.
:::. C,an, 3. C. S., Io*o"as, I., Sil-o, !., 1ilyk, M., 1arolet, !., Amsel, !. 4ooley,
C., g 2litorinos, A. 7:;;:8. Comarison o+ two o/lar met,ods +or remo"al and
killin* o+ -acteria +rom dent/res. " Can Dent ssoc , '%9;=%-=;.
::>. #a**ar, D. C., g Harrison, A. 7:;;'8. Dent/re cleansin*t,e -est aroac,. #r
Dent " , :%(9&:=-:%.
::=. McCa-e, #. F., M/rray, I. F., g 2elly, ). #. 7:;;'8. 5,e e++icacy o+ dent/re
cleaners. !ur " Prosthodont Restor Dent , =9>$=-%.
::&. Nakamoto, 2., 5amanoto, M., g Hamada, 5. 7:;;:8. 3"al/ation o+ dent/re
cleaners wit, and wit,o/t en@ymes a*ainst Candida al-icans. " Prosthet Dent ,
<<9%;>-;'.
::'. Gwinnett, A. #., g Co/to, .. 7:;(=8. 5,e e++ecti"eness o+ /ltrasonic dent/re
cleanin*9 A scannin* electron microscoe st/dy. " Prosthet Dent , '$9>$->'.
::<. S,ay, 2., !enner, !. )., g 5r/,lar, M. !. 7:;;%8. Oro,aryn*eal candidosis in
t,e older atient. " mer 0eriatr Soc , &'9(<=-%$.
::%. Heasman, ). A., #aco-s, D. #., g C,ale, I. .. 7:;(;8. An e"al/ation o+ t,e
e++ecti"eness and atient comliance wit, la?/e control met,ods in t,e re"ention o+
eriodontal disease. Clin Prevent Dent , ::9>&->(.
::(. #o,ansson, .. A., Oster, 1., g Ham, S. 3. 7:;(&8. 3"al/ation o+ ca/se-related
eriodontal t,eray and comliance wit, maintenance care recommendations. " Clin
Periodontol, :'9<(;-;;.
::;. #a,n, C. A. 7>$$$8. A/tomated oral ,y*iene sel+-care de"ices9 Makin* e"idence-
-ased c,oices to imro"e client o/tcomes. " Dent Hy$iene, >9:%:-(<.
:>$. A-t, 3. 7:;;;8. 3"idence--ased dentistry9 An o"er"iew o+ a new aroac, to
dental ractice. 0en Dent, #/l-A/*, =<;-%=.
reser"ed.
Chapter 8. Water Fluoridation - %, !laine &eenan %i*e !asley %ichael Rui1,
Research ssistant
Objectives
:. De+ine water +l/oridation and t,e rationale +or /sin* water systems to ro"ide +or
rimary re"ention o+ dental caries.
>. .ist and descri-e t,e +o/r ,istorical eriods in t,e e"ol/tion and de"eloment o+
comm/nity water +l/oridation.
=. Disc/ss t,e -ene+its and e++icacyBe++ecti"eness o+ water +l/oridation.
&. Descri-e t,e cariostatic mec,anisms o+ +l/oride, incl/din* t,e re- and ost-
er/ti"e e++ects.
'. De+ine t,e imact o+ m/ltile so/rces o+ +l/oride on t,e decline o+ dental caries and
t,e role o+ water +l/oridation.
<. Disc/ss +l/orosis, +l/oride s/lementation, and t,e need to monitor e0os/re to
+l/oride.
%. Descri-e t,e e++ect on caries re"alence w,en water +l/oridation is discontin/ed in
a comm/nity.
(. Descri-e t,e economic asects o+ water +l/oridation.
;. State t,e otimal +l/oride concentration ran*e, in arts er million 7m8, +or
ma0im/m caries rotection wit, minimal risk o+ +l/orosis.
:$. .ist t,e c,emicals /sed +or water +l/oridation and -rie+ly descri-e t,e tec,nical
asects o+ +l/oridation, incl/din* monitorin* and s/r"eillance o+ water +l/oridation in
t,e United States.
::. Disc/ss t,e Sa+e Drinkin* 4ater Act and t,e 3)A standards +or nat/ral +l/oride
le"els.
:>. Disc/ss t,e sa+ety o+ +l/oridation in terms o+ imact on ,ealt,.
:=. De+ine t,e role o+ dental-,ealt, ro+essionals in contin/in* to ed/cate t,e /-lic
a-o/t water +l/oridation.
:&. Disc/ss t,e mec,anisms in w,ic, comm/nity water +l/oridation may -e enacted
in t,e United States.
:'. S/mmari@e t,e readiness assessment +actors +or initiatin* a +l/oridation camai*n.
:<. Disc/ss SandmanCs rinciles o+ risk ercetion, t,e rinciles o+ risk
comm/nication and t,e myt,s related to risk comm/nication.
:%. S/mmari@e t,e tec,ni?/es /sed -y oonents o+ water +l/oridation and ela-orate
on t,e means to o"ercome t,ese o-Aections.
:(. S/mmari@e t,e c/rrent stat/s o+ water +l/oridation as it relates to Healt,y )eole
>$:$, t,e National Healt, O-Aecti"es.
Introduction
Comm/nity water +l/oridation 7,erea+ter known as +l/oridation8 is de+ined as t,e
/ward ad7ustment of the natural fluoride level in a comm/nityCs water s/ly to
re"ent dental caries. It is a o/lation--ased met,od o+ rimary re"ention t,at /ses
ied water systems to deli"er low-dose +l/oride o"er +re?/ent inter"als. 5,ro/*,
water +l/oridation, t,e re"enti"e -ene+its accr/e to cons/mers, re$ardless of a$e or
socioeconomic status, Fl/oridation ,as -een cited as one o+ t,e top2ten /-lic-,ealt,
ac,ie"ements o+ t,e cent/ry. 30tensi"e researc, o"er t,e ast ,al+-cent/ry ,as
consistently con+irmed t,e e++icacy, sa+ety, and cost-e++ecti"eness o+ +l/oridation.
Fl/oridation, a maAor contri-/tor to t,e doc/mented decline in dental caries in t,e
:;'$s to :;($s, ,as contin/ed to -e e++icacio/s in caries red/ction d/rin* t,e ast >$
years in w,ic, multiple sources of fluoride 7esecially +l/oride-containin* denti+rices8
,a"e layed a role in caries red/ction. Contin/ed monitorin* o+ +l/oride e0os/re,
esecially +rom adA/ncti"e so/rces like +l/oride-containin* denti+rices, is imortant in
ac,ie"in* t,e aroriate -alance -etween maximum caries preventive 4enefit and
minimal ris* of fluorosis, 3nactment o+ +l/oridation can occ/r at t,e state le"el -/t
more o+ten ,as -een imlemented at t,e local le"el t,ro/*, administrative action or a
vote o+ t,e electorate. Initiatin* a +l/oridation camai*n re?/ires t,at an assessment
-e done to determine comm/nity readiness. 30ternal +orces, incl/din* /-lic oinion,
t,e olitical climate, role o+ t,e media, "oter t/rno/t, knowled*e, skills, and sa""y o+
camai*n committee, etc., imact t,e a-ility to *arner maAority s/ort +or t,is iss/e.
4,ile +l/oridation is so/nd /-lic olicy, t,e ractice o+ +l/oridatin* comm/nity
water s/lies ,as -een c,allen*ed -y "ocal oonents since its incetion.
Conse?/ently, comm/nities o+ten -ecome em-roiled in maAor camai*ns attractin*
si*ni+icant media attention. Dental-,ealt, ro+essionals need to remain in+ormed
a-o/t +l/oridation and kee a-reast o+ t,e literat/re and latest researc,. 5,ey also
need to ro"ide acc/rate in+ormation to t,eir atients and remain reared to address
any concerns andBor +ears. 3?/ally as imortant, t,ey need to -e a-le to assess t,e
+orces t,at a++ect /-lic attit/des, e"al/ate t,e olicy rocess, and /nderstand t,e
strate*ies emloyed -y t,e oosition. 5,is c,ater re"iews t,e ,istory, as well as t,e
e++icacy, cariostatic mec,anisms o+ action, sa+ety, cost-e++ecti"eness, and en*ineerin*
asects o+ +l/oridation. Additionally, strate*ies /sed -y oonents o+ +l/oridation are
disc/ssed alon* wit, t,e rinciles o+ risk comm/nication.
Definition and Background
5,e American Dental Association o++icially de+ines water +l/oridation as Ft,e
adA/stment o+ t,e nat/ral +l/oride concentration o+ +l/oride-de+icient water s/lies to
the recommended level +or otimal dental ,ealt,.F
:
For all ractical /roses,
+l/oridation can -e considered a >$t, cent/ry adatation o+ a nat/rally occ/rrin*
rocess since virtually all sources of community drin*in$ 3ater in the United States
contain some nat/ral +l/oride.
:
Fl/oridation is classi+ied as a rimary /-lic-,ealt,
inter"ention +or dental-disease re"ention -eca/se e"eryone -ene+its A/st -y drinkin*
+l/oridated water.
Fl/oridation can also -e t,o/*,t o+ as a +orm o+ nutritional supplementation in w,ic,
+l/oride is added to t,e drinkin* water. N/tritional s/lementation is +re?/ently /sed
to re"ent diseases wit, t,e addition o+9 "itamin C to +r/it A/ices to re"ent sc/r"yD
"itamin D to milk and -reads to re"ent ricketsD iodine to ta-le salt to re"ent *oiterD
+olic acid to *rains, cereals, and astas to re"ent -irt, de+ects 7incl/din* sina
-i+ida8D and ot,er "itamins and minerals to -reak+ast cereals to romote normal
*rowt, and de"eloment.
>-=
5,e treatment o+ water +or /-lic cons/mtion is a rimary /-lic-,ealt, acti"ity t,at
,as -een /sed -y /-lic-,ealt, a*encies to re"ent diseases since t,e :(&$s. 4ater
treatment re"ents diseases s/c, as9 amoe-ic dysentery, c,olera, enteroat,o*enic
diarr,ea 7!, coli8, *iardiasis, ,eatitis A, letosirosis, araty,oid +e"er,
sc,istosomiasis, ty,oid +e"er, and many ot,er diseases incl/din* dental caries.
>-=
Fl/oridation is an e0amle o+ an ideal /-lic-,ealt, inter"ention in t,at9 7a8 it is
socially e?/ita-le and does not discriminate a*ainst any *ro/D 7-8 cons/mers recei"e
continuous protection wit, no conscio/s e++ort on t,eir art to articiate w,en t,ey
drink otimally +l/oridated waterD 7c8 it works wit,o/t re?/irin* indi"id/als to *at,er
in a central location as wit, ot,er disease-re"ention ro*rams, s/c, as
imm/ni@ationsD 7d8 it does not re5uire the costly services of health professionals to
deli"erD 7e8 t,ere are no daily2dosa$e schedules to remem-erD 7+8 t,ere are no -ad-
tastin* oral medications to -e takenD and 7*8 no painful inoculations ,a"e to -e
end/red in order to recei"e t,e -ene+its.
>-=
30tensi"e scienti+ic doc/mentation o"er t,e ast ,al+-cent/ry, incl/din* se"eral
comre,ensi"e re"iews ,as esta-lis,ed and consistently rea++irmed t,e safety and
efficacy o+ comm/nity-water +l/oridation. 1ased on t,e reonderance o+ scienti+ic
e"idence, e"ery U.S. S/r*eon General since :;'$ ,as ad"ocated t,e adotion o+ water
+l/oridation -y comm/nities. Dr. ./t,er 5erry, U.S. S/r*eon General, :;<: to :;<',
descri-ed water +l/oridation as one o+ t,e +o/r *reat ad"ances in /-lic ,ealt,, callin*
it one o+ t,e Jfour horsemen of pu4lic health,J alon* wit, chlorination,
pasteuri1ation, and immuni1ation, Dr. C 3"erett 2oo, U.S. S/r*eon General, :;(: to
:;(; stated t,e +ollowin*9 FFl/oridation is t,e sin*le most imortant commitment t,at
a comm/nity can make to t,e oral ,ealt, o+ its c,ildren and to +/t/re *enerations.F
&
In
:;;>, Dr. Antonia No"ello, t,e U.S. S/r*eon General at t,at time, stated t,at Ft,e
otim/m standard +or t,e s/ccess o+ any re"ention strate*y s,o/ld -e meas/red -y
its a-ility to prevent or minimi1e disease, ease of implementation, hi$h 4enefit2to2cost
ratio, and safety, Comm/nity water +l/oridation to re"ent toot, decay clearly meets
t,is standard.F
'
Most recently, U.S. S/r*eon General Da"id Satc,er stated9
Fcomm/nity water +l/oridation remains one o+ t,e *reat ac,ie"ements o+ /-lic ,ealt,
in t,e twentiet, cent/ryF and Fan ine0ensi"e means o+ imro"in* oral ,ealt, t,at
4enefits all residents o+ a comm/nity, yo/n* and old, ric, and oor alike.F
<
In t,e
+irst-e"er reort released in May >$$$, on oral ,ealt, in t,e United States, FOral
Healt, in America9 A !eort o+ t,e S/r*eon General,F Dr. Satc,er noted t,at F. . ..
one o+ my ,i*,est riorities as S/r*eon General is reducin$ the disparities in health
t,at ersist amon* o/r "ario/s o/lations. Fl/oridation ,olds *reat otential to
contri-/te toward elimination o+ t,ese disarities.F
%
Fl/oridation is a o/lation--ased met,od o+ rimary re"ention desi*ned to ser"e as
t,e cornerstone +or t,e re"ention o+ dental caries, one o+ t,e most re"alent
c,ild,ood diseases. It was initiated on "anuary <>, CHB> w,en Grand !aids,
Mic,i*an +l/oridated its /-lic-water s/ly. Since t,en, more t,an :&,=$$
comm/nity-water systems ser"in* nearly :$,'$$ American comm/nities ,a"e
+l/oridated t,eir water systems.
(
5,is incl/des BD of the >: lar$est U S, cities w,ere
+l/oridation is eit,er acti"ely racticed or w,ere it is in t,e rocess o+ -ein*
imlemented +ollowin* aro"al -y *o"ernmentalBle*islati"e -odies or "oters. See
comanion we-site ta-le.
a
a
On Fe-. ::, >$$=, Cali+orniaCs lar*est water a*encyMetro 4ater District o+ Sonata,
Cali+orniaaro"ed a meas/re to add +l/oride to its water s/ly. 5,is in"ol"es ><
cities and water districts, t,e lar*est -ein* San Die*o.
History of Community Water Fluoridation
5,e ,istory o+ comm/nity water +l/oridation in t,e United States can -e traced -ack
to t,e early years o+ t,e >$t, cent/ry and may -e cate*ori@ed into +o/r searate
eriods or ,ases.
=,;-:>
5,e four eriods are9 7:8 clinical disco"ery ,aseD 7>8
eidemiolo*ical ,aseD 7=8 demonstration ,aseD and 7&8 tec,nolo*y trans+er ,ase.
5,e +irst eriod, t,e clinical discovery phase, :;$: to :;==, was c,aracteri@ed -y t,e
/rs/it o+ knowled*e relati"e to t,e ca/se o+ de"elomental enamel de+ects resent in
dental enamel o+ eole li"in* in certain western areas o+ t,e United States. Dr,
'rederic* %c)ay, a Colorado Srin*s, Colorado, dentist, noticed t,at some o+ ,is
atients resented wit, an enamel de+ect t,at occ/rred d/rin* toot, +ormation and
aeared to -e /nderminerali@ed or hypominerali1ed,
:=
.ocal dental ractitioners
noted t,at t,e de+ects, w,ic, -ecame known -y local residents as JColorado #ro3n
Stain,J "aried in de*ree o+ hypominerali1ation o+ t,e teet, wit, t,e most se"ere +orm
consistin* o+ a -rown stain and ittin* 7mottlin$) o+ t,e enamel.
:=
Dr. Mc2ay noti+ied
t,e dental ro+ession a-o/t ,is +indin*s t,ro/*, /-lication o+ ,is o-ser"ations in
Dental Cosmos, t,e remier national dental Ao/rnal o+ t,e times. A+ter reortin* ,is
+indin*s, Dr. Mc2ay so/*,t t,e cons/ltation o+ Dr. G. 6. 1lack, a noted researc,er,
and s/-se?/ently -e*an to e0amine c,ildren in "ario/s near-y comm/nities in order
to determine t,e e0tent o+ t,e condition in t,e o/lation. Not only was Mc2ay a-le
to demonstrate t,at w,at ,e now termed Fmottled enamelF was con+ined to seci+ic
*eo*ra,ic areas, -/t ,e also ,yot,esi@ed t,at it was directly related to somethin$ in
t,e drinkin* water in t,ese areas.
=,:=
Aro/nd t,e same time eriod 7early :;=$s8, H, =, Churchill, a chemist wit, t,e
Al/min/m Comany o+ America 7A.COA8, demonstrated an association -etween
,i*, le"els o+ nat/rally occ/rrin* +l/oride in t,e drinkin* water and mottled teet,.
:=-:&

S/-se?/ently, researc,ers Smit, and Smit, s/-mitted a reort, demonstratin* a
causal relationship -etween +l/oride and mottlin* w,ic, was identi+ied in t,e
scienti+ic literat/re as dental fluorosis,
:=-:&
Drs. Mc2ay and 1lack also o-ser"ed a corollary +indin*9 People 3ho had dental
fluorosis also experienced less dental decay, 5,e searc, +or additional in+ormation
a-o/t t,e role o+ +l/oride in t,e ca/se o+ dental +l/orosis and t,e re"ention o+ dental
caries led to w,at is known as t,e second eriod, t,e epidemiolo$ical phase 7:;== to
:;&'8. D/rin* t,is ,ase, a ma7or epidemiolo$ical study, known as FDeanCs >:-City
St/dy,F was cond/cted -y Dr, H, Trendley Dean wit, assistance +rom collea*/es at
t,e U. S. )/-lic Healt, Ser"iceCs National Instit/tes o+ Healt,. In t,is st/dy, teams o+
researc,ers e0amined t,e teet, o+ c,ildren w,o li"ed in >: di++erent comm/nities wit,
"aryin* le"els o+ nat/rally occ/rrin* +l/oride in t,e drinkin* water.
:=-:&
Dean and ,is
team doc/mented the num4er of carious lesions and fluorosed teeth o-ser"ed in eac,
o+ t,e >: comm/nities and compared the findin$s 3ith the fluoride concentration in
t,e resecti"e water s/lies. 5,e +indin*s +rom FDeanCs >:-City St/dy,F s,owed t,at9
7:8 t,e more +l/oride in t,e water, t,e +ewer dental caries in c,ildren, constit/tin* an
inverse relationship -etween t,e le"el o+ nat/ral +l/oride in t,e water and t,e
re"alence o+ dental cariesD and 7>8 ,i*,er le"els o+ +l/oride were associated wit,
+l/orosis o+ t,e teet,, meanin* t,at t,ere was a direct relationship -etween t,e le"el
o+ nat/ral +l/oride in t,e water and t,e re"alence o+ dental +l/orosis.
:=
DeanCs res/lts
s,owed t,at -ot, a decreased risk o+ dental caries and a decreased risk o+ dental
+l/orosis were attained wit, water +l/oride le"els o+ aro0imately C part per million
(ppm) of fluoride,
:=
At t,is le"el, s/-stantial red/ctions (up to 9:;) in dental caries
were e0,i-ited wit, aro0imately :$E o+ t,e o/lation e0,i-itin* very mild dental
+l/orosis, w,ic, t,e in"esti*ators considered to -e acceta-le and cosmetically
inconse?/ential.
:=
5,e /nattracti"e +orm o+ fluorosis 7o+ten called mottlin$8 t,at was
associated wit, ,i*,er le"els o+ +l/oride did not occ/r at t,e : m le"el.
Conse?/ently, : m -ecame t,e -enc,mark le"el /sed -y t,e U.S. )/-lic Healt,
Ser"ice in esta-lis,in* t,e otimal ran*e, :,D to C,< ppm re?/ired to ma0imi@e t,e
-ene+its o+ dental caries red/ction and minimi@e t,e risk +or dental +l/orosis.
:'-:<

7Otimal le"els disc/ssed in s/-se?/ent section8 7see Fi*/re (-:, DeanCs
Inde0BcariesB+l/orosis c/r"e8.
5,e t,ird eriod, known as t,e demonstration phase, -e*an in #an/ary :;&', and was
c,aracteri@ed -y a series o+ clinical trials t,at comared t,e dental and medical res/lts
+ollowin* t,e deli-erate addition o+ +l/oride to t,e drinkin* water in +o/r cities.
:=-:&

5,ese +o/r cities were also aired wit, +o/r Fcontrol cities,F in w,ic, t,e same st/dy
criteria were o-ser"ed in comm/nities wit, ne*li*i-le le"els o+ nat/rally occ/rrin*
+l/oride. Fl/oride was added to t,e /-lic water s/ly o+ 0rand Rapids, %ichi$an,
in order to test t,e ,yot,esis t,at an /ward adA/stment o+ t,e nat/ral +l/oride le"el
to a concentration o+ :.$ m wo/ld re"ent dental caries in t,e o/lation. Grand
!aids was t,e first city in t,e world to +l/oridate its drinkin* water as a dental ,ealt,
romotionBdisease re"ention meas/reD a+ter CA to CB years, a >>; reduction in t,e
rates o+ decayed, missin*, and +illed teet, 7dm+t8 +or c,ildren :> to :& years o+ a*e
was o-ser"ed. 5,ree ot,er e0erimental cities, 3"anston, IllinoisD New-/r*,, New
HorkD and 1rant+ord, Ontario articiated in similar controlled +l/oridation st/dies,
ac,ie"in* similar red/ctions in dental caries rates 7&( to %$E8 a+ter := to :' years
%,:=-:&
75a-le (-:, Demonstration ),ase8.
5,e demonstration phase lasted /ntil a-o/t :;'& w,en t,e -ene+its o+ t,e otimal
adA/stment o+ +l/oride le"els in drinkin* water -ecame so aarent t,at many U.S.
cities -e*an +l/oridation ro*rams +or t,eir citi@ens. 5,/s t,e demonstration phase
o"erlaed sli*,tly wit, t,e +o/rt, eriod in t,e ,istory o+ comm/nity water
+l/oridation, t,e technolo$y transfer phase,
5,e technolo$y transfer phase -e*an a-o/t :;'$ w,en lannin* +or t,e
imlementation o+ +l/oridation -e*an in earnest in many lar*e U.S. Cities. Contin/in*
to t,is day, t,e tec,nolo*y trans+er ,ase is c,aracteri@ed -y t,e esta-lis,ment o+ a set
o+ national ,ealt, *oals, w,ic, incl/des +l/oridation. 5,e Year 2010 Health
Objectives for the Nation call +or t,e imlementation o+ water +l/oridation in all
merican communities that have communal 3ater sources 3here implementation is
technolo$ically feasi4le, The tar$et $oal for fluoridation is6 D>; of the population on
community23ater systems should live in communities 3ith fluoridated 3ater 4y the
year <:C:,
:%
In :;;>, w,en t,e last 'luoridation Census was /-lis,ed, aro0imately CA> million
mericans were cons/min* +l/oridated water w,ile an additional C: million were
drinkin* water wit, otimal le"els o+ naturally occurrin$ fluoride, e?/atin* to '%E o+
t,e entire o/lation or 9<; o+ t,ose w,o are ser"ed -y centrali1ed piped23ater
systems,
%-(
7see 5a-le (->.8 As o+ >$$$, t,e ercenta*e o+ t,e o/lation recei"in*
otimally +l/oridated water t,ro/*, /-lic water systems ,as risen to <'.(E and ><
states ac,ie"ed t,e Healt,y )eole >$$$ *oal o+ %'E o+ t,e o/lation ser"ed -y
comm/nity water +l/oridation
(
7see Fi*/re (->8. From :;;> to >$$$, >( cities adoted
+l/oridation, wit, an estimated (,>;',''> million eole added to t,e Fl/oridation
Cens/s.
:(
In t,e &ovem4er <::: residential election, >= U.S citiesBco/nties "oted on
+l/oridation ordinancesBas eit,er re+erenda or initiati"es.
:;
O+ t,e >= cities, ; cities
wit, a total o/lation o+ A,H>D,:DH approved fluoridation w,ile :& cities wit, a total
o/lation o+ A99,ABD re7ected fluoridation at t,e olls. 4,ile t,e act/al n/m-ers o+
cities reAectin* +l/oridation e0ceeded t,ose aro"in* t,e meas/re d/rin* t,is
election, t,e o/lation "otin* to -ene+it +rom +l/oridation e0ceeded t,e o/lation
denyin* t,emsel"es t,e -ene+its -y ten-+old.
5,e technolo$y transfer phase ,as e0tended +l/oridation 3orld3ide, wit, Sin*aore
imlementin* +l/oridation in :;'(, ser"in* :$$E o+ t,e o/lation.
>$
5,e !e/-lic o+
Ireland -ecame t,e +irst co/ntry to act/ally le*islate mandatory nationwide
+l/oridation in :;<$. Israel initiated its mandatory /ni"ersal +l/oridation ro*ram in
:;(:. C/rrently, a national +l/oridation e++ort is /nderway in C,ile in conA/nction
wit, t,e )an American Healt, Or*ani@ation. Ad"ocated -y t,e 4orld Healt,
Or*ani@ation, +l/oridation -ene+its o"er =<$ million eole in <$ co/ntries
worldwide.
:,>:
1eca/se o+ its '<-year ,istory o+ e++ecti"eness in red/cin* t,e re"alence o+ dental
caries in t,e United States, water +l/oridation was recently cited as one o+ t,e to-:$
/-lic-,ealt, ac,ie"ements o+ t,e >$t, cent/ry -y t,e U. S. Centers +or Disease
Control and )re"ention.
>>
Fi*/re (-: As t,e +l/oride content o+ water increases -eyond : m, t,e inde0
o+ +l/orosis escalates more raidly t,an t,e decayed, missin*, +illed ermanent
7DMF8 decreases. 7From Horowit@ HS. n Update for Dental Practice, New
Hork9 American Academy o+ )edodontics, MedCom, Inc., :;%<.8
Fi*/re (-> )ercenta*e o+ U.S. )o/lation -y State Ser"ed -y Fl/oridated )/-lic
4ater S/ly, >$$$. 7Source6 CDC, >$$$D %%-R <::<8 ':7$%8D :&&-%.8
Question 1
4,ic, i+ any o+ t,e +ollowin* statements, isBare correcte
A. 6irt/ally all so/rces o+ water +or comm/nity water systems in t,e United States
contain some nat/ral +l/oride.
1. Fl/oridation does not in"ol"e addin* anyt,in* to t,e water s/ly t,at is not
already t,ere.
C. 5,e ,istory o+ t,e water +l/oridation story in t,e United States -e*an wit, t,e
in"esti*ation o+ FColorado -rown stainF -y Dr. Frederick Mc2ay and Dr. G. 6. 1lack
D. H. 5rendley Dean o+ t,e U.S. )/-lic Healt, Ser"ice esta-lis,ed t,e relations,i
-etween +l/oride and dental +l/orosis.
3. 5,e otimal concentration o+ +l/oride in drinkin* water +or dental t,erae/tic
/roses, is -etween >.$ and &.$ m.
Benefits and Efficacy/Effectiveness of Fluoridation
O"er t,e ast '< years, n/mero/s st/dies ,a"e -een cond/cted on t,e effectiveness of
fluorides and +l/oridation in preventin$ dental caries and decreasin$ caries rates,
4,en Grand !aids, Mic,i*an, decided to +l/oridate its water s/ly in :;&', a lon*-
term st/dy o+ sc,oolc,ildren was initiated to determine t,e e++ecti"eness o+
+l/oridation in decreasin* dental caries ratesD t,e st/dy +o/nd t,at a+ter :: years o+
+l/oridation, dental caries rates declined -y >: to 9A;,
:,:=,>=
Corro-orati"e st/dies in
t,e same era cond/cted in New Hork 7New-/r*,-2in*ston8 and Illinois 73"anston-
Oak )ark8 reorted red/ctions in caries rates +rom '% to %$E.
:,:=
FO+ %= st/dies
/-lis,ed -etween :;'< and :;%;, t,e most +re?/ently reorted caries red/ction was
'$ to <$E and it was *enerally acknowled*ed t,at +l/oridatin* a comm/nityCs water
s/ly wo/ld reduce dental decay 4y half,F
:=
4,ile c,ildren and adolescents are t,e maAor -ene+iciaries o+ +l/oridation, ad/lts can
also -ene+it. 5,e imact o+ +l/oride on t,e teet, o+ ad/lts ,as -ecome more imortant
as ad/lts are retainin* t,eir teet, lon*er t,an in re"io/s decades -eca/se o+ imro"ed
dental-,ealt, ractices and a"aila-ility o+ re"enti"e inter"entions, esecially
+l/oridation. 4it, a*in*, teet, remain s/sceti-le to coronal caries, and more o+ t,e
root s/r+aces -ecome e0osed to t,e oral en"ironment, res/ltin* in increased
s/sceti-ility to root caries. !esearc, indicates t,at Jroot caries mani+ests as a
si*ni+icant dental ro-lem as early as a*es A> to BB, dou4lin$ in the B>2 to >B2year
a*e *ro/, and redou4lin$ in the >>2 to 992year *ro/.F
:=,>&
!es/lts o+ a national
s/r"ey o+ root caries +o/nd t,at <%E o+ men and <:E o+ women -etween a*es <' and
(&K ,ad root-s/r+ace lesions.
:=,>'
St/dies in ad/lts ,a"e consistently reorted less coronal and root caries in t,e teet, o+
ad/lts residin* in comm/nities wit, ,i*,er le"els o+ water--orne +l/oride.
;
!es/lts o+
one st/dy o+ yo/n* ad/lts a*ed >$ to =& years, s,owed >'E less coronal caries
7decayed, +illed s/r+aces8 in t,ose w,o resided in +l/oridated 7adA/sted or nat/ral8
comm/nities comared wit, t,ose w,o ,ad no e0os/re to +l/oridated water.
:=,><

Similar +indin*s were noted in a st/dy o+ older ad/lts, mean a*es &$ and &= w,ere
residents o+ comm/nities wit, :.< m +l/oride in t,e water ,ad >(E +ewer coronal
caries and :%E +ewer root caries t,an residents o+ comm/nities wit, $.> m
+l/oride.
:=,>&
New-r/n ,as estimated t,at t,e red/ction in caries attri-/ta-le to water
+l/oridation +or ad/lts, a$ed <: to BB, is -etween <: to A:; +or coronal caries and <:
to B:; +or root caries,
:=,>%
D/rin* t,e early eriods o+ +l/oridation, t,e rimary so/rce o+ +l/oride was t,e
drinkin* waterD conse?/ently, t,e red/ctions in dental caries rates attri-/ted to water
+l/oridation were si*ni+icant. Decades later, an eidemiolo*ical st/dy o+ more t,an
=;,$$$ c,ildren a*ed ' t,r/ :% years was cond/cted in :;(<B:;(% -y t,e National
Instit/te o+ Dental !esearc, 7NID!8.
:=,>(,>;
5,is st/dy determined t,at yo/n*er
c,ildren w,o ,ad li"ed all t,eir li"es in otimally +l/oridated comm/nities
e0erienced =;E +ewer cario/s lesions and +illin*s w,en comared wit, t,ose
c,ildren w,o ,ad li"ed in comm/nities t,at were not +l/oridated.
:=,>(,>;
Ot,er reorts
s,owed similar le"els o+ red/ction in decay rates.
In :;;>, New-r/n estimated t,at +l/oridation re"ents A: to AH; o+ dental caries in
t,e primary dentition, :: to =(E in t,e mixed dentition, and A>; in t,e permanent
dentition.
>%
5,e decline in ercenta*es o+ caries red/ction ,as -een +o/nd in -ot,
+l/oridated and non+l/oridated comm/nities, wit, c,ildren w,o ,ad always -een
e0osed to comm/nity water +l/oridation demonstratin* mean DMFS scores ran*in*
+rom :( to &$E lower t,an t,ose w,o ,ad ne"er li"ed in +l/oridated
comm/nities.
:(,>%,=$,=:
4ater +l/oridation ,as layed a dominant role in t,e decline in
caries e"en t,o/*, t,e a-sol/te di++erences in caries re"alence t,at once were
o-ser"ed -etween +l/oridated and non+l/oridated comm/nities aears to -e
diminis,in*.
>(
5,e recently released Hork re"iew 7/-lis,ed in >$$$8 o+ >< st/dies on
+l/oridation e++ecti"eness, +o/nd t,at +l/oridation o+ drinkin* water s/lies red/ces
caries re"alence in "aria-le ran*es wit, a median o+ :&.<E red/ction in rates as
meas/red -y t,e c,an*e in dm+tBDMF5 scores and t,e roortion o+ caries-+ree
c,ildren.
=>
5,e reort also attemted to address t,e impact of fluoride2containin$
toothpaste on t,e e++ecti"eness o+ +l/oridation.
==
5,e a/t,ors o+ t,e re"iew
acknowled*ed t,at t,e e++ecti"eness estimates co/ld -e -iased -eca/se o+ inade?/ate
adA/stment +or t,e imact o+ otential con+o/ndin* "aria-les.
=>
Dental scientists
contend t,at t,e +ail/re to adA/st +or con+o/ndin* "aria-les in t,e re"iew made it
di++ic/lt to interret t,e +indin*s. 5,e /se o+ a median ran*e o+ red/ction in caries -y
t,e a/t,ors was considered misleadin* and inaroriate +or esta-lis,in* +l/oridation
e++ecti"eness. Nonet,eless, it is clear +rom st/dies cited re"io/sly t,at t,ere ,as -een
a worldwide decline in dental-caries rates e"en t,o/*, certain o/lation *ro/s are
still disroortionately a++ected -y dental caries. 5,e decline in dental-caries rates ,as
-een attri-/ted to t,e widesread /se o+ m/ltile +l/orides +rom "ario/s so/rces9
comm/nity 3ater supplies, supplements, fluoride rinses $els, and varnishes, and
dentifrices,
:=,=&-=<
5,e red/ction in t,e a-sol/te meas/ra-le -ene+its o+ water +l/oridation ,as -een
attri-/ted to t,e dilution and diffusion e++ects.
:=
Dilution res/lts +rom t,e increased
a"aila-ility o+ +l/oride +rom m/ltile so/rces, dilutin$ the impact of any one source of
fluoride, incl/din* water.
;,>;,=<-=%
Accordin* to !ia, Jdilution is the apparent
reduction in the measura4le 3ater fluoridation 4enefits resultin$ from the u4i5uitous
availa4ility of fluoride from other sources in 4oth the fluoridated and the fluoride
deficient comparison community,F
:=
5oday, t,e most /ni"ersally a"aila-le so/rce o+
+l/oride in t,e United States is +l/oride-containin* denti+rice 7toot,aste8.
:=,='
All
fluoride2containin$ dentifrices ,a"e very hi$h levels of fluoride (C,C:: to C,>:: ppm)
and are a si*ni+icant so/rce o+ +l/oride o"ere0os/re and +l/orosis. Moreo"er, t,ey
are not meant to -e swallowed, esecially d/rin* t,e years w,en t,e crowns o+ teet,
are +ormin*. Nearly +o/r decades a*o, t,e American Dental Association 7ADA8 *a"e
its seal o+ aro"al to Crest toot,aste, t,e only +l/oride denti+rice a"aila-le at t,at
time. Howe"er, -y :;($, HF; of the availa4le dentifrices contained fluoride,
:=,=(
In searate st/dies, 1r/nelle and Carlos in :;;$ and M/rray in :;;> +o/nd *reater
ercenta*es o+ caries-+ree c,ildren and lower caries-re"alence rates in +l/oridated
comm/nities w,ere ot,er so/rces o+ +l/oride were also a"aila-le. A+ter adA/stin* +or
ot,er so/rces o+ +l/oride, t,ey +o/nd a >'E di++erence in dental-caries re"alence.
5,e +indin*s o+ t,ese two st/dies led t,e researc,ers to concl/de t,at 3ater
fluoridation remains an important contri4utor to caries re"ention.
;,>;
5,e ot,er maAor modi+yin* +actor re*ardin* t,e e++ecti"eness o+ +l/oridation, t,e
diffusion e++ect, res/lts +rom t,e cons/mtion o+ commercial +oods and -e"era*es t,at
were rocessed in a +l/oridated comm/nity and transorted to +l/oride-de+icient
comm/nities,
:=,=;
makin* +l/oride a"aila-le to cons/mers in t,e +l/oride-de+icient
comm/nity.
:=,=;
!ia descri-ed diffusion as Jthe extension of 4enefits of community
3ater fluoridation to residents of fluoride2deficient communities,J
:=
Diffusion ,as also
-een called t,e Jhalo effect,J 5,e di++erences in caries re"alence rates -etween
+l/oridated and non+l/oridated comm/nities are diminis,in*.
:=,&$
Accordin* to !ia,
Ft,e weaker association reorted -y contemorary st/dies -etween e0os/re to
+l/oridated drinkin* water and caries e0erience, t,ere+ore, is not d/e to a lessenin*
o+ t,e e++ects o+ water-orne +l/oride, -/t is act/ally ca/sed -y t,e e0tension o+ t,ose
e++ects, t,ro/*, a rocess o+ Cdiffusion,C o+ +l/oride into +l/oride-de+icient areas.F
:=

Increased tra"elin* to +l/oridated comm/nities imacts t,e e++ect o+ di++/sion as well.
Also, residents w,o li"e in a +l/oride-de+icient comm/nity and work on a military
4ase in t,e same comm/nity may -e e0osed to +l/oridated water since most military
-ases are +l/oridated.
As descri-ed a-o"e, t,e decline in dental-caries rates was *reatest 7/ to <' to %$E8
in t,e earlier years 7:;&$s, :;'$s, :;<$s8 o+ +l/oridation w,en water was t,e rimary
so/rce o+ +l/oride and t,e a"aila-ility o+ ot,er so/rces o+ +l/oride was limited. 5,e
caries-in,i-ition e++ecti"eness o+ +l/oride in water res/lted in a arallel r/s, to
de"elo ot,er so/rces o+ +l/orides9 7:8 adA/ncti"e systemic fluorides, s/c, as ta-lets,
dros, lo@en*es, and "itamins wit, +l/oride, w,ic, are meant to -e swallowed and are
rescrition items intended to -e disensed to t,e /-lic -y licensed ,ealt,
ro+essionalsD and 7>8 toical +l/orides, w,ic, are intended only +or toical
alication and are not meant to -e swallowed.
:=,=&
Some topical fluorides are /sed -y
ro+essionals in t,e dental o++ice w,ile ot,ers are /sed in /-lic-,ealt, ro*rams and
in sc,ools. Additionally, o"er-t,e-co/nter 7O5C8 rod/cts are /sed -y cons/mers.
:=,=&

As more cities adoted +l/oridation and t,e in*estion o+ dietary +l/oride s/lements
increased in +l/oride-de+icient comm/nities, cons/mer /se o+ +l/oride-containin*
rod/cts s/c, as toot,astes, mo/t,rinses, and *els also increased. As a res/lt,
e0os/re to +l/oride +rom n/mero/s so/rces ,as -ecome more widesread, wit,
-ene+its accr/in* at "aryin* le"els. At t,e same time, it is -ecomin* more difficult to
accurately determine the level of reduction in caries rates attri-/ted to +l/oridated
water alone "ers/s ot,er so/rces. Most researc,ers now -elie"e t,at t,e JdilutionJ
and JdiffusionJ e++ects are resonsi-le +or t,e decline in dental caries rates in
non+l/oridated, and to a lesser de*ree, in +l/oridated comm/nities.
;
Mechanisms of Action
Systemic +l/orides are -ene+icial in decay re"ention in t,at t,ey are in*ested and
incororated directly into t,e ,ydro0yaatite crystalline str/ct/re o+ t,e de"eloin*
toot,. 5,e smaller +l/oride ions relace ,ydro0yl ions in t,e crystalline str/ct/re o+
t,e toot,, rod/cin* a less-sol/-le aatite crystal
:=,&:
O"er t,e ast se"eral decades,
t,e caries-re"enti"e roerties o+ +l/oride ,a"e -een attri-/ted rimarily to its pre2
eruptive effects on t,e de"eloin* teet,. 1/t systemic +l/orides also ro"ide a toical
e++ect res/ltin* in marked post2eruptive 4enefits, Sali"a, w,ic, contains +l/oride +rom
in*estion, is contin/ally a"aila-le at t,e toot, s/r+ace and -ecomes concentrated in
dental la?/e w,ere it in,i-its acid-rod/cin* cario*enic -acteria +rom deminerali@ed
toot, enamel. Fl/oride accomlis,es t,is -y inter+erin* wit, t,e en@ymatic acti"ity o+
t,e -acteria and -y controllin* intracell/lar H, t,/s red/cin* -acterial acid
rod/ction and t,ere-y red/cin* dissol/tion o+ toot, enamel.
:,>>,&>-&(
Accordin* to
1owen, +l/oride concentration in t,e la?/e is '$ to :$$ times ,i*,er t,an in t,e
w,ole sali"a.
:=,&;
Fl/oride also interacts wit, calci/m and ,os,ate ions +rom sali"a and adsor-s to t,e
toot, s/r+ace, t,ere-y en,ancin* reminerali@ation.
'$
!ecent researc, s,ows t,at
reminerali@ation reresents t,e rimary mec,anism -y w,ic, +l/oride works,
occ/rrin* a+ter toot, er/tion, and makin* t,e toical e++ect imortant in caries
red/ction +or eole o+ all a*es.
In s/mmary, systemic +l/oride ,as -een +o/nd to red/ce dental decay -y t,ree
mec,anisms9 7:8 t,e con"ersion o+ ,ydro0yaatite into +l/oraatite w,ic, red/ces t,e
sol/-ility o+ toot, enamel in acid and makes it more resistant to decayD 7>8 red/ction
o+ acid rod/ction -y dental-la?/e or*anismsD and 7=8 t,e reminerali@ation o+ toot,
enamel t,at ,as -een deminerali@ed -y acids rod/ced -y decay ca/sin* -acteria.
:
Question 2
4,ic, o+ t,e +ollowin* statements, i+ any, isBare correcte
A. Fl/oridation re"ents an estimated >$ to =$E o+ coronal caries in ad/lts and an
estimated >$ to &$E o+ root caries.
1. Dilution is t,e Faarent red/ction in meas/ra-le water +l/oridation -ene+its
res/ltin* +rom t,e /-i?/ito/s a"aila-ility o+ +l/oride +rom ot,er so/rcesF s/c, as
+l/oride-containin* denti+rice, +l/oride mo/t,rinses, and ro+essionally-alied
toical +l/orides.
C. Diffusion is t,e Fe0tension o+ t,e -ene+its o+ comm/nity water +l/oridation to
residents o+ +l/oride-de+icient comm/nitiesF s/c, as occ/rs w,en residents o+
non+l/oridated comm/nities work in +l/oridated comm/nities, w,en, c,ildren +rom
non+l/oridated comm/nities attend sc,ool in +l/oridated comm/nities, and w,en
eole +rom non+l/oridated comm/nities cons/me certain +oods rocessed in
+l/oridated comm/nities.
D. All +l/oride-containin* denti+rices ,a"e "ery low le"els o+ +l/oride and do not
contri-/te to +l/oride o"ere0os/re and +l/orosis.
3. Fl/oride red/ces 7:8 acid rod/ction in t,e la?/e w,ic, 7>8 red/ces t,e amo/nt o+
deminerali@ation, w,ic, 7=8 allows t,e toot, to more easily FreairF itsel+ -y
reminerali@ation.
Dental Fl/orosis
Dental +l/orosis ,as -een descri-ed as a series o+ conditions occ/rrin* in t,ose teet,
t,at ,a"e -een e0osed to e0cessi"e so/rces o+ +l/oride in*ested d/rin* enamel
+ormation. Dental +l/orosis can resent in a n/m-er o+ ways, +rom a -arely
discerna-le w,ite lacy aearance to a more se"ere +orm t,at co/ld -e classi+ied as a
de"elomental de+ect o+ t,e enamel.
:=
Fl/orosis, re*ardless o+ se"erity, cannot occur
once enamel formation is complete and the teeth have erupted8 therefore older
children and adults are not at ris* for dental fluorosis,
:,':-'>
Dental +l/orosis occ/rs
w,en c,ildren cons/me e0cessi"e le"els o+ +l/oride in "ario/s ways, s/c, as w,en
drinkin* water +rom ri"ate wells or comm/nity-water systems wit, ,i*,er-t,an-
otim/m le"els o+ nat/rally occ/rrin* +l/oride. Howe"er, t,e *reatest likeli,ood o+
e0os/re to e0cess +l/oride in c,ildren res/lts +rom9 7:8 inadvertent in$estion of
toothpaste containin* "ery ,i*, concentrations o+ +l/oride and 7>8 takin* o+
inaroriately rescri-ed dietary +l/oride s/lements.
:,'=
5,e de*ree o+ +l/orosis
deends on t,e total dose o+ +l/oride, as well as on t,e timin* and d/ration o+ +l/oride
e0os/re.
'&
In :;&>, H. 5rendley Dean de"eloed a system of classification for dental fluorosis,
He esta-lis,ed a series o+ cate*ories t,at ran*ed +rom ?/estiona-le 7w,ite +lecks or
sots or Fsnowcain*F8, to "ery mild 7small oa?/e aer-w,ite areas or streaks
known as "einin*, co"erin* less t,an >'E o+ t,e toot, s/r+ace, to mild 7oa?/e w,ite
areas co"erin* less t,an >'E o+ t,e toot, s/r+ace8, to moderate 7marked wear on
occl/salBincisal s/r+aces, may incl/de -rown stains8, to se"ere 7mottlin* and -rown
stainin* a++ectin* all toot, s/r+aces8.
:=
DeanCs +l/orosis inde0 contin/es to -e widely
/sed today.
:,''
Howe"er, not all enamel oacities are ca/sed -y +l/orosisD some are
ca/sed -y ot,er c,emical a*ents s/c, as strontium or ,armace/tical a*ents s/c, as
tetracycline, Idioat,ic oacities also e0ist +or w,ic, t,e ca/se7s8 isBare c/rrently
/nknown.
:=,'<
Accordin* to a s/r"ey cond/cted -y t,e National Instit/te o+ Dental
!esearc, in :;(< to :;(%, t,e maAority o+ +l/orosis cases identi+ied 3ere classified as
4ein$ very mild or mild, 5,e minor +orms o+ +l/orosis 7?/estiona-le, "ery mild, or
mild +l/orosis8 are not considered to -e a-normal, nor are t,ey considered to
constit/te an ad"erse ,ealt, e++ect. Howe"er, -ot, researc,ers and ractitioners
s,o/ld contin/e to monitor and assess t,e risk o+ dental +l/orosis in order to ens/re
t,at t,e more se"ere +orms o+ +l/orosis do not occ/r. In :;=<, 5rendley Dean
estimated t,at aro0imately C:; o+ c,ildren w,o drank otimally +l/oridated water
wo/ld de"elo very mild dental fluorosis,
'%
More recent st/dies ,a"e s,own t,at
dental +l/orosis attri-/ted to +l/oridation is aro/nd CA;,
:,'(
As re"io/sly mentioned, ?/estiona-le, "ery mild, and mild +l/orosis /s/ally res/lt
+rom "ery yo/n* c,ildren swallowin* too m/c, +l/oride-containin* toot,aste or
+rom t,e inaroriate s/lementation wit, rescrition +l/oride rod/cts s/c, as 7:8
w,en ,ysicians and dentists indeendently rescri-e +l/oride s/lements, or 7>8
w,en ,ysicians and dentists rescri-e +l/oride s/lements wit,o/t c,eckin* t,e
+l/oride content o+ t,e c,ildCs water s/ly so t,at, in eit,er case, a c,ild *ets a
Fdo/-leF dose o+ +l/oride on a daily -asis. Monitorin* total +l/oride intake is
comlicated considerin* t,e a"aila-ility o+ m/ltile so/rces o+ +l/oride. Also, +l/oride
+rom ta-letsBdros is in*ested and a-sor-ed at one time o+ day as oosed to +l/oride
in water w,ere t,e in*estion and a-sortion o+ low-dose +l/oride is distri-/ted
t,ro/*,o/t t,e day. 5,ese +actors ,a"e -een considered in t,e esta-lis,ment o+
+l/oride dosa*e sc,ed/les w,ere in recent years, t,e dosa*es ,a"e -een lowered,
artic/larly in t,e +irst < mont,s o+ li+e. 5,e Dietary 'luoride Supplement Schedule
aro"ed -y t,e American Dental Association, t,e American Academy o+ )ediatrics,
and t,e American Academy o+ )ediatric Dentistry s,o/ld -e +ollowed w,en
rescri-in* +l/oride s/lements
%
7see 5a-le (-=, +l/oride s/lements8. Fl/oride
in*estion s,o/ld -e red/ced d/rin* t,e a*es o+ toot, de"eloment, artic/larly /nder
t,e a*e o+ t,ree. )arents need to assist in attainment o+ t,is *oal 4y supervisin$ small
children d/rin* toot,-r/s,in* to ens/re t,at t,eir c,ildren do not swallow t,e
toot,aste.
Anti+l/oridation *ro/s +re?/ently and inaroriately e0,i-it ,oto*ra,s o+
c,ildren andBor ad/lts ,a"in* se"ere fluorosis in w,ic, ittin* or mottlin* o+ t,e
enamel and -rown stains are e"ident and attri-/te t,ese mani+estations directly to
water +l/oridation, o+ten descri-in* dental +l/orosis as a maAor risk +actor +or eole
o+ all a*es. In makin* dental-,ealt, decisions, atients deend /on t,e dental
ro+essional team to assist t,em in e"al/atin* t,e risks "ers/s t,e -ene+its o+ a *i"en
roced/re or /-lic ,ealt, meas/re. 5o do t,is, dentists and dental ,y*ienists need to
stay c/rrent re*ardin* t,e scienti+ic literat/re and to /se t,is knowled*e as a -asis +or
ed/catin* t,emsel"es and t,eir atients. 5,e risk o+ de"eloin* very mild fluorosis
versus t,e -ene+it o+ decreased dental caries and attendant treatment costs s,o/ld -e
comm/nicated to atients w,o e0ress concern.
Discontin/ation o+ 4ater Fl/oridation
Oosition to +l/oridation, as well as *o"ernmental action, ,as res/lted in t,e
discontin/ance o+ t,is /-lic-,ealt, meas/re in "ario/s locales. Interestin*ly eno/*,,
t,e cessation or discontinuation o+ +l/oridation ,as res/lted in t,e imlementation o+
se"eral st/dies to determine t,e imact o+ s/c, re"ersals on dental ,ealt,. !es/lts
,a"e consistently s,own t,at dental-caries rates increase dramatically w,en
+l/oridation is discontin/ed. In :;<$, t,e city o+ Anti*o, 4isconsin, discontin/ed
+l/oridation a+ter ,a"in* +l/oridation +or :: years. Si0 years later, w,en Anti*o
elementary sc,ool c,ildren were +o/nd to ,a"e s/-stantial increases in caries rates,
ran*in* +rom BC to D: percent, fluoridation 3as reinstated,
:=,';
Similar +indin*s
occ/rred in Scotland /on cessation o+ +l/oridation w,ere in t,e town o+ 4ick, caries
rates increased -y B:; in primary teeth and 4y <D; in permanent teeth, 5,is
dramatic increase in dental-caries rates occ/rred despite +l/oride toot,aste -ein*
readily a"aila-le and national-caries rates in Scotland contin/in* to decline.
:=,<$

Moreo"er, ' years a+ter +l/oridation was discontin/ed in t,e town o+ Stranraer, caries
rates increased to le"els aroac,in* t,ose +o/nd in t,e non+l/oridated town o+
Annan. In Stranraer, restorati"e dental treatment costs +or decay alone rose -y
CC>;,
:,:=,<:
Similar res/lts can occ/r i+ a city c,an*es its water so/rce +rom one t,at is otimally
+l/oridated to one t,at is +l/oride-de+icient. 5,e imact wo/ld -e e?/i"alent to
discontin/ation o+ +l/oridation. In a )/-lic Healt, Ser"ice !eort on risks and
-ene+its o+ +l/oride, it stated t,at Fone way to demonstrate t,e e++ecti"eness o+ a
t,erae/tic a*ent, s/c, as +l/oride, is to o-ser"e i+ t,e -ene+its are lost w,en t,e a*ent
is remo"ed.F
:=,<>
Clearly, t,ese st/dies ser"e to demonstrate t,at t,e discontin/ation o+
comm/nity water +l/oridation ,as res/lted in t,e si*ni+icant loss o+ dental caries
re"enti"e -ene+its.
:,<=
Cost of Water Fluoridation
4ater +l/oridation ro"ides si*ni+icant cost sa"in*s +or a comm/nity and ,as -een
descri-ed as Fone o+ t,e most cost-e++ecti"e re"enti"e dental ro*rams a"aila-le.F
:=,<&
3stimates o+ t,e cost o+ water +l/oridation will "ary deendin* /on t,e +actors
incl/ded in t,e calc/lations.
:=,<'
5,e si@e and comle0ity o+ t,e water system,
incl/din* t,e n/m-er o+ systems, t,e n/m-er o+ wells, w,et,er or not t,e systems /se
a dry +eeder or sol/tion 7wet8 +eeder system, /rc,ase o+ e?/iment and installation,
/rc,ase o+ +l/oride, la-or, and maintenance, as well as t,e n/m-er o+ ser"ice
connections and si@e o+ t,e o/lation all +actor into t,e cost o+ +l/oridation.
:=,<&-<<
JThe cost of 3ater fluoridation is usually expressed as the annual cost per person of
the population 4ein$ served,J
:=
An in"erse relations,i e0ists -etween t,e cost er
erson and t,e o/lation o+ a comm/nity. Conse?/ently, t,e cost er erson is lower
in lar*er comm/nities and ,i*,er in smaller comm/nities w,ere t,e act/al cost o+
+l/oridation may aroac, t,at o+ ot,er met,ods o+ caries re"ention.
<'
Fl/oridation
also eliminates or diminis,es additional costs inc/rred t,ro/*, ot,er +orms o+ +l/oride
administration, s/c, as costs inc/rred w,en accessin* ro+essionals in order to o-tain
ro"ider-rescri-ed +l/oride rod/cts, comliance irre*/larities, and t,e lower
e++ecti"eness o+ ot,er +orms o+ +l/oride distri-/tion. Fl/oridation is t,e most cost-
e++icient and cost-e++ecti"e met,od o+ dental caries re"ention +or almost all
comm/nities
%
7see 5a-le (-&, costB-ene+it8.
Anot,er way to look at cost-sa"in* -ene+its is to determine t,e -ene+iciaries o+ dental-
treatment cost sa"in*s. 3mloyers w,o ay reaid dental-care +rin*e -ene+its +or
t,eir emloyees sa"e on costs. Hidden rod/ction or ser"ice costs ca/sed -y dentally-
related missed workdays -y emloyees are also minimi@ed t,ro/*, +l/oridation.
5a0ayers w,o s/ort /-lic ro*rams wo/ld also -ene+it +rom dental-treatment
cost sa"in*s. In +act, skyrocketin* dental Medicaid e0endit/res in Cali+ornia 7a state
wit, a low ercenta*e o+ t,e o/lation ,a"in* access to +l/oridation8 ro"ided t,e
imet/s +or t,e enactment o+ a statewide mandatory +l/oridation -ill t,ere in :;;'.
<%-<(
As will -e disc/ssed later, recent st/dies comarin* dental Medicaid e0endit/res in
.o/isiana and 5e0as also demonstrated t,at treatment costs were si*ni+icantly ,i*,er
in non+l/oridated comm/nities t,an t,ey were in +l/oridated comm/nities. )atients
can also -e e0ected to -ene+it +rom lower ,ealt,-care -ills, lower dental-care costs,
and lower ins/rance remi/ms -eca/se o+ lower costs inc/rred -y ro"iders +or
/ncomensated care.
>
4it, t,e a"aila-ility o+ -aseline le"els o+ dental-caries rates and treatment costs, two
di++erent tyes o+ analyses can -e done to determine 7:8 t,e effectiveness o+
+l/oridation as a dental2caries preventive measure (cost2effectiveness analysis) as well
as 7>8 associated cost sa"in*s 7a cost24enefit analysis,8
:=
!ia ,as stated t,at Ft,e
$reater the initial caries prevalence and treatment costs, t,e $reater the potential
4enefits to -e reali@ed -y t,e introd/ction o+ +l/oridation.F
:=
5,e national a"era*e
rec/rrin* cost o+ water +l/oridation ,as -een estimated at f$.'$ er erson er year
w,ile t,e national a"era*e cost o+ one simle restoration is f<>.
%,<<
I+ one were to
m/ltily t,e aro0imate a"era*e li+e e0ectancy o+ a U.S. resident 7%' years8 -y t,e
ann/al er caita cost o+ +l/oridation 7f$.'$8, it aears e"ident t,at t,e KAD,>: total
+or a lifetime of protection t,ro/*, +l/oridation wo/ld more t,an o++set t,e cost o+ A/st
one simle restoration +or one toot,.
=,:=,<;
Additionally, +or e"ery cario/s lesion
initially re"ented, t,e need +or reeated restorations and treatment o+ recurrent
cario/s lesions is red/ced o"er a li+etime.
:=,%$
Di++erent st/dies ,a"e s,own t,at t,e
relacement rates +or amal*am restorations ca/sed -y rec/rrent decay "aries -etween
=( and '$ED t,e sa"in*s to -e reali@ed +rom re"ention are s/-stantial.
:=,%:,%>
5,e
national a"era*e -ene+it-to-cost ratio +or +l/oridation is9 ($9:D 7MM4!B CDC8 on
a"era*e, for every KC dollar spent on fluoridation, KF: is saved in treatment costs,
=,<<
5,ree recent st/dies +/rt,er demonstrate t,e s/-stantial cost--ene+its *enerated
t,ro/*, comm/nity water +l/oridation. 1rown and collea*/es, in a comre,ensi"e
st/dy +or t,e 5e0as Deartment o+ Healt, were a-le to demonstrate cost-sa"in*s +or
t,e /-licly +/nded 5e0as Healt, Stes )ro*ram 75e0as 3)SD5-Medicaid )ro*ram8
w,en comarin* ro*ram costs +or clients +rom +l/oridated comm/nities wit, t,ose
+rom non-+l/oridated comm/nities.
%=
Similarly, 1arsley and collea*/es were a-le to
demonstrate t,at t,e costs +or ,osital--ased treatment o+ ac/te dental conditions to
.o/isianaCs /-licly +/nded Medicaid )ro*ram were m/c, less +or residents o+
+l/oridated comm/nities t,an +or residents o+ non+l/oridated comm/nities.
%&,%'
Finally,
4ri*,t and collea*/es esta-lis,ed concl/si"ely t,at +l/oridation remains an e0tremely
cost-e++ecti"e /-lic-,ealt, ro*ram in New Iealand in t,eir comre,ensi"e :;;;
reort +or t,e New Iealand Ministry o+ Healt,.
%<
Question 3
4,ic, o+ t,e +ollowin* statements, i+ any isBare correcte
A. Dental +l/orosis occ/rs w,en an e0cessi"e amo/nt o+ +l/oride is in*ested d/rin*
t,e eriod o+ enamel +ormation only,
1. Dental +l/orosis does not occ/r once enamel +ormation is comlete and t,e teet,
,a"e er/ted, t,ere+ore older c,ildren and ad/lts are not at risk +or dental +l/orosis.
C. Discontin/ation o+ +l/oridation ,as no imact on dental caries rates.
D. 5,e national cost--ene+it ratio attri-/ted to water +l/oridation is ;'9:.
3. 5,e national a"era*e cost to +l/oridate a /-lic water system in t,e U.S. is
aro0imately f$.'$ er erson er year.
Otimal Fl/oride .e"els
5,e U.S. )/-lic Healt, Ser"ice esta-lis,ed an otimal standard +or +l/oride in t,e
drinkin* water in t,e United States -ased /on t,e annual avera$e of maximum daily
air temperature, As a res/lt, t,e otimal le"el is act/ally a ran*e, $.% to :.> m 7see
5a-le (-', otimal le"els8, w,ic, ass/mes *reater water cons/mtion in ,otter
climates and less water cons/mtion in colder climates.
:&
Conse?/ently, the hi$her
the avera$e temperature in a community, the lo3er the recommended 3ater fluoride
level,
Howe"er, determinin* daily +l/oride intake is imacted -y ot,er +actors s/c, as
cons/mer /se o+ ,ome distillation and re"erse-osmosis water-treatment systems
w,ic, can remo"e si*ni+icant amo/nts o+ +l/oride +rom t,e water s/ly.
:=,%%-($
5,e
cons/mtion o+ -ottled water and ot,er -e"era*es, s/c, as so+t drinks and +r/it A/ices,
comlicate t,e matter since +l/oride le"els in t,ese -e"era*es "aries *reatly.
:=,%(,($-(:

Additionally, determination o+ +l/oride intake may -e altered -y t,e widesread /se
o+ air conditionin* in ,omes, a/tomo-iles, and worklaces s/c, t,at some eole
+rom warmer climates no lon*er re?/ire t,e ,i*,er "ol/mes o+ li?/id. For t,ese
reasons, 1/rt ,as ca/tioned t,at temerat/re */idelines /sed in esta-lis,in* t,e
otimal ran*e need to -e eriodically monitored in order to determine t,e need +or
re"ision.
:&
Hon* 2on* ,as adA/sted its water +l/oride le"el since initiatin* +l/oridation
to ac,ie"e its *oal o+ ma0imi@in* t,e -ene+its o+ caries red/ction w,ile minimi@in*
t,e risk o+ +l/orosis in an en"ironment o+ increased +l/oride e0os/re.
(>
In a :;;&
reort iss/ed -y t,e 4orld Healt, Or*ani@ation, it was recommended t,at some
re*ions, esecially troical and s/-troical areas, re"ise t,e otimal ran*e to esta-lis,
aroriate ,i*,er and lower limits.
(>
Safety of Water Fluoridation
5,e iss/e o+ sa+ety relati"e to addin* +l/oride to t,e water s/ly ,as o+ten -een
raised in +l/oridation camai*ns -y oonents w,o attri-/te nearly e"ery disease
known to mankind to +l/oridation. It is common ractice +or +l/oridation oonents to
distri-/te ict/res o+ c,ildren alle*ed to ,a"e crilin* skeletal +l/orosis and attri-/te
t,e malady to +l/oridation. Skeletal +l/orosis occ/rs in India and ot,er areas t,at ,a"e
extremely hi$h natural fluoride levels, ran*in* from <: to F: ppm,
(=
Decades a*o, +i"e
doc/mented cases o+ skeletal +l/orosis were +o/nd in t,e United States, 7in r/ral areas
wit, well water in w,ic, t,e nat/ral +l/oride le"el was +o/nd to -e "ery ,i*,8.
:,(=
At
t,e time, /-lic ,ealt, a/t,orities resol"ed t,e ro-lem -y installin* defluoridation
e?/iment and since t,en, t,ere ,as not -een a doc/mented case o+ skeletal +l/orosis
in t,e United States ot,er t,an a-o/t >' cases occ/rrin* +rom occ/ational
e0os/res.
:
1eca/se o+ +l/orideCs a++inity +or -ones and teet,, its imact on -one
,ealt, is o+ten called into ?/estion -y anti-+l/oridationists. 1y imlementin* water
+l/oridation at t,e recommended le"el 7$.% to :.> m8, t,ere is no e"idence o+
anyone de"eloin* skeletal +l/orosis.
:
C/rrently, in t,e United States, nat/rally
occ/rrin* +l/oride le"els "ary widely +rom less t,an $.: m to *reater t,an := m.
5,e "ariation in +l/oride le"els in /-lic water systems is amena-le to adA/stment9 7a8
/ward to ac,ie"e dentally t,erae/tic le"els in comm/nity water s/lies t,at are
+l/oride de+icient t,ro/*, +l/oridation or 7-8 downward to attain t,e ma0im/m
concentration o+ +l/oride allowa-le -y defluoridation,
:=
Howe"er, instances o+
defluoridation are rare 7disc/ssed in later section8.
In *eneral, sa+ety concerns a-o/t +l/oridation relate to a n/m-er o+ +actors, incl/din*9
to0icity o+ +l/oride, total +l/oride intake, +l/oride a-sortion, t,e imact on ,/man
,ealt,, t,e e++ect on t,e en"ironment, water ?/ality, and t,e en*ineerin* asects. O"er
t,e ast '< years, n/mero/s st/dies ,a"e -een cond/cted in comm/nities w,ere t,e
nat/ral +l/oride le"el is eit,er ,i*,er t,an or e?/i"alent to t,e recommended le"el +or
dental-caries re"ention, as well as in comm/nities w,ere t,e +l/oride le"el ,as -een
adA/sted to t,e otimal le"elD res/lts ,a"e reeatedly and con"incin*ly con+irmed t,e
sa+ety o+ +l/oride in t,e water s/ly.
(&-(<
Since t,e late :;%$s, alle*ations a*ainst +l/oridation ,a"e +oc/sed on cancer. 5,e
ossi-ility o+ a cancer risk associated wit, +l/oridation o+ /-lic-water s/lies was
raised in a :;%% sel+-/-lis,ed aer a-o/t >$ U.S. cities.
(%-((
5,e analyses /rorted
to s,ow t,at +l/oridation o+ drinkin* water in :$ o+ t,e cities ca/sed a :$E increase in
cancer mortality in t,ose cities comared wit, :$ ot,er cities t,at did not ,a"e
+l/oridation. Accordin* to t,e a/t,ors, -e+ore +l/oridation, t,e a"era*e cancer deat,
rates were increasin* in a similar manner in -ot, *ro/s o+ cities -/t immediately
a+ter t,e start o+ +l/oridation, t,e rates di"er*ed wit, ,i*,er cancer mortality rates
seen in t,e +l/oridated *ro/ "s. t,e non+l/oridated *ro/.
(%-((
5,e immediate
di"er*ence in rates +ailed to +actor in t,e latency eriod +or cancer 7/s/ally o"er '
years, and +or some cancers, as lon* as >$ to =$ years8.
(;-;$
Mani+estation o+ a
di"er*ence in cancer mortality rates wo/ld re?/ire ' to :$ years -etween e0os/re
and deat, +rom cancer. Since t,e di"er*ence in cr/de cancer mortality occ/rred at t,e
e0act same time t,at +l/oridation was introd/ced, it is inacc/rate and disin*en/o/s to
attri-/te t,e di"er*ence to +l/oridation.
(;-;$
Also, a"era*e cr/de deat, rates were /sed
in t,e st/dy, i*norin* t,e di++erences and c,an*es in a*e, race, and se0 comosition,
widely reco*ni@ed risk +actors known to a++ect t,e deat, rates +rom seci+ic tyes o+
cancer.
(;-;$
S/-se?/ent analyses o+ t,e same set o+ data -y National Cancer Instit/te
in"esti*ators, /sin* internationally acceted eidemiolo*ical met,ods and controllin*
+or con+o/ndin* "aria-les, concl/ded t,at t,ere was no evidence t,at +l/oridation
ca/sed cancer in t,e :$ +l/oridated cities.
;:
Follow-/ st/dies, incl/din* st/dies in
o/lations wit, ,i*, le"els o+ nat/rally occ/rrin* +l/oride in water in t,e U.S. and
"ario/s ot,er co/ntries also +ailed to s,ow a ositi"e relations,i -etween +l/oridation
and cancer.
;>-;(
!es/lts o+ st/dies o+ +l/oridation and cancer were reorted -y t,e
!oyal Colle*e o+ ),ysicians in 1ritain in :;%< in w,ic, t,ey concl/ded9 Ft,ere is no
e"idence t,at +l/oride increases t,e incidence or mortality o+ cancer in any or*an.F
S/-se?/ently, 1ritis, researc,ers, Drs. Doll and 2inlen, reorted in t,e (ancet t,at
Fnone o+ t,e e"idence ro"ided any reason to s/ort t,at +l/oridation is associated
wit, an increase in cancer mortality, let alone ca/ses it.F
;;
In :;;$ two searate st/dies -y t,e National 5o0icolo*y )ro*ram 7N5)8 o+ t,e
National Instit/te o+ 3n"ironmental Healt, Sciences and )rocter and Gam-le were
cond/cted to assess t,e carcino*enicity o+ sodi/m +l/oride in w,ic, rats and mice
were deli-erately +ed e0cessi"e amo/nts o+ +l/oride 7%' to :>' m8. One *ro/, male
rats, s,owed Fe?/i"ocalF e"idence o+ carcino*enicity, w,ere Fe?/i"ocalF is de+ined -y
t,e N5) as a mar*inal increase in osteosarcomas t,at may -e c,emically related, -/t
in w,ic, t,ere is ins/++icient e"idence to ro"e or disro"e t,at a relations,i
e0ists.
:,:$$-:$>
S/-se?/ently, t,e U.S. )/-lic Healt, Ser"ice esta-lis,ed a
S/-committee on Fl/oride to re"iew t,e st/dies. 5,e S/-committee on Fl/oride
determined t,at t,e two animal st/dies +ailed to esta-lis, an association -etween
+l/oride and cancer. 5,e N5) !eort romted a comre,ensi"e F!e"iew o+ +l/oride9
-ene+its and risksF -y t,e U.S. )/-lic Healt, Ser"ice in :;;: in w,ic, it concl/ded
t,at +l/oride in water is not carcino*enic. Ot,er comre,ensi"e re"iews came to t,e
same concl/sion.
:,(&,(<,;%,:$=-:$&
Additionally, scientists at t,e National Cancer Instit/te e0amined more t,an >.>
million deat, records and :>',$$$ cancer case records in co/nties /sin* +l/oridated
water and concl/ded t,at t,ere was no indication o+ a cancer risk associated wit,
+l/oridated drinkin* water.
:
In a reort reared in :;;= -y t,e National Academy o+ Science, National !esearc,
Co/ncil at t,e re?/est o+ 3n"ironmental )rotection A*ency 73)A8, a re"iew o+ t,e
literat/re +oc/sed on to0icity and ,ealt, risks o+ +l/oride. 5,is reort stated t,at t,e
Fc/rrently allowa-le +l/oride le"els in drinkin* water do not ose a risk +or ,ealt,
ro-lems s/c, as cancer, kidney +ail/re or -one diseaseF and t,at t,e 3)ACs rimary
standard o+ & m +or nat/rally occ/rrin* +l/oride wo/ld ro"ide an ade?/ate mar*in
o+ sa+ety a*ainst ad"erse ,ealt, e++ects.
:,(<,:$'-:$<
The Safe Drin*in$ -ater ct, enacted -y Con*ress in :;(<, esta-lis,ed primary and
secondary standards +or natural fluoride levels in /-lic drinkin* water in t,e United
States. 5,e le*islation set t,e primary standard 7t,e ma0im/m concentration o+
+l/oride allowed in /-lic drinkin* water systems8 at B,: ppm and +/rt,er stated t,at
natural water so/rces e0ceedin* t,is le"el must -e de+l/oridated,
:=,:&,:$%
alt,o/*, no
comm/nities ,a"e de+l/oridated /nder t,is ro"ision. A secondary standard o+ >.$
m +or a natural so/rce was also esta-lis,ed as t,e recommended ma0im/m. Under
t,is secondary standard, w,en t,e water e0ceeds >.$ m, comm/nity residents are
informed o+ t,e *reater risk +or dental +l/orosis.
:=,:$%
4,ereas t,e 3)A is resonsi-le +or monitorin* /-lic-water systems in t,e United
States, it re?/ires t,at /-lic-water systems not e0ceed +l/oride le"els o+ & mD
/-lic water systems wit, nat/ral le"els e0ceedin* t,e limit are e0ected to
defluoridate in accordance wit, t,e rimary standard. Defluoridation is in+re?/ently
imlemented in t,e United States rimarily -eca/se o+ t,e lack o+ demand on t,e art
o+ t,e /-lic li"in* in ,i*, nat/ral +l/oride areas o+ t,e co/ntry.
:=
Defluoridation also
,as -/d*etary imlications in t,at t,e cost o+ de+l/oridation +or a comm/nity ,a"in*
,i*, nat/ral +l/oride le"els is aro0imately C: times $reater t,an t,e cost o+
+l/oridatin* a water s/ly in a comm/nity wit, de+icient nat/ral +l/oride le"els.
:=

Also, some comm/nities may -e +orced to +ind alternati"e water s/lies in t,e e"ent
o+ +orced clos/re o+ e0istin* water s/lies ,a"in* nat/ral +l/oride le"els e0ceedin*
t,e primary standard, Findin* alternati"e water s/lies oses a maAor c,allen*e +or
many comm/nities in t,e United States. Comliance wit, 3)A standards in
*eo*ra,ical areas ,a"in* ,i*, nat/ral +l/oride le"els may -e *reatly a++ected -y
t,ese +actors.
:=,:&
4,en +l/oride is in*ested, it is raidly a-sor-ed +rom t,e stomac, and small intestine
into t,e systemic circ/lation, w,ere a-o/t ,al+ -ecomes -o/nd to t,e ,ard tiss/es 7t,e
-ones and /ner/ted teet,8 and t,e rest is eliminated "ia e++icient /rinary e0cretion.
Since t,e maAor site o+ +l/oride acc/m/lation in t,e -ody is t,e -one, almost no
+l/oride is resent in t,e so+t tiss/es.
:=
As stated -y !ia in t,e re"io/s edition o+ t,is
te0t-ook9 F+l/oride can -e deosited in t,e 7:8 adsor4ed layer o+ t,e -one, 7>8 t,e
crystal structure, and 7=8 t,e 4one matrix,
:=,&;,:$(-:$;
5,e +l/oride in t,e adsor-ed layer
is in e?/ili-ri/m wit, t,e -lood and can -e raidly raised or lowered, deendin* on
in*estion atterns and t,e e++iciency o+ kidney +/nction.F
:=
It is known t,at F-lood
lasma +l/oride le"els -e*in to rise a-o/t :$ min/tes a+ter in*estion and reac,
maximal levels 3ithin 9: minutes, s/-se?/ently ret/rnin* to re-in*estion le"els a+ter
:: to :' ,o/rs.F
:=,::$
In crystal +ormation, t,e +l/oride ion is t,o/*,t to -e in"ol"ed in
an ionic e0c,an*e wit, t,e ,ydro0yl ion and is incororated into t,e crystals o+ t,e
-one, w,ere it is more slowly remo"ed, most likely t,ro/*, t,e osteoclastic action
seen in remodelin*.F
:=
Fl/oride t,at is not stored in -one is raidly e0creted t,ro/*,
t,e kidneys, w,ere t,e rate is ,i*,est t,e +irst ,o/r, t,en -e*ins to +all +or t,e ne0t =
,o/rs, a+ter w,ic, t,ere is a low, contin/o/s latea/.
:=
4it, t,e cons/mtion o+
+l/oridated water, t,e e0cretion rate is more constant -eca/se o+ a more contin/o/s
intake o+ +l/oride.
:=
1eca/se o+ t,e role o+ t,e kidneys in +l/oride e0cretion, concerns ,a"e -een raised -y
anti-+l/oridationists a-o/t t,e sa+ety o+ +l/oridation in atients wit, imaired kidney
+/nction or w,o ,a"e kidney +ail/re re?/irin* dialysis. Imact on kidney +/nction was
addressed -y t,e National !esearc, Co/ncil in w,ic, it concl/ded t,at t,e Fin*estion
o+ +l/oride at c/rrently recommended concentrations is not likely to rod/ce kidney
to0icity in ,/mans.F
(<
5,e standard o+ care relati"e to t,e treatment o+ kidney +ail/re
atients on ,emodialysis mac,ines w,o are e0osed to lar*e ?/antities o+ water, calls
+or t,e remo"al o+ all minerals, incl/din* +l/oride, +rom water /sed in dialysis.
:,:::-::>

5,is re?/irement +or remo"al o+ minerals 7incl/din* +l/oride8 only applies to the
dialysate /sed d/rin* t,e dialysis rocess and does not apply to minerals in$ested
t,ro/*, drinkin* water. In ot,er words, renal dialysis atients and atients wit,
c,ronic kidney disease can contin/e to in*est water wit, otimal +l/oride le"els.
Additionally, n/mero/s st/dies o+ eole wit, lon*-term e0os/re to drinkin* water
wit, +l/oride concentrations, some as ,i*, as ( m, s,owed no increase in kidney
disease.
::>
Concerns a-o/t t,e acc/m/lation o+ +l/oride in t,e -ody
::=-::'
relate rimarily to
eoleCs concerns a-o/t t,e e++ect o+ +l/oridation on -one mineral density and
w,et,er or not t,ere is increased risk +or osteoorosis and +ract/res. 5,e res/lts o+
se"eral ecolo*ical st/dies o"er a >$ year eriod +rom :;($->$$$, comarin* +ract/re
rates in +l/oridated and non-+l/oridated comm/nities were mi0ed, +rom increased
rates in ,i,
::<-::(
ro0imal ,/mer/s and distal +orearm +ract/res
::;
to no e++ect on
+ract/re risk
:>$-:>=
to decreased risk o+ ,i +ract/re.
:>&,:>'
Since ecolo*ical st/dies /se
comm/nity-wide data, con+o/ndin* "aria-les associated wit, rates o+ +ract/re
incl/din* a*e, se0, estro*en /se, smokin*, and -ody wei*,t cannot -e controlled. 5o
address t,ese de+iciencies and t,e limitations o+ ecolo*ical st/dy desi*n, a m/lticenter
rosecti"e st/dy on risk +ract/res +or osteoorosis and +ract/res was done -y ),is
et al. in w,ic, in"esti*ators assessed -one mass, risk +actors, de"eloment o+ incident
nonsinal +ract/res, ascertainment o+ re"alent and incident "erte-ral +ract/res, and
e0os/re to +l/oridated water in %,:>; women <' years and older.
:><
5,e concl/sions
o+ t,is st/dy reorted in Octo-er >$$$ were as +ollows9 7:8 Flon* term e0os/re to
+l/oridation does not increase t,e risk o+ osteoorotic +ract/re amon* older women
and may red/ce t,e risk o+ +ract/re o+ t,e ,i and "erte-rae in older w,ite womenF
and 7>8 Fo/r res/lts s/ort t,e sa+ety o+ +l/oridation as a /-lic ,ealt, meas/re +or
t,e re"ention o+ dental cariesF.
:><
Interestin*ly eno/*,, sodi/m +l/oride ,as -een /sed to treat esta-lis,ed osteoorosis
+or o"er =$ years.
:>%
Data on t,e /se o+ ,i*,-dose sodi/m +l/oride 7%' m* daily8 +or
t,e treatment o+ "erte-ral osteoorosis s/**ests t,at t,e incidence o+ ,i +ract/re may
-e increased and -one density may -e diminis,ed w,ile t,e /se o+ low-dose sodi/m
+l/oride 7>'-'$ m* daily8 t,eray aears to ,a"e a rotecti"e e++ect a*ainst sine
+ract/res -/t no aarent e++ect on ,i or wrist +ract/re risk.
:>(
Accordin* to t,e National Instit/te o+ Dental and Cranio+acial !esearc, 7NIDC!8,
Fno credi-le scienti+ic e"idence s/orts an association -etween +l/oridated water and
conditions s/c, as cancer, -one +ract/re, DownCs syndrome, or ,eart disease as
claimed -y some oonents o+ water +l/oridation.F
:>;
Most recently, t,e Hork !e"iew e0amined st/dies relati"e to t,e sa+ety o+ +l/oridation
and concl/ded t,at t,ere was no e"idence o+ any ad"erse ,ealt, a++ect ca/sed -y
=>
3n*ineerin* Asects9 C,emicals and 5ec,nical Systems Used
4ater-treatment c,emicals are /sed +or a n/m-er o+ reasons incl/din*9 disin+ection,
a-sortion, al*ae control, decolori@ation, o0idation, metal coa*/lation, water
so+tenin*, +iltration, H control, iron control, coa*/lation, corrosion control,
c,lorination, and +l/oridation.
:=,:=$-:=:
)rimarily, t,ree c,emicals are /sed +or water
+l/oridation in t,e United States and are re?/ired -y t,e states to meet t,e American
4ater 4orks Association 7A44A8 standards +or t,e seci+ic c,emical9 sodium
fluoride, sodium silicofluoride, and hydrofluosilicic acid,
&(
Sodi/m +l/oride 7*ran/lar
or owder8 and sodi/m silico+l/oride 7*ran/lar8 are /sed in distri-/tion systems t,at
/se FdryF como/nds, w,ile ,ydro+l/osilicic acid, a li?/id, is /sed in sol/tion or
FwetF systems. Sodi/m +l/oride was t,e +irst como/nd /sed in controlled water-
+l/oridation ro*rams and is still widely /sed in smaller comm/nity-water systems
7/s/ally t,ose ser"in* +ewer t,an ',$$$ eole8.
:=,:=$-:=:
Sodium silicofluoride is
s/-stantially less e0ensi"e t,an sodium fluoride and tends to -e /sed in comm/nity-
water systems ser"in* -etween ',$$$ and '$,$$$ eole. 5oday, t,e most +re?/ently
/sed como/nd +or water +l/oridation in t,e United States is hydrofluosilicic acid,
-eca/se o+ its low cost and ease o+ ,andlin*D it is /sed rimarily in lar*er
comm/nities wit, water-distri-/tion systems ser"in* '$,$$$ or more eole and
reresents aro0imately '%E o+ all +l/oridation systems in t,e United States.
:=$,:=>

Oonents o+ +l/oridation o+ten attemt to distin*/is, -etween sodium fluoride and
t,e ,e0a+l/orosilicates, sodium silicofluoride and hydrofluosilicic acid in terms o+
a"aila-ility o+ t,e +l/oride ion. Fl/oridation oonents disara*e t,e
,e0a+l/orosilicates as FA/nk d/med into t,e drinkin* waterF t,at Fcontaminates t,e
water wit, a ,arm+/l resid/e.F Howe"er, accordin* to t,e 3n"ironmental )rotection
A*ency 73)A8, no ,e0a+l/orosilicate remains in drinkin* water at e?/ili-ri/m, w,ic,
is readily ac,ie"ed.
:==
5,is means t,at t,ere is no di++erence in t,e so/rce o+ +l/oride
ions +rom t,e t,ree c,emicals /sed in +l/oridation as t,e detractors wo/ld ,a"e one
-elie"e.
:==
In resonse to anti-+l/oridationist claims, New-r/n stated t,at Ft,e /se o+
+l/orosilicates is a *ood e0amle o+ s/ccess+/l recyclin* w,ic, -ene+its -ot, t,e
en"ironment and t,e cons/mer.F
:=&
Determination o+ t,e aroriate como/nd to /se in +l/oridation deends lar*ely
/on t,e tye o+ distri-/tion system /sed -y t,e indi"id/al water lant. Accordin* to
!ee"es, National Fl/oridation 3n*ineer at t,e U.S. Centers +or Disease Control, t,e
most common met,ods -y w,ic, +l/oride is added to water s/lies in t,e United
States are9 7:8 t,e volumetric dry feeder system w,ic, deli"ers a redetermined
?/antity o+ +l/oride c,emical 7eit,er sodi/m +l/oride or sodi/m silico+l/oride8 in a
*i"en time inter"al. Howe"er, sodi/m +l/oride is not recommended +or "ol/metric dry
+eeders -eca/se o+ its ,i*,er cost w,ic, is nearly two and a ,al+ times t,at o+ sodi/m
silico+l/orideD 7>8 t,e acid2feed system, in w,ic, a small meterin* /m is /sed to
add hydrofluosilicic acid to t,e water-s/ly systemD and 7=8 the saturator feed
system, w,ic, is /ni?/e to water +l/oridation, /ses an /+low sat/rator to ro"ide
sat/rated sol/tions o+ sodi/m +l/oride in constant stren*t,s o+ &E and is /med into
t,e water system "ia a small meterin* /m.
:=$-:=:
Additionally, t,e 6ent/ri
+l/oridation system is /sed -y t,e U.S. Indian Healt, Ser"ice in some e0tremely small
r/ral comm/nities.
Monitorin* and S/r"eillance o+ Fl/oridation
5,e rocess o+ addin* +l/oride to drinkin* water s/lies to t,e le"el recommended
+or ac,ie"in* t,e ma0im/m dental t,erae/tic -ene+its is tec,nically simle,
/ncomlicated, and similar to t,e rocesses /sed w,en dealin* wit, c,lorine and
ot,er water-treatment c,emicals.
:=,:=$
All t,ree tyes o+ +l/oride c,emicals /sed in t,e
water +l/oridation rocess are certi+ied as to t,eir /rity and sa+ety w,en /sed
aroriately. Interestin*ly, t,ere are &( additional c,emicals aro"ed -y t,e U.S.
3n"ironmental )rotection A*ency and certi+ied as sa+e +or addition to drinkin* water
-y t,e American 4ater 4orks Association and NSF International 7National
Sanitation Fo/ndation8. Contrary to o/lar ercetion, +l/oride does not a++ect t,e
taste, odor, color, or t/r-idity o+ t,e water at t,e le"els /sed +or water
+l/oridation.
:=,:=$-:=:
In order +or +l/oridation to -e imlemented, a n/m-er o+ +actors s,o/ld -e taken into
consideration. O+ rime imortance is t,e compati4ility o+ t,e +l/oride c,emical to -e
/sed wit, t,e e0istin* water-treatment and distri-/tion system.
:=,:=$-:=:
Ot,er +actors
imactin* t,e tec,nical en*ineerin* asects o+ +l/oridation incl/de9 7a8 so/rce o+
water/nder*ro/nd or s/r+ace water, 7-8 si@e o+ t,e water lantD 7c8 n/m-er and
tyes o+ oint so/rces o+ water 7one treatment lant or many treatment lants wit,
water comin* +rom wells, reser"oirs, ri"ers, a?/ed/cts, or desalination lants8D 7d8
n/m-er o+ inAection oints 7w,ere +l/oride is introd/ced into t,e water8D 7e8 +l/oride
c,emical costs, incl/din* transortationD 7+8 modi+ication o+ e0istin* lant "s.
constr/ction o+ a new lantD 7*8 need +or trainin* o+ water-lant oeratorsD and 7,8
tye o+ monitorin* and s/r"eillance system to -e /sed.
%,:=,:=$-:=:
Modern water-lant desi*n ens/res t,at e0cessi"e amo/nts o+ +l/oride are re"ented
+rom enterin* t,e water s/ly. )roerly desi*ned +l/oridation systems re"ent t,e
addition o+ e0cess +l/oride to t,e water system in se"eral ways9 7:8 only a limited
amo/nt o+ +l/oride is maintained in t,e ,oers 7or day tanks8, 7>8 ositi"e controls
,a"e -een installed +or +eedin* +l/oride +rom t,e ,oers into t,e dissol"in* tanks,
and 7=8 meterin* /ms are installed so t,at t,ey are electrically connected to t,e
water /m in a manner t,at ens/res t,at i+ one +ails, -ot, sto oeratin* and no
+l/oride is added to t,e system.
:=,:=$-:=:
Maintainin* a constant le"el o+ +l/oride in t,e water s/ly is t,e resonsi-ility o+ t,e
water-lant oerators. 6ariation in t,e ad- A/sted water +l/oride le"els ,as occ/rred in
water lants w,ere t,e oerators are not roerly trained andBor t,e oerator t/rno"er
is ,i*,.
'$-'<
6aria-ility in water +l/oride concentration may also occ/r i+ a water lant
+ails to ro"ide ade?/ate and aroriate stora*e +acilities, i+ t,ere is mal+/nctionin*
o+ +eed e?/iment, or i+ roer water-analysis e?/iment is lackin*, all o+ w,ic, are
readily a"oida-le wit, roer lannin* and imlementation. Most o+ t,e "ariances in
+l/oride concentrations t,at ,a"e occ/rred are d/e to oor monitorin* at water
treatment +acilities and ,a"e res/lted in +l/oride le"els 4elo3 t,e recommended le"el
(hypofluoridation),
:=,:='
For t,is reason, comm/nities t,at ,a"e imlemented
+l/oridation m/st contin/e to monitor t,e +l/oride le"els in order to ens/re t,at t,e
+/ll -ene+its o+ +l/oridation will accr/e in a comm/nity. Hyperfluoridation occ/rs
w,en an e0cess amo/nt o+ +l/oride is added to t,e drinkin* water o"er se"eral days,
/s/ally secondary to an o"er+eed +rom mal+/nctionin* e?/iment andBor maintenance
errors.
:=,:=<-:=%
O"er t,e ast '< years t,ere ,a"e -een se"en instances o+
hyperfluoridation w,ic, res/lted in o/t-reaks o+ ac/te +l/oride oisonin* in t,e
United States, all o+ w,ic, co/ld ,a"e easily -een re"ented.
:=,:=(
5,/s, w,en a
comm/nity decides to +l/oridate its /-lic-water s/lies, it also m/st ass/me t,e
resonsi-ility +or monitorin* t,e e?/iment, trainin* t,e water-lant oerators, and
imlementin* er+ormance re"iews to ens/re t,at t,e rocess is in lace to rotect t,e
/-lic +rom an o"er+eed. 5,e Centers +or Disease Control and )re"ention o++ers
weeklon* water-lant oerators trainin* ro*rams desi*ned to assist lant oerators in
s/stainin* and monitorin* t,eir +l/oridation systems.
:=:
Question 4
4,ic, o+ t,e +ollowin* statements, i+ any isBare tr/ee
A. N/mero/s st/dies o"er t,e ast se"eral years ,a"e consistently demonstrated t,e
sa+ety o+ water +l/oridation.
1. 5,e National Cancer Instit/te ,as re"iewed t,e literat/re on +l/oridation and ,as
concl/ded t,at t,ere is s/-stantial credi-le e"idence associatin* +l/oridation wit,
cancer and ,as recommended t,at +l/oridation -e ,alted worldwide immediately.
C. Sodi/m +l/oride is t,e most +re?/ently /sed c,emical +or water +l/oridation in t,e
United States.
D. Monitorin* o+ +l/oride le"els at water treatment lants is essential to re"ent -ot,
,yo+l/oridation and ,yer+l/oridation.
3. Fl/oride does not a++ect t,e taste, color, odor, or t/r-idity o+ t,e water at t,e le"els
/sed +or +l/oridation.
Ot,er Fl/oride 6e,icles
Many co/ntries wit,o/t centrali@ed water distri-/tion systems ,a"e c,osen to add
+l/oride to ta-le salt, a rocess known as Jsalt fluoridation,J in order to ro"ide
rimary dental caries re"enti"e -ene+its to t,eir o/lationsD aro0imately &$
million eole /se +l/oridated salt.
(>
Usin* salt as a "e,icle o+ +l/oride
s/lementation is similar to t,e concet o+ iodine s/lementation and is a relati"ely
ine0ensi"e met,od o+ +l/oride deli"ery. .ike water +l/oridation, salt fluoridation
res/lts in small amo/nts o+ +l/oride -ein* released +rom lasma t,ro/*,o/t t,e day.
:=;-
:&$
In order to ac,ie"e dental-caries red/ctions at le"els comara-le to water
+l/oridation, t,e le"el o+ +l/oride s/lementation o+ re+ined salt s,o/ld -e at least
>$$ m* FBk* as NaF or Ca CaF
>
.
:&:-:&>
Salt fluoridation re?/ires centrali@ed salt
rod/ction, as well as monitorin*.
(>
Since t,e cons/mtion o+ ,i*, ?/antities o+
sodi/m is a risk +actor +or ,yertension, t,e /se o+ +l/oridated salt is not
recommended +or t,ose at risk.
(>,:&=
Co/ntries /tili@in* salt fluoridation e0tensi"ely
incl/de Swit@erland, France, Costa !ica, #amaica, and Germany.
:&&,:&'
It ,as also -een
introd/ced in Me0ico, Sain, Col/m-ia, 1ra@il, and H/n*ary w,ere its /se ,as -een
+o/nd to -e aroriate.
(>,:=;,:&>,:&<-:&(
Also, Jmil* fluoridation,J t,e addition o+ ' m* o+ +l/oride to : litre o+ milk ,as -een
introd/ced as a "e,icle o+ sc,ool--ased +l/oride deli"ery in some co/ntries 71/l*aria,
C,ile, C,ina, t,e !/ssian Federation, and t,e United 2in*dom8.
(>
4,ile enco/ra*in*
res/lts ,a"e -een reorted wit, mil* fluoridation, no widesread clinical trials ,a"e
-een reorted.
(>
Additional st/dies are re?/ired to ade?/ately assess mil* fluoridation
as a "ia-le caries re"ention strate*y. Accordin* to t,e 4HO !eort, Ft,e distri-/tion
o+ +l/oridated milk can -e more comlicated t,an t,at o+ +l/oride s/lements 7ta-lets
or dros8.F
(>
As a res/lt, t,e e0istence o+ an esta-lis,ed distri-/tion system t,at
incl/des ro"isions +or aste/ri@ation and re+ri*eration is a limitin* +actor in mil*
fluoridation ro*rams.
(>
'luoride mouthrinses were de"eloed in t,e :;<$s as a school24ased /-lic-,ealt,
meas/re desi*ned to ro"ide access to +l/oride wit,o/t re?/irin* a "isit to t,e dentist
o++ice. School24ased 3ee*ly fluoride rinse pro$rams /sin* $.>E sodi/m +l/oride ,a"e
-een s,own to -e e++ecti"e in re"entin* coronal caries in sc,ool c,ildren w,o are at
risk +or dental caries. 3stimates o+ dental caries red/ctions o-ser"ed rior to t,e
esta-lis,ment o+ e++icacy, ran*e +rom >$ to '$E. Since t,e esta-lis,ment o+ e++icacy
+or +l/oride mo/t,rinses, t,e le"el o+ caries red/ction aears to -e less t,an
ori*inally o-ser"ed. Additionally, t,e cost-e++ecti"eness o+ +l/oride mo/t,rinse
ro*rams aears to -e diminis,ed -eca/se o+ t,e declinin* re"alence o+ dental
caries in *eneral.
%,:&;
Imlementation re?/ires t,at c,ildren enrolled in t,e ro*ram articiate consistently
o"er time to recei"e ma0im/m -ene+it. Howe"er, many c,ildren as t,ey *et older
7middleB,i*, sc,ool years8 decline to articiate, -elie"in* t,at +l/oride rinsin* is a
ro*ram +or yo/n*er c,ildren. Si*ni+icant coordination and monitorin* in t,e sc,ools,
arental consent, trackin* c,ildren as t,ey mo"e +rom elementary sc,ool to middle
and ,i*, sc,ool, and commitment on t,e art o+ sc,ool o++icials is re?/ired +or caries-
red/ction o/tcomes. Accordin* to t,e Centers +or Disease Control, =.>' million
sc,oolc,ildren were articiatin* in +l/oride-rinse ro*rams in :;((.
%
3nactment o+ 4ater Fl/oridation as )/-lic )olicy
In May >$$:, )artners,i +or )re"ention, a nonro+it, nonartisan or*ani@ation iss/ed
a reort, Priorities in Prevention6 +ral Health, in w,ic, it stated t,at Foral ,ealt, is
not solely deendent on indi"id/al -e,a"iors.F 5,is reort identi+ied re"ention
oort/nities +or olicy makers and -/sinessBcomm/nity leaders wit, comm/nity
water +l/oridation toin* t,e list o+ oral-,ealt, strate*ies t,at work.
:'$
Fl/oridation is not le*islated at t,e +ederal le"el in t,e United States. Howe"er,
le*islation may -e introd/ced in state le*islat/res, alt,o/*, "ery +ew o+ t,ese
meas/res ,a"e -een enacted at t,e state le"el in recent years. Statewide fluoridation
la3s were enacted rimarily in t,e late :;<$s and re?/ire +l/oridation in ten states9
Cali+ornia, Connectic/t, Delaware, Geor*ia, Illinois, Minnesota, Ne-raska, Ne"ada,
O,io, and So/t, Dakota. Moreo"er, t,e District o+ Col/m-ia and t,e U.S.
Commonwealt, o+ )/erto !ico also le*islated A/risdiction-wide mandatory
+l/oridation. In addition, 2ent/cky mandates +l/oridation o+ all /-lic water systems
ser"in* :,'$$ ersons or more -y administrative re$ulation /nder t,e a/t,ority o+ its
state ,ealt, commissioner 7see 5a-le (-<, statewide +l8. .e*islation re?/irin*
+l/oridation +ailed in two states in :;(; alon* wit, anti-+l/oridation -ills t,at +ailed in
+i"e states. Anti-+l/oridation -ills +ailed in +o/r states in :;;$ as well 7ADA, :;;:8.
S/ccess+/l adotion -y le*islat/res o+ mandated statewide +l/oridation laws in recent
,istory incl/de Ne"ada and Delaware. Cali+ornia assed le*islation in :;;',
mandatin* +l/oridation in comm/nities ,a"in* :$,$$$ or more ser"ice connections,
endin* a"aila-ility o+ +/nds. Aro/nd t,e same time eriod, a -ill was introd/ced in
Ore*on, re?/irin* t,at comm/nities +l/oridateD i+ t,ey +ailed to comly, t,ey wo/ld -e
re?/ired to reim-/rse t,e ,ealt, deartment +or dental-treatment -ills.
:':-:'>
3conomics
aears to ,a"e -een t,e dri"in* +orce and t,e common denominator in t,ese state
le*islati"e initiati"es. For some states, esecially t,ose in w,ic, a small ercenta*e o+
t,e o/lation ,as access to +l/oridated water andBor t,ose states wit, ,i*, dental-
caries rates and ,i*, Medicaid costs, mandatory statewide +l/oridation laws co/ld -e
a "ia-le strate*y. 3?/ally imortant, ,owe"er, is t,e olitical will to imlement
+l/oridation at t,e local le"el as FmandatoryF state laws o+ten ,a"e local otion
ro"isions.
From a /-lic-olicy ersecti"e, +l/oridation is more o+ten ercei"ed as a local iss/e
t,at is enacted eit,er -y $overnmental administrative action 7ordinance t,at is "oted
/on -y a city co/ncil or cityBco/nty commission8 or -y a "ote o+ t,e /-lic.
Interestin*ly eno/*,, t,e local ,ealt, o++icial o+ten ,as -ot, t,e ower and a/t,ority
/nder cityBco/nty c,arter to order t,e +l/oridation o+ /-lic water systems -/t rarely
in"oke s/c, ower. Generally seakin*, a "ote o+ t,e /-lic is re+erred to as a voter
initiative i+ t,e "ote is to imlement +l/oridation or as a voter referendum, i+ t,e "ote
is to con+irm, alter, or eliminate an e0istin* mandatory +l/oridation law. Fre?/ently, a
voter initiative is o+ten re+erred to as an initiative referendum, =oter initiative and a
voter referendum ,a"e -een /sed interc,an*ea-ly. Conse?/ently, it is imortant to
re"iew t,e city c,arter to ascertain t,e correct mec,anism to -e /rs/ed in a
comm/nity.
In some cases, /-lic o++icials seek to a"oid contro"ersy -y otin* to /t an ordinance
on t,e -allotD in ot,er cases, a re+erend/m "ote can -e +orced -y a si*nat/re etition.
A +orced etition re+erend/m /s/ally re?/ires a ercenta*e o+ si*nat/res, /s/ally :$
to >$E 7"aries accordin* to city or co/nty c,arter ro"isions or state constit/tional
re?/irements8 o+ re*istered "oters w,o "oted in t,e re"io/s election. In t,e +inal
analysis, imlementation o+ +l/oridation in t,e United States is now ac,ie"ed
rimarily -y $overnmental administrative decision or -y a vote of the electorate,
Fl/oridation Actions
In t,e :;'$s to :;<$s, Finitiative referendaF reresented t,e maAority o+ +l/oridation
actions in t,e United StatesD o+ t,e :,$$; initiative referenda, +l/oridation was
adoted in &:: comm/nities and de+eated in ';( comm/nities.
<(
In t,e :;($s, two o/t
o+ e"ery t,ree +l/oridation initiative referenda were de+eated, w,ile *ains were
ac,ie"ed -y %%E 7:;;B>'(8 o+ comm/nities /tili@in* t,e *o"ernmental administrative
mechanism, In t,e late :;($s and early :;;$s9 city co/ncilBcommission
administrative action a/t,ori@ed +l/oridation in =:( comm/nities w,ile => initiative
referenda were ,eld in w,ic, :; were won and := were lost, indicatin* an
imro"ement in initiative referenda s/ccess comared to re"io/s decades. In :;;&,
&% U.S. comm/nities a/t,ori@ed +l/oridation9 &< were city co/ncil or commission
actions and one was an Finitiative referendaF action.
<(,:'=
O+ t,e &< comm/nities,
a/t,ori@in* +l/oridation -y administrati"e action, =< ,ad o/lations less t,an :$,$$$
w,ile t,e remainin* :$ comm/nities ,ad o/lations *reater t,an :$,$$$. Greater
s/ccesses in terms o+ n/m-ers o+ comm/nities ,a"e -een ac,ie"ed t,ro/*, t,e
*o"ernmental administrati"e decision rocess -/t t,ey are concentrated in t,e smaller
comm/nities.
:'&-:'%
As re"io/sly stated, >= U.S citiesBco/nties "oted on +l/oridation ordinances in t,e
No"em-er >$$$ residential election. O+ t,e >= cities, ; cities wit, a total o/lation
o+ =,(>;,:(' aro"ed +l/oridation w,ile :& cities wit, a total o/lation o+ =(:,(((
reAected +l/oridation at t,e olls 7see 5a-le (-% and 5a-le (-(8. F/rt,er analysis o+ t,is
data s,ows t,at in *eneral, t,e initiativeLreferenda wins occ/rred in lar*er o/lation
centers 7e0cet Nort, Attle-oro, MA, and .ea"enwort,, 2S8 w,ile t,e
initiativeLreferenda losses tended to occ/r in t,e smaller comm/nities, e0cet
Sokane, 4A.
:;,:'(
!eadiness Assessment +or Initiatin* a Fl/oridation Camai*n
In order +or t,e United States to ac,ie"e t,e *oal o+ %'E +l/oridation -y t,e year
>$:$, t,e o-stacles t,at a++ect t,e le*al +ramework in w,ic, +l/oridation is
imlemented m/st -e care+/lly analy@ed. An assessment o+ a n/m-er o+ +actors t,at
imact t,e imlementation o+ +l/oridation in t,e United States is essential to
de"eloin* tar*eted ed/cational strate*ies and de+inin* t,e +l/oridation camai*n
messa*e. Some o+ t,e maAor +actors incl/de9 demo*ra,ic trend data, e0ternal +orces,
/-lic oinion, olitical climate, media in+l/ence, "oter t/rno/tBaat,y, lack o+ /-lic
awareness o+ t,e -ene+its o+ +l/oridation, ercetion o+ -ene+its "s. risks o+
+l/oridation, and lack o+ olitical camai*n skills amon* ,ealt, ro+essionals.
Demo*ra,ics
Accordin* to roAections, t,e United States will need to add aro0imately =$ million
eole, ser"ed -y more t,an :,$$$ water systems to t,e 'luoridation Census in order
to *et wit,in strikin* ran*e o+ t,e Hear >$:$ Goal.
%
1etween :;;$ and :;;(, t,e
*reatest o/lation *rowt, occ/rred in metroolitan areas in t,e 4est 7mo/ntain and
aci+ic states8 and So/t, 7so/t, atlantic, east so/t, central, and west so/t, central
states8 re*ions o+ t,e United States.
:'(
5,e :' lar*est non+l/oridated cities in t,e
United States ,a"e a total o/lation aro0imatin* ' million eoleD :> o+ t,e
lar*est non+l/oridated cities are located in t,e 4est and So/t, re*ions w,ere
metroolitan o/lation *ains ran*ed +rom :=.:E in t,e So/t, to :=.(E in t,e
4est.
:'(
At t,e same time, nonmetroolitan o/lation *ains ran*ed +rom %.'E in t,e
So/t, to :<.:E in t,e 4est.
:'(
As re"io/sly stated, % o+ t,e lar*est non+l/oridated
cities are in Cali+ornia w,ere +l/oridation le*islation assed in :;;'. A si*ni+icant
ercenta*e o+ t,e needed +l/oridation cens/s *ains will ,a"e to come +rom o/r
nationCs cities w,ic, contin/e to -e t,e o/lation ma*nets and reresent
aro0imately ($E ercent o+ t,e total o/lation in t,e United States.
:';
Ac,ie"in*
+l/oridation, w,et,er -y city co/ncilBcommission action or -y voter initiative or voter
referendum, is more di++ic/lt in o/r /r-an centers w,ere massi"e reso/rces and
rotracted maAor *rass-roots, c/lt/rally rele"ant camai*ns are *enerally re?/ired.
4,ile s/-/r-anites tend to "ote, inner-city residents o+ten tend not to "ote. 5,e
imlications o+ /r-ani@ationBs/-/r-ani@ation will ,a"e an imact on e++orts to
+l/oridate many o+ t,e non+l/oridated cities.
5,e di"ersity o+ t,e U.S. o/lation resents a c,allen*e to t,e re"enti"e ,ealt,
ed/cational and olitical e++orts -eca/se eac, racial and et,nic *ro/ ,as /ni?/e
attit/des, -elie+s, and e0ectations a-o/t re"enti"e ,ealt, o/tcomes t,at need to -e
considered. 4,ile racial and et,nic minorities are not as likely to "ote as w,ites,
e++orts s,o/ld -e made to ro"ide acc/rate in+ormation to t,e entire comm/nity, as
well as to enco/ra*e -roader articiation in t,e "otin* rocess -y all "oters.
Additionally, t,e a-ility to comm/nicate in a lan*/a*e ot,er t,an 3n*lis, may also -e
imortant in a local camai*n e++ort. In :;;$, nearly => million 7:&E o+ t,e nationCs
o/lation ' years and o"er8 said t,at t,ey soke a lan*/a*e ot,er t,an 3n*lis, at
,ome, comared wit, >= million 7::E8 a decade earlier.
<(
O"er ,al+ o+ t,ose w,o said
t,ey soke a lan*/a*e ot,er t,an 3n*lis, at ,ome reorted seakin* Sanis,.
<(

America is also a*in*. More and more eole in t,eir '$s and <$s ,a"e s/r"i"in*
arents, a/nts, and /ncles and +o/r-*eneration +amilies are common. 5,ose a*ed <'
years and older comrised :%E o+ t,e ad/lt o/lation -/t cast >>E o+ t,e -allots
w,ile t,ose a*ed :( to >& comrised :&E o+ t,e "otin* a*e o/lation, -/t acco/nted
+or only <E o+ "oters.
:<$
Older o/lations ,a"e ,i*,er rates o+ edent/lo/sness and
are less likely to "isit t,e dentist.
<<
As noted, t,e elderly do "ote and t,ey also tend to
"iew +l/oridation as a -ene+it rimarily directed at c,ildren and t,ere+ore may -e less
likely to -e s/orti"e. Framin* +l/oridation solely as a c,ildrensC ,ealt, iss/e is
ro-lematic +or camai*n or*ani@ers.
5,e likeli,ood o+ "otin* increases wit, ed/cation as well as a*e and income, res/ltin*
in certain *ro/s makin* / a disroortionate s,are o+ "oters. Accordin* to t,e
Cens/s 1/rea/, (&E o+ all ad/lts, a*es >' and older, ,ad comleted ,i*, sc,ool w,ile
only ><E ,ad comleted a -ac,elorCs de*ree.
:<:
Homeowners were a-o/t twice as
likely as renters to "ote 7'=E "s. >%E8.
:<>,:<=
One i
n t,ree c,ildren -orn in America li"e in o"erty.
:<&
5,e oor are also less likely to
,a"e dental ins/rance or to o-tain re"enti"e care. And w,ile t,e economically
disad"anta*ed stand to -ene+it t,e most +rom +l/oridation, t,ey o+ten do not "ote.
Geo*ra,ic mo-ility o+ t,e o/lation, o+ten related to t,e Ao- market, can also
imact +l/oridation s/ccess at t,e olls. )eole w,o ,a"e li"ed in +l/oridated
comm/nities are o+ten s/rrised to +ind t,at t,eir new comm/nity is not +l/oridated
and are e"en more s/rrised -y t,e contro"ersy *enerated w,en +l/oridation is laced
on t,e /-lic a*enda. Ha"in* li"ed in a +l/oridated area re"io/sly, it is sec/lated
t,at new residents to a non+l/oridated comm/nity wo/ld *enerally tend to +a"or
+l/oridation.
:<'
30ternal ForcesB)/-lic OinionB)olitical Climate
O"er t,e ast two decades, t,ere ,as -een a mo"e towards +ederal decentrali@ation,
t,at is trans+errin* ower, control, and +/ndin* +rom t,e +ederal *o"ernment -ack to
t,e states to administer ro*rams. States are +aced wit, ro-lems associated wit,
many o+ t,e social iss/es t,at are likely to ,a"e si*ni+icant -/d*etary imlications. As
a res/lt o+ stat/tes re?/irin* -alanced -/d*ets, *o"ernors ,a"e -een +orced to control
costs. !aid increases in Medicaid costs alone ,a"e strained many state -/d*ets,
ca/sin* *reater scr/tiny o+ e0endit/res. Dental Medicaid e0endit/res were amon*
t,ose e0amined -y t,e state o+ Cali+ornia and "iewed -y some as t,e imet/s +or
assin* +l/oridation le*islation in :;;'.
<(
Fl/oridation camai*n committees need to researc, t,eir local city or co/nty c,arter
to ascertain t,e mec,anismsBrocesses -y w,ic, t,eir comm/nity can +l/oridate as
well as t,e ro"isions and time+rames, takin* into acco/nt early "otin* andBor
e0tended "otin* eriods w,ic, imact t,e camai*n. Fl/oridation camai*n
committees also m/st analy@e t,e economic climate, as well as t,e res/lts o+ recent
local iss/e elections, incl/din* t,e imact o+ ne*ati"e camai*ns, in order to assess
t,e mood o+ t,e electorate. 5,e oosition, its stren*t, and credi-ility m/st also -e
assessedD /nderestimatin* t,e ener*y, tenacity, and in*en/ity o+ t,e oosition are
maAor ca/ses o+ +l/oridation ordinance +ail/res. !esearc,, incl/din* an assessment o+
e0ternal +orces, s/c, as in a S4O5 analysis 7stren*t,s, weaknesses, oort/nities,
and t,reats8 is critical to t,e de"eloment o+ a strate*ic camai*n lan. Fl/oridation
committees also need to determine i+ comm/nity leaders and elected o++icials ,a"e t,e
olitical will to s,e,erd a +l/oridation meas/re t,ro/*, t,e enactment o+ an
ordinance, eit,er -y administrati"e action or a "ote o+ t,e electorate.
In ,is -ook, Rational (ives6 &orms and =alues in Politics and Society, Dennis C,on*
noted t,at indi"id/als make decisions across -ot, social and economic realms and t,at
Fo/r re+erences ine"ita-ly re+lect t,e costs and -ene+its o+ t,e a"aila-le otions and
t,e in+l/ence o+ syc,olo*ical disositions +ormed o"er t,e li+e san.F
:<<
2nowin* t,e
/-lic stance on a artic/lar iss/e is also imortant. In a :;;$ National Healt,
Inter"iew S/r"ey 7NHIS8 o+ &:,:$& ad/lts re*ardin* /-lic knowled*e o+ t,e /rose
o+ +l/oridation, <>E correctly identi+ied t,e /rose.
<<
2nowled*e o+ t,e /rose o+
+l/oridation was ,i*,est amon* ersons a*ed =' to '& years o+ a*e 7<( to %$E8 w,ile
yo/n*er 7:( to >&8 and older 7 %'8 ersons ,ad less /nderstandin*, at &;E and &$E,
resecti"ely.
<<
Ot,er +indin*s s,owed t,at ersons wit, ,i*,er ed/cational attainment
le"els were more t,an twice as likely as t,ose wit, less t,an a ,i*, sc,ool ed/cation
to correctly identi+y t,e /rose o+ +l/oridation 7%<E "s. =<E8.
<<
4,en resented
wit, con+lictin* in+ormation re*ardin* -ene+its and risks o+ +l/oridation, discernment
and t,e a-ility o+ t,e electorate to make in+ormed decisions may -e comromised.
Additionally, t,e dynamics in,erent in le-iscites 7+ears, an0ieties, discontentment,
an*er, resistance to a/t,ority, and resentment o+ ro+essionals8 can derail t,e
decision-makin* rocess.
:<%
Direct democracy oses a si*ni+icant c,allen*e +or
roonents o+ any iss/e -eca/se t,ey m/st Fsettle t,e /-licCs mind on all asects o+ a
?/estion and t,ey m/st -ear t,e -/rden o+ restraint.F
:<%
Sec/rin* maAority s/ort +or
any iss/e laced -e+ore t,e "oters re?/ires a "ery ,i*, le"el o+ initial s/ort in order
to ac,ie"e a s/ccess+/l res/lt on election day -eca/se s/ort erodes o"er t,e d/ration
o+ a camai*n.
:<',:<%
Intensi"e and on*oin* e++orts to ed/cate t,e /-lic a-o/t +l/oridation s,o/ld -e
imlemented rior to initiation o+ a olitical camai*n and s/stained t,ro/*, t,e
decision makin* rocess and contin/ed t,erea+ter. It took >' years to en,ance /-lic
knowled*e and c,an*e attit/des a-o/t smokin* in t,e United StatesD to s/stain t,e
*ains, t,e ed/cation m/st contin/e. Similarly, A/st -eca/se comm/nica-le diseases are
rare today, it doesnCt +ollow t,at imm/ni@ation ro*rams s,o/ld recei"e less em,asis.
)/-lic-,ealt, ro+essionals ,a"e learned t,e ,ard way t,at eliminatin* /-lic-,ealt,
ro*rams, s/c, as imm/ni@ation, is ?/ickly +ollowed -y a raid reaearance o+
re"io/sly rare diseases. 5,ey also reco*ni@e t,at once diseases are /nder control, t,e
most di++ic/lt task is to ed/cate t,e /-lic a-o/t t,e need to contin/e s/ccess+/l
ro*rams in order to re"ent ret/rn o+ t,e disease. Similarly, +l/oridation ed/cation
s,o/ld contin/e.
In a tele,one s/r"ey cond/cted -y !esearc,kAmerica in May >$$$, ('E o+
Americans resonded t,at oral ,ealt, is very important to t,eir o"erall ,ealt,.
:'$,:<(
A
:;;( national Gall/ oll o+ cons/mersC oinions a-o/t water +l/oridation s,owed
t,at %$E s/orted +l/oridation,
:,:<;,:%$
,owe"er, a local oll may -e necessary to
ro"ide local elected o++icials wit, /-lic oinion data in order +or t,em to enter t,e
+l/oridation +ray. )/-lic oinion olls may -e essential in determinin* a comm/nityCs
willin*ness to adot +l/oridationD t,ey can also ro"ide cr/cial in+ormation relati"e to
cra+tin* a clear +l/oridation messa*e. 2nowin* w,o "otes is also imortant.
Additionally, it s,o/ld -e ointed o/t t,at not all "oters are wealt,y, or are -etter
ed/cated s/-/r-anites, and not all non"oters are oor, less ed/cated inner city
dwellers. Accordin* to a national s/r"ey, t,ere are ' di++erent *ro/s o+ non"oters9
FdoersF, F/nl/**edsF, Firrita-lesF, FdonCt knowsF, and Falienateds.F
:%:
A common
strate*y /sed in camai*ns is to +oc/s on consistent "oters and elderly "oters w,ile
ne*lectin* t,e non"oters, incl/din*, in some cases, t,e inner city "oter.
:%:
.imited
reso/rces mean many camai*ns limit t,eir +oc/s to *ro/s o+ e0ected "oters, a
ractice t,at is contrary to t,e rincile o+ incl/si"eness, and *enerally ill-ad"ised,
esecially wit, contro"ersial iss/es.
)er,as t,e most cr/cial arameters +or assessin* +l/oridation s/ccess are timin$,
readiness, and or$ani1ation, 5,ere are n/mero/s e0amles o+ comm/nities
t,ro/*,o/t t,e United States w,ere timin*, readiness, and or*ani@ation ,a"e layed a
role in t,e s/ccess or +ail/re o+ a +l/oridation -allot meas/reD many comm/nities ,a"e
,eld more t,an one +l/oridation initiativeL referendum to o-tain assa*e. )ro+essional
camai*n mana*ers, artic/larly t,ose wit, e0erience r/nnin* iss/es camai*ns, can
assist local +l/oridation committees in e"al/atin* t,e 5IMING otions and in
esta-lis,in* a timeline. Fl/oridation camai*ns also re?/ire +inancial reso/rces to *et
t,e messa*e o/t. F/ndraisin* can -e a maAor st/m-lin* -lock +or many comm/nities
and needs to -e considered early on in t,e camai*n.
)/-lic )ercetion o+ !isks "s. 1ene+its o+ Fl/oridation
A mandatory law t,at assed in -ot, ,o/ses o+ t,e Cali+ornia state le*islat/re
<%
and
was si*ned into law -y t,e *o"ernor in :;;', re?/ires comm/nities to +l/oridate -/t it
also laced t,e cost at t,e local le"el w,ere it co/ld -e interreted as an Junfunded
mandate,J Many unfunded mandates are seen -y t,e electorate to -e desi*ned to ,el
t,e oor at t,e e0ense o+ t,e workin* middle class. Unfunded mandates *enerally are
"iewed as -ein* coerci"e 7not "ol/ntary8 and as -ein* controlled -y society rat,er
t,an -y t,e indi"id/al, and as s/c,, may -e t,o/*,t to raise t,e le"el o+ /-lic o/tra*e
7disc/ssed in later section8. Accordin* to Sandman 7:;;$8, t,e /-licCs ercetion o+
risk is -ased on t,e le"el o+ o/tra*e +elt wit, resect to a *i"en otential or ercei"ed
,a@ard w,ile t,e scienti+icB/-lic ,ealt, comm/nity "iews risk in terms o+ t,e de*ree
o+ act/al ,a@ard. 5,ese di++erin* ersecti"es are e0loited -y +l/oridation oonents
w,o seek to increase t,e ercetion o+ ,a@ard.
:%>
In SandmanCs risk ercetion
analysis o+ +l/oridation 7see 5a-le (-;8, := "aria-les were e0amined in w,ic, an
o"erall ne*ati"e score o+ % was assi*ned.
<(,:%>
Only & "aria-les were considered to -e
ositi"e wit, resect to miti*atin* /-lic o/tra*e. On t,e ne*ati"e side, +l/oridation
was s/mmari@ed as -ein*9 Fcoerci"e w,en done -y administrati"e actionD ind/strial or
man-made 7arti+icial8D dreaded -eca/se o+ alle*ed association wit, cancerD
/nknowa-le d/e to t,e scienti+ic contro"ersy t,at res/lts w,en e0erts aear to
disa*reeD controlled w,en t,e /-lic is e0cl/ded +rom t,e decision makin* rocessD
not tr/stwort,y wit, resect to t,e so/rce o+ in+ormation and mec,anisms o+
acco/nta-ilityD as ,a"in* closed or secret so/rces, *i"in* t,e imression t,at
in+ormation is -ein* wit,,eldD and is "iewed as -ein* arro*ant, as e"idenced -y
contemt +or t,e /-licCs ercetion.F
:%=
5,e c,allen*e +or +l/oridation ad"ocates is to
e++ecti"ely comm/nicate riskB-ene+it in+ormation, /sin* strate*ies tar*eted at red/cin*
t,e o/tra*e towards +l/oridation.
:%>,:%=
75,ese strate*ies are disc/ssed in a later
section.8
Question 5
A. Many co/ntries wit,o/t centrali@ed water distri-/tion systems /se salt
fluoridation, a rocess w,ere-y +l/oride is added to ta-le salt, in order to ro"ide
rimary dental caries re"enti"e -ene+its to t,eir o/lations.
1. An o-Aecti"e o+ t,e U.S. )/-lic Healt, Ser"ice is to ,a"e %'E o+ United States
citi@ens cons/min* +l/oridated water -y >$:$.
C. 5,e likeli,ood o+ "otin* decreases wit, ed/cation as well as a*e and income,
res/ltin* in certain *ro/s makin* / a disroortionate s,are o+ "oters.
D. 5,e /-licCs ercetion o+ risk is -ased on t,e le"el o+ o/tra*e +elt wit, resect to a
*i"en otential or ercei"ed ,a@ard w,ile t,e scienti+icB/-lic ,ealt, comm/nity
"iews risk in terms o+ t,e de*ree o+ act/al ,a@ard.
3. From a /-lic-olicy ersecti"e, +l/oridation is more o+ten ercei"ed as a +ederal
or national iss/e t,at is mandated -y le*islation.
!ole o+ Media in Formin* )/-lic Oinion and )/-lic )olicy
Accordin* to a recent reort, ;=E o+ ersons s/r"eyed said t,at t,ey re*/larly
watc,ed local news, w,ile &(E reorted ,a"in* watc,ed tele"ision network news and
'$E reorted ,a"in* read a newsaer, t,e re"io/s ni*,tD :(E listened re*/larly to
talk radio.
:%&
O"er t,e ast decade, t,ere ,as -een increased interest on t,e art o+
sc,olars, olitical scientists, sociolo*ists, ollsters, oliticians, and Ao/rnalists in
trackin* t,e role o+ mass media on /-lic olicy, /-lic oinion, and "otin*
-e,a"iors.
:%&
!eortin* on ,ealt, iss/es ,as not -een imm/ne to t,e con+l/ence o+
+orces w,ere t,e media o+ten resort to *eneratin* contro"ersy in order to increase
readers,i andBor listenin*B "iewin* a/dience. Also, man/+act/rin* o+ t,e news seems
to -e a trend on t,e rise in t,e United States, raisin* ?/estions o+ acco/nta-ility. A
:;;' U.S. News oll +o/nd t,at t,e /-lic aears wary o+ -ot, t,e mainstream
media and talk radio.
:%&
Older, wealt,ier, and more ed/cated cons/mers are more likely to read a newsaer.
More o+ten t,an not, +l/oridation is e0lored more t,oro/*,ly in t,e rint media, yet
readers,i is declinin* all o"er t,e co/ntry, as newsaers mer*e or s,/t down
oerations. 4,ile t,e rint media ,a"e o+ten editoriali@ed in +a"or o+ +l/oridation at
t,e time o+ a /-lic "ote, it o+ten comes too late, as do/-t ,as -een solidi+ied in t,e
minds o+ t,e /-lic. In some cases, ,owe"er, t,e media ,a"e taken a roacti"e role in
enactin* +l/oridation
:%'
D t,is occ/rred in ),oeni0, Ari@ona, in :;(; and conse?/ently,
: million eole were added to t,e +l/oridation cens/s.
A -/sier cons/mer o+ten t/rns to t,e 56 +or a ?/ick cas/le "iew o+ w,at is
,aenin* locally, aro/nd t,e state, nationally, and internationally.
:%<
Conse?/ently,
messa*es are transmitted "ia :- to >-min/te so/nd -ites w,ere t,e ne*ati"e
ersecti"e is more amena-le to t,e world o+ so/nd -ites t,an t,e ositi"e
ersecti"e. Con"ertin* detailed data to so/nd -ites is a c,allen*e +or roonents o+ a
comle0 /-lic-olicy iss/e, w,o are ,eld to a "eracity standard. In ot,er words, it is
+ar easier to con"ey oosition to /-lic olicy t,an it is to con"ey s/ort.
Additionally, t,e "is/al imact o+ t,is medi/m can -e /sed eit,er +or or a*ainst a
/-lic olicy iss/e and m/st -e considered in a media camai*n strate*y. In a
networkCs attemt to -e +air and *et t,e "iewers attention, mi0ed messa*es are o+ten
con"eyed t,ro/*, /se o+ a news cli t,at ortrays a ,i*,ly ne*ati"e "is/al ima*e
co/led wit, a "er-al messa*e t,at is ositi"e and ed/cational. Mi0ed messa*es can
create do/-t and sometimes aat,y andBor cynicism.
!adio, and esecially talk radio is not a mass medi/m to t,e e0tent t,at tele"ision is.
O"er t,e ast decade, t,e n/m-er o+ radio talk s,ows ,as escalated dramatically, wit,
nearly :$E o+ radio stations ,a"in* a talk +ormat, ser"in* as a "e,icle +or t,e listenin*
/-lic to articiate in t,e olitical de-ate.
:%&
!adio talk s,ows or Ftalk radioF are a
ower+/l +orce in U.S. olitics today, in art -eca/se o+ t,e end o+ t,e Fairness
Doctrine as well as to c,an*in* tec,nolo*y.
:%&
In :;(', t,e Federal Comm/nications
Commission 7FCC8 r/led t,at t,e Fairness Doctrine, re?/irin* t,at -roadcasters
ro"ide a reasona-le oort/nity +or t,e resentation o+ oosin* "iews on
contro"ersial /-lic iss/es, was no lon*er needed.
:%&
5,e FCCCs r/lin* was /,eld -y
a Federal Aeals co/rt in :;(;.
:%&
4it, t,e end o+ t,e Fairness Doctrine, neit,er
radio ro*ram ,osts nor stations ,a"e an o-li*ation to ro"ide -alance or resent
cometin* "iews.
:%&
Conse?/ently, talk radio is an imortant "e,icle +or t,e /-lic to
o-tain in+ormation on a *i"en toic, incl/din* +l/oridation. I+ only one "iewoint is
e0ressed on +l/oridation, t,e imact on /-lic oinion co/ld -e si*ni+icant *i"en t,at
talk radio listeners tend to -e more olitically acti"e.
5,e /se o+ t,e satellite dis, ,as ena-led stations to recei"e -roadcast ?/ality +rom
anyw,ere in t,e co/ntry at a relati"ely low costD it ,as also +ostered national
syndication, allowin* local ,osts to ,a"e access to an instant network.
:%&
5,is ,as
-een demonstrated in "ario/s local e++orts to -rin* +l/oridation to t,e +ore+ront o+
"ario/s comm/nitiesC a*endas. 5alk radio ,osts connect t,e listeners wit,
sokesersons +rom aro/nd t,e co/ntry, sometimes esta-lis,in* a lat+orm +or anti-
science ersecti"es t,at are reeated o"er and o"er, yet, ,a"e not -een s/-stantiated
or s/-Aected to e"idence--ased re"iew. It is not /n,eard o+ to enco/nter talk radio in
w,ic, a maAority o+ t,e callers tend to -e t,e solid Fa*iner "otin* -lockF t,at "otes
a*ainst any iss/e -ro/*,t +orward -y local, state, or +ederal *o"ernment. National
syndication ,owe"er, cannot */arantee listeners,i in todayCs ,i*,-seed world w,ere
cometition +or lar*e a/diences in maAor markets is +ierce.
:%&
!adio is an imortant
medi/m +or disseminatin* in+ormation and s,o/ld -e +actored into ed/cational and
olitical media strate*ies.
5alk radio can -e considered an intimate medi/m in w,ic, t,e caller is /s/ally
anonymo/s and t,e disc/ssion is sontaneo/s.
:%&
Accordin* to a reort released in
:;;< -y t,e Annen-er* )/-lic )olicy Center9 7a8 :(E o+ ad/lts in t,e United States
listen to at least one olitical call-in radio s,ow twice a week or moreD and 7-8
olitical talk-s,ow listeners are more likely to cons/me all news media 7ot,er t,an
56 news8 and to -e more olitically sa""y and in"ol"ed, re*ardless o+ ideolo*y.
:%&
Accordin* to a recent nationwide oll o+ talk radio ro*rams, t,ree-+o/rt,s o+ t,e talk
radio a/dience is yo/n*er t,an a*e <$ and listeners tend to ,a"e ,i*,er incomes and
-e -etter ed/cated, wit, =;E ,oldin* colle*e de*rees, comared wit, >:E o+
Americans o"erall. Also, ; o+ e"ery :$ olitical talk-radio listeners are re*istered to
"ote, comared wit, < o+ :$ Americans in *eneral.
:%&
As /-lic-olicy iss/es, incl/din* +l/oridation, s/r+ace in a *i"en comm/nity, t,ey
are s/-Aected to media re"iew. 5,e role o+ mass media in +ramin* critical iss/es and
in+l/encin* /-lic olicy as well as t,eir imact on ,ow /-lic oinion and "al/es are
+ormed is imortant to American democracy. Understandin* and workin* wit, t,e
media in ed/catin* t,e /-lic a-o/t /-lic olicy iss/es, incl/din* +l/oridation is
critical to an in+ormed electorate.
!ecent ad"ances in tec,nolo*y, s/c, as t,e in+ormation s/er,i*,way, ,a"e ro"ided
yet anot,er ower+/l comm/nication toolt,e -orld -ide -e4 (internet), 5,e
roli+eration o+ we-sites ,as e0loded in t,e ast +ew years and wit, it, t,e
instantaneo/s dissemination o+ in+ormation and oinions on e"ery toic ima*ina-le.
5,e internet ,as -een em-raced -y t,e /-lic as a means o+ ready access to
in+ormation. 5,ere are a n/m-er o+ ,ealt,-related we-sites, incl/din* t,ose dealin*
wit, water +l/oridation. I+ one searc,es t,e internet /sin* "ario/s searc, en*ines, a
si*ni+icant ?/antity o+ in+ormation can -e +o/nd. One searc, en*ine t/rned / >&,:$$
matc,es w,ile anot,er ,ad >,'$$ matc,es +or F+l/oridation.F 5,e downside o+ internet
/se as a so/rce o+ "alid in+ormation is t,at m/c, o+ t,e ,ealt, in+ormation a"aila-le
on t,e we- is oinion--ased and ,as not *one t,ro/*, a ri*oro/s scienti+ic re"iew
rocess, /ttin* t,e on/s on t,e /-lic +or discernin* tr/t, +rom +iction re*ardin* t,e
in+ormation resented. Anot,er ro-lem associated wit, +l/oridation in+ormation on
t,e internet is t,e a/city o+ in+ormation +rom credi-le researc,--ased entities and
reco*ni@ed ro+essional or*ani@ations. Un+ort/nately, t,e /-lic is s/-Aected "ia t,e
internet to redominately ne*ati"e in+ormation +rom -iased oosition *ro/s, rat,er
t,an -ein* ro"ided o-Aecti"e, science--ased in+ormation a-o/t t,e sa+ety, e++icacy,
and cost-e++ecti"eness o+ +l/oridation.
6oter 5/rno/tB6oter Aat,y
2nowled*e o+ "oter articiation is imortant -eca/se fluoridation is the only pu4lic2
health issue that is re$ularly voted on in a community, Many Americans ,a"e oted
o/t o+ t,e olitical decision-makin* rocess -eca/se o+ -/sinessBtime constraints,
aat,y, and ot,er +actors.
:%%
In t,e No"em-er >$$$ residential election, only ':.>:E
o+ eli*i-le "oters 7"otin* a*e o/lationall ersons o+ a*e :( or o"er8 act/ally cast
"otes comared to <=.$<E in :;<$. Historically, "oter t/rno/t ,as -een ,i*,er in
residential election years t,an in +ederal election Fo++ yearsF w,ere "oter t/rno/t
went +rom &%.>%E in :;<> to =<.&E in :;;( 7see Fi*/re (-=8. Since :;;$, nearly
t,ree-?/arters o+ t,e *rowt, in t,e "otin*-a*e o/lation occ/rred in t,e &'- to <&-
year-old a*e *ro/, reresentin* aro0imately = o+ :$ o+ t,e "otin*-a*e
o/lation.
:%(
Accordin* to t,e Cens/s 1/rea/, t,e most likely "oters tend to -e9
w,ite, women, older, married, t,ose wit, more ed/cation, t,ose ,a"in* ,i*,er
incomes, t,ose w,o are emloyed, and t,ose w,o are ,omeowners andBor lon*time
residents. Interestin*ly eno/*,, eole li"in* in t,e 4est are t,e least likely to
re*ister to "ote -/t t,ose w,o do re*ister to "ote are most likely to "ote 7see Fi*/re (-
&, maB"otin*BUS8.
6oter t/rno/t at t,e local le"el ,as +ollowed t,e same attern as seen at t,e state and
national le"els, wit, ercenta*es diin* into t,e teens.
<(
.ow "oter t/rno/ts and
secial elections ,a"e traditionally selled disaster +or +l/oridation, esecially in
lar*er cities w,ere t,e Fa*iner +actorF 7a constant -lock o+ "oters w,o "ote a*ainst any
*o"ernment initiati"e or *o"ernment in"ol"ed roosal8 is s/re to "ote in an
initiativeLreferendum, S/orters o+ +l/oridation, seekin* a "ote o+ t,e electorate,
s,o/ld consider lacin* an ordinance +or +l/oridation on a re*/larly called -allot t,at
is e0ected to ,a"e ,i*,er "oter t/rno/ts. Mayoral or co/nty commissioners elections
7or e"en */-ernatorial or residential elections i+ election laws allow +or local iss/es8
*enerally ,a"e "oter-t/rno/t rates t,at are *reater t,an t,ose o-ser"ed in a secial
election. In cases w,ere local *o"ernin* a/t,orities decide to call a /-lic "ote on
+l/oridation in order to let t,e "oters decide, t,ey o+ten ot to ,a"e a secial election
or "ote to lace it on any ot,er election ot,er t,an t,e mayoral or co/nty
commissioners election, in order to a"oid takin* a osition on +l/oridation t,at mi*,t
a++ect t,eir election or reelection stat/s.
<(
1eca/se o+ low "oter t/rno/t, t,e re"ailin* wisdom amon* roonents o+
+l/oridation s/**ests t,at re+erenda -e a"oided, -/t t,is is contrary to SandmanCs
7:;;$8 warnin* t,at decisions t,at are ercei"ed as -ein* coerci"e or as not allowin*
+or indi"id/al controlB+reedom o+ c,oice, are more likely to increase t,e le"el o+
o/tra*e, and t,ere+ore decrease acceta-ility. In "iew o+ t,e sketicism o+ t,e
electorate and takin* SandmanCs risk ercetion rinciles into consideration, it may
-e necessary to consider t,e +/ll ran*e o+ otions +or imlementin* +l/oridation in
comm/nities w,ere city co/ncilBcommission action are not ossi-le.
<(
)er,as t,e
initiati"e rocess or c,an*es in t,e A/risdictional c,arter s,o/ld -e considered as art
o+ a comre,ensi"e olitical strate*y. Some A/risdictions, ,owe"er, may not allow
citi@ens t,e ri*,t to etition. Additionally, in many U.S. comm/nities today, "otin*
eriods ,a"e -een e0tended. 5,e imact o+ t,ese +actors on an initiativeLreferenda
camai*n can -e s/-stantial in terms o+ or*ani@ation, reso/rces, and s/stainin* *et-
o/t-t,e-"ote 7GO568 e++orts.
<(
Ne*ati"e camai*nin* ,as also contri-/ted to /-lic disill/sionment wit, olicy
iss/es as well as to "oter aat,y. )olitical ad"ertisements ,a"e not -een s/-Aect to t,e
same scr/tiny as ot,er +orms o+ camai*nin*, alt,o/*, some networks are takin* on
t,e c,allen*e o+ analy@in* s/c, ad"ertisements. 3n*enderin* +ear and an*er amon*
t,e electorate is t,e -asis o+ ne*ati"e camai*nin*. Fl/oridation is one o+ t,ose iss/es
t,at lends itsel+ "ery well to ne*ati"e camai*nin* -eca/se eoleCs +ears andBor an*er
are e0loited -y t,e oosition. Un+ort/nately, t,e electorate doesnCt necessarily ,a"e
to a*ree wit, t,ose oosed to +l/oridation +or t,e iss/e to +ail at t,e olls. Instead,
t,e "oters o+ten react to t,e "icio/s ne*ati"e camai*nin* and t/ne o/t alto*et,er,
otin* o/t -y "otin* t,e iss/e down or +ailin* to "ote at all 7no-s,ows8 in ,oes t,at
t,e Fcontro"ersyF will *o away. 3"en i+ t,e "oters ?/estion t,e claims o+ t,e anti-
+l/oridation +action, t,ey may -e enco/ra*ed to "ote a*ainst +l/oridation A/st -eca/se
t,ey ,a"e a scintilla o+ do/-t a-o/t w,ic, side is ri*,t and ot to Fwait and seeF /ntil
all F?/estionsF ,a"e -een answered.
Mistr/st o+ *o"ernment and erosion o+ /-lic con+idence in t,e *o"ernmentCs a-ility
to sol"e ro-lems, an*er at -ein* le+t o/t o+ t,e rocess, an*er at ta0 increases, +ear o+
t,e +/t/re -eca/se o+ loss o+ economic sec/rity, +ear o+ emloyment layo++s, an*er
and +ear ca/sed -y declinin* incomes and -ene+its, +ear o+ crime, +ear o+ loss o+
indi"id/al ri*,ts and +reedom, and a sense t,at t,e *o"ernment is ine++ecti"e, ,a"e
,ad t,e e++ect o+ sim/ltaneo/sly immo-ili@in* a lar*e sector o+ t,e o/lation w,ile
mo-ili@in* a ne*ati"ely moti"ated electorate.
<(
An*er and +ear are t,e two most
ower+/l +actors moti"atin* eole to act and -ot, take +ront-and-center sta*e in a
+l/oridation camai*n. 5,ey are also t,e emotions caitali@ed /on -y t,e anti-
+l/oridationists to de+eat +l/oridation and t,ey are t,e -asis o+ SandmanCs risk
ercetion rinciles.
Sketicism on t,e art o+ t,e /-lic res/ltin* +rom ro*rammatic +ail/res in /-lic
,ealt, 7e.*., swine-+l/ "accine8 com-ined wit, a distr/st o+ esta-lis,ed scienti+ic
met,ods and con+/sion o"er recommended ,ealt, ractices t,at seem to c,an*e
weekly, tend to +/el t,e +lames, an*erin* and +r/stratin* t,e /-lic.
:%;
)/-lic
knowled*e and attit/des toward +l/oridation demonstrate t,e need +or ,ealt,
ro+essionals to contin/ally ad"ocate +or +l/oridation in order to reser"e t,e
s/ccesses already ac,ie"ed.
:%<,:($-:(=
Fl/oridation camai*ns t,at are not s/++iciently
-road--ased wit, m/ltile constit/encies in"ol"ed in t,e decision-makin* rocess are
likely to enco/nter ro-lems w,en olitical decisions ,a"e to -e made.
:'&,:(&-:((

Fl/oridation committees comosed o+ ,ealt, ro+essionals alone are not eno/*, to
reali@e a +l/oridation win on a -allot meas/re, or +or t,at matter, in *o"ernmental
-ody actions.
)olitical Skills and 2nowled*e o+ Fl/oridation Committees
3"en t,o/*, +l/oridation is t,e only ,ealt, iss/e t,at is o+ten "oted on 7le-iscite8, it
is ta/*,t as a /-lic-,ealt, inter"ention, not as a olitical iss/e. Healt, ro+essionals
are +re?/ently called /on to -e in"ol"ed in +l/oridation e++orts, yet t,ey o+ten lack
olitical e0erience, skills in mediation and con+lict resol/- tion, or media e0ertise to
deal wit, t,e iss/es raised in a camai*n. 2nowled*e and e0erience in mana*in* an
act/al olitical camai*n, incl/din* marketin* t,e ro-+l/oride messa*e, +/ndraisin*,
or*ani@in* ,one -anks and *et-o/t-t,e-"ote 7GO568 e++orts, s/c, as -lockwalkin*,
are not normally ta/*,t in t,e c/rric/la o+ t,e ,ealt, discilines, and certainly not in
U.S. dental sc,ools.
<(
),ysicians and dentists are o+ten co-oted into reactin*
ne*ati"ely, -y wit,drawin* and disaearin* and -y -ein* de+ensi"e and
condescendin* w,en con+ronted wit, a otential "oter w,o disa*rees wit, t,e remise
t,at +l/oridation is t,e -est caries re"enti"e met,od t,at a comm/nity can adot.
<(

Sometimes, ,ealt, ro+essionals +ail to *et in"ol"ed in +l/oridation e++orts -eca/se
t,ey donCt +eel con+ident t,at t,ey can cite e"idence--ased re-/ttals to t,e -road, all-
incl/si"e la/ndry list o+ alle*ations and o-Aections to +l/oridation.
>,:(;-:;>
Familiarity
wit, SandmanCs risk ercetion rinciles 7see 5a-le (-;8 as t,ey relate to +l/oridation
and knowin* ,ow to decrease t,e le"el o+ o/tra*e are critical skills t,at e"ery ,ealt,
ro+essional s,o/ld ,a"e -/t are not ta/*,t. Healt, ro+essional st/dents are ta/*,t to
deli"er care to indi"id/als not to comm/nities. 3"en in /-lic ,ealt, ro*rams,
st/dents do not learn t,ese skills, creatin* a leaders,i *a as it relates to ad"ocatin*
+or +l/oridation. In t,e +inal analysis, t,e desired o/tcome is more deendent /on
olitical skills t,an on knowled*e o+ +l/oridation.
<(
Fi*/re (-= 6oter 5/rno/t )residential g Con*ressional 3lections9 :;<$->$$$.
7Source6 Cens/s 1/rea/, >$$$.8
Fi*/re (-& 6otin* )ercenta*es in t,e United States -y State, :;;(. 7Source6
U.S. Cens/s 1/rea/, Current Population Survey, )>$-'>=!6, A/*/st >$$$.8
Question 6
A. Newsaers /s/ally are ,el+/l in screenin* misin+ormation contained in letters to
t,e editor and -y col/mnists
1. 5,e Federal Comm/nications Commission 7FCC8 r/led in :;(' t,at t,e Fairness
Doctrine is necessary -eca/se it re?/ires t,at -roadcasters ro"ide a reasona-le
oort/nity +or t,e resentation o+ oosin* "iews on contro"ersial /-lic iss/es.
C. 5alk-radio ro*rams are *ood +or/ms +or serio/s de-ates on contro"ersial s/-Aects
-eca/se t,ey resent all sides o+ an iss/e e?/ally.
D. Con"ertin* detailed data to so/nd -ites is a c,allen*e +or roonents o+ a comle0
/-lic-olicy iss/e -eca/se t,ey are ,eld to a "eracity standard.
3. Internet /se is a *ood so/rce o+ "alid ,ealt, in+ormation -eca/se t,e internet site
*/arantees t,at all t,e in+ormation ro"ided ,as *one t,ro/*, a ri*oro/s scienti+ic
re"iew rocess and t,ere+ore t,e /-lic need not -e concerned a-o/t discernin* tr/t,
+rom +iction re*ardin* t,e in+ormation resented.
4,y Dentists and Dental Hy*ienists S,o/ld 1e In"ol"ed in )romotin* Comm/nity-
4ater Fl/oridation
5,e t,ird o+ t,e +i"e maAor et,ical rinciles incl/ded in t,e American Dental
AssociationCs Principles of !thics and Code of Professional Conduct is t,e Principle
of #eneficence t,at e0ressly states F. . . t,at ro+essionals ,a"e t,e d/ty to act +or t,e
-ene+it o+ ot,ers.F Directly related to t,is seci+ic et,ical rincile is a desi*nated
Code o+ )ro+essional !esonsi-ility re*ardin* Comm/nity Ser"ice, t,at +/rt,er states
t,at F. . . dentists ,a"e an o-li*ation to /se t,eir skills, knowled*e, and e0erience +or
t,e imro"ement o+ t,e dental ,ealt, o+ t,e /-lic and t,ey are enco/ra*ed to -e
leaders in t,eir comm/nity . . .. F
:;=
F/rt,ermore, t,e +o/rt, rincile is t,e )rincile
o+ #/stice em,asi@in* t,at Ft,e dentist ,as a d/ty to treat eole +airly.F In concert
wit, t,is rincile is t,e desi*nated Code of Professional Responsi4ility t,at states,
Fin its -roadest sense, t,is rincile e0resses t,e concet t,at t,e dental ro+ession
s,o/ld acti"ely seek allies t,ro/*,o/t society on seci+ic acti"ities t,at will ,el
imro"e access to care +or all,F Mincludin$ access to *no3n preventive measures li*e
community23ater fluoridationN,
-
5,e American Dental AssociationCs et,ical standards
are -/t one reason t,at comm/nity-water +l/oridation, clearly t,e *old standard o+
comm/nity--ased ro*rams +or t,e re"ention o+ dental caries, s,o/ld -e acti"ely
s/orted -y racticin* dentists and dental ,y*ienists. Similarly, t,e merican Dental
Hy$ienists ssociation?s Code of !thics states t,at Fet,ics comel /s to en*a*e in
,ealt, romotionBdisease re"ention acti"itiesF
:;&
ad"ocatin* +or water +l/oridation
meets t,is criteria.
5,e o-li*ation to romote scienti+ically A/sti+ied comm/nity--ased ro*rams, s/c, as
comm/nity-water +l/oridation, also stems +rom a dentistCsBdental ,y*ienistCs o-li*ation
to ser"e t,e comm/nity in e0c,an*e +or t,e comm/nityCs contri-/tion to t,e
dentistCsBdental ,y*ienistCs ri"ile*e o+ racticin* dentistryBdental ,y*iene. First, t,e
ri"ile*e o+ racticin* dentistryBdental ,y*iene ,as -een *ranted to dentistsBdental
,y*ienists -y t,e /-lic, t,ro/*, t,eir state le*islators, in t,e +orm o+ a statewide
dental ractice act mana*ed -y a state dental-licensin* -oard. 5,e ri"ile*e o+
racticin* dentistryBdental ,y*iene ,as -een allocated to dentistsBdental ,y*ienists
-eca/se o+ societyCs reco*nition o+ t,e need +or ,a"in* ?/ali+ied ractitioners to ser"e
t,e /-licCs oral-,ealt, needs. Society retains t,e ri*,t to maintain, modi+y, or cancel
t,ese ri"ile*es at any oint t,at t,ey +eel t,at t,e dentistsBdental ,y*ienists o+ t,eir
state are not meetin* societyCs needs. 1y assistin* comm/nities to a/t,ori@e and
imlement comm/nity-water +l/oridation, dentistsBdental ,y*ienists demonstrate in
one small way, t,eir desire to meet t,eir many o-li*ations to society.
-
1racketed ,rase added. 1rackets enclose a ,rase added -y a/t,ors to +/rt,er
ill/strate t,e relations,i o+ t,e dentistCs o-li*ation to romote comm/nity-water
+l/oridation to t,e ADACs Code o+ 3t,ics and Code o+ )ro+essional Cond/ct.
Opposition to Community-Water Fluoridation
4,ile +l/oridation is *enerally not considered contro"ersial amon* t,e scienti+ic
comm/nity, it ersists as a olitical li*,tenin* rod, an iss/e to -e a"oided at all costs
-y t,e olitical comm/nity. )aste/ri@ation, imm/ni@ation, and c,lorination all +aced
oosition initially w,ic, s/-se?/ently s/-sided.
:;'
Howe"er, since Grand !aids,
Mic,i*an, -e*an +l/oridatin* its /-lic-water s/ly in #an/ary :;&', t,ere ,as -een
a relentless e++ort -y a small -/t determined oosition to /ndermine t,e e++orts o+
,ealt, ro+essionals and ci"ic leaders to imlement +l/oridation aro/nd t,e world.
Interestin*ly eno/*,, F/re-water committeesF seem to srin* / w,ere"er t,ere
aears to -e a +l/oridation meas/re on t,e /-lic a*enda. S/c, committees de+ine
/re water as +l/oride-+reeD +orty-ei*,t ot,er c,emicals +re?/ently /sed in water
treatment are e0cl/ded +rom t,eir de+inition o+ /re water. In"okin* Ft,e /re
waterB+l/oride-+ree @oneF is a cle"er tactic desi*ned to /s, emotional -/ttons a*ainst
+l/oridation. On t,e ot,er ,and, +l/oridation roonents ass/me t,at t,e
misin+ormation disseminated -y t,e oonents will -e easily re+/ted andBor readily
dismissed since t,e +acts +a"orin* +l/oridation are mistakenly t,o/*,t to -e clear and
con"incin*. Howe"er, s/c, a miscalc/lation may -e t,e -asis +or /nderestimatin* t,e
ower o+ t,e ,i*,ly moti"ated oosition w,o -elie"e t,at +l/oridation is a rime
e0amle o+ *o"ernment intr/sion.
<(
5ec,ni?/es 3mloyed -y Oonents o+ Fl/oridation
1ern,ardt g Sra*/e comiled a list o+ tec,ni?/es +re?/ently /sed -y t,e oosition
in attemtin* to sto t,e rocess o+ +l/oridation.
:;<
Se"eral additional tec,ni?/es ,a"e
-een cate*ori@ed and incl/ded in t,e +ollowin* s/mmary o+ "ario/s tec,ni?/es
emloyed -y oonents o+ +l/oridation.
:. &eutrali1in$ Politicians9 Once t,e +l/oridation le*islationBordinance ,as -een
introd/ced, oonents attemt to con"ince state and local elected o++icials to remain
ne/tral, rat,er t,an make t,e aroriate ,ealt, olicy decision to +l/oridate t,e water
s/ly. Oonents o+ten attemt to *i"e t,e imression t,at t,ere is Fscienti+icF
le*itimacy +or t,eir ositions -y ?/otin* Falternati"e medicineF we-sites or /sin*
se/do-scienti+ic sokesersons in ,earin*s, corresondence, and distri-/ted
roa*anda. Anti-+l/oridationists try to con"ince t,e elected o++icials to re+er t,e iss/e
to /-lic "ote, /s/ally, a secial election w,ere t,ere is inade?/ate time +or
roonents to or*ani@e e++ecti"ely, rat,er t,an to decide t,e iss/e t,ro/*, t,e normal
le*islati"eBadministrati"e rocess. 5,is strate*y is +a"ora-le to +l/oridation oonents
w,o are o+ten more adet at r/nnin* a scare camai*n +oc/sed on ne*ati"e claims
a-o/t +l/oridation t,an t,ey are at con"incin* sketical le*islatorsBcityBco/nty
o++icials to a*ree wit, t,eir "iews wit,o/t "eri+ication.
5,e oosition o+ten resorts to massi"e letter-writin* and ,one-callin* camai*ns
desi*ned to *i"e t,e imression t,at Fe"eryone is a*ainst +l/oridation,F w,en in +act
t,e "ast maAority o+ citi@ens may "ery well -e s/orti"e o+ +l/oridation. 5,e strate*y
also in"ol"es -om-ardin* t,e rint media wit, letters-to-t,e-editors to +oster t,e
notion t,at t,ere is widesread disaro"al o+ +l/oridation. Swamin* le*islators
andBor city leaders wit, reams o+ roa*anda +alsely claimin* Fe"idence o+ ,arm,F
wit,o/t s/-stantiation or o+ inter+erence wit, t,eir F+reedom o+ c,oice,F e"en t,o/*,
le*itimate researc, res/lts /ni"ersally re+/te claims o+ ,arm and t,e co/rts ,a"e
reeatedly ,eld t,at +l/oridation inter+eres wit, no onesC constit/tional +reedoms, is
art o+ t,e o"erall strate*y.
Co-otin* le*islators andBor city leaders is anot,er strate*y desi*ned to ne/trali@e
/-lic o++icials. O"erestimatin* t,e e0tent o+ t,e oosition o+ten res/lts in leaders
takin* t,e at, o+ least resistance and concl/din* t,at it is sa+er to ,a"e t,e electorate
make t,e decision rat,er t,an enter t,e +ray. 1y aro/sin* serio/s do/-ts a-o/t sa+ety,
anti+l/oride @ealots *i"e local elected o++icials an e0edient e0c/se to delay +a"ora-le
administrati"e action. 5,/s, not only ,as t,e le*islati"eBcityBco/nty o++icial -een
ne/trali@ed, t,e anti+l/oridationists ,a"e *ained more time to in/ndate t,e /-lic wit,
ne*ati"e roa*anda desi*ned to create +ear and do/-t amon* t,e /-lic and alter
/-lic ercetion o+ +l/oridation.
>. Use of the #i$ (ie6 Anti-+l/oridationists reeatedly alle*e t,at +l/oride ca/ses
cancer, kidney disease, ,eart disease, *enetic dama*e, osteoorosis, DownCs
syndrome, AIDS, Al@,ei- merCs disease, nym,omania, "iolent -e,a"ior, crime, and
ractically e"ery ot,er malady known to mana "erita-le la/ndry list o+ /nro"ed
alle*ations. Nonet,eless, t,ese la/ndry lists are reeated so +re?/ently in anti-+l/oride
am,lets, letters-to-t,e-editor, and ,one calls to talk-radio s,ows, t,at t,e /-lic
may act/ally -e*in to -elie"e t,e /ns/-stantiated claims. In order to lend some a/ra
o+ le*itimacy to t,e /nro"ed claims, se/do-scientists +re?/ently aear as t,e
a/t,ors o+ s/c, letters. In t,e +all o+ >$$$, a leadin* anti-+l/oridationist sokesman
anno/nced to radio listeners in San Antonio, 5e0as, t,at +l/oridation was directly
resonsi-le +or =',$$$ deat,s eac, year in t,e United States. I+ t,ere were any tr/t, to
t,is -i* lie, +l/oridation wo/ld cease sim/ltaneo/sly all o"er t,e United States and
aro/nd t,e world. Het, w,ile t,is -i* lie is clearly o++ t,e c,arts, some ?/estioned w,y
anyone wo/ld make s/c, a serio/s alle*ation i+ it werenCt tr/e, or ossi-ly tr/e. )/-lic
sketicism o+ten res/lts +rom s/c, a scenario.
5,e aearance o+ an alle*ation in rint 7s/c, as in t,e letters to t,e editor section o+
local newsaers8 is o+ten -elie"ed -y t,e /-lic to -e e"idence o+ t,e alle*ationCs
"alidity. 5,e /-lic incorrectly ass/mes t,at t,e Fa/t,oritiesF 7in t,is case rint media
editors8 wo/ld not allow alle*ations to -e rinted i+ t,ey were /ntr/e. 5,/s, t,e media
o+ten -ecome /nwittin* awns o+ t,e anti-+l/oridationists, /nless t,e newsaers are
lar*e eno/*, and so,isticated eno/*, to ,a"e emloyed ?/ali+ied and resonsi-le
science editors to eliminate +rom /-lication t,ose letters t,at are scienti+ically
/nso/nd and w,ic, constit/te a otential +or ,arm to t,e /-lic.
=. 5,e /se o+ Half2Truths, w,ere an o/t-o+-conte0t statement is /sed to imly a ca/se-
and-e++ect relations,i wit, some ne*ati"e res/lt alle*ed to ,a"e -een ca/sed -y
+l/oridation9 For e0amle, +l/oridation oonents claim t,at F+l/oride is oison, so
donCt let t,em /t it in o/r water.F 5,is statement i*nores t,e rincile t,at to0icity is
related to dose o+ a s/-stance and not to mere e0os/re to t,e s/-stance itsel+.
C,lorine, "itamin D, ta-le salt, iodine, anti-iotics, e"en water, ser"e as e0cellent
e0amles o+ s/-stances t,at are ,arm+/l in t,e wron* amo/nts -/t -ene+icial in t,e
correct amo/nts.
Anot,er e0amle is9 F+l/oride ca/ses dental +l/orosis or mottlin*.F 1y itsel+, t,is
claim +ails to take into acco/nt eit,er t,e so/rce o+ t,e +l/oride, t,e amo/nt o+
+l/oride, t,e mec,anism o+ +l/oride e0os/re, or t,e time o+ e0os/re as related to t,e
dental a*e o+ t,e erson e0osed. 4,en t,is claim is made, oonents disin*en/o/sly
e?/ate +l/oridation wit, t,e se"ere +orm o+ +l/orosis, not t,e milder +orms, e"en
t,o/*, t,ey know t,eir in+ormation is a misreresentation o+ t,e +acts. Comm/nity-
water +l/oridation is not resonsi-le +or ca/sin* t,e se"ere dental +l/orosis deicted in
t,e ,otos dislayed -y t,e anti-+l/oridationists. As stated re"io/sly, aro0imately
:=E o+ c,ildren w,o drink otimally +l/oridated water will de"elo "ery mild
+l/orosis. Dental +l/orosis as seen in t,e United States mani+ests rimarily as t,e
milder +orms and ,as -een mostly attri-/ted to t,e inaroriate in*estion o+ lar*e
amo/nts o+ +l/oride-containin* denti+rice -y yo/n* c,ildren w,o were not roerly
s/er"ised d/rin* toot,-r/s,in* and to imroer s/lementation o+ +l/oride t,ro/*,
careless rescriti"e ractices. Anti-+l/oridationists +re?/ently adot t,e intellect/ally
dis,onest ractice o+ s,owin* ,oto*ra,s o+ teet, wit, tetracycline stainin* or o+
e0tremely rare cases o+ se"ere dental +l/orosis t,at ,a"e occ/rred in ot,er co/ntries
-eca/se o+ e0tensi"e ind/strial oll/tion or lon*-term in*estion o+ e0tremely ,i*,
nat/rally-occ/rrin* +l/oride le"els +rom noncomm/nal water so/rces. 5,ey t,en
+alsely claim t,at t,is will -e t,e res/lt +or anyone, incl/din* ad/lts, w,o mi*,t drink
+l/oridated water. As stated re"io/sly, ad/lts are not at risk +or dental +l/orosis.
Anot,er ,al+-tr/t, eso/sed +re?/ently in t,e :;($s was9 F5,e maAority o+ AIDS
"ictims come +rom +l/oridated cities.F 5,is ,al+-tr/t, was +re?/ently made in
mis*/ided attemts to ers/ade San FranciscoCs /-lic into stoin* +l/oridation in
t,at city. 5,is claim contin/ed to -e made, e"en a+ter t,e disco"ery o+ t,e "ir/s t,at
ca/ses AIDS. 4,ile most AIDS atients coincidentally reside in maAor metroolitan
areas and most maAor metroolitan areas are +l/oridated 7&% o+ t,e '$ lar*est cities in
t,e United States8, t,e anti-+l/oridationists lo*ic ne"er did e0lain t,e ,i*, incidence
o+ AIDS in .os An*eles, San Die*o, or Newark 7New #ersey8, all not +l/oridated at
t,e time o+ t,e claim. 5,is same anti-+l/oridationist aarently c,an*ed ,is mind and
claimed d/rin* ,is /ns/ccess+/l :;;> t,ird-arty camai*n +or t,e U.S. residency,
t,at AIDS is ca/sed -y t,e AIDS dr/* AI5, imlyin* t,at t,ere is a lot -y medical
ro+essionals, dr/* comanies, and t,e *o"ernment to in+ect certain *ro/s wit,
AIDS.
&. Utili@ation o+ /nnuendo6 A +re?/ently /sed +l/oro,o-ic tome is, t,at Fw,ile one
*lass o+ +l/oridated water will not kill anyone, it is t,e *lass a+ter *lass o+ +l/oridated
water, as wit, ci*arette a+ter ci*arette, t,at takes its toll in ,/man ,ealt, and li+e.F
5,is tec,ni?/e /ses a */ilt--y-association loy, attemtin* to link t,e known ,ealt,
risks o+ ci*arette smokin* 7+or w,ic, t,ere is s/-stantial scienti+ic e"idence8 to
alle*ed risks +rom drinkin* +l/oridated water 7+or w,ic, t,ere is no scienti+ic
e"idence8.
Anot,er o+t-/sed claim -y +l/oridation oonents is t,at Fins/++icient researc, ,as
-een carried o/t to ro"e a-sol/te sa+ety, and t,ere+ore cons/mers and *o"ernment
o++icials are /r*ed to wait /ntil all do/-t a-o/t t,e sa+ety o+ +l/oridation ,as -een
Cscienti+icallyC resol"ed.F 5,is ar*/ment co/ld -e /sed inde+initely in t,at it is
imossi-le to e"er ro"e a-sol/te sa+ety +or all time +or anyt,in*. Un?/ali+ied
accetance o+ t,is ar*/ment wo/ld mean t,at literally all tec,nolo*ic ad"ancements
ac,ie"ed in t,e a*e o+ science wo/ld ,a"e to -e eliminated. 5,o/sands o+ st/dies and
/ntold risk--ene+it analyses ,a"e s,own t,at +l/oridation is sa+e and e++ecti"e +or t,e
entire o/lation.
'. Euotin$ of /naccurate Statements and the Use of Statements Ta*en +ut of Context6
5,e -est way to ill/strate t,is common tec,ni?/e o+ anti-+l/oridationists is to re+er to
two +re?/ently /sed anti-+l/oridation /-lications, t,e (ifesavers 7Sic8 0uide to
'luoridation 7a am,let8
:;%
and 'luoride6 the $in$ 'actor,
:;(
7a -ook8. 1ot, /se
essentially t,e same Fscienti+ic re+erences,F -ot, are distri-/ted +re?/ently in
camai*ns, oosin* +l/oridation, and -ot, doc/ments were marketed -y t,eir a/t,or
as Fscienti+ic doc/ments.F 5,e one-s,eet am,let claimed o"er >'$ re+erences.
S/-se?/ently, a *ro/ o+ >$ scientists and /-lic ,ealt, o++icials +rom aro/nd t,e
United States did a systematic re"iew, trackin* down t,e ori*inal re+erences in order
to e"al/ate t,eir "alidity as /sed -y t,e a/t,or. 5,e roAect took two years and
res/lted in t,e rod/ction o+ a :(&-a*e mono*ra,, entitled 4use of the Scientific
(iterature in an nti2fluoridation Pamphlet,
:;;
In t,e mono*ra,, t,e >$ scientists
doc/mented t,at t,e in+ormation in t,e (ifesavers (Sic) 0uide to 'luoridation
:;%

am,let was rimarily +a-ricated se/do-science +or w,ic, no scienti+ic e"idence
was a"aila-le. Some o+ t,e +indin*s o+ t,is rotracted re"iew incl/ded9 7a8 o+ t,e >'$
re+erences, only&( were +rom re/ta-le scienti+ic Ao/rnalsD 7-8 ::< o+ t,e >'$
re+erences ,ad no rele"ance to comm/nity water +l/oridation w,atsoe"erD 7c8 many o+
t,e re+erences act/ally s/orted +l/oridation wit, t,e works o+ resected scientists
selecti"ely ?/oted, mis?/oted, and misreresented in order to make t,em aear to
disco/ra*e t,e /se o+ +l/orides.
:;(
<. Euotin$ of !xperts6 Some o+ t,e ?/oted e0erts ,a"e le*itimate academic or
ro+essional credentials, alt,o/*, not necessarily in discilines ?/ali+ied to ser"e as
e0erts in ,ealt, researc, seci+ic to +l/orides. Moreo"er, anti-+l/oridationists
occasionally +ind a credentialed indi"id/al to seak a*ainst mainstream science. 5,e
statements -y t,ese mar*inali@ed indi"id/als, w,ile o+ ?/estiona-le a/t,ority, are
o+ten e0loited -y t,e oosition.
Some nationally known +i*/res w,o may ,a"e oosed +l/oridation early in t,eir
ro+essional li+e rior to t,e acc/m/lation o+ o"erw,elmin* scienti+ic e"idence in its
+a"or, o+ten ,a"e t,eir earlier statements ?/oted -y anti-+l/oridationists desite ,a"in*
/-licly c,an*ed t,eir osition to one o+ s/ort +or +l/oridation. As an e0amle, t,e
oosition reeatedly claim t,at No-el .a/reate and ,ysician H/*o 5,eorell
FcondemnsF +l/oridation w,en, in +act, ,e /-licly c,an*ed ,is osition to one o+
s/ort as +ar -ack as :;<%. 5,e /-lic is +/rt,er con+/sed w,en anti-+l/oride @ealots
/tili@e t,e ser"ices o+ Falternati"e medicineF sokesersons to Fro"eF t,at t,e
medical comm/nity is di"ided in its osition on +l/oridation. Una-le to discriminate
-etween le*itimate scientists and /r"eyors o+ /nro"en t,eraies, some in t,e /-lic
see t,e dis/te as a con+lict -etween cometin* ,ealt, care ,iloso,ies and
ideolo*ies.
%. The Conspiracy 0am4it6
:;<
1eca/se alle*ed consiracies are di++ic/lt to disro"e,
t,ey are a +a"orite o+ t,e ,ealt,-consiracy t,eorists. 5,e alle*ed FconsiratorsF o+ten
incl/de t,e American Medical Association, t,e American Dental Association, t,e
American Co/ncil on Science and Healt,, t,e e?/iment and c,emical s/ly
comanies, t,e Comm/nist )arty, -ot, t,e al/min/m and ,os,ate +ertili@er
ind/stries, toot,aste man/+act/rers, or any ot,er or*ani@ation aearin* to -e
t,reatenin* to t,e anti-+l/oridationists. Hi*,est on t,eir list o+ consirators is t,e
F*o"ernmentF 7incl/din* t,e )/-lic Healt, Ser"ice, t,e 3n"ironmental )rotection
A*ency, t,e resti*io/s National Instit/tes o+ Healt,, t,e world-renowned Centers +or
Disease Control, and t,e Food g Dr/* Administration8. Consiracies *enerate a
tremendo/s amo/nt o+ an*er amon* t,ose s/sceti-le to consiracy roa*anda, a
+actor t,at ne*ati"ely imacts +l/oridation e++orts.
(. The use of Scare -ords6
:;<
Anti-+l/oridationists +re?/ently lay on t,e c/rrent
,o-ias and concerns o+ t,e /-lic -y descri-in* +l/oridation in ecolo*ically-linked
or en"ironmentally-loaded terms or ,rases s/c, as, Foll/tant, to0ic waste rod/ct,
c,emical -y-rod/ct, d/med in t,e water, or +orced down o/r t,roats.F Fl/oride is
also +re?/ently linked -y +l/oro,o-ics wit, words like Foison, *enetic dama*e,
cancer, AIDS, or arti+icialFwords t,at certainly conA/re / +ear -y t,e /-lic w,en
linked to somet,in* to w,ic, t,ey t,ink t,ey will -e /nwittin*ly e0osed. Fear is a
maAor +actor t,at ne*ati"ely imacts +l/oridation e++orts.
;. The De4ate Ploy6
:;<,>$$
5,e oonents o+ +l/oridation o+ten try to entice
/ns/sectin* media commentators, *o"ernment o++icials, or ro*ram lanners into
,oldin* a de-ate on t,e Fros and consF o+ +l/oridation. )roonents o+ +l/oride are
t,en o+ten traed into consentin* to /-lic de-ates. #ar"is ,as /-lis,ed a list o+
reasons +or not de-atin* t,e anti-science ,ealt, "iewoint9 7a8 t,e /rose o+ t,e
de-ate is to win t,e a/dience, not to disco"er tr/t,. Science is not decided -y de-atin*
in a /-lic +or/m, -/t -y care+/l e0erimentation, con+irmation o+ +indin*s t,ro/*,
indeendently cond/cted e0eriments, s/-mission o+ all +indin*s to ?/ali+ied
collea*/es and eers +or critical analysis, and /-lication o+ +indin*s in re/ta-le
eer-re"iewed Ao/rnals. In a de-ate, e"en t,o/*, t,e roonents may win t,e de-ate,
t,ey are A/st as likely to lose t,e a/dience. 7-8 In media circles, t,ere is a sayin* t,at
Fe"eryone is t,e same si@e on tele"ision.F In ot,er words, de-ates *i"e t,e ill/sion
t,at a scienti+ic contro"ersy e0ists w,en, in reality, t,is is not t,e case. )/-lic de-ates
also romote t,e ill/sion t,at t,ere are e?/al n/m-ers o+ FscientistsF on eac, side o+
t,e iss/e. 5,e "ision o+ Fd/elin* ),DCs or d/elin* doctorsF enco/ra*es t,e /-lic to
reAect +l/oridation /ntil t,e Fe0erts on -ot, sides can a*ree.F 7c8 An oonent o+
+l/oridation, /tili@in* t,e la/ndry list aroac,, can resent more misin+ormation in '
min/tes t,an can -e re+/ted in ' ,o/rs, t,/s +osterin* con+/sion on t,e art o+ t,e
/-lic. )roonents are ne"er ro"ided eno/*, time to ade?/ately re+/te t,e
oonentsC c,ar*es, -eca/se comlete re+/tations, -y t,eir nat/re, take m/c, lon*er
t,an t,e so/nd--ite len*t, c,ar*es o+ t,e anti-+l/oridationists. 7d8 )/-lic e0os/re
+a"ors t,e oonent, ena-lin* ,im or ,er to *ain name reco*nition +or t,e "iewoint
t,ey are romotin*. 1y s,arin* t,e lat+orm wit, resected scientists w,o are t,ere to
de+end +l/oridation, e?/al stat/s and credi-ility is *ranted. Anti-+l/oride *ro/s o+ten
Fattac,F t,emsel"es to ot,er or*ani@ationsC e"ents in order to draw attention to t,eir
ca/se. 7e8 It is di++ic/lt to comete in a de-ate wit,o/t aearin* to discredit t,e
oonents ersonally. 4,en a +l/oridation roonent is re+/tin* a ne*ati"e statement
made -y t,e anti-+l/oridation sokeserson w,o is sreadin* misin+ormation, t,e
roonent ,as to -e a-le to searate t,e anti-science messa*e +rom t,e anti-science
messen*er, an e0tremely di++ic/lt task. Moreo"er, t,e de-ate +ormat o+ten +a"ors t,e
ma"erick "iewoint as t,e ercei"ed /nderdo*, as in a Da"id "s. Goliat, s,owdown,
*eneratin* symat,y +or t,e anti-+l/oridation ersecti"e. One o+ t,e strate*ies /sed
-y anti-+l/oridationists in a de-ate settin* is to intimidate t,e roonent7s8 -y
t,reatenin* to +ile a laws/it +or de+amation o+ c,aracter. 5,is strate*y is "ery
/nsettlin* +or an /ntrained roonent w,o o+ten loses +oc/s, con+idence, and -ecomes
ine++ecti"e as a de-ater. 4,en s/c, a t,reat is made in a de-ate, it is ,ard to
remem-er t,at +ew laws/its ,a"e act/ally -een +iled and none o+ t,ese laws/its ,a"e
-een s/ccess+/lly rosec/ted -y any o+ t,e anti-+l/oridationists.
Fi"e additional anti-+l/oridationist tec,ni?/es not cited -y 1ern,ardt g Sra*/e in
t,eir aer -eca/se t,ey ,a"e aeared since its /-lication incl/de t,e /se o+
contri"ed or*ani@ations, s/-"ersion o+ t,e media, commandeerin* esta-lis,ed
or*ani@ations, mis/se o+ electronic /-lis,in*, and commandeerin* meetin*s.
>
7:8 5,e use of contrived or$ani1ations is most dist/r-in*9
>
5,e oonents o+ten +orm
t,eir own se/do-scienti+ic or*ani@ations ,a"in* names t,at so/nd like le*itimate
scienti+ic entities, -/t w,ic, are in reality, +ront or*ani@ations +or t,e anti-
+l/oridationist mo"ement.
7>8 Su4version of the media9
>
5,e Ao- o+ t,e media is to resent all sides o+ an iss/e.
O+ten t,e media aear to -e more interested in /-lici@in* a contro"ersy t,an in
acc/rately reresentin* an iss/e.
>
Many camai*n committees ,a"e enco/ntered a
o/lar media ,iloso,y Fi+ it -leeds, it leadsF. Moreo"er, it is o+ten more ro+ita-le
+or t,e media to do a story on t,e Fdan*ersF o+ +l/oridation w,ic, can -e
sensationali@ed t,an to do one on t,e many scienti+ically so/nd, -/t emotionally
/ne0citin*, reasons +or s/ortin* +l/oridation. Also, t,e anti-esta-lis,ment and anti-
science "iewoint tends to -e more +lam-oyant and interestin* to a media seekin* to
ortray readily /nderstanda-le e0amles o+ #o,n j. )/-lic +i*,tin* city ,all. It is
imortant to remem-er t,at scienti+ic re-/ttals to +lam-oyant anti-+l/oridation claims
are o+ten, -y t,eir nat/re, dry, /nemotional, comle0, di++ic/lt to e0lain in lay terms,
,ard +or t,e /-lic to *ras concet/ally, and di++ic/lt +or t,e media to interret and
reort.
7=8 Commandeerin$ !sta4lished +r$ani1ations6
>
In se"eral instances, anti-
+l/oridationists ,a"e commandeered esta-lis,ed or*ani@ations in an attemt to *ain
access to t,e or*ani@ationCs credi-ility +or t,e anti-+l/oride ca/se.
>
5wo recent
e0amles in"ol"e t,e )ennsyl"ania Sierra Cl/- and one o+ t,e collecti"e -ar*ainin*
/nits +or t,e U.S. 3n"ironmental )rotection A*ency. In A/*/st :;;%, a mem-er o+ t,e
)ennsyl"ania C,ater o+ t,e Sierra Cl/- ,eld a ress con+erence in Harris-/r* in
w,ic, s,e claimed t,at t,e Sierra Cl/- called +or a -an on +l/oridation in t,at state.
>,>$:
4it,in a +ew days, t,e o++icers o+ t,e C,ater iss/ed an o++icial statement re-/kin*
t,e mem-erCs action and statin* t,at t,e ress con+erence was ,eld Fwit,o/t t,e
knowled*e or a/t,ori@ation o+ any )ennsyl"ania Sierra Cl/- o++icer.F
>,>$>
5,e U.S. 3n"ironmental )rotection A*ency 73)A8 ,as o"er :(,$$$ emloyees
reresented mostly -y +o/r collecti"e -ar*ainin* /nits. 5,e smallest o+ t,ese
-ar*ainin* /nits was .ocal >$'$ o+ t,e National Federation o+ Federal 3mloyees
7NFF38, a /nion t,at "ario/sly claimed to reresent a-o/t ;$$, :$$$, ::$$, and
+inally :''$ 3)A emloyees, -/t w,ose d/es-ayin* mem-ers,i was aarently
m/c, less.
>
A-o/t >$ dissident mem-ers o+ t,e /nion ,eld a meetin* on #/ly >, :;;%,
w,ere a minority o+ t,em "oted to oose Cali+orniaCs mandatory +l/oridation law.
>
A
s/-se?/ent ress con+erence +alsely claimed t,at all /nion mem-ers /nanimo/sly
aro"ed t,e resol/tion and s/-se?/ent mass mailin*s o+ roa*anda lea+lets +rom
two o+ t,e /nionCs anti-+l/oride acti"ists +alsely imlied t,at t,e US3)A oosed
+l/oridation.
>,>$=
7&8 %isuse of !lectronic Pu4lishin$6
>
N/mero/s anti-+l/oridation we-sites ,a"e -een
esta-lis,ed in order to romote t,e anti-+l/oride olitical a*enda and to recr/it
con"erts to t,eir mo"ement.
>
In addition, many Falternati"e medicineF we-sites ,a"e
incl/ded anti-+l/oridation sections as art o+ t,eir marketin* e++ort, alon* wit,
in+ormation t,at9 ooses traditional scienti+ic medical ractice, attacks ort,odo0
medical ractice, incl/din* s/c, widely acceted /-lic-,ealt, ractices as
imm/ni@ation ro*rams. Many o+ t,ese anti-+l/oridation we- sites contain Farticles,F
letters, endorsements, or re+erences to /r"eyors o+ Falternati"eF or Fcomlementary
medicine.F Some also contain links to we-sites oerated -y ractitioners and
marketers o+ non-scienti+ic t,eraies.
7'8 Commandeerin$ %eetin$s9
>
O+ten, anti-+l/oridation sokesersons attemt to
insert t,emsel"es into t,e a*enda o+ sc,ed/led meetin*s or ,earin*s in order to *ain a
+or/m +rom w,ic, to disseminate t,eir anti-+l/oridation messa*e.
>
It is not /ncommon
+or anti-+l/oridationists to attemt to /tili@e ?/estion and answer eriods in /-lic
meetin*s to eso/se t,e Fit+allsF o+ +l/oridation rat,er t,an to ask ?/estions o+
sc,ed/led seakers. 5own meetin*s, alle*edly sc,ed/led to ro"ide oort/nities +or
roonents and oonents to resent t,eir cases, o+ten ser"e as a con"enient +or/m
+rom w,ic, anti-+l/oridation sokesersons try to dominate t,e a"aila-le time.
Question 7
4,ic, o+ t,e +ollowin* statements is correct, i+ anye
A. )se/do-science can re"ail o"er science w,en t,e electorate is not +amiliar wit,
eit,er side o+ t,e s/-Aect -ein* de-ated.
1. Fear is o+ten /sed -y +l/oridation oonents to create do/-t a-o/t t,e sa+ety and
-ene+its o+ +l/oridation.
C. S/ort -y racticin* dentists and dental ,y*ienists +or comm/nity water
+l/oridation is incon*r/ent wit, American Dental AssociationCs et,ical standards.
D. 5,e /se o+ ,al+-tr/t,s to imly a ca/se-and-e++ect relations,i s/c, as F+l/oride is a
oison, so donCt let t,em /t it in o/r waterF is a common tec,ni?/e emloyed -y
+l/oridation oonents.
3. In a de-ate, one seakerCs tr/t, is no more a/t,oritati"e t,an t,e second seakerCs
misin+ormation in a ,i*,ly tec,nical disc/ssion.
Risk Communication
Comm/nity water +l/oridation, w,ile lon* acceted -y ?/ali+ied scientists and
credi-le ro+essional or*ani@ations as a sa+e, e++ecti"e, e++icient, economic, socially
e?/ita-le, and en"i- ronmentally so/nd /-lic-,ealt, acti"ity, ,as end/red attacks
+rom a small, -/t ,i*,ly "ocal, *ro/ o+ tenacio/s anta*onists t,ro/*,o/t its '<-year
,istory. 5,ese attacks ,a"e ser"ed to raise ?/estions amon* some mem-ers o+ t,e
/-lic, ,a"e sometimes ser"ed as a con"enient e0c/se +or elected o++icials to a"oid
makin* decisions to +l/oridate indi"id/al comm/nity water systems, and ,a"e
accommodated some in t,e media w,ere t,e iss/e is o+ten e0loited so as to aear to
-e a ri+t amon* Fe0ertsF on -ot, sides o+ t,e iss/e, creatin* do/-t amon* t,e /-lic
a-o/t t,e iss/e. Most comm/nities s/ccess+/lly work t,ro/*, t,e Fcontro"ersy,F
/s/ally a res/lt o+ ,ard work -y ,ealt, ro+essionals and s/stained o-Aecti"ity on t,e
art o+ comm/nity leaders and elected o++icials. O+ten misin+ormation is -roadly
disseminated, ad"ersely in+l/encin* comm/nity sentiment s/c, t,at ot,er meas/res
-ecome necessary to co/nter t,e mass ,o-ia sometimes *enerated d/rin* t,e
le*islati"e, camai*n or administrati"e rocess.
!isk comm/nication is a recent addition to t,e armamentari/m o+ ,ealt, ro+essionals
romotin* +l/oridation in t,eir comm/nities. It ser"es as a mec,anism -y w,ic, to
co/nter some o+ t,e ne*ati"e comm/nity sentiment *enerated d/rin* attemts to
+l/oridate comm/nities. Sandman ,as classi+ied t,is intense ne*ati"e +eelin* a-o/t
w,at is ercei"ed -y some to -e a ,ealt, risk as outra$e,
:%>
Accordin* to Sandman,
t,e /-lic de+ines risk in terms o+ Fle"els o+ o/tra*eF. 5,e scienti+ic and ,ealt,
comm/nity, w,o de+ine risk in terms o+ F,a@ard, are o+ten too slow to reco*ni@e t,e
disarity -etween act/al risk 7,a@ard8 as calc/lated -y t,e scienti+ic comm/nity and
ercei"ed risk 7o/tra*e8 as ec,oed -y t,e /-lic.
:%>
Accordin* to Sandman, t,e /-lic
ays +ar too little attention to ,a@ard, w,ile most e0erts ay a-sol/tely no attention
to o/tra*e.
:%>
A /-lic w,ose le"el o+ o/tra*e ,as -een ,ei*,tened -y a well-
orc,estrated anti-+l/oridation camai*n, will -e less receti"e to ed/cational
camai*ns -y roonents o+ +l/oride /ntil t,e le"el o+ o/tra*e is red/ced. )ertinent
risk in+ormation cannot -e comm/nicated w,en t,e le"el o+ o/tra*e is ,i*, -eca/se
t,e intended reciients o+ t,e in+ormation cannot collate t,e comle0 e0lanations
w,ile +ri*,tened -y t,e +l/oridation messa*e andBor an*ry at t,e +l/oridation
messen*er.
Sc,olars o+ risk ercetion ,a"e de+ined more t,an >$ +actors t,at a++ect t,e /-licCs
le"el o+ o/tra*e. A +ew o+ SandmanCs +a"orite +actors are resented as +ollows 7see
Sand-manB5a-le (-;8.
Voluntariness: A "ol/ntary risk is m/c, more acceta-le to eole t,an a risk +elt
-y t,e /-lic to ,a"e -een coerced -eca/se a "ol/ntary risk *enerates little or no
o/tra*e.
>$&
6ol/ntariness ,els e0lain w,y anti+l/oridation roa*andists will o++er
or*ani@ed "ol/ntary +l/oride s/lement ro*rams as an acceta-le 7to t,em8
alternati"e to FcoercedF comm/nity water +l/oridation.
>$&
Control: 4,en disease re"ention and e0os/re miti*ation are in t,e ,ands o+
indi"id/als 7+l/oride s/lements8, t,e risk 7t,o/*, not t,e ,a@ard8 is ercei"ed -y
t,em to -e m/c, lower t,an w,en t,e same ro*rams are controlled -y a *o"ernment
a*ency 7m/nicial water system and ,ealt, deartment8.
Fairness: )eole w,o +eel t,at t,ey are end/rin* *reater risks t,an t,eir nei*,-ors,
esecially i+ t,ey +eel t,at t,ey are wit,o/t access to *reater -ene+its, are nat/rally
o/tra*ed, more so i+ t,e rationale +or increasin* t,eir risk aears to ,a"e -een
decided t,ro/*, t,e olitical rocess rat,er t,an t,ro/*, science.
>$&
3"en t,o/*,
+l/oridation -ene+its eole o+ all a*es, older Americans o+ten ass/me t,at it only
-ene+its c,ildren and +re?/ently comlain t,at t,ey are -ein* /t at risk wit,o/t
accr/in* any -ene+its t,emsel"es.
Process: Sometimes t,e rocess -y w,ic, +l/oridation is aro"ed -ecomes t,e
rincile +oc/s o+ t,e /-licCs o/tra*e, artic/larly w,en t,e a*ency or *ro/
romotin* +l/oridation ortrays itsel+ as arro*ant rat,er t,an concerned, dis,onest
rat,er t,an tr/stwort,y, and mani/lati"e rat,er t,an colla-orati"e.
>$&
Morality: American society ,as e"ol"ed in its t,inkin* a-o/t oll/tion to +eel t,at it
is not A/st ,arm+/l, it is morally e"il.
>$&
Fl/oridation oonents o+ten attemt to
ortray +l/oridation as a +orm o+ oll/tion and claim t,at +l/oride c,emicals are
rod/cts marketed -y t,e c,emical ind/stry as -ene+icial 7+l/oridation8 in order to
a"oid ayin* t,e costs to disose o+ t,ese c,emicals. 4,en +l/oridation roonents
start talkin* a-o/t cost-risk tradeo++s in t,is kind o+ olitical climate, t,ey o+ten
aear to -e callo/sly ad"ocatin* a morally rele"ant risk.
Familiarity: 30otic, ,i*,-tec, +acilities and rocesses 7com/ter-monitored water
treatment lants t,at add +l/oride and ot,er c,emicals8 ro"oke more o/tra*e t,an do
+amiliar risks 7+l/oride-containin* toot,aste as art o+ ,ome dental care8.
>$&
Memorability: A memora-le accident 7esecially one in"ol"in* c,emicals or
radiation, like .o"e Canal 7New Hork8, 1,oal 7India8, 5imes 1eac, 7Misso/ri8,
5,ree-Mile Island 7)ennsyl"ania8, or C,erno-yl 7Ukraine8, makes t,e otential risk
easier to ima*ine and t,ere+ore, ercei"ed to -e more risky.
>$&
A strate*y /sed -y
+l/oridation oonents is to attemt to en*ender +ear amon* t,e /-lic -y
em,asi@in* t,e statistically min/te otential o+ o"er+l/oridation or ,yer+l/oridation
as i+ it were a likely catastro,ic e"ent.
Dread: Illnesses like cancer, AIDS, Al@,eimerCs disease, or end sta*e renal disease
are more dreaded t,an dental caries.
>$&
Fl/oridation oonents ,el incite +ear amon*
t,e /-lic -y +alsely claimin* t,at +l/oridation ca/ses t,ese dreaded diseases or makes
t,em inc/ra-le, w,ile at t,e same time attemtin* to minimi@e +l/oridationCs stron*
re"enti"e e++ect on dental caries.
Diffusion in Time and Space: Ha@ard-A 7ramant dental caries8 /ltimately co/ld
res/lt in t,e deat,s o+ '$ or more anonymo/s eole a year across t,e co/ntry, w,ile
Ha@ard-1 7a oorly monitored and oorly oerated +l/oridation system8 res/lted in
one "ery well /-lici@ed deat, recently 7desite '< years o+ sa+e, e++ecti"e
+l/oridation e++orts t,at daily -ene+ited tens o+ millions o+ eole8.
>$&
Myt,s and Actions !elated to !isk Comm/nication
Some o+ t,ose in"ol"ed in comm/nity or*ani@ation +or +l/oridation romotion +ail to
roerly consider t,e role o+ o/tra*e in t,e comm/nity decision-makin* rocess.
5,ey ass/me t,at t,e /-lic will tr/st t,em and t,at -y merely resentin* t,e
scienti+ic data, t,e /-lic will -e Fwon o"er.F 1y i*norin* t,e role o+ o/tra*e, t,ey
miss t,e oort/nity to s/cceed t,ro/*, /se o+ a colla-orati"e e++ort in comm/nity
ed/cation and comm/nity decision-makin*. C,ess and ot,ers ,a"e cate*ori@ed a
n/m-er o+ myths and actions related to ris* communication,
>$'
5en o+ t,em incl/de9
Myth 1: 1eca/se t,e +l/oridation re+erend/m is so close, we donCt ,a"e eno/*, time
and reso/rces to ,a"e a risk comm/nication ro*ram.
>$'
Action 1: 5rain +l/oridation roonents to comm/nicate more e++ecti"ely. )lan
roAects s/c, t,at t,ere is time to in"ol"e t,e /-lic in riority settin* and decision-
makin*.
>$'
Myth 2: 5ellin* t,e /-lic a-o/t a otential risk related to +l/oridation is more
likely to /nd/ly alarm eole t,an keein* ?/iet.
>$'
Action 2: Fl/oridation roonents can decrease t,e otential +or alarm -y *i"in* t,e
/-lic a c,ance to e0ress t,eir concerns and -y aroriately resondin* to t,ese
concerns.
>$'
Myth 3: Comm/nication is less imortant t,an ed/cation. I+ eole knew t,e tr/e
risks related to +l/oridation, t,ey wo/ld accet t,em.
>$'
Action 3: )ay as m/c, attention to yo/r rocess +or dealin* wit, eole and t,eir
+ears o+ +l/oridation as yo/ do to e0lainin* t,e scienti+ic data.
>$'
Myth 4: 4e s,o/ldnCt *o to t,e /-lic /ntil we can ro"ide answers or sol/tions to
all t,eir ercei"ed +ears a-o/t +l/oridation.
>$'
Action 4: )ro"ide in+ormation a-o/t +l/oridation and disc/ss concerns a-o/t risk
mana*ement otions. In"ol"e t,e comm/nity in t,e de"eloment o+ strate*ies +or
w,ic, t,ey ,a"e a stake.
>$'
Myth 5: 5,ese iss/es and t,is scienti+ic data re*ardin* +l/oridation are too di++ic/lt
+or t,e /-lic to /nderstand.
>$'
Action 5: Searate /-lic disa*reement wit, yo/r +l/oridation romotion ractices
+rom mis/nderstandin* o+ t,e ,i*,ly tec,nical iss/es related to +l/oridation.
>$'
Myth 6: One o+ t,e easiest myt,s +or dental ro+essionals to em-race is t,at
tec,nical decisions s,o/ld -e le+t in t,e ,ands o+ tec,nical eole.
>$'
Action 6: )ro"ide t,e /-lic wit, in+ormation a-o/t +l/oridation. .isten to
comm/nity concerns a-o/t +l/oridation. In"ol"e eole wit, di"erse -ack*ro/nds on
t,e +l/oridation committee so t,at m/c, t,o/*,t and disc/ssion *oes into de"eloin*
+l/oridation olicies and strate*ies.
>$'
Myth 7: I am A/st a dentistBdental ,y*ienist, risk comm/nication is not my Ao-.
>$'
Action 7: As a /-lic ser"ant, w,et,er t,e +l/oridation romoter works +or a ,ealt,
deartment or ,as a ri"ate dentalBdental ,y*iene ractice, yo/ ,a"e a resonsi-ility
to t,e /-lic. .earn to inte*rate risk comm/nication into yo/r e++orts and ,el ot,ers
+rom t,e +l/oridation committee do t,e same.
>$'
Myth 8: I+ we *i"e t,em an inc,, t,ey will take a mile.
>$'
Action 8: I+ yo/ listen to eole w,en t,ey are askin* +or inc,es, t,ey are less likely
to demand miles. A"oid t,e -attle*ro/nd t,at co/ld res/lt +rom attemts to sti+le
disc/ssion a-o/t all asects o+ +l/oridation. Do not attemt to sti+le disc/ssion o+
iss/es a-o/t w,ic, +l/oridation roonents are /ncom+orta-le. In"ol"e t,e /-lic
early and o+ten.
>$'
Myth 9: I+ we listen to t,e /-lic comlain a-o/t risks +rom +l/oridation, we will
de"ote scarce reso/rces to iss/es t,at are not really a *reat t,reat to t,e /-licCs
,ealt,.
>$'
Action 9: .isten care+/lly and early to a"oid contro"ersy and t,e otential +or
disroortionate attention to lesser iss/es.
>$'
Myth 10: Acti"ist anti-+l/oride *ro/s are resonsi-le +or stirrin* / /nwarranted
concerns.
>$'
Action 10: Anti-+l/oride acti"ists ,el to +oc/s /-lic an*er. 4ork ,ard to *ain t,e
/-licCs tr/st early, so t,at yo/ can work wit, resonsi-le /-lic *ro/s to romote
t,e adotion o+ resonsi-le /-lic olicy re*ardin* +l/oridation.
>$'
Co"ello and Allen
>$<,>$%
,a"e de"eloed a list o+ Ten Deadly Sins of Communication,
5,ey are +airly sel+-e0lanatory and +ollow9 7:8 aearin* /nrearedD 7>8 ,andlin*
?/estions imroerlyD 7=8 aolo*i@in* +or yo/rsel+ or yo/r or*ani@ationD 7&8 not
knowin* knowa-le in+or- mationD 7'8 /nro+essional /se o+ a/dio"is/al aidsD 7<8
seemin* to -e o++ sc,ed/leD 7%8 not in"ol"in* articiantsD 7(8 not esta-lis,in* raortD
7;8 aearin* disor*ani@edD and 7:$8 ro"idin* t,e wron* content.
It remains o-"io/s t,at t,e mere dissemination o+ in+ormation to t,e /-lic, wit,o/t
any attemts to comm/nicate t,e comle0ities and /ncertainties o+ risk, does not
necessarily ens/re t,at t,e /-lic will /nderstand or accet comm/nity water
+l/oridation. 4ell-mana*ed risk-comm/nication e++orts will ,el ens/re t,at t,e
/-lic is ro"ided wit, messa*es t,at are constr/cti"ely +orm/lated, transmitted, and
recei"ed, and t,at t,ey will -e more likely to res/lt in ositi"e t,o/*,ts and an
accetance o+ +l/oridation. In t,e words o+ 1ar/c, Fisc,,o++, FI+ we ,a"e not *otten
o/r messa*e across, t,en we o/*,t to ass/me t,at t,e +a/lt is not wit, o/r recei"ers.F
>$(
)rinciles o+ !isk Comm/nication
5,e principles of ris* communication, i+ racticed /ni"ersally, can *o a lon* way
towards increasin* t,e seed wit, w,ic, t,e /-lic accets comm/nity water
+l/oridation as a local olicy otion. Co"ello and Allen
>$(
,a"e de"eloed Seven
Cardinal Principles of Ris* Communication, all desi*ned to ,el +l/oridation
romoters accomlis, t,eir *oals.
:. Accept and involve the public as a partner. Ho/r *oal is to rod/ce a /-lic
in+ormed a-o/t t,e ad"anta*es o+ +l/oridation, not to de+/se /-lic concerns or
relace actions.
>. Plan carefully and evaluate your efforts. Di++erent *oals, a/diences, and media
re?/ire di++erent aroac,es and di++erent actions.
=. Listen to the public's specific concerns. )eole o+ten care more a-o/t tr/st,
credi-ility, cometence, +airness, and emat,y t,an a-o/t statistics and details.
&. Be honest, frank, and open. 5r/st and credi-ility are di++ic/lt to o-tain and, once
lost, are almost imossi-le to re*ain.
'. Work with other credible sources. Con+licts and disa*reements amon*
or*ani@ations make comm/nication wit, t,e /-lic m/c, more di++ic/lt.
<. Meet the needs of the media. 5,e media are /s/ally more interested in
contro"ersy t,an risk, simlicity t,an comle0ity, dan*er t,an sa+ety. Hel t,em
/nderstand t,e di++erences.
%. Speak clearly and with compassion. Ne"er let yo/r e++orts re"ent yo/r
acknowled*in* t,e tra*edy o+ an illness, inA/ry, or deat,, or e"en t,eir otential.
Acknowled*e and emat,i@e wit, eoleCs +ears. )eole can /nderstand risk
in+ormation, -/t t,ey may still not a*ree wit, yo/. Some eole will ne"er -e
satis+ied wit, yo/r answers.
Summary
4ater +l/oridation is t,e rime e0amle o+ comm/nity--ased caries re"ention w,ere
t,e -ene+its accr/e to all indi"id/als cons/min* drinkin* water t,at is otimally
+l/oridated wit,o/t re*ard to socioeconomic stat/s. Fl/oridation remains a sa+e,
e++ecti"e, e++icient, economical, en"ironmentally so/nd, and socially e?/ita-le /-lic
,ealt, meas/re to re"ent dental caries.
>
It also +/l+ills all o+ t,e re?/irements o+ an
e0cellent /-lic olicy.
>
1ased /on e0tensi"e scienti+ic e"idence, re*ardin* t,e
sa+ety and e++ecti"eness o+ +l/oridation, n/mero/s national and international
or*ani@ations and a*encies ,a"e ad"ocated +or t,e adotion o+ +l/oridation as a means
o+ red/cin* dental caries in a comm/nity. Desite some minor oosition t,at
soradically delayed +l/oridationCs imlementation in some locales, s/-stantial
ro*ress ,as -een made toward ac,ie"in* t,e lon*-term *oal o+ /ni"ersal +l/oridation
in t,e United States. 4,ile t,e oosition to +l/oridation ,as -een +airly disor*ani@ed
and *enerally not too e++ecti"e, recent oosition +rom Falternati"e medicineF @ealots
and /r"eyors o+ /nro"ed ,ealt, modalities s/**ests t,at t,e /-lic, elected
o++icials, and t,e media may -e -ot, con+/sed and /nd/ly in+l/enced in t,e +/t/re -y
s/c, oen s/ort o+ anti-+l/oridation e++orts. Oen oosition to +l/oridation *i"es
t,e Falternati"e medicineF romoters a con"enient /-lic +or/m wit, w,ic, to stress
t,eir F,iloso,icalF di++erences +rom traditional science--ased ,ealt, care. 5,e
dental ro+ession s,o/ld ed/cate t,e /-lic, /sin* risk-comm/nication rinciles as a
standard -/siness ractice to assist atients in o-tainin* acc/rate in+ormation a-o/t
+l/oridation.
4,at needs to -e ket in ersecti"e is t,e tremendo/s s/ccess t,at ,ealt,
ro+essionals ,a"e ,ad in -rin*in* comm/nity water +l/oridation, one o+ t,e *reatest
/-lic-,ealt, ac,ie"ements o+ t,e >$t, cent/ry, to more and more Americans eac,
year. 5,e S/r*eon General o+ t,e United States ,as incl/ded a +l/oridation o-Aecti"e
in ,is Hear >$:$ Healt, O-Aecti"es +or t,e Nation.
%,>$;
1y t,e year >$:$, %'E o+ t,e
o/lation on comm/nity-water systems s,o/ld li"e in comm/nities wit, +l/oridated
water accordin* to one o+ t,e doc/mentCs *oals. Gi"en t,e s/-stantial *rowt, in
o/lation in t,e U.S. since t,e last o++icial +l/oridation cens/s was /-lis,ed in :;;>
w,ere o"er <>E o+ t,e o/lation on comm/nity-water systems were -ene+itin* +rom
+l/oridation, and t,e addition o+ millions o+ eole -eca/se o+ recent s/ccess+/l
+l/oridation camai*ns in .os An*eles, San Die*o, .as 6e*as, San Antonio, and Salt
.ake City, t,e *a -etween t,ose w,o ,a"e access to +l/oridated water and t,ose w,o
do not ,a"e access to t,is /-lic-,ealt, meas/re is -e*innin* to -e acknowled*ed -y
olicy makers, comm/nity leaders, and ,ealt, ro+essionals 7see Fi*/re (-',
Fl/oridation Growt,8.
As ,ealt, ro+essionals, we m/st reali@e Foral ,ealt, is not solely deendent on
indi"id/al -e,a"iors,F t,at attainment o+ otimal oral ,ealt, re?/ires a artners,i
-etween t,e dental ,ealt, ro+ession and -ot, t,e atient and t,eir comm/nity.
FUni"ersal access to +l/oride re?/ires a comm/nityCs commitment to water
+l/oridationF and t,e dental ro+ession m/st ro"ide t,e leaders,i, tec,nical
e0ertise and */idance to olicy makers as well as to t,e /-lic to -rin* +l/oridation
to +r/ition. 3"ery dental o++ice, dental ,ealt, deartment, comm/nity dental ,ealt,
ro*ram, and dental sc,ool s,o/ld ,a"e coies o+ t,e American Dental AssociationCs
mono*ra,, Fl/oridation Facts in its li-raries in order to -e ade?/ately -rie+ed on t,e
iss/e.
Fi*/re (-' Fl/oridation Growt,, -y )o/lation, United States, :;&'->$$$.
7Source6 Centers +or Disease Control, >$$$D U.S. Cens/s 1/rea/D %%-R <::<,
':7$%8D:&&-%.8
:. A, 1, C, Dcorrect.
3incorrect. 5,e recommended otimal ran*e o+ +l/oride concentrations in drinkin*
water is. % to :.> m deendin* on mean ann/al temerat/re.
>. A, 1, C, 3correct.
Dincorrect. All +l/oride-containin* denti+rices ,a"e "ery ,i*, le"els o+ +l/oride
7:,:$$ to :,'$$ m8 and are a si*ni+icant so/rce o+ +l/oride o"ere0os/re and
+l/orosis.
=. A, 1, 3correct.
Cincorrect. Discontin/ation o+ +l/oridation ,as a si*ni+icant deleterio/s imact on
dental-caries ratesD se"eral st/dies ,a"e consistently s,own t,at dental-caries rates
increase dramatically w,en +l/oridation is discontin/ed.
Dincorrect. 5,e national cost--ene+it ratio ,as -een demonstrated to -e ($9: w,ere
+or e"ery f: dollar sent on +l/oridation, f($ is sa"ed in treatment costs.
&. A, D, 3correct.
1incorrect. No credi-le scienti+ic e"idence ,as associated water +l/oridation wit,
cancer, and t,e National Cancer Instit/te ,as not recommended t,e cessation o+
+l/oridation.
Cincorrect. Hydro+l/osilicic acid is t,e most +re?/ently /sed c,emical +or
'. A, 1, Dcorrect.
Cincorrect. 5,e likeli,ood o+ "otin* increases wit, ed/cation as well as a*e and
income, res/ltin* in certain *ro/s makin* / a disroortionate s,are o+ "oters.
3incorrect. From a /-lic-olicy ersecti"e, +l/oridation is more o+ten ercei"ed
as a local issue t,at is enacted eit,er -y $overnmental administrative action
7ordinance t,at is "oted /on -y a city co/ncil or cityBco/nty commission8 or -y a
"ote o+ t,e /-lic.
<. Dcorrect.
Aincorrect. First, newsaers /s/ally do not ,a"e e0erts in all tec,nical areasD
secondly, t,ey try to /-lis, an e?/al n/m-er +rom eac, side o+ an iss/e to -e +air, to
enco/ra*e de-ateand to romote t,e sale o+ t,e aer.
1incorrect. In :;(', t,e Federal Comm/nications Commission 7FCC8 r/led t,at t,e
Fairness Doctrine, re?/irin* t,at -roadcasters ro"ide a reasona-le oort/nity +or t,e
resentation o+ oosin* "iews on contro"ersial /-lic iss/es is no lon$er needed,
4it, t,e end o+ t,e Fairness Doctrine, neit,er radio ro*ram ,osts nor stations ,a"e
an o-li*ation to ro"ide -alance or resent cometin* "iews.
Cincorrect +or t,e same reasons as A.
3incorrect. 5,e downside o+ internet /se as a so/rce o+ "alid in+ormation is t,at
m/c, o+ t,e ,ealt, in+ormation a"aila-le on t,e we- is oinion--ased and ,as not
*one t,ro/*, a ri*oro/s scienti+ic re"iew rocess, /ttin* t,e on/s on t,e /-lic +or
discernin* tr/t, +rom +iction re*ardin* t,e in+ormation resented.
%. A, 1, D, 3correct.
Cincorrect. 5,e t,ird o+ t,e +i"e maAor et,ical rinciles incl/ded in t,e American
Dental AssociationCs Principles of !thics and Code of Professional Conduct is t,e
Principle of #eneficence t,at e0ressly states F. . . t,at ro+essionals ,a"e t,e d/ty to
act +or t,e -ene+it o+ ot,ers.F Directly related to t,is seci+ic et,ical rincile is a
desi*nated Code o+ )ro+essional !esonsi-ility re*ardin* Comm/nity Ser"ice, t,at
+/rt,er states t,at F. . . dentists ,a"e an o-li*ation to /se t,eir skills, knowled*e, and
e0erience +or t,e imro"ement o+ t,e dental ,ealt, o+ t,e /-lic and t,ey are
enco/ra*ed to -e leaders in t,eir comm/nity. S/ort -y racticin* dentists and
dental ,y*ienists +or comm/nity water +l/oridation is con$ruent wit, t,e American
Dental AssociationCs et,ical standards.
Self-Evaluation Questions
:. 5,e +irst erson to demonstrate t,e relations,i -etween dental caries and water
+l/oride le"els in t,e United States was iiiiiiiii 7U.S. )/-lic Healt, O++icer8.
>. 5,e aarent red/ction in meas/ra-le water +l/oridation -ene+its res/ltin* +rom t,e
/-i?/ito/s a"aila-ility o+ +l/oride +rom ot,er so/rces in -ot, +l/oridated and +l/oride-
de+icient comarison comm/nities is known as iiiiiiiii.
=. 5,e e0tension o+ t,e -ene+its o+ comm/nity water +l/oridation to residents o+
+l/oride-de+icient comm/nities d/e to t,e transort o+ +ood and -e"era*es
commercially reared wit, +l/oridated water is known as iiiiiiiiiD it is called t,e
iiiiiiiii e++ect.
&. A iiiiiiiii analysis is /sed to relate t,e dollar cost o+ water +l/oridation to t,e
treatment costs sa"ed.
'. 5,e maAor oster/ti"e e++ect o+ +l/oride +rom comm/nity water s/lies is its
red/ction o+ iiiiiiiii and en,ancement o+ iiiiiiiii.
<. Ot,er comm/nity--ased met,ods o+ ro"idin* +l/oride to comm/nities w,ere water
+l/oridation is not +easi-le incl/de iiiiiiiii and iiiiiiiii.
%. iiiiiiiiicomm/nication is a new tool to -e /sed -y dental and /-lic ,ealt,
ro+essionals in order to assist comm/nities in c,oosin* to +l/oridate t,eir comm/nity
water systems.
(. #ar"is recommends t,at dental and /-lic ,ealt, ro+essionals not *et in"ol"ed in a
iiiiiiiii wit, anti+l/oridationists -eca/se t,e rimary *oal o+ s/c, an acti"ity is to
win t,e a/dience rat,er t,an to disco"er scienti+ic tr/t,s.
;. iiiiiiiii,as stated t,at t,e /se o+ sodi/m silico+l/oride and ,ydro+l/osilicic acid
+or +l/oridatin* comm/nity water systems ser"es as an e0cellent e0amle o+
-ene+icial recyclin*, w,ere -ot, ind/stry and t,e /-lic -ene+it.
:$. iiiiiiiii state7s8 7l/s t,e District o+ Col/m-ia and )/erto !ico8 c/rrently
mandate7s8 statewide +l/oridation t,ro/*, le*islation, w,ile state7s8 ,a"eB,as
mandated statewide +l/oridation t,ro/*, administrati"e re*/lation.
::. 3"ery recent iiiiiiiii o+ t,e U.S. )/-lic Healt, Ser"ice ,as reco*ni@ed t,e
"al/e o+ comm/nity water +l/oridation and ,as romoted its adotion as *ood /-lic
olicy.
:>. 5,e le"el o+ risk as ercei"ed -y t,e /-lic 7ercei"ed risk8 is o+ten de+ined -y
comm/nity or*ani@ers as iiiiiiiii w,ile t,e le"el o+ risk as determined -y science-
-ased e0erts 7act/al risk8 is o+ten de+ined -y comm/nity or*ani@ers as iiiiiiiii
:=. A iiiiiiiii is an election w,ic, ,as -een desi*ned to a++irm, c,an*e, or cancel
re"io/sly esta-lis,ed le*islation, w,ile a "oter iiiiiiiii is an election t,at was
etitioned -y "oters to esta-lis, a law re?/irin* somet,in* 7+or e0amle re?/irin*
+l/oridation or -annin* +l/oridation8.
:&. In t,e +inal analysis, winnin* a +l/oridation camai*n deends more /on
iiiiiiiii t,an on knowled*e o+ +l/oridation.
:'. !adio talk s,ows or Ftalk radioF are a ower+/l +orce in U.S. olitics today, in art
-eca/se o+ t,e end o+ t,e iiiiiiiii as well as c,an*in* tec,nolo*y.
References
:. American Dental Association Co/ncil on Access, )re"ention and Interro+essional
!elations 7:;;;8. 'luoridation 'acts,
>. 3asley, M. 7>$$$8. Oosition to comm/nity water +l/oridation and connections to
t,e Falternati"e medicineF mo"ement. Sci Rev ltern %ed, >7:89>&-=:.
=. 3asley, M. 4. 7:;;'8. Cele-ratin* '$ years o+ +l/oridation9 a /-lic ,ealt, s/ccess
story. #r Dent ", #an/ary >:9%>-'.
&. U.S. Deartment o+ Healt, and H/man Ser"ices, )/-lic Healt, Ser"ice 7:;(=8.
Sur$eon 0eneral statement on community 3ater fluoridation (Dr, C, !verett )oop),
4as,in*ton, DC9 Fe-r/ary (.
'. U.S. Deartment o+ Healt, and H/man Ser"ices, )/-lic Healt, Ser"ice 7:;;'8.
Sur$eon 0eneral statement on community 3ater fluoridation (Dr, ntonio &ovello),
4as,in*ton, DC9 Decem-er :&.
<. National Instit/te o+ Dental and Cranio+acial !esearc,, National Instit/tes o+
Healt, 7>$$$8. 'irst2ever Sur$eon 0eneral?s Report on +ral Health 'inds Profound
Disparities in &ation?s Population, 1et,esda, MD9 Marc, >'.
%. U.S. Deartment o+ Healt, and H/man Ser"ices 7>$$$8. +ral Health in merica6 a
report of the sur$eon $eneral, !ock"ille, MD9 U.S. Deartment o+ Healt, and H/man
Ser"ices, National Instit/te o+ Dental and Cranio+acial !esearc,, National Instit/tes o+
Healt,.
(. U.S. Deartment o+ Healt, and H/man Ser"ices, Centers +or Disease Control,
'luoridation Census, Setem-er :;;= and S/lementD Atlanta.
;. !ia, .. 4. 7:;;;8. 4ater Fl/oridation 7C,ater (8. In9 Harris, N.O., g Garcia-
Godoy, F., eds. Primary Preventive Dentistry, >th ed, Stam+ord, Connectic/t9
Aleton and .an*e, <'( .
:$. McCl/re, F. #. 7:;%$8. -ater fluoridation, The search and the victory,
4as,in*ton, DC9 U.S. Go"ernment )rintin* O++ice.
::. M/rray, #. #., !/**-G/nn, A. #., g #enkins, G. N. 7:;;:8. 'luorides in caries
prevention 7=rd ed.8 O0+ord9 1/tterwort,-Heinemann, .td.
:>. .eske, G. S. 7:;(=8. 4ater +l/oridation. In Mell-er*, #. !., g !ia, .. 4., 3ds.
'luoride in preventive dentistry, C,ica*o9 j/intessence )/-lis,in* Co., . >;$.
:=. Harris, N. O., g Garcia-Godoy, F. 7:;;;8. Primary Preventive Dentistry, >th ed,
Stam+ord, Connectic/t9 Aleton and .an*e, <'( .
:&. 1/rt, 1. A., g 3kl/nd, S. A. 7:;;>8. Dentistry, dental practice, and the
community 7Bth ed,8 ),iladel,ia, )A9 4.1. Sa/nders Comany.
:'. Dean, H. 5. 7:;=(8. 3ndemic +l/orosis and its relation to dental caries. Pu4lic
Health Reports, '=7==89:&&=-'>.
:<. Dean, H. 5., Arnold, F. A., g 3l"o"e, 3. 7:;&>8. Domestic water and dental
caries. Pu4lic Health Reports, '%7=>89::''-%;.
:%. U.S. Deartment o+ Healt, and H/man Ser"ices 7:;;(8. Healthy People <:C:
+47ectives6 Draft for pu4lic comment 7Oral Healt, Section8. 4as,in*ton, DC9 U.S.
Go"ernment )rintin* O++ice, Setem-er :'.
:(. )ersonal comm/nications 7e-mail8 +rom Dr. Mark GreerD No"em-er :=, >$$$.
:;. )ersonal comm/nications 7e-mail8 +rom 5eran Gall, CDAD No"em-er :=, >$$$.
>$. .o,, 5. 7:;;<8. 5,irty-ei*,t years o+ water +l/oridationt,e Sin*aore scenario.
Community Dent Health, :=7S/l >89&%-'$.
>:. 1ritis, Fl/oridation Society 7:;;(8. +ptimal 3ater fluoridation6 status
3orld3ide, .i"erool, May.
>>. U.S. Centers +or Disease Control g )re"ention 7:;;;8. 5en *reat /-lic ,ealt,
ac,ie"ements9 United States, :;$$-:;;;. %%-R, &(7:>89>&:-&=.
>=. Arnold, F. A. #r., .ikins, !. C., !/ssell, A. .., g Scott, D. 1. 7:;<>8. Fi+teent,
year o+ t,e Grand !aids +l/oridation st/dy. " m Dent ssoc, <'9%($-('.
>&. Stamm, #. 4., 1antin*, D. 4., g Imrey, ). 1. 7:;;$8. Ad/lt root caries s/r"ey o+
two similar comm/nities wit, contrastin* nat/ral water +l/oride le"els. " m Dent
ssoc, :>$9:&=-&;.
>'. National Instit/tes o+ Healt, 7:;(%8. +ral health of United States adults, The
national survey of oral health in U,S, employed adults and seniors6 CHF>2CHF9,
&ational findin$s, NIH )/-. No. (%->(<(. U.S. Deartment o+ Healt, and H/man
Ser"ices9 A/*/st.
><. Grem-owski, D., Fiset, .., g Sada+ora, A. 7:;;>8. How +l/oridation a++ects ad/lt
dental caries. " m Dent ssoc, :>=9&;-'&.
>%. New-r/n, 3. 7:;(;8. 3++ecti"eness o+ water +l/oridation. " Pu4lic Health Dent,
&;7Secial Iss/e89>%;-(;.
>(. New-r/n, 3. 7:;;>8. C/rrent re*/lations and recommendations concernin* water
+l/oridation, +l/oride s/lements, and toical +l/oride a*ents. " Dent Res, <%9:>''-
<'.
>;. 1r/nelle, #. A., g Carlos, #. ). 7:;;$8. !ecent trends in dental caries in U.S.
c,ildren and t,e e++ect o+ water +l/oridation. / Dent Res, <;7Secial Iss/e89%>=->%.
=$. 2aminsky, .. S., Ma,oney, M. C., .eac,, #., Meli/s, #., g Miller, M. #. 7:;;$8.
Fl/oride -ene+its and risks o+ e0os/re. Crit Rev +ral #iol %ed, :9><:-(:.
=:. 1arnard, ). D., g Si"aneswaran, S. 7:;;$8. Oral ,ealt, o+ 5amwort,
sc,oolc,ildren >& years a+ter +l/oridation. " Dent Res, <;7Di". A-str.89 ;=&. A-str. ;.
=>. McDona*,, M. 4,itin*, )., 1radley, M., Cooer, #., S/tton, A., C,estn/tt, I.,
Misso, 2., 4ilson, )., 5reas/re, 3., g 2leiAnen, #. 7>$$$8. systematic revie3 of
pu4lic 3ater fluoridation, Uni"ersity o+ Hork9 NHS Centre +or !e"iews and
Dissemination.
==. Morris, #., g 4,ite, D. 7>$$$8. 5,e Hork !e"iew o+ 4ater Fl/oridation-key
oints +or t,e -/sy ractitioner. Dent Update, Decem-er, &%&-'.
=&. 1/rt, 1. A. 7:;('8, Fl/oride9 How m/c, o+ a *ood t,in*e " Pu4lic Health Dent,
'9=%-=(.
='. Horowit@, H. S. 7:;;:8. Aroriate /ses o+ +l/oride9 Considerations +or t,e C;$s.
" Pu4lic Health Dent, ':9>$->>.
=<. !o@ler, !. G. 7:;;'8. 5,e e++ecti"eness o+ comm/nity water +l/oridation9 1eyond
d/mmy "aria-les +or +l/oride e0os/re. / Pu4lic Health Dent, ''9:;'.
=%. Horowit@, H. S. 7:;;<8. 5,e e++ecti"eness o+ comm/nity water +l/oridation in t,e
United States. " Pu4lic Health Dent, '<7' Sec No89>'=-(.
=(. Stookey, G. 2. 7:;;&8. !e"iew o+ +l/orosis risk o+ sel+-alied toical +l/orides9
Denti+rices, mo/t,rinses and *els. Community Dent +ral !pidemiol, >>9:(:-(<.
=;. Clo"is, #., g Har*rea"es, #. A. 7:;((8. Fl/oride intake +rom -e"era*e
cons/mtion. Community Dent +ral !pidemiol, :<9::-:'.
&$. Slade, G. D., Da"ies, M. #., Sencer, A. #., g Stewart, #. F. 7:;;'8. Associations
-etween e0os/re to +l/oridated drinkin* water and dental caries e0erience amon*
c,ildren in two A/stralian states. " Pu4lic Health Dent, ''9>:(->(.
&:. Moreno, 3. C. 7:;(=8. !ole o+ Ca-)-F in caries re"ention9 C,emical asects. /nt
Dent ", &=9%:-($.
&>. New-r/n, 3. 7:;(<8. 'luorides and dental caries 7Ard ed,8 Srin*+ield, I.9 C,arles
C. 5,omas, /-lis,er, . >(;.
&=. .am-ro/, D., .arsen, M., FeAersko", O., g 5ac,os, 1. 7:;(:8. 5,e e++ect o+
+l/oride in sali"a on reminerali@ation o+ dental enamel in ,/mans. Caries Res, :'9=&:-
'.
&&. 1acker-Dirks, O., 2/n@el, 4., g Carlos, #. ). 7:;%(8. Caries-re"enti"e water
+l/oridation. In )ro*ress in caries re"ention. 3ricsson H, 3d. Caries Res, :>7S/l
:89%-:&.
&'. Sil"erstone, .. M. 7:;;=8. !eminerali@ation and enamel caries9 new concets.
Dental Update, May9 ><:-%=.
&<. Feat,erstone, #. D. 7:;(%8. 5,e mec,anism o+ dental decay. &utrition Today,
>>7=89 :$-:<.
&%. FeAersko", O., 5,ylstr/, A., g .arsen, M. #. 7:;(:8. !ational /se o+ +l/orides in
caries re"ention. cta +dontol Scan, =;9>&:-;.
&(. Sil"erstone, .. M., 4e+el, #. S., Iimmerman, 1. F., Clarkson, 1. H., g
Feat,erstone, M. #. 7:;(:8. !eminerali@ation o+ nat/ral and arti+icial lesions in ,/man
dental enamel in "itro. Caries Res, :'9:=(-'%.
&;. 1owen, 4. H., g Geddes, D. A. M. 7:;;$8. S/mmary o+ Session III9 Fl/oride in
sali"a and dental la?/e. " Dent Res, <;7Secial Iss/e89<=%.
'$. 1eltran, 3. D., g 1/rt, 1. A. 7:;((8. 5,e re- and ost-er/ti"e e++ects o+ +l/oride
in t,e caries decline. " Pu4lic Health Dent, &(9>==-&$.
':. 4,it+ord, G. M. 7:;;<8. 5,e meta-olism and to0icity o+ +l/oride 7>nd re". ed.8
%ono$raphs in +ral Science, 6ol. :<. 1asel, Swit@erland9 2ar*er.
'>. Horowit@, H. S. 7:;(<8. Inde0es +or meas/rin* dental +l/orosis. " Pu4lic Health
Dentistry , &<7&89:%;-(=.
'=. )endrys, D. G. 7>$$$8. !isk o+ enamel +l/orosis in non+l/oridated and otimally
+l/oridated o/lations9 considerations +or t,e dental ro+essional. " m Dent ssoc,
:=:9%&<-''.
'&. Den 1esten, ). 2. 7:;;;8. Mec,anism and timin* o+ +l/oride e++ects on
de"eloin* enamel. " Pu4lic Health Dent, ';7&89>&%-':.
''. Dean, H. 5. 7:;&>8. 5,e in"esti*ation o+ ,ysiolo*ical e++ects -y t,e
eidemiolo*ical met,od. In Mo/lton, F. !., 3d. Fl/orine and dental ,ealt,. merican
ssociation for the dvancement of Science, )/-lication No. :;. 4as,in*ton DC9 >=-
=:.
'<. C/tress, 5. 4., g S/cklin*, G. 4. 7:;;$8. Di++erential dia*nosis o+ dental
+l/orosis. " Dent Res, <;7Secial Iss/e89%:&-%>$. Disc/ssion %>:.
'%. Dean, H. 5. 7:;=<8. C,ronic endemic dental +l/orosis. " m %ed ssoc,
:$%7:<89:><;-%=.
'(. .ewis, D. 4., g 1antin*, D. 4. 7:;;&8. 4ater Fl/oridation9 c/rrent e++ecti"eness
and dental +l/orosis. Community Dent +ral !pidemiol, >>9:'=-(.
';. .emke, C. 4., Do,erty, #. M., g Arra, M. C. 7:;%$8. Controlled +l/oridation9 5,e
dental e++ects o+ discontin/ation in Anti*o, 4isconsin. " m Dent ssoc, ($9%(>-(<.
<$. Ste,en, 2. 4., McCall, D. !., g 5/llis, #. I. 7:;(%8. Caries re"alence in
Nort,ern Scotland -e+ore and ' years a+ter water de+l/oridation. #rit Dent ", :<=9=>&-
><.
<:. Attwood, D., g 1link,orn, A. S. 7:;;:8. Dental ,ealt, in sc,oolc,ildren ' years
a+ter water +l/oridation ceased in so/t,-west Scotland. /nt Dent ", &:7:89&=-(.
<>. U.S. )/-lic Healt, Ser"ice 7:;;:8. Report of the d Hoc Su4committee on
'luoride of the Committee to Coordinate !nvironmental Health and Related
Pro$rams, Revie3 of 'luoride #enefits and Ris*s, 4as,in*ton, DC9 U.S. Det. o+
Healt, and H/man Ser"ices.
<=. 4ay, !. M. 7:;<&8. 5,e e++ect on dental caries o+ a c,an*e +rom a nat/rally
+l/oridated to a +l/oride-+ree comm/nal water. " Dent Child, =:9:':-%.
<&. 4,ite, 1. A., Ante@ak-1o/ckoms, A. A., g 4einstein, M. C. 7:;(;8. Iss/es in t,e
economic e"al/ation o+ comm/nity water +l/oridation. " Dent !duc, '=9<&<-'%.
<'. !in*el-er*, M. .., Allen, S. #., g #ackson 1rown, .. 7:;;>8. Cost o+ +l/oridation9
&& Florida comm/nities. " Pu4lic Health Dent, '>9%'-($
<<. U.S. Deartment o+ Healt, and H/man Ser"ices, Centers +or Disease Control
7:;;>8. Mor-idity and mortality weekly reort9 a +ramework +or assessin* t,e
e++ecti"eness o+ disease and inA/ry re"ention. %%-R, &:9:-%.
<%. Seier and 1rown, Assem-ly Mem-ers, and Maddy, Cali+ornia .e*islat/re, :;;'-
;<, !e*/lar Session Senator, Assem-ly 1ill No. %==, Fe-r/ary >>, :;;'.
<(. Neenan, M. 3. 7:;;<8. O-stacles to e0tendin* +l/oridation in t,e United States.
Community Dental Health, :=7S/l >89:$->$.
<;. 1lair, 2. ). 7:;;>8. Fl/oridation in t,e :;;$s. " m Coll Dent, ';9=.
%$. MAor, I. A. 7:;(;8. Amal*am and comosite resin restorations9 .on*e"ity and
reasons +or relacement. In An/sa"ice, 2. #., 3d. Euality !valuations of Dental
Restorations, C,ica*o9 j/intessence )/-lis,in* Co. . <:-%>.
%:. MacInnis, 4. A., Ismail, A., 1ro*an, H., g 2a"ana*,, M. 7:;;$8. )lacement and
relacement o+ restorations in a military o/lation. " Dent Res, <;7Secial
Iss/e89:%;. A-str. '<&.
%>. j"ist, #., j"ist, 6., g MAor, I. A. 7:;;$8. )lacement and lon*e"ity o+ amal*am
restorations in Denmark. " Dent Res, <;7Secial Iss/e89>=<. A-str. :$:(.
%=. 1rown, #. ). 7>$$$8. -ater fluoridation costs in Texas6 Texas Health Steps
(!PSDT2%edicaid), May.
%&. 1arsley, !. S/t,erland #., g McFarland .. 7:;;;8. 4ater Fl/oridation and t,e
Costs o+ Medicaid 5reatment +or Dental Decay, .o/isiana, :;;'-:;;<. %%-R,
BF7=&89%'=-%'%.
%'. U. S. )/-lic Healt, Ser"ice, Centers +or Disease Control. 4ater +l/oridation and
costs o+ medicaid treatment +or dental decay.o/isiana, :;;'-:;;< 7:;;;8 %%-R,
BF7=&89%'=-%'%.
%<. 4ri*,t, #., 1ates, M., C/tress, 5., g .ee, M. 7:;;;8. 5,e cost-e++ecti"eness o+
+l/oridatin* water s/lies in New Iealand9 a reort +or t,e New Iealand Ministry o+
Healt,. )orir/a, &e3 @ealand6 /nstitute of !nvironmental Science and Research,
No"., :-=:.
%%. !o-inson, S. N., Da"ies, 3. H., g 4illiams, 1. 7:;;:8. Domestic water treatment
aliances and t,e +l/oride ion. #rit Dent ", :%:9;:-;=.
%(. .e"y, S. M. 7:;;&8. !e"iew o+ +l/oride e0os/res and in*estion. Community Dent
+ral !pidemiol, >>9:%=-($.
%;. 1rown, M. D., g Aaron, G. 7:;;:8. 5,e e++ect o+ oint-o+-/se conditionin*
systems on comm/nity +l/oridated water. Pediatr Dent, :=7:89='-(.
($. .e"y, S. M., 2iritsy, M. C., g 4arren, #. #. 7:;;'8. So/rces o+ +l/oride intake in
c,ildren. " Pu4lic Health Dent, ''7:89=;-'>.
(:. 2iritsy, M. C., .e"y, S. M., 4arren, #. #., G/,a-C,owd,/ry, N., Heilman, #. !., g
Mars,all 5. 7:;;<8. Assessin* +l/oride concentrations o+ A/ices and A/ice-+la"ored
drinks. " m Dent ssoc, :>%9(;'-;$>.
(>. 4orld Healt, Or*ani@ation 7:;;&8. 'luorides and oral health, Gene"a9 4orld
Healt, Or*ani@ation 75ec,nical !eort Series (&<8.
(=. Instit/te o+ Medicine, Food and N/trition 1oard 7In ress8. Dietary reference
inta*es for calcium, phosphorous, ma$nesium, vitamin D and fluoride, Report of the
Standin$ Committee on the Scientific !valuation of Dietary Reference /nta*es,
4as,in*ton, DC9 National Academy )ress.
(&. U.S. Deartment o+ Healt, and H/man Ser"ices, )/-lic Healt, Ser"ice 7:;;:8.
Revie3 of fluoride6 4enefits and ris*s, Report of the d Hoc Su4committee on
'luoride, 4as,in*ton, DC9 Fe-r/ary.
('. 'luoride, teeth and health 7:;%<8. !oyal Colle*e o+ ),ysicians. )itman Medical,
.ondon.
(<. National !esearc, Co/ncil 7:;;=8. Health effects of in$ested fluoride, Report of
the Su4committee on Health !ffects of /n$ested 'luoride, 4as,in*ton, DC9 National
Academy )ress.
(%. Hiamo/yiannis, #. A., g 1/rk, D. 7:;%'8. A de+inite link -etween +l/oridation and
cancer deat, rate. &at Health 'ed #ul, >:9;.
((. Hiamo/yiannis, #. A., g 1/rk, D. 7:;%%8. Fl/oridation and cancer9 a*e-
deendence o+ cancer mortality related to arti+icial +l/oridation. 'luoride, :$7=89:$>-
>=.
(;. Hoo"er, !. N., Mc2ay, F. 4., g Fra/meni, #. F. 7:;%<8. Fl/oridated drinkin*
water and t,e occ/rrence o+ cancer. " &atl Cancer /nst, '%7&89%'%-<(.
;$. 3rickson, #. D. 7:;%(8. Mortality in selected cities wit, +l/oridated and non-
+l/oridated water s/lies. &e3 !n$ " %ed, >;(7>$89:::>-<.
;:. Hoo"er, !. N., De6esa, S. S., Cantor, 2., g Fra/meni, #. F. 7:;;$8. Fl/oridation
o+ drinkin* water and s/-se?/ent cancer incidence and mortality. Report to the
Director of the &ational Cancer /nstitute, #/ne.
;>. C,il"ers, C. 7:;(=8. Cancer mortality and +l/oridation o+ water s/lies in =' U.S.
cities. /nt " !pidemiol, :>7&89=;%-&$&.
;=. 2inlen, .. 7:;%'8. Cancer incidence in relation to +l/oride le"el in water s/lies.
#r Dent ", :=(9>>:-&.
;&. C,il"ers, C., g Conway, D. 7:;('8. Cancer mortality in 3n*land in relation to
le"els o+ nat/rally occ/rrin* +l/oride in water s/lies. " !pidemiol Comm Health,
=;9&&-%.
;'. Cook-Mo@a++ari, ). C., 1/l/s/, .., g Doll, !. 7:;(:8. Fl/oridation o+ water
s/lies and cancer mortality I9 a searc, +or an e++ect in t,e U2 on risk o+ deat, +rom
cancer. " !pidemiol Comm Health, ='9>>%-=>.
;<. !ic,ards, G. A., g Ford, #. M. 7:;%;8. Cancer mortality in selected New So/t,
4ales localities wit, +l/oridated and non-+l/oridated water s/lies. %ed " ust,
>9'>:-=.
;%. International A*ency +or !esearc, on Cancer 7:;(>8. /RC mono$raphs on the
evaluation of the carcino$enic ris* of chemicals to humans, 6ol. >%. Swit@erland.
;(. Clemmesen, #. 7:;(=8. 5,e alle*ed association -etween arti+icial +l/oridation o+
water s/lies and cancer9 a re"iew. #ulletin of the -orld Health +r$ani1ation,
9C 7'89(%:-(=.
;;. Doll, !., g 2inlen, .. 7:;%%8. Fl/oridation o+ water and cancer9 mortality in t,e
USA. (ancet i, :=$$-$>.
:$$. 1/c,er, #. !., HeAtmancik, M. !., 5o+t, #. D. II, )ersin*, !. .., 3/stis, S. .., g
Haseman, #. 2. 7:;;:8. !es/lts and concl/sions o+ t,e National 5o0icolo*y )ro*ramCs
rodent carcino*enicity st/dies wit, sodi/m +l/oride. /nt " Cancer, &(9%==-%.
:$:. Ma/rer, #. 2., C,en*, M. C., 1oysen, 1. G., g Anderson, !. .. 7:;;$8. 5wo-year
carcino*enicity st/dy o+ sodi/m +l/oride in rats. " &atl Cancer /nst, (>9:::(-><.
:$>. U.S. Deartment o+ Healt, and H/man Ser"ices, NIH, National 5o0icolo*y
)ro*ram 7:;;:8. Toxicolo$y and carcino$enesis studies of sodium fluoride (CS&o,
D9FC2BH2B) in 'ABBL& rats and #9CA'l mice (Drin*in$ -ater Studies), )/-lication
No ;:->(&(. 5ec,nical !eort =;=. 4as,in*ton, D.C.9 U.S. Deartment o+ Healt,
and H/man Ser"ices, )/-lic Healt, Ser"ice.
:$=. 2no0, 3. G. 7:;('8. 'luoridation of 3ater and cancer6 a revie3 of the
epidemiolo$ical evidence, Report of the -or*in$ Party, .ondon9 Her MaAestyCs
Stationary O++ice.
:$&. Sa+e Drinkin* 4ater Committee, National !esearc, Co/ncil 7:;%%8. Drinkin*
water and ,ealt,. &ational cademy of Sciences, 4as,in*ton, DC.
:$'. <> 'ed, Re$, <&>;% 7Dec. ', :;;%8.
:$<. National !esearc, Co/ncil, Committee on 5o0icolo*y 7:;;=8. Health !ffects of
/n$ested 'luoride, 4as,in*ton, DC9 National Academy )ress.
:$%. Cor-in, S. 1. 7:;;>8. Fl/oridation Symosi/m. )olicy otions +or +l/oride /se. "
m Coll Dent, ';9:(->=.
:$(. Hod*e, H. C. 7:;'<8. Fl/oride meta-olism9 its si*ni+icance in water +l/oridation.
" m Dent ssoc, '>9=$:-:&.
:$;. 4,it+ord, G. M. 7:;;$8. 5,e ,ysiolo*ical and to0icolo*ical c,aracteristics o+
+l/oride. " Dent Res, <;7Sec Iss89'=;-&;.
::$. 5ra/tner, 2., g Sie-ert, G. 7:;(<8. An e0erimental st/dy o+ -io-a"aila-ility o+
+l/oride +rom dietary so/rces in man. rch +ral #iol, =:9>>=->(.
:::. U.S. Deartment o+ Healt, and H/man Ser"ices, )/-lic Healt, Ser"ice 7:;($8.
Sur$eon 0eneral?s advisory6 treatment of 3ater for use in dialysis6 artificial *idney
treatments, 4as,in*ton, DC9 Go"ernment )rintin* O++ice (%>-$>:, #/ne.
::>. Centers +or Disease Control 7:;($8. Fl/oride in a dialysis /nit-Maryland.
%%-R, <H7:>89:=&-<.
::=. .eone, N. C., S,imkin, M. 1., Arnold, F. A. Ste"enson, C. A., Iimmermann, 3.
!., Geiser, ). 1., g .ie-erman, #. 3. 7:;'&8. Medical asects o+ e0cessi"e +l/oride in
a water s/ly. Pu4lic Health Rep, 9H7:$89;>'-=<.
::&. Gee"er, 3. F., .eone, N. C., Geiser, )., g .ie-erman, #. 7:;'(8. )at,olo*ic
st/dies in man a+ter rolon*ed in*estion o+ +l/oride in drinkin* water I9 necrosy
+indin*s in a comm/nity wit, a water le"el o+ >.' m. " m Dent ssoc, '<9&;;-'$%.
::'. Sc,lesin*er, 3. !., O"erton, D. 3., C,ase, H. C., g Cantwell, 2. 5. 7:;'<8.
New-/r*,-2in*ston caries-+l/orine st/dy GIII9 ediatric +indin*s a+ter ten years. "
m Dent ssoc, '>9>;<-=$<
::<. #aco-sen, S. #., OCFallon, 4. M., g Melton, .. #. 7:;;=8. Hi +ract/re incidence
-e+ore and a+ter t,e +l/oridation o+ t,e /-lic water s/ly, !oc,ester, Minnesota.
m " Pu4lic Health, (=7'89<(;-;=.
::%. Danielson, C., .yon, #. .., 3**en, M., g Good Go/*,, G. 2. 7:;;>8. Hi
+ract/res and +l/oridation in Uta,Cs elderly o/lation. " m %ed ssoc, A/* :>,
<9F7<89%&<-(.
::(. #aco-sen, S. #., Gold-er*, #., Cooer, C., g .ockwood, S. A. 7:;;>8. 5,e
association -etween water +l/oridation and ,i +ract/re amon* w,ite women and men
a*ed <' years and older9 a national ecolo*ic st/dy. nn !pidemiol, >7'89<:%-><.
::;. 2ara*as, M. !., 1aron, #. A., 1arrett, #. A., g #aco-sen, S. #. 7:;;<8. )atterns o+
+ract/re amon* t,e United States elderly9 *eo*ra,ic and +l/oride e++ects. nn
!pidemiol, <7=89>$;-:<.
:>$. Madans, #., 2leinman, #. C., g Corroni-H/ntley, #. 7:;(=8. 5,e relations,i
-etween ,i +ract/re and water +l/oridation9 an analysis o+ national data. m " Pu4lic
Health, MarD %=7=89>;<-(.
:>:. A"orn, #., Niessen, .. C. 7:;(<8. !elations,i -etween lon* -one +ract/res and
water +l/oridation. 0eriodontics, >9:%'-%;.
:>>. Arnala, I., Al,a"a, 3. M., 2i"i"/ori, !., g 2a/ranen, ). 7:;(<8. Hi +ract/re
incidence not a++ected -y +l/oridation. Osteo+l/orosis st/died in Finland. cta +rthop
Scand, A/*D '%7&89=&&-(.
:>=. Cooer, C., 4ick,am, C., .acey, !. F., g 1arker, D. #. 7:;;$8. 4ater +l/oride
concentration and +ract/re o+ t,e ro0imal +em/r. " !pidemiol Community Health,
MarD &&7:89:%-;.
:>&. Simonen, O., et al. 7:;('8. Does +l/oridation o+ drinkin* water re"ent -one
+ra*ility and osteoorosise (ancet, A/* >&D >7(&'>89&=>-&.
:>'. #aco-sen, S. #., Gold-er*, #., Miles, 5. )., 1rody, #. A., Stiers, 4., g !imm, A.
A. 7:;;$8. !e*ional "ariation in t,e incidence o+ ,i +ract/re9 U.S. w,ite women a*ed
<' years and older. m %ed ssoc, ><&7&89'$$->.
:><. ),is, 2. !., Orwoll, 3. S., Mason, #. D., g Ca/ley, #. A. 7>$$$8. Comm/nity
water +l/oridation, -one mineral density, and +ract/res9 rosecti"e st/dy o+ e++ects in
older women. #rit %ed ", =>:9(<$-&.
:>%. 2anis, #. A. 7:;;=8. 5reatment o+ symtomatic osteoorosis wit, +l/oride. m "
%ed, ;'7S/l 'A89'=S-<:S.
:>(. Hillier, S., Cooer, C., 2ellin*ray, S., !/ssell, G., H/*,es, H., g Co**on, D.
7>$$$8. Fl/oride in drinkin* water and risk o+ ,i +ract/re in t,e U29 a case-control
st/dy. (ancet, =''9><'-;
:>;. U.S. )/-lic Healt, Ser"ice, Deartment o+ Healt, and H/man Ser"ices 7#/ne
>$$$8. &ational /nstitute of Dental and Craniofacial Research Statement on -ater
'luoridation,
:=$. !ee"es, 5. G. 7:;;<8. 5ec,nical asects o+ water +l/oridation in t,e United States
and an o"er"iew o+ +l/oridation en*ineerin* world-wide. Community Dent Health,
:=7S/l >89>:-><.
:=:. U.S. Deartment o+ Healt, and H/man Ser"ices 7Set. :;(<8. U.S. )/-lic Healt,
Ser"ice Centers +or Disease Control 4ater Fl/oridation. %anual for !n$ineers and
Technicians,
:=>. Hinman, A. !., Sterritt, G. !., g !ee"es, 5. G. 7:;;<8. 5,e U.S. e0erience wit,
+l/oridation. Community Dent Health, CA 7S/l >89'-;.
:==. Ur-ansky, 3. 5., g Sc,ock, M. !. 7>$$$8. Can +l/oridation a++ect lead 7II8 in
ota-le watere He0a+l/orosilicate and +l/oride e?/ili-ria in a?/eo/s. /ntern " !nviron
Studies, '%9';%-<=%.
:=&. )ersonal comm/nication 7email8 +rom Dr. 3rnest New-r/m in resonse to ?/ery
-y 3leanor Nadler, C,air o+ t,e San Die*o Coalition +or Fl/oridation, #an/ary :<,
>$$$.
:='. S,annon, I. .. 7:;%(8. 5,e +l/oride concentration in drinkin* water o+
+l/oridatin* comm/nities in 5e0as. Tex Dent ", ;<7<89:$-:>.
:=<. .eland, D. 3., )owell, 2. 3., g Anderson, !. S. 7:;($8. A +l/oride o"er+eed
incident at Har-or Srin*s, Mic,i*an. " m -ater -or*s ssoc, %>9>=(-&=.
:=%. )etersen, .. !., Denis, D., 1rown, D., Hadler, #. .., Hel*erson, S. D. 7:;;(8.
Comm/nity ,ealt, e++ects o+ a m/nicial water s/ly ,yer+l/oridation accident. m
" Pu4lic Health, %(9 %::-:=.
:=(. Gessner, 1. D., 1eller, M., Midda/*,, #. )., g 4,it+ord, G. M. 7:;;&8. Ac/te
+l/oride oisonin* +rom a /-lic water system. & !n$l " %ed, ==$9;'-;;.
:=;. 1er*mann, 2. 3., g 1er*mann, !. .. 7:;;'8. Salt +l/oridation and *eneral
,ealt,. dv Dent Res, ;9:=(-&=.
:&$. )ak,omo", G. N., I"ano"a, 2., Moller, I. #., g 6ra-c,e"a, M. 7:;;'8. Dental
caries-red/cin* e++ects o+ a milk +l/oridation roAect in 1/l*aria. " Pu4lic Health
Dent, ''7&89>=&-%.
:&:. MeAia, !., 3sinal, F., 6ele@, H., g A*/irre, M. 7:;%<8. 3st/dio so-re la
+l/or/racion de la sal. 6III !es/ltados o-tenidos de :;<& a :;%>. #oll +f Sanit
Panam, ($9<%-($.
:&>. 2/n@el, 4. 7:;;=8. Systemic /se o+ +l/orideot,er met,ods9 salt, s/*ar, milk,
etc. Caries Res, >%7S/l :89:<->>.
:&=. Intersalt Cooerati"e !esearc, Gro/ 7:;((8. Intersalt9 an international st/dy o+
electrolyte e0cretion and -lood ress/re. !es/lts +or >& ,o/r /rinary and otassi/m
e0cretion. #r %ed ", >;%9=:;->(.
:&&. Steiner, M., Men*,ini, G., g Mart,aler, 5. M. 7:;(;8. 5,e caries incidence in
sc,oolc,ildren in t,e Canton o+ Glar/s := years a+ter t,e introd/ction o+ ,i*,ly
+l/oridated salt. Sch3ei1 %onatss @ahnmed, ;;9 (;%-;$:.
:&'. M/rray, #. #., 3d. ppropriate use of fluorides for human health, Gene"a9 4orld
Healt, Or*ani@ation, :;(<.
:&<. 5ot,, 2. 7:;%<8. A st/dy o+ ( years domestic salt +l/oridation +or re"ention o+
caries. Community Dent +ral !pidemiol, &9:$<-:$.
:&%. !estreo, D. 7:;<%8. Salt +l/oridation9 an alternati"e meas/re to water
+l/oridation. /nt Dent ", :%9&-;.
:&(. Mart,aler, 5. M., MeAia, !., g 6ines, #. #. 7:;%(8. Caries-re"enti"e salt
+l/oridation. Caries Res, :>7S/l :89:'->:
:&;. 2lein, S. )., 1o,annan, H. M., 1ell, !. M., Disney, #. A., Foc,, C. 1., g Gra"es,
!. C. 7:;('8. 5,e cost and e++ecti"eness o+ sc,ool--ased re"enti"e dental care. m "
Pu4lic Health, Ar, D>7&89=(>-;:.
:'$. )artners,i +or )re"ention 7>$$:8. Oral ,ealt,9 Common and re"enta-le
ailments. Priorities in Prevention, May9:-(.
:':. Committee on Healt, and H/man Ser"ices, <(t, Ore*on .e*islati"e Assem-ly.
Re$ular Session, Senate #ill HDA (filed at the re5uest of Tas* 'orce on ccess to +ral
Health Services, +re$on Dental Hy$ienists ssociation), Salem, Ore*on9 Ore*on
.e*islati"e Assem-ly, :;;'.
:'>. Carter, 1rown, 3i*,mey, Gordly, #o,nston, and S,i-ley 7!eresentati"es8, and
1rad-/ry, Ham-y, and McCoy 7Senators8. 9Fth +re$on (e$islative ssem4ly Re$ular
Session, House #ill AAC< (filed at re5uest +re$on Dental ssociation), Salem,
Ore*on9 Ore*on .e*islati"e Assem-ly, :;;'.
:'=. Association o+ State and 5erritorial Dental DirectorsBADA, May :;;', ersonal
comm/nication.
:'&. U.S. Go"ernment )rintin* O++ice. &ational Summary of 'luoridation Referenda
Reported #et3een &ovem4er CH>: and Decem4er AC, CH9D, :;<(.
:''. Faine, !. C., Collins, #. #., Daniel, #., Isman, 1., 1oriskin, #., Ho/n*, 2. ..,
Fit@*erald, C. M. 7:;(:8. 5,e :;($ Fl/oridation Camai*ns9 A Disc/ssion o+ !es/lts.
" Pu4lic Health Dent, BC 7=89:=(-&>.
:'<. #ones, !. 1., Mormann, D. N., g D/rtsc,e, 5. 1. 7:;(;8. Fl/oridation
re+erend/m in .a Crosse, 4isconsin9 contri-/tin* +actors to s/ccess. m " Pu4lic
Health, %;9:&$'-$%.
:'%. 3asley, M. 4. 7:;;$8. 5,e stat/s o+ comm/nity water +l/oridation in t,e United
States. Pu4lic Health Rep, :$'9=&(-'=.
:'(. U.S. Cens/s 1/rea/. General )o/lation Data, Cens/s >$$$.
:';. U.S. Cens/s 1/rea/, Deartment o+ Commerce 7#/ly >$$$8. )o/lation trends in
metroolitan areas and central cities. Current Population Reports, Series )>'-::==.
:<$. U.S. Deartment o+ Commerce, 1/rea/ o+ t,e Cens/s. =otin$ a$e population,
Cens/s 1/rea/ )ress !elease, C1;>->&. Cens/s and Ho/, Marc, :;;>. 4as,in*ton,
DC9 U.S. Deartment o+ Commerce.
:<:. U.S. Cens/s 1/rea/, Deartment o+ Commerce 7Dec. >$$$8. 3d/cational
attainment in t,e United States 7Udate8. Current Population Reports, Series )>$-
'=<.
:<>. U.S. Cens/s 1/rea/, Deartment o+ Commerce 7:;;>8. 6otin* a*e and
re*istration in t,e election No"em-er :;;>. Current Population Reports, #an/ary,
Series )->$.
:<=. U.S. Deartment o+ Commerce, 1/rea/ o+ t,e Cens/s 7:;;>8. Ho/sin*
c,aracteristics o+ recent mo"ers9 :;(;. Current Housin$ Reports, Fe-r/ary, Series
H:>:B;:->.
:<&. U.S. Deartment o+ Commerce, 1/rea/ o+ t,e Cens/s 7:;;>8. Poverty in the
United States6 CHH<, Series )<$-:('. Cens/s and Ho/, No"em-er :;;>. 4as,in*ton,
DC9 U.S. Deartment o+ Commerce.
:<'. poll of li*ely voters in San ntonio, Texas, Hill !esearc, Cons/ltants. A/*/st
::, >$$$.
:<<. C,on*, D. 7>$$$8. Rational lives6 &orms and values in politics and society,
Uni"ersity o+ C,ica*o )ress.
:<%. 1on,am, G. 7:;;=8. Direct Democracy9 .essons +rom +l/oridation. Can " Pu4lic
Health, (&7>89(>-(=.
:<(. Harris Interacti"e, Inc. +or !esearc,kAmerica 7>$$$8. May >$$$ Omni-/s
S/r"ey. New Hork, NH9 Harris /nteractive, /nc,
:<;. Scott, D. 1. 7:;;<8. 5,e dawn o+ a new era. " Pu4lic Health Dent, '<7' Sec
No89>='-(.
:%$. Gall/ Or*ani@ation, Inc. 7:;;:8. 0allup study of parents? 4ehavior,
*no3led$e and attitudes to3ard fluoride, )rinceton, N#9 Gall/ Or*ani@ation, Inc.
:%:. Doelt, #. C., g S,earer, 3. 7:;;;8. &onvoters6 merica?s &o2Sho3s, 5,o/sand
Oaks, CA9 Sa*e )/-lications, . >&<.
:%>. Sandman, ). M. 7:;;$8. Ha1ard =ersus +utra$e6 Pu4lic Perception of
'luoridation Ris*s, 3n"ironmental Committee !esearc, )ro*ram, Cook Colle*e,
!/t*ers Uni"ersity, New 1r/nswick, N#, Aril.
:%=. )ark, 1., Smit,, 2., Mal"it@, D., g F/rman, .. 7:;;$8. Ha@ard "s. o/tra*e9
)/-lic ercetion o+ +l/oridation risks. " Pu4lic Health Dent, '$9%-&&.
:%&. Caella, #. N., 5/row, #., g #amieson, 2. H. 7:;;<8. Call2in tal* radio6
4ac*$round, content, audiences, portrayal in mainstream media, Annen-/r* )/-lic
)olicy CenterCs !eort Series, A/*/st %9:-<(.
:%'. Smit,, 2. G., g C,risten, 2. A. 7:;;$8. A +l/oridation camai*n9 t,e ),oeni0
e0erience. " Pu4lic Health Dent, '$9=:;->>.
:%<. Isman, !. 7:;(=8. )/-lic "iews on +l/oridation and ot,er re"enti"e dental
ractices. Community Dent +ral !pidemiol, ::9>:%->=.
:%%. U.S. Cens/s 1/rea/, Deartment o+ Commerce 7#/ly :;;(8. 6otin* and
re*istration in t,e election o+ No"em-er :;;<. Current Population Reports, Series
)>$-'$&.
:%(. U.S. Cens/s 1/rea/, Deartment o+ Commerce. 7A/* >$$$8. 6otin* and
re*istration in t,e election o+ No"em-er :;;(. Current Population Reports, Series
)>$-'>=!6.
:%;. 3"ans, C. A., g )ickles, 5. 7:;%(8. Statewide Anti+l/oridation Initiati"es9 A New
C,allen*e to Healt, 4orkers. m " Pu4lic Health, 9F 7:89';-<>.
:($. .emke, C. 4., Do,erty, #. M., g Arra, M. C. 7:;%$8. Controlled +l/oridation9 t,e
dental e++ects o+ discontin/ation in Anti*o, 4isconsin. " m Dent ssoc, ($9%(>-<.
:(:. Glasard, ). H., g Fra@ier, ). #. 7No". :;, :;('8. 'uture teachers? *no3led$e and
opinions a4out methods to prevent oral diseases, Presented at merican Pu4lic
Health ssociation annual meetin$, 4as,in*ton, DC.
:(>. 2ay, 3. #., g 1link,orn, A. S. 7:;(;8. A st/dy o+ mot,ersC attit/des towards t,e
re"ention o+ caries wit, artic/lar re+erences to +l/oridation and "accination.
Community Dent Health, 9 7&89='%-<=.
:(=. .ennon, M. A. 7:;;=8. )romotin* water +l/oridation. Community Dent Health,
:$9'%-<=.
:(&. Dolinsky, H. 1., et al. 7:;(:8. A Healt, Systems A*ency and a Fl/oridation
Camai*n. " Pu4lic Health Policy, < 7>89:'(-<=.
:('. McG/ire, 2. M. 7:;(:8. Strate*ies +or a +l/oridation camai*n. " %ichi$an Dent
ssoc, <=9<(:-(<.
:(<. 1orinskin, #. M., g Fine, #. I. 7:;;=8. Fl/oridation election "ictory9 a case st/dy
+or dentistry in e++ecti"e olitical action. " m Dent ssoc, :$>9&(<-;:.
:(%. 1arrett, S. 7:;(=8. 4innin* a Camai*n +or Fl/oridation. CD", ::7:89 <:-<.
:((. Clark, D. C., g Hann, H. #. 7:;(;8. A 4in +or Fl/oridation in S?/amis,, 1ritis,
Colom-ia. " Pu4lic Health Dent, &;7=89:%$-:.
:(;. 3lwell, 2. !., g 3aslick, 2. 7:;<$8. Classification and appraisal of o47ections to
fluoridation, Ann Ar-or, Mic,i*an9 5,e Uni"ersity o+ Mic,i*an.
:;$. 4atson, M. .. 7:;('8. 5,e Oosition to Fl/oride )ro*rams9 !eort o+ a S/r"ey.
" Pu4lic Health Dent, &'7=89:&>-&(.
:;:. 3asley, M. 4. 7:;(&8. 5,e anti+l/oridation mo"ement. Health %atrix, >9%&-%%.
:;>. 3asley, M. 4. 7:;('8. 5,e new anti+l/oridationists9 w,o are t,ey and ,ow do
t,ey oeratee " Pu4lic Health Dent, &'D :==-&:.
:;=. American Dental Association, )rinciles o+ 3t,ics and Code o+ )ro+essional
Cond/ct 7:;;(8. C,ica*o9 The ssociation, iii.
:;&. American Dental Hy*ienistsC Association, Code o+ 3t,ics 7:;;'8. C,ica*o9
ADHA.
:;'. New-r/n, 3. 7:;;<8. 5,e +l/oridation war9 a scienti+ic dis/te or a reli*io/s
ar*/mente " Pu4lic Health Dent, '<7' Sec Iss89>&<-'>.
:;<. 1ern,ardt, M., g Sra*/e, 1. 7:;($8. 5,e oisonmon*ers. In 1arrett S, !o"in S,
3ds. The tooth ro44ers 7. :-(8. ),iladel,ia9 GF Stickley.
:;%. Hiamo/yiannis, #. 7:;(=8. (ifesavers $uide to fluoridation, Delaware, OH9
Sa+ewater Fo/ndation.
:;(. Hiamo/yiannis, #. 7:;(=8. 'luoride6 The a$in$ factor, Delaware, OH9 Healt,
Action )ress.
:;;. 4/l+, C. A., H/*,es, 2. F., Smit,, 2. G., g 3asley, M. 4., 3ds. 7:;;;8. 4use
of the scientific literature in an antifluoridation pamphlet 7>nd ed.8. Atlanta9 Centers
+or Disease Control g )re"ention, 000".
>$$. #ar"is, 4. 7:;(=8. S,o/ld we de-ate ?/ackse CCH' (California Council
$ainst Health 'raud) &e3sletter, #/ly-A/*, <9%.
>$:. S,earer, D. 7:;;%8. Sierra cl/- to take on water +l/oridation. Pitts4ur$h Post2
0a1ette, A/*/st :=, . C:.
>$>. Coleman, ). 7:;;%8. Not a/t,ori@ed. .etter to t,e 3ditor. Pitts4ur$h Post2
0a1ette, A/*/st >&, . 1=.
>$=. Citi@ens +or Sa+e Drinkin* 4ater. !P scientists ta*e stand a$ainst fluoridation
(Press Release), #/ly >, :;;%.
>$&. Hance, 1., C,ess, C., g Sandman, ). 7:;;$8. /ndustry ris* communication
manual, 1oca !aton, F.9 C!C )ressB.ewis )/-lis,ers, :;;$.
>$'. C,ess, C., Hance, 1., g Sandman, ). 7:;((8. /mprovin$ dialo$ue 3ith
communities6 a ris* communication manual for $overnment, 5renton, N#9 Di"ision o+
Science and !esearc,, New #ersey Deartment o+ 3n"ironmental )rotection, :;((.
>$<. Co"ello, 6. 7:;(;8. Iss/es and ro-lems in /sin* risk comarisons +or
comm/nicatin* ri*,t-to-know in+ormation on c,emical risks. !nvironmental Science
and Technolo$y, <A7:>89:&&&-;.
>$%. Co"ello, 6., g Allen, F. 7:;((8. Seven cardinal rules of ris* communication,
4as,in*ton, DC9 U.S. 3n"ironmental )rotection A*ency, O++ice o+ )olicy Analysis.
>$(. Fisc,o++, 1., .ic,tenstein, S., Slo"ic, )., g 2eeney, D. 7:;(:8. ccepta4le ris*,
Cam-rid*e, MA9 Cam-rid*e Uni"ersity )ress, :;(:.
>$;. U.S. )/-lic Healt, Ser"ice 7>$$$8. Healthy people <:C: 76ol. >, >nd ed.89
O-Aecti"es +or imro"in* ,ealt, 7)art 1, +oc/s areas :'->(8. 4as,in*ton, DC9 U.S.
Go"ernment )rintin* O++ice, No"em-er, <<&.
reser"ed.
4orkin*...
Chapter 9. Topical Fluoride Therapy - )evin ", Donly 0eor$e ), Stoo*ey
Objectives
:. Indicate t,e only t,ree +l/oride como/nds acceted +or ro+essional alications
to control caries and indicate t,eir relati"e e++ecti"eness.
>. Disc/ss t,e ossi-le c,emical reactions associated wit, t,e toical alication o+
sodi/m +l/oride 7NaF8, stanno/s +l/oride 7SnF
>
8, and acid/lated ,os,ate +l/oride
7A)F8.
=. !elate w,at ercenta*es o+ NaF and SnF
>
are a"aila-le +or o++ice and ,ome /se 7as
sol/tions or as *els8.
&. Descri-e ,ow a li?/id or *el toical alication o+ +l/oride is alied to t,e teet,.
3m,asi@e artic/larly t,ose arts o+ t,e tec,ni?/e t,at are esecially imortant wit,
re*ard to sa+ety and e++icacy.
'. Nearly all denti+rices on t,e market contain +l/oride. Indicate w,y t,e early
denti+rices did not rod/ce t,e e0ected caries decrements.
<. State t,e e0ected decrease in caries +ormation +ollowin* /se o+ denti+rices and
mo/t,rinses containin* +l/oride.
%. Descri-e +l/oridated "arnis,es and +l/oride-releasin* dental restorati"e materials
and t,e otential o+ t,ese materials to in,i-it deminerali@ation and en,ance
reminerali@ation.
Introduction
4,en comm/nal-water s/lies are a"aila-le, water +l/oridation clearly reresents
t,e most effective, efficient, and economical o+ all known meas/res +or t,e re"ention
o+ dental caries alt,o/*, similar res/lts ,a"e -een o-ser"ed wit, +l/oridated salt in
many co/ntries. Un+ort/nately, +l/oridated water is a"aila-le to only a-o/t two-t,irds
o+ t,e o/lation. 5,/s it is o-"io/s t,at additional meas/res are needed +or t,e dental
ro+ession to ro"ide *reater rotection a*ainst caries to as many se*ments o+ t,e
o/lation as ossi-le.
5,e term topical fluoride therapy re+ers to t,e /se o+ systems containin* relati"ely
lar*e concentrations o+ +l/oride t,at are alied locally, or toically, to er/ted toot,
s/r+aces to re"ent t,e +ormation o+ dental caries. 5,/s t,is term encomasses t,e /se
o+ +l/oride rinses, denti+rices, astes, *els, and sol/tions t,at are alied in "ario/s
manners.
Mechanism of Action
St/dies o+ t,e /se o+ ro+essional toical +l/oride alications +or t,e control o+ dental
caries -e*an in t,e early :;&$s. Since t,at time, it ,as -een *enerally acceted t,at t,e
+l/oride content o+ enamel is inversely related to t,e re"alence o+ dental caries.
Usin* in vivo enamel-samlin* tec,ni?/es and imro"ed analytic met,ods
in"esti*ators ,a"e -een -etter a-le to ?/antitate t,is relations,i. For e0amle, 2eene
and coworkers
:
e0lored t,is relations,i in yo/n* na"al recr/its :% to >> years o+
a*eD t,eir o-ser"ations are s/mmari@ed in 5a-le ;-:. 5,ese data s/**est t,at t,e
resence o+ elevated le"els o+ +l/oride in s/r+ace enamel is associated wit, minimal
caries e0erience.
A m/c, more e0tensi"e in"esti*ation o+ t,is relations,i was reorted -y De)aola
and coworkers.
>
5,ese in"esti*ators similarly e0amined :,&&% s/-Aects, :> to :< years
o+ a*e, w,o were li+etime residents o+ selected +l/oridated and non+l/oridated
comm/nitiesD a*ain t,e in"erse relations,i -etween enamel +l/oride content and
caries re"alence is aarent.
At t,e time o+ toot, er/tion, t,e enamel is not yet comletely calci+ied and
/nder*oes a post2eruptive period, aro0imately < years in len*t,, d/rin* w,ic,
enamel calci+ication contin/es. 5,ro/*,o/t t,is eriod, called t,e eriod o+ enamel
maturation, +l/oride, as well as ot,er elements, contin/es to acc/m/late in t,e more
s/er+icial ortions o+ enamel. 5,is +l/oride is deri"ed +rom t,e saliva as well as +rom
t,e e0os/re o+ t,e teet, to +l/oride-containin* 3ater and food. Followin* t,e eriod
o+ enamel mat/ration, relati"ely little additional +l/oride is incororated +rom s/c,
so/rces into t,e enamel s/r+ace.
=
5,/s, most o+ t,e +l/oride t,at is incororated into
t,e de"eloin* enamel occ/rs d/rin* t,e pre2eruptive eriod o+ enamel +ormation and
t,e post2eruptive eriod o+ enamel mat/ration.
5,e contin/ed deosition o+ +l/oride into enamel d/rin* t,e later sta*es o+ enamel
+ormation, and esecially d/rin* t,e eriod o+ enamel mat/ration, res/lts in a
concentration *radient o+ +l/oride in enamel. In"aria-ly t,e hi$hest concentration o+
+l/oride occ/rs at t,e "ery o/termost ortion o+ t,e enamel s/r+ace, wit, t,e +l/oride
content decreasin$ as one ro*resses inward to3ard the dentin.
&,'
5,is decrease in
+l/oride concentration is e0tremely raid in t,e o/termost > to C: microns o+ enamel
and is m/c, less rono/nced t,erea+ter. 5,is c,aracteristic +l/oride concentration
*radient ,as -een o-ser"ed in /ner/ted teet, as well as in er/ted teet, and in -ot,
t,e ermanent and decid/o/s dentition, re*ardless o+ t,e amo/nt o+ re"io/s e0os/re
to +l/oride.
5,e resence o+ ele"ated concentrations o+ +l/oride in s/r+ace enamel ser"es to make
t,e toot, s/r+ace more resistant to t,e de"eloment o+ dental caries. Fl/oride ions,
w,en s/-stit/ted into t,e hydroxyapatite crystal, +it more er+ectly into t,e crystal
t,an do hydroxyl ions. 5,is +act co/led wit, t,e *reater -ondin* otential o+ +l/oride
ser"es to make t,e aatite crystals more comact and more sta-le. S/c, crystals are
t,ere-y more resistant to t,e acid dissolution
<,%
t,at occ/rs d/rin* caries initiation.
5,is e++ect is e"en more aarent as the pH o+ t,e enamel en"ironment decreases d/e
to t,e momentary loss o+ min/te ?/antities o+ +l/oride +rom t,e dissol"in* enamel and
its nearly sim/ltaneo/s reprecipitation as a +l/or,ydro0yaatite.
(
Most o+ t,e initial st/dies concernin* toical +l/oride alications were cond/cted
wit, sodi/m +l/oride. It was reco*ni@ed at t,at time t,at rolon*ed e0os/re o+ t,e
teet, to low concentrations o+ +l/oride in t,e dental o++ice was not ractical. 5o
o"ercome t,is ro-lem, two aroac,es were e0lored9 increasin$ the fluoride
concentration and decreasin$ the pH of the application solution.
Alt,o/*, t,e a-ility o+ sodi/m +l/oride to increase t,e resistance o+ enamel to acid
dissol/tion ,ad -een reorted on se"eral occasions, it ,ad also -een reorted t,at
lowerin* t,e H o+ t,e sodi/m +l/oride sol/tion *reatly increased its rotection
a*ainst enamel decalci+ication. Fi"e clinical caries st/dies were cond/cted to e"al/ate
t,e e++ecti"eness o+ acidulated sodium fluoride toical sol/tions. 5,e +l/oride
sol/tions were acid/lated in "ario/s manners 7e.*., acetic acid, acid ,t,alate8 and
/sed wit, "aryin* conditions, -/t in no instance was a statistically si*ni+icant caries-
re"enti"e e++ect o-ser"ed. 5,/s, t,e /se o+ acid/lated sodi/m +l/oride systems was
a-andoned, at least temporarily.
On t,e ot,er ,and, t,e o-ser"ed res/lts o+ increasin* concentrations o+ +l/oride were
"ery enco/ra*in*, artic/larly w,en m/ltile alications were /sed. Alt,o/*, it was
initially ost/lated t,at t,e e++ecti"eness o+ toically alied sodi/m +l/oride was d/e
to t,e +ormation o+ a +l/or,ydro0yaatite,
;,:$
s/-se?/ent in"esti*ations indicated t,at
t,e rimary reaction rod/ct in"ol"ed t,e trans+ormation o+ s/r+ace ,ydro0yaatite to
calcium fluoride.
::-:<
Question 1
A. 5,e mat/ration o+ enamel is an occ/rrence t,at contin/es at a linear rate +rom
er/tion into ad/lt,ood.
1. 5,e +l/oride content is ,i*,est at t,e o/ter s/r+ace o+ t,e enamel and decreases at a
linear rate toward t,e dentin.
C. As a res/lt o+ acid-ind/ced deminerali@ation +ollowed -y reminerali@ation in t,e
resence o+ +l/oride, ,ydro0yaatite can -ecome +l/or,ydro0yaatite.
D. 5,e enamel is relati"ely more rotected -y ne/tral H +l/oride sol/tions t,an
acid/lated sol/tions.
3. 4it, ,i*,er concentrations o+ +l/oride, t,e main reaction rod/ct is
+l/or,ydro0yaatite.
5,e recedin* reaction in"ol"es t,e -reakdown o+ t,e aatite crystal into its
comonents +ollowed -y t,e reaction o+ +l/oride and calci/m ions to +orm calci/m
+l/oride wit, a net loss o+ ,os,ate ions +rom treated enamel. Newer +l/oride
systems incororate a means o+ re"entin* s/c, ,os,ate loss.
5,e early in"esti*ators o+ t,e reaction -etween sol/-le +l/oride and enamel o-ser"ed
t,at t,e nat/re o+ t,e reaction rod/cts was markedly in+l/enced -y a n/m-er o+
+actors, incl/din* +l/oride concentration, t,e pH o+ t,e sol/tion, and t,e len*t, o+
exposure. For e0amle, t,e /se o+ acidic fluoride sol/tions *reatly +a"ored t,e
+ormation o+ calcium fluoride.
::
&eutral sodium fluoride sol/tions wit, +l/oride
concentrations o+ C:: ppm or less res/lted rimarily in t,e +ormation o+ fluorapatite,
w,ereas ,i*,er +l/oride concentrations res/lted in t,e +ormation o+ calcium fluoride.
:'
1eca/se toical alications o+ sodi/m +l/oride in"ol"e t,e /se o+ >.$E sol/tions
7sli*,tly o"er ;,$$$ m8, it +ollows t,at t,e /se o+ t,ese sol/tions essentially
in"ol"es t,e +ormation o+ calcium fluoride.
:&
5,e second +l/oride como/nd de"eloed
:%,:(
+or toical /se in t,e dental o++ice
d/rin* t,e :;'$s was stannous fluoride 7SnF
>
8. Comared wit, t,at o+ sodi/m
+l/oride, t,e reaction o+ SnF
>
wit, enamel is /ni?/e in t,at 4oth t,e cation 7stanno/s8
and t,e anion 7+l/oride8 react c,emically wit, enamel comonents. 5,is reaction is
commonly deicted as +ollows9
Note +rom t,e e?/ation t,at t,e +ormation o+ stannous fluorophosphate re"ents, at
least temorarily, t,e phosphate loss tyical o+ sodi/m +l/oride alications.
Incidentally, t,e e0act nat/re o+ t,e tin-containin* reaction rod/cts "aries deendin*
on reaction conditions, incl/din* H, concentration, and len*t, o+ e0os/re 7or
reaction time8.
:;,>$
A t,ird toical +l/oride system +or ro+essional /se was de"eloed d/rin* t,e :;<$s
and is widely known as A)F, acidulated phosphate fluoride. 5,is system was
de"eloed -y 1r/de"old and coworkers
>:,>>
in an e++ort to ac,ie"e *reater amo/nts o+
+l/or,ydro0yaatite and lesser amo/nts o+ calci/m +l/oride +ormation. 5,ese
in"esti*ators re"iewed t,e "ario/s c,emical reactions o+ +l/oride wit, enamel
7,ydro0yaatite8 and concl/ded t,at 7:8 i+ t,e H o+ t,e +l/oride system was made
acidic to en,ance t,e rate o+ reaction o+ +l/oride wit, ,ydro0yaatite and 7>8 i+
,os,oric acid was /sed as t,e acid/lant to increase t,e concentration o+ ,os,ate
resent at t,e reaction site, it s,o/ld -e ossi-le to o-tain *reater amo/nts o+ +l/oride
deosited in s/r+ace enamel as fluorhydroxyapatite wit, minimal +ormation o+
calcium fluoride and minimal loss o+ enamel phosphate. On t,e -asis o+ t,is c,emical
reasonin*, A)F systems were de"eloed and s,own to -e e++ecti"e +or caries
re"ention.
S/-se?/ent indeendent st/dies o+ t,e reactions o+ A)F wit, enamel indicated,
,owe"er, t,at t,e ori*inal c,emical o-Aecti"es were only artially ac,ie"ed. 5,e
maAor reaction rod/ct o+ A)F wit, enamel is also calcium fluoride,
:>,>=,>&
alt,o/*, a
*reater amo/nt o+ +l/or,ydro0yaatite is +ormed t,an wit, t,e re"io/s toical
+l/oride systems. 5,e c,emical reaction o+ A)F wit, enamel may -e written as
+ollows9
It is o-"io/s +rom t,e recedin* disc/ssion t,at t,e rimary c,emical reaction rod/ct
wit, all t,ree tyes o+ toical +l/oride systems 7i.e., NaF, SnF
>
, and A)F8 is t,e
+ormation o+ calcium fluoride on t,e enamel s/r+ace.
5,e initial deosition o+ calci/m +l/oride on t,e treated toot, s/r+aces is -y no means
ermanentD a relati"ely raid loss o+ +l/oride occ/rs wit,in t,e +irst <B hours,
>'
wit,
some contin/ed loss occ/rrin* d/rin* t,e next C> days.
><->;
5,e rate o+ loss "aries
-etween atients and is in+l/enced -y t,e nat/re o+ t,e +l/oride treatment.
=$,=:

Ne"ert,eless, it is known t,at each indi"id/al ro+essionally-alied +l/oride
treatment res/lts in an increase in t,e ermanently--o/nd +l/oride content o+ t,e
o/termost layers o+ t,e enamel wit, a s/-se?/ent decrease in t,e s/sceti-ility o+ t,e
enamel +or caries initiation and ro*ression.
5,e role o+ t,e calci/m +l/oride deosits on t,e enamel s/r+ace +ollowin* ro+essional
+l/oride alications in ro"idin* t,e o-ser"ed cariostatic -ene+its ,as -een t,e
s/-Aect o+ n/mero/s in"esti*ations. It is known t,at t,e most desira4le form of
fluoride in enamel +or caries re"ention is fluorhydroxyapatite and t,at t,e most
e++icient means o+ +ormin* t,is reaction rod/ct occ/rs wit, prolon$ed exposure o+
t,e enamel to lo3 concentrations o+ +l/oride. It is also known t,at calcium fluoride
may ser"e as a +l/oride source for enamel reminerali1ation,
=>,==
and t,at calci/m
+l/oride dissol"es m/c, more slowly in t,e oral en"ironment t,an in an a?/eo/s
sol/tion d/e to t,e resence o+ a ,os,ate or rotein-ric, coatin* o+ t,e *lo-/lar
deosits o+ calci/m +l/oride on t,e enamel s/r+ace.
=&
As a res/lt o+ t,is contin/ed
researc,, t,ere is a *rowin* -ody o+ con"incin* e"idence s/**estin* t,at t,e deosits
o+ calci/m +l/oride ser"e as an imortant fluoride reservoir and t,at t,ese ,os,ate-
coated *lo-/les are dissol"ed in t,e resence o+ la?/e acids ro"idin* an a"aila-le
source of 4oth fluoride and phosphate to +acilitate t,e reminerali@ation o+ decalci+ied
areas.
='
!e*ardless o+ t,e mec,anism o+ action o+ ro+essionally alied toical +l/oride
treatments, t,e res/lts o+ clinical trials clearly indicate t,at t,e 4enefits are related to
the num4er of treatments. 5a-le ;-> s/mmari@es a clinical st/dy
=<
in w,ic,
sc,oolc,ildren were *i"en a dental ro,yla0is and a toical alication o+ ( ercent
SnF
>
at <-mont, inter"als t,ro/*,o/t a =-year eriod. Dental-caries e0aminations
were er+ormed initially and eac, year t,erea+ter. It is aarent +rom t,ese data t,at
t,e caries-re"enti"e -ene+its increased in relation to t,e n/m-er o+ treatments.
Similar o-ser"ations ,a"e -een noted wit, t,e ot,er two +l/oride systems /sed +or
ro+essional alications. 5,e ori*inal sodi/m +l/oride toical alication roced/re
de"eloed -y 2n/tson
=%
seci+ied a series o+ +o/r treatment d/rin* a >-week eriod.
Mell-er*
=(
and coworkers
=;
,a"e also indicated t,e need +or reeated toical
alications o+ A)F to o-tain ma0imal -ene+its. 5,/s, it +ollows t,at ma0imal atient
-ene+its can only -e o-tained wit, reeated toical alications re*ardless o+ t,e
nat/re o+ t,e +l/oride system /sed.
It was noted earlier t,at t,e reaction o+ SnF
>
wit, enamel res/lted in t,e +ormation o+
tin-containin* como/nds. Alt,o/*, m/c, less is known re*ardin* t,e recise nat/re
and /ltimate +ate o+ t,ese como/nds, it aears t,at t,ey contri-/te si*ni+icantly to
t,e cariostatic acti"ity o+ SnF
>
. 5,e tin reaction rod/cts +ormed on so/nd enamel
s/r+aces aear to -e leac,ed +rom t,e enamel in a manner similar to t,at +or calci/m
+l/oride.
&$
5,e *reatest acc/m/lation o+ stanno/s comle0es occurs in circumscri4ed
areas of enamel defectsD tyically s/c, areas are hypominerali@ed and are +re?/ently
t,e res/lt o+ decalci+ication associated wit, t,e initiation o+ t,e caries rocess.
30tremely ,i*, concentrations o+ tin, a-o/t >$,$$$ m, ,a"e -een reorted in t,ese
locations.
&:
Clinically, t,ese areas, w,ic, ,a"e -een descri-ed as +rank cario/s areas,
4ecome pi$mented 7res/ma-ly -eca/se o+ t,e resence o+ t,e tin comle0es8 and
aear to -e more calci+ied +ollowin* t,e alication o+ SnF
>
. 5,is i*mentation ,as
t,/s -een s/**ested as -ein* indicati"e o+ t,e arrest o+ cario/s lesions and is tyically
retained +or < to :> mont,s or lon*er, imlyin* t,at t,ese stanno/s reaction rod/cts
are o+ considera-ly $reater si*ni+icance t,an t,ose +ormed on so/nd enamel.
At red/ced concentrations o+ :,C: to :,C>; fluoride, all o+ t,e +ore*oin* +l/oride
como/nds ,a"e also -een aro"ed +or /se in denti+rices and *els intended +or
ersonal /se, and sodi/m +l/oride at a concentration o+ :,:>; ,as also -een aro"ed
+or /se in mouthrinses sold over2the2counter. In *eneral, it is reco*ni@ed t,at t,e
mec,anism o+ action o+ t,ese +l/oride como/nds is similar at all t,e concentrations
/tili@ed +or -ot, ro+essional and ,ome-/se rod/cts.
One additional +l/oride como/nd, sodium monofluorophosphate, ,as -een aro"ed
+or /se in denti+ricesD t,is como/nd ,as t,e emirical +orm/la Na
>
)O
=
F and is
commonly known as MF). 5,o/*, e"al/ated in one st/dy as an a*ent +or toical
+l/oride alication in t,e dental o++ice, its /se in t,is manner ,as recei"ed little
consideration. Alt,o/*, t,e mec,anism o+ action o+ MF) is t,o/*,t to in"ol"e a
c,emical reaction wit, s/r+ace enamel, t,e recise nat/re o+ t,is reaction is poorly
understood. Some in"esti*ators ,a"e s/**ested t,at t,e +l/oro,os,ate moiety,
)O
=
F
'
, may /nder*o an e0c,an*e reaction wit, ,os,ate ions in t,e aatite str/ct/re
-/t t,e resence o+ )O
=
F
'
in enamel ,as ne"er -een demonstrated, and s/c, a reaction
mec,anism aears /nlikely. Ot,ers ,a"e s/**ested t,at t,e )O
=
F
'
comle0 is
en@ymatically dissociated -y ,os,atases resent in sali"a and dental la?/e into
)O
=
>
and F
>
, wit, t,e ionic +l/oride reactin* wit, ,ydro0yaatite in a manner similar
to t,at descri-ed earlier. 5,e +act t,at t,e treatment o+ enamel wit, MF) res/lts in less
+l/oride deosition and less rotection a*ainst enamel decalci+ication t,an is o-ser"ed
wit, simle inor*anic +l/oride como/nds s/c, as sodi/m +l/oride, w,ile yet
imartin* nearly comara-le cariostatic acti"ity, is indicati"e o+ a more comle0
mec,anism o+ action.
For t,e most art, t,e +ore*oin* disc/ssion o+ t,e c,emical reactions o+ concentrated
+l/oride sol/tions wit, enamel s/**ests t,at t,e reactions occ/r on t,e outer enamel
surface and ser"e to make t,at s/r+ace more resistant to deminerali@ation. It is
aarent t,at t,is rocess is artic/larly redominant in newly er/ted teet, t,at are
/nder*oin* contin/ed enamel mat/ration 7calci+ication8 +or t,e +irst > years +ollowin*
er/tion into t,e oral ca"ity. In s/c, instances, some o+ t,e alied +l/oride readily
enetrates t,e relati"ely ermea-le enamel s/r+ace to depths of <: to A: millimeters
and readily reacts wit, t,e calci+yin* aatite to +orm a +l/or,ydro0yaatite.
F/rt,ermore, t,e dissol/tion o+ t,e calci/m +l/oride deosited on t,e enamel s/r+ace
ro"ides additional +l/oride ions, w,ic, -ecome incororated in mat/rin* enamel.
It ,as -ecome increasin*ly aarent, ,owe"er, d/rin* t,e last decade t,at "ery little
+l/oride deosition lastin$ more than <B hours occ/rs w,en +l/oride is alied to
so/nd, fully maturated enamel, 5,is sit/ation aarently occ/rs re*ardless o+ t,e
nat/re o+ t,e +l/oride como/nd, t,e concentration o+ +l/oride, or t,e manner o+
alication. 5,/s, t,ere aears to -e no re"enti"e -ene+its +rom t,e alication o+
+l/oride to mat/rated, so/nd enamel.
As noted in C,ater =, t,e caries rocess -e*ins wit, a deminerali@ation o+ t,e apatite
ad7acent to the crystal sheaths. 5,is ermits t,e di++/sion o+ weak acids into t,e
s/-s/r+ace enamel, and -eca/se t,e s/-s/r+ace enamel ,as a lower +l/oride content
and is less resistant to acid deminerali@ation, it is preferentially dissol"ed, +ormin* an
incipient, su4surface lesion. As t,is rocess contin/es, it -ecomes clinically aarent
as a so-called F3hite spotF t,at, in reality, is a rat,er e0tensi"e s/-s/r+ace lesion
co"ered -y a relati"ely intact enamel s/r+ace. 5,/s, enamel s/r+aces t,at clinically
aear to -e so/nd or +ree o+ deminerali@ation +re?/ently ,a"e areas t,at ,a"e -een
sli*,tly decalci+ied wit, minute su4surface lesions t,at are not yet detecta-le
clinically. 5,is sit/ation is artic/larly likely to e0ist in atients wit, clinical e"idence
o+ caries activity on other teeth.
It now aears t,at t,e redominant mec,anism o+ action o+ +l/oride in"ol"es its
a-ility to facilitate the reminerali1ation o+ t,ese deminerali@ed areas. 5oically
alied +l/oride clearly diffuses into t,ese deminerali@ed areas and reacts wit,
calci/m and ,os,ate to +orm +l/or,ydro0yaatite in t,e reminerali@ation rocess. It
is also notewort,y t,at s/c, reminerali@ed enamel is more resistant to s/-se?/ent
deminerali@ation t,an was t,e ori*inal enamel. 5,is rocess ,as -een s,own to occ/r
wit, all +orms and concentrations o+ +l/oride, incl/din* concentrations as low as :
m s/c, as is +o/nd in otimally +l/oridated drinkin* water. St/dies cond/cted in
o/r la-oratories, ,owe"er, ,a"e clearly s,own t,at t,e amo/nt o+ +l/oride deosition
in s/-s/r+ace lesions +ollowin* a toical +l/oride alication is m/c, *reater t,an t,at
occ/rrin* +ollowin* t,e /se o+ lesser concentrations o+ +l/oride ro"ided -y +l/oride
rinses or denti+rices. As a res/lt, toical +l/oride alications aear to -e an effective
means of inducin$ the reminerali1ation of incipient lesions,
Question 2
A. On deminerali@ation, more ,os,ate is lost +rom t,e ,ydro0yaatite crystal in t,e
resence o+ sodi/m +l/oride t,an w,en stanno/s +l/oride is resent.
1. Calci/m +l/oride deosits on t,e toot, s/r+ace ser"e as a +l/oride reser"oir.
C. As t,e n/m-er o+ treatments wit, toical +l/oride increases, so does t,e caries-
re"enti"e -ene+it.
D. Stanno/s +l/oride is deosited in *reatest concentration w,ere t,e enamel is least
er+ectly minerali@ed.
3. 5,e /se o+ MF) res/lts in less cariostatic action t,an ot,er ne/tral +l/orides, e"en
t,o/*, a ,i*,er concentration is /s/ally +o/nd on t,e toot, s/r+ace.
Effects of Fluoride on Plaque and Bacterial Metabolism
5,/s +ar, we ,a"e ass/med t,at t,e cariostatic e++ects o+ +l/oride are mediated t,ro/*,
a c,emical reaction -etween t,is ion and t,e o/termost ortion o+ t,e enamel s/r+ace.
5,e reonderance o+ data s/orts t,is "iew. A *rowin* -ody o+ in+ormation
s/**ests, ,owe"er, t,at t,e caries-re"enti"e action o+ +l/oride may also incl/de an
inhi4itory effect on the oral flora involved in the initiation of caries. 5,e a-ility o+
+l/oride to inhi4it $lycolysis -y inter+erin* wit, t,e en@yme enolase ,as lon* -een
knownD concentrations o+ +l/oride as low as '$ m ,a"e -een s,own to inter+ere wit,
-acterial meta-olism. Moreo"er, +l/oride may accumulate in dental pla5ue in
concentrations a4ove C:: ppm. Alt,o/*, t,e +l/oride normally resent in la?/e is
lar*ely -o/nd 7and t,/s /na"aila-le +or anti-acterial action8, it dissociates to ionic
+l/oride w,en t,e H o+ la?/e decreases 7i.e., w,en acids are +ormed8. 5,/s, w,en
t,e cario/s rocess starts and acids are +ormed, la?/e +l/oride in ionic +orm may
ser"e to interfere wit, +/rt,er acid rod/ction -y la?/e microor*anisms. In addition,
it may react wit, t,e /nderlyin* layer o+ dissol"in* enamel, promotin$ its
reminerali1ation as fluorhydroxyapatite. 5,e end res/lt o+ t,is rocess is a
F,ysiolo*icF restoration o+ t,e initial lesion 7-y reminerali@ation o+ enamel8 and t,e
+ormation o+ a more resistant enamel s/r+ace. 5,e a-ility o+ +l/oride to romote t,e
rereciitation o+ calci/m ,os,ate sol/tions in aatitic +orms ,as -een reeatedly
demonstrated.
In addition to t,ese ossi-le e++ects o+ +l/oride, se"eral in"esti*ators ,a"e reorted
t,at t,e resence o+ tin, esecially as ro"ided -y stanno/s +l/oride, is associated wit,
si*ni+icant anti4acterial activity, w,ic, ,as -een reorted to decrease 4oth t,e
amo/nt o+ dental pla5ue and $in$ivitis in -ot, animals
&>
and ad/lt ,/mans.
&=
30istin*
e"idence s/**ests t,at t,ese anti-acterial e++ects o+ +l/oride and tin may also
contri-/te to t,e o-ser"ed cariostatic acti"ity o+ toically alied +l/orides.
Topical Fluoride Applications
5,e /se o+ concentrated +l/oride sol/tions alied toically to t,e dentition +or t,e
re"ention o+ dental caries ,as -een st/died e0tensi"ely d/rin* t,e ast '$ years,
alt,o/*, +ew st/dies ,a"e -een cond/cted since t,e :;%$s. 5,is roced/re res/lts in a
si*ni+icant increase in t,e resistance o+ t,e e0osed toot, s/r+aces to t,e de"eloment
o+ dental caries and, as a res/lt, ,as -ecome a standard roced/re in most dental
o++ices.
At resent, t,ree di++erent +l/oride systems ,a"e -een ade?/ately e"al/ated and
aro"ed +or /se in t,is manner in t,e United States. 5,ese t,ree systems are <;
sodium fluoride, F; stannous fluoride, and acidulated phosphate fluoride systems
containin$ C,<A; fluoride,
A"aila-le Forms
4,en toical +l/oride alications -ecame a"aila-le to t,e ro+ession, t,e +l/oride
como/nds 7sodi/m +l/oride and stanno/s +l/oride8 were o-tained in owder or
crystalline +orm, and a?/eo/s sol/tions were reared immediately rior to /se.
S/-se?/ently it was reali@ed t,at sodi/m +l/oride sol/tions were sta-le i+ stored in
lastic containers, and t,is como/nd -ecame a"aila-le in li?/id and *el, as well as
owder, +orm. 4it, contin/ed researc, o+ di++erent tyes o+ a*ents and reco*nition -y
t,e dental ro+ession o+ t,eir in,erent disad"anta*es wit, re*ard to atient accetance
and sta-ility, as well as t,e need to /se ro+essional time more e++iciently, t,e trend
,as -een toward t,e /se o+ ready-to-/se, sta-le, +la"ored rearations in *el +orm.
Sodium 'luoride (&a')
5,is material is a"aila-le in owder, *el, and li?/id +orm. 5,e como/nd is
recommended +or /se in a >E concentration, w,ic, may -e prepared -y dissol"in*
$.> * o+ owder in :$ m. o+ distilled water. 5,e reared sol/tion or *el ,as a -asic
H and is sta-le i+ stored in lastic containers. !eady-to-/se >E sol/tions and *els o+
NaF are commercially a"aila-leD -eca/se o+ t,e relati"e a4sence of taste
considerations wit, t,is como/nd, t,ese sol/tions *enerally contain little +la"orin*
or sweetenin* a*ents.
Stannous 'luoride (Sn'
<
)
5,is como/nd is a"aila-le in owder +orm eit,er in -/lk containers or rewei*,ed
cas/les. 5,e recommended and aro"ed concentration is F;, w,ic, is o-tained -y
dissol"in* $.( * o+ t,e owder in :$ m. o+ distilled water. Stanno/s +l/oride sol/tions
are ?/ite acidic, wit, a H o+ a-o/t >.& to >.(. A?/eo/s sol/tions o+ SnF
>
are not
sta-le -eca/se o+ t,e +ormation o+ stanno/s ,ydro0ide and, s/-se?/ently, stannic
o0ide, w,ic, is "isi-le as a w,ite reciitate. As a res/lt, sol/tions o+ t,is como/nd
m/st -e reared immediately rior to /se. As will -e noted later, SnF
>
sol/tions ,a"e
a -itter, metallic taste. 5o eliminate t,e need to reare t,is sol/tion +rom t,e owder
and to imro"e atient accetance, a sta-le, +la"ored sol/tion can -e reared wit,
*lycerine and sor-itol to retard ,ydrolysis o+ t,e SnF
>
and wit, any o+ a "ariety o+
comati-le +la"orin* a*ents. !eady-to-/se sol/tions or *els wit, t,e roer SnF
>

concentration, ,owe"er, are not commercially a"aila-le.
cidulated Phosphate 'luoride (P')
5,is treatment system is a"aila-le as eit,er a solution or $el, -ot, o+ w,ic, are sta-le
and ready to /se. 1ot, +orms contain :.>=E +l/oride, *enerally o-tained -y t,e /se o+
>.$E sodi/m +l/oride and $.=&E ,ydro+l/oric acid. ),os,ate is /s/ally ro"ided as
ort,o,os,oric acid in a concentration o+ $.;(E. 5,e H o+ tr/e A)F systems
s,o/ld -e a-o/t A,>. Gel rearations +eat/re a *reater "ariation in comosition,
artic/larly wit, re*ard to t,e so/rce and concentration o+ ,os,ate. In addition, t,e
*el rearations *enerally contain t,ickenin* 7-inders8, +la"orin*, and colorin*
a*ents.
Anot,er +orm o+ acid/lated ,os,ate +l/oride +or toical alications, namely
thixotropic *els, is also a"aila-le. 5,e term t,i0otroic denotes a sol/tion t,at sets in a
*el-like state -/t is not a tr/e *el. On t,e alication o+ ress/re, t,i0otroic *els
-e,a"e like sol/tionsD it ,as -een s/**ested t,at t,ese rearations are more easily
+orced into t,e interro0imal saces t,an con"entional *els. 5,e acti"e +l/oride
system in t,i0otroic *els is identical to con"entional A)F sol/tions. Alt,o/*, t,e
initial t,i0otroic *els e0,i-ited somew,at oorer -iolo*ic acti"ity in in "itro st/dies,
s/-se?/ent +orm/lations were at least e?/i"alent to con"entional A)F systems. 3"en
t,o/*, +ew clinical e++icacy st/dies ,a"e -een reorted,
&&
t,e collecti"e data were
considered ade?/ate e"idence o+ acti"ityD t,ese rearations ,a"e -een approved 4y
the merican Dental ssociation,
4it,in t,e ast +ew years, a +oam +orm o+ A)F ,as -ecome a"aila-le. .a-oratory
st/dies indicate t,at t,e amo/nt o+ +l/oride /take in enamel +ollowin* alications
/sin* t,e +oam is compara4le to t,at o-ser"ed wit, con"entional A)F *els and
sol/tions. 5,e rimary ad"anta*e o+ +oam rearations is t,at arecia-ly less
material is /sed +or a treatment and t,ere+ore lesser amo/nts are likely to -e
inad"ertently swallowed -y yo/n* c,ildren d/rin* t,e ro+essional alication.
Alication )roced/re
In essence, two roced/res are a"aila-le +or administerin* toical +l/oride treatments.
One roced/re, in -rie+, in"ol"es t,e isolation o+ teet, and contin/o/sly aintin* t,e
sol/tion onto t,e toot, s/r+aces. 5,e second, and currently more o/lar, roced/re
in"ol"es t,e /se o+ +l/oride *els alied wit, a disposa4le tray.
Until recently it was ass/med t,at it was necessary to administer a t,oro/*, dental
ro,yla0is rior to t,e toical alication o+ +l/oride. 5,is ,yot,esis was s/orted
-y t,e res/lts o+ an early st/dy t,at s/**ested t,at toically alied sodi/m +l/oride
was more e++ecti"e i+ a ro,yla0is receded t,e treatment.
&'
5,e res/lts o+ +o/r
clinical trials,
&<-&;
,a"e indicated t,at a ro,yla0is immediately rior to t,e toical
alication o+ +l/oride is not necessary. In t,ese st/dies, t,e c,ildren were *i"en
toical alications o+ A)F in t,e con"entional manner e0cet t,at t,ree di++erent
roced/res were /sed to clean t,e teet, immediately rior to eac, treatmentD t,ese
roced/res were eit,er a dental ro,yla0is, toot,-r/s,in* and +lossin*, or no
cleanin* roced/re. 5,e res/lts indicated t,at t,e cariostatic acti"ity o+ t,e A)F
treatment was not in+l/enced -y t,e di++erent realication roced/res. 5,/s, t,e
administration o+ a dental ro,yla0is rior to t,e toical alication o+ +l/oride m/st
-e considered optionalD it s,o/ld -e er+ormed i+ t,ere is a $eneral need +or a
ro,yla0is, -/t it need not -e er+ormed as a rere?/isite +or toical +l/oride
alications.
Fi*/res ;-:, ;->, ;-=, ;-&, ;-', and ;-< ill/strate t,e maAor stes recommended +or
alyin* toical +l/oride sol/tions. 5,e essential armamentari/m +or t,e alication
o+ concentrated +l/oride sol/tions consists o+ c/t cotton rolls, s/ita-le cotton-roll
,olders, cotton alicators, and treatment sol/tion. I+ a ro,yla0is is er+ormed, t,e
atient is allowed to rinse t,oro/*,ly, and t,en t,e cotton rolls and ,olders are
ositioned so as to isolate t,e area to -e treated. It is a common ractice w,en /sin*
+l/oride sol/tions to isolate 4oth ri*,t or le+t ?/adrants at one time so as to -e a-le to
treat one-,al+ o+ t,e mo/t, sim/ltaneo/sly. 5,e isolated teet, are t,en dried wit,
comressed air, and t,e +l/oride sol/tion is alied /sin* cotton alicators. Care
s,o/ld -e taken to -e certain t,at all toot, s/r+aces are treated. 5,e alication is
er+ormed -y merely swa--in* or Faintin*F t,e "ario/s toot, s/r+aces wit, a cotton
alicator t,oro/*,ly moistened wit, t,e +l/oride sol/tion. 5,e swa--in* roced/re
is reeated continuously and methodically wit, reeated Floadin*F o+ t,e cotton
alicator so as to kee t,e toot, s/r+aces moist t,ro/*,o/t t,e treatment eriod. At
t,e concl/sion o+ t,is eriod, t,e cotton rolls and ,olders are remo"ed, t,e atient is
allowed to e0ectorate, and t,e rocess is reeated +or t,e remainin* ?/adrants.
It s,o/ld -e stressed t,at "ario/s reca/tions s,o/ld -e ro/tinely taken to minimi1e
t,e amo/nt o+ +l/oride t,at is inad"ertently swallowed -y t,e atient d/rin* t,e
alication roced/re. A n/m-er o+ reorts
'$-'<
,a"e s,own t,at :$ to =$ m* o+
+l/oride may -e inadvertently swallowed d/rin* t,e alication roced/re, and it ,as
-een s/**ested t,at t,e in*estion o+ t,ese ?/antities o+ +l/oride -y yo/n* c,ildren
may contri-/te to t,e de"eloment o+ dental +l/orosis in t,ose teet, t,at are /ner/ted
and in t,e de"elomental sta*e. )reca/tions t,at s,o/ld -e /ndertaken incl/de 7:8
/sin* only t,e re5uired amo/nt o+ t,e +l/oride sol/tion or *el to er+orm t,e treatment
ade?/atelyD 7>8 ositionin* t,e atient in an upri$ht ositionD 7=8 /sin* e++icient saliva
aspiration or s/ctionin* aarat/sD and 7&8 re?/irin* t,e atient to expectorate
thorou$hly on completion o+ t,e +l/oride alication. 5,e /se o+ t,ese roced/res ,as
-een s,own to red/ce t,e amo/nt o+ inad"ertently swallowed +l/oride to less than <
m$, w,ic, may -e e0ected to -e o+ little conse?/ence.
'%
A+ter t,e toical alication is comleted, t,e atient is ad"ised not to rinse, drink, or
eat +or A: min/tes. 5,e necessity o+ t,e latter roced/re ,as not -een s/-stantiatedD
t,e +act t,at it ,as -een +ollowed in most o+ t,e rior clinical st/dies ser"es as t,e
rimary -asis +or t,is recommendation. 5,is recommendation is also s/orted,
,owe"er, -y a :;(< st/dy
'(
t,at meas/red t,e amo/nt o+ +l/oride deosition in
inciient lesions 7s/-s/r+ace enamel deminerali@ation8 in atients w,o eit,er were, or
were not, ermitted to rinse, eat, or drink d/rin* t,is =$-min/te osttreatment eriod.
It was +o/nd t,at si$nificantly $reater fluoride deposition occurred 3hen the patients
3ere not permitted to rinse, eat, or drin* follo3in$ the fluoride treatment,
4,ic,e"er +l/oride system is /sed +or toical +l/oride alications, t,e teet, s,o/ld
-e e0osed to t,e +l/oride +or B minutes +or ma0imal cariostatic -ene+its. 5,is
treatment time ,as consistently -een recommended +or -ot, sodi/m +l/oride and A)F.
Some con+/sion ,as arisen, ,owe"er, wit, re*ard to stanno/s +l/oride, -eca/se s,orter
alication eriods o+ :' to =$ seconds wit, stanno/s +l/oride ,a"e -een reorted to
res/lt in si*ni+icant cariostatic -ene+its. Ne"ert,eless, t,e collecti"e res/lts o+ t,ese
and s/-se?/ent clinical in"esti*ations indicate t,at ma0im/m caries rotection is
ac,ie"ed only wit, t,e /se o+ t,e lon$er e0os/re eriod. 5,/s, alt,o/*, red/ced
e0os/re eriods o+ =$ to <$ seconds mi*,t -e aroriate as a +l/oride maintenance
or re"enti"e meas/re in atients wit, "ery little caries acti"ity, t,e /se o+ t,e lon*er,
&-min/te alication s,o/ld -e re5uired +or atients wit, e0istin* or otential caries
acti"ity.
Alication )roced/reFl/oride Gels
A sli*,tly di++erent tec,ni?/e is commonly s/**ested +or ro"idin* treatments wit,
+l/oride *els. Alt,o/*, t,ese rearations may -e alied -y /sin* t,e same -asic
roced/re as descri-ed +or sol/tions, t,e /se o+ plastic trays ,as -een s/**ested as a
more con"enient roced/re. As wit, t,e /se o+ toical +l/oride sol/tions, t,e
treatment may -e receded -y a ro,yla0is i+ indicated -y e0istin* oral conditions.
4it, t,e so-called tray alication tec,ni?/e, t,e armamentari/m consists simly o+ a
suita4le tray and the fluoride $el.
Many di++erent tyes o+ trays are a"aila-leD selection o+ a tray ade?/ate +or t,e
indi"id/al atient is an imortant art o+ t,e tec,ni?/e. Most man/+act/rers o+ trays
o++er si@es to +it atients o+ di++erent a*es. An ade?/ate tray s,o/ld cover all the
patient?s dentitionD it s,o/ld also ,a"e eno/*, det, to reac, -eyond t,e neck o+ t,e
teet, and contact t,e al"eolar m/cosa to re"ent sali"a +rom dil/tin* t,e +l/oride *el.
Some o+ t,e trays /sed in t,e ast did not meet t,ese re?/irements. Some were made
o+ "inyl and +re?/ently eit,er did not reac, t,e m/cosa or imin*ed on t,e tiss/e, t,/s
+orcin* t,e dentist to c/t t,e +lan*es o+ t,e tray. C/rrently, disosa-le soft styrofoam
trays are a"aila-le and seem to -e ade?/ate. 5,ese trays can -e -ent to insert in t,e
mo/t, and are so+t eno/*, to rod/ce no discom+ort w,en t,ey reac, t,e so+t tiss/es.
4it, t,ese trays, as well as wit, some o+ t,e re"io/s tyes o+ trays, it is ossi-le to
treat 4oth arches simultaneously.
I+ a ro,yla0is is *i"en, t,e atient is ermitted to rinse, and t,e teet, o+ t,e arc, to
-e treated are dried wit, comressed air. A ri--on o+ *el is laced in t,e tro/*,
ortion o+ t,e tray and t,e tray seated o"er t,e entire arc,. 5,e met,od /sed m/st
ens/re t,at t,e *el reac,es all o+ t,e teet, and +lows interro0imally. I+, +or instance, a
so+t lia-le tray is /sed, t,e tray is ressed or molded a*ainst t,e toot, s/r+aces, and
t,e atient may also -e instr/cted to -ite *ently a*ainst t,e tray. Some o+ t,e early
trays contained a son*e-like material t,at Fs?/ee@edF t,e *el a*ainst t,e teet, w,en
t,e atient was asked to -ite li*,tly or sim/late a c,ewin* motion a+ter t,e trays were
inserted. It is recommended t,at t,e trays -e ket in lace +or a B2minute treatment
period +or otimal +l/oride /take, alt,o/*, some systems recommend a :-min/te
alication time. As noted re"io/sly, t,e atient is ad"ised not to eat, drink, or rinse
+or A: min/tes +ollowin* t,e treatment.
'(
Fi*/re ;-% ill/strates t,e tray tec,ni?/e o+
+l/oride *el alication.
Fi*/re ;-: It is ad"isi-le to seat t,e atient in an /ri*,t osition to ,el
minimi@e t,e +low o+ toical sol/tion down t,e c,ildCs t,roat.
Fi*/re ;-> I+ desired, t,e toical alication may -e receded -y a t,oro/*,
ro,yla0is. 5,e smoot, toot, s/r+aces are cleaned wit, a ro,ylactic aste
alied wit, a ro,y c/, A, +ollowin* t,e *ross remo"al o+ ,ea"y e0o*eno/s
deosits 7calc/l/s8 wit, ,and instr/ments. A ro,y -r/s, is similarly /sed on
t,e occl/sal s/r+aces, B, w,ile /nwa0ed dental +loss is /sed to draw t,e aste
interro0imally to clean t,e ro0imal s/r+aces, C.
Fi*/re ;-= A <-inc, and &-inc, roll are laced in a Garmer ,older in s/c, a
manner t,at, A, t,e lin*/al roll e0tends across t,e midline to isolate an area
-eyond t,e central incisors, and B, t,e lon* -/ccal roll is -ent so as to isolate
-ot, t,e /er and lower "esti-/les.
Fi*/re ;-& 5,e cotton-roll ,older is laced in t,e mo/t,, t,ere-y isolatin* -ot,
an /er and lower ?/adrant +rom t,e retromolar to a oint -eyond t,e central
incisors.
Fi*/re ;-' 5,e isolated teet, are, A, dried wit, an air syrin*e in a systematic
manner, B, so as to a"oid missin* any toot, s/r+ace.
Fi*/re ;-< Usin* t,e same alication attern as in Fi*/re ;-'1, +l/oride
sol/tion is alied wit, a cotton alicator, wit, contin/al realications to
maintain all toot, s/r+aces moist wit, t,e sol/tion +or a &-min/te eriod.
Fi*/re ;-% Aroriate si@ed so+t styro+oam trays are /sed to a"oid inc,in* t,e
so+t tiss/es. A ri--on o+ *el is disensed into t,e tro/*, o+ t,e tray. 3no/*, *el
s,o/ld -e /sed to co"er all toot, s/r+aces, -/t care s,o/ld -e /sed to a"oid an
e0cess w,ic, will +low into t,e mo/t,. 730erience will teac, t,e oerator ,ow
m/c, *el to /se.8 5,e atient is s,own t,e loaded mandi-/lar tray, A, w,ic, is
ready +or insertion, B. 5,e ma0illary tray is inserted a+ter t,e mandi-/lar is in
lace. 5,e atient is t,en asked to -ite to*et,er so as to -e more com+orta-le
and, at t,e same time, to +orce t,e *el a*ainst t,e teet,. 5,e /se o+ t,i0otroic
*els +acilitates t,e wettin* o+ all toot, s/r+aces. 5,e trays s,o/ld -e maintained
in lace +or & min/tes.
Question 3
A. Ass/min* t,at less t,an : m o+ +l/oride is in t,e sali"a 7tr/e8, t,e dental la?/e
may ,a"e :$$ times t,is le"el.
1. Stanno/s +l/oride is ?/ite sta-le w,en stored in a?/eo/s ,ase.
C. A t,i0otroic *el looks like a *el, acts like a *el, and is a *el.
D. A+ter a toical alication o+ +l/oride, a atient s,o/ld not eat or drink +or a ,al+-
,o/r.
3. A li?/id toical sol/tion s,o/ld -e maintained on t,e teet, +or t,e same time as a
*el tray treatment9 & min/tes.
Alication Fre?/ency
As re"io/sly mentioned, alt,o/*, a sin*le, toical alication is acceted as not
-ein* a-le to imart ma0imal caries rotection, considera-le con+/sion ,as arisen
re*ardin* t,e re+erred +re?/ency +or administerin* toical +l/oride treatments. M/c,
o+ t,is con+/sion is ca/sed -y t,e a-sence o+ controlled, clinical e"al/ations o+ t,is
"aria-le, artic/larly wit, t,e most commonly /sed a*ent, acid/lated ,os,ate
+l/oride.
5,e ori*inal 2n/tson tec,ni?/e
=%
+or t,e toical alication o+ sodi/m +l/oride
consisted o+ a series o+ +o/r alications ro"ided at aro0imately :-week inter"als
wit, only t,e +irst alication receded -y a ro,yla0is. It was +/rt,er s/**ested t,at
t,is series o+ alications -e administered at a*es =, %, :$, and := years, wit, t,ese
a*es selected, or "aried, in accordance wit, t,e er/tion attern o+ t,e teet,.
';
5,e
o-Aecti"e o+ t,e timin* was to ro"ide rotecti"e -ene+its to Ft,e ermanent teet,
d/rin* t,e eriod o+ c,an*in* dentition.F 1eca/se t,is treatment se?/ence did not
coincide wit, t,e common atient-recall attern in t,e dental o++ice, Gala*an and
2n/tson
<$
e0lored t,e ossi-le /se o+ lon*er inter"als o+ = or < mont,s -etween t,e
indi"id/al alications constit/tin* eac, treatment series. 5,e res/lts o+ t,eir work
indicated t,at alt,o/*, si*ni+icant -ene+its were o-tained wit, sin*le alications
ro"ided at =- or <-mont, inter"als, ma0imal -ene+its were o-tained only wit, a series
o+ treatments. Ne"ert,eless, t,e administration o+ sin*le alications o+ sodi/m
+l/oride at =- to <-mont, inter"als -ecame a common ractice, -eca/se t,ese inter"als
were more con"enient to t,e dentist and ,is or ,er normal recall system.
4,en stanno/s +l/oride and acid/lated ,os,ate +l/oride were s/-se?/ently
de"eloed and e"al/ated, aarently little i+ any attemt was made to determine t,e
otimal treatment +re?/ency. Instead, t,e treatments were administered as sin*le
alications ro"ided at <- or :>-mont, inter"als, w,ic, were con"enient to t,e
normal o++ice sc,ed/les. 1eca/se t,ese treatment inter"als res/lted in si*ni+icant
cariostatic -ene+its, t,e roced/re t,at was /ltimately aro"ed and recommended
in"ol"ed t,is alication +re?/ency.
In "iew o+ t,is -ack*ro/nd, it seems t,at t,e +re?/ency o+ toical alications s,o/ld
-e dictated 4y the conditions and needs presented 4y each patient and not 4y the
convenience of the dental office, 5,is concl/sion is s/orted -y t,e data cited earlier
t,at a series o+ alications is re?/ired to imart ma0imal caries resistance to t,e toot,
s/r+ace.
5,/s, it is recommended t,at new atients, re*ardless o+ a*e, wit, acti"e caries -e
*i"en an initial series o+ +o/r toical +l/oride alications wit,in a eriod o+ > to &
weeks. I+ desired, t,e initial alication may -e receded -y a t,oro/*, ro,yla0is,
t,e remainin* t,ree alications constit/tin* t,e initial treatment series s,o/ld -e
preceded 4y tooth4rushin$ to remo"e la?/e and oral de-ris. It s,o/ld -e o-"io/s t,at
t,is series o+ treatments may -e "ery con"eniently com-ined wit, t,e la?/e control,
dietary co/nselin*, and initial restorati"e ro*rams t,at t,e dentist ,as de"ised +or
t,ese atients. Followin* t,is initial series o+ treatments, t,e atient s,o/ld -e *i"en
sin*le, toical alications at inter"als o+ =, <, or :> mont,s, dependin$ on his or her
caries status, )atients wit, little e"idence o+ e0istin* or anticiated caries s,o/ld -e
*i"en sin*le alications e"ery :> mont,s as a re"enti"e meas/re.
Secial e++ort s,o/ld -e made -y t,e dentist to sc,ed/le toical +l/oride alications
so as to ro"ide t,e treatment to newly er/ted teet, wit,in :> mont,s a+ter er/tion,
and re+era-ly as close to eruption as possi4le. As noted earlier, an aro0imate >-
year enamel mat/ration eriod occ/rs immediately +ollowin* toot, er/tion. As
ill/strated in 5a-le ;-=, t,e re"enti"e -ene+its o+ +l/oride are in"aria-ly m/c, *reater
on ne3ly erupted teeth t,an on re"io/sly er/ted teet,. 5,is +indin* is aarent
re*ardless o+ t,e +l/oride system /sed and is res/ma-ly d/e to t,e *reater reacti"ity,
ermea-ility, and ease o+ +ormation o+ +l/or,ydro0yaatite in enamel still /nder*oin*
calci+ication 7or mat/ration8.
Alt,o/*, it is imortant to e0ose newly er/ted teet, to toical +l/oride, it may -e
more aroriate to /tili@e a +l/oride "arnis, +or newly er/ted rimary teet,.
C,ildren at t,is yo/n* a*e may swallow too m/c, o+ a toical +l/oride *el and may
,a"e recooerati"e -e,a"ior makin* it di++ic/lt to /se tyical toical +l/oride *els or
+oams.
3++icacy o+ 5oical Fl/oride 5,eray
4ell o"er :$$ ,/man clinical st/dies demonstrate t,at toical +l/oride t,eray
contri-/tes si*ni+icantly to t,e artial control o+ dental caries. Un+ort/nately, t,e
ractitioner is +re?/ently concerned, and sometimes con+/sed, a-o/t w,ic, roced/re
or a*ent s,o/ld -e emloyed in a *i"en sit/ation to ro"ide a ma0imal de*ree o+
dental caries rotection +or t,e atient. S/c, concern and con+/sion is /nderstanda-le
w,en it is reali@ed t,at dental caries in"esti*ators t,emsel"es +re?/ently do not a*ree
on t,ese matters.
5,e res/lts o+ t,e n/mero/s clinical in"esti*ations wit, "ario/s toical +l/oride a*ents
and treatment roced/res ,a"e -een t,e s/-Aect o+ se"eral re"iews.
<&-%<
5,ere+ore no
attemt is made to reeat t,ese re"iews ,ere.
As noted earlier, t,ree di++erent tyes o+ +l/oride systems 7i.e., NaF, SnF
>
, and A)F8
,a"e -een e"al/ated and aro"ed as sa+e and e++ecti"e +or toical +l/oride
alications 4y 4oth the merican Dental ssociation (D)
%%
and the 'ood and
Dru$ dministration ('D),
%(
5o determine w,ic, o+ t,ese systems may -e t,e most
e++ecti"e, it wo/ld -e desira-le to comare t,e res/lts o+ indeendent clinical st/dies
in w,ic, all t,ree systems ,a"e -een tested w,en /sed in t,e recommended manner.
Un+ort/nately, s/c, data are not a"aila-le, and alternati"e roced/res m/st -e so/*,t.
Di++erent aroac,es ,a"e -een taken to estimate t,e ma*nit/de o+ t,e cariostatic
-ene+its t,at may -e e0ected +rom toical alications o+ t,e di++erent aro"ed
+l/oride systems. One aroac, is simly to list all o+ t,e ertinent clinical trials and
t,en determine t,e arit,metic mean o+ t,e reorted caries red/ction. 5,is aroac,
,as -een /tili@ed -y se"eral in"esti*ators,
<;-%:
and t,e res/lts o-ser"ed +or c,ildren
residin* in a non+l/oridated comm/nity are s/mmari@ed in 5a-le ;-&. Anot,er
aroac, is to /tili@e an emirically -ased roced/re wit, e0istin* clinical data to
redict t,e e++icacy o+ di++erent systemsD
%;
t,ese data are also s,own in 5a-le ;-&.
4,ate"er t,e aroac,, study desi$ns varied in a num4er of 3ays, s/c, as t,e n/m-er
and +re?/ency o+ toical alications and t,e st/dy d/ration. 5,ese "ariations ser"e to
con+o/nd estimates o+ cariostatic e++icacy. Ne"ert,eless, it is aarent +rom 5a-le ;-&
t,at all t,ree tyes o+ toical +l/oride systems res/lt in apprecia4le cariostatic
4enefits o+ comara-le ma*nit/de wit, ercenta*e red/ctions ran*in* +rom >% to
=<E. F/rt,ermore, t,e data s/**est t,at +l/oride alied in *el +orm may -e sli*,tly
less e++ecti"e t,an sol/tions.
Considera-ly less in+ormation is a"aila-le to doc/ment t,e e++icacy o+ toical +l/oride
alications in ad/lts. A total o+ :& clinical trials were cond/cted in ad/lts d/rin* t,e
eriod :;&& t,ro/*, :;%&, -/t t,e st/dies /tili@ed a wide "ariety o+ e0erimental
conditions, incl/din* t,e tye o+ toical +l/oride system, +re?/ency o+ alications,
and d/ration o+ t,e test eriod.
($-;=
Alt,o/*, most o+ t,e met,ods res/lted in a
si*ni+icant cariostatic -ene+it, t,e ma*nit/de o+ t,is e++ect "aried considera-ly, as
mi*,t -e e0ected. F/rt,ermore, none o+ t,ese st/dies /sed t,e alication +re?/ency
s/**ested earlier +or c,ildren.
It is *enerally reco*ni@ed -y dental scientists, ,owe"er, t,at t,e dental caries rocess
is +/ndamentally t,e same in 4oth children and adults, alt,o/*, t,e rate o+
ro*ression in yo/n* and middle-a*ed ad/lts is +re?/ently m/c, slower -eca/se o+ a
"ariety o+ +actors, incl/din* more e++icient oral ,y*iene and +ewer -etween-meal
snacks. Con"ersely, in older ad/lts t,e rate o+ ro*ression may increase -eca/se o+
medications t,at reduce salivary flo3, It is commonly ass/med, t,ere+ore, t,at toical
+l/oride alications are e++ecti"e +or coronal caries re"ention re$ardless of the a$e
of the patient, !oot caries will -e disc/ssed later. Once a*ain t,e +re?/ency o+
alication s,o/ld -e dictated -y t,e needs o+ t,e atientD in t,e resence o+ +rank or
inciient caries acti"ity, an initial series o+ alications s,o/ld -e *i"en +ollowed -y
maintenance applications at =, <, or :> mont,s, deendin* on atient needs 7i.e.,
e"idence and e0tent o+ caries acti"ity8. Similarly, t,e c,oice o+ t,e +l/oride system
7NaF, A)F, SnF
>
8 may -e at t,e discretion o+ t,e dentist -eca/se t,ere aears to -e
little, i+ any, di++erence in t,eir e++icacy.
On occasion it ,as -een s/**ested t,at resent toical +l/oride treatment systems
in"ol"e t,e /se o+ e0cessi"e concentrations o+ +l/oride. For e0amle, some ,a"e
s/**ested t,at t,e /se o+ $.&E rat,er t,an (E stanno/s +l/oride is ade?/ate to o-tain
ma0imal -ene+its +rom toical alications o+ t,is como/nd. 5,e -asis +or s/c,
s/**estions in"aria-ly rests wit, t,e res/lts o+ in vitro st/dies, ?/ite commonly
enamel-sol/-ility st/dies, in w,ic, ma0imal e++ects are ac,ie"ed wit, lesser
concentrations o+ +l/oride. Un+ort/nately, in vitro data do not necessarily redict
clinical e++ects, and t,e res/lts o+ a clinical in"esti*ation
;&
clearly contradict t,ese
s/**estions. As s,own in 5a-le ;-', t,e /se o+ lower concentrations o+ stanno/s
+l/oride res/lted in smaller caries-re"enti"e -ene+its in c,ildren. 5,/s, /ntil
considera-ly more clinical data to t,e contrary -ecome a"aila-le, t,ere is no
le*itimate -asis +or /sin* concentrations o+ +l/oride +or toical alications other
than those that have 4een ade5uately evaluated clinically and aro"ed -y re"iew
*ro/s.
5,e relati"e s/eriority o+ acid/lated ,os,ate +l/oride *el or sol/tion systems is a
+re?/ent toic +or researc,. Fi"e clinical trials directly in"esti*ated t,is ?/estion, and
t,e res/lts are s/mmari@ed in 5a-le ;-<. Fo/r o+ t,ese st/dies
<=,;'-;%
in"ol"ed sin*le
ann/al alicationsD anot,er one
&&
in"ol"ed semiann/al treatments. 5,ese data s/**est
t,at t,e two +orms are ?/ite comara-le, artic/larly w,en alied semiann/ally. In
ractice t,e *els are *reatly re+erred d/e to t,eir ease o+ alication and red/ced
c,air time w,en trays are /sed.
Question 4
A. 5,e semiann/al alication o+ +l/oride to t,e teet, ,as ro"ed to -e t,e most
e++ecti"e time inter"al to red/ce caries incidence.
1. 5,ere are no doc/mented st/dies in w,ic, sodi/m +l/oride, stanno/s +l/oride, and
acid/lated ,os,ate +l/oride ,a"e -een tested in t,e same st/dy.
C. Stanno/s +l/oride is -etter t,an acid/lated +l/oride and sodi/m +l/oride in
non+l/oridated areas.
D. 1ot, stanno/s +l/oride and acid/lated +l/oride are e++ecti"e on c,ildren, -/t neit,er
is e++ecti"e on ad/lts.
3. A li?/id toical o+ a $.&E sol/tion o+ stanno/s +l/oride is as e++ecti"e as an (E
sol/tion.
!oot S/r+ace Caries
As noted elsew,ere, t,e increased retention o+ t,e teet, d/rin* ad/lt,ood -eca/se o+
"ario/s caries-re"enti"e meas/res and t,e increase in li+e e0ectancy in many
co/ntries ,as res/lted in an increased re"alence o+ root s/r+ace caries in ad/lts.
Accordin* to t,e :;(' to :;(< United States )/-lic Healt, Ser"ice 7US)HS8 s/r"ey
o+ ad/lts,
;(
a-o/t one-,al+ o+ U.S. ad/lts are a++licted wit, root s/r+ace caries -y a*e
'$, wit, an a"era*e re"alence o+ a-o/t t,ree lesions -y a*e %$. Interestin*ly, a st/dy
cond/cted at t,e Uni"ersity o+ Iowa
;;
,as indicated t,at ad/lts o"er a*e <' can e0ect
an incidence o+ a-o/t $.; newly decayed, missin*, or +illed 7DMF8 coronal s/r+aces
er year as well as a-o/t $.< new DMF root s/r+aces er year. 5,/s, t,is +orm o+
caries ,as recei"ed increased attention o+ dental scientists d/rin* t,e ast decade, wit,
in"esti*ations co"erin* -ot, its cause and measures for prevention.
j/ite clearly, +l/oride is "ery e++ecti"e +or t,e re"ention o+ root s/r+ace caries as
e"idenced -y a limited n/m-er o+ clinical trials and n/mero/s in vitro as well as in
situ st/dies. For e0amle, t,e res/lts o+ se"eral eidemiolo*ic st/dies ,a"e
demonstrated t,at t,e resence o+ fluoridated drin*in$ 3ater t,ro/*,o/t t,e li+etime
o+ an indi"id/al re"ents t,e de"eloment o+ root s/r+ace caries.
:$$-:$=
5,e ma*nit/de
o+ t,is e++ect is consistently $reater than >:;. F/rt,ermore, it ,as -een o-ser"ed
:$&

t,at t,e /se o+ a NaF denti+rice res/lts in a si*ni+icant decrease in root s/r+ace caries
o+ more than 9>;.
M/c, less in+ormation is a"aila-le, ,owe"er, to doc/ment t,e e++ect o+ toical
+l/oride alications on t,e re"ention o+ root caries and artic/larly t,e relati"e
e++icacy o+ di++erent +l/oride systems. Ny"ad and FeAersko"
:$'
reorted t,e arrestment
o+ root s/r+ace caries +ollowin* t,e toical alication o+ >E NaF and t,e daily /se o+
a +l/oride denti+rice. 4allace and coworkers
:$<
reorted a D:E red/ction in t,e
incidence o+ root s/r+ace caries +ollowin* semiann/al alications o+ an A)F *el
d/rin* a &-year st/dy eriod. 5o o-tain some ersecti"e on t,e otential e++icacy o+
di++erent toical +l/oride systems
:$%,:$(
we ,a"e /tili@ed an esta-lis,ed animal root
caries model. 5,e res/lts o+ t,is in"esti*ation are s/mmari@ed in 5a-le ;-%. From
t,ese data it is aarent t,at all t,ree aro"ed toical +l/oride systems decreased t,e
+ormation o+ root caries -y 9A to D9E in t,is reclinical model. In t,e a-sence o+ t,e
res/lts o+ similar clinical data and wit, t,e reco*nition t,at t,e alication o+ (E SnF
>
imarts a -rown i*mentation to e0osed dentin, it seems aroriate to recommend
t,e toical /se o+ <; &a' +or t,e re"ention o+ root caries.
RecommendationsTopical Fluoride Treatments
On t,e -asis o+ t,e +ore*oin* disc/ssion, it is aarent t,at alt,o/*, eriodic toical
alications o+ any o+ t,e t,ree aro"ed a*ents ro"ide rotection a*ainst dental
caries, ma0imal atient -ene+its may -e e0ected only t,ro/*, t,e /se o+ selected
roced/res. 5,ese recommended roced/res incl/de t,e +ollowin*9
Accetin* t,e relati"e ine++iciency o+ sin*le, toical alications o+ +l/oride
sol/tions, atients wit, e0istin* e"idence o+ caries acti"ity, w,ate"er t,eir a*e, s,o/ld
-e *i"en an initial series of topical fluoride treatments follo3ed 4y 5uarterly,
semiannual, or annual treatments as re?/ired to maintain cariostasis. 5,e initial series
o+ treatments s,o/ld consist o+ +o/r alications administered d/rin* a >- to &-week
eriod, wit, t,e +irst treatment receded -y a t,oro/*, ro,yla0is i+ indicated.
4,ate"er +l/oride system is selected, t,e alication eriod 7i.e., t,e time t,e teet,
are ket in contact wit, t,e +l/oride system8 s,o/ld -e & min/tes in all atients wit,
e0istin* caries acti"ity. S,orter treatment eriods may -e ermissi-le in t,e
er+ormance o+ treatments to maintain cariostasis.
Fl/oride 6arnis,es
Fl/oride-containin* "arnis,es ,a"e more recently -ecome a"aila-le in t,e United
States and are -ein* recommended +or ro"idin* toical +l/oride treatments,
artic/larly +or "ery yo/n* c,ildren. Most "arnis,es contain >,:; sodium fluoride
7>.><E +l/oride8 and a tyical alication re?/ires only $.= to $.' m. o+ t,e "arnis,,
w,ic, contains = to < m* o+ +l/oride. 5,e alication roced/re in"ol"es cleanin* t,e
toot, s/r+aces -y toot,-r/s,in*, aintin* t,e "arnis, on t,e teet,, and dryin*. 5,e
varnish is retained for <B to BF hours d/rin* w,ic, time +l/oride is released +or
reaction wit, t,e /nderlyin* enamel. It is recommended t,at t,e alications -e
reeated at &- to <-mont, inter"als.
5,e e++icacy o+ +l/oride "arnis,es +or caries re"ention ,as -een reeatedly
demonstrated in 3/roe, w,ere t,ey ,a"e -een in common /se +or many years, and
t,e res/lts o+ t,ese st/dies ,a"e -een s/mmari@ed in recent re"iews.
%<,:$;,::$
5,ese
st/dies ,a"e consistently demonstrated a si*ni+icant red/ction in t,e incidence o+
dental caries and also ,a"e indicated t,at t,e ma*nit/de o+ t,e -ene+it is related to t,e
+re?/ency o+ alication, artic/larly in c,ildren at ,i*, risk +or caries. )romisin*
researc, ,as -een cond/cted in t,e United States, seci+ically aimed at /sin* +l/oride
"arnis,es as a re"enti"e a*ent +or c,ildren at hi$h ris* for early childhood caries.
:::
.ittle in+ormation is a"aila-le to comare t,e e++ecti"eness o+ +l/oride "arnis,es wit,
ro+essionally alied toical +l/oride sol/tions or *els. 5,e res/lts o+ a clinical
st/dy
::>
cond/cted in c,ildren in India comarin* t,e e++icacy o+ a +l/oride "arnis,
wit, toical alications o+ an A)F *el indicated t,at w,ile -ot, treatments res/lted
in a si*ni+icant red/ction in caries, t,e fluoride varnish 3as more effective, Sea and
coworkers
::=
recently reorted t,e res/lts o+ a clinical trial comarin* semiann/al
alications o+ t,e sodi/m +l/oride "arnis, wit, similar alications o+ an A)F *el in
:>- and :=-year-old c,ildren wit, ,i*, ast caries e0erience, and o-ser"ed no
si*ni+icant di++erences -etween t,e two treatment re*imens. In t,e a-sence o+
additional clinical data it aears t,at t,ese t3o treatment procedures are at least
e5uivalent,
Initiation o+ 5,eray
)ractitioners +re?/ently wonder w,en t,ey s,o/ld recommend and initiate a toical
+l/oride alication ro*ram. All too +re?/ently t,e tendency is to de+er s/c,
treatments /ntil t,e c,ild is ( to :$ years o+ a*e and a maAority o+ t,e ermanent
dentition ,as already er/ted.
As disc/ssed earlier, it is well esta-lis,ed t,at t,e enamel s/r+ace o+ a newly er/ted
toot, is not comletely calci+ied and t,ere+ore t,at t,e eriod w,en t,e toot, is most
s/sceti-le to cario/s attack is t,e +irst +ew mont,s a+ter er/tion. F/rt,ermore, it ,as
-een s,own t,at toical +l/oride treatments are e++ecti"e +or -ot, t,e decid/o/s and
ermanent dentitions. 5,/s, it +ollows t,at toical +l/oride t,eray s,o/ld -e initiated
3hen the child reaches a4out < years of a$e, w,en most o+ t,e decid/o/s dentition
s,o/ld ,a"e er/ted. 5,e treatment re*imen s,o/ld -e maintained at least on a
semiann/al -asis t,ro/*,o/t t,e eriod o+ increased caries s/sceti-ility, w,ic,
persists for a4out < years after eruption o+ t,e ermanent second molars 7i.e., /ntil t,e
c,ild is a-o/t :' years o+ a*e8.
It s,o/ld -e added t,at t,e s/sceti-ility o+ t,e dentition to dental caries does not end
at a$e C>. It is ro-a-le, ,owe"er, t,at t,e *rad/al decrease in caries suscepti4ility
3ith increasin$ a$e will ermit a less +re?/ent toical alication ro*ram to
maintain cariostasis in many atients, and ann/al +l/oride treatments may s/++ice.
)ro-lems and Disad"anta*es
Some clinical sit/ations may alter t,e selection o+ t,e treatment a*ent. For e0amle,
t,e /se o+ stanno/s +l/oride may -e contraindicated +or aest,etic reasons in seci+ic
instances. 5,e reaction o+ tin ions wit, enamel, artic/larly cario/s enamel, res/lts in
t,e +ormation o+ tin phosphates, some o+ w,ic, are -rown in color. 5,/s, t,e /se o+
t,is a*ent rod/ces a temorary -rownis, i*mentation o+ cario/s toot, str/ct/re.
5,is stain may e0a**erate e0istin* aest,etic ro-lems w,en t,e atient ,as cario/s
lesions in t,e anterior teet, t,at will not -e restored. Stanno/s +l/oride, ,owe"er, ,as
not -een +o/nd to discolor comosite restorati"e materials.
Anot,er ro-lem +re?/ently raised, artic/larly -y edodontists, concerns t,e stron*,
/nleasant, metallic taste o+ stanno/s +l/oride. Alt,o/*, e0erienced ractitioners can
,andle t,is ro-lem, t,ere is no ?/estion t,at +la"ored, A)F rearations are m/c,
4etter accepted 4y children, 30erimental, +la"ored, stanno/s +l/oride rearations
t,at diminis,, -/t -y no means eliminate, t,e taste ro-lem ,a"e -een e"al/ated
clinically -/t are not yet commercially a"aila-le.
=<
Until t,e taste ro-lem o+ stanno/s
+l/oride is sol"ed, most edodontists a*ree t,at t,e a$ent of choice +or c,ildren is
A)F.
Acid/lated ,os,ate +l/oride systems ,a"e t,e disad"anta*e o+ ossi-ly etc,in*
ceramic or orcelain s/r+aces. As a res/lt, orcelain "eneer +acin*s and similar
restorations s,o/ld -e protected 3ith cocoa 4utter, vaseline, or isolation rior to
alyin* A)F. Alternati"ely, sodi/m +l/oride may -e /sed instead o+ A)F.
4it,o/t do/-t, t,e tendency in many dental o++ices is to /se a seci+ic toical +l/oride
system and treatment re*imen +or e"ery atient. It s,o/ld -e em,asi@ed, ,owe"er,
t,at t,e seci+ic needs o+ t,e atient s,o/ld -e ascertained initially and a seci+ic
treatment ro*ram de"eloed to +/l+ill t,ose needs. For e0amle, t,e /se o+ a series o+
+o/r or more toical +l/oride alications wit,in a &-week eriod +ollowed -y
reeated sin*le alications at =- to <-mont, inter"als s,o/ld -e considered +or a
atient wit, a se"ere caries ro-lem. .ikewise, a red/ced toical alication time o+
=$ seconds as oosed to & min/tes may -e ade?/ate to maintain a atient wit, little
or no c/rrent caries acti"ity. In ot,er words, t,e ractitioner s,o/ld -e +amiliar wit,
t,e indications and contraindications +or /sin* "ario/s aroac,es and select t,e
treatment system and conditions t,at -est meet t,e needs o+ t,e atient.
Fl/oride-Containin* )ro,ylactic )astes
Fl/oride-containin* ro,ylactic astes ,a"e -een a"aila-le and widely /sed in dental
o++ices +or more t,an &$ years to clean and olis, accessi-le toot, s/r+aces and
restorations. 1eca/se t,ese astes contain a-rasi"es, w,ic, are ,arder t,an enamel, in
order to clean and olis, e++iciently, ine"ita-ly a small amount of the enamel surface
3ill 4e removed 4y a4rasion durin$ the prophylaxis. 5,e act/al amo/nt o+ enamel
remo"ed d/rin* a ro,yla0is is "ery small and ,as -een s,own
::&,::'
to in"ol"e t,e
loss o+ s/r+ace enamel to a det, o+ a-o/t $.: to :.$ microns d/rin* a :$-second
olis,in*. Since it ,as -een noted t,at t,e *reatest concentrations o+ +l/oride in
enamel occ/r in t,e o/termost s/r+ace layers, it +ollows t,at t,e loss o+ e"en t,is small
amo/nt o+ s/r+ace enamel d/rin* a ro,yla0is res/lts in t,e e0os/re o+ an enamel
s/r+ace ,a"in* a lo3er concentration o+ +l/oride t,an was resent rior to t,e
ro,yla0is.
::<,::%
4,en +l/oride-containin* ro,ylactic astes +irst -ecame a"aila-le in t,e :;'$s it
was t,o/*,t t,at t,e /se o+ t,e rearations to er+orm a ro/tine dental ro,yla0is
wo/ld res/lt in a si*ni+icant red/ction in t,e s/-se?/ent de"eloment o+ dental caries
and a n/m-er o+ clinical trials were cond/cted to determine t,e ma*nit/de o+ t,is
-ene+it. 5,e res/lts o+ t,ese in"esti*ations, considered collecti"ely, indicated t,at t,e
/se o+ t,ese astes res/lted in a "ery modest increase in t,e resistance o+ t,e toot,
s/r+aces to t,e de"eloment o+ dental caries, -/t t,e ma*nit/de o+ t,is e++ect was not
statistically si*ni+icant. As a res/lt, +l/oride-containin* ro,ylactic astes ,a"e
never 4een accepted as t,erae/tic a*ents -y re"iew a*encies s/c, as t,e ADA or t,e
FDA. Howe"er, t,ey are commonly recommended +or /se d/rin* a ro,yla0is in
order to at least relace t,e +l/oride lost +rom t,e enamel s/r+ace -y a-rasion d/rin*
t,e roced/re. S,o/ld t,e clinician /se +l/oride-containin* ,o,yla0is astese In
s/mmary, t,e +ollowin* recommendations are roosed9
4,en a simle ro,yla0is is administered, w,ic, will not -e +ollowed -y a toical
+l/oride alication, +l/oride-containin* ro,ylactic astes s,o/ld -e /sed to
relenis, t,e +l/oride lost d/rin* t,e roced/re.
4,en a toical +l/oride alication is *i"en to a caries-s/sceti-le atient and a
ro,yla0is is deemed to -e necessary, it is ad"isa-le to administer t,e recedin*
ro,yla0is wit, a +l/oride-containin* aste. Alt,o/*, no de+initi"e roo+ o+ t,e
additi"e -ene+its o+ -ot, roced/res e0ists as yet, an increased -ene+it ,as -een s,own
in some st/dies. 3"en w,en do/-t e0ists, it is re+era-le to *i"e t,e atient t,e
ossi-le -ene+it o+ any increased rotection.
Question 5
A. 5,e +irst acti"e ro*rams +or toical +l/oride t,eray s,o/ld -e initiated +ollowin*
t,e er/tion o+ t,e +irst ermanent molar.
1. A+ter a*e :', t,e need +or toical alications o+ +l/oride ceases.
C. A ro,yla0is increases t,e e++ecti"eness o+ t,e toical alication o+ +l/orides.
D. From $.: to :.$ mm o+ enamel is remo"ed d/rin* a ro,yla0is.
3. 5,e /se o+ a +l/oride-containin* ro,ylactic aste res/lts in a si*ni+icant
red/ction in caries +ormation.
Denti+rices
5,ro/*, t,e years denti+rices ,a"e -een de+ined as rearations intended +or /se wit,
a toot,-r/s, to clean t,e accessi-le toot, s/r+aces. 5,ey ,a"e -een reared in a
"ariety o+ +orms, incl/din* astes, owders, and li?/ids. 5,e ,istory o+ denti+rices
dates -ack se"eral cent/ries. 5,e earliest writin*s concernin* meas/res to ac,ie"e
oral cleanliness re+er to t,e /se o+ toot,icks, c,ewsticks, and son*esD s/**ested
denti+rice in*redients were dried animal arts, ,er-s, ,oney, and minerals.
Materials act/ally detrimental to oral ,ealt, were /sed +or many yearsD t,ese materials
incl/ded e0cessi"ely a-rasi"e materials, lead ores, and s/l+/ric and acetic acids. 4it,
t,e areciation +or t,e need o+ sa+e and e++icient denti+rices came t,e researc, and
de"eloment t,at ,a"e led to t,e denti+rices a"aila-le today and t,e de"eloment o+ a
maAor ind/stry. In t,e United States alone, denti+rice sales aroac,ed KC,> 4illion
durin$ C;;', and maAor man/+act/rers ,a"e in"ested millions o+ dollars, artic/larly
d/rin* t,e ast t,ree decades, to imro"e t,ese rod/cts +/rt,er and to e0and t,eir
caacities to romote oral ,ealt,. 4it,o/t ?/estion t,e dental ro+ession and t,e
scienti+ic comm/nity, as well as t,e *eneral o/lation, ,a"e ro+ited immeas/ra-ly,
-ot, directly and indirectly, +rom t,e e++orts o+ t,e denti+rice ind/stry.
As a res/lt, t,e +/nctions o+ resent-day denti+rices ,a"e -een considera-ly e0anded
to incl/de t,e +ollowin*9 7:8 cleanin* accessi-le toot, s/r+aces, 7>8 olis,in*
accessi-le toot, s/r+aces, 7=8 decreasin* t,e incidence o+ dental caries, 7&8 romotin*
*in*i"al ,ealt,, and 7'8 ro"idin* a sensation o+ oral cleanliness, incl/din* t,e control
o+ mo/t, odors. 5,ese +/nctions s,o/ld -e accomlis,ed in a sa+e manner wit,o/t
/nd/e a-rasion to t,e oral ,ard tiss/e, artic/larly dentin, and wit,o/t irritation to t,e
oral so+t tiss/es.
5,is c,ater makes no attemt to re"iew t,e comonents and +/nctions o+ denti+rices.
For in+ormation on t,ese toics, as well as a re"iew o+ t,e early attemts to de"elo
t,erae/tic denti+rices /sin* a*ents ot,er t,an +l/oride, t,e reader is re+erred to
se"eral e0cellent re"iews
::(-:>=
7see also C,ater <8.
'luoride Dentifrices
At resent +l/oride is -y +ar t,e most effective dentifrice additi"e +or caries re"ention.
5,e initial st/dies wit, +l/oride-containin* denti+rices were only modestly
enco/ra*in*. 5,e res/lts o+ two clinical trials indicated a si*ni+icant -ene+icial e++ect
wit, +orm/lations containin* +l/oraatites and rock ,os,ates. Howe"er, st/dies
/sin* rod/cts containin* sodi/m +l/oride at concentrations o+ $.$: to $.:' ercent
+ailed to indicate any -ene+icial e++ect.
::(
In retrosect, t,ese and later +ail/res were
ro-a-ly lar*ely ca/sed -y t,e /se o+ an incompati4le a4rasive system 7i.e., calci/m
car-onate8 in t,e +orm/lations. In t,e &$-year eriod since t,e initial clinical trials
wit, +l/oride-containin* denti+rices, t,e res/lts o+ more t,an :&$ controlled clinical
st/dies ,a"e -een /-lis,ed. For a re"iew o+ many o+ t,ese st/dies, t,e reader is
re+erred to a recent reort.
:>=
In :;'&, t,e +irst reort was /-lis,ed concernin* t,e /se o+ a denti+rice containin*
stanno/s +l/oride 7$.&E8D t,is st/dy indicated a si*ni+icant -ene+icial e++ect
attri-/ta-le to t,is a*ent.
:>&
Since t,en t,e res/lts o+ more t,an <$ clinical
in"esti*ations wit, stanno/s +l/oride-containin* denti+rices ,a"e -een reortedD t,e
"ast maAority o+ t,is work ,as -een er+ormed wit, +orm/lations containin* calcium
pyrophosphate as t,e a-rasi"e a*ent, alt,o/*, insol/-le sodi/m meta,os,ate and
,ydrated silica ,a"e also -een /sed.
4it,o/t do/-t, t,e most e0tensi"e doc/mentation o+ t,e cariostatic -ene+its o+
+l/oride denti+rices was *enerated wit, t,e ori*inal stanno/s +l/oride-calci/m
yro,os,ate +orm/lation 7i.e., Crest8 wit, s/orti"e in+ormation /sin* t,is +l/oride
como/nd wit, ot,er a-rasi"e systems. 5,e res/lts o+ t,ese in"esti*ations not only
indicated t,at t,e normal ,ome /se o+ t,e stanno/s +l/oride denti+rice res/lted in a
si*ni+icant decrease in t,e incidence o+ dental caries in c,ildren -/t t,at similar
4enefits 3ere derived 4y adults. F/rt,ermore, t,ese e++ects were +o/nd to -e additi"e
to t,ose ro"ided -y comm/nal +l/oridation and -y toical +l/oride treatments. As a
res/lt o+ t,ese +indin*s, t,e Co/ncil on Dental 5,erae/tics o+ t,e ADA +irst awarded
comlete accetance to a +l/oride denti+rice, seci+ically t,e stanno/s +l/oride-
calci/m yro,os,ate +orm/lation (Crest), in :;<&.
)rimarily -eca/se o+ t,e identi+ication o+ a +ormal mec,anism -y t,e ADA to
reco*ni@e denti+rices on t,e -asis o+ clinical doc/mentation o+ a cariostatic acti"ity,
m/c, e++ort was de"oted -y denti+rice man/+act/rers to t,e de"eloment and
doc/mentation o+ e++ecti"e +orm/lations d/rin* t,e ast +o/r decades. A n/m-er o+
e++ecti"e rod/cts s/-se?/ently -ecame a"aila-le.
D/rin* t,e :;<$s, a n/m-er o+ reorts o+ clinical trials indicated t,at t,e /se o+
sodium monofluorophosphate 7MF)8, Na
>
)O
=
F, in a denti+rice likewise contri-/ted
si*ni+icantly to t,e control o+ dental caries. 5,e +irst rod/ct, Col$ate %'P, /sed
insol/-le sodi/m meta,os,ate as t,e a-rasi"e system, and t,is +orm/lation was
s,own to red/ce t,e incidence o+ caries in c,ildren -y as m/c, as =&E. On t,e -asis
o+ t,ese st/dies, t,is denti+rice was approved as safe and effective 4y the 'D in CH9D
and accepted 4y the D in CH9H.
An interestin* and /ni?/e c,aracteristic o+ MF) is its comati-ility wit, a 3ide
variety of dentifrice a4rasive systems. In contrast to ot,er +l/oride como/nds, s/c,
as sodi/m +l/oride and stanno/s +l/oride, w,ic, are almost comletely dissociated in
a?/eo/s sol/tion to yield +l/oride ions t,at readily react wit, a"aila-le cations, t,e
+l/oride in MF) remains lar*ely comle0ed as )O
=
F
'
in sol/tion. 5,is +l/oride
comle0 is comati-le wit, a wide "ariety o+ a-rasi"e systems and t,ere+ore may -e
readily incororated into a "ariety o+ di++erent denti+rice +orm/lations w,ile
contin/in* to ro"ide cariostatic acti"ity.
Additional st/dies wit, denti+rices containin* sodi/m +l/oride ,a"e indicated t,at t,is
a*ent also e++ecti"ely contri-/tes to t,e control o+ dental caries in c,ildren. 5,e +irst
o+ t,e sodi/m +l/oride denti+rices to -e s/-stantiated in t,is re*ard incl/ded sodi/m
meta,os,ate as t,e a-rasi"e a*ent. On t,e -asis o+ t,ree +a"ora-le clinical trials,
t,is rod/ct 7D/renamel8 was *i"en provisional acceptance -y t,e ADA Co/ncil on
Dental 5,erae/ticsD ,owe"er, t,is rod/ct is no lon$er availa4le. Anot,er sodi/m
+l/oride denti+rice ,as -een t,e s/-Aect o+ se"eral clinical trials. 5,is +orm/lation
7Gleem8 contains calci/m yro,os,ate as t,e a-rasi"e a*ent and ,as -een +o/nd to
e0ert a si*ni+icant -ene+icial e++ect on t,e incidence o+ dental caries in c,ildren in
-ot, low-+l/oride and otimal +l/oride areas.
In :;(:, t,e +orm/lation o+ Crest was c,an*ed -y relacin* stanno/s +l/oride wit,
sodi/m +l/oride and /sin* ,ydrated silica in lace o+ calci/m yro,os,ate as t,e
a-rasi"e system. Interestin*ly, t,ese c,an*es and t,e res/ltant increase in t,e amo/nt
o+ a"aila-le and -iolo*ically acti"e +l/oride in t,e rod/ct res/lted in t,e re"ised
+orm/lation -ein* si*ni+icantly more e++ecti"e t,an t,e +orm/lation ori*inally
aro"ed.
:>',:><
Since t,at time, many additional rod/cts containin* sodi/m +l/oride
,a"e -een aro"ed -y t,e ADA. One reason +or t,e increased /se o+ sodi/m +l/oride
is t,at it is t,e re+erred a*ent +or /se in tartar2 control formulations containin$
solu4le pyrophosphates. F/rt,ermore, as noted later in t,is section, t,ere is e"idence
t,at sodi/m +l/oride +orm/lated in a ,i*,ly comati-le a-rasi"e system may -e a
s/erior anticaries a*ent. In terms o+ +l/oride concentration, most denti+rices c/rrently
marketed in t,e United States contain C,::: ppm fluoride, 3ith t3o exceptions. 5,e
Crest +amily o+ rod/cts contain a ,ydrated silica a-rasi"e system w,ic, is less dense
t,an ot,er con"entionally /sed a-rasi"e systems. 1eca/se denti+rice is disensed -y
t,e cons/mer on t,e -asis o+ "ol/me, not wei*,t, t,e concentration o+ +l/oride 3as
increased to C,C:: ppm so t,at t,e dose deli"ered wo/ld -e comara-le to nonsilica-
-ased rod/cts. On t,e ot,er ,and, !xtra Stren$th im, 3hich contains C,>:: ppm
+l/oride +rom sodi/m mono+l/oro,os,ate, ,as an ele"ated +l/oride content in an
attemt to en,ance its anticaries e++icacy. Se"eral controlled clinical trials ,a"e s,own
t,at, in denti+rices emloyin* silica-a-rasi"e systems and sodi/m
mono+l/oro,os,ate as t,e +l/oride so/rce, :,'$$ m o+ +l/oride is statistically
si$nificantly more effective than C,::: ppm, wit, a mar*in o+ s/eriority o+ a-o/t
:'E.
:>%-:>;
5,e otential role o+ +l/oride denti+rices in t,e etiolo*y o+ dental +l/orosis needs to -e
mentioned. Se"eral reorts ,a"e indicated an increasin$ prevalence of fluorosis in t,e
United States.
:=$-:=>
A national s/r"ey o+ U.S. c,ildren cond/cted -etween :;(< and
:;(% indicated t,at a-o/t >>E dislayed some e"idence o+ dental +l/orosisD ,owe"er,
it is imortant to note t,at, in terms o+ se"erity, a ma7ority had either very mild or
mild fluorosis, and only a-o/t C; 3ere classified as moderate or severe.
:==,:=&

Certainly a n/m-er o+ so/rces o+ +l/oride may -e resonsi-le, indi"id/ally or
collecti"ely, +or ca/sin* +l/orosis. In e"al/atin* t,e role +l/oride toot,astes may
lay, ,owe"er, t,e ractitioner s,o/ld consider se"eral imortant +actors. First, +or
+l/orosis to occ/r, e0cessi"e le"els o+ +l/oride m/st -e in*ested durin$ the time of
enamel formation.
:='
For ractical /roses, t,e anterior teeth are o+ most concern
aest,etically, and t,ese are only suscepti4le to 4ecomin$ fluorotic durin$ the first A
years of life
:=<
and particularly durin$ the period of C> to <: months of a$e.
:=%
O+
co/rse, t,e risk o+ toot,aste in*estion is increased in yo/n*er c,ildren, and some
st/dies ,a"e s,own t,at "ery yo/n* c,ildren may in*est eno/*, toot,aste to -e at
risk o+ dental +l/orosis.
:=(
In +act, one st/dy +o/nd t,at c,ildren w,o -r/s, wit, a
+l/oride toot,aste 4efore < years of a$e have an elevenfold $reater ris* of
developin$ fluorosis than children 3ho 4e$in 4rushin$ later.
:=;
5,ese considerations
,a"e romted t,e ADA to recommend t,at children under a$e A should 4e advised
to use only a Jpea2si1edJ 5uantity of a fluoride dentifrice for 4rushin$ and that this
5uantity 4e $radually increased 3ith a$e so that not until a$e 9 is the child usin$ a
Jfull2stripJ of dentifrice on the 4rush head. In makin* recommendations, t,e
ractitioner m/st consider w,at ot,er so/rces o+ +l/oride t,e c,ild may -e in*estin*,
s/c, as +l/oride or +l/oride-"itamin s/lements, +l/oridated comm/nal-water
s/lies, and in+ant +orm/la reared wit, +l/oridated water.
:=;
Not in+re?/ently, t,e ractitioner is asked i+ all +l/oride denti+rices ro"ide t,e same
amo/nt o+ caries-re"enti"e -ene+its. In an attemt to answer t,is ?/estion, a
re"iew
:>=
e0amined t,e res/lts o+ all /-lis,ed st/dies in"ol"in* +l/oride denti+rices.
It was concl/ded on t,e -asis o+ a considera-le -ody o+ in+ormation t,at t,e /se o+
sodium fluoride 3ith hi$hly compati4le a4rasive systems, such as hydrated silica or
acrylic particles, is the most effective dentifrice system for caries prevention at this
time.
S/-se?/ent literat/re re"iews comared all a"aila-le clinical data re*ardin* t,e
relati"e e++icacy o+ comati-le sodi/m +l/oride denti+rices and t,ose containin*
sodi/m mono+l/oro,os,ate.
:&$-:&>
Usin* di++erent statistical roced/res, t,ese
re"iews concl/ded t,at sodi/m +l/oride was si*ni+icantly more e++ecti"e t,an sodi/m
mono+l/oro,os,ate. 1ased on a meta-analysis, #o,nson
:&=
concl/ded t,at t,e
ma*nit/de o+ t,is di++erence was %E. It is interestin* t,at many +l/oride denti+rices
marketed o/tside t,e United States contain mi0t/res o+ sodi/m +l/oride and sodi/m
mono+l/oro,os,ate wit, a total +l/oride content o+ :,'$$ m. Clinical e++icacy
data o+ t,ese latter systems ,a"e also -een re"iewed recently
:&$,:&:
wit, t,e concl/sion
t,at t,ey are n/merically less e++ecti"e t,an an e?/i"alent concentration o+
-ioa"aila-le sodi/m +l/oride.
It is si*ni+icant t,at t,e e0tensi"e researc, wit, +l/oride denti+rices ,as res/lted in t,e
re*/lar /se o+ t,ese rod/cts -y a maAor se*ment o+ o/r o/lation. In terms o+ total
denti+rice sales, nearly H>; consists o+ t,e accepted or approved formulations. For an
/dated listin* o+ +l/oride-containin* denti+rices recei"in* accetance -y t,e ADA,
the reader is referred to the D 3e4site at http6LL333,ada,or$, 5,e widesread
accetance and /se o+ t,ese rod/cts -y t,e *eneral /-lic ,as -een considered one o+
t,e rimary +actors contri-/tin* to t,e aarent decrease in t,e re"alence o+ dental
caries o-ser"ed in t,e United States.
:&&,:&'
In *eneral, it s,o/ld -e aarent +rom t,is -rie+ re"iew t,at t,e /se o+ aro"ed
+l/oride denti+rices res/lts in a si*ni+icant decrease in t,e incidence o+ dental caries.
In "iew o+ t,is, t,e /se o+ s/c, rearations s,o/ld -e ro/tinely recommended.
Question 6
A. 5,e /se o+ +l/oride denti+rices ,a"e yielded e?/i"ocal res/lts as caries control
a*ents w,en /sed as t,e sole met,od o+ +l/oride alication.
1. Fl/oride denti+rices aear to red/ce caries in a ran*e o+ aro0imately >$ to &'E.
C. 5,e sa+ety o+ a new denti+rice containin* new +l/oride como/nds m/st -e
aro"ed -y t,e FDA -e+ore it is acceted -y t,e ADA.
D. In :;(:, Crest c,an*ed t,e +l/oride in its +orm/la +rom sodi/m +l/oride to stanno/s
+l/oride.
3. Desite t,e +act t,at se"eral denti+rices contain +l/oride, aro0imately &$E o+ t,e
o/lation re+ers non+l/oride-containin* -rands.
Multiple Fluoride Therapy
From t,e rior disc/ssions o+ "ario/s meas/res to aly +l/oride to er/ted teet,, it is
aarent t,at no sin*le +l/oride treatment ro"ides total protection a*ainst dental
caries. !eco*nition o+ t,is +act led early in"esti*ators to e"al/ate t,e /se o+
com-inations o+ +l/oride meas/res.
M/ltile +l/oride t,eray is a term t,at ,as -een /sed to descri-e t,ese +l/oride
com-ination ro*rams. As ori*inally de"eloed, t,is ro*ram incl/ded t,e alication
o+ +l/oride in t,e dental o++ice in t,e +orm o+ -ot, a +l/oride-containin* ro,ylactic
aste and a toically alied +l/oride sol/tion and t,e ,ome /se o+ an aro"ed
+l/oride denti+rice. In addition, some +orm o+ systemic +l/oride in*estion, re+era-ly
comm/nal-water +l/oridation, was incl/ded.
5,e only /-lis,ed reorts o+ clinical in"esti*ations t,at attemted to assess t,e total
e++ect o+ t,is tye o+ m/ltile +l/oride t,eray on dental caries in"ol"ed t,e /se o+
stanno/s +l/oride toical systems.
:&<-:':
In eac, o+ t,ese st/dies, t,e toical +l/oride
treatments were administered semiann/allyD t,e res/lts are s/mmari@ed in 5a-le ;-(.
5,e res/lts o+ t,ese in"esti*ations indicate t,at t,e com-ination o+ topical fluoride
applications and home use of a fluoride dentifrice resulted in a4out >H; fe3er
carious lesions.
5,e +act t,at t,e ma*nit/de o+ t,is -ene+it is somew,at less t,an t,at o+ t,e
comonents e"al/ated indi"id/ally indicates t,at t,e caries-rotection e++ects o+ t,e
indi"id/al comonents 7i.e., ro,ylactic aste, toical sol/tion, and denti+rice8 are
only artially additi"e. Ne"ert,eless, it is imortant to note t,at t,e com-ination o+
stanno/s +l/oride treatments not only red/ced t,e incidence o+ caries -y more t,an
'$E in -ot, c,ildren and yo/n* ad/lts -/t did so in -ot, t,e presence and a4sence of
communal fluoridation, I+ one accets a '$E caries red/ction attri-/ta-le to water
+l/oridation and anot,er '$E red/ction o+ t,e remainin* caries +rom t,e /se o+
m/ltile +l/oride treatments, it is aarent t,at t,e /se o+ m/ltile +l/oride t,eray,
incl/din* comm/nal +l/oridation, res/lts in an overall reduction in caries of a4out
D>;.
D/rin* t,e ast +ew years, clinical in"esti*ators ,a"e e0lored com-inations o+
+l/oride treatments /sin* a*ents ot,er t,an stanno/s +l/oride wit, "aria-le s/ccess.
For e0amle, 1eiswan*er and coworkers
:'>
reorted t,at additi"e -ene+its were
o-ser"ed wit, toical alications o+ acid/lated ,os,ate +l/oride and t,e ,ome /se
o+ a stanno/s +l/oride denti+rice. Neit,er Downer and associates
:'=
nor Mainwarin*
and Naylor,
:'&
,owe"er, were a-le to demonstrate additi"e -ene+its +rom t,e com-ined
/se o+ a sodi/m mono+l/oro,os,ate denti+rice and toical alication o+ acid/lated
,os,ate +l/oride.
5,e a"aila-le data relatin* to m/ltile +l/oride t,eray t,/s s/**est additi"e -ene+its
+rom t,e /se o+ eit,er stanno/s +l/oride or acid/lated ,os,ate +l/oride in t,e dental
o++ice and t,e ,ome /se o+ denti+rices containin* +l/oride. 5,is does not necessarily
mean t,at ot,er com-inations o+ +l/oride treatments may not ro"ide additi"e -ene+its
-/t merely t,at t,ey ,a"e not yet -een e"al/atedD ,oe+/lly t,e res/lts o+ +/t/re
in"esti*ations will clari+y t,is matter. In t,e meantime, t,e dental ractitioner is
stron*ly ad"ised to /se com4inations of fluoride treatments to provide maximal caries
protection for patients.
Fl/oride !inses
In :;<$, reorts -e*an to aear indicatin* t,at t,e re*/lar /se o+ ne/tral sodi/m
+l/oride sol/tions decreased t,e incidence o+ caries. In an attemt to identi+y toical
+l/oride meas/res esecially aroriate +or /se in dental pu4lic health pro$rams, t,is
aroac, was st/died e0tensi"ely d/rin* t,e s/-se?/ent :' years. 4,ereas t,ese
st/dies emloyed a wide "ariety o+ e0erimental conditions, a n/m-er o+
in"esti*ations in"ol"ed eit,er t,e daily /se o+ sol/tions containin* >$$ to >>' m or
t,e weekly /se o+ sol/tions containin* a-o/t ;$$ m +l/oride. 5,e maAority o+ t,ese
st/dies were cond/cted in schools wit, s/er"ised /se o+ t,e rinse t,ro/*,o/t t,e
sc,ool year.
5,e res/lts o+ t,ese in"esti*ations ,a"e -een s/mmari@ed on se"eral occasions and
will not -e reeated ,ere.
%%,:>:,:''-:'(
In *eneral, -ot, tyes o+ +l/oride rinses res/lted in
si*ni+icant caries red/ction o+ a-o/t A: to A>;. On t,e -asis o+ t,ese +indin*s, t,e
simlicity o+ administration, and t,e lack o+ need +or ro+essional dental s/er"ision,
weekly +l/oride-rinse ro*rams in sc,ools are -ecomin* increasin*ly o/lar and are
-ein* a**ressi"ely romoted -y dental /-lic-,ealt, a*encies. Fl/oride rinses were
aro"ed as sa+e and e++ecti"e -y t,e FDA in CHDB
%(
and -y t,e Co/ncil o+ Dental
5,erae/tics o+ t,e ADA in CHD>.
:'%
A FG/ide to t,e Use o+ Fl/orideF was /-lis,ed
in t,e Setem-er :;(< iss/e o+ t,e "ournal of the merican Dental ssociation. 5,e
comosition and recommended /se o+ aro"ed rod/cts is s,own in 5a-le ;-;.
Nearly all o+ t,e early in"esti*ations /sin* +l/oride rinses in"ol"ed c,ildren residin*
in areas in w,ic, t,e drinkin* water was de+icient in +l/oride. As a res/lt, t,e
aro"als *i"en to +l/oride rinses were related to t,eir /se in non+l/oridated
comm/nities. !eorts
<:,:>>,:';,:<$
indicated, ,owe"er, si*ni+icant -ene+its +rom +l/oride
rinses /sed in t,e resence o+ an otimal concentration o+ +l/oride in t,e drinkin*
water. 5,ree additional reorts ,a"e aeared relati"e to t,e /se o+ +l/oride rinses in
c,ildren residin* in +l/oridated comm/nities. 5,e res/lts o+ all t,ree st/dies indicate
t,at cariostatic 4enefits provided 4y fluoride rinses are additive to those derived from
communal fluoridation.
:<:-:<=
In "iew o+ t,ese collecti"e o-ser"ations t,ere aears to
-e no reason to restrict t,e /se o+ +l/oride rinses to non+l/oridated comm/nities.
5,e aro"al o+ +l/oride rinses -y t,e FDA and t,e ADACs Co/ncil on Dental
5,erae/tics +or /se in /-lic ,ealt, ro*rams oened t,e door +or t,e ,ome /se o+
t,ese rod/cts as a comonent o+ m/ltile +l/oride re"enti"e ro*rams. Alt,o/*, t,e
aro"ed rearations were intended to -e a"aila-le strictly -y rescrition, a :,:>;
neutral sodium fluoride rinse 7Fl/ori*ard8 was s/-se?/ently introd/ced +or o"er-t,e-
co/nter 7O5C8 sale. Ultimately, aro"al was *i"en to +l/oride rinses distri-/ted O5C
+or ,ome /se, alt,o/*, some restrictions were re?/ired. 5,ese restrictions incl/ded
t,e distri-/tion o+ ?/antities containin* no more than A:: m$ fluoride in a sin$le
container, a cautionary la4el to avoid s3allo3in$, and an indication that the
preparations should not 4e used 4y children youn$er than 9 years of a*e. At resent
t,ere are se"eral +l/oride rinses distri-/ted in t,is mannerD t,ese rod/cts contain
a-o/t >>' m +l/oride and are intended for daily usa$e.
5,e ?/estion o+ additi"ity o+ t,e e++ects o+ +l/oride rinses to t,ose o-tained /sin*
+l/oride wit, ot,er "e,icles ,as recei"ed contradictory answers. As,ley and
associates
:<&
+o/nd a modest additi"ity o+ -ene+its +rom t,e s/er"ised daily rinsin* in
sc,ool wit, an acid/lated ,os,ate +l/oride rinse co/led wit, s/er"ised -r/s,in*
in sc,ool l/s normal ,ome /se o+ a sodi/m mono+l/oro,os,ate denti+rice. A
similar o-ser"ation was reorted -y 5riol and coworkers.
:<'
On t,e ot,er ,and,
1link,orn and coworkers
:<<
+ailed to o-ser"e any indication o+ additi"e caries
rotection -etween t,e similar s/er"ised daily /se o+ a ne/tral $.$'E sodi/m
+l/oride and t,e ,ome /se o+ t,is same denti+rice. .ikewise, !in*el-er* and
associates
:<%
+ailed to +ind additi"ity -etween a daily sodi/m +l/oride rinse and ,ome
/se o+ a stanno/s +l/oride denti+rice. Similarly, Horowit@ and coworkers,
:<(
in a st/dy
in"ol"in* t,e s/er"ised weekly /se o+ a sodi/m +l/oride rinse and daily +l/oride
ta-lets l/s t,e ,ome /se o+ aro"ed +l/oride denti+rices, o-ser"ed a caries red/ction
comara-le in ma*nit/de to t,at reorted earlier -y t,ese in"esti*ators wit, +l/oride
ta-lets or rinses /sed indi"id/ally.
Additi"e e++ects can also -e in+erred +rom t,e n/mero/s sc,ool +l/oride rinse st/dies
in w,ic, caries red/ctions +rom =$ to ='E were o-ser"ed. 1eca/se t,e maAority o+
t,ese c,ildren in -ot, t,e control and e0erimental *ro/s /sed +l/oride-containin*
denti+rices, it +ollows t,at t,e -ene+its o-ser"ed in t,ose st/dies were o-tained a-o"e
t,ose ro"ided -y t,e +l/oride denti+rices. 5,e same concl/sion can -e reac,ed +rom
t,e data reorted -y 1irkeland and coworkers
:''
in Norway, a co/ntry w,ere over
H:; of the children use fluoride dentifrices, A+ter :$ years o+ a mo/t,rinsin*
ro*ram, t,ese a/t,ors +o/nd a caries red/ction o+ over >:; and reduction in the
need for restoration of more than D:;.
It can t,/s -e concl/ded t,at +l/oride rinses ,a"e a lace as a comonent o+ a
re"enti"e ro*ram alon$ 3ith, -/t not as s/-stit/tes +or, ot,er modalities o+ +l/oride
/se. 5,eir main /se is +or atients wit, a ,i*, risk o+ contractin* caries. Alt,o/*,
e0istin* e"idence may lead some to do/-t w,et,er additional -ene+its +or t,e atients
accr/e +rom t,e /se o+ rinses, it is re+era-le in t,ese instances to *i"e t,e atients t,e
-ene+it o+ t,e do/-t. 30amles o+ atients +or w,om +l/oride rinses s,o/ld -e
recommended incl/de9
)atients w,o, -eca/se o+ t,e /se o+ medication, s/r*ery, radiot,eray, and so on,
,a"e red/ced sali"ation and increased caries +ormation.
)atients wit, ort,odontic aliances or remo"a-le rost,eses, w,ic, act as tras +or
la?/e acc/m/lation.
)atients /na-le to ac,ie"e acceta-le oral ,y*iene.
)atients wit, e0tensi"e oral re,a-ilitation and m/ltile restorati"e mar*ins, w,ic,
reresent sites o+ ,i*, caries risk.
)atients needin* +l/oride in t,eir ,ome care -/t cannot tolerate a c/stom-+itted tray.
)atients wit, *in*i"al recession and s/sceti-ility to root caries.
)atients wit, ramant caries, at least as lon* as t,e ,i*, caries acti"ity ersists.
As a *eneral r/le, daily rinses s,o/ld -e recommended rat,er t,an a weekly re*imenD
not only does t,e daily roced/re aear to -e sli*,tly more e++ecti"e, -/t, as a
ractical consideration, it is easier +or atients to remem-er and comly wit, a daily
roced/re. In all t,ese instances, it is imortant to remem-er t,at t,e rinses s,o/ld not
4e used in place of any of the other modalities o+ +l/oride /se -/t as art o+ a
comre,ensi"e, re"enti"e ro*ram t,at s,o/ld also comrise la?/e control,
+re?/ent +l/oride toical alications, t,e ,ome /se o+ a +l/oride denti+rice, diet
control, and testin* to determine i+ and w,en t,e oral en"ironment is no lon*er
cond/ci"e to caries. For c,ildren li"in* in non+l/oridated areas, t,e rescrition o+
+l/oride s/lements may also -e considered.
Fl/oride Gels +or Home Use
D/rin* t,e ast :' years, a n/m-er o+ +l/oride *els ,a"e -ecome a"aila-le as
additional meas/res t,at may -e /sed to ,el ac,ie"e caries control. 5,ese roced/res
contain $.&E stanno/s +l/oride (C,::: ppm fluoride8 or :.$E sodi/m +l/oride (>,:::
ppm8 and are +orm/lated in a nona?/eo/s *el -ase t,at does not contain an a4rasive
system. 5,eir recommended manner o+ /sa*e in"ol"es toot,-r/s,in* wit, *el 7similar
to /sin* a denti+rice8, allowin* t,e *el to remain in t,e oral ca"ity +or : min/te, and
t,en e0ectoratin* t,oro/*,ly.
3"en t,o/*, no controlled clinical trials ,a"e -een cond/cted o+ t,ese rod/cts /sed
in t,is manner, a n/m-er o+ t,em ,a"e -een aro"ed -y t,e ADACs Co/ncil on
Dental 5,erae/tics as an additional caries-re"enti"e meas/re +or /se in atients
wit, ramant caries. 5,e -asis +or t,e aro"al o+ t,ese rod/cts ,as -een t,e
n/mero/s rior clinical caries st/dies /sin* denti+rices containin* t,e same amo/nt o+
stanno/s +l/oride co/led wit, analytic data demonstratin* t,e sta-ility o+ t,ese
rearations.
From a ractical oint o+ "iew, t,e recommended /se o+ +l/oride *els is *enerally
similar to t,at cited earlier +or +l/oride rinses. In ot,er words, t,ey may -e considered
as an alternative to t,e /se o+ +l/oride rinses and an ad7unct to t,e /se o+ ro+essional,
toical +l/oride alications and +l/oride denti+rices as a collecti"e means o+
ac,ie"in* caries control in atients w,o are esecially rone to caries +ormation. .ike
+l/oride rinses, t,e /se o+ t,ese *els is *enerally restricted to t,e eriod re?/ired to
ac,ie"e caries control. Comared wit, +l/oride rinses, ,owe"er, +l/oride *els aear
to ,a"e an advanta$e in terms of patient compliance. 1eca/se t,ese rearations are
only distri-/ted to atients -y t,eir dentists, it is commonly t,o/*,t t,at atients are
more likely to /se t,em in comliance wit, t,e recommendations o+ t,eir dentist.
It s,o/ld -e stressed t,at +l/oride *els s,o/ld not 4e used in place of fluoride
dentifrices. 1eca/se t,e *els contain no a4rasive system to control t,e deosition o+
ellicle, t,eir /se in lace o+ a denti+rice res/lts in t,e acc/m/lation o+ stained ellicle
in t,e maAority o+ atients wit,in a +ew weeks. Ne"ert,eless, t,e roer /se o+ t,ese
rearations in com-ination wit, ro+essional toical +l/oride alications and t,e
,ome /se o+ +l/oride denti+rices may -e e0ected to ,el ac,ie"e caries control in
caries-acti"e atients.
Question 7
A. I+ a >$E red/ction in caries occ/rs +rom water +l/oridation and t,en anot,er >'E
+rom toical +l/oride t,eray, t,e total red/ction is &'E.
1. Fl/oride rinses are o+ little "al/e in +l/oridated areas.
C. A +l/oride-rinse container s,o/ld not contain more t,an =$$ m* o+ +l/oride.
D. A sc,ool rinse ro*ram can -e e0ected to rod/ce caries red/ction on t,e order o+
=$E.
3. It is more ractical to ,a"e eole /se a daily rinse t,an a weekly rinse.
Fl/oride-!eleasin* Dental !estorati"e Materials
Fl/oride-releasin* dental restorati"e materials may ro"ide an additional -ene+it in
re"enti"e dentistry. Alt,o/*, not c/rrently a"aila-le in t,e United States, a
+l/oride-releasin* amal*am ,as demonstrated recurrent caries inhi4ition at enamel
and dentin restoration mar*ins.
:<;
.ikewise, -ot, c,emical-c/red and li*,t-c/red
$lass ionomer cements ,a"e demonstrated caries in,i-ition at enamel and dentin
restoration mar*ins.
:%$-:%=
Fl/oride-releasin* resin composites ,a"e also consistently
demonstrated rec/rrent caries in,i-ition at enamel mar*ins, yet t,ere are conflictin$
results 3hether caries inhi4ition occurs at dentin mar$ins.
:%$,:%:,:%=,:%&
)reliminary
st/dies indicate t,at *lass ionomer cement and +l/oride-releasin* resin comosite
,a"e syner*istic e++ects wit, +l/oride rinses and +l/oridated denti+rices, in t,e
reminerali1ation of incipient enamel caries.
:%'-:%(
5,e materials may act as a +l/oride
deli"ery system. Uon e0os/re to additional e0ternal +l/oride, t,e material s/r+ace
under$oes an increase in fluoride. 5,is +l/oride is s/-se?/ently released and ,as
demonstrated deminerali@ation in,i-ition and e"en reminerali@ation at adAacent toot,
str/ct/re. F/rt,er clinical researc, to e"al/ate t,ese +l/oride-releasin* restorati"e
materials may ro"ide more in+ormation +or clinical recommendations.
Question 8
4,ic, o+ t,e +ollowin* statements is incorrecte
A. Fl/oride-releasin* dental restorati"e materials can e++ecti"ely in,i-it adAacent
enamel deminerali@ation.
1. Fl/oride-releasin* dental restorati"e materials ,a"e -een s,own to e++ecti"ely
in,i-it enamel deminerali@ation on adAacent interro0imal toot, s/r+aces.
C. Glass ionomer cements and +l/oride-releasin* resin comosites ,a"e similar
e++ecti"eness o+ adAacent deminerali@ation in,i-ition.
D. Glass ionomer cements and resin comosites can /take +l/oride at t,e s/r+ace,
+ollowin* e0os/re to toical +l/orides, and s/-se?/ently release t,e +l/oride.
Toxicology of Fluoride
5,e ,andlin* o+ +l/orides is care+/lly re*/lated in ind/stry -y occupational safety
health le$islation and in t,e marketlace -y the 'D. Commercial dental +l/oride
rod/cts and ro+essional ractices can -e to0ic and e"en let,al w,en /sed
inaroriately. 5,e let,al dose +or an ad/lt is somew,ere -etween >.' and :$ *, wit,
t,e avera$e lethal dose 4ein$ B to > $. 5,e /se o+ t,e Fa"era*e let,al doseF is a "ery
imrecise desi*nation t,at makes it di++ic/lt to redict t,e o/tcome o+ an accidental
swallowin* o+ an e0cess o+ +l/oride. 5o correct t,is ro-lem, a -ody-wei*,t -ased,
pro4a4le toxic dose 7)5D8 standard ,as -een recommended as a more ractical
aroac, to makin* treatment decisions. 4it, it, t,e /r*ency +or +irst aid and more
de+initi"e emer*ency treatment can -e determined raidly. 5,e )5D aroac,, +irst
reorted -y 1ayless and 5inano++, -ases t,e le"el and /r*ency o+ treatment on t,e
num4er of multiples of > m$L*$ o+ +l/oride in*ested 75a-le ;-:$8.
I+ t,e amo/nt in*ested is less than > m$L*$, t,e o++ice /se o+ a"aila-le calci/m,
al/min/m, or ma*nesi/m rod/cts as +irst aid antidotes s,o/ld s/++ice. I+ t,e amo/nt
is over > m$L*$, +irst aid meas/res s,o/ld -e expeditiously alied, follo3ed 4y
hospital o4servation +or ossi-le +/rt,er care. Finally, i+ t,e amo/nt o+ +l/oride
in*ested aroac,es or exceeds C> m$L*$, t,e immediate +irst aid treatment s,o/ld -e
+ollowed -y a most ur$ent action to move the patient s3iftly into a hospital
emer$ency room 3here cardiac monitorin$, electrolyte evaluation, and shoc* support
is availa4le, /n$estion of C> m$L*$ fluoride can 4e lethal.
Fl/oride 5o0icity
Fl/oride acts in +o/r *eneral ways9 7:8 w,en a concentrated +l/oride salt contacts
moist skin or m/co/s mem-rane, ,ydro+l/oric acid +orms, ca/sin* a chemical 4urnD
7>8 it is a *eneral protoplasmic poison t,at acts to in,i-it en@yme systemsD 7=8 it 4inds
calcium needed +or ner"e actionD and 7&8 hyper*alemia occurs, contri4utin$ to
cardiotoxicity.
4,en dry +l/oride owder contacts t,e m/co/s mem-rane or t,e moist skin, a
reddened lesion occ/rs, and later t,e area -ecomes swollen and aleD still later,
/lceration and necrosis may occ/r. In ast years, skin -/rns o+ t,is tye were common
+or many water en*ineers w,o emtied dr/ms o+ +l/oride a*ents into t,e ,oers
+eedin* water s/lies. Federal and state occ/ational sa+ety acts ,a"e *reatly
red/ced t,is dan*er.
Followin* e0cessi"e in*estion o+ +l/oride, na/sea and "omitin* can occ/r. 5,e
"omitin* is /s/ally ca/sed -y t,e +ormation o+ ,ydro+l/oric acid in t,e acid
en"ironment o+ t,e stomac,, causin$ dama$e to the linin$ cells of the stomach 3all.
.ocal or *eneral si*ns o+ muscle tetany ens/e ca/sed -y t,e dro in -lood calci/m.
5,is can -e accomanied -y a-dominal crampin$ and ain. Finally, as t,e
,yocalcemia and ,yerkalemia intensi+y, t,e se"erity o+ t,e condition 4ecomes
ominous 3ith the onset of the three C?s that can portend deathcoma, convulsions,
and cardiac arrhythmias. Generally, deat, +rom in*estion o+ e0cessi"e +l/oride occ/rs
wit,in & ,o/rsD if the individual survives for B hours, the pro$nosis is $uarded to
$ood.
Emergency Treatment
Fo/r actions are salient in treatin* +l/oride oisonin*9 7:8 immediate treatment, 7>8
induced vomitin$, 7=8 rotection o+ t,e stomac, -y -indin* +l/oride wit, orally
administered calcium or aluminum preparations, and 7&8 maintenance o+ -lood
calci/m le"els 3ith intravenous calcium. Ur*ent and decisi"e treatment is mandatory
once t,e )5D o+ :' m*Bk* ,as -een aroac,ed or e0ceeded. 5,e seed o+ initiatin*
roer treatment can -e critical to a ersonCs c,ance +or s/r"i"al.
:%;
5,e -lood le"el
reac,es its ma0im/m +rom $.' to : ,o/r a+ter t,e +l/oride is in*ested, #y that time it
can 4e too late.
I+ an e0cessi"e amo/nt o+ sodi/m +l/oride is in*ested, first aid treatment can 4e
initiated. Milk, or -etter yet, milk and e**s s,o/ld -e *i"en, +or two reasons9 7:8 As
dem/lcents, t,ey ,el rotect t,e m/co/s mem-rane o+ t,e /er-GI tract +rom
c,emical -/rnsD and 7>8 t,ey ro"ide t,e calci/m t,at acts as a -inder +or t,e +l/oride.
.ime water 7calci/m ,ydro0ide8 or Maalo0 7an al/min/m rearation8, can -e dr/nk
to accomlis, t,e same /rose. )lenty o+ +l/id, prefera4ly mil*
a
s,o/ld -e in*ested
to ,el dil/te t,e +l/oride como/nd in t,e stomac,. =omitin$ is 4eneficial and o+ten
occ/rs sontaneo/slyD it also can -e ind/ced -y di$ital stimulus to t,e -ase o+ t,e
ton*/e or wit, syr/ o+ iecac, i+ a"aila-le. 4,en "omitin* does occ/r, t,e maAority
o+ t,e in*ested +l/oride is o+ten e0elled. )re+era-ly, t,e atient s,o/ld -e taken
directly to the emer$ency room of a hospital, Ot,erwise t,e closest emer*ency
medical ser"ice /nit or ,ysician caa-le o+ dealin* wit, +l/oride to0icity is t,e
alternati"e. Once in a well-e?/ied medical +acility, se"eral otions are ossi-le,
s/c, as $astric lava$e, 4lood dialysis, or oral intravenous calcium $luconate to
maintain the 4lood calcium levels, !very effort should 4e made to rid the 4ody
rapidly of the fluoride or to ne$ate its toxicity 4efore a refractory hyper*alemia and
cardiac fi4rillation 4ecome a $reater pro4lem than the fluoride intoxication.
:($
U.S. o/lation, and alternati"e met,ods +or t,e ro"ision o+ systemic +l/oride lea"e
m/c, to -e desired. 5,/s, additional meas/res are o-"io/sly needed +or ro"idin*
*reater rotection a*ainst caries to as many se*ments o+ t,e o/lation as ossi-le.
5,e term toical +l/oride t,eray re+ers to t,e /se o+ systems containin* relati"ely
lar*e concentrations o+ +l/oride t,at are alied locally, or toically, to er/ted toot,
s/r+aces to re"ent t,e +ormation o+ dental caries. 5,is term encomasses t,e /se o+
+l/oride rinses, denti+rices, astes, *els, and sol/tions t,at are alied in "ario/s
manners. Amon* dental ractitioners, ,owe"er, t,is term is *enerally considered to
re+er to ro+essional toical +l/oride treatments er+ormed in t,e dental o++ice.
C,ronic Fl/oride 30os/re
At ,i*, le"els o+ ind/strial +l/oride e0os/re, as e0erienced -y cryolite and -a/0ite
workers rior to t,e era o+ occ/ational sa+ety re*/lations, t,e com-ined intake o+
+l/oride t,ro/*, in,alation, in*estion, and water cons/mtion o+ten res/lted in a daily
dose o+ o"er >$ m*. 5,is e0ceedin*ly ,i*, le"el o+ contin/al intake +or :$ to >$ years
res/lted in a severe s*eletal fluorosis c,aracteri@ed -y osteosclerosis, calcification of
the tendons, and the appearance of multiple exostoses. 5,is same crilin* -one
+l/orosis can also occ/r +rom lon*-term cons/mtion o+ nat/rally +l/oridated waters
+o/nd in some parts of the 3orld, 3hich contain CB ppm or more of fluoride. Ot,er
+actors t,at increase t,e se"erity o+ -one +l/orosis are ,i*, temerat/res wit, a
concomitant increase in drinkin* eisodes, an ele"ated intake o+ +l/oride in +ood,
n/tritional diseases, and low-calci/m diets. &o cases o+ skeletal +l/orosis ,a"e -een
reorted in t,e United States w,ere water +l/oridation concentrations were /nder =.;
m.
:(:
Desite all reca/tions, t,ere is a otential +or si*ns and symtoms o+ +l/oride to0icity
in dental o++ice and ,ome /se o+ toical +l/oride. 5,e most ro-a-le ca/se is in
children in the C>2 to A:2month a$e 4rac*et ,a"in* an e0cess o+ denti+rice laced on
t,e toot,-r/s, and t,en swallowin* t,e +l/oride-laden sali"a. In most cases, t,is
res/lts in a "ery mild, o+ten /nnoticea-le c,an*e in t,e enamel o+ er/tin* teet,
aro/nd a*e <. A more serio/s to0icity can arise in t,e dental o++ice +rom t,e
mis,andlin* and in*estion o+ +l/oride salts /sed +or ro+essional /roses. 5o -e
reared +or s/c, an /nlikely emer*ency, t,e ro+essional sta++ s,o/ld -e reared +or
instit/tin* ossi-le emer*ency roced/res.
Home Security of Fluoride Products
5,e lac* of home stora$e security o+ O5C and rescrition +l/oride rod/cts oses
,a@ards to cons/mers. As resently acka*ed, t,e +l/oride content o+ O5C +l/oride
rod/cts can e0ceed t,e )5D +or c,ildren.
:(>
5,at t,e dan*er at ,ome is real is
attested -y two deaths of children after s3allo3in$ fluoride ta4lets9 one in A/stria,
and t,e ot,er in A/stralia.
:(=
In one year 7:;(<-:;(%8, := cases o+ +l/oride oisonin*
were reorted to t,e Nort, Carolina )oison Center. It was noted -y t,e oison center
t,at no health2care providers 3ho contacted the center 3ere familiar 3ith the
treatment of the 0/ symptoms induced 4y fluoride poisonin$.
:(&
Clearly, arents need
to -e ed/cated a-o/t t,e ,a@ards o+ +l/oride-containin* dental rod/cts. Denti+rices,
mo/t,rinses, and +l/oride s/lements need to -e sec/rely stored. 3?/ally, ,ealt,
ro+essionals need to -e ed/cated a-o/t t,e emer*ency treatment rotocol +ollowin*
e0cessi"e intake o+ +l/oride.
In a lar*er st/dy, t,e American Association o+ )oison Control Centers reorted t,at
t,e n/m-er o+ +l/oride-related calls ,ad increased +rom =,('< cases in :;(& to %,%;&
in :;(;. O+ t,ese, t,e n/m-er seekin* clinical treatment was =<< in :;(& and <<( in
:;(;. In eac, o+ t,ese years, yo/n* c,ildren were in"ol"ed in ;$E o+ t,e calls.
:('
Question 9
A. 5,e in*estion o+ =<$ m* o+ +l/oride -y a ;$-k*, >:-year-old ad/lt is not as
dan*ero/s as t,e in*estion o+ >($ m* o+ +l/oride -y a &$-k*, :'-year-old adolescent.
1. Hyocalcemia and ,yerkalemia are si*ns o+ an imendin* cardioto0icity.
C. I+ a atient ,as in*ested an e0cessi"e amo/nt o+ +l/oride, t,e occ/rrence o+ na/sea
and "omitin* is a +a"ora-le si*n.
D. 5,e +re?/ent toical alications o+ +l/oride to t,e teet, at a*e < is -elie"ed to -e
t,e ca/se o+ +l/orosis.
3. 5,e in*estion o+ :' m*B2 o+ +l/oride re?/ires t,at t,e atient -e /nder aroriate
emer*ency medical care -e+ore =$ min/tes ,as elased.
Summary
A n/m-er o+ di++erent asects o+ toical +l/oride t,eray ,a"e -een re"iewed in t,e
+ore*oin* material. 4it,o/t do/-t, t,e /se o+ toical +l/oride t,eray contri-/tes
si*ni+icantly to t,e control o+ dental cariesD ,owe"er, one cannot e0ect to control
dental caries comletely t,ro/*, t,e /se o+ +l/orides alone. F/rt,ermore, -eca/se no
sin*le +l/oride treatment roced/re ro"ides t,e ma0imal de*ree o+ caries rotection
ossi-le wit, +l/oride, t,e /se o+ m/ltile +l/oride t,eray is ad"ocated. In artic/lar,
t,e dentist s,o/ld identi+y t,e needs o+ eac, atient and instit/te a m/ltile +l/oride
treatment ro*ram desi*ned seci+ically to +/l+ill t,ose needs.
:. Ccorrect.
Aincorrect. 3namel mat/ration is "ery raid t,e +irst mont,, slows down o"er t,e
ne0t year or so, and t,en remains relati"ely sta-le.
1incorrect. Fl/oride content decreases "ery raidly in t,e +irst :$ mm and t,en
more slowly, /ntil t,e dentinoenamel A/nction is reac,ed.
Dincorrect. As t,e H +alls, t,e +l/oride -ecomes more e++ecti"e in rotectin* t,e
enamelD at a ne/tral H no rotection is needed.
3incorrect. 5,e main reaction rod/ct is calci/m +l/oride.
>. A, 1, C, and Dcorrect.
3incorrect. 5,ere is a lesser concentration on t,e toot, wi
t, MF) and a-o/t t,e same cariostatic action as +or ot,er inor*anic +l/orides.
=. A, D, and 3correct.
1incorrect. Stanno/s +l/oride in water *oes to a ,ydro0ide and t,en a w,ite o0ide.
Cincorrect. 5,i0otroic *el looks like a *el, acts like a *el, -/t is not a *el.
&. 1correct.
Aincorrect. A series o+ alications wit,in a s,ort eriod aears -est.
Cincorrect. 5,ere aears to -e little, i+ any, di++erence in t,eir e++icacy.
Dincorrect. 5,e +irst art is correctD t,e second art is incorrectD -ot, are e++ecti"e,
-/t t,e amo/nt o+ di++erence -etween t,e SnF
>
and A)F is de-ata-le.
3incorrect. In t,e critical +ield st/dies, t,e ( E sol/tion wins easily.
'. Dcorrect.
Aincorrect. 5oical +l/oride t,eray s,o/ld -e started as soon as ossi-le a+ter t,e
er/tion o+ t,e +irst decid/o/s toot,.
1incorrect. Fl/oride is a li+elon* adA/nct +or dental ,ealt,.
Cincorrect. !ecent st/dies ,a"e s,own t,at it is not necessary to *i"e a ro,yla0is
rior to a +l/oride alication.
3incorrect. 5,e /se o+ t,ese rod/cts did not res/lt in si*ni+icant red/ctions in
caries.
<. A, 1, and Ccorrect.
Dincorrect. 6ice "ersa. Crest started wit, SnF
>
-/t now ,as NaF.
3incorrect. )eole /se t,e +l/oride denti+rices/ to ;$E.
%. A, C, D, and 3correct.
1incorrect. 5,e e++ects o+ +l/oride are additi"eD t,e more o+ten it is alied, t,e
-etter.
(. A, 1, and Dcorrect.
Cincorrect. Glass ionomer cements ,a"e *reater adAacent deminerali@ation
in,i-ition.
;. 1, C, and 3correct.
Aincorrect. First t,e a*e o+ t,e indi"id/al is not ertinentD w,at is critical is t,e
m*B2. In t,is case, t,e +irst indi"id/al ,as ,ad = m*B2 7=<$B;$8, w,ereas t,e second
indi"id/al ,as in*ested % m*B2, >($B&$a otentially let,al dose.
Dincorrect. Fl/oride in*estion at a*e < or later will not ca/se +l/orosis since re-
er/ti"e enamel +ormation is essentially comleted.
:. 5,ere is an 7in"erse8 7direct8 relations,i -etween t,e amo/nt o+ +l/oride 7F8 in t,e
s/r+ace o+ t,e enamel and t,e n/m-er o+ caries. It re?/ires a-o/t iiiiiiiii 7time8
+or t,e enamel s/r+ace to mat/re +ollowin* er/tion. 5,e *reatest amo/nt o+ F in t,e
enamel is located in t,e o/ter iiiiiiiii 7distance8 o+ t,e enamel.
>. 5,e reaction o+ ele"ated concentrations o+ +l/oride wit, ,ydro0yaatite 7HA8 is
accomanied -y t,e +ormation o+ iiiiiiiii 7on t,e s/r+ace8 7in t,e aatite crystal8
and a loss o+ iiiiiiiii 7one o+ t,e key elements o+ HA8. 5,is element is not lost
w,en SnF
>
is one o+ t,e reactants, in w,ic, case, t,e como/nd iiiiiiiii 7name8 is
+ormed. Alon* wit, t,is como/nd, iiiiiiiii 7anot,er F como/nd8 is +ormed on
t,e s/r+ace.
=. 5,e calci/m +l/oride 7CaF
>
8 +ormed on t,e s/r+ace o+ t,e toot, wit, ne/tral sodi/m
+l/oride, A)F, or SnF
>
, is lost relati"ely raidly +or iiiiiiiii 7time8 and almost
comletely lost in iiiiiiiii 7time8. D/rin* t,is eriod, t,e calci/m +l/oride 7is8 7is
not8 rotecti"e. Alon* wit, t,e +ormationt,en losso+ CaF
>
, t,ere is a slow c,an*e
in t,e aatite crystal +rom iiiiiiiii 7aatite8 to iiiiiiiii 7name o+ crystalline
+orm8, w,ic, is more ermanent. 1eca/se st/dies indicate t,at t,e CaF
>
is leac,ed
+rom t,e toot,, t,e lon*-term -ene+it m/st -e +rom t,e iiiiiiiii 7crystalline +orm8.
5,/s, i+ t,e -/ild-/ o+ t,e crystalline +orm is slow, 7m/ltile8 7sin*le8 alications o+
+l/oride ro-a-ly ro"ide t,e -est lon*-term re"ention.
&. Fl/oride acc/m/lates to a *reater e0tent in deminerali@ed areas 7tr/e8D two +l/oride
como/nds wit, a low H t,at de-minerali@e enamel 7and t,/s increase F /take8 are
iiiiiiiii and iiiiiiiii. 5wo times w,en t,e toot, is not otimally minerali@ed
are A/st a+ter iiiiiiiii 7e"ent8 o+ t,e toot, and A/st a+ter -acterial iiiiiiiii
7e"ent8 o+ enamelD in eit,er e"ent, +l/oride aids in t,e minerali@ation or
reminerali@ation rocess.
'. 5,e t,ree di++erent sol/tions o+ +l/oride /sed in o++ice alied toical alications
are NaF, iiiiiiiii ED A)F, iiiiiiiii ED and SnF
>
, iiiiiiiii E. 5,e A)F is
made acidic -y addin* two acids, iiiiiiiii and iiiiiiiii to a iiiiiiiii
iiiiiiiii E.
<. 5,e t,ree FCCsF indicatin* imendin* deat, +rom +l/oride into0ication are
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F
=
)O
&
9
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:(
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>9><=-<<.
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on t,e e++icacy o+ toical +l/oride treatment. 5wo-year res/lts. Clin Prev Dent , '7&89(-
:$.
&%. 2at@, !. 6., Meskin, .. H., #ensen, M. 3., g 2eller, D. 7:;(&8. 5oical +l/oride
and ro,yla0is9 A =$-mont, clinical trial. " Dent Res, <=7)ro*. g A-stracts8. A-str.
%%:.
&(. !ia, .. 4., .eske, G. S., Sosato, A., g 6arma, A. 7:;(=8. 3++ect o+ rior
toot,cleanin* on -iann/al ro+essional A)F toical +l/oride *el-tray treatments.
!es/lts a+ter two years. Clin Prev Dent , '7&89=-%.
&;. 1iAella, M. F. 5. 1., 1iAella, 6. 5., .oes, 3. S., g 1ostos, #. !. 7:;('8.
Comarison o+ dental ro,yla0is and toot,-r/s,in* rior to toical A)F
alications. Community Dent +ral !pidemiol , :=9>$(-::.
'$. 3kstrand, #., g 2oc,, G. 7:;($8. Systemic +l/oride a-sortion +ollowin* +l/oride
*el alication. " Dent Res , ';9:$<%.
':. 3kstrand, #., 2oc,, G., .ind*ren, .. 3., g )etersson, .. G. 7:;(:8.
),armacokinetics o+ +l/oride *els in c,ildren and ad/lts. Caries Res , :'9>:=->$.
'>. .eComte, 3. #., g 4,it+ord, G. M. 7:;(>8. ),armacokinetics o+ +l/oride +rom
A)F *el and +l/oride ta-lets in c,ildren. " Dent Res , <:9&<;-%>.
'=. .eComte, 3. #., g Doyle, 5. 3. 7:;(>8. Oral +l/oride retention +ollowin* "ario/s
toical alication tec,ni?/es in c,ildren. " Dent Res , <:9:=;%-:&$$.
'&. .eComte, 3. #., g !/-enstein, .. 2. 7:;(&8. Oral +l/oride rentention wit,
t,i0otroic and A)F *els and +oam-lined and /nlined trays. " Dent Res , <=9<;-%$.
''. McCall, D. !., 4atkins, 5. !., Ste,an, 2. 4., Collins, 4. #., g Smalls, M. #.
7:;(=8. Fl/oride in*estion +ollowin* A)F *el alication. #r Dent " , :''9===-=<.
'<. )o/r-ai0, S., g Desa*er, #. ). 7:;(=8. Fl/oride a-sortion9 A comarati"e st/dy
o+ :E and >E +l/oride *els. " #iol #uccale , ::9:$=-(.
'%. .eComte, 3. #., g Doyle, 5. 3. 7:;('8. 3++ects o+ s/ctionin* de"ices on oral
+l/oride retention. " m Dent ssoc , ::$9='%-<$.
'(. Stookey, G. 2., Sc,eme,orn, 1. !., Drook, C. A., g C,eet,am, 1. .. 7:;(<8. 5,e
e++ect o+ rinsin* wit, water immediately a+ter a ro+essional +l/oride *el alication
on +l/oride /take in deminerali@ed enamel9 An in vivo st/dy. Pediatr Dent , (7=89:'=-
'%.
';. A"erill, H. M., A"erill, #. 3., g !it@, A. G. 7:;<%8. A two-year comarison o+
t,ree toical +l/oride a*ents. " m Dent ssoc , %&9;;<-:$$:.
<$. Gala*an, D. F., g 2n/tson, #. 4. 7:;&(8. 3++ect o+ toically alied sodi/m
+l/oride on dental caries e0erience. 6I. 30eriments wit, sodi/m +l/oride and
calci/m c,loride. 4idely saced alications. Use o+ di++erent sol/tion
concentrations. Pu4lic Health Rep, <=9:>:'->:.
<:. Horowit@, H. S., g Hei+et@, S. 1. 7:;<;8. 3"al/ation o+ toical +l/oride
alications o+ stanno/s +l/oride to teet, o+ c,ildren -orn and reared in a +l/oridated
comm/nity9 Final reort. " Dent Child , =<9=''-<:.
<>. M/,ler, #. C. 7:;<$8. 5,e anticario*enic e++ecti"eness o+ a sin*le alication o+
stanno/s +l/oride in c,ildren residin* in an otimal comm/nal +l/oride area. II.
!es/lts at t,e end o+ =$ mont,s. " m Dent ssoc, <:9&=:-=(.
<=. S@weAda, .. F. 7:;%>8. Fl/orides in comm/nity ro*rams9 A st/dy o+ +o/r years o+
"ario/s +l/orides alied toically to t,e teet, o+ c,ildren in +l/oridated comm/nities.
" Pu4lic Health Dent , =>9>'-==.
<&. 1r/de"old, F., g NanAoks, !. 7:;%(8. Caries re"enti"e +l/oride treatment o+ t,e
indi"id/al. Caries Res , :>7S/l. :89'>-<&.
<'. Forrester, D. #. 7:;%:8. A re"iew o+ c/rrently a"aila-le toical +l/oride a*ents. "
Dent Child, =(9'>-'(.
<<. Horowit@, H. S., g Hei+et@, S. 1. 7:;%$8. 5,e c/rrent stat/s o+ toical +l/orides in
re"enti"e dentistry. " m Dent ssoc , (:9:<<-%%.
<%. Forrester, D. #., g S,/l@, 3. M., 3ds. 7:;%&8. International 4orks,o o+ Fl/orides
and Dental Caries !ed/ctions. 1altimore9 Uni"ersity o+ Maryland.
<(. Stookey, G. 2. 7:;%$8. Fl/oride t,eray. In 1ernier, #. .., g M/,ler, #. C., 3ds.
/mprovin$ dental practice throu$h preventive measures 7>nd ed.8 St. .o/is9 Mos-y.
. ;>-:'<.
<;. !ia, .. 4. 7:;(:8. )ro+essionally 7oerator8 alied toical +l/oride t,eray9 A
criti?/e. /nt Dent " , =:9:$'->$.
%$. Mell-er*, #. !., g !ia, .. 4. 7:;(=8. )ro+essionally alied toical +l/oride. In
Fl/oride in )re"enti"e Dentistry. 5,eory and Clinical Alications. C,ica*o9
j/intessence, :(:->:&.
%:. 2at@, S., McDonald, #. .., g Stookey, G. 2. 7:;%;8. Preventive dentistry in
action, 7=rd ed.8 Uer Montclair, N#9 DC) )/-lis,in* Comany.
%>. !ia, .. 4. 7:;(;8. !e"iew o+ t,e anticaries e++ecti"eness o+ ro+essionally
alied and sel+-alied toical +l/oride *els. " Pu4lic Health Dent , &;9>;%-=$;.
%=. !ia, .. 4. 7:;;$8. An e"al/ation o+ t,e /se o+ ro+essional 7oerator-alied8
toical +l/orides. " Dent Res , <;9%(<-;<.
%&. 4ei, S. H. H., g Hi/, C. 2. H. 7:;;=8. 3"al/ation o+ t,e /se o+ toical +l/oride
*el. Caries Res , >%7S/l. :89>;-=&.
%'. #o,nston, D. 4. 7:;;&8. C/rrent stat/s o+ ro+essionally alied toical +l/orides.
Community Dent +ral !pidemiol , >>9:';-<=.
%<. Horowit@, H. S., g Ismail, A. I. 7:;<<8. 5oical +l/orides in caries re"ention. In
FeAersko", O., 3kstrand, #., g 1/rt, 1. A., 3ds. 'luoride in dentistry, >nd ed. 7.
=::->%8 Coen,a*en9 M/nks*aard.
%%. Co/ncil on Dental 5,erae/tics 7:;(&8. Fl/oride como/nds. In ccepted dental
therapeutics, 7&t, ed.8 C,ica*o9 American Dental Association. . =;'-&>$.
%(. Fine, S. D. 7:;%&8. 5oical +l/oride rearations +or red/cin* incidence o+ dental
caries. Notice o+ stat/s. 'ederal Re$ister, =;9:%>&'.
%;. Clark, D. C., Hanley, #. A., Stamm, #. 4., et al. 7:;('8. An emirically -ased
system to estimate t,e e++ecti"eness o+ caries-re"enti"e a*ents. A comarison o+ t,e
e++ecti"eness estimates o+ A)F *els and sol/tions, and +l/oride "arnis,es. Caries Res,
:;9(=-;'.
($. Arnold, F. A. #r., Dean, H. 5., g Sin*leton, D. C. #r. 7:;&&8. 5,e e++ect on caries
incidence o+ a sin*le toical alication o+ a +l/oride sol/tion to t,e teet, o+ yo/n*
ad/lt males o+ a military o/lation. " Dent Res, >=9:''-<>.
(:. Frank, !. 7:;'$8. !esearc, and clinical e"al/ation o+ local alications o+ sodi/m
+l/oride. Sch3ei1 %schr @ahnh, <$9>(=-(%.
(>. Driak, F. 7:;':8. 2ariesro,la0e mit -esonderer 1er/cksic,ti*/n* der
Imra*nier/n*smet,oden. +ester @tschr Stomat, &(9:'=-<(.
(=. 2linken-er*, 3., g 1i--y, 1. G. 7:;'$8. 3++ect o+ toical alications o+ +l/orides
on dental caries in yo/n* ad/lts. " Dent Res, >;9&-(.
(&. !ickles, N. H., g 1ecks, H. 7:;':8. 5,e e++ects o+ an acid and a ne/tral sol/tion
o+ sodi/m +l/oride on t,e incidence o+ dental caries in yo/n* ad/lts. " Dent Res,
=$9%'%-<'.
('. 2/tler, 1., g Ireland, !. .. 7:;'=8. 5,e e++ect o+ sodi/m +l/oride alication on
dental caries e0erience in ad/lts. " Dent Res, =>9&'(-<>.
(<. Carter, 4. #., #ay, )., S,klair, I. .., g Daniel, .. H. 5,e e++ect o+ toical +l/oride
on dental caries e0erience in ad/lt +emales o+ a military o/lation. " Dent Res,
=&9%=-%<.
(%. M/,ler, #. C. 7:;'%8. 3++ect on *in*i"a and occ/rrence o+ i*mentation on teet,
+ollowin* t,e toical alication o+ stanno/s +l/oride or stanno/s c,loro+l/oride. "
Periodont, >(9>(:-(<.
((. M/,ler, #. C. 7:;'(8. 5,e e++ect o+ a sin*le toical alication o+ stanno/s +l/oride
on t,e incidence o+ dental caries in ad/lts. " Dent Res, =%9&:'-:<.
(;. )rot,eroe, D. H. 7:;<:8. A st/dy to determine t,e e++ect o+ toical alication o+
stanno/s +l/oride on dental caries in yo/n* ad/lts. Roy Can D Corps E =9:(->=.
;$. Harris, N. O., Hester, 4. !., g M/,ler, #. C., g Allen, #. F. 7:;<&8. Stanno/s
+l/oride toically alied in a?/eo/s sol/tion in caries re"ention in a military
o/lation. SAM-5D!-<&-><. 1rooks Air Force 1ase, 5G9 United States Air Force
Sc,ool o+ Aerosace Medicine.
;:. O-ers@tyn, A., 2olwinski, 2., 5rykowski, #., g Starosciak, S. 7:;%;8. 3++ects o+
stanno/s +l/oride and amine +l/orides on caries incidence and enamel sol/-ility in
ad/lts. ust Dent " , >&9=;'-;%.
;>. 6ie*as, H. 7:;%$8. 5,e caries in,i-itin* e++ect o+ a sin*le toical alication o+ an
acidic ,os,ate sol/tion in yo/n* ad/lts. A one year e0erience. Rev Saude Pu4lica ,
&9''-<$.
;=. C/rson, I. 7:;%=8. 5,e e++ect on caries increments in dental st/dents o+ toically
alied acid/lated ,os,ate +l/oride 7A)F8. " Dent , :9>:<-:(.
;&. Mercer, 6. H., g M/,ler, #. C. 7:;%>8. Comarison o+ sin*le toical alication
o+ sodi/m +l/oride and stanno/s +l/oride. " Dent Res , ':9:=>'-=$.
;'. In*ra,am, !. j., g 4illiams, #. 3. 7:;%$8. An e"al/ation o+ t,e /tility o+
alication and cariostatic e++ecti"eness o+ ,os,ate-+l/orides in sol/tion and *el
states. " Tenn Dent ssoc , '$9'-:>.
;<. Cons, N. C., #aneric,, D. 5., g Sennin*, !. S. 7:;%$8. Al-any toical +l/oride
st/dy. " m Dent ssoc , ($9%%%-(:.
;%. Horowit@, H. S., g Doyle, #. 7:;%:8. 5,e e++ect on dental caries o+ toically
alied acid/lated ,os,ate-+l/oride9 !es/lts a+ter t,ree years. " m Dent ssoc ,
(>9=';-<'.
;(. U.S. )/-lic Healt, Ser"ice. 7A/* :;(%8. Oral ,ealt, o+ United States ad/lts. 5,e
national s/r"ey o+ oral ,ealt, in U.S. emloyed ad/lts and seniors9 :;('-:;(<.
National +indin*s. &/H Pu4l, &o, FD2<F9F.
;;. Hand, #. S., H/nt, !. S., g 1eck, #. D. 7:;((8. Incidence o+ coronal and root
s/r+ace caries in an older ad/lt o/lation. " Pu4 Health Dent , &(9:&-:;.
:$$. 1/rt, 1. A., Ismail, A. I., g 3kl/nd, S. A. 7:;(<8. !oot caries in an otimally
+l/oridated and a ,i*,-+l/oride comm/nity. " Dent Res , <'9::'&-'(.
:$:. 1r/stman, 1. A. 7:;(<8. Imact o+ e0os/re to +l/oride-ade?/ate water on root
s/r+ace caries in elderly. 0erodontics , >9>$=-%.
:$>. H/nt, !. #., 3ldred*e, #. 1., g 1eck, #. D. 7:;(;8. 3++ect o+ residence in a
+l/oridated comm/nity on t,e incidence o+ coronal and root caries in an older ad/lt
o/lation. " Pu4 Health Dent , &;9:=(-&:.
:$=. Stamm, #. 4., 1antin*, D. 4., g Imrey, ). 1. 7:;;$8. Ad/lt root caries s/r"ey o+
ssoc , :>$9:&=-&;.
:$&. #ensen, M. 3., g 2o,o/t, F. #. 7:;((8. 5,e e++ect o+ a +l/oridated denti+rice on
root and coronal caries in an older ad/lt o/lation. " m Dent ssoc , ::%9(>;-=>.
:$'. Ny"ad, 1., g FeAersko", O. 7:;(<8. Acti"e root s/r+ace caries con"erted into
:$<. 4allace, M. C., !etie+, D. H., g 1radley, 3. .. 7:;;=8. 5,e &(-mont, increment
o+ root caries in an /r-an o/lation o+ older ad/lts articiatin* in a re"enti"e
dental ro*ram. " Pu4 Health Dent , '=9:==-=%.
:$%. Stookey, G. 2. 7:;;$8. Critical e"al/ation o+ t,e comosition and /se o+ toical
+l/orides. " Dent Res , <;9($'-:>.
:$(. Stookey, G. 2., !odl/n, C. A., 4arrick, #. M., g Miller, C. H. 7:;(;8.
)ro+essional toical +l/oride systems "s root caries in ,amsters. " Dent Res, <(9=%>,
A-str. :'>:.
:$;. )etersson, .. G. 7:;;=8. Fl/oride mo/t,rinses and +l/oride "arnis,es. Caries Res ,
>% 7S/l. :89='-&>.
::$. )etterson, .. G., Art,/rsson, .., Ost-er*, C., #onsson, G., g Gleer/, A. 7:;;:8.
Carries-in,i-itin* e++ects o+ di++erent modes o+ D/ra,at "arnis, realication9 A =-
year radio*ra,ic st/dy. Caries Res , >'9%$-%=.
:::. 4einstein, )., Domoto, )., 2oday, M., g .ero/0, 1. 7:;;&8. !es/lts o+ a
romisin* trial to re"ent -a-y -ottle toot, decay9 A +l/oride "arnis, st/dy. " Dent
Child , <:9==(-&:.
::>. S,o-,a, 5., Nandlal, 1., )ra-,akar, A. !., g S/d,a, ). 7:;(%8. Fl/oride "arnis,
"ers/s acid/lated ,os,ate +l/oride +or sc,ool c,ildren in Manial. " /nd Dent ssoc ,
';9:'%-<$.
::=. Sea, .., .eanen, 5., g Ha/sen, H. 7:;;'8. Fl/oride "arnis, "ers/s
acid/lated ,os,ate +l/oride *el9 A =-year clinical trial. Caries Res , >;9=>%-=$.
::&. 1iller, I. !., H/nter, 3. .., Feat,erstone, M. #., g Sil"erstone, .. M. 7:;($8.
3namel loss d/rin* a ro,yla0is olis, in "itro. " /nt ssoc Dent Child , ::9%-:>.
::'. Stookey, G. 2. 7:;%(8. /n vitro estimates o+ enamel and dentin a-rasion
associated wit, a ro,yla0is. " Dent Res , '%9=<.
::<. 6r-ic, 6., 1r/de"old, F., g McCann, H. G. 7:;<%8. Ac?/isition o+ +l/oride -y
enamel +rom +l/oride /mice astes. Helv +dont cta , ::9>:-><.
::%. 6r-ic, 6., g 1r/de"old, F. 7:;%$8. Fl/oride /take +rom treatment wit, di++erent
+l/oride ro,yla0is astes and +rom t,e /se o+ astes containin* a sol/-le al/min/m
salt +ollowed -y toical alication. Caries Res , &9:'(-<%.
::(. 1i--y, 1. G. 7:;&'8. 5est o+ t,e e++ect o+ +l/oride-containin* denti+rices on
dental caries. " Dent Res, >&9>;%-=$=.
::;. Gers,on, S. D., g )ader, M. 7:;%>8. Denti+rices, In 1alsam H., g Sa*arin H.,
3ds. Cosmetics, science and technolo$y 7>nd ed.8 7. &>=-'=:8. New Hork9 4iley.
:>$. M/,ler, #. C., Hine, M. 2., g Day, H. G. 7:;'&8. Preventive dentistry. St. .o/is9
Mos-y.
:>:. 6ole, A. !. 7:;(>8. Denti+rices and mo/t, rinses. In Caldwell, !. C., g
Stallard, !. 3., 3ds. text4oo* of preventive dentistry. ),iladel,ia9 4.1. Sa/nders.
:>>. 4ei, S. H. H. 7:;%&8. 5,e otential -ene+its to -e deri"ed +rom toical +l/orides
in +l/oridated comm/nities. In Forrester, D. #., g Sc,/l@, 3. M. #r., 3ds. International
4orks,o on Fl/oride and Dental Caries !ed/ctions. 1altimore9 Uni"ersity o+
Maryland, . :%(->':.
:>=. Stookey, G. 2. 7:;(=8. Are all +l/oride denti+rices t,e samee In 4ei, S. H. H.,
3d. Clinical uses of fluorides. ),iladel,ia9 .ea g Fe-i*er. . :$'-:=:.
:>&. M/,ler, #. C., !adike, A. 4., Ne-er*all, 4. H., g Day, H. G. 7:;'&8. 5,e e++ect
o+ a stanno/s +l/oride-containin* denti+rice on caries red/ction in c,ildren. " Dent
Res, ==9<$<-:>.
:>'. 1eiswan*er, 1. 1., Gis,, C. 4., g Mallatt, M. 3. 7:;(:8. 3++ect o+ a sodi/m
+l/oride-silica a-rasi"e denti+rice /on caries. Pharmacol Ther Dent , <9;-:<.
:><. Iac,erl, 4. A. 7:;(:8. A t,ree-year clinical caries e"al/ation o+ t,e e++ect o+ a
sodi/m +l/oride-silica a-rasi"e denti+rice. Pharmacol Ther Dent , <9:-%.
:>%. Fo*els, H. !., Meade, #. #., Gri++it,, #., Mira?li/olo, !., g Cancro, .. ). 7:;((8.
A clinical in"esti*ation o+ a ,i*,-le"el +l/oride denti+rice. SDC " Dent Child ,
''7=89>:$-:'.
:>(. Conti, A. #., .ot@kar, S., Daley, !., Cancro, .., Marks, !. G., g Menkal, D. !.
7:;((8. A =-year clinical trial to comare e++icacy o+ denti+rices containin* :.:&E and
$.%<E sodi/m mono+l/oro,os,ate. Comm Dent +ral !pidemiol , :<7=89:='-=(.
:>;. Ste,en, 2. 4., !/ssell, #. I., Creanor, S. .., g 1/rc,ell, C. 2. 7:;(%8.
Comarison o+ +i-er otic transill/mination wit, clinical and radio*ra,ic caries
dia*nosis. Comm Dent +ral !pidemiol , :'7>89;$-;&.
:=$. S@/nar, S. M., g 1/rt, 1. A. 7:;(%8. 5rends in t,e re"alence o+ dental
+l/orosis in t,e United States9 A re"iew. " Pu4 Health Dent , &%9%:-%;.
:=:. Hei+et@, S. 1., Driscoll, 4. S., Horowit@, H. S., et al. 7:;((8. )re"alence o+
dental caries and dental +l/orosis in areas wit, otimal and a-o"e-otimal water
+l/oride concentrations. " m Dent ssoc , ::<9&;$-;'.
:=>. )endrys, D. G., g Stamm, #. 4. 7:;;$8. !elations,i o+ total +l/oride intake to
-ene+icial e++ects and enamel +l/orosis. " Dent Res , <;7Secial Iss/e89'>;-=(.
:==. 1r/nelle, #. A. 7:;(;8. 5,e re"alence o+ dental +l/orosis in U.S c,ildren. " Dent
Res, <(7Secial Iss/e89;;'. A-str.
:=&. U.S. Deartment o+ Healt, and H/man Ser"ices 7:;(;8. Oral ,ealt, o+ United
States c,ildren. 5,e national s/r"ey o+ dental caries in U.S. sc,oolc,ildren9 :;(<-
:;(% national and re*ional +indin*s. NIH )/-. No. (;->>&%.
:='. .arsen, M. #., !ic,ards, A., g FeAersko", O. 7:;('8. De"eloment o+ dental
+l/orosis accordin* to a*e at start o+ +l/oride administration. Caries Res , :;9':;->%.
:=<. ten Cate, A. !. 7:;('8. +ral histolo$ydevelopment, structure and function. St.
.o/is9 Mos-y.
:=%. 3"ans, !., g Dar"ell, 1. 7:;;'8. !e+inin* t,e estimate o+ t,e critical eriod +or
s/sceti-ility to enamel +l/orosis in ,/man ma0illary central incisors. " Pu4 Health
Dent , ''9>=(-&;.
:=(. 1eltran, 3. D., g S@/nar, S. M. .. 7:;((8. Fl/oride in toot,aste +or c,ildren9
S/**estion +or c,an*e. Pediatr Dent , :$9:('-((.
:=;. Os/Ai, O. O., .eake, M. .., C,iman, G., Niki .or/k, G., .ocker, D., g .e"ine,
N. 7:;((8. !isk +actors +or dental +l/orosis in a +l/oridated comm/nity. " Dent Res ,
<%9:&((-;>.
:&$. 1eiswan*er, 1. 1., g Stookey, G. 2. 7:;(;8. 5,e comarati"e clinical cariostatic
e++icacy o+ sodi/m +l/oride and sodi/m mono+l/oro,os,ate denti+rices9 A re"iew o+
trials. " Dent Child , '<9==%-&%.
:&:. Stookey, G. 2., De)aola, ). F., Feat,erstone, #. D. 1., FeAersko", O., Mollen, I.
#., !ot-er*, S., Ste,en, 2. 4., g 4e+el, #. S. 7:;;=8. A critical re"iew o+ t,e relati"e
anticaries e++icacy o+ sodi/m +l/oride and sodi/m mono+l/oro,os,ate denti+rices.
Caries Res , >%9==%-<$.
:&>. 1owen, 4. H. 7:;;&8. !elati"e e++icacy o+ sodi/m +l/oride and sodi/m
mono+l/oro,os,ate as anti-caries a*ents in denti+rices. .ondon9 5,e !oyal Society
o+ Medicine )ress .td.
:&=. #o,nson, M. F. 7:;;=8. Comarati"e e++icacy o+ NaF and MF) denti+rices in
caries re"ention9 A meta-analytic o"er"iew. Caries Res , >%9=>(-=<.
:&&. Glass, !. .., Sc,einin, A., g 1armes, D. 3. 7:;(:8. C,an*in* caries re"alence
in two c/lt/res. " Dent Res, <$7Secial Iss/e A89 =<:, A-str. >$>.
:&'. Iac,erl, 4. A., g .on*, D. M. 7:;%;8. !ed/ction in caries attack
ratenon+l/oridated comm/nity. " Dent Res, '(7Secial Iss/e A89 >>%, A-str. '='.
:&<. 1i0ler, D., g M/,ler, #. C. 7:;<<8. 3++ect on dental caries in c,ildren in a
non+l/oride area o+ com-ined /se o+ t,ree a*ents containin* stanno/s +l/oride9 A
ro,ylactic aste, a sol/tion, and a denti+rice. II. !es/lts at t,e end o+ >& and =<
mont,s. " m Dent ssoc, %>9=;>-;<.
:&%. Gis,, C. 4., g M/,ler, #. C. 7:;<'8. 3++ect on dental caries in c,ildren in a
nat/ral +l/oride area o+ com-ined /se o+ t,ree a*ents containin* stanno/s +l/oride9 A
ro,ylactic aste, a sol/tion, and a denti+rice. " m Dent ssoc, %$9;:&->$ 7and
ersonal comm/nication8.
:&(. M/,ler, #. C., Sear, .. 1. #r., 1i0ler, D., g Stookey, G. 2. 7:;<%8. 5,e
arrestment o+ inciient dental caries in ad/lts a+ter t,e /se o+ t,ree di++erent +orms o+
SnF
>
t,eray9 !es/lts a+ter =$ mont,s. " m Dent ssoc , %'9:&$>-<.
:&;. O-ers@tyn, A., )iotrowski, I., 2owinski, 2., g 3kler, 1. 7:;%=8. Stanno/s
+l/oride in t,e ro,yla0is o+ caries in ad/lts. C1as Stomat , ><9::(:-(%.
:'$. Scola, F. )., g Ostrom, C. A. 7:;<(8. Clinical e"al/ation o+ stanno/s +l/oride
w,en /sed as a constit/ent o+ a comati-le ro,ylactic aste, as a toical sol/tion,
and in a denti+rice in na"al ersonnel. II. !eort o+ +indin*s a+ter two years. " m
Dent ssoc , %%9';&-;%.
:':. Scola, F. ). 7:;%$8. Sel+-rearation stanno/s +l/oride ro,ylactic tec,ni?/e in
re"enti"e dentistry9 !eort a+ter two years. " m Dent ssoc , (:9:=<;-%>.
:'>. 1eiswan*er, 1. 1., 1illin*s, !. #., St/r@en-er*er, O. )., g 1ollmer, 1. 4.
7:;%(8. 3++ect o+ an SnF
>
Ca
>
)
>
O
%
denti+rice and A)F toical alications. " Dent
Child , &'9:=%-&:.
:'=. Downer, M. C., Holloway, ). #., g Da"ies, 5. G. H. 7:;%<8. Clinical testin* o+ a
toical +l/oride caries re"ention ro*ram. #r Dent " , :&:9>&>-&%.
:'&. Mainwarin*, ). #., g Naylor, N. M. 7:;%(8. A t,ree-year clinical st/dy to
determine t,e searate and com-ined caries-in,i-itory e++ects o+ sodi/m
mono+l/oro,os,ate toot,aste and an acid/lated ,os,ate +l/oride *el. Caries
Res , :>9>$>-:>.
:''. 1irkeland, #. M., 1roc,, .., g #orkAend, #. 7:;%%8. 1ene+its and ro*noses
+ollowin* :$ years o+ a +l/oride mo/t,rinsin* ro*ram. Scand " Dent Res , ('9=:-=%.
:'<. 1irkeland, #. M., g 5orell, ). 7:;%(8. Caries-re"enti"e +l/oride mo/t,rinses.
Caries Res , :>7S/l. :89=(-':.
:'%. !eorts on Co/ncils and 1/rea/s, Co/ncil on Dental 5,erae/tics, American
Dental Association 7:;%'8. Co/ncil classi+ies +l/oride mo/t,rinses. " m Dent ssoc ,
;:9:>'$-'>.
:'(. 5orell, )., g 3ricsson, H. 7:;%&8. 5,e otential -ene+its to -e deri"ed +rom
+l/oride mo/t,-rinses. In Forrester, D. #., g Sc,/l@, 3. M. #r, 3ds. International
4orks,o on Fl/orides and Dental Caries !ed/ctions. 1altimore9 Uni"ersity o+
Maryland, . ::=-:%<.
:';. Hei+et@, S. 1., Franc,i, G. #., Mosley, G. 4., MacDo/*all, O., g 1r/nelle, #.
7:;%;8. Com-ined anticario*enic e++ect o+ +l/oride *el-trays and +l/oride
mo/t,rinsin* in an otimally +l/oridated comm/nity. " Clinic Prevent Dent <9>:->=.
:<$. !adike, A. 4., Gis,, C. 4., )eterson, #. 2., 2in*, #. D., g Ie*reto, 6. A.
7:;%=8. Clinical e"al/ation o+ stanno/s +l/oride as an anticaries mo/t,rinse. " m
Dent ssoc , (<9&$&-(.
:<:. Driscoll, 4. S., Swan*o, ). A., Horowit@, A. M., g 2in*man, A. 7:;(:8. Caries-
re"enti"e e++ects o+ daily and weekly +l/oride mo/t,rinsin* in an otimally
+l/oridated comm/nity9 Findin*s a+ter :( mont,s. Pediatr Dent , =9=:<->$.
:<>. #ones, #. C., M/r,y, !. F., g 3dd, ). A. 7:;%;8. Usin* ,ealt, ed/cation in a
+l/oride mo/t,rinse ro*ram9 5,e /-lic ,ealt, ,y*ienistCs role. Dent Hy$ , '=9&<;-%=.
:<=. 2awall, 2., .ewis, D. 4., g Har*rea"es, #. A. 7:;(:8. 5,e e++ect o+ a +l/oride
mo/t,rinse in an otimally +l/oridated comm/nity+inal two year res/lts. " Dent
Res, <$7Secial Iss/e A89&%:. A-str. <&<.
:<&. As,ley, F. )., Mainwarin*, ). F., 3mslie, !. D., g Naylor, M. N. 7:;%%8.
Clinical testin* o+ a mo/t,rinse and a denti+rice containin* +l/oride. A two-year
s/er"ised st/dy in sc,ool c,ildren. #r Dent " , :&=9===-=(.
:<'. 5riol, C. 4., Fran@, S. M., 6ole, A. !., Frankl, N., Alman, #. 3., g Allard, !. ..
7:;($8. Anticaries e++ect o+ a sodi/m +l/oride rinse and an MF) denti+rice in a
non+l/oridated water area. A t,irty-mont, st/dy. Clin Prev Dent , >9:=-:'.
:<<. 1link,orn, A. S., Holloway, ). #., g Da"ies, 5. G. H. 7:;%%8. 5,e com-ined
e++ect o+ a +l/oride mo/t,rinse and denti+rice in t,e control o+ dental caries. " Dent
Res, '<7Secial Iss/e D89D:::.
:<%. !in*el-er*, M. .., 4e-ster, D. 1., Di0on, D. O., g .e@otte, D. C. 7:;%;8. 5,e
caries-re"enti"e e++ect o+ amine +l/orides and inor*anic +l/orides in a mo/t,rinse or
denti+rice a+ter =$ mont,s o+ /se. " m Dent ssoc , ;(9>$>-(.
:<(. Horowit@, H. S., Hei+et@, S. 1., Meyers, !. #., Driscoll, 4. S., g 2orts, D. C.
7:;%;8. 3"al/ation o+ a com-ination o+ sel+-administered +l/oride roced/res +or t,e
control o+ dental caries in a non+l/oride area9 Findin*s a+ter +o/r years. " m Dent
ssoc , ;(9>:;->=.
:<;. Skart"eit, .., 4e+el, #. S., g 3kstrand, #. 7:;;:8. 3++ect o+ +l/oride amal*ams on
arti+icial rec/rrent enamel and root caries. Scand " Dent Res , ;;9>(%-;&.
:%$. Donly, 2. #. 7:;;'8. 3namel and dentin deminerali@ation in,i-ition o+ +l/oride-
releasin* materials. m " Dent, %9>%'-%(.
:%:. 3rickson, !. .., g Glassoole, 3. A. 7:;;'8. Model in"esti*ations o+ caries
in,i-ition -y +l/oride-releasin* dental materials. dv Dent Res , ;9=:'->=.
:%>. ten Cate, #. M., g "an D/inen, !. N. 1. 7:;;'8. Hyer-minerali@ation o+ dentinal
lesions adAacent to *lass-ionomer cement restorations. " Dent Res , %&9:><<-%:.
:%=. Donly, 2. #., Se*/ra, A., 2anellis, M., g 3rickson, !. .. 7:;;;8. Clinical
er+ormance and caries in,i-ition o+ resin-modi+ied *lass ionomer cement and
amal*am restorations. "D :=$9:&';-<<.
:%&. !awls, H. !. 7:;;:8. )re"enti"e dental materials9 s/stained deli"ery o+ +l/oride
and ot,er t,erae/tic a*ents. dv Dent Res , '9'$-<.
:%'. #ones, D. 4., #ackson, G., S/ttow, 3. #., Hall, A. C., g #o,nson, #. 7:;((8.
Fl/oride release and +l/oride /take -y *lass ionomer materials 7a-stract <%>8. " Dent
Res, <%7A89:;%.
:%<. Marinelli, C. 1., Donly, 2. #., 4e+el, #. S., #ako-sen, #. !., g Dene,y, G. 3.
7:;;%8. An in "itro comarison o+ t,ree +l/oride re*imens on enamel reminerali@ation.
Caries Res , =:9&:(->>.
:%%. 1yn/m, A. M., g Donly, 2. #. 7:;;;8. 3namel deBreminerali@ation on teet,
adAacent to +l/oride releasin* materials wit,o/t denti+rice e0os/re. SDC " Dent
Child , <<9(;-;>.
:%(. Donly, 2. #., Se*/ra, A., 4e+el, #. S., g Ho*an, M. M. 7:;;;8. 3"al/atin* t,e
e++ects o+ +l/oride-releasin* dental materials on adAacent interro0imal caries. "D ,
:=$9(:%->'.
:%;. Hei+et@, S. 1., g Horowit@, H. S. 7:;(<8. 5,e amo/nts o+ +l/oride in c/rrent
+l/oride t,eraiesD sa+ety considerations +or c,ildren. " Dent Child , %%9(%<-(>.
:($. Mel"or, M. 3. 7:;(%8. Delayed +atal ,yerkalemia in a atient wit, ac/te
+l/oride into0ication. nn !mer$ %ed , :<9::<'-<%.
:(:. Deartment o+ Healt, and H/man Ser"ices 7:;;:8. U.S. )/-lic Healt, Ser"ice.
!eort o+ t,e Ad Hoc S/-committee to Coordinate 3n"ironmental Healt, and !elated
)ro*rams. !e"iew o+ Fl/oride 1ene+its and !isks. 4as,in*ton, DC9 U.S. Deartment
o+ Healt, and H/man Ser"ices.
:(>. 4,it+ord, G. M. 7:;(%8. Fl/oride in dental rod/cts9 Sa+ety considerations. "
Dent Res , <<9:$'<-<$.
:(=. New-r/n, 3. 7:;;>8. C/rrent re*/lations and recommendations concernin* water
+l/oridation, +l/oride s/lements, and toical +l/oride a*ents. " Dent Res, <%9:>''-
<'.
:(&. 2eels, M. A., Oster,o/t, S., g 6ann, 4. F. #r. 7:;((8. Incidence and nat/re o+
accidental +l/oride in*estions. " Dent Res, <%7Secial Iss/e89=='. A-str. :%%(.
:('. 4,it+ord, G. M. 7:;;>8. Ac/te and c,ronic +l/oride to0icity. " Dent Res ,
%:9:>&;-'&.
reser"ed.
Chapter 10. Pit-and-Fissure Sealants - 'ran*lin 0arcia20odoy &orman +, Harris
Denise %uesch Helm
Objectives
:. 30lain ,ow sealants can ro"ide a rimary re"enti"e means o+ red/cin* t,e need
+or oerati"e treatment as %%E o+ t,e c,ildren :> to :% years old in t,e United States
,a"e dental caries in t,eir ermanent teet,.
:
>. Disc/ss t,e ,istory o+ sealant de"eloment t,ro/*, t,e >$t, cent/ry.
=. .ist t,e criteria +or selectin* teet, +or sealant lacement and t,e +o/r essentials in
attainin* ma0im/m retention o+ sealants.
&. Descri-e t,e se"eral stes reliminary to, d/rin*, and a+ter t,e lacement o+ a
sealantincl/din* s/r+ace cleanliness, dry +ields, details o+ t,e alication roced/re,
and remedial meas/res +ollowin* t,e e0cess alication o+ sealant.
'. 30lain t,e rationale +or addin* +l/orides to sealants.
<. Comare t,e ad"anta*es and disad"anta*es o+ li*,t-c/red and sel+-c/red sealants.
%. Disc/ss t,e ad"anta*es o+ rotectin* t,e occl/sal s/r+aces o+ teet, wit, sealants.
(. Cite +i"e reasons *i"en +or t,e /nder/se o+ sealants -y ractitioners and analy@e t,e
"alidity o+ t,e reasons.
Introduction
Fl/orides are ,i*,ly e++ecti"e in red/cin* t,e n/m-er o+ cario/s lesions occ/rrin* on
t,e smooth surfaces o+ enamel and cement/m. Un+ort/nately, +l/orides are not
e?/ally e++ecti"e in rotectin* t,e occl/sal its and +iss/res, w,ere t,e maAority o+
cario/s lesions occ/r.
>
Considerin* t,e +act t,at t,e occl/sal s/r+aces constit/te only
:>E o+ t,e total n/m-er o+ toot, s/r+aces, it means t,at t,e pits and fissures are
approximately ei$ht times as vulnera4le as the smooth surfaces, 5,e lacement o+
sealants is a ,i*,ly e++ecti"e means o+ re"entin* t,ese.
=
Historically se"eral a*ents ,a"e -een tried to rotect dee its and +iss/res on
occl/sal s/r+aces.
In :(;', 4ilson reorted t,e lacement o+ dental cement in its and +iss/res to
re"ent caries.
>
In :;>;, 1odecker
&
s/**ested t,at dee +iss/res co/ld -e -roadened
wit, a lar*e ro/nd -/r to make t,e occl/sal areas more sel+-cleansin*, a roced/re
t,at is called enameloplasty,
'
5wo maAor disad"anta*es, ,owe"er, accomany
enamelolasty. First, it re?/ires a dentist, w,ic, immediately limits its /se. Second, in
modi+yin* a dee +iss/re -y t,is met,od, it is o+ten necessary to remo"e more so/nd
toot, str/ct/re t,an wo/ld -e re?/ired to insert a small restoration.
In :;>= and a*ain in :;=<, Hyatt
<
ad"ocated t,e early insertion o+ small restorations
in dee its and +iss/res -e+ore cario/s lesions ,ad t,e oort/nity to de"elo. He
termed t,is roced/re prophylactic odontotomy. A*ain, t,is oeration is more o+ a
treatment roced/re t,an a re"enti"e aroac,, -eca/se it re?/ires a dentist +or t,e
c/ttin* o+ toot, str/ct/re.
Se"eral met,ods ,a"e -een /ns/ccess+/lly /sed in an attemt eit,er to seal or to
make t,e +iss/res more resistant to caries. 5,ese attemts ,a"e incl/ded t,e /se o+
toically alied @inc c,loride and otassi/m +errocyanide
%
and t,e /se o+
ammoniacal sil"er nitrateD
(
t,ey ,a"e also incl/ded t,e /se o+ coer amal*am acked
into t,e +iss/res.
;
Fl/orides t,at rotect t,e smoot, s/r+aces o+ t,e teet, are less e++ecti"e in rotectin*
t,e occl/sal s/r+aces.
:$
Followin* t,e /se o+ +l/orides, t,ere is a lar*e red/ction o+
incidence in smoot,-s/r+ace caries -/t a smaller red/ction in occl/sal it-and-+iss/re
caries. 5,is res/lts in an increased proportion in t,e ratio o+ occl/sal to interro0imal
lesions, e"en t,o/*, t,e total n/m-er may -e less.
A +inal co/rse o+ action to deal wit, it-and-+iss/re caries is one t,at is o+ten /sed9
do nothin$8 3ait and 3atch, 5,is otion a"oids t,e need to c/t *ood toot, str/ct/re
/ntil a de+inite cario/s lesion is identi+ied. It also res/lts in many teet, -ein* lost
w,en indi"id/als do not ret/rn +or eriodic e0ams. 5,is aroac,, alt,o/*, +re?/ently
/sed is a "iolation o+ t,e et,ical rincile o+ -ene+icence and atient a/tonomy.
In t,e late :;<$s and early :;%$s, anot,er otion -ecame a"aila-let,e /se o+ it-
and-+iss/re sealants.
::
4it, t,is otion, a li?/id resin is +lowed o"er t,e occl/sal
s/r+ace o+ t,e toot, w,ere it enetrates t,e dee +iss/res to +ill areas t,at cannot -e
cleaned wit, t,e toot,-r/s, 7Fi*/re :$-:8.
:>
5,e ,ardened sealant resents a -arrier
-etween t,e toot, and t,e ,ostile oral en"ironment. Conc/rrently, t,ere is a
si*ni+icant red/ction o+ Stretococc/s m/tans on t,e treated toot, s/r+ace.
:=
)its and
+iss/res ser"e as reser"oirs +or m/tans stretococci, sealin* t,e nic,e t,ere-y red/ces
t,e oral co/nt.
Fi*/re :$-: One o+ t,e reasons t,at '$E o+ t,e cario/s lesions occ/r on t,e
occl/sal s/r+ace. Note t,at t,e toot,-r/s, -ristle ,as a *reater diameter t,an t,e
widt, o+ t,e +iss/re. 7Co/rtesy o+ Dr. #. McC/ne, #o,nson g #o,nson.8
Criteria for Selecting Teeth for Sealant Placement
Followin* are t,e criteria +or selectin* teet, +or sealin*. 1eca/se no ,arm can occ/r
+rom sealin*, w,en in do/-t, seal and monitor,
A dee occl/sal +iss/re, +ossa, or incisal lin*/al it is resent.
A sealant is contraindicated if:
)atient -e,a"ior does not ermit /se o+ ade?/ate dry-+ield tec,ni?/es t,ro/*,o/t t,e
roced/re.
An oen cario/s lesion e0ists.
Caries e0ist on ot,er s/r+aces o+ t,e same toot, in w,ic, restorin* will disr/t an
intact sealant.
A lar*e occl/sal restoration is already resent.
A sealant is probably indicated if:
5,e +ossa selected +or sealant lacement is well isolated +rom anot,er +ossa wit, a
restoration.
5,e area selected is con+ined to a +/lly er/ted +ossa, e"en t,o/*, t,e distal +ossa is
imossi-le to seal d/e to inade?/ate er/tion.
An intact occl/sal s/r+ace is resent w,ere t,e contralateral tooth s/r+ace is cario/s
or restoredD t,is is -eca/se teet, on oosite sides o+ t,e mo/t, are /s/ally e?/ally
rone to caries.
An incipient lesion e0ists in t,e it-and-+iss/re.
Sealant material can -e +lowed o"er a conser"ati"e class I comosite or amal*am to
imro"e t,e mar*inal inte*rity, and into t,e remainin* its and +iss/res to ac,ie"e a
de facto e0tension +or re"ention.
Other Considerations in Tooth Selection
All teet, meetin* t,e re"io/s criteria s,o/ld -e sealed and resealed as needed. 4,ere
t,e cost--ene+it is critical and riorities m/st -e esta-lis,ed, s/c, as occ/rs in many
/-lic ,ealt, ro*rams, a*es = and & years are t,e most imortant times +or sealin*
t,e eli*i-le decid/o/s teet,D a*es < to % years +or t,e +irst ermanent molarsD
:&
and
a*es :: to := years +or t,e second ermanent molars and remolars.
:'
C/rrently, %%E
o+ t,e c,ildren :>-to-:%-years-old in t,e United States ,a"e dental caries in t,eir
ermanent teet,.
:
Many sc,ool days wo/ld -e sa"ed, and -etter dental ,ealt, wo/ld
-e ac,ie"ed in Sc,ool Dental Healt, Clinic ro*rams -y com-inin* sealant lacement
and re*/lar +l/oride e0os/re.
:<
The disease suscepti4ility of the tooth should 4e considered 3hen selectin$ teeth for
sealants, not the a$e of the individual, Sealants aear to -e e?/ally retained on
occl/sal s/r+aces in rimary, as well as ermanent teet,.
=
Sealants s,o/ld -e laced
on t,e teet, o+ ad/lts i+ t,ere is e"idence o+ e0istin* or imendin* caries
s/sceti-ility, as wo/ld occ/r +ollowin* e0cessi"e intake o+ s/*ar or as a res/lt o+ a
dr/*- or radiation-ind/ced 0erostomia. 5,ey s,o/ld also -e /sed in areas w,ere
+l/oride le"els in comm/nity water is otimi@ed, as well as in non-+l/oridated areas.
:%
5,e +ollowin* are two *ood ill/strations o+ t,is ,iloso,y. A+ter a =-year st/dy, !ia
and collea*/es
:(
concl/ded t,at t,e time t,e teet, ,ad -een in t,e mo/t, 7some +or %
to :$ years8 ,ad no e++ect on t,e "/lnera-ility o+ occl/sal s/r+aces to caries attack.
Also, t,e incidence o+ occl/sal caries in yo/n* Na"y
:;
and Air Force
>$
recr/its 7w,o
are /s/ally in t,eir late teens or early >$s8 is relati"ely ,i*,.
Background of Sealants
1/onocore +irst descri-ed t,e +/ndamental rinciles o+ lacin* sealants in t,e late
:;<$s.
:$,>:
He descri-es a met,od to -ond oly-met,ylmet,acrylate 7)MMA8 to
,/man enamel conditioned wit, ,os,oric acid. )ractical /se o+ t,is concet
,owe"er, was not reali@ed /ntil t,e de"eloment o+ -is,enol A-*lycidyl
met,acrylate 71is-GMA8, /ret,ane dimet,acrylates 7UDMA8 and trit,ylene *lycol
dimet,acrylates 753GDMA8 resins t,at ossess -etter ,ysical roerties t,an
)MMA. 5,e +irst s/ccess+/l /se o+ resin sealants was reorted -y 1/onocore in t,e
:;<$s.
>>
Bisphenol A-Glycidyl Methylacrylate Sealants
1is,enol A-*lycidyl met,ylacrylate 71is-GMA8 is now t,e sealant o+ c,oice. It is a
mi0t/re o+ 1is-GMA and met,yl met,acrylate.
>=
)rod/cts c/rrently acceted -y t,e
American Dental Association 7ADA8 incl/de9
>&
1aritone .=, 5ye II Confi-Dental Products Co.
Al,a-Dent C,emical C/re )it and Fiss/re Sealant Dental Technologies, Inc.
Al,a-Dent .i*,t C/re )it and Fiss/re Sealant Dental Technologies, Inc.
)risma-S,ield Com/les 5is 6.C 5inted )it g Fiss/re Sealant Dentsply L.D.
Caulk Division
)risma-S,ield 6.C Filled )it g Fiss/re Sealant Dentsply L.D. Caulk Division
Helioseal F, 5ye II Ivoclar-Vivadent, Inc.
Helioseal, 5ye II Ivoclar-Vivadent, Inc.
Seal-!ite .ow 6iscosity, 5ye II Pulpdent Corp.
Seal-!ite, 5ye II Pulpdent Corp.
5,e ADA National Standard sets aside seci+ic criteria o+ it-and-+iss/re sealants
statin*D Seci+ication No. =; esta-lis,ed t,e +ollowin* re?/irements9
5,at t,e workin* time +or tye I sealants is not less t,an &' secondsD
5,at t,e settin* time is wit,in =$ seconds o+ t,e man/+act/rerCs instr/ction and does
not e0ceed t,ree min/tesD
5,at t,e c/rin* time +or tye II sealants is not more t,e <$ secondsD
5,at t,e det, o+ c/re +or tye II sealant is not less t,an $.%' millimeterD
5,at t,e /nc/red +ilm t,ickness is not more t,an $.: millimeterD
5,at sealants meet t,e -icomati-ility re?/irements o+ American Nation a
StandardBAmerican Dental Association Doc/ment No. &: +or !ecommended Standard
)ractices +or 1iolo*ical 3"al/ation o+ Dental Materials.
>'
Sealant rod/cts acceted -y t,e American Dental Association carried t,e statement9
Fc)rod/ct named ,as -een s,own to -e acceta-le as an a*ent +or sealin* o++ an
anatomically de+icient re*ion o+ t,e toot, to s/lement t,e re*/lar ro+essional care
in a ro*ram o+ re"enti"e dentistry.F
><
N/"a-Seal was t,e +irst s/ccess+/l commercial sealant to -e laced on t,e market, in
:;%>. Since t,en more e++ecti"e second- and t,ird-*eneration sealants ,a"e -ecome
a"aila-le see 5a-le :$-:. 5,e +irst sealant clinical trials /sed cyanoacrylate--ased
materials. Dimet,acrylate--ased rod/cts relaced t,ese. 5,e rimary di++erence
-etween sealants is t,eir met,od o+ olymeri@ation. First-*eneration sealants were
initiated -y /ltra"iolet li*,t, second-*eneration sealants are a/toolymeri@ed, and
t,ird-*eneration sealants /se "isi-le li*,t.
Some sealants contain fillers, w,ic, makes it desira-le to classi+y t,e commercial
rod/cts into filled and unfilled sealants. 5,e filled sealants contain microscoic *lass
-eads, ?/art@ articles, and ot,er +illers /sed in comosite resins. 5,e +illers are
coated wit, rod/cts s/c, as silane, to +acilitate t,eir com-ination wit, t,e 1is-GMA
resin. 5,e +illers make t,e sealant more resistant to a4rasion and 3ear, 1eca/se t,ey
are more resistant to a-rasion t,e occl/sion s,o/ld -e c,ecked and t,e sealant ,ei*,t
may need to -e adA/sted a+ter lacement. In contrast, /n+illed sealants wear ?/icker
-/t /s/ally do not need occl/sal adA/stment.
Fluoride-Releasing Sealants
5,e addition o+ +l/oride to sealants was considered a-o/t >$ years a*o,
>%
and it was
ro-a-ly attemted -ased on t,e +act t,at t,e incidence and se"erity o+ secondary
caries 3as red/ced aro/nd +l/oride-releasin* materials s/c, as t,e silicate cements
/sed +or anterior restorations.
>(,>;
1eca/se +l/oride /take increases t,e enamelCs
resistance to caries,
=$
t,e /se o+ a +l/oridated resin--ased sealant may ro"ide an
additional anticario*enic e++ect i+ t,e +l/oride released +rom its matri0 is incororated
into t,e adAacent enamel.
Fl/oride-releasin* sealants ,a"e s,own anti-acterial roerties
=:-==
as well as a *reater
arti+icial caries resistance comared to a non+l/oridated sealant.
=&-=<
A recent in vitro
st/dy s,owed t,at it-and-+iss/re sealants containin* +l/oride ro"ided a caries-
in,i-itin* e++ect wit, a si*ni+icant red/ction in lesion det, in t,e s/r+ace enamel
adAacent and a red/ction in t,e +re?/ency o+ wall lesion.
=%
Moreo"er, t,e +l/oridated
sealant la-oratory -ond stren*t, to enamel,
=(
and clinical er+ormance,
=;,&$
is similar to
t,at o+ non+l/oridated sealants.
&:,&>
In a recent st/dy, it was s,own t,at teet, sealed
wit, 5eet,mate F +l/oridated sealant re"ealed ,i*, amo/nts o+ enamel +l/oride /take
in "itro and in "i"o to a det, ran*in* +rom :$ to >$ /m +rom t,e s/r+ace.
&=
5,e
resid/al +l/oride was also o-ser"ed wit,in t,e sealin* material. 5,is a*rees wit,
anot,er st/dy s,owin* t,e ,i*, amo/nt o+ +l/oride released +rom 5eet,mate F-:.
&&
5,e addition o+ +l/oride to t,e sealants will *reatly increase t,eir "al/e in t,e
re"enti"e and restorati"e /se as mentioned a-o"e. Fl/oride is added to sealants -y
two met,ods. 5,e +irst is -y addin* a sol/-le +l/oride to t,e /nolymeri@ed resin. 5,e
+l/oride can -e e0ected to leac, o/t o"er a eriod o+ time into t,e adAacent enamel.
3"ent/ally t,e +l/oride content o+ t,e sealant s,o/ld -e e0,a/sted, -/t t,e content o+
t,e enamel *reatly increased.
5,e second met,od o+ incororatin* +l/oride is -y t,e addition o+ an or*anic +l/oride
como/nd t,at is c,emically -o/nd to t,e resin to +orm an ion e0c,an*e resin. As
s/c,, w,en +l/oride is low in t,e sali"a, +l/oride wo/ld -e released. 6ice "ersa, w,en
t,e +l/oride in t,e en"ironment is ,i*,, it s,o/ld -ind to t,e resin to +ormat least
t,eoreticallya contin/o/s reser"oir +or +l/oride release and rec,ar*e.
&'
See 5a-le
:$-> on a*e >;> +or a list o+ c/rrent a"aila-le sealant materials.
Polymerization of the Sealants
5,e li?/id resin is called t,e monomer, 4,en t,e catalyst acts on t,e monomer,
reeatin* c,emical -onds -e*in to +orm, increasin* in n/m-er and comle0ity as t,e
,ardenin* rocess 7polymeri1ation8 roceeds. Finally, t,e res/ltant ,ard rod/ct is
known as a olymer. 5wo met,ods ,a"e -een emloyed to cataly@e olymeri@ation9
7:8 li*,t c/rin* -y /se o+ a "isi-le -l/e li*,t 7synonyms9 ,otoc/re, ,otoacti"ation,
li*,t acti"ation8 and 7>8 sel+-c/rin*, in w,ic, a monomer and a catalyst are mi0ed
to*et,er 7synonyms9 cold c/re, a/toolymeri@ation, and c,emical acti"ation8.
5,e two ori*inal Ca/lk rod/cts, N/"a-Seal and N/"a-Cote, were t,e only sealants in
t,e United States re?/irin* /ltra"iolet li*,t +or acti"ation. 1ot, ,a"e -een replaced -y
ot,er li*,t-c/red sealants t,at re?/ire visi4le 4lue li$ht, In t,e man/+act/re o+ t,ese
latter rod/cts, a catalyst, s/c, as camphoro5uinone, w,ic, is sensiti"e to "isi-le
-l/e-li*,t +re?/encies, is laced in t,e monomer at t,e time o+ man/+act/re. .ater,
w,en t,e monomer is e0osed to t,e "isi-le -l/e li*,t, olymeri@ation is initiated.
4it, t,e a/toolymeri@in* sealants, t,e catalyst is incororated wit, t,e monomerD in
addition, anot,er -ottle contains an initiator/s/ally 4en1oyl peroxide, 4,en t,e
monomer and t,e initiator are mi0ed, polymeri1ation -e*ins.
Light-Cured Versus Self-Cured Sealants
5,e main ad"anta*e o+ t,e li*,t-c/red sealant is t,at t,e oerator can initiate
olymeri@ation at any suita4le time, )olymeri@ation time is s,orter wit, t,e li*,t-
c/red rod/cts t,an wit, t,e sel+-c/rin* sealants. 5,e li*,t-c/red rocess does re?/ire
t,e /rc,ase o+ a li*,t so/rce, w,ic, adds to t,e e0ense o+ t,e roced/re. 5,is li*,t,
,owe"er, is t,e same one t,at is /sed +or olymeri@ation o+ comosite restorations,
makin* it a"aila-le in all dental o++ices. 4,en /sin* a li*,t-c/red sealant in t,e o++ice,
it is r/dent to store t,e rod/ct away +rom -ri*,t o++ice li*,tin*, w,ic, can
sometimes initiate olymeri@ation.
Con"ersely, t,e sel+-c/rin* resins do not re?/ire an e0ensi"e li*,t so/rce. 5,ey do,
,owe"er, ,a"e t,e *reat disad"anta*e t,at once mi0in* ,as commenced, i+ some
minor ro-lem is e0erienced in t,e oeratin* +ield, t,e oerator m/st eit,er contin/e
mi0in* or sto and make a new mi0. For t,e a/toolymeri@in* resin, t,e time allowed
+or sealant mani/lation and lacement must not 4e exceeded, e"en t,o/*, t,e
material mi*,t still aear li?/id. Once t,e ,ardenin* -e*ins, it occurs very rapidly,
and any manipulation of the material durin$ this critical time 7eopardi1es retention,
5,e li*,t-c/red sealants ,a"e a ,i*,er comressi"e stren*t, and a smoot,er s/r+aceD
&<

w,ic, is ro-a-ly ca/sed -y air -ein* introd/ced into t,e sel+-c/re resins d/rin*
mi0in*
&%
Desite t,ese di++erences, -ot, t,e ,otoc/red and t,e a/toolymeri@in*
rod/cts aear to -e e?/al in retention.
&=,&(-'$
The High-Intensity Light Source
5,e li*,t-emittin* de"ice consists o+ a ,i*,-intensity 3hite li$ht, a -l/e +ilter to
rod/ce t,e desired 4lue color, /s/ally -etween &$$ to '$$ nm, and a li*,t-
cond/ctin* rod. Some ot,er systems consist o+ a -l/e li*,t rod/ced -y li*,t-emittin*
diodes 7.3D8 7Fi*/re :$->8. Most ,a"e timers +or a/tomatically switc,in* o++ t,e
li*,ts a+ter a redetermined time inter"al. In /se, t,e end o+ t,e rod is ,eld only a +ew
millimeters a-o"e t,e sealant d/rin* t,e +irst :$ seconds, a+ter w,ic, it can -e rested
on t,e ,ardened s/r+ace o+ t,e artially olymeri@ed sealant. 5,e time re?/ired +or
olymeri@ation is set 4y the manufacturer and is /s/ally aro/nd <: to A: seconds. 5,e
depth o+ c/re is in+l/enced -y t,e intensity of li$ht, w,ic, can di++er *reatly wit,
di++erent rod/cts and len*t, o+ e0os/re. O+ten it is desira-le to set t,e a/tomatic
li*,t timer +or lon*er t,an t,e man/+act/rerCs instr/ctions.
':
3"en a+ter cessation o+
li*,t e0os/re, a +inal, slow olymeri@ation can continue o"er a >&-,o/r eriod.
'>
It is not known w,et,er lon*-term e0os/re to t,e intense li*,t can dama*e t,e eye.
Starin* at t,e li*,ted oeratin* +ield is /ncom+orta-le and does rod/ce a+terima*es.
5,is ro-lem is circ/m"ented -y t,e /se o+ a ro/nd, &-inc, dark-yellow disk, w,ic,
+its o"er t,e li*,t ,o/sin*. 5,e disk +ilters o/t t,e intense -l/e li*,t in t,e &$$- to
'$$-nanometers ran*e as well as -ein* s/++iciently dark to s/-d/e ot,er li*,t
+re?/encies.
Fi*/re :$-> .i*,t emittin* diode 7.3D8 c/rin* /nit +or direct, intraoral
e0os/re.
Question 1
A. In an area wit, +l/oridated water, a lo3er incidence o+ caries can -e e0ected,
alon* wit, a lo3er proportion o+ occl/sal to smoot,-s/r+ace lesions.
1. Sealants s,o/ld never -e +lowed o"er inciient caries.
C. 1is-GMA are t,e initials /sed to seci+y t,e c,emical +amily o+ resins containin*
-is,enol A-*lycidyl met,yl-acrylate.
D. A monomer can olymeri@e, -/t a olymer cannot monomeri@e.
3. Sealants are contraindicated +or ad/lts.
Requisites for Sealant Retention
For sealant retention t,e s/r+ace o+ t,e toot, m/st 7:8 ,a"e a maximum surface area,
7>8 ,a"e deep, irre$ular pits and fissures, 7=8 -e clean, and 7&8 -e a4solutely dry at t,e
time o+ sealant lacement and /ncontaminated wit, sali"a resid/e. These are the four
commandments for successful sealant placement, and they cannot 4e violated,
Increasing the Surface Area
Sealants do not -ond directly to t,e teet,. Instead, t,ey are retained mainly -y
adhesive forces,
'=
5o increase t,e s/r+ace area, w,ic, in t/rn increases t,e ad,esi"e
otential, tooth conditioners 7also called etchants8, w,ic, are comosed o+ a =$ to
'$E concentration o+ ,os,oric acid, are laced on t,e occl/sal s/r+ace rior to t,e
lacement o+ t,e sealant.
'&
5,e etc,ant may -e eit,er in li5uid or $el +orm. 5,e +ormer
is easier to aly and easier to remo"e. 1ot, are e?/al in a-ettin* retention.
'','<
I+ any
etc,ed areas on t,e toot, s/r+ace are not co"ered -y t,e sealant or i+ t,e sealant is not
retained, t,e normal aearance o+ t,e enamel ret/rns to t,e toot, wit,in : ,o/r to a
+ew weeks due to a reminerali1ation +rom constit/ents in t,e sali"a.
'%
5,e etc,ant
s,o/ld -e care+/lly alied to a"oid contact wit, t,e so+t tiss/es. I+ not con+ined to t,e
occl/sal s/r+ace, t,e acid may rod/ce a mild in+lammatory resonse. It also rod/ces
a s,ar acid taste t,at is o+ten o-Aectiona-le.
Pit-and-Fissure Depth
Dee, irre*/lar its and +iss/res o++er a m/c, more +a"ora-le s/r+ace conto/r +or
sealant retention comared wit, -road, s,allow +ossae 7Fi*/re :$-=8. 5,e deeer
+iss/res rotect t,e resin sealant +rom t,e s,ear +orces occ/rrin* as a res/lt o+
masticatory mo"ements. O+ arallel imortance is t,e ossi-ility o+ caries
de"eloment increasin* as t,e fissure depth and slope o+ t,e inclined lanes
increases.
'(,';
5,/s, as the potential for caries increases, so does the potential for
sealant retention,
Fi*/re :$-= An electron scannin* microscoe "iew o+ t,e dee its and +iss/res
o+ t,e occl/sal s/r+ace o+ a molar. 7Co/rtesy o+ Dr. A. #. Gwinnett, State
Uni"ersity o+ New Hork, Stony 1rook.8
Surface Cleanliness
5,e need and met,od +or cleanin* t,e toot, s/r+ace rior to sealant lacement are
contro"ersial. Us/ally t,e acid etc,in* alone is s/++icient +or s/r+ace cleanin*. 5,is is
attested to -y t,e +act t,at two o+ t,e most cited and most e++ecti"e sealant lon*e"ity
st/dies -y Simonsen
<$
and Mert@-Fair,/rst
<:
were accomlis,ed wit,o/t /se o+ a rior
ro,yla0is. !ecently, ,owe"er, it was s,own t,at cleanin* teet, wit, t,e newer
ro,yla0is astes wit, or wit,o/t +l/oride 7N/)ro, 5oe08 did not a++ect t,e -ond
stren*t, o+ sealants,
<>
comosites,
<=
or ort,odontic -rackets.
Ot,er met,ods /sed to clean t,e toot, s/r+ace rior to lacin* t,e sealant incl/ded,
air-olis,in*, ,ydro*en ero0ide, and enamelolasty.
<=-<'
5,e /se o+ an air-olis,er
,as ro"en to t,oro/*,ly clean and remo"es resid/al de-ris +rom its and +iss/res.
<'-<(

Hydro*en ero0ide ,as t,e disad"anta*e t,at it rod/ces a reciitate on t,e enamel
s/r+ace.
<(
3namelolasty, ac,ie"ed -y -/r or air a-rasion ,as ro"en e++ecti"e. Het,
no si*ni+icant di++erences were o-ser"ed in comarison wit, eit,er etc,in* or -/r
rearation o+ t,e +iss/res on t,e enetration to t,e -ase o+ t,e sealant. Howe"er, t,e
/se o+ enamelolasty, e"en i+ e?/al or sli*,tly s/erior wo/ld ,a"e "ery serio/s
rami+ications. 5,e laws o+ most states re?/ire a dentist to /se air a-rasion andBor to
c/t a toot,, a re?/irement t,at wo/ld se"erely c/rtail ,y*ienists and assistants
articiation in o++ice and sc,ool re"enti"e dentistry ro*rams.
<;
4,ate"er t,e cleanin* re+erenceseit,er -y acid etc,in* or ot,er met,odsall
,ea"y stains, deosits, de-ris, and la?/e s,o/ld -e remo"ed +rom t,e occl/sal
s/r+ace -e+ore alyin* t,e sealant.
Preparing the Tooth for Sealant Application
5,e reliminary stes +or t,e li*,t-acti"ated and t,e a/toolymeri@ed resins are
similar / to t,e time o+ alication o+ t,e resin to t,e teet,. A+ter t,e selected teet,
are isolated, t,ey are t,oro/*,ly dried +or aro0imately C: seconds, 5,e :$-second
dryin* eriod can -e mentally estimated -y co/ntin* o++ t,e seconds:,$$$,
>,$$$/ntil :$,$$$ ,as -een reac,ed. 5,e li?/id etc,ant is t,en laced on t,e toot,
wit, a small resin son*e or cotton led*et ,eld wit, cotton liers. 5raditionally, t,e
etc,in* sol/tion is *ently da/-ed, not ru44ed, on t,e s/r+ace +or C minute +or
ermanent teet, and +or ::B> minutes +or decid/o/s teet,.
%$,%:
Ot,er clinical st/dies,
,owe"er, ,a"e s,own t,at acid etc,in* t,e enamel o+ -ot, rimary and ermanent
teet, +or only >$ seconds rod/ced similar sealant
%$
and comosite
%>
retention as t,ose
etc,ed +or : and ::B> min/tes. C/rrently, <: to A: seconds enamel-etc,in* time is
recommended. Alternati"ely, acid *els are alied wit, a s/lied syrin*e and le+t
/ndist/r-ed. Anot,er :' seconds o+ etc,in* is indicated +or +l/orosed teet, to
comensate +or t,e *reater acid resistance o+ t,e enamel. 5,e etc,in* eriod s,o/ld -e
timed wit, a cloc*, At t,e end o+ t,e etc,in* eriod, t,e asirator ti is ositioned
wit, t,e -e"el interosed 4et3een the cotton roll and the tooth, For :$ seconds t,e
water +rom t,e syrin*e is +lowed o"er t,e occl/sal s/r+ace and t,ence into t,e
asirator ti. A*ain, t,is :$-second eriod can -e mentally co/nted. Care s,o/ld -e
e0ercised to ens/re t,at t,e asirator ti is close eno/*, to t,e toot, to re"ent any
water +rom reac,in* t,e cotton rolls, yet not so close t,at it di"erts t,e stream o+ water
directly into t,e asirator 7see Fi*/re :$-'8.
Followin* t,e water +l/s,, t,e toot, s/r+ace is dried +or C: seconds, 5,e air s/ly
needs to -e a-sol/tely dry. 5,e dried toot, s/r+ace s,o/ld ,a"e a w,ite, d/ll, +rosty
aearance. 5,is is -eca/se t,e etc,in* will remo"e aro0imately ' to :$ /m o+ t,e
ori*inal s/r+ace,
%=
alt,o/*, at times interrod enetrations o+ / to :$$ /m may
occ/r.
%&
5,e etc,in* does not al3ays in"ol"e t,e interrod areasD sometimes t,e central
ortion o+ t,e rod is etc,ed, and t,e eri,ery is /na++ected. 5,e attern on any one
toot, is /nredicta-le.
%'
In any e"ent, t,e s/r+ace area is *reatly increased -y t,e acid
etc,.
Fi*/re :$-' S,owin* osition o+ asirator ti -etween t,e -ic/sid and cotton
roll d/rin* +l/s,in*, A, and -etween water +low and cotton roll looed aro/nd
second molar, B. Complete dryness o+ t,e cotton rolls can -e maintained wit,
t,is tec,ni?/e.
Question 2
A. A/toolymeri@in* sealants and li*,t-c/red sealants ,a"e aro0imately t,e same
record +or lon*e"ity.
1. A &$E ,os,oric acid etc,ant s,o/ld -e satis+actory +or -ot, etc,in* and
cleanin* t,e a"era*e toot, s/r+ace rior to sealant lacement.
C. Fossae wit, dee inclined lanes tend to ,a"e more cario/s +iss/resD +ossae wit,
dee inclined lanes tend to retain sealants -etter.
D. In st/dies in w,ic, a r/--er dam was /sed to maintain a dry +ield +or sealant
lacement, t,e retention o+ sealants was *reater t,an w,en cotton rolls were /sed.
3. In lacin* a sealant, :$ seconds are de"oted to eac, o+ t,e dryin* and etc,in*
,ases and : min/te to t,e +l/s,in* o+ t,e etc,ant +rom t,e toot,.
Dryness
5,e teet, must -e dry at t,e time o+ sealant lacement -eca/se sealants are
,ydro,o-ic. 5,e resence o+ sali"a on t,e toot, is e"en more detrimental t,an water
-eca/se its or*anic comonents interose a -arrier -etween t,e toot, and t,e sealant.
4,ene"er t,e teet, are dried wit, an air syrin*e, t,e air stream s,o/ld -e chec*ed to
ens/re t,at it is not moist/re-laden. Ot,erwise, s/++icient moist/re srayed on t,e
toot, will re"ent ad,esion o+ t,e sealant to t,e enamel. A c,eck +or moist/re can -e
accomlis,ed -y directin* t,e air stream onto a cool mo/t, mirrorD any +o**in*
indicates t,e resence o+ moist/re. )ossi-ly t,e omission o+ t,is simle ste acco/nts
+or t,e inter-oerator "aria-ility in t,e retention o+ +iss/re sealants.
A dry +ield can -e maintained in se"eral ways, incl/din* /se o+ a ru44er dam,
emloyment o+ cotton rolls, and t,e lacement o+ 4i4ulous pads o"er t,e oenin* o+
t,e arotid d/ct. 5,e r/--er dam ro"ides an ideal way to maintain dryness +or an
e0tended time. 1eca/se a r/--er dam is /s/ally emloyed in accomlis,in* ?/adrant
dentistry, sealant lacement +or t,e ?/adrant s,o/ld also -e accomlis,ed d/rin* t,e
oeration. Under most oeratin* conditions, ,owe"er, it is not +easi-le to aly t,e
dam to t,e di++erent ?/adrants o+ t,e mo/t,D instead it is necessary to emloy cotton
rolls, com-ined wit, t,e /se o+ an e++ecti"e hi$h2volume, lo32vacuum aspirator,
Under s/c, ro/tine oeratin* conditions, cotton rolls, wit, and wit,o/t t,e /se o+
-i-/lo/s ads, can /s/ally -e emloyed as e++ecti"ely as t,e dam +or t,e relati"ely
s,ort time needed +or t,e roced/re. The t3o most successful sealant studies have
used cotton rolls for isolation,
<$,<:
In one st/dy in w,ic, retention was tested /sin* a
r/--er dam "ers/s cotton rolls, t,e sealant retention was aro0imately e5ual,
%<

Ot,ers ,a"e s,own e0cellent sealant retention a+ter = years
%%
and a+ter :$ to >$
years.
<$,%(
In ro*rams wit, hi$h patient volume w,ere cotton rolls are /sed, it is -est to ,a"e
two indi"id/als in"ol"edt,e operator, w,ose main task is to reare t,e toot, and
to aly t,e sealant, and t,e assistant, w,ose task is to maintain dryness. An oerator
workin* alone, ,owe"er, can maintain a ma0im/m dry +ield +or t,e time needed to
lace t,e sealants, alt,o/*, it is not recommended, artic/larly +or yo/n* c,ildren or
t,ose t,at are di++ic/lt to mana*e. For t,e ma0illa, t,ere s,o/ld -e little ro-lem wit,
t,e lacement o+ cotton rolls in t,e -/ccal "esti-/le and, i+ desira-le, t,e lacement o+
a 4i4ulous pad o"er t,e arotid d/ct. For t,e mandi-le, a '-inc, se*ment o+ a <-inc,
cotton roll s,o/ld -e looed aro/nd t,e last molar and t,en ,eld in lace -y t,e
atient /sin* t,e inde0 and t,ird +in*ers o+ t,e oosite ,and +rom t,e side -ein*
worked on 7Fi*/re :$-&8. 4it, aid +rom t,e atient and wit, aroriate asiration
tec,ni?/es, t,e cotton rolls can /s/ally -e ket dry t,ro/*,o/t t,e entire roced/re.
Cotton roll ,olders may -e /sed, -/t t,ey can -e c/m-ersome w,en /sin* t,e
asirator or w,en attemtin* to mani/late or remo"e a roll. I+ a cotton roll does
-ecome sli$htly moist, many times anot,er s,ort cotton roll can -e laced on to o+
t,e moist se*ment and ,eld in lace +or t,e d/ration o+ t,e roced/re. In t,e e"ent t,at
it -ecomes necessary to relace a wet cotton roll, it is essential t,at no sali"a contacts
t,e etc,ed toot, s/r+aceD i+ t,ere is any do/-t, it is necessary to reeat all roced/res
/ to t,e time t,e dry +ield was comromised. 5,is incl/des a :'-second etc, to
remo"e any resid/al sali"a, in lie/ o+ t,e ori*inal :-min/te etc,.
Anot,er romisin* dry-+ield isolatin* de"ice t,at can -e /sed +or sin*le oerator /se,
esecially w,en /sed wit, cotton rolls, is -y /sin* eAector moist/re-control systems.
a

In one st/dy comarin* t,e 6ac-3Aector "ers/s t,e cotton roll +or maintainin*
dryness, t,e two were +o/nd to -e e?/ally e++ecti"e.
%;
a
4,aledent International, New Hork, NH
Fi*/re :$-& Fo/r-,anded dentistry wit, no assistant. 5,e atient ,olds t,e
cotton rolls wit, t,e inde0 and t,ird +in*er, t,/m- /nder c,in. )atient also ,olds
asirator wit, ot,er ,and w,en it is not -ein* /sed -y oerator.
Application of the Sealant
4it, eit,er t,e li*,t-c/red or a/toolymeri@ed sealants, t,e material s,o/ld +irst -e
laced in t,e +iss/res w,ere t,ere is t,e ma0im/m det,. At times enetration o+ t,e
+iss/re is ne*ated -y t,e resence o+ de-ris, air entrament, narrow ori+ices, and
e0cessi"e "iscosity o+ t,e sealant.
($
5,e sealant s,o/ld not only +ill t,e +iss/res -/t
s,o/ld ,a"e some 4ul* over the fissure, A+ter t,e +iss/res are ade?/ately co"ered, t,e
material is t,en -ro/*,t to a kni+e ed*e aro0imately half3ay / t,e inclined lane.
Followin* olymeri@ation, t,e sealants s,o/ld -e e0amined care+/lly 4efore
discontin/in* t,e dry +ield. I+ any "oids are e"ident, additional sealant can -e added
3ithout t,e need +or any additional etc,in*. 5,e ,ardened sealant ,as an oil resid/e
on t,e s/r+ace. 5,is is /nreacted monomer t,at can -e eit,er wied o++ wit, a *a/@e
son*e or can -e le+t. I+ a sealant re?/ires reair at any time a+ter t,e dry +ield is
discontin/ed, it is r/dent to reeat t,e same etc,in* and dryin* roced/res as
initially /sed. 1eca/se all t,e commercial sealants-ot, t,e li*,t-c/red and sel+-
c/redare o+ t,e same 1is-GMA c,emical +amily, they easily 4ond to one another,
(:
Occlusal and Interproximal Discrepancies
At times an e0cess o+ sealant may -e inad"ertently +lowed into a +ossa or into t,e
adAoinin* interro0imal saces. 5o remedy t,e +irst ro-lem, t,e occl/sion s,o/ld -e
c,ecked "is/ally or, i+ indicated, wit, artic/latin* aer. Us/ally any minor
discreancies in occl/sion are raidly remo"ed -y normal c,ewin* action. I+ t,e
remat/re contact o+ t,e occl/sal contact is /nacceta-le, a lar*e, no, F, round cuttin$
-/r may -e /sed to raidly create a -road resin +ossa.
5,e inte*rity o+ t,e interro0imal saces can -e c,ecked wit, t,e /se o+ dental +loss.
I+ any sealant is resent, t,e /se o+ scalers may -e re?/ired to accomlis, remo"al.
5,ese correcti"e actions are rarely needed once ro+iciency o+ lacement is attained.
Question 3
A. 5,e etc,ant predicta4ly attacks t,e center o+ t,e enamel rism, lea"in* t,e
eri,ery intact.
1. 4,en t,e data o+ a st/dy indicate t,at <'E o+ t,e ori*inal sealants are retained +or
% years, it is t,e same as sayin* t,at an a"era*e o+ 'E is lost eac, year.
C. 1is-GMA rod/cts -y di++erent man/+act/rers are incomati-le wit, one anot,er.
D. An etc,ed area t,at is not raidly sealed will retain its ro/*,, oro/s s/r+ace
indefinitely,
3. 5,e cleansin* and etc,in* o+ t,e occl/sal s/r+ace wit, ,oso,oric acid is
accomlis,ed -y ru44in$ t,e s/r+ace d/rin* t,e etc,in* rocess.
Evaluating Retention of Sealants
5,e +inis,ed sealant s,o/ld -e c,ecked +or retention wit,o/t /sin* /nd/e +orce. In t,e
e"ent t,at t,e sealant does not ad,ere, t,e lacement roced/res s,o/ld -e reeated,
wit, only a-o/t :' seconds o+ etc,in* needed to remo"e t,e resid/al sali"a -e+ore
a*ain +l/s,in*, dryin*, and alyin* t,e sealant. I+ t3o attemts are /ns/ccess+/l, t,e
sealant alication s,o/ld -e ostoned /ntil reminerali@ation occ/rs.
!esin sealants are retained -etter on recently er/ted teet, t,an in teet, wit, a more
mat/re s/r+aceD t,ey are retained -etter on +irst molars t,an on second molars. 5,ey
are -etter retained on mandi-/lar t,an on ma0illary teet,. 5,is latter +indin* is
ossi-ly ca/sed -y t,e lower teet, -ein* more accessi-le, direct si*,t is also ossi-leD
also, *ra"ity aids t,e +low o+ t,e sealant into t,e +iss/res.
&:
5eet, t,at ,a"e -een sealed and t,en ,a"e lost t,e sealant ,a"e ,ad +ewer lesions t,an
control teet,.
(>
5,is is ossi-ly d/e to t,e resence o+ ta*s t,at are retained in the
enamel a+ter t,e -/lk o+ t,e sealant ,as -een s,eared +rom t,e toot, s/r+ace. 4,en t,e
resin sealant +lows o"er t,e reared s/r+ace, it enetrates t,e +in*er-like deressions
created -y t,e etc,in* sol/tion. 5,ese roAections o+ resin into t,e etc,ed areas are
called ta$s,
(=
7Fi*/re :$-<8. 5,e ta*s are essential +or retention. Scannin* electron
microscoic st/dies o+ sealants t,at ,a"e not -een retained ,a"e demonstrated lar*e
areas de"oid o+ ta*s or incomlete ta*s, /s/ally ca/sed -y sali"a contamination. I+ a
sealant is +orce+/lly searated +rom t,e toot, -y masticatory ress/res, many o+ t,ese
ta*s are retained in t,e etc,ed deressions.
5,e n/m-er o+ retained sealants decreases at a curvolinear rate,
&:
O"er t,e +irst =
mont,s, t,e raid loss o+ sealants is ro-a-ly ca/sed -y faulty techni5ue in lacement.
5,e +allo/t rate t,en -e*ins to latea/, wit, t,e ens/in* sealant losses ro-a-ly -ein*
d/e to a-normal masticatory stresses, A+ter a year or so, t,e sealants -ecome "ery
di++ic/lt to see or to discern tactilely, esecially i+ t,ey are a-raded to t,e oint t,at
t,ey +ill only t,e +iss/res. In researc, st/dies t,is lack o+ "isi-ility o+ten leads to
underestimatin$ t,e e++ecti"eness o+ t,e sealants t,at remain -/t cannot -e identi+ied.
1eca/se t,e most raid +allo++ o+ sealants occ/rs in t,e early sta*es, an initial =-mont,
recall +ollowin* lacement s,o/ld -e ro/tine +or determinin* i+ sealants ,a"e -een
lost. I+ so, t,e teet, s,o/ld -e resealed. 5eet, s/ccess+/lly sealed +or < to % years are
likely to remain sealed.
(=
In a re"iew o+ t,e literat/re, lon*est-term st/dy reorted t,at at t,e +ollow-/
e0amination o+ t,e +irst molars, >$-years a+ter sealant ,ad -een alied, <'E s,owed
complete retention and >%E artial retention 3ithout caries. At a :'-year +ollow-/ o+
t,e same sealants t,e second molars demonstrated t,e corresondin* +i*/res <'E and
=$E, resecti"ely. 5,is st/dy s,owed t,at it-and-+iss/re sealants alied d/rin*
c,ild,ood ,a"e a lon$2lastin$, caries preventive effect,
<$,%%
Mert@-Fair,/rst
(=
cited
st/dies in w,ic, ;$ to :$$E o+ t,e ori*inal sealants were retained o"er a :-year
eriod 75a-le :$-:8. One :$-year st/dy /sin* =M Concise Sealant ,ad a '%E
comlete retention and a >:E artial retention o+ sealant, all 3ith no caries, Anot,er
st/dy, /sin* Delton, re*istered <(E retention a+ter < years.
:$(
7Fi*/re :$-%8. 5,ese are
st/dies in w,ic, t,e sealant was laced and t,en o-ser"ed at eriodic inter"alsD t,ere
was no resealin* w,en a sealant was lost. -here resealin$ is accomplished as needed
at recall appointments, a hi$her and more continuous level of protection is achieved,
More recent st/dies reort (>E o+ t,e sealants laced are retained +or ' years.
%$
Fi*/re :$-< 5a*s, =$ /m. Sealant was +lowed o"er etc,ed s/r+ace, allowed to
olylmeri@e, and toot, s/r+ace s/-se?/ently dissol"ed away in acid. 7Co/rtesy,
Sil"erstone .M, Do*on I.. The cid !tch Techni5ue, St. )a/l, MN9 Nort,
Central )/-lis,in* Co, :;%'.8
Fi*/re :$-% A: '-year sealant9 Fi"e years a+ter lacement o+ a w,ite it-and-
+iss/re sealant in t,e matc,ed air to t,e control s/-Aect. Sealant and control
s/-Aects were matc,ed on a*e, se0, caries ,istory and ot,er +actors. B: '-year
control9 5,is matc,ed air to t,e sealed atient. 5,is s/-Aect did not recei"e
sealant. 5,e +irst ermanent molar ,as already -een restored wit, two amal*am
restorations in t,e re"io/s '-year eriod. C: :'-year sealant9 :' years a+ter t,e
sin*le alication o+ a w,ite it-and-+iss/re sealant. 5,is is t,e same toot, as
seen in Fi*/re :, '-year sealant, -/t :$ years later. As can -e seen, t,e sealant
,as ser"ed its /rose e"en t,o/*, t,ere ,as -een some loss in t,e eri,eral
+iss/res. 7Co/rtesy o+ Dr. !ic,ard #. Simonsen, D.8
Colored Versus Clear Sealants
1ot, clear and colored sealants are a"aila-le. 5,ey "ary +rom transl/cent to w,ite,
yellow, and ink. Some man/+act/rers sell -ot, clear and colored sealants in eit,er
t,e li*,t-c/rin* or a/toolymeri@in* +orm. 5,e selection o+ a colored "ers/s a clear
sealant is a matter o+ indi"id/al re+erence. 5,e colored rod/cts ermit a more
precise placement o+ t,e sealant, wit, t,e "is/al ass/rance t,at t,e eri,ery e0tends
,al+way / t,e inclined lanes. Retention can 4e more accurately monitored -y -ot,
t,e atient and t,e oerator lacin* t,e sealant. On t,e ot,er ,and, a clear sealant may
-e considered more esthetically acceta-le.
Some clinicians re+er t,e clear sealants -eca/se t,ey are more discrete t,an w,ite.
Ot,ers re+er t,e w,ite sealants as t,ey are easier to monitor at recall aointments.
On t,e ot,er ,and, some clinicians seem to re+er t,e clear sealants -eca/se it is
ossi-le to see /nder t,e sealant i+ a cario/s lesion is acti"e or ad"ancin*. Howe"er,
no clinical st/dy ,as comre,ensi"ely comared t,ese iss/es. !ecently, some it-and-
+iss/re sealants ,a"e -een introd/ced t,at will c,an*e color as t,ey are -ein* li*,t-
olymeri@ed. 5,is roerty ,as not -een +/lly in"esti*ated and seems to -e only o+
relati"e ad"anta*e to t,e dental ersonnel alyin* t,e sealant.
Placement of Sealants Over Carious Areas
Sealin* o"er a cario/s lesion is imortant -eca/se o+ t,e ro+essionalsC concern a-o/t
t,e ossi-ility o+ caries ro*ression /nder t,e sealant sites. In teet, t,at ,a"e -een
e0amined in vivo and later s/-Aected to ,istolo*ic e0amination +ollowin* e0traction
+or ort,odontic reasons, it ,as -een +o/nd t,at areas o+ inciient or o"ert caries o+ten
occ/r /nder many +iss/res, w,ic, cannot -e detected wit, t,e e0lorer.
('
In some
st/dies, sealants ,a"e -een /rosely laced o"er small, o"ert lesions.
(=,(<
4,en
comared wit, control teet,, many o+ t,e sealed cario/s teet, ,a"e -een dia*nosed as
so/nd = and ' years later.
(%
Handelman ,as indicated t,at sealants can -e considered a
"ia-le modality +or arrest o+ it-and-+iss/re caries.
((
In ot,er st/dies o+ sealed lesions,
t,e n/m-er o+ -acteria reco"ered +rom t,e sealed area decreased raidly.
==,=&,(<-(;
5,is
decrease in -acterial o/lation is ro-a-ly d/e to t,e inte*rity o+ t,e seal o+ t,e resin
to t,e etc,ed toot, s/r+ace
;$
seal t,at does not ermit t,e mo"ement o+ +l/ids or tracer
isotoes -etween t,e sealant and t,e toot,.
;:
Sealants ,a"e -een laced o"er more e0tensi"e lesions in w,ic, cario/s dentin is
in"ol"ed.
;>
3"en wit, t,ese lar*er lesions, t,ere is a decrease in t,e -acterial
o/lation and arrest o+ t,e cario/s rocess as a +/nction o+ time. In anot,er st/dy,
clinically detecta-le lesions into t,e dentin were co"ered +or ' years wit, N/"a-Seal.
A+ter t,at time t,e -acterial c/lt/res were essentially ne*ati"e, and an aarent (=E
reversal +rom a caries-acti"e to a caries-inacti"e state was ac,ie"ed.
(<
#ordan and
S/@/ki
;=
sealed small lesions in =$$ teet,. D/rin* clinical and 0-ray o-ser"ations o"er
a '-year eriod, t,ey +o/nd no chan$e in si1e of the carious lesion, so lon* as t,e
sealant remained intact. More recently, Mert@-Fair,/rst and collea*/es
;&
demonstrated
t,at sealed lesions -ecame inactive -acteriolo*ically, wit, t,e resid/al cario/s
material s/**estin* decay cessation. 5,is a-ility to arrest inciient and early lesions is
,i*,li*,ted -y t,e statement in t,e :;%; /-lication o+ t,e ADACs Co/ncil on Dental
5,erae/tics9 FSt/dies indicate t,at t,ere is an aarent red/ction in microor*anisms
in in+ected dentin co"ered wit, sealant. . .. 5,ese st/dies aear to s/-stantiate t,at
t,ere is no ,a@ard in sealin* cario/s lesions.F 5,e statements end wit, t,e cautionary
note9 FHowe"er, additional lon*-term st/dies are re?/ired -e+ore t,is roced/re can
-e e"al/ated as an alternati"e to traditional restorati"e roced/res.
;'
4,en sealin*
inciient lesions, care s,o/ld -e taken to monitor t,eir retention at s/-se?/ent
recallBann/al dental e0aminations. In addition, t,ere ,a"e -een reorts o+ sealants
-ein* /sed to ac,ie"e enetration o+ inciient smoot,-s/r+ace lesions 7Fw,ite sotsF8
o+ +acial s/r+aces.F
;<
Question 4
A. 5a*s can -e easily determined -y t,eir ro/*, +eel w,en c,eckin* t,e surface o+ a
sealant wit, an e0lorer.
1. 5eet, t,at lose a sealant are more s/sceti-le to caries t,an ones t,at retain a
sealant -/t less caries-rone t,an a control toot, t,at was ne"er sealed.
C. 5,e +allo++ o+ sealants is linear as a +/nction o+ time.
D. A st/dy in w,ic, t,e eriodic resealin* o+ +iss/res occ/rs wo/ld -e e0ected to
,a"e a lesser caries rate t,an a lon*-term st/dy in w,ic, t,e same ann/al +allo++ is
e0erienced, -/t w,ere no resealin* is accomlis,ed.
3. Followin* lacement o+ a sealant o"er a +iss/re wit, an /ndetecta-le cario/s lesion,
t,e si@e o+ t,e s/-s/r+ace lesion *rad/ally increases,
Sealants Versus Amalgams
Comarin* sealants and amal*ams is not an e?/ita-le comarison -eca/se sealants
are /sed to prevent occl/sal lesions, and amal*am is /sed to treat occl/sal lesions t,at
co/ld ,a"e -een re"ented. Het, t,e comarison is necessary. One o+ t,e maAor
o-stacles to more e0tensi"e /se o+ sealants ,as -een t,e -elie+ t,at amal*ams, and not
sealants, s,o/ld -e laced in anatomically de+ecti"e +iss/resD t,is -elie+ stems +rom
misinformation t,at amal*ams can -e laced in less time, and t,at once laced, t,ey
are a ermanent restoration. Se"eral st/dies ,a"e addressed t,ese s/ositions. For
instance, sealants re?/ire aro0imately < to ; min/tes to lace initially, amal*ams :=
to :' min/tes.
;%,;(
Many st/dies on amal$am restorations ,a"e indicated a lon$evity +rom only a +ew
years to an a"era*e li+e san o+ :$ years.
;;-:$>
3?/ally ert/r-in* is t,e +act t,at in one
lar*e st/dy o+ sc,oolc,ildren, :<.>E o+ all s/r+aces +illed wit, amal*am ,ad mar*inal
leaka*e and needed replacement,
:$=
5,e li+e san o+ an amal*am is s,orter wit,
yo/n*er c,ildren t,an wit, ad/lts.
:$&
5o em,asi@e t,e ro-lem o+ relacement o+
older restorations, a recent ?/estionnaire st/dy +rom ;: dentists in Iceland was
cond/cted to determine t,e ca/se +or relacement o+ (,=;' restorations. 5,e reason
*i"en +or t,e relacement o+ comosites, amal*ams, *lass-ionomers, and +or resin
modi+ied *lass ionomers was +ailed restorations 7&%.>E8, rimary caries 7&'.=E8 and
non-cario/s de+ects 7%.'E8. For e"ery restoration inserted +or an o"ert lesion, t,ere
was a need +or one to -e reinserted re"io/slyk
:$'
5,e retention data +rom t,e earlier sealant st/dies were disco/ra*in*. In recent years,
/sin* later-*eneration sealants, alon* wit, t,e $reater care in techni5ue /sed +or t,eir
insertion, m/c, lon*er retention eriods ,a"e -een reorted. In +i"e lon*-term st/dies
+rom = to % years, t,e a"era*e sealant loss er year ran*ed +rom :.= to %E.
:$<
I+ t,e
yearly loss o+ t,ese st/dies is e0traolated, t,e a"era*e li+e o+ t,ese sealants comares
+a"ora-ly or e0ceeds t,at o+ amal*am.
:$%
4,en roerly laced, sealants are no lon*er
a temorary e0edient +or re"entionD instead, t,ey are t,e only effective predicta4le
clinical roced/re a"aila-le +or re"entin* occl/sal caries.
5,e most +re?/ent ca/se +or sealant relacement is loss of material, w,ic, mainly
occ/rs d/rin* t,e +irst < mont,sD t,e most likely ca/se +or amal*am relacement is
mar$inal decay,
:$(
wit, & to ( years -ein* t,e a"era*e li+e san.
:$=
5o relace t,e
sealant, only resealin* is necessary. No dama*e occ/rs to t,e toot,. Amal*am
relacement /s/ally re?/ires c/ttin* more toot, str/ct/re wit, eac, relacement.
3"en i+ lon*e"ity merits were e?/al, t,e sealant ,as t,e ad"anta*e o+ -ein* ainless to
aly and aest,etic, as well as em,asi@in* t,e hi$hest o47ectives o+ t,e dental
ro+essionprevention and sound teeth,
Options for Protecting the Occlusal Surfaces
5,e /se o+ sealants ,as sawned an entirely di++erent concet o+ conser"ation o+
occl/sal toot, str/ct/re in t,e mana*ement o+ dee its and +iss/res -e+ore, or early in
caries in"ol"ement. 5,e preventive dentistry restoration em-odies t,e concets o+
-ot, ro,ylactic odontotomy insertion o+ a restoration and coverin$ the restoration
and the connectin$ fissure system 3ith a resin 4ased sealant, )ain and are,ension
are sli*,t, and aest,etics and toot, conser"ation are ma0imi@ed.
:$(
Se"eral otions are
now a"aila-le to rotect t,e occl/sal s/r+aces, wit, t,e selection deendin* on ris*
and professional?s 7ud$ment,
:$;
5,e +irst le"el o+ rotection is simly to lace a
con"entional sealant o"er t,e occl/sal +iss/re system. 5,is sealin* reemts +/t/re
it-and-+iss/re caries, as well as arrests inciient or re"erses small o"ert lesions.
5,e second otion reorted -y Simonsen in :;%(,
::$
ad"ocated t,e /se o+ t,e smallest
-/r to remo"e t,e cario/s material +rom t,e -ottom o+ a it or +iss/re and t,en /sin*
an aroriate instr/ment to tease either sealant or composite into t,e ca"ity
rearation. 5,is ,e termed a re"enti"e dentistry restoration. Followin* insertion o+
t,e restoration, sealant was laced over t,e olymeri@ed material as well as +lowed
over the remainin$ fissure system, Aside +rom rotectin* t,e +iss/res +rom +/t/re
caries, it also rotects t,e comosite or inserted sealant +rom a-rasion.
:::
5,e t,ird otion is /se o+ *lass-ionomers material +or sealants, w,ic, is contro"ersial.
D/e to t,eir +l/oride release and cariostatic e++ect, *lass-ionomers ,a"e -een /sed in
lace o+ traditional materials, as a it-and-+iss/re sealant, ,owe"er, resin sealants ,a"e
s,own m/c, ,i*,er -ond stren*t, to enamel t,an *lass-ionomers. Clinical trials
::>,::=

,a"e s,own oor retention o"er eriods as s,ort as < to :> mont,s. 5,o/*,, in "itro
st/dies ,a"e s/**ested t,at etc,in* re"io/s to alication en,ances t,e -ondin* o+
*lass-ionomer sealant in +iss/re enamel.
::&-::<
One st/dy s,owed t,at a con"entional
sil"er-rein+orced *lass-ionomer ,ad s/erior clinical er+ormance comared to a
con"entional resin sealant.
::%
!esin-rein+orced *lass-ionomer cements ,a"e -een in"esti*ated +or t,eir e++ecti"eness
as it-and-+iss/re sealants. 5,e :-year res/lts re"ealed t,at alt,o/*, clinically t,e
*lass-ionomer wears at a +aster rate t,an a con"entional resin sealant, in t,e scannin*
electron microscoic e"al/ation t,e material co/ld -e seen at t,e dee recesses o+ t,e
its-and-+iss/res wit, no cario/s lesion resent.
::=
A recent st/dy s,owed t,at a+ter =
years t,e *lass-ionomer sealant was comletely lost in almost ;$E o+ t,e teet,
comared to less t,an :$E o+ t,e resin sealed teet,D t,e relati"e risk o+ a toot, sealed
wit, *lass-ionomer o"er t,at o+ a toot, sealed wit, resin was ,i*,er. Also, t,e *lass-
ionomer sealant ,ad oorer retention and less caries rotecti"e e++ect.
::(
Glass-ionomer does not carry t,e ADA seal o+ aro"al as sealant material. 5,e
readers s,o/ld decide t,eir ersonal ,iloso,y -ased on t,e e"idence.
A +o/rt, otion reorted -y Garcia-Godoy in :;(< in"ol"es t,e /se o+ a *lass-
ionomer cement as t,e preventive $lass2ionomer restoration 7)GI!8.
::;
5,e *lass-
ionomer cement 7con"entional or resin-modi+ied8 is laced only in t,e ca"ity
rearation. 7Fi*/re :$-(8. 5,e occl/sal s/r+ace is t,en etc,ed wit, a *el etc,ant
a"oidin*, i+ ossi-le, etc,in* t,e *lass-ionomer. 3tc,in* t,e *lass-ionomer may
remo"e some o+ t,e *lass articles weakenin* t,e material. 5,e con"entional resin
sealant is laced over the $lass2ionomer and the entire occlusal fissure system, In t,e
e"ent sealant is lost, t,e +l/oride content o+ t,e *lass-ionomer helps prevent +/t/re
rimary and secondary caries +ormation. 5,e same tec,ni?/e ,as s/ccess+/lly
rotected t,e mar*inal inte*rity o+ "ery small amal*am restoration, as well as
ro"idin* a rotection to t,e entire +iss/re system.
3ac, o+ t,ese otions re?/ires a A/d*ment decision -y t,e clinician. 5,at decision can
well -e -ased on t,e criterion t,at i+ an o"ert lesion cannot -e visuali1ed, it s,o/ld -e
sealedD i+ it can -e "is/ali@ed, t,e smallest ossi-le re"enti"e dentistry restoration
s,o/ld -e /sed alon* wit, its re?/ired sealant Ftoin*.F Mert@-Fair,/rst and
associates
:>$
,a"e ointed o/t t,at t,e +irst otion co/ld ro"ide t,e re+erred model
+or conser"ati"e treatment o+ incipient and small overt, it-and-+iss/re caries. It co/ld
also ser"e as an interim treatment +or lar*er lesions. 5,ese otions wo/ld -e
esecially "al/a-le in areas o+ t,e world wit, ins/++icient ro+essional dental
ersonnel and w,ere re"enti"e dental a/0iliaries ,a"e -een trained to lace sealants.
In all cases, t,e re"enti"e dental +illin* s,o/ld -e considered as an alternati"e to t,e
traditional class I amal*am wit, its accomanyin* e0tension +or re"ention t,at o+ten
incl/des t,e entire +iss/re system.
Fi*/re :$-( )re"enti"e *lass ionomer restoration 7)GI!8. Ca"ity rearation +or
recetion o+ *lass-ionomer cement. 7Co/rtesy o+ Dr. Franklin Garcia-Godoy,
The Sealant as Part of a Total Preventive Package
5,e sealant is /sed to rotect t,e occl/sal s/r+aces. A maAor e++ort s,o/ld -e made to
incororate t,e /se o+ sealants alon* wit, ot,er rimary re"enti"e dentistry
roced/res, s/c, as la?/e control, +l/oride t,eray, and s/*ar disciline. 4,ene"er a
sealant is laced, a toical alication o+ +l/oride s,o/ld +ollow i+ at all ossi-le. In
t,is manner t,e w,ole toot, can -e rotected. !ia and collea*/es
:>:
comleted a >-
year st/dy +or c,ildren in second and t,ird *rades assessin* t,e e++ecti"eness o+ a
$.>E +l/oride mo/t,rinse /sed alone comared wit, a rinse l/s sealants. 5wenty-
+o/r occl/sal lesions de"eloed in t,e ': rinse s/-Aects, and only = in t,e (& s/-Aects
recei"in* t,e rinse l/s sealants. 5,e concl/sion was t,at caries co/ld -e almost
completely eliminated -y t,e com4ined /se o+ t,ese two re"enti"e roced/res. In
many /-lic-,ealt, ro*rams, ,owe"er, it is not ossi-le to instit/te +/ll-scale
re"ention ro*rams, eit,er -eca/se o+ aat,y or lack o+ time and money. In s/c,
cases, t,ere is some consolation in knowin* t,at at least t,e most vulnera4le o+ all
toot, s/r+aces 7t,e occl/sal8 is -ein* rotected.
Manpower
5,e cost o+ sealant lacement increases directly wit, t,e le"el o+ ro+essional
ed/cation o+ t,e oerator. Dentists, ,y*ienists, assistants, and ot,er a/0iliaries can -e
trained to lace sealants.
:>>-:>&
In "iew o+ t,e cost-e++ecti"eness, dental a/0iliaries
s,o/ld -e considered as t,e lo*ical indi"id/als to lace sealants. 5,is is imortant i+
manower is to -e increased.
O+ten a/0iliaries w,o ,a"e recei"ed sealant instr/ction, eit,er t,ro/*, contin/in*-
ed/cation co/rses or as art o+ a c/rric/l/m, are stymied eit,er -eca/se o+ state laws
interdictin* t,eir lacin* sealants or -y t,e nat/re and ,iloso,y o+ t,e ractice o+
t,e emloyin* dentist.
:>'
Only +o/rteen states allow ,y*ienists to ractice /nder less
restricti"e or /ns/er"ised ractice models in w,ic, t,ey can initiate treatment -ased
on assessment o+ atient, treat t,e atient, and maintain a ro"ider-atient relations,i
wit,o/t t,e articiation o+ t,e atientsC dentist o+ record. For e0amle, Maine and
New Hams,ire ,a"e a searate s/er"ision +or settin*s o/tside o+ t,e dental o++ice
/-lic-,ealt, s/er"ision, w,ic, is less restricti"e t,an *eneral s/er"ision. New
Me0ico allows +or a colla-orati"e-ractice a*reement -etween dentists and ,y*ienists
in o/tside settin*s. Het, in states s/c, as Geor*ia and Illinois, ,y*ienists are re?/ired
to ractice /nder direct s/er"ision. 5,is means t,e dentist m/st -e resent in t,e
o++ice w,ile t,e care is -ein* ro"ided.
:><
In a Swedis, st/dy, %% dental assistants workin* in :> dental clinics sealed =,>:( +irst
and second molars wit, a '-year retention rate o+ -etween %& and ;&E.
:>%
1eca/se
many dentists consider t,e lacement o+ sealants to -e a relati"ely simle roced/re,
+ew are ret/rnin* +or contin/in*-ed/cation ro*rams to learn t,e e0actin* and recise
rocess necessary to ens/re ma0im/m sealant retention. 3"en w,en t,e dental
ro+essionals desire to articiate in s/c, contin/in* ed/cation, a s/r"ey +o/nd
relati"ely +ew co/rses a"aila-le.
:>(
Economics
1ear in mind t,at not e"ery toot, recei"in* a sealant wo/ld necessarily -ecome
cario/sD ,ence t,e cost o+ re"entin* a sin*le cario/s lesion is *reater t,an t,e cost o+
a sin*le sealant alication. For instance, .e"erett and collea*/es calc/lated t,at +i"e
sealants wo/ld need to -e laced on so/nd teet, to re"ent one lesion o"er a '-year
eriod,
:>;
and !ock and Anderson estimated one toot, +or e"ery t,ree sealant
alications are re"ented +rom -ecomin* cario/s.
:=$
Sealants wo/ld -e most cost-
e++ecti"e i+ t,ey co/ld -e laced in only t,ose its and +iss/res t,at are destined to
-ecome cario/s. Un+ort/nately, we do not ,a"e a caries redictor test o+ s/c,
e0actit/de, -/t, t,e /se o+ "ision l/s an economic, orta-le electronic de"ice t,at
o-Aecti"ely meas/res cond/ctance 7or resistance8 wo/ld *reatly aid in e"al/atin*
occl/sal risk.
:=:
4it,o/t s/c, a de"ice, it is necessary to rely on ro+essional
A/d*ment, -ased on t,e se"erity o+ t,e caries acti"ity indicators9 n/m-er o+ FstickyF
+iss/res, le"el o+ la?/e inde0, n/m-er o+ inciient and o"ert lesions, and
micro-iolo*ic test indications.
In an o++ice settin*, it is estimated t,at it costs :.< times more to treat a toot, t,an to
seal.
''
5,e 5ask Force on Comm/nity )re"enti"e Ser"ices, an indeendent, non-
+ederal *ro/ +ormed to e"al/ated oral-,ealt, inter"entions, was c,ar*ed wit,
determinin* inter"entions t,at romote and imro"e oral ,ealt,. 5,e 5ask Force
e0amined si0 /-lic-,ealt, ro*rams cost o+ lacin* it-and-+iss/re sealants re"ealin*
a mean cost o+ f=;.:$ er erson.
:=>
Howe"er, e"en t,ese n/m-ers are misleadin*.
For instance, w,at is t,e "al/e o+ an intact toot, to its ownere How m/c, does it cost
+or a dentist and assistant to restore a toot,, comared to t,e cost o+ sealin* a toot,e
.ater in li+e, w,at is t,e cost o+ -rid*es and dent/res t,at ,ad t,eir *enesis w,en
c,ildren were at ,i*, risk wit, little access to dental caree
Use of Pit-and-Fissure Sealants
1y t,e mid-:;($s most o+ t,e answers were a"aila-le as to t,e need and effectiveness
o+ 1is-GMA sealants to red/ce t,e incidence o+ occl/sal caries, and t,e techni5ues o+
lacement o+ it-and-+iss/re sealants were known.
:==
5,e safety o+ t,eir lacement ,as
-een demonstrated -y many st/dies s,owin* t,at e"en w,en laced o"er inciient and
minimally o"ert caries sites, t,ere was no ro*ression as lon$ as the sealant remained
intact,
:=&
Finally, se"eral clinical st/dies ,a"e ointed o/t t,at sealants co/ld -e
applied 4y properly trained auxiliaries, t,/s ro"idin* a more economical so/rce o+
manower +or ri"ate and military ractices as well as +or lar*e sc,ool and /-lic
,ealt, ro*rams.
1is-GMA sealant /sa*e ,as -een stron*ly s/orted -y t,e ADA Fas a sa+e and
e++ecti"e means +or caries control.F
>'
5,e United States )/-lic Healt, Ser"ice, in a
re?/est +or a roosal +or a sc,ool it-and-+iss/re st/dy, stated JThis com4ination of
preventive techni5ues (com4ined use of fluoride and sealants) is expected to
essentially eliminate caries in teeth eruptin$ after the initiation of the study,J
:='

Desite t,e s/ort +rom t,e two lar*est or*ani@ations most interested in t,e dental
,ealt, o+ t,e nation, t,e rank-and-+ile o+ t,e dental ro+ession have not accepted
sealants as a routine method for prevention,
In site o+ all t,e knowled*e o+ t,e roerties and s/ccesses o+ t,e sealants /sa*e ,as
la**ed, wit, a-o/t :$E o+ t,e osterior teet, o+ c,ildren demonstratin* t,e resence
o+ sealants.
:=<
For e0amle, a :;;& e0amination o+ ::%,$$$ c,ildren in Nort, Carolina
-etween t,e a*es o+ < and :% +o/nd t,at aro0imately :>E ,ad sealants,
:=%
w,ile t,e
ercenta*e +or ;>%,$$$ in 5ennessee was :$E.
:=(
Ot,er states demonstrate similar
sealant /sa*e. One st/dy re"ealed t,at (( c,ildren did ,a"e sealants w,ile '$( did not
,a"e needed sealants.
:=;
For recr/its enterin* t,e U.S. Air Force, sealants were +o/nd
on :=.:E o+ t,e teet, w,ile t,ere was a need +or &%.'E more. In t,e latter case, it was
noted t,at a t,ird o+ t,ese ersonnel ,ad occl/sal caries t,at mi*,t ,a"e -een
re"ented -y t,e sealants.
>$
Many -arriers e0ist in meetin* t,e Healt,y )eole >$:$ O-Aecti"e +or sealants. In
>$$:, t,e State o+ Ala-ama was lannin* ,ow to meet national dental o-Aecti"es,
w,en '$E o+ U.S. c,ildren are e0ected to ,a"e dental sealants on at least one
ermanent molar -y t,e a*e o+ :& years.
:&$
7C/rrently, >>E o+ t,e c,ildren -etween
:> to :& years ,a"e at least one sealant claim.8 A +inal assessment o+ t,e >$:$
rosects and t,e c/rrent StateCs demo*ra,ics concl/ded t,at racial and *ender
disarities, di++ic/lty in accessin* care, t,e nona"aila-ility o+ Medicaid-articiatin*
dentists in a co/ntry, and a lower aymentBclaim ratio may make t,e national sealant
o-Aecti"e di++ic/lt to ac,ie"e.
:&$
It s,o/ld -e mentioned t,at in many s/r"eys, c,ildren
+rom lower socioeconomic *ro/s ,ad *reater sealant needs t,an t,ose +rom more
a++l/ent nei*,-or,oods.
On t,e ot,er ,and, ot,er co/ntries ,a"e ,ad marked s/ccess wit, increasin* t,e
n/m-er o+ teet, sealed. A st/dy in"ol"in* <(,%$& c,ildren li"in* in .anarks,ire,
Scotland +o/nd aro0imately :$E o+ t,e occl/sal s/r+aces were sealed.
:&:
Fi"e years
later, in 3n*land t,e ercenta*e o+ c,ildren havin$ sealants dramatically increased
-etween >$ to '$E in se"eral areas.
:&>
5,e lacement o+ sealants is makin* slow ro*ress. 5,e :;;(-;; O,io State s/r"ey o+
=rd-*rade st/dents in Sc,ool 1asedBSc,ool .ink ro*rams +o/nd t,at in addition to
oral-,ealt, -ene+its, F)ro"idin* sealant ro*rams in all eli*i-le, ,i*,-risk sc,ools
co/ld red/ce or eliminate racial and economic disarities in t,e re"alence o+ dental
sealantsF.
:&=
Het, t,ere are ro-lems in e0aminin* t,e n/m-er o+ sealants versus t,e
need +or sealants.
Dentist Involvement
)it-and-+iss/re sealants are /nder/sed in ri"ate ractice and /-lic ,ealt,. 5,ere are
many comle0 reasons +or s/c, /nder /se, -/t e++orts s,o/ld -e /ndertaken to
increase sealant /se.
=
Increasin* sealant /se is deendent, in art, on dentistsC
accetance and /nderstandin* o+ t,e re"enti"e tec,ni?/e. In a mail s/r"ey in
Minnesota, ;'E o+ =%' dentists reorted t,e /se o+ sealants, "aryin* +rom : to >' er
week. )ossi-ly, t,e incon*r/ity o+ n/m-ers stems +rom t,e +act t,at alt,o/*, t,e
maAority o+ dentists /se sealants, t,e fre5uency o+ /se is lo3,
:&&
!easons +or t,is aat,y ,a"e ran*ed +rom alle*ed concerns o+ sealin* o"er cario/s
lesions, lack o+ tec,nical skill, s,ort lon*e"ity o+ sealants, and t,e need +or more
researc,all ro-lems t,at ,a"e -een ade?/ately addressed in t,e literat/re.
:==

)ro-a-ly t,e most imortant +actor now restrictin* t,e lacement o+ sealants is t,e
lack o+ an ade?/ate ins/rance +ee sc,ed/le.
:&'
Anot,er is t,at most dentists are
treatment-oriented. 5,is +act is amli+ied -y an e0lanation -y Galarnea/ and 1rode/r
t,at FA dentists lack o+ com+ort wit, wit,,oldin* treatment may sto ,imB,er +rom
o++erin* re"enti"e care and ca/se ,im to +ollow a restoration-oriented ractice.F
:&<

Anot,er +actor is t,at dentists rarely e0lain t,e oral-,ealt, ad"anta*es o+ sealants
o"er dental restorations.
:&%
In attemtin* to alter t,e attit/des o+ dentist on sealant /se, se"eral st/dies ,a"e -een
cond/cted to meas/re chan$es in *no3led$e and attitudes +ollowin* contin/in*-
ed/cation co/rses. 5,e +ollow-/ indicated t,at t,ere ,ad -een an increase in
*no3led$e -/t little c,an*e in attitudes concernin* sealant /se.
:&(
In Colorado,
ediatric dentists, w,o are contin/ally in"ol"ed in treatin* c,ildren, laced more
sealants t,an *eneral dentistsa*ain, ro-a-ly a mani+estation o+ attit/des.
:&'
!e*ardless o+ increased r,etoric a-o/t re"ention, t,e concets and actions o+
re"ention are not -ein* +/lly imlemented in dental sc,ools.
:&;
Dental sc,ool
+ac/lties need to -e ed/cated a-o/t t,e e++ecti"eness and met,ods o+ alyin*
sealants.
:'$,:':
)ossi-ly t,e de"eloment o+ a model c/rric/l/m +or teac,in* it-and-
+iss/re sealant /sa*e wo/ld ,el.
:'>
5,e dental comm/nity m/st de"elo a consens/s
a-o/t t,e "al/e and economic e++ect o+ re"enti"e meas/res.
:'$
Ot,er -arriers to e++ecti"e deli"ery o+ sealants incl/de 7:8 state--oard restrictions on
a/0iliary lacement o+ sealants, 7>8 lack o+ cons/mer knowled*e o+ t,e e++ecti"eness
o+ sealants, and, res/ltantly, a lack o+ demand +or t,e rod/ct.
:>>
The economics and
education of the profession and of the pu4lic are the prime re5uisites for expanded
sealant acceptance,
:'=
Question 5
A. 5,e lon*e"ity e0ectation +or a roerly laced amal*am restoration is
aro0imately twice t,at o+ a roerly laced sealant.
1. Sealants s,o/ld -e laced only on ermanent teet, o+ c,ildren / to a*e :<.
C. Sealants are +o/nd on aro0imately '&E o+ U.S. c,ildren.
D. Followin* t,e *rad/ation o+ st/dents resently in dental sc,ools, a lar*e increase in
t,e /se o+ sealants can -e e0ected.
3. Caries does not ro*ress /nder a roerly sealed comosite or amal*am.
Other Pit-and-Fissure Initiatives
5,e +indin*s o+ t,e +ollowin* st/dies m/st -e considered an important extension o+
t,e resent /se o+ it-and-+iss/re sealants, w,ic, are /sed to re"ent t,e de"eloment
o+ inciient lesions and to arrest minimal o"ert lesions. I+ ro+essional A/d*ment
dictates, conser"ati"e sealed amal*ams or comosites co/ld -e /sed to maintain
mar$inal inte$rity, extend the lon$evity of the restorative materials, and for achievin$
a de facto extension for prevention 3ithout the need to remove sound tooth structure
to extend the restoration over the entire fissure system, 5,ese two /ses o+ resins +or
re"ention and restorations wit,o/t maAor oerati"e considerations s,o/ld -e o+ *reat
"al/e in de"eloin* co/ntries w,ere ro+essional manower is at a minim/m and t,e
demand +or dental care is *reat.
)ro-a-ly t,e most imortant recent researc, on t,e /se o+ 1is-GMA sealants and
cario/s lesions were descri-ed -y Mert@-Fair,/rst and coworkers.
(%,:'&
In t,e :$-year
st/dy,
:'&
atients wit, aired ermanent molars or remolars wit, o4vious clinical
and radio$raphic class / lesions were selected. 5,e cario/s lesions e0tended ,al+way
into t,e dentin or to t,e nearest /l ,orn. 5,e randomi@ed lacement o+ restorations
+or eac, o+ t,e toot, airs consisted o+ two o+ t,e +ollowin*9 7:8 a classic amal*am
restoration, comlete wit, e0tension +or re"ention o+ all connectin* +iss/res 7%;
s/-Aects8D 7>8 a conservative amal*am restoration in"ol"in* only t,e cario/s site wit,
a sealant Ftoin*,F t,e latter w,ic, was e0tended into t,e entire it-and-+iss/re
system 7%% s/-Aects8D and 7=8 wit, eac, one o+ t,e amal*am restorations, a aired
comosite restoration laced o"er t,e cario/s tiss/e wit, a Ftoin*F o+ sealant t,at
incl/ded all t,e its and +iss/res 7:'< s/-Aects8. In t,e rearation +or t,e comosite,
no attempt 3as made to remove the carious tissue, A :-millimeter wide, &$- to <$-
de*ree -e"el was made in t,e so/nd enamel s/rro/ndin* t,e lesion. 5,e area was
was,ed, dried, and a -ondin* a*ent was laced on t,e -e"el. Hand instr/ments were
/sed to lace t,e comosite, a+ter w,ic, rotary instr/ments were /sed to s,ae t,e
occl/sal anatomy. Followin* t,is ste, t,e occl/sal s/r+ace was treated as +or t,e
lacement o+ t,e a"era*e sealantdry, etc,, rinse, and dry -e+ore lacin* t,e resin
o"er t,e comosite and t,e entire +iss/re system.
5,e concl/sions o+ t,is st/dy a+ter :$ years were9 7:8 4oth t,e sealed comosites and
t,e sealed amal*am restorations e0,i-ited superior clinical performance and
lon$evity comared to t,e /nsealed amal*am restorationsD 7>8 -onded and sealed
comosite restorations laced o"er t,e +rank ca"itated lesions arrested the clinical
pro$ress of these lesions for the C: years of the study,
Summary
5,e maAority o+ all cario/s lesions t,at occ/r in t,e mo/t, occ/r on t,e occl/sal
s/r+aces. 4,ic, teet, will -ecome cario/s cannot -e redictedD ,owe"er, i+ t,e
s/r+ace is sealed wit, a it-and-+iss/re sealant, no caries will de"elo as lon* as t,e
sealant remains in lace. !ecent st/dies indicate an aro0imate ;$E retention rate o+
sealants :-year a+ter lacement. 3"en w,en sealants are e"ent/ally lost, most st/dies
indicate t,at t,e caries incidence +or teet, t,at ,a"e lost sealants is less t,an t,at o+
control s/r+aces t,at ,ad ne"er -een sealed. !esearc, data also indicate t,at many
inciient and small o"ert lesions are arrested w,en sealed. Not one reort ,as s,own
t,at caries de"eloed in its or +iss/res w,en /nder an intact sealant. Sealants are easy
to aly, -/t t,e alication o+ sealants is an e0tremely sensiti"e tec,ni?/e. 5,e
s/r+aces t,at are to recei"e t,e sealant m/st -e comletely isolated +rom t,e sali"a
d/rin* t,e entire roced/re, and etc,in*, +l/s,in*, and dryin* roced/res m/st -e
timed to ens/re ade?/ate rearation o+ t,e s/r+ace +or t,e sealant. Sealants are
comara-le to amal*am restorations +or lon*e"ity and do not re?/ire t,e c/ttin* o+
toot, str/ct/re. Sealants do not cost as m/c, to lace as amal*ams. Desite t,eir
ad"anta*es, t,e /se o+ sealants ,as not -een em-raced -y all dentists, e"en t,o/*,
endorsed -y t,e ADA and t,e U.S. )/-lic Healt, Ser"ice. 3"en w,en small o"ert it-
and-+iss/re lesions e0ist, t,ey can -e dealt wit, conser"ati"ely -y /se o+ re"enti"e
dentistry restorations. 4,at now aears to -e re?/ired is t,at t,e dental sc,ools
teac, sealants as an e++ecti"e inter"ention, t,at t,e dental ro+essional /se t,em, t,at
t,e ,y*ienists and t,e a/0iliary ersonnel -e ermitted to aly t,em, and t,e /-lic
demand t,em.
:. C and Dcorrect.
Aincorrect. 1eca/se t,e +l/orides rotect t,e smoot, s/r+ace, t,ere will -e a *reater
roortion o+ it-and-+iss/re lesions.
1incorrect. 1y de+inition, an inciient lesion ,as not -een in"aded -y -acteriaD t,/s
t,e /se o+ a sealant is an ideal re"enti"e meas/re.
3incorrect. !emem-er, it is t,e caries s/sceti-ility o+ t,e teet, t,at is
imortantnot t,e a*e o+ t,e indi"id/al.
Dincorrect. All t,e maAor, s/ccess+/l, lon*-term retention st/dies ,a"e /sed cotton-
roll isolationD in t,e one st/dy o+ r/--er dam "ers/s cotton rolls, t,e rolls were e?/al
to, or -etter t,an, t,e dam.
3incorrect. 5en seconds are /sed +or t,e dryin* and +l/s,in* roced/res, and >$ to
=$ seconds +or t,e etc,in*.
=. A and 1correct.
Cincorrect. 1is-GMA lastics are o+ t,e same c,emical +amily and will -ond to
eac, ot,er re*ardless o+ man/+act/rer.
Dincorrect. !eminerali@ation +rom sali"a constit/ents occ/rs raidly in a eriod o+
,o/rs to days.
3incorrect. Cleansin* and etc,in* do occ/rD ,owe"er, r/--in* tends to o-literate
t,e delicate etc,in* attern and red/ce retention otential.
&. 1 and Dcorrect.
Aincorrect. 5,e ta*s o+ t,e sealant cannot -e +elt wit, t,e e0lorerD t,ey e0tend into
t,e enamel +rom t,e /nderneat, side o+ t,e lastic.
Cincorrect. 5,e c/r"olinear +allo++ is *reatest at = mont,s, less at < mont,s, a+ter
w,ic, it *rad/ally latea/s.
3incorrect. 5,e literat/re is /nanimo/s t,at caries does not ro*ress /nder an intact
sealant.
'. C and 3correct.
Aincorrect. 5,ere is little di++erence -etween t,e lon*e"ity o+ a well-laced
amal*am comared wit, a well-laced sealant.
1incorrect. I+ a toot, is s/sceti-le to caries, it s,o/ld -e sealed, w,ate"er t,e
atientCs a*e.
Dincorrect. All si*ns indicate t,at t,e teac,in* o+ sealant lacement is *reatly
ne*lected in dental sc,ools.
:. Aro0imately iiiiiiiii E o+ all cario/s lesions occ/r on t,e occl/sal s/r+acesD
t,e contin/al /se o+ +l/orides 7increases8 7decreases8 t,is ercenta*e.
>. Fo/r di++erent met,ods /sed rior to t,e ad"ent o+ oly/ret,ane, cyanoacrylate, and
1is-GMA sealants, were iiiiiiiii, iiiiiiiii, iiiiiiiii, and iiiiiiiii.
=. One condition t,at indicates the use of a sealant is iiiiiiiiiD four conditions that
contraindicate t,e /se o+ sealants are iiiiiiiii, iiiiiiiii, iiiiiiiii, and
iiiiiiiiiD t,ree conditions t,at pro4a4ly indicate t,e /se o+ sealants are iiiiiiiii,
iiiiiiiii, and iiiiiiiii.
&. 5wo ,otoacti"ated, and two c,emically acti"ated sealants t,at ,a"e -een acceted,
or ro"isionally acceted, -y t,e ADA are 7,otoacti"ated8 iiiiiiiii, iiiiiiiii,
and 7c,emically acti"ated8 iiiiiiiii and iiiiiiiii.
'. 5,e li?/id resin in a sealant kit is known as t,e iiiiiiiiiD w,en it is cataly@ed t,e
,ardenin* rocess is known as iiiiiiiii. 5,e catalyst /sed +or t,e olymeri@ation
o+ c,emically acti"ated sealants is iiiiiiiii and +or "isi-le ,otoacti"ation,
iiiiiiiii.
<. 5wo ad"anta*es to li*,t-c/red sealants are iiiiiiiii and iiiiiiiiiD and two
ad"anta*es o+ a/toolymeri@ed sealants are iiiiiiiii and iiiiiiiii.
%. iiiiiiiii +orces, not c,emical -ondin*, ca/ses retention o+ t,e sealant to t,e
toot,D t,e +o/r commandments to ens/re ma0im/m retention are iiiiiiiii,
(. 5,ree met,ods -y w,ic, a dry +ield can -e esta-lis,ed are iiiiiiiii, iiiiiiiii,
and iiiiiiiii.
;. 5,e lacement o+ sealants is e0tremely tec,ni?/e-sensiti"eD a+ter selection o+ t,e
toot, +or sealant lacement, it s,o/ld -e dried +or iiiiiiiii 7time8D t,en etc,ed +or
iiiiiiiiiii 7time8, +ollowed -y a water +l/s, o+ iiiiiiiii 7time8, and +inally,
dried +or iiiiiiiii 7time8 -e+ore lacin* t,e sealant.
:$. 30cessi"ely ,i*, sealants t,at inter+ere wit, occl/sion can -e red/ced -y /se o+ a
n/m-er iiiiiiiii 7c/ttin*8 7+inis,in*8 -/r.
::. 5,e +allo++ o+ sealants is 7linear8 7c/r"ilinear8D lon*-term st/dies w,ere <'E o+ t,e
sealants are retained a+ter % years indicate an a"era*e yearly loss o+ iiiiiiiii E.
A+ter :$ years, iiiiiiiii iiiiiiiii E wo/ld -e retained. 5,is contracts to an
a"era*e li+e e0ectancy o+ an amal*am o+ aro0imately iiiiiiiii 7years8.
:>. 5o rotect t,e total toot,, t,e alication o+ a sealant s,o/ld -e +ollowed -y an
alication o+ iiiiiiiii.
:=. 5o ens/re t,at sealant lacement tec,ni?/es ,a"e -een er+ected in dental and
dental ,y*iene sc,ools, it s,o/ld -e necessary +or iiiiiiiii 7state dental-re*/latin*
a*ency8 to re?/ire a demonstration o+ ro+iciency +or all candidates rior to state
licens/re.
:&. 5,e t,ree key comonents o+ a li*,t so/rce o+ olymeri@in* sealants are
iiiiiiiii, iiiiiiiii, and iiiiiiiii 7w,ic, res/lts in t,e -l/e color8.
:'. 5,e t,ree -asic otions +or a re"enti"e dentistry restoration are iiiiiiiii,
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>=. 1owen, !. .. Dental +illin* material comrisin* "inyl silane treated +/sed silica
and a -inder consistin* o+ t,e reaction rod/ct o+ -is-,enol and *lycidyl acrylate.
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>(. Swart@, M. .., ),illis, !. 4., Norman, !. D., et al. 7:;%<8. Addition o+ +l/oride
to it-and-+iss/re sealants9 A +easi-ility st/dy. " Dent Res, ''9%'%-%:.
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+ormation in "itro aro/nd *lass ionomer restorations. Euint /nt, :%9'>%-=:.
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<%9::%->>.
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A comarison st/dy. "D, :$<9&%:-%&.
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'<.
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Dent Child '(9& >;%-;.
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''9><->;.
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m Dent ssoc, (;9::$>-<.
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<:. Mert@-Fair,/rst, 3. #. 7:;(&8. )ersonal comm/nication.
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+per Dent, >&9==:-<.
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<%. Garcia-Godoy, F., g Medlock, #. 4. 7:;((8. An S3M st/dy o+ t,e e++ects o+ air-
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<(. 5itley, 2. C., 5orneck, C. D., g Smit,, D. C. 7:;((8. 5,e e++ect o+ concentrated
,ydro*en ero0ide sol/tion on t,e s/r+ace mor,olo*y o+ ,/man toot, enamel. "
Dent Res, <%7Secial Iss/e89=<:, A-str. :;(;.
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3"al/ation o+ /mice, +iss/re enamelolasty and air a-rasion on sealant microleaka*e.
Pediatr Dent, >&9:;;->$=.
%$. Dental Sealants ADA Co/ncil o+ Access and )re"ention and Interro+essional
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etc,in*. m " +rthod, %(9;;-:$(.
%>. 3idelman, 3., S,aira, #., g Ho/t, M. 7:;((8. 5,e retention o+ +iss/re sealants
/sin* twenty-second etc,in* time9 5,ree-year +ollow-/. " Dent Child, ''9::;->$.
%=. )a,la"an, A., Dennison, #. 1., g C,ar-enea/, G. 5. 7:;%<8. )enetration o+
restorati"e resins into acid-etc,ed ,/man enamel. "D, :;%<D ;=9:$%$-%<.
%&. Sil"erstone, .. M. 7:;%&8. Fiss/re sealants, la-oratory st/dies. Caries Res, (9>-><.
%'. 1o@alis, 4. 1., g Mars,all, G. 4. 7:;%%8. Acid etc,in* atterns o+ rimary
enamel. " Dent Res, '<9:('.
%<. Stra++on, .. H., More, F. G., g Dennison, #. 1. 7:;(&8. 5,ree year clinical
e"al/ation o+ sealant alied /nder r/--er dam isolation. " Dent Res, <=9>:'. IAD!
A-str. &$$.
%%. 4endt, .. 2., 2oc,, G., g 1ir,ed, D. 7>$$:8. On t,e retention and e++ecti"eness
o+ +iss/re sealant in ermanent molars a+ter :'->$ years9 a co,ort st/dy. Community
Dent +ral !pidemiol >;9& =$>-%.
%(. 4ood, A. #., Sara"ia, M. 3., g Farrin*ton, F. H. 7:;(;8. Cotton roll isolation
"ers/s 6ac-3Aector isolation. " Dent Child, '<9&=(-&$.
%;. )owell, 2. !., g Crai*, G. G. 7:;%(8. An in vitro in"esti*ation o+ t,e enetratin*
e++iciency o+ 1is-GMA resin it-and-+iss/re coatin*s. " Dent Res, '%9<;:-;'.
($. Sil"erstone, .. M. 7:;(=8. Fiss/re sealants9 5,e enamel-resin inter+ace. " Pu4lic
Health Dent, &=9>$'-:'.
(:. Myers, C. .., !ossi, F., g Cart@, .. 7:;%&8. Ad,esi"e ta*-like e0tensions into
acid-etc,ed toot, enamel. " Dent Res, '=9&='-&:.
(>. Hindin*, #. 7:;%&8. 30tended cariostasis +ollowin* loss o+ it-and-+iss/re sealant
+rom ,/man teet,. " Dent Child, &:9&:-&=.
(=. Mert@-Fair,/rst, 3. #. 7:;(&8. C/rrent stat/s o+ sealant retention and caries
re"ention. " Dent !duc, &(9:(-><.
(&. Mert@-Fair,/rst, 3. #., Fair,/rst, C. 4., 4illiams, #. 3., Della-Gi/stina, 6. 3.,
1rooks, #. D. 7:;(>8. A comarati"e clinical st/dy o+ two it-and-+iss/re sealants9 Si0
year res/lts in A/*/st, Ga. "D, :$'9>=%-;.
('. Miller, #., g Ho-son, ). 7:;'<8. Determination o+ t,e resence o+ caries in
+iss/res. #r Dent ", :$$9:'-:(.
(<. Goin*, !. 3., .oesc,e, 4. #., Grain*er, D. A., g Syed, S. A. 7:;%(8. 5,e "ia-ility
o+ or*anisms in cario/s lesions +i"e years a+ter co"erin* wit, a +iss/re sealant. "D,
;%9&''-<%.
(%. Mert@-Fair,/rst, 3. #., !ic,ards, 3. 3., 4illiams, #. 3., Smit,, C. D., Mackert, #.
!., Sc,/ster, G. S., S,errer, #. D., OCDell, N. .., )ierce, 2. .., 4enner, 2. 2., g
3r*le, #. 4. 7:;;>8. Sealed restorations9 '-year res/lts. m " Dent, '9'-:$.
((. Handelman, S. .., 4as,-/rn, F., g 4oerer, ). 7:;%<8. 5wo year reort o+
sealant e++ect on -acteria in dental caries. "D, ;=9;%<-($.
(;. #eronim/s, D. #., 5ill, M. #., g S"een, O. 1. 7:;%'8. !ed/ced "ia-ility o+
microor*anisms /nder dental sealants. " Dent Child, &>9>%'-($.
;$. 5,eilade, 3., FeAersko", O., Mi*asena, 2., g )rac,ya-r/ed, 4. 7:;%%8. 3++ect o+
+iss/re sealin* on t,e micro+loral in occl/sal +iss/res o+ ,/man teet,. rch +ral #iol,
>>9>':-';.
;:. #ensen, O. 3., g Handelman, S. .. 7:;%(8. /n vitro assessment o+ mar*inal leaka*e
o+ si0 enamel sealants. " Prosthet Dent, =<9=$&-<.
;>. Handleman, S. 7:;(>8. 3++ects o+ sealant lacement on occl/sal caries
ro*ression. Clin Prevent Dent, &9::-:<.
;=. #ordan, !. 3., g S/@/ki, M. 7:;(&8. Un/-lis,ed reort, ?/oted -y Goin*, !.3.
Sealant e++ect on inciient caries, enamel mat/ration and +/t/re caries s/sceti-ility. "
Dent !duc, &(7S/l.8 >9='-&:.
;&. Mert@-Fair,/rst, 3. #., S,/ster, G. S., g Fair,/rst, C. 4. 7:;(<8. Arrestin* caries
-y sealants9 !es/lts o+ a clinical st/dy. "D, ::>9:;&->$=.
;'. ccepted Dental Therapeutics, =;t, ed. American Dental Association, C,ica*o,
Ill. :;(>.
;<. Micik, !. 3. 7Mar :;%>8. Fate o+ in "itro Caries-like .esions Sealed wit,in 5oot,
Str/ct/re. /DR Pro$ram, A-str. %:$.
;%. 1/rt, 1. A. 7:;(&8. Fiss/re sealants9 Clinical and economic +actors. " Dent !duc,
&( 7S/l.8 >9;<-:$>.
;(. Dennison, #. 1., g Stra++on, .. H. 7:;(&8. Clinical e"al/ation comarin* sealant
and amal*am a+ter se"en years+inal reort. " Dent Res, :;(&D <=7Secial Iss/e89>:'.
A-str. &$:.
;;. Allen, D. N. 7:;%%8. A lon*it/dinal st/dy o+ dental restorations. #r Dent ",
:&=9(%-(;.
:$$. Cecil, #. C., Co,en, M. 3., Sc,roeder, D. C., et al. 7:;(>8. .on*e"ity o+ amal*am
restorations9 A retrosecti"e "iew. " Dent Res, <:9:('. A-str. '<.
:$:. Healey, H. #., g ),illis, !. 4. 7:;&;8. A clinical st/dy o+ amal*am +ail/res. "
Dent Res, >(9&=;-&<.
:$>. .a"ell, C. .. 7:;%<8. A cross-sectional, lon*it/dinal s/r"ey into t,e d/ra-ility o+
amal*am restorations. " Dent, &9:=;-&=.
:$=. !o-inson, A. D. 7:;%:8. 5,e li+e o+ a +illin*. #r Dent ", :=$9>$<-(.
:$&. H/nter, 1. 7:;(>8. 5,e li+e o+ restorations in c,ildren and yo/n* ad/lts. " Dent
Res, <:9'=%. A-str. :(.
:$'. MAor, I. A., S,en, C., 3liasson, S. 5., g !ic,ters, S. 7>$$>8 )lacement and
relacement o+ restorations in *eneral dental ractice in Iceland. +per Dent, >%9::%-
>=.
:$<. Hassal, D. C., g Mellor, A. C. 7>$$:8. 5,e sealant restoration9 indications,
s/ccess and clinical tec,ni?/e. #r Dent ", :;:9='(-<>.
:$%. Dennison, #. 1., g Stra++on, .. H. 7:;(:8. Clinical e"al/ation comarin* sealant
and amal*am& years reort. " Dent Res, <$7Secial Iss/e A89'>$. A-str. (&=.
:$(. Swi+t, 3. #. 7:;(%8. )re"enti"e resin restorations. "D, ::&9(:;->:.
:$;. S,aw, .. 7>$$$8. Modern t,o/*,t on +iss/re sealants. Dent Update, >%9=%$-&.
::$. Simonsen, !. #. 7:;%(8. )re"enti"e resin restorations. Euintessence /nt, ;9<;-%<.
:::. Dickinson, G., .ein+elder, 2. F., g !/ssell, C. M. 7:;((8. 3"al/ation o+ wear -y
alication o+ a s/r+ace sealant. " Dent Res, <%9=<>. A-str. :;;;.
::>. Aranda, M., g Garcia-Godoy, F. 7:;;'8. Clinical e"al/ation o+ a *lass ionomer
it-and-+iss/re sealant. " Clin Pediatr Dent, :;9>%=-%.
::=. O"re-o, !. C., g !aadal, M. 7:;;$8. Microleaka*e in +iss/res sealed wit, resin
or *lass ionomer cement. Scand " Dent Res, ;(9<<-<;.
::&. De ./ca-Fra*a, .. !., g Freire )imienta, .. A. 7>$$:8. Clinical e"al/ation o+
*lass-ionomerB resin--ased ,y-rid materials /sed as it-and-+iss/re sealants.
Euintessence /nt, =>9< &<=-(.
::'. 2er"anto-Seala, S., .a"oni/s, 3., 2eros/o, 3., g )ietilla, I. 7>$$$8. Can *lass-
ionomer sealants -e cost-e++ecti"ee " Clin Dent, ::9::-=.
::<. )ereira, A. C., )ardi, 6., 1astin*, !. 5. Meni*,im, M. C., )inelli, C.,
Am-rosano, G. M., g Garcia-Godoy, F. 7>$$:8. Clinical e"al/ation o+ *lass-ionomers
/sed as +iss/re sealants9 twenty +o/r-mont, res/lts. SDC " Dent Child, <(9:<(-%&.
::%. Forss, H., g Halme, 3. 7:;;(8. !etention o+ a *lass ionomer cement and resin-
-ased +iss/re sealant and e++ect on cario/s o/tcome a+ter % years. Community Dent
+ral !pidemiol, ><9>:->'.
::(. )o/lsen, S., 1eir/ti, N., g Sadar, N. 7>$$:8. A comarison o+ retention and t,e
e++ect on caries o+ +iss/re sealin* wit, a *lass-ionomer and a resin--ased sealant.
Community Dent +ral !pidemiol, >;9>;(-=$:.
::;. Garcia-Godoy, F. 7:;(<8. )re"enti"e *lass-ionomer restorations. Euintessence
/nt, :%9<:%-:;.
:>$. Mert@-Fair,/rst, 3. #., Call-Smit,, 2. M., S,/ster, G. S., 4illiams, G. 3., Da"is,
j. 1., Smit,, C. D., 1ell, !. A., S,errer, #. D., Myers, D. !., g Morse, ). 2. 7:;(%8.
Clinical er+ormance o+ sealed comosite restorations laced o"er caries comared
wit, sealed and /nsealed amal*am restorations. " m Dent ssoc, ::'9<(;-;&.
:>:. !ia, .. 4., .eske, G. S., g Forte, F. 7:;(%8. 5,e com-ined /se o+ it-and-
+iss/re sealants and +l/oride mo/t,rinsin* in second and t,ird *rade c,ildren9 Final
clinical res/lts a+ter two years. Pediatr Dent, ;9::(->$.
:>>. Harris, N. O., .indo, F., 5ossas, A., et al. 7:;%$8. 5,e )re"enti"e Dentistry
5ec,nician9 Concet and Utili@ation. Mono*ra,, 3ditorial U)!. Uni"ersity o+ )/erto
!ico, Octo-er :.
:>=. .eske, G., Cons, N., g )ollard, S. 7:;%%8. Cost e++ecti"eness considerations o+ a
it-and-+iss/re sealant. " Dent Res, '<91-%:, A-str. %%.
:>&. Horowit@, H. S. 7:;($8. )it-and-+iss/re sealants in ri"ate ractice and /-lic
,ealt, ro*rammes9 analysis o+ cost-e++ecti"eness. /nternational Dental "ournal,
A: 7>89::%-><.
:>'. De/-en, C. #., I/llos, 5. G., g S/mmer, 4. .. 7:;(:8. S/r"ey o+ e0anded
+/nctions incl/ded wit,in dental ,y*iene c/rric/la. !duc Direc, <9>>->;.
:><. Access to Care )osition )aer, >$$:, American Dental Hy*ienistsC Association,
a"aila-le at9 ,tt9BBwww.ad,a.or*Bro+iss/esBaccessitoicare.,tm. Accessed #an/ary
>$$=.
:>%. Holst, A., 1ra/n, 2., g S/lli"an A. 7:;;(8. A +i"e-year e"al/ation o+ +iss/re
sealants alied -y dental assistants. S3ed Dent ", >>9:;'->$:.
:>(. American Dental Association. Deartment o+ 3d/cational S/r"eys 7:;;:8. .e*al
)ro"isions +or Dele*atin* F/nctions to Dental Assistants and Dental Hy*ienists, :;;$.
C,ica*o, Aril.
:>;. .e"erett, D. H., Handelman, S. .., 1renner, C. M., et al. 7:;(=8. Use o+ sealants
in t,e re"ention and early treatment o+ cario/s lesions9 Cost analysis. "D, :$<9=;-
&>.
:=$. !ock, 4. )., g Anderson, !. #. 7:;(>8. A re"iew o+ /-lis,ed +iss/re sealant
trials /sin* m/ltile re*ression analysis. " Dent, :$9=;-&=.
:=:. )ereira, A. C., 6erdonsc,ot, 3. H., g H/ysmans, M. C. 7>$$:8. Caries detection
met,ods9 can t,ey aid decision makin* +or in"asi"e sealant treatmente Caries Res,
='9(=-(;.
:=>. 5r/man, 1. I., Gooc,, 1. F., S/lemana, I., Gi+t, H. C., Horowit@, A. M., 3"ans,
C. A. #r., Gri++in, S. O., g Carande-2/lis, 6. G. 7>$$>8. 5,e task +orce on comm/nity
re"enti"e ser"ices. !e"iews o+ e"idence on inter"entions to re"ent dental caries,
oral and ,aryn*eal cancers, and sorts-related cranio+acial inA/ries. merican
"ournal of Preventive %edicine, >=,:9>:-'&.
:==. !ia, .. 4. 7:;;=8. Sealants re"isited9 An /date o+ t,e e++ecti"eness o+ it-and-
+iss/re sealants. Caries Res, >%9%%-(>.
:=&. Handelman, S. .. 7:;;:8. 5,erae/tic /se o+ sealants +or inciient or early
cario/s lesions in c,ildren and yo/n* ad/lts. Proc 'inn Dent Soc, (%9&<=-%'.
:='. National Instit/te o+ Dental !esearc,. !F) No., NIH-NID!-'-(>, I!.
4as,in*ton, DC9 National Instit/tes o+ Healt,, May :;(>.
:=<. Gerlac,, !. 4., g Sennin*, #. H. 7:;;:8. Mana*in* sealant /tili@ation amon*
ins/red o/lations9 !eort +rom 6ermontCs F5oot, FairyF ro*ram. SDC " Dent
Child, '(9&<-&;.
:=%. !o@ier, !. G., Sratt, C. #., 2oc,, C. G., g Da"ies, G. M. 7:;;&8. 5,e re"alence
o+ dental sealants in Nort, Carolina sc,oolc,ildren. " Pu4 Health Dent, '&9:%%-(=.
:=(. Gillcrist, #. A., Collier, D. !., g 4ade, G. 5. 7:;;>8. Dental caries and sealant
re"alences in sc,oolc,ildren in 5ennessee. " Pu4 Health Dent, '>9<;-%&.
:=;. Selwit@, !. H., Colley, 1. #., g !o@ier, !. G. 7:;;>8. Factors associated wit,
arental accetance o+ dental sealants. " Pu4 Health Dent, '>9:=%-&'.
:&$. Dasanayake, A. )., .i, H., ),ili, S., 2irk, 2., 1ronstein, #., g C,ilders, N. 2.
7>$$:8. Utili@ation o+ dental sealants -y Ala-ama Medicaid c,ildren -arriers in
meetin* t,e year >$:$ o-Aecti"es. Pediatr Dent, >=9&$:-<.
:&:. C,estn/tt, I. G., S,a+er, F., #aco-son, A. )., g Ste,en, 2. 4. 7:;;&8. 5,e
re"alence and e++ecti"eness o+ +iss/re sealants in Scottis, adolescents 7.etter8. #r
Dent ", :%%9:>'->;.
:&>. Hassal, D. C., Mellor, A. C., g 1link,orn, A. S. 7:;;;8. )re"alence and attit/des
to +iss/re sealants in t,e *eneral dental ser"ices in 3n*land. /nt " Paediatr Dent,
;9>&=-':.
:&=. %%-R %or4 %or Rep >$$$D A/* =:D '$9%=<-(. Imact o+ inte*rated sc,ool-
-ased dental sealant ro*rams in red/cin* racial and economic disarities in sealant
re"alence amon* sc,ool c,ildren.
:&&. Gon@ale@, C. D., Fra@ier, ). #., g Messer, .. 1. 7:;((8. Sealant knowled*e and
/se -y ediatric dentists. :;(%, Minnesota s/r"ey. " Dent Child, ''9&=&-=(.
:&'. Hicks, M. #., Flait@, C. M., g Call, !. .. 7:;;$8. Comarison o+ it-and-+iss/re
sealant /tili@ation -y ediatric and *eneral dentists in Colorado. " Pedodont, :&9;%-
:$>.
:&<. Galarnea/, C., g 1rode/r, #. M. 7:;;(8. Inter-dentist "aria-ility in t,e ro"ision
o+ +iss/re sealants. " Can Dent ssoc, <&9%:(->'.
:&%. Sil"erstone, .. M. 7:;(>8. 5,e /se o+ it-and-+iss/re sealants in dentistry9
)resent stat/s and +/t/re de"eloments. Pediatr Dent, &9:<->:.
:&(. .an*, 4. )., Far*,aly, M. M., 4ool+olk, M. 4., Iiemiecki, 5. .., g FaAa, 1. 4.
7:;;:8. 3d/catin* dentists a-o/t +iss/re sealants9 3++ects on knowled*e, attit/des and
/se. " Pu4 Health Dent, ':9:<&-<;.
:&;. 5erkla, .. G. 7:;(:8. 5,e /se o+ it-and-+iss/re sealants in United States dental
sc,ools. In )roceedin*s o+ t,e Con+erence on )it-and-+iss/re Sealants9 4,y 5,eir
.imited Usa*e. C,ica*o9 American Dental Association, =:-=<.
:'$. Fra@ier, ). .. #. 7:;(=8. )/-lic ,ealt, ed/cation and romotion +or caries9 5,e
role o+ t,e dental sc,ools. " Pu4lic Health Dent, &=9>(-&>.
:':. Mc.eran, #. H. 7:;(:8. C/rrent c,allen*es and resonse o+ t,e Colle*e o+
Dentistry. /o3a Dent #ull, :>9>:.
:'>. American Association o+ )/-lic Healt, Dentistry. !ecommendations +or
teac,in* it-and-+iss/re sealants. " Pu4lic Health Dent, &(9::>-:&.
:'=. Co,en, .., 1a1elle, A., g !om-er*, 3. 7:;((8. 5,e /se o+ it-and-+iss/re
sealants in ri"ate ractice9 A national s/r"ey. " Pu4lic Health Dent, &(9><-='.
:'&. Mert@-Fair,/rst, 3. #., C/rtis, #. 4. #r., 3r*le, #. 4., !/e**e-er*, F. A., g Adair,
S. M. 7:;;(8. Ultraconser"ati"e and cariostatic sealed restorations9 !es/lts at year :$.
"D, :>;9''-<<.
reser"ed.
Denise %uesch Helm
Objectives
:
Introduction
>
=
occl/sal s/r+aces.
re"ent caries.
>
In :;>;, 1odecker
&
'
<
%
and t,e /se o+
(
into t,e +iss/res.
;
:$
::
:>
:=
)its and
t,e oral co/nt.
roced/re.
intact sealant.
restoration.
rone to caries.
:&
and
:'
C/rrently, %%E
ermanent teet,.
:
:<
=
:%
and collea*/es
:(
:;
and Air Force
>$
recr/its 7w,o
:;<$s.
:$,>:
:;<$s.
>>
>=
>&
Caulk Division
>'
><
>%
and it was
>(,>;
=$
=:-==
=&-=<
A recent in vitro
=%
=(
=;,&$
is similar to
&:,&>
&=
5,e
&&
&'
See 5a-le
&<

mi0in*
&%
&=,&(-'$
':
'>
+re?/encies.
e0os/re.
Question 1
adhesive forces,
'=
'&
'','<
I+ any
'%
5,e etc,ant
increases.
'(,';
sealant retention,
Surface Cleanliness
st/dies -y Simonsen
<$
and Mert@-Fair,/rst
<:
<>
comosites,
<=
<=-<'
<'-<(

s/r+ace.
<(
<;
%$,%:
%$
and comosite
%>
retention as t,ose
ori*inal s/r+ace,
%=
occ/r.
%&
%'
etc,.
t,is tec,ni?/e.
Question 2
Dryness
<$,<:
%<

%%
and a+ter :$ to >$
years.
<$,%(
a

%;
a
($
(:
Question 3
eri,ery intact.
indefinitely,
&:
control teet,.
(>
called ta$s,
(=
&:
O"er t,e +irst =
(=
<$,%%
Mert@-Fair,/rst
(=
cited
:$(
%$
('
In some
(=,(<
4,en
(%
((
==,=&,(<-(;
5,is
;$
;:
in"ol"ed.
;>
(<
#ordan and
S/@/ki
;=
;&
demonstrated
;'
4,en sealin*
;<
Question 4
to :' min/tes.
;%,;(
;;-:$>
:$=
:$&
:$'
:$<
I+ t,e
:$%
mar$inal decay,
:$(
:$=
5o relace t,e
:$(
Se"eral otions are
:$;
::$
:::
::>,::=

::&-::<
::%
::=
::(
::;
5,e *lass-
associates
:>$
:>:
comleted a >-
Manpower
:>>-:>&
:>'
:><
:>%
1eca/se
:>(
Economics
eriod,
:>;
:=$
occl/sal risk.
:=:
seal.
''
:=>
:==
intact,
:=&
,ealt, ro*rams.
>'
:='

o+ sealants.
:=<
:=%
w,ile t,e
:=(
:=;
>$
:&$
:&$
:&:
Fi"e years
:&>
sealantsF.
:&=
need +or sealants.
Dentist Involvement
=
:&&
:==

:&'
:&<

:&%
:&(
In Colorado,
:&'
:&;
Dental sc,ool
sealants.
:'$,:':
:'>
:'$
:>>
The economics and
sealant acceptance,
:'=
Question 5
(%,:'&
In t,e :$-year
st/dy,
:'&
Summary
demand t,em.
:. C and Dcorrect.
=. A and 1correct.
,o/rs to days.
&. 1 and Dcorrect.
sealant.
'. C and 3correct.
atientCs a*e.
iiiiiiiii.
and iiiiiiiii.
licens/re.
References
<<.
&>.
>;9:&>$-><.
;'.
" Dent !duc, &(7S/l. >89&>-&&.
&%9==. A-str.
o/lation. "D, :(&9:(>-(&.
U.S. )atent l=,$$<,::>. No"em-er :;<>.
:B::B>$$=.
Res, ('9'$=-&.
<%9::%->>.
Dent, :$9=9::'-:;.
Dent, ::9'(-<$.
'<.
''9><->;.
m Dent ssoc, (;9::$>-<.
+per Dent, >&9==:-<.
etc,in*. m " +rthod, %(9;;-:$(.
A-str. &$$.
+iss/res. #r Dent ", :$$9:'-:(.
;%9&''-<%.
>>9>':-';.
Dent !duc, &(7S/l.8 >9='-&:.
Ill. :;(>.
&( 7S/l.8 >9;<-:$>.
A-str. &$:.
:&=9(%-(;.
Dent Res, >(9&=;-&<.
Res, <:9'=%. A-str. :(.
>=.
/nt, :%9<:%-:;.
!ico, Octo-er :.
A: 7>89::%-><.
>$$=.
C,ica*o, Aril.
&>.
='9(=-(;.
Child, '(9&<-&;.
Dent ", :%%9:>'->;.
;9>&=-':.
:$>.
"D, :>;9''-<<.
reser"ed.
Denise %uesch Helm
Objectives
:
Introduction
>
=
occl/sal s/r+aces.
re"ent caries.
>
In :;>;, 1odecker
&
'
<
%
and t,e /se o+
(
into t,e +iss/res.
;
:$
::
:>
:=
)its and
t,e oral co/nt.
roced/re.
intact sealant.
restoration.
rone to caries.
:&
and
:'
C/rrently, %%E
ermanent teet,.
:
:<
=
:%
and collea*/es
:(
:;
and Air Force
>$
recr/its 7w,o
:;<$s.
:$,>:
:;<$s.
>>
>=
>&
Caulk Division
>'
><
>%
and it was
>(,>;
=$
=:-==
=&-=<
A recent in vitro
=%
=(
=;,&$
is similar to
&:,&>
&=
5,e
&&
&'
See 5a-le
&<

mi0in*
&%
&=,&(-'$
':
'>
+re?/encies.
e0os/re.
Question 1
adhesive forces,
'=
'&
'','<
I+ any
'%
5,e etc,ant
increases.
'(,';
sealant retention,
Surface Cleanliness
st/dies -y Simonsen
<$
and Mert@-Fair,/rst
<:
<>
comosites,
<=
<=-<'
<'-<(

s/r+ace.
<(
<;
%$,%:
%$
and comosite
%>
retention as t,ose
ori*inal s/r+ace,
%=
occ/r.
%&
%'
etc,.
t,is tec,ni?/e.
Question 2
Dryness
<$,<:
%<

%%
and a+ter :$ to >$
years.
<$,%(
a

%;
a
($
(:
Question 3
eri,ery intact.
indefinitely,
&:
control teet,.
(>
called ta$s,
(=
&:
O"er t,e +irst =
(=
<$,%%
Mert@-Fair,/rst
(=
cited
:$(
%$
('
In some
(=,(<
4,en
(%
((
==,=&,(<-(;
5,is
;$
;:
in"ol"ed.
;>
(<
#ordan and
S/@/ki
;=
;&
demonstrated
;'
4,en sealin*
;<
Question 4
to :' min/tes.
;%,;(
;;-:$>
:$=
:$&
:$'
:$<
I+ t,e
:$%
mar$inal decay,
:$(
:$=
5o relace t,e
:$(
Se"eral otions are
:$;
::$
:::
::>,::=

::&-::<
::%
::=
::(
::;
5,e *lass-
associates
:>$
:>:
comleted a >-
Manpower
:>>-:>&
:>'
:><
:>%
1eca/se
:>(
Economics
eriod,
:>;
:=$
occl/sal risk.
:=:
seal.
''
:=>
:==
intact,
:=&
,ealt, ro*rams.
>'
:='

o+ sealants.
:=<
:=%
w,ile t,e
:=(
:=;
>$
:&$
:&$
:&:
Fi"e years
:&>
sealantsF.
:&=
need +or sealants.
Dentist Involvement
=
:&&
:==

:&'
:&<

:&%
:&(
In Colorado,
:&'
:&;
Dental sc,ool
sealants.
:'$,:':
:'>
:'$
:>>
The economics and
sealant acceptance,
:'=
Question 5
(%,:'&
In t,e :$-year
st/dy,
:'&
Summary
demand t,em.
:. C and Dcorrect.
=. A and 1correct.
,o/rs to days.
&. 1 and Dcorrect.
sealant.
'. C and 3correct.
atientCs a*e.
iiiiiiiii.
and iiiiiiiii.
licens/re.
References
<<.
&>.
>;9:&>$-><.
;'.
" Dent !duc, &(7S/l. >89&>-&&.
&%9==. A-str.
o/lation. "D, :(&9:(>-(&.
U.S. )atent l=,$$<,::>. No"em-er :;<>.
:B::B>$$=.
Res, ('9'$=-&.
<%9::%->>.
Dent, :$9=9::'-:;.
Dent, ::9'(-<$.
'<.
''9><->;.
m Dent ssoc, (;9::$>-<.
+per Dent, >&9==:-<.
etc,in*. m " +rthod, %(9;;-:$(.
A-str. &$$.
+iss/res. #r Dent ", :$$9:'-:(.
;%9&''-<%.
>>9>':-';.
Dent !duc, &(7S/l.8 >9='-&:.
Ill. :;(>.
&( 7S/l.8 >9;<-:$>.
A-str. &$:.
:&=9(%-(;.
Dent Res, >(9&=;-&<.
Res, <:9'=%. A-str. :(.
>=.
/nt, :%9<:%-:;.
!ico, Octo-er :.
A: 7>89::%-><.
>$$=.
C,ica*o, Aril.
&>.
='9(=-(;.
Child, '(9&<-&;.
Dent ", :%%9:>'->;.
;9>&=-':.
:$>.
"D, :>;9''-<<.
reser"ed.
Chapter 11. Oral Biologic Defenses in Tooth Demineralization and
Remineralization - &orman +, Harris "ohn Hic*s
Objectives
:. Descri-e at least +i"e -ody de+ense systems t,at are oerational in and-aro/nd t,e
oral ca"ity.
>. .ist t,e names o+ t,e maAor sali"ary *lands in rank order o+ -ot, t,eir daily o/t/t
o+ /nstim/lated 7restin*8 sali"a and t,e amo/nt o+ stim/lated o/t/t.
=. .ist t,ree means o+ stim/latin* sali"a o/t/t and t,ree met,ods o+ in,i-itin* sali"a
o/t/t.
&. De+ine and comare t,e terms sialorr,ea, 0erostomia, and tyalism.
'. Descri-e t,e aearance and t,e imlications o+ t,e conto/r o+ t,e Ste,an C/r"e.
<. Descri-e ,ow t,e +l/id "iscosity o+ t,e la?/e a++ects di++/sion wit,in t,e la?/e.
%. Descri-e t,e /ltramicroscoic mor,olo*y o+ enamel rods, enamel crystals and t,e
/nit cell o+ ,ydro0yaatite 7HA)8.
(. 30lain w,y an e0tracted toot, immersed in a li?/id acid sol/tion 7in vitro8 will not
yield an inciient lesion, w,ereas, i+ it is immersed in a -/++ered *el o+ similar H, t,e
inciient lesion de"elos.
;. 30lain w,y a newly er/ted toot, is at ,i*, risk to de"elo a cario/s lesion.
:$. !eco/nt t,e key e"ents t,at ca/se and occ/r in deminerali@ation, and ,ow t,e
re"erse e"ents o+ reminerali@ation can o+ten reair t,e dama*e.
Introduction
MChapter CC is a continuation of Chapter A, -hereas Chapter A emphasi1ed the
4asics of the caries process, chapter CC concentrates on the saliva and the
ultramicroscopic structure of the tooth, as they affect de2 and reminerali1ation,N
5,e mo/t, is t,e *ateway +or +ood and drink destined +or t,e *astrointestinal 7GI8
tract. 5o ens/re t,e sa+ety o+ t,e -ody +rom t,e o+t-/nknown ?/ality o+ +oods -ein*
-ro/*,t into t,e mo/t,, two ower+/l e"ol/tionary monitorin* sensory systems e0ist
to ,el determine sa+ety and ?/ality 4efore in*estin* t,e */statory +arevision and
smell, 1ot, o+ t,ese senses allow t,e ,ost to reAect +ood deemed to -e /ndesira-le.
Once wit,in t,e oral ca"ity, t,ere is t,e rotecti"e /m-rella o+ t,e -odyCs imm/ne
systemthe cellular and the secretory immune systems, 5,e +ormer is cell-mediated
and consists o+ t,e ,a*ocytic and lym,oid elements in"ol"ed in re"entin*
in+ection. 5,e secretory system mainly rotects m/co/s mem-ranes wit, secretions o+
anti-odies, s/c, as sI*A 7secretory imm/no*lo-/lin A8.
:
5wo ot,er de+ense
mec,anisms are taste
>
and tactile sense, As an e0amle, tactile sense allows +or
roriocetion
a
"ia ner"es in t,e oral tiss/es to e"al/ate morsel si@e, te0t/re and s,ae
o+ t,e enterin* +oodD to se*re*ate +oods t,at need to -e c,ewed +rom +ood t,at needs
to -e incisedD and to determine w,en a -ol/s o+ +ood is o+ t,e correct si@e and
consistency +rom c,ewin* to -e sa+ely swallowed.
=
5,e de+ense +/nctions o+ t,e saliva are art o+ t,e total -odyCs a-ility to maintain
homeostasis, i.e., t,e a-ility to resist ro/tine daily c,allen*es -y c,emical and
-acterial a*ents, and to reair limited amo/nts o+ tiss/e dama*e tyical o+ t,e wear
and tear o+ daily li+e.
&
It is only w,en t,e -acterial c,allen*e e0ceeds t,e -odyCs
de+ense caa-ilities andBor t,ere is a lack o+ a ersonCs commitment to sel+-care, t,at
dental caries ens/es.
5,e saliva ,els mod/late and a/*ment t,e re"io/sly descri-ed maAor -ody de+ense
systems in rotectin* oral tiss/es. Howe"er, in t,e deminerali@tion and
reminerali@tion rocess o+ toot, str/ct/re 7caries and reair8, t,e sali"a cannot -e
isolated +rom an interrelated t,ree comartment model consistin* o+ saliva, pla5ue
and teeth,
'
a
)roriocetion h 5,e recetion o+ sensory ner"e stim/li t,at locate t,e location o+
osition o+ arts o+ t,e -ody. 30amle9 4,ile eatin*, a diner wit, e"ery -ite, ro"ides
t,e -rain wit, in+ormation as to w,ere t,e oosin* teet, are in time to re"ent a
tra/matic occl/sion.
The Saliva Compartment
5,e sali"a is deri"ed mainly +rom t,e maAor sali"ary *landst,e arotid,
s/-mandi-/lar, and s/-lin*/al *lands. O+ t,ese, t,e arotid ela-orates a sero/s
7watery, m/co/s-oor8 +l/id containin* eletrolytes, -/t is relati"ely low in or*anic
s/-stances. 5,e arotid *land secretes t,e maAority o+ t,e sodium 4icar4onate t,at is
essential in ne/trali@in* acids rod/ced -y cario*enic -acteria in t,e dental la?/e,
<,%

and t,e maAority o+ t,e en@yme amylase t,at initiates intraoral di*estion o+
car-o,ydrates. 5,e s/-mandi-/lar *land secretes a mi0ed sero/s and m/c/os +l/id,
w,ile t,e s/-lin*/al *land ,as a *reater roortion o+ m/co/s o/t/t t,an t,e ot,er
maAor *lands. 5,e minor *landsalatal, lin*/al, -/ccal, and la-ial sali"ary *lands
emty onto t,e m/c/s mem-rane in many locationson t,e alate, /nder t,e ton*/e,
and on t,e inner side o+ t,e c,eeks and lis. 5,ese minor *lands are mainly m/co/s
secretin* *lands t,at l/-ricate t,ese s/r+aces and allows +or imro"ed mastication and
assa*e o+ +ood s/-stance into t,e eso,a*/s.
=
5,e minor sali"ary *lands also
contri-/te +l/oride t,at -at,es t,e teet, and en,ances caries resistance.
(,;,:$
)/re sali"a rod/ced -y t,e oral *lands is sterile, /ntil it is disc,ar*ed into t,e mo/t,.
4,en t,e +l/ids +rom all maAor and minor *lands mi0 wit, eac, ot,er, t,is secretion
-ecomes known as 3hole saliva, 4,ole sali"a is +/rt,er altered -y t,e resence o+
articles o+ +ood, tiss/e +l/id, lysed -acteria, and slo/*,ed eit,elial cells. It -ecomes
e"en more comle0 wit, t,e incl/sions o+ livin$ cells and their meta4olic products,
+or e0amle, -acteria and le/cocytes, t,e latter deri"ed +rom t,e *in*i"al cre"ices and
tonsils.
F/nctions o+ sali"a
5,e ,ysical and c,emical rotecti"e +/nctions o+ sali"a can -e di"ided into +i"e
con"enient cate*ories7:8 l/-rication, 7:8 +l/s,in*Brinsin*, 7>8 c,emical, 7=8
antimicro-ial 7incl/des anti-acterial, anti+/n*al and anti"iral8, and 7&8 maintenance o+
s/ersat/ration o+ calci/m and ,os,ate le"el -at,ein* t,e enamel, ,elin* to stymie
deminerali@ation andBor to aid reminerali@ation o+ toot, str/ct/re.
::,:>
5o rein+orce t,e
concet e0ressed in 7&8, )eret@ atly oined t,at sali"a can -e considered similar to
enamel -/t in a li?/id ,ase.
:=
5,e sali"ary de+ensi"e system +/nctions contin/o/sly, -/t its secretion -ecomes
*reatest and most acti"e d/rin* +oodst/++ in*estion. It ,as t,e lowest +low rate d/rin*
t,e slee eriod o+ t,e daily >&-,o/r cycle.
./-rication and Fl/s,in*
A "ery t,in microscoic layer o+ m/c/s rotects t,e oral ,ard and so+t tiss/es +rom
t,e o+ten ,ars, and a-rasi"e +oods, as t,ey are -ein* c,ewed and swallowed. It also
rotects t,e so+t tiss/es +rom dessication and t,e teet, +rom a-rasion. 5,e moistenin*
o+ +ood -y sali"a facilitates che3in$ and s3allo3in$, Seec, is en,anced -y t,e
red/ced +riction -etween t,e dry ton*/e and so+t tiss/es. Co"ersely, a lack o+ sali"a
7xerostomia8 res/lts in a *reatly increased risk o+ caries wit, its accomaniment o+ an
e0tremely annoyin$ dry2mouth sensation, C,ewin*, swallowin* and seakin* can all
-e di++ic/lt and /ncom+orta-le wit, dry2mouth syndrome and o+ten re?/ires +re?/ent
amelioratin* sis o+ water.
Flow !ate
)ro"idin* a constant +l/id +low is ro-a-ly t,e most imortant de+ense +/nction o+ t,e
sali"ary *lands, -eca/se it is t,e +l/id t,at transorts t,e -/++erin* a*ents, t,e
antimicro-ials, and t,e mineral content o+ sali"a to ,el control t,e e?/ili-ri/m
-etween t,e deminerali@ation and reminerali@ation o+ toot, str/ct/re. Also, t,e +l/id
o/t/t o+ t,e *lands is essential +or dilutin$ acids, flushin$ +ood articles em-edded
aro/nd t,e teet,, clearin$ re+ined car-o,ydrates 7acid-rod/cin* s/*ar s/-strates8 and
,ysically removin$ any displaced -acteria
:>
Oral +l/ids in contact wit, +ood articles
res/lts in sol/-ili@in* +ood s/-stances t,at interact wit, t,e taste -/ds to ro"ide an
acc/rate assessment o+ taste.
>
5,e comosition o+ sali"a "aries, deendin* on w,et,er it is stimulated or
unstimulated (restin$), D/rin* t,e day, s/-mandi-/lar *lands secrete t,e *reatest
roortion o+ t,e /nstim/lated sali"a, alt,o/*, t,e +low rate o+ restin* sali"a +or all
t,ree *lands is "ery low, -ein* a-o/t one tent, t,at d/rin* stim/lated +low.
Aro0imately >B= o+ t,e restin$ sali"a is deri"ed +rom t,e s/-mandi-/lar *lands,
one-?/arter is +rom t,e arotids, and a-o/t :B>$ is +rom t,e s/-lin*/al *lands. 5,e
minor sali"ary *lands secrete almost :B:$ o+ t,e total amo/nt o+ sali"a. 5,e
/nstim/lated +low rate o+ t,e sali"ary *lands is s/-Aect to a circadian r,yt,m, wit, t,e
,i*,est +low in mid-a+ternoon and t,e lowest aro/nd &9$$ A.M.
Uon moderate stimulation, t,e s/-mandi-/lar and arotid *lands secrete
aro0imately e?/al amo/nts o+ sali"a, w,ereas at +/ll stim/lation t,e arotid ,as t,e
*reatest o/t/t. 4,en sali"ary +low is stim/lated -y c,ewin* */m or ara++in, : to >
m. o+ w,ole sali"a er min/te can -e e0ected. 5,e minim/m le"el o+ stim/lated
sali"ary +low necessary to maintain ,ard- and so+t-tiss/e ,ealt, is /nknown, -/t w,en
it is 4elo3 C m(Lminute, t,ere is ca/se +or concern re*ardin* a ossi-le dry mo/t, and
caries +ormation. Once t,e +low rate is -elow :,D m(Lminute, a dia*nosis o+
0erostomia may -e rendered. In t,e co/rse o+ a sin*le day, / to : liter 7: ?/art8 o+
sali"a is secreted into t,e oral ca"ity.
5,e total amo/nt o+ sali"a secreted "aries considera-ly -etween and wit,in
indi"id/als, deendin* on t,e en"ironmental +actors. Seasonal "ariations occ/r, wit,
+low -ein* lower in warm weat,er and ,i*,er in cold. 5,e act o+ smokin* increases
+low rates. Flow is *reater w,ile standin* t,an w,en sittin* and *reater w,en
rec/m-ent, wit, t,ese ost/ral c,an*es arallelin* c,an*es in systemic -lood
ress/re.
Sali"a +low may -e stimulated 7:8 ,ysiolo*ically, 7>8 ,armacolo*ically 7o"er t,e
co/nter dr/*s, ,er-als and rescrition medications8 and -y 7=8 many di++erent
disease states
:&,:'
30amles o+ ,ysiolo*ic stim/lation are t,e simle acts o+ che3in$
+ood and */m, $ustatory stimuli ca/sed -y tastin$ an enAoya-le +ood, w,ile
psycholo$ic stim/lation +or +ood can -e e"oked -y anticiatin* t,e +irst -ite o+ a
delicio/s +ood "ia t,e sense o+ si*,t andBor smell. Sali"a can also -e stim/lated -y t,e
/se o+ dru$s, s/c, as ilocarine. Under certain conditions, sali"a +low can -e
a-normally ,i*,a condition termed sialorrhea,7or ptyalism8 w,ic, is o+ten
mani+ested -y droolin*. Under some conditions dr/* t,eray can -e /sed,
:<, :$
-/t
sialorrhea or ptyalism may -e so se"ere as to re?/ire s/r*ical remo"al 7e0cision8o+
t,e resonsi-le *land or li$ation o+ t,e *land d/ct.
:%
Sali"a +low can also -e suppressed ,ysiolo*ically, ,armacolo*ically
:<
andBor -y
disease. 5,e dry mo/t, sensation 70erostomia8 t,at accomanies fear is an e0amle o+
a ,ysiolo*ical resonseD ,armacolo*ically it may +ollow t,e intake, amon* ot,ers,
o+ antideressant and anti,yertensi"e dr/*sD
:(,:;
it occ/rs w,en t,ere are sialoliths
7stones8 wit,in t,e *land d/cts res/ltin* in o-str/ction o+ sali"a +low,
:;,>$
or +ollowin*
radiation e0os/re o+ t,e *lands d/rin* cancer t,eray.
5,e concentration o+ t,e "ario/s sali"a comonents secreted -y t,e *lands is closely
related to t,e +low rate. Stim/lation o+ t,e rate o+ +low -y stim/lation increases t,e
concentration o+ some constit/ents and decreases it +or ot,ers. Stim/lation o+ t,e
arotid *lands ca/ses an increase in calci/m, sodi/m, c,loride, -icar-onate and H.
5,e same sali"a demonstrates a concomitant decrease in ,os,ate and otassi/m.
In addition to t,e secretion o+ di++erent roortions o+ electrolytes, or$anic molec/les
are secreted t,at can -e cate*ori@ed into +i"e maAor *ro/s9 amylase, m/cins,
,os,oroteins, *lycoroteins, and imm/no*lo-/lins. 5wo o+ t,e +amilies o+ small
sali"ary roteins,istadine and stat,erindeser"e seci+ic mention -eca/se t,ey
,el control t,e stat/s o+ calci/m and ,os,ate in t,e sali"a. 5,ese roteins re"ent
+all-o/t o+ t,e calci/m and ,os,ate t,at maintain s/ersat/ration in relation to
HA). 5,ey re"ent a raid dro in sali"a H and aid in its ?/icker reco"ery. In
addition, t,ey -ot, are anti+/n*al and ,el re"ent m/cosal in+ections.
Question 1
4,ic, o+ t,e +ollowin* statements, i+ any, is correcte
A. sI*A 7secretory imm/no*lo-/lin A8 is a */ardian o+ moist eit,elial s/r+aces
7m/co/s mem-ranes8.
1. 5,e maAor sali"ary *lands are t,e arotid, alatal, and t,e s/-mandi-/lar.
C. 5,e sali"a o/t/t o+ t,e maAor sali"ary *lands increases in de+ense e++ecti"eness at
t,e time o+ c,ewin*.
D. In t,e order o+ ma0im/m +low rate, t,e arotid is +irst, t,e s/-lin*/al second, and
t,e minor sali"ary *lands t,ird.
3. All t,e maAor sali"ary *lands can -e -ot, stim/lated or retarded in +low rate -y
,ysiolo*ical stim/l/s, dr/*s, or disease.
)rotecti"e F/nctions o+ Sali"a
5,e rotecti"e +/nctions o+ sali"a are +rom its physical, chemical, and antimicro4ial
roerties.
:$
Sali"a is not e?/ally distri-/ted aro/nd t,e oral ca"ity -eca/se o+
di++erences in anatomical and ort,odontic +eat/res. It also ,as a tendency to stay on
t,e side it was secreted.
>:
5,ese di++erences mean t,ere is an increased risk +or caries
+ormation owin* to retention o+ re+ined car-o,ydrates at di++ic/lt-to-reac, sites in t,e
mo/t,.
>>
O+ arallel imortance, a "iscid sali"a is not as e++ecti"e in clearin* +ood
articles and snacks, as is normal sali"a.
Anti-acterial F/nctions
5,e most easily /nderstood maAor anti-acterial +/nction is er+ormed -y one o+ t,e
*lycoroteinst,e m/cinst,at tra or a$$re$ate -acteria t,at are e"ent/ally
swallowed. 5,e same m/cins ro"ide a t,in +ilm o"er t,e m/co/s mem-rane and
teet, to ser"e as l/-ricants.
Fo/r imortant antimicro-ial roteins +o/nd in sali"a are9 lyso@yme, lacto+errin,
sali"ary ero0idase and secretory imm/no-lo-/lin A 7sI*A8. /n vitro, lacto+errin
stron*ly in,i-ited ad,erence o+ m/tans stretococci to sali"a coated ,ydro0yaatite
7HA)8 -locks.
>=
.acto+errin com-ines wit, iron and coer to deprive -acteria o+
t,ese essential n/trients. Sali"ary ero0idase reacts wit, sali"a to +orm t,e
antimicro-ial como/nd hypothiocyanate, w,ic, in t/rn in,i-its t,e caa-ility o+ t,e
-acteria to fully use $lucose, .actoero0idase stron*ly adsor-s to ,ydro0yaatite as a
comonent o+ t,e ac?/ired ellicle, and can influence t,e ?/alitati"e and ?/antitati"e
c,aracteristics o+ t,e micro-ial o/lation o+ dental la?/e. 5,e role o+ t,e -odyCs
cell/lar and imm/nolo*ic de+ense systems in moderatin* t,e co/rse o+ t,e la?/e-
ind/ced disease needs clari+ication. 5,e main access t,at ,a*ocytic cells and t,eir
anti-acterial rod/cts, ,a"e to t,e oral ca"ity is t,ro/*, t,e *in*i"al cre"ice and t,e
tonsils. It is di++ic/lt to concei"e o+ t,e cell/lar imm/ne system oeratin* in t,e
-acterial la?/e, yet a-o/t '$$ le/kocytes er second are estimated as emi*ratin*
+rom t,e tiss/es t,ro/*, t,e *in*i"al cre"ice into t,e oral ca"ity. 5,e maAority o+
t,ese soon disinte*rate in t,e sali"a, a ,enomenon t,at may -e related to t,e +act t,at
more intact olymor,on/clear le/kocytes occ/r in caries-+ree t,an in caries-
s/sceti-le indi"id/als. On a researc, -asis, t,ere is reason to -elie"e t,at a linka*e
e0ists -etween normal ,/moral and cell/lar de+enses, and -ot, caries and eriodontal
disease. How t,e cells and imm/no*lo-/lins e0ercise t,is otential is /nclear. 5,e
de"eloment o+ a s/ccess+/l "accine a*ainst caries and ossi-ly, a*ainst eriodontal
disease will /ltimately deend on s/c, a clari+ication.
5,e )la?/e Comartment
5,e la?/e comartment -e*ins wit, t,e ac?/ired 7sali"ary8 ellicle, w,ic, is an
acell/lar rotein layer o+ sali"a comonents t,at is adsor-ed onto t,e s/r+ace o+ t,e
enamel 7C,ater >8. Uon t,is ellicle, t,e -acteria coloni@e. 5,e ellicle l/s t,e
-acteria and t,e *el t,ey create, constit/tes a 4iofilm (dental lac?/e), For se"eral
,o/rs a+ter a ro,yla0is 7t,at remo"es -io+ilm8 t,ere is a steady c,an*e in t,e
?/antity and comosition o+ t,e ellicle as new roteins are added +rom t,e sali"a.
Glycoroteins aear to mediate t,e attac,ment sites o+ t,e s/-se?/ent coloni@in*
la?/e -acteria. 3"en t,o/*, m/cins are a minor comonent o+ t,e ellicle, t,ey can
-e "ery rotecti"e a$ainst acid diffusion,
5o /nderstand t,e e++ect t,at la?/e ,as on teet,, it is neccesary to +oc/s on t,e action
o+ acid in deminerali@in* teet,. 5o red/ce t,e otential o+ deminerali@ation, it is
necessary to 7:8 red/ce t,e num4er o+ -acteria rod/cin* t,e acid, 7>8 red/ce t,e
amount of acid rod/ced -y t,e e0istin* -acteria, andBor 7=8 ne*ate t,e e++ects o+ t,e
acid rod/ced -y la?/e.
),ysical C,aracter o+ )la?/e
A maAor consideration in t,e de+ense o+ t,e toot, is t,e ,ysical c,aracter o+ la?/e
itsel+. In order +or t,e +l/id and c,emical comonents o+ sali"a and la?/e to +/nction,
t,ey m/st -e a-le to di++/se +reely 7intermi08 wit, t,e constit/ents o+ t,e la?/e. 5,is
di++/sion re?/ires time, w,ic, is contin*ent on two imortant +actors. 7:8 I+ t,e +l/id
content in t,e la?/e is relati"ely ,i*,, incomin* and e0itin* ions di++/se raidly. 7>8
I+ t,e colloid and *l/can content o+ t,e la?/e is ,i*,, t,e di++/sion is slow, t,/s
retainin$ any acid a$ainst the tooth surface lon$er,
)ro-a-ly t,e most /nredicta-le +actor relatin* to t,e la?/e di++/sion is t,e c,aracter
o+ t,e micro-ial o/lation. 6ariations in -acterial secies +rom one la?/e to anot,er
or in di++erent arts o+ t,e same la?/e res/lt in di++erent di++/sion atterns. In ot,er
words t,e -acteria and t,eir meta-olites can act as eit,er a 4arrier, or as a $ate3ay to
t,e assa*e o+ selected anions, cations and roteins. For e0amle, -acteria /se
,os,ate in t,eir meta-olisma meta-olic need t,at is accentuated d/rin* eriods
o+ acido*enesis. Thus, the 4acterial need for phosphate from the pla5ue meta4olic
pool occurs at the same time that the same phosphate is re5uired to maintain
supersaturation at the pla5ue tooth interface,
Not all -acteria are -ad. 6eillonella, w,en resent, meta-oli@es lactic acid *enerated
-y m/tans stretococci, lacto-acilli, actinomycetes, and ot,er acido*enic or*anism.
)res/ma-ly t,is action decreases t,e amo/nt o+ acid a"aila-le to deminerali@e toot,
str/ct/re. Se"eral st/dies indicate t,at t,e resence o+ 6eillonella, indeed, decreases
caries risk. 5,/s t,e "arieties, meta-olic c,aracteristics and interrelations,is o+ t,e
la?/e -acteria at any one time, are imortant in determinin* w,et,er caries will
occ/r.
Question 2
A. All arts o+ t,e mo/t, are e?/ally assessa-le to t,e +l/s,in* e++ect o+ sali"a.
1. 5,e +ollowin* are anti-micro-ial a*ents +o/nd in sali"a9 lyso@me, lacto+errin, and
sali"ary ero0idase.
C. I+ a cross section o+ a la?/e coated crown o+ a toot, is st/died, t,e +ollowin*
str/ct/res wo/ld -e seen startin* wit, t,e toot, s/r+ace9 t,e enamel s/r+ace, ac?/ired
7sali"ary ellicle8, -acterial la?/e, and +inally, sali"a.
D. 5,e -acteria o+ t,e la?/e cannot /se t,e ,os,ate di++/sin* o/t o+ t,e ores +or
t,eir own met-olism.
3. )la?/e acido*enesis co/ld ro-a-ly -e red/ced to inoc/lo/s le"els -y a maAor
commitment to s/*ar disciline as a art o+ sel+-care.
!ed/cin* Acid )rod/ction
5oot,-r/s,in*, +lossin* and irri*ation 7F-r/s,, +loss and +l/s,F8 are ideal +or ersonal
sel+-care. Howe"er, t,ere are natural oral de+ense mec,anisms t,at e0ist in t,e -ody
t,at are not dependent on the frailities of human motivation, memories or tec,ni?/es.
:. Great n/m-ers o+ -acteria in t,e sali"a are eliminated -y flushin$, a**re*ation and
s3allo3in$,
>. 5,e -acterial o/lations in t,e sali"a and la?/e are contin/ally e0osed to t,e
antimicro4ial elements of saliva,
!ed/cin* t,e amo/nt o+ acid rod/ced -y t,e -acteria is mainly a +/nction o+ limitin*
t,e intake o+ re+ined car-o,ydrates 7i.e., su$ar discipline8. 5,is s/-Aect is disc/ssed in
detail in later c,aters dealin* wit, s/*ars, n/trition and clinical re"enti"e dentistry.
The in$estion of refined su$ars ma*es dental caries a self2inflicted disease,
!ed/cin* t,e Acid Dama*e
5,e la?/e H can dro to as low as &.$ on t,e Ste,an C/r"e a+ter a *l/cose mo/t,
rinse. Dama*e control +rom acid in t,e la?/e, is ac,ie"ed -y dil/tion, c,emical
-/++erin*, and -y increasin* t,e rotecti"e ions 7mainly, calci/m, ,os,ate and
+l/oride8 in t,e en"irons o+ t,e teet,.
>&,:$
5,e water content o+ t,e sali"a and la?/e
aid *reatly in dil/tin* t,e acid and in transortin* acid into t,e main +low o+ sali"a
w,ere it is +/rt,er dil/ted and swallowed. 5,is dil/tional e++ect is s/lemented -y
t,e -/++erin* caacity o+ t,e la?/e w,ic, can -e :$ times ,i*,er t,an +or t,e +l/oride
in t,e sali"a. 5,is ,i*,er adsortion caacity +or +l/oride in t,e la?/e also occ/rs to
di++erin* e0tents in increasin* -icar-onates, ,os,ates and ammonia concentrations
deri"ed +rom t,e sali"a. 5,ese ne/trali@in* actions ser"e as a -rake in t,e raidity and
e0tent to w,ic, t,e H can dro d/rin* eriods o+ acido*enesis.
3ac, indi"id/l ,as a di++erent otential +or modi+yin* t,e dro and reco"ery o+ t,e H
reresented -y ,isB,er indi"id/al Ste,an C/r"e. As an e0amle, i+ a *ro/ o+
indi"id/als is *i"en a *l/cose mo/t, rinse, eac, erson demonstrates a di++erent, -/t
rerod/ci-le H attern. Once t,e H ,as started to +all, t,e a"aila-ility o+ stat,erin
and ot,er sali"ary -/++ers ,el to s,orten t,e time t,at t,e H is at its lowest and most
dama*in* le"el.
5,e 5oot, Comartment
Coronal caries in"ol"es t,e enamel ca
-
and t,e /nderlyin* dentin. 3namel is more
minerali@ed t,an -one or dentin. It is estimated t,at enamel is comosed o+
aro0imately ;<E mineral -y wei*,t wit, an a"era*e "ol/me o+ (%E. 5,e enamel
contains millions o+ enamel rods t,at r/n +rom t,e dentinoenamel A/nction 7D3#8 to
t,e toot, s/r+ace. 5,e rods are aro0imately & to % micrometers, and -y < to (
micrometers in cross section +or rimary and ermanent teet,, resecti"ely. In cross
sections t,ey resem-le key,oles, more t,an rods. Aro/nd eac, rod t,ere is an
en"eloin* rotein matri0. D/rin* +ormation o+ t,e crown, t,is or*anic matri0 +orms
t,e temlate t,at is in"ol"ed in determinin* crystal and rod si@e and orientation
7C,ater =8.
5,e inor*anic ,ase o+ enamel is -ased on t,e mineral, ,ydro0yaatite 7HA)8, made
/ mainly o+ calci/m 7Ca8, ,os,ate 7)O
&
8 and ,ydro0yl 7OH8 ions. It also contains
trace amo/nts o+ ot,er elements t,at ,aen to -e in t,e -loodstream d/rin* enamel
+ormation, in +act more t,an &$ elements ,a"e -een identi+ied in analysis o+ enamel.
3ac, rod is made / o+ millions o+ crystals eac, w,ic, are s,aed m/c, like a
carenters ,e0a*onal lead encilone t,at is sli*,tly +lattened on two oosite sides
-etween t,e s/-microscoic crystals t,ere are also su4microscopic amounts of
matrix, 5,ese en"eloin* rotein wras o+ -ot, t,e enamel rods and crystals are t,e
main c,annels +or di++/sion +or deminerali@in* acids and reminerali@in* electrolytes
as e0lained in C,ater =.
cIn order to -etter /nderstand t,e toot, ,istolo*y at increasin* ma*ni+ications, t,is is
to in"ite yo/ to Aoin t,e +ollowin* art and ,oto*ra,ic to/r +eat/rin* t,e FAnatomy
o+ a 5oot,.F 5,e startin* oint is Fi*/re ::-:. Ho/ will need t,is in+ormation
t,ro/*,o/t yo/r career.
Ill/stration ::-:a is a cross section o+ enamel, s,owin* ,ow eac, o+ t,e tails are
cradled -etween t,e ,eads o+ t,e adAoinin* rods. 5,e drawin* ::-:- ro"ides a
concet o+ a sin*le enamel rod.
c
4it, t,ese two -ack*ro/nd sc,ematics, t,e ,ead and
tail ositionin* -ecomes e"en more /nderstanda-le w,en "iewed on an electron
micro*ra,, 7Fi*/re ::->8 t,at s,ows t,e rod as a cr/de key,ole str/ct/re. Fi*/re ::-
: c is o+ a sin*le crystal ortrayed as a carenter-s,aed encil con+i*/ration. 3ac,
crystal is comosed o+ Ca, )O
&
and 7OH8 7and ot,er e0traneo/s contaminants8. 3ac,
o+ t,e crystals makin* / t,e enamel rod is considered as a /nit cell.7::-:d8 A /nit
cell is t,e smallest s/-di"ision o+ a crystalline s/-stance t,at is entirely reresentati"e
o+ t,e str/ct/re o+ t,e crystal. 5,is means t,at all rods o+ any dimensions can -e
constr/cted 7or reminerali@ed8 -y addin* additional /nit cells, m/c, as a -/ildin* can
-e increased in si@e -y addin* additional -ricks. It is imortant to reco*ni@e t,at /nit
cells, /nlike t,e -ricks, ,a"e no ,ysical meanin* as s/c,D t,ey are A/st a con"enient
means o+ concet/ali@in* t,e atomic str/ct/re and relations,i o+ crystals at t,e
simlest le"el.
I+ one /nit cell co/ld -e detac,ed alon* t,e c-a0is, it wo/ld resem-le a windc,imes on
a strin*, wit, eac, s/ccessi"e trian*/lar *ro/in* -ein* comrised o+ calci/m,
,os,ate and ,ydro0l ions e?/idistant +rom adAacent *ro/in*s 7Fi*/re ::-: e8
4,en lookin* at t,e arran*ement +rom t,e to o+ t,e col/mn, t,e center osition is
occ/ied -y ,ydro0yl ions, s/rro/nded -y a trian*l/lar con+i*/ration wit, a calci/m
ion at eac, oint o+ t,e trian*le. Immediately eri,eral to eac, calci/m ion is a
,os,ate *ro/in* 7::-:+8. 3ac, s/ccessi"e trian*/lar *ro/in* *ro/in* alon* t,e
c-a0is is rotated :($-de*rees +rom t,e ones a-o"e and -elow, as ill/strated -y t,e
solid and dotted lines in Fi*/re ::-: +8. 3ac, o+ t,e atoms can -e relaced -y ot,er
atoms. For instance, a ,ydro0yl *ro/ can -e s/-stit/ted -y +l/orideD a calci/m ion -y
stronti/m, and a ,os,ate -y a car-onate.
Ne0t, let /s take a more detailed look at ,ow a crystal dissol"es startin* wit, Fi*/res
::-: c, and t,en ill/strations in Fi*/re ::-= arts :, >, and = t,at s,ow t,e se?/ence o+
dissol/tion o+ a crystal, w,ic, starts wit, a central etch pit, 5,e etc, its on t,e -asal
+aces are -ea/ti+/lly ill/strated at electron microscoe le"el, as are t,e ima*es o+
,allowed o/t crystals s,own in Fi*/re ::-&, arts : and &, resecti"ely.
-
I+ an intact toot, is stried o+ all dentin and cement/m, t,e remainin* ortion o+ t,e
toot, is t,e Fenamel caF.
c
3namel rods can -e correctly called enamel risms.
Deminerali@ation
5,ere were a +ew early interestin* e0eriments -y Sil"erstone w,o +irst +oc/sed
worldwide attention to t,e o"erall s/-Aect o+ de- and reminerali@ation. Se"eral
decades a*o, researc,ers co/ld not /nderstand t,e reason w,y a tyical ca"ity did not
+orm w,en a toot, was directly laced in acid Instead t,e o/ter layers o+ t,e toot,
wo/ld contin/e to dissol"e, -/t t,ere were no w,ite sots. 5,ere were no inciient
7s/-s/r+ace8 lesions. Howe"er, w,en Sil"erstone /sed an acidi+ied H $el 7instead o+
an acid sol/tion8 in w,ic, to immerse t,e toot,, an inciient lesion did +orm wit, t,e
e0ected +o/r @ones o+ enamel caries.
>'->%
5,e s/r+ace @one ,ad s/++icient calci/m and
,os,ate e0itin* +rom t,e -ody o+ t,e lesion to t,e s/r+ace @one to create a
s/ersat/ration o+ calci/m and ,os,ate ions to ca/se a HA) reciitation 4et3een
the $el and the tooth surface, 5,e ne0t st/dy -y Sil"erstone was to *rind o++ t,e entire
mat/re s/r+ace o+ t,e crown and a*ain immerse t,e toot, in t,e -/++ered *el. 5,e
entire s/r+ace area o+ t,e toot, was recreated, s,owin* t,at t,e o/tward di++/sin*
minerals ,ad attained s/++icient sat/ration to reciitate and +orm t,e e0terior o+ t,e
enamel. 5,is was interestin*, -/t ,e carried t,e st/dy one or two stes +/rt,er towards
ractical alication.
4,en a toot, wit, a care+/lly preserved pellicle was s/-Aected to t,e same *el
immersion treatment, t,ere was t,e same -/ild-/ o+ mat/re enamel and closin* o+
t,e pores 4et3een the tooth surface and the pellicle, He reasoned t,at t,e ellicle
acted as a temlate to maintain t,e conto/r o+ t,e reminerali@ed area. 5,is
demonstrated +or t,e +irst time t,at the pellicle served as a protective layer,
4,en /sin* sali"a as t,e reminerali@ation sol/tion, t,e a-ility to reminerali@e toot,
sections in "itro "aries wit, t,e sali"a +rom different individuals, -/t occ/rs
consistently wit, t,e sali"a o+ eac, indi"id/al, indictatin* t,at some eole ,a"e a
*reater caacity +or reminerali@ation (host resistance8 t,an ot,ers.
Fl/oride ,as a maAor in+l/ence on -ot, deminerali@ation and reminerali@ation.
>(

Fort/nately, only small concentrations o+ +l/oride are needed to in,i-it
deminerali@ation or to en,ance reminerali@ation. As little as $.: m +l/oride can
red/ce t,e amo/nt o+ enamel dissol/tion in vitro, 5,e resence o+ +l/oride at t,e
reminerali@in* site can accelerate re,ardenin* -y a +actor o+ / to +i"e+old. In t,e
mo/t,, t,e +l/oride can come +rom +o/r so/rces 7:8 transitory contact wit, +l/oridated
drinkin* waterD 7>8 t,e contin/al low +l/oride o//t o+ t,e sali"ary *landsD 7=8 t,e
-o/nd +l/oride occ/rrin* in t,e la?/e w,ic, is released w,en t,e H dros to aro/nd
'.'D or, 7&8 +rom t,e +l/oride contained in t,e mat/re enamel layer +ollowin*
deminerali@ation.
Fi*/re ::-: 3namel9 From t,e electron microscoe to t,e molec/le. a. An
electron microscoe model o+ t,e key,ole mor,olo*y o+ enamel. Note t,at t,e
crystals 7dotted lines8 wit,in any sin*le rism are coa0ial wit, t,e rism in t,e
,ead re*ion. From Meckel, A. H., Grie-stein, 4. #. and Neal. !. #. /nternational
Symposium on the Composition, Properties and 'undamental Structure of Tooth
!namel, Aril :;<&. Co/rtesy9 3d. Stack, M. 6., and Fearn,ead, !. 4., 1ristol,
3n*land9 #o,n 4rite and Sons, .td, :;<'. b. Indi"id/al enamel rod, s,owin*
di++erent crystal orientations in ,ead and tail. c. Ill/stration o+ a crystal wit,
la-els a, -, and c a0es. d. 5,eoretic resentation o+ /nit cells t,at make / t,e
crystallites. e. 6ertical arran*ement o+ ,ydro0yaatite alon* C a0is o+ t,e /nit
cell. f. S,owin* ,ow e"ery ot,er molec/lar con+i*/ration is rotated :($ as
ill/strated -y t,e solid and t,en t,e dotted lines. 7Co/rtesty o+ N. O. Harris,
Fi*/re ::-> Same electron micro*ra, as =->a. Same cation. 7A reeat8
3lectron micro*ra, o+ rod c/t erendic/lar to lon* a0is, s,owin* ,ead 7H8 and
tail 758 relations,i.
Fi*/re ::-= Dissol/tion o+ t,e crystal sc,ematic9 3ac, enamel rism is made /
o+ arallel crystals o+ ,ydro0yaatite t,at ,a"e a sli*,tly +lattened ,e0a*onal
aearance. 1. 5,e initial etc,in* o+ t,e crystal -e*ins at t,e ends wit,, 2. t,e
+ormation o+ etc,its. 3. 5,ese etc,its deeen alon* t,e c-a0is to e"ent/ally
rod/ce a ,ollow core. 7From Arends #. #an*er-loed 4.. Ultrastr/ct/re st/dies
o+ synt,etic aatite crystals. " Dent Res, :;%; cSecial Iss/e 1dD '(9(=%-(&=.8
Fi*/re ::-& Dissol/tion o+ t,e crystal, ,oto*ra,ic. 1. Arti+icially *rown
aatite crystal wit, etc,it on -asal +ace, ori*inal ma*ni+iction '$$. 2. A
,e0a*onal etc,it in +l/oraatite, ori*inal ma*ni+iction >'$$. 3. 53M ict/re
o+ so/nd enamel crystallites, ori*inal ma*ni+ication :$$,$$$D and 4. 53M
ict/re o+ etc,ed enamel crystallites t,at are artially ,ollowed o/t, ori*inal
ma*ni+ication :$$,$$$. 7Co/rtesy o+ Dr. 4... #on*e-loed, I. Molenaar and ..
Arends. Uni"ersity o+ Gronin*en, The &etherlands and "oel &e3s, #aan. :;%<D
:=e7>89:&.8
Question 3
4,ic, o+ t,e +ollowin* statements, i+ any, is correcte
A. 5,e enamel is a solid iece o+ ,ydro0yaatite.
1. 5,e crystal o+ a rod is t,e +irst comonent o+ t,e enamel ca to dissol"eD it is also
t,e +irst to -e reconstit/ted in reminerali@ation.
C. A rotein matri0 en"elos eac, crystal as well as eac, rod.
D. 5,e central con+i*/ration o+ t,e /nit cell is made / o+ calci/m and ,os,ate, t,e
OH is at t,e corners o+ t,e trian*le.
3. It re?/ires more acid o+ t,e same H to dissol"e a crystal t,an to dissol"e t,e rod.
!eminerali@ation
!eminerali@ation is t,e repair o+ enamel rod str/ct/re +ollowin* acido*enic eisodes.
4,en teet, er/t, t,ey are anatomically comlete, -/t crystallo*ra,ically incomlete
and immat/re. Followin* er/tion, t,e missin* ions are s/lied +rom t,e sali"a, a
rocess termed post2eruptive maturation, 5,ro/*,o/t li+e, minerals +rom t,e sali"a
are /sed to reair acid-dama*ed toot, str/ct/re. 5,is reair rocess can ran*e +rom an
almost immediate relacement o+ daily ion losses +rom t,e enamel s/r+ace, to a slow
reair 7/nder roer conditions8 o+ more e0tensi"e s/-s/r+ace 7w,ite sot8 lesions.
4it,o/t seci+ic knowled*e o+ t,e caries rocess, a lay erson is likely to en"ision t,e
de"eloment o+ a caries lesion as a contin/o/s rocess, accomanied -y an e"er-
increasin* loss o+ toot, mineral /ntil t,e sta*e is reac,ed w,en a clinically discerni-le
ca"ity is resent. Fort/nately, t,is concetion is incorrect. 5,e rocess o+
deminerali@ation is not irreversi4le or inevita4ly pro$ressive, I+ dama*e ,as not
ro*ressed -eyond a still yet to -e de+ined oint, lost mineral can 4e replaced,
Considera-le clinical e"idence e0ists +or reminerali@ation. Head, a ,ysician and a
dentist, ointed o/t in :;:> t,at teet, /nderwent cycles o+ so+tenin* and ,ardenin*.
>;

1y :;==, 1oedecker
=$
ad"ocated t,e /se o+ AndreasenCs met,od o+ reminerali@in*
Fso+tF teet, and Fw,ite sots.F AndreasenCs reminerali@in* owder consisted o+ tartaric
acid, *elatin, calci/m ,os,ate, calci/m car-onate, ma*nesi/m car-onate, sodi/m
-icar-onate and sodi/m c,loride. 1oedecker commented as +ollows9 F5,e /rose
t,at t,is owder is to +/l+ill, is to *o into sol/tion in t,e sali"a and in t,is state,
ermeate and recalci+y t,e oro/s area in t,e enamel . . . and a+ter t,e reminerali@in*
owder ,as -een /sed +or < weeks, decay aro/nd +illin*s will come to a standstill.F
M/,ler, in se"eral clinical st/dies o+ t,e anticaries e++ecti"eness o+ stanno/s +l/oride,
o+ten +o/nd t,at t,e e0erimental s/-Aects ,ad more so/nd teet, later in t,e st/dy t,an
at t,e initial e0amination.
=:
In"aria-ly, t,e n/m-er o+ t,ese re"ersals was *reater in
t,e stanno/s +l/oride treatment *ro/s t,an in t,e controls. 6on der Fe,r and
collea*/es were a-le to ind/ce w,ite sots wit, s/crose mo/t, rinses and re"ersed t,e
rocess wit, +l/oride rinses.
=>
1acker-Dirks,
==
in a lon*-term st/dy, noted t,at o"er '$
ercent o+ t,e interro0imal lesions seen at t,e initial e0amination did not ro*ress,
indicatin* an arrestment ,enomenon d/e to reminerali@ation. Additional s/ort +or
reminerali@ation is deri"ed +rom t,e +re?/ent o-ser"ations o+ teet, t,at are acid-
etc,ed rior to lacement o+ it-and-+iss/re sealants. For t,ose etc,ed areas not
co"ered wit, t,e resin, t,e c,alky w,ite aearance disaears o"er a eriod o+ a +ew
days and t,e enamel re*ains its initial transl/cent, *lossy aearance.
30cet /nder /n/s/al circ/mstances, s/c, as occ/r +ollowin* t,e destr/ction o+ t,e
sali"ary *lands d/rin* cancer radiot,eray or diseases o+ t,e *lands, de"iations +rom
reminerali@in* conditions in t,e mo/t, are transient. For e0amle, t,e local H may
-e lowered to w,ere enamel deminerali@ation occ/rs d/rin* t,e in*estion o+ acid
+oods or +rom t,e rod/ction o+ acid -y t,e la?/e -acteria +ollowin* t,e in*estion o+
re+ined car-o,ydrates. I+ t,e ins/lts are 4rief and 3idely searated in time,
reminerali@in* conditions can -e restored in t,e inter"enin* eriods and t,e sli*,t
dama*e reaired. On t,e ot,er ,and, +re?/ent or rotracted eriods o+ acido*enesis,
wit, ins/++icient time inter"als +or reminerali@ation, /ltimately lead to t,e
de"eloment o+ o"ert caries.
Crystal Si@e in Deminerali@ation and !eminerali@ation
Si"erstone, w,en ,e /-lis,ed t,e article, F5,e si*ni+icance o+ reminerali@ation in
caries re"ention.F oened / a new area o+ conser"ati"e dentistryan era t,at ten
Cate calls Fnonin"asi"e restorati"e care.F In ,is re"iew o+ reminerali@ation.
Sil"erstone ointed o/t t,at crystal si@es di++er redicta-ly in eac, o+ t,e @ones o+ t,e
inciient lesion and in reminerali@ed caries areas.
=&
In t,e inciient cario/s lesions, t,e
crystals in t,e two @ones o+ deminerali@ationt,e -ody o+ t,e lesion and t,e
translucent 1onewere smaller t,an in so/nd enamel. 7Fi*/re ::-'8. 5,e crystals in
t,e two @ones o+ reminerali@ationt,e dark and t,e s/r+ace @oneswere e?/al to, or
*reater in si@e t,an t,ose +o/nd in normal enamel. )redicta-ly, w,en a reminerali@in*
sol/tion wit, +l/oride is /sed to reminerali@e t,e s/-s/r+ace lesion, t,e crystal si@es
are *reater t,an +or normal so/nd enamel.
Fi*/re ::-' Ill/stration o+ t,e relati"e crystal diameters in so/nd enamel
7-ottom8 and in t,e +o/r ,istolo*ical @ones o+ t,e enamel lesions 7ri*,t8.
7Co/rtesy o+ Sil"erstone .M. 5,e si*ni+icance o+ reminerali@tion in caries
re"ention. " Can Dent ssn, :;(&D '$9 :'%-:(&.8
Question 4
A. 5,e concet o+ reminerali@ation dates +rom t,e last ?/arter o+ t,e >$t, cent/ry.
1. 5,e crystals o+ t,e -ody o+ t,e lesion are lar*er t,an t,ose o+ t,e dark @one.
C. An inciient lesion wit, a low H and a low sali"a calci/m and ,o,ate
concentration is more likely to reminerali@e t,an one wit, a ,i*, sali"a H and is
s/ersat/rated wit, calci/m and ,os,ate.
D. 5,e anti-caries -ene+its o+ sali"a d/rin* t,e Ste,an C/r"e -ot, slows
deminerali@ation and accelerates reminerali@ation.
3. A reminerali@ed rod in t,e resence o+ +l/oride is a more acid resistant rod t,an one
ori*inally made / o+ ,ydro0yaatite.
Summary
It ,as -een em,asi@ed t,at oral disease, in +act, all disease occ/rs w,en t,e c,allen*e
osed -y at,o*ens e0ceed t,e -odyCs caa-ility +or de+ense and reair. In t,e case o+
dental caries, t,e de+ense and sel+-reair mec,anisms o+ t,e -ody oerate
contin/o/sly in t,e sali"a, in t,e la?/e, and in t,e enamel ca. Aside +rom t,e ,ostCs
/s/al ,/moral and cell/lar de+ense +/nctions to destroy at,o*ens, t,e oral ca"ity is
rotected -y t,e senses o+ smell and "ision, taste and tactile sensation, t,e -odyCs
imm/nolo*ical de+enses, and t,e sali"a. Deminerali@ation is deendent on two maAor
+actorsH o+ t,e la?/e, and sat/ration o+ t,e toot, minerals. I+ t,e sat/ration is
,i*, and t,e H ,i*,, deminerali@ation will not occ/r. I+ -ot, t,e H and t,e
sat/ration are low, t,e risk o+ caries is ,i*,. 5,e o/t/t o+ restin* sali"a is moderate
to low t,ro/*,o/t t,e dayD it is only t,ro/*, t,e eriod o+ t,e Ste,an C/r"e t,at t,e
ma0im/m stim/lated sali"a rotection occ/rs.
1acterial acido*enesis in t,e dental la?/e ca/ses t,e la?/e H to +all and reco"er is
a manner redicted -y t,e Ste,an C/r"e. I+ t,e ma0im/m dro in H is -elow t,e
'.' to '.$ ran*e, deminerali@ation occ/rs wit, t,e e0tent deendent on calci/m and
,os,ate sat/ration le"el as well as t,e d/ration and +re?/ency o+ t,e acid attacks.
5,e increased secretions o+ ,atins and stat,erin slow t,e dro in H. An increased
amo/nt o+ sali"ary -/++erin* minimi@es t,e a++ect o+ t,e acido*enic end-rod/cts o+
t,e la?/e -acteria. 5,e increased +low o+ sali"a, wit, its ,i*, +l/id content, en,ances
t,e remo"al o+ cario*enic resid/es. As t,e H dros, s/ersat/ration o+ calci/m and
,os,ate ions decline alon* t,e la?/e-toot, inter+ace. Ions, s/c, as ma*nesi/m and
car-onate t,at are adsor-ed onto t,e toot,, dissol"e re+erentially and add to t,e
-/++erin* caacity o+ t,e local en"ironment. 4,en /ndersat/ration occ/rs,
somew,ere -etween H '.' and '.$, calci/m +l/oride, HA) and FHA -e*in to
dissol"e in s/ccessi"e order. 5,ese dissol"in* crystals add to t,e sat/ration alon* t,e
dissol"in* la?/e-toot, inter+ace, t,/s slowin* and e"ent/ally arrestin* toot,
deminerali@ation. At t,at time, reminerali@ation takes o"er. Ions necessary +or mineral
reair are a*ain a"aila-le +rom t,e inor*anic comonents o+ t,e la?/e t,at articiate
in t,e reminerali@ation rocess and are ready +or com-atin* t,e ne0t acido*enic cycle.
:. A, C, and 3correct.
1incorrect. 5,e palatal *lands are minor sali"ary *lands. 5,e correct answer
s,o/ld ,a"e incl/ded t,e s/-mandi-/lar *land, not t,e alatal *land.
Dincorrect. 5,e order s,o/ld -e9 arotid, s/-ma0illary, and s/-lin*/al *lands.
>. 1, C, and 3correct.
Aincorrect. 5,ere can -e teet, t,at o"erla, t,e alate can -e mal+ormed andBor an
a-normally lar*e ton*/e can -lock sali"a +low to some arts o+ t,e oral ca"ity. 5,is
ro-lem o+ di++ic/lt-to-reac, areas is -est sol"ed -y a co/nselin* session wit, a dental
,y*ienist.
D1acteria need ,os,ate +or ener*yD t,ere is no way to tell t,e )O
&
+rom one
so/rce comared to anot,er.
=. 1 and Ccorrect.
Aincorrect. 5,e enamel ca is oro/s wit, o"er :$E o+ t,e sacin* -ein* -etween
t,e rods and crystalsalso in areas s/c, as t,e ,yominerali@ation o+ t,e D3#, stria
o+ !et@i/s, sindles and t/+ts.
Dincorrect. 5,e central core o+ t,e HA) crystal is made / o+ mainly ,ydro0yl
ions, -/t can incl/de e0c,an*ed elements.
3It re?/ires m/c, less acid to dissol"e an indi"id/al crystal t,an a rod. 7#/st
remem-er t,e rod is made / o+ crystals, not "ice "ersa.8
&. D and 3correct.
Aincorrect. !eminerali@ation is mentioned in Dental Cosmos 7an early dental
Ao/rnal8 rior to t,e t/rn o+ t,e >$t, Cent/ry and -ecame o+ interest to researc,ers in
t,e mid >$t, cent/ry. I+ is rarely /sed in ri"ate or /-lic ,ealt, ractice in t,e United
States. 7Now ro/tinely /sed in New Iealand and Scandina"ia /-lic ,ealt, sc,ool
ro*rams8.
1incorrect. 5,e crystals in t,e two @ones o+ recrystali@ationt,e s/r+ace and t,e
dark @ones are t,e lar*er.
Cincorrect. 5,e ,i*,er t,e H and sat/ration o+ t,e sali"a t,e *reater t,e c,ance +or
reminerali@ation.
:. 5,e a-ility o+ t,e -rain to contin/ally monitor t,e location and action o+ a -ody art
is known as iiiiiiiii.
>. 5,e arotid *land rod/ces t,e most amylase 7en@yme to -reak down
car-o,ydrates8 and iiiiiiiii. 7ne/trali@in* a*ent8.
=. 5,e a-ility o+ t,e -ody to -alance t,e +actors ca/sin* disease, and t,e e"ents
romotin* -ody ,ealt, is known as maintainin* iiiiiiiii.
&. 5,e ?/antity and ?/ality associated wit, Ste,anCs C/r"e in 7restin*87stim/lated8
sali"a is /s/ally seen at t,e time o+ 7eatin*87+astin* -etween meals8. Circle correct
resonses.
'. Sialorr,ea is -est treated wit, 7a sali"a stim/lant8 7an antisialo*o*/e8.
d
Circle
correct resonse.
<. A desali"ated animal 7*lands remo"ed8 or a erson wit, e0cised *lands wo/ld ,a"e
a ro-lem wit, iiiiiiiii.
%. A ellicle acts to slow t,e transit o+ acid +rom t,e la?/e to t,e s/-s/r+ace iiiiii.
(. 5,e *lycorotein o+ t,e sali"a t,at ser"es to l/-ricate t,e oral tiss/es 7to red/ce
+riction and a-rasion8 and to a**re*ate -acteria +or swallowin* is iiiiiiiii.
;. It was iiiiiiiiii 7name o+ indi"id/al8 w,o *a"e t,e maAor imet/s to t,e modern
-asic concets o+ de- and reminerali@ation.
d
ntisialo$o$ue O an antidote to sialorrhea,
References
:. )roctor, G. 1., g Carenter, G. H. 7>$$:8. C,ewin* stim/lates secretion o+ ,/man
sali"ary secretory imm/no*lo-/lin A. " Dent Res, ($9;$;-:=.
>. Mats/o, !. 7>$$$8. !ole o+ sali"a in t,e maintenance o+ taste sensiti"ity. Rev +ral
#iol %ed, ::9>:<->;.
=. )edersen, A. M., 1ardow, A., #ensen, S. 1., g Na/nto+te, 1. 7>$$>8. Sali"a and
*astrointestinal +/nctions o+ taste, mastication, swallowin* and di*estion. +ral Dis,,
(9::%->;.
&. 5andler, 1., Gresick, 3. 4., Na*oto, 5., g ),illiss, C. #. 7>$$:8. Secretion -y
striated d/cts o+ mammalian maAor *lands9 a re"iew o+ /ltrastr/ct/ral, +/nctional and
e"ol/tionary esecti"e. nat, Rec, ><&9:>'-&'.
'. 5anaka, M., Mats/na*a, 2., g 2adoma, H. 7>$$$8. Correlation in inor*anic content
-etween sali"a and la?/e +l/id. " %ed Dent Sci, &%9''-;.
<. )ark, 2., H/rley, ). 5., !o/ssa, 3., et al. 7>$$>8. 30ansion o+ sodi/m -icar-onate
cotransorter in ,/man arotid *lands. rch +ral #iol, &%9:-;.
%. 1ardow, A., Madson, #., g Na/to+te, 1. 7>$$$8. 5,e -icar-onate concentration in
,/man sali"a does not e0ceed t,e lasma le"el /nder normal ,ysiolo*ical conditions.
Clin /nvesti$, &>9&'-'=.
(. Fer/son, D. 1. 7:;;;8. 5,e +low rate and comosition o+ ,/man la-ial *land sali"a.
rch +ral #iol, && S/l :'::-&.
;. 1oros, I., 2esler, )., g Ielles, 5. 7:;;;8. St/dy o+ sali"a secretion and t,e sali"ary
+l/oride concentration o+ t,e ,/man minor la-ial *lands -y a new met,od. rch +ral
#iol, &&9 S/l :9'::-:&.
:$. .a*ero+, F., g Oli"e-y A. 7:;;&8. Caries-rotecti"e +actors in sali"a. dv Dent
Res, (9>>;-=(.
::. Dowd, F. #. 7:;;'8. Sali"a and dental caries. Dent Clin &orth merica, &=9'%;-<.
:>. .a*ero++, F. 7:;;(8. Sali"a9 nat/ral rotection a*ainst caries. Rev #el$e %ed Dent,
==%-&(:.
:=. )eret@, 1., Sarnat, H., g Moss, S. #. 7:;;$8. Caries rotecti"e asects o+ sali"a and
enamel. &. State Dental ", '<9>'%.
:&. Sree-ny, .. M. 7>$$$8. Sali"a in ,ealt, and disease9 an araisal and /date. /nt
Dent ", :&9&(-'<.
:'. C,a/sa/, S., 1ecker, A., C,a/sa/, G., g S,ariro, #. 7>$$>8. Stim/lated arotid
sali"a +low rates in atients wit, Down syndrome. Spec Care Dentist, :$=9=%(-(=.
:<. 1ot,well, #., Clarke, 2., Dooley, #., Gordon, 2. 3., Anderson, A., 4ood, 3. ).,
Cam+ield, C. S., g Cam+ield, ). !. 7>$$>8. 1ot/lin/m to0in as a treatment +or
e0cessi"e droolin* in c,ildren. >%9:(.
:%. 1ardow, A., My"ad, 1., g Nonto+te, 1. 7>$$:8. !elation -etween medication
intake to dry mo/t,, sali"ary +low rate and comosition and t,e rate o+ toot,
deminerali@ation in sit/. rch +ral #iol, &%9&:=->=.
:(. 1er*d,al, M., g 1er*d,al, #. 7>$$$8. .ow /nstim/lated sali"ary +low and
s/-Aecti"e oral drynessD association wit, medication, an0iety, deression and stress. "
Dent Res, >%9:(.
:;. Salerno, S., Canni@@aro, F., .o Castro, A., .oin-ardo, F., 1arress, 1., Seciale, !.,
g .a*alla, !. 7>$$>8. Inter"entional treatment o+ sialolit,s in main sali"ary *lands.
Radiol %ed (Torino), :=9=%(-(=.
>$. Stern, H., Feinmesser, !., Collins, M., S,otts, S. !., g Cotton, !. 5. 7>$$>8.
1ilateral s/-mandi-/lar *land e0cision and arotid d/ct li*ation +or treatment o+
sialorr,ea in c,ildren9 lon* term res/lts. rch +tolaryn$ol Head and &ec* Sur$,
:>(9($:-=.
>:. McDonnell, S. 5., g Hector, M. ). 7>$$:8. 5,e distri-/tion o+ stim/lated sali"a in
c,ildren. /nt " Paedriatric Dent, ::9&:%->=.
>>. 4eat,erell, #. A., Stron*, M., !o-inson, C., Naka*aki, H., g !al,, #. ). 7:;(;8.
!etention o+ *l/cose in oral +l/id at di++erent sites in t,e mo/t,. Car Res, >=9=;;-&$'.
>=. O,o, 5., Mitoma, M., g 2oya, 5. 7>$$>8. F/nctional domain o+ -o"ine milk
lacto+errin w,ic, in,i-its t,e ad,erence o+ Stretococc/s m/tans cells to a sali"ary
+ilm. /nf /mmun, %$9'>%;-(>.
>&. 3d*ar, 4. M., Hi*,am, S. M., g Mannin*, !. H. 7:;;&8. Sali"a stim/lation and
caries re"ention. dv Dent Res, (9>=;-&'.
>'. Sil"erstone, .. M. 7:;((8. !eminerali@tion and enamel caries9 new concets. Dent
Update, :;9<(=-%::.
><. Sil"erstone, .. M., Feat,erstone, M. #., g Hic,s, M. #. 7:;((8. Dynamic +actors
a++ectin* lesion initiation and ro*ression in ,/man dental enamel. )art I. 5,e
dynamic nat/re o+ enamel caries. Euintessence /nt, :;9<(=-%::.
>%. Sil"erstone, .. M., Feat,erstone, M. #., g Hicks, M. #. 7:;;&8. Dynamic +actors
a++ectin* lesion initiation and ro*ression in ,/man dental enamel. )art II. S/r+ace
mor,olo*y o+ so/nd enamel and caries-like lesions o+ enamel. Euintessence /nt,
:;9===-('.
>(. 5eno/"o, #. 7:;;%8. Sali"ary arameters o+ rele"ance +or assessin* caries acti"ity
in indi"id/als and o/lations. Community Dent +ral !pidemiol, >'9(>-(<.
>;. Head, #. A. 7:;:>8. A st/dy o+ sali"a and its action on toot, enamel in re+erence to
its ,ardenin* and so+tenin*. "%, :;9===-('.
=$. 1odecker, C. F. 7:;==8. Dental erosion, its ossi-le ca/se and treatment. Dental
Cosmos, %'9:$'<-<=.
=:. M/,ler, #. C. 7:;<:8. A ractical met,od o+ red/cin* dental caries in c,ildren not
recei"in* t,e esta-lis,ed -ene+its o+ comm/nal +l/oridation. " Dent Child, >(9'-:>.
=>. "on der Fe,r, F. !., .oe, H., g 5,eilade, F. 7:;%$8. 30erimental caries in man.
Caries Res, &9:=:-&(.
==. 1acker-Dirks, O. 7:;%$8. )oster/ti"e c,an*es in dental enamel. " Dent Res,
&9:=:-&(.
=&. Sil"erstone, .. M. 7:;(&8. 5,e si*ni+icance o+ reminerali@ation in caries
re"ention. " Can Dent ssn, '$9:'%-<%.
reser"ed.
Chapter 12. Caries Risk Assessment and Caries Activity Testing - Svante
T3etman 'ran*lin 0arcia20odoy
Objectives
:. State t,e /rose o+ caries acti"ity tests.
>. Indicate t,e limitations and ad"anta*es o+ caries acti"ity tests.
=. Identi+y t,e two -acteria most o+ten meas/red in caries acti"ity tests to determine
t,e ma*nit/de o+ t,e -acterial c,allen*e to t,e teet,.
&. Understand terms /sed in caries-rediction tests.
'. 30lain t,e *eneral aroac, o+ caries-risk assessment.
<. .ist t,e -ack*ro/nd data o+ imortance +or caries acti"ity.
%. )er+orm a clinical e0amination +or e"al/ation o+ caries acti"ity.
(. Name caries acti"ity tests /sed in t,e dental o++ice.
;. Cite new met,ods a"aila-le to assess caries risk.
Introduction
Dental caries can 4e defined as a car4ohydrate2modified transmissi4le local infection
3ith saliva as a critical re$ulator,
:
5,e dia*nosis is most o+ten -ased on a clinical
e0amination. 5erms like rimary and secondary caries, initial and ca"itated lesions,
w,ite sot lesions, arrested caries, and root caries are o+ten /sed in an e++ort to
descri-e t,e acti"ity and se"erity o+ t,e disease. Alt,o/*, t,ese o-ser"ations certainly
are imortant, t,e modern dentistry dia*nosis s,o/ld -e e0tended wit, identi+ication
and e"al/ation o+ +actors related to, or t,e causative a$ents of, the disease, 5,e
m/lti+actorial etiolo*y o+ dental caries today is relati"ely well known and t,e disease
is t,ere+ore not only a treata-le, -/t in most asects also a preventa4le, infection,
3"al/ation o+ etiolo*ic +actors can -e made -e+ore clinical si*ns occ/r as well as in
cases wit, already e0istin* lesions or +illin*s. S/-se?/ently, meas/res can -e taken to
red/ce risk +actors considered to create ro-lems in t,e +/t/re. 5,is c,ater deals wit,
di++erent met,ods to determine caries risk and caries acti"ity, +oc/sin* on t,e
re"ention o+ t,e disease. 5,e resentation is +oc/sed on t,e descrition o+ clinical
tests and met,ods t,at can -e incororated in t,e daily work and concentrated on t,e
indi"id/al atientD t,ere+ore, t,e comm/nity aroac, is less disc/ssed. For a more
t,oro/*, disc/ssion o+ t,e -ack*ro/nd o+ caries, t,e reader s,o/ld re+er to aroriate
te0t-ooks and o"er"iew aers cited in t,e re+erences at t,e end o+ t,is c,ater. 5o -e
a-le to disc/ss clinical imlications, ,owe"er, it mi*,t -e ,el+/l to take a closer look
at t,e e"ents leadin* to deminerali@ation.
CariesA Transmissible Local Infection
It is *enerally reco*ni@ed t,at certain strains o+ mutans streptococci
a
and lacto4acilli
are ,i*,ly cario*enic 7re"iewed -y "an Ho/te
:
8. 5,e +ormer *ro/ lays an acti"e role
in t,e early sta*es o+ lesion +ormation w,ile t,e latter is linked to t,e pro$ression of
the cavity, 3"idence s/**estin* a micro-ial t,ree-ste e"ent in caries de"eloment
e0ists 7Fi*/re :>-:8.
>
5,e +irst ste is t,e primary infection wit, m/tans stretococciD t,e second is a local
acc/m/lation o+ m/tans stretococci and ot,er acid/ric microor*anisms to
patho$enic levels in t,e dental la?/ea micro-ial s,i+t t,at is an ecolo*ic
conse?/ence o+ local acid conditionsD t,e t,ird ste is t,e deminerali1ation and
cavitation o+ t,e enamel. Conse?/ently, t,ree le"els o+ re"entionlinked to t,e
stesco/ld -e de+ined, eac, wit, its own ro+ile and c,aracteristic.
Primary prevention 7ste :8to re"ent t,e intra+amily transmission o+ m/tans
stretococci and delay t,e esta-lis,ment in in+ants, toddlers, and yo/n* c,ildren.
Secondary prevention 7ste >8to re"ent, arrest, or re"erse t,e micro-ial s,i+t
-e+ore any clinical mani+estations o+ t,e disease occ/r.
Tertiary prevention 7ste =8+oc/ses on limitin* 7stoin*8 t,e ro*ression o+ t,e
caries rocess -y initiatin* reminerali@ation t,eray o+ t,e e0istin* lesions.
a
5,e term m/tans stretococci incl/des se"eral secies o+ stretococci w,ic,
,istorically were o+ten collecti"ely re+erred to as Stretococc/s m/tans.
First Ste5ransmission and 3sta-lis,ment o+ M/tans Stretococci
1e+ore t,e er/tion o+ t,e +irst rimary teet,, no m/tans stretococci can -e ,ar-ored
ermanently in t,e oral ca"ity -eca/se t,e -acteria need a nonsheddin$ surface 7i.e., a
toot,8 to coloni@e. From se"eral st/dies it ,as -een s/**ested t,at t,e transmission o+
m/tans stretococci in most cases occ/rs "ertical wit,in t,e +amily. The main source
is the mother of the child
=
-/t recent st/dies /sin* DNA +in*errintin* s/**est t,at
t,e c,ild may also -e in+ected -y +at,ers and ot,er caretakers +rom o/tside t,e
+amily.
&
5,e most common ro/tes o+ in+ection are close contacts and e"eryday
n/rsin* items s/c, as aci+iers, -a-y -ottles, and soons 7Fi*/re :>->8. 5,e
coloni@ation and esta-lis,ment o+ m/tans stretococci is ,i*,ly +acilitated -y a
+re?/ent and s/crose-ric, diet of the parent as 3ell as the child, 5,e ,i*,er t,e co/nts
in mot,ers, t,e more +re?/ent and t,e earlier risk +or coloni@ation in t,eir c,ildren.
'-%

5,ere are also a "ariety o+ ot,er +actors, s/c, as sali"ary imm/no*lo-/lins and
a**l/tinins, resence o+ cometin* -acteria, toot, anatomy, and H, t,at mi*,t
in+l/ence t,e coloni@ation. F/rt,ermore, t,e earlier t,e esta-lis,ment and t,e more
m/tans stretococci resent in c,ildren, t,e more caries is likely to de"elo in t,e
rimary and ermanent dentition.
(,;
5,e re"alence o+ m/tans stretococci in+ection increases wit, a*e and t,e n/m-er o+
er/ted teet,. Amon* toddlers, aro0imately ' to :$E o+ a o/lation ,ar-or t,e
-acteri/m and a raid increase in re"alence / to aro/nd '$ to <$E in t,e late
resc,ool a*es ,as -een o-ser"ed.
-,:$,::
In +act, it ,as -een s/**ested t,at c,ildren are
most s/sceti-le +or m/tans stretococci coloni@ation -etween CH and AC months of
a$e, a so2called J3indo3 of infectivity,J
:>,:=
5,is is mainly e0lained -y a
com-ination o+ +re?/ent and close maternal contacts, cessation o+ lactation wit, its
rotecti"e anti-odies, and an immat/re imm/ne resonse o+ t,e c,ild as well as an
indi"id/al s/sceti-ility. Aro0imately ($E o+ all adolescents and ad/lts are
ositi"e +or m/tans stretococci, so t,e oral ca"ity can -e re*arded as a nat/ral ,a-itat
+or t,e -acteria.
-
5,ese data are reresentati"e +or Sweden and t,e ercenta*es may -e di++erent in
ot,er co/ntries.
Second SteMicro-ial S,i+t
Once a m/tans stretococci- and lacto-acilli-containin* micro+lora is esta-lis,ed in
t,e oral ca"ity, t,ere is a ris* +or +/t/re caries de"eloment. It is ,owe"er a *eneral
mis/nderstandin* t,at t,e disease is an ine"ita-le res/lt o+ t,e coloni@ation. Instead, it
is more common to ,ar-or m/tans stretococci wit,o/t s/-se?/ent decay. A cr/cial
rocess de"elos if, and 3hen, t,e caries associated microor*anisms t/rn at,o*enic
and t,is in t/rn is re*/lated and modi+ied -y local en"ironment. 3arly in li+e, and
esecially in connection to noct/rnal and ni*,tly n/rsin* -ottle meals, t,e micro-ial
s,i+t is o+ten concomitant wit, coloni@ation w,ile at later a*es, t,e s,i+t mi*,t occ/r
at any time d/e to a dist/r-ed ,omeostasis o+ t,e oral ecolo*y.
Once esta-lis,ed, t,e FnormalF content o+ m/tans stretococci and lacto-acilli
constit/te less t,an :E o+ t,e total micro-ial comm/nity in sali"a and dental la?/e.
Durin$ lon$2term acidic conditions, ho3ever, aciduric 4acterial strains 3ill 4e
favored, .acto-acilli are t,e most acid-toleratin* o+ t,e secies in t,e dental la?/e
and are a-le to maintain t,eir meta-olic acti"ity down to H =.$.
:&
M/tans
stretococci are also ,i*,ly acid/ric and can *row at H '.$ and contin/e acid
rod/ction to /nder H &.'.
:'
Common reasons +or t,e rolon*ed acid conditions are
increased +re?/ency o+ s/*ar intake, red/ced oral clearance d/e to low sali"a
secretion or imaired -/++er caacity, and la?/e acc/m/lation d/e to ins/++icient oral
,y*iene or inter+erence -y +i0ed ort,odontic aliances. Conse?/ently, t,e roortion
o+ t,e e0tremely acid-toleratin* m/tans stretococci and lacto-acilli will increase on
t,e e0ense o+ nonm/tans stretococci and ot,er -acteria. 5,e ,i*,er t,e roortion
o+ acido*enic and acid/ric microor*anisms in la?/e, t,e more acid is rod/ced and a
ne*ati"e trend ,as -een started. For e0amle, t,e roortion o+ m/tans stretococci in
la?/e associated wit, n/rsin* -ottle caries can -e / to =$ ercent o+ t,e total "ia-le
co/nts.
:<
It is imortant, ,owe"er, to oint o/t t,at t,e micro-ial s,i+t is a local e"ent
and it does not ,aen at t,e same time in t,e w,ole oral ca"ity. 5,e s,i+t is most
likely to occ/r in +iss/res and interdental areas t,at are well-known redilection sites
+or caries. 5,ey are also t,e sites o+ *reatest la?/e acc/m/lation. F/rt,ermore, it
s,o/ld -e stressed t,at micro-ial s,i+ts can 4e reversed -y temorary means 7i.e.,
dr/*s, anti-acterial a*ents8 and ermanent c,an*es 7i.e., diet alteration, s/*ar
restriction8 in t,e local en"ironment. 1y /sin* selecti"e anti-acterial meas/res, t,e
cario*enic +lora can -e s/ressed and a noncario*enic +lora can -e reesta-lis,ed
7re"iewed -y 3milson
:%
8. Howe"er, i+ t,e ca/sati"e +actors o+ t,e local s,i+t remain
/nc,an*ed, a recoloni@ation -ack to at,o*enic le"el is sooner or later likely to
occ/r.
:(
It s,o/ld also -e mentioned t,at t,e ran*e o+ -acteria otentially in"ol"ed in
enamel deminerali@ation ,as widened in recent years. 5,ere is e"idence s/**estin*
t,at Actinomyces secies and Flow H,F non-m/tans stretococci /nder selected
en"ironmental conditions can contri-/te to caries in t,e a-sence o+ m/tans
stretococci.
:,:;
In rare occasions, t,ese or*anisms resem-lin* S, an$inosus, S, mitis,
S, $ordonii, and S, oralis, are t,o/*,t to -e resonsi-le +or t,e esta-lis,ment o+ an
initial low-H en"ironment.
5,ird SteDeminerali@ation o+ 3namel
At +ood intake, t,e acc/m/lated la?/e is +ed wit, car-o,ydrates, w,ic, raidly will
-e con"erted to or*anic acids, mainly lactic acid, t,ro/*, t,e meta-olism o+
acido*enic -acteria.
>$
5,is will +/rt,er tri**er t,e acidic milie/ and a res/lt in a local
H dro o+ t,e la?/e +l/ids. D/rin* t,is dro, rotons are di++/sin* into t,e enamel
wit, calci/m and ,os,ates lea"in* t,e toot, and a deminerali@ation o+ t,e ,ard
tiss/e occ/rs. From t,e time o+ t,e local micro-ial s,i+t on a clinically so/nd enamel
s/r+ace, an Finc/-ationF eriod o+ aro0imately < to ; 3ee*s can -e e0ected -e+ore
t,e +irst "is/al si*ns o+ enamel deminerali@ation 7Fw,ite sotsF8 on a smoot, s/r+ace
can -e o-ser"ed. In e"eryday ractice, t,is is not an /ncommon side e++ect associated
wit, +i0ed ort,odontic aliances.
>:
Interdentally, ,owe"er, it takes / to ; months or
more -e+ore t,e enamel lesion is "isi-le as radiol/cency on a -itewin* radio*ra,.
>>

5,is is a serio/s concern in modern dentistry t,at /ts ,i*, demands on t,e
dia*nostic rocess. 5,ere is an e"ident risk t,at atients, w,o in +act ,a"e /nder*one
a -acterial s,i+t, still are clinically /ne"ent+/l w,en e0amined and not *i"en t,e
aroriate re"enti"e care.
In normal cases, a+ter car-o,ydrate 7s/*ar8 intake t,e acid rod/ction diminis,es
w,en t,e -acterial s/-strate is cons/med or was,ed away -y sali"a dil/tion. 5,e H
will ret/rn to normal and a eriod o+ FreairF 7reminerali@ation8 will a*ain occ/r. 5,is
rocess is +acilitated i+ +l/orides are resent locally. The 4alance 4et3een net loss and
net $ain of mineral is crucial 3hether pro$ression or re$ression of a lesion 3ill
occur, It is imortant to stress t,at t,is is not a contin/o/s rocess in eit,er direction
and t,at caries-acti"e and caries-inacti"e eriods will +ollow eac, ot,er t,ro/*, t,e
li+esan. A Fw,ite sotF enamel lesion 3ithout cavitation can -e comletely reaired
t,ro/*, reminerali@ation w,ile a lesion t,at ,as reac,ed t,e dentin, irresecti"e o+
enamel s/r+ace -reakdown, ,as /s/ally assed t,e Foint o+ no ret/rn.F Alt,o/*, it is
/nlikely t,at s/c, a lesion can -e totally reaired -y a**ressi"e reminerali@ation
t,eray, a conser"ati"e attit/de toward oerati"e treatment is recommended +a"orin*
Fwatc,+/l-waitin*F and close monitorin* d/rin* t,e re"enti"e treatment eriod.
Se"eral clinical st/dies ,a"e demonstrated an e0treme slow ro*ression rate, i+ any, o+
enamel and dentine lesions s/-Aected to e++ecti"e and contin/o/s re"ention.
>=,>&
For
e0amle, t,e ro*ression rate in enamel was +o/nd to -e m/c, slower t,an t,ro/*,
t,e o/ter ,al+ o+ t,e dentin t,at, in t/rn, e0,i-ited a median s/r"i"al time o+ =.: years
in a co,ort o+ c,ildren t,at was +ollowed rosecti"ely +rom :: to >> years o+ a*e.
>'
Fi*/re :>-: 3namel deminerali@ation - caries - can -e descri-ed as a t,ree-ste
e"ent.
Fi*/re :>-> Common ro/tes o+ m/tans stretococci transmission9 an in+ected
d/mmy and soon.
Caries Risk and Caries Activity
It is well known t,at certain indi"id/als de"elo m/c, more caries t,an ot,ers. 5,e
o-Aect o+ caries prediction
c
and caries ris* assessment
d
is to improve oral health in
c,ildren, adolescents, and ad/lts and to /tili@e reso/rces in a cost-e++ecti"e way. !isk
is de+ined as t,e pro4a4ility that a harmful (or un3anted) event 3ill occur, From t,e
material resented a-o"e, it mi*,t -e /se+/l to searate caries risk assessment +rom
attemts to determine t,e caries activity, 1y de+inition, a caries risk assessment is a
roced/re to predict future caries development -e+ore t,e clinical onset o+ t,e disease,
t,/s limited to stes : and >D w,ile a caries acti"ity test re+era-ly s,o/ld estimate t,e
act/al state o+ disease acti"ity 7ro*ressionBre*ression8, as +o/nd in ste = 75a-le :>-
:8.
5,e caries-risk assessment is er+ormed in order to introd/ce ca/sal meas/res -e+ore
irre"ersi-le lesions ,a"e -ecome esta-lis,ed, w,ile t,e caries acti"ity test is carried
o/t in order to decide and monitor correct and e++icient treatment o+ a atient. 4,en
alied on o/lations, t,e caries-risk roced/re is termed Fcaries rediction.F As
recently e0ressed -y Ha/sen,
><
Fclinicians assess risk, researc,ers redict.F For t,e
clinician it mi*,t -e /se+/l in t,is asect to distin*/is, -etween ris* factors and ris*
indicators 7risk markers8. A risk +actor lays an essential role in t,e etiolo*y and
occ/rrence o+ t,e disease, w,ile a risk indicator is a +actor or circ/mstance t,at is
indirectly associated wit, t,e disease.
>%
!isk +actors are t,e li+e-style and -ioc,emical
determinants to w,ic, t,e toot, is directly e0osed and w,ic, contri-/te to t,e
de"eloment or ro*ression o+ t,e lesion 7la?/e, sali"a, diet, etc.8. 30amles on risk
indicators are socioeconomic +actors 7socially deri"ed, low ed/cation le"el, oor
economy, sel+-esteem8, +actors related to *eneral ,ealt, 7diseases, ,andica8, and
eidemiolo*ic +actors 7li"in* in a ,i*,-caries area or co/ntry, ,i*, ast-caries
e0erience8. Caries-risk assessment as well as caries-acti"ity e"al/ation are -ased on
de+ined and selected risk +actors and risk indicators t,at are e"al/ated and /t to*et,er
to an indi"id/al ro+ile.
c
)rediction is a clinical decision a-o/t t,e o/tcome o+ a disease rocess -ased on
a"aila-le in+ormation and ro+essional e0erience.
d
!isk assessment is a ro+essional A/d*ement o+ an indi"id/alCs +/t/re risk o+ disease
-ased on t,e -est in+ormation a"aila-le.
Terms Used in Prediction
5o st/dy t,e "alidity
e
o+ a caries dia*nostic test and w,et,er or not it is /se+/l +or
caries rediction, t,e relation to caries incidence
+
m/st -e esta-lis,ed. It m/st -e
immediately ointed o/t t,at a close association in cross-sectional st/dies -etween en
etiolo*ic +actor or its meas/re in a test on one ,and and caries on t,e ot,er does not
necessarily mean t,at it also is a ower+/l redictor o+ t,e disease. 5,e redicti"e
a-ility o+ caries tests or risk indicators m/st t,ere+ore -e e"al/ated in lon*it/dinal
st/dies. 5,e res/lts are *enerally e0ressed in terms o+ sensitivity, specificity, and
pro$nostic values, 5,e roortion o+ diseased s/-Aects w,ose test 7or risk +actor8 is
ositi"e is termed sensiti"ity. Similarly, t,e roortion o+ non-diseased s/-Aects
w,ose test 7or risk +actor8 is ne*ati"e is called seci+icity. 5,e redicti"e "al/es are
er,as o+ ,i*,er interest +or t,e clinician, and a ,i*,er redicti"e "al/e indicates a
more "alid test. 5,e ositi"e redicti"e "al/e 7)6:8 denotes t,e ro-a-ility o+ an
indi"id/al to de"elo t,e disease, w,ile t,e ne*ati"e redicti"e "al/e 7)6>8 *i"es t,e
ro-a-ility to stay ,ealt,y. All t,e a-o"e meas/res s,o/ld -e looked at as airs. For
instance, knowin* t,e sensiti"ity o+ a caries test ,as a limited meanin* i+ one does not
know t,e resecti"e seci+icity o+ t,e test. More recently, odds2ratio values, re+errin*
to t,e c,ance o+ an e"ent "ers/s t,e c,ance o+ a none"ent, ,a"e -een introd/ced in
rediction models. 5,e odds-ratio ro"ides in+ormation on t,e c,ance t,at t,e disease
will occ/r *i"en a seci+ic condition. It m/st, ,owe"er, -e /nderstood t,at all "al/es
a-o"e are ,i*,ly deendent on a n/m-er o+ +actors t,at m/st -e de+ined and
considered to -e a-le to /nderstand t,e redicti"e ower9
>(
5,e le"el o+ caries re"alence and incidence in t,e st/dy o/lation or st/dy *ro/
5,e met,ods /sed +or data collection and esecially t,e criteria +or caries scorin*
5,e "alidity o+ t,e test met,od
5,e n/m-er o+ tests andBor t,e com-inations o+ tests alied
5,e atientCs access to re"enti"e and restorati"e care
A*e o+ t,e articiants
For instance, t,e redicti"e "al/e o+ a m/tans stretococci sali"a samle is deendent
on t,e disease le"el. It is +airly easy to /nderstand t,at it is ,arder to redict t,e
er/tion o+ a rare disease comared wit, a common one. 4,en a test is alied to a
o/lation wit, a ,i*, re"alence o+ disease comared to a o/lation wit, a lower
re"alence, t,e ositi"e redicti"e "al/e will increase and t,e ne*ati"e redicti"e
"al/e will decrease. 5,e de+inition o+ caries acti"ity 7disease8 is o+ co/rse "ery
imortant. 4ere only new lesions or also ro*ression o+ re"io/s lesions considerede
Is a certain n/m-er o+ new ca"ities wit,in t,e dentin or a sin*le early enamel lesion
re*arded as diseasee 5,e selected c/to++ oints +or ositi"e tests and disease and t,e
moti"ation w,y t,ey were c,osen m/st -e considered. F/rt,ermore, restorative
treatment and preventive efforts conducted in predictive investi$ations may o4scure
the predictive po3er of the tested model, 3n"ironmental +actors, s/c, as t,e nat/ral
content o+ +l/oride in t,e drinkin* water, can inter+ere wit, t,e redicti"e rocess.
::

5,e redicti"e ower may also -e in+l/enced -y a*e. It is *enerally -elie"ed t,at
caries risk assessments are more acc/rate in resc,oolers comared wit, older a*e
*ro/s and ad/lts. For instance, Swedis, in"esti*ators demonstrated in a rosecti"e
st/dy t,at m/tans stretococci coloni@ation, immi*rant -ack*ro/nd, cons/mtion o+
candy and mot,ersC le"el o+ ed/cation were si*ni+icant redictors +or caries -e+ore =.'
years o+ a*e.
>;
4,en all t,ese "aria-les were resent at : year o+ a*e, t,e ro-a-ility
+or caries de"eloment was (%E. 5,/s, one can state t,at redicti"e "al/es are "alid
only +or t,e o/lation st/died and +or t,e $iven time w,en t,e in"esti*ation was
cond/cted. 5,is does not mean t,at s/c, st/dies lack meriton t,e
contraryconsidera-le e0erience ,as -een *at,ered wit,in t,e +ield and +orms t,e
-ase +or many national oral ,ealt, care ro*rams.
5,e n/m-er o+ +alse resonses +ollowin* a test s,o/ld nat/rally -e as +ew as ossi-le.
For caries, ,owe"er, t,e occ/rrence o+ false2positive answers are less cr/cial as lon*
as t,ey only res/lt in an intensi+ied re"ention ro*ram and not in /nneeded
restorations. 'alse2ne$ative res/lts, on t,e ot,er ,and, can serio/sly Aeoardi@e dental
,ealt, d/e to ne*lected treatment.
e
6alidity means s/++iciently s/orted -y act/al +act, so/nd, *ood or e++ecti"e means.
+
Caries incidence is t,e n/m-er o+ lesions t,at occ/r o"er a *i"en eriod o+ time.
5,/s, two e0aminations are re?/ired to determine incidenceD one -e+ore and one at t,e
end o+ a selected eriod.
General Approach of Caries Risk Assessment
As disc/ssed earlier, a risk-assessment strate*y can -e alied on t,ree di++erent
le"els, eac, wit, somew,at di++erent aims9 7:8 for populations, 7>8 for $roups, and 7=8
for the individual, For re"enti"e strate*ies today, it is imortant to distin*/is,
o/lations wit, contrastin* re"alence o+ t,e disease. On a national le"el, it seems
imortant to e"al/ate t,e act/al Fc,allen*eF to t,e teet, and data can -e o-tained
t,ro/*, caries tests in eidemiolo*ic in"esti*ations. S/c, +indin*s e"al/ated in
com-ination wit,, +or e0amle, s/*ar-cons/mtion +i*/res, are o+ ,i*,est rele"ance
+or oral-,ealt, lanners. 1ased on s/c, data, t,e comm/nity can imlement
re"enti"e ro*rams or disense ,ealt, care reso/rces in a cost-e++ecti"e way. 5,e
same aroac, can -e alied to *ro/s +or w,ic, t,e c/rrent ro*nostic "al/e can -e
esta-lis,ed. For t,e indi"id/al, caries acti"ity tests can ma etiolo*ic +actors +or caries
and ser"e as a meas/re o+ comliance to a *i"en treatment. Howe"er, -e+ore
descri-in* t,e met,ods /sed in t,e risk assessment roced/re, it is "al/a-le to disc/ss
,istorically w,y t,e risk aroac, ,as *ained so m/c, attention d/rin* t,e recent
decades.
=$
/n communities 3ith a hi$h prevalence of caries, the need for a ris* approach is
limited, 5,is was t,e sit/ation in most ind/striali@ed 4estern co/ntries a +ew decades
a*o. A w,ole o/lation strate*y wit, *eneral re"enti"e meas/res *i"en to
e"eryone, s/c, as water +l/oridation and +l/oride s/lements, were ,i*,ly cost-
e++ecti"e since t,e "ast maAority o+ t,e o/lation -ene+ited +rom t,ese ro*rams.
Hence, caries declined raidly and t,e olari@ed distri-/tion o+ today -ecame
e"ident.
=:
A lar*e and increasin* roortion o+ t,e o/lation -ecame caries-+ree,
w,ile ot,ers still e0,i-ited a ,i*, caries acti"ity. In order to limit t,e costs +or dental
,ealt, care in a eriod o+ economic recession and limited reso/rces, t,e e++orts were
t,en directed to t,e relati"e minority o+ indi"id/als t,at de"eloed oral diseases.
Conse?/ently, a risk aroac, was instit/ted and caries-risk assessment -ecame a art
o+ dental ractice. A+ter caries-risk assessment, t,e ersons wit, t,e ,i*,est need +or
treatment were ro"ided intensi"e tar*eted actions wit, indi"id/ali@ed recalls. .ow-
risk indi"id/als did not recei"e +/rt,er attention wit, recall eriods e0tended / to >&
mont,s. 3idemiolo*ic and analytic s/r"eys, ,owe"er, soon identi+ied certain
s/-*ro/s o+ indi"id/als wit, a ,i*, re"alence and incidence wit,in t,e skewed
caries distri-/tion.
=>
Common e0amles are et,nic and c/lt/ral *ro/s, immi*rants
7esecially re+/*ees8, and in,a-itants o+ low-socioeconomic areas. F/rt,ermore,
medically comromised indi"id/als co/ld also constit/te s/c, a *ro/. In t,ese
*ro/s and s/-*ro/s, screenin* roced/res o+ c,ildren at "ario/s a*es in sc,ool ,a"e
-een ro"en rational and cost-e++ecti"e. Howe"er, in comarison wit, w,ole
o/lation strate*ies, t,e *eneral e++ects o+ t,e indi"id/ali@ed aroac, are less
e"al/ated and doc/mented. 5,ere+ore, a 4alanced mix of a ris* selection strate$y and
collective measures seem to 4e the Jstate of the artJ in many communities today, It
s,o/ld -e em,asi@ed t,at in an e0treme low-caries o/lation w,ere ractically no
ersons de"elo caries, a risk assessment wo/ld -e o+ little /se. It ,as also -een
claimed t,at t,e risk selection roced/re, a+ter roer ed/cation, can -e dele$ated to
auxiliary personnel, w,ic, may red/ce t,e cost +or t,e atient and t,e society.
==
Question 1
A. Caries can -e de+ined as a car-o,ydrate-modi+ied transmissi-le local in+ection.
1. A caries ris* factor incidence test re?/ires only one dental e0amination.
C. Sensiti"ity o+ a caries acti"ity test denotes t,e ro-a-ility +or caries de"eloment.
D. A risk-assessment strate*y is most imortant in comm/nities wit, ,i*,-caries
re"alence.
3. For re"enti"e care, a +alse-ositi"e caries-acti"ity test wo/ld ro-a-ly -e more
ad"anta*eo/s to t,e atient t,an a +alse-ne*ati"e test.
Community and Group Approach of Caries Risk Assessment
Since t,e re"alence o+ caries in many co/ntries s,ows a skewed distri-/tion, t,e
interest o+ +indin* met,ods +or rediction o+ indi"id/als or *ro/s o+ atients at risk
wit,in t,e comm/nity ,as -ecome widesread. The methods used for this
identification are predominantly 4ased on past dental caries, oral hy$iene, dietary
varia4les, micro4ial and salivary factors, and social varia4les,
=&,='
It ,as -een
roosed t,at -ot, t,e sensiti"ity and seci+icity m/st -e at least ($E to -e /se+/l in
caries-redicti"e models or w,en added, e0ceed :'$E.
=<
In ractice, t,is means t,at
e"ery +i+t, indi"id/al wit, a tr/e ,i*, risk wo/ld remain /ndetected and not recei"e
intensi+ied re"ention. Corresondin*ly, e"ery +i+t, indi"id/al wit, a tr/e low risk
wo/ld recei"e treatment wit, no or little e++ect. F/rt,ermore, it is t,o/*,t t,at a risk
model s,o/ld select not more t,an >$ to =$E o+ a o/lation -elie"ed to -e at risk to
-e mana*ea-le. 4it, s/c, reca/tions, t,e sensiti"ity o+ t,e -acterial tests and ast
caries e0erience, sin*le or com-ined, are commonly reorted wit,in t,e ran*e o+ <$
to ($E. On t,e ot,er ,and, t,e rediction o+ atients at low risk seems more relia-le
t,an t,ose at ,i*, risk wit, a seci+icity aro/nd ($ to ;$E. 5,is means t,at it aears
to -e more rele"ant to select atients wit, low risk +or +/t/re caries de"eloment t,an
redictin* t,ose at risk.
D/e to t,e comle0 and m/lti+actorial etiolo*y o+ dental caries, it is *enerally t,o/*,t
t,at a m/lti"ariate aroac, rat,er t,an t,e /se o+ sin*le "aria-les imro"es t,e
redicti"e a-ility. 1ioc,emical "aria-les ,a"e -een com-ined wit, sociodemo*ra,ic
and dental -e,a"ior data.
=%,=(
Howe"er, res/lts +rom recent st/dies /sin* s/c,
m/lti"ariate met,ods ,a"e -een /ne0ectedly oor.
=',=;
5,e acc/racy ro"ed to -e
m/c, lower t,an anticiated considerin* t,e ower o+ t,e indi"id/al redictors. In
+act, t,e ,i*,ly comlicated relations,i ,as raised t,e ?/estion w,et,er rediction o+
caries wit, reasona-le, simle, and ine0ensi"e met,ods will e"er -e a reality. 4,ile
t,e rediction o+ caries risk /sin* c/rrently a"aila-le met,ods is /se+/l in certain
comm/nities wit, a skewed caries distri-/tion and in *ro/s o+ indi"id/als wit,
medi/m and ,i*, caries le"els, its "al/e in a low caries comm/nity can -e ?/estioned.
5,e clinical "al/e o+ caries prediction models, t,ere+ore, may di++er +rom o/lation
to o/lation and +rom c,ildren to ad/lts, as recently re"iewed -y )owell.
&$
5,e n/m-er and t,e de*ree o+ so,istication o+ redicti"e met,ods are o+ co/rse
limitin* +actors in t,e o/lation -eca/se o+ racticalities and costs. 5,ere+ore, +ew
and stron* "aria-les ,a"e to -e ad"ocated on t,e o/lation le"el w,ile a ,i*,er
de*ree o+ com-inations can -e /tili@ed in smaller *ro/s and +or t,e indi"id/al. An
e0amle o+ a "ery simle comm/nity rotocol +or risk selection is *i"en in 5a-le :>-
>. 5,e concet canand s,o/ldo+ co/rse -e altered deendin* on local conditions
and t,e a*e o+ t,e tar*et *ro/. 5,e ast caries e0erience is t,o/*,t to -e t,e most
ower+/l sin*le indicator o+ +/t/re caries de"eloment in c,ildren.
=;
It can ,owe"er -e
ar*/ed t,at it does not recede t,e disease -/t rat,er is a res/lt o+ an already
e0istin*or treateddisease and reresents an acc/m/lation o+ lon*-term disease
e0erience. 5,/s, considera-le interest ,as -een +oc/sed on anticiated risk +actors
and risk indicators, i.e., simle c,airside met,ods +or sali"a e"al/ation, directly
deendent on t,e state o+ oral micro-iolo*y at a *i"en time, w,ic, will -e disc/ssed
-elow.
Ages of Interest for Caries Risk Assessment
Data on t,e time w,en caries-risk assessment is most cost-e++ecti"e in c,ild,ood are
sarse. /t is 3ell *no3n, ho3ever, that all ne3ly erupted teeth are more or less
deficient in mineral content and thus more suscepti4le for caries than after some
years of posteruptive maturation,
&:
Moreo"er, t,e er/tion o+ teet, constit/tes a caries
risk per se, since new s/r+aces -ecome a"aila-le +or t,e disease. 5,ere+ore, in t,is
asect it mi*,t -e ossi-le to de+ine certain ris* a$es o+ /tmost imortance o+ risk
assessment roced/res.
An early dental e0amination and dia*nosis m/st -e re*arded as e0tremely imortant
+or e++icient re"enti"e inter"ention. !ecent st/dies ,a"e /n"eiled t,at aro0imately
%'E o+ all ca"ities +o/nd in >-year-old c,ildren were located in t,e /er incisors and
t,at ;$E o+ t,ose e0,i-itin* caries in t,e /er +ront also de"eloed ca"ities in t,e
rimary molars.
&>,&=
F/rt,ermore, t,e rimary molars are caries-rone -etween & and <
years o+ a*e,
&&
and t,e er/tion o+ t,e +irst ermanent molars constit/te a well-known
occl/sal risk. Finally, t,e early teena*e eriod 7:> to :< years8 o++ers a ,i*, n/m-er
o+ newly er/ted s/r+aces s/sceti-le +or decay. 1ased on recent eidemiolo*ic data
on caries incidence, t,e Fkey a*esF as s/**ested in 5a-le :>-= mi*,t -e considered
+or caries-risk assessment.
Individual Approach of Caries Activity
For an aroriate assessment o+ caries acti"ity, +acts +rom t,e case ,istory, clinical
and radio*ra,ic e0aminations, dietary ,istory, and s/lementary la-oratory tests
m/st -e taken into acco/nt.
&'
An indi"id/al aroac, ,as -een s/**ested and
descri-ed -y 1ratt,all and 5yneli/s-1ratt,all.
&<
Accordin* to t,eir met,od,
-ioc,emical and demo*ra,ic arameters s,o/ld -e com-ined wit, a clinical
7ud$ment 7F*/t +eelin*F8 o+ t,e dental ro+essional to elicit roer res/lts. First,
determine w,ic, artic/lar +actors are in"ol"ed. Ne0t, +ind o/t 3hy t,ese +actors are
resent. Finally, try to c,an*e t,e sit/ation -y tar*eted actions a*ainst identi+ied
+actors. Some e0amles are *i"en in 5a-le :>-& to ill/strate t,is concet.
4,en re"iewin* t,e +indin*s o+ an indi"id/al, t,e tradin* o+ m/ltile ros and cons
-ecomes "ery comle0 to e"al/ate. For e0amle, t,ink a-o/t two caries-+ree c,ildren
wit, contrastin* le"els o+ m/tans stretococci in t,eir sali"a. I+ eac, ,as t,e same
diet, it is "ery likely t,at t,e c,ild wit, t,e ,i*, co/nts will de"elo more caries t,an
t,e one wit, low co/nts. Howe"er, i+ t,e c,ild wit, low co/nts eats candy +re?/ently
and t,e one wit, ,i*, co/nts ,as a "ery restricted s/*ar intake, w,ic, one now ,as t,e
*reatest c,ance o+ de"eloin* cariese 5,e ?/estion -ecomes ,arder to answer e"en
t,o/*, most ro+essionals ro-a-ly wo/ld ,a"e an oinion. Ima*ine in t,e ne0t ste
t,at t,e +irst c,ild wit, low -acterial co/nts and +re?/ent s/*ar intake is s/lemented
wit, +l/oride and t,e ot,er is oosin* t,e /se o+ +l/orideD w,o will, /nder s/c,
circ/mstances, de"elo t,e most cariese Is t,e -/++er caacity contrastin*e In t,is
way, -y addin* se"eral a**ra"atin* and co/nteractin* risk +actors and risk indicators,
t,ere are t,o/sands o+ ossi-le com-inations to consider. 5o -e a-le to ,andle t,is, it
is imortant to reali@e t,at a risk "al/e, s/c, as ,i*, m/tans stretococci le"els,
indicates a certain Fress/reF on t,e teet,. 4it, a roer diet and otimal +l/oride
administration, t,e risk can -e controlled. 4,en se"eral risk "al/es are disclosed, a
"ery stron* ress/re is e"ident and more co/nteractin* +actors are needed to -alance
t,e sit/ation. S/**ested c/t-o++ "al/es +or commonly /sed risk +actors in ediatric
dentistry are listed in 5a-le :>-'. It can -e recommended to /se interacti"e so+tware
tool t,at are de"eloed as an aid +or t,e clinician in t,e caries redicti"e rocess. S/c,
an e0amle is t,e ed/cational FCario*ram.F
*,&%
Gra,ically, t,e )C-ro*ram mas t,e
interaction -etween caries related +actors, a rocess known as cario*ra,y 7Fi*/re :>-
=8. 1ack*ro/nd data and clinical +indin*s, wit, t,eir "aryin* imact on caries, are
entered into a com/ter and t,e +actors are wei*,ed a*ainst eac, ot,er +ormin* a Frisk
ro+ileF o+ t,e atient. 5,e ro*ram can -e adA/sted +or local conditions s/c, as
socioeconomic stat/s and +l/oride content in t,e ied water. 5,e chance, e0ressed
as ercenta*e, +or a erson to avoid ne3 decay is t,erea+ter resented *ra,ically on
t,e screen. 5,e ro*ram also ro"ides an indi"id/ali@ed s/**estion on s/ita-le
re"enti"e acti"ities w,en needed. 5,e Cario*ram concet ,as recently -een
e"al/ated in a rosecti"e st/dy in w,ic, t,e assessed risk at -aseline in a *ro/ o+ :$
to ::-year-old sc,oolc,ildren was comared wit, t,e act/al caries increment a+ter >
years.
&(
Alt,o/*, t,e *eneral caries incidence was low in t,e st/dy o/lation, t,e
Cario*ram was t,e most ower+/l e0lanatory "aria-le. For e0amle, c,ildren in t,e
,i*,est risk *ro/ 7$ to >$E c,ance to a"oid caries8 ,ad '$ times ,i*,er risk 7odds
ratio8 t,an t,e c,ildren in t,e lowest risk *ro/ 7(: to :$$E c,ance to a"oid caries8.
4e will now +oc/s and comment on t,e clinical imlication o+ caries-risk assessment
o+ t,e indi"id/al, co"erin* -ack*ro/nd data 7case ,istory8, clinical e0amination, and
caries acti"ity tests.
*
Coyri*,t )ro+. D. 1ratt,all.
Fi*/re :>-= 5,e Cario*raman ed/cational interacti"e )C-ro*ram +or caries
risk e"al/ation.
Background Data of Importance for Caries Activity
5,e -ack*ro/nd +actors t,at directly or indirectly can -e o+ imortance +or t,e disease
/s/ally -elon* to one or more o+ t,e +ollowin* *ro/s9
General diseases
Medication
SocialB+amily sit/ation
Dietary ,a-itsB+eedin*
Oral-,y*iene ro/tines, +l/oride s/ort
4,en inter"iewin* t,e atient +or t,e case ,istory, ?/estions s,o/ld -e asked to
clari+y t,ese oints. 5,ere are +ew *eneral diseases t,at directly a++ect t,e teet,,
alt,o/*, t,ere are se"eral t,at indirectly in+l/ence t,e cario/s rocess. In +act, and
esecially re*ardin* c,ildren, -ein* ill wit, medication in com-ination wit, an0io/s
and sometimes o"errotecti"e arents constit/tes a *reater caries risk t,an t,e disease
itsel+. Se"eral dr/*s contain a ,i*, content o+ +ermenta-le car-o,ydrates and ,a"e a
low H. F/rt,ermore, t,e deressin* in+l/ence on sali"a secretion e0erted -y "ario/s
medicines is a well-doc/mented risk.
&;
A tro/-led +amily or social sit/ation mi*,t -e
re+lected -y +actors s/c, as stress 7decreased sali"a secretion8, lack o+ interest in
,y*iene 7oor la?/e control8, and low income 7cario*enic diet8. 5,e toic o+ diet and
caries is "ast and needs its own te0t-ook to -e ade?/ately co"ered, -/t it can -e stated
t,at t,e diet clearly a++ects t,e teet, in a direct 7in t,e +orm o+ erosion8 and indirect
7t,ro/*, toot, +ormation, sali"a secretion, and -acterial acti"ity8 way. In de"eloin* a
risk ro+ile, t,e diet s,o/ld always -e considered. An inter"iew or a F=-day recordF o+
all +ood and snack intakes are common met,ods /sed to o-tain in+ormation a-o/t t,e
diet o+ a atient.
Clinical Examination for Evaluation of Caries Activity
One aim o+ t,e clinical e0amination is to *et a ?/antitati"e estimation o+ t,e caries
ro-lem / to t,e resent and anot,er aim is to re"eal i+ t,e disease is on*oin* or i+
o-ser"ed lesions or +illin*s re+lect a ast disease acti"ity. A +ew imortant oints +or
estimatin* caries acti"ity are disc/ssed -elow.
For t,e indi"id/al atient, it is imortant to collect data in a standardi@ed and
systematic way. As stated earlier, t,e ast caries re"alence is always imortant, -/t
one is not necessarily at risk in site o+ =$ re"io/s +illin*s. It is "ery /se+/l to try to
look F-e,indF t,e recorded decayed, missin*, or +illed rimary or ermanent teet,
7dm+tBDMF58 "al/es as indicated in 5a-le :>-<. First, one s,o/ld consider i+ t,ere are
more or +ewer +illin*s or e0tractions t,an considered normal +or a artic/lar a*e
*ro/. 5,e atients s,o/ld t,en -e asked ?/estions s/c, as F-hy and 3hen were t,e
teet, e0tracted 7caries, eriodontal disease, ort,odontics8, or were t,e restorations
laced lon* a*o or recentlyeF C,eck t,e n/m-er, e0tension, and aearance o+ t,e
lesions, ca"ities, and +illin*s. 5,e te0t/re and locali@ation o+ lesions mi*,t ro"ide
imortant ,ints +or caries acti"ity 7Fi*/re :>-&8. For e0amle, resence o+ early
enamel lesions 7Fw,ite sotsF8 on newly er/ted teet, indicates an acti"e
deminerali@ation rocess. 5,e e"al/ation will ro"ide t,e e0aminer wit, in+ormation
on t,e e0tent o+ t,e ro-lem and i+ caries seems to -e a ast or resent ro-lem. In t,e
ne0t ste, local a**ra"atin* +actors s/c, as crowded arc,es, dee +iss/res, imer+ect
+illin*s and e0osed root s/r+aces are e"al/ated. 5,e mor,olo*y o+ t,e enamel m/st
always -e c,ecked. Alt,o/*, t,e resent e"idence s/ortin* an in,erited
s/sceti-ility to dental caries is limited, altered enamel de"eloment, s/c, as
increased orosity and decreased mineral content are directly linked to an increased
caries risk.
'$
Finally, t,e estimation o+ t,e oral ,y*iene standard wit, a disclosin*
sol/tion can -e recommended. It s,o/ld -e em,asi@ed t,at "isi-le la?/e on t,e
la-ial s/r+aces o+ ma0illary incisors o+ a yo/n* c,ild is a serio/s si*n o+ caries risk.
':
Fi*/re :>-& Caries in a dist/r-ed ,omeostasis. At t,e clinical e0amination,
insect care+/lly t,e aearance o+ t,e lesion. An acti"e lesion, as in t,e +i*/re,
is o+ten so+t li*,t in color, or s/rro/nded -y enamel wit, early w,itis,
deminerali@ation. An arrested lesion is /s/ally darker wit, a ,arder s/r+ace.
Caries-Activity Tests for the Dental Office
It is well known t,at dental caries ,as a m/lti+actorial and comle0 etiolo*y, and
/n+ort/nately, t,ere is no sin*le test a"aila-le t,at can +/lly e0lain or redict t,e
disease. 5,e term Fcaries-acti"ity testF may +/rt,ermore -e misleadin* since, at -est,
in+ormation can only -e o-tained on selected +actors o+ imortance +or t,e rocess.
Ideally, la-oratory tests s,o/ld -e simle, ine0ensi"e, raid, and acc/rately re+lect
t,e t,ree o"erlain* circles resented -y 2eyes
'>
in :;<>9 7:8 t,e -acterial c,allen*e,
7>8 t,e s/*ar content o+ t,e diet, and 7=8 toot, and ,ost resistance 7s/sceti-ility8 wit,
reminerali@ation otential. In t,e li*,t o+ t,ese re?/irements and circles, t,e +ollowin*
set-/ o+ tests mi*,t -e s/**ested9
#acterial challen$edetermination o+ m/tans stretococci as an indicator o+
relati"e risk.
Dietdetermination o+ lacto-acilli as an indicator o+ s/*ar content in diet.
Reminerali1ation potentialsali"ary +low rate and -/++er caacity as an indicator o+
otential -iolo*ic reair.
Host suspecti4ilitycaries e0erience as an indicator o+ ast acti"ity.
A+ter samlin*, t,e clinician can c,oose -etween sendin* t,e tests to a +/lly e?/ied
micro-iolo*ic la-oratory or to /se commercial test kits t,at can -e rocessed wit,in
t,e dental o++ice. In -ot, cases, t,e res/lts will -e a"aila-le a+ter a +ew days. 5,e
simli+ied testin* met,ods now a"aila-le can -e c,aracteri@ed as semi?/antitati"e,
alt,o/*, t,ey are *enerally considered to si*ni+icantly corresond wit, con"entional
a*ar late tec,ni?/es.
'=,'&
5,e most common so/rces +or samlin* are sali"a and
dental la?/e. The saliva test $ives an overall estimation 3hether or not the patient is
coloni1ed and reflects the num4er of coloni1ed surfaces and the prevalence in
pla5ue,
''
It does not ,owe"er indicate w,ere t,e -acteria are ,ar-ored, w,ic, is
imortant to /nderstand since t,e cario*enic microor*anisms coloni@e t,e dentition in
a milie/-re*/lated, locali@ed way.
'<
5,e la?/e samle can t,ere+ore -e /sed +or a
detailed Fmain*F o+ t,e atientCs dentition wit, secial re+erences to selected sites.
5,is aroac, ena-les an assessment o+ not only at2ris* individuals -/t also at2ris*
teeth and e"en ris* surfaces, Sali"ary tests are *enerally more ractical t,an tests
-ased on la?/e since t,e collection is less demandin*. In addition to t,e dia*nostic
"al/e o+ sali"a and la?/e tests, t,e didactic roerties as an indi"id/ali@ed atient-
moti"atin* tool in caries re"ention are today widely acknowled*ed 7Fi*/re :>-'8.
'%-';
4,en S,o/ld 5ests 1e Usede
5,is iss/e ,as -een li"ely de-ated t,ro/*, t,e last decades. It is, o+ co/rse, not
realistic or e"en A/sti+ied -y cost-e++ecti"e means to test all atients li"in* in a low-
caries society eac, time t,ey are recalled or wit, certain re*/larity. A simle answer
is t,at a test s,o/ld -e er+ormed eac, time t,ere is a need +or e0tra in+ormation on
+actors o+ imortance +or caries?/antitati"e as well as ?/alitati"e.
&<
5,/s, selected
tests co/ld -e A/sti+ied in se"eral clinical sit/ations to9
Clari+y t,e reasons -e,ind an on*oin* disease and +orm/late and moti"ate t,e
re"enti"e strate*y to t,e atient
Determine t,e e++ect o+ a ca/sal treatment at +ollow-/ "isits
)redict caries de"eloment 7i.e., make a ro*nosis8 at c,eck-/ "isits
For t,e selected s/-Aects, reeated tests are re+erred comared to sin*le in order to
esta-lis, t,e normal "al/es o+ t,e atient and -e a-le to monitor any de"iation +rom
t,e Fnorm,F indicatin* an altered oral en"ironment. For e0amle, i+ t,e /nstim/lated
secretion rate s/ddenly decreases, t,is is a si*n o+ an altered ecolo*ic en"ironment
wit, increased caries risk and s,o/ld -e +ollowed -y a closer c,eck-/ o+ t,e medical
and syc,osocial conditions and dr/* intake.
M/tans Stretococci Co/nts
As already mentioned, m/tans stretococci are stron*ly associated wit, t,e initiation
o+ dental caries.
:,<$,<:
5,ey ,a"e se"eral cario*enic roerties t,at are en,anced in t,e
resence o+ s/crose. 5,e most imortant are t,e a-ility to9
Coloni@e and *row on nons,eddin* s/r+aces
)rod/ce acids, acido*enic
4it,stand low H, acid/ric
Form and store e0tra- and intracell/lar olysacc,arides
5olerate ,i*,-s/crose concentrations
5,e ,/man dentition is t,e nat/ral ,a-itat +or m/tans stretococci 7Fi*/re :>-<8. 5,ey
,a"e a locali@ed way o+ *rowin* w,ic, means t,at in one indi"id/alCs mo/t,, some
teet, may ,ar-or -acteria w,ile ot,ers do not. 5,e le"els o+ m/tans stretococci in
sali"a and on t,e toot, s/r+aces 7la?/e8 re+lect t,e n/m-er o+ coloni@ed sites in t,e
mo/t,.
<>
5,e hi$her the mutans streptococci count on the teeth, the more caries,
<=
A
n/m-er o+ di++erent strains can -e +o/nd in ,/mans and t,e re"alence seems to "ary
-y a*e and o/lation. 5,e most common in,a-itants in ,/mans worldwide are
Streptococcus mutans and Streptococcus so4rinus,
<&
A-o/t :$ to =$E o+ a o/lation
,a"e low le"els o+ t,e -acteri/m, w,ile :$ to '$E are ,i*,ly coloni@ed.
5,e ?/antitati"e e"al/ation o+ m/tans stretococci in sali"a and la?/e is er+ormed
at t,e la-oratory on a*ar lates wit, a selecti"e media, t,e mitis-sali"ari/s--acitracin
a*ar.
<'
A serial dil/tion o+ t,e samle is er+ormed and ali?/ots are laced on t,e a*ar
s/r+ace wit, a iette. A+ter & days o+ anaero-ic inc/-ation, t,e n/m-er o+ colony
+ormin* /nits 7CFU8
,
are co/nted. 5,e -acteria ,a"e a si*ni+icant mor,olo*ic
aearance and it is ossi-le to distin*/is, -etween "ario/s strains. 6ariations o+ t,is
tec,ni?/e ,a"e -een s/**ested to adot and +acilitate /se in t,e dental o++ice, i.e.,
direct imressions on a wooden sat/la on an ele"ated a*ar.
<<
Howe"er, t,e s,ort
storin* d/ration o+ t,e lates in com-ination wit, demandin* inc/-ation re?/irements
make t,e late co/nts -est s/ited +or t,e researc, la-oratory.
,
Colony-+ormin* /nits 7CFUs8 denote t,e n/m-er o+ "is/al -acterial colonies t,at are
+ormed +ollowin* inc/-ation, not t,e act/al n/m-er o+ -acterial cells. 3ac, colony
can consist o+ many sin*le -acteria.
Stri M/tans Met,od +or M/tans Stretococci Co/nts
Se"eral simle c,airside met,ods ,a"e -een de"eloed in recent years +or t,e
estimation o+ m/tans stretococci le"els in sali"a.
<%,<(
5,ese simli+ied met,ods,
,owe"er, are not only /sed in t,e modern dental o++ice -/t also in dental researc, as
descri-ed in n/mero/s aers. 5,e most common met,od today is t,e Strip mutans
tec,ni?/e 7Dentoc/lt-SM8
i
de"eloed -y #ensen and 1ratt,all.
<;
5,is met,od /tili@es
t,e a-ility o+ m/tans stretococci to *row on a ,ard s/r+ace in a selecti"e mitis
sali"ari/s -rot, containin* >$E s/crose. 5,e kit incl/des a secially reared
ro/nded lastic stri +or t,e samlin*. 5,e s/r+ace o+ t,e stri is sli*,tly ro/*,ened
on one side to romote -acterial ad,erence. Fi+teen min/tes rior to t,e samlin*, a '-
m* -acitracin ta-let is added to t,e -rot,. As t,e -acitracin can -e added A/st -e+ore
/se, t,e s,el+-li+e o+ t,e test is rolon*ed comared to a*ar lates. A+ter > min/tes o+
ara++in-c,ewin*, t,e lastic stri is rotated a co/le o+ times on t,e dors/m o+ t,e
ton*/e and t,en wit,drawn throu$h li$htly closed lips, ,ere-y coated wit, a de+ined
amo/nt o+ sali"a +ilm. 5,e stri is t,en immediately attac,ed to a ca t,at is screwed
to a *lass "ial, and inc/-ated at =%C +or &( ,o/rs.
5,e m/tans stretococci colonies will aear on t,e stri as small -l/e dots -/t t,e
color can "ary +rom dark -l/e to ale -l/e. 5,e density o+ t,e colonies is e"al/ated
a*ainst a c,art ro"ided -y t,e man/+act/rer 7Fi*/re :>-%8 and scored $ to =, w,ere
t,e scores > and = corresond to aro0imately : :$
'
CFU and >: :$
<
CFUBm.
sali"a, resecti"ely. 4,en dry, t,e stris can also -e e"al/ated and di"ided into
*ro/s wit, t,e aid o+ a secial de"ice in a stereo microscoe wit, <->'
ma*ni+ication.
%$
5,e stri m/tans tec,ni?/e ,as -een ro"en relia-le to /se and
si*ni+icantly related to con"entional tec,ni?/es. Sometimes, *as-+ormin* or ot,er
nonm/tans -acteria can *row in t,e -rot, 7*rayis,8, -/t not on t,e stri. F/rt,ermore,
lar*e m/tans stretococci colonies may -e +o/nd on t,e -ottom o+ t,e t/-e. 5,ey
normally +all +rom t,e smoot, side o+ t,e stri, -/t /s/ally t,is will not a++ect t,e
scorin*. A /se+/l ad"anta*e wit, t,is met,od is t,at t,e stris can -e stored +or years
in a lastic +oil +or +/t/re comarisons.
%:
A +/rt,er modi+ication o+ t,e Stri m/tans tec,ni?/e ,as recently -een de"eloed +or
site2specific micro-ial la?/e dia*nosis.
%>
5,e samlin* o+ selected sites is carried o/t
eit,er wit, a wooden toot,ick
%=
or a small saline-wetted -r/s,
%&
and trans+erred
strai*,t across t,e lastic stri on an ele"ated ad, t,/s ena-lin* +o/r sites to -e
samled on eac, stri. A+ter t,e c/lti"ation roced/re as descri-ed a-o"e, t,e CFUs
are co/nted and scored on t,e redetermined area in a microscoe or -y aid o+ a c,art
7Fi*/re :>-(8. 5,is met,od is esecially /se+/l +or monitorin* t,e o/tcome o+ a site-
seci+ic anti-acterial treatment.
%'
i
A"aila-le +rom Orion Dia*nostica, Helsinki, Finland.
.acto-acilli Co/nts
.acto-acilli constit/te an acido*enic and acid/ric *ro/ o+ microor*anisms associated
wit, dental caries.
%<
5,e -acteria need retenti"e sites +or t,e coloni@ation o+ toot,
s/r+aces, s/c, as +iss/res, +illin*s, *as, o"er,an*s, etc. .acto-acilli are o+ten +o/nd in
t,e dee arts o+ t,e caries lesion. 5,/s, t,ey are considered as secondary in"aders
and resonsi-le +or t,e pro$ression of already esta4lished lesions,
:&
(acto4acilli levels are hi$hly influenced 4y the inta*e of dietary car4ohydrates, thus
reflectin$ the amount of 4acterial su4strate and indicatin$ an acid environment
3ithin the oral cavity, 5,e re"alence o+ lacto-acilli is lower comared wit, m/tans
stretococci. Aro0imately '$E o+ a o/lation e0,i-its low "al/es w,ile :$ to >$E
,a"e ,i*, co/nts.
%%
It co/ld ,owe"er -e noted t,at reorts +rom Scandina"ia s/**est a
decreasin* re"alence o+ lacto-acilli in c,ildren
%(
in site o+ /nc,an*ed or e"en
increased s/*ar cons/mtion, and t,is may artly -e e0lained -y diminis,in*
n/m-ers o+ retenti"e sites 7ca"ities and restorations8 in t,e yo/n* o/lation. 5,e
roortion o+ lacto-acilli in t,e la?/e is normally low 7<:E8, and t,e resence in
sali"a and la?/e are determined /sin* a selecti"e medi/m 7!o*osa S.-a*ar
%;
8 wit,
con"entional c/lt/rin* met,ods at t,e la-oratory.
Dip Slide %ethod for (acto4acilli Counts
5,e n/m-er o+ sali"ary lacto-acilli can -e estimated wit, t,e aid o+ t,e Dentoc/lt-.1
,
met,od,
($
consistin* o+ a lastic de"ice co"ered wit, selecti"e a*ar. )ara++in-
stim/lated sali"a is collected in a c/ or a t/-e. 5,e sali"a is o/red o"er -ot, sides
o+ t,e slide, and t,e e0cess allowed droin* o++. 5,e slide is t,en inserted in a lastic
container and inc/-ated at =%C +or & days. A+ter inc/-ation, t,e lacto-acilli aear as
small w,itis, dots and t,e n/m-er on t,e a*ar s/r+ace is estimated -y comarison
wit, a c,art s/lied -y t,e man/+act/rer 7see Fi*/re :>-%8. As an alternati"e, t,e
slide can -e inc/-ated in room temerat/re +or % days. Howe"er, t,is may lead to an
increased reco"ery o+ yeasts, w,ic, may Aeoardi@e t,e e"al/ation o+ t,e slide.
(:
5,e
res/lts o+ t,e test can -e s,own directly to t,e atient -/t t,e slides cannot -e stored
+or lon*er eriods, /nless t,ey are stored in a com/ter wit, t,e /se o+ a "ideo
camera.
,
Colony-+ormin* /nits 7CFUs8 denote t,e n/m-er o+ "is/al -acterial colonies t,at are
+ormed +ollowin* inc/-ation, not t,e act/al n/m-er o+ -acterial cells. 3ac, colony
can consist o+ many sin*le -acteria.
General Comments on 1acterial 6al/es
Most selecti"e media /nderestimate t,e real n/m-er o+ tar*eted -acterial strains. 5,is
does not imair t,e "al/e o+ t,e samle as lon* as t,e le"els are wit,in t,ose o+
clinical rele"ance. It is ,i*,ly ad"isa-le not to re*ard t,e test res/lts as e0act -acterial
n/m-ers -/t rat,er as ran$es o+ -acterial co/nts. F/rt,ermore, it m/st -e em,asi@ed
t,at co/nts o-tained wit, di++erent met,ods cannot -e directly comared wit, eac,
ot,er. 5,ere is no aarent association -etween m/tans stretococci and lacto-acilli
co/nts alt,o/*, a tendency to ,i*, le"els o+ 4oth secies o+ten can -e seen in caries-
acti"e atients.
(>
5,is +act em,asi@es t,e ass/mtion t,at t,e tests meas/re two
searate sta*es o+ t,e caries rocess in t,e oral milie/ and cannot -e s/-stit/ted -y
eac, ot,er.
/t is recommended not to have a JfixedJ position to threshold values re$arded as a
caries ris*, 5,e risk le"el +or one +actor deends on t,e in+l/ence o+ ot,er +actors.
One million m/tans stretococci er ml o+ sali"a may, /nder certain conditions, lead
to ca"ity +ormation, -/t wit, a roer diet and +l/oride administration, t,e risk will -e
considera-ly lower. For e0amle, a certain le"el o+ -acteria or sali"a secretion rate
does not mean t,e same +or an indi"id/al li"in* in a +l/oridated area comared wit,
an indi"id/al +rom a low +l/oridated or non+l/oridated area.
(=,(&
A common ?/estion is to w,at e0tent m/st t,e samlin* +or t,e /se o+ t,e tests -e
standardi@ed. It is well known t,at a n/m-er o+ +actors s/c, as anti-iotics, diet,
smokin*, toot,-r/s,in*, sali"a secretion, and retenti"e sites can a++ect t,e n/m-er o+
-acteria in t,e oral ca"ity.
>(
A normal "ariation o"er time o+ -ot, lacto-acilli, m/tans
stretococci, -/++er caacity, and sali"a +low rate s,o/ld always -e e0ected.
('

St/dies ,a"e s,own t,at pronounced nat/ral "ariations are rare in t,e s,ort-term
ersecti"e.
'',%:
5,e ,i*,est -acterial co/nts in sali"a are /s/ally +o/nd in t,e mornin*
-e+ore toot,-r/s,in*. D/rin* daytime, t,e le"els seem to -e +airly sta-le i+ no
artic/lar meas/res are taken. In eidemiolo*ic s/r"eys, a strict and well-de+ined
collection roced/re is o+ co/rse cr/cial w,ile s/c, reca/tions are somew,at
limitin* +or t,e daily ro/tine work. For t,e indi"id/al atient, t,e res/lts m/st -e
e"al/ated in t,e li*,t o+ racticalitiest,ey reresent t,e challen$e at the time they
3ere ta*en, Howe"er, c,eck i+ t,e atient is takin* or recently ,ad 7wit,in : mont,8
an anti-iotic medication and, i+ ossi-le, try to a"oid samlin* A/st a+ter toot,-r/s,in*
or eatin*.
Fi*/re :>-' Sali"a tests are /se+/l as didactic and moti"atin* tools in caries
re"ention.
Fi*/re :>-< Close-/ o+ m/tans stretococci, c/lti"ated on MS1-a*ar (A) and
as aearin* in a scannin* electron microscoe (B).
Fi*/re :>-% A c,art +or e"al/atin* c,airside sali"a tests as indicated. Fo/r
classes are /sed +or -acterial en/meration w,ile t,ree le"els are /sed +or
-/++erin* caacity.
Fi*/re :>-( A secially desi*ned stri +or site-seci+ic en/meration o+ m/tans
stretococci in la?/e.
Question 2
A. A "alid test can -e -ot, acc/rate and relia-le.
1. )resence o+ m/tans stretococci in t,e oral ca"ity always imlies a caries risk.
C. A /se+/l caries redictor s,o/ld ,a"e a stron* and sta-le association to caries
re"alence.
D. A -etter correlation /s/ally e0ists -etween low--acterial co/nts and low-caries risk
t,an -etween ,i*, co/nts and ,i*, risk.
3. .acto-acilli, -ein* ,i*,ly acid/ric, are linked to t,e initiation o+ t,e enamel lesion.
Sali"a Flow !ate
An aroriate +low o+ sali"a is essential +or t,e maintenance o+ oral ,ealt,. It is
e"ident t,at t,e oral -acteria are s/-Aected to se"eral imortant sali"ary +/nctions,
w,ic, a++ect t,eir coloni@ation, s/r"i"al, and meta-olism. 5,e most imortant
mec,anisms -y w,ic, sali"a can a++ect caries are9
Mec,anical cleansin* o+ de-ris and la?/e -acteria
Anti-acterial acti"ity a*ainst t,e oral micro+lora, i.e., lysis and a**re*ation
1/++erin* and ne/trali@ation o+ la?/e acids
3n,ancement o+ reminerali@ation
5,e sali"ary +low +rom -ot, maAor and minor *lands is controlled -y arasymat,etic
7water, electrolytes8 and symat,etic 7roteins8 stim/li. 5,e water +raction is most
imortant +or t,e clearance rocess w,ile t,e antimicro-ial acti"ity resides mainly in
t,e rotein +raction.
Salivary flo3 rate is considered as a J*eyJ parameter in caries2ris* assessment,
(<

Alt,o/*, t,ere is no linear association -etween sali"ary +low rate and caries acti"ity,
it is imortant to e"al/ate w,et,er t,e secretion is normal or imaired. A-sence o+
sali"a, 0erostomia, or ,yosali"ation can res/lt in an e0tremely increased caries risk.
A decreased +low rate is a common side e++ect to a lar*e n/m-er o+ medicines and
radiation t,eray.
(%
For t,e indi"id/al, a re*/lar and lon*it/dinal +ollow/ o+ t,e +low
rate is o+ ,i*,er clinical "al/e t,an a sin*le meas/rement to -e a-le to identi+y
red/ction and alterations o"er time.
('
%easurement of Saliva 'lo3 Rate
4,en meas/rin* t,e +low rate, one can eit,er samle /nstim/lated or stim/lated
w,ole sali"a. In addition, sali"a +rom searated secretions, arotid or
s/-mandi-/larBs/-lin*/al, can -e collected. Stim/lated w,ole sali"a samles are
most often /sed +or ro/tine work. 5,e stim/lation can -e done -y ara++in c,ewin* or
-y addin* drolets o+ a so/r li?/id 7=E citric acid8 on t,e -ack o+ t,e ton*/e. 5,e
amo/nt o+ sali"a o-tained is divided 4y the collection time and t,e secretion is
e0ressed as mlBmin/te or m.B'min.
For ad/lt atients, a normal stim/lated secretion rate is aro/nd C,: to C,> m(Lminute,
6al/es -elow $.% mlBmin/te s,o/ld -e considered as low and indicate a caries risk.
((

4omen *enerally ,a"e somew,at lower stim/lated and /nstim/lated secretion rates
t,an men. In c,ildren, t,e le"els ,i*,ly deend on a*e and cooeration, -/t t,e
corresondin* le"els in resc,oolers +or stim/lated and /nstim/lated secretions are
aro/nd $.' and $.= m.Bmin/te, resecti"ely.
For collection o+ /nstim/lated 7restin*8 sali"a, t,e atient is seated in an /ri*,t
rela0ed osition wit, t,e ,ead -ent +orward. 5,e s/-Aect lets t,e sali"a assi"ely dri
into a *rad/ated t/-e +or ' to :' min/tes. An /nstim/lated secretion o+ less t,an $.:
m.Bmin/te is considered as a risk "al/e. In cases o+ ,yosali"ation, t,e sali"a is o+ten
"isco/s and F+oamyF and t,e secreted "ol/me is di++ic/lt to determine. A *ra"itation
met,od is t,ere+ore ad"ocated. 5,e test t/-e is wei*,ed -e+ore and a+ter samlin* and
: *ram corresonds to aro0imately one milliliter o+ sali"a.
Question 3
A. An a"era*e collection o+ %.' m. o+ stim/lated w,ole sali"a o"er ' min/tes is
considered a-normally low.
1. A lacto-acilli test re+lects t,e car-o,ydrate intake and retenti"e sites in t,e oral
ca"ity.
C. A sali"a samle ro"ides acc/rate in+ormation on w,ere in t,e mo/t, cario*enic
-acteria are ,ar-ored.
D. Caries-risk assessment +or t,e indi"id/al *at,ers data +rom case ,istory, clinical
e0amination, and la-oratory tests.
3. A erson wit, a m/tans stretococci score o+ = 7,i*, co/nts8 cannot stay caries-
+ree and deminerali@ation will ine"ita-ly occ/r.
1/++erin* Caacity o+ Sali"a
5,e -/++erin* caacity o+ sali"a is imortant +or t,e maintenance o+ normal H le"els
in sali"a and la?/e. A low secretion mi*,t indicate a low -/++erin* e++ect and a weak
in"erse relations,i to caries ,as -een noted -y se"eral in"esti*ators.
(;,;$
1ot, t,e
sali"a secretion rate and -/++er caacity di++er ,owe"er at di++erent arts o+ t,e mo/t,.
5,e comosition and acido*enicity o+ la?/e may -e a++ected di++erently w,en
sit/ated close to a sali"ary d/ct or ,idden dee down in a +iss/re. Ne"ert,eless,
/n+a"ora-le "al/es o+ -/++er caacity and sali"ary +low rate s,o/ld -e considered as
risk +actors +or t,e indi"id/al. 5,e tests commonly /sed are -ased on t,e titration
tec,ni?/e wit, t,e +inal H determined -y a dye color c,an*e.
Dento-/++ Met,od +or Meas/rement o+ 1/++er Caacity
A simle c,airside met,od to meas/re t,e -/++er caacity o+ sali"a, t,e Dento-/++
stri
A
, ,as -een de"eloed -y 3ricsson and 1ratt,all.
;:
A small amo/nt o+ acid is
imre*nated on a H indicator stri. One drolet o+ stim/lated sali"a is laced on t,e
testin* ad o+ t,e stri in a +lat osition to dissol"e t,e acid. A+ter e0actly ' min/tes,
t,e color o+ t,e stri is comared wit, a ro"ided c,art, indicatin* t,e +inal H. 5,e
met,od re+lects mainly t,e -icar-onate -/++er system and identi+ies sali"a wit, low
7yellow8, intermediate 7*reen8, and normal 7-l/e8 -/++er caacity 7see Fi*/re :>-%8. It
is imortant t,at t,e test is read a+ter e0actly ' min/tes as color will c,an*e wit, time
and t,/s *i"e misleadin* res/lts. 5,e yellow color indicates a +inal H o+ & or less,
meanin* t,at t,e sali"a was /na-le to raise t,e H. 5,is res/lt s,o/ld -e considered as
a risk "al/e.
A
Orion Dia*nostica, 3soo, Finland
Collectin* 1acterial and Sali"a Samles
5o o-tain in+ormation +rom all t,e c,airside met,ods t,e +ollowin* roced/re is
recommended.
)reare t,e c,airside kits and in+orm t,e atient.
Start t,e samlin* wit, t,e atient in an /ri*,t osition. Ask t,e atient to c,ew
ara++in and swallow t,e sali"a a+ter : min/te. 5,en start a timer +or t,e secretion rate
and instr/ct t,e atient to sit +re?/ently into a *raded test t/-e.
Sto sittin* a+ter ' min/tes and take t,e Stri m/tants test on t,e ton*/e.
Meas/re t,e amo/nt o+ sali"a and calc/late secretion rate.
5ake a drolet o+ t,e sali"a wit, a iette on t,e Dento-/++ stri. Set timer +or '
min/tes.
)o/r t,e remainin* sali"a on -ot, sides o+ t,e Dentoc/lt .1 a*ar and let e0cess dri
o++.
Inc/-ate m/tans stretococci and lacto-acilli tests.
3"al/ate -/++er stri a+ter ' min/tes, m/tans stretococci a+ter > days, and
lacto-acilli a+ter & days.
4,at Is t,e Ne0t Stee
5,e e++ecti"eness o+ caries risk and caries acti"ity tests ,as -een e"al/ated in "ario/s
o/lations o"er t,e ast decades wit, more or less enco/ra*in* +indin*s.
&$,;>,;=
5,e
risk or acti"ity aroac, per se is not a contro"ersial iss/e -/t rat,er -y w,ic, means
t,is assessment s,o/ld -e done. 3"en t,o/*, t,e m/lti+actorial models are ro"en as
/se+/l in one co/ntry or society, it mi*,t -e less /se+/l in ot,ers.
;&
Anot,er imortant
+act is t,at risk assessment ro*rams m/st -e e"al/ated contin/o/sly since t,e "al/e
can "ary o"er time. A strikin* e0amle can -e taken +rom lacto-acilli tests w,en /sed
as a didactic tool to red/ce s/*ar-cons/mtion in sc,oolc,ildren. 5wo decades a*o,
t,is ro*ram red/ced caries increment wit, '$E
'%
w,ile it was o+ only limited "al/e
w,en recently ree"al/ated wit,in t,e same comm/nity.
;'
For t,e indi"id/al, t,e identi+ication o+ +actors resonsi-le +or caries risk and caries
acti"ity s,o/ld +orm t,e -asis +or tar*eted action a*ainst t,e etiolo*ical +actors
in"ol"ed. 2nowled*e o+ risk +actors *i"es t,e atient an oort/nity to re+lect o"er ,is
or ,er sit/ation and an otion to take a ersonal resonsi-ility +or t,e +/t/re oral
,ealt,. It may -e ar*/ed t,at t,ere is a weak scienti+ic s/ort +or t,e +act t,at *ained
knowled*e is an e++icient tool to c,an*e a non,ealt,y dental -e,a"ior.
;<
5,is may -e
tr/e +or a non-seci+ic *eneral messa*e and t,ere+ore it seems e"en more imortant to
indi"id/ali@e t,e in+ormation, as disclosed -y t,e tests. 1ot, t,e t,eraist and t,e
atient can -e made aware on t,e main ro-lem and +oc/s on one strate*y rat,er t,en
t,e w,ole concet. In t,at asect, t,e tests are also a matter o+ ?/ality care and a
*/idance simly to do t,e ri*,t t,in* at t,e ri*,t costs. As re"io/sly stated, t,e
relati"e imortance o+ one risk +actor may di++er +rom one atient or *ro/ o+ atients
to anot,er. For e0amle, it ,as -een s,own t,at t,e main risk +actor +or w,ite-sot
lesions d/rin* treatment wit, +i0ed ort,odontic aliances was oor oral ,y*iene,
;%

and t,ere+ore, it may not -e meanin*+/l or cost-e++ecti"e to +oc/s on diet. Similarly,
as t,e le"el o+ meta-olic control seem to -e a stron*er redictor +or caries t,an m/tans
stretococci in c,ildren wit, 5ye : dia-etes,
;(
t,e +oc/s s,o/ld -e on diet rat,er t,an
anti-acterial meas/res. In many cases, ,owe"er, more t,an one risk +actor or risk
indicator are stron*ly in"ol"ed. A common ?/estion is t,en w,et,er or not it is
meanin*+/l to c,an*e or imro"e only one o+ t,em. Hes, it is o+ a-sol/te imortance
since t,e -alance in t,e oral en"ironment -etween deminerali@ation and
reminerali@ation is e?/i"ocal and in many cases, also a minor imro"ement may ,el
t,e atient o"er t,e t,res,old le"el and to -e on track. Moreo"er, a+ter a s/ccess+/l
mana*ement o+ one etiolo*ical +actor, t,e sel+-esteem and moti"ation may *row to
roceed wit, t,e ne0t +actor.
5,e ot,er way aro/nd is ro-a-ly o+ e"en *reater imortance. 5,ere is consens/s in
literat/re on t,e ,i*, seci+icity o+ caries risk and acti"ity assessments to select
indi"id/als at low risk +or +/t/re caries. 5,is is a "ery ositi"e messa*e to
comm/nicate and t,e atient may ,a"e an otion to e0tend t,e recall inter"als.
5,ere-y, reso/rces can -e redirected and money sa"ed +or t,e atient and +or t,e
society. At t,e end o+ t,e day, it is a matter o+ ,iloso,y and ?/alityt,e teet, are,
wit, "ery +ew e0cetions, ,ealt,y w,en t,ey er/t and itCs a c,allen*e +or t,e dental
ro+ession to */ide and assist t,eir atients to kee t,em t,at way in a cost-e++icient
way.
Other Suggested Caries Activity Tests
In order to redict caries risk or determine t,e disease acti"ity, a "ariety o+ ot,er
met,ods ,a"e -een s/**ested. A +ew o+ t,ese are -rie+ly descri-ed and commented on
-elow.
Snyder 5est
In t,is test, s/**ested -y Snyder,
;;
samled sali"a is inoc/lated into a *l/cose a*ar
and acid +ormation is determined -y a color indicator. 5,e roced/re re+lects t,e total
n/m-er and t,e acido*enicity o+ t,e sali"ary -acteria and can -e /sed as an alternati"e
to t,e lacto-acilli test.
'=
6iscosity o+ Sali"a
5,e "iscosity o+ sali"a is an imortant +actor +or t,e s/-Aecti"e ercetion o+ dry
mo/t, and ,yosali"ation. 5oday, ,owe"er, t,ere are no met,ods o+ clinical
si*ni+icance in /se to estimate t,e "iscosity and +/rt,ermore, its relation to caries
incidence is not clear. Meas/rement o+ oral m/cosal +riction -y t,e aid o+ a r,eolo*ic
de"ice ,as -een de"eloed and may, in t,e li*,t o+ t,e widesread /se o+ 0ero*enic
dr/*s, *row in imortance +or elderly atients.
:$$
Di-Slide Meas/rement o+ Sali"ary Heast
In *eneral, t,e resence o+ an oral yeast in+ection can -e considered as a re+lection o+
t,e ,ost resonse and indicati"e o+ a medically comromised atient. A ,i*, n/m-er
o+ sali"ary yeasts are o+ten +o/nd in atients wit, ,yosali"ation. Moreo"er, +/n*i are
acid/ric and t,eir resence mi*,t -e a re+lection o+ an acidic en"ironment and caries
acti"ity.
:$:
A di-slide system +or meas/rin* oral yeast 7Candida al4icans8 in+ection,
O!ICU.5-N,
k
7Fi*/re :>-%8 ,as -een de"eloed and is commercially a"aila-le.
:$>
k
Orion Dia*nostica, 3soo, Finland
)la?/e-+ormin* !ate
General la?/e ,as -een s/**ested as a caries redictor.
:$=
5,e seed o+ la?/e
de"eloment can -e estimated -y t,e la?/e-+ormin*-rate inde0 7)F!I8.
:$&
5wenty-
+o/r ,o/rs a+ter ro+essional toot, cleanin*, la?/e reacc/m/lation rate is assessed on
a scale +rom : to ' on < meas/rin* oints er toot,. No oral ,y*iene meas/res are
carried o/t d/rin* t,e >&-,o/r eriod. Alt,o/*, /sed in se"eral clinical st/dies wit, a
ositi"e relations,i to caries incidence, t,e met,od ,as not *ained a widesread
clinical accetance.
)la?/e H Meas/rementAcid Formation -y Dental )la?/e
)la?/e H can -e directly meas/red intraorally -y /sin* eit,er *lass or antimony
electrodes.
:$'
Caries-acti"e s/-Aects e0,i-it lower restin* H and +inal H +ollowin*
s/crose rinses comared to caries-+ree ersons. 5elemetric monitorin*, ,owe"er,
seems more /se+/l in e"al/atin* H c,an*es a+ter intake o+ "ario/s +oods t,an in
determinin* caries acti"ity.
:$<
Conse?/ently, t,e tec,ni?/e is more o+ten /sed in
researc, la-oratories at /ni"ersities rat,er t,an in t,e e"eryday dental o++ice.
F/t/re Met,ods
A serio/s concern wit, t,e c/lt/rin* met,ods o+ today is t,e time san +rom samlin*
/ntil t,e res/lts are a"aila-le +or t,e ro+essionals and t,eir atients. F/rt,ermore,
samlin* m/st -e lanned to +it weekends and ot,er acti"ities. It is not likely t,at t,e
c/rrent a"aila-le tests can -e si*ni+icantly imro"ed, esecially i+ t,ey are to -e
s/ita-le +or c,airside /se or aimed +or +ield conditions. New tests, meas/rin* +or
e0amle -acterial ad,esion and -acteria--indin* sali"a li*ands as *enetically
determinin* +actors +or caries, mi*,t -e de"eloed. 30istin* imm/nolo*ic met,ods
like en@yme-linked imm/nosor-ent assay 73.ISA8 kits will ro-a-ly -e trans+erred
+rom t,e seciali@ed la-oratory to t,e dental clinic in comin* years. A call +or +aster
and more acc/rate tec,ni?/es will certainly stim/late t,e de"eloment o+ new and
imro"ed rod/cts. Moreo"er, imro"ed knowled*e o+ li+estyle-+actors s/c, as oral
,y*iene and s/*ar cons/mtion attern o-tained t,ro/*, ?/alitati"e st/dies can add
recision to t,e caries risk e"al/ation rocess.
Question 4
A. Sali"ary m/tans stretococci le"els are in+l/enced -y anti-iotic medication.
1. A ,i*,--/++er caacity is o+ten +o/nd in atients wit, a low-secretion rate.
C. Micro-iolo*ic caries acti"ity tests can -e /sed as didactic and moti"atin* tools in
caries re"ention.
D. )ast caries e0erience is +o/nd to -e t,e most "al/a-le sin*le redictor in many
caries risk st/dies.
3. 5,e redicti"e a-ility o+ a test deends on t,e re"alence o+ t,e disease in t,e
o/lation.
Summary
Caries is a transmissi-le local in+ection and acid/ric microor*anisms, like m/tans
stretococci and lacto-acilli, are t,e rime at,o*ens. 5,is c,ater ,as re"iewed t,e
ecolo*ic e"ents leadin* to caries de"eloment9 7:8 early esta-lis,ment o+ m/tans
stretococci, 7>8 micro-ial s,i+t and, 7=8 enamel deminerali@ation. 5,is rocess can -e
re"ented, arrested, or re"ersed wit, t,e knowled*e o+ +actors s/c, as t,e micro-ial
c,allen*e, intake o+ re+ined car-o,ydrates, and t,e -odyCs caacity o+ sel+-reair.
Caries-risk assessment strate*ies can -e alied +or o/lations, lar*er or smaller
*ro/s, or indi"id/als. 5,ere is no sin*le test t,at can acc/rately re+lect t,e comle0
etiolo*y o+ caries. Alt,o/*, tests o+ m/tans stretococci and lacto-acilli s,ow stron*
correlation wit, caries in cross-sectional and lon*it/dinal s/r"eys, t,ey are *enerally
o+ limited "al/e +or risk-screenin* /roses in comm/nities wit, a low re"alence o+
caries. In *ro/s o+ indi"id/als wit, ,i*,er caries incidence s/c, as medically
comromised atients, in,a-itants o+ low socioeconomic areas, and low +l/oride
areas, t,e redicti"e ower and t,e "al/e o+ t,e micro-ial tests are increased.
Ne*ati"e or "ery low co/nts o+ m/tans stretococci and lacto-acilli are ,i*,ly
redicti"e +or s/-Aects at low risk o+ *ettin* caries. 5,e ast caries re"alence is t,e
most ower+/l sin*le redictor on a o/lation -asis.
For t,e indi"id/al atient, a risk assessment is er+ormed -y comilin* data o+
imortance +or caries de"eloment +rom t,e case ,istory, clinical e0amination, and
c,airside tests. Micro-iolo*ic tests s,o/ld -e re*arded as monitors o+ t,e oral ecolo*y
and reeated samlin*s may indicate de"iations +rom t,e normality o+ t,e indi"id/al.
Any increase in t,e c,allen*e +actors or decrease in de+ense and reair +actors at any
time s,o/ld -e considered as a warnin* si*n. 5,is knowled*e s,o/ld +orm t,e -asis
+or an indi"id/ali@ed and tar*eted re"enti"e oral ,ealt, care ro*ram.
C,airside tests co"erin* -acterial c,allen*e, diet, and reminerali@ation otential o+
sali"a are descri-ed. 5,e simli+ied met,ods can -e c,aracteri@ed as semi?/antitati"e
alt,o/*, t,ey si*ni+icantly corresond to con"entional la-oratory met,ods.
F/rt,ermore, t,e c,airside met,ods ,a"e -een ro"en /se+/l as a didactic tool in
atient ed/cation and moti"ation.
Many dia*nostic criteria o+ caries acti"ity t,at are /sed today reresent ,istoric
e"ents. 5,e c,airside micro-iolo*ic tests imro"e ?/ality and add a ossi-ility o+
early risk assessment and dia*nosis. 4e ,oe t,at t,is c,ater ,as *i"en t,e reader
insiration to incororate caries acti"ity tests in t,eir daily work, +or t,e -ene+it o+
t,eir atients.
:. A and 3correct.
1incorrect. 5wo e0aminations are necessary to determine t,e n/m-er o+ cario/s
lesions occ/rrin* o"er a *i"en amo/nt o+ time.
Cincorrect. Sensiti"ity is t,e ercenta*e o+ s/-Aects wit, a ositi"e test w,o
de"elo t,e disease.
Dincorrect. Caries-risk assessment is recommended in a low caries o/lation wit,
a skewed distri-/tion.
>. A, 1, C, and Dcorrect.
3incorrect. .acto-acilli are more commonly associated wit, ca"itation and
ro*ression o+ e0istin* lesions.
=. 1 and Dcorrect.
Aincorrect. 5,e stim/lated secretion rate o+ w,ole sali"a is :.' m.Bmin/te, w,ic,
is normal.
Cincorrect. )la?/e samles disclose w,ere t,e -acteria are ,ar-ored.
3incorrect. Score = 7corresondin* to :$
<
CFUs8 indicates caries risk -/t not
necessarily deminerali@ation.
&. A, C, D, and 3correct.
1incorrect. A low -/++erin* caacity is o+ten +o/nd in atients wit, a low
stim/lated secretion rate.
:. I+ an eidemiolo*ic clinical caries s/r"ey is -ein* cond/cted, t,e n/m-er o+
decayed teet, 7dD D8 resent at t,at time constit/tes a caries iiiiiiiii st/dyD i+ t,e
same atients are ree0amined : year later, t,e n/m-er o+ new decayed teet,
constit/tes a caries iiiiiiiii st/dy.
>. 5,e two most common m/tans stretococci strains in ,/mans are Streptococcus
iiiiiiiii and Streptococcus iiiiiiiii.
=. An inciient enamel lesion can -e seen wit, t,e /naided eye. 75r/e, False8
&. Us/ally, m/tans stretococci are esta-lis,ed d/rin* c,ild,ood, -etween a*es
iiiiiiiii and iiiiiiiii, -/t may increase in n/m-ers d/rin* t,e +ollowin* years.
'. St/dies ,a"e s,own a +amily attern concernin* m/tans stretococci, meanin* t,at
-acteria o+ten are trans+erred +rom iiiiiiiii to c,ildren, -/t ot,er so/rces may also
-e +o/nd.
<. C,airside -acterial test res/lts in sali"a s,o/ld -e re*arded as iiiiiiiii rat,er
t,an e0act -acterial n/m-ers.
%. A risk +actor lays an essential role in t,e iiiiiiiii o+ t,e disease w,ile a closely
associated "aria-le t,at is not ca/sati"e is called a iiiiiiiii.
(. 4it, t,e decreasin* re"alence o+ caries seen o"er t,e last decades in t,e
ind/striali@ed world, one co/ld e0ect a *reater n/m-er o+ 7+alse-ne*ati"es8 7+alse-
ositi"es8 to -e dia*nosed.
;. A micro-ial s,i+t in dental la?/e can occ/r w,en iiiiiiiiiiii microor*anism7s8
are +a"ored.
:$. 5,e ositi"e redicti"e "al/e 7)6K8 is ro-a-ly o+ ,i*,est interest +or t,e
clinician since t,e iiiiiiiii +or an indi"id/al wit, a ositi"e test to de"elo t,e
disease is denoted.
Useful Dental Websites for Caries Activity Information
4orld Healt, Or*ani@ation 74HO89 Oral Healt, Co/ntry )ro+ile )roAect
,ttBBwww.w,ocolla-.odont.ma,.seBinde0.,tml
International Healt, Care Fo/ndation 7IHCF89 Caries-risk assessmentD sali"a
interacti"e site, 444--ased mana*ement o+ dental re"entionD Cario*ramD ot,er
dental we- sites o+ interest ,tt9BBwww.i,c+.li
Malmo Uni"ersity, Fac/lty o+ Odontolo*y9 contin/o/sly /dated list o+ re+erences
on caries risk assessment, m/tans stretococci and lacto-acilli.
,tt9BBwww.d-.ma,.seBcarBdataBrisk-asic.,tml
NIH Consens/s De"eloment Con+erence on Dia*nosis and Mana*ement o+ Dental
Caries 5,ro/*,o/t .i+e9 comlete "ersion o+ aers on caries dia*nosis and caries
risk. ,tt9BBnidcr.ni,.*o"BnewsBconsens/s.as
Orion Dia*nostics, 5/rk/, Finland9 man/+act/rer o+ kits +or sali"a dia*nosis
,tt9BBwww.oriondia*nostica.+i
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ractice. /nt Dent ", &>9:;;->$(.
';. 5wetman, S., Sta,l, 1., g Neder+ors, 5. 7:;;&8. Use o+ Stri m/tans test in t,e
assessment o+ caries risk in a *ro/ o+ resc,ool c,ildren. /nt " Paediatr Dent, &9>&'-
'$.
<$. Mac),erson, .. M. D., MacFarlane, 5. 4., g Ste,en, 2. 4. 7:;;$8. An intra-
oral aliance st/dy o+ t,e la?/e micro+lora associated wit, early enamel
deminerali@ation. " Dent Res, <;9:%:>-:<.
<:. 5,i-odea/, 3. A., g OCS/lli"an, D. M. 7:;;'8. Sali"ary m/tans stretococci and
incidence o+ caries in resc,ool c,ildren. Caries Res, >;9:&(-'=.
<>. .ind?/ist, 1., 3milson, C. G., g 4enner,olm, 2. 7:;(;8. !elations,i -etween
m/tans stretococci in sali"a and t,eir coloni@ation o+ toot, s/r+aces. +ral %icro4iol
/mmunol, &9%:-%<.
<=. 2risto++ersson, 2., Gronda,l, H. G., g 1ratt,all, D. 7:;('8. 5,e more
Streptococcus mutans, t,e more caries on aro0imal s/r+aces. " Dent Res, <&9'(-<:.
<&. Coykendall, A. .., g G/sta+son, 2. 1. 7:;(<8. 5a0onomy o+ Streptococcus
mutans, In Hamada S. et al., )roceedin*s o+ an International Con+erence on Cell/lar,
Molec/lar and Clinical Asects o+ Streptococcus mutans, Amsterdam, New Hork,
O0+ord9 3lse"ier, :'%.
<'. Gold, O., #ordan, H. 6., g "an Ho/te, #. 7:;%=8. A selecti"e medi/m +or
Streptococcus mutans, rchs +ral #iol, :(9:='%-<&.
<<. 2o,ler, 1., g 1ratt,all, D. 7:;%;8. )ractical met,od to +acilitate estimation o+
Streptococcus mutans le"els in sali"a. " Clin %icro4iol, ;9';&-;(.
<%. Mats/k/-o, 5., O,ta, 2., Maki, H., 5ake/c,i, M., g 5aka@oe I. 7:;(:8. A
semi?/antitati"e determination o+ Streptococcus mutans /sin* its ad,erent a-ility in
selecti"e medi/m. Caries Res, :'9&$-&'.
<(. #ordan, H. 6., .araway, !., Snirc,, !., g Marmel, M. 7:;(%8. A simli+ied
dia*nostic system +or c/lt/ral detection and en/meration o+ Streptococcus mutans, "
Dent Res, <<9'%-<:.
<;. #ensen, 1., g 1ratt,all, D. 7:;(;8. A new met,od +or t,e estimation o+ m/tans
stretococci in sali"a. " Dent Res, <(9&<(-%:.
%$. 5wetman, S., g Frostner, N. 7:;;:8. Sali"ary m/tans stretococci and caries
re"alence in (-year-old Swedis, sc,oolc,ildren. S3ed Dent ", :'9:&'-':.
%:. 3l-Nade+, M. A. I., g 1ratt,all, D. 7:;;:8. Indi"id/al "ariations in co/nt o+
m/tans stretococci meas/red -y FStri m/tansF met,od. Scand " Dent Res, ;;9(-:>.
%>. 1ratt,all, D., Hos@ek, A., g I,ao, G. 7:;;%8. 3"al/ation o+ a simli+ied met,od
+or site-seci+ic determination o+ m/tans stretococci le"els. S3ed Dent ", >$9>:'->$.
%=. 4allman, C., g 2rasse, 1. 7:;;=8. A simle met,od +or monitorin* m/tans
stretococci in mar*ins o+ restorations. " Dent, >:9>:<-:;.
%&. 5wetman, S. 7:;;'8. 3ine ein+ac,e met,ode Met,ode @/r U-err/+/n* der
4irk/n* der toikalen 1e,andl/n* mit einem anti-akteriellem .ack. @-R, :$&9=(:-
(=.
%'. 5wetman, S., g )etersson, .. G. 7:;;%8. 3++ect o+ di++erent c,lor,e0idine "arnis,
re*imens on m/tans stretococci le"els in interdental la?/e and sali"a. Caries Res,
=:9:(;-;=.
%<. Crossner, C. G. 7:;(:8. Sali"ary lacto-acill/s co/nts in t,e rediction o+ caries
acti"ity. Community Dent +ral !pidemiol, ;9:(>-;$.
%%. 2lock, 1., g 2rasse, 1. 7:;%%8. Micro-ial and sali"ary conditions in ;-:> year old
c,ildren. Scand " Dent Res, ('9'<-<=.
%(. Nylander, A., 2/mlin, I., Martinsson, M., g 5wetman, S. 7>$$$8. Decreasin*
re"alence o+ sali"ary lacto-acilli in Swedis, sc,oolc,ildren :;(%-:;;(. !ur " +ral
Sci, :$(9>''-'(.
%;. !o*osa, M., Mitc,ell, #. A., g 4ieseman, !. F. 7:;':8. A selecti"e medi/m +or
t,e isolation and en/meration o+ oral lacto-acilli. " Dent Res, =$9<(>-(;.
($. .armas, M. 7:;%'8. A new di-slide met,od +or t,e co/ntin* o+ sali"ary
lacto-acilli. Proc 'inn Dent Soc, %:9=:-='.
(:. Crossner, C. G., g Ha*-er*, C. 7:;%%8. A clinical and micro-iolo*ical e"al/ation
o+ t,e Dentoc/lt di-slide test. S3ed Dent ", :9('-;&.
(>. Iickert, I., 3milson, C. G., g 2rasse, 1. 7:;('8. )rediction o+ caries incidence
-ased on sali"ary S. m/tans and lacto-acilli co/nts. " Dent Res, <&9=&%.
(=. 5wetman, S., Mat,iasson, A., 6arela, #., g 1ratt,all, D. 7:;;$8. M/tans
stretococci in sali"a and dental caries in c,ildren li"in* in a ,i*, and a low +l/oride
area. +ral %icro4iol /mmunol, <9:<;-%:.
(&. 5wetman, S., )etersson, .. G., g )ak,omo", G. N. 7:;;<8. Caries incidence in
relation to sali"ary m/tans stretococci and +l/oride "arnis, alications in resc,ool
c,ildren +rom low- and otimal-+l/oride areas. Caries Res, =$9=&%-'=.
('. 5/kia-2/lmala, H., g 5eno"/o, #. 7:;;=8. Intra- and inter-indi"id/al "ariation in
sali"ary +low rate, -/++er e++ect, lacto-acilli, and m/tans stretococci amon* ::- to
:>-year-old sc,oolc,ildren. cta +dontol Scand, ':9=:-=%.
(<. 5eno"/o, #. 7:;;%8. Sali"ary arameters o+ rele"ance +or assessin* caries acti"ity
in indi"id/als and o/lations. Community Dent +ral !pidemiol, >'9(>-(<.
(%. Sree-ny, .. M., g 6aldini, A. 7:;(%8. Gerostomia. A ne*lected symtom. rch
/ntern %ed, :&%9:===-=%.
((. Heint@e, U., 1irk,ed, D., g 1Aorn, H. 7:;(=8. Secretion rate and -/++er e++ect o+
restin* and stim/lated w,ole sali"a as a +/nction o+ a*e and se0. S3ed Dent ", %9>>%-
=(.
(;. 3ricsson, H. 7:;';8. Clinical in"esti*ations on t,e sali"ary -/++erin* action. cta
+dontol Scand, :%9:=:-<'.
;$. Alal//s/a, S., 2leemoAa-2/Aala, 3., Gronros, .., g 3"ala,ti, M. 7:;;$8. Sali"ary
caries tests as redictors o+ +/t/re caries increment in teena*ers. A t,ree-year
lon*it/dinal st/dy. +ral %icro4iol /mmunol, '9%%-(:.
;:. 3ricson, D., g 1ratt,all, D. 7:;(;8. A simli+ied met,od to estimate t,e sali"ary
-/++er caacity. Scand " Dent Res, ;%9&$'-&$%.
;>. "an )alenstein Helderman, 4. H., Mik0, F. H., 6anCt Ho+, M. A., 5r"in G, g
2als-eek, H. 7>$$:8. 5,e "al/e o+ sali"ary -acterial co/nts as a s/lement to ast
caries e0erience as caries redictor in c,ildren. Caries Res, :$;9=:>-:'.
;=. )ieni,akkinen, 2., g #okela, #. 7>$$>8. Clinical o/tcomes o+ risk--ased caries
re"ention in re-sc,ool a*ed c,ildren. Community Dent +ral !pidemiol, =$9:&=-'$.
;&. Iero, D., Fontano, M., g .ennon, A. 7>$$:8. Clinical alications and o/tcomes
o+ /sin* indicators o+ risk in caries mana*ement. " Dent !duc, <'9::><-=>.
;'. Nylander, A., 2/mlin, I., Martinsson, M., g 5wetman, S. 7>$$:8. 3++ect o+ a
sc,ool--ased re"entin* ro*ram wit, sali"ary lacto-acill/s co/nts as a s/*ar-
moti"atin* tool on caries increment in adolescents. cta +dontol Scand, ';9((-;>.
;<. 2ay, 3. #., g .ocker, D. 7:;;<8. Is dental ,ealt, ed/cation e++ecti"ee A systematic
re"iew o+ c/rrent e"idence. Community Dent +ral !pidemiol, >&9>=:-='.
;%. O*aard, 1., .arsson, 3., g 1irk,ed, D. 7>$$>8. )rediction o+ w,ite sot lesion
de"eloment d/rin* ort,odontic treatment. Caries Res, =<9:%&->>>.
;(. 5wetman, S., #o,ansson, I., 1irk,ed, D., g Neder+ors, 5. 7>$$>8. Caries incidence
in yo/n* tye : dia-etes mellit/s atients in relation to meta-olic control and caries-
associated risk +actors. Caries Res, =<9=:-='.
;;. Snyder, M. 7:;':8. .a-oratory met,ods in t,e clinical e"al/ation o+ caries
acti"ity. " m Dent ssoc, &>9&$$-:=.
:$$. Neder+ors, 5., Henriksson, 6., 3ricson, 5., g Da,lo+, C. 7:;;=8. Oral m/cosal
+riction and s/-Aecti"e ercetion o+ dry mo/t, in relation to sali"ary secretion. Scand
" Dent Res, :$:9&&-&(.
:$:. )ieni,akkinen, 2. 7:;((8. Sali"ary lacto-acilli and yeasts in relation to caries
increment. cta +dontol Scand, &<9'%-<>.
:$>. )ar"inen, 5., g .armas, M. 7:;(:8. 5,e relation o+ stim/lated sali"ary +low rate
and H to lacto-acill/s and yeast concentrations in sali"a. " Dent Res, <$9:;>;-='.
:$=. 4endt, .. 2., Hallonsten, A. .., 2oc,, G, 1irk,ed, D. 7:;;&8. Oral ,y*iene in
relation to caries de"eloment and immi*rant stat/s in in+ants and toddlers. Scand "
Dent Res, :$>9><;-%=.
:$&. A0elsson, ). 7:;;:8. A +o/r-oint scale +or selection o+ caries risk atients, -ased
on sali"ary S. mutans le"els and la?/e +ormation rate inde0. In #o,nson N., 3d. Ric*
mar*ers for oral diseases, 6ol. : 7. :'(-%$8. .ondon9 Cam-rid*e Uni"ersity )ress.
:$'. Ne++, D. 7:;<%8. Acid rod/ction +rom di++erent car-o,ydrate so/rces in ,/man
la?/e in sit/. Caries Res, :9%(-(%.
:$<. .in*strom, )., g 1irk,ed, D. 7:;;=8. )la?/e H and oral retention a+ter
cons/mtion o+ starc,y snack rod/cts at normal and low secretion rate. cta
+dontol Scand, ':9=%;-((.
reser"ed.
Chapter 13. Periodontal Disease Prevention: Facts, Risk Assessment, and
Evaluation - &orman +, Harris Donald !, -illmann
Objectives
:. Cite t,e one main si*n t,at delineates *in*i"itis +rom eriodontitis.
>. 30lain t,e rationale +or t,e latest classi+ication o+ t,e eriodontal diseases.
=. 30lain t,e /rose o+ OC.earyCs Inde0, Silness and .oeCs )la?/e Inde0, and .oe
and SilnessCs Gin*i"al Inde0.
&. Descri-e ,ow man/al eriodontal ro-es are /sed, and contrast t,em to constant-
+orce electronic ro-es.
'. 30lain ,ow ocket det, and attac,ment loss are meas/red and ,ow *in*i"al
recession meas/rements are related to -ot,.
<. Clari+y t,e di++erences -etween t,e Comm/nity )eriodontal Inde0 o+ 5reatment
Needs 7C)I5N8 and t,e )eriodontal Screenin* and !ecordin* System 7)S!8.
%. Disc/ss t,e "al/e o+ t,e *in*i"al cre"ic/lar +l/id and ,ow t,e +low is ?/antitated.
(. 30lain w,y smokin* constit/tes a ,i*,-risk ,a-it t,at Aeoardi@es t,e re"ention,
treatment and maintenance o+ t,e eriodontal diseases.
Introduction
In :(%', !i**sC disease,
a
7later known as yorr,ea
-
al"eolaris
:,>
and still later as
eriodontal disease8 was easy to dia*nose. I+ /s co/ld -e e0elled +rom t,e *in*i"al
cre"ice -y e0ertin* +in*er ress/re o"er t,e root, +rom t,e ae0 towards t,e crown,
t,e correct dia*nosis was yorr,ea al"eolaris.
=
5,is dia*nosis co/ld -e con+irmed -y
lacin* a dro or two o+ */aiac/m on t,e e0/date rod/cin* a dee -l/e color.
&
At t,e
time it was estimated t,at ;'E o+ all eole o"er >' were Fmore or less a++ected.F
'
O+
interest is t,e +act t,at systemic conditions were s/sect as ossi-ly associated wit,,
or as ca/sal a*ents o+ yorr,ea al"eolariss/c, conditions as *astric dysesia,
,t,isis,
c
adenoids, nasal catarr,, constiation, *eneral con*estion d/e to
intemerance, maln/trition, and cold +eet or ot,er e0tremities t,at indicate oor
circ/lation.
=
5,ro/*,o/t t,e +irst ,al+ o+ t,e >$t, cent/ry, yorr,ea al"olaris and recedin* */ms
remained t,e o/lar terms +or t,e disease -y -ot, t,e ro+ession and lay ersons.
5,e ca/se o+ yorr,ea al"eolaris at t,e time was attri-/ted to t,e resence o+
calc/l/s.
<
1ot, t,e lon*-time terminolo*y and t,e well-esta-lis,ed calc/l/s etiolo*y
was to a*ain c,an*e. )eriodontal disease was to s/ercede t,e desi*nation o+
yorr,ea al"eolaris w,ile t,e acceted etiolo*y o+ calc/l/s
<
was droed in +a"or o+ a
nonseci+ic la?/e ,yot,esis. Accordin* to t,e nonseci+ic ,yot,esis, eriodontal
disease was ca/sed -y a mi0ed o"er*rowt, o+ known and /nknown or*anisms in t,e
dental la?/e.
%,(
It was still ass/med t,at once a atient was Fin+ected wit, eriodontal
disease,F t,e rocess -ecame more se"ere wit, timeD in ot,er words, eriodontal
disease was considered a at,olo*ic enalty +or a*in*. 5,e /-lic still contin/ed to
reco*ni@e eriodontal disease as an in+lammatory disease c,aracteri@ed -y
periododontal poc*ets accomanied wit, a silent 4one loss,
1y t,e mid->$t, cent/ry, t,e FnonF o+ t,e nonseci+ic ,yot,esis was droed in
+a"or o+ a new, Fseci+ic -acterial ,yot,esisF t,at now ost/lated t,at *in*i"itis and
eriodontitis were ca/sed -y seci+ic as well as still-/nknown -acterial secies
indi*ent to t,e la?/e.
(
At t,e same time, a consens/s -e*an to emer*e t,at t,e one-
time sin*le eriodontal disease was instead, a series o+ di++erent, -/t related diseases
cate*ori@ed as 7:8 *in*i"itis and 7>8 ad/lt, re/-ertal, A/"enile, raidly ro*ressi"e,
and re+ractory eriodontitis. 4it, t,is c,an*e, calc/l/s re-o/nded into a secondary
etiolo*ical role, w,ere its oro/s s/r+ace was, and still is, -elie"ed to ser"e -ot, as a
ha4itat +or la?/e -acteria and t,eir end rod/cts and as an irritant to t,e mar*inal
*in*i"al tiss/es.
;-::
5,e resence o+ s/-*in*i"al calc/l/s contri-/tes to t,e
ro*ression and c,ronicity o+ eriodontal disease.
;,:>
5,e relations,i -etween t,e di++erent eriodontal diseases was not, and is not yet
well /nderstood. 5,is was /nderscored -y t,e ast classi+ication system t,at was
-ased on a narrati"e descrition t,at related to t,e atientCs a*e at t,e time o+ onset,
raidity o+ disease ro*ression, resonse to t,eray, and se"erity o+ t,e diseaseand
not to de+inite ca/sal a*ents like +or caries, w,ere m/tans stretococci and lacto-acilli
are t,e rime cario*enic at,o*ens.
:=
5,ere are still maAor "oids o+ knowled*e a-o/t t,e seci+ic eriodontal at,o*ens, or
t,ose t,at mi*,t -e indicted in t,e +/t/re as syner*istic or ca/sal to t,e eriodontal
disease rocess. )la?/e samles +rom indi"id/als wit, eriodontitis can demonstrate
aro0imately ='$ micro-ial secies in t,e dental la?/e and a-o/t :'$ secies in t,e
s/ra*in*i"al la?/e, ton*/e,and ot,er oral str/ct/res.
:&
Het, sin*/larly or in
com-ination, a "ery stron* case can now -e made +or imlicatin* amon* ot,ers,
ctino4acillus actinomycetemcomitans 7Aa8, Porphyromonas $in$ivalis 7)*8,
#acteroides forsythus, Prevotella intermedia 7)i8, !i*enella corrodens,
'uso4acterium nucleatum, Campy4acterrectus and Treponema 7siroc,etes8.
:'-:(
!o/tine la-oratory, and more so,isticated DNA ro-e analyses 7descri-ed later8 can
-e accomlis,ed to identi+y s/sect -acteria. S/c, ositi"e identi+ications aid t,e
clinician in selectin* dr/*s to s/ress t,e or*anisms +o/nd in t,e di++erent
eriodontal diseases.
In :;;(, t,e ro+ession e0erienced anot,er nomenclat/re c,an*e. 5,is ne3
classification system eliminated t,e *ro/in*s -ased on a*e o+ onset, raidity o+ onset,
etc., and relaced it wit, a classi+ication that attempts to identify the local and
systemic causes of $in$ivitis and periodontitis, For instance, -acteria in t,e la?/e
ca/se eriodontal disease, -/t t,e action o+ any o+ t,e same -acteria may -e modified
-y systemic +actors s/c, as t,e endocrines, -lood dyscrasias, in*ested medication, etc.
5,e +/ll classi+ication wit, s/- *ro/in*s and e0amles is contained in Aendi0 :=-
:.
:;
5,is new classi+ication system will -e incororated into +/t/re Dental and Dental
Hy*ienist National 1oard 30aminations.
a
!i**sC disease9 Named a+ter a 1oston Dentist. Dr. !i**s e0tracted t,e +irst toot, e"er
to -e e0tracted /nder *eneral anest,esia. His atient was Dr. Horace 4ells, t,e dentist
*i"en credit +or t,e disco"ery o+ nitro/s o0ide as a anest,etic.
-
)yorr,ea h /s.
c
),t,isis h ast,ma.
Facts about Gingivitis and Periodontitis
Alt,o/*, -acteria are t,e ca/sati"e +actor o+ t,e eriodontal diseases, t,ere are
ower+/l in+l/encin* +actors t,at can modi+y t,e co/rse o+ t,e diseases s/c, as 7:8
smo*in$, 7>8 $enetic differences, 7=8 -aseline se"erity o+ disease, 7&8 )resence o+ P,
$in$ivalis, P, intermedia, and #, forsythus, and ctino4acillus
actinomycetemcomitans, and 7'8 individual compliance wit, esta-lis,ed standards +or
oral sel+-care.
>$,>:
O+ interest to married co/les is t,e +act t,at so/ses and c,ildren o+
an ad/lt eriodontitis atient mi*,t -e at a relati"ely ,i*, risk o+ de"eloin* a
eriodontal -reakdown.
>>
Anot,er stron* risk indicator is t,e o-ser"ed relations,i o+
se"eral systemic diseases to *in*i"itis and eriodontitis. Amon* t,ese are dia-etes
mellit/s,
>=
DownCs syndrome,
>&
and more rarely dia*nosed conditions s/c, as Haim-
M/nk syndrome and )aillon-.e Fe"re syndromes.
>'
Also noticed ,as -een a *reater
+re?/ency o+ cardio"asc/lar accidents and non,emorr,a*ic strokes amon* indi"id/als
wit, eriodontitis.
><,>%
1ot, *in*i"itis and eriodontitis a++ect t,e tiss/es o+ t,e eriodonti/m. 1y definition,
a la?/e-ind/ced *in*i"itis is an in+lammation o+ t,e mar*inal *in*i"a 3ithout any
loss of the epithelial attachment, Once t,ere is a loss o+ t,e eit,elial attac,ment,
a*ain -y definition, eriodontitis -e*ins. 5,e term eriodontitis can -e de+ined as 7:8
an in+lammation o+ t,e mar*inal *in*i"al 3ith 7>8 a loss o+ t,e eit,elial attac,ment,
plus 7=8 irre"ersi-le dama*e to any o+ t,e ot,er t,ree remainin* comonents o+ t,e
eriodonti/m, i.e., t,e cement/m, al"eolar -one, and t,e eriodontal li*ament t,at
connects t,e latter two str/ct/res.
Question 1
A. One o+ t,e ,i*,ly s/sect -acteria associated wit, eriodontitis ,as -een
a--re"iated AaD t,e correct +/ll sellin* o+ t,e -acteria is ctino4acillus
actinomycetemcomitans,
1. 5,e last Fo++icialF c,an*e o+ eriodontal disease classi+ication in :;;( s,o/ld make
it easier to determine t,e etiolo*y 7or co+actors8 to t,e eriodontal diseases.
C. 5,ree ower+/l non-acterial +actors t,at in+l/ence t,e co/rse o+ eriodontal disease
are *enetic di++erences, smokin* and ade?/ate daily sel+-care.
D. 5,ree systemic diseases t,at are associated wit, eriodontitis are cardiac disease,
dia-etes mellit/s and most "iral diseases.
3. It is ossi-le to ,a"e a &-millimeter dee ocket wit, a slow aical mi*ration o+ t,e
eit,elial attac,ment, and yet ,a"e a *in*i"itis.
4it, *ood oral ,y*iene ractices, a la?/e-ind/ced *in*i"itis o+ -acterial ori*in can
-e cured, i.e., t,e +ree mar*in o+ t,e *in*i"a can -e ret/rned to its ori*inal ,istolo*y.
On t,e ot,er ,and, -eca/se o+ t,e irre"ersi-le c,an*es t,at occ/r to t,e comonents o+
t,e eriodonti/m in eriodontitis, it is /s/ally not ossi-le +or t,e a++ected tiss/es to
ret/rn to normal. Once eriodontal treatment is comleted, any +/rt,er re"enti"e
andBor treatment t,eray is considered as maintenance 7and not a c/re8 and is
intended to s/stain t,e stat/s ?/o o+ t,e toot, as m/c, as ossi-le t,ro/*,o/t a
li+etime. 5,e reco*nition o+ t,e early si*ns and symtoms o+ *in*i"itis andBor
eriodontitis and -e*innin* immediate treatment is cr/cial to t,e arrest and control o+
disease ro*ression. 5,is *atekeeer +/nction can -est -e ser"ed -y t,e $eneral
dentist,
>(
5,ere is a-/ndant e"idence t,at t,e micro-ial o/lation o+ t,e supra*in*i"al la?/e
is associated wit, *in*i"itis, and t,e su4*in*i"al la?/e wit, eriodontitis.
In t,e earliest sta*es o+ *in*i"itis, t,ere is an in+iltration o+ -ody de+ense cells -eneat,
t,e cre"ic/lar eit,eli/m. I+ t,e *in*i"itis is not arrested at an early time, t,e color o+
t,e mar*inal *in*i"a c,an*es +rom a ale pin*2to2redD t,e conto/r o+ t,e mar*inal
*in*i"al -ecomes edematous, and t,ere is 4leedin$ on ro-in* or d/rin*
toot,-r/s,in* 7Fink toot,-r/s,F8. Any *in*i"al -leedin* at any a$e and at any time
is not normal and s,o/ld -e "iewed wit, concern -y -ot, t,e clinician and t,e atient.
Het, -eca/se *in*i"al -leedin* is considered s/c, a commonly occ/rrin* entity,
dentists and atients alike o+ten +ail to reco*ni@e early in+lammatory *in*i"al c,an*es,
even thou$h this is the time that complete recovery (cure) is possi4le, )atients are
o+ten not in+ormed o+ t,e resence o+ eriodontal disease /ntil t,e oort/nity +or
c/re or early arrest is ast. In one st/dy, only &(E o+ t,e atients wit, dia*nosed
ad"anced eriodontitis ,ad -een in+ormed o+ t,eir condition -y t,eir dentist. Only
:>E o+ t,ose wit, *in*i"itis and >$E o+ t,e atients wit, early eriodontitis ,ad -een
made aware o+ t,eir conditions.
>;,=$
5,ese data s/ort t,e +act t,at one o+ t,e
comlaints a-o/t eriodontal disease dia*noses, is t,at t,ey o+ten occ/r too late to -e
really ,el+/l.
>(
5,is +indin* ,as -ot, ethical and le$al o"ertones.
=:,=>
Mar*inal *in*i"itis is e0tremely common amon* all a*e *ro/s, and is not necessarily
related to a*in* er se. Many Senior citi@ens enAoy e0cellent eriodontal ,ealt, into
old a*e.
==
On t,e ot,er ,and, many ad"anced cases o+ eriodontitis seen in a*in* are
t,e res/lt o+ li+elon* ne*lect o+ sel+-care.
Un+ort/nately, many eriodontal cases can -e traced -ack to yo/t,. For e0amle, in
!eykAa"ik, Iceland, *in*i"al -leedin* was +o/nd in :<E o+ >=$ <-year old c,ildren.
=&

In a military o/lation o+ :,==& soldiers, &$.=E were +o/nd to ,a"e *in*i"itis, w,ile
='.%E o+ t,e s/-Aects ,ad ocket det,s o+ = to ' millimeters 7considered as ossi-le
early eriodontitis8.
='
1,at reorted =&E o+ :&- to :%-year-old yo/t,s ,ad
s/ra*in*i"al, and >=E ,ad s/-*in*i"al calc/l/s.
=<
It is o+ concern t,at so many
c,ildren and yo/n* ersons are not /nder ro+essional care.
=%
C,ildren or adolescents
wit, *in*i"itis, s/-*in*i"al calc/l/s, or early si*ns o+ al"eolar -one loss s,o/ld -e
considered as ,i*, eriodontitis-risk indi"id/als and s,o/ld -e entered into a
monitored re"enti"e ro*ram as early as ossi-le. 5,ese reeated +indin*s o+
*in*i"itis t,at occ/r at relati"ely early a*es, are a ,ar-in*er +or t,e eriodontal disease
t,at -ecomes t,e leadin* ca/se o+ toot, loss a+ter t,e t,ird decade.
=(
Nonin"asi"e 5reatment G/idelines +or Gin*i"itis
Gin*i"itis o+ la?/e ori*in is a preventa4le and cura4le eriodontal disease. 5,e
o47ective of professional and home self2care is to eliminate or severely reduce the
etiolo$ic or$anisms in the dental pla5ue and to prevent or reverse $in$ival
inflammation, 5,is e++ort can -e a-etted -y a t,oro/*, ro,yla0is, s/lemented at
,ome -y /se o+ t,e tooth4rush, dental floss and an irri$ation device, Generally, an
electric toot,-r/s, is more e++ecti"e t,an a man/al -r/s, 7see C,aters ', <, and %8.
5,is F-r/s,, +loss, and +l/s,F ro/tine can -e en,anced -y t,e daily /se o+ a +l/oride
toot,aste, o"er-t,e-co/nter rod/cts wit, essential oils, s/c, as .isterine, or dentist
rescri-ed chlorhexidine mo/t,rinses.
5,e daily sel+-care ro/tine s,o/ld -e ,a-it/ated +rom early c,ild,ood to re"ent
c,allen*e or*anisms +rom si*ni+icantly o/latin*, or reo/latin* t,e la?/e. In t,e
e"ent t,at t,ese emirical meas/res +ail, a di++erential dia*nosis s,o/ld -e considered
to determine i+ one o+ t,e la?/e modi+ied etiolo*ies +or *in*i"itis listed in Aendi0
:=-: is t,e rimary ca/se.
:;
I+ so, a medical re+erral may -e in order.
Nonin"asi"e )rimary )re"enti"e Care +or )eriodontitis
Once a atient de"elos periodontitis, t,eray /s/ally incl/des additional meas/res to
t,ose recommended +or *in*i"itis. As t,e ro-in* det, increases, it -ecomes more
di++ic/lt to eliminate t,e -acteria o+ t,e s/-*in*i"al la?/e. In addition to ro/tine
calc/l/s remo"al at t,e time o+ t,e ro,yla0is, scalin$ and root planin$ needs to -e
accomlis,ed.
=;
Many clinicians ad"ocate irri*atin* t,e deeer ockets. 5,e det, o+
enetration o+ irri*ation sol/tions into t,e ocket deends on t,e ti desi*n o+ t,e
irri*ator, t,e +l/id ress/re, and t,e calc/l/s resent t,at mi*,t di"ert t,e irri*ant
stream.
&$
C,lor,e0idine,
&:
stanno/s +l/oride,
&>,&=
and .isterine
&&
are -/t a +ew o+ t,e
sol/tions t,at ,a"e -een /sed. !esearc, to +ind more e++ecti"e antimicro-ial a*ents is
a contin/in* ?/est.
&'
5,e dental hy$ienist is pro4a4ly the *ey person to deliver the
su4$in$ival irri$ation therapy,
&<
as 3ell as to instruct the patient on ho3 to
accomplish the tas* at home,
&%
7See Fi*/re :=-:.8
5,e mo/t,rinses /sed in a sel+-care ro*rams do not enetrate deely eno/*, into t,e
eriodontal ockets. Howe"er, w,en irri*ation is accomlis,ed in t,e o++ice, a *reater
enetration o+ t,e ocket can -e attained -y lacin* t,e t,erae/tic irri*atin* sol/tion
in t,e +l/id container o+ t,e /ltrasonic scaler.
&(
5o comlete t,e treatment, o+ten a
slow-deli"ery medication is laced in t,e ocket, or anti-iotic t,eray can -e
initiated to eliminate micro-es t,at ,a"e in"aded t,e s/lc/lar tiss/es.
&;
Once a
ma0im/m treatment s/ccess ,as -een ac,ie"ed, an e"ery-=-mont, monitorin* is
mandatory,
In"asi"e )roced/res !e?/ired to Access t,e S/-*in*i"al )ocket
As t,e ocket contin/es to deeen it -ecomes more di++ic/lt to aly nonin"asi"e
re"enti"e roced/res. 5o sol"e t,is ro-lem, t,e eriodontist can sometimes er+orm
flap sur$ery, a s/r*ical roced/re t,at remo"es a circ/m+erential ortion art o+ t,e
mar*inal *in*i"a and e0oses t,e root. Followin* t,e oeration, t,e re"io/s
inaccessi-le s/-*in*i"al ocket area -ecomes more accessi-le to aly ro/tine dental
,y*iene roced/res. It s,o/ld -e em,asi@ed t,at t,is s/r*ery is not a c/reit only
ro"ides a rerie"e to ,el arrest a disease t,at ,as -een o/t o+ control.
Ad"anced )eriodontal S/r*ery
On t,e -asis o+ st/dies, it is estimated t,at aro0imately ' to >$E o+ ad/lts ,a"e
se"ere eriodontal disease w,ile t,e maAority ,a"e mild-to-moderate eriodontitis.
'$

In t,e ad"anced sta*e o+ eriodontal disease t,ere is a dramatic loss o+ t,e eit,elial
attac,ment wit, a conc/rrent loss o+ s/ortin* al"eolar -one t,at can se"erely
comromise t,e s/ort o+ a toot,. A disc/ssion o+ ad"anced s/r*ical tec,ni?/es is
-eyond t,e scoe o+ t,is -ookD ,owe"er, t,ere are s/r*ical roced/res t,at can o+ten
-e /sed to reair dama*e ca/sed -y eriodontitis.
In an e++ort to comensate +or losses o+ -one and tiss/e, $uided re$enerative
techni5ues
d
,a"e -een introd/ced in t,e ast se"eral years wit, a di"ided em,asis on
4one as well as soft2tissue re*eneration. 5,is is accomlis,ed -y /se o+ -one *ra+ts
and -one stim/lants, as well as lastic s/r*ery roced/res to res,ae so+t tiss/es. At
times w,en t,e -ony s/ort is minimal, rost,etic de"ices interlinkin* se"eral teet,
are constr/cted to act as a slint to re"ent any one or more teet, -ein* s/-Aected to
e0cessi"e lateral toot, mo"ement /on mastication.
Followin* s/r*ical inter"entions to mana*e moderate and se"ere sta*es o+
eriodontitis, t,e re"enti"e actions t,at m/st -e taken still re5uire meticulous
mechanical (J4rush, floss, and flushJ) and chemical pla5ue control (antimicro4ial
mouthrinses), C,lor,e0idine is ro-a-ly t,e antimicro-ial mo/t, rinse o+ c,oice to
rotect t,e inte*rity o+ t,e restored tiss/es and to ,el s/ress t,e transmission o+
eriodontoat,o*ens +rom ot,er so+t and ,ard tiss/e locations in t,e mo/t,.
d
)eriodontal re*eneration means ,ealin* a+ter eriodontal s/r*erya ,ealin* t,at
res/lts in a artial or comlete restoration o+ t,e toot, s/ortin* tiss/es, namely
cement/m, al"eolar -one and eriodontal li*ament. Ann )eriodontolo*y, :;;%D >9>:'-
>>.
4,at Is )eri-imlantitise
5o imro"e est,etics and +/nction +ollowin* t,e e0traction o+ a toot,, t,e "oid can
/s/ally -e +illed -y eit,er a -rid*e or an imlant. For a -rid*e, it is necessary to
reare two intact teet, as anc,or teet,. 5,is can in"ol"e a considera-le loss o+ toot,
str/ct/re. On t,e ot,er ,and, an implant can -e FimlantedF -etween t,e two adAacent
teet, to +/nction m/c, as a normal toot,.
An imlant consists o+ noncorrosi"e metallic FrootF t,at is inserted into a cylindrical
rearation in t,e al"eolar -one. 7Fi*/re :=->8. A+ter -one ,ealin*, a reared crown
is cemented to t,e reared ortion o+ t,e imlant t,at remains a-o"e t,e m/cosa.
5,is allows t,e imlant to ser"e t,e same function as ot,er nat/ral teet,.
Un+ort/nately, t,e imlant is also e0osed to t,e same -acterial +lora as are all t,e
ot,er normal teet,teet, t,at de"elo *in*i"itis and eriodontitis. 5,e same rimary-
re"enti"e roced/res are necessary +or s/r"i"al o+ an imlant as +or t,e ot,er teet, o+
t,e mo/t,D ne*lect o+ sel+-care res/lts in t,e same *in*i"al in+ection and se?/ela as
+or eriodontitis. 5,e same destr/cti"e -acteria are in"ol"ed as in eriodontitis. 5,e
+ail/re and remo"al o+ an imlant arallels t,e terminal e0traction o+ a nat/ral toot,
+rom eriodontal disease7s8. In ot,er words, t,e same ro-lems and t,e nearly same
sol/tions aly to an imlant wit, peri2implantitis as +or a nat/ral toot, wit,
eriodontitis.
Fi*/re :=-: A. An irri*ator is an o/tstandin* de"ice to /se a plentiful amo/nt o+
water to +l/s, de-ris still remainin* a+ter -r/s,in* and +lossin* 7F-r/s, and
+l/s,F8. B. An irri*ator wit, t,e /se o+ an accessory no@@les can /tili@e a limited
amo/nt o+ antimicro-ial sol/tion to care+/lly irri*ate eriodontal ockets.
7Co/rtesy o+ Hydro Floss, Inc., 1irmin*,am, A., ='>&&.8
Fi*/re :=-> 5wo -ic/sid crowns will -e laced on t,e imlants once t,e -one
wo/nd ,as ,ealed. At t,at time t,ey will ser"e t,e same +/nctions as nat/ral
teet,. 7Dr. Donald 4illmann, Uni"ersity o+ 5e0as Dental Sc,ool at San Antonio,
5G.8
Question 2
A. A case o+ *in*i"itis can -e c/red 7c/red h *in*i"al tiss/es ret/rned to ori*nal
,istolo*y8.
1. A case o+ eriodontitis can -e c/red. 7c/red h *in*i"al tiss/es ret/rned to ori*inal
,istolo*y8.
C. 5,e mec,anical art o+ sel+-care consists o+ /se o+ a toot,-r/s,, +loss, and an
irri*ator 7F-r/s,, +loss, and +l/s,F8.
D. Mo/t,rinses are e++ecti"e in t,e irri*ation o+ dee ockets to treat eriodontitis.
3. An imlant -etween two teet, re?/ires a-/ttment teet, +or s/ort.
Epidemiology and Risk Assessment
)eriodontal Disease Indicators
5wo o-Aecti"es ,a"e -een esta-lis,ed +or t,is c,ater9 7:8 5o ro"ide some 4asic
facts a-o/t *in*i"itis and eriodontitis, ,i*,li*,tin* t,e role o+ re"enti"e
dentistryw,ic, ,as -een done, and 7>8 to now e0lain ,ow some evidence--ased
tests
e
and indices can -e /sed to assess risk, se"erity, and re"alence o+ t,e
eriodontal diseases. Some o+ t,ese indicators were de"eloed to screen populations
to determine t,e prevalence and severity o+ eriodontal conditions, w,ile ot,ers were
de"eloed to e"al/ate t,e eriodontal health of individuals in a private practice,
Ot,ers ser"e -ot, /roses, -/t no sin$le index is appropriate for all types of studies,
5,ose tests and indices /sed to e"al/ate t,e "ario/s sta*es o+ *in*i"itis and
eriodontitis /s/ally incl/de one or more o+ t,e +ollowin*9 7:8 ocket det,D 7>8
amo/nt and location o+ dental la?/eD 7=8 e0tent o+ *in*i"al in+lammationD 7&8
calc/l/s deositsD 7'8 -acterial identi+icationD 7<8 e"idence o+ eit,elial attac,ment
lossD and 7%8 smokin* ,a-its.
5,e -leedin* inde0 is a most ositi"e indicator o+ existin$ $in$ivitis, w,ile a smokin*
,istory is ro-a-ly t,e most relia-le predictor o+ eriodontal disease.
e
3"idence-de"eloed indicator h a si*n or test t,at ,as a scienti+ic -ack*ro/d linkin*
t,e indicator to t,e disease.
Measuring Dental Plaque
OC.earyCs )la?/e !ecord 7Inde08
5,e relations,i -etween la?/e and *in*i"itis was +irst esta-lis,ed -y .oe et al. in
:;<'.
':
Se"en years later, OC.eary de"eloed one o+ t,e +irst /se+/l and widely /sed
indices to identi+y t,e location and e0tent o+ la?/e. OC.earyCs inde0 is /se+/l +or
monitorin* atientsC la?/e control er+ormance, is easy to accomlis,, is economical,
and is rerod/ci-le.
'>
Only a mo/t, mirror and e0lorer are necessary. 5,e comleted
c,art indicates t,e locations w,ere la?/e acc/m/lates and w,ere imro"ed -r/s,in*
and +lossin* tec,ni?/es are re?/ired.
5,e stes +or man/ally recordin* and interretin* t,e OC.eary Inde0 are as +ollows.
:. 5,e smoot, s/r+aces o+ t,e teet, in t,e mo/t, are di"ided at t,e anatomic line
an*les into +o/r sectionsmesial, -/ccal, distal, and lin*/al 7Fi*/re :=-=8.
>. All missin* teet, are crossed o/t, and t,e total n/m-er o+ remainin* teet, are
determined. For la?/e control /roses, t,e ontic7s8 o+ a +i0ed -rid*e and imlants
s,o/ld -e scored in a manner similar to t,at o+ nat/ral teet,.
=. 5,e atient is +irst asked to rinse "i*oro/sly wit, water to dislod*e any loose +ood
de-ris.
&. 5,e la?/e is t,en disclosed -y alyin* a disclosin$ solution to all teet,, makin*
s/re t,at t,e dento*in*i"al A/nction is co"ered wit, t,e a*ent. As an alternati"e, a
disclosin* ta4let can -e c,ewed and t,e colored sali"a swis,ed aro/nd t,e mo/t,.
'. 5,e mo/t, is a*ain rinsed "i*oro/sly wit, water. 5,e oerator t,en /ses t,e
e0lorer or ti o+ a eriodontal ro-e to con+irm t,e resence o+ disclosed
acc/m/lations o+ la?/e at t,e dento*in*i"al A/nction. I+ t,e la?/e on a toot, s/r+ace
is in contact wit, t,e *in*i"al mar*in or aillae, t,e entire toot, s/r+ace sace is
+illed in wit, a red encil to increase "isi-ility and to en,ance t,e +ormCs imact on
t,e atient. Areas ,a"in* stained ellicle alone s,o/ld not -e scored as ,a"in* la?/e.
5,e total n/m-er o+ scored toot, s/r+aces is t,en co/ntedD t,e s/m is t,en di"ided -y
t,e n/m-er o+ a"aila-le teet, 7incl/din* ontics and imlants8, and m/ltilied -y :$$
in order to esta-lis, t,e la?/e score as a ercenta*e. 5,is -aseline la?/e score
s,o/ld -e comared wit, +/t/re recall scores to o-Aecti"ely monitor a atientCs
ro*ress.
OC.eary and collea*/es
'>
,a"e stated t,at a s/ita-le *oal in teac,in* ersonal sel+-care
is to red/ce t,e la?/e inde0 to C:; or less, It is s/**ested t,at no eriodontal
s/r*ery or +i0ed rost,eses s,o/ld -e started /ntil t,is *oal ,as -een reac,ed. I+
s/r*ical or rost,etic inter"ention is not contemlated, an initial red/ction to :'E is
ro-a-ly more realistic +or most indi"id/als.
Se"eral record +orms are a"aila-le t,at are modi+ications o+ OC.earyCs ori*inal
resentation 7Aendi0 >=-:8. 4it, t,e introd/ction o+ t,e c,airside com/ter
recordin* o+ dental e0aminations, t,ese com/ter *enerated la?/e inde0 records will
e"ent/ally -ecome art o+ t,e FaerlessF dental o++ice.
5,e )la?/e Inde0 o+ Silness and .oe
5,e la?/e inde0 o+ Silness and .oe ro"ides a modication o+ OC.earyCs inde0. It too
is "is/al and re?/ired only a mo/t, mirror. A de+iciciency o+ t,e OC.eary inde0 is t,at
it re?/ires t,at t,e s/r+aces o+ e"ery toot, -e e0amined +or la?/e -/t t,at t,ere was
no *radations -etween a *reat amo/nt o+ la?/e and no la?/e.
5,e inde0 o+ Silness and .oe also re?/ires t,at t,e +o/r s/r+aces o+ desi*nated teet,
-e "is/ally e0amined and a score recorded, "i@., t,e ma0illary ri*,t +irst molar,
ma0illary ri*,t lateral incisor, and t,e le+t +irst -ic/sidD t,e t,e mandi-le, t,e
mandi-/lar le+t +irst molar, t,e le+t lateral incisor and t,e ri*,t +irst -ic/sida total
o+ si0 teet,. For eac, o+ t,e s/r+aces o+ t,ese teet, a score o+ $ to = is *i"en t,at
matc,es t,e se"erity o+ t,e listin*s in 5a-le :=-:. In t,is way, t,e a"era*e amo/nt o+
la?/e +or eac, toot, can -e determine -y di"idin* -y &D t,e scores +or all si0 teet, -e
di"ided -y < to *et t,e a"era*e +or t,e mo/t,. 5,e ,i*,est scores can -e e0ected to
occ/r on t,e interro0imal s/r+aces.
5,e inde0 ,as t,e ad"anta*e o+ ro"idin* more data on t,e sel+-care ,a-its o+ t,e
atient, as well as takin* less time to e"al/ate t,an to record entire dentitionsa +act
t,at is imortant in lar*e-scale eidemiolo*y st/dies. 5,e data +rom t,e Silness and
.oe inde0 can also -e /sed to comare wit, ot,er inde0es, +or instance to e"al/ate t,e
amo/nt o+ la?/e a*ainst t,e *in*i"al -leedin* inde0 o+ .oe and Silness 7descri-ed
later8 t,ro/*,o/t t,e mont,s o+ re*nancy.
'=
Oral-Hy*iene Inde0 and Simli+ied Oral-Hy*iene Inde0
One o+ t,e most o/lar indicators +or determinin* oral ,y*iene stat/s in
eidemiolo*y st/dies is t,e Oral Hy*iene Inde0 7OHI8. It was de"eloed in :;<$ -y
Greene and 6ermillion
'&
and modi+ied & years later as t,e OHI-S.
''
5,e simli+ied 7S8
"ersion ro"ides m/c, t,e same in+ormation, as did t,e earlier "ersion, -/t can -e
accomlis,ed m/c, more raidly. It is "ery /se+/l +or lar*e-scale eidemiolo*y
s/r"eys -/t is not *enerally -elie"ed to -e sensiti"e eno/*, to acc/rately e"al/ate t,e
oral ,y*iene stat/s o+ an indi"id/al atient. 5,e OHI ,as two comonents9 t,e oral
de-ris score and t,e calc/l/s score. 5,e term oral de-ris incl/des Fla?/e, materia
al-a, and +ood remnants.F 4it, t,e OHI-S, so+t and ,ard deosits are e"al/ated only
on t,e +acial or lin*/al s/r+aces o+ si0 selected teet,. 5,ey are t,e 4uccal s/r+aces o+
t,e /er first molars of 4oth sides, t,e la4ial s/r+aces o+ t,e upper ri$ht and lo3er
left central incisors, and t,e lin$ual surfaces of 4oth lo3er first molars, 5,e criteria
+or t,e OHI-S scores are s,own in 5a-le :=->. 5,e total OHI-S score can -e di"ided
-y t,e n/m-er o+ s/r+aces e0amined to calc/late t,e a"era*e oral ,y*iene score.
Gin*i"al 1leedin* Inde0 o+ .oe and Silness
One o+ t,e most commonly /sed inde0es to determine t,e re"alence and se"erity o+
*in*i"al in+lammation is t,e Gin*i"al Inde0 o+ .oe and Silness.
'<
4it, t,e .oe and
Silness inde0 it is ossi-le -y its codin* +rom $ to = to record -leedin* tendencies,
color and conto/r c,an*es o+ t,e *in*i"al, alterations in t,e consistency o+ tiss/e and
t,e resence o+ /lcerations 75a-le :=-=8.
.ike t,e Silness and .oe la?/e inde0, only si0 teet, are selected. Data can -e
com/ted +or indi"id/al teet,, or +or all t,e si0. 5,e e"al/ation, codin*, and recordin*
are ?/ite raid and /se+/l in lar*er-scale eidemiolo*y st/dies.
As a art o+ a +/ll-scale eriodontal e0amination o+ a atient, it is desira-le to
determine *in*i"al -leedin* -y ro-in* o+ t,e mar*inal *in*i"a. 5,is roced/re must
-e care+/lly controlled to a"oid false positives and iatro$enic dama$e to the
periodontium,
>F
/n the test for $in$ival 4leedin$, the pro4e should 4e run alon$ the
soft tissue 3all at the orifice of the periodontal sulcus or periodontal poc*et, )ro-in*
at t,e -ottom o+ t,e ocket is a poor indicator,
';
5,e -asic o-Aecti"e o+ a -leedin*
inde0 is not to determine t,e s/lc/s
+
det,, not to e"al/ate t,e e0tent o+ loss o+ t,e
eit,elial attac,ment, not to determine -one loss, -/t only to e"al/ate w,et,er t,ere
is, or is not, *in*i"al -leedin*. 4,en all teet, are incl/ded, t,e data can -e /sed as an
eidemiolo*y instr/ment or +or a atientCs clinical record.
+
S/lc/s and cre"ice are o+ten /sed interc,an*ea-ly. For e0amle, *in*i"al s/lc/s and
*in*i"al cre"ice.
Fi*/re :=-= 5,e c,art /sed +or OC.earyCs )la?/e Inde0.
Question 3
A. 5wo dental la?/e indices are t,ose o+ OC.eary and Silness and .oe.
1. A la?/e score o+ :$E +or t,e OC.eary la?/e inde0 is considered mar*inally
satis+actory.
C. Gin*i"al -leedin* w,en t,ere is no loss o+ eit,elial attac,ment is a ositi"e si*n
o+ *in*i"itis.
D. 5,e .oe-Silness inde0 is oriented towards monitorin* *in*i"al ,ealt,.
3. 1leedin* d/rin* toot,-r/s,in* 7Fink toot,-r/s,F8 can only -e dia*nosed -y a
dentist as a *in*i"itis.
Periodontal Probes
As ill/strated in Fi*/re :=-&, t,ere are se"eral "ariations o+ eriodontal ro-es. 3ac,
,as circ/m+erential markin*s on t,e ro-in* ti to aid in determinin* s/lc/lar det,D
ot,ers also ,a"e color-codin* to +/rt,er +acilitate acc/rate meas/rements. 5,e ro-e is
/sed +or +o/r main /roses9 7:8 t,e meas/rement o+ poc*et depth, 7>8 t,e
meas/rement o+ eit,elial attachment loss, 7=8 induction o+ *in*i"al andBor aillary
-leedin*, and 7&8 t,e detection o+ su4$in$ival calculus as art o+ t,e eriodontal
e0amination. 5,e ro-e may -e o+ metal, or o+ a ,ard olymer.
<$
5,e ro-in* ti is
aro0imately $.' millimeter in diameter. Its tactile reproduci4ility and accuracy
deends m/c, /on t,e e0erience o+ t,e oerator.
5,ere is always a need +or ca/tion in ro-in*, esecially in t,e resence o+
in+lammation. )ro-in* in+lamed *in*i"al tiss/e sites wit, its +ra*ile caillaries risks
ind/cin* a 4acteremia, For indi"id/als at risk o+ in+ecti"e endocarditis, -ot, a clinical
and radio*ra,ic assessment is indicated rior to a decision to ro-e. )ro,ylactic
anti-iotic co"era*e may -e indicated.
<>
7See Fi*/re :=-'.8
A new era o+ eriodontal ro-in* was /s,ered in -y t,e co/lin* o+ t,e com/ter and
t,e constant +orce electronic ro-es 7Fi*/re :=-<8.
*
One e0amle o+ t,e electronic
ro-e is t,e Florida ro-e,
e
w,ic, ,as -een ro/tinely /sed since :;'' in t,e
Uni"ersity o+ FloridaCs Disease !esearc, Center.
<=,<&
In one well-controlled st/dy, t,e
Florida ro-e was s,own to -e e0tremely acc/rate and rerod/ci-le. 5,e minim/m
ro-in* error was +o/nd to -e aro/nd :,< millimeter,
<',<<
In contrast, t,e resol/tion o+
t,e standard man/al ro-e is C millimeter, 4,en /sin* a constant-+orce ro-e, as soon
as t,e resistance at t,e -ottom o+ t,e s/lc/s reac,es a reset le"el s/c, as :' to >$
*rams, t,e det, o+ t,e s/lc/s is automatically entered into t,e com/ter record +orm
7Aendi0 :=->8. 7For comarison, a +orce o+ >' *rams is A/st -elow t,e t,res,old o+
ain w,en a ro-e is inserted /nder t,e +in*ernailD 7see Fi*/re :=-%8.
Anot,er electronic ro-e is t,e 5oronto ro-e t,at /ses air ress/re to e0tend and
retract t,e meas/rin* tiD t,is action ,els control t,e ro-in* +orce. An Ala-ama
ro-e a/tomatically detects t,e cementoenamel A/nction and meas/res t,e clinical
attac,ment le"els to t,e -ottom o+ t,e ocket wit,in a $.> millimeters tolerance
le"el.
<%
1eca/se o+ t,e acc/racy o+ t,e electronic ro-es, t,e time needed to identi+y
eriodontal disease acti"ity 7attac,ment loss8 -etween recall inter"als can -e
s,ortened. )rinto/ts can -e made t,at ermit comarisons -etween di++erent
e0aminations. As can -e noted in Aendi0 :=->, t,e same com/ter so+tware can -e
/sed to record t,e main eriodontal disease indicatorsocket det,, *in*i"al
recession, la?/e, -leedin*, and toot, mo-ility. 5,is is accomlis,ed artially -y
/sin* red, yellow, and *reen or ot,er com/ter color desi*nations +or t,e "ario/s
entries.
A /ni?/e con"enience is t,at as ocket and -leedin* sites are seen on t,e monitor and
entered in t,e record, t,e in+ormation can -e called o/t in a com/ter-*enerated male
or +emale "oicenot t,at o+ t,e dentist. Additional color-coded coies o+ t,e
comleted atientCs record can -e rinted o/t +or atient records and atient
in+ormation, as well as +or ins/rance +ilin*.
e
3"idence-de"eloed indicator h a si*n or test t,at ,as a scienti+ic -ack*ro/d linkin*
t,e indicator to t,e disease.
*
A"aila-le +rom Com/teri@ed )ro-e, Inc., Florida )ro-e Com/teri@ed Systems,
Okla,oma City, O2.
Fi*/re :=-& Di++erent tyes o+ cali-rated eriodontal ro-es /se+/l in assessin*
t,e det, and con+i*/ration o+ eriodontal ockets.
Fi*/re :=-' Dia*ram o+ 4HO eriodontal ro-e. It ,as a -all-ti end to a"oid
+alse assessment -y o"er-meas/rement and +or easier detection o+ s/-*in*i"al
calc/l/s. 5,e color-coded art +rom =.' to '.' mm *reatly +acilitates raid
assessment o+ eriodontal ocket det,. 7From 4HO 5ec,nical !eort Series
<>:, :;%(.8
Fi*/re :=-< 5,e Florida )ro-e. Note t,e slim -arrel and t,e ease wit, w,ic, it
+its wit,in t,e ,and. 5,e tis are remo"a-le and sterili@a-le. 7Co/rtesy Florida
)ro-e Cororation, Gaines"ille, F..8
Fi*/re :=-% )ractical test +or esta-lis,in* >$ to >' * eriodontal ro-in*
ress/re. 5,e eriodontal ro-e is laced /nderneat, t,e +in*ernail w,ere t,e
sensiti"ity aro0imates t,at o+ t,e -ottom o+ a eriodontal ocket. 5,e correct
amo/nt o+ +orce s,o/ld not ca/se ain to t,e atient on ro-in*. 7Dr. Arden
C,risten, Indiana Uni"ersity Sc,ool o+ Dentistry, Indianaolis, IN.8
Periodontal Probing
As re"io/sly mentioned, two o+ t,e main /roses o+ eriodontal ro-in* are to
determine poc*et depth, and to meas/re t,e amo/nt o+ attachment loss, 1ot, ,a"e one
re?/irement in common, namely a care+/l ste--y-ste circ/m+erential ro-in*
aro/nd eac, toot,.
<(
5o determine ocket det,D t,e ro-e is inserted into t,e mesial
ro0imal s/lc/s. It is ali*ned as "ertically as ossi-le, -/t wit, a sli*,t an*le away
+rom t,e midoint o+ t,e toot, -/cco-lin*/ally -eca/se o+ t,e contact oint. 4it,o/t
-ein* wit,drawn, t,e ro-e is t,en FwalkedF alon* t,e +acial s/r+ace o+ t,e cre"ice
/ntil t,e distal ro0imal contact area is reac,ed. 5,e ro-e is t,en wit,drawn and
reinserted +rom t,e lin*/al s/r+ace and FwalkedF -ack to t,e ro0imal s/r+ace. As t,e
ro-in* roceeds, a record is made o+ t,e distance +rom t,e deeest site o+ t,e ocket
to t,e crest o+ t,e +ree *in*i"al mar*in on eac, o+ t,e +o/r s/r+aces. A more detailed
second ro-in* mi*,t -e indicated w,ere t,e initial s/lc/lar det, ,as -een +o/nd to
-e o+ concern.
<;
Ot,er atterns o+ ro-in* are acceta-le. 5,e main o-Aecti"e is to
incl/de all s/r+aces and all ro-lem areas. )ro-in* det, can -e in+l/enced -y "ario/s
+actors, s/c, as t,e tye o+ ro-e, an*/lation o+ t,e ro-e to t,e toot,, ress/re /sed
in ro-in*, and in+lammation o+ t,e +ree *in*i"al mar*inall create ossi-ilities +or
error in meas/rin* ocket det, or attac,ment loss. In +act, t,e ro-in* det, seldom
corresonds to t,e e0act microscoic 7,istolo*ic8 det, o+ a normal s/lc/s or ocket
det,. Howe"er, t,e clinical ocket det, does re+lect t,e relati"e le"el o+ t,e act/al
ocket det,. It does ro"ide t,e clinician wit, a /se+/l reproduci4le estimate o+ t,e
location o+ t,e most coronal insertion o+ t,e +i-ers o+ t,e eriodontal li*ament
-etween t,e al"eolar -one and t,e cement/m. 7See Fi*/re :=-(.8
5,e meas/rement o+ epithelial attachment loss in"ol"es t,e same +ormat o+ ro-in* as
+or determinin* poc*et depth, 5,e main difference is t,e reference point from 3hich
t,e meas/rement is recorded. For ocket det,, it is +rom t,e det, o+ t,e ocket to
the crest o+ t,e +ree mar*inal *in*i"a. For calc/latin* attac,ment loss, t,e
meas/rement is made +rom t,e det, o+ t,e ocket on eac, s/r+ace to a fixed site,
s/c, as t,e cementoenamel A/nction or occl/sal lane.
%$
5wo meas/rements
separated in time -/t at t,e same site are necessary to estimate t,e amo/nt o+ aical
mi*ration 7i+ any8 o+ t,e eit,elial attac,ment. Sites t,at s,ow a >-millimeter loss o+
attac,ment -etween two se?/ential recall e0aminations s,o/ld -e considered as
acti"e.
5,e di"idin* line -etween *in*i"itis and eriodontitis in a ractice is o-Aecti"e and
rerod/ci-le. It is -ased on t,e consistent +indin* t,at a normal *in*i"al s/lc/s det,
is aro0imately = millimeters in det,. I+ a ro-in* det, o+ t,ree millimeters is
enco/ntered wit, no -leedin* and no loss o+ eit,elial attac,ment, t,e eriodonti/m is
considered in *ood ,ealt,. A ro-in* det, o+ & to < millimeters is considered in t,e
*ray area -etween eriodontal ,ealt, and disease.
%:
I+ -leedin* is enco/ntered, t,e
ro-lem may -e either *in*i"itis or eriodontitis, deendin* on t,e e0aminerCs
e"al/ation o+ eit,elial attac,ment loss. 4,en a atient is in t,is *ray @one, +re?/ent
monitorin* and scr//lo/s oral ,y*iene is re?/ired. On t,e ot,er ,and, a loss o+
*reater t,an < millimeters /s/ally constit/tes an ad"anced eriodontitis.
%:
A atient
wit, a ocket det, meas/rements o+ < to ; millimeters can /s/ally e0ect s/r*ical
treatment, care+/l monitorin* and a li+etime necessity o+ ma0im/m sel+-care. In
e0treme cases, ocket det,s o+ / to :> millimeters ,a"e -een recorded -e+ore a
toot, ,as -een e0+oliated or e0tracted. As t,e ro-in* det, increases -eyond =
millimeters, professional 7ud$ment -ecomes an increasin*ly maAor +actor in
determinin* w,et,er re"enti"e meas/res alone, or w,et,er a com-ination o+
nonin"asi"e re"enti"e and in"asi"e treatment strate*ies are necessary.
Gin*i"al !ecession
At t,is oint, t,e term $in$ival recession s,o/ld -e introd/ced. As t,e attac,ment loss
contin/es, t,e +ree *in*i"al mar*in may recede aically alon* wit, t,e eit,elial
attac,ment as well as t,e /nderlyin* al"eolar -one. In s/c, a case, t,e ocket det,
may -e near normal 7as meas/red +rom t,e crest o+ t,e +ree *in*i"al mar*in8, w,ile
t,e attac,ment loss increases 7as meas/red +rom t,e cementoenamel A/nction8.
4it, a recedin* +ree mar*inal *in*i"a, t,ere is a loss o+ s/ortin* al"eolar -one.
5,ere is also a loss o+ t,e "ertical ,ei*,t o+ t,e attached *in*i"a. For e"ery millimeter
o+ attac,ment loss, t,ere is a corresondin* loss o+ attac,ed *in*i"a. I+ +or instance, it
is ass/med t,at t,ere were :> millimeters o+ attac,ed *in*i"a
,
at t,e time o+
eriodontal normalcy, -/t a+ter >$ years, t,e attac,ment loss is < millimeters, t,en
t,ere is only aro0imately < millimeters o+ attac,ed *in*i"a 7ori*inal :> mm min/s
< mm eit,elial attac,ment loss h < mm resent attac,ed *in*i"a8.
,
5,e attac,ed *in*i"a is attac,ed to t,e side o+ t,e al"eol/s, and e0tends +rom t,e
-ase o+ t,e mar*inal *in*i"al to t,e m/co-/ccal +old.
Fi*/re :=-( 30amles o+ ro-in*. A. S,allow s/lc/s on lin*/al sideD B. deeer
s/lc/s 7ocket8 on -/cal s/r+ace. 7Dr. Arden C,risten, Indiana Uni"ersity Sc,ool
o+ Dentistry, Indianaolis, IN.8
Question 4
A. I+ one is ro-in* an in+ected area 7meanin*, eriodontal ocket8 and er+orates a
+ew caillaries, it can set o++ a -acteremia w,ic, can -e dan*ero/s to a cardio"asc/lar
atient.
1. 5,e raidity o+ aical mi*ration o+ t,e eit,elial attac,ment can only -e
determined -y meas/rements made at two aroriately searated times.
C. 5,e com/ter linked eriodontal ro-e is rerod/ci-le in relicate ocket det,
meas/rements wit,in a ran*e o+ : millimeterD w,ereas, t,e man/al ro-e ,as an e?/al
or -etter record o+ rerod/ci-ility +or ocket det, meas/rements.
D. 5,e ro-in* +or ocket det, is t,e same as +or ro-in* +or eit,elial attac,ment
lossD t,e only di++erence is t,e re+erence oint +rom w,ic, meas/rements are made.
3. 5,ere is an in"erse relations,i -etween t,e det, o+ a eriodontal ocket and t,e
"ertical ,ei*,t o+ t,e attac,ed *in*i"al, i.e., t,e deeer t,e ocket, t,e lessenin* o+ t,e
,ei*,t o+ t,e attac,ed *in*i"a.
Comm/nity )eriodontal Inde0 o+ 5reatment Needs 7C)I5N8
5,e re"io/s la?/e, oral de-ris and -leedin* indices were eidemiolo*ical
instr/ments t,at co/ld -e visually accomlis,ed +or e"ents occ/rrin* a4ove t,e
*in*i"al mar*in. 5,e ne0t two widely /sed eidemiolo*y indices, t,e Comm/nity
)eriodontal Inde0 o+ 5reatment Needs 7C)I5N8 and t,e )eriodontal !ecordin*
System 7)S!8 re?/ire ro-in* to e"al/ate t,e eriodontal ,ealt, 7or ot,erwise8 t,at
occ/rs -elow t,e *in*i"al mar*in.
5,e Federation Dentaire Internationale 7FDI8 in colla-oration wit, t,e Oral Healt,
Unit o+ t,e 4orld Healt, Or*ani@ation 74HO8 de"eloed t,e Comm/nity )eriodontal
Inde0 o+ 5reatment Needs 7C)I5N8
%>
to attain more /ni+orm worldwide eidemiolo*y
data. In t,is screenin* inde0, t,e eriodontal treatment needs are recorded +or si0
se*ments 7se0tants8. 5,e se*ments are t,e anterior and two osterior sets o+ ma0illary
and mandi-/lar teet,. 5,e system e0cl/des t,e t,ird molars, e0cet w,ere t,e t,ird
molars are +/nctionin* in t,e lace o+ t,e second molars. A se0tant m/st ,a"e at least
two +/nctional teet,. 5,e hi$hest 7worst8 o+ t,e coded conditions in 5a-le :=-& is
recorded +or each sextant,
A secial color-coded -lack -anded ro-e +rom =.' to '.' mm and circ/lar rin*s at (.'
and ::.' +acilitates /ni+ormity o+ scores in t,e world-wide accomlis,ment o+ t,e
C)I5N.
%>
I+ t,e -lack -and cannot -e seen a-o"e t,e mar*inal *in*i"al +ollowin*
insertion, a code & is recorded. Ot,er ossi-ilities wit, lesser eriodontal in"ol"ement
are code = i+ t,e mar*inal *in*i"al +alls wit,in t,e ran*e o+ t,e -lack -and, code > i+
t,ere is s/ra- or s/-*in*i"al calc/l/s, code : i+ *in*i"al -leedin* on *entle ress/re,
and code $ i+ t,ere is no si*n o+ disease. 5,ere is no r/le seci+yin* t,e n/m-er o+
searate ro-in* to -e made.
%>
)eriodontal Screenin* and !ecordin* System 7)S!8
5,is system o+ screenin* was introd/ced -y t,e American Dental Association 7ADA8
i

and t,e American Academy o+ )eriodontolo*y in :;;>. It was de"eloed to
enco/ra*e dentists to screen indi"id/al atients :( years o+ a*e and older +or
/ndetected eriodontal disease. Only ' min/tes is needed to accomlis, t,e screenin*
7ro-in*8. 5,e same ro-e and t,e same scorin* o+ $ to & -asis is /sed as wit, t,e
C)I5N. 5,e ,i*,est recordin* o+ F&F indicates a ro-in* det, o+ o"er '.' millimeters
+or at least one tooth in t,e se0tant. A wei*,t +orce o+ no more t,an >$ to >' * is
considered s/++icient to detect at,olo*y wit,o/t ca/sin* ain 7see Fi*/re :=-'8. 5,e
ma7or difference -etween t,e C)I5N and t,e )S! is t,at wit, t,e latter, a $uideline
for treatment is s/**ested to matc, t,e le"el o+ treatment needs wit, t,e le"el o+
disease se"erity 7Aendi0 :=-= and Aendi0 :=-&8.
i
Additional in+ormation can -e sec/red +rom ,tt9BBwww.
ada.or*Bro+BracBiss/esB/-sBsrB.
Identi+ication o+ )eriodontoat,o*ens -y DNA Analysis
5,e DNA analysis, 7sometimes called Fro-e analysisF8 is an acc/rate dia*nostic
met,od +or identi+yin* -acteria.
%&-%<
It does not deend on t,e resence o+ li"in*
-acteria, and t,/s re?/ires no secial acka*in* -e+ore -ein* sent to t,e la-oratory.
5,e test is -ased on t,e +act t,at t,e two molec/lar strands o+ DNA o+ a -acteri/m are
always comlementary 7as in a ,/man8 and can -e searated. One sin*le control
strand o+ t,e DNA +rom an /nknown -acterial secies ta*en from the patient?s
s/-*in*i"al la?/e is matc,ed wit, a comlementary strand o+ t,e DNA -acteria
from a *no3n la4oratory culture, 5,e la-oratory strand is marked wit, a radioisotoe
so t,at it can -e ?/anitated i+ it com-ines wit, t,e atientCs DNA comlementary
strand, +or instance +rom ctino4acillus actinomycetemcomitans 7Aa8,
Porphyromonas $in$ivalis 7)*8, or Prevotella intermedia 7)i8. As t,e n/m-er o+
comlementary strand co/lin*s increase, t,e amo/nt o+ radioacti"ity also increases.
It is t,e total le"el o+ radioacti"ity detected t,at +orms t,e -asis o+ t,e +inal reort.
5,e American Dental Association ,as *ranted its Seal of cceptance to two DNA
assay systems, t,e DMD and t,e )at,otek )at,o*en Detection Systems. 5,e DMD
test meas/res individual levels of radioactivity +or Aa or )* or )i, wit, t,e res/lts
reorted as ne*ati"e, low, moderate, or ,i*, radioacti"ity +or each o+ t,e or*anisms.
A color-ill/strated reort *ra,ically ill/strates eriodontal risk le"els. 5,is reort can
-e /sed +or /roses o+ treatment, atient ed/cation and moti"ation. )at,otek detects
all three patho$ens and reorts on t,eir com-ined total le"el.
5,e DNA assay tests are simle to aly. 5,e site at t,e ori+ice o+ t,e *in*i"al cre"ice
to -e samled is cleaned o+ s/ra*in*i"al la?/e and a aer oint is *ently inserted
into t,e s/lc/s and remo"ed a+ter :$ seconds. It is t,en laced in a "ial t,at is mailed
to t,e la-oratory +or analysis. 5est res/lts are *enerally a"aila-le wit,in :$ days a+ter
mailin* or wit,in a +ew days i+ a tele,one reort is desired.
5,e Imm/ne Factor
Since t,e maAority o+ treatment +or eriodontitis centers aro/nd s/ressin* or
eliminatin* t,e -acterial c,allen*e o+ t,e la?/e or*anisms, it is nat/ral to -e*in to
look at t,e -odyCs ,/moral and cell/lar imm/ne system +or ,el.
%%,%(
Many "accines
,a"e -een de"eloed +or other diseasesD
%;
a model animal system ,as -een de"eloed
+or serio/s eriodontal disease "accine testin*D
($
one romisin* "accine st/dy is now
/nderway in 3n*land +or caries 7see C,ater >=8D
(:
and daily, t,e function of ne3
$enes is -ein* anno/nced 5,ere is no do/-t t,at t,e terminolo*y o+ recom-inant
tec,nolo*y, com-ination "accines, *enetically tailored "accines, and re+ormed
anti-odies are -/t a +ew new terms +or t,e dental le0icon o+ t,e +/t/re.
%;
5,e recent comletion o+ t,e Human 0enome Pro7ect wit, its decodin* o+
deso0yn/cleic acid, ,as set t,e sta*e +or a tremendo/s s/r*e o+ knowled*e a-o/t
c,romosomes, *enes, and anti-odies, and t,eir relation to disease and a-normalities.
3++orts are c/rrently directed towards identi+yin* markers ,el+/l in re"entin*,
dia*nosin*, redictin*, and c/rin* diseases. Dr/* comanies are st/dyin* anti-odies
to w,ic, dr/*s can -e co/led to de"elo er+ectly tar*eted Fma*ic -/llets.F Ot,ers
are workin* on ,i*, riority "accines to control diseases s/c, as dia-etes mellit/s
w,ere t,e s/ccess+/l de"eloment o+ s/c, a "accine wo/ld immediately ,a"e t,e
e++ect on red/cin* t,e *reat n/m-er o+ associated eriodontal cases.
A +ew e0amles o+ indi"id/al accomlis,ments can -e cited. 2ornman ,as ointed
o/t t,at t,e pro2inflammatory cyto*ine, interle/kin-: can -e /sed as a redictor +or
+/t/re se"ere eriodontitis.
(>,(=
Cyto*ines are rod/ced -y "ario/s cell tyes s/c, as
macropha$es, neutrophils, and fi4rocytes w,ic, wo/ld -e e0ected to -e t,e de+ense
and reair elements in t,e area7s8 o+ in+lammation.
(&
Anot,er st/dy +o/nd t,at a
latelet-acti"atin* +actor 7)AF8 ro*ressi"ely increased as t,e se"erity o+ eriodontitis
increased.
('
5,ere is researc, -ein* accomlis,ed tar*eted at ad,esins, wit, t,e ,oe
t,at anti2adhesin anti-odies will ne*ate t,e a-ility o+ a -acteri/m to ad,ere to a toot,
s/r+ace or to so+t tiss/e.
(<,(%
A dramatic clinical o/tcome relates to a <-year old *irl
dia*nosed wit, c,ronic, ro-a-ly con*enital ne/troenia, relete wit, rec/rrent oral
/lcerations and si*ni+icant eriodontal -reakdown resem-lin* re/-ertal
eriodontitis. Gran/locytic colony stim/latin* +actor 7G-CSF8 was administered,
res/ltin* in an increase in *ran/locyte co/nt. In two weeks, t,ere was a resol/tion o+
t,e ne/troenic-ind/ced /lceration.
((
Un+ort/nately, t,ere is yet no /ni+orm inte*ratin* t,eory +or t,e myriad o+ *enes
in"ol"ed in t,e maAority o+ diseases
(;
m/c, as t,e )eriodic 5a-le t,at made ossi-le
t,e a-ility to redict t,e roerties o+ elements t,at were not yet disco"ered.
Question 5
A. 5,e C)I5N is a eriodontal inde0 in w,ic, ocket meas/rements o+ all teet, in t,e
7si08 se0tants are recorded.
1. 5,e )S! s/**ests t,e le"el o+ treatment o+ care needed to matc, t,e se"erity o+ t,e
eriodontal +indin*s.
C. I+ one strand o+ a -acteri/mCs DNA +rom a atientCs mo/t, matc,es a
comlementary strand o+ a -acteri/m +rom a known la-oratory -acteri/m, it ro"ides
a ositi"e identity o+ t,e atientCs or*anism.
D. In+lammatory cytokines are released -y -ody de+ense cells s/c, as t,e
macro,a*e, ne/tro,il and +i-rocyte.
3. 5,e worldwide e++ort to s/ccess+/lly decode t,e deso0yn/cleic acid molec/le is
known as t,e H/man Genetic )roAect.
Crevicular Fluid Assessment
Gin*i"al Cre"ic/lar Fl/id Meas/rement and Analysis
5,e ,ysiolo*ic +low o+ *in*i"al cre"ic/lar +l/id ser"es 7:8 to +l/s, o/t meta-olic
cata-olites in t,e s/lc/s,
;$
and 7>8 t,is +l/id also contains rotecti"e elements o+ t,e
,ostCs ,/moral and cell/lar de+ense system t,at continually -at,es t,e +o/r smoot,
s/r+aces o+ t,e teet,. As *in*i"itis increases in se"erity, so does t,e +low o+ *in*i"al
cre"ic/lar +l/id/s/ally roortional to se"erity o+ t,e *in*i"itis,
;:
-/t not to t,e
se"erity o+ eridontitis. 5,/s, t,e meas/rement o+ t,e +low rate o+ cre"ic/lar +l/id ,as
-een roosed as a means o+ monitorin* t,e de*ree o+ *in*i"al in+lammation.
;>,;=

Ot,ers ,a"e roosed t,at t,e le"el o+ some o+ t,e c,emical constit/ents o+ sali"a
co/ld also -e /sed as markers o+ *in*i"al disease stat/s.
;&
5,e resence o+ *in*i"al cre"ic/lar +l/id 7GCF8 as a *in*i"itis indicator wo/ld ,a"e
n/mero/s ad"anta*es. 5,e knowled*e t,at eriodontal destr/ction ro*resses t,ro/*,
eriodic -/t unpredicta4le cycles o+ ac/te eisodes +ollowed -y eriods o+ ?/iescence
,as stim/lated in"esti*ation o+ t,e GCF comonents. 5,e res/lts +rom GCF analysis
may ro"ide in+ormation on t,e ,ostCs resonses to in+lammation and tiss/e
destr/ction d/rin* t,ese eisodes. 5,e +low o+ GCF is site-seci+ic, sometimes
a++ectin* only one indi"id/al toot,, or e"en one seci+ic site on t,at one seci+ic
toot,. Gin*i"al cre"ic/lar +l/id is a con"eniently samled trans/date t,at contains
comonents deri"ed +rom -ot, t,e ,ost tiss/es and t,e s/-*in*i"al la?/e.
;>
It is relati"ely simle to meas/re t,e rate o+ cre"ic/lar +low. Howe"er, t,e +l/id is
now mainly /sed as a researc, tool, wit, t,e ,oe o+ disco"erin* some marker t,at
si*nals eit,er acti"e or inacti"e stat/s. 5,e roced/re +or collectin* t,e GCF is as
+ollows.
:. A+ter t,e *in*i"a ,as -een isolated wit, cotton rolls, t,e tiss/e is dried wit, a *entle
stream o+ air +or ' seconds.
>. A aer stri is inserted into t,e s/lc/s +or ' seconds, remo"ed, and discarded.
=. A second stri is eit,er laced at t,e entrance to t,e *in*i"al s/lc/s7e0tras/lc/lar
met,od8 or inserted into t,e s/lc/s /ntil a +rictional -ind is enco/ntered 7intras/lc/lar
tec,ni?/e8. 75,e intras/lc/lar met,od can itsel+ irritate t,e cre"ic/lar eit,eli/m and
tri**er t,e +low o+ cre"ic/lar +l/id.8
&. 5,e stris are allowed to remain in lace +or ' seconds.
'. 5,e amo/nt o+ cre"ic/lar +l/id can -e ?/antitated -y lacin* t,e stris in a *in*i"al
+l/id meter meas/rin* de"ice called t,e )eriotron. 5,e e0tent o+ wetness o+ t,e aer
stri rod/ced -y t,e *in*i"al +l/id a++ects t,e +low o+ a c/rrent t,ro/*, a moist/re-
sensiti"e sensor. 5,e amo/nt o+ c/rrent +low is dislayed as a di*ital reado/t.
;:,;'
It is claimed t,at t,is met,od ro"ides an Fearly warnin* systemF +or t,e detection o+
*in*i"itis.
Smoking as a Major Risk Factor for Periodontal Disease
In t,e United States t,ere are an estimated '$ million smokers, and anot,er /nknown
n/m-er o+ indi"id/als e0osed to assi"e smoke.
;<
It is well reco*ni@ed t,at smokin*
is t,e ca/se o+ many systemic at,olo*ies, o+ w,ic, lun$ cancer, cardiac disease, and
stro*e are -est known and most +eared.
;%
Un+ort/nately, let,al to-acco
rod/ctsci*arette and /se o+ smokeless 7FsitF8 to-acco,a"e *one /nnoticed as
ca/sal a*ents +or disa-lin* and dis+i*/rin* oral and ,aryn*eal cancer.
;(
5,ere ,a"e
also -een many articles /-lis,ed o"er t,e ast +i"e decades ointin* o/t t,at to-acco
is a ca/sal a*ent +or periodontal disease, an oral disease t,at a++ects millions. 5,e
enormity o+ t,is relations,i is +o/nd in a statement t,at smo*in$ accounts for one2
half of all periodontal cases and three2fourths of oral cancer cases in t,e United
States.
;;
5,e role o+ smokeless 7FsitF8
A
to-acco on oral mor-idity and mortality ,as recei"ed
little media attention.
:$$,:$:
For instance, in ro"idin* a -alanced resentation on t,e
oral ,a@ards o+ smokin*, c,ewin* to-acco m/st also -e associated wit, an increased
risk o+ root caries as well as eriodontal disease.
:$>,:$=
Men w,o /sed c,ewin* to-acco
were +o/r times more likely t,an t,ose w,o ,ad ne"er /sed to-acco, to ,a"e one or
more decayed or +illed root s/r+aces.
It is now -e*innin* to emer*e t,at ro-a-ly one o+ t,e most imortant ?/estions t,at
can -e asked on t,e atientCs dental and medical ,istory +orm is, JDo you smo*e or
live 3ith someone 3ho smo*es, andLor do you use smo*eless to4accoPJ
Smokin* is a ,i*,-risk ,a-it and constit/tes a maAor eriodontal ro-lem.
:$$,:$&-:$%

Mir-od ,as ro"ided a litany o+ to-acco-associated lesions +o/nd in t,e
mo/t,s?/amo/s-cell carcinoma, *in*i"itis and eriodontitis, -/rns and keratosis
atc,es, -lack ,airy ton*/e, alate erosions, le/kolakia and eit,elial dyslasia, and
toot, stainin*.
:$(
All can -e "is/ally detected early w,en a**ressi"e treatment
rod/ces t,e -est res/lts.
5,e /se o+ to-acco rod/cts ,as an ad"erse e++ect o+ t,e onset, re"ention, ro*nosis,
treatment and maintenance ,ases o+ eriodontitis. )art o+ t,is ne*ati"e o/tlook is
-eca/se smokin* also ca/ses ad"erse c,an*es in t,e -odyCs imm/ne resonse system
t,at resent maAor -arriers to s/ccess+/l eriodontal treatment.
:$%,:$;
Smokin* is
associated wit, al"eolar -one loss, wit, eit,elial attac,ment loss, *in*i"al recession,
and wit, eriodontal ocket de"eloment.
:$&
In an e0tensi"e re"iew o+ t,e literat/re
Ha-er disc/sses many o+ ,is own st/dies and o-ser"ations to e0lain ,ow a atientCs
smokin* ,istory di++ers +rom a nonsmoker and its e++ect on eriodontal disease.
::$
For
e0amle9
5o-acco /sers are >.' to < times more likely to de"elo eriodontal disease t,an
nonsmokers.
:$;
A atientCs smokin* ,istory is a /se+/l clinical indicator o+ future eriodontal
disease acti"ity.
::$
5,ere are more c/rrent smokers w,o seek ro+essional eriodontal care t,an
nonsmokers.
:::,::>
5,ere aears to -e a relations,i -etween t,e num4er of ci$arettes smo*ed and t,e
risk o+ de"eloin* eriodontal diseases.
:$;,::=
As t,e n/m-er o+ ci*arettes smoked increases, so does t,e se"erity o+ t,e
eriodontal disease.
::$,:$'
More smokers t,an nonsmokers are classi+ied as ,a"in* se"ere ad/lt eriodontitis
and se"ere early-onset *enerali@ed eriodontitis.
::&
Almost C::; o+ =$- to &$-year-old ,ea"y smokers ,a"e eriodontitisD
::=
t,e
resonse o+ t,ese atients to t,eray is not as +a"ora-le as +or nonsmokers.
::',;(
Aro0imately (< to ;$E o+ re+ractory eriodontitis 7not resonsi"e to treatment8
atients are c/rrent smokers.
::=
5,ere is a stron* association -etween smokin* and al"eolar 4one and tooth loss,
::<-
::(,:$<
Smokin* is associated wit, ad"erse c,an*es in t,e -odyCs imm/ne system.
:$&
5,e $in$ival fi4ro4lastic repair function is altered, res/ltin* in a t,ickened +i-rotic
*in*i"a.
::$,::;
Followin* treatment, t,e imro"ements in ro-in* det,s and eit,elial attac,ments
are still more +a"ora-le +or t,e nonsmoker.
:>$,::'
5,ere is more ocketin* o+ t,e anterior se*ments o+ teet, +or smokers t,an
nonsmokers.
It is "ery di++ic/lt to ers/ade a atient to ?/it smokin* as art o+ t,e treatment lan.
A seminal article, -y 1ar-o/r and associates, +oc/ses on t,e de*raded imm/ne
resonse o+ smokers wit, eriodontitis w,en comared to nonsmokers. 5,ey con+irm
Ha-erCs o-ser"ation t,at t,ere is a neutrophilic deficiency, -/t in addition oint o/t
many ot,er +/nctions o+ t,e imm/ne system t,at are comromisedincl/din*
,a*ocytosis, c,emota0is, imm/ne s/ression, imm/ne s/r"eillance, and alterations
o+ imm/no*lo-/lin +/nction. 3ac, o+ t,e areas is well doc/mented and disc/ssed.
One o+ t,e considerations o+ t,e st/dy was to determine t,e e++ects o+ smokin* on
eriodontal disease, esecially ,ow it was related to ,ost de+ense mec,anisms.
:$;
An
intri*/in* ?/estion wo/ld -e, FIn "iew o+ t,e altered imm/ne resonse, is eriodonitis
a redictor o+ s/sceti-ility to ot,er smokin* diseases t,at ,a"e a later onseteF
A
Sit to-acco9 A desi*nation o+ a to-acco associated wit, t,is ,a-it.
Smokin* Cessation and !eco"ery
Smokin* cessation is an essential comonent +or t,e s/ccess+/l treatment o+
eriodontal diseaset,ere is little rationale +or treatin* eriodontitis wit,o/t
eliminatin* one o+ t,e maAor ca/ses o+ t,e disease.
::=
5,/s, t,ere is also t,e ?/estion
o+ w,et,er eriodontal s/r*ical treatment is indicated wit,o/t a commitment -y t,e
atient to ?/it smokin*.
::=
As wit, ot,er smokin* diseases, cessation is only t,e +irst
ste o+ a lon* ,ealin* rocess w,ere t,e smoker o+ten does not aroac, t,e lower
risk o+ t,e nonsmoker +or :$ to >$ years.
;%,;(
2rall and coworkers estimated t,at t,e
risk o+ toot, loss :> years a+ter smokin* cessation was red/ced -y >$E.
::(
Howe"er,
t,e +act t,at t,e rate o+ toot, loss o+ e0-smokers +alls -etween t,e data +or c/rrent
smokers and t,ose w,o ne"er smoked indicates t,at reco"ery is takin* lace.
::(
5,e
eriodontal stat/s and -one loss o+ e0-smokers also aears to -e intermediate
-etween c/rrent smokers and t,ose w,o ne"er smoked.
::$,::<,::%
Gin*i"al imro"ement is more raid +ollowin* smokin* cessation alt,o/*, a -it
?/i0otic. Us/ally a smokerCs *in*i"a ,as a *la@ed +i-rotic aearance wit, rolled
ed*es a+ter years o+ smokin*. #leedin$ is minimal on -r/s,in*. It is -elie"ed t,at t,is
is d/e to t,e local e++ect o+ t,e to-acco smoke ossi-ly s/ressin* t,e in+lammatory
reaction. 5,is local and direct e++ect o+ comonents in t,e ci*arette smoke are
-elie"ed to also acco/nt +or a *reater amo/nt o+ ocketin* t,at occ/rs in t,e anterior
teet,. Howe"er, a-o/t :$ to :> weeks a+ter ?/ittin* smokin*, t,ere is an increase in
-leedin*, ossi-ly ca/sed -y a reco"ery o+ t,e in+lammatory resonse. A-o/t a year
a+ter cessation, t,e +i-rotic, t,ickened anatomy o+ t,e *in*i"a -e*ins to ass/me a
more normal aearance and t,e eriodontitis aears to sta-ili@e. For t,e maAority o+
atients, attac,ment loss ceases or dramatically slows.
::$,::;
5,e resent met,ods +or re"ention and treatment o+ *in*i"itis and eriodontal
disease em,asi@e t,e need +or metic/lo/s day-to-day oral ,y*iene roced/res. 3"en
so t,ese re"enti"e actions are not intended to, nor are t,ey ade?/ate to contin/o/sly
relace a comromised ortion o+ t,e imm/ne system -ro/*,t on -y smokin*. 4,ere
smokin* occ/rs, t,e c,emical and man/al met,ods o+ la?/e control still ,el to
red/ce t,e -acterial c,allen*e. Howe"er, wit, ro/nd-t,e-clock imaired ,/moral and
cell/lar -ody de+enses, and wit, an imaired *in*i"al +i-ro-lastic reair caa-ility,
t,e entire de+ense and reco"ery rocess is Aeoardi@ed.
:>$,::'
5,ere is a need to ro"ide smokin* cessation co/nselin* ro*rams as an inte*ral art
o+ t,e eriodontal treatment lan. 5,e American Cancer Society, American Heart
Association, and American ./n* Association
k
sonsor many FNo Smokin*F classes
t,ro/*,o/t t,e nation to +acilitate smokin* cessation. For youthful smokers and
otential smokers, t,e em,asis s,o/ld -e on smo*in$ avoidance and refusal
tec,ni?/es. 5,is task can ro-a-ly -e -est accomlis,ed in t,e /-lic-sc,ool system
7see C,ater :;8.
5,e o/tcome o+ s/c, co/nselin* will ro-a-ly -e more s/ccess+/l i+ linked wit, a
disc/ssion o+ t,e *reat amo/nt o+ re"enta-le mor4idity and mortality ca/sed -y
acti"e and assi"e smokin* and t,e /se o+ smokeless to-acco. To teach dental
students to accet t,is co/nselin* resonsi-ility, t,e Uni"ersity o+ Indiana Dental
Sc,ool ,as esta-lis,ed an antismokin* c/rric/l/m ro*ram +or st/dent teac,in* and
atient ed/cation.
:>:
In addition t,ere is an Indiana Uni"ersity Nicotine Deendence
)ro*ram at t,e Uni"ersity Cancer Center t,at is oerated in conA/nction wit, t,e
medical sc,ool and se"eral area ,ositals.
:>>
k
5o identi+y t,e nearest location o+ no-smokin* classes in t,e United States, call :-
($$-.UNG-USA.
Question 6
A. An increasin* +low o+ Gin*i"al Cre"ic/lar Fl/id 7GFC8 is indicati"e o+ an
increasin* se"erity o+ *in*i"itis, -/t not o+ eridontitis.
1. I+ resent to-acco smokin* was to cease, aro0imately one-,al+ o+ t,e resent
need +or eriodontal care wo/ld also cease.
C. Smokin* o+ ci*arettes and /se o+ smokeless to-acco can act directly on t,e oral
tiss/es, as e0emli+ied -y t,e resence o+ oral and ,aryn*eal cancer.
D. 5,e smokin* ,istory o+ an indi"id/al can aid in redictin* t,e ossi-ility o+ +/t/re
onset, as well as t,e e"ent/al lon*-ran*e o/tcome o+ t,e treatment o+ eriodontal
disease.
3. Smokin* can -e t,e ca/se o+ t,e earlier de"eloment o+ eriodontitis, an increase
in its se"erity, and red/ction in t,e ro-a-ility o+ a s/ccess+/l treatment o/tcome.
Summary
5wo o+ t,e most imortant messa*es o+ t,e entire c,ater are9 7:8 at t,e +irst si*n o+
*in*i"al -leedin*, re*ardless o+ a*e, a dentist s,o/ld -e seen immediately +or
dia*nosis, treatment, ed/cation and monitorin*D and, 7>8 +or all atients w,o smoke, to
enco/ra*e and ,el +acilitate t,eir articiation in an anti-smokin* ro*ram.
Many indices are /sed to determine t,e re"alence and se"erity o+ *in*i"itis andBor
eriodontitis amon* a *i"en o/lation, or to determine t,e se"erity o+ *in*i"itis
andBor eriodontitis amon* indi"id/al atients. 5,e most commonly /sed markers are
a la?/e inde0, *in*i"al -leedin*, loss o+ eit,elial attac,ment and ocket det,.
4it, com/ter so+tware, data collection can -e easily e0tended to incl/de recession,
s//ration, +/rcation in"ol"ement, toot, mo-ility and ot,ers. 5,e most imortant
detail t,at delineates *in*i"itis +rom eriodontitis is t,e inte*rity o+ t,e eit,elial
attac,ment. As lon* as t,e ocket det, meas/rements aro0imate = millimeters
wit, no -leedin* and no recent loss o+ eit,elial attac,ment, t,e eriodonti/m can -e
considered in e0cellent ,ealt,. As t,e ocket ro-in* det,s -ecome *reater,
nonin"asi"e re"enti"e roced/res -ecome more di++ic/lt to aly w,ile in"asi"e
treatment -ecomes more +re?/ent and comle0. Man/al ro-es are /sed to determine
s/lc/s det,D ,owe"er, t,e constant-+orce electronic ro-es aear to -e more
acc/rate, rerod/ci-le and easier to /se in recordin* data. .a-oratory tests are o+ten
/sed to determine t,e microor*anisms o+ t,e s/-*in*i"al la?/e. Some ro*ress ,as
-een made, -/t t,e ca/se-and-e++ect o+ t,ese -acteria is not as well /nderstood as are
t,e cario*enic m/tans stretococci and lacto-acill/s. Imm/ne st/dies are ermittin*
t,e researc,ers to -etter /nderstand t,e dynamic interaction -etween t,e at,o*enic
or*anisms and t,e -ody de+enses. )ossi-ly one o+ t,e most imortant ,ar-in*ers o+
*in*i"itis and eriodontitis is ci*arette smokin* andBor /se o+ smokeless to-acco
rod/cts. Many st/dies ,a"e +o/nd t,at toot, loss +rom eriodontal disease is
associated wit, to-acco /se. In"esti*ators ,a"e reorted t,at c/rrent smokers ,a"e a
*reater re"alence o+ se"ere eriodontal ro-lems, as well as accomanyin*
-reakdowns o+ "ario/s comonents o+ t,e imm/ne system t,an do indi"id/als w,o
,a"e ne"er smoked. 4it, smokin*, t,e c,allen*e or*anisms are rarely con+ronted -y
a +/lly e++ecti"e imm/ne de+ense system.
:. A, 1, and Ccorrect.
Dincorrect. 5,e +irst two, cardiac disease and dia-etes are correctD most "iral
diseases is incorrect.
3incorrect. I+ t,ere is a slow aical mi*ration o+ t,e eit,elial attac,ment ast t,e
C3#, it is -y de+inition a eriodontitis. Once t,at dia*nosis is correctly made, it cannot
re"ert to a *in*i"itis.
>. A and Ccorrect.
1incorrect. Once eriodontitis is correctly dia*nosed, t,ere is no way to restore t,e
tiss/es to t,eir re"io/s ,istololo*yD ,owe"er, +/t/re ro*ress can -e controlled-/t
not c/red.
Dincorrect. Mo/t,rinses do not enetrate t,e s/-*in*i"al la?/e to t,e e0tent
necessary to kill or to remo"e t,e eriodontoat,o*ens.
3incorrect. An imlant is anc,ored in al"eolar -one. It is a +ree-standin* str/ct/re
t,at needs no s/ort.
=. A and Ccorrect.
1incorrect. An OC.eary Inde0 score o+ :$E is considered e0cellentnot mar*inal.
Dincorrect. 5,e .oe-Silness Inde0 is /sed to record *in*i"al -leedin*not la?/e.
3incorrect. 1leedin* can occ/r as a res/lt o+ eit,er *in*i"itis or a eriodontitis. It
re?/ires a di++erential dia*nosis to determine w,ic,.
&. A, 1, D, and 3correct.
Cincorrect. It s,o/ld -e "ice "ersa. 5,e com/ter linked eriodontal ro-e is
rerod/ci-le to wit,in $.> millimeterD t,e man/al ro-e to wit,in : millimeter.
'. 1, C, and Dcorrect.
Aincorrect. Only one toot,t,e toot, wit, t,e worst 7,i*,est8 $ to & score in eac,
se0tant is recorded.
3incorrect. 5,e title to t,e ro*ram was t,e H/man 0enome )roAect.
<. A, 1, C, D, and 3correct.
:. 5wo o/lar indices +or determinin* t,e location o+ la?/e on smoot, s/r+aces o+
t,e teet, are t,e iiiiiiiii Inde0 and t,e iiiiiiiii Inde0.
>. Greene and 6ermillion de"eloed t,e iiiiiiiii Inde0 and t,en tr/ncated it +or
con"enience in eidemiolo*y st/dies.
=. 5,e iiiiiiiii is an instr/ment to meas/re t,e +low o+ *in*i"al c/rric/lar +l/id.
&. Name t,ree de"ices /sed in sel+-care, o+ w,ic, one is a toot,-r/s,D t,e ot,er two
are iiiiiiiii and an iiiiiiiii.
'. 5,e e?/i"alent o+ eriodontitis aro/nd an imlant is called iiiiiiiii.
<. 5,e disease o+ t,e eriodonti/m t,at roceeds eriodontitis is iiiiiiiii.
%. 5,e de"ice /sed to determine ocket det, and eit,elial attac,ment loss is called a
iiiiiiiii.
(. For e"ery millimeter loss o+ eit,elial attac,ment, t,ere is a corresondin* loss o+
t,e same distance o+ t,e iiiiiiiii *in*i"a.
;. A ersonal ,a-it t,at acco/nts +or aro0imately one-,al+ o+ all t,e eriodontal
diseases in t,e United States is iiiiiiiii.
:$. 5,e sin*le delineatin* +actor 7-y de+inition8 t,at searates *in*i"itis +rom
eriodontitis is iiiiiiiii.
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:$$. 1er*strom, #., g 3liasson, S. 7:;(%8. No0io/s e++ect o+ ci*arette smokin* on
eriodontal ,ealt,. " Periodontol Res, >9':=-:%.
:$:. !o-ertson, ). 1., 4als,, M., Greene, #., et al. 7:;;$8. )eriodontal e++ects
associated wit, t,e /se o+ smokeless to-acco. " Periodontol, <:9&=(-&=.
:$>. 5omar, S. .., g 4inn, D. M. 7:;;;8. C,ewin* to-acco /se and dental caries
amon* U.S. men. "D, :=$9:<$:-:$.
:$=. !o-insom, ). 1., 4als,, M. M., Green, #. C. 7:;;%8. Oral 3++ects o+ smokeless
to-acco /se -y ro+essional -ase-all layers. dv Dent Res, ::9=$%-:>.
:$&. 1er*strom, #., g )re-er, H. 7:;;&8. 5o-acco /se as a risk +actor. " Clin
Periodontol, <'9><$-<%.
:$'. Ha-er, #., 4attles, #., Crowley, M., Mandell, !., #os,i/ra, 2., g 2ent, !. ..
7:;;=8. 3"idence o+ ci*arette smokin* as a maAor risk +actor +or eriodontis. "
Periodontol, <&9:<->=.
:$<. Holm, G. 7:;;&8. Smokin* as an additional risk +or toot, loss. " Periodontol,
<'9'&'-'$.
:$%. Iam-on, #. #., Grossi, S. G., Mac,teri, 3. 3., Ho, A. 4., D/n+ord, !., g Genco,
!. #. 7:;;<8. Ci*arette smokin* increases t,e risk o+ s/-*in*i"al in+ection wit,
eriodontal at,o*ens. " Periodontol, <%9:$'$-'&.
:$(. Mir-od, S. M., g A,in*, S. I. 7>$$$8. 5o-acco-associated lesions o+ t,e oral
ca"ity9 )art I. Nonmali*nant lesions. " Can Dent ssn, <<9>'>-<.
:$;. 1ar-o/r, S. 3., Nakas,ima, 2., I,an*, #. 1., 5an*ada, S., Ha,n, C. ..,
Sc,enkein, H. A. g 5ew, #. G. 7:;;%8. 5o-acco and smokin*9 3n"ironmental +actors
t,at modi+y t,e ,ost resonse 7imm/ne system8 and ,a"e an imact on eriodontal
,ealt,. Crit Rev +ral #iol %ed, (9&=%-<$.
::$. Ha-er, #. 7:;;&8. Ci*arette smokin*9 A maAor risk +actor +or eriodontitis. Comp
Cont !d Dent, :'9:$$>-:=.
:::. )re-er, H., g 1er*strom, #. 7:;(<8. Ci*arette smokin* in atients re+erred +or
eriodontal treatment. Scan " Dent Res, ;&9:$>-(.
::>. Ha-er, #., g 2ent, !. .. 7:;;>8. Ci*arette smokin* in a eriodontics ractice. "
Clin Periodontol, <=9:$$-<.
::=. MacFarlane, G. D., Her@-er*, M. C., g 4ol++, .. 7:;;>8. !e+ractory
eriodontitis associated wit, a-normal olymor,on/clear le/kocyte ,a*ocytosis
and ci*arette smokin*. " Periodontol, <(9;$(-:=.
::&. Sc,enkein, H. A., G/nsalley, #. C., 2oert*e, 5. 3., Sc,enkein, #. G., g 5ew, #. C.
7:;;'8. Smokin* and its e++ects on early-onset eriodontitis. "D, :><9:$$%-:=.
::'. A,, M. 2., #o,nson, G. 2., 2alda,l, 4. 1., )atil, 2. D., g 2alkwar+, 2. ..
7:;;&8. 5,e e++ect o+ smokin* on t,e resonse to eriodontal s/r*ery. " Clin
Periodontol, >:9;:-%.
::<. 1er*strom, #., 3liason, S., g )re-er, H. 7:;;:8. Ci*arette smokin* and
eriodontal -one loss. " Periodontol, <>9>&>-&<.
::%. 1olin, A., .a"stedt, S., Frit,io+, .., g Henrikson, C. ). 7:;(<8. )ro0imal al"eolar
-one loss in a lon*it/dinal radio*ra,ic in"esti*ation. I6. Smokin* and some ot,er
+actors in+l/encin* t,e ro*ress in indi"id/als wit, at least >$ remainin* teet,. cta
+dontol Scan, &&9><=-<;.
::(. 2rall, 3. A., Dawson-H/*,s, 1., Gar"ey, A. #., g Garcia, !. I. 7:;;%8. Smokin*,
smokin* cessation, and toot, loss. " Dent Res, %<9:<'=.
::;. )re-er, H., g 1er*strom, #. 7:;('8. Occ/rrence o+ *in*i"al -leedin* in smoker
and non-smoker atients. cta +dont Scand, &=9=:'->$.
:>$. )re-er, H., .inder, .., g 1er*strom, #. 7:;;'8. )eriodontol ,ealin* and
erioat,o*enic micro+lora in smokers and non-smokers. " Clin Periodontol, >>9;&<-
'>.
:>:. C,risten, A. G. 7>$$:8. 5o-acco cessation, t,e dental ro+ession, and t,e role o+
dental ed/cation. " Dent !duc, <'9=<(-%&.
:>>. C,risten, A. G. 7:;;;8. )ersonal comm/nication.
reser"ed.
Chapter 14. Sugar and Other Sweeteners - Peter !, Cleaton2"ones Connie %o4ley
Objectives
:. Name t,e t,ree s/*ars t,at are comosed o+ molec/les o+ *l/cose, +r/ctose, or
*alactose, all o+ w,ic, can rod/ce caries.
>. De+ine s/*ars, sweeteners, and s/*ar relacers.
=. Descri-e t,e otential imact o+ an e0cessi"e intake o+ added s/*ars on t,e ?/ality
o+ t,e ,/man diet.
&. .ist t,ree olyols t,at are sweeteners and cite t,eir ad"anta*es and disad"anta*es in
in+l/encin* caries incidence.
'. De+end t,e Food and Dr/* Administration 7FDA8 +or eit,er remo"in* or attemtin*
to remo"e sacc,arin and cyclamate +rom t,e marketlace.
<. Name a sweetener t,at ,as recently recei"ed FDA aro"al, and list t,ree more t,at
are candidates +or aro"al.
Introduction
5o most eole t,e term s/*ar re+ers to t,e common ,o/se,old +oodst/++ ta-le s/*ar
7s/crose8. Het s/crose is only one o+ many nat/rally occ/rrin* s/*ars /sed in t,e
,/man diet. 5ec,nically t,e term s/*ar alies to two classi+ications o+
car-o,ydrates. Free-+orm monosacc,arides 7simle s/*ars8 incl/de t,e more common
*l/cose, +r/ctose, and *alactose. Disacc,arides 7two simle s/*ar molec/les linked
to*et,er8 incl/de t,e most common s/crose, lactose, and maltose. Nat/rally occ/rrin*
s/*ars are a"aila-le in +r/its, "e*eta-les, *rains, and dairy +oods.
Sweeteners are added s/*ars t,at are /sed as in*redients to -ot, satis+y o/r taste and
in some cases ro"ide added ener*y. Gro/in* sweeteners as Fn/triti"eF or Fnon-
n/triti"eF acknowled*es a di++erence in t,e amo/nt o+ ener*y ro"ided -y t,e
sweetener. N/triti"e sweeteners may -e re+erred to as caloric and incl/de s/*ars and
s/*ar alco,ols. Non-n/triti"e sweeteners o++er no ener*y and can sweeten wit, little
"ol/me. 1ot, t,e s/*ar alco,ols and non-n/triti"e sweeteners can relace t,e s/*ars
and are sometimes re+erred to as s/*ar s/-stit/tes, s/*ar relacers or alternati"e
sweeteners.
:
5a-le :&-: lists sweeteners a"aila-le in t,e +ood s/ly and t,eir /ni?/e
c,aracteristics.
Sensation of Taste
It is di++ic/lt to determine w,et,er taste is *enetically linked, ac?/ired in /tero,
neonatal, or in+l/enced -y "is/al, a/ditory, or taste stim/li d/rin* in+ancy, early
c,ild,ood, or e"en ad/lt,ood.
>
5aste -/ds are resent and +/nctionin* -e+ore -irt,, a +act demonstrated -y inAectin*
sweetenin* a*ents into t,e amniotic +l/id d/rin* t,e +o/rt, mont, o+ re*nancy.
=
5,e
sweetened amniotic +l/id res/lts in an increased rate o+ swallowin* -y t,e +et/s. At
-irt,, in+ants s,ow a taste re+erence +or s/crose, and t,eir taste cells are more
resonsi"e to s/crose t,an to ot,er s/*ars. 4,et,er it is simly a leas/ra-le taste or
a tr/e meta-olic need is not known.
5aste sensation is initiated -y t,e arri"al o+ a stim/l/s at t,e taste -/ds. 5aste
reco*nition occ/rs w,en t,e recetor sites o+ t,e cells o+ t,e taste -/ds carry, -y
cranial ner"es, a ?/alitati"e and ?/antitati"e messa*e to t,e -rain. 5,e messa*es are
rocessed, and t,e stim/l/s is reco*ni@ed as eit,er sweet, so/r, salty, or -itter, or
some com-ination o+ t,ese +o/r.
The Historic Importance of Sweeteners
5,e +irst recorded e"idence o+ sweeteners dates to ><$$ 1.C. Drawin*s in 3*ytian
tom-s ill/strate -eekeein* ractices +or ,oney rod/ction. 5,e ,oney was reser"ed
+or t,e ric, and ower+/l.
C/lti"atin* s/*ar cane -e*an in so/t,east Asia, India, and C,ina aro/nd :$$ 1.C. 5,e
earliest known written re+erence to s/*ar cane occ/rs in a scroll datin* to =%' A.D.
5,e Ara-s de"eloed t,e +irst rocess +or re+inin* s/*ar cane into s/crose. 5,e
c/lti"ation o+ s/*ar cane was racticed in so/t,ern 3/roe in t,e :=t, cent/ry, and
e"ent/ally knowled*e o+ it sread to t,e New 4orld. 5,e c/lti"ation o+ t,e root cro
called s/*ar -eets started more t,an >$$ years a*o.
&
Nort, American Indians ,ad de"ised a met,od o+ -leedin* t,e sa o+ t,e s/*ar male
tree lon* -e+ore t,e )il*rims arri"ed in Massac,/setts. 5,e s/*ar in t,e sa o+ t,e
mat/re s/*ar male is almost e0cl/si"ely s/crose.
Sweeteners made +rom corn starc, -e*an to aear aro/nd :;:$. 5,e lesser sweetness
o+ t,e s/*ars deri"ed +rom corn starc,, mainly *l/cose 7also re+erred to as de0trose8,
was resonsi-le +or c,aracteri@in* t,em as s/-stit/te sweeteners. 5,is identity
imosed restrictions on t,eir /se. In t,e :;<$s and :;%$s, new c,emical rocesses
were de"eloed w,ic, res/lted in t,e a-ility to con"ert t,e *l/cose contained in corn
starc, to +r/ctose. 5,is con"ersion led to t,e rod/ction o+ a "ariety o+ ,i*,-+r/ctose
corn syr/s 7HFCS8. 1eca/se +r/ctose is twice as sweet as *l/cose, its /se ,as
increased raidly.
5,e amo/nt o+ HFCS /sed as a sweetener s/rassed t,at o+ s/crose in :;('.
Asartame, w,ic, is aro0imately :($ times sweeter t,an s/crose, is t,e most
+re?/ently /sed noncaloric sweetener. From its disco"ery in :;<', it is now -ein*
/sed -y more t,an :$$ million eole worldwide.
'
Sucrose
S/crose is t,e most commonly /sed ta-leto sweetener. A-sol/te /sa*e in a co/ntry
is not known -/t t,e disaearance o+ s/crose +rom t,e market is t,e commonly /sed
estimate -/t it m/st -e /nderstood t,at t,is estimate incl/des wasta*e w,ic, is not
in*ested -y eole. In t,e United States estimated /sa*e ,as decreased +rom t,e ,i*,
o+ :$> l- 7&< k*8 er erson in :;%: to <'.( l- 7=$ k*8 er erson in >$$$
%
7Fi*/re :&-
:8. For t,e United 2in*dom t,e :;;= /sa*e was && l- 7>$ k*8 er erson.
(
In t,e ast,
t,is /sa*e was considered cons/mtion dataD ,owe"er, t,is is a misnomer. Usa*e is
act/ally t,e ?/antity o+ sweeteners deli"ered to commercial esta-lis,ments to -e /sed
in "ario/s ways. It does not acco/nt +or any loss ca/sed -y waste, nor does it incl/de
any additional nat/ral s/*ars cons/med. It ,as -een reorted t,at / to =:E o+ total
s/*ars cons/med -y adolescents are ,idden s/*ars in +oods, s/c, as in milk and +r/it.
;
Indi"id/al "ariation in cons/mtion also occ/rs. Males *enerally cons/me more
s/crose t,an +emales, and teena*ers are -y +ar t,e *reatest cons/mers. )eak
cons/mtions occ/r amon* :'- to :(-year-old males.
:&
A decreased cons/mtion
rates occ/rs amon* mem-ers o+ lar*e +amilies.
Fi*/re :&-: Sweetener /se in t,e United States :;$$->$$$ in l- er caita.
<,%,::-:=
Uses of Sucrose
S/crose ,as se"eral attri-/tes t,at make it desira-le +or t,e +ood ind/stry. It is ideal in
t,e +ollowin* roles9
Sweetenin* a*ent9 5,e c,aracter o+ t,e sweet taste can -e "aried accordin* to H
and temerat/re /sed to make a rod/ct, as well as -y its interaction wit, ot,er
in*redients in t,e +orm/lation. 5,e le"el o+ sweetness is imortant to t,e accetance
o+ certain +oods.
Fla"or -lender and modi+ier9 In some +oods, s/c, as mayonnaise, s/crose is a +la"or
-lenderD in ot,er +oods, s/c, as ickles, it red/ces t,e acidic -ite and so/r taste.
5e0t/re and -odyin* a*ent9 S/crose *i"es a te0t/re t,at is ,i*,ly acceta-le to
cons/mers. It ro"ides -ody and a distincti"e Fmo/t, +eelF to +ood rod/cts.
Disersin*Bl/-ricatin* a*ent9 In dry acka*ed mi0es, s/crose is /sed as an a*ent to
kee ot,er in*redients +rom ackin* too closely. 5,is, in t/rn, ermits a -etter
-lendin* o+ t,e in*redients d/rin* +ood rearation.
Carameli@ationBcolor a*ent9 Carameli@ation d/rin* -akin* rod/ces a -rown color,
w,ic, increases accetance. It ro"ides a desira-le, c,aracteristic +la"or and aroma to
t,e +ood rod/ct.
1/lkin* a*ent9 4,en a noncaloric sweetener t,at may -e >$$ times sweeter t,an
s/*ar relaces s/crose, ot,er in*redients m/st -e added to relace t,e lost s/crose
F-/lkF to maintain t,e +oodCs normal aearance and consistency.
3arlier in t,is cent/ry, ,ome cannin* and -akin* res/lted in a ,i*,er er caita
cons/mtion o+ s/crose t,an +or ind/strially rocessed +oods. Modern-day a++l/ence,
t,e desire to -e li-erated +rom t,e kitc,en, and a ,i*,er ercenta*e o+ workin* women
are +actors t,at ,a"e ,eled re"erse t,e trend. Se"enty-+i"e ercent o+ t,e s/crose
man/+act/red -etween :;:$ and :;=$ was deli"ered to ,o/se,olds. In :;'$,
ind/strial /ses o+ s/crose s/rassed t,at /sed at ,ome.
=
5,e +ood-rocessin* ind/stry
,as *reatly c,an*ed t,e eatin* ,a-its o+ t,e a"era*e American -y increasin* t,e
o/t/t o+ rocessed +oods. No lon*er are t,ere only t,ree meals d/rin* t,e dayD
instead, indi"id/al +ood intake atterns ,a"e -een e0tended to incl/de a contin/o/s
mornin*-to-ni*,t intake o+ snacks and -e"era*es, many o+ t,em containin* s/crose.
In a less-de"eloed co/ntry, So/t, A+rica, ,ome /se is still %$E o+ total /se and in t,e
>$$$B>$$: season was <& l- 7>; k*8 er erson.
:'
S/crose ,as se"eral disad"anta*es t,at restrict its ind/strial /se.
5,e ,i*, concentration 7osmolarity8 /sed in cannin* o+ten ca/ses s,rinka*e and
wrinklin* o+ canned +r/its. 1ot, c,aracteristics detract +rom t,e "is/al aeal o+ t,e
rod/ct.
It a-sor-s moist/re 7,y*roscoic8 and accordin*ly makes it di++ic/lt to +ree@e-dry
+ood containin* ,i*, concentrations o+ s/crose.
It c,ars at ,i*, temerat/resD t,/s, it cannot -e /sed to sweeten items t,at m/st -e
+ried-acon, +or instance.
It s/orts -acterial *rowt,D ,ence, its /se in reared +ood increases t,e otential
+or -acterial contamination and soila*e.
3"al/ation o+ t,e Healt, Asects o+ S/crose
)rior to :;'(, +ew re*/latory constraints e0isted on t,e introd/ction o+ new rod/cts
into +oods. I+ ro-lems de"eloed, t,e United States Food and Dr/* Administration
7FDA8 ,ad to re"ail on t,e conscience o+ t,e man/+act/rer to wit,draw t,e rod/ct
or to ro"e in co/rt t,at t,e rod/ct was not sa+e. 1ot, otions were rat,er da/ntin*
-eca/se considera-le +inancial interest was /s/ally in"ol"ed. In :;'(, t,e U.S.
Con*ress assed t,e Foods Additi"e Amendment t,at re?/ired reliminary marketin*
clearance. 5,e act re?/ired t,e +ollowin* in+ormation on additi"es9 7:8 c,emical
comosition, 7>8 met,od o+ man/+act/re, 7=8 analytic met,od /sed +or t,e detection o+
t,e additi"e, 7&8 roo+ t,at t,e additi"e accomlis,ed its intended e++ect and t,at it did
not occ/r in e0cess o+ t,e amo/nt re?/ired to ac,ie"e t,at e++ect, and 7'8 roo+ t,at it
was sa+e.
:<
5,e -/rden o+ roo+ in s/-stantiatin* any o+ t,ese +actors resided in t,e
etitioner alyin* +or t,e clearance, and not wit, t,e FDA.
5,e Foods Additi"e Amendment decreed t,at all comonents added to rocessed
+oodst/++s rior to :;'( were classi+ied as +ood in*redients, w,ereas t,ose added
t,erea+ter were called +ood additi"es. 4it, t,is act, Con*ress a/t,ori@ed a list o+ +ood
in*redients w,ic, it called *enerally re*arded as sa+e 7G!AS8. S/crose was listed as a
+ood in*redient and laced on t,e G!AS list. At t,at time, items on t,e list were
considered as relati"ely imm/ne +rom +/t/re re*/latory action. 4it, t,e assa*e o+
time, ,owe"er, all t,e items listed on t,e ori*inal G!AS list o+ +ood in*redients ,a"e
come /nder re"iew.
:%
In :;(<, t,e FDA +ormed a S/*ars 5ask Force t,at critically re"iewed all o+ t,e recent
scienti+ic literat/re addressin* otentially ad"erse ,ealt, e++ects associated wit,
s/*ars cons/mtion. 5,ey in"esti*ated t,e ca/se-and-e++ect relations,i -etween t,e
/se o+ s/*ar and dia-etes, cardio"asc/lar disease, ,yertension, ,eart disease, and
o-esity. 5,e task +orce determined t,at no concl/si"e -ody o+ researc, links any o+
t,e a-o"e to s/*ar cons/med in moderation.
:&
N/trition and Ho/r Healt,9 Dietary
G/idelines +or Americans states, FC,oose -e"era*es and +oods to moderate yo/r
intake o+ s/*ar.F
:(
In t,e United 2in*dom, t,e Committee on Medical Asects o+ Food )olicy 7COMA8
!eort noted t,at c/rrent cons/mtion o+ s/*ars, artic/larly s/crose, layed no
direct role in t,e de"eloment o+ cardio"asc/lar disease, essential ,yertension, or
dia-etes mellit/sD ,owe"er, t,e reort stated t,at s/*ars are t,e most imortant dietary
+actor in t,e ca/se o+ dental caries.
:;
Ot,ers s,are t,e "iew, -ased on eidemiolo*ical
e"idence, t,at s/*ars are one o+ t,e essential m/lti+actorial a*ents in t,e re"alence
and ro*ression o+ caries.
>$,>:
It ,as -een s/**ested t,at trends in cons/mtion o+ added s/*ar raise concern t,at it
may also -e associated wit, increasin* rates o+ o-esity and inade?/ate intakes o+
essential n/trients, esecially calci/m. In"esti*ators /sed data +rom t,e U.S.
Deartment o+ A*ric/lt/reCs :;;&-;< Contin/in* S/r"ey o+ Food Intakes -y :',$::
indi"id/als -etween > years and older, to identi+y t,ose w,o cons/med more t,an ><
teasoons o+ added s/*ars daily. 5,ese indi"id/als tended to -e -ot, yo/n*er and
male and to +re?/ently o"er cons/me total ener*y.
>>
Usin* t,ese same data, G/t,rie and Morton identi+ied re*/lar so+t drinks, +ollowed -y
ta-le s/*arBsweeteners and sweetened *rains like cookies and cakes as t,e rimary
so/rce o+ added s/*ar in t,e U.S. diet. )ercent total ener*y +rom added s/*ars, ran*ed
+rom :>E +or t,ose <' years and older to >$E +or :>- to :%-year-olds, wit, a mean
intake +or t,e entire o/lation o+ :<E.
>=
Dislacement o+ milk in t,e diet -y re*/lar
so+t drinks in c,ildren and adolescents ,as -een demonstrated -y se"eral
researc,ers.
>&,>'
MaAor so/rces o+ added s/*ars in t,e U.S. diet are9 ta-le s/*ar, ,oney, syr/, candy,
Aam or Aelly, *elatin desserts, so+t drinks, +r/itades, lemonades and ot,er +r/it /nc,es,
sweetened *rains like cookies and cakes, dairy desserts s/c, as ice cream, sweetened
milks and yo*/rts. 5,ese do not incl/de diet or s/*ar-+ree "arieties wit, s/*ar
relacers or s/-stit/tes.
!ole in Caries Formation
S/*ar in la?/e is a contri-/tory +actor in dental caries.
><
5wo animal st/dies and
t,ree ,/man clinical st/dies ,a"e contri-/ted to t,e /nderstandin* o+ t,e imortance
o+ s/*ar in t,e de"eloment o+ caries.
In :;'', t,e +irst animal st/dy
>%
was cond/cted wit, rodents in a *noto-iotic 7*erm-
+ree8 en"ironment. One *ro/ o+ rats was +ed a caries-rod/cin* diet containin* lar*e
amo/nts o+ s/*ar. 5,e second *ro/ was +ed t,e same diet, -/t at t,e same time
seci+ic microor*anisms were introd/ced to t,e ot,erwise *erm-+ree en"ironment.
5,ose rats recei"in* t,e cario*enic diet alone did not de"elo cariesD t,ose wit, t,e
cario*enic diet l/s t,e -acteria did de"elo lesions 75a-le :&->8. O-ser"ations at t,at
time and since ,a"e concl/si"ely demonstrated t,at certain microor*anisms and
strains o+ or*anisms are more caries-rod/cti"e t,an ot,ers.
In a second rodent st/dy,
>(
one *ro/ o+ rats was +ed a caries-rod/cin* diet -y means
o+ a stomac, t/-e, wit, no +ood comin* in contact wit, t,e teet,. No caries res/lted.
4,en t,e same diet was +ed orally and allowed to come in contact wit, t,e teet,,
caries did occ/r 75a-le :&-=8.
5,ese two st/dies concl/si"ely demonstrate t,at 7:8 -acteria are essential +or caries
de"eloment, re*ardless o+ diet, and 7>8 t,e action o+ t,e s/*ar in cario/s
de"eloment is local, not systemic.
Se"eral ,/man st/dies ,a"e reorted and +/rt,er clari+ied t,e animal st/dies. 5wo o+
t,e most o+ten cited occ/rred at Hoewood Ho/se
>;
in A/stralia and at 6ie,olm in
Sweden.
=$
Hoewood Ho/se was an or,ana*e in A/stralia t,at accommodated / to (>
c,ildren. From its -e*innin*, s/*ar and ot,er re+ined car-o,ydrates were e0cl/ded
+rom t,e c,ildrenCs diet. Car-o,ydrates were ser"ed in t,e +orm o+ w,ole meal -read,
soy-eans, w,eat *erm, oats, rice, otatoes, and some molasses. Dairy rod/cts, +r/its,
raw "e*eta-les, and n/ts were rominently +eat/red in t,e tyical men/. As ill/strated
in Fi*/re :&->, dental s/r"eys o+ t,ese c,ildren +rom t,e a*es o+ ' to :: years
re"ealed a *reatly red/ced caries incidence comared wit, t,e state-sc,ool o/lation
in t,at a*e *ro/. 5,e c,ildrenCs oral ,y*iene was oor, wit, a-o/t %'E s/++erin*
+rom *in*i"itis. 4,en t,e c,ildren -ecame old eno/*, to earn wa*es in t,e o/tside
economy, t,ey de"iated +rom t,e ori*inal diet. A stee increase o+ decayed, missin*,
and +illed teet, 7DMF58 a+ter t,e a*e o+ :: years indicates t,at t,e teet, did not
ac?/ire any ermanent resistance to caries 7see Fi*/re :&->8.
5,e 6ie,olm st/dy was cond/cted at a mental instit/tion in t,at city located in
so/t,ern Sweden. Ad/lt atients on a n/tritionally ade?/ate diet were o-ser"ed +or
se"eral years and +o/nd to de"elo caries at a slow rate. S/-se?/ently, t,e atients
were di"ided into se"en *ro/s to comare t,e cario*enicity accomanyin* "ario/s
c,an*es in +re?/ency and consistency o+ car-o,ydrate intake. S/crose was incl/ded in
t,e diet as to++ee, c,ocolate, caramel, in -read, or in li?/id +orm. Caries increased
si*ni+icantly w,en +oods containin* s/crose were in*ested -etween meals. In addition
to t,e +re?/ency o+ eatin*, t,e consistency o+ t,e s/*ar-containin* +ood was "ery
imortant. Sticky or ad,esi"e +orms o+ +ood t,at maintained ,i*, s/*ar le"els in t,e
mo/t, +or a lon*er time were m/c, more cario*enic t,an +orms t,at were raidly
cleared.
5,e 6ie,olm st/dy also demonstrated t,at it was ossi-le to increase t,e a"era*e
cons/mtion o+ s/*ar +rom a-o/t =$ to ==$ * er day wit, little increase in caries,
ro"ided t,e additional s/*ar was cons/med at mealtime in sol/tion +orm.
=$
5wo
oints to remem-er a-o/t t,e 6ie,olm st/dy are t,at a-normal ?/antities and
resentations o+ +ood were /sed and t,at, -y modern standards, t,e st/dy wo/ld not
recei"e et,ical clearance.
Finally, some eole s/++er +rom a condition known as ,ereditary +r/ctose intolerance
7HFI8. A+ter t,e intake o+ +r/ctose, t,ese ersons -ecome na/seated, "omit, and sweat
e0cessi"elyD malaise, tremor, coma, and con"/lsions may de"elo. As a res/lt, t,ese
indi"id/als learn to care+/lly a"oid +oods wit, +r/ctose or s/crose w,ere +r/ctose is
one o+ t,e meta-olic rod/cts. 5,ose HFI indi"id/als w,o ,a"e s/r"i"ed t,is disorder
-y s/ccess+/lly a"oidin* +r/ctose or s/crose +rom any so/rce are eit,er caries-+ree or
,a"e "ery +ew caries.
=:
5,e low re"alence o+ caries in HFI atients indicates t,at
starc,y +oods alone do not rod/ce decay, w,ereas s/*ary +oods do.
4,at is t,e t,res,old le"el o+ s/*ar content a-o"e w,ic, a +ood is ,i*,ly cario*enice
4,ile many animal and ,/man st/dies ,a"e e0amined t,e dro and reco"ery o+
la?/e H +ollowin* cons/mtion o+ seci+ic +oods, a tr/ly sa+e le"el ,as not -een
esta-lis,ed alt,o/*, s/*ar cons/mtion o+ -etween :$ and :' k* er erson er year
,as -een s/**ested.
=>
5wo similar eidemiolo*ic st/dies o+ t,e caries re"alence in :>-year-olds and t,e er
caita s/*ar /se ,a"e -een done. 5,e +irst, cond/cted in &% co/ntries,
==
re"ealed a
statistically si*ni+icant relations,i -etween t,e a"aila-ility o+ s/*ar and t,e n/m-er
o+ DMF5. 4,en daily er caita s/ly o+ s/*ar was less t,an '$ *, t,e DMF5 inde0
was less t,an =.$ 75a-le :&-&8. More recently, a st/dy in ;$ co/ntries s,owed a
statistically si*ni+icant relations,i -etween t,e lo*arit,m o+ DMF5 and s/*ar
cons/mtion at a sloe o+ $.$>: er k* er erson er year.
=&
5,is si*ni+icant
association disaeared w,en only t,e data +rom t,e >; ind/striali@ed co/ntries were
analy@ed. 5,is indicates t,at +actors ot,er t,an s/*ar cons/mtion 7i.e., oral ,y*iene,
ro+essional care, +l/oride /se8, m/st -e taken into acco/nt in e0lainin* "ariation in
caries re"alence.
5,e erroneo/s imression t,at oral ,y*iene and otim/m +l/oride e0os/re will
rotect teet, +rom -ad dietary ractices s/orts t,e o"ersimli+ied "iew t,at A/st
remo"in* Fs/*arF +rom t,e diet is an ade?/ate aroac, to re"entin* caries
ro*ression. 5,e caries romotin* acti"ity o+ car-o,ydrates and sweeteners "ary
-ased on +re?/ency o+ intake as well as com-ined intake wit, ot,er +oods t,at may
"ary in rotein or +at content. )rocessed ,i*,-starc, snacksw,et,er *elatini@ed,
-aked, or +riedrod/ce as m/c, acid in dental la?/e as s/crose alone -/t at a
slower rate.
=',=<
Foods containin* -ot, cooked starc, and s/crose, like +ried otatoes
and -read, ,a"e -een s,own to en,ance caries otential.
=%
4,en s/crose is added to
cooked starc, +oods t,e caries romotin* otential is increased -eca/se t,e starc,
-rin*s t,e s/crose into closer contact wit, t,e toot, s/r+ace.
=(
5,/s, added s/*ars can
-e art o+ a total diet w,en +ollowin* */idelines t,at s/**est t,at +ew +oods or
-e"era*es containin* s/*ars or starc,es -e eaten -etween meals.
:(
Stretococc/s m/tans is *enerally re*arded as t,e microor*anism ,a"in* t,e *reatest
cario*enic otential in ,/mans. S/crose en,ances t,e coloni@ation and *rowt, o+ S,
mutans in dental la?/e more t,an ot,er monosacc,arides or disacc,arides. 5,ese
-acteria 7:8 +erment s/crose raidly, rod/cin* acidsD 7>8 con"ert s/crose to
e0tracell/lar olysacc,arides t,at +acilitate t,e ad,erence o+ t,e -acteria to teet, and
may +/nction as a reser"e o+ +ermenta-le car-o,ydrate necessary +or t,e rod/ction o+
acidsD and 7=8 red/ce la?/e ermea-ility t,at in t/rn decreases t,e rate at w,ic,
sali"a can ne/trali@e or dil/te acids +ormed in t,e det,s o+ t,e la?/e.
=;
Fi*/re :&-> )lot o+ t,e mean n/m-er o+ DMF5 "ers/s c,ronolo*ic a*e in state
sc,ools in A/stralia and in Hoewood Ho/se. 7!erinted -y ermission +rom
Mart,aler, Caries Res, :, :;<%.
>:
8
Question 1
A. Some sweeteners wit, a er-*ram calorie content e?/al to s/crose can res/lt in a
lesser calorie intake -eca/se o+ t,eir intense sweetness.
1. 5,e 'oods dditive mendment of CH>F esta-lis,ed t,e -asis +or t,e G!AS list.
C. A food additive is less s/-Aect to FDA st/dy t,an a food in$redient,
D. Aro0imately '$E more s/*ar is re?/ired in t,e diet o+ *noto-iotic 7*erm-+ree8
rats to ind/ce caries t,an in t,e diet o+ control rats.
3. Indi"id/als wit, ,ereditary +r/ctose intolerance 7HFI8 /s/ally ,a"e more caries
t,an s/*ar-tolerant indi"id/als.
Corn Sweetener Use
5,e lar*e increase in t,e cost o+ s/crose in :;%& romted a searc, +or a less
e0ensi"e alternati"e. 5,e a"aila-ility o+ ,i*,-+r/ctose corn syr/ 7HFCS8 wit, &>E
+r/ctose ro"ided one alternati"e. 1y late :;%%, a rocess to rod/ce ''E +r/ctose
syr/s was de"eloed. 5,e /se o+ HFCS er caita in t,e United States ,as A/med
+rom $.% l- 7$.= k*8 in :;%$ to <:.< l- 7>( k*8 in >$$$.
%
5,e w,olesale list rice o+
HFCS is aro0imately two-t,irds t,at o+ s/crose. 5,e caloric sweetener HFCS seems
to -e reac,in* ma0im/m /se on a er caita -asis, and its rod/ction is not e0ected
to contin/e increasin* as raidly in t,e +/t/re as it did in t,e :;%$s and early :;($s.
Hi*,-+r/ctose corn syr/ /se in so+t drinks acco/nted +or o"er %$E o+ its /se in
:;;>.
&$
HFCS /sa*e o/tside t,e United States is low.
A st/dy -y Sc,einin
&:
determined t,e relati"e cario*enicity o+ +r/ctose and s/crose.
Fr/ctose was /sed e0cl/si"ely -y one *ro/ w,o de"eloed =.( new cario/s lesions,
w,ereas t,e s/crose *ro/ de"eloed %.> new lesions. 5,e lar*e decrease in caries
incidence in t,e United States may artially -e e0lained -y t,e increased /se o+
HFCS sweeteners wit, a conc/rrent decrease in s/crose.
5,e cons/mtion o+ *l/cose and de0trose corn syr/ ,as remained +airly constant in
t,e United States o"er t,e ast <$ years at =.' l- 7:.< k*8. 5,e t,ree leadin* /ses are
t,e -rewin* ind/stry, con+ectionary, and cereal rod/cts.
:>
3++ects o+ Ot,er S/*ars
Fr/ctose, maltose, and lactose are also caloric s/*ars +o/nd in nat/re. A considera-le
amo/nt o+ t,e +irst two s/*ars is contained in +r/its and "e*eta-les. .actose in "aryin*
concentrations is resent in all mammalian milk. 5,e sweetness o+ t,ese ot,er s/*ars
ran*es +rom $.> to :.( times t,e sweetness o+ s/crose 75a-le :&-'8.
5,e s/-Aecti"e e"al/ation o+ t,e sweetness o+ a s/-stance is /s/ally A/d*ed -y taste
anels. Se"eral met,ods are /sed9 7:8 ,a"in* t,e mem-ers o+ t,e anel write down in
t,eir own words a s/-Aecti"e ercetion o+ t,e sweetness, time o+ onset, a+tertaste, or
ot,er descriti"e termsD and 7>8 comarin* t,e test sweetener a*ainst a re+erence
sweetener, most likely s/crose. 5,ese two e"al/ations indicate ?/ality -/t not
intensity o+ t,e test material. For intensity, t,res,old detection and reco*nition le"els
are noted. For t,res,old detection testin*, e0treme dil/tions o+ t,e sweetener are /sed.
5,e t,res,old le"el is t,e lowest concentration at w,ic, sweetness can -e discerned.
!eco*nition tests are -ased on t,e lowest concentration at w,ic, a anel can
reco*ni@e t,e seci+ic sweetener -ein* tested. 5estin* is accomlis,ed wit, t,e
samle sol/tions at =%C -eca/se temerat/re does modi+y taste ercetion. 5,e
t,res,old le"el is m/c, lower t,an t,e reco*nition le"el.
5,e )olyols as Sweeteners
5,e most commonly known olyols incl/de sor-itol, mannitol, and 0ylitol. 5,ese
olyols are not s/*ars in t,e strictest sense. 3ac, molec/le resem-les a s/*ar, wit, t,e
e0cetion t,at an alco,ol *ro/in* is attac,ed to eac, car-on atom o+ t,e olyol.
O+ten t,ey are re+erred to as Fs/*ar alco,ols.F
5,e olyols ,a"e &$ to %'E o+ t,e caloric content o+ s/crose. Gylitol ,as t,e same
sweetness as s/crose. )olyols ,a"e similar ,ysical c,aracteristics to s/crose, and
t,eir s/-stit/tion does not c,an*e t,e c/stomary si@e and wei*,t o+ a rod/ct.
1rownin* or carameli@ation, ,owe"er, does not occ/r wit, +ood rod/cts t,at ,a"e
-een sweetened wit, olyols.
Sor4itol
Sor-itol, +irst isolated in :(%>, is mainly /sed in c,ewin* */m, toot,aste, +ro@en
desserts, and some candy. 5,e dental interest in sor-itol res/lts +rom its /se in so-
called s/*ar-+ree */m, w,ic, ,as -een claimed to -e noncario*enic. 5,is claim o+
noncario*enicity ,as not -een s/-stantiated -y clinical trials, -/t intraoral st/dies
,a"e indicated t,at t,e la?/e H seldom dros -elow '.% a+ter c,ewin* sor-itol-
sweetened */m.
&>
5,e need +or +/rt,er st/dies is em,asi@ed -y t,e +act t,at S.
m/tans is known to meta-oli@e sor-itol.
%annitol
Mannitol, w,ic, occ/rs nat/rally in seaweed, is also deri"ed +rom t,e s/*ar mannose.
5,is sweetener is meta-oli@ed "ery slowly -y oral microor*anisms and ,as "irt/ally
no cario*enic otential.
&=
Mannitol is /sed in toot,astes, mo/t, rinses, and as a
d/stin* a*ent +or c,ewin* */m.
5,e )olyols as Sweeteners
Gylitol
5,e olyol t,at ,as recei"ed t,e *reatest amo/nt o+ attention -y t,e dental ro+ession
is 0ylitol. Gylitol is deri"ed +rom -irc, trees, corn co-s, and oats, as well as +rom
-ananas, straw-erries and certain m/s,rooms. As wit, ot,er olyols, t,e aearance
and te0t/re o+ 0ylitol is similar to s/crose. Its cost is a-o/t :$ times t,at o+ s/crose.
3"en wit, a si*ni+icant e0ansion in 0ylitol rod/ction, t,e cost cannot -e red/ced -y
m/c, more t,an ,al+.
Clinical, sali"ary c,emistry and micro-iolo*ic e"idence s/**est t,at 0ylitol is t,e -est
n/triti"e s/crose s/-stit/te wit, resect to caries re"ention. It ,as -een s,own to -e
nonacido*enic and t,ere+ore noncario*enic.
a,&&
5,e main /se o+ 0ylitol aears to -e
w,ere it is /sed in artial s/-stit/tion +or ot,er s/*ars. 5,is takes ad"anta*e o+ its
micro-ial action, wit, t,e +ood item still -ein* cometiti"e in rice.
All o+ t,ese s/*ar alco,ols ,a"e -een reco*ni@ed as ,a"in* a low otential o+
rod/cin* dental caries. 5,ere+ore, in t,e United States, Con*ress ,as a/t,ori@ed
rod/cts containin* less t,an $.' * o+ s/*ar and a s/*ar alco,ol to -e la-eled as
Fred/cin*F or Fnot romotin*F toot, decay.
&'
5,is la-elin* went into e++ect in #an/ary
:;;(.
!e*ardin* dental-caries re"ention, t,e main /se today o+ t,e olyols, nota-ly
sor-itol and 0ylitol, is in c,ewin* */ms.
&<
It is -elie"ed, ,owe"er, t,at t,e caries
re"enti"e e++ect o+ s/-stit/ted c,ewin* */ms is t,e c,ewin* rocess itsel+ rat,er t,an
t,e s/*ar-s/-stit/tes s/c, as t,e olyols.
&%
a
Noncario*enic h Does not ca/se caries.
Question 2
A. Hoewood Ho/se in A/stralia esta-lis,ed t,e +act t,at restrictin$ refined
car4ohydrate inta*e red/ces caries incidence, w,ereas t,e 6ie,olm st/dy in Sweden
demonstrated t,at fre5uency of inta*e and consistency o+ s/*ar rod/cts are imortant
in e"al/atin* cario*enicity o+ +oods.
1. A ,i*,er concentration o+ a sweetener is re?/ired +or reco*nition t,an +or
detection.
C. It is ossi-le +or a noncario*enic s/-stance to -e anticario*enic,
-
-/t not all
noncario*enic a*ents are anticario*enic.
D. All rod/cts wit, olyol sweeteners are considered s/*ar-+ree.
3. Gylitol is t,e -est n/triti"e s/crose s/-stit/te wit, resect to caries re"ention.
-
Anticario*enic h !e"erses t,e caries rocess rior to ca"itation -y en,ancin*
reminerali@ation.
Intense Sweeteners
5,e need +or intense sweeteners is ac/te. For rimary re"enti"e dentistry ractices,
a noncario/s rod/ct t,at co/ld -e /sed in oral medications, mo/t,rinses, denti+rices,
and all +orms o+ FcandyF or -etween-meal snacks is ,i*,ly desira-le. 5,e American
Dental Association 7ADA8 is enco/ra*in* t,e /se o+ intense, or arti+icial, sweeteners.
6ery small amo/nts o+ intense sweeteners can -e /sed to ac,ie"e acceta-le le"els o+
sweetness. 3"en t,o/*, t,e cost o+ t,ese sweeteners may -e :$$ times *reater t,an an
e?/al amo/nt o+ s/crose, t,ey are ;$ ercent more economical t,an s/crose -eca/se
t,eir e?/i"alent sweetness can -e :,$$$ times t,at o+ s/crose.
In :;%%, t,e U.S. Senate Select Committee on N/trition and H/man Needs roosed
as a dietary *oal +or t,e United States t,at no more t,an :$E o+ oneCs total daily
calories -e +rom re+ined s/*ars and ot,er caloric sweeteners. In :;%(, t,e a"era*e
daily diet ro"ided :(E
&(
o+ total calories t,ro/*, s/*ar and ot,er caloric sweeteners.
In :;(<, ,owe"er, t,at ercenta*e was estimated to -e ::E
:&
7Fi*/re :&-=8. !eac,in*
closer to t,is *oal was made ossi-le -y a red/ction in s/*ar intake and a ossi-le
increase in t,e /se o+ acceta-le intense sweeteners alt,o/*, e"idence +or t,e latter is
lackin*.
5,e most o/lar intense sweeteners in t,e United States are sacc,arin, asartame,
aces/l+ame-2, and s/cralose.
Saccharin
Sacc,arin is considered aro0imately =$$ times sweeter t,an s/crose. In :;((,
aro0imately < l- 7= k*8 o+ sacc,arin er erson 7s/*ar-sweetness e?/i"alent wei*,t8
was deli"ered +or /se as a sweetener in t,e United States, a dro +rom :$ l- 7' k*8 in
:;(&. 1eca/se o+ its intense sweetness, t,e /se o+ sacc,arin is only a-o/t &E as costly
as an e?/i"alent sweetness deri"ed +rom s/crose.
&;
Sacc,arin is comati-le wit, most
+ood and dr/* in*redients. Its maAor deterrent, a metallic a+tertaste, can -e reco*ni@ed
-y most /sers.
On Aril :', :;%%, on t,e -asis o+ alle*ed carcino*enicity, t,e re"ocation o+ re"io/s
aro"als +or sacc,arin was roosed -y t,e FDA wit, t,e recommendation t,at
sacc,arin -e classi+ied as a dr/*, meanin* it co/ld only -e sold -y rescrition. 5,is
decision set o++ a cons/mer +/ror across t,e nation, res/ltin* in -ills -ein* assed in
Con*ress to ostone t,e -an on sacc,arin +or :( mont,s. Con*ress ,as reacted wit, a
series o+ >-year moratori/ms t,at ro,i-it t,e FDA +rom -annin* /se o+ sacc,arin in
diet sodas and +ood w,ile ermittin* more time +or +/rt,er researc,. In :;(%, :;;>,
and :;;<, '-year moratori/ms were assed -y Con*ress. In :;;>, t,e FDA +ormally
wit,drew its :;%% roosal to -an t,e /se o+ sacc,arin. 5,e a*ency did not address
t,e sa+ety o+ sacc,arin, -/t stated it wo/ld reroose t,e -an later s,o/ld s/c, action
-e warranted.
'$
spartame
Asartame, -etter known -y one o+ its tradenames, N/traSweet, is "oid o+ an
/nleasant a+tertaste. It is a dietide o+ two nat/rally occ/rrin* amino acids,
,enylalanine and asartic acid, -/t it is not +o/nd in nat/re. It was a serendiito/s
disco"ery -y #ames Sc,latter, a c,emist wit, G. D. Searle g Comany, w,o rod/ced
asartame in :;<' w,ile workin* on a new anti/lcer dr/*.
'
Asartame ,as & CalB*,
w,ic, is c,aracteristic o+ roteinsD ,owe"er, -eca/se it is :($ times sweeter t,an
s/crose, t,e caloric intake is insi*ni+icant.
Asartame was ori*inally aro"ed +or /se in #/ly :;%& -y t,e FDA as a n/triti"e
sweetener. D/rin* t,e re"iew eriod +ollowin* t,e initial aro"al, o-Aections were
+iled. In Decem-er :;%', t,e FDA retracted its asartame aro"al endin* a more
detailed insection o+ t,e man/+act/rerCs researc, and /-lic ,earin*s. In #/ly :;(:,
asartame was rearo"ed +or /se as an arti+icial sweetener. In ( years its er caita
/se increased to :& l- 7< k*8 7s/*ar-sweetness e?/i"alent wei*,t8. More eole ,a"e
"ol/ntarily cons/med considera-le ?/antities o+ asartame wit,in a +ew years o+ its
introd/ction t,an any ot,er new c,emical entity in ,istory.
':
Ori*inally, asartame
was a-o/t =$ times more e0ensi"e t,an sacc,arinD ,owe"er, in :;;>, t,e N/traSweet
atent e0ired and t,e cost o+ t,e sweetener decreased s/-stantially. In Canada t,e
e0iration o+ t,e atent reciitated a '$E dro in cost +or t,e rod/ct. It is aro"ed
as a +ree-+lowin* s/*ar s/-stit/te +or ta-le /se, and +or /se -y man/+act/rers in o"er
:$$ rod/cts, s/c, as cold cereals, drink mi0es, instant co++ee, instant tea, so+t drinks,
*elatins, /ddin*s, ie +illin*s, toin*s, dairy rod/cts, m/lti"itamin +ood
s/lements, and ot,er rod/cts w,ere t,e Fstandards o+ identity do not recl/de s/c,
/se.F
'>
5,e commissioner o+ t,e FDA concl/ded ,is statement on asartame -e+ore
t,e Committee on .a-or and H/man !eso/rces o+ t,e United States Senate -y statin*,
Fwe do not ,a"e any medical or scienti+ic e"idence t,at /ndermines o/r con+idence in
t,e sa+ety o+ asartame.F
'=
Asartame is a +la"or en,ancer, esecially +or sweetenin*
acid +la"ors. It is also a +la"or e0tender, len*t,enin* t,e eriod o+ +la"or +or c,ewin*
*/m +or +i"e to se"en times as lon* as */ms sweetened wit, s/*ar. Asartame aears
to -e noncario*enic. 5,e ADA ,as iss/ed a statement s/ortin* t,e aro"al o+
asartame as a sweetener.
'&
)eole wit, ,enylketon/ria 7)2U8 s,o/ld a"oid t,e
intake o+ asartame -eca/se o+ its ,enylalanine content. )rod/cts sweetened wit,
asartame m/st -e la-eled wit, t,e statement F),enylketon/rics9 Contains
),enylalanine.F
cesulfame )
Aces/l+ame 2 is a non-caloric sweetener >$$ times sweeter t,an s/crose, wit, a
leasant taste. Its sweetness is ?/ickly erceti-le and diminis,es *rad/ally wit,o/t
any /nleasant a+tertaste. It is a deri"ati"e o+ acetoacetic acid. It is marketed /nder t,e
tradename S/nette -y t,e Hoec,st Celanese Cororation and is classi+ied as a
noncario*enic sweetener.
5,is sweetener was disco"ered in :;<%D ,owe"er, it was not aro"ed +or /se -y t,e
FDA in t,e United States /ntil t,e s/mmer o+ :;((. Aces/l+ame ,as -een tested in
more t,an ;$ st/dies and was in widesread /se in <$ co/ntries -e+ore it was
aro"ed +or /se in t,e United States. In aro"in* t,e sweetener, t,e FDA stated t,at
t,e st/dies it ,ad re"iewed did Fnot s,ow any to0ic e++ects t,at co/ld -e attri-/ted to
t,e sweetener.F
''
It is aro"ed +or /se in s/c, items as toot,astes, mo/t,was,es,
,armace/ticals, dry -e"era*e mi0es, instant co++ee and tea, c,ewin* */m, *elatins,
/ddin*s, and as a ta-leto sweetener. It ,as a syner*istic action wit, ot,er low-
calorie sweeteners, as do most o+ t,e intense sweeteners. 5,is means t,e com-ination
o+ in*redients is sweeter t,an t,e s/m o+ t,e indi"id/al in*redients in sweetness. It is
e0creted ?/ickly and totally, /nmeta-oli@ed -y -ot, animals and ,/mans.
Sucralose
S/cralose is a noncaloric sweetener <$$ times sweeter t,an s/crose t,at is deri"ed
+rom s/crose. It also e0,i-its syner*istic e++ects. It is not -roken down nor a-sor-ed in
t,e ,/man -ody and t,ere+ore ro"ides no calories. S/cralose does not romote toot,
decay. More t,an :$$ st/dies, incl/din* ,/man researc,, s/ort t,e sa+ety o+
s/cralose. In :;;:, Canada was t,e +irst co/ntry to aro"e its /se in +oods. It was
aro"ed +or /se in t,e United States in :;;(.
'<
Cyclamate
Cyclamate ,as a leasant, sweet taste and a relati"e sweetness aro0imately =$ times
*reater t,an s/crose. It was ori*inally incl/ded on t,e G!AS list. In :;<$, t,e FDA
re?/irements +or st/dies were e0anded to incl/de testin* +or teratolo*y and
carcino*enicity. In early Octo-er :;<;, t,ere were indications o+ some cases o+ rodent
-ladder cancer. 5,e FDA r/led in :;%$ t,at cyclamate wo/ld no lon*er -e allowed
e"en i+ it were classi+ied as a dr/*.
)romisin* New Noncaloric Sweeteners
Many sweeteners ,a"e -een s/-mitted to t,e FDA +or aro"al in t,e United States.
5wo o+ t,e more romisin* ones are Alitame and Sweetener >$$$.
Alitame is >$$$ times sweeter t,an s/crose. It is comosed o+ two amino acids, .-
asartic acid and D-alanine. It is meta-oli@ed in t,e -odyD ,owe"er, -eca/se o+ its
intense sweetness, t,e caloric contri-/tion to t,e diet is insi*ni+icant. It ,as a
syner*istic e++ect wit, ot,er sweeteners. Alitame ,as a clean taste and is sta-le -ot, at
,i*, temerat/res and -road H ran*es.
Sweetener >$$$ is :$,$$$ times sweeter t,an s/crose. Ori*inally disco"ered and
atented -y researc,ers at Cla/de 1ernard Uni"ersity in .yon, France, Sweetener
>$$$ is e0cl/si"ely licensed -y t,e N/traSweet Comany. It tastes similar to s/*ar
and romises e0cellent sta-ility in all ossi-le alications. It co/ld literally c,an*e
t,e way t,e world t,inks a-o/t sweeteners.
'%
Ot,er sweeteners are -ein* /sed in ot,er arts o+ t,e world 75a-le :&-<8.
'(,';
O"er :'$
lants ,a"e -een identi+ied as ossessin* a sweet taste.
<$
Fi*/re :&-= Sweeteners are makin* si*ni+icant inroads into t,e s/crose market.
Current Legislation Regarding Sweetener Use
5,e seci+ic /se o+ a sweetener m/st -e stated -e+ore it can -e aro"ed +or
commercial /se. 4ill it -e /sed as a +la"orin*, or will it -e /sed as an anticaries
a*ente S/c, di++erences in intended /se can *reatly a++ect t,e cost o+ *ettin* t,e
rod/ct on t,e market. I+ it is to -e /sed as a sweetener, t,en only sa+ety, teratolo*y,
m/ta*enicity, and carcino*enicity are s/-Aects o+ in"esti*ation. I+ anticario*enicity is
claimed, s/c, as is ossi-le in t,e /se o+ 0ylitol, a *reat amo/nt o+ additional money
m/st -e sent in animal and ,/man caries incidence st/dies -e+ore s/c, claims can -e
ad"ertised. 3stimates on t,e time and e0ense o+ marketin* an entirely new sweetener
ran*e / to :$ years and as ,i*, as f>$ million, resecti"ely. I+ t,e sweetener is
classi+ied as a new dr/*, it may re?/ire a dosa*e statement and acka*e insert
carryin* warnin*s o+ comlications, contraindications, and incomati-ility wit, ot,er
dr/*s.
<:
On t,e ot,er ,and, /-lic sa+ety is aramo/nt. Many o+ t,e ori*inal +ood additi"es
were c,osen +rom or*anic and inor*anic como/nds t,at were intended +or +a-ric and
aer coloration, wit, sa+ety -ein* secondary to rod/ct aeal.
Question 3
A. 5,e two amino acids in asartame are ,enylalanine and asartic acid.
1. Sweetener >$$$ ,as e?/i"alent sweetness to sacc,arin -/t no reorted a+tertaste.
C. S/nette, t,e sweetener, is known as aces/l+ame 2.
D. Sweetness is related to cario*enicity.
Summary
5,ere is little do/-t t,at t,e cons/mtion o+ s/*ar is associated wit, t,e caries
rocess, -/t s/*ar alone is not t,e sole determinant o+ w,et,er +ood is cario*enic.
<>

Sweetness is s/c, a c/lt/ral c,aracteristic, ,owe"er, t,at -e,a"ior modi+ication to
e0cl/de it +rom t,e diet is considered an imossi-ility. Also, t,e nonsweetenin*
-ene+its o+ s/crose in ind/stry wo/ld ro-a-ly */arantee its contin/ed /se. In many
ind/strial alications in t,e rearation and rocessin* o+ +ood, ot,er caloric and
noncaloric sweeteners are re+era-le to s/crose. New sweeteners ,a"e -een
introd/ced recently t,at are less cario*enic and many ,/ndred or t,o/sand times
sweeter t,an s/crose. Many o+ t,em are nonacido*enic and noncaloric. From a dental
standoint t,ese new sweeteners o++er t,e otential +or a considera-le decrease in
caries incidence. At t,e resent time no one sweetener dominates anot,er +rom t,e
clinical ersecti"e o+ caries re"ention.
&=
:. A and 1correct
Cincorrect. A +ood additi"e is considered s/sect, w,ereas t,e +ood in*redient ,as a
lon*-term record o+ /se and aarent sa+ety.
Dincorrect. 4it,o/t -acteria, no amo/nt o+ s/*ar is *oin* to rod/ce caries in t,e
*noto-iotic rats.
3incorrect. )eole wit, HFI cannot cons/me s/crose wit,o/t ad"erse systemic
ro-lems and ,ence e0erience +ew, i+ any, caries.
>. A, C, D, and 3correct
1incorrect. It re?/ires more sweetener to identi+y t,e rod/ct t,an to identi+y t,e
sweet taste.
=. A and Ccorrect
1incorrect. Sweetener >$$$ is :$,$$$ times sweeter t,an s/crose, w,ereas
sacc,arin is =$$ times t,e sweetness o+ s/*ar.
Dincorrect. Cario*enicity is related to s/*ar, not sweetness.
:. 5wo synt,etic caloric sweeteners are iiiiiiiii and iiiiiiiiiD two synt,etic
noncaloric sweeteners are iiiiiiiii and iiiiiiiii.
>. )ean/t -rittle made wit, sacc,arin wo/ld -e a "ery /n/s/al rod/ct, mainly
-eca/se t,e sweetener lacks t,e iiiiiiiii 7c,aracteristic8 t,at s/crose imarts to a
rod/ct. 5,ree ot,er attri-/tes o+ s/crose t,at are desira-le +rom a commercial
"iewoint are iiiiiiiii, iiiiiiiii, and iiiiiiiii.
=. Fo/r roerties o+ s/crose t,at make it /ndesira-le +or t,e rearation o+ some
cons/mer rod/cts are iiiiiiiii, iiiiiiiii, iiiiiiiii, and iiiiiiiii.
&. 5,e acronym G!AS re+ers to iiiiiiiii.
'. 5,e 6ie,olm st/dy demonstrated t,at two key +actors relatin* to cario*enicity o+
+oods were 7:8 +re?/ency o+ intake and 7>8 iiiiiiiiiD t,e lesson learned at
Hoewood Ho/se was iiiiiiiii.
<. 5,e lowest concentration at w,ic, a s/-stance is identi+ied to -e sweet is known as
t,e iiiiiiiii concentrationD t,e tastin* o+ ,i*,er concentrations to identi+y seci+ic
s/*ars is known as iiiiiiiii testin*.
%. 5,e s/*ar alco,ols are more correctly re+erred to as iiiiiiiii 7name8. 5,ree o+
t,ese como/nds are iiiiiiiii, iiiiiiiii, and iiiiiiiii.
(. 5,e noncario*enicity o+ 0ylitol is -eca/se it is iiiiiiiii.
;. A sweetener t,at is m/c, sweeter t,an s/crose is re+erred to as an iiiiiiiii
sweetener.
:$. 5,ree o+ t,e most o/lar sweeteners are iiiiiiiii, iiiiiiiii, and
iiiiiiiii.
::. One sweetener t,at is on t,e market today -eca/se o+ con*ressional action is
iiiiiiiii.
:>. A new rod/ct to -e acceted m/st incl/de data relatin* to carcino*enicity,
iiiii, and iiiiiiiii.
:=. Asartic acid and ,enylalanine are t,e two molec/les t,at make / iiiiiiiii
7name o+ sweetener8.
:&. 5,e c,emical name +or S/nette is iiiiiiiii.
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t,eir +ood *ro/ so/rces o+ +at. 'am !con &utr Rev, ::9&&-'%.
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!eort. No. SS!6:%N&. 4as,in*ton, DC9 U.S. Go"ernment )rintin* O++iceD
Decem-er :;;>.
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'=9>(=%;-(=.
'<. U.S. Food and Dr/* Administration. 7Aril =, :;;(8. Food additi"es ermitted +or
direct addition +or ,/man cons/mtion9 S/cralose. 'ederal Re$ister, 9A7<&89:<&:%-
==.
'%. Sweetener +or t,e >:st cent/rye 7:;;:8. 'ood Processin$, '>9'&.
'(. 6litos, A. #. 7Marc, >%, :;;<8. A comre,ensi"e o"er"iew o+ sweeteners
a"aila-le on t,e worldwide market and an analysis o+ ,ow t,ey comete in ractice on
rice, alication and le*islation. )aer resented at 4orld S/*ar and Sweetener
Con+erence, 1an*kok, 5,ailand.
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re"ention. /srael " Dent Sci, >9>$$-:=.
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considerations. Pharmacol Ther Dent, =9<;-%&.
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reser"ed.
Chapter 15. Nutrition, Diet, and Oral Conditions - Carole , Palmer (inda D,
#oyd
Objectives
:. 30lain t,e /nderlyin* rationale +or t,e !e+erence Daily Intakes, Food G/ide
)yramid, and +ood la-els.
>. Disc/ss t,e otential oral e++ects o+ se"ere maln/trition d/rin* or*ano*enesis.
=. Disc/ss w,y +oods wit, e?/al amo/nts o+ s/*ar are not necessarily e?/ally
cario*enic.
&. Descri-e ,ow dietary atterns and +ood comosition a++ects cario*enic otential.
'. Disc/ss t,e e++ects o+ +ood on -/++erin* caacity.
<. Disc/ss t,e role o+ n/trition in eriodontal disease.
%. 30lain w,y elderly atients are at ,i*,er n/tritional risk t,an ot,er a*e *ro/s.
(. Disc/ss t,e rele"ant n/tritional considerations +or atients w,o ,a"e dia-etes,
imm/nocomromisin* conditions, or ,ead and neck s/r*ery.
Introduction
Oral ,ealt,, diet, and n/tritional stat/s are closely linked 7Fi*/re :'-:8. N/trition is an
essential +or t,e *rowt,, de"eloment, and maintenance o+ oral str/ct/res and tiss/es.
D/rin* eriods o+ raid cell/lar *rowt,, n/trient de+iciencies can ,a"e an irreversi4le
e++ect on t,e de"eloin* oral tiss/es. )rior to toot, er/tion, n/tritional stat/s can
in+l/ence toot, enamel mat/ration and c,emical comosition as well as toot,
mor,olo*y and si@e.
:
3arly maln/trition increases a c,ildCs s/sceti-ility to dental
caries in t,e decid/o/s teet,.
>
5,ro/*,o/t li+e, n/tritional de+iciencies or to0icities
can a++ect host resistance, ,ealin*, oral +/nction, and oral-tiss/e inte*rity. For
e0amle, imm/ne resonse to local irritants and ,ealin* o+ eriodontal tiss/es may -e
imaired w,en n/tritional stat/s is comromised. 1eca/se t,e oral eit,eli/m ,as
more raid cell t/rno"er t,an most ot,er tiss/es in t,e -ody, clinical si*ns o+
maln/trition are o+ten mani+est +irst in t,e oral ca"ity.
A+ter toot, er/tion, t,e e++ects o+ diet on t,e dentition are toical rat,er t,an
systemic. Dietary +actors and eatin* atterns can initiate e0acer-ate or minimi@e
dental decay. Fermenta-le car-o,ydrates are essential +or t,e imlantation,
coloni@ation, and meta-olism o+ -acteria in dental la?/e. Factors s/c, as eatin*
+re?/ency and retenti"eness o+ car-o,ydrates in+l/ence t,e ro*ression o+ cario/s
lesions, w,ile +oods containin* calci/m and ,os,or/s, s/c, as c,eese, en,ance
reminerali@ation. Fre?/ent intake o+ acidic foods or -e"era*es can ca/se enamel
erosion. Con"ersely, imaired dental +/nction may lead to oor n/tritional ,ealt,.
Older ad/lts wit, loose or missin* teet,, or ill-+ittin* dent/res o+ten red/ce t,eir
intake o+ +oods t,at re?/ire c,ewin*, s/c, as +res, +r/its, "e*eta-les, meats, and
-reads.
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4,en t,e "ariety o+ +oods in a diet is red/ced, t,ere is *reater risk o+ n/trient
inade?/acies. 5,e atient w,o /nder*oes oral or eriodontal s/r*ery may re?/ire
dietary */idance to re"ent deleterio/s c,an*es in t,e diet. )atients wit, dia-etes
mellit/s, oral cancer, or deressed imm/ne +/nction may s/++er +rom oral conditions
t,at comromise n/tritional stat/s. 5,e dental clinician needs to understand ,ow diet
and n/trition can a++ect oral ,ealt,, and ,ow oral conditions can a++ect +ood c,oices
and /ltimately n/tritional stat/s. 5,is c,ater ro"ides an o"er"iew o+ t,e
relations,is -etween diet, n/trition and dental ractice, and o++ers aroriate
s/**estions +or atient */idance.
Fi*/re :'-: !elations,is -etween N/trition and Healt,.
Importance of Diet Assessment and Counseling in Dentistry
5,e modern dental ractitioner is not only concerned wit, ed/catin* atients +or t,e
re"ention o+ caries and eriodontal disease, -/t also lays an imortant role in
screenin* atients +or ot,er ,ealt, risks. #/st as a medical ,istory and -lood ress/re
e"al/ation are /sed to screen +or /nderlyin* medical conditions, a dietary assessment
and screenin* can ,el inoint otential n/tritional ro-lems t,at may a++ect or -e
a++ected -y dental care. 1eca/se o+ t,e lar*e n/m-er o+ atients seen re*/larly in
dental ractice, t,e dental team is in an e0cellent osition to reco*ni@e areas o+
nutritional ris*, 5,e role o+ t,e dental team s,o/ld -e to screen patients +or n/tritional
risk, ro"ide dietary $uidance related to oral ,ealt,, and refer patients to n/trition
ro+essionals +or treatment o+ ot,er n/trition-related systemic conditions.
=
Question 1
4,at are aroriate n/trition inter"entions +or dental clinicianse
A. Assess atientsC n/tritional stat/s /sin* la-oratory and ot,er -ioc,emical
assessment tools.
1. Screen atients +or n/tritional risk.
C. !eco*ni@e dietary ro-lems in dent/re atients.
D. )ro"ide diet */idance related to oral ,ealt,.
The Basis for a Healthy Diet
Dietary !e+erence Intakes
Daily +ood intake m/st -e s/++icient to meet meta-olic re?/irements +or ener*y and
ro"ide t,e essential n/trients t,at t,e -ody cannot synt,esi@e in s/++icient ?/antities
to meet ,ysiolo*ic needs. Since t,e :;&$s, t,e 'ood and &utrition #oard 7FN18 o+
t,e National Academy o+ Sciences ,as /-lis,ed t,e Recommended Dietary
llo3ances 7!DA8, w,ic, were recommendations +or daily n/trient intake t,at wo/ld
s/ort *rowt, and maintenance o+ -ody tiss/es, and re"ent de+iciency diseases. 7&-
Food and N/trition 1oard8. 1e*innin* in :;;%, t,e Food and N/trition 1oard -e*an
to make maAor c,an*es to t,e +ormat and /rose o+ t,e n/trition recommendations.
The Dietary Reference /nta*es (DR/) expands and replaces the RD
'
-y addressin*
t,e re"ention o+ chronic de$enerative diseases and t,e risk o+ excess inta*e of
nutrients,
'
5,e D!I are ?/antitati"e estimates o+ n/trient "al/es to -e /sed +or lannin* and
assessin* diets +or ,ealt,y eole.
'
5,ese re+erence "al/es "ary -y $ender and life
sta$e $roup, D!I consist not only o+ !DA -/t also t,ree ot,er tyes o+ re+erence
"al/es s,own in 5a-le :'-:.
3"al/ation o+ t,e tr/e n/tritional stat/s o+ an indi"id/al re?/ires a com4ination o+
clinical, -ioc,emical, and ant,roometric data.
'
So i+ an indi"id/al reorts an intake
o+ a n/trient -elow t,e !DA, more in+ormation wo/ld -e necessary to determine i+ an
act/al de+iciency e0ists. Con"ersely, n/trient intakes t,at meet t,e !DA o"er time
,a"e a low ro-a-ility o+ -ein* inade?/ate.
Dietary G/idelines +or Americans
5,e Dietary 0uidelines for mericans were +irst /-lis,ed in :;($, and are re"ised
e"ery > years.
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5,e */idelines are desi*ned to comlement t,e D!Is -y makin*
recommendations +or +ood c,oices to romote ,ealt,. 5,e >$$$ Dietary G/idelines
+or Americans contain :$ recommendations, *ro/ed into three areas called the #C
o+ *ood ,ealt,. 5,ey are s,own in 5a-le :'->.
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5,ese ne3est */idelines lace more
em,asis on physical activity and healthy 3ei$ht comared to re"io/s editions. 5,e
+oc/s on re"entin* o-esity is ca/sed -y t,e increased risk it resents +or many
c,ronic and de*enerati"e diseases, s/c, as ,eart disease, stroke, dia-etes, art,ritis,
,i*, -lood ress/re, and some kinds o+ cancer. 5,e recommendations em,asi@e
-alance, moderation, and "ariety in +ood c,oices, and romote increased /se o+ w,ole
*rains, +r/its and "e*eta-les, and decreased /se o+ sat/rated +at, c,olesterol, and salt.
In addition, +or t,e +irst time, t,e */idelines address +ood sa+ety in an e++ort to com-at
+ood--orne illness, an imortant /-lic ,ealt, concern.
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5,e >$$$ Dietary G/idelines +or Americans de+ine a ,ealt,y wei*,t accordin* to t,e
#ody %ass /ndex (#%/), 5,e 1MI is a medical standard +or de+inin* o-esity t,at not
only is ,i*,ly correlated wit, indeendent meas/res o+ -ody +at, -/t is also /sed to
determine i+ a erson is at increased ,ealt, risk d/e to e0cess wei*,t
%
75a-le :'-=8. A
,ealt,y 1MI o+ :; to >' is associated wit, t,e lowest statistical ,ealt, risk c(-Meisler,
:;;<d. )ersons wit, 1MI a-o"e >' are considered o-ese, and t,e recommendation is
to lose : to > 1MI /nits 7:$ to :' o/nds8 to red/ce t,eir risk +or c,ronic disease.
%
Food G/ide )yramid
5o ,el eole select n/trient-ric, +oods and to +ollow t,e Dietary G/idelines, t,e
'ood 0uide Pyramid was de"eloed -y t,e U.S. Deartment o+ A*ric/lt/re.
;
5,e
Food G/ide )yramid dislays +oods in +i"e cate*ories -ased on t,eir n/trient
comosition 7Fi*/re :'->8. 4,ole *rains, s/c, as rice, asta, cereals, and -reads,
+o/nd at t,e -road -ase o+ t,e )yramid s,o/ld +orm t,e +o/ndation o+ a ,ealt,+/l diet.
5,ey are *ood so/rces o+ car-o,ydrate 7incl/din* +i-er8 and minerals. Fr/its and
"e*eta-les +orm t,e ne0t le"el o+ t,e )yramid. 5,e meat *ro/ contains *ood so/rces
o+ rotein, "itamins, and minerals. Meat alternates, le*/mes, e**s, n/ts, and to+/, are
incl/ded in t,e meat *ro/. 5,e dairy *ro/ is comrised rimarily o+ *ood calci/m
so/rces. 5,e small trian*le at t,e to o+ t,e )yramid is +or t,e +ats, oils, and sweets
t,at ro"ide rimarily added calories and, t,/s, s,o/ld -e eaten in small amo/nts. No
sin*le +ood *ro/ is more imortant t,an anot,erD eac, *ro/ ro"ides some, -/t not
all, o+ t,e essential n/trients.
Standardi@ed ser"in* si@es and t,e recommended n/m-er o+ ser"in*s +or "ario/s a*e
*ro/s are seci+ied. Howe"er, t,e caloric content o+ +oods "aries widely wit,in a
+ood *ro/. 5,e desira-le n/m-er o+ ser"in*s +rom eac, +ood *ro/ deends not only
/on a*e and se0, -/t also t,e calorie *oal. For e0amle, i+ :,<$$ calories were t,e
daily ener*y *oal, an indi"id/al wo/ld c,oose t,e minim/m n/m-er o+ ser"in*s o+
low-+at +ood c,oices +rom eac, *ro/. I+ additional calories are needed, increased
ser"in*s s,o/ld come +rom t,e *rain, +r/it, and "e*eta-le *ro/s, rat,er t,an t,e to
o+ t,e yramid.
Food .a-els
5,e N/trition Facts anel +o/nd on most rocessed +ood acka*es ,els t,e cons/mer
select +oods t,at meet t,e Dietary G/idelines 7Fi*/re :'-=8. 5,e &ational (a4elin$
and !ducation ct of CHH: re?/ires t,at comre,ensi"e n/trition in+ormation must
aear on t,e la-els o+ most rocessed +oods and rocessed meats and o/ltry
rod/cts. In addition, n/trition in+ormation at oint o+ /rc,ase is voluntary +or +res,
+r/its, "e*eta-les, and raw +is,. In accord wit, t,e mandatory +ood la-elin*
re*/lations /-lis,ed -y t,e Food and Dr/* Administration in :;;&,
:$
t,e n/trition
anel on rocessed +oods m/st incl/de t,e +ollowin*9
standardi1ed portion si1e 7desi*ned to make n/tritional comarisons o+ similar
rod/cts easier, and re+lects t,e ser"in* si@es t,at eole act/ally eat8.
5,e n/m-er o+ servin$s per container,
5,e amo/nts o+ total calories and calories from fat er ser"in*.
5,e num4er of $rams er ser"in* o+ total +at, sat/rated +at, c,olesterol, sodi/m, total
car-o,ydrates, dietary +i-er, s/*ars, and rotein.
In addition, t,e n/tritional contri-/tion o+ one ser"in* o+ t,e rod/ct m/st -e stated as
a percenta$e of the Daily =alues, 5,e Daily 6al/es are -ased on t,e !DA +or rotein,
"itamins, and minerals and on standards desi*ned esecially +or +ood la-els +or
n/trients not co"ered in t,e !DA s/c, as +at, c,olesterol, total car-o,ydrates, dietary
+i-er, and sodi/m. 5,e calc/lations to determine t,e ercents o+ Daily 6al/es are
-ased on a <,:::2calorie diet, Deendin* on a ersonCs a*e, *ender, and acti"ity le"el,
a erson may need more or less t,an :$$E o+ a Daily 6al/e. 5,e Daily 6al/e also
,els cons/mers see ,ow a +ood +its into an o"erall daily diet.
Ot,er in+ormation, s/c, as t,e amo/nts o+ oly/nsat/rated or mono/nsat/rated +ats or
ot,er "itamins and minerals, is otional. In addition, descritors s/c, as F+ree,F Flow,F
F,i*,,F Fli*,t,F Flean,F or Fred/ced,F may -e /sed on t,e la-el as lon* as a standard
ortion meets defined criteria, For e0amle, to -e la-eled Flow-calorieF a ser"in*
m/st ,a"e no more t,an &$ calories. 5o -e la-eled Flow-+at,F no more t,an = *rams o+
+at er ser"in* is allowed.
Healt, claims +or t,e otential -ene+it o+ a n/trient or +ood in relation to a disease or
,ealt, condition will -e allowed on la-els i+ t,ey are s/orted -y scienti+ic e"idence
and are aro"ed -y t,e Food and Dr/* Administration 7FDA8. 5,e :> ,ealt, claims
c/rrently allowed to -e laced on +ood la-els are s,own in 5a-le :'-&.
::
Fi*/re :'-> 5,e Food G/ide )yramid9 A G/ide to Daily Food C,oices is an
o/tline o+ w,at to eat eac, day. Not a ri*id rescrition -/t a *eneral */ide t,at
lets eac, erson c,oose a ,ealt,+/l diet, t,e )yramid calls +or eatin* a "ariety o+
+oods to *et t,e needed n/trients w,ile cons/min* t,e ri*,t amo/nt o+ calories to
maintain a ,ealt,y wei*,t. 7Co/rtesy U.S. Deartment o+ A*ric/lt/re, H/man
N/trition In+ormation Ser"ice.8
Fi*/re :'-= Food .a-el.
Question 2
5,e Daily !e+erence Intakes 7D!I8 are set at9
A. t,e minim/m amo/nt o+ a n/trient needed to re"ent de+iciency.
1. t,e ma0im/m amo/nt t,at will not ca/se to0icity.
C. t,e a"era*e estimated re?/irement +or ,ealt,y eole.
D. t,e a"era*e re?/irement l/s a mar*in o+ sa+ety.
Nutrition in the Development and Integrity of Oral Tissues and Structures
N/trition lays an imortant role in t,e initial *rowt, and de"eloment or oral tiss/es
and in t,eir contin/o/s inte*rity t,ro/*, t,e li+esan. Otimal n/trition d/rin* eriods
o+ ,ard and so+t tiss/e de"eloment allow t,ese tiss/es to reac, t,eir otimal otential
+or *rowt, and resistance to disease. Maln/trition 7eit,er o"er or /nder-n/trition8
d/rin* critical eriods o+ or$ano$enesis can ,a"e irreversi4le e++ects on de"eloin*
tiss/es. 30amles o+ t,is e++ect can -e seen in t,e tetracycline stainin$ o+ teet,, in
dental fluorosis, and in t,e +e"er-ind/ced enamel hypoplasia seen in t,e rimary
teet,.
:>
In t,e dentition, maln/trition is less well doc/mented in ,/mans t,an in
animals, -/t it aears t,at d/rin* t,e Fcritical eriods,F maln/trition can res/lt in
dentition wit, increased caries s/sceti-ility.
:=
Maln/trition after initial or*an and
tiss/e de"eloment is usually reversi4le, -/t can still comromise tiss/e re*eneration
and ,ealin* and increase s/sceti-ility to oral diseases. N/trients +or w,ic,
de+iciencies or e0cesses ,a"e -een directly associated wit, oral conditions are roteinD
ener*yD "itamins C, A, DD iodineD and +l/oride.
)roteinBCalorie Maln/trition
)rotein is t,e most a-/ndant or*anic como/nd in t,e -ody and is re?/ired +or t,e
synt,esis o+ "irt/ally all -ody tiss/es and str/ct/res. )roteins acco/nt +or t,e str/ct/re
o+ DNA, t,e tensile stren*t, o+ colla*en, and t,e "iscosity o+ sali"a. 5,/s, a-errations
in rotein n/trit/re can ,a"e +ar reac,in* oral and systemic e++ects.
5,e normal t/rno"er o+ eit,elial tiss/e in t,e oral ca"ity re?/ires a contin/al s/ly
o+ n/trients. For e0amle, every A to 9 days, the 4asal epithelium of the $in$iva
under$oes rene3al,
:&
5,/s, any se"ere de+iciency o+ roteinBcalorie intake will res/lt
in a decrease in mitotic acti"ity in t,e cre"ic/lar eit,eli/m, as well as elsew,ere
t,ro/*,o/t t,e -ody.
:'
In a comarison o+ eriodontal in"ol"ement in atients wit,
se"ere maln/trition 7kwas,iorkor8 wit, t,at o+ ,ealt,y controls in So/t, India,
:<
+ewer
caries and more eriodontal disease was +o/nd amon* t,e /nderno/ris,ed *ro/.
Since t,e oral ,y*iene indices o+ -ot, *ro/s were similar, it was ass/med t,at t,e
di++erence was d/e to n/tritional +actors. 7It s,o/ld -e noted t,at any maln/trition o+
t,e se"erity o+ kwas,iorkor reresents a m/lti-n/trient de+iciency8. Imaired rotein
synt,esis ,as -een +o/nd i+ rotein maln/trition occ/rs d/rin* t,e de"elomental
sta*e in animals.
:%
In animal models, s,ort-term +astin* 7& days8 res/lted in a &$E
red/ction in colla*en rod/ction.
:(
In t,e same st/dy, a :$E decrease in colla*en
synt,esis was noted wit, a red/ced dietary intake meetin* >$E o+ re?/irements.
:(

5,ese +indin*s s/**est t,at e"en s,ort-term states o+ /ndern/trition may imact
colla*en synt,esis.
In chronically malnourished c,ildren, se"eral st/dies ,a"e s,own delays in toot,
er/tion atterns, and increased toot, enamel sol/-ility, leadin* to increased caries
s/sceti-ility.
:;->'
5,e linear hypoplasia reorted in t,e enamel o+ rimary teet, o+ c,ildren in
/nderri"ile*ed o/lations is t,o/*,t to contri-/te to t,eir ,i*, re"alence o+ dental
caries. 5,is tye o+ ,yolasia aears to -e related to t,e se"erity o+ t,e
maln/trition.
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4it, t,e e0cetion o+ t,e cleansin$ and dilutin$ e++ects o+ sali"a, oral de+ense
mec,anisms deend on an ade?/ate s/ly o+ roteins. 5,e $lycoproteins t,at res/lt
in a**re*ation o+ -acteria arise +rom t,e sali"ary *lands. (yso1yme, salivary
peroxidase, and lactoferrin are also $lycoproteins, Secretory /$ 7sI*A8 arises mainly
+rom t,e la-ial and -/ccal *lands and is an imm/no*lo-/lin. 5,e cell tyes in"ol"ed
in cell/lar imm/nity 7olymor,on/clear lym,ocytes and macro,a*es and t,e
en@ymes /sed in ,a*ocytosis8 also re?/ire rotein +or t,eir rod/ction.
>%
)ro-a-ly one o+ t,e most deleterious e++ects o+ roteinBcalorie de+iciency is t,e
deletion o+ t,e cellular and immunocellular defenses o+ -ot, t,e oral and t,e
connecti"e sides o+ t,e -arrier eit,elial cells linin* t,e *in*i"al cre"ice. In *eneral,
t,e se"erity o+ t,e imaired imm/nolo*ic resonse arallels t,e se"erity o+ t,e rotein
or calorie de+iciency.
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Minerals
Calci/m, in association wit, "itamin D and ,os,or/s is essential +or roer
de"eloment and maintenance o+ minerali@ed tiss/es 7teet, and al"eolar -one8. A
de+iciency o+ t,ese n/trients d/rin* critical ,ases o+ toot, de"eloment in c,ildren
res/lts in ,yo-minerali@ation o+ de"eloin* teet,, and ossi-le delayed er/tion
atterns.
>;
3namel ,yolasia may -e seen in remat/rely -orn "ery low -irt,-wei*,t
76.148 in+ants d/e to t,e ,i*,er needs +or calci/m and ,os,or/s in t,ese
in+ants.
=$
In addition, 6.14 in+ants ,a"e immat/re kidneys and may not meta-oli@e
ade?/ate le"els o+ "itamin D.
=$
Iron is o+ interest since iron de+iciency is t,e most common deficiency in t,e United
States. Iron de+iciency anemia is mani+est in t,e oral ca"ity -y allor o+ oral tiss/es,
esecially t,e ton*/e. 5,e ton*/e may aear s,iny, wit, -l/nted +ili+orm aillae.
5,e e++ects o+ iron de+iciency on minerali@ed tiss/es are less clear. In rats, e"en a
mar*inal de+iciency o+ iron in t,e rat diet redisoses t,e rats to caries. Con"ersely,
s/lementin* a caries-romotin* diet wit, iron rod/ced a maAor red/ction in caries
wit, t,e *reatest e++ect s,own in t,e neonatal eriod.
=:
In addition, iron ser"es as a
co+actor wit, ascor-ic acid in colla*en synt,esis, as is coer.
=>
Iinc re*/lates function in inflammation -y in,i-itin* t,e release o+ lysosomal
en@ymes and ,istamines. A @inc de+iciency can in,i-it colla*en +ormation and red/ce
cell-mediated imm/nity.
==
5,e e++ect o+ @inc in modi+yin* eriodontal de+ense
mec,anisms ,as -een s,own in ra--its,
='
-/t ,as yet to -e clearly delineated in
,/mans.
=<, =%
6itamins
6itamin A is essential +or t,e de"eloment and contin/ed inte*rity o+ all -ody or*ans
and tiss/es, incl/din* t,e epithelial mucosa o+ t,e oral ca"ity. In "itamin-A
de+iciency, cell di++erentiation is imaired9 %ucus2secretin$ cells are relaced wit,
keratin-rod/cin* cells. 5,e res/lt is de+ecti"e tiss/e +ormation, and imaired ,ealin*.
6itamin-A de+iciency also res/lts in imairment o+ 4oth specific and nonspecific
immunoprotective mechanisms, De+iciency can a++ect tiss/e resonse to -acterial
in+ection, m/cosal imm/nity, arasitic and "iral in+ection, nat/ral killer-cell acti"ity,
and ,a*ocytosis.
=(
6itamin-A to0icity can s,ow similar e++ects, wit, imaired
,ealin* resonse -ein* t,e most direct a++ect on t,e oral ca"ity.
=;
3++ects incl/de
roli+eration o+ oral eit,eli/m, red/ction o+ t,e keratin layer, t,ickenin* o+ t,e -asal
mem-rane, and increase in t,e *ran/lar layer. A atient w,o took >$$,$$$ IU o+
"itamin A daily +or o"er < mont,s resented wit, ain+/l *in*i"al lesions, alon* wit,
na/sea, "omitin*, 0erostomia, and ,eadac,es. Clinical e0amination re"ealed *in*i"al
erosions, /lcerations, -leedin*, swellin*, loss o+ keratini@ation, color c,an*es, and
des?/amation o+ t,e lis.
=;
All at,olo*ic mani+estations disaeared wit,in > mont,s
o+ t,e elimination o+ t,e "itamin A s/lements w,en oral ,y*iene ,a-its were
/nc,an*ed.
6itamin C 7ascor-ic acid8 is essential to oral ,ealt,. Synt,esis o+ hydroxyproline, an
essential comonent o+ colla$en, re?/ires ascor-ic acid. De+ects in colla*en synt,esis
are resonsi-le +or t,e many mani+estations o+ "itamin-C de+iciency 7scurvy8. In t,e
oral ca"ity t,ese incl/de sontaneo/s -leedin*, in+/sions o+ -lood into interdental
aillae, loosenin* and e0+oliation o+ teet,, detac,ment o+ oral eit,elial tiss/e, and
imaired wo/nd ,ealin*.
5,e e++ects o+ "itamin-C de+iciency are -est st/died in animal models, w,ere all
+actors can -e controlled. Ac/te sc/r"y can -e rod/ced -y lacin* monkeys on a
"itamin-C de+icient diet +or :> weeks. 5,e ,ydro0yroline content o+ t,e *in*i"a
started to decline in t,e +irst +o/r weeks and occ/rred at a +aster rate t,an in skin.
&$
1y
t,e end o+ t,e (t, week, t,e synt,esis o+ ,ydro0yroline was totally imaired.
&$
5,e
res/lts are e0tensi"e *in*i"al ocket +ormation and toot, mo-ility d/e to de*radation
o+ t,e colla*en makin* / eriodontal li*ament +i-ers.
>'
Alt,o/*, +rank sc/r"y is rare, e"en mar*inal de+iciencies may res/lt in alterations in
colla*en synt,esis. 5,/s de+icient or mar*inal ascor-ic acid intakes may -e a
conditionin* +actor in t,e de"eloment o+ *in*i"itis and one o+ t,e early
mani+estations o+ "itamin-C de+iciency.
&:
5,e most recent eidemiolo*ic data +rom
NHAN3S III 7National Healt, and N/trition 30amination S/r"ey8 s/**ests t,at t,e
odds o+ ,a"in* eriodontal disease are :.> times *reater in t,ose wit, low dietary
"itamin-C intakes.
&>
In t,e same st/dy, smo*ers and former smo*ers wit, low
"itamin-C intake are at :.< times *reater risk o+ ,a"in* eriodontal disease.
&>

!esearc, +indin*s s/**est t,at eole wit, mar*inal "itamin-C de+iciency
s/lemented wit, ascor-ic acid ,a"e a statistically si*ni+icant increase in
,ydro0yroline in eriodontal tiss/es.
&=
Ascor-ic acid is essential to imm/ne related +/nctions, s/c, as resistance to oral
in+ection, "ia its role in le/kocyte +ormation and s/-se?/ent pha$ocytosis,
Con"ersely, c,ronic "itamin C e0cess may reciitate a sc/r"y-like condition
7re-o/nd sc/r"y8 /on cessation o+ t,e "itamin. 1eca/se t,e imact o+ de+icient le"els
o+ "itamin C is +irst o-ser"ed in *in*i"al tiss/es, dentists and dental ,y*ienists in
clinical ractice may -e t,e +irst to dia*nose t,e ,enomenon.
&&
5,e 1-comle0
"itamins rimarily +/nction as co2en1ymes in ener$y meta4olism, 1-comle0 "itamins
are +o/nd widely in +oods, and /s/ally to*et,er. 4it, t,e e0cetion o+ 1
:>
in t,e
elderly and +olic acid in re*nant women, de+iciencies o+ sin*le 1 "itamins are
/ncommon. Oral si*ns and symtoms o+ 1-comle0 "itamin de+iciencies incl/de
cracks in t,e corners o+ t,e mo/t, 7c,eilosis8, in+lammation, -/rnin*, redness, ain
and swellin* o+ t,e ton*/e.
&'
Question 3
4,ic, is true a-o/t "itamins and oral ,ealt,e
A. 6itamin-C-de+icient wo/nds ,eal as well as non-"itamin-C-de+icient wo/nds
1. 6itamin A-to0icity does not ,a"e oral e++ects
C. 5,e oral mani+estations o+ "itamin-C de+iciency are related to de+ects in colla*en
+ormation
D. 3++ects o+ de+iciency and to0icity are -est st/died in ,/mans
Diet and Nutrition in Oral Conditions: Background and Counseling Strategies
4,o Needs Diet G/idance Caries )re"ention
Dietary education and $uidance are imortant +or t,e re"ention and control o+ dental
caries. )atients s,o/ld -e care+/lly assessed to determine t,e le"el o+ re"ention and
n/trition */idance needed +ollowin* t,ese Instit/te o+ Medicine re"ention
*/idelines9
&<
Selective Prevention6 5,is strate*y tar*ets s/-set o+ t,e total o/lation t,at are
deemed to -e at risk +or caries +or a "ariety o+ reasons. 30amles incl/de9
Adolescents at risk o+ caries -eca/se o+ ,i*, intake o+ so+t drinks and snack +oods.
Caries-re"ention co/nselin* +or atients wit, 0erostomia or cario*enic diet atterns.
)roacti"e diet s/**estions +or new dent/re wearers or t,ose ,a"in* Aaw +i0ation.
Diet ad"ice rior to radiation or c,emot,eray.
Usin* c/rrent diet atterns as a -asis +or disc/ssion, atients s,o/ld -e ta/*,t t,e role
o+ diet in caries, w,at are cario*enic and noncario*enic eatin* atterns, and ,ow to
adat c/rrent diet to lower cario*enic risk.
/ndicated Prevention6 5,is strate*y tar*ets indi"id/als s,owin* early dan*er si*ns o+
caries, s/c, as e0tensi"e cer"ical deminerali@ation. 5,ese indi"id/als need t,e
immediate a+orementioned inter"entions as well as more detailed */idance on ,ow to
red/ce cario*enicity o+ t,eir c/rrent diet. 5,is will in"ol"e determinin* t,e +actors
in+l/encin* c/rrent ,a-its, and workin* wit, t,e atient to de"elo aroriate and
acceta-le strate*ies +or imro"ement. )atients need to -e +ollowed / on a re*/lar
-asis to romote lon*-term c,an*e.
Question 4
5,e diet assessment rocess in dentistry is desi*ned to9
A. dia*nose n/trient de+iciencies
1. ,el screen atients +or oral-,ealt, risk +actors
C. ser"e as a teac,in* tool
D. determine atientsC daily caloric intake
3. ro"ide a t,erae/tic diet rescrition +or atients
F. -e art o+ total re"enti"e assessment
Dental Caries9 !ole o+ Car-o,ydrates in Caries De"eloment
Dental caries is a common la?/e-deendent -acterial in+ection t,at is stron*ly
a++ected -y diet. De"eloment o+ clinical caries is contin*ent /on t,e interaction o+
t,ree local +actors in t,e mo/t,9 a suscepti4le tooth, cario$enic 4acteria, and
fermenta4le car4ohydrate 7Fi*/re :'-&8. A-sence o+ one o+ t,ese +actors dramatically
red/ces caries risk. M/tans stretococci are t,e redominant oral -acteria t,at initiate
t,e caries rocess. Newly er/ted teet, wit, a t,in enamel layer are "ery caries
s/sceti-le. 5oot, mor,olo*y, esecially t,e resence o+ dee its and +iss/res,
in+l/ences t,e likeli,ood t,at m/tans stretococci will attac, to and coloni@e t,e
toot,Cs s/r+ace. )la?/e -acteria +erment starc,es and s/*ars, rod/cin* or*anic acids.
5,ese acids deminerali@e dental enamel.
&%
Ot,er dietary +actors counteract t,e dama*in* e++ects o+ car-o,ydrates. 5,e resence
o+ rotecti"e minerals and ions s/c, as fluoride, calcium, and phosphorus in pla5ue
and saliva, romote reminerali@ation o+ inciient lesions. In addition to transortin*
minerals, sali"a contains 4ufferin$ a$ents, 4icar4onate and phosphates, t,at
ne/trali@e or*anic acids. 5,/s, t,e amo/nt and comosition o+ sali"a a++ect t,e caries
rocess. Ot,er ,ost +actors t,at in+l/ence caries risk incl/de9 *enetic redisosition,
imm/ne stat/s, maln/trition d/rin* toot, +ormation, ed/cation le"el, and income
stat/s.
In t,e most recent national ,ealt, and e0amination s/r"ey 7NHAN3S III, ),ase I8
;&E o+ ad/lts s,owed e"idence o+ coronal caries and >>.'E o+ ad/lts ,ad root
caries.
&(
In t,e same s/r"ey, >'E o+ t,e c,ildren and teens a*ed ' to :% ,ad ($E o+
t,e dental caries detected in t,e ermanent teet,.
&;
For t,ese caries-rone c,ildren and
ad/lts, nutrition counselin$ a-o/t t,e dama*in* e++ects o+ +ermenta-le car-o,ydrates
on teet, is essential.
5,ro/*, eidemiolo*ical and clinical st/dies disc/ssed in C,ater :&, t,e ca/sal
relations,i -etween s/*ar cons/mtion and dental caries ,as -een esta-lis,ed.
Animal st/dies s/**est t,at an increase in t,e concentration o+ s/crose in t,e diet
red/ces dental la?/e +ormation and increases t,e incidence o+ dental caries.
'$,':

)eole wit, "ery low s/*ar intakes ,a"e low-caries scores. )eole in nations t,at ,a"e
,i*, s/*ar intakes ,a"e ,i*, rates o+ caries.
'>
It is /nclear i+ t,is is rimarily t,e
toical e++ect o+ s/*ar cons/mtion or systemic e++ects on dentin +ormation. Howe"er,
t,e amo/nt o+ s/*ar cons/med is not t,e sole dietary "aria-le associated wit, caries
de"eloment. S/crose lays a more dominant role t,an ot,er s/*ars in t,e
de"eloment o+ smoot, s/r+ace caries. One o+ s/croseCs meta-olic -y-rod/cts, an
e0tracell/lar olysacc,aride called $lucan, ena-les t,e m/tans stretococci to ad,ere
to t,e smoot, enamel s/r+aces.
'=
Howe"er, t,e amo/nt o+ s/crose necessary +or t,e
imlantation o+ m/tans stretococci is "ery low.
Alt,o/*, s/*ar intake is ,i*, amon* most ersons in ind/striali@ed co/ntries, it is
more di++ic/lt to demonstrate a correlation -etween caries re"alence and t,e amo/nt
o+ s/*ar cons/med t,an in de"eloin* co/ntries w,ere s/*ar intake is lower. 5,ree
recent clinical trials o+ 3n*lis,, United States, and Canadian sc,oolc,ildren e0amined
t,e relations,i -etween s/*ar intake and dental caries. In 3n*land, &$' c,ildren wit,
a mean a*e o+ ::.< years were +ollowed +or > years. 5otal s/*ar intake 7::( *rams er
day or >:E o+ total calorie intake8 ,ad t,e ,i*,est si*ni+icant correlation wit, caries
rates.
'&
Intake o+ s/*ary +oods -e+ore -edtime was ,i*,ly correlated wit, caries
incidence. In t,e United States, &;; c,ildren a*ed :: to :' years, li"in* in
non+l/oridated r/ral Mic,i*an comm/nities, were +ollowed +or = years. 5,e a"era*e
increase in decayed, missin*, and +illed s/r+aces 7DMFS8 o"er t,e = years was =.: in
*irls and >.% +or -oys. 5,e daily a"era*e s/*ar intake was :&> *rams, t,is reresented
><.'E o+ t,eir total ener*y intake. C,ildren w,o o-tained a ,i*,er ercent o+ t,eir
total calories +rom s/*ars ,ad more ro0imal s/r+ace caries. 5,e a"era*e n/m-er o+
eatin* occasions and t,e n/m-er o+ s/*ary -etween-meal snacks cons/med were not
related to caries increment.
''
'ifty percent o+ >=> ::-year-old c,ildren in a Canadian st/dy ,ad inade5uate diets,
C,ildren wit, s/erior diets tended to de"elo +ewer cariesD ,owe"er, t,e association
was not statistically si*ni+icant.
'<
Di++erences in eatin* atterns and intake o+ caries-
romotin* +oods amon* t,e c,ildren in t,ese st/dies may ,a"e -een too small to
res/lt in si*ni+icant di++erences in caries e0erience. Ot,er +actors contri-/tin* to t,e
caries decline in western co/ntries are9 +l/oride intake +rom water, t,e /se o+
+l/oridated denti+rices, imro"ed la?/e control, t,e /se o+ dental sealants, and more
+re?/ent "isits to t,e dentist.
'%
5,e /se o+ su$ar alcohols and alternative s3eeteners in +oods also ,as ,ad a role in
reducin$ caries. )er,as one o+ t,e most romisin* s/*ar s/-stit/tes to -e st/died is
xylitol, a s/*ar alco,ol t,at ,as -een demonstrated to -e non-cario*enic as well as
romotin* reminerali@ation.
'(
GylitolCs a-ility to in,i-it meta-olic acid rod/ction -y
m/tans stretococci res/lts in minimal deression o+ la?/e H. Maintenance o+ t,e
pla5ue pH close to the saliva pH also +osters reminerali@ation o+ teet,.
';
In addition,
t,e s/-stit/tion o+ 0ylitol +or +ermenta-le s/*ars in t,e diet res/lts in a less cario*enic
-acterial +lora. 5,e imortance o+ ot,er non-+ermenta-le sweeteners in caries control
is detailed in C,ater :&.
Simle s/*ars are not t,e only car-o,ydrate t,at in+l/ences t,e de"eloment o+ a
cario/s lesion. Hi*,ly re+ined coo*ed starch2su$ar com4inations s/c, as do/*,n/ts,
cookies, otato c,is, and some ready-to-eat -reak+ast cereals produce a prolon$ed
acido$enic response w,en retained in interro0imal saces.
<$
4,en starc,es are
cooked, t,ey are artially de*raded. 5,is allows t,e sali"ary al,a-amylase to con"ert
starc, articles retained on t,e ton*/e, oral m/cosa, and teet, to maltose, Makin*
maltose a"aila-le to la?/e -acteria e0tends t,e len*t, o+ time t,e la?/e H will
remain low and ermit enamel deminerali@ation to occ/r. 5,/s, retenti"e ,i*, starc,
+oods may -e more acido*enic t,an ,i*,-s/*ar-low-starc, +oods t,at are raidly
eliminated +rom t,e mo/t,.
<:
3++ects o+ 3atin* )atterns and ),ysical Form o+ Foods
Ot,er dietary +actors t,at may ,inder or en,ance caries de"eloment incl/de9 t,e
+re?/ency o+ eatin*, t,e physical form o+ t,e car-o,ydrate 7li?/id "s. solid8,
retentiveness o+ a +ood on t,e toot, s/r+ace, t,e se5uence in w,ic, +oods are
cons/med 7e.*., c,eese eaten -e+ore a sweet +ood limits t,e H dro8, and t,e
resence o+ minerals in a +ood.
Fre?/ent -etween-meal snackin* on s/*ar or rocessed starc,-containin* +oods
increases la?/e +ormation and e0tends t,e len*t, o+ time t,at -acterial acid
rod/ction can occ/r. 4,en total daily s/*ar intake was ,eld constant, increasin* t,e
+re?/ency o+ s/*ar intake +or *ro/s o+ rats res/lted in increased n/m-er o+
Streptocococi mutans in la?/e and t,e amo/nt o+ caries e0erienced.
<>
5,e ositi"e
relations,i -etween +re?/ency o+ s/*ar intake and caries in ,/mans was +irst
demonstrated in t,e =ipeholm st/dy.
<=
S/-Aects w,o cons/med candies 4et3een meals
de"eloed more caries t,an t,ose w,o were +ed e?/al amo/nts o+ s/*ars 3ith meals.
Fre?/ent snackin* -etween meals kees t,e la?/e H low and e0tends t,e time +or
enamel and dentin deminerali@ation to occ/r.
1acterial +ermentation can contin/e as lon* as car-o,ydrate ad,eres to t,e enamel and
e0osed dentinal toot, s/r+aces. 3"en t,o/*, starc,y +oods "ary in t,eir cario*enic
otential, t,e ,i*,ly re+ined starc,y +oods, s/c, as so+t -read and otato c,is, t,at
are retained on toot, s/r+aces +or rolon*ed eriods o+ time, res/lt in a lowered H
w,ic, may last up to 9: minutes,
<&,<:
Hi*,-s/crose con+ectionery +oods deli"er ,i*,
le"els o+ s/*ar to t,e oral -acteria immediately a+ter t,e +oods are cons/med, w,ereas
,i*,-starc, +oods deli"er ro*ressi"ely increasin* concentrations o+ s/*ars o"er a
considera-ly lon*er eriod o+ time.
5,e se5uence in w,ic, +oods are eaten a++ects ,ow m/c, t,e la?/e H +alls. S/*ared
co++ee cons/med at t,e end o+ a meal will ca/se t,e la?/e H to remain lo3 for a
lon$er time t,an w,en an /nsweetened +ood is eaten follo3in$ intake o+ s/*ared
co++ee.
<'
I+ ean/ts are eaten -e+ore or a+ter s/*ar-containin* +oods, t,e la?/e H is
less deressed.
<<
Some comonents o+ +oods are protective a*ainst dental caries. )rotein, +at,
,os,or/s, and calci/m in,i-it caries in rats.
<%
A*ed nat/ral c,eeses ,a"e -een
s,own to -e cariostatic.
<(
4,en c,eese is eaten +ollowin* a s/crose rinse, t,e la?/e
H remains ,i*,er t,an w,en no c,eese +ollows a s/crose rinse. In addition, enamel
deminerali@ation, meas/red /sin* t,e intraoral cario*enicity test, is red/ced. 5,e
rotecti"e e++ect o+ c,eeses is attri-/ted to their texture t,at stimulates salivary flo3,
and t,eir rotein, calci/m, and ,os,ate content t,at neutrali1es pla5ue acids,
Fl/oride +o/nd in drinkin* water, +oods, and denti+rices increases a toot,Cs resistance
to decay and en,ances reminerali@ation o+ cario/s lesions.
(ipids seem to accelerate oral clearance o+ +ood articles. Some +atty acids, linoleic
and oleic, in low concentration, in,i-it *rowt, o+ m/tans stretococc/s. .ectins,
roteins +o/nd in lants, aear to inter+ere wit, micro-ial coloni@ation and may
a++ect sali"ary +/nction.
<;
Fi*/re :'-& Factors !e?/ired +or Caries De"eloment.
Question 5
In t,e diet o+ a atient wit, ramant dental caries, w,ic, is most relevant to t,e
ro-leme
A. total amo/nt o+ s/crose cons/med
1. total amo/nt o+ sticky sweets cons/med
C. n/trient ?/ality o+ t,e meals and snacks
D. n/m-er o+ meals and snacks
3. w,at is eaten +or desert in t,e e"enin*
Meas/rin* t,e Cario*enic )otential o+ Foods
Since it is /net,ical to cond/ct ,/man e0eriments to meas/re t,e tr/e cario*enic
otential o+ +oods, ot,er indirect tests ,a"e -een de"eloed. 5,ese tests ena-le
researc,ers to classi+y +oods into at least t,ree cate*ories9 rotecti"e, low, and ,i*,
cario*enic otential. C/rrently t,e cario*enic otential or t,e a-ility to ind/ce caries
in ,/mans may -e assessed indirectly -y meas/rin* t,e a-ility o+ a test +ood to ca/se9
caries +ormation in animals, acid rod/ction in dental la?/e, or deminerali@ation o+
enamel.
:
Animal st/dies ,a"e -een cond/cted /sin* a pro$rammed feedin$ machine, In one
st/dy, >$ common snack +oods were resented to rats at seci+ied inter"als d/rin* t,e
day.
%$
A+ter s/lcal and smoot, s/r+ace caries were scored in t,e animals, cario*enic
otential indices 7C)ICs8 were com/ted +or eac, +ood 7t,e s/crose *ro/ ,ad a C)I
"al/e o+ one8 75a-le :'-'8. A +ood wit, a C)I o+ $.& ,ad low cario*enic otential.
5,ose snack +oods wit, ,i*, cario*enic otential ,ad :E or more ,ydroly@a-le starc,
in com-ination wit, s/crose or ot,er s/*ars.
Acid rod/ction in t,e mo/t, d/rin* -acterial +ermentation o+ a +ood is redicti"e o+
t,e contri-/tion o+ t,at +ood to t,e caries rocess. Meas/rement o+ la?/e
acido*enicity can -e meas/red -y determinin* t,e H o+ a la?/e samle taken +rom
t,e mo/t, or in situ,
:
Foods t,at ca/se t,e la?/e H to +all -elow t,e critical
deminerali@ation le"el 7pH >,> to >,:8 are considered acido*enic. Meas/rement o+ oral
la?/e H re?/ires lacement o+ a wire-telemetric appliance containin* a H
microelectrode in t,e sace w,ere a toot, is missin* in t,e mo/t,. As t,e test +ood is
c,ewed, t,e H /nder /ndist/r-ed la?/e at t,e site o+ t,e indwellin* electrode is
contin/ally transmitted to an e0ternal recei"er. 5,e rate o+ t,e +all and rise o+ t,e H
at an interro0imal site can -e recorded contin/o/sly /sin* la?/e telemetry. Foods
+o/nd to ,a"e low acido*enic otential /sin* t,is met,od incl/de9 a*ed c,eeses, some
"e*eta-les, meats, +is,, and n/ts.
%:
5o assess t,e a-ility o+ a +ood to deminerali@e dental enamel, an intraoral
cario$enicity test ,as -een de"eloed. 1o"ine or ,/man dental enamel sla-s are
im-edded in a rost,esis and laced in t,e mo/t, w,ere a toot, is missin*. A+ter
in*estin* a test +ood, c,an*es in s/r+ace micro,ardness or enamel orosity are
determined.
%>
Since eac, test meas/res a di++erent asect o+ cario*enicity, +oods will
-e ranked di++erently. It is recommended t,at two testin* met,ods -e /sed to
determine +ood acidoBcario*enicity otential.
%=,%&
5a-le :'-< s,ows t,e acido*enic
otential o+ +oods. 5a-le :'-% ro"ides diet s/**estions +or caries re"ention.
Question 6
5oot, erosion can -e ca/sed -y
A. acid +rom "omitin*
1. s/*ar-containin* car-onated -e"era*es
C. *astro-eso,a*eal re+l/0
D. s/*ar-+ree car-onated -e"era*es
3. all o+ t,e a-o"e
3arly C,ild,ood Caries
One o+ t,e most se"ere +orms o+ caries occ/rs in in+ants. Inaroriate +eedin*
ractices may res/lt in ro*ressi"e dental caries on t,e -/ccal and lin*/al s/r+aces o+
newly er/ted rimary ma0illary anterior teet, o+ in+ants and toddlers. 5,e o"erall
re"alence o+ early c,ild,ood caries 7also called 4a4y 4ottle tooth decay or nursin$
caries8 is estimated to -e 'E.
%'
Howe"er, a m/c, ,i*,er re"alence ,as -een seen
amon* Alaskan and Okla,oma Nati"e American c,ildren 7'=E8 and Na"aAo 7%>E8
and C,erokee 7''E8 Head Start c,ildren attendin* Head Start ro*rams.
%<, %%
)rimary risk +actors +or early c,ild,ood caries incl/de /ttin* a c,ild to slee at
natime or -edtime wit, a -ottle containin* a li?/id other than plain 3ater, allowin*
an in+ant to -reast-+eed at will d/rin* t,e ni*,t, and e0tended /se o+ t,e n/rsin* -ottle
or siy c/ -eyond : year o+ a*e. !es/lts o+ t,e :;;: National Healt, Inter"iew
S/r"ey s,ow t,at :<.%E or =.' million c,ildren -etween < mont,s and ' years o+ a*e
are /t to slee wit, a li?/id in t,e -ottle ot,er t,an lain water.
%(
Inaroriate
+eedin* ractices were reorted more o+ten -y arents wit, less than a hi$h school
education, low incomes, Hisanic -ack*ro/nds, and t,ose arents w,ose c,ildren ,ad
not -een to a dentist in t,e ast year.
C,ildren w,o de"elo ma0illary anterior caries are at increased risk o+ de"eloin*
osterior caries in t,e +/t/re.
%;
5o re"ent early c,ild,ood caries, dentists,
ediatricians, and ot,er ,ealt, care ro+essionals s,o/ld ask arents a-o/t t,eir in+ant
+eedin* ractices. 5,ose arents w,o reort inaroriate +eedin* ractices s,o/ld
recei"e co/nselin*. )ro*rams ser"in* low-income +amilies, s/c, as t,e Secial
S/lemental Food )ro*ram +or 4omen, In+ant, and C,ildren 74IC8, can lay a
maAor role in ro"idin* ed/cation to arents at ,i*,er risk +or /sin* inaroriate
+eedin* ractices.
N/trition and )eriodontal Disease
.ike caries, eriodontal disease is an in+ectio/s disease, m/lti+actorial in etiolo*y, and
occ/rs w,en "ir/lence o+ t,e -acterial c,allen*e is $reater than the host defense and
repair capa4ility, 5,e co/rse o+ eriodontal disease in"ol"es eriods o+ ro*ression
and remission. Unlike t,e direct ca/sati"e relations,i -etween car-o,ydrates and
caries, n/tritional +actors seem to lay a m/c, more s/-tle role in eriodontal stat/s.
N/tritional +actors can alter host suscepti4ility to eriodontal disease andBor mod/late
its ro*ress.
($
5,e n/tritional +actors related to preventin$ infection and enhancin$
3ound healin$ in *eneral alies to t,e re"ention and mana*ement o+ eriodontal
disease as well.
(:
/f -ot, t,e c,allen*e to and t,e de+ense and reair caa-ilities o+ t,e
eriodontal tiss/es are in -alance, n/trition co/ld -e t,e decidin* +actor in w,et,er
,ealt, or disease res/lts. 3"en w,en t,e eriodonti/m is ,ealt,y, t,ere is contin/al
need +or n/trients to maintain t,e tiss/es. Once in+lammation is esta-lis,ed, t,e need
+or n/trients increases, 5,ere is a close relations,i -etween maln/trition and
in+ection, wit, in+ection a**ra"atin* maln/trition and maln/trition a-ettin* in+ection.
De+ense in t,e *in*i"al cre"ice and connecti"e tiss/e all re?/ire an ade?/ate intake o+
all n/trients to ens/re ade?/ate rod/ction and +/nction o+ de+ense and s/ortin*
cells.
(>-(<
4it, t,e increased needs o+ cell/lar imm/nity and t,e additional demands
-y t,e tiss/e cells attemtin* to maintain and reair dama*ed areas, a *reater s/ly
o+ all n/trients is needed. 5,is ,as led to e"idence s,owin* t,at n/trient re?/irements
may -e ,i*,er at local sites o+ increased stress t,an in t,e rest o+ t,e -ody. S/c,
locali@ed c,allen*es may res/lt in end2or$an nutrient deficiencies,
(%, ((
Diet 0uidelines
4,ene"er ro/tine scalin*, ro,yla0is, and oral la?/e control roced/res +ail to
re"erse *in*i"itis and -e+ore any treatment +or eriodontitis is attemted, a t,oro/*,
diet e"al/ation and atient co/nselin* session is indicated. 5,e atient s,o/ld -e
in+ormed a-o/t t,e imortance o+ systemic n/trition in t,e de+ense and reair o+ oral
tiss/es. !ecommendations s,o/ld -e made to ,el ens/re otimal n/trition to ,el
re"ent and mana*e eriodontal disease. 5,ese incl/de9
3at a nutritionally ade5uate diet +ollowin* t,e +ood yramid */idelines.
Increase t,e /se o+ sali"a-stim/latin* +i-ro/s +oods.
M/lti"itaminBmineral s/lements s,o/ld -e in doses no hi$her t,an one to two
times !ecommended Dietary Allowance le"els.
void fad diets w,ic, co/ld -e de+icient in n/trients.
A"oid sin$le "itamin s/lements.
void potentially detrimental me$adoses o+ "itamins and minerals 7:$ !DA or
,i*,er8.
Question 7
)eriodontal disease is ca/sed -y dietary de+iciencies. Calci/m de+iciency is t,o/*,t to
-e a contri-/tin* +actor in al"eolar -one loss in ,/mans.
A. -ot, statements are tr/e.
1. -ot, statements are +alse.
C. t,e +irst statement is tr/e9 t,e second is +alse.
D. t,e +irst statement is +alse t,e second is tr/e.
3atin* Disorders
3atin* disorders, esecially 4ulimia, are o+ten +irst dia*nosed in t,e dental o++ice.
)atients, /s/ally yo/n* +emales, resent wit, se"ere erosion o+ t,e lin*/al toot,
s/r+aces. 5,e oral tiss/es are o+ten red, sore, and ain+/l. 5,e eso,a*/s may -e
in+lamed, and arotid sali"ary *lands are o+ten swollen. 1/limia is c,aracteri@ed -y
rec/rrent eisodes o+ 4in$e eatin$ 7cons/mtion o+ lar*e amo/nts o+ +oods at a time8
+ollowed -y sel+-ind/ced re*/r*itation 7/r*in*8. 5,e a"era*e intake o+ +ood d/rin* a
-in*e is =,&$$ calories o"er an ,o/r, wit, some indi"id/als in*estin* as m/c, as
'$,$$$ calories in >& ,o/rs.
(;
)atients may also /se la0ati"es andBor di/retics to
ind/ce mala-sortion and +l/id loss. 5,e acid +rom stomac, re*/r*itation irritates t,e
eso,a*/s and t,e oro,aryn*eal so+t tiss/es. 5,e re*/r*itated acid in com-ination
wit, 0erostomia, res/lts in raid and e0tensi"e destr/ction o+ toot, enamel.
;$
)atients o+ten +irst deny ,a"in* an eatin* disorder. Howe"er, w,en con+ronted wit,
t,e oral e"idence, t,ey o+ten admit to t,e disorder. 5,e dentist s,o/ld re+er t,e atient
to an eatin*-disorder mana*ement ro*ram and elicit atient a*reement to /nder*o
treatment. 5,e dia*nosis o+ t,is disorder -y t,e dentist and t,e reali@ation o+ t,e
dental destr/ction ca/sed -y t,e disorder, o+ten con"ince atients to a*ree to
treatment. A multidisciplinary aroac, to treatment is needed, incl/din* ,ysicians,
syc,iatrists, syc,olo*ists, n/tritionists, and social workers. 5,e atient m/st -e
ca/tioned t,at +or dental re,a-ilitation to -e s/ccess+/l, t,e /nderlyin* ro-lem 7t,e
eatin* disorder and its ca/ses8 m/st -e resol"ed.
Question 8
Oral ro-lems t,at may -e seen in atients wit, eatin* disorders incl/de9
A. swollen sali"ary *lands
1. oran*e-stained teet,
C. decreased sali"ary +low
D. decreased oral H
3. se"ere enamel deminerali@ation
5,e A*in* )atient
5,e a*in* atient is o+ten +aced wit, a "ariety o+ c,allen*es t,at can /ndermine -ot,
oral ,ealt, and n/tritional stat/s.
;:
As a res/lt, t,e elderly are considered artic/larly
s/sceti-le to maln/trition.
;>
Comared to yo/n*er indi"id/als, elders ,a"e a
si*ni+icantly decreased a-ility to resond to ,ysiolo*ic c,allen*es. Sensory +/nction
decreases leadin* to impaired taste and smell,
;=
C,an*es in t,e *astrointestinal system
can a++ect t,e a-ility to di*est, a-sor- and /tili@e +ood roerly. F/nctional ro-lems,
s/c, as art,ritis or "ision di++ic/lties can a++ect t,e a-ility to reare and eat +ood.
)syc,osocial ro-lems s/c, as loneliness, deression, lack o+ money, and oor access
to +ood can all /ndermine *ood eatin* ,a-its.
)ro-lems in t,e oral ca"ity, s/c, as 0erostomia and loose teet,, ,a"e -een considered
maAor contri-/tors to t,e oor eatin* ,a-its o+ t,e elderly and may -e a maAor
contri-/tor to maln/trition.
;>,:$',;&,;'
Se"eral st/dies ,a"e s,own t,at dentate stat/s can
a++ect eatin* a-ility
;<
and s/-se?/ent diet ?/ality.
;%, ;(, ;;
Indi"id/als wit, one or two
comlete dent/res ,ad a >$E decline in diet ?/ality comared to t,ose wit, at least
artial dentition in one or -ot, arc,es.
:$$
Anot,er st/dy s,owed t,at comared to
t,ose wit, >' or more teet,, edent/lo/s indi"id/als cons/med less +i-er and carotene,
+ewer "e*eta-les, and more c,olesterol, sat/rated +at and calories.
:$:
Dent/res can
a++ect taste and s3allo3in$ a4ility, esecially i+ t,ey are ma0illary dent/res. 5,e
dent/re co"ers t,ose taste -/ds +o/nd on t,e /er alate. And w,en t,e /er alate
is co"ered, it -ecomes di++ic/lt to detect t,e location o+ +ood in t,e mo/t,. For t,is
reason, dent/res are considered to -e t,e ma7or cause of cho*in$ in ad/lts.
:$>
Dry mouth (xerostomia8 is common in t,e older o/lation, in art -eca/se o+
0erostomic medications commonly taken. Gerostomia makes eatin* more di++ic/lt and
increases t,e cario*enic otential o+ t,e diet.
:$=,:$&
It ,as also -een associated wit,
-/rnin* mo/t, syndrome and inade?/ate diet.
:$'
Con"ersely, n/trition is an imortant +actor in oral stat/s.
:$<
In a samle o/lation o+
(&= elderly eole, t,ere was a si*ni+icant association -etween low ascor-ic acid
le"els and t,e re"alence o+ oral m/cosal lesions.
:$%
.ow calci/m intake t,ro/*,o/t
li+e ,as -een s,own to contri4ute to osteoporosis, In t/rn, osteoorosis in al"eolar
-one is t,o/*,t to -e an imortant contri-/tin* +actor to t,e resortion o+ al"eolar
-one t,at /ltimately res/lts in toot, loss.
:$(
5,e al"eolar rocess is comosed
rimarily o+ tra-ec/lar -one, w,ic, is more la-ile to calci/m im-alances t,an is
cortical -one. 5,/s, t,e al"eolar -one ro"ides a otential la-ile so/rce o+ calci/m
a"aila-le to meet other tiss/e needs. Since t,e al"eolar rocess is t,o/*,t to /nder*o
resortion prior to ot,er -onesD it is roAected t,at c,an*es detected in t,e al"eolar
rocess may e"ent/ally -e /sed +or early detection o+ osteoorosis.
:$;
Mandi-/lar
-one mass was correlated wit, total -ody calci/m and -one mass o+ t,e radi/s and
"erte-rae in dentate and edent/lo/s ostmenoa/sal women wit, osteoorosis,
::$
wit,
t,e ,i*,est correlation -etween total -ody and mandi-/lar -one mass. 5,/s, t,e
mandi-le re+lects t,e mineral stat/s o+ t,e entire skeleton. Calci/m intake in
ostmenoa/sal osteoorotic women was also correlated wit, mandi-/lar densityD
s/ortin* t,e ,yot,esis t,at low calci/m intake may contri-/te to red/ced -one
density.
:::,::>
In a st/dy o+ =>; ,ealt,y ost-menoa/sal women, an in"erse
relations,i was s,own -etween -one mineral density and n/m-er o+ e0istin* teet,,
wit, t,ose women w,o recei"ed dent/res a+ter t,e a*e o+ +orty ,a"in* t,e lowest -one
mineral density.
::=
Older atients s,o/ld -e care+/lly screened +or n/tritional risk +actors, and s,o/ld -e
ed/cated a-o/t t,e imortance o+ *ood n/trition to *eneral and oral ,ealt,.
::&, ::'
I+
maAor n/tritional ro-lems are s/sected t,e atient s,o/ld -e re+erred to a
n/tritionist.
::<
4,en new dent/res are ro"ided, atients s,o/ld -e co/nseled on ,ow
to adat t,eir /s/al diet to a so+ter consistency +or t,e +irst +ew days a+ter dent/re
insertion.
Question 9
4,ic, is tr/e a-o/t a*in*e
A. Dry mo/t, always occ/rs wit, a*in*.
1. Dent/res imro"e taste ercetion.
C. 5aste and smell ac/tely tend to decrease.
D. Calci/m intake is not o+ concern wit, t,is *ro/.
5,e Dia-etic )atient
5,e dia4etic dental atient is at $reater ris* +or de"eloin* oral in+ections and
eriodontal disease t,an t,e nondia-etic atient.
::%,::(
5,e dental team needs to -e
aware o+ c/rrent aroac,es to dia-etes mana*ement and care+/lly monitor t,e
atientCs ,ealt, stat/s rior to initiatin* dental treatment.
5,e n/trition care lan *enerally re?/ires t,at atients ,a"e meals and snacks o+
seci+ic n/trient comosition at re$ularly scheduled intervals, coordinated wit,
medications 7ins/lin or oral a*ents8 and e0ercise. Dietary mana*ement ,as c,an*ed
+rom t,e ,i*, +at, low car-o,ydrate diets o+ ast decades to t,e more li-eral /se o+
comle0 car-o,ydrates and t,e red/ctions in +at recommended today.
::;,:$%
A well-
-alanced dia-etic diet s,o/ld -e low in cario*enicity, since t,e /se o+ cario*enic
+ermenta-le car-o,ydrates s,o/ld -e in+re?/ent. Fre?/ent /se o+ ,ard candies or ot,er
+oods taken to co/nteract ,yo*lycemia are an indication t,at t,e dia-etes is not well
controlled. )atients wit, /ncontrolled dia-etes s,o/ld -e re+erred to t,eir ,ysician
+or +/rt,er mana*ement. /n the dental office, 5uic*ly assimilated car4ohydrate
sources such as 7uices, mil*, and crac*ers, should 4e *ept readily availa4le in the
event that a dia4etic patient develops symptoms of hypo$lycemia,
)atients wit, Imm/nocomromisin* Conditions 7Cancer, AIDS8
Imm/nocomromised atients, s/c, as t,ose wit, cancer or AIDS, o+ten ,a"e
increased re?/irements +or n/trients w,ile ,a"in* maAor ,ysiolo*ic and syc,osocial
imediments to eatin*. Cancer o+ten sets / a syndrome o+ wei*,t loss and wastin* in
w,ic, -ot, meta-olism and n/trient losses increase, 5,e cancer o+ten ca/ses se"ere
anore0ia, taste c,an*es, and early satiety. 5,e ain and discom+ort o+ oral in+ections
s/c, as t,e ,eres simle0 and oral candidiasis +o/nd in AIDS and c,emot,eray
atients, can also imair t,e desire and a-ility to eat.
:>$
+ver half of all head and nec*
cancer patients are nutritionally compromised at initial dia$nosis,
:>:
!adiation
t,eray increases eatin* di++ic/lty -y ca/sin* ain+/l oral mucositis, dyspha$ia, and
se"ere xerostomia,
:>>
4,en ro"idin* dental treatment to atients s/++erin* +rom cancer or AIDS, team
mem-ers need to /nderstand t,e n/trition rinciles /nderlyin* t,e care, so t,at
dental ser"ices ro"ided can -e coordinated e++ecti"ely wit, total care. 5,e n/trition
care lan initially +oc/ses on ro"idin* hi$h caloric inta*e in fre5uent small meals,
.i?/id s/lements may -e /sed i+ otimal n/trit/re cannot -e ac,ie"ed "ia +ood
alone. In more serio/s cases, atients may need enteral 7t/-e8 +eedin*s or more
ad"anced n/tritional s/ort. A ,i*, calorie diet will likely -e ,i*, in s/*ars and total
calories.
:>=
In t,ese cases, t,e dental team s,o/ld not ca/tion atients to red/ce t,e
+re?/ency o+ eatin*, since t,is will contradict n/tritional mana*ement *oals. !at,er,
t,oro/*, cleanin* a+ter eac, eatin* eriod, and /se o+ +l/oride mo/t, rinses and
toical +l/oride trays -e+ore -ed s,o/ld -e stressed. 5,is aroac, is standard
rotocol +or imm/nocomromised atients as art o+ an a**ressi"e re"enti"e dental
ro*ram.
:>&
Cancer atients s,o/ld -e ca/tioned, ,owe"er, a-o/t t,e otential oral
se?/elae o+ an increased +re?/ency o+ eatin*. )atients s,o/ld also -e ca/tioned to
a"oid t,e /se o+ slowly dissol"in* ,ard candy o+ten /sed to ass/a*e t,e 0erostomia.
5,e most imortant monitorin$ tool +or t,ese atients is 3ei$ht status, 5,e atient
s,o/ld -e ?/eried at eac, "isit a-o/t ,ow t,eir wei*,t is -ein* maintained.
In"ol/ntary wei*,t loss o+ :$ o/nds or more is a warnin* +or t,e need +or more
intensi"e care.
Oral S/r*ery and Interma0illary Fi0ation
5,e atient w,o ,as ,ad oral s/r*ery, w,et,er t,erae/tic or as a res/lt o+ tra/ma,
needs secial n/tritional consideration 7:>'-2endall, :;(>8. An ade?/ate diet 4efore
sur$ery is needed to support ade5uate post2sur$ical response, I+ +ood cons/mtion
will -e imaired +or a s,ort eriod o+ time, t,e risk o+ n/tritional de+iciency is low.
5,e risk o+ de+iciency increases wit, len*t, o+ eatin* imairment. 5,e s/r*ery itsel+
can res/lt in an anore0ia, ina-ility to c,ew, and increased meta-olic re?/irements.
:><

A+ter s/r*ery, a atient may need a li5uid diet for C or < days, -/t s,o/ld ro*ress as
soon as ossi-le to a so+t diet o+ ,i*, n/tritional ?/ality, /ntil a normal diet can -e
res/med. In some cases, n/tritionally comlete li?/id s/lements may -e aroriate
and s,o/ld -e rescri-ed in cons/ltation wit, t,e atientCs dietitian and ,ysician.
O+ten atients re+er /rees o+ normal +oods o"er commercial li?/id s/lements.
:>%

M/lti"itaminB mineral s/lements may -e aroriate as well.
Question 10
4,ic, o+ t,e +ollowin* isBare tr/ee
A. A well-controlled dia-etic diet s,o/ld -e low in caries risk.
1. )atients wit, cancer o+ten ,a"e increased n/trient needs.
C. )atients wit, imm/ne-comromisin* conditions s,o/ld -e told to red/ce t,e
+re?/ency o+ eatin* to red/ce caries risk.
D. 5,e oral s/r*ery atient may re?/ire a li?/id diet +or : to > days a+ter s/r*ery -/t
s,o/ld ret/rn to a normal diet as soon as it is ossi-le.
Summary
N/tritional stat/s and dietary ,a-its can a++ect and -e a++ected -y seci+ic oral
conditions. Comre,ensi"e atient care re?/ires t,at n/tritional +actors -e considered
in t,e etiolo*y, ro*ression, and se?/elae o+ oral ro-lems.
:>(, :>;
Dental-team mem-ers s,o/ld ro/tinely screen atients +or n/tritional iss/es, ro"ide
dentally-oriented co/nselin*, and re+er atients to dietitians +or +/rt,er care. 5,e
n/tritional imlications in dental conditions are many and comle0. No lon*er can
n/trition in dentistry -e s/mmari@ed as Fs/*ar is -ad, and +l/oride is *ood.F
:. -, c, and dcorrect.
aincorrect. It is not aroriate or ossi-le +or t,e dental team to attemt to assess
act/al n/tritional stat/s. 5,is re?/ires so,isticated la-oratory testin* /nder t,e
s/er"ision o+ a ?/ali+ied medical ro+essional.
>. dcorrect.
aincorrect. 5,e minim/m amo/nt o+ a n/trient needed to re"ent de+iciency is not
considered an aroriate standard o+ ade?/acy
-incorrect. 5,e ma0im/m amo/nt o+ a n/trient t,at will not ca/se to0icity is t,e
U. or /er tolera-le limit
cincorrect. 5,e a"era*e estimated re?/irement +or ,ealt,y eole wo/ld mean t,at
,al+ o+ t,e o/lation wo/ld re?/ire more. 5,/s it is not /sed as t,e criteria +or
,ealt,y o/lations
=. ccorrect.
aincorrect. 6itamin C-de+icient wo/nds ,a"e oorer ,ealin* a-ility
-incorrect. 6itamin-C de+iciency a++ects all eit,elial tiss/es incl/din* t,ose in t,e
oral ca"ity
dincorrect. It is not et,ical to cond/ct s/c, st/dies in ,/mans
&. -, c, and +correct.
aincorrect. 5,e diet assessment rocess can -e /sed to screen atients +or ossi-le
n/trition risk, -/t cannot -e /sed +or tr/e n/tritional assessment
dincorrect. Daily calorie intake cannot -e determined /sin* a diet screenin* tool.
)atientCs daily calorie intake is -est assessed -y a re*istered dietitian /sin* an
assessment tool desi*ned +or t,at /rose.
eincorrect. 5,e dental team can /se screenin* in+ormation to re+er t,e atient to a
re*istered dietitian w,o is ?/ali+ied to ro"ide t,erae/tic diets. 5,e dental team can
ro"ide n/trition in+ormation a-o/t ,ealt,y diet and dietBoral ,ealt, relations,is.
'. dcorrect
aincorrect. S/crose is not t,e only cario*enic +actor, and t,e amo/nt is not as
imortant as t,e distri-/tion in t,e diet.
-incorrect. 5,e amo/nt o+ sticky sweets is not as rele"ant as t,e +re?/ency o+ /sa*e
o+ t,ese items.
cincorrect. 5,e n/trient ?/ality o+ t,e diet is only related to t,e caries rocess a+ter
toot, er/tion t,ro/*, reminerali@ation e++ects.
eincorrect. Dessert is only one o+ many contri-/tin* +actors to dental caries.
<. ecorrect.
5oot, erosion can -e ca/sed -y acid +rom "omitin*, s/*ar-containin* car-onated
-e"era*es, *astroeso,a*eal re+l/0, and s/*ar-+ree car-onated -e"era*es to name -/t
a +ew +actors.
%. dcorrect.
)eriodontal disease is not caused -y dietary de+iciencies. Howe"er, calci/m
de+iciency is t,o/*,t to -e a contri-/tin* +actor to al"eolar -one loss in ,/mans.
(. a, c, d, ecorrect.
-incorrect. Oran*e-stained teet, are not necessarily ca/sed -y eatin* disorders. 5,e
stainin* can come +rom +ood, -e"era*es, or ot,er so/rces.
;. ccorrect.
aincorrect. Dry mo/t, is associated rimarily wit, t,e /se o+ medications and is not
ine"ita-le wit, a*in*.
-incorrect. Dent/res can imair taste ercetion i+ t,ey co"er taste -/ds on t,e
/er alate.
dincorrect. Calci/m is imortant +or all a*e *ro/s. Calci/m intake is associated
wit, -one density in *eneral and may -e a +actor in al"eolar -one ,ealt, as well.
:$. a, -, and dcorrect
dincorrect. )atients wit, imm/ne comromisin* conditions s,o/ld not -e told to
red/ce t,e +re?/ency o+ eatin* to red/ce caries risk. 5,ese atients are at ,i*, risk +or
n/tritional de+iciency and m/st eat ,i*, calorie +oods on a +re?/ent -asis t,ro/*,o/t
t,e day. Oral risk s,o/ld -e red/ced -y ,a"in* atients rinse t,e mo/t, and clean t,e
teet, as -est t,ey can a+ter eac, eatin* eriod and /se reminerali@in* rinses.
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;%. 5o/*er-Decker, !., Sc,ae+er, M., Flinton, !., g Stein-er*, .. 7:;;<8. 3++ect o+
toot, loss and dent/res on diet ,a-its. " Prosthet Dent, %'9(=:.
;(. Se-rin*, N. G., G/ckes, A. D., .i, S., g McCart,y, G. !. 7:;;'8. N/tritional
ade?/acy o+ reorted intake o+ edent/lo/s s/-Aects treated wit, new con"entional or
imlant-s/orted mandi-/lar dent/res. " Prosthet Dent, %&9 ='(-<=.
;;. Greksa, .. )., )arra*a, I. M., g Clark, C. A. 7:;;'8. 5,e dietary ade?/acy o+
edent/lo/s older ad/lts. " Prosthet Dent, %=9:&>-'.
:$$. )aas, A., )almer, C., McGandy, !., Hart@, S. C., g !/ssell, !. M. 7:;(%8.
Dietary and n/tritional +acctors in relation to dental caries in elderly s/-Aects.
0erodontics, =9=$-=%.
:$:. #os,i/ra, 2., 4illett, 4., g Do/*lass, C. 7:;;<8. 5,e imact o+ edent/lo/sness
on +ood and n/trient intake. "D, Aril, :>%9&';-<%.
:$>. Anderson, D. .. 7:;%%8. Deat, +rom imroer mastication. /nt Dent ", >%9=&;.
:$=. Dormen"al, 6., 1/dt@-#or*ensen, 3., MoAon, )., 1r/yere, A., g !ain, C. H.
7:;;'8. N/trition, *eneral ,ealt, stat/s and oral ,ealt, stat/s in ,ositali@ed elders.
0erodontolo$y, C< 7:>89%=-($.
:$&. Faine, M., Allender, D., 1aa-, D., )ersson, !., g .amont, !. #. 7:;;>8. Dietary
and sali"ary +actors associated wit, root caries. Special Care in Dentistry , C< 7&89:%%-
(>.
:$'. Maresky, .. S., "an der 1iAl, )., g Gird, I., 7Marc, :;;=8. 1/rnin* mo/t,
syndrome. 3"al/ation o+ m/ltile "aria-les amon* (' atients. +ral Sur$ery, +ral
%edicine, +ral Patholo$y, D>7=89 =$=-%.
:$<. M/lli*an, !. 7:;(;8. Oral ,ealt,9 3++ect on n/trition and re,a-ilitation in older
ersons. Top 0eriatr Reha4, '9>%-='.
:$%. 6aanen, M. 2., Markkanen, H. A., 5/o"inen, 6. #., 2/llaa, A. M., 2arina/, A.
M., g 2/m/salo, 3. A. 7:;;=8. )eriodontal ,ealt, related to lasma ascor-ic acid.
Proc 'inn Dent Soc, FH 7:->89':-;.
:$(. )a*anini-Hill, A. 7:;;'8. 5,e -ene+its o+ estro*en relacement t,eray on oral
,ealt,. 5,e .eis/re 4orld co,ort. rchives /ntern %ed, C>> 7>:89>=>'-;.
:$;. 4,alen, #. )., g 2rook, .. 7:;;<8. )eriodontal disease as t,e early mani+estation
o+ osteoorosis 7editorial8. &utrition, C< 7:89'=-&.
::$. 2ri--s, ). #., C,estn/t, C. H., Ott, S., g 2ilcoyne, !. F. 7:;;$8. !elations,is
-etween mandi-/lar and skeletal -one in a o/lation o+ normal women. " Prosthet
Dent 9A 7:89(<-(;.
:::. 2ri--s, ). #. 7:;;$8. comarison o+ mandi-/lar -one in normal and osteoorotic
women. " Prosthet Dent, 9A 7>89>:(->>.
::>. Ho/ki, 2., DiM/@io, M. 5., g Fattore, .. 7:;;&8. Mandi-/lar -one density and
systemic osteoorosis in elderly edent/lo/s women. " #one %iner Res, ;
7s/l:89S>::.
::=. 2rall, 3. A., Dawson-H/*,es, 1., )aas, A., g Garcia, !. I. 7:;;&8. 5oot, loss
and skeletal -one density in ,ealt, ostmenoa/sal women. +steoporosis /nt, &9:$&-
;.
::&. &utrition /nterventions %anual for Professionals Carin$ for +lder mericans
7:;;>8. 4as,in*ton DC9 N/trition Screenin* Initiati"e.
::'. Sa/nders, M. #. 7:;;'8. Incororatin* t,e n/trition screenin* initiati"e into t,e
dental ractice. Special Care in Dentistry , C> 7:89><-=%.
::<. )la, G. 4. 7:;;&8. Oral ,ealt, and n/trition. Primary Care6 Clinics in +ffice
Practice, <C 7:89:>:->=.
::%. Holdren, !. S., g )atton, .. .. 7:;;=8. Oral conditions associated wit, dia-etes
mellit/s. Dia4etes Spectrum, 97:89::-:%.
::(. Cleary, 5. #., g H/tton, #. 3. 7:;;'8. An assessment o+ t,e association -etween
+/nctional edent/lism, o-esity, and NIDDM. Dia4etes Care, :(9:$$%-:$$;.
::;. 5,e DCC5 !esearc, Gro/ 7:;;=8. N/trition inter"entions +or intensi"e t,eray
in t,e dia-etes control and comlications trial. " m Diet ssoc, ;=9%<(-%>.
:>$. !o-ertson, ). 1., g Greensan, #. S., 3ds. 7:;((8. Perspectives on oral
%anifestations of ids6 Dia$nosis and mana$ement of H/=2associated infections,
.ittleton, MA9 )SG )/-lis,in*.
:>:. 1assett, M. !., g Do-ie, !. A. 7:;(=8. )atterns o+ n/tritional de+iciency in ,ead
and neck cancer. +tolaryn$ol Head &ec* Sur$, ;:9::;->'.
:>>. Nikoskelainen, #. 7:;;$8. Oral in+ections related to radiation and
imm/nos/ressi"e t,eray. " Clin Periodont, CD 7%89'$&-%.
:>=. Smit,, 5. #., Dwyer, #. 5., g .aFrancesca, #. ). 7:;;$8. N/trition and t,e cancer
atient. In Osteen, !. 5., Cady, 1., g !osent,al, )., 3ds. Cancer %anual 7(t, ed.8
7C,ater =;.(8 1oston9 American Cancer Society.
:>&. Dwyer, #. 5., 3+stat,ion, M. S., )almer, C., g )aas, A. 7:;;:8. N/tritional
s/ort in treatment o+ oral carcinomas. &utr Rev, &;9 ==>-=%.
:>'. 2endall, 1. D., Fonseca, !. #., g .ee, M. 7:;(>8. )ostoerati"e n/tritional
s/lementation +or t,e ort,o*nat,ic s/r*ery atient. " +ral %axillofac Sur$, &$9>$'-
>:=.
:><. Solia,, 2. 7:;(%8. Clinical e++ects o+ Aaw s/r*ery and wirin* on -ody
comosition9 A case st/dy. Dietetic Currents, "ol/me :&. Col/m-/s, OH9 !oss
.a-oratories, .:=-:<.
:>%. )atten, #. A. 7:;;'8. N/trition and wo/nd ,ealin*. Compendium of Continuin$
!ducation in Dentistry , C9 7>89>$$-:&.
:>(. .oks,in, M. F. 7:;;&8. )re"enti"e oral ,ealt, care9 A re"iew +or +amily
,ysicians. merican 'amily Physician, >: 7(89:<%%-(&, :<(%.
:>;. 2ar, 4. 1. 7:;;&8. N/trition /date +or t,e dental ,ealt, ro+essional. " Calif
Dent ssoc, << 7(89><-;.
reser"ed.
Chapter 15. Nutrition, Diet, and Oral Conditions - Carole , Palmer (inda D,
#oyd
Objectives
:. 30lain t,e /nderlyin* rationale +or t,e !e+erence Daily Intakes, Food G/ide
)yramid, and +ood la-els.
>. Disc/ss t,e otential oral e++ects o+ se"ere maln/trition d/rin* or*ano*enesis.
=. Disc/ss w,y +oods wit, e?/al amo/nts o+ s/*ar are not necessarily e?/ally
cario*enic.
&. Descri-e ,ow dietary atterns and +ood comosition a++ects cario*enic otential.
'. Disc/ss t,e e++ects o+ +ood on -/++erin* caacity.
<. Disc/ss t,e role o+ n/trition in eriodontal disease.
%. 30lain w,y elderly atients are at ,i*,er n/tritional risk t,an ot,er a*e *ro/s.
(. Disc/ss t,e rele"ant n/tritional considerations +or atients w,o ,a"e dia-etes,
imm/nocomromisin* conditions, or ,ead and neck s/r*ery.
Introduction
Oral ,ealt,, diet, and n/tritional stat/s are closely linked 7Fi*/re :'-:8. N/trition is an
essential +or t,e *rowt,, de"eloment, and maintenance o+ oral str/ct/res and tiss/es.
D/rin* eriods o+ raid cell/lar *rowt,, n/trient de+iciencies can ,a"e an irreversi4le
e++ect on t,e de"eloin* oral tiss/es. )rior to toot, er/tion, n/tritional stat/s can
in+l/ence toot, enamel mat/ration and c,emical comosition as well as toot,
mor,olo*y and si@e.
:
3arly maln/trition increases a c,ildCs s/sceti-ility to dental
caries in t,e decid/o/s teet,.
>
5,ro/*,o/t li+e, n/tritional de+iciencies or to0icities
can a++ect host resistance, ,ealin*, oral +/nction, and oral-tiss/e inte*rity. For
e0amle, imm/ne resonse to local irritants and ,ealin* o+ eriodontal tiss/es may -e
imaired w,en n/tritional stat/s is comromised. 1eca/se t,e oral eit,eli/m ,as
more raid cell t/rno"er t,an most ot,er tiss/es in t,e -ody, clinical si*ns o+
maln/trition are o+ten mani+est +irst in t,e oral ca"ity.
A+ter toot, er/tion, t,e e++ects o+ diet on t,e dentition are toical rat,er t,an
systemic. Dietary +actors and eatin* atterns can initiate e0acer-ate or minimi@e
dental decay. Fermenta-le car-o,ydrates are essential +or t,e imlantation,
coloni@ation, and meta-olism o+ -acteria in dental la?/e. Factors s/c, as eatin*
+re?/ency and retenti"eness o+ car-o,ydrates in+l/ence t,e ro*ression o+ cario/s
lesions, w,ile +oods containin* calci/m and ,os,or/s, s/c, as c,eese, en,ance
reminerali@ation. Fre?/ent intake o+ acidic foods or -e"era*es can ca/se enamel
erosion. Con"ersely, imaired dental +/nction may lead to oor n/tritional ,ealt,.
Older ad/lts wit, loose or missin* teet,, or ill-+ittin* dent/res o+ten red/ce t,eir
intake o+ +oods t,at re?/ire c,ewin*, s/c, as +res, +r/its, "e*eta-les, meats, and
-reads.
=
4,en t,e "ariety o+ +oods in a diet is red/ced, t,ere is *reater risk o+ n/trient
inade?/acies. 5,e atient w,o /nder*oes oral or eriodontal s/r*ery may re?/ire
dietary */idance to re"ent deleterio/s c,an*es in t,e diet. )atients wit, dia-etes
mellit/s, oral cancer, or deressed imm/ne +/nction may s/++er +rom oral conditions
t,at comromise n/tritional stat/s. 5,e dental clinician needs to understand ,ow diet
and n/trition can a++ect oral ,ealt,, and ,ow oral conditions can a++ect +ood c,oices
and /ltimately n/tritional stat/s. 5,is c,ater ro"ides an o"er"iew o+ t,e
relations,is -etween diet, n/trition and dental ractice, and o++ers aroriate
s/**estions +or atient */idance.
Fi*/re :'-: !elations,is -etween N/trition and Healt,.
Importance of Diet Assessment and Counseling in Dentistry
5,e modern dental ractitioner is not only concerned wit, ed/catin* atients +or t,e
re"ention o+ caries and eriodontal disease, -/t also lays an imortant role in
screenin* atients +or ot,er ,ealt, risks. #/st as a medical ,istory and -lood ress/re
e"al/ation are /sed to screen +or /nderlyin* medical conditions, a dietary assessment
and screenin* can ,el inoint otential n/tritional ro-lems t,at may a++ect or -e
a++ected -y dental care. 1eca/se o+ t,e lar*e n/m-er o+ atients seen re*/larly in
dental ractice, t,e dental team is in an e0cellent osition to reco*ni@e areas o+
nutritional ris*, 5,e role o+ t,e dental team s,o/ld -e to screen patients +or n/tritional
risk, ro"ide dietary $uidance related to oral ,ealt,, and refer patients to n/trition
ro+essionals +or treatment o+ ot,er n/trition-related systemic conditions.
=
Question 1
4,at are aroriate n/trition inter"entions +or dental clinicianse
A. Assess atientsC n/tritional stat/s /sin* la-oratory and ot,er -ioc,emical
assessment tools.
1. Screen atients +or n/tritional risk.
C. !eco*ni@e dietary ro-lems in dent/re atients.
D. )ro"ide diet */idance related to oral ,ealt,.
The Basis for a Healthy Diet
Dietary !e+erence Intakes
Daily +ood intake m/st -e s/++icient to meet meta-olic re?/irements +or ener*y and
ro"ide t,e essential n/trients t,at t,e -ody cannot synt,esi@e in s/++icient ?/antities
to meet ,ysiolo*ic needs. Since t,e :;&$s, t,e 'ood and &utrition #oard 7FN18 o+
t,e National Academy o+ Sciences ,as /-lis,ed t,e Recommended Dietary
llo3ances 7!DA8, w,ic, were recommendations +or daily n/trient intake t,at wo/ld
s/ort *rowt, and maintenance o+ -ody tiss/es, and re"ent de+iciency diseases. 7&-
Food and N/trition 1oard8. 1e*innin* in :;;%, t,e Food and N/trition 1oard -e*an
to make maAor c,an*es to t,e +ormat and /rose o+ t,e n/trition recommendations.
The Dietary Reference /nta*es (DR/) expands and replaces the RD
'
-y addressin*
t,e re"ention o+ chronic de$enerative diseases and t,e risk o+ excess inta*e of
nutrients,
'
5,e D!I are ?/antitati"e estimates o+ n/trient "al/es to -e /sed +or lannin* and
assessin* diets +or ,ealt,y eole.
'
5,ese re+erence "al/es "ary -y $ender and life
sta$e $roup, D!I consist not only o+ !DA -/t also t,ree ot,er tyes o+ re+erence
"al/es s,own in 5a-le :'-:.
3"al/ation o+ t,e tr/e n/tritional stat/s o+ an indi"id/al re?/ires a com4ination o+
clinical, -ioc,emical, and ant,roometric data.
'
So i+ an indi"id/al reorts an intake
o+ a n/trient -elow t,e !DA, more in+ormation wo/ld -e necessary to determine i+ an
act/al de+iciency e0ists. Con"ersely, n/trient intakes t,at meet t,e !DA o"er time
,a"e a low ro-a-ility o+ -ein* inade?/ate.
Dietary G/idelines +or Americans
5,e Dietary 0uidelines for mericans were +irst /-lis,ed in :;($, and are re"ised
e"ery > years.
<
5,e */idelines are desi*ned to comlement t,e D!Is -y makin*
recommendations +or +ood c,oices to romote ,ealt,. 5,e >$$$ Dietary G/idelines
+or Americans contain :$ recommendations, *ro/ed into three areas called the #C
o+ *ood ,ealt,. 5,ey are s,own in 5a-le :'->.
<
5,ese ne3est */idelines lace more
em,asis on physical activity and healthy 3ei$ht comared to re"io/s editions. 5,e
+oc/s on re"entin* o-esity is ca/sed -y t,e increased risk it resents +or many
c,ronic and de*enerati"e diseases, s/c, as ,eart disease, stroke, dia-etes, art,ritis,
,i*, -lood ress/re, and some kinds o+ cancer. 5,e recommendations em,asi@e
-alance, moderation, and "ariety in +ood c,oices, and romote increased /se o+ w,ole
*rains, +r/its and "e*eta-les, and decreased /se o+ sat/rated +at, c,olesterol, and salt.
In addition, +or t,e +irst time, t,e */idelines address +ood sa+ety in an e++ort to com-at
+ood--orne illness, an imortant /-lic ,ealt, concern.
<
5,e >$$$ Dietary G/idelines +or Americans de+ine a ,ealt,y wei*,t accordin* to t,e
#ody %ass /ndex (#%/), 5,e 1MI is a medical standard +or de+inin* o-esity t,at not
only is ,i*,ly correlated wit, indeendent meas/res o+ -ody +at, -/t is also /sed to
determine i+ a erson is at increased ,ealt, risk d/e to e0cess wei*,t
%
75a-le :'-=8. A
,ealt,y 1MI o+ :; to >' is associated wit, t,e lowest statistical ,ealt, risk c(-Meisler,
:;;<d. )ersons wit, 1MI a-o"e >' are considered o-ese, and t,e recommendation is
to lose : to > 1MI /nits 7:$ to :' o/nds8 to red/ce t,eir risk +or c,ronic disease.
%
Food G/ide )yramid
5o ,el eole select n/trient-ric, +oods and to +ollow t,e Dietary G/idelines, t,e
'ood 0uide Pyramid was de"eloed -y t,e U.S. Deartment o+ A*ric/lt/re.
;
5,e
Food G/ide )yramid dislays +oods in +i"e cate*ories -ased on t,eir n/trient
comosition 7Fi*/re :'->8. 4,ole *rains, s/c, as rice, asta, cereals, and -reads,
+o/nd at t,e -road -ase o+ t,e )yramid s,o/ld +orm t,e +o/ndation o+ a ,ealt,+/l diet.
5,ey are *ood so/rces o+ car-o,ydrate 7incl/din* +i-er8 and minerals. Fr/its and
"e*eta-les +orm t,e ne0t le"el o+ t,e )yramid. 5,e meat *ro/ contains *ood so/rces
o+ rotein, "itamins, and minerals. Meat alternates, le*/mes, e**s, n/ts, and to+/, are
incl/ded in t,e meat *ro/. 5,e dairy *ro/ is comrised rimarily o+ *ood calci/m
so/rces. 5,e small trian*le at t,e to o+ t,e )yramid is +or t,e +ats, oils, and sweets
t,at ro"ide rimarily added calories and, t,/s, s,o/ld -e eaten in small amo/nts. No
sin*le +ood *ro/ is more imortant t,an anot,erD eac, *ro/ ro"ides some, -/t not
all, o+ t,e essential n/trients.
Standardi@ed ser"in* si@es and t,e recommended n/m-er o+ ser"in*s +or "ario/s a*e
*ro/s are seci+ied. Howe"er, t,e caloric content o+ +oods "aries widely wit,in a
+ood *ro/. 5,e desira-le n/m-er o+ ser"in*s +rom eac, +ood *ro/ deends not only
/on a*e and se0, -/t also t,e calorie *oal. For e0amle, i+ :,<$$ calories were t,e
daily ener*y *oal, an indi"id/al wo/ld c,oose t,e minim/m n/m-er o+ ser"in*s o+
low-+at +ood c,oices +rom eac, *ro/. I+ additional calories are needed, increased
ser"in*s s,o/ld come +rom t,e *rain, +r/it, and "e*eta-le *ro/s, rat,er t,an t,e to
o+ t,e yramid.
Food .a-els
5,e N/trition Facts anel +o/nd on most rocessed +ood acka*es ,els t,e cons/mer
select +oods t,at meet t,e Dietary G/idelines 7Fi*/re :'-=8. 5,e &ational (a4elin$
and !ducation ct of CHH: re?/ires t,at comre,ensi"e n/trition in+ormation must
aear on t,e la-els o+ most rocessed +oods and rocessed meats and o/ltry
rod/cts. In addition, n/trition in+ormation at oint o+ /rc,ase is voluntary +or +res,
+r/its, "e*eta-les, and raw +is,. In accord wit, t,e mandatory +ood la-elin*
re*/lations /-lis,ed -y t,e Food and Dr/* Administration in :;;&,
:$
t,e n/trition
anel on rocessed +oods m/st incl/de t,e +ollowin*9
standardi1ed portion si1e 7desi*ned to make n/tritional comarisons o+ similar
rod/cts easier, and re+lects t,e ser"in* si@es t,at eole act/ally eat8.
5,e n/m-er o+ servin$s per container,
5,e amo/nts o+ total calories and calories from fat er ser"in*.
5,e num4er of $rams er ser"in* o+ total +at, sat/rated +at, c,olesterol, sodi/m, total
car-o,ydrates, dietary +i-er, s/*ars, and rotein.
In addition, t,e n/tritional contri-/tion o+ one ser"in* o+ t,e rod/ct m/st -e stated as
a percenta$e of the Daily =alues, 5,e Daily 6al/es are -ased on t,e !DA +or rotein,
"itamins, and minerals and on standards desi*ned esecially +or +ood la-els +or
n/trients not co"ered in t,e !DA s/c, as +at, c,olesterol, total car-o,ydrates, dietary
+i-er, and sodi/m. 5,e calc/lations to determine t,e ercents o+ Daily 6al/es are
-ased on a <,:::2calorie diet, Deendin* on a ersonCs a*e, *ender, and acti"ity le"el,
a erson may need more or less t,an :$$E o+ a Daily 6al/e. 5,e Daily 6al/e also
,els cons/mers see ,ow a +ood +its into an o"erall daily diet.
Ot,er in+ormation, s/c, as t,e amo/nts o+ oly/nsat/rated or mono/nsat/rated +ats or
ot,er "itamins and minerals, is otional. In addition, descritors s/c, as F+ree,F Flow,F
F,i*,,F Fli*,t,F Flean,F or Fred/ced,F may -e /sed on t,e la-el as lon* as a standard
ortion meets defined criteria, For e0amle, to -e la-eled Flow-calorieF a ser"in*
m/st ,a"e no more t,an &$ calories. 5o -e la-eled Flow-+at,F no more t,an = *rams o+
+at er ser"in* is allowed.
Healt, claims +or t,e otential -ene+it o+ a n/trient or +ood in relation to a disease or
,ealt, condition will -e allowed on la-els i+ t,ey are s/orted -y scienti+ic e"idence
and are aro"ed -y t,e Food and Dr/* Administration 7FDA8. 5,e :> ,ealt, claims
c/rrently allowed to -e laced on +ood la-els are s,own in 5a-le :'-&.
::
Fi*/re :'-> 5,e Food G/ide )yramid9 A G/ide to Daily Food C,oices is an
o/tline o+ w,at to eat eac, day. Not a ri*id rescrition -/t a *eneral */ide t,at
lets eac, erson c,oose a ,ealt,+/l diet, t,e )yramid calls +or eatin* a "ariety o+
+oods to *et t,e needed n/trients w,ile cons/min* t,e ri*,t amo/nt o+ calories to
maintain a ,ealt,y wei*,t. 7Co/rtesy U.S. Deartment o+ A*ric/lt/re, H/man
N/trition In+ormation Ser"ice.8
Fi*/re :'-= Food .a-el.
Question 2
5,e Daily !e+erence Intakes 7D!I8 are set at9
A. t,e minim/m amo/nt o+ a n/trient needed to re"ent de+iciency.
1. t,e ma0im/m amo/nt t,at will not ca/se to0icity.
C. t,e a"era*e estimated re?/irement +or ,ealt,y eole.
D. t,e a"era*e re?/irement l/s a mar*in o+ sa+ety.
Nutrition in the Development and Integrity of Oral Tissues and Structures
N/trition lays an imortant role in t,e initial *rowt, and de"eloment or oral tiss/es
and in t,eir contin/o/s inte*rity t,ro/*, t,e li+esan. Otimal n/trition d/rin* eriods
o+ ,ard and so+t tiss/e de"eloment allow t,ese tiss/es to reac, t,eir otimal otential
+or *rowt, and resistance to disease. Maln/trition 7eit,er o"er or /nder-n/trition8
d/rin* critical eriods o+ or$ano$enesis can ,a"e irreversi4le e++ects on de"eloin*
tiss/es. 30amles o+ t,is e++ect can -e seen in t,e tetracycline stainin$ o+ teet,, in
dental fluorosis, and in t,e +e"er-ind/ced enamel hypoplasia seen in t,e rimary
teet,.
:>
In t,e dentition, maln/trition is less well doc/mented in ,/mans t,an in
animals, -/t it aears t,at d/rin* t,e Fcritical eriods,F maln/trition can res/lt in
dentition wit, increased caries s/sceti-ility.
:=
Maln/trition after initial or*an and
tiss/e de"eloment is usually reversi4le, -/t can still comromise tiss/e re*eneration
and ,ealin* and increase s/sceti-ility to oral diseases. N/trients +or w,ic,
de+iciencies or e0cesses ,a"e -een directly associated wit, oral conditions are roteinD
ener*yD "itamins C, A, DD iodineD and +l/oride.
)roteinBCalorie Maln/trition
)rotein is t,e most a-/ndant or*anic como/nd in t,e -ody and is re?/ired +or t,e
synt,esis o+ "irt/ally all -ody tiss/es and str/ct/res. )roteins acco/nt +or t,e str/ct/re
o+ DNA, t,e tensile stren*t, o+ colla*en, and t,e "iscosity o+ sali"a. 5,/s, a-errations
in rotein n/trit/re can ,a"e +ar reac,in* oral and systemic e++ects.
5,e normal t/rno"er o+ eit,elial tiss/e in t,e oral ca"ity re?/ires a contin/al s/ly
o+ n/trients. For e0amle, every A to 9 days, the 4asal epithelium of the $in$iva
under$oes rene3al,
:&
5,/s, any se"ere de+iciency o+ roteinBcalorie intake will res/lt
in a decrease in mitotic acti"ity in t,e cre"ic/lar eit,eli/m, as well as elsew,ere
t,ro/*,o/t t,e -ody.
:'
In a comarison o+ eriodontal in"ol"ement in atients wit,
se"ere maln/trition 7kwas,iorkor8 wit, t,at o+ ,ealt,y controls in So/t, India,
:<
+ewer
caries and more eriodontal disease was +o/nd amon* t,e /nderno/ris,ed *ro/.
Since t,e oral ,y*iene indices o+ -ot, *ro/s were similar, it was ass/med t,at t,e
di++erence was d/e to n/tritional +actors. 7It s,o/ld -e noted t,at any maln/trition o+
t,e se"erity o+ kwas,iorkor reresents a m/lti-n/trient de+iciency8. Imaired rotein
synt,esis ,as -een +o/nd i+ rotein maln/trition occ/rs d/rin* t,e de"elomental
sta*e in animals.
:%
In animal models, s,ort-term +astin* 7& days8 res/lted in a &$E
red/ction in colla*en rod/ction.
:(
In t,e same st/dy, a :$E decrease in colla*en
synt,esis was noted wit, a red/ced dietary intake meetin* >$E o+ re?/irements.
:(

5,ese +indin*s s/**est t,at e"en s,ort-term states o+ /ndern/trition may imact
colla*en synt,esis.
In chronically malnourished c,ildren, se"eral st/dies ,a"e s,own delays in toot,
er/tion atterns, and increased toot, enamel sol/-ility, leadin* to increased caries
s/sceti-ility.
:;->'
5,e linear hypoplasia reorted in t,e enamel o+ rimary teet, o+ c,ildren in
/nderri"ile*ed o/lations is t,o/*,t to contri-/te to t,eir ,i*, re"alence o+ dental
caries. 5,is tye o+ ,yolasia aears to -e related to t,e se"erity o+ t,e
maln/trition.
><
4it, t,e e0cetion o+ t,e cleansin$ and dilutin$ e++ects o+ sali"a, oral de+ense
mec,anisms deend on an ade?/ate s/ly o+ roteins. 5,e $lycoproteins t,at res/lt
in a**re*ation o+ -acteria arise +rom t,e sali"ary *lands. (yso1yme, salivary
peroxidase, and lactoferrin are also $lycoproteins, Secretory /$ 7sI*A8 arises mainly
+rom t,e la-ial and -/ccal *lands and is an imm/no*lo-/lin. 5,e cell tyes in"ol"ed
in cell/lar imm/nity 7olymor,on/clear lym,ocytes and macro,a*es and t,e
en@ymes /sed in ,a*ocytosis8 also re?/ire rotein +or t,eir rod/ction.
>%
)ro-a-ly one o+ t,e most deleterious e++ects o+ roteinBcalorie de+iciency is t,e
deletion o+ t,e cellular and immunocellular defenses o+ -ot, t,e oral and t,e
connecti"e sides o+ t,e -arrier eit,elial cells linin* t,e *in*i"al cre"ice. In *eneral,
t,e se"erity o+ t,e imaired imm/nolo*ic resonse arallels t,e se"erity o+ t,e rotein
or calorie de+iciency.
>(
Minerals
Calci/m, in association wit, "itamin D and ,os,or/s is essential +or roer
de"eloment and maintenance o+ minerali@ed tiss/es 7teet, and al"eolar -one8. A
de+iciency o+ t,ese n/trients d/rin* critical ,ases o+ toot, de"eloment in c,ildren
res/lts in ,yo-minerali@ation o+ de"eloin* teet,, and ossi-le delayed er/tion
atterns.
>;
3namel ,yolasia may -e seen in remat/rely -orn "ery low -irt,-wei*,t
76.148 in+ants d/e to t,e ,i*,er needs +or calci/m and ,os,or/s in t,ese
in+ants.
=$
In addition, 6.14 in+ants ,a"e immat/re kidneys and may not meta-oli@e
ade?/ate le"els o+ "itamin D.
=$
Iron is o+ interest since iron de+iciency is t,e most common deficiency in t,e United
States. Iron de+iciency anemia is mani+est in t,e oral ca"ity -y allor o+ oral tiss/es,
esecially t,e ton*/e. 5,e ton*/e may aear s,iny, wit, -l/nted +ili+orm aillae.
5,e e++ects o+ iron de+iciency on minerali@ed tiss/es are less clear. In rats, e"en a
mar*inal de+iciency o+ iron in t,e rat diet redisoses t,e rats to caries. Con"ersely,
s/lementin* a caries-romotin* diet wit, iron rod/ced a maAor red/ction in caries
wit, t,e *reatest e++ect s,own in t,e neonatal eriod.
=:
In addition, iron ser"es as a
co+actor wit, ascor-ic acid in colla*en synt,esis, as is coer.
=>
Iinc re*/lates function in inflammation -y in,i-itin* t,e release o+ lysosomal
en@ymes and ,istamines. A @inc de+iciency can in,i-it colla*en +ormation and red/ce
cell-mediated imm/nity.
==
5,e e++ect o+ @inc in modi+yin* eriodontal de+ense
mec,anisms ,as -een s,own in ra--its,
='
-/t ,as yet to -e clearly delineated in
,/mans.
=<, =%
6itamins
6itamin A is essential +or t,e de"eloment and contin/ed inte*rity o+ all -ody or*ans
and tiss/es, incl/din* t,e epithelial mucosa o+ t,e oral ca"ity. In "itamin-A
de+iciency, cell di++erentiation is imaired9 %ucus2secretin$ cells are relaced wit,
keratin-rod/cin* cells. 5,e res/lt is de+ecti"e tiss/e +ormation, and imaired ,ealin*.
6itamin-A de+iciency also res/lts in imairment o+ 4oth specific and nonspecific
immunoprotective mechanisms, De+iciency can a++ect tiss/e resonse to -acterial
in+ection, m/cosal imm/nity, arasitic and "iral in+ection, nat/ral killer-cell acti"ity,
and ,a*ocytosis.
=(
6itamin-A to0icity can s,ow similar e++ects, wit, imaired
,ealin* resonse -ein* t,e most direct a++ect on t,e oral ca"ity.
=;
3++ects incl/de
roli+eration o+ oral eit,eli/m, red/ction o+ t,e keratin layer, t,ickenin* o+ t,e -asal
mem-rane, and increase in t,e *ran/lar layer. A atient w,o took >$$,$$$ IU o+
"itamin A daily +or o"er < mont,s resented wit, ain+/l *in*i"al lesions, alon* wit,
na/sea, "omitin*, 0erostomia, and ,eadac,es. Clinical e0amination re"ealed *in*i"al
erosions, /lcerations, -leedin*, swellin*, loss o+ keratini@ation, color c,an*es, and
des?/amation o+ t,e lis.
=;
All at,olo*ic mani+estations disaeared wit,in > mont,s
o+ t,e elimination o+ t,e "itamin A s/lements w,en oral ,y*iene ,a-its were
/nc,an*ed.
6itamin C 7ascor-ic acid8 is essential to oral ,ealt,. Synt,esis o+ hydroxyproline, an
essential comonent o+ colla$en, re?/ires ascor-ic acid. De+ects in colla*en synt,esis
are resonsi-le +or t,e many mani+estations o+ "itamin-C de+iciency 7scurvy8. In t,e
oral ca"ity t,ese incl/de sontaneo/s -leedin*, in+/sions o+ -lood into interdental
aillae, loosenin* and e0+oliation o+ teet,, detac,ment o+ oral eit,elial tiss/e, and
imaired wo/nd ,ealin*.
5,e e++ects o+ "itamin-C de+iciency are -est st/died in animal models, w,ere all
+actors can -e controlled. Ac/te sc/r"y can -e rod/ced -y lacin* monkeys on a
"itamin-C de+icient diet +or :> weeks. 5,e ,ydro0yroline content o+ t,e *in*i"a
started to decline in t,e +irst +o/r weeks and occ/rred at a +aster rate t,an in skin.
&$
1y
t,e end o+ t,e (t, week, t,e synt,esis o+ ,ydro0yroline was totally imaired.
&$
5,e
res/lts are e0tensi"e *in*i"al ocket +ormation and toot, mo-ility d/e to de*radation
o+ t,e colla*en makin* / eriodontal li*ament +i-ers.
>'
Alt,o/*, +rank sc/r"y is rare, e"en mar*inal de+iciencies may res/lt in alterations in
colla*en synt,esis. 5,/s de+icient or mar*inal ascor-ic acid intakes may -e a
conditionin* +actor in t,e de"eloment o+ *in*i"itis and one o+ t,e early
mani+estations o+ "itamin-C de+iciency.
&:
5,e most recent eidemiolo*ic data +rom
NHAN3S III 7National Healt, and N/trition 30amination S/r"ey8 s/**ests t,at t,e
odds o+ ,a"in* eriodontal disease are :.> times *reater in t,ose wit, low dietary
"itamin-C intakes.
&>
In t,e same st/dy, smo*ers and former smo*ers wit, low
"itamin-C intake are at :.< times *reater risk o+ ,a"in* eriodontal disease.
&>

!esearc, +indin*s s/**est t,at eole wit, mar*inal "itamin-C de+iciency
s/lemented wit, ascor-ic acid ,a"e a statistically si*ni+icant increase in
,ydro0yroline in eriodontal tiss/es.
&=
Ascor-ic acid is essential to imm/ne related +/nctions, s/c, as resistance to oral
in+ection, "ia its role in le/kocyte +ormation and s/-se?/ent pha$ocytosis,
Con"ersely, c,ronic "itamin C e0cess may reciitate a sc/r"y-like condition
7re-o/nd sc/r"y8 /on cessation o+ t,e "itamin. 1eca/se t,e imact o+ de+icient le"els
o+ "itamin C is +irst o-ser"ed in *in*i"al tiss/es, dentists and dental ,y*ienists in
clinical ractice may -e t,e +irst to dia*nose t,e ,enomenon.
&&
5,e 1-comle0
"itamins rimarily +/nction as co2en1ymes in ener$y meta4olism, 1-comle0 "itamins
are +o/nd widely in +oods, and /s/ally to*et,er. 4it, t,e e0cetion o+ 1
:>
in t,e
elderly and +olic acid in re*nant women, de+iciencies o+ sin*le 1 "itamins are
/ncommon. Oral si*ns and symtoms o+ 1-comle0 "itamin de+iciencies incl/de
cracks in t,e corners o+ t,e mo/t, 7c,eilosis8, in+lammation, -/rnin*, redness, ain
and swellin* o+ t,e ton*/e.
&'
Question 3
4,ic, is true a-o/t "itamins and oral ,ealt,e
A. 6itamin-C-de+icient wo/nds ,eal as well as non-"itamin-C-de+icient wo/nds
1. 6itamin A-to0icity does not ,a"e oral e++ects
C. 5,e oral mani+estations o+ "itamin-C de+iciency are related to de+ects in colla*en
+ormation
D. 3++ects o+ de+iciency and to0icity are -est st/died in ,/mans
Diet and Nutrition in Oral Conditions: Background and Counseling Strategies
4,o Needs Diet G/idance Caries )re"ention
Dietary education and $uidance are imortant +or t,e re"ention and control o+ dental
caries. )atients s,o/ld -e care+/lly assessed to determine t,e le"el o+ re"ention and
n/trition */idance needed +ollowin* t,ese Instit/te o+ Medicine re"ention
*/idelines9
&<
Selective Prevention6 5,is strate*y tar*ets s/-set o+ t,e total o/lation t,at are
deemed to -e at risk +or caries +or a "ariety o+ reasons. 30amles incl/de9
Adolescents at risk o+ caries -eca/se o+ ,i*, intake o+ so+t drinks and snack +oods.
Caries-re"ention co/nselin* +or atients wit, 0erostomia or cario*enic diet atterns.
)roacti"e diet s/**estions +or new dent/re wearers or t,ose ,a"in* Aaw +i0ation.
Diet ad"ice rior to radiation or c,emot,eray.
Usin* c/rrent diet atterns as a -asis +or disc/ssion, atients s,o/ld -e ta/*,t t,e role
o+ diet in caries, w,at are cario*enic and noncario*enic eatin* atterns, and ,ow to
adat c/rrent diet to lower cario*enic risk.
/ndicated Prevention6 5,is strate*y tar*ets indi"id/als s,owin* early dan*er si*ns o+
caries, s/c, as e0tensi"e cer"ical deminerali@ation. 5,ese indi"id/als need t,e
immediate a+orementioned inter"entions as well as more detailed */idance on ,ow to
red/ce cario*enicity o+ t,eir c/rrent diet. 5,is will in"ol"e determinin* t,e +actors
in+l/encin* c/rrent ,a-its, and workin* wit, t,e atient to de"elo aroriate and
acceta-le strate*ies +or imro"ement. )atients need to -e +ollowed / on a re*/lar
-asis to romote lon*-term c,an*e.
Question 4
5,e diet assessment rocess in dentistry is desi*ned to9
A. dia*nose n/trient de+iciencies
1. ,el screen atients +or oral-,ealt, risk +actors
C. ser"e as a teac,in* tool
D. determine atientsC daily caloric intake
3. ro"ide a t,erae/tic diet rescrition +or atients
F. -e art o+ total re"enti"e assessment
Dental Caries9 !ole o+ Car-o,ydrates in Caries De"eloment
Dental caries is a common la?/e-deendent -acterial in+ection t,at is stron*ly
a++ected -y diet. De"eloment o+ clinical caries is contin*ent /on t,e interaction o+
t,ree local +actors in t,e mo/t,9 a suscepti4le tooth, cario$enic 4acteria, and
fermenta4le car4ohydrate 7Fi*/re :'-&8. A-sence o+ one o+ t,ese +actors dramatically
red/ces caries risk. M/tans stretococci are t,e redominant oral -acteria t,at initiate
t,e caries rocess. Newly er/ted teet, wit, a t,in enamel layer are "ery caries
s/sceti-le. 5oot, mor,olo*y, esecially t,e resence o+ dee its and +iss/res,
in+l/ences t,e likeli,ood t,at m/tans stretococci will attac, to and coloni@e t,e
toot,Cs s/r+ace. )la?/e -acteria +erment starc,es and s/*ars, rod/cin* or*anic acids.
5,ese acids deminerali@e dental enamel.
&%
Ot,er dietary +actors counteract t,e dama*in* e++ects o+ car-o,ydrates. 5,e resence
o+ rotecti"e minerals and ions s/c, as fluoride, calcium, and phosphorus in pla5ue
and saliva, romote reminerali@ation o+ inciient lesions. In addition to transortin*
minerals, sali"a contains 4ufferin$ a$ents, 4icar4onate and phosphates, t,at
ne/trali@e or*anic acids. 5,/s, t,e amo/nt and comosition o+ sali"a a++ect t,e caries
rocess. Ot,er ,ost +actors t,at in+l/ence caries risk incl/de9 *enetic redisosition,
imm/ne stat/s, maln/trition d/rin* toot, +ormation, ed/cation le"el, and income
stat/s.
In t,e most recent national ,ealt, and e0amination s/r"ey 7NHAN3S III, ),ase I8
;&E o+ ad/lts s,owed e"idence o+ coronal caries and >>.'E o+ ad/lts ,ad root
caries.
&(
In t,e same s/r"ey, >'E o+ t,e c,ildren and teens a*ed ' to :% ,ad ($E o+
t,e dental caries detected in t,e ermanent teet,.
&;
For t,ese caries-rone c,ildren and
ad/lts, nutrition counselin$ a-o/t t,e dama*in* e++ects o+ +ermenta-le car-o,ydrates
on teet, is essential.
5,ro/*, eidemiolo*ical and clinical st/dies disc/ssed in C,ater :&, t,e ca/sal
relations,i -etween s/*ar cons/mtion and dental caries ,as -een esta-lis,ed.
Animal st/dies s/**est t,at an increase in t,e concentration o+ s/crose in t,e diet
red/ces dental la?/e +ormation and increases t,e incidence o+ dental caries.
'$,':

)eole wit, "ery low s/*ar intakes ,a"e low-caries scores. )eole in nations t,at ,a"e
,i*, s/*ar intakes ,a"e ,i*, rates o+ caries.
'>
It is /nclear i+ t,is is rimarily t,e
toical e++ect o+ s/*ar cons/mtion or systemic e++ects on dentin +ormation. Howe"er,
t,e amo/nt o+ s/*ar cons/med is not t,e sole dietary "aria-le associated wit, caries
de"eloment. S/crose lays a more dominant role t,an ot,er s/*ars in t,e
de"eloment o+ smoot, s/r+ace caries. One o+ s/croseCs meta-olic -y-rod/cts, an
e0tracell/lar olysacc,aride called $lucan, ena-les t,e m/tans stretococci to ad,ere
to t,e smoot, enamel s/r+aces.
'=
Howe"er, t,e amo/nt o+ s/crose necessary +or t,e
imlantation o+ m/tans stretococci is "ery low.
Alt,o/*, s/*ar intake is ,i*, amon* most ersons in ind/striali@ed co/ntries, it is
more di++ic/lt to demonstrate a correlation -etween caries re"alence and t,e amo/nt
o+ s/*ar cons/med t,an in de"eloin* co/ntries w,ere s/*ar intake is lower. 5,ree
recent clinical trials o+ 3n*lis,, United States, and Canadian sc,oolc,ildren e0amined
t,e relations,i -etween s/*ar intake and dental caries. In 3n*land, &$' c,ildren wit,
a mean a*e o+ ::.< years were +ollowed +or > years. 5otal s/*ar intake 7::( *rams er
day or >:E o+ total calorie intake8 ,ad t,e ,i*,est si*ni+icant correlation wit, caries
rates.
'&
Intake o+ s/*ary +oods -e+ore -edtime was ,i*,ly correlated wit, caries
incidence. In t,e United States, &;; c,ildren a*ed :: to :' years, li"in* in
non+l/oridated r/ral Mic,i*an comm/nities, were +ollowed +or = years. 5,e a"era*e
increase in decayed, missin*, and +illed s/r+aces 7DMFS8 o"er t,e = years was =.: in
*irls and >.% +or -oys. 5,e daily a"era*e s/*ar intake was :&> *rams, t,is reresented
><.'E o+ t,eir total ener*y intake. C,ildren w,o o-tained a ,i*,er ercent o+ t,eir
total calories +rom s/*ars ,ad more ro0imal s/r+ace caries. 5,e a"era*e n/m-er o+
eatin* occasions and t,e n/m-er o+ s/*ary -etween-meal snacks cons/med were not
related to caries increment.
''
'ifty percent o+ >=> ::-year-old c,ildren in a Canadian st/dy ,ad inade5uate diets,
C,ildren wit, s/erior diets tended to de"elo +ewer cariesD ,owe"er, t,e association
was not statistically si*ni+icant.
'<
Di++erences in eatin* atterns and intake o+ caries-
romotin* +oods amon* t,e c,ildren in t,ese st/dies may ,a"e -een too small to
res/lt in si*ni+icant di++erences in caries e0erience. Ot,er +actors contri-/tin* to t,e
caries decline in western co/ntries are9 +l/oride intake +rom water, t,e /se o+
+l/oridated denti+rices, imro"ed la?/e control, t,e /se o+ dental sealants, and more
+re?/ent "isits to t,e dentist.
'%
5,e /se o+ su$ar alcohols and alternative s3eeteners in +oods also ,as ,ad a role in
reducin$ caries. )er,as one o+ t,e most romisin* s/*ar s/-stit/tes to -e st/died is
xylitol, a s/*ar alco,ol t,at ,as -een demonstrated to -e non-cario*enic as well as
romotin* reminerali@ation.
'(
GylitolCs a-ility to in,i-it meta-olic acid rod/ction -y
m/tans stretococci res/lts in minimal deression o+ la?/e H. Maintenance o+ t,e
pla5ue pH close to the saliva pH also +osters reminerali@ation o+ teet,.
';
In addition,
t,e s/-stit/tion o+ 0ylitol +or +ermenta-le s/*ars in t,e diet res/lts in a less cario*enic
-acterial +lora. 5,e imortance o+ ot,er non-+ermenta-le sweeteners in caries control
is detailed in C,ater :&.
Simle s/*ars are not t,e only car-o,ydrate t,at in+l/ences t,e de"eloment o+ a
cario/s lesion. Hi*,ly re+ined coo*ed starch2su$ar com4inations s/c, as do/*,n/ts,
cookies, otato c,is, and some ready-to-eat -reak+ast cereals produce a prolon$ed
acido$enic response w,en retained in interro0imal saces.
<$
4,en starc,es are
cooked, t,ey are artially de*raded. 5,is allows t,e sali"ary al,a-amylase to con"ert
starc, articles retained on t,e ton*/e, oral m/cosa, and teet, to maltose, Makin*
maltose a"aila-le to la?/e -acteria e0tends t,e len*t, o+ time t,e la?/e H will
remain low and ermit enamel deminerali@ation to occ/r. 5,/s, retenti"e ,i*, starc,
+oods may -e more acido*enic t,an ,i*,-s/*ar-low-starc, +oods t,at are raidly
eliminated +rom t,e mo/t,.
<:
3++ects o+ 3atin* )atterns and ),ysical Form o+ Foods
Ot,er dietary +actors t,at may ,inder or en,ance caries de"eloment incl/de9 t,e
+re?/ency o+ eatin*, t,e physical form o+ t,e car-o,ydrate 7li?/id "s. solid8,
retentiveness o+ a +ood on t,e toot, s/r+ace, t,e se5uence in w,ic, +oods are
cons/med 7e.*., c,eese eaten -e+ore a sweet +ood limits t,e H dro8, and t,e
resence o+ minerals in a +ood.
Fre?/ent -etween-meal snackin* on s/*ar or rocessed starc,-containin* +oods
increases la?/e +ormation and e0tends t,e len*t, o+ time t,at -acterial acid
rod/ction can occ/r. 4,en total daily s/*ar intake was ,eld constant, increasin* t,e
+re?/ency o+ s/*ar intake +or *ro/s o+ rats res/lted in increased n/m-er o+
Streptocococi mutans in la?/e and t,e amo/nt o+ caries e0erienced.
<>
5,e ositi"e
relations,i -etween +re?/ency o+ s/*ar intake and caries in ,/mans was +irst
demonstrated in t,e =ipeholm st/dy.
<=
S/-Aects w,o cons/med candies 4et3een meals
de"eloed more caries t,an t,ose w,o were +ed e?/al amo/nts o+ s/*ars 3ith meals.
Fre?/ent snackin* -etween meals kees t,e la?/e H low and e0tends t,e time +or
enamel and dentin deminerali@ation to occ/r.
1acterial +ermentation can contin/e as lon* as car-o,ydrate ad,eres to t,e enamel and
e0osed dentinal toot, s/r+aces. 3"en t,o/*, starc,y +oods "ary in t,eir cario*enic
otential, t,e ,i*,ly re+ined starc,y +oods, s/c, as so+t -read and otato c,is, t,at
are retained on toot, s/r+aces +or rolon*ed eriods o+ time, res/lt in a lowered H
w,ic, may last up to 9: minutes,
<&,<:
Hi*,-s/crose con+ectionery +oods deli"er ,i*,
le"els o+ s/*ar to t,e oral -acteria immediately a+ter t,e +oods are cons/med, w,ereas
,i*,-starc, +oods deli"er ro*ressi"ely increasin* concentrations o+ s/*ars o"er a
considera-ly lon*er eriod o+ time.
5,e se5uence in w,ic, +oods are eaten a++ects ,ow m/c, t,e la?/e H +alls. S/*ared
co++ee cons/med at t,e end o+ a meal will ca/se t,e la?/e H to remain lo3 for a
lon$er time t,an w,en an /nsweetened +ood is eaten follo3in$ intake o+ s/*ared
co++ee.
<'
I+ ean/ts are eaten -e+ore or a+ter s/*ar-containin* +oods, t,e la?/e H is
less deressed.
<<
Some comonents o+ +oods are protective a*ainst dental caries. )rotein, +at,
,os,or/s, and calci/m in,i-it caries in rats.
<%
A*ed nat/ral c,eeses ,a"e -een
s,own to -e cariostatic.
<(
4,en c,eese is eaten +ollowin* a s/crose rinse, t,e la?/e
H remains ,i*,er t,an w,en no c,eese +ollows a s/crose rinse. In addition, enamel
deminerali@ation, meas/red /sin* t,e intraoral cario*enicity test, is red/ced. 5,e
rotecti"e e++ect o+ c,eeses is attri-/ted to their texture t,at stimulates salivary flo3,
and t,eir rotein, calci/m, and ,os,ate content t,at neutrali1es pla5ue acids,
Fl/oride +o/nd in drinkin* water, +oods, and denti+rices increases a toot,Cs resistance
to decay and en,ances reminerali@ation o+ cario/s lesions.
(ipids seem to accelerate oral clearance o+ +ood articles. Some +atty acids, linoleic
and oleic, in low concentration, in,i-it *rowt, o+ m/tans stretococc/s. .ectins,
roteins +o/nd in lants, aear to inter+ere wit, micro-ial coloni@ation and may
a++ect sali"ary +/nction.
<;
Fi*/re :'-& Factors !e?/ired +or Caries De"eloment.
Question 5
In t,e diet o+ a atient wit, ramant dental caries, w,ic, is most relevant to t,e
ro-leme
A. total amo/nt o+ s/crose cons/med
1. total amo/nt o+ sticky sweets cons/med
C. n/trient ?/ality o+ t,e meals and snacks
D. n/m-er o+ meals and snacks
3. w,at is eaten +or desert in t,e e"enin*
Meas/rin* t,e Cario*enic )otential o+ Foods
Since it is /net,ical to cond/ct ,/man e0eriments to meas/re t,e tr/e cario*enic
otential o+ +oods, ot,er indirect tests ,a"e -een de"eloed. 5,ese tests ena-le
researc,ers to classi+y +oods into at least t,ree cate*ories9 rotecti"e, low, and ,i*,
cario*enic otential. C/rrently t,e cario*enic otential or t,e a-ility to ind/ce caries
in ,/mans may -e assessed indirectly -y meas/rin* t,e a-ility o+ a test +ood to ca/se9
caries +ormation in animals, acid rod/ction in dental la?/e, or deminerali@ation o+
enamel.
:
Animal st/dies ,a"e -een cond/cted /sin* a pro$rammed feedin$ machine, In one
st/dy, >$ common snack +oods were resented to rats at seci+ied inter"als d/rin* t,e
day.
%$
A+ter s/lcal and smoot, s/r+ace caries were scored in t,e animals, cario*enic
otential indices 7C)ICs8 were com/ted +or eac, +ood 7t,e s/crose *ro/ ,ad a C)I
"al/e o+ one8 75a-le :'-'8. A +ood wit, a C)I o+ $.& ,ad low cario*enic otential.
5,ose snack +oods wit, ,i*, cario*enic otential ,ad :E or more ,ydroly@a-le starc,
in com-ination wit, s/crose or ot,er s/*ars.
Acid rod/ction in t,e mo/t, d/rin* -acterial +ermentation o+ a +ood is redicti"e o+
t,e contri-/tion o+ t,at +ood to t,e caries rocess. Meas/rement o+ la?/e
acido*enicity can -e meas/red -y determinin* t,e H o+ a la?/e samle taken +rom
t,e mo/t, or in situ,
:
Foods t,at ca/se t,e la?/e H to +all -elow t,e critical
deminerali@ation le"el 7pH >,> to >,:8 are considered acido*enic. Meas/rement o+ oral
la?/e H re?/ires lacement o+ a wire-telemetric appliance containin* a H
microelectrode in t,e sace w,ere a toot, is missin* in t,e mo/t,. As t,e test +ood is
c,ewed, t,e H /nder /ndist/r-ed la?/e at t,e site o+ t,e indwellin* electrode is
contin/ally transmitted to an e0ternal recei"er. 5,e rate o+ t,e +all and rise o+ t,e H
at an interro0imal site can -e recorded contin/o/sly /sin* la?/e telemetry. Foods
+o/nd to ,a"e low acido*enic otential /sin* t,is met,od incl/de9 a*ed c,eeses, some
"e*eta-les, meats, +is,, and n/ts.
%:
5o assess t,e a-ility o+ a +ood to deminerali@e dental enamel, an intraoral
cario$enicity test ,as -een de"eloed. 1o"ine or ,/man dental enamel sla-s are
im-edded in a rost,esis and laced in t,e mo/t, w,ere a toot, is missin*. A+ter
in*estin* a test +ood, c,an*es in s/r+ace micro,ardness or enamel orosity are
determined.
%>
Since eac, test meas/res a di++erent asect o+ cario*enicity, +oods will
-e ranked di++erently. It is recommended t,at two testin* met,ods -e /sed to
determine +ood acidoBcario*enicity otential.
%=,%&
5a-le :'-< s,ows t,e acido*enic
otential o+ +oods. 5a-le :'-% ro"ides diet s/**estions +or caries re"ention.
Question 6
5oot, erosion can -e ca/sed -y
A. acid +rom "omitin*
1. s/*ar-containin* car-onated -e"era*es
C. *astro-eso,a*eal re+l/0
D. s/*ar-+ree car-onated -e"era*es
3. all o+ t,e a-o"e
One o+ t,e most se"ere +orms o+ caries occ/rs in in+ants. Inaroriate +eedin*
ractices may res/lt in ro*ressi"e dental caries on t,e -/ccal and lin*/al s/r+aces o+
newly er/ted rimary ma0illary anterior teet, o+ in+ants and toddlers. 5,e o"erall
re"alence o+ early c,ild,ood caries 7also called 4a4y 4ottle tooth decay or nursin$
caries8 is estimated to -e 'E.
%'
Howe"er, a m/c, ,i*,er re"alence ,as -een seen
amon* Alaskan and Okla,oma Nati"e American c,ildren 7'=E8 and Na"aAo 7%>E8
and C,erokee 7''E8 Head Start c,ildren attendin* Head Start ro*rams.
%<, %%
)rimary risk +actors +or early c,ild,ood caries incl/de /ttin* a c,ild to slee at
natime or -edtime wit, a -ottle containin* a li?/id other than plain 3ater, allowin*
an in+ant to -reast-+eed at will d/rin* t,e ni*,t, and e0tended /se o+ t,e n/rsin* -ottle
or siy c/ -eyond : year o+ a*e. !es/lts o+ t,e :;;: National Healt, Inter"iew
S/r"ey s,ow t,at :<.%E or =.' million c,ildren -etween < mont,s and ' years o+ a*e
are /t to slee wit, a li?/id in t,e -ottle ot,er t,an lain water.
%(
Inaroriate
+eedin* ractices were reorted more o+ten -y arents wit, less than a hi$h school
education, low incomes, Hisanic -ack*ro/nds, and t,ose arents w,ose c,ildren ,ad
not -een to a dentist in t,e ast year.
C,ildren w,o de"elo ma0illary anterior caries are at increased risk o+ de"eloin*
osterior caries in t,e +/t/re.
%;
5o re"ent early c,ild,ood caries, dentists,
ediatricians, and ot,er ,ealt, care ro+essionals s,o/ld ask arents a-o/t t,eir in+ant
+eedin* ractices. 5,ose arents w,o reort inaroriate +eedin* ractices s,o/ld
recei"e co/nselin*. )ro*rams ser"in* low-income +amilies, s/c, as t,e Secial
S/lemental Food )ro*ram +or 4omen, In+ant, and C,ildren 74IC8, can lay a
maAor role in ro"idin* ed/cation to arents at ,i*,er risk +or /sin* inaroriate
+eedin* ractices.
N/trition and )eriodontal Disease
.ike caries, eriodontal disease is an in+ectio/s disease, m/lti+actorial in etiolo*y, and
occ/rs w,en "ir/lence o+ t,e -acterial c,allen*e is $reater than the host defense and
repair capa4ility, 5,e co/rse o+ eriodontal disease in"ol"es eriods o+ ro*ression
and remission. Unlike t,e direct ca/sati"e relations,i -etween car-o,ydrates and
caries, n/tritional +actors seem to lay a m/c, more s/-tle role in eriodontal stat/s.
N/tritional +actors can alter host suscepti4ility to eriodontal disease andBor mod/late
its ro*ress.
($
5,e n/tritional +actors related to preventin$ infection and enhancin$
3ound healin$ in *eneral alies to t,e re"ention and mana*ement o+ eriodontal
disease as well.
(:
/f -ot, t,e c,allen*e to and t,e de+ense and reair caa-ilities o+ t,e
eriodontal tiss/es are in -alance, n/trition co/ld -e t,e decidin* +actor in w,et,er
,ealt, or disease res/lts. 3"en w,en t,e eriodonti/m is ,ealt,y, t,ere is contin/al
need +or n/trients to maintain t,e tiss/es. Once in+lammation is esta-lis,ed, t,e need
+or n/trients increases, 5,ere is a close relations,i -etween maln/trition and
in+ection, wit, in+ection a**ra"atin* maln/trition and maln/trition a-ettin* in+ection.
De+ense in t,e *in*i"al cre"ice and connecti"e tiss/e all re?/ire an ade?/ate intake o+
all n/trients to ens/re ade?/ate rod/ction and +/nction o+ de+ense and s/ortin*
cells.
(>-(<
4it, t,e increased needs o+ cell/lar imm/nity and t,e additional demands
-y t,e tiss/e cells attemtin* to maintain and reair dama*ed areas, a *reater s/ly
o+ all n/trients is needed. 5,is ,as led to e"idence s,owin* t,at n/trient re?/irements
may -e ,i*,er at local sites o+ increased stress t,an in t,e rest o+ t,e -ody. S/c,
locali@ed c,allen*es may res/lt in end2or$an nutrient deficiencies,
(%, ((
Diet 0uidelines
4,ene"er ro/tine scalin*, ro,yla0is, and oral la?/e control roced/res +ail to
re"erse *in*i"itis and -e+ore any treatment +or eriodontitis is attemted, a t,oro/*,
diet e"al/ation and atient co/nselin* session is indicated. 5,e atient s,o/ld -e
in+ormed a-o/t t,e imortance o+ systemic n/trition in t,e de+ense and reair o+ oral
tiss/es. !ecommendations s,o/ld -e made to ,el ens/re otimal n/trition to ,el
re"ent and mana*e eriodontal disease. 5,ese incl/de9
3at a nutritionally ade5uate diet +ollowin* t,e +ood yramid */idelines.
Increase t,e /se o+ sali"a-stim/latin* +i-ro/s +oods.
M/lti"itaminBmineral s/lements s,o/ld -e in doses no hi$her t,an one to two
times !ecommended Dietary Allowance le"els.
void fad diets w,ic, co/ld -e de+icient in n/trients.
A"oid sin$le "itamin s/lements.
void potentially detrimental me$adoses o+ "itamins and minerals 7:$ !DA or
,i*,er8.
Question 7
)eriodontal disease is ca/sed -y dietary de+iciencies. Calci/m de+iciency is t,o/*,t to
-e a contri-/tin* +actor in al"eolar -one loss in ,/mans.
A. -ot, statements are tr/e.
1. -ot, statements are +alse.
C. t,e +irst statement is tr/e9 t,e second is +alse.
D. t,e +irst statement is +alse t,e second is tr/e.
3atin* Disorders
3atin* disorders, esecially 4ulimia, are o+ten +irst dia*nosed in t,e dental o++ice.
)atients, /s/ally yo/n* +emales, resent wit, se"ere erosion o+ t,e lin*/al toot,
s/r+aces. 5,e oral tiss/es are o+ten red, sore, and ain+/l. 5,e eso,a*/s may -e
in+lamed, and arotid sali"ary *lands are o+ten swollen. 1/limia is c,aracteri@ed -y
rec/rrent eisodes o+ 4in$e eatin$ 7cons/mtion o+ lar*e amo/nts o+ +oods at a time8
+ollowed -y sel+-ind/ced re*/r*itation 7/r*in*8. 5,e a"era*e intake o+ +ood d/rin* a
-in*e is =,&$$ calories o"er an ,o/r, wit, some indi"id/als in*estin* as m/c, as
'$,$$$ calories in >& ,o/rs.
(;
)atients may also /se la0ati"es andBor di/retics to
ind/ce mala-sortion and +l/id loss. 5,e acid +rom stomac, re*/r*itation irritates t,e
eso,a*/s and t,e oro,aryn*eal so+t tiss/es. 5,e re*/r*itated acid in com-ination
wit, 0erostomia, res/lts in raid and e0tensi"e destr/ction o+ toot, enamel.
;$
)atients o+ten +irst deny ,a"in* an eatin* disorder. Howe"er, w,en con+ronted wit,
t,e oral e"idence, t,ey o+ten admit to t,e disorder. 5,e dentist s,o/ld re+er t,e atient
to an eatin*-disorder mana*ement ro*ram and elicit atient a*reement to /nder*o
treatment. 5,e dia*nosis o+ t,is disorder -y t,e dentist and t,e reali@ation o+ t,e
dental destr/ction ca/sed -y t,e disorder, o+ten con"ince atients to a*ree to
treatment. A multidisciplinary aroac, to treatment is needed, incl/din* ,ysicians,
syc,iatrists, syc,olo*ists, n/tritionists, and social workers. 5,e atient m/st -e
ca/tioned t,at +or dental re,a-ilitation to -e s/ccess+/l, t,e /nderlyin* ro-lem 7t,e
eatin* disorder and its ca/ses8 m/st -e resol"ed.
Question 8
Oral ro-lems t,at may -e seen in atients wit, eatin* disorders incl/de9
A. swollen sali"ary *lands
1. oran*e-stained teet,
C. decreased sali"ary +low
D. decreased oral H
3. se"ere enamel deminerali@ation
5,e A*in* )atient
5,e a*in* atient is o+ten +aced wit, a "ariety o+ c,allen*es t,at can /ndermine -ot,
oral ,ealt, and n/tritional stat/s.
;:
As a res/lt, t,e elderly are considered artic/larly
s/sceti-le to maln/trition.
;>
Comared to yo/n*er indi"id/als, elders ,a"e a
si*ni+icantly decreased a-ility to resond to ,ysiolo*ic c,allen*es. Sensory +/nction
decreases leadin* to impaired taste and smell,
;=
C,an*es in t,e *astrointestinal system
can a++ect t,e a-ility to di*est, a-sor- and /tili@e +ood roerly. F/nctional ro-lems,
s/c, as art,ritis or "ision di++ic/lties can a++ect t,e a-ility to reare and eat +ood.
)syc,osocial ro-lems s/c, as loneliness, deression, lack o+ money, and oor access
to +ood can all /ndermine *ood eatin* ,a-its.
)ro-lems in t,e oral ca"ity, s/c, as 0erostomia and loose teet,, ,a"e -een considered
maAor contri-/tors to t,e oor eatin* ,a-its o+ t,e elderly and may -e a maAor
contri-/tor to maln/trition.
;>,:$',;&,;'
Se"eral st/dies ,a"e s,own t,at dentate stat/s can
a++ect eatin* a-ility
;<
and s/-se?/ent diet ?/ality.
;%, ;(, ;;
Indi"id/als wit, one or two
comlete dent/res ,ad a >$E decline in diet ?/ality comared to t,ose wit, at least
artial dentition in one or -ot, arc,es.
:$$
Anot,er st/dy s,owed t,at comared to
t,ose wit, >' or more teet,, edent/lo/s indi"id/als cons/med less +i-er and carotene,
+ewer "e*eta-les, and more c,olesterol, sat/rated +at and calories.
:$:
Dent/res can
a++ect taste and s3allo3in$ a4ility, esecially i+ t,ey are ma0illary dent/res. 5,e
dent/re co"ers t,ose taste -/ds +o/nd on t,e /er alate. And w,en t,e /er alate
is co"ered, it -ecomes di++ic/lt to detect t,e location o+ +ood in t,e mo/t,. For t,is
reason, dent/res are considered to -e t,e ma7or cause of cho*in$ in ad/lts.
:$>
Dry mouth (xerostomia8 is common in t,e older o/lation, in art -eca/se o+
0erostomic medications commonly taken. Gerostomia makes eatin* more di++ic/lt and
increases t,e cario*enic otential o+ t,e diet.
:$=,:$&
It ,as also -een associated wit,
-/rnin* mo/t, syndrome and inade?/ate diet.
:$'
Con"ersely, n/trition is an imortant +actor in oral stat/s.
:$<
In a samle o/lation o+
(&= elderly eole, t,ere was a si*ni+icant association -etween low ascor-ic acid
le"els and t,e re"alence o+ oral m/cosal lesions.
:$%
.ow calci/m intake t,ro/*,o/t
li+e ,as -een s,own to contri4ute to osteoporosis, In t/rn, osteoorosis in al"eolar
-one is t,o/*,t to -e an imortant contri-/tin* +actor to t,e resortion o+ al"eolar
-one t,at /ltimately res/lts in toot, loss.
:$(
5,e al"eolar rocess is comosed
rimarily o+ tra-ec/lar -one, w,ic, is more la-ile to calci/m im-alances t,an is
cortical -one. 5,/s, t,e al"eolar -one ro"ides a otential la-ile so/rce o+ calci/m
a"aila-le to meet other tiss/e needs. Since t,e al"eolar rocess is t,o/*,t to /nder*o
resortion prior to ot,er -onesD it is roAected t,at c,an*es detected in t,e al"eolar
rocess may e"ent/ally -e /sed +or early detection o+ osteoorosis.
:$;
Mandi-/lar
-one mass was correlated wit, total -ody calci/m and -one mass o+ t,e radi/s and
"erte-rae in dentate and edent/lo/s ostmenoa/sal women wit, osteoorosis,
::$
wit,
t,e ,i*,est correlation -etween total -ody and mandi-/lar -one mass. 5,/s, t,e
mandi-le re+lects t,e mineral stat/s o+ t,e entire skeleton. Calci/m intake in
ostmenoa/sal osteoorotic women was also correlated wit, mandi-/lar densityD
s/ortin* t,e ,yot,esis t,at low calci/m intake may contri-/te to red/ced -one
density.
:::,::>
In a st/dy o+ =>; ,ealt,y ost-menoa/sal women, an in"erse
relations,i was s,own -etween -one mineral density and n/m-er o+ e0istin* teet,,
wit, t,ose women w,o recei"ed dent/res a+ter t,e a*e o+ +orty ,a"in* t,e lowest -one
mineral density.
::=
Older atients s,o/ld -e care+/lly screened +or n/tritional risk +actors, and s,o/ld -e
ed/cated a-o/t t,e imortance o+ *ood n/trition to *eneral and oral ,ealt,.
::&, ::'
I+
maAor n/tritional ro-lems are s/sected t,e atient s,o/ld -e re+erred to a
n/tritionist.
::<
4,en new dent/res are ro"ided, atients s,o/ld -e co/nseled on ,ow
to adat t,eir /s/al diet to a so+ter consistency +or t,e +irst +ew days a+ter dent/re
insertion.
Question 9
4,ic, is tr/e a-o/t a*in*e
A. Dry mo/t, always occ/rs wit, a*in*.
1. Dent/res imro"e taste ercetion.
C. 5aste and smell ac/tely tend to decrease.
D. Calci/m intake is not o+ concern wit, t,is *ro/.
5,e Dia-etic )atient
5,e dia4etic dental atient is at $reater ris* +or de"eloin* oral in+ections and
eriodontal disease t,an t,e nondia-etic atient.
::%,::(
5,e dental team needs to -e
aware o+ c/rrent aroac,es to dia-etes mana*ement and care+/lly monitor t,e
atientCs ,ealt, stat/s rior to initiatin* dental treatment.
5,e n/trition care lan *enerally re?/ires t,at atients ,a"e meals and snacks o+
seci+ic n/trient comosition at re$ularly scheduled intervals, coordinated wit,
medications 7ins/lin or oral a*ents8 and e0ercise. Dietary mana*ement ,as c,an*ed
+rom t,e ,i*, +at, low car-o,ydrate diets o+ ast decades to t,e more li-eral /se o+
comle0 car-o,ydrates and t,e red/ctions in +at recommended today.
::;,:$%
A well-
-alanced dia-etic diet s,o/ld -e low in cario*enicity, since t,e /se o+ cario*enic
+ermenta-le car-o,ydrates s,o/ld -e in+re?/ent. Fre?/ent /se o+ ,ard candies or ot,er
+oods taken to co/nteract ,yo*lycemia are an indication t,at t,e dia-etes is not well
controlled. )atients wit, /ncontrolled dia-etes s,o/ld -e re+erred to t,eir ,ysician
+or +/rt,er mana*ement. /n the dental office, 5uic*ly assimilated car4ohydrate
sources such as 7uices, mil*, and crac*ers, should 4e *ept readily availa4le in the
event that a dia4etic patient develops symptoms of hypo$lycemia,
)atients wit, Imm/nocomromisin* Conditions 7Cancer, AIDS8
Imm/nocomromised atients, s/c, as t,ose wit, cancer or AIDS, o+ten ,a"e
increased re?/irements +or n/trients w,ile ,a"in* maAor ,ysiolo*ic and syc,osocial
imediments to eatin*. Cancer o+ten sets / a syndrome o+ wei*,t loss and wastin* in
w,ic, -ot, meta-olism and n/trient losses increase, 5,e cancer o+ten ca/ses se"ere
anore0ia, taste c,an*es, and early satiety. 5,e ain and discom+ort o+ oral in+ections
s/c, as t,e ,eres simle0 and oral candidiasis +o/nd in AIDS and c,emot,eray
atients, can also imair t,e desire and a-ility to eat.
:>$
+ver half of all head and nec*
cancer patients are nutritionally compromised at initial dia$nosis,
:>:
!adiation
t,eray increases eatin* di++ic/lty -y ca/sin* ain+/l oral mucositis, dyspha$ia, and
se"ere xerostomia,
:>>
4,en ro"idin* dental treatment to atients s/++erin* +rom cancer or AIDS, team
mem-ers need to /nderstand t,e n/trition rinciles /nderlyin* t,e care, so t,at
dental ser"ices ro"ided can -e coordinated e++ecti"ely wit, total care. 5,e n/trition
care lan initially +oc/ses on ro"idin* hi$h caloric inta*e in fre5uent small meals,
.i?/id s/lements may -e /sed i+ otimal n/trit/re cannot -e ac,ie"ed "ia +ood
alone. In more serio/s cases, atients may need enteral 7t/-e8 +eedin*s or more
ad"anced n/tritional s/ort. A ,i*, calorie diet will likely -e ,i*, in s/*ars and total
calories.
:>=
In t,ese cases, t,e dental team s,o/ld not ca/tion atients to red/ce t,e
+re?/ency o+ eatin*, since t,is will contradict n/tritional mana*ement *oals. !at,er,
t,oro/*, cleanin* a+ter eac, eatin* eriod, and /se o+ +l/oride mo/t, rinses and
toical +l/oride trays -e+ore -ed s,o/ld -e stressed. 5,is aroac, is standard
rotocol +or imm/nocomromised atients as art o+ an a**ressi"e re"enti"e dental
ro*ram.
:>&
Cancer atients s,o/ld -e ca/tioned, ,owe"er, a-o/t t,e otential oral
se?/elae o+ an increased +re?/ency o+ eatin*. )atients s,o/ld also -e ca/tioned to
a"oid t,e /se o+ slowly dissol"in* ,ard candy o+ten /sed to ass/a*e t,e 0erostomia.
5,e most imortant monitorin$ tool +or t,ese atients is 3ei$ht status, 5,e atient
s,o/ld -e ?/eried at eac, "isit a-o/t ,ow t,eir wei*,t is -ein* maintained.
In"ol/ntary wei*,t loss o+ :$ o/nds or more is a warnin* +or t,e need +or more
intensi"e care.
Oral S/r*ery and Interma0illary Fi0ation
5,e atient w,o ,as ,ad oral s/r*ery, w,et,er t,erae/tic or as a res/lt o+ tra/ma,
needs secial n/tritional consideration 7:>'-2endall, :;(>8. An ade?/ate diet 4efore
sur$ery is needed to support ade5uate post2sur$ical response, I+ +ood cons/mtion
will -e imaired +or a s,ort eriod o+ time, t,e risk o+ n/tritional de+iciency is low.
5,e risk o+ de+iciency increases wit, len*t, o+ eatin* imairment. 5,e s/r*ery itsel+
can res/lt in an anore0ia, ina-ility to c,ew, and increased meta-olic re?/irements.
:><

A+ter s/r*ery, a atient may need a li5uid diet for C or < days, -/t s,o/ld ro*ress as
soon as ossi-le to a so+t diet o+ ,i*, n/tritional ?/ality, /ntil a normal diet can -e
res/med. In some cases, n/tritionally comlete li?/id s/lements may -e aroriate
and s,o/ld -e rescri-ed in cons/ltation wit, t,e atientCs dietitian and ,ysician.
O+ten atients re+er /rees o+ normal +oods o"er commercial li?/id s/lements.
:>%

M/lti"itaminB mineral s/lements may -e aroriate as well.
Question 10
4,ic, o+ t,e +ollowin* isBare tr/ee
A. A well-controlled dia-etic diet s,o/ld -e low in caries risk.
1. )atients wit, cancer o+ten ,a"e increased n/trient needs.
C. )atients wit, imm/ne-comromisin* conditions s,o/ld -e told to red/ce t,e
+re?/ency o+ eatin* to red/ce caries risk.
D. 5,e oral s/r*ery atient may re?/ire a li?/id diet +or : to > days a+ter s/r*ery -/t
s,o/ld ret/rn to a normal diet as soon as it is ossi-le.
Summary
N/tritional stat/s and dietary ,a-its can a++ect and -e a++ected -y seci+ic oral
conditions. Comre,ensi"e atient care re?/ires t,at n/tritional +actors -e considered
in t,e etiolo*y, ro*ression, and se?/elae o+ oral ro-lems.
:>(, :>;
Dental-team mem-ers s,o/ld ro/tinely screen atients +or n/tritional iss/es, ro"ide
dentally-oriented co/nselin*, and re+er atients to dietitians +or +/rt,er care. 5,e
n/tritional imlications in dental conditions are many and comle0. No lon*er can
n/trition in dentistry -e s/mmari@ed as Fs/*ar is -ad, and +l/oride is *ood.F
:. -, c, and dcorrect.
aincorrect. It is not aroriate or ossi-le +or t,e dental team to attemt to assess
act/al n/tritional stat/s. 5,is re?/ires so,isticated la-oratory testin* /nder t,e
s/er"ision o+ a ?/ali+ied medical ro+essional.
>. dcorrect.
aincorrect. 5,e minim/m amo/nt o+ a n/trient needed to re"ent de+iciency is not
considered an aroriate standard o+ ade?/acy
-incorrect. 5,e ma0im/m amo/nt o+ a n/trient t,at will not ca/se to0icity is t,e
U. or /er tolera-le limit
cincorrect. 5,e a"era*e estimated re?/irement +or ,ealt,y eole wo/ld mean t,at
,al+ o+ t,e o/lation wo/ld re?/ire more. 5,/s it is not /sed as t,e criteria +or
,ealt,y o/lations
=. ccorrect.
aincorrect. 6itamin C-de+icient wo/nds ,a"e oorer ,ealin* a-ility
-incorrect. 6itamin-C de+iciency a++ects all eit,elial tiss/es incl/din* t,ose in t,e
oral ca"ity
dincorrect. It is not et,ical to cond/ct s/c, st/dies in ,/mans
&. -, c, and +correct.
aincorrect. 5,e diet assessment rocess can -e /sed to screen atients +or ossi-le
n/trition risk, -/t cannot -e /sed +or tr/e n/tritional assessment
dincorrect. Daily calorie intake cannot -e determined /sin* a diet screenin* tool.
)atientCs daily calorie intake is -est assessed -y a re*istered dietitian /sin* an
assessment tool desi*ned +or t,at /rose.
eincorrect. 5,e dental team can /se screenin* in+ormation to re+er t,e atient to a
re*istered dietitian w,o is ?/ali+ied to ro"ide t,erae/tic diets. 5,e dental team can
ro"ide n/trition in+ormation a-o/t ,ealt,y diet and dietBoral ,ealt, relations,is.
'. dcorrect
aincorrect. S/crose is not t,e only cario*enic +actor, and t,e amo/nt is not as
imortant as t,e distri-/tion in t,e diet.
-incorrect. 5,e amo/nt o+ sticky sweets is not as rele"ant as t,e +re?/ency o+ /sa*e
o+ t,ese items.
cincorrect. 5,e n/trient ?/ality o+ t,e diet is only related to t,e caries rocess a+ter
toot, er/tion t,ro/*, reminerali@ation e++ects.
eincorrect. Dessert is only one o+ many contri-/tin* +actors to dental caries.
<. ecorrect.
5oot, erosion can -e ca/sed -y acid +rom "omitin*, s/*ar-containin* car-onated
-e"era*es, *astroeso,a*eal re+l/0, and s/*ar-+ree car-onated -e"era*es to name -/t
a +ew +actors.
%. dcorrect.
)eriodontal disease is not caused -y dietary de+iciencies. Howe"er, calci/m
de+iciency is t,o/*,t to -e a contri-/tin* +actor to al"eolar -one loss in ,/mans.
(. a, c, d, ecorrect.
-incorrect. Oran*e-stained teet, are not necessarily ca/sed -y eatin* disorders. 5,e
stainin* can come +rom +ood, -e"era*es, or ot,er so/rces.
;. ccorrect.
aincorrect. Dry mo/t, is associated rimarily wit, t,e /se o+ medications and is not
ine"ita-le wit, a*in*.
-incorrect. Dent/res can imair taste ercetion i+ t,ey co"er taste -/ds on t,e
/er alate.
dincorrect. Calci/m is imortant +or all a*e *ro/s. Calci/m intake is associated
wit, -one density in *eneral and may -e a +actor in al"eolar -one ,ealt, as well.
:$. a, -, and dcorrect
dincorrect. )atients wit, imm/ne comromisin* conditions s,o/ld not -e told to
red/ce t,e +re?/ency o+ eatin* to red/ce caries risk. 5,ese atients are at ,i*, risk +or
n/tritional de+iciency and m/st eat ,i*, calorie +oods on a +re?/ent -asis t,ro/*,o/t
t,e day. Oral risk s,o/ld -e red/ced -y ,a"in* atients rinse t,e mo/t, and clean t,e
teet, as -est t,ey can a+ter eac, eatin* eriod and /se reminerali@in* rinses.
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Cario*enic otential o+ +oods II. !elations,i o+ +ood comosition, la?/e micro-ial
co/nts, and sali"ary arameters to caries in t,e rat model. Caries Res, >(9:$<-:'.
<(. #ensen, M. 3., Harlander, S. 2., Sc,ac,tele, C. F. 7:;(&8. 3"al/ation o+ t,e
acido*enic and antacid roerties o+ c,eeses -y telemetric recordin* o+ dental la?/e.
In He++eren, #. #., 2oe,ler, H. M. and Os-orn, #. C. 3ds. 'ood, nutrition and dental
health, 6ol. 6. )ark Forest So/t,, I.9 )at,oto0.
<;. 1owen, 4. H. 7:;;&8. Food comonents and caries. dv Dent Res, (9>:'->$.
%$. M/ndor++, S. A., Feat,erstone, #. D. 1., g 1i--y, 1. G. 7:;;$8. Cario*enic
otential o+ +oods I. Caries in t,e rat model. Caries Res, >&9=&&-''.
%:. #ensen, M. 3. 7:;('8. Dental caries9 A diet-related disease. CurrentsLEuarterly,
:9:(->$.
%>. 2o/lo/rides, 5., g C,ien, M. C. 7:;;>8. 5,e IC5 in situ e0erimental model in
dental researc,. " Dent Res, %:9(>>->%.
%=. De)aola, D. 7:;(<8. 30ec/ti"e s/mmary9 scienti+ic consens/s con+erence on
met,ods +or assessment o+ t,e cario*enic otential o+ +oods. " Dent Res, <'7Sec
Iss89:'&$-&=.
%&. C/r@on, M. 3. #., g )ollard, M. A. 7:;;<8. Inte*ration o+ met,ods +or determinin*
t,e acidBcario*enic otential o+ +oods9 a comarison o+ se"eral di++erent met,ods.
Caries Res, =$9:><-=:.
%'. !ia, .. 4. 7:;((8. N/rsin* caries9 A comre,ensi"e re"iew. Pediatr Dent,
:$9><(-(>.
%<. 2elly, M., g 1r/erd, 1. 7:;(%8. 5,e re"alence o+ -a-y -ottle toot, decay amon*
two Nati"e American o/lations. " Pu4 Health Dent, &%9;&-;%.
%%. 1roderick, 3., Ma-ry, #., !o-ertson, D., g 5,omson, #. 7:;(;8. 1a-y -ottle toot,
decay in Nati"e American c,ildren in Head Start Centers. Pu4 Health Rep, :$&9'$-'&.
%(. 2aste, .. M., g Gi+t, H. C. 7:;;'8. Inaroriate in+ant -ottle +eedin*. rch
Pediatr dolesc %ed, :&;9%(<-;:.
%;. OCS/lli"an, D. M., g 5inano++, N. 7:;;=8. Ma0illary anterior caries associated
wit, increased caries risk in ot,er rimary teet,. " Dent Res, %>9:'%%-($.
($. 6o*el, !., g Al"ares, O. F. 7:;('8. N/trition and eriodontal disease. In )ollack,
!. .., g 2ra"it@, 3., 3ds. &utrition in oral health and disease, 7. :=<-'$8.
),iladel,ia9 .ea g Fe-i*er.
(:. Na"ia, #. M., g Menaker, .. 7:;%<8. N/tritional imlications in wo/nd ,ealin*.
Dent Clin &orth m, >$7=89'&;-<%.
(>. Al+ano, M. C., Miller, S. A., g Dr/mmond, #. F. 7:;%'8. 3++ect o+ ascor-ic acid
de+iciency on t,e ermea-ility and colla*en -iosynt,esis o+ oral m/cosal eit,eli/m.
nn &. cad Sci, >'(9>'=-<=.
(=. Al+ano, M. C., g Masi, C. 4. 7:;%(8. 3++ect o+ ac/te +olic acid de+iciency on t,e
oral m/cosal ermea-ility. " Dent Res, '%9=:>, A-stract ;&;.
(&. #ose,, C. 3., As,ra+i, S. H., Stein-er*, A. D., g 4ater,o/se, #. ). 7:;(>8. Iinc
de+iciency c,an*es in t,e ermea-ility o+ ra--it eriodonti/m to
:&-
C-,enytoin and
:&
C-al-/min. " Periodont, '=9>':-'<.
('. Al+ano, M. C. 7:;%<8. Contro"ersies, ersecti"es and clinical imlications o+
n/trit/ion in eriodontal disease. Dent Clin &orth m, >$9':;-&(.
(<. De)aola, D. )., g 2/+tinec, M. M. 7:;%<8. N/trition in *rowt, and de"eloment
(%. Malleck, H. M. 7:;%(8. An in"esti*ation o+ t,e role o+ ascor-ic acid and iron in
t,e etiolo*y o+ *in*i"itis in ,/mans. Doctoral 5,esis. Cam-rid*e, MA9 /nstitute
rchives, Massac,/setts Instit/te o+ 5ec,nolo*y.
((. 4,ite,ead, N., !yner, F., g .inden-a/m, #. 7:;%=8. Me*alo-lastic c,an*es in t,e
cer"ical eit,eli/m. Association wit, oral contraceti"e t,eray and re"ersal wit,
+olic acid. "%, <<9 7:>89:&>:->&.
(;. Iac,ariasen, !. D. 7:;;'8. Oral mani+estations o+ -/limia ner"osa. -omen and
Health, << 7&89<%-%<.
;$. 1rown, S., g 1oni+a@i, D. I. 7:;;=8. An o"er"iew o+ anore0ia and -/limia
ner"osa, and t,e imact o+ eatin* disorders on t,e oral ca"ity. Compendium6 The
Compendium of Continuin$ !ducation in Dentistry, Dec, CB7:>89:';&, :';<-:<$>,
:<$&-(D ?/i@ :<$(.
;:. Do/*lass, C. 4., #ette, A. M., Fo0, C. H., 5ennstedt, S. .., #os,i, A., Feldman, H.
A., McG/ire, S. M., g Mc2inlay, #. 1. 7:;;=8. Oral ,ealt, stat/s o+ t,e elderly in
New 3n*land. " 0erontolo$y, &(9M=;-&<:.
;>. )almer, C. A. 7:;;:8. N/trition and oral ,ealt, o+ t,e elderly. In )aas, A.,
Niessen, .., g C,a/ncy, H. 0eriatric dentistry6 $in$ and oral health 7. ><&-(>8.
St. .o/is9 Mos-y Hear 1ook.
;=. Sc,i++man, S. S. 7:;;:8. 5aste and smell losses wit, a*e. Contemporary
&utrition, General Mills N/trition Deartment9 :<9>9 <-(.
;&. 1rode/r, #. M., .a/rin, D., 6allee, !., g .ac,aelle, D. 7No" :;;=8. N/trient
intake and *astrointestinal disorders related to masticatory er+ormance in t,e
edent/lo/s elderly. " Prosthetic Dentistry, D:7'89&<(-%=.
;'. )osition o+ t,e American Dietetic Association9 Oral ,ealt, and n/trition 7:;<<8. "
m Diet ss, H97>89:(&-(;.
;<. Sla*ter, A. )., Olt,o++, .. 4., 1osman, F., g Steen, 4. H. 7:;;>8. Masticatory
a-ility, dent/re ?/ality, and oral conditions in edent/lo/s s/-Aects. " Prosthetic
Dentistry , 9F 7>89>;;-=$%.
;%. 5o/*er-Decker, !., Sc,ae+er, M., Flinton, !., g Stein-er*, .. 7:;;<8. 3++ect o+
toot, loss and dent/res on diet ,a-its. " Prosthet Dent, %'9(=:.
;(. Se-rin*, N. G., G/ckes, A. D., .i, S., g McCart,y, G. !. 7:;;'8. N/tritional
ade?/acy o+ reorted intake o+ edent/lo/s s/-Aects treated wit, new con"entional or
imlant-s/orted mandi-/lar dent/res. " Prosthet Dent, %&9 ='(-<=.
;;. Greksa, .. )., )arra*a, I. M., g Clark, C. A. 7:;;'8. 5,e dietary ade?/acy o+
edent/lo/s older ad/lts. " Prosthet Dent, %=9:&>-'.
:$$. )aas, A., )almer, C., McGandy, !., Hart@, S. C., g !/ssell, !. M. 7:;(%8.
Dietary and n/tritional +acctors in relation to dental caries in elderly s/-Aects.
0erodontics, =9=$-=%.
:$:. #os,i/ra, 2., 4illett, 4., g Do/*lass, C. 7:;;<8. 5,e imact o+ edent/lo/sness
on +ood and n/trient intake. "D, Aril, :>%9&';-<%.
:$>. Anderson, D. .. 7:;%%8. Deat, +rom imroer mastication. /nt Dent ", >%9=&;.
:$=. Dormen"al, 6., 1/dt@-#or*ensen, 3., MoAon, )., 1r/yere, A., g !ain, C. H.
7:;;'8. N/trition, *eneral ,ealt, stat/s and oral ,ealt, stat/s in ,ositali@ed elders.
0erodontolo$y, C< 7:>89%=-($.
:$&. Faine, M., Allender, D., 1aa-, D., )ersson, !., g .amont, !. #. 7:;;>8. Dietary
and sali"ary +actors associated wit, root caries. Special Care in Dentistry , C< 7&89:%%-
(>.
:$'. Maresky, .. S., "an der 1iAl, )., g Gird, I., 7Marc, :;;=8. 1/rnin* mo/t,
syndrome. 3"al/ation o+ m/ltile "aria-les amon* (' atients. +ral Sur$ery, +ral
%edicine, +ral Patholo$y, D>7=89 =$=-%.
:$<. M/lli*an, !. 7:;(;8. Oral ,ealt,9 3++ect on n/trition and re,a-ilitation in older
ersons. Top 0eriatr Reha4, '9>%-='.
:$%. 6aanen, M. 2., Markkanen, H. A., 5/o"inen, 6. #., 2/llaa, A. M., 2arina/, A.
M., g 2/m/salo, 3. A. 7:;;=8. )eriodontal ,ealt, related to lasma ascor-ic acid.
Proc 'inn Dent Soc, FH 7:->89':-;.
:$(. )a*anini-Hill, A. 7:;;'8. 5,e -ene+its o+ estro*en relacement t,eray on oral
,ealt,. 5,e .eis/re 4orld co,ort. rchives /ntern %ed, C>> 7>:89>=>'-;.
:$;. 4,alen, #. )., g 2rook, .. 7:;;<8. )eriodontal disease as t,e early mani+estation
o+ osteoorosis 7editorial8. &utrition, C< 7:89'=-&.
::$. 2ri--s, ). #., C,estn/t, C. H., Ott, S., g 2ilcoyne, !. F. 7:;;$8. !elations,is
-etween mandi-/lar and skeletal -one in a o/lation o+ normal women. " Prosthet
Dent 9A 7:89(<-(;.
:::. 2ri--s, ). #. 7:;;$8. comarison o+ mandi-/lar -one in normal and osteoorotic
women. " Prosthet Dent, 9A 7>89>:(->>.
::>. Ho/ki, 2., DiM/@io, M. 5., g Fattore, .. 7:;;&8. Mandi-/lar -one density and
systemic osteoorosis in elderly edent/lo/s women. " #one %iner Res, ;
7s/l:89S>::.
::=. 2rall, 3. A., Dawson-H/*,es, 1., )aas, A., g Garcia, !. I. 7:;;&8. 5oot, loss
and skeletal -one density in ,ealt, ostmenoa/sal women. +steoporosis /nt, &9:$&-
;.
::&. &utrition /nterventions %anual for Professionals Carin$ for +lder mericans
7:;;>8. 4as,in*ton DC9 N/trition Screenin* Initiati"e.
::'. Sa/nders, M. #. 7:;;'8. Incororatin* t,e n/trition screenin* initiati"e into t,e
dental ractice. Special Care in Dentistry , C> 7:89><-=%.
::<. )la, G. 4. 7:;;&8. Oral ,ealt, and n/trition. Primary Care6 Clinics in +ffice
Practice, <C 7:89:>:->=.
::%. Holdren, !. S., g )atton, .. .. 7:;;=8. Oral conditions associated wit, dia-etes
mellit/s. Dia4etes Spectrum, 97:89::-:%.
::(. Cleary, 5. #., g H/tton, #. 3. 7:;;'8. An assessment o+ t,e association -etween
+/nctional edent/lism, o-esity, and NIDDM. Dia4etes Care, :(9:$$%-:$$;.
::;. 5,e DCC5 !esearc, Gro/ 7:;;=8. N/trition inter"entions +or intensi"e t,eray
in t,e dia-etes control and comlications trial. " m Diet ssoc, ;=9%<(-%>.
:>$. !o-ertson, ). 1., g Greensan, #. S., 3ds. 7:;((8. Perspectives on oral
%anifestations of ids6 Dia$nosis and mana$ement of H/=2associated infections,
.ittleton, MA9 )SG )/-lis,in*.
:>:. 1assett, M. !., g Do-ie, !. A. 7:;(=8. )atterns o+ n/tritional de+iciency in ,ead
and neck cancer. +tolaryn$ol Head &ec* Sur$, ;:9::;->'.
:>>. Nikoskelainen, #. 7:;;$8. Oral in+ections related to radiation and
imm/nos/ressi"e t,eray. " Clin Periodont, CD 7%89'$&-%.
:>=. Smit,, 5. #., Dwyer, #. 5., g .aFrancesca, #. ). 7:;;$8. N/trition and t,e cancer
atient. In Osteen, !. 5., Cady, 1., g !osent,al, )., 3ds. Cancer %anual 7(t, ed.8
7C,ater =;.(8 1oston9 American Cancer Society.
:>&. Dwyer, #. 5., 3+stat,ion, M. S., )almer, C., g )aas, A. 7:;;:8. N/tritional
s/ort in treatment o+ oral carcinomas. &utr Rev, &;9 ==>-=%.
:>'. 2endall, 1. D., Fonseca, !. #., g .ee, M. 7:;(>8. )ostoerati"e n/tritional
s/lementation +or t,e ort,o*nat,ic s/r*ery atient. " +ral %axillofac Sur$, &$9>$'-
>:=.
:><. Solia,, 2. 7:;(%8. Clinical e++ects o+ Aaw s/r*ery and wirin* on -ody
comosition9 A case st/dy. Dietetic Currents, "ol/me :&. Col/m-/s, OH9 !oss
.a-oratories, .:=-:<.
:>%. )atten, #. A. 7:;;'8. N/trition and wo/nd ,ealin*. Compendium of Continuin$
!ducation in Dentistry , C9 7>89>$$-:&.
:>(. .oks,in, M. F. 7:;;&8. )re"enti"e oral ,ealt, care9 A re"iew +or +amily
,ysicians. merican 'amily Physician, >: 7(89:<%%-(&, :<(%.
:>;. 2ar, 4. 1. 7:;;&8. N/trition /date +or t,e dental ,ealt, ro+essional. " Calif
Dent ssoc, << 7(89><-;.
reser"ed.
Chapter 16. Understanding Human Motivation for Behavior Change - %ary
)aye Sa3yer2%orse lexandra !vans
Objectives
:. De+ine moti"ation.
>. .ist reasons w,y indi"id/als may not -e moti"ated to recei"e re*/lar oral care.
=. Descri-e two di++erent aroac,es to moti"ate indi"id/als to c,an*e -e,a"ior.
&. Descri-e elements o+ t,ree common -e,a"ioral ,ealt, romotion t,eories.
'. 30lain t,e imortance o+ aroriate ,ealt, ro"ider comm/nication.
<. Descri-e +o/r common client-ro"ider comm/nication styles.
%. Descri-e moti"ational inter"iewin* and F!AM3S.
Introduction
5,e mo/t, reresents an area o+ t,e -ody o+ secial imortance and "al/e. Accordin*
to Horowit@ and coworkers,
:
t,e mo/t, is associated wit, t,e de"eloment o+ 7:8 a
,ealt,y ersonality, 7>8 ercetions, and 7=8 t,e o"erall e0erience o+ leas/re. Many
areas o+ t,e mo/t,, esecially t,e *in*i"al tiss/es, are easily accessi-le +or sel+-
dia*nosis and rimary re"enti"e treatment. Indi"id/als can easily detect */ms t,at
are red or -leedin*. In addition, t,e ton*/e, wit, its ,i*,ly de"eloed ne/rosensory
+eed-ack system, can -e /se+/l in ,elin* eole to assess t,eir own la?/e le"els and
res/ltant need +or imro"ed oral ,y*iene -e,a"ior. As a res/lt, dental ro+essionals
s,o/ld de"ise strate*ies +or moti"atin* oral sel+-care -e,a"ior -y teac,in* clients ,ow
to reco*ni@e t,eir own si*ns o+ dental distress or ne*lect.
In t,is c,ater t,e interrelations,i o+ moti"ation, ed/cation, and -e,a"ioral
modi+ication are consideredall wit, t,e o-Aecti"e o+ ,elin* dental ro+essionals
de"elo more e++ecti"e interersonal skills, t,ere-y -ecomin* more e++ecti"e ,ealt,
ed/cators and co/nselors.
>
5,e task o+ ed/catin* t,e client can -e *reatly simli+ied
-y a knowled*e o+ and t,e alication o+ a +ew -asic constr/cts o+ ed/cational and
,ealt, romotion and ,/man moti"ation. 5,ese same constr/cts aly e?/ally to
eit,er ri"ate or /-lic ,ealt, ractices.
The Problem: Oral ,ealt, is an essential comonent o+ ,ealt, t,ro/*,o/t li+e. )oor
oral ,ealt, and /ntreated oral diseases can ,a"e a si*ni+icant e++ect on ?/ality o+ li+e.
5,e mo/t, is t,e entry oint +or +ood and t,e -e*innin* o+ t,e *astrointestinal tract.
5,e a-ility to c,ew and swallow is a critical +/nction re?/ired to o-tain essential
n/trients +or t,e -odyt,e -/ildin* -locks o+ *ood ,ealt,.
=
Howe"er, millions o+
indi"id/als in t,e United States ,a"e dental caries and eriodontal disease, res/ltin*
in /nnecessary ain, di++ic/lty in c,ewin*, swallowin*, and seakin*, increased
medical costs, loss o+ sel+-esteem, decreased economic rod/cti"ity t,ro/*, lost work
and sc,ool days, and, in e0treme cases, deat,.
&
5,e Healt,y )eole >$:$ doc/ment
reco*ni@es t,e imortance o+ oral ,ealt, and incl/des :% seci+ic o-Aecti"es related to
t,e o"erall *oal9 5o re"ent and control oral and cranio+acial diseases, conditions, and
inA/ries and imro"e access to related ser"ices.
'
!e*/lar and timely dental "isits ro"ide an oort/nity +or t,e early dia*nosis,
re"ention, and timely treatment o+ oral diseases and conditions, as well as +or t,e
assessment o+ sel+-care ractices. Howe"er, aro0imately <<E o+ eole in t,e
United States do not see a dentist re*/larly,
'
and amon* seci+ic s/-o/lations, s/c,
as certain et,nic *ro/s or low-income *ro/s, t,e roortion not recei"in* re*/lar
care is e"en ,i*,er.
<
For e0amle, t,e Medical 30endit/re )anel S/r"ey in :;;<
indicated t,at &&E o+ t,e total o/lation "isited a dentist in t,e ast year, w,ile '$E
o+ non-Hisanic w,ites, =$E o+ Hisanics, and >%E o+ non-Hisanic -lacks ,ad a
"isit. In addition, ''E o+ t,ose indi"id/als wit, some colle*e ed/cation ,ad a ast-
year "isit comared to >&E o+ t,ose wit, less t,an a ,i*, sc,ool ed/cation.
%
5,e reasons indi"id/als may not -e moti"ated to seek re*/lar and timely care incl/de9
,i*, cost o+ dental care, lack o+ dental ins/rance, lack o+ ro"iders +rom /nderser"ed
racial and et,nic *ro/s, +ear o+ dental "isits, ,a-it/al ersonal ne*lect, lack o+
knowled*e, limited oral-,ealt, literacy, and ne*ati"e +eed-ack or /n+latterin*
statements a-o/t dentistry recei"ed +rom +riends or relati"es.
'
Ot,er +actors t,at ,a"e
contri-/ted to eole losin* con+idence in dentists incl/de rior ne*ati"e e0erienced
wit, dentists 7oorly e0ec/ted or ine++ecti"e treatment and /nnecessary or
?/estiona-le e0tractions or ot,er treatments8, dental treatment t,at did not last lon*
eno/*,, and lack o+ access to aroriate dental care. )re"io/s ain+/l e0eriences
and ercei"ed ne*ati"e dentist -e,a"iors 7e.*. arro*ance, sarcasm, or inconsideration8
aear to -e esecially imortant to t,e an0io/s indi"id/al w,o is mentally rearin*
+or dental treatment.
(
See 5a-le :<-:. Most o+ t,ese -arriers can -e o"ercome -y
e++ecti"e client ed/cation and moti"ation ro*rams and more e++ecti"e interersonal
comm/nication -y t,e dental ro+essional.
Dental Education and Motivational Programs
In re"io/s c,aters, it is stated t,at rimary re"enti"e dentistry can -e e++ecti"ely
imlemented -y /sin* t,e +ollowin* +i"e actions9 :8 la?/e control, >8 red/ction o+
s/*ar in t,e diet, =8 +l/oride t,eray, &8 /se o+ it-and-+iss/re sealants, and '8 client
ed/cation. 5,e s/ccess+/l /se o+ any o+ t,ese actions re?/ires e++ecti"e relations
-etween dental ro+essionals and clients to ac,ie"e and maintain a ma0im/m le"el o+
oral ,ealt,. 5,ree maAor ena-l-in* +actors are necessary to er+orm t,e a-o"e listed
actionsaroriate skill--ased ed/cation, client sel+-moti"ation, and aroriate
syc,omotor skills.
For any re"enti"e dentistry ro*ram to s/cceed, in+ormation a-o/t w,at needs to -e
done and ,ow it is to -e accomlis,ed m/st -e a"aila-le to -ot, t,e dental
ro+essional and t,e client. For t,e client, t,is in+ormation 7and sometimes
misin+ormation8 is o+ten learned t,ro/*, sc,ool--ased ,ealt, ro*ramsD t,e dentist,
media, and ad"ertisin*D and +rom eers, +riends, nei*,-ors, or relati"es. On t,e ot,er
,and, dental ro+essionals learn re"enti"e dentistry as art o+ t,e c/rric/l/m in
dental and dental ,y*iene sc,ools, t,ro/*, readin* ro+essional dental Ao/rnals, -y
attendin* ro+essional meetin*s and con+erences, and t,ro/*, articiation in
contin/in* ed/cation ro*rams. In some cases, t,e *a -etween t,e in+ormation
ossessed -y t,e clients and t,e dental ro+essionals is *reat. 5,is *a in knowled*e
oses a ro-lem -eca/se eole tend to seek w,at t,ey already -elie"e and a"oid
e0os/re to anyt,in* t,at mandates c,an*es.
In *eneral, t,e ersonality c,aracteristics o+ dentists indicate t,at tec,nical
ro+iciency and attention to detail may -e more common t,an stron* interersonal
comm/nication skills.
;
For t,is reason dental ro+essionals may need to c/lti"ate
seci+ic knowled*e and e0ertise in t,e area o+ ,/man -e,a"ior and moti"ation
tec,ni?/es. 1eca/se t,e skills to accomlis, t,ese tasks are not commonly ta/*,t in
dental sc,ool, many dental ro+essionals do not ,a"e ade?/ate skills to ro"ide
in+ormation to clients aroriately.
In addition, many dental ro+essionals are ta/*,t t,at ro"idin* knowled*e to a client
is s/++icient to c,an*e t,e clientCs -e,a"ior. Howe"er, e0tensi"e researc, indicates
t,at in+ormation -y itsel+ is necessary, -/t not s/++icient. H/man -e,a"ior is a rod/ct
o+ t,e interaction o+ m/ltile +actors s/c, as attit/de, sel+-e++icacy, knowled*e, or
ercei"ed risk and -ene+its. Any one +actor can -e ower+/l -/t none acts
indeendently.
:$
5,ere+ore, not only do many dental ro+essionals need to ac?/ire or
stren*t,en skills on ,ow to ro"ide in+ormation to clients, t,ey also need to learn ,ow
to aroriately moti"ate clients so t,at -e,a"ior c,an*e can occ/r. Many ,ealt,
-e,a"iors t,eories e0lain ,ealt, -e,a"ior and can */ide e++ecti"e -e,a"ior c,an*e.
For +/rt,er descrition o+ t,ree common ,ealt, -e,a"ior t,eories, see section Healt,
)romotion Aroac, to 1e,a"ior C,an*e.
Motivation
4,at is moti"atione 3"eryone is moti"ated to action or inaction. 5o not -e moti"ated
is to -e dead. Some ar*/e t,at ,/mans are rimarily instinct/al in nat/re. 5,is
ar*/ment is di++ic/lt to accet -eca/se o+ t,e "aried nat/re o+ ,/man -e,a"ior. I+ t,e
Finstinct t,eoryF was "alid, all ,/mans wo/ld s,ow a /ni+ormity o+ -e,a"ior across
all c/lt/res.
::
5,is, o+ co/rse, is not t,e case. Ot,ers -elie"e t,at -e,a"ior is learned
and t,at o/r en"ironment determines o/r actions. Indeed, no one s,o/ld downlay t,e
imortance o+ en"ironmental +orces on ,/man -e,a"ior. Moti"ation may -e descri-ed
as t,e interaction -etween t,e en"ironment, ersonal and -e,a"ioral +actors.
:>
Desite
t,e +act t,at ,/man -e,a"ior is ,i*,ly "aria-le and at times /nredicta-le, one t,in* is
certain9 Indi"id/alsC er+ormances or -e,a"iors are -ased on t,e de*ree to w,ic, t,ey
are moti"ated. Moti"ation makes t,e di++erence.
H/man moti"ation is comle0. It is -ased on a -lendin* o+ e0ectations, ideas,
+eelin*s, desires, ,oes, attit/des, "al/es, and ot,er +actors t,at initiate, maintain, and
re*/late -e,a"ior toward ac,ie"in* a *i"en *oal or o/tcome. Ot,er +actors, s/c, as
re"io/s ad"erse e0eriences, ed/cational ins/++iciency, nonaccetance -y eers, a
oor sel+-ima*e, and imo"eris,ed socioeconomic circ/mstances can si*ni+icantly
in+l/ence -e,a"ior. Moti"ation +actors can c,an*e wit, t,e assa*e o+ time. H/mans
are stron*ly *oal-oriented and can demonstrate a tremendo/s dri"e to ac,ie"e t,eir
ersonal am-itions. For some, ,owe"er, a si*ni+icant art o+ t,e leas/re is deri"ed
+rom workin* toward a *oalD a+ter t,ey ,a"e Farri"ed,F t,eir leas/re is somew,at
diminis,ed. For t,ese indi"id/als, *ettin* t,ere is not only ,al+ t,e +/n, it is ossi-ly
all t,e +/n. For e0amle, some indi"id/als eriodically -ecome intensely moti"ated to
/*rade t,eir oral ,ealt, stat/s. Aointments are made wit, t,e dentist, all
restorati"e work is comleted, re"enti"e ro*rams are de"eloed wit, a *reat
amo/nt o+ client articiation /ntil all dental care ,as -een comleted, at w,ic, time
t,e indi"id/al aears to lose interest /ntil anot,er s/dden +l/rry o+ interest may occ/r
at a later date.
Moti"ation t,en is seen not as a ersonality ro-lem or trait -/t rat,er as a state o+
readiness or ea*erness to c,an*e. 5,is readiness may +l/ct/ate +rom one time or
sit/ation to anot,er and can -e in+l/enced -y t,e dental ro+essional.
:=
Question 1
A. 5,e layerson w,o is /ndered/cated in dental ,ealt, readily accets s/**ested
c,an*es in re"enti"e ro*rams t,at are directed to -etter oral ,ealt,.
1. )ercei"ed ne*ati"e dentist -e,a"iors may deter atients +rom seekin* necessary
dental treatment.
C. )rimarily, ,/man moti"ation can -e e0lained and /nderstood as -ein* instinct/al
in nat/re.
D. In *eneral, ro"idin* atients wit, knowled*e is s/++icient to +acilitate -e,a"ior
c,an*e.
Educational Approach to Behavior Change
5,e .earnin* )rocess
1eca/se in+ormation transmittal in"ol"es learnin*, it is desira-le to t/rn to t,e
teac,in* ro+ession +or ,ow in+ormation is -est imarted to ens/re lon*-term
retention. 3ns/rin* t,at a client ad,eres wit, a ,ome care re*imen can -e t,e most
di++ic/lt art o+ t,eray.
:&
Accordin* to 1loomCs ta0onomy o+ ed/cational o-Aecti"es,
a ,ierarc,y o+ si0 le"els o+ learnin* attainment ro*resses +rom a comlete lack o+
in+ormation to *oal attainment 7see Fi*/re :<-:8.
:'
5,ese s/ccessi"e le"els are
knowled*e, comre,ension, alication, analysis, synt,esis, and e"al/ation. Most
teac,in* today is at t,e lowest knowled*e sta*e. A+ter mastery o+ t,is sta*e, t,e
learner can only de+ine, reeat, or name +actsD it is only artial learnin* at -est.
)ossi-le "er-s /sed in statin* co*niti"e o/tcomes o+ teac,in* ro*rams startin* wit,
t,e knowled*e le"el / to e"al/ation are listed in Fi*/re :<->. I+ material is only
ta/*,t at t,e lower le"els o+ t,e ta0onomy, learnin* is incomlete.
5,e imlication o+ artial learnin* is aarent w,en alied to la?/e control
met,ods. 5,e a"era*e erson knows and comre,ends t,at -r/s,in* and +lossin*
clean t,e teet,. 5,ey can e"en demonstrate t,at t,ey can -r/s, t,eir teet, in some
+as,ion. 1/t ,ow many eole can e"al/ate t,e e++ecti"eness o+ t,eir e++ortse How
many can analy@e w,ere ro-lems lie, and ,ow many can roose inno"ations to t,eir
ersonal oral ,y*iene ro*ram t,at mi*,t make it more e++ecti"ee
5eac,in* at t,e ,i*,er le"els o+ 1loomCs ta0onomy is necessary to accomlis, t,is
tye o+ learnin*. At eac, co*niti"e le"el t,e teac,in* s,o/ld +eat/re an e0lanation o+
t,e s/-Aect, +ollowed in se?/ence -y demonstration, alications, +eed-ack, and
rein+orcement. 5,e /se o+ t,ese se?/ential stes in all teac,in* ,els to ens/re a
mastery o+ t,e desired toic or skill. In mo"in* +rom one le"el o+ comle0ity to t,e
ne0t, t,e learner is e0osed to an or*ani@ed contin//m o+ interrelated +acts. 3"en a+ter
s/ccess+/lly masterin* all le"els o+ 1loomCs ,ierarc,y, ,owe"er, it is "ery ossi-le
t,at a skill or s/-Aect area learned in an academic or clinical en"ironment is not
alied at ,ome, in a more in+ormal en"ironment on a ro/tine -asis. Day-to-day
alication occ/rs only a+ter an indi"id/al ,as learned s/++icient in+ormation to
determine t,at a seci+ic -ene+it accr/es to ,im or ,er +rom its /se and t,/s ,as
-ecome moti"ated. 3d/cation in"ol"es learnin*D ractical alication in"ol"es sel+-
moti"ation.
:<
At t,is oint, t,e knowled*e needs to -e incororated into t,e clientCs
e0istin* "al/e systems.
Incororatin* 2nowled*e into 6al/e Systems
)ersonal -elie+ systems and "al/es stron*ly in+l/ence an indi"id/alCs -e,a"ior. 6al/es
are de"eloed t,ro/*, t,e alication o+ knowled*e, w,ic, t,/s re?/ires t,at an
indi"id/al ,as eno/*, +acts to de"elo concets and t,en a s/++icient n/m-er o+
concets to de"elo a "al/e.
:%
5,is concet is ortrayed *ra,ically in Fi*/re :<-=.
5,e -ase o+ t,e yramid consists o+ +acts, w,ic, are t,e -/ildin* -locks o+ all
learnin*. Sometimes *reat "oids or e"en misin+ormation occ/r in t,is -ody o+
in+ormation. Het, re*ardless o+ its comleteness or acc/racy, t,is s/-strat/m o+
in+ormation is w,ere concets are +ormed -y /se o+ oneCs reasonin* ower. Concets,
less n/mero/s t,an +acts, reresent t,e or*ani@ation and classi+ication o+ +acts into
meanin*+/l ersonal ,a-its or atterns. 5,e *reater n/m-er o+ correct +acts arisin*
+rom di++erent in/ts, t,e *reater t,e ossi-ility o+ de"eloin* correct concets. On
to o+ t,ese s/ortin* +acts and concets rest "al/es-elie+s and -odies o+
knowled*e imortant to t,e indi"id/al.
5,ese "al/es are only as stron* as t,e s/ortin* in+ormation. It s,o/ld -e noted t,at
not all dental "al/es are ositi"e. For e0amle, +or indi"id/als li"in* /nder
imo"eris,ed conditions w,o do not areciate t,e "al/e o+ teet, +rom a ,ealt, or
social "iewoint or w,ere t,e loss o+ teet, is considered as normal, +acts, concets,
and "al/es are o+ten ne*ati"e. 5,ese ne*ati"e ercetions can moti"ate
nonarticiation in dental ro*rams.
:(
It ,as also -een noted t,at a clientCs relations,i
wit, t,e dental ro+essional in+l/ences t,eir an0iety le"el and res/ltin* comliance
wit, s/**ested oral ,ealt,-care ractices.
(
5,e dental ro+essional m/st care+/lly
consider t,e ossi-le myriad +acts and concets t,at can make / t,is yramid w,en
tryin* to c,an*e a clientCs "al/e systema "al/e system t,at is "alid to only t,e
indi"id/al client.
6al/es are not ne/tral -/t are ,eld wit, ersonal +eelin*.
:%
4,en t,ey are c,allen*ed,
t,ey +re?/ently *enerate an emotional, de+ensi"e resonse. Makin* c,an*es in oneCs
-e,a"ior is o+ten "ery di++ic/lt and in"ol"es dealin* wit, con+lict. Hayakawa
:;

e0ands t,is idea w,en ,e writes, Ft,e rocess o+ learnin*, w,ic, is also t,e rocess
o+ *rowt,, is essentially a means o+ resol"in* con+licts . . . a con+lict m/st always -e
resent -e+ore learnin* can occ/r . . . con+lict t,en is a necessary accomaniment o+
ersonality de"eloment, and t,e ro*ressi"e assimilation o+ dist/r-in* stim/li is t,e
only ractical means -y w,ic, a sta-le or*ani@ation can -e o-tained. 4it,o/t con+lict,
no learnin* res/lts.F
5,ere+ore it is necessary t,at t,e dental ro+essional /nderstand t,at -eca/se o+ t,e
clientCs "al/e system, resistance is normal and ermanent c,an*es in some +orms o+
-e,a"ior are di++ic/lt to ac,ie"e. 5,is same resistance is met +rom t,e client in t,e
dental o++ice, or +rom many in t,e comm/nity, w,en new ,ealt, ro*rams are
roosed. For e0amle, s/*ar disciline is di++ic/lt to instill -eca/se o+ concets and
"al/es s,aed early in c,ild,ood -y t,e media and candy-laden s,el"es in t,e
s/ermarketsD water +l/oridation e++orts ,a"e +ailed in some areas -eca/se o+ a
-arra*e o+ misin+ormation and distorted +acts, leadin* to stron*ly ,eld "al/es -y t,ose
"otin* a*ainst +l/oridation. S/c, resistance to c,an*e s,o/ld not re"ent t,e contin/al
ed/cation and ress/re +or more e++ecti"e oral disease control ro*rams. In t,is ?/est,
,owe"er, we m/st -e care+/l ,ow we aroac, t,e "al/e systems o+ o/r clients or o+
t,e comm/nity. 4e m/st resect t,e +act t,at ot,ers ,a"e t,eir own "al/e systems
tied to t,eir own set o+ e0ectations t,at may -e ?/ite di++erent +rom o/rs.
Can ,/man "al/es -e c,an*ede 5,e answer is yes, -/t t,is statement m/st -e
?/ali+ied. 6al/es are slow to +orm and slow to c,an*e.
:%
3"en i+ t,e +act/al
in+ormation is comlete and ade?/ate, time is re?/ired +or concets to e"ol"e and
mat/reD e"en more time is re?/ired -e+ore ot,er additional +acts and concets are
ac?/ired to s/ort a new "al/e. Stated anot,er way, a dental ro+essional s,o/ld not
e0ect dramatic and immediate c,an*es in client -e,a"ior as a res/lt o+ only one or
two co/nselin* sessions. 5,/s to attain a -e,a"ioral c,an*e, a ,ealt, ed/cation
ro*ram is o+ten con+ronted wit, t,e imosin* re?/irement to modi+y or reconstr/ct
comletely t,e +acts and concets makin* / an e0istin* "al/e str/ct/re. No wonder
so many ,ealt, ed/cation ro*rams +ail. A *ood e0amle is smokin* -e,a"ior.
6irt/ally all smokers ,a"e eno/*, +acts necessary to de"elo t,e concet t,at t,e
-e,a"ior, ci*arette smokin*, is ,arm+/l. Het many ,a"e not acceted t,is concet into
t,eir own "al/e systems to t,e oint o+ -e,a"ioral c,an*e, namely o+ not smokin*. It
is also seen in caries and eriodontal disease control ro*rams in w,ic, clients are
/nwillin* to cond/ct li+elon* ro*rams o+ la?/e control.
Fi*/re :<-: 1loomCs 5a0onomy o+ 3d/cational O-Aecti"es.
Fi*/re :<-> Some ossi-le "er-s +or /se in statin* co*niti"e o/tcomes.
7Co/rtesy o+ Mary-elle Sa"a*e.8
Fi*/re :<-= 5,e interrelations,i -etween "al/es, concets, and +acts /sin* oral
,ealt, as a ositi"e end "al/e. .earnin* on all t,ree le"els ,els indi"id/als
discern +acts, make sense o+ t,em and, +inally, to li"e -y t,e meanin* t,ey
ercei"e.
Question 2
A. Di++erent *ro/s o+ indi"id/als resented wit, t,e same +acts can de"elo di++erent
concets.
1. Once +acts and concets are a art o+ an indi"id/alCs li+e, "al/es +all in lace.
C. Most ed/cation res/lts in t,e learner -ein* a-le to attain t,e co*niti"e le"el o+
e"al/ation on 1loomCs ,ierarc,y.
D. 5,e dental ro+essional m/st acknowled*e t,at "al/es are slow to c,an*e and t,at
resistance to c,an*in* "al/es is normal.
Health Promotion Approach to Behavior Change
An alternati"e way o+ e0aminin* ,/man moti"ation draws +rom t,e ,ealt, ed/cation
and ,ealt, romotion literat/re. Alt,o/*, many de+initions +or ,ealt, romotion e0ist,
one o+ t,e more common ones states t,at ,ealt, romotion is Fany com-ination o+
,ealt, ed/cation and related or*ani@ational, olitical, and economic inter"entions
desi*ned to +acilitate -e,a"ioral and en"ironmental c,an*es cond/ci"e to ,ealt,.F
>$
Central to all ,ealt, romotion de+initions is t,e concet o+ ,ealt, -e,a"ior. )ositi"e
in+ormed c,an*es in ,ealt, -e,a"ior are /s/ally t,e /ltimate *oals o+ ,ealt,
romotion acti"ities. Healt, -e,a"ior re+ers to Ft,ose ersonal attri-/tes s/c, as
-elie+s, e0ectations, moti"es, "al/es, ercetions, and ot,er co*niti"e elementsD
ersonality c,aracteristics, incl/din* a++ecti"e and emotional states and traitsD and
o"ert -e,a"ioral atterns, actions, and ,a-its t,at relate to ,ealt, maintenance, to
,ealt, restoration, and to ,ealt, imro"ement.F
>:
Seci+ic to t,e +ield o+ dental care,
,ealt, -e,a"iors incl/de *ettin* re*/lar dental c,eck-/s, re*/lar -r/s,in* and
+lossin*, and red/cin* s/*ar intake.
Identi+yin* t,e ersonal attri-/tes most si*ni+icant +or certain ,ealt, -e,a"iors is
critical +or t,e de"eloment o+ s/ccess+/l inter"entions. For e0amle, to increase t,e
n/m-er o+ indi"id/als w,o o-tain re*/lar and timely dental c,eck-/s, dental ,ealt,-
care ro"iders need to -e aware o+ t,e ersonal attri-/tes, or t,e redisosin* +actors,
t,at contri-/te to eole *ettin* re*/lar c,eck-/s. 5,is in+ormation can come +rom
two so/rces9 emirical data and ,ealt, romotion t,eories. 3mirical data can ro"ide
/s wit, data o-tained t,ro/*, eidemiolo*ical st/dies. Healt,-romotion t,eories can
e0lain and redict w,y eole -e,a"e t,e way t,ey do.
Healt, 1e,a"ior C,an*e 5,eories
5,ree rominent t,eories t,at will -e disc/ssed in t,e +ollowin* sections incl/de t,e
Healt, 1elie+ Model 7H1M8,
>>
Social Co*niti"e 5,eory 7SC58,
:>
and t,e
5ranst,eoretical Model 755M8.
>=
5,ese t,eories s,are t,e central ass/mtions t,at
eole are caa-le o+ +oret,o/*,t, lannin*, and rational decision makin*. )eole are
*oal oriented and sel+-re*/latin* -ein*s. All o+ t,ese t,eories e0licitly or imlicitly
reco*ni@e t,at eole e0erience t,eir decision makin* and sel+-re*/lation as art o+ a
dynamic social-learnin* rocess.
:>
4,ile t,e H1M mainly redicts -e,a"ior, SC5
and 55M address t,e rocesses o+ -e,a"ior c,an*e and allow +or t,e identi+ication o+
aroriate strate*ies to +acilitate -e,a"ior c,an*e.
Indi"id/alsC moti"ation is central to most ,ealt, -e,a"ior t,eories +or eit,er rediction
or -e,a"ior c,an*e /roses. As will -e noted -elow, most o+ t,ese t,eories incl/de
t,e ass/mtion t,at indi"id/als are interested in lannin* and controllin* t,eir actions
and are not assi"e Fl/ms o+ clay.F
Healt, 1elie+ Model
5,e Healt, 1elie+ Model 7H1M8 is a commonly /sed t,eory to redict indi"id/alCs
-e,a"ior re*ardin* re"enti"e ,ealt, care. Ori*inally de"eloed in t,e :;'$s to
e0lain widesread +ail/re o+ eole to articiate in inter"entions to re"ent
t/-erc/losis,
>&
H1M ,as -een e0tended to aly to eoleCs resonses to symtoms
and to t,eir comliance wit, medical re*imens.
>>
H1M incl/des +i"e main comonents9 perceived suscepti4ility, perceived severity,
perceived 4enefits, perceived 4arriers, and self2efficacy. Perceived suscepti4ility
re+ers to a ersonCs s/-Aecti"e ercetion o+ t,e risk o+ -ecomin* sick, w,ile ercei"ed
se"erity re+ers to t,e ersonCs +eelin*s o+ t,e serio/sness o+ -ecomin* sick or lea"in*
t,e illness /ntreated 7-ot, medical and clinical and social conse?/ences8. 5,e
com-ination o+ s/sceti-ility and se"erity is o+ten la-eled perceived threat. 1e+ore a
erson will take action and c,an*e -e,a"ior, t,e ercei"ed t,reat needs to ,i*,. For
e0amle, -e+ore a erson will consider +lossin* e"ery day, ,e or s,e needs to -elie"e
t,at not +lossin* will lead to eriodontal disease and t,at eriodontal disease can ,a"e
serio/s ne*ati"e conse?/ences +or ,im or ,er.
4,en an indi"id/al ,as a ,i*, perceived threat, t,at erson will analy@e t,e
perceived 4enefits and 4arriers o+ er+ormin* a certain -e,a"ior. Perceived 4enefits
re+er to t,e -elie+s re*ardin* t,e e++ecti"eness o+ t,e a"aila-le actions in red/cin* t,e
disease t,reat. 5,/s, a erson w,o -elie"es t,at +lossin* e"ery day will red/ce t,e risk
o+ de"eloin* eriodontal disease will -e more likely to er+orm t,is -e,a"ior t,an a
erson w,o does not ,a"e t,is -elie+. Contrary to ercei"ed -ene+its, perceived
4arriers 7e.*. ain+/l, di++ic/lt, /settin*, incon"enient, time-cons/min*8 can act as
imediments to en*a*in* in t,e ,ealt, -e,a"ior. 5,/s a sort o+ cost--ene+it analysis
occ/rs w,en indi"id/als decide w,et,er t,e ercei"ed -ene+its o"erride t,e ercei"ed
-arriers. I+ t,ey do, t,ose indi"id/als will most likely er+orm t,e -e,a"ior. I+ t,e
-arriers o/twei*, t,e -ene+its, t,e -e,a"ior will ro-a-ly not occ/r. 5,/s, e"en i+ a
erson +eels a ,i*, t,reat +or eriodontal disease, ,e or s,e may not c,an*e ,is c/rrent
-e,a"ior to daily +lossin* w,en t,e ercei"ed -arriers +or +lossin* e"ery day 7e.*.,
time-cons/min*, ain+/l, incon"enient8 are stron*er t,an t,e -ene+its.
Determinin* t,eir clientCs ercei"ed t,reat, ercei"ed -ene+its, and -arriers can -e
"ery ,el+/l +or a dental ro+essional w,o wants to enco/ra*e a client to c,an*e
-e,a"iors. 1y askin* t,e ri*,t tye o+ ?/estions, all ,ealt, ro+essionals can o-tain
t,is in+ormation. 5,e dental ro+essional can t,en address any ercei"ed
misconcetions and, conse?/ently, +acilitate -e,a"ior c,an*e.
Social Co*niti"e 5,eory
H1M, is a t,eory t,at +oc/ses on syc,osocial +actors wit,in t,e indi"id/al t,at can
a++ect -e,a"ior c,an*e. Social Co*niti"e 5,eory 7+ormerly known as Social .earnin*
5,eory8 incl/des -ot, indi"id/al as well as en"ironmental in+l/ences. 5,/s, SC5
e0lains ,/man -e,a"ior in terms o+ a triadic, and recirocal model, in w,ic,
ersonal +actors, en"ironmental in+l/ences, and -e,a"ior interact contin/o/sly.
:>
In
addition to e0lainin* w,y a erson -e,a"es in a certain manner, SC5 can +acilitate
-e,a"ior c,an*e -y ro"idin* seci+ic learnin* strate*ies 7e.*., modelin*8. For a more
detailed descrition o+ t,e "ario/s SC5 constr/cts, lease see Health #ehavior and
!ducation 7:;;%8 -y Glan@ et al.
!ecirocal determinism is t,e /nderlyin* ass/mtion o+ SC5. It e0lains t,at
-e,a"ior, en"ironmental +actors, and indi"id/al in+l/ences are contin/o/sly
interactin* and eac, one a++ects t,e ot,er. For e0amle, a erson w,o ,as ,i*, dental
an0iety 7a ersonal +actor8 and recei"es no rein+orcement to see a dentist re*/larly
7en"ironmental +actor8 is not likely to *o +or re"enti"e dental c,eck /s. Howe"er, i+
t,is erson recei"es ositi"e +eed-ack +or seein* a dentist 7en"ironmental +actor8, and
,as a role model w,o "isits a dentist e"ery < mont,s 7en"ironmental +actor8, ,er le"el
o+ dental an0iety may act/ally decrease. As a res/lt, s,e may -e more likely to *o see
a dentist. SC5 /nderscores t,e imortance o+ a"oidin* simlistic Fsin*le direction o+
c,an*eF t,inkin*. 1e,a"iors do not occ/r in isolation and inter"entions s,o/ld +oc/s
-ot, on t,e indi"id/al and t,e en"ironment.
:$
Modelin*, one o+ t,e key learnin* strate*ies roosed -y SC5, ,as -een s/ccess+/lly
/sed wit, dental clients to decrease dental +ear and an0iety. A st/dy er+ormed -y
1ernstein 7:;(>8 looked at t,e e++ecti"eness o+ di++erent strate*ies to red/ce +ear o+
dentistry in ad/lt clients w,o ,ad a"oided dental treatment +or +rom : to :$ years.
5,e strate*ies st/dies incl/ded articiant modelin* 7a SC5 strate*y8, sym-olic
modelin*, and *rad/ated e0os/re. !es/lts s/**ested t,at e"en t,o/*, t,e strate*ies
were e?/ally e++ecti"e +or t,e s,ort-term, articiant modelin* was most e++ecti"e +or
red/cin* +ear +or lon*-term eriod.
>'
Sta*es o+ C,an*e Model
Oral ,ealt, care ro"iders ,a"e so/*,t to /nderstand and create t,ose conditions t,at
wo/ld lead to -ene+icial and ,el+/l -e,a"ior c,an*es +or t,eir clients. 5,e
5ranst,eoretical Model 755M8, de"eloed -y two syc,olo*ists, Drs. )roc,aska and
DiClemente
>=
is a ower+/l and widely acceted model +or /nderstandin* ,ow and
w,y eole c,an*e, eit,er on t,eir own or wit, t,e assistance o+ ot,ers. 5,e model is
-ased on t,e indi"id/alCs state o+ readiness or willin*ness to c,an*e, w,ic, may
+l/ct/ate +rom one time or sit/ation to anot,er.
5,e 5ranst,eoretical Model is comosed o+ t,ree main constr/cts, one o+ w,ic, is t,e
Sta*es o+ C,an*e. 5,e sta*es o+ c,an*e constr/ct descri-es a series o+ +i"e
ro*ressi"e sta*es t,ro/*, w,ic, indi"id/als ass in t,e co/rse o+ c,an*in* a
-e,a"ior. 5,e Fw,eel o+ c,an*eF deri"ed +rom t,e )roc,aska-DiClemente model
7Fi*/re :<-&8 re+lects t,e reality t,at in almost any c,an*e rocess, it is ossi-le +or a
erson to *o aro/nd t,e Fw,eelF or relase se"eral times -e+ore ac,ie"in* a sta-le
c,an*e. For e0amle, an indi"id/al w,o is willin* and ready to start +lossin* once a
day may -e*in t,is ractice recei"in* in+ormation +rom ,is dentist, t,en relase a+ter
se"eral weeks, and t,en start t,e daily +lossin* ro/tine a*ain a+ter anot,er dental "isit.
5,/s, accordin* to t,e Sta*es o+ C,an*e, relases or slis to re"io/s -e,a"iors is
normal and a realistic occ/rrence.
5,e +i"e sta*es o+ c,an*e as linked to t,e de"eloment o+ ,ealt, -e,a"iors, incl/din*
otimal oral ,y*iene ,a-its, are descri-ed -elow. Daily +lossin* will -e /sed as t,e
seci+ic e0amle to ill/strate t,is t,eory.
PrecontemplationIndi"id/als in t,is sta*e are not aware o+ t,e ositi"e
conse?/ences o+ daily +lossin* and ,a"e no conscio/s intentions o+ startin* to +loss
daily wit,in t,e ne0t < mont,s.
ContemplationIndi"id/als in t,e Contemlation sta*e are aware o+ t,e ositi"e
conse?/ences o+ c,an*in* t,eir c/rrent -e,a"iors and lan to start +lossin* wit,in t,e
ne0t < mont,s 7near +/t/re8.
PreparationIndi"id/als in t,is sta*e are makin* concrete stes to adotin* oral
,y*iene ractices. 5,ey may ,a"e -o/*,t new +loss or sc,ed/led dental
aointments.
ctionIndi"id/als in t,e Action sta*e are act/ally +lossin* e"ery day -/t ,a"e done
so less t,an < mont,s.
%aintenanceIndi"id/als ,a"e +lossed daily +or o"er < mont,s.
As disc/ssed earlier, at any time an indi"id/al may relase to a re"io/s sta*e, t,/s an
indi"id/al in t,e Action sta*e co/ld relase to t,e )rearation or e"en t,e
Contemlation sta*e.
Corresondin* to eac, sta*e are aroriate co/nselin* tec,ni?/es. 5,/s, -y
/nderstandin* t,e seci+ic sta*es o+ -e,a"ior c,an*e and t,e corresondin* emotions
t,at may accomany t,em, oral ,ealt, care ro"iders can -etter /nderstand t,e
actions, or inactions, o+ t,eir clients. 4it, a -etter /nderstandin*, t,ey will -e more
a-le to meet t,e immediate needs o+ t,eir clients and co/nsel t,em aroriately. For
e0amle, recontemlators are not ready to c,an*e t,eir -e,a"ior and t,ey do not
want to ,ear t,reatenin* messa*es. 5,ey ,a"e a "ery stron* reonderance o+ FrosF
a-o/t t,eir c/rrent -e,a"ior and ,a"e a oor acknowled*ement o+ t,e Fcons.F 5,ese
indi"id/als s,o/ld -e *i"en -alanced in+ormation a-o/t t,e c/rrent -e,a"ior, ,andled
wit, kindness and care, and le+t alone. It is not reasona-le to -lame t,ese indi"id/als
+or -ein* /nmoti"ated to c,an*e t,eir c/rrent oral ,y*iene ractices.
Indi"id/als w,o are in t,e contemlation sta*e tend to ,a"e a -alance -etween t,e
ositi"e and ne*ati"e +eelin*s a-o/t t,eir c/rrent -e,a"iors. 5,ey are o+ten still
am-i"alent a-o/t c,an*in*. 3"en w,en contemlators mo"e into t,e rearation
sta*e, w,en t,e stren*t,s o+ t,e ros +or c,an*in* -e,a"iors ,a"e increased o"er t,e
cons, t,ey may still ,a"e ositi"e +eelin*s a-o/t t,eir c/rrent -e,a"iors t,at are
stron*.
5,e Sta*es o+ C,an*e model indicates t,at t,e *oal o+ t,e oral ,ealt, care ro"ider is
not necessarily one o+ action. 1eca/se many indi"id/als tend to -e in t,e
recontemlation or contemlation sta*es, it is "ery wort,w,ile to try to Fmo"eF t,ese
indi"id/als to t,e ne0t sta*e.
Fi*/re :<-& )roc,aska and DiClementeCs si0 sta*es o+ c,an*e 7as modi+ied -y
C,risten, et al., :;;&8.
Question 3
A. A++ectin* knowled*e is central to most ,ealt, -e,a"ior t,eories.
1. 5,e sta*es o+ c,an*e model s/**est t,at t,ere is a one-way, linear ro*ression
t,ro/*, +i"e sta*es9 recontemlation, contemlation, rearation, action, and
maintenance.
C. SC5 e0lains t,at -e,a"ior is recirocally a++ected -y ersonal and en"ironmental
+actors.
D. All ,ealt, romotion t,eories can redict ,ealt, -e,a"ior and address rocesses o+
c,an*e.
Approaches for Different Levels of Client Motivation and Adherence
)la?/e-control meas/res are di++ic/lt to accomlis, and re?/ire considera-le time,
skill, and erse"erance. In +act, c/rrent meas/res o+ oral ,y*iene re?/irin* +astidio/s
remo"al o+ all s/ra*in*i"al la?/e may -e -eyond t,e a"era*e indi"id/al.
><
5,/s a
-lend o+ ed/cation, moti"ation, and syc,omotor skills are necessary to ens/re *ood
ersonal oral ,y*iene meas/res. No *ood e"idence s/orts t,e +act t,at mass
ed/cation alters indi"id/al -e,a"ior. Instead, indi"id/ali@ed aroac,es are /s/ally
necessary, and e"en t,ese are not always s/ccess+/l.
For a dentist entr/sted wit, t,e re"enti"e care o+ a moderately moti"ated indi"id/al,
t,e recall ro*ram s,o/ld -e at s/++iciently +re?/ent inter"als to comensate +or lases
in client sel+-care ro/tines. At t,e same time, t,e ed/cational and moti"ation ,ases o+
client ed/cation s,o/ld -e em,asi@ed to imro"e t,e articiation and e++ecti"eness
in sel+-care ro*rams. In t,is way, t,e dental ro+essional ass/mes t,e task o+ carin*
+or t,e client to t,e e0tent t,at comensates +or t,e s,ortcomin*s o+ t,e client w,ile
rearin* t,e client to adot a *reater role in maintainin* ersonal oral ,ealt, stat/s.
Ultimately, it is t,e client w,o m/st ass/me as m/c, resonsi-ility +or sel+-care as
ossi-le and to seek o/t t,e dental ro+essional +or e"al/ation 7e0amination8 and
rein+orcement w,en de+iciencies are noted or s/sected.
Once an indi"id/al -ecomes s/++iciently moti"ated and c,an*es ,is or ,er -e,a"ior,
t,e ne0t imortant iss/e is ad,erence. Ad,erence imlies t,at eole c,oose +reely to
/ndertake -e,a"ioral lans, ,a"e in/t to t,em, and ,a"e colla-orati"e in"ol"ement in
adA/stin* t,eir lans.
>%
4,at makes an indi"id/al contin/e to +ollow dental
recommendations and ad,ere to ractice oral ,y*ienee Alt,o/*, t,ere is a a/city o+
literat/re in t,e area o+ ad,erence to oral ,y*iene ractices, literat/re related to ot,er
,ealt, -e,a"iors can ro"ide some in+ormation.
Alt,o/*, t,ere are some common +actors, otential determinants o+ ad,erence are not
consistently detected. A clinically-oriented +ramework -y Meic,en-a/m and 5/rk
7:;(%8 may -e /se+/l +or oral ,ealt,-care ro+essionals. 5,is +ramework di"ides
+actors related to ad,erence into c,aracteristics o+ t,e indi"id/al 7e.*., knowled*e,
attit/des, -elie+s, e0ectancies a-o/t ,ealt,, treatment8, disease 7e.*., comle0ity,
d/ration, side e++ects8, t,e treatment re*imen 7e.*., comle0ity, d/ration, tye, cost8,
relations,i to t,e ,ealt,-care-ro"ider clinic sta++ 7e.*., client-ro"ider sta++8, and
clinic or*ani@ation 7e.*., sta++ ent,/siasm8.
>(
5,is +ramework can -e /sed to ro"ide order to a list o+ determinants and can ,el
identi+y cate*ories o+ otential moderators o+ ad,erence to treatments. 5,/s, to
imro"e ad,erence to seci+ic re*imen, oral ,ealt, care ro+essionals can /se t,is
+ramework to e0amine t,eir clients and clinics to determine otential areas o+
imro"ement.
Selecting Methods of Influencing Behavior Change
Client-)ro"ider !elations,iBComm/nication Styles
Determinin* t,e most aroriate tye o+ client-,ysician relations,i is e0tremely
imortant +or t,e racticin* dentist. 4,ile some ,ealt,-care ro+essionals re+er to -e
t,e e0ert and a/t,ority, ot,ers /nderstand t,at not all clients resond well to t,is tye
o+ relations,i. 4,en a client does not resond well to t,e tye o+ relations,i
racticed -y t,e ,ealt, care ro"ider, imortant in+ormation may -e lost. On t,e ot,er
,and, t,e ositi"e -ene+its deri"ed +rom *ood doctor-client comm/nication incl/de
-ot, immediate e++ects d/rin* t,e "isit and lon* term e++ects +ollowin* t,e "isits and
in"ol"e comliance wit, rescri-ed re*imen, ain e0erience, ,ysiolo*ic c,an*es,
seed o+ reco"ery, and +/nctional state.
>;
5,ere are +o/r arc,etyal +orms o+ t,e doctor-client relations,i9 aternalism,
cons/merism, m/t/ality, and de+a/lt. )aternalism is re*arded as t,e more traditional
and ro-a-ly t,e most common +orm o+ t,e doctor-client relations,i.
=$
5,e
aternalistic model ro"ides a social control +/nction in t,at t,e ,ealt, care ro"ider
is seen as t,e e0ert and dominant, controllin* +i*/re, w,ile t,e client is assi"e and
+ree +rom social resonsi-ilities. 5,e ,ysician maintains emotional detac,ment and
acts only in ,is or ,er s,ere o+ e0ertise. Alt,o/*, some may "iew t,is tye
relations,i as ne*ati"e, some clients may act/ally draw com+ort and s/ort +rom a
doctor-+at,er +i*/re. 5,e s/orti"e nat/re o+ aternalism seems to -e "ery imortant
w,en a client is in need o+ e0tensi"e ser"ices and t,ere+ore is "/lnera-le. In times o+
emer*ency, w,en correct decisions m/st -e made ?/ickly to a"oid li+e-t,reatenin*
e"ents, t,e ,ealt,-care ro"ider m/st take control and t,e aternalistic +orm is /s/ally
necessary.
5,e cons/merism rototye is t,e oosite o+ aternalism. In t,is tye o+ relations,i,
t,e ower relations,i -etween t,e client and t,e ,ysician are re"ersed9 t,e client or
t,e cons/mer ,as more ower or control t,an t,e ,ysician.
:$
3secially w,en tryin*
to FsellF re"ention to t,e client, t,e ,ysicianCs role is to con"ince t,e client o+ t,e
necessity o+ non-c/rati"e ser"ices s/c, as re*/lar dental c,eck/s or daily -r/s,in*.
Se"eral a/t,ors ,a"e de+ined cons/merism as a client c,allen*e to /nilateral decision
makin* -y ,ysicians w,en reac,in* clos/re on dia*nosis and treatment lans.
=:
In
t,is rototye, t,e ,ealt, ro"ider and client co-Aointly e0lore t,e "ario/s otions
and lannin* o-Aecti"es. 5,is tye o+ relations,i aeals to ,i*,er order means o+
accetance, incl/din* reasonin*, nont,reatenin* ers/asion, and rewards. 5,e
,ealt,care ro"ider tyically talks less, listens more, ?/estions, reacts, and synt,esi@es
w,en necessary.
=>
Comared to cons/merism, t,e m/t/ality rototye o++ers a more moderate
alternati"e. 5,e client still ,as a *reat deal o+ ower -/t so does t,e ,ysician. In
m/t/ality, -ot, indi"id/als 7client and ,ysician8 -rin* reco*ni@ed stren*t,s and
reso/rces to t,e relations,i. In t,is model, t,e client reco*ni@es ,is or ,er role as art
o+ a Aoint "ent/re w,ile t,e ,ysician /nderstands t,e centrality o+ t,e client in ,is or
,er care.
:$
In some cases, t,e client and ,ysician remain at odds and cannot ne*otiate a c,an*e
in t,e relations,i d/e to oor +it. In t,is case, a total lack o+ control e0ists and t,e
de+a/lt rototye occ/rs.
>;
Alt,o/*, t,e client and ,ysician may still see eac, ot,er
d/rin* re*/lar "isits, t,e client may +ail to make a commitment to rescri-ed re*imens
and t,e ,ysician may cease to -e en*a*ed or try to ed/cate t,e client.
Moti"ational Inter"iewin* in t,e C,an*e )rocess
Moti"ational inter"iewin*, introd/ced -y Miller and !ollnick 7:;;:8 is a artic/lar
met,od to ,el eole reco*ni@e and do somet,in* a-o/t t,eir resent and otential
-e,a"ioral ro-lems.
==
It is artic/larly /se+/l +or t,ose clients w,o are rel/ctant to
c,an*e and am-i"alent a-o/t c,an*in*. 5,is tec,ni?/e attemts to ,el resol"e
am-i"alence and to mo"e t,e indi"id/al alon* t,e at, to c,an*e. Am-i"alence is a
state o+ mind in w,ic, a erson ,as coe0istin* -/t con+lictin* +eelin*s a-o/t some
iss/e. 5,is FI want to -/t I donCt want toF dilemma is at t,e ,eart o+ t,e ro-lem o+ all
c,an*e. Am-i"alence is a tye o+ con+lict wit,in an indi"id/al t,at ,as t,e otential
+or keein* eole Fst/ckF and creatin* stress. Am-i"alent smokers w,o ,a"e -een
told -y t,eir eriodontist t,at to-acco /se can ca/se eriodontal disease, mi*,t readily
acknowled*e t,at t,eir oral ,ealt, is endan*ered, yet may +eel e?/ally concerned
a-o/t t,eir a-ility to coe wit, stress+/l sit/ations wit,o/t smokin*.
Oral-,ealt,-care ro"iders m/st /nderstand t,at am-i"alence is not merely a F-ad
si*n.F It s,o/ld -e re*arded as normal, acceta-le, common, and /nderstanda-le art
o+ t,e c,an*e rocess. 4,at is ,i*,ly "al/ed -y some 7e.*., ,a"in* *ood oral ,ealt,8
will -e o+ little imortance to ot,ers.
Fi"e -road clinical rinciles /nderlie moti"ational inter"iewin*.
==
5,ese rinciles
em,asi@e t,at t,e clinician s,o/ld9 :8 e0ress emat,y 7t,ro/*, skill+/l re+lecti"e
listenin*, t,e clinician seeks to /nderstand and accet t,e clientCs +eelin*s and
ersecti"e wit,o/t A/d*in*, critici@in* or -lamin*, and reali@es t,at am-i"alence is
normal8D >8 de"elo discreancy 7,el t,e client /nderstand t,e discreancy -etween
t,eir resent -e,a"ior and t,eir a-ility to reac, t,eir imortant *oalsD clients s,o/ld
disco"er and resent t,eir own ar*/ments +or and a*ainst c,an*e8D =8 a"oid
ar*/mentation 7a *ently ers/asi"eBso+t con+rontation aroac, s,o/ld -e /sedone
t,at asserts t,at clients ,a"e t,e +reedom to do as t,ey leaseD a"oid sendin* t,e
messa*e t,at FICm t,e e0ert and ICm *oin* to tell yo/ ,ow to r/n yo/r li+eFD do not
acc/se clients o+ -ein* Fin denialF or la-el t,eir -e,a"ior8D &8 roll wit, resistance
7in"ite t,e client to consider new in+ormation and o++er new ersecti"es, wit,o/t
-ein* imosin*8D '8 s/ort sel+-e++icacy 7it is essential to s/ort t,e clientCs sel+-
esteem and t,eir *eneral sel+-re*ardD t,e client is resonsi-le +or c,oosin* and
carryin* o/t ersonal c,an*e and t,e o"erall messa*e is o+ ,oe and +ait, to t,e
clientD FHo/ can do it. Ho/ can s/cceed.F8.
5,e F!AM3S 1rie+ Co/nselin* 3lements
Miller and !ollnick
=&
,a"e descri-ed si0 ractical co/nselin* elements t,at are acti"e
in*redients in e++ecti"e and -rie+ co/nselin* inter"entions. 5,ey are s/mmari@ed in
t,e acronym FF!AM3S.F
Feed-ack5,e client is *i"en +eed-ack o+ t,eir c/rrent stat/s. 5,e imortance o+
cond/ctin* a t,oro/*, assessment ro"ides t,e client an oort/nity to re+lect in
detail /on t,eir sit/ation.
!esonsi-ility5,ere is an em,asis on t,e indi"id/alCs ersonal resonsi-ility +or
c,an*e. FItCs / to yo/ to decide w,at to do wit, t,is in+ormation. No-ody can decide
+or yo/, and no one can c,an*e yo/r ,a-it atterns i+ yo/ donCt want to c,an*e.F
Ad"iceSimle, clear ad"ice to t,e client to make a c,an*e in t,eir li+estyle is
*i"en.
Men/1y o++erin* clients a men/ o+ alternati"e strate*ies +or c,an*in* t,eir
ro-lem -e,a"ior, t,e clinician ro"ides a ran*e o+ otions, w,ic, allows clients to
select strate*ies t,at matc, t,eir artic/lar needs and sit/ations.
3mat,yUnderstand anot,erCs meanin* t,ro/*, t,e /se o+ re+lecti"e listenin*,
w,et,er yo/ ,a"e ,ad similar e0eriences yo/rsel+. Use o+ warmt,, resect,
s/orti"eness, carin*, concern, symat,etic /nderstandin*, commitment, and acti"e
interest to con"ey t,is element.
Sel+-e++icacy!ein+orcin* t,e clientCs ,oe or otimism in t,eir a-ility to make
c,an*es romotes sel+-e++icacy. !emem-er t,at yo/r -elie+ in t,e clientCs a-ility to
c,an*e is o+ten a si*ni+icant determinant o+ o/tcomes.
Basic Philosophy
A -asic ,iloso,y o+ re"ention is itsel+ a "al/e. One -asic ,iloso,y concernin*
re"enti"e dentistry is t,at clients deser"e to know t,e ca/se o+ t,eir dental diseases
and ,ow t,ey can re"ent t,em. 5,is is a resonsi-ility +or t,e ,ealt, ed/cator. Once
armed wit, t,e knowled*e, ,owe"er, t,e client reser"es t,e ri*,t to remain sick. 5,is
is a ro-lem o+ sel+-moti"ation. Clients are /ltimately resonsi-le +or t,eir own dental
,ealt,. In t,e +inal analysis, re"ention is a s,ared resonsi-ility -etween t,e
ractitioner and t,e client.
Summary
5,e maintenance o+ *ood oral ,ealt, re?/ires a artners,i -etween t,e dental
ro+essional and t,e atient. No re"enti"e ro*ram can -e a s/ccess /nless t,e
atient articiates in a ,ome sel+-care ro*ram to s/lement o++ice care ro*rams,
wit, t,e le"el o+ s/ccess -ein* roortionate to t,e amo/nt o+ articiation.
Ma0im/m articiation can -e e0ected w,en t,e atient knows w,at to do, ,ow to
do it, and a-o"e all ,as t,e moti"ation to ad,ere to recommended roced/res.
3d/cational strate*ies can -e /sed to teac, +acts and skills, -/t t,ese are /seless
wit,o/t moti"ation. Moti"ation can -e initiated -y an indi"id/al -ased on some need
or desire, or it can -e +acilitated -y ers/asion +rom e0ternal so/rces. 4it, or wit,o/t
moti"ation, learnin* is -est ac,ie"ed in se?/ential stes, as descri-ed -y 1loomCs
,ierarc,y o+ co*niti"e le"els. As an indi"id/al acc/m/lates +acts, t,e +acts mer*e into
concets and /ltimately into "al/es, w,ic, in t/rn en*ender moti"ation. At times
moti"ation ro"ides t,e dri"e to alter li+estyle to attain ,a-it atterns necessary to
maintain *ood oral ,ealt,. 5,e dental ro+essional can e0ert a direct or indirect
in+l/ence on s/c, a c,an*e -y ro"idin* aroriate -e,a"ior modelin*, -y takin* a
more acti"e role as an a/t,oritarian, or -y articiatin* as a nona/t,oritarian in
de"eloin* a ro*ram o+ lanned c,an*e wit, t,e atient. All ,ealt, ed/cation
re?/ires learnin*, -/t t,e s/ccess+/l alication o+ all ,ealt, knowled*e re?/ires
moti"ation.
:. 1correct.
Aincorrect. 5,e a"era*e layerson does not accet c,an*e wit,o/t considera-le
ers/asion.
Cincorrect. H/man moti"ation is comle0 in nat/re and -est descri-ed as t,e
interaction -etween t,e en"ironment, ersonal, and -e,a"ioral +actors.
Dincorrect. 2nowled*e is rarely s/++icient to c,an*e -e,a"ior.
>. A, Dcorrect.
1incorrect. Facts and concets reresent /nor*ani@ed and or*ani@ed t,o/*,ts,
resecti"elyD "al/es reresent t,e accetance and ersonal alication o+ +acts and
concets.
Cincorrect. Most ed/cation is directed to t,e initial le"el+actsD "ery little learnin*
ends / at t,e e"al/ation le"el.
=. Ccorrect.
Aincorrect. Most ,ealt,--e,a"ior t,eories attemt to e0lain or redict -e,a"ior.
1incorrect. 5,e sta*es o+ c,an*e model s/**est t,at -e,a"ior c,an*e does not
tyically +ollow a linear ro*ression -/t rat,er is cyclical as an indi"id/al e0eriences
relase and adots new -e,a"iors.
Dincorrect. Healt,-romotion t,eories attempt to e0lain or redict -e,a"ior wit,
"aryin* de*rees o+ acc/rateness.
:. Healt, romotion can -e de+ined as iiiiiiiiii.
>. An indi"id/al, t,ro/*, reasonin*, or*ani@es +acts into iiiiiiiiiiD w,ic, in t/rn
are t,e -asis +or a7n8 iiiiiiiiii.
=. 5,e central ass/mtion /nderlyin* ,ealt, romotion t,eories is iiiiiiiiii.
&. 5,e +i"e main concets o+ t,e Healt, 1elie+ Model incl/de9 iiiiiiiiii,
iiiiiiiiii, iiiiiiiiii, iiiiiiiiii, iiiiiiiiii.
'. 5,e si0 co*niti"e le"els o+ 1loomCs ,ierarc,y o+ learnin* are knowled*e,
iiiiiiiii, iiiiiiiiii, iiiiiiiiii, iiiiiiiiii, iiiiiiiiii, and iiiiiiiiii.
<. 5,e one main di++erence -etween H1M and Social Co*niti"e 5,eory is
iiiiiiiiii.
%. iiiiiiiiii is t,e /nderlyin* ass/mtion o+ SC5.
(. iiiiiiiiii imlies t,at an indi"id/al c,ooses +reely to /ndertake -e,a"ioral
lans, ,a"e in/t to t,em, and ,as a colla-orati"e in"ol"ement in modi+yin* t,e lan.
;. In t,e dentist-atient artners,i, it is t,e iiiiiiiiii w,o m/st ass/me
resonsi-ility +or ,ome care ro*rams, w,ereas t,e iiiiiiiiii m/st ass/me
resonsi-ility o+ identi+yin* and correctin* de+iciencies t,at occ/r in a ,ome care
ro*ram.
:$. In t,e de"eloment o+ otimal oral ,y*iene ,a-its, atients enco/nter +i"e
ro*ressi"e sta*es o+ c,an*e. 5,ey are9 iiiiiiiiii, iiiiiiiiii, iiiiiiiii,
::. In t,e rocess o+ alyin* moti"ational inter"iewin*, t,e clinician s,o/ld aly
+i"e rinciles, w,ic, are9 iiiii, iiiii, iiiii, iiiii, and iiiii.
:>. 5,e rocess w,ere-y t,e clinician seeks to /nderstand and accet t,e atientCs
+eelin*s and ersecti"es wit,o/t A/d*ment, critici@in*, or -lamin* is called9 iiiii.
References
:. Horowit@, .. G., Dillen-er*, #., g !attray, #. 7:;(%8. Sel+-care moti"ation9 A model
+or rimary re"enti"e oral ,ealt, -e,a"ior c,an*e. " Sch Health , '%9::&-:(.
>. 1arkley, !. 7:;%>8. A rational -asis +or a -e,a"iorally so/nd dental ractice.
Successful Preventive Dental Practices. Macom-, I.9 )re"enti"e Dentistry )ress,
:;%>.
=. American Dietetic Association 7:;(<8. ADA reorts9 )osition o+ t,e American
Dietetic Association9 Oral ,ealt, and n/trition. m " Diet ssoc, G;<9 :(&-(;.
&. !eisine, S., g .ocker, D. 7:;;'8. Social, syc,olo*ical, and economic imacts o+
oral conditions and treatments. In .. 2. Co,en g H. C. Gi+t, 3ds. Disease prevention
and oral health promotion6 Socio2dental sciences in action 7. ==-%:8. Coen,a*en9
M/nks*aard and la Federation Dentaire Internationale.
'. Healt,y )eole >$:$9 National Healt, )romotion and Disease O-Aecti"es. 7>$$$8
DHHS )/-lication No. 7)HS8 4as,in*ton, DC9 )/-lic Healt, Ser"ice.
<. U. S. General Acco/ntin* O++ice 7GAO8 !eort o+ Con*ressional !e?/estors. Oral
Healt, in .ow-Income )o/lations. 7GAOBH3HS-$$-%>8. 4as,in*ton, DC9 GAO,
>$$$.
%. A*ency +or Healt,care !esearc, and j/ality 7AH!j8 7:;;<8. Medical 30endit/re
)anel S/r"ey 7M3)S8, /n/-lis,ed data.
(. Doerr, ). A., .an*, 4. )., Ny?/ist, .. 6., g !onis, D. .. 7:;;(8. Factors associated
wit, dental an0iety. " m Dent ssoc , :>;9::::-:(.
;. Hammer, A. .., g Macdaid, G. ). 7:;;>8. M15I Career !eort9 Form G. )alo
Alto, CA9 Cons/ltin* )syc,olo*ists )ress.
:$. Glan@, 2., .ewis, M. .., g !imer, 1. 2., 3ds. 7:;;%8. Health 4ehavior and health
education 7>nd ed.8. San Francisco9 #ossey-1ass )/-lis,ers.
::. H/tc,ins, D. 4. 7:;<(8. Moti"ation in re"enti"e dentistry. !eort on t,e
Proceedin$s of the 'ourth nnual Preventive Dentistry -or*shop. 4as,in*ton, DC9
#/ly >'-><. Col/m-ia, MO9 5,e C/rators, Uni"ersity o+ Misso/ri.
:>. 1and/ra, A. 7:;(<8 Social foundation of thou$ht and action. 3n*lewood Cli++s,
N#9 )rentice-Hall.
:=. Smit,, 5. A., 2roe*er, !. F., .yon, H. 3., g M/llins, M. !. 7:;;$8. 3"al/atin* a
-e,a"ioral met,od to mana*e dental +ear9 a >-year st/dy o+ dental ractices. " mer
Dent ssoc, C<C 7:$8 '>'-=$.
:&. 6an Ho/ten, ). 7:;(;8. Moti"atin* atients to sel+-care takes t,e sta++Cs ersonal
in"ol"ement. Dent +ff , :9(-;.
:'. 1loom, 1. S., 3n*lel,art, M. D., F/rst, 3. #., et al. 7:;%'8. Taxonomy of
educational o47ectives, Hand4oo* /6 Co$nitive domain. New Hork9 D. Mc2ay Co.
:<. Sa"a*e, M. 1., #o,nson, !. 1., g #o,nson, S. !., 3ds. 7:;%:8. ssurin$ learnin$
3ith self2instructional pac*a$es, or . . . up the up staircase. C,ael Hill, NC9 Sel+-
Instr/ctional )acka*es, Inc., :&:.
:%. C,risten, A. 7:;(&8. 5,e de"eloment o+ ositi"e ,ealt, "al/es. Health =alues,
(9'-:>.
:(. 2leinknec,t, !. A., 2leac, !. 2., g Ale0ander, .. D. 7:;%=8. Ori*ins and
c,aracteristics o+ +ear o+ dentistry. " m Dent ssoc , (<9(&>-&<.
:;. Mittelman, #. S. 7:;((8. Gettin* t,ro/*, to yo/r atients9 )syc,olo*ic moti"ation.
Dent Clin &orth m , =>9>;-==.
>$. Green, .. 4., g 2re/ter, M. H. 7:;;;8. Health promotion plannin$6 n
educational and ecolo$ical approach 7=rd ed.8 Mo/ntain 6iew, CA9 May+ield
)/-lis,in*.
>:. Hoc,-a/m, G. M., Sorenson, #. !., g .ori*, 2. 7:;;>8. 5,eory in ,ealt,
ed/cation ractice. Health !ducation Euarterly, CH 7=89>;'-=:=.
>>. 1ecker, M. H. 7:;%&8. 5,e Healt, 1elie+ Model and ersonal ,ealt, -e,a"ior.
Healt, 3d/cation Mono*ra,s :;%&D >9 =>&-&%=.
>=. )roc,aska, #. O., g DiClemente, C. C. 7:;('8. Common rocesses o+ sel+-c,an*e
in smokin*, wei*,t control, and syc,olo*ical distress. In S,i++man, S., g 4ills, 5.,
3ds. Copin$ and su4stance use 7. =&'-<&8. Orlando, F.9 Academic )ress.
>&. Hoc,-a/m, G. M. 7:;'(8. )/-lic articiation in medical screenin* ro*rams9 A
sociosyc,olo*ical st/dy. )/-lic Healt, Ser"ice N/m-er '%>.
>'. 1ernstein, D. A. 7:;(>8. M/ltile aroac,es to t,e red/ction o+ dental +ear. "
#ehav Ther and !xp Psychiat, CA 7&89 >(%-;>.
><. 1rady, 4. F. 7:;(&8. )eriodontal disease awareness. " m Dent ssoc , :$;9%$<-
:$.
>%. 1rawley, .. !., g C/los-!eed, S. 7>$$$8. St/dyin* ad,erence to t,erae/tic
re*imens9 O"er"iew, t,eories, recommendations. Controlled Clinical Trials , >:9
:'<S-:<=S.
>(. Meic,en-a/m, D., g 5/rk, D. C. 7:;(%8. 'acilitatin$ treatment adherence6
practitioner?s $uide4oo*. New Hork9 )len/m.
>;. !oter, D. .., g Hall, #. A. 7:;(>8. Doctors tal*in$ to patients tal*in$ to doctors6
/mprovin$ communication in medical visits. 4estort, C59 A/-/rn Ho/se.
=$. S@as@, ). S., g Hollender, M. H. 7:;'<8. A contri-/tion to t,e ,iloso,y o+
medicine9 5,e -asic model o+ t,e doctor-atient relations,i. rchi /ntern %ed,
;%9'('-;>.
=:. Ha/*, M., g .a"in, 1. 7:;(=8. Consumerism in medicine6 Challen$in$ physician
authority. 5,o/sand Oaks, CA9 Sa*e.
=>. Iwata, 1. A., g 1ecks+ort, C. M. 7:;(:8. 1e,a"ioral researc, in re"enti"e
dentistry9 3d/cational and contin*ency mana*ement aroac,es to t,e ro-lem o+
atient comliance. pplied #ehavioral nal , :&9:::->$.
==. Miller, 4. !., g !ollnick, S. 7:;;:8. %otivational intervie3in$. New Hork9 5,e
G/il+ord )ress.
reser"ed.
Chapter 16. Understanding Human Motivation for Behavior Change - %ary
)aye Sa3yer2%orse lexandra !vans
Objectives
:. De+ine moti"ation.
>. .ist reasons w,y indi"id/als may not -e moti"ated to recei"e re*/lar oral care.
=. Descri-e two di++erent aroac,es to moti"ate indi"id/als to c,an*e -e,a"ior.
&. Descri-e elements o+ t,ree common -e,a"ioral ,ealt, romotion t,eories.
'. 30lain t,e imortance o+ aroriate ,ealt, ro"ider comm/nication.
<. Descri-e +o/r common client-ro"ider comm/nication styles.
%. Descri-e moti"ational inter"iewin* and F!AM3S.
Introduction
5,e mo/t, reresents an area o+ t,e -ody o+ secial imortance and "al/e. Accordin*
to Horowit@ and coworkers,
:
t,e mo/t, is associated wit, t,e de"eloment o+ 7:8 a
,ealt,y ersonality, 7>8 ercetions, and 7=8 t,e o"erall e0erience o+ leas/re. Many
areas o+ t,e mo/t,, esecially t,e *in*i"al tiss/es, are easily accessi-le +or sel+-
dia*nosis and rimary re"enti"e treatment. Indi"id/als can easily detect */ms t,at
are red or -leedin*. In addition, t,e ton*/e, wit, its ,i*,ly de"eloed ne/rosensory
+eed-ack system, can -e /se+/l in ,elin* eole to assess t,eir own la?/e le"els and
res/ltant need +or imro"ed oral ,y*iene -e,a"ior. As a res/lt, dental ro+essionals
s,o/ld de"ise strate*ies +or moti"atin* oral sel+-care -e,a"ior -y teac,in* clients ,ow
to reco*ni@e t,eir own si*ns o+ dental distress or ne*lect.
In t,is c,ater t,e interrelations,i o+ moti"ation, ed/cation, and -e,a"ioral
modi+ication are consideredall wit, t,e o-Aecti"e o+ ,elin* dental ro+essionals
de"elo more e++ecti"e interersonal skills, t,ere-y -ecomin* more e++ecti"e ,ealt,
ed/cators and co/nselors.
>
5,e task o+ ed/catin* t,e client can -e *reatly simli+ied
-y a knowled*e o+ and t,e alication o+ a +ew -asic constr/cts o+ ed/cational and
,ealt, romotion and ,/man moti"ation. 5,ese same constr/cts aly e?/ally to
eit,er ri"ate or /-lic ,ealt, ractices.
The Problem: Oral ,ealt, is an essential comonent o+ ,ealt, t,ro/*,o/t li+e. )oor
oral ,ealt, and /ntreated oral diseases can ,a"e a si*ni+icant e++ect on ?/ality o+ li+e.
5,e mo/t, is t,e entry oint +or +ood and t,e -e*innin* o+ t,e *astrointestinal tract.
5,e a-ility to c,ew and swallow is a critical +/nction re?/ired to o-tain essential
n/trients +or t,e -odyt,e -/ildin* -locks o+ *ood ,ealt,.
=
Howe"er, millions o+
indi"id/als in t,e United States ,a"e dental caries and eriodontal disease, res/ltin*
in /nnecessary ain, di++ic/lty in c,ewin*, swallowin*, and seakin*, increased
medical costs, loss o+ sel+-esteem, decreased economic rod/cti"ity t,ro/*, lost work
and sc,ool days, and, in e0treme cases, deat,.
&
5,e Healt,y )eole >$:$ doc/ment
reco*ni@es t,e imortance o+ oral ,ealt, and incl/des :% seci+ic o-Aecti"es related to
t,e o"erall *oal9 5o re"ent and control oral and cranio+acial diseases, conditions, and
inA/ries and imro"e access to related ser"ices.
'
!e*/lar and timely dental "isits ro"ide an oort/nity +or t,e early dia*nosis,
re"ention, and timely treatment o+ oral diseases and conditions, as well as +or t,e
assessment o+ sel+-care ractices. Howe"er, aro0imately <<E o+ eole in t,e
United States do not see a dentist re*/larly,
'
and amon* seci+ic s/-o/lations, s/c,
as certain et,nic *ro/s or low-income *ro/s, t,e roortion not recei"in* re*/lar
care is e"en ,i*,er.
<
For e0amle, t,e Medical 30endit/re )anel S/r"ey in :;;<
indicated t,at &&E o+ t,e total o/lation "isited a dentist in t,e ast year, w,ile '$E
o+ non-Hisanic w,ites, =$E o+ Hisanics, and >%E o+ non-Hisanic -lacks ,ad a
"isit. In addition, ''E o+ t,ose indi"id/als wit, some colle*e ed/cation ,ad a ast-
year "isit comared to >&E o+ t,ose wit, less t,an a ,i*, sc,ool ed/cation.
%
5,e reasons indi"id/als may not -e moti"ated to seek re*/lar and timely care incl/de9
,i*, cost o+ dental care, lack o+ dental ins/rance, lack o+ ro"iders +rom /nderser"ed
racial and et,nic *ro/s, +ear o+ dental "isits, ,a-it/al ersonal ne*lect, lack o+
knowled*e, limited oral-,ealt, literacy, and ne*ati"e +eed-ack or /n+latterin*
statements a-o/t dentistry recei"ed +rom +riends or relati"es.
'
Ot,er +actors t,at ,a"e
contri-/ted to eole losin* con+idence in dentists incl/de rior ne*ati"e e0erienced
wit, dentists 7oorly e0ec/ted or ine++ecti"e treatment and /nnecessary or
?/estiona-le e0tractions or ot,er treatments8, dental treatment t,at did not last lon*
eno/*,, and lack o+ access to aroriate dental care. )re"io/s ain+/l e0eriences
and ercei"ed ne*ati"e dentist -e,a"iors 7e.*. arro*ance, sarcasm, or inconsideration8
aear to -e esecially imortant to t,e an0io/s indi"id/al w,o is mentally rearin*
+or dental treatment.
(
See 5a-le :<-:. Most o+ t,ese -arriers can -e o"ercome -y
e++ecti"e client ed/cation and moti"ation ro*rams and more e++ecti"e interersonal
comm/nication -y t,e dental ro+essional.
Dental Education and Motivational Programs
In re"io/s c,aters, it is stated t,at rimary re"enti"e dentistry can -e e++ecti"ely
imlemented -y /sin* t,e +ollowin* +i"e actions9 :8 la?/e control, >8 red/ction o+
s/*ar in t,e diet, =8 +l/oride t,eray, &8 /se o+ it-and-+iss/re sealants, and '8 client
ed/cation. 5,e s/ccess+/l /se o+ any o+ t,ese actions re?/ires e++ecti"e relations
-etween dental ro+essionals and clients to ac,ie"e and maintain a ma0im/m le"el o+
oral ,ealt,. 5,ree maAor ena-l-in* +actors are necessary to er+orm t,e a-o"e listed
actionsaroriate skill--ased ed/cation, client sel+-moti"ation, and aroriate
syc,omotor skills.
For any re"enti"e dentistry ro*ram to s/cceed, in+ormation a-o/t w,at needs to -e
done and ,ow it is to -e accomlis,ed m/st -e a"aila-le to -ot, t,e dental
ro+essional and t,e client. For t,e client, t,is in+ormation 7and sometimes
misin+ormation8 is o+ten learned t,ro/*, sc,ool--ased ,ealt, ro*ramsD t,e dentist,
media, and ad"ertisin*D and +rom eers, +riends, nei*,-ors, or relati"es. On t,e ot,er
,and, dental ro+essionals learn re"enti"e dentistry as art o+ t,e c/rric/l/m in
dental and dental ,y*iene sc,ools, t,ro/*, readin* ro+essional dental Ao/rnals, -y
attendin* ro+essional meetin*s and con+erences, and t,ro/*, articiation in
contin/in* ed/cation ro*rams. In some cases, t,e *a -etween t,e in+ormation
ossessed -y t,e clients and t,e dental ro+essionals is *reat. 5,is *a in knowled*e
oses a ro-lem -eca/se eole tend to seek w,at t,ey already -elie"e and a"oid
e0os/re to anyt,in* t,at mandates c,an*es.
In *eneral, t,e ersonality c,aracteristics o+ dentists indicate t,at tec,nical
ro+iciency and attention to detail may -e more common t,an stron* interersonal
comm/nication skills.
;
For t,is reason dental ro+essionals may need to c/lti"ate
seci+ic knowled*e and e0ertise in t,e area o+ ,/man -e,a"ior and moti"ation
tec,ni?/es. 1eca/se t,e skills to accomlis, t,ese tasks are not commonly ta/*,t in
dental sc,ool, many dental ro+essionals do not ,a"e ade?/ate skills to ro"ide
in+ormation to clients aroriately.
In addition, many dental ro+essionals are ta/*,t t,at ro"idin* knowled*e to a client
is s/++icient to c,an*e t,e clientCs -e,a"ior. Howe"er, e0tensi"e researc, indicates
t,at in+ormation -y itsel+ is necessary, -/t not s/++icient. H/man -e,a"ior is a rod/ct
o+ t,e interaction o+ m/ltile +actors s/c, as attit/de, sel+-e++icacy, knowled*e, or
ercei"ed risk and -ene+its. Any one +actor can -e ower+/l -/t none acts
indeendently.
:$
5,ere+ore, not only do many dental ro+essionals need to ac?/ire or
stren*t,en skills on ,ow to ro"ide in+ormation to clients, t,ey also need to learn ,ow
to aroriately moti"ate clients so t,at -e,a"ior c,an*e can occ/r. Many ,ealt,
-e,a"iors t,eories e0lain ,ealt, -e,a"ior and can */ide e++ecti"e -e,a"ior c,an*e.
For +/rt,er descrition o+ t,ree common ,ealt, -e,a"ior t,eories, see section Healt,
)romotion Aroac, to 1e,a"ior C,an*e.
Motivation
4,at is moti"atione 3"eryone is moti"ated to action or inaction. 5o not -e moti"ated
is to -e dead. Some ar*/e t,at ,/mans are rimarily instinct/al in nat/re. 5,is
ar*/ment is di++ic/lt to accet -eca/se o+ t,e "aried nat/re o+ ,/man -e,a"ior. I+ t,e
Finstinct t,eoryF was "alid, all ,/mans wo/ld s,ow a /ni+ormity o+ -e,a"ior across
all c/lt/res.
::
5,is, o+ co/rse, is not t,e case. Ot,ers -elie"e t,at -e,a"ior is learned
and t,at o/r en"ironment determines o/r actions. Indeed, no one s,o/ld downlay t,e
imortance o+ en"ironmental +orces on ,/man -e,a"ior. Moti"ation may -e descri-ed
as t,e interaction -etween t,e en"ironment, ersonal and -e,a"ioral +actors.
:>
Desite
t,e +act t,at ,/man -e,a"ior is ,i*,ly "aria-le and at times /nredicta-le, one t,in* is
certain9 Indi"id/alsC er+ormances or -e,a"iors are -ased on t,e de*ree to w,ic, t,ey
are moti"ated. Moti"ation makes t,e di++erence.
H/man moti"ation is comle0. It is -ased on a -lendin* o+ e0ectations, ideas,
+eelin*s, desires, ,oes, attit/des, "al/es, and ot,er +actors t,at initiate, maintain, and
re*/late -e,a"ior toward ac,ie"in* a *i"en *oal or o/tcome. Ot,er +actors, s/c, as
re"io/s ad"erse e0eriences, ed/cational ins/++iciency, nonaccetance -y eers, a
oor sel+-ima*e, and imo"eris,ed socioeconomic circ/mstances can si*ni+icantly
in+l/ence -e,a"ior. Moti"ation +actors can c,an*e wit, t,e assa*e o+ time. H/mans
are stron*ly *oal-oriented and can demonstrate a tremendo/s dri"e to ac,ie"e t,eir
ersonal am-itions. For some, ,owe"er, a si*ni+icant art o+ t,e leas/re is deri"ed
+rom workin* toward a *oalD a+ter t,ey ,a"e Farri"ed,F t,eir leas/re is somew,at
diminis,ed. For t,ese indi"id/als, *ettin* t,ere is not only ,al+ t,e +/n, it is ossi-ly
all t,e +/n. For e0amle, some indi"id/als eriodically -ecome intensely moti"ated to
/*rade t,eir oral ,ealt, stat/s. Aointments are made wit, t,e dentist, all
restorati"e work is comleted, re"enti"e ro*rams are de"eloed wit, a *reat
amo/nt o+ client articiation /ntil all dental care ,as -een comleted, at w,ic, time
t,e indi"id/al aears to lose interest /ntil anot,er s/dden +l/rry o+ interest may occ/r
at a later date.
Moti"ation t,en is seen not as a ersonality ro-lem or trait -/t rat,er as a state o+
readiness or ea*erness to c,an*e. 5,is readiness may +l/ct/ate +rom one time or
sit/ation to anot,er and can -e in+l/enced -y t,e dental ro+essional.
:=
Question 1
A. 5,e layerson w,o is /ndered/cated in dental ,ealt, readily accets s/**ested
c,an*es in re"enti"e ro*rams t,at are directed to -etter oral ,ealt,.
1. )ercei"ed ne*ati"e dentist -e,a"iors may deter atients +rom seekin* necessary
dental treatment.
C. )rimarily, ,/man moti"ation can -e e0lained and /nderstood as -ein* instinct/al
in nat/re.
D. In *eneral, ro"idin* atients wit, knowled*e is s/++icient to +acilitate -e,a"ior
c,an*e.
Educational Approach to Behavior Change
5,e .earnin* )rocess
1eca/se in+ormation transmittal in"ol"es learnin*, it is desira-le to t/rn to t,e
teac,in* ro+ession +or ,ow in+ormation is -est imarted to ens/re lon*-term
retention. 3ns/rin* t,at a client ad,eres wit, a ,ome care re*imen can -e t,e most
di++ic/lt art o+ t,eray.
:&
Accordin* to 1loomCs ta0onomy o+ ed/cational o-Aecti"es,
a ,ierarc,y o+ si0 le"els o+ learnin* attainment ro*resses +rom a comlete lack o+
in+ormation to *oal attainment 7see Fi*/re :<-:8.
:'
5,ese s/ccessi"e le"els are
knowled*e, comre,ension, alication, analysis, synt,esis, and e"al/ation. Most
teac,in* today is at t,e lowest knowled*e sta*e. A+ter mastery o+ t,is sta*e, t,e
learner can only de+ine, reeat, or name +actsD it is only artial learnin* at -est.
)ossi-le "er-s /sed in statin* co*niti"e o/tcomes o+ teac,in* ro*rams startin* wit,
t,e knowled*e le"el / to e"al/ation are listed in Fi*/re :<->. I+ material is only
ta/*,t at t,e lower le"els o+ t,e ta0onomy, learnin* is incomlete.
5,e imlication o+ artial learnin* is aarent w,en alied to la?/e control
met,ods. 5,e a"era*e erson knows and comre,ends t,at -r/s,in* and +lossin*
clean t,e teet,. 5,ey can e"en demonstrate t,at t,ey can -r/s, t,eir teet, in some
+as,ion. 1/t ,ow many eole can e"al/ate t,e e++ecti"eness o+ t,eir e++ortse How
many can analy@e w,ere ro-lems lie, and ,ow many can roose inno"ations to t,eir
ersonal oral ,y*iene ro*ram t,at mi*,t make it more e++ecti"ee
5eac,in* at t,e ,i*,er le"els o+ 1loomCs ta0onomy is necessary to accomlis, t,is
tye o+ learnin*. At eac, co*niti"e le"el t,e teac,in* s,o/ld +eat/re an e0lanation o+
t,e s/-Aect, +ollowed in se?/ence -y demonstration, alications, +eed-ack, and
rein+orcement. 5,e /se o+ t,ese se?/ential stes in all teac,in* ,els to ens/re a
mastery o+ t,e desired toic or skill. In mo"in* +rom one le"el o+ comle0ity to t,e
ne0t, t,e learner is e0osed to an or*ani@ed contin//m o+ interrelated +acts. 3"en a+ter
s/ccess+/lly masterin* all le"els o+ 1loomCs ,ierarc,y, ,owe"er, it is "ery ossi-le
t,at a skill or s/-Aect area learned in an academic or clinical en"ironment is not
alied at ,ome, in a more in+ormal en"ironment on a ro/tine -asis. Day-to-day
alication occ/rs only a+ter an indi"id/al ,as learned s/++icient in+ormation to
determine t,at a seci+ic -ene+it accr/es to ,im or ,er +rom its /se and t,/s ,as
-ecome moti"ated. 3d/cation in"ol"es learnin*D ractical alication in"ol"es sel+-
moti"ation.
:<
At t,is oint, t,e knowled*e needs to -e incororated into t,e clientCs
e0istin* "al/e systems.
Incororatin* 2nowled*e into 6al/e Systems
)ersonal -elie+ systems and "al/es stron*ly in+l/ence an indi"id/alCs -e,a"ior. 6al/es
are de"eloed t,ro/*, t,e alication o+ knowled*e, w,ic, t,/s re?/ires t,at an
indi"id/al ,as eno/*, +acts to de"elo concets and t,en a s/++icient n/m-er o+
concets to de"elo a "al/e.
:%
5,is concet is ortrayed *ra,ically in Fi*/re :<-=.
5,e -ase o+ t,e yramid consists o+ +acts, w,ic, are t,e -/ildin* -locks o+ all
learnin*. Sometimes *reat "oids or e"en misin+ormation occ/r in t,is -ody o+
in+ormation. Het, re*ardless o+ its comleteness or acc/racy, t,is s/-strat/m o+
in+ormation is w,ere concets are +ormed -y /se o+ oneCs reasonin* ower. Concets,
less n/mero/s t,an +acts, reresent t,e or*ani@ation and classi+ication o+ +acts into
meanin*+/l ersonal ,a-its or atterns. 5,e *reater n/m-er o+ correct +acts arisin*
+rom di++erent in/ts, t,e *reater t,e ossi-ility o+ de"eloin* correct concets. On
to o+ t,ese s/ortin* +acts and concets rest "al/es-elie+s and -odies o+
knowled*e imortant to t,e indi"id/al.
5,ese "al/es are only as stron* as t,e s/ortin* in+ormation. It s,o/ld -e noted t,at
not all dental "al/es are ositi"e. For e0amle, +or indi"id/als li"in* /nder
imo"eris,ed conditions w,o do not areciate t,e "al/e o+ teet, +rom a ,ealt, or
social "iewoint or w,ere t,e loss o+ teet, is considered as normal, +acts, concets,
and "al/es are o+ten ne*ati"e. 5,ese ne*ati"e ercetions can moti"ate
nonarticiation in dental ro*rams.
:(
It ,as also -een noted t,at a clientCs relations,i
wit, t,e dental ro+essional in+l/ences t,eir an0iety le"el and res/ltin* comliance
wit, s/**ested oral ,ealt,-care ractices.
(
5,e dental ro+essional m/st care+/lly
consider t,e ossi-le myriad +acts and concets t,at can make / t,is yramid w,en
tryin* to c,an*e a clientCs "al/e systema "al/e system t,at is "alid to only t,e
indi"id/al client.
6al/es are not ne/tral -/t are ,eld wit, ersonal +eelin*.
:%
4,en t,ey are c,allen*ed,
t,ey +re?/ently *enerate an emotional, de+ensi"e resonse. Makin* c,an*es in oneCs
-e,a"ior is o+ten "ery di++ic/lt and in"ol"es dealin* wit, con+lict. Hayakawa
:;

e0ands t,is idea w,en ,e writes, Ft,e rocess o+ learnin*, w,ic, is also t,e rocess
o+ *rowt,, is essentially a means o+ resol"in* con+licts . . . a con+lict m/st always -e
resent -e+ore learnin* can occ/r . . . con+lict t,en is a necessary accomaniment o+
ersonality de"eloment, and t,e ro*ressi"e assimilation o+ dist/r-in* stim/li is t,e
only ractical means -y w,ic, a sta-le or*ani@ation can -e o-tained. 4it,o/t con+lict,
no learnin* res/lts.F
5,ere+ore it is necessary t,at t,e dental ro+essional /nderstand t,at -eca/se o+ t,e
clientCs "al/e system, resistance is normal and ermanent c,an*es in some +orms o+
-e,a"ior are di++ic/lt to ac,ie"e. 5,is same resistance is met +rom t,e client in t,e
dental o++ice, or +rom many in t,e comm/nity, w,en new ,ealt, ro*rams are
roosed. For e0amle, s/*ar disciline is di++ic/lt to instill -eca/se o+ concets and
"al/es s,aed early in c,ild,ood -y t,e media and candy-laden s,el"es in t,e
s/ermarketsD water +l/oridation e++orts ,a"e +ailed in some areas -eca/se o+ a
-arra*e o+ misin+ormation and distorted +acts, leadin* to stron*ly ,eld "al/es -y t,ose
"otin* a*ainst +l/oridation. S/c, resistance to c,an*e s,o/ld not re"ent t,e contin/al
ed/cation and ress/re +or more e++ecti"e oral disease control ro*rams. In t,is ?/est,
,owe"er, we m/st -e care+/l ,ow we aroac, t,e "al/e systems o+ o/r clients or o+
t,e comm/nity. 4e m/st resect t,e +act t,at ot,ers ,a"e t,eir own "al/e systems
tied to t,eir own set o+ e0ectations t,at may -e ?/ite di++erent +rom o/rs.
Can ,/man "al/es -e c,an*ede 5,e answer is yes, -/t t,is statement m/st -e
?/ali+ied. 6al/es are slow to +orm and slow to c,an*e.
:%
3"en i+ t,e +act/al
in+ormation is comlete and ade?/ate, time is re?/ired +or concets to e"ol"e and
mat/reD e"en more time is re?/ired -e+ore ot,er additional +acts and concets are
ac?/ired to s/ort a new "al/e. Stated anot,er way, a dental ro+essional s,o/ld not
e0ect dramatic and immediate c,an*es in client -e,a"ior as a res/lt o+ only one or
two co/nselin* sessions. 5,/s to attain a -e,a"ioral c,an*e, a ,ealt, ed/cation
ro*ram is o+ten con+ronted wit, t,e imosin* re?/irement to modi+y or reconstr/ct
comletely t,e +acts and concets makin* / an e0istin* "al/e str/ct/re. No wonder
so many ,ealt, ed/cation ro*rams +ail. A *ood e0amle is smokin* -e,a"ior.
6irt/ally all smokers ,a"e eno/*, +acts necessary to de"elo t,e concet t,at t,e
-e,a"ior, ci*arette smokin*, is ,arm+/l. Het many ,a"e not acceted t,is concet into
t,eir own "al/e systems to t,e oint o+ -e,a"ioral c,an*e, namely o+ not smokin*. It
is also seen in caries and eriodontal disease control ro*rams in w,ic, clients are
/nwillin* to cond/ct li+elon* ro*rams o+ la?/e control.
Fi*/re :<-: 1loomCs 5a0onomy o+ 3d/cational O-Aecti"es.
Fi*/re :<-> Some ossi-le "er-s +or /se in statin* co*niti"e o/tcomes.
7Co/rtesy o+ Mary-elle Sa"a*e.8
Fi*/re :<-= 5,e interrelations,i -etween "al/es, concets, and +acts /sin* oral
,ealt, as a ositi"e end "al/e. .earnin* on all t,ree le"els ,els indi"id/als
discern +acts, make sense o+ t,em and, +inally, to li"e -y t,e meanin* t,ey
ercei"e.
Question 2
A. Di++erent *ro/s o+ indi"id/als resented wit, t,e same +acts can de"elo di++erent
concets.
1. Once +acts and concets are a art o+ an indi"id/alCs li+e, "al/es +all in lace.
C. Most ed/cation res/lts in t,e learner -ein* a-le to attain t,e co*niti"e le"el o+
e"al/ation on 1loomCs ,ierarc,y.
D. 5,e dental ro+essional m/st acknowled*e t,at "al/es are slow to c,an*e and t,at
resistance to c,an*in* "al/es is normal.
Health Promotion Approach to Behavior Change
An alternati"e way o+ e0aminin* ,/man moti"ation draws +rom t,e ,ealt, ed/cation
and ,ealt, romotion literat/re. Alt,o/*, many de+initions +or ,ealt, romotion e0ist,
one o+ t,e more common ones states t,at ,ealt, romotion is Fany com-ination o+
,ealt, ed/cation and related or*ani@ational, olitical, and economic inter"entions
desi*ned to +acilitate -e,a"ioral and en"ironmental c,an*es cond/ci"e to ,ealt,.F
>$
Central to all ,ealt, romotion de+initions is t,e concet o+ ,ealt, -e,a"ior. )ositi"e
in+ormed c,an*es in ,ealt, -e,a"ior are /s/ally t,e /ltimate *oals o+ ,ealt,
romotion acti"ities. Healt, -e,a"ior re+ers to Ft,ose ersonal attri-/tes s/c, as
-elie+s, e0ectations, moti"es, "al/es, ercetions, and ot,er co*niti"e elementsD
ersonality c,aracteristics, incl/din* a++ecti"e and emotional states and traitsD and
o"ert -e,a"ioral atterns, actions, and ,a-its t,at relate to ,ealt, maintenance, to
,ealt, restoration, and to ,ealt, imro"ement.F
>:
Seci+ic to t,e +ield o+ dental care,
,ealt, -e,a"iors incl/de *ettin* re*/lar dental c,eck-/s, re*/lar -r/s,in* and
+lossin*, and red/cin* s/*ar intake.
Identi+yin* t,e ersonal attri-/tes most si*ni+icant +or certain ,ealt, -e,a"iors is
critical +or t,e de"eloment o+ s/ccess+/l inter"entions. For e0amle, to increase t,e
n/m-er o+ indi"id/als w,o o-tain re*/lar and timely dental c,eck-/s, dental ,ealt,-
care ro"iders need to -e aware o+ t,e ersonal attri-/tes, or t,e redisosin* +actors,
t,at contri-/te to eole *ettin* re*/lar c,eck-/s. 5,is in+ormation can come +rom
two so/rces9 emirical data and ,ealt, romotion t,eories. 3mirical data can ro"ide
/s wit, data o-tained t,ro/*, eidemiolo*ical st/dies. Healt,-romotion t,eories can
e0lain and redict w,y eole -e,a"e t,e way t,ey do.
Healt, 1e,a"ior C,an*e 5,eories
5,ree rominent t,eories t,at will -e disc/ssed in t,e +ollowin* sections incl/de t,e
Healt, 1elie+ Model 7H1M8,
>>
Social Co*niti"e 5,eory 7SC58,
:>
and t,e
5ranst,eoretical Model 755M8.
>=
5,ese t,eories s,are t,e central ass/mtions t,at
eole are caa-le o+ +oret,o/*,t, lannin*, and rational decision makin*. )eole are
*oal oriented and sel+-re*/latin* -ein*s. All o+ t,ese t,eories e0licitly or imlicitly
reco*ni@e t,at eole e0erience t,eir decision makin* and sel+-re*/lation as art o+ a
dynamic social-learnin* rocess.
:>
4,ile t,e H1M mainly redicts -e,a"ior, SC5
and 55M address t,e rocesses o+ -e,a"ior c,an*e and allow +or t,e identi+ication o+
aroriate strate*ies to +acilitate -e,a"ior c,an*e.
Indi"id/alsC moti"ation is central to most ,ealt, -e,a"ior t,eories +or eit,er rediction
or -e,a"ior c,an*e /roses. As will -e noted -elow, most o+ t,ese t,eories incl/de
t,e ass/mtion t,at indi"id/als are interested in lannin* and controllin* t,eir actions
and are not assi"e Fl/ms o+ clay.F
Healt, 1elie+ Model
5,e Healt, 1elie+ Model 7H1M8 is a commonly /sed t,eory to redict indi"id/alCs
-e,a"ior re*ardin* re"enti"e ,ealt, care. Ori*inally de"eloed in t,e :;'$s to
e0lain widesread +ail/re o+ eole to articiate in inter"entions to re"ent
t/-erc/losis,
>&
H1M ,as -een e0tended to aly to eoleCs resonses to symtoms
and to t,eir comliance wit, medical re*imens.
>>
H1M incl/des +i"e main comonents9 perceived suscepti4ility, perceived severity,
perceived 4enefits, perceived 4arriers, and self2efficacy. Perceived suscepti4ility
re+ers to a ersonCs s/-Aecti"e ercetion o+ t,e risk o+ -ecomin* sick, w,ile ercei"ed
se"erity re+ers to t,e ersonCs +eelin*s o+ t,e serio/sness o+ -ecomin* sick or lea"in*
t,e illness /ntreated 7-ot, medical and clinical and social conse?/ences8. 5,e
com-ination o+ s/sceti-ility and se"erity is o+ten la-eled perceived threat. 1e+ore a
erson will take action and c,an*e -e,a"ior, t,e ercei"ed t,reat needs to ,i*,. For
e0amle, -e+ore a erson will consider +lossin* e"ery day, ,e or s,e needs to -elie"e
t,at not +lossin* will lead to eriodontal disease and t,at eriodontal disease can ,a"e
serio/s ne*ati"e conse?/ences +or ,im or ,er.
4,en an indi"id/al ,as a ,i*, perceived threat, t,at erson will analy@e t,e
perceived 4enefits and 4arriers o+ er+ormin* a certain -e,a"ior. Perceived 4enefits
re+er to t,e -elie+s re*ardin* t,e e++ecti"eness o+ t,e a"aila-le actions in red/cin* t,e
disease t,reat. 5,/s, a erson w,o -elie"es t,at +lossin* e"ery day will red/ce t,e risk
o+ de"eloin* eriodontal disease will -e more likely to er+orm t,is -e,a"ior t,an a
erson w,o does not ,a"e t,is -elie+. Contrary to ercei"ed -ene+its, perceived
4arriers 7e.*. ain+/l, di++ic/lt, /settin*, incon"enient, time-cons/min*8 can act as
imediments to en*a*in* in t,e ,ealt, -e,a"ior. 5,/s a sort o+ cost--ene+it analysis
occ/rs w,en indi"id/als decide w,et,er t,e ercei"ed -ene+its o"erride t,e ercei"ed
-arriers. I+ t,ey do, t,ose indi"id/als will most likely er+orm t,e -e,a"ior. I+ t,e
-arriers o/twei*, t,e -ene+its, t,e -e,a"ior will ro-a-ly not occ/r. 5,/s, e"en i+ a
erson +eels a ,i*, t,reat +or eriodontal disease, ,e or s,e may not c,an*e ,is c/rrent
-e,a"ior to daily +lossin* w,en t,e ercei"ed -arriers +or +lossin* e"ery day 7e.*.,
time-cons/min*, ain+/l, incon"enient8 are stron*er t,an t,e -ene+its.
Determinin* t,eir clientCs ercei"ed t,reat, ercei"ed -ene+its, and -arriers can -e
"ery ,el+/l +or a dental ro+essional w,o wants to enco/ra*e a client to c,an*e
-e,a"iors. 1y askin* t,e ri*,t tye o+ ?/estions, all ,ealt, ro+essionals can o-tain
t,is in+ormation. 5,e dental ro+essional can t,en address any ercei"ed
misconcetions and, conse?/ently, +acilitate -e,a"ior c,an*e.
Social Co*niti"e 5,eory
H1M, is a t,eory t,at +oc/ses on syc,osocial +actors wit,in t,e indi"id/al t,at can
a++ect -e,a"ior c,an*e. Social Co*niti"e 5,eory 7+ormerly known as Social .earnin*
5,eory8 incl/des -ot, indi"id/al as well as en"ironmental in+l/ences. 5,/s, SC5
e0lains ,/man -e,a"ior in terms o+ a triadic, and recirocal model, in w,ic,
ersonal +actors, en"ironmental in+l/ences, and -e,a"ior interact contin/o/sly.
:>
In
addition to e0lainin* w,y a erson -e,a"es in a certain manner, SC5 can +acilitate
-e,a"ior c,an*e -y ro"idin* seci+ic learnin* strate*ies 7e.*., modelin*8. For a more
detailed descrition o+ t,e "ario/s SC5 constr/cts, lease see Health #ehavior and
!ducation 7:;;%8 -y Glan@ et al.
!ecirocal determinism is t,e /nderlyin* ass/mtion o+ SC5. It e0lains t,at
-e,a"ior, en"ironmental +actors, and indi"id/al in+l/ences are contin/o/sly
interactin* and eac, one a++ects t,e ot,er. For e0amle, a erson w,o ,as ,i*, dental
an0iety 7a ersonal +actor8 and recei"es no rein+orcement to see a dentist re*/larly
7en"ironmental +actor8 is not likely to *o +or re"enti"e dental c,eck /s. Howe"er, i+
t,is erson recei"es ositi"e +eed-ack +or seein* a dentist 7en"ironmental +actor8, and
,as a role model w,o "isits a dentist e"ery < mont,s 7en"ironmental +actor8, ,er le"el
o+ dental an0iety may act/ally decrease. As a res/lt, s,e may -e more likely to *o see
a dentist. SC5 /nderscores t,e imortance o+ a"oidin* simlistic Fsin*le direction o+
c,an*eF t,inkin*. 1e,a"iors do not occ/r in isolation and inter"entions s,o/ld +oc/s
-ot, on t,e indi"id/al and t,e en"ironment.
:$
Modelin*, one o+ t,e key learnin* strate*ies roosed -y SC5, ,as -een s/ccess+/lly
/sed wit, dental clients to decrease dental +ear and an0iety. A st/dy er+ormed -y
1ernstein 7:;(>8 looked at t,e e++ecti"eness o+ di++erent strate*ies to red/ce +ear o+
dentistry in ad/lt clients w,o ,ad a"oided dental treatment +or +rom : to :$ years.
5,e strate*ies st/dies incl/ded articiant modelin* 7a SC5 strate*y8, sym-olic
modelin*, and *rad/ated e0os/re. !es/lts s/**ested t,at e"en t,o/*, t,e strate*ies
were e?/ally e++ecti"e +or t,e s,ort-term, articiant modelin* was most e++ecti"e +or
red/cin* +ear +or lon*-term eriod.
>'
Sta*es o+ C,an*e Model
Oral ,ealt, care ro"iders ,a"e so/*,t to /nderstand and create t,ose conditions t,at
wo/ld lead to -ene+icial and ,el+/l -e,a"ior c,an*es +or t,eir clients. 5,e
5ranst,eoretical Model 755M8, de"eloed -y two syc,olo*ists, Drs. )roc,aska and
DiClemente
>=
is a ower+/l and widely acceted model +or /nderstandin* ,ow and
w,y eole c,an*e, eit,er on t,eir own or wit, t,e assistance o+ ot,ers. 5,e model is
-ased on t,e indi"id/alCs state o+ readiness or willin*ness to c,an*e, w,ic, may
+l/ct/ate +rom one time or sit/ation to anot,er.
5,e 5ranst,eoretical Model is comosed o+ t,ree main constr/cts, one o+ w,ic, is t,e
Sta*es o+ C,an*e. 5,e sta*es o+ c,an*e constr/ct descri-es a series o+ +i"e
ro*ressi"e sta*es t,ro/*, w,ic, indi"id/als ass in t,e co/rse o+ c,an*in* a
-e,a"ior. 5,e Fw,eel o+ c,an*eF deri"ed +rom t,e )roc,aska-DiClemente model
7Fi*/re :<-&8 re+lects t,e reality t,at in almost any c,an*e rocess, it is ossi-le +or a
erson to *o aro/nd t,e Fw,eelF or relase se"eral times -e+ore ac,ie"in* a sta-le
c,an*e. For e0amle, an indi"id/al w,o is willin* and ready to start +lossin* once a
day may -e*in t,is ractice recei"in* in+ormation +rom ,is dentist, t,en relase a+ter
se"eral weeks, and t,en start t,e daily +lossin* ro/tine a*ain a+ter anot,er dental "isit.
5,/s, accordin* to t,e Sta*es o+ C,an*e, relases or slis to re"io/s -e,a"iors is
normal and a realistic occ/rrence.
5,e +i"e sta*es o+ c,an*e as linked to t,e de"eloment o+ ,ealt, -e,a"iors, incl/din*
otimal oral ,y*iene ,a-its, are descri-ed -elow. Daily +lossin* will -e /sed as t,e
seci+ic e0amle to ill/strate t,is t,eory.
PrecontemplationIndi"id/als in t,is sta*e are not aware o+ t,e ositi"e
conse?/ences o+ daily +lossin* and ,a"e no conscio/s intentions o+ startin* to +loss
daily wit,in t,e ne0t < mont,s.
ContemplationIndi"id/als in t,e Contemlation sta*e are aware o+ t,e ositi"e
conse?/ences o+ c,an*in* t,eir c/rrent -e,a"iors and lan to start +lossin* wit,in t,e
ne0t < mont,s 7near +/t/re8.
PreparationIndi"id/als in t,is sta*e are makin* concrete stes to adotin* oral
,y*iene ractices. 5,ey may ,a"e -o/*,t new +loss or sc,ed/led dental
aointments.
ctionIndi"id/als in t,e Action sta*e are act/ally +lossin* e"ery day -/t ,a"e done
so less t,an < mont,s.
%aintenanceIndi"id/als ,a"e +lossed daily +or o"er < mont,s.
As disc/ssed earlier, at any time an indi"id/al may relase to a re"io/s sta*e, t,/s an
indi"id/al in t,e Action sta*e co/ld relase to t,e )rearation or e"en t,e
Contemlation sta*e.
Corresondin* to eac, sta*e are aroriate co/nselin* tec,ni?/es. 5,/s, -y
/nderstandin* t,e seci+ic sta*es o+ -e,a"ior c,an*e and t,e corresondin* emotions
t,at may accomany t,em, oral ,ealt, care ro"iders can -etter /nderstand t,e
actions, or inactions, o+ t,eir clients. 4it, a -etter /nderstandin*, t,ey will -e more
a-le to meet t,e immediate needs o+ t,eir clients and co/nsel t,em aroriately. For
e0amle, recontemlators are not ready to c,an*e t,eir -e,a"ior and t,ey do not
want to ,ear t,reatenin* messa*es. 5,ey ,a"e a "ery stron* reonderance o+ FrosF
a-o/t t,eir c/rrent -e,a"ior and ,a"e a oor acknowled*ement o+ t,e Fcons.F 5,ese
indi"id/als s,o/ld -e *i"en -alanced in+ormation a-o/t t,e c/rrent -e,a"ior, ,andled
wit, kindness and care, and le+t alone. It is not reasona-le to -lame t,ese indi"id/als
+or -ein* /nmoti"ated to c,an*e t,eir c/rrent oral ,y*iene ractices.
Indi"id/als w,o are in t,e contemlation sta*e tend to ,a"e a -alance -etween t,e
ositi"e and ne*ati"e +eelin*s a-o/t t,eir c/rrent -e,a"iors. 5,ey are o+ten still
am-i"alent a-o/t c,an*in*. 3"en w,en contemlators mo"e into t,e rearation
sta*e, w,en t,e stren*t,s o+ t,e ros +or c,an*in* -e,a"iors ,a"e increased o"er t,e
cons, t,ey may still ,a"e ositi"e +eelin*s a-o/t t,eir c/rrent -e,a"iors t,at are
stron*.
5,e Sta*es o+ C,an*e model indicates t,at t,e *oal o+ t,e oral ,ealt, care ro"ider is
not necessarily one o+ action. 1eca/se many indi"id/als tend to -e in t,e
recontemlation or contemlation sta*es, it is "ery wort,w,ile to try to Fmo"eF t,ese
indi"id/als to t,e ne0t sta*e.
Fi*/re :<-& )roc,aska and DiClementeCs si0 sta*es o+ c,an*e 7as modi+ied -y
C,risten, et al., :;;&8.
Question 3
A. A++ectin* knowled*e is central to most ,ealt, -e,a"ior t,eories.
1. 5,e sta*es o+ c,an*e model s/**est t,at t,ere is a one-way, linear ro*ression
t,ro/*, +i"e sta*es9 recontemlation, contemlation, rearation, action, and
maintenance.
C. SC5 e0lains t,at -e,a"ior is recirocally a++ected -y ersonal and en"ironmental
+actors.
D. All ,ealt, romotion t,eories can redict ,ealt, -e,a"ior and address rocesses o+
c,an*e.
Approaches for Different Levels of Client Motivation and Adherence
)la?/e-control meas/res are di++ic/lt to accomlis, and re?/ire considera-le time,
skill, and erse"erance. In +act, c/rrent meas/res o+ oral ,y*iene re?/irin* +astidio/s
remo"al o+ all s/ra*in*i"al la?/e may -e -eyond t,e a"era*e indi"id/al.
><
5,/s a
-lend o+ ed/cation, moti"ation, and syc,omotor skills are necessary to ens/re *ood
ersonal oral ,y*iene meas/res. No *ood e"idence s/orts t,e +act t,at mass
ed/cation alters indi"id/al -e,a"ior. Instead, indi"id/ali@ed aroac,es are /s/ally
necessary, and e"en t,ese are not always s/ccess+/l.
For a dentist entr/sted wit, t,e re"enti"e care o+ a moderately moti"ated indi"id/al,
t,e recall ro*ram s,o/ld -e at s/++iciently +re?/ent inter"als to comensate +or lases
in client sel+-care ro/tines. At t,e same time, t,e ed/cational and moti"ation ,ases o+
client ed/cation s,o/ld -e em,asi@ed to imro"e t,e articiation and e++ecti"eness
in sel+-care ro*rams. In t,is way, t,e dental ro+essional ass/mes t,e task o+ carin*
+or t,e client to t,e e0tent t,at comensates +or t,e s,ortcomin*s o+ t,e client w,ile
rearin* t,e client to adot a *reater role in maintainin* ersonal oral ,ealt, stat/s.
Ultimately, it is t,e client w,o m/st ass/me as m/c, resonsi-ility +or sel+-care as
ossi-le and to seek o/t t,e dental ro+essional +or e"al/ation 7e0amination8 and
rein+orcement w,en de+iciencies are noted or s/sected.
Once an indi"id/al -ecomes s/++iciently moti"ated and c,an*es ,is or ,er -e,a"ior,
t,e ne0t imortant iss/e is ad,erence. Ad,erence imlies t,at eole c,oose +reely to
/ndertake -e,a"ioral lans, ,a"e in/t to t,em, and ,a"e colla-orati"e in"ol"ement in
adA/stin* t,eir lans.
>%
4,at makes an indi"id/al contin/e to +ollow dental
recommendations and ad,ere to ractice oral ,y*ienee Alt,o/*, t,ere is a a/city o+
literat/re in t,e area o+ ad,erence to oral ,y*iene ractices, literat/re related to ot,er
,ealt, -e,a"iors can ro"ide some in+ormation.
Alt,o/*, t,ere are some common +actors, otential determinants o+ ad,erence are not
consistently detected. A clinically-oriented +ramework -y Meic,en-a/m and 5/rk
7:;(%8 may -e /se+/l +or oral ,ealt,-care ro+essionals. 5,is +ramework di"ides
+actors related to ad,erence into c,aracteristics o+ t,e indi"id/al 7e.*., knowled*e,
attit/des, -elie+s, e0ectancies a-o/t ,ealt,, treatment8, disease 7e.*., comle0ity,
d/ration, side e++ects8, t,e treatment re*imen 7e.*., comle0ity, d/ration, tye, cost8,
relations,i to t,e ,ealt,-care-ro"ider clinic sta++ 7e.*., client-ro"ider sta++8, and
clinic or*ani@ation 7e.*., sta++ ent,/siasm8.
>(
5,is +ramework can -e /sed to ro"ide order to a list o+ determinants and can ,el
identi+y cate*ories o+ otential moderators o+ ad,erence to treatments. 5,/s, to
imro"e ad,erence to seci+ic re*imen, oral ,ealt, care ro+essionals can /se t,is
+ramework to e0amine t,eir clients and clinics to determine otential areas o+
imro"ement.
Selecting Methods of Influencing Behavior Change
Client-)ro"ider !elations,iBComm/nication Styles
Determinin* t,e most aroriate tye o+ client-,ysician relations,i is e0tremely
imortant +or t,e racticin* dentist. 4,ile some ,ealt,-care ro+essionals re+er to -e
t,e e0ert and a/t,ority, ot,ers /nderstand t,at not all clients resond well to t,is tye
o+ relations,i. 4,en a client does not resond well to t,e tye o+ relations,i
racticed -y t,e ,ealt, care ro"ider, imortant in+ormation may -e lost. On t,e ot,er
,and, t,e ositi"e -ene+its deri"ed +rom *ood doctor-client comm/nication incl/de
-ot, immediate e++ects d/rin* t,e "isit and lon* term e++ects +ollowin* t,e "isits and
in"ol"e comliance wit, rescri-ed re*imen, ain e0erience, ,ysiolo*ic c,an*es,
seed o+ reco"ery, and +/nctional state.
>;
5,ere are +o/r arc,etyal +orms o+ t,e doctor-client relations,i9 aternalism,
cons/merism, m/t/ality, and de+a/lt. )aternalism is re*arded as t,e more traditional
and ro-a-ly t,e most common +orm o+ t,e doctor-client relations,i.
=$
5,e
aternalistic model ro"ides a social control +/nction in t,at t,e ,ealt, care ro"ider
is seen as t,e e0ert and dominant, controllin* +i*/re, w,ile t,e client is assi"e and
+ree +rom social resonsi-ilities. 5,e ,ysician maintains emotional detac,ment and
acts only in ,is or ,er s,ere o+ e0ertise. Alt,o/*, some may "iew t,is tye
relations,i as ne*ati"e, some clients may act/ally draw com+ort and s/ort +rom a
doctor-+at,er +i*/re. 5,e s/orti"e nat/re o+ aternalism seems to -e "ery imortant
w,en a client is in need o+ e0tensi"e ser"ices and t,ere+ore is "/lnera-le. In times o+
emer*ency, w,en correct decisions m/st -e made ?/ickly to a"oid li+e-t,reatenin*
e"ents, t,e ,ealt,-care ro"ider m/st take control and t,e aternalistic +orm is /s/ally
necessary.
5,e cons/merism rototye is t,e oosite o+ aternalism. In t,is tye o+ relations,i,
t,e ower relations,i -etween t,e client and t,e ,ysician are re"ersed9 t,e client or
t,e cons/mer ,as more ower or control t,an t,e ,ysician.
:$
3secially w,en tryin*
to FsellF re"ention to t,e client, t,e ,ysicianCs role is to con"ince t,e client o+ t,e
necessity o+ non-c/rati"e ser"ices s/c, as re*/lar dental c,eck/s or daily -r/s,in*.
Se"eral a/t,ors ,a"e de+ined cons/merism as a client c,allen*e to /nilateral decision
makin* -y ,ysicians w,en reac,in* clos/re on dia*nosis and treatment lans.
=:
In
t,is rototye, t,e ,ealt, ro"ider and client co-Aointly e0lore t,e "ario/s otions
and lannin* o-Aecti"es. 5,is tye o+ relations,i aeals to ,i*,er order means o+
accetance, incl/din* reasonin*, nont,reatenin* ers/asion, and rewards. 5,e
,ealt,care ro"ider tyically talks less, listens more, ?/estions, reacts, and synt,esi@es
w,en necessary.
=>
Comared to cons/merism, t,e m/t/ality rototye o++ers a more moderate
alternati"e. 5,e client still ,as a *reat deal o+ ower -/t so does t,e ,ysician. In
m/t/ality, -ot, indi"id/als 7client and ,ysician8 -rin* reco*ni@ed stren*t,s and
reso/rces to t,e relations,i. In t,is model, t,e client reco*ni@es ,is or ,er role as art
o+ a Aoint "ent/re w,ile t,e ,ysician /nderstands t,e centrality o+ t,e client in ,is or
,er care.
:$
In some cases, t,e client and ,ysician remain at odds and cannot ne*otiate a c,an*e
in t,e relations,i d/e to oor +it. In t,is case, a total lack o+ control e0ists and t,e
de+a/lt rototye occ/rs.
>;
Alt,o/*, t,e client and ,ysician may still see eac, ot,er
d/rin* re*/lar "isits, t,e client may +ail to make a commitment to rescri-ed re*imens
and t,e ,ysician may cease to -e en*a*ed or try to ed/cate t,e client.
Moti"ational Inter"iewin* in t,e C,an*e )rocess
Moti"ational inter"iewin*, introd/ced -y Miller and !ollnick 7:;;:8 is a artic/lar
met,od to ,el eole reco*ni@e and do somet,in* a-o/t t,eir resent and otential
-e,a"ioral ro-lems.
==
It is artic/larly /se+/l +or t,ose clients w,o are rel/ctant to
c,an*e and am-i"alent a-o/t c,an*in*. 5,is tec,ni?/e attemts to ,el resol"e
am-i"alence and to mo"e t,e indi"id/al alon* t,e at, to c,an*e. Am-i"alence is a
state o+ mind in w,ic, a erson ,as coe0istin* -/t con+lictin* +eelin*s a-o/t some
iss/e. 5,is FI want to -/t I donCt want toF dilemma is at t,e ,eart o+ t,e ro-lem o+ all
c,an*e. Am-i"alence is a tye o+ con+lict wit,in an indi"id/al t,at ,as t,e otential
+or keein* eole Fst/ckF and creatin* stress. Am-i"alent smokers w,o ,a"e -een
told -y t,eir eriodontist t,at to-acco /se can ca/se eriodontal disease, mi*,t readily
acknowled*e t,at t,eir oral ,ealt, is endan*ered, yet may +eel e?/ally concerned
a-o/t t,eir a-ility to coe wit, stress+/l sit/ations wit,o/t smokin*.
Oral-,ealt,-care ro"iders m/st /nderstand t,at am-i"alence is not merely a F-ad
si*n.F It s,o/ld -e re*arded as normal, acceta-le, common, and /nderstanda-le art
o+ t,e c,an*e rocess. 4,at is ,i*,ly "al/ed -y some 7e.*., ,a"in* *ood oral ,ealt,8
will -e o+ little imortance to ot,ers.
Fi"e -road clinical rinciles /nderlie moti"ational inter"iewin*.
==
5,ese rinciles
em,asi@e t,at t,e clinician s,o/ld9 :8 e0ress emat,y 7t,ro/*, skill+/l re+lecti"e
listenin*, t,e clinician seeks to /nderstand and accet t,e clientCs +eelin*s and
ersecti"e wit,o/t A/d*in*, critici@in* or -lamin*, and reali@es t,at am-i"alence is
normal8D >8 de"elo discreancy 7,el t,e client /nderstand t,e discreancy -etween
t,eir resent -e,a"ior and t,eir a-ility to reac, t,eir imortant *oalsD clients s,o/ld
disco"er and resent t,eir own ar*/ments +or and a*ainst c,an*e8D =8 a"oid
ar*/mentation 7a *ently ers/asi"eBso+t con+rontation aroac, s,o/ld -e /sedone
t,at asserts t,at clients ,a"e t,e +reedom to do as t,ey leaseD a"oid sendin* t,e
messa*e t,at FICm t,e e0ert and ICm *oin* to tell yo/ ,ow to r/n yo/r li+eFD do not
acc/se clients o+ -ein* Fin denialF or la-el t,eir -e,a"ior8D &8 roll wit, resistance
7in"ite t,e client to consider new in+ormation and o++er new ersecti"es, wit,o/t
-ein* imosin*8D '8 s/ort sel+-e++icacy 7it is essential to s/ort t,e clientCs sel+-
esteem and t,eir *eneral sel+-re*ardD t,e client is resonsi-le +or c,oosin* and
carryin* o/t ersonal c,an*e and t,e o"erall messa*e is o+ ,oe and +ait, to t,e
clientD FHo/ can do it. Ho/ can s/cceed.F8.
5,e F!AM3S 1rie+ Co/nselin* 3lements
Miller and !ollnick
=&
,a"e descri-ed si0 ractical co/nselin* elements t,at are acti"e
in*redients in e++ecti"e and -rie+ co/nselin* inter"entions. 5,ey are s/mmari@ed in
t,e acronym FF!AM3S.F
Feed-ack5,e client is *i"en +eed-ack o+ t,eir c/rrent stat/s. 5,e imortance o+
cond/ctin* a t,oro/*, assessment ro"ides t,e client an oort/nity to re+lect in
detail /on t,eir sit/ation.
!esonsi-ility5,ere is an em,asis on t,e indi"id/alCs ersonal resonsi-ility +or
c,an*e. FItCs / to yo/ to decide w,at to do wit, t,is in+ormation. No-ody can decide
+or yo/, and no one can c,an*e yo/r ,a-it atterns i+ yo/ donCt want to c,an*e.F
Ad"iceSimle, clear ad"ice to t,e client to make a c,an*e in t,eir li+estyle is
*i"en.
Men/1y o++erin* clients a men/ o+ alternati"e strate*ies +or c,an*in* t,eir
ro-lem -e,a"ior, t,e clinician ro"ides a ran*e o+ otions, w,ic, allows clients to
select strate*ies t,at matc, t,eir artic/lar needs and sit/ations.
3mat,yUnderstand anot,erCs meanin* t,ro/*, t,e /se o+ re+lecti"e listenin*,
w,et,er yo/ ,a"e ,ad similar e0eriences yo/rsel+. Use o+ warmt,, resect,
s/orti"eness, carin*, concern, symat,etic /nderstandin*, commitment, and acti"e
interest to con"ey t,is element.
Sel+-e++icacy!ein+orcin* t,e clientCs ,oe or otimism in t,eir a-ility to make
c,an*es romotes sel+-e++icacy. !emem-er t,at yo/r -elie+ in t,e clientCs a-ility to
c,an*e is o+ten a si*ni+icant determinant o+ o/tcomes.
Basic Philosophy
A -asic ,iloso,y o+ re"ention is itsel+ a "al/e. One -asic ,iloso,y concernin*
re"enti"e dentistry is t,at clients deser"e to know t,e ca/se o+ t,eir dental diseases
and ,ow t,ey can re"ent t,em. 5,is is a resonsi-ility +or t,e ,ealt, ed/cator. Once
armed wit, t,e knowled*e, ,owe"er, t,e client reser"es t,e ri*,t to remain sick. 5,is
is a ro-lem o+ sel+-moti"ation. Clients are /ltimately resonsi-le +or t,eir own dental
,ealt,. In t,e +inal analysis, re"ention is a s,ared resonsi-ility -etween t,e
ractitioner and t,e client.
Summary
5,e maintenance o+ *ood oral ,ealt, re?/ires a artners,i -etween t,e dental
ro+essional and t,e atient. No re"enti"e ro*ram can -e a s/ccess /nless t,e
atient articiates in a ,ome sel+-care ro*ram to s/lement o++ice care ro*rams,
wit, t,e le"el o+ s/ccess -ein* roortionate to t,e amo/nt o+ articiation.
Ma0im/m articiation can -e e0ected w,en t,e atient knows w,at to do, ,ow to
do it, and a-o"e all ,as t,e moti"ation to ad,ere to recommended roced/res.
3d/cational strate*ies can -e /sed to teac, +acts and skills, -/t t,ese are /seless
wit,o/t moti"ation. Moti"ation can -e initiated -y an indi"id/al -ased on some need
or desire, or it can -e +acilitated -y ers/asion +rom e0ternal so/rces. 4it, or wit,o/t
moti"ation, learnin* is -est ac,ie"ed in se?/ential stes, as descri-ed -y 1loomCs
,ierarc,y o+ co*niti"e le"els. As an indi"id/al acc/m/lates +acts, t,e +acts mer*e into
concets and /ltimately into "al/es, w,ic, in t/rn en*ender moti"ation. At times
moti"ation ro"ides t,e dri"e to alter li+estyle to attain ,a-it atterns necessary to
maintain *ood oral ,ealt,. 5,e dental ro+essional can e0ert a direct or indirect
in+l/ence on s/c, a c,an*e -y ro"idin* aroriate -e,a"ior modelin*, -y takin* a
more acti"e role as an a/t,oritarian, or -y articiatin* as a nona/t,oritarian in
de"eloin* a ro*ram o+ lanned c,an*e wit, t,e atient. All ,ealt, ed/cation
re?/ires learnin*, -/t t,e s/ccess+/l alication o+ all ,ealt, knowled*e re?/ires
moti"ation.
:. 1correct.
Aincorrect. 5,e a"era*e layerson does not accet c,an*e wit,o/t considera-le
ers/asion.
Cincorrect. H/man moti"ation is comle0 in nat/re and -est descri-ed as t,e
interaction -etween t,e en"ironment, ersonal, and -e,a"ioral +actors.
Dincorrect. 2nowled*e is rarely s/++icient to c,an*e -e,a"ior.
>. A, Dcorrect.
1incorrect. Facts and concets reresent /nor*ani@ed and or*ani@ed t,o/*,ts,
resecti"elyD "al/es reresent t,e accetance and ersonal alication o+ +acts and
concets.
Cincorrect. Most ed/cation is directed to t,e initial le"el+actsD "ery little learnin*
ends / at t,e e"al/ation le"el.
=. Ccorrect.
Aincorrect. Most ,ealt,--e,a"ior t,eories attemt to e0lain or redict -e,a"ior.
1incorrect. 5,e sta*es o+ c,an*e model s/**est t,at -e,a"ior c,an*e does not
tyically +ollow a linear ro*ression -/t rat,er is cyclical as an indi"id/al e0eriences
relase and adots new -e,a"iors.
Dincorrect. Healt,-romotion t,eories attempt to e0lain or redict -e,a"ior wit,
"aryin* de*rees o+ acc/rateness.
:. Healt, romotion can -e de+ined as iiiiiiiiii.
>. An indi"id/al, t,ro/*, reasonin*, or*ani@es +acts into iiiiiiiiiiD w,ic, in t/rn
are t,e -asis +or a7n8 iiiiiiiiii.
=. 5,e central ass/mtion /nderlyin* ,ealt, romotion t,eories is iiiiiiiiii.
&. 5,e +i"e main concets o+ t,e Healt, 1elie+ Model incl/de9 iiiiiiiiii,
iiiiiiiiii, iiiiiiiiii, iiiiiiiiii, iiiiiiiiii.
'. 5,e si0 co*niti"e le"els o+ 1loomCs ,ierarc,y o+ learnin* are knowled*e,
iiiiiiiii, iiiiiiiiii, iiiiiiiiii, iiiiiiiiii, iiiiiiiiii, and iiiiiiiiii.
<. 5,e one main di++erence -etween H1M and Social Co*niti"e 5,eory is
iiiiiiiiii.
%. iiiiiiiiii is t,e /nderlyin* ass/mtion o+ SC5.
(. iiiiiiiiii imlies t,at an indi"id/al c,ooses +reely to /ndertake -e,a"ioral
lans, ,a"e in/t to t,em, and ,as a colla-orati"e in"ol"ement in modi+yin* t,e lan.
;. In t,e dentist-atient artners,i, it is t,e iiiiiiiiii w,o m/st ass/me
resonsi-ility +or ,ome care ro*rams, w,ereas t,e iiiiiiiiii m/st ass/me
resonsi-ility o+ identi+yin* and correctin* de+iciencies t,at occ/r in a ,ome care
ro*ram.
:$. In t,e de"eloment o+ otimal oral ,y*iene ,a-its, atients enco/nter +i"e
ro*ressi"e sta*es o+ c,an*e. 5,ey are9 iiiiiiiiii, iiiiiiiiii, iiiiiiiii,
::. In t,e rocess o+ alyin* moti"ational inter"iewin*, t,e clinician s,o/ld aly
+i"e rinciles, w,ic, are9 iiiii, iiiii, iiiii, iiiii, and iiiii.
:>. 5,e rocess w,ere-y t,e clinician seeks to /nderstand and accet t,e atientCs
+eelin*s and ersecti"es wit,o/t A/d*ment, critici@in*, or -lamin* is called9 iiiii.
References
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+or rimary re"enti"e oral ,ealt, -e,a"ior c,an*e. " Sch Health , '%9::&-:(.
>. 1arkley, !. 7:;%>8. A rational -asis +or a -e,a"iorally so/nd dental ractice.
Successful Preventive Dental Practices. Macom-, I.9 )re"enti"e Dentistry )ress,
:;%>.
=. American Dietetic Association 7:;(<8. ADA reorts9 )osition o+ t,e American
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&. !eisine, S., g .ocker, D. 7:;;'8. Social, syc,olo*ical, and economic imacts o+
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)anel S/r"ey 7M3)S8, /n/-lis,ed data.
(. Doerr, ). A., .an*, 4. )., Ny?/ist, .. 6., g !onis, D. .. 7:;;(8. Factors associated
wit, dental an0iety. " m Dent ssoc , :>;9::::-:(.
;. Hammer, A. .., g Macdaid, G. ). 7:;;>8. M15I Career !eort9 Form G. )alo
Alto, CA9 Cons/ltin* )syc,olo*ists )ress.
:$. Glan@, 2., .ewis, M. .., g !imer, 1. 2., 3ds. 7:;;%8. Health 4ehavior and health
education 7>nd ed.8. San Francisco9 #ossey-1ass )/-lis,ers.
::. H/tc,ins, D. 4. 7:;<(8. Moti"ation in re"enti"e dentistry. !eort on t,e
Proceedin$s of the 'ourth nnual Preventive Dentistry -or*shop. 4as,in*ton, DC9
#/ly >'-><. Col/m-ia, MO9 5,e C/rators, Uni"ersity o+ Misso/ri.
:>. 1and/ra, A. 7:;(<8 Social foundation of thou$ht and action. 3n*lewood Cli++s,
N#9 )rentice-Hall.
:=. Smit,, 5. A., 2roe*er, !. F., .yon, H. 3., g M/llins, M. !. 7:;;$8. 3"al/atin* a
-e,a"ioral met,od to mana*e dental +ear9 a >-year st/dy o+ dental ractices. " mer
Dent ssoc, C<C 7:$8 '>'-=$.
:&. 6an Ho/ten, ). 7:;(;8. Moti"atin* atients to sel+-care takes t,e sta++Cs ersonal
in"ol"ement. Dent +ff , :9(-;.
:'. 1loom, 1. S., 3n*lel,art, M. D., F/rst, 3. #., et al. 7:;%'8. Taxonomy of
educational o47ectives, Hand4oo* /6 Co$nitive domain. New Hork9 D. Mc2ay Co.
:<. Sa"a*e, M. 1., #o,nson, !. 1., g #o,nson, S. !., 3ds. 7:;%:8. ssurin$ learnin$
3ith self2instructional pac*a$es, or . . . up the up staircase. C,ael Hill, NC9 Sel+-
Instr/ctional )acka*es, Inc., :&:.
:%. C,risten, A. 7:;(&8. 5,e de"eloment o+ ositi"e ,ealt, "al/es. Health =alues,
(9'-:>.
:(. 2leinknec,t, !. A., 2leac, !. 2., g Ale0ander, .. D. 7:;%=8. Ori*ins and
c,aracteristics o+ +ear o+ dentistry. " m Dent ssoc , (<9(&>-&<.
:;. Mittelman, #. S. 7:;((8. Gettin* t,ro/*, to yo/r atients9 )syc,olo*ic moti"ation.
Dent Clin &orth m , =>9>;-==.
>$. Green, .. 4., g 2re/ter, M. H. 7:;;;8. Health promotion plannin$6 n
educational and ecolo$ical approach 7=rd ed.8 Mo/ntain 6iew, CA9 May+ield
)/-lis,in*.
>:. Hoc,-a/m, G. M., Sorenson, #. !., g .ori*, 2. 7:;;>8. 5,eory in ,ealt,
ed/cation ractice. Health !ducation Euarterly, CH 7=89>;'-=:=.
>>. 1ecker, M. H. 7:;%&8. 5,e Healt, 1elie+ Model and ersonal ,ealt, -e,a"ior.
Healt, 3d/cation Mono*ra,s :;%&D >9 =>&-&%=.
>=. )roc,aska, #. O., g DiClemente, C. C. 7:;('8. Common rocesses o+ sel+-c,an*e
in smokin*, wei*,t control, and syc,olo*ical distress. In S,i++man, S., g 4ills, 5.,
3ds. Copin$ and su4stance use 7. =&'-<&8. Orlando, F.9 Academic )ress.
>&. Hoc,-a/m, G. M. 7:;'(8. )/-lic articiation in medical screenin* ro*rams9 A
sociosyc,olo*ical st/dy. )/-lic Healt, Ser"ice N/m-er '%>.
>'. 1ernstein, D. A. 7:;(>8. M/ltile aroac,es to t,e red/ction o+ dental +ear. "
#ehav Ther and !xp Psychiat, CA 7&89 >(%-;>.
><. 1rady, 4. F. 7:;(&8. )eriodontal disease awareness. " m Dent ssoc , :$;9%$<-
:$.
>%. 1rawley, .. !., g C/los-!eed, S. 7>$$$8. St/dyin* ad,erence to t,erae/tic
re*imens9 O"er"iew, t,eories, recommendations. Controlled Clinical Trials , >:9
:'<S-:<=S.
>(. Meic,en-a/m, D., g 5/rk, D. C. 7:;(%8. 'acilitatin$ treatment adherence6
practitioner?s $uide4oo*. New Hork9 )len/m.
>;. !oter, D. .., g Hall, #. A. 7:;(>8. Doctors tal*in$ to patients tal*in$ to doctors6
/mprovin$ communication in medical visits. 4estort, C59 A/-/rn Ho/se.
=$. S@as@, ). S., g Hollender, M. H. 7:;'<8. A contri-/tion to t,e ,iloso,y o+
medicine9 5,e -asic model o+ t,e doctor-atient relations,i. rchi /ntern %ed,
;%9'('-;>.
=:. Ha/*, M., g .a"in, 1. 7:;(=8. Consumerism in medicine6 Challen$in$ physician
authority. 5,o/sand Oaks, CA9 Sa*e.
=>. Iwata, 1. A., g 1ecks+ort, C. M. 7:;(:8. 1e,a"ioral researc, in re"enti"e
dentistry9 3d/cational and contin*ency mana*ement aroac,es to t,e ro-lem o+
atient comliance. pplied #ehavioral nal , :&9:::->$.
==. Miller, 4. !., g !ollnick, S. 7:;;:8. %otivational intervie3in$. New Hork9 5,e
G/il+ord )ress.
reser"ed.
Chapter 17. Dental Public-Health Programs - %ar* D, %ace* and Harold S,
0oodman
Objectives
:. .ist t,e core +/nctions o+ /-lic ,ealt,.
>. De+ine dental /-lic ,ealt, and relate t,is de+inition to dental /-lic-,ealt,
ro*rams.
=. Comare t,e met,ods o+ /-lic ,ealt,-care ractitioners and ersonal ,ealt,-care
ractitioners.
&. Descri-e t,e se"en-ste model +or assessin* oral-,ealt,-care needs and relate t,is
model to a lannin* cycle +or /-lic-,ealt, ro*rams.
'. O/tline t,e scoe o+ traditional dental /-lic-,ealt, ro*rams.
<. Descri-e recent c,an*es in t,e United States t,at are rele"ant to dental /-lic-
,ealt, ractice.
%. .ist t,e "ario/s or*ani@ations t,at maintain and s/ort /-lic ,ealt, ro*rams.
(. Descri-e ,ow t,e S/r*eon GeneralCs reort on oral ,ealt, in America ,as imacted
dental /-lic-,ealt, ro*rams.
Introduction
In :;;&, t,e Core 'unctions of Pu4lic Health Steerin$ Committee, co-c,aired -y Drs.
),ili !. .ee 7Assistant Secretary +or Healt,8 and M. #oycelyn 3lders 7S/r*eon
General o+ t,e U.S. )/-lic Healt, Ser"ice8, rod/ced a consens/s statement o/tlinin*
t,e essential ser"ices o+ /-lic ,ealt, in t,e United States.
:
5,e new statement
ro"ided a "ision +or /-lic ,ealt,Healthy People in Healthy Communitiesand
de+ined its mission9 Promote physical and mental health and prevent disease, in7ury,
and disa4ility, 5,e consens/s statement also ro"ided -roader descrition o+ t,e core
+/nctions o+ /-lic ,ealt,assessment, policy development, and assurance,
>

Accordin* to t,e statement, t,e purpose of pu4lic health incl/ded9 :8 re"entin*
eidemics and t,e sread o+ diseaseD >8 rotectin* a*ainst en"ironmental ,a@ardsD =8
re"entin* inA/riesD &8 romotin* and enco/ra*in* ,ealt,y -e,a"iors and mental
,ealt,D '8 resondin* to disasters and assistin* comm/nities in reco"eryD and <8
ass/rin* t,e ?/ality and accessi-ility o+ ,ealt, ser"ices. 5,e practice of pu4lic health
incl/ded9 :8 monitorin* ,ealt, stat/s to identi+y and sol"e comm/nity-,ealt,
ro-lemsD >8 dia*nosin* and in"esti*atin* ,ealt, ro-lems and ,ealt, ,a@ards in t,e
comm/nityD =8 in+ormin*, ed/catin*, and emowerin* eole a-o/t ,ealt, iss/esD &8
mo-ili@in* comm/nity artners,is and action to identi+y and sol"e ,ealt, ro-lemsD
'8 de"eloin* olicies and lans t,at s/ort indi"id/al and comm/nity ,ealt, e++ortsD
<8 en+orcin* laws and re*/lations t,at rotect ,ealt, and ens/re sa+etyD %8 linkin*
eole to needed ersonal-,ealt, ser"ices and ass/rin* t,e ro"ision o+ ,ealt, care
w,en ot,erwise /na"aila-leD (8 ass/rin* a cometent /-lic and ersonal ,ealt,-care
work+orceD ;8 e"al/atin* e++ecti"eness, accessi-ility, and ?/ality o+ ersonal and
o/lation--ased ,ealt, ser"icesD :$8 researc,in* +or new insi*,ts and inno"ati"e
sol/tions to ,ealt, ro-lems.
In :;%<, t,e American Dental Association adoted a de+inition o+ dental pu4lic
health, statin* t,at it was9
. . . t,e science and art o+ re"entin* and controllin* dental diseases and romotin*
dental ,ealt, t,ro/*, or*ani@ed comm/nity e++orts. It is t,at +orm o+ dental ractice
w,ic, ser"es t,e comm/nity as a atient rat,er t,an t,e indi"id/al. It is concerned
wit, t,e dental ed/cation o+ t,e /-lic, wit, alied dental researc,, and wit, t,e
administration o+ *ro/ dental care ro*rams as well as t,e re"ention and control o+
dental diseases on a comm/nity -asis. . .
=
.
Gi"en t,is de+inition, dental pu4lic2health pro$rams re+er to or*ani@ed e++orts t,at
stri"e to re"ent and control oral and cranio+acial diseases at t,e comm/nity le"el.
Dental /-lic-,ealt, ro*rams are ,i*,ly "aried and incl/de acti"ities t,at co"er a
wide sectr/m, +rom small-scale local roAects to lar*e-scale national and
international "ent/res. Gi"en t,at a comm/nity is t,e +oc/s, dental /-lic-,ealt,
ro*rams m/st satis+y t,e criteria o+ racticality, +easi-ility, acceta-ility, sa+ety,
e++ecti"eness, and e++iciency.
Historic Perspective
Dental disease ,as -een a si*ni+icant ro-lem +or Americans since t,e nationCs early
,istory.
<
1etween :(<> and :(<&, loss o+ teet, was t,e +o/rt, most +re?/ent ca/se +or
reAection o+ yo/n* men +or dra+t into t,e Union Army d/rin* t,e Ci"il 4ar.
%
In :;:(,
military dra+tees +or 4orld 4ar I were reAected-eca/se o+ de+ecti"e and de+icient
teet,at a rate t,at e0ceeded :$E in some states.
(
D/rin* t,e conscrition eriod o+
4orld 4ar II, t,e U,S, -ar Department %o4ili1ation Re$ulation re?/ired t,at a
recr/it ,a"e a minim/m o+ t,ree ser"icea-le, nat/ral anterior and osterior teet, in
oosition, er arc,, to -e acceta-le +or military ser"ice. Fi+teen ercent o+ recr/its
were reAected, -eca/se t,ey co/ld not ass t,ese rat,er li-eral criteria.
<
D/rin* t,e
:;>$s, t,e Metroolitan .i+e Ins/rance Comany cond/cted one o+ t,e earliest
eidemiolo*ical st/dies o+ t,e dental condition o+ a lar*e, ,etero*eneo/s, ad/lt,
ci"ilian o/lation.
;
Oral e0aminations o+ more t,an :>,$$$ ad/lts re"ealed t,at,
amon* >$- to >&-year-olds, more t,an ,al+ o+ t,e teet, ,ad -een a++ected -y dental
caries, and t,is roortion increased steadily in older a*e *ro/s.
D/rin* t,e ne0t se"eral decades, t,e n/m-er o+ eidemiolo*ical s/r"eys cond/cted
amon* ci"ilians increased dramatically.
:$-:'
It was not s/rrisin* t,at t,ese st/dies
re+lected t,e ,i*, dental caries re"alence le"els noted in earlier st/dies and
cond/cted amon* military recr/its. 5,e s/r"eys s,owed t,at dental caries was a
serio/s ,ealt, ro-lem amon* yo/n* ad/lts, and o+ten res/lted in toot, loss. 5,e
st/dies also s,owed t,at dental caries -e*an early in li+e and a++ected yo/n* c,ildren.
1etween :;== and :;=&, t,e U.S. )/-lic Healt, Ser"ice 7US)HS8 sonsored a s/r"ey
cond/cted amon* t,o/sands o+ <- to :&-year-old c,ildren in >< states across t,e
United States.
:<
5,e st/dy re"ealed ,i*, dental caries re"alence le"els in c,ildren, as
well. In :;=%, t,e classic Ha*erstown, Maryland, st/dy,
:%
w,ic, introd/ced t,e
Decayed, Missin* and Filled inde0 +or teet, 7DMF58 and toot, s/r+aces 7DMFS8,
s,owed moderately ,i*, caries re"alence le"els amon* t,e e0amined c,ildren. 5,e
st/dy also s,owed t,at c,ildren wit, t,e ,i*,est dental-caries inde0 scores recei"ed
only >E o+ t,e treatment time rendered -y dentists.
5,e dental-caries e0erience o+ c,ildren and t,e ro*ression o+ t,e disease in ad/lts
ro"ided t,e rationale +or t,e alication o+ dental /-lic-,ealt, ro*rams to address
t,e ro-lem. 5,e e++orts, cooeration, and interactions o+ a n/m-er o+ indi"id/als and
a*encies led to one s/c, dental /-lic-,ealt, ro*ram, t,e imlementation o+ adA/sted
water +l/oridation.
Fl/oridationA Mon/mental )/-lic-Healt, S/ccess Story
Fl/oridation is t,e rincial dental /-lic ,ealt, re"enti"e ro*ram a"aila-le in t,e
control o+ dental caries in t,e o/lation. D/rin* a national ,ealt, con+erence in :;<<,
+ormer S/r*eon General Dr. ./t,er .. 5erry stated, FControlled +l/oridation is one o+
t,e +o/r *reat mass re"enti"e ,ealt, meas/res o+ all time. 5,e +o/r ,orsemen o+
,ealt, are9 t,e aste/ri@ation o+ milk, t,e /ri+ication o+ water, imm/ni@ation a*ainst
disease, and controlled +l/oridation o+ water.F
:(
5,e Centers +or Disease Control and
)re"ention recently listed +l/oridation amon* t,e to ten /-lic ,ealt, tri/m,s o+ t,e
>$t, cent/ry.
:;
5,e ,istoric de"eloment o+ +l/oridation in t,e United States ser"es as an e0amle o+
t,e contri-/tions o+ indi"id/als o+ "aried -ack*ro/nds reresentin* ersonal and
/-lic se*ments o+ t,e ro+ession. For e0amle, Dr. H. 5rendley Dean, considered t,e
F+at,er o+ +l/oridation,F ,ad a rominent role in t,e early de"eloin* story o+ t,e
imortance o+ +l/oride to toot, enamel.
>$
Dean was an o++icer in t,e US)HS w,o led
e0tensi"e st/dies t,at later esta-lis,ed t,at : art er million 7m8 o+ +l/oride in a
comm/nity water s/ly red/ced dental-caries re"alence.
>:
As imortant as t,e contri-/tions o+ Dean and t,e US)HS were to t,e s/-se?/ent
imlementation o+ comm/nity +l/oridation, one s,o/ld not lose si*,t o+ t,e roles
layed -y Dr. Frederick Mc2ay, a ersonal ,ealt,-care ractitioner in Colorado
Srin*s, Colorado, and Dr. G. 6. 1lack, a ractitioner and rominent dental ed/cator.
Mc2ay and 1lack cond/cted n/mero/s in"esti*ations o+ Colorado 4ro3n stain, a
condition indicati"e o+ e0cessi"e amo/nts o+ nat/rally occ/rrin* +l/oride ion d/rin*
toot, de"eloment, and +o/nd t,at dental caries was less re"alent amon* t,ose
a++licted.
>>
In addition, one s,o/ld consider t,e in+l/ence o+ an ind/strial c,emist, H.
6. C,/rc,ill, w,o de"eloed t,e analytic met,od t,at co/ld detect min/te ?/antities
o+ +l/oride in water, a critical ste necessary to esta-lis, t,e link -etween t,e le"el o+
+l/oride ions in water and t,e dental caries e0erience o+ t,e o/lation cons/min*
t,e water.
>=
At t,e same time, Smit, and Smit,,
>&
a*ric/lt/ral researc,ers, also linked
mottled enamel wit, water +l/oride concentrations. Followin* t,ese and ot,er
st/dies,
>'
indeendent researc,ers cond/cted controlled trials o+ t,e e++ect t,at
+l/oride ion in a comm/nity water system mi*,t ,a"e on dental caries e0erience in
c,ildren. 1e*innin* in :;&' and roceedin* t,ro/*, t,e mid-:;'$s, researc,ers added
+l/oride to t,e water systems o+ +o/r test comm/nities 7Grand !aids, Mic,i*anD
New-/r*,, New HorkD 3"anston, IllinoisD and 1rant+ord, Ontario8 and o-ser"ed t,e
dental caries e0erience o+ t,eir residents. 5,ese trials s/ccess+/lly demonstrated t,at
adA/sted water +l/oridation, at concentrations o+ :.$ to :.> m, co/ld dramatically
red/ce dental caries e0erience in c,ildren.
><->;
Accordin* to t,e most recent national data a"aila-le, aro0imately :<> million
ersons, or aro0imately <'.(E o+ t,e total U.S. o/lation, drink adA/sted or
nat/rally occ/rrin* +l/oridated water.
=$
Howe"er, t,is reresents a nearly &E increase
since :;;>. 3++orts to increase t,e roortion o+ t,e world o/lation drinkin*
+l/oridated water still ,a"e -een t,warted, in art, -eca/se o+ t,e contin/in* olitical
acti"ities o+ t,e anti-+l/oridation mo"ement. S/orters o+ t,is mo"ement contin/e to
oose adA/sted +l/oridation +or many reasons, t,e "ast maAority o+ w,ic, are
e?/i"ocal.
=:
Desite t,e e++orts o+ oosition *ro/s, comm/nity-water +l/oridation contin/es to
recei"e widesread s/ort +rom -ot, t,e ersonal and /-lic ,ealt,-care sectors.
N/mero/s ,ealt, ro+essional or*ani@ations, cons/mer and ad"ocacy *ro/s, and t,e
S/r*eon General contin/e to endorse comm/nity-water +l/oridation.
=>-='
AdA/stment
o+ water +l/oride concentrations to otimal le"els is an e0amle o+ a s/ccess+/l dental
/-lic-,ealt, ro*ram*ro/s workin* to*et,er to re"ent and control oral and
cranio+acial diseases in t,e comm/nity.
Current Problem
1/rt and 3kl/nd
=<
de+ine a pu4lic2health pro4lem as meetin* two criteria9 a8 a
condition or sit/ation t,at is a widesread act/al or otential ca/se o+ mor-idity or
mortalityD and -8 an e0istin* ercetion t,e condition is a /-lic-,ealt, ro-lem on
t,e art o+ t,e /-lic, *o"ernment, or /-lic ,ealt, a/t,orities. A n/m-er o+ oral and
cranio+acial diseases and conditions reresent /-lic ,ealt, ro-lems in t,e United
States today, and are -rie+ly disc/ssed -elow. 5,ese are t,e rincial concerns t,at
need to -e addressed -y -ot, t,e ersonal and /-lic ,ealt,care sectors to imro"e
oral ,ealt, at t,e comm/nity le"el.
Dental Caries
Dental caries is one o+ t,e most re"alent diseases in t,e United States. A-o/t :%E o+
c,ildren a*ed > to & years ,a"e ,ad a cario/s lesion in a rimary toot, d/rin* t,eir
li+etime, and t,e re"alence A/ms to &;.%E amon* c,ildren a*ed ' to ; years.
=%

Amon* ermanent teet,, ><.$E o+ c,ildren a*ed ' to :: years ,a"e ,ad a cario/s
lesion and <%.=E o+ c,ildren a*ed :> to :% years ,a"e ,ad a cario/s lesion.
=%
Dental
caries is also ,i*,ly re"alent amon* U.S. ad/lts, as aro0imately ;&E o+ dentate
ad/lts a*ed :( years or older ,a"e ,ad a cario/s lesion d/rin* t,eir li+etime.
=(
Dental-caries re"alence and se"erity also is associated wit, raceBet,nicity and
socioeconomic stat/s 7Fi*/re :%-:8. Certain minority c,ildren e0,i-it a ,i*,er
re"alence o+ rimary toot, decay t,an do t,eir eers, as =&.>E o+ non-Hisanic
w,ite c,ildren a*ed > to ; years ,a"e ,ad a cario/s lesion, w,ereas =(.(E o+ non-
Hisanic -lack c,ildren and '=.$E o+ Me0ican-American c,ildren ,a"e ,ad a cario/s
lesion.
=%
Amon* adolescents a*ed :> to :% years, lower o"erty stat/s is associated
wit, ,i*,er mean dental-caries e0erience scores and a *reater ercenta*e o+
/ntreated disease.
=;
)eriodontal Diseases
Gin*i"itis, one o+ t,e eriodontal diseases, is moderately re"alent in ersons a*ed :=
years or older. On a"era*e, <>.;E o+ ersons in t,is a*e ran*e e0,i-it *in*i"al
-leedin*, and :>.$E o+ sites are in"ol"ed.
&$
Gin*i"itis, as meas/red -y *in*i"al
-leedin*, is also more re"alent amon* Me0ican-Americans t,an it is amon* non-
Hisanic -lacks and non-Hisanic w,ites a*ed =$ years or older.
&:
Calc/l/s, a
contri-/tin* +actor in *in*i"itis, is resent in (;.;E o+ ersons a*ed := years or
older.
&$
Alt,o/*, most ersons wo/ld not consider *in*i"itis a serio/s t,reat to oneCs
,ealt,, it recei"es a *reat deal o+ attention in t,e aearance-conscio/s United States,
*i"en t,e conditionCs e++ect on est,etics and *in*i"itis recedes, -/t does not
necessarily ro*ress to eriodontitis.
)eriodontitis is t,e second o+ t,e eriodontal diseases and is associated wit, *reater
mor-idity t,an is *in*i"itis, and as s/c,, is considered a more serio/s /-lic-,ealt,
ro-lem. On a"era*e, >%.$E o+ males and :%.'E o+ +emales a*ed := years or older
,a"e at least one site wit, 'Kmm loss o+ eriodontal attac,ment.
&$
5,is *ender
di++erence is statistically si*ni+icant. 5,e re"alence o+ attac,ment loss is also
si*ni+icantly ,i*,er amon* minority *ro/s, as >&.;E o+ non-Hisanic -lacks and
:%.:E o+ non-Hisanic w,ites a*ed := years or older e0,i-it t,e condition.
&$
Oral and ),aryn*eal Cancer
5,ere are aro0imately =$,>$$ cases o+ oral and ,aryn*eal cancer detected in t,e
United States eac, year, and t,is n/m-er acco/nts +or some >.&E o+ all cancers. O+
ersons wit, oral and ,aryn*eal cancer, aro0imately %,($$ die eac, year. 5,e
o"erall '-year s/r"i"al rate +or ersons wit, oral and ,aryn*eal cancer is '>E, w,ic,
is lower t,an t,at +or cancers o+ t,e rostate, -reast, -ladder, laryn0, cer"i0, colon,
and rect/m.
&>
)ersons dia*nosed wit, oral and ,aryn*eal cancer at an early sta*e
,a"e a m/c, -etter ro*nosis t,an do t,ose dia*nosed at a later sta*e, as t,e '-year
s/r"i"al rate is (:.=E +or early-sta*e dia*nosis and >:.<E +or ad"anced-sta*e
dia*nosis. Only ='E o+ indi"id/als wit, oral and ,aryn*eal cancer are dia*nosed at
an early sta*e o+ t,e disease.
&>
Cranio+acial 1irt, De+ects
Oral cle+ts are amon* t,e most common classes o+ con*enital mal+ormations in t,e
United States. On a"era*e, t,ere are :.> cases o+ cle+t li 7wit, or wit,o/t cle+t alate8
er :,$$$ li"e -irt,s and $.'< cases o+ cle+t alate er :,$$$ li"e -irt,s in t,e *eneral
o/lation 7Fi*/re :%->8.
&=
5,ese de+ects may a++ect +acial aearance t,ro/*,o/t
li+e. Cle+t alate occ/rs more +re?/ently in +emales, w,ereas cle+t li or cle+t liBalate
occ/rs more +re?/ently in males.
&&-&%
5,e oral cle+t incidence rate +or w,ites is more
t,an = times t,e incidence rate +or -lacks.
Intentional and Unintentional InA/ries
It is ass/med t,at inA/ries to t,e ,ead, +ace, and teet, are relati"ely common, ,owe"er
t,e maAority o+ o/r knowled*e re*ardin* t,e n/m-er o+ inA/ries comes +rom
emer*ency deartment data and more se"ere inA/ries. 5,e leadin* ca/ses o+ s/c,
inA/ries incl/de +alls, assa/lts, sorts inA/ries, and motor-"e,icle collisions.
&(-'$

Accordin* to data collected in :;;= and :;;&, t,ere were aro0imately >$ million
"isits to emer*ency deartments er year +or cranio+acial inA/ries. Falls and assa/lts
eac, acco/nted +or a-o/t =:E o+ "isits and sorts-related inA/ries acco/nted +or
aro0imately :;E o+ inA/ries.
':
InA/ries res/ltin* +rom -icycles and tricycles
acco/nted +or 'E o+ ,ead and :;E o+ +ace inA/ries.
'>
O"erall, >&.;E o+ ersons a*ed
< to '$ years ,a"e ,ad an inA/ry t,at res/lted in dama*e to one or more incisor teet,.
'=
Accordin* to data collected in :;;:, ersonal ,ealt,-care dentists treated more t,an
'.; million cranio+acial inA/ries.
'&
Fi*/re :%-: Disarities in re"alence o+ /nrestored dental caries e0ist -etween
oor and non-oor. 7From U.S. Deartment o+ Healt, and H/man Ser"ices. +ral
Health in merica6 Report of the Sur$eon 0eneral, 1et,esda, MD9 U.S.
Deartment o+ Healt, and H/man Ser"ices, National Instit/tes o+ Dental and
Cranio+acial !esearc,, >$$$7='89<=.8
Fi*/re :%-> Incidence o+ selected con*enital de+ects. 7From Sc,/lman et al.,
:;;=.
&=
8
Dental Public-Health Methods
)ersonal oral-,ealt,-care ractitioners ser"e t,e oral ,ealt, needs o+ indi"id/al
atients, and t,e ersonal ,ealt,-care deli"ery system re?/ires a one-on-one
interaction -etween ractitioner and indi"id/al atient. )/-lic-,ealt, dentistry
+oc/ses on t,e comm/nity and, as s/c,, does not necessarily re?/ire a one-on-one
interaction -etween ractitioner and indi"id/al atient. 4,en a dental /-lic-,ealt,
ro*ram s/c, as water +l/oridation is s/ccess+/lly imlemented in a comm/nity, a
m/c, -roader cross section o+ t,e comm/nity -ene+its m/c, -roader t,an co/ld -e
e0ected -y ersonal ,ealt,-care ractitioners, alone.
2n/tson
''
contrasted t,e met,ods emloyed -y ersonal and /-lic ,ealt,care
ractitioners. 3ac, consisted o+ si0, se?/ential stes t,at ermit a lo*ical ro*ression
+rom identi+ication o+ a ro-lem to its sol/tion 75a-le :%-:8. For t,e indi"id/al
atient, a ersonal ,ealt,care ractitioner initiates treatment wit, a care+/l
e0amination and ,istory, w,ic, leads to an acc/rate dia*nosis o+ t,e ro-lem.
A+terwards, t,e ersonal ,ealt,care ractitioner lans a co/rse o+ treatment. Once
treatment ser"ices ,a"e -een ro"ided, and +ees aid, s/-se?/ent "isits ro"ide +or
e"al/ation and +ollow-/. 5,e met,ods emloyed in /-lic-,ealt, ractice arallel
t,ose o+ t,e ersonal ,ealt,-care ractitioner, -/t in"ol"e t,e total comm/nity instead
o+ an indi"id/al atient. Dental /-lic-,ealt, met,ods are disc/ssed in *reater detail
-elow.
30amination "ers/s S/r"ey
4,en a ersonal ,ealt,-care ractitioner -e*ins t,e e0amination rocess, ,e or s,e
collects s/-Aecti"e in+ormation +rom t,e atient and o-Aecti"e in+ormation, s/c, as
"is/al and tactile data, radio*ra,ic ima*es, and ot,er si*ns o+ disease. 1y contrast,
w,en a /-lic ,ealt,-care ractitioner assesses t,e e0tent o+ disease in a comm/nity,
,e or s,e m/st rely on descriti"e in+ormation, s/c, as e0istin* s/r"ey data or ot,er
eidemiolo*ical assessments.
Question 1
A. As a *eneral r/le, c,ildren wit, t,e *reatest oral-,ealt, treatment needs are also t,e
c,ildren w,o recei"e riority care.
1. 5,e o"erw,elmin* maAority o+ Americans die wit, at least one cario/s or restored
toot,.
C. 5,e incidence o+ oral cle+ts is ,i*,er amon* -lacks t,an it is amon* w,ites.
D. Core +/nctions o+ /-lic ,ealt, incl/de assessment, olicy de"eloment, and
ass/rance.
3. Dental /-lic-,ealt, ro*rams do not necessarily re?/ire a one-on-one interaction
-etween ractitioner and indi"id/al atient.
Some descriti"e s/r"ey data ,a"e -een collected and reorted re"io/sly. At t,e
national le"el, s/r"eys s/c, as t,e National Healt, 30amination S/r"ey, National
Healt, and N/trition 30amination S/r"ey, National Healt, Inter"iew S/r"ey, and
s/r"eys cond/cted -y t,e National Instit/te o+ Dental and Cranio+acial !esearc,
'<

,a"e ro"ided assessments at t,e comm/nity le"el re*ardin* t,e distri-/tion o+
diseases, s/c, as dental caries and eriodontitis, as well as oral ,ealt, knowled*e and
-e,a"ioral ractices. At t,e state le"el, s/r"eys s/c, as t,e 1e,a"ioral !isk Factor
S/r"eillance System or cancer re*istries ,a"e ro"ided /se+/l descriti"e in+ormation
re*ardin* oral ,ealt, care /tili@ation ractices and incidence o+ oral and ,aryn*eal
cancer. Selected states ,a"e also administered s/r"eys to assess t,e oral-,ealt, stat/s
o+ t,eir citi@ens 7Fi*/re :%-=8.
For t,e dental /-lic-,ealt,-care ractitioner, t,e +oc/s o+ t,e s/r"ey ste is to
comile all o+ t,e descriti"e in+ormation t,at e0ists in a state, co/nty, re*ion, or local
area. 4,en descriti"e data do not e0ist, t,e dental /-lic-,ealt,-care ractitioner
m/st +ind a way to collect /se+/l in+ormation. D/rin* t,e mid-:;;$s, romted -y t,e
newly de+ined essential +/nctions o+ /-lic ,ealt,, t,e Association o+ State and
5erritorial Dental Directors 7AS5DD8 de"eloed a model +or t,e collection o+ oral
,ealt, data at state and local le"els,
'%
re+erred to as t,e Seven2step %odel for
ssessin$ +ral Health &eeds, 5,e se"en stes incl/ded9
:. Identi+yin* artners and +ormin* an ad"isory committee.
>. Cond/ctin* sel+-assessment to determine *oals and reso/rces.
=. )lannin* t,e needs assessment.
Cond/ct in"entory o+ a"aila-le rimary and secondary data
Determine need +or rimary data collection
Identi+y reso/rces
Select met,ods
De"elo work lan
&. Collect data.
'. Or*ani@e and analy@e data.
<. !eort +indin*s and /tili@e t,e data +or ro*ram lannin*, ad"ocacy, and ed/cation.
%. 3"al/ate needs assessment and ret/rn to +irst ste, as necessary.
AS5DD intended t,at t,e collected data -e /sed as art o+ a lannin* cycle 7Fi*/re
:%-&8 t,at wo/ld lead to t,e imlementation o+ necessary dental /-lic-,ealt,
ro*rams. #/st as a ersonal ,ealt,-care ractitioner wo/ld not consider initiatin*
treatment on a atient wit,o/t s/-Aecti"e and o-Aecti"e data at ,and, t,e /-lic ,ealt,-
care ractitioner wo/ld not consider initiatin* a dental /-lic-,ealt, ro*ram wit,o/t
descriti"e data re*ardin* t,e needs o+ t,e comm/nity.
Dia*nosis "ers/s Analysis
Once a ersonal ,ealt,-care ractitioner ,as *at,ered s/++icient s/-Aecti"e and
o-Aecti"e in+ormation +rom t,e atient, ,e or s,e /ses ro+essional A/d*ment and
e0erience to dia*nosis a disease or condition, i+ one e0ists. Once a /-lic ,ealt,-care
ractitioner ,as collected s/++icient s/r"ey data, ,e or s,e analy@es t,e in+ormation in
order to answer seci+ic ?/estions. Is t,ere a dental /-lic ,ealt, ro-leme I+ so, w,at
is t,e e0tent o+ t,e ro-leme Are t,ere aroriate sol/tions a"aila-le to address t,e
ro-leme
5,e analysis ste ,els t,e /-lic ,ealt,-care ractitioner assess w,en a ro-lem
e0ists and ,els to ?/anti+y its e0tent. )/-lic ,ealt,-care ractitioners rely on standard
statistical met,ods to s/mmari@e s/r"ey data +indin*s d/rin* t,e analysis ste. For
e0amle, state-seci+ic s/r"ey data may s,ow t,at &'E o+ sc,oolc,ildren ,a"e
/nrestored dental caries, and t,at t,is ercenta*e is si*ni+icantly ,i*,er t,an wo/ld -e
e0ected at a national le"el. 5,e si*ni+icant di++erence in ercenta*es may oint to a
dental /-lic ,ealt, ro-lem in t,at state. In addition, s/r"ey data may s,ow t,at oral
and ,aryn*eal cancer incidence in one co/nty is si*ni+icantly ,i*,er t,an is t,e rate
in a nei*,-orin* co/nty. One wo/ld e0ect t,e +irst co/nty to recei"e secial attention
or a tar*eted dental /-lic ,ealt, ro*ram. 4it,o/t t,e analysis ste, ,owe"er, t,e
di++erence -etween t,e two co/nties mi*,t -e less o-"io/s.
In order +or a /-lic ,ealt,-care ractitioner to comare analytical +indin*s to ot,er
s/r"ey data, or transmit analytical +indin*s to ot,er /-lic ,ealt,-care ractitioners, ,e
or s,e /ses standard meas/rement tools and descriti"e */idelines, called dental
inde0es. A "ariety o+ dental inde0es ,a"e -een de"eloed +or seci+ic oral and
cranio+acial diseases and conditions. Some o+ t,e more common inde0es are listed
-elow.
Dental Inde0es
An imortant tool /sed in e0aminations o+ a o/lation *ro/ is a dental index, a
n/meric score t,at ?/anti+ies t,e ma*nit/de o+ t,e disease meas/red. A n/m-er o+
inde0es ,a"e -een de"eloed +or t,e /rose o+ ro"idin* t,e o-Aecti"e meas/rement
o+ t,e oral ,ealt, stat/s o+ a o/lation *ro/. 5,e n/m-er o+ teeth t,at are decayed,
missin*, or +illedt,e DMF5 inde0
:%
is a total score o+ all a++ected teet, and
ro"ides a dental caries e0erience score +or an indi"id/al. A co/nt o+ tooth surfaces
t,at are decayed, missin*, or +illed is a DMFS inde0 and ro"ides *reater recision
re*ardin* t,e dental caries ,istory o+ an indi"id/al or o/lation. 5,e mean DMF5
score +or a o/lation *ro/ is t,e total a"era*e dental caries e0erience at a
artic/lar time. Dental caries e0erience in t,e rimary dentition is denoted -y t,e /se
o+ lo3er case letters to reresent t,e n/m-er o+ decayed, e0tracted, or +illed rimary
teeth and surfaces8 deft and defs,
'(
5,is inde0 ,as recently -een modi+ied to dft and
dfs, -eca/se o+ t,e di++ic/lty in distin*/is,in* a rimary toot, t,at ,as -een e0tracted
+rom one t,at ,as -een lost to t,e nat/ral rocess o+ e0+oliation.
5,e stat/s o+ eriodontal tiss/es ,as -een e"al/ated /sin* se"eral inde0es. 5,e
0in$ival /ndex 7GI8 o+ .oe and Silness
';
is artic/larly s/ited +or assessin* c,an*es in
*in*i"al ,ealt, t,at mi*,t -e o-ser"ed d/rin* t,e e"al/ation eriod o+ an oral ,y*iene
ro*ram. Se"eral la?/e inde0es ,a"e also -een de"eloed to assess t,e stat/s o+ oral
,y*iene in o/lation *ro/s. 5,e Pla5ue /ndex 7)8 o+ Silness and .oe
<$
?/anti+ies
t,e e0tent o+ la?/e on de+ined areas o+ seci+ic toot, s/r+aces. 5,e +ral Hy$iene
/ndexSimplified 7OHI-S8 o+ Greene and 6ermillion
<:
meas/res oral de-ris and
calc/l/s on seci+ic toot, s/r+aces.
5,e Periodontal /ndex 7)I8 o+ !/ssell
<>
and t,e Periodontal Disease /ndex 7)DI8 o+
!am+Aord
<=
were once /sed +or assessin* t,e se"erity o+ eriodontitis, -/t are no
lon*er considered "alid. 4,en t,ese inde0es were de"eloed, it was -elie"ed t,at
*in*i"itis and eriodontitis were on a contin//mD as *in*i"itis -ecame more se"ere,
eriodontitis res/lted. Conse?/ently, t,e )I and )DI were de"eloed as comosite
inde0es, assessin* *in*i"itis and eriodontitis to*et,er. 5oday, it is well esta-lis,ed
t,at *in*i"itis does not necessarily lead to eriodontitis, and t,at t,e two diseases are
/ni?/e. Alt,o/*, t,e )I and )DI are no lon*er /sed, t,e )DI le+t -e,ind a
meas/rement comonent t,at is "alid +or assessin* tiss/e destr/ction. 5,e s/r"i"in*
meas/rement comonent, sometimes re+erred to as loss of attachment or (+,
calc/lates t,e loss o+ eriodontal attac,ment t,at ,as occ/rred adAacent to a toot,. 5,e
Community Periodontal /ndex of Treatment &eed 7C)I5N8 is not an inde0 o+
eriodontitis, -/t a meas/re o+ t,e necessity +or eriodontal treatment.
<&
5,e C)I5N
,as -een /sed -y nations aro/nd t,e world.
4,en /-lic ,ealt,care ractitioners emloy a dental inde0 d/rin* t,e analysis ste,
t,ey m/st ay artic/lar attention to t,e trainin* o+ e0aminers. Consistency in t,e
alication o+ scorin* criteria is aramo/nt to t,e "alidity o+ inde0 scores. A
comarison o+ DMF5 scores +rom one co/nty to anot,er wo/ld -e o+ little "al/e, +or
e0amle, i+ t,e e0aminers in t,e two co/nties alied t,e scorin* criteria in di++erent
ways.
5reatment )lannin* "ers/s )ro*ram )lannin*
Once a ersonal ,ealt,-care ractitioner ,as identi+ied a disease or condition, and
assessed its e0tent, ,e or s,e is ready to transmit t,e in+ormation to t,e atient and
lan a treatment strate*y. Once a /-lic ,ealt,-care ractitioner ,as identi+ied t,e
e0istence o+ a dental /-lic-,ealt, ro-lem and assessed its e0tent, ,e or s,e is ready
to transmit t,e in+ormation to concerned indi"id/als and comm/nity artners.
5o*et,er, t,e /-lic ,ealt,-care ractitioner and artners de"elo a /-lic-,ealt,
ro*ram t,at is tailored to t,e needs o+ t,e comm/nity.
D/rin* t,e treatment lannin* and ro*ram lannin* stes, decisions m/st take into
consideration s/c, +actors as a"aila-le time, +inances, knowled*e, e0erience,
attit/des, and willin*ness to comlete t,e lan. #/st as an indi"id/al atient m/st
consider ,is or ,er ersonal circ/mstances w,en selectin* treatment otions,
comm/nity leaders m/st consider comm/nity reso/rces and riorities w,en selectin*
aroriate /-lic ,ealt, ro*ram otions.
5reatment "ers/s )ro*ram Oeration
Once t,e atient and ersonal ,ealt,-care ractitioner ,a"e decided on an aroriate
treatment lan, treatment o+ t,e disease or condition -e*ins. Once t,e comm/nity and
/-lic ,ealt,care ractitioner ,a"e decided on an aroriate ro*ram lan, t,e /-lic
,ealt, ro*ram is set in motion. )ro*ram oeration /s/ally incl/des t,ree +eat/res,
incl/din* ,ealt, ed/cation, disease re"ention, and ro"ision o+ ser"ices.
<'
Gi"en t,at
administrations c,an*e, reso/rces s,i+t, and attit/des and moti"ations e"ol"e, t,e
ro*ram oeration ste is ne"er static. Comm/nity inter"entions are *enerally more
di++ic/lt to orc,estrate t,an are lans t,at address an indi"id/al, -eca/se more +actors
m/st -e taken into consideration at t,e comm/nity le"el.
Fi*/re :%-= S/r"eys desi*ned to esta-lis, t,e oral ,ealt, needs o+ c,ildren
+re?/ently take lace in a sc,ool settin*. 7Co/rtesy o+ Dr. Art,/r 1enito,
!esearc, 5rian*le Instit/te, Nort, Carolina.8
Fi*/re :%-& Dental /-lic-,ealt, ro*ram lannin* cycle.
Question 2
A. Treatment plannin$ re?/ires t,e in/t o+ t,e ersonal ,ealt,care ractitioner and
in+ormed consent o+ t,e atient, w,ereas pro$ram plannin$ re?/ires t,e in/t o+ t,e
/-lic-,ealt, dentist and in+ormed consent o+ in"ol"ed comm/nity leaders.
1. Indi"id/al State Healt, Deartments oerate /nder t,e administrati"e control o+ t,e
U.S. Deartment o+ Healt, and H/man Ser"ices.
C. 5,e examination ste o+ ersonal ,ealt, care is analo*o/s to t,e analysis ste o+
/-lic ,ealt, care.
D. Comm/nity-water +l/oridation camai*ns o+ten +ail -eca/se o+ olitical
iss/esnot -eca/se o+ ,ealt, deartment decisions.
3. 5,e Community Periodontal /ndex of Treatment &eed 7C)I5N8 is a "alid meas/re
o+ eriodontal tiss/e destr/ction.
)ayment +or Ser"ices "ers/s Financin*
For t,e indi"id/al atient +acin* a treatment lan, t,e scoe and e0tent o+ treatment
ser"ices deend on ersonal reso/rces andBor t,e e0istence o+ t,ird-arty ayment
lans. For t,e comm/nity lookin* +orward to t,e initiation o+ a dental /-lic-,ealt,
ro*ram, t,e scoe and e0tent o+ t,e ro*ram deend on t,e e0istence o+ a"aila-le
/-lic and ersonal ,ealt,-care +/nds. In most cases, /-lic ro*rams are +/nded "ia
t,e +ederal *o"ernment or t,e state. )ro*ram administration and +/ndin* tyically
ori*inate +rom state-le"el ,ealt, deartments, or co/nty-le"el or local area-le"el
,ealt, deartments, w,en t,ey e0ist.
3"al/ation "ers/s Araisal
4,en a ersonal ,ealt,-care ractitioner comletes an indi"id/al atientCs treatment
lan, ,e or s,e e"al/ates t,e indi"id/al d/rin* eriodic inter"als, to ass/re t,at t,e
oral ,ealt, is maintained and any arisin* treatment needs are identi+ied and met. 5,e
resonsi-ilities o+ t,e /-lic ,ealt,-care ractitioner are comara-le. D/rin* t,e
araisal ste, t,e /-lic ,ealt,-care ractitioner +irst needs to assess w,et,er t,e
ro*ram ,as ade?/ately addressed t,e needs o+ t,e comm/nity. As s/c,, all /-lic-
,ealt, ro*rams s,o/ld ,a"e a meas/ra-le set o+ o-Aecti"es a*ainst w,ic, s/ccess or
+ail/re may -e araised. I+, +or e0amle, a dental /-lic-,ealt, ro*ram were
initiated to red/ce t,e oral-cancer incidence in a co/nty e0eriencin* /n/s/ally ,i*,
rates, t,en t,e ro*ram s,o/ld contain a tar*et incidence rate t,at wo/ld si*ni+y
s/ccess. Once t,e /-lic ,ealt,-care ractitioner ,as assessed w,et,er an o-Aecti"e
,as -een met, ,e or s,e m/st monitor t,e e0istence o+ a /-lic ,ealt, ro*ram on a
re*/lar -asis. I+ new s/r"ey data are re?/ired, t,e /-lic ,ealt,-care ractitioner
s,o/ld sec/re t,em. I+ t,e standard a*ainst w,ic, s/ccess is A/d*ed s,o/ld c,an*e,
t,e /-lic ,ealt,-care ractitioner s,o/ld reassess w,et,er t,e ro*ram wo/ld -e
considered a s/ccess.
For -ot, t,e ersonal and /-lic ,ealt,-care ractitioners, t,e e"al/ation and araisal
stes reresent t,e link -etween t,e end o+ a treatment lan or /-lic-,ealt, ro*ram
and t,e -e*innin* o+ a new lan or ro*ram. As lon* as indi"id/al atients ,a"e
treatment needs or comm/nities ,a"e /-lic-,ealt, ro-lems, t,e si0 stes o+ t,e
ersonal and /-lic ,ealt,-care ractitioner can -e alied.
An 30amle o+ a Dental )/-lic-Healt, )ro*ram
A dental sealant is a lastic material t,at is alied to t,e it-and-+iss/re s/r+aces o+
t,e teet, -y oral ,ealt,-care ro+essionals. Dental sealants +/nction as a rimary
re"enti"e a*ent a*ainst dental caries -y o-str/ctin* t,e it-and-+iss/re s/r+ace +rom
-acteria. Dental sealants also may ser"e as a secondary re"enti"e a*ent a*ainst
dental caries w,en alied to inciient lesions. Dentists and dental ,y*ienists aly
dental sealants in ri"ate ,ealt,-care +acilities, ,owe"er t,is means o+ ro"idin* t,e
re"enti"e a*ent is limited -y access to t,e +acilities and t,e ersonal circ/mstances
o+ t,e atients in need.
5,is section o+ t,e c,ater resents a dental /-lic ,ealt, ro-lem in a +ictitio/s
comm/nity called .ourto3n and roceeds t,ro/*, t,e si0 stes o+ t,e /-lic
,ealt,care ractitionerCs met,od, in order to ill/strate ,ow a dental sealant camai*n
mi*,t -e emloyed as an e++ecti"e dental /-lic ,ealt, ro*ram 7Fi*/re :%-'8.
Alt,o/*, t,is e0ercise descri-es a seci+ic ro-lem and ro*ram sol/tion, t,e
rinciles may -e alied more -roadly to ot,er ro-lems and sol/tions.
Survey
5,e s/r"ey ste o+ t,e rocess encomasses t,e se"en-ste model o+ assessin* oral
,ealt, needs. Dr. Sally Sealem, t,e co/nty ,ealt, o++icer in Ho/rtown, -e*an t,e
rocess -y identi+yin* artners and +ormin* an ad"isory committee o+ interested
arties. Dr. Sealem asked administrators +rom t,e sc,ool -oard to Aoin ,er, as well as
sta++ mem-ers +rom t,e ,ealt, deartment, t,e director o+ t,e dental ,y*iene trainin*
ro*ram at Ho/rtown Comm/nity Colle*e, t,e state dental director, and t,e
administrator o+ a nonro+it ,ealt,-care +acility.
D/rin* t,e ad"isory committeeCs +irst meetin*, t,e mem-ers disc/ssed t,eir reso/rces
and limitations. Dr. Sealem knew t,at t,e most cost-e++ecti"e dental sealant ro*ram
wo/ld in"ol"e sc,ool-a*ed c,ildren. 5,e sc,ool administrators ass/red t,e ,ealt,
o++icer t,at a dental sealant ro*ram wo/ld -e welcomed into t,e local sc,ools. 5,e
administrators also said t,at t,e rincials, teac,ers, and sc,ool n/rses wo/ld -e
willin* to coordinate comm/nication wit, arents and st/dents. Dr. Sealem also
reco*ni@ed t,at oral ,ealt,-care ro+essionals wo/ld need to articiate in t,e
ro*ram. 5,e dental director told ,er t,at ,e wo/ld disc/ss t,e roosed ro*ram
wit, t,e state and local dental society. He was +airly s/re t,at t,e dental society wo/ld
em-race t,e ro*ram and ro"ide t,e names o+ a +ew retired ractitioners w,o mi*,t
-e interested in "ol/nteerin* t,eir time to t,e ro*ram. 5,e director o+ t,e trainin*
ro*ram in dental ,y*iene also o++ered t,e assistance o+ ,er +ac/lty and st/dents.
5,e dental director also said t,at t,ere was little money in t,e -/d*et +or a dental
sealant ro*ram. Uon ,earin* t,at t,e dental directorCs -/d*et did not allow +or a
dental sealant ro*ram, t,e administrator o+ t,e non-ro+it ,ealt,care +acility said t,at
t,eir treatment clinic wo/ld -e willin* to donate some money and s/lies to t,e
ro*ram and t,e attendees +rom t,e ,ealt, deartment said t,at t,ey wo/ld look into
t,e e0istence o+ *rant money +rom ri"ate cororations, comm/nity *ro/s, and t,e
+ederal *o"ernment.
)rior to t,e meetin*, Dr. Sealem comiled demo*ra,ic data +or Ho/rtown and all o+
t,e rele"ant data re*ardin* dental caries and re"enti"e oral ,ealt, ro*rams. S,e
disco"ered t,at t,e comm/nity contained aro0imately :$,$$$ sc,ool-a*ed c,ildren.
Most o+ t,ese c,ildren li"ed wit,in :$ miles o+ t,eir resecti"e sc,ools, ,owe"er a
+ew were transorted "ia -/s +rom nei*,-orin* r/ral areas. 5,e socioeconomic stat/s
7S3S8 ro+ile o+ t,e comm/nity was relati"ely low, wit, aro0imately '<E o+
c,ildren ?/ali+yin* +or +ree or red/ced meals at sc,ool. Dr. Sealem also learned t,at
Ho/rtown did not ,a"e access to +l/oridated comm/nity water. Dr. Sealem ,ad no
data descri-in* t,e dental caries re"alence or t,e re"alence o+ dental sealants in
Ho/rtown, ,owe"er s,e did ,a"e access to data +rom se"eral national s/r"eys.
5,e ad"isory committee reco*ni@ed t,at s/r"ey data +rom Ho/rtown wo/ld ,a"e
ro"ided a more comlete ict/re o+ t,e oral-,ealt, conditions in t,eir comm/nity
t,an t,e national data, -/t t,ey also reco*ni@ed t,at in order to collect s/c, data, t,ey
wo/ld ,a"e to cond/ct a s/r"ey +or w,ic, t,ey ,ad limited reso/rces. Gi"en t,e
circ/mstances, t,e ad"isory committee /ltimately decided t,at t,ey wo/ld rely on t,e
national data to draw concl/sions a-o/t t,eir comm/nity.
nalysis
From st/dies o+ national data,
=;
Dr. Sealem knew t,at dental caries re"alence was
,i*,er amon* oor c,ildren t,an it was amon* t,eir non-oor co/nterarts. S,e also
knew t,at t,e ercenta*e o+ /nrestored disease was ,i*,er amon* t,e oor c,ildren.
In addition, national st/dies s,owed t,at only :(.'E o+ c,ildren a*ed ' to :% years
,ad one or more sealed teet,.
<<
Gi"en t,at t,ere was a si@ea-le roortion o+ oor
c,ildren in Ho/rtown and *i"en t,at national s/r"ey data s,owed t,at oor c,ildren
,ad *reater needs, t,e ad"isory committee concl/ded t,at t,ere was *ood reason to
initiate a dental sealant ro*ram in t,eir comm/nity.
Pro$ram Plannin$
D/rin* t,e ro*ram-lannin* sta*e, t,e ad"isory committee listed all o+ t,e ossi-le
ways to imlement a dental-sealant ro*ram in Ho/rtown. Some o+ t,e otions
incl/ded /se o+ a mo-ile dental "an, "isits to c,/rc,es and ot,er meetin* laces,
e0ansion o+ ser"ices at t,e ,ealt, deartment, e0ansion o+ ser"ices at t,e nonro+it
,ealt,-care +acility, and a sc,ool--ased ro*ram. In decidin* on t,e -est aroac,, t,e
ad"isory committee considered a"aila-le reso/rces and otential ad"anta*es and
disad"anta*es o+ eac, otion. Gi"en t,at sc,ool administrators ro"ided ready access
to sc,ools, and -eca/se t,is was w,ere t,e maAority o+ c,ildren co/ld -e +o/nd, t,e
ad"isory committee decided t,at t,ey wo/ld /se a sc,ool--ased dental-sealant
ro*ram. 5,ey also decided t,at t,ey wo/ld /se st/dents +rom t,e dental-,y*iene
trainin* ro*ram at t,e comm/nity colle*e to ed/cate arents and teac,ers a-o/t t,e
-ene+its o+ t,is re"enti"e oral-,ealt, meas/re, and t,ey wo/ld /se t,e retired dentists
+rom t,e comm/nity to administer t,e dental sealants.
In reco*nition o+ t,e -/d*etary constraints, t,e nonro+it ,ealt,-care +acility ro"ided
disosa-le *lo"es, masks, dental mirrors, and ton*/e -lades to t,e ro*ram. In
addition, sta++ mem-ers +rom t,e ,ealt, deartment were a-le to roc/re *rant
+/ndin* +rom a local ,ilant,roic or*ani@ation and dental sealant materials +rom a
national dental s/ly distri-/tor. 5,e ad"isory committee /sed t,e *rant +/nds to
/rc,ase a orta-le dental c,air, *enerator, and li*,t so/rce.
Pro$ram +peration
A+ter t,oro/*, consideration o+ t,e ro-lem and analysis o+ its se"erity, care+/l
lannin*, and roc/rement o+ +/ndin*, t,e sc,ool--ased dental sealant ro*ram was
/t into oeration. In rearation +or t,e initiation o+ t,e ro*ram, in-ser"ice trainin*
ro*rams were cond/cted +or all articiants to a++irm *oals and standardi@e treatment
rotocols. 5,e alication o+ dental sealants to t,e sc,ool c,ildren ro*ressed well,
-eca/se t,e ad"isory committee ,ad aid s/c, care+/l attention d/rin* t,e re"io/s
sta*es.
'inancin$
Alt,o/*, t,e ad"isory committee was a-le to solicit t,e necessary +/nds +or t,e +irst
year o+ t,e dental sealant ro*ram, t,ey reali@ed t,at in order +or t,e ro*ram to ,a"e
a lastin* imact, t,ey wo/ld need to roc/re new +/ndin* o"er time. 5,e *reat
s/ccess o+ t,e ro*ram made t,is ste relati"ely easy. 5,e ad"isory committee created
ress releases and *a"e t,em to t,e rint media. Dr. Sealem asked t,e local tele"ision
stations to inter"iew ,er d/rin* F,ealt, sotsF on t,e local news. 5,e ad"isory
committee caitali@ed on t,e o/larity o+ t,e ro*ram amon* arents and
comm/nity leaders -y askin* t,em to re?/est additional +/nds +rom t,eir le*islati"e
reresentati"es +or t,e stateCs ,ealt, -/d*et. Sta++ mem-ers at t,e ,ealt, deartment
wrote new *rant alications and contin/ed to solicit +/nds o+ ot,er a*encies and
or*ani@ations.
ppraisal
5,e ad"isory committee /sed national data to determine w,et,er t,eir comm/nity
wo/ld -e a *ood candidate +or a dental sealant ro*ram. 5,is aroac, was
satis+actory +or t,e initiation o+ t,e ro*ram, -/t it wo/ld not s/++ice d/rin* t,e
araisal sta*e. In order +or t,e ad"isory committee to e"al/ate w,et,er t,e dental
sealant ro*ram ,ad -een s/ccess+/l in red/cin* dental caries e0erience in
Ho/rtown, t,ey wo/ld need new dataD a -aseline assessment and eriodic assessments
o+ dental-caries and dental-sealant re"alence amon* t,e sc,ool c,ildren.
5,e araisal sta*e is ar*/a-ly one o+ t,e most di++ic/lt comonents o+ a dental /-lic
,ealt, ro*ram. It re?/ires care+/l delineation o+ meas/ra-le *oals and o-Aecti"es and
a detailed lan to collect e"al/ation data o"er many years. 5,e araisal sta*e m/st
take into consideration t,e -ene+its o+ t,e ro*ram and wei*, t,em a*ainst t,e cost. It
m/st also consider alternati"e re"enti"e and treatment re*imens as t,ey de"elo, and
assess w,et,er t,ese new strate*ies mi*,t -e a -etter otion.
3nt,/siasm and e0citement +re?/ently dri"e t,e +irst +ew years o+ a new ro*ram,
,owe"er +/ndin* a*encies and le*islators will e"ent/ally demand t,at t,eir reso/rces
are -ein* alied to an e++icient and e++ecti"e ro*ram. 4it,o/t a "alid araisal lan
in lace, t,e a-ility +or an administrator s/c, as Dr. Sealem to demonstrate e++iciency
and e++ecti"eness is all -/t imossi-le.
Alt,o/*, t,is may -e t,e most di++ic/lt comonent o+ a dental /-lic ,ealt, ro*ram,
administrators ,a"e a n/m-er o+ reso/rces at t,eir disosal. Healt, deartments
tyically ,a"e eidemiolo*ists and s/r"ey researc,ers a"aila-le +or cons/ltation.
AS5DD and t,e Di"ision o+ Oral Healt, at t,e Centers +or Disease Control and
)re"ention also ,a"e cons/ltants a"aila-le.
Fi*/re :%-' Sc,ool--ased dental sealant ro*rams ,a"e -een +o/nd to -e an
e++ecti"e aroac, to red/cin* dental caries in it-and-+iss/re toot, s/r+aces.
7Co/rtesy o+ O,io Di"ision o+ Dental Healt,.8
Levels of Dental Public Health Operation
5,ere are n/mero/s international and national or*ani@ations t,at ,a"e as a rimary or
secondary +oc/s, t,e re"ention and control o+ oral and cranio+acial diseases at t,e
comm/nity le"el. At t,e international le"el, t,e 4orld Healt, Or*ani@ation 74HO8
,as acceted t,e resonsi-ility o+ coordinatin* t,e e++orts o+ all mem-er or*ani@ations
in de"eloin* and imro"in* oral and medical ,ealt, ro*rams t,ro/*,o/t t,e world.
4HO ,as se"eral re*ional o++ices located t,ro/*,o/t t,e world t,at aid in
administerin* ro*rams on a local le"el.
1ased in 4as,in*ton, D.C., t,e )an American Healt, Or*ani@ation 7)AHO8 is one
s/c, re*ional o++ice +or t,e Americas. Mem-er States o+ )AHO incl/de all ='
co/ntries in t,e Americas and )/erto !ico is an Associate Mem-er. France, t,e
Net,erlands, and t,e United 2in*dom o+ Great 1ritain and Nort,ern Ireland are
)articiatin* States, and )ort/*al and Sain are O-ser"er States. 5,e mission o+
)AHO is to stren*t,en national and local ,ealt, systems and imro"e t,e ,ealt, o+ t,e
eoles o+ t,e Americas. It works in colla-oration wit, Ministries o+ Healt,, ot,er
*o"ernment and international a*encies, non*o"ernmental or*ani@ations, /ni"ersities,
social sec/rity a*encies, comm/nity *ro/s, and many ot,ers. )AHO tar*ets t,e most
"/lnera-le *ro/s, incl/din* mot,ers and c,ildren, workers, t,e oor, t,e elderly, and
re+/*ees and dislaced ersons. It +oc/ses on access iss/es and a )an-American
aroac,, enco/ra*in* nations to work colla-- orati"ely on common iss/es.
5,e 4orld Dental Federation 7FDI8 is an indeendent, ro+essional or*ani@ation +or
dentistry. 5,e acti"ities o+ t,e FDI co"er all asects o+ ersonal and /-lic oral
,ealt,care and take lace all o"er t,e world. Amon* its "aried resonsi-ilities, FDI
contri-/tes to t,e de"eloment and dissemination o+ statements re*ardin* olicies,
standards, and in+ormation related to oral ,ealt, care. In addressin* t,is resonsi-ility,
FDI rod/ces t,e statements "ia its Scienti+ic Commission or in colla-oration wit,
ot,er ro+essional or*ani@ation t,ro/*,o/t t,e world.
At t,e national le"el, t,e U.S. Deartment o+ Healt, and H/man Ser"ices 7DHHS8 is
t,e Ca-inet-le"el -ranc, o+ t,e +ederal *o"ernment t,at is resonsi-le +or t,e lannin*
and imlementation o+ a -road array o+ ,ealt, ro*rams, +rom s/ort +or and
rotection o+ Americans o+ all a*es, to aid +or ersons wit, disa-ilities, as well as
assistance and new oort/nities +or t,ose in need. In s,ort, DHHS is resonsi-le +or
/-lic ,ealt, in t,e United States, s/ortin* t,e worldCs lar*est medical researc,
e++ort, ass/rin* t,e sa+ety o+ +oods and ,ealt, care rod/cts, and +i*,tin* t,e ra"a*es
o+ dr/* and alco,ol a-/se. )lannin* -e*ins in 4as,in*ton, D.C., wit, o-Aecti"es
e"ol"in* as ,ealt, needs s,i+t. For e0amle, at one time t,ere was a need to +inance
new dental and medical sc,ools to increase t,e o/t/t o+ ,ealt, ro+essionalsD more
recently t,ere ,as -een a need +or seci+ically +oc/sed ro*rams to accelerate
de"eloment o+ control meas/res +or eit,er caries or eriodontal disease, and
contin/ally t,ere are e++orts to re+ine ro*rams o++erin* -etter access to, or less cost
+or, medical and oral ,ealt,care. DHHS resonsi-ilities in t,e United States are
di"ided into :$ *eo*ra,ic re*ions 7I to G8, eac, one ,a"in* a central o++ice. 5,ese
o++ices +acilitate administration -y ro"idin* cons/ltation and monitorin* e0ertise
+or re*ional and local ,ealt, ro*rams in"ol"in* +ederal +/nds.
DHHS o"ersees :> maAor or*ani@ations, eac, wit, a di++erent in+l/ence o"er /-lic
,ealt, iss/es and dental /-lic ,ealt, ro*rams 7Fi*/re :%-<8. 5,e dministration for
Children and 'amilies 7ACF8 is resonsi-le +or n/mero/s ro*rams t,at ro"ide
ser"ices and assistance to needy c,ildren and +amilies, administers t,e new state-
+ederal wel+are ro*ram 7Temporary ssistance to &eedy 'amilies8, administers t,e
Head Start ro*ram, ro"ides +/nds to assist low-income +amilies in ayin* +or c,ild
care, and s/orts state ro*rams to ro"ide +or +oster-care and adotion assistance.
5,e Health Resources and Services dministration 7H!SA8 ,els ro"ide ,ealt,
reso/rces +or medically /nderser"ed o/lations, s/orts a nationwide network o+
comm/nity and mi*rant ,ealt, centers and rimary care ro*rams +or t,e ,omeless
and residents o+ /-lic ,o/sin*, works to -/ild t,e ,ealt,-care work+orce, maintains
t,e National Healt, Ser"ice Cors, works to imro"e c,ild ,ealt,, and ro"ides
ser"ices to ersons wit, AIDS t,ro/*, t,e !yan 4,ite CA!3 Act ro*rams. 5,e
$ency for Healthcare Research and Euality 7AH!j8 s/orts in"esti*ator-initiated
researc, desi*ned to imro"e t,e o/tcomes and ?/ality o+ ,ealt, care, red/ce its costs,
address atient sa+ety and medical errors, and -roadens access to e++ecti"e ser"ices.
5,e Centers for Disease Control and Prevention 7CDC8 administer a ,ealt,
s/r"eillance system desi*ned to monitor and re"ent o/t-reaks o+ disease. It also
*/ards a*ainst international disease transmission, maintains national-,ealt, statistics
and ro"ides +or imm/ni@ation ser"ices and s/orts researc, into disease and inA/ry
re"ention. 5,e CDCCs Di"ision o+ Oral Healt, maintains and reorts on national and
local oral-,ealt, s/r"eillance data, cons/lts wit, states and local ,ealt, deartments
re*ardin* oral-,ealt, assessments and s/r"ey tec,ni?/es, administers t,e 4ater
Fl/oridation !eortin* System, and /-lis,es olicy statements re*ardin* control o+
in+ection. 5,e $ency for Toxic Su4stances and Disease Re$istry 7A5SD!8 works
wit, states and ot,er +ederal a*encies to re"ent e0os/re to ,a@ardo/s s/-stances
+rom waste sites. 5,e S/-stance A-/se and Mental Healt, Ser"ices Administration
7SAMSHA8 stri"es to imro"e t,e ?/ality and a"aila-ility o+ s/-stance a-/se
re"ention, addiction treatment, and mental ,ealt, ser"ices. 5,e dministration on
$in$ 7AoA8 ro"ides and s/orts om-/dsman ser"ices +or elderly, and ro"ides
olicy leaders,i on a*in* iss/es. 5,e 'ood and Dru$ dministration 7FDA8 ass/res
t,e sa+ety o+ +oods and cosmetics, and t,e sa+ety and e++icacy o+ ,armace/ticals,
-iolo*ical rod/cts, and medical de"ices, incl/din* t,ose /sed in ersonal oral ,ealt,
care settin*s and dental /-lic ,ealt, ro*rams. 5,e Centers for %edicare and
%edicaid Services 7CMS8, +ormerly Health Care 'inancin$ dministration 7HCFA8,
ser"es t,e needs o+ Medicaid and Medicare -ene+iciaries. 5,e /ndian Health Service
7IHS8 o"ersees and s/orts a network o+ ,ositals, ,ealt, centers, sc,ool--ased
,ealt, centers, ,ealt, stations, and /r-an Indian ,ealt, centers t,at ro"ide ser"ices to
nearly :.' million Nati"e Americans and Alaska Nati"es. 5,e &ational /nstitutes of
Health 7NIH8, t,e worldCs remier medical researc, or*ani@ation, s/orts researc,
roAects nationwide in diseases like ,eart ailments, dia-etes, cancer, HI6, Al@,eimerCs
Disease, and ast,ma. 5,e &ational /nstitute for Dental and Craniofacial Research
7NIDC!8, one o+ t,e NIH instit/tes, s/orts intram/ral and e0tram/ral researc,
re*ardin* dental caries, eriodontitis, oral and ,aryn*eal cancer, +acial cle+ts, oral
,ealt, disarities, and re"enti"e oral ,ealt, t,eraies. 5,e Pro$ram Support Center
7)SC8 ro"ides, +or a +ee, sol/tion- and c/stomer-oriented s/ort +or administrati"e
oerations, +inancial mana*ement and ,/man reso/rces t,ro/*,o/t DHHS, as well as
ot,er deartments and +ederal a*encies.
5,e US)HS encomasses t,e Commissioned Cors, t,e /ni+ormed ser"ice o+ t,e
DHHS. Dental o++icers in t,e Commissioned Cors ser"e t,e oral ,ealt, treatment
needs o+ Nati"e Americans and Alaska Nati"es as art o+ t,e IHSD acti"e d/ty
mem-ers, deendents, and retirees o+ t,e U.S. Coast G/ardD and ersons incarcerated
/nder t,e Federal 1/rea/ o+ )risons. 5,e S/r*eon General leads t,e Commissioned
Cors o+ t,e US)HS.
3ac, state ,as a ,ealt, deartment t,at may or may not incl/de an oral-,ealt,
di"ision. O+ t,ose states wit, an oral ,ealt, +oc/s, many di"ide t,eir A/risdictional
oeration into re*ions to -etter administer and monitor state-administered oral-,ealt,
ro*rams. 5,e re*ional ro*rams incl/de oeration o+ clinics +or needy o/lations,
state rison systems, and in some cases, sc,ool systems. Cons/ltations wit,
comm/nities desirin* to esta-lis, or to imro"e comm/nity oral ,ealt,, /-lic ,ealt,
ed/cation ro*rams, and +l/oride initiati"es recei"e maAor em,asis.
4it,in eac, state, o/lo/s co/nties and cities may administer comm/nity oral ,ealt,
treatment clinics t,ro/*, local ,ealt, deartments. 5,ese clinics /s/ally oerate in
sc,ools, economically /nderri"ile*ed areas, or amon* o/lation s/-*ro/s t,at do
not ot,erwise ,a"e access to ro/tine ersonal oral-,ealt, care. Federal, state, and local
ta0 +/nds are intermi0ed in t,e deli"ery o+ care at all le"els.
Fi*/re :%-< Or*ani@ational c,art +or t,e U.S. Deartment o+ Healt, and H/man
Ser"ices.
Dental Public Health Programs
Healt, )romotion and Healt, 3d/cation
Healt, romotion and ,ealt, ed/cation are inte*ral comonents o+ most s/ccess+/l
dental /-lic-,ealt, ro*rams 75a-le :%->8. Health promotion consists o+ any lanned
com-ination o+ ed/cational, olitical, re*/latory, and or*ani@ational s/orts +or
actions and conditions cond/ci"e to t,e ,ealt, o+ a comm/nity or *ro/ o+ indi"id/als
in a de+ined *eo*ra,ic location 7<%8. )roAects desi*ned to -e administered in sc,ools,
s/c, as +l/oride mo/t,rinse ro*rams and dental-sealant ro*rams, ,a"e -een
artic/larly s/ccess+/l, -eca/se dental caries is re"alent in c,ildren and t,ose wit,
t,e *reatest needs may reside wit, arentsB*/ardians w,o are ot,erwise /na-le to
ro"ide +or t,eir treatment needs in ersonal ,ealt,care +acilities. Sc,ool--ased ,ealt,
care ro*rams are disc/ssed elsew,ere in t,is te0t-ook. Healt,-romotion acti"ities
do not re?/ire acti"e articiation o+ its reciients, ,owe"er. )/-lic sanitation
meas/res, +or e0amle, romote ,ealt, amon* ,/mans aro/nd t,e world, yet most o+
t,ese ersons enAoy t,e -ene+its wit,o/t action or awareness. Conse?/ently, ,ealt,-
romotion acti"ities are "itally imortant to dental /-lic-,ealt, ro*rams, -eca/se
t,ey do not /s/ally deend on reciient awareness or cooeration +or s/ccess.
Question 3
A. 5,e American Dental Association is /nder t,e a/sices o+ t,e 4orld Healt,
Or*ani@ation.
1. 5,e ,ealt, olicies o+ t,e U.S. Deartment o+ Healt, and H/man Ser"ices are
administrated +rom t,e :$ !e*ional O++ices o+ t,e Centers +or Disease Control and
)re"ention.
C. Aro0imately :&& million ersons in t,e United States drink +l/oridated water.
D. Healt, romotion +re?/ently yields more immediate e++ects on t,e /-lic t,an does
ed/cation o+ t,e /-lic.
3. 5,e S/r*eon GeneralCs !eort on Oral Healt, in America, released in >$$$, was
one o+ many s/c, reorts dedicated to dentistry.
Health education incl/des any com-ination o+ learnin* e0eriences desi*ned to
ena-le t,e "ol/ntary adotion o+ -e,a"iors or actions t,at are cond/ci"e to ,ealt, and
,ealt,+/l li"in* 7Fi*/re :%-%8.
<(
4,ereas ,ealt,-romotion acti"ities do not re?/ire
t,e acti"e articiation o+ its reciients, ,ealt, ed/cation does. For t,is reason, dental
/-lic-,ealt, ro*rams t,at rely ,ea"ily on ,ealt, ed/cation are s/-Aect to t,e
attit/des, -elie+s, and ot,er moti"atin* +actors o+ t,e reciients. In addition, alt,o/*,
knowled*e is an imortant element o+ emowerment, knowled*e does not */arantee
t,at aroriate actions or -e,a"ioral c,an*es will +ollow.
<;
Healt,-romotion
acti"ities in dental /-lic ,ealt, ro*rams +re?/ently incl/de ,ealt,-ed/cation
comonents, -/t ,ealt,-ed/cation, alone, is not s/++icient to re"ent oral diseases or
conditions.
Comm/nity-4ater Fl/oridation
Comm/nity-water +l/oridation, or t,e addition o+ aroriate concentrations o+
+l/oride como/nds into water systems to re"ent dental caries, is a ,ealt, romotion
acti"ity wit,in a dental /-lic ,ealt, ro*ram. As -ene+icial as water +l/oridation is in
t,e -attle a*ainst dental caries, t,e addition o+ +l/oride to water is not an a/tomatic
condition, ,owe"er, and +re?/ently re?/ires t,e sa""y and care+/l coordination o+
dental /-lic-,ealt, ro+essionals, water en*ineers, le*islators, and or*ani@ed
dentistry. In order to cond/ct a s/ccess+/l +l/oridation camai*n, one m/st
/nderstand olitical realities and reco*ni@e a"aila-le reso/rces in t,e comm/nity t,at
can -e /sed to assist in sec/rin* a +a"ora-le o/tcome.
%$
S/ccess+/l camai*ns re?/ire
dedicated and ent,/siastic ersons w,o are coordinated -y an indi"id/al wit, *ood
olitical skills. S/ort +rom all se*ments o+ t,e o/lation, not A/st ,ealt,
ro+essionals, is cr/cial. 5,e -est met,od to ac,ie"e +l/oridation in a small
comm/nity is t,ro/*, city co/ncil action i+ state laws do not re?/ire a re+erend/m.
3ndorsements o++ered -y strate*ic role models, s/c, as a mayor, city co/ncil mem-er,
or ot,er comm/nity leaders, lay an imortant role in t,e rocess.
Coordination o+ acti"ities is also imortant once a water +l/oridation ro*ram ,as
-een initiated. St/dies s,ow t,at water distri-/tion centers +re?/ently maintain
a?/eo/s +l/oride concentrations t,at are lower t,an recommended le"els.
%:
In order to
com-at t,is reality, a/t,ority s,o/ld rest wit, an administrator w,o is dedicated to t,e
dental /-lic ,ealt, ro*ram and w,o is in a osition to mana*e t,e system.
Fre?/ently, t,e dental director o+ t,e state ,ealt, deartment is an ideal c,oice +or t,e
administrati"e osition. 4,en a dental director is /na"aila-le, dental /-lic ,ealt,
ro+essionals s,o/ld assi*n a erson w,o ,as t,e resonsi-ility o+ water +l/oridation
s/r"eillance and mana*ement.
Secial )o/lation Gro/s
Selected dental /-lic-,ealt, ro*rams incl/de roAects t,at +oc/s on artic/lar
o/lation s/-*ro/s. Certain *ro/s, +or e0amle, -eca/se o+ ,ealt, stat/s, osition
in society, attit/dinal -arriers, or *eo*ra,ic location, do not ,a"e ready access to
ersonal ,ealt,care ro"iders and m/st recei"e care in secial clinics, s/orted -y
/-lic or ri"ate +/nds. 5,e oral ,ealt, care needs o+ t,ese *ro/s, w,ic, incl/de
Nati"e Americans and Alaska Nati"es, lon*-term-care o/lations, mi*rant *ro/s,
medically comromised indi"id/als, -ene+iciaries o+ t,e Deartment o+ 6eterans
A++airs, ersons wit, de"elomental disa-ilities, ,omeless indi"id/als, t,e elderly,
and ersons wit, low socioeconomic stat/s, are /s/ally si*ni+icantly *reater t,an t,ey
are +or t,e *eneral o/lation.
'<,%>-('
For e0amle, medically comromised indi"id/als
and ersons wit, Ac?/ired Imm/node+iciency Syndrome 7AIDS8 are +re?/ently
redisosed to raidly ro*ressin* eriodontitis and ot,er oral ro-lems.
(<,(%

Al@,eimerCs disease and ot,er dementias comromise t,e a-ility o+ many older
ersons to take care o+ t,eir mo/t,s.
((, (;
5,e a-ilities and limited e0erience le"els o+ some ersonal oral ,ealt,-care
ro+essionals, as well as t,e conditions wit,in w,ic, t,ey work may stand in t,e way
o+ e++ecti"e ro"ision o+ care +or some o+ t,ese secial o/lation *ro/s.
;$-;>
For
e0amle, ro/tine treatment +acilities are +re?/ently inaccessi-le to a erson w,o is
,ome-o/nd -eca/se o+ ,ysical or mental disa-ilities or limitations. Dentists and
a/0iliaries, trained in t,e /se o+ mo-ile treatment e?/iment and mana*ement o+ t,e
disa-led atient, are necessary in order to ro"ide oral-,ealt, care to t,e
,ome-o/nd.
;=
In t,is e0amle, t,e remo"al o+ -arriers to care is an e0amle o+ an
e++ecti"e dental /-lic-,ealt, ro*ram.
Dental /-lic-,ealt, ro+essionals in /-lic-,ealt, a*encies, local or state ,ealt,
deartments, and academic instit/tions are called /on to ro"ide cons/ltation or
initiate ro*rams +or indi"id/als wit, artic/lar diseases or conditions. 30amles may
incl/de ed/cational ro*rams aimed toward mot,ers and desi*ned to address +eedin*
-e,a"iors leadin* to early c,ild,ood caries, ro*rams desi*ned to rod/ce mo/t,
*/ards +or ,i*, sc,ool at,letes, ro*rams desi*ned to assess t,e +/nction o+
remo"a-le rost,eses in a *eriatric o/lation, ro*rams desi*ned to ro"ide +l/oride
t,eray to cancer atients /nder*oin* ,ead and neck radiation, ro*rams desi*ned to
screen low-income c,ildren +or oral diseases, or ro*rams desi*ned to ro"ide
in+ormation re*ardin* oral and ,aryn*eal cancer re"ention.
Fi*/re :%-% Classroom dental-ed/cation ro*rams are imortant, -/t it is
critical to e"al/ate t,eir e++ect. 7Co/rtesy o+ t,e National Instit/te o+ Dental and
Cranio+acial !esearc,.8
New Strategies Needed
C,an*in* Disease )atterns
D/rin* t,e early :;$$s, ac/te in+ectio/s diseases were more re"alent t,an t,ey are
today and acco/nted +or *reater mor-idity and ,i*,er mortality amon* t,e *eneral
o/lation. D/rin* t,e :;'$s and :;<$s, wit, t,e ad"ent o+ imm/ni@ations and
anti-iotics, /-lic ,ealt, ro+essionals -e*an to s,i+t t,eir attention to c,ronic
diseases, s/c, as ,eart ailments, cancer, strokes, and dia-etes. Dental /-lic ,ealt,
ro*rams ,a"e ,ad to adat to c,an*in* disease re"alence, as well .
One o+ t,e tr/ly si*ni+icant de"eloments in dental /-lic ,ealt, ,as -een t,e decline
in dental-caries re"alence d/rin* t,e ast :' years.
'<, ;&-:$>
!ed/ced s/sceti-ility to
dental caries, artic/larly amon* c,ildren and yo/n* ad/lts, is alterin* t,e oral-,ealt,
stat/s o+ t,e o/lation. NIH estimated t,at t,e United States sa"ed aro0imately
f:$$ -illion in dental e0endit/res d/rin* t,e :;($s as a res/lt o+ t,is imro"ement in
oral ,ealt,.
:$=
5,e c,an*e in dental-caries re"alence reresents a maAor s/ccess +or
ersonal oral ,ealt, re"enti"e and treatment ser"ices and dental /-lic ,ealt,
ro*rams, -/t it also resents new c,allen*es to t,e ro+ession .
D/rin* t,e early-:;$$s, dental caries was ,i*,ly re"alent across a*e *ro/s and
o/lation s/--*ro/s. 3"eryone re?/ired treatment ser"ices.
:$&
5oday, as a res/lt o+
e++ecti"e re"ention and imro"ed treatment re*imens, dental caries is concentrated in
a s/-stantially smaller roortion o+ t,e o/lation. 5,e c,allen*e to dental /-lic-
,ealt, ro+essionals is to concentrate on identi+yin* ,i*,-risk indi"id/als and
e0andin* ser"ices +or t,ose w,o ,a"e not ,ad access to care. C/rrent trends to
decrease sendin* +or /-lic ro*rams as well as red/ce ,ealt,-care costs s,o/ld
+a"or re"enti"e ro*rams t,at are tar*eted to t,ose w,o ,a"e ,i*,er /nmet le"els o+
oral disease.
:$'-:$<
C,an*in* )/-lic-Healt, )ractices
Dental /-lic-,ealt, ro*rams s,o/ld -e or*ani@ed to meet t,e needs o+ t,e
o/lation. As needs c,an*e, dental /-lic ,ealt, e++orts s,o/ld e"ol"e to address
t,ese c,an*in* needs.
:$%
An acceted c,aracteristic o+ a ro+ession is t,at it s,all -e
willin* to resond to c,an*in* needs as a res/lt o+ its own s/ccess+/l re"enti"e and
treatment acti"ities.
:$(
Concern o"er t,e c/rrent a-ility o+ t,e /-lic-,ealt, ro+ession
to adat to c,an*e is addressed in an Instit/te o+ Medicine reort, entitled The 'uture
of Pu4lic Health,
:$;
5,e reort contends t,at /-lic ,ealt, in t,e United States is
disor*ani@ed, slintered, and /nreared to accommodate and address +/t/re
c,allen*es. 5,e reort *oes on to state t,at t,e means to maintain and e0and /-lic
,ealt, ro*rams and meet t,e demands o+ a c,an*in* en"ironment is "ia assessment,
olicy de"eloment, and ass/rance .
Contrary to t,e reortCs recommendations, olitical and economic +orces in t,e United
States ,a"e ser"ed to red/ce or discontin/e many dental /-lic ,ealt, ro*rams. 5,e
decline o+ dental /-lic ,ealt, ro*rams at t,e national, state and local le"els is, in
art, a res/lt o+ t,e ercetion t,at oral ,ealt, is not a maAor concern.
::$
Nei*,-or,ood, r/ral, mi*rant, and ,omeless ,ealt, centers ,a"e s/++ered se"ere
c/t-acks in +ederal o/tlays +or oral ,ealt, care ser"ices, ersonnel, and scoe o+
ro*rams.
::$
)/-lic-,ealt, dentistry c/rric/la in many sc,ools o+ /-lic ,ealt, are
e0eriencin* maAor red/ctions or dissol/tion. Many comm/nity-dentistry ro*rams
in dental sc,ools are only modest in scoe, relati"e to t,e concentration o+ reso/rces
de"oted to t,ese ro*rams w,en +irst initiated .
4,y ,as t,e downsi@in* o+ dental /-lic-,ealt, ro*rams ro*ressed wit, relati"ely
+ew c,allen*ese One answer may -e t,e lack o+ an or*ani@ed constit/ency or
ad"ocacy *ro/ +or dental /-lic-,ealt, iss/es. A artners,i -etween t,e /-lic and
ersonal ,ealt,-care dental sectors is essential i+ oral ,ealt, concerns are to -e
e++ecti"ely romoted. O+ten t,e aims o+ ro+essional *ro/s wit,in dentistry tend to
-e comartmentali@ed and narrowly de+ined. )/-lic dental ro*rams may also -e seen
as cometiti"e wit, ersonal ,ealt,care ractitioners. )re"enti"e aroac,es are at to
-e erroneo/sly classi+ied as /-lic sector or ersonal ,ealt,care sector ro*rams. Het
t,e e++orts o+ -ot, s,o/ld rein+orce common *oals. Fl/oridation, +or e0amle, may -e
seen as an e++ecti"e /-lic ,ealt, meas/re -/t t,e romotion o+ +l/oride denti+rices
may not -e. Het t,ey comlement eac, ot,er and -ot, are /-lic-,ealt, meas/res.
:::
Cooeration -etween dental /-lic-,ealt, or*ani@ations, s/c, as, t,e American
Association o+ )/-lic Healt, Dentistry 7AA)HD8, t,e American )/-lic Healt,
Association 7A)HA8 Oral Healt, Section, and t,e American Dental Association
7ADA8 co/ld ,el resol"e t,e di++erin* ersecti"es o+ t,e ersonal ,ealt,care and
/-lic sectors. Cooeration co/ld also +oster an in+l/ential alliance in local and
national camai*ns addressin* dental /-lic ,ealt, iss/es. Colla-oration wit, a
m/ltit/de o+ national and local "ol/ntary non-dental ,ealt, and ed/cational
or*ani@ations, s/c, as, t,e C,ildrenCs De+ense F/nd, American Association o+ !etired
)ersons, or t,e National Healt, 3d/cation Coalition is e?/ally imortant to romote
oral ,ealt, as essential to o"erall ,ealt, and to inte*rate oral ,ealt, iss/es wit,in t,e
,ealt,, ed/cational, and olicy directi"es o+ t,ese or*ani@ations. 1y workin* to*et,er
on certain -road--ased o/lar iss/es 7i.e. access to ,ealt, ser"ices8, t,ese searate
artners,is can e"ol"e into a coalition, s/c, as t,e National Oral Healt, Alliance t,at
can -e recr/ited to acti"ely s/ort seci+ic oral ,ealt, iss/es .
In :;;(, '=.( -illion dollars were sent on oral ,ealt, care ser"ices, reresentin*
a-o/t &.%E o+ t,e total ,ealt, e0endit/res -/d*et +or t,at year.
::>
30endit/res +or
oral ,ealt, care ser"ices increased -etween :;;% and :;;( at aro0imately t,e same
rate as e0endit/res +or medical ,ealt, care 7'.= "ers/s '.<E8. Alt,o/*, t,ese +i*/res
s/**est t,at oral ,ealt,-care ser"ices were ade?/ately +/nded, comarisons wit,
+/ndin* le"els +rom earlier decades aint a di++erent ict/re. In :;<$, +or e0amle, >
-illion dollars were sent on oral ,ealt,-care ser"ices, -/t t,is reresented %.=E o+ t,e
total -/d*et.
='
4it, red/ctions in +/nds to s/ort oral ,ealt,-care ser"ices, /-lic-
,ealt, ro*ram administrators will ,a"e to -ecome more oort/nistic and adati"e in
order to cond/ct e++ecti"e ro*rams .
Ot,er ad"ocacy meas/res t,at can -e /rs/ed in s/ort o+ dental /-lic-,ealt,
ro*rams may -e ad"anced t,ro/*, re*/latory and le*islati"e ro/tes. An area o+
acti"ity o+ten entered wit, some rel/ctance is t,e olitical arena. 5,ose in dental
/-lic-,ealt, ro*rams c,aracteristically *o a-o/t t,eir d/ties ?/ietly, content to li"e
wit,in t,e constraints imosed -y citi@ens w,o, +or e0amle, "ote a*ainst +l/oridation.
Niessen -elie"es t,at t,ere are comm/nity re*/latory roles +or dental /-lic ,ealt,
re*ardin* comliance wit, +l/oridation and in+ection control standards.
::=
I+
s/ccess+/l, e++orts to ed/cate and ers/ade ot,ers o+ t,e imortance o+ t,ese iss/es
co/ld ay -i* di"idends. 5,e re"enti"e -ene+it ro"ided to a comm/nity -y initiatin*
andBor monitorin* +l/oridation or a ractice act t,at addresses in+ection control may
-e *reater t,an t,e -ene+it attained +rom a li+etime o+ ractice -y a do@en dentists .
S/ccess+/l /-lic-,ealt, workers need to -e oinion leaders and comm/nity decision
makers re*ardin* oral ,ealt, ro*rams and ser"ices. Ga/ e0ands t,is notion w,en
statin* t,at, FIt is oort/ne +or t,e oral ,ealt, interest *ro/s to strike o/t on t,eir
own -y workin* toward a national, comre,ensi"e, oral ,ealt, -ill.F
::&
!eso/rce
de"eloment co/ld also -e e0edited i+ dental /-lic-,ealt, ro*rams attained
in+l/ence in t,e re*/latory and le*islati"e arenas .
&ational +ral2Health +47ectives
5,e US)HS reco*ni@es t,at an e++ecti"e means to e0and ad"ocacy and re*/latory
acti"ities and *enerate s/ort +or oral-,ealt, ro*rams is "ia t,e settin* o+
meas/ra-le and ac,ie"a-le, national ,ealt, o-Aecti"es. In :;($, t,e +ederal
*o"ernment esta-lis,ed a ro*ram, entitled Promotin$ HealthLPreventin$ Disease6
+47ectives for the &ation, CHH:,
::'
to identi+y and monitor a "ariety o+ ,ealt,
o-Aecti"es, incl/din* :> t,at addressed oral ,ealt, and +l/oridation. Alt,o/*, t,is
ro*ram ro"ided an early oort/nity to romote oral ,ealt, alon*side ot,er national
,ealt, riorities, it did not ade?/ately address t,e means -y w,ic, states and localities
co/ld meet t,e o-Aecti"es. S/-se?/ent national-,ealt, o-Aecti"es +or >$$$
::<
-/ilt
/on t,e re"io/s +ramework, -y ro"idin* strate*ies t,at wo/ld -e ,el+/l in
meetin* t,e new o-Aecti"es. 5oward t,at end, t,e US)HS o/tlined twenty-nine
meas/ra-le oral ,ealt, o-Aecti"es and indicators in anot,er doc/ment, entitled
Healthy Communities <:::6 %odel Standards,
::%
and called +or eriodic reorts
::(->$$
and consortia
:>:
to romote t,e national ,ealt, o-Aecti"es +or >$$$ .
In >$$$, t,e US)HS released national ,ealt, o-Aecti"es +or >$:$, w,ic, incl/ded an
oral ,ealt, +oc/s area
:>>
75a-le :%-=8. 5,ese oral ,ealt, o-Aecti"es di++ered +rom
re"io/s ones, in t,at t,ey incororated a F-etter t,an t,e -estF standard +or settin*
*oals, as oosed to settin* disarate *oals +or certain o/lation s/--*ro/s. For
e0amle, t,e -est "al/e attained +or any sin*le o/lation s/-*ro/ in >$$$ was /sed
to determine t,e *oal +or all o/lation s/--*ro/s in >$:$. 5,e rationale -e,ind t,is
standard-settin* met,od was to esta-lis, a sin*le ,i*, *oal +or all *ro/s, rat,er t,an
to eret/ate disarities o"er time .
Special Populations
D/rin* t,e last two decades, t,e United States ,as e0erienced an increase in t,e
n/m-er o+ secial o/lation *ro/s, incl/din* ersons in lon*-term care,
%&
medically
comromised indi"id/als,
%(
and t,e ,omeless.
(:,(>
Hi*,er /nmet needs in t,ese secial
o/lation *ro/s ,as -een ,amered -y limited +inancial reso/rces at t,e +ederal and
state le"els. 5,e roortion o+ older ersons in t,e o/lation ,as also increased
:>=
and will contin/e to increase, as t,e F-a-y--oomF *eneration a*es. 5,e increased oral
,ealt, care needs o+ older Americans co/ld ,a"e dramatic e++ects on t,e oral ,ealt,-
care deli"ery system
',:>&-:><
and t,e a-ility to meet t,e national ,ealt, o-Aecti"es +or
>$:$ i+ ersonal and /-lic ,ealt,-care ro*rams are not de"eloed to address t,e
demand .
.imited access to oral ,ealt,-care ser"ices +or t,e secial o/lation *ro/s also
co/ld a++ect t,e a-ility to meet t,e national-,ealt, o-Aecti"es +or >$:$. Only a small
roortion o+ t,e secial o/lation *ro/s ,a"e ersonal dental-ins/rance co"era*e,
and oral ,ealt,-care -ene+its "ia /-lic ro*rams ,as not ket ace wit, c,an*in*
demands.
:>%,:>(
Medicaid e0endit/res +or oral ,ealt,-care ser"ices ,a"e decreased -y
almost =$E since :;(%, +ar more t,an any ot,er ,ealt,-care ser"ice.
::>,:>;
In :;;(,
Medicaid e0endit/res +or oral ,ealt, care reresented only :.=E o+ t,e total
Medicaid e0endit/res -/d*et.
::>
+ther Trends ffectin$ +ral Health
Ot,er trends co/ld in+l/ence t,e attainment o+ national-,ealt, o-Aecti"es, incl/din*
ad"ances in tec,nolo*y, ersonnel re?/irements, and ro+essional ed/cation.
Ad"ances in imlant materials, restorati"e met,ods, c,emot,erae/tic a*ents,
*enetics, and t,e identi+ication o+ risk markers +or disease,
:=$
+or e0amle, s,o/ld
a++ect ersonal and /-lic ,ealt,care deli"ery systems well into t,e +/t/re. Ad"ances
in com/ter tec,nolo*y s,o/ld lead to de"eloments in all areas o+ -iomedical
researc,, inno"ati"e ways to mana*e and retrie"e data, and t,e ro"ision o+ ,ealt,
care ser"ices .
H/man reso/rces are a critical +actor in any dental /-lic ,ealt, ro*ram. C,an*es in
t,e distri-/tion o+ oral ,ealt,-care ersonnel certainly co/ld imact meetin* t,e
national ,ealt, o-Aecti"es +or >$:$. !ecent data ,a"e s/**ested t,at t,e n/m-er o+
dentists will decline d/rin* t,e ne0t :' to >$ years,
:=:
,owe"er t,e rediction models
/sed to determine FaroriateF le"els o+ ersonnel +re?/ently ,a"e s/++ered +rom a
lack o+ data and *enerally ,a"e -een /na-le to acco/nt +or eidemiolo*ical, social,
economic, and olitical "aria-ility o"er time.
:=>
Conse?/ently, w,et,er t,e nation as a
w,ole +aces an /nders/ly o+ oral ,ealt, care ro+essionals remains /nclear,
,owe"er, /nless actions are taken to address t,e lack o+ ersonal and /-lic ,ealt,care
ro+essionals in desi*nated Fdental ,ealt, manower s,orta*e areas,F
:==
it is +airly
certain t,at t,ese arts o+ t,e co/ntry will +ind it di++ic/lt meetin* t,e national-,ealt,
o-Aecti"es .
5,e ro+essional ed/cational c/rric/la is e"ol"in* contin/o/sly, as a res/lt o+
-/d*etary constraints and redistri-/tions in enrollment, distri-/tions o+ disease,
treatment and ,ealt,-care deli"ery systems, in+ormation trans+er, and demo*ra,ics.
C,an*es in t,e c/rric/la *enerally re?/ire additional interdiscilinary researc,,
re"enti"e modalities, and comm/nity--ased initiati"es.
:=&
!mer$in$ Pu4lic Concerns
)/-lic and ro+essional reactions to ercei"ed risks in t,e oral ,ealt, care deli"ery
system a++ect treatment modalities, ser"ice /tili@ation, and /ltimately oral ,ealt,
stat/s. 4ell /-lici@ed reorts o+ indi"id/als contractin* a n/m-er o+ conditions +rom
+l/oride, and amal*am restorations ,a"e romted t,e dental researc, comm/nity to
re"iew t,e risks associated wit, t,e /se o+ t,ese +/ndamental comonents o+ dental
re"ention and treatment.
:=',:=<
O+ e"en *reater t,reat to t,e ractice o+ dentistry and
t,e recr/itment o+ +/t/re dental ersonnel is t,e +ear o+ contractin* an HI6
in+ectionBAIDS in t,e dental o++ice -y -ot, ,ealt,-care ro"iders and atients.
:=%,:=(
4,ile dental /-lic-,ealt, ro+essionals ,a"e -een at t,e +ore+ront in ens/rin* access
+or atients in+ected wit, t,e AIDS "ir/s, many dental ractitioners are still rel/ctant
to treat known AIDS atients. On t,e ot,er ,and, t,e re"elation o+ t,e ro-a-le
occ/ational transmission o+ t,e AIDS "ir/s +rom a dentist to +i"e o+ ,is atients ,as
*enerated a ,i*, le"el o+ concern and an0iety a-o/t recei"in* dental care amon* t,e
/-lic.
:=(-:&$
Dental /-lic-,ealt, acti"ities ,a"e -een directed at re"entin* transmission o+
in+ectio/s diseases in t,e dental o++ice -y re?/irin* dentists to comly wit,
recommended ADA and CDC in+ection control */idelines and t,e Occ/ational
Sa+ety and Healt, Administration 7OSHA8 1lood-orne )at,o*ens Standard.
Howe"er, imlementation o+ t,ese edicts is already dramatically c,an*in* t,e scoe
and cost o+ deli"erin* oral ,ealt,-care ser"ices in ersonal and /-lic ,ealt,-care
settin*s.
:&:-:&=
Surgeon General's Report
In :;;%, Donna S,alala, t,en Secretary o+ DHHS, commissioned t,e O++ice o+ t,e
S/r*eon General to create a reort to, FDe+ine, descri-e, and e"al/ate t,e interactions
-etween oral ,ealt, and *eneral ,ealt, and well--ein* 7?/ality o+ li+e8, t,ro/*, t,e
li+e san, in t,e conte0t o+ c,an*es in society.F
:&&
D/rin* t,e ne0t t,ree years, /nder
t,e direction o+ t,e National Instit/te o+ Dental and Cranio+acial !esearc,, )roAect
Director Dr. Caswell A. 3"ans s/er"ised an imressi"e list o+ contri-/tin* a/t,ors
and content e0erts. On May >', >$$$, at S,e,erd 3lementary Sc,ool in
4as,in*ton, D.C., Assistant Secretary +or Healt, and S/r*eon General, Da"id
Satc,er, released +ral Health in merica6 Report of the Sur$eon 0eneral,
='
t,e
+irst-e"er S/r*eon GeneralCs reort e0cl/si"ely dedicated to oral ,ealt, iss/es. In ,is
resentation to t,e Nation t,at day, S/r*eon General Satc,er s/mmari@ed key t,emes
o+ t,e reort9 :8 oral ,ealt, means m/c, more t,an ,ealt,y teet,, >8 oral ,ealt, is
inte*ral to *eneral ,ealt,, =8 sa+e and e++ecti"e disease re"ention meas/res e0ist t,at
e"eryone can adot to imro"e oral ,ealt, and re"ent disease, and &8 *eneral ,ealt,-
risk +actors, s/c, as to-acco /se and oor dietary ractices, also a++ect oral and
cranio+acial ,ealt, .
5,e S/r*eon GeneralCs !eort was di"ided into +i"e arts, eac, relatin* to a artic/lar
?/estion. )art One asked 3hat is oral health, )art 5wo asked 3hat is the status of
oral health in merica, )art 5,ree asked 3hat is the relation 4et3een oral health and
$eneral health and 3ell24ein$, )art Fo/r asked ho3 is oral health promoted and
maintained and ho3 are oral diseases prevented, and )art Fi"e asked 3hat are the
needs and opportunities to enhance oral health, In answerin* t,ese ?/estions, t,e
S/r*eon GeneralCs !eort listed se"eral +indin*s t,at re+lected t,e +o/r rincial
t,emes 9
Oral diseases and disorders, in and o+ t,emsel"es, a++ect ,ealt, and well--ein*
t,ro/*,o/t li+e .
Sa+e and e++ecti"e meas/res e0ist to re"ent t,e most common dental
diseasesdental caries and eriodontal diseases .
.i+estyle -e,a"iors t,at a++ect *eneral ,ealt, s/c, as to-acco /se, e0cessi"e alco,ol
/se, and oor dietary c,oices a++ect oral and cranio+acial ,ealt,, as well .
5,ere are ro+o/nd and conse?/ential oral ,ealt, disarities wit,in t,e U.S.
o/lation .
Additional in+ormation is needed to imro"e AmericaCs oral ,ealt, and eliminate
,ealt, disarities .
5,e mo/t, re+lects *eneral ,ealt, and well--ein* .
Oral diseases and conditions are associated wit, ot,er ,ealt, ro-lems .
Scienti+ic researc, is key to +/rt,er red/ction in t,e -/rden o+ diseases and disorders
t,at a++ect t,e +ace, mo/t,, and teet, .
5,e S/r*eon GeneralCs !eort s/mmari@ed dramatic c,an*es in oral ,ealt, iss/es
d/rin* t,e last cent/ry, and it also -ro/*,t to li*,t some serio/s c,allen*es +or t,e
+/t/re. It stated t,at, alt,o/*, oral ,ealt, ,as imro"ed in t,e United States,
disarities in ,ealt, still e0ist. Seci+ic o/lation *ro/s, s/c, as in+ants and yo/n*
c,ildren, t,e oor, t,ose residin* in r/ral locations, t,e ,omeless, ersons wit,
disa-ilities, racial and et,nic minorities, t,e instit/tionali@ed, and t,e +rail elderly,
contin/e to e0erience a *reater -/rden o+ oral and cranio+acial diseases. 5,e S/r*eon
GeneralCs !eort also stated t,at t,ere were *reat disarities in access to oral ,ealt,
care and /tili@ation o+ re"enti"e ser"ices, eac, cr/cial to t,e esta-lis,ment and
maintenance o+ otimal oral and *eneral ,ealt,. Finally, t,e reort reco*ni@ed t,at
t,ere were ins/++icient data to descri-e t,e o/lation s/-*ro/s in *reatest need +or
oral ,ealt,-care ser"ices and dental /-lic-,ealt, ro*rams. 5,e lack o+ data will
make t,e de"eloment o+ rele"ant and e++ecti"e dental /-lic ,ealt, ro*rams a more
di++ic/lt task .
1y /-lis,in* t,e S/r*eon GeneralCs !eort, t,e O++ice o+ t,e S/r*eon General ,as
made a"aila-le imortant and timely in+ormation to ,ealt,-care ractitioners, /-lic-
,ealt, ro+essionals, olicy makers, and t,e /-lic. For access to t,e reort, t,e
O++ice o+ t,e S/r*eon General ro"ides an electronic "ersion o+ t,e doc/ment and
o++ers a +ree ,ardcoy o+ t,e reort to all w,o re?/est one .
Summary
5,e core +/nctions o+ /-lic ,ealt, incl/de assessment, olicy de"eloment, and
ass/rance. 5,ese +/nctions are also essential comonents o+ dental /-lic ,ealt,,
w,ic, is de+ined as t,e science and art o+ re"entin* and controllin* dental diseases
and romotin* ,ealt, t,ro/*, or*ani@ed comm/nity e++orts. It +ollows, t,en, t,at
dental /-lic-,ealt, ro*rams are any or*ani@ed e++orts t,at stri"e to re"ent and
control oral and cranio+acial diseases at t,e comm/nity le"el .
,istory. Ar*/a-ly, one o+ t,e most s/ccess+/l dental /-lic ,ealt, ro*rams e"er
created to address t,ese ro-lems ,as -een comm/nity water +l/oridation. As
s/ccess+/l as +l/oridation ,as -een, ,owe"er, new dental /-lic-,ealt, ro*rams need
to -e de"eloed to meet t,e needs o+ o/lation s/-*ro/s w,o ,a"e s/++ered +rom
,i*,er -/rdens o+ disease and ,a"e ,ad oorer access to timely re"enti"e and
treatment ser"ices. 5,e S/r*eon GeneralCs !eort on Oral Healt, in America
,i*,li*,ted some o+ t,ese concerns and laced t,em in t,e conte0t o+ e0istin*
ro*rams and olitical realities. In addition, t,e +ederal *o"ernment reco*ni@ed t,at
one way to address some o+ t,e oral ,ealt, disarities t,at e0ist is to esta-lis, realistic
national ,ealt, o-Aecti"es +or >$:$ .
5,e initiation and imlementation o+ any dental /-lic-,ealt, ro*ram +ollows an
esta-lis,ed lannin* cycle, t,e +irst sta*e o+ w,ic, in"ol"es assessin* t,e oral-,ealt,
needs o+ t,e comm/nity. Once a ro-lem is tentati"ely identi+ied, it is addressed
t,ro/*, t,e /se o+ si0 se?/ential stes o+ t,e /-lic ,ealt,care ractitionerCs
met,ods/r"ey, analysis, ro*ram lannin*, ro*ram oeration, +inancin*, and
araisal. AS5DD esta-lis,ed a se"en-ste model +or needs assessment w,ic,
+/nctions well d/rin* t,e +irst ste .
4,en traditional dental /-lic-,ealt, ro*rams ro"e ine++ecti"e, t,ey m/st -e
relaced -y more cost-e++ecti"e aroac,es. 5,e com-ination o+ less disease, more
e++ecti"e /se o+ ersonnel, and imro"ed tec,nolo*y and re"enti"e met,ods,
artic/larly dental sealants, ro"ides oort/nities to create dental /-lic-,ealt,
ro*rams +or t,ose w,o ,a"e -een traditionally ne*lected. In order to +/l+ill t,ese
oort/nities, ,owe"er, a constit/ency o+ /-lic and ersonal dental and non-dental
ad"ocacy *ro/s is re?/ired .
Dental /-lic-,ealt, ro*rams lay a critical role in t,e romotion and maintenance
o+ oral ,ealt, in America. 5,e c,allen*e +or dental /-lic-,ealt, ractitioners is to
de"ise ro*rams t,at are e++ecti"e, yet incororate t,e rinciles o+ so/nd lannin*
and imlementation. 5,e oral ,ealt, o+ t,e /-lic deends on it .
: . 1, D, and 3correct .
Aincorrect. C,ildren wit, t,e *reatest treatment needs are /s/ally at t,e -ottom o+
t,e economic scale and ,a"e +ewer reso/rces a"aila-le. Until access to care +or t,ese
c,ildren is imro"ed, t,ey will contin/e to -e in *reat need o+ oral-,ealt, treatment
ser"ices .
Cincorrect. In t,e United States, t,e incidence o+ oral cle+ts is t,ree times ,i*,er
amon* w,ites t,an it is amon* -lacks .
> . A and Dcorrect .
1incorrect. 5,e State Healt, Deartments are /nder t,e administrati"e control o+
State *o"ernment. 5,ere is o+ten cooeration -etween t,e U.S. Deartment o+ Healt,
and H/man Ser"ices and State Healt, Deartments, ,owe"er, -eca/se many ,ealt,
ro*rams are +inanced -y t,e +ederal *o"ernment .
Cincorrect. 5,e examination ste o+ ersonal-,ealt, care is analo*o/s to t,e survey
ste o+ /-lic-,ealt, care .
3incorrect. 5,e C)I5N is a "alid meas/re o+ treatment need. A "alid meas/re o+
tiss/e destr/ction is an assessment o+ loss o+ eriodontal attac,ment 7.OA .7
= . C and Dcorrect .
Aincorrect. 5,e American Dental Association is not /nder t,e a/sices o+ t,e
4orld Healt, Or*ani@ation, ,owe"er it is a mem-er o+ t,e 4orld Dental Federation
7FDI .7
1incorrect. 5,e ten !e*ional O++ices are o+ t,e U.S. Deartment o+ Healt, and
H/man Ser"ices, not t,e CDC .
3incorrect. 5,e S/r*eon GeneralCs !eort on Oral Healt, in America was t,e +irst
e"er reort o+ its kind .
: . 5,e core +/nctions o+ /-lic ,ealt, incl/de iiiiiiiii, iiiiiiiii, and
.iiiiiiiii
> . 1y de+inition, dental /-lic-,ealt, ro*rams are .iiiiiiiii
= . Accordin* to :;;( estimates, aro0imately fiiiiiiiii was sent on oral ,ealt,-
care ser"ices in t,e United States .

Engineering Books
www.allislam.net
&. D%'S reresents decayed, missin*, and +illed toot, s/r+aces, w,ereas, iiiiiiiii
reresents a caries e0erience inde0 +or rimary teet,.
'. 1y de+inition, a /-lic-,ealt, ro-lem is one t,at meets t,e +ollowin* criteria9
iiiiiiiii and iiiiiiiii.
<. 5,e +ollowin* are comarati"e met,ods /sed in ersonal and /-lic ,ealt,care
ractice9
Si0 stes o+ ersonal-,ealt, care Si0 stes o+ /-lic-,ealt, care
30amination S/r"ey
iiiiiiiiiiiiiiiiii iiiiiiiiiiiiiiiiii
5reatment lannin* )ro*ram lannin*
5reatment iiiiiiiiiiiiiiiiii
)ayment +or ser"ices Financin*
iiiiiiiiiiiiiiiiii Araisal
%. 5wo dental /-lic-,ealt, ro*ram strate*ies +or rimary re"ention o+ oral and
,aryn*eal cancer are9 iiiiiiiii and iiiiiiiii.
(. .ist t,ree national oral ,ealt, o-Aecti"es +or >$:$9 iiiiiiiii, iiiiiiiii, and
iiiiiiiii.
;. .ist t,e +o/r rincile t,emes o+ t,e S/r*eon GeneralCs !eort on Oral Healt,9
iiiiiiiii, iiiiiiiii, iiiiiiiii, and iiiiiiiii.
:$. Healt, romotion consists o+ any9 iiiiiiiii.
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S/r"eillance System, U.S. Cons/mer )rod/ct Sa+ety Commission.
'=. 2aste, .. M., Gi+t, H. C., 1,at, M., et al. 7:;;<8. )re"alence o+ incisor tra/ma in
ersons < to '$ years o+ a*e9 United States, :;((-:;;:. " Dent Res, %'7Sec Iss89<;<-
%$'.
'&. Gi+t, H. C., g 1,at, M. 7:;;=8. Dental "isits +or oro+acial inA/ry9 de+inin* t,e
dentistCs role. " m Dent ssoc, :>&9;>-<,;(.
''. 2n/tson, #. 4. 7:;''8. 4,at is /-lic ,ealt,e In Dentistry in pu4lic health 7>nd
ed.8 7. >$->;8. ),iladel,ia9 Sa/nders.
'<. U.S. Deartment o+ Healt, and H/man Ser"ices 7:;(;8. National Instit/tes o+
Healt,. National Instit/te o+ Dental !esearc,. +ral health of United States Children6
The &ational Survey of Dental Caries in U,S, School Children, CHF92CHFD, DHHS
)/-. No. 7NIH8 (;->>&%. 1et,esda, MD9 U.S. Go"ernment )rintin* O++ice.
'%. Sie*al, M. D., g 2/t,y, !. A. 7:;;'8. ssessin$ oral health needs, STDD
Seven2step %odel, #e++erson City, MO9 Association o+ State and 5erritorial Dental
Directors.
'(. Gr/e--el, A. O. 7:;&&8. A meas/rement o+ dental caries re"alence and treatment
ser"ice +or decid/o/s teet,. " Dent Res, >=9:<=-<(.
';. .oe, H., g Silness #. 7:;<=8. )eriodontal disease in re*nancy. I. )re"alence and
se"erity. cta +dont Scand, >:9'==-':.
<$. Silness, #, g .oe H. 7:;<&8. )eriodontal disease in re*nancy. II. Correlation
-etween oral ,y*iene and eriodontal condition. cta +dont Scand, >>9::>-='.
<:. Greene, #. C., g 6ermillion, #. !. 7:;<&8. 5,e simli+ied oral ,y*iene inde0. " m
Dent ssoc, <(9>'-=:.
<>. !/ssell, A. .. 7:;'<8. A system o+ classi+ication and scorin* +or re"alence
s/r"eys o+ eriodontal disease. " Dent Res, ='9='$-';.
<=. !am+Aord, S. ). 7:;';8. Inde0es +or re"alence and incidence o+ eriodontal
disease. " Periodont, =$9':-';.
<&. 4orld Healt, Or*ani@ation 7:;(&8. Comm/nity )eriodontal Inde0 o+ 5reatment
Needs, de"eloment, +ield testin*, and statistical e"al/ation. Gene"a, Swit@erland9
Oral Healt, Unit, 4orld Healt, Or*ani@ation.
<'. 2/t,y, !. A., g Odom, #. G. 7:;((8. .ocal dental ro*rams9 a descriti"e
assessment o+ +/ndin* and acti"ities. " Pu4lic Health Dent, &(9=<-&>.
<<. Selwit@, !. H., 4inn, D. M., 2in*man, A., g Iion, G. !. 7:;;<8. 5,e re"alence
o+ dental sealants in t,e US o/lation9 +indin*s +rom NHAN3S III, :;((-:;;&. "
Dent Res, %'7Sec Iss89<'>-<$.
<%. Fra@ier, ). #., g Horowit@, A. M. 7:;;'8. )re"ention9 A /-lic ,ealt, ersecti"e.
In Co,en, .. 2., g Gi+t, H. C., 3ds. Disease prevention and oral health promotion,
Coen,a*en9 M/nks*aard. . :$;-'>.
<(. Green, .. 4., g #o,nson, 2. 4. 7:;(=8. Healt, ed/cation and ,ealt, romotion.
In Mec,anic, D., 3d. Hand4oo* of health, healthcare and the health professions, New
Hork9 4iley. . %&&-<'.
<;. 2ay, 3. #., g .ocker, D. 7:;;<8. Is dental ,ealt, ed/cation e++ecti"ee A systematic
re"iew o+ c/rrent e"idence. Community Dent +ral !pidemiol, >&9>=:-'.
%$. Faine, !. C., Collins, #. #., Daniel, #. 7:;(:8. Isman, 1., 1oriskin, #., Ho/n*, 2. ..,
g Fit@*erald, C. M. 5,e :;($ +l/oridation camai*ns9 a disc/ssion o+ res/lts. "
Pu4lic Health Dent, &:9:=(-&>.
%:. 1ronstein, 3. 7:;%;8. .etters to t,e editor9 Fl/oridation monitorin*. " Pu4lic
Health Dent, =;9>&(.
%>. National Instit/te o+ Dental !esearc, 7:;(%8. 5,e oral ,ealt, o+ United States
ad/lts9 t,e national s/r"ey o+ oral ,ealt, in U.S. emloyed ad/lts and seniors, :;(<-
:;(<. U.S. Deartment o+ Healt, and H/man Ser"ices, National Instit/tes o+ Healt,.
DHHS )/-. No. 7NIH8 (%->(<(. 1et,esda, MD9 U.S. Go"ernment )rintin* O++ice.
%=. 2aste, .. M., Marianos, D., g C,an*, !., et al. 7:;;>8. 5,e assessment o+ n/rsin*
caries and its relations,i to ,i*, caries in t,e ermanent dentition. " Pu4lic Health
Dent, '>9<&-<(.
%&. American Dental Association 7:;(>8. Oral ,ealt, stat/s o+ 6ermont n/rsin* ,ome
residents. Co/ncil on Dental Healt, and Healt, )lannin*, 1/rea/ o+ 3conomic and
1e,a"ioral !esearc,. " m Dent ssoc, :$&9<(-<;.
%'. Gi+t, H. C., C,erry-)eers, G., g Oldakowski, !. #. 7:;;%8. Oral ,ealt, stat/s
and related -e,a"io/rs o+ U.S. n/rsin* ,ome residents, :;;'. 0erodontolo$y,
:&7>89(;-;;.
%<. 4ool+olk, M., Hamard, M., g 1a*ramian, !. A. 7:;(&8. Oral ,ealt, o+ c,ildren o+
mi*rant +arm workers in nort,west Mic,i*an. " Pu4 Health Dent, &&9:$:-'.
%%. 3ntwistle, 1. A., g Swanson, 5. M. 7:;(;8. Dental needs and ercetions o+ ad/lt
Hisanic mi*rant +armworkers in Colorado. " Dent Hy$, <=9>(<-(;.
%(. .ittle, #. 4., g Falace, D. A., Miller, C. S., g !,od/s, N. .. 7>$$>8. Dental
mana$ement of the medically compromised patient, St. .o/is9 C6 Mos-y.
%;. Niessen, .., g D/nlea"y, H. A. 7:;(&8. Meetin* t,e oral ,ealt, needs o+ t,e a*in*
"eteran. In 4etle, 5., g !owe, #. 4., 3ds. +lder veterans6 (in*in$ = and
community resources, 7. =<;-&$%8. Cam-rid*e, MA9 Har"ard Uni"ersity )ress.
($. U.S. Deartment o+ Healt, and H/man Ser"ices 7:;($8. Special Report6 Dental
Care for Handicapped People, DHHS )/-. No.7)HS8 (:-'$:'&. 4as,in*ton, DC9
U.S. Go"ernment )rintin* O++ice.
(:. Gel-er*, .., .inn, .. S., g !osen-er*, D. #. 7:;((8. Dental ,ealt, o+ ,omeless
ad/lts. Spec Care Dent, (9:<%-%>.
(>. Gi-son, G., !osen,eck, !., 5/llner, #. 1., Grimes, !. M., Sei-yl, C. .., !i"era-
5orres, A., Goodman, H. S., g N/nn, M. 3. 7>$$=8. A national s/r"ey o+ t,e oral
,ealt, stat/s o+ ,omeless "eterans. " Pu4lic Health Dent, <=7:89=$-%.
(=. 1eck, #. D. 7:;((8. 5rends in oral disease and ,ealt,. 0erondontol, %9>:->'.
(&. 1eck, #. D., g H/nt, !. #. 7:;('8. Oral ,ealt, stat/s in t,e United States9 ro-lems
o+ secial atients. " Dent !duc, &;9&$%->'.
('. 2lein, S. )., 1o,annon, H. M., 1ell, !. M., et al. 7:;('8. 5,e cost and
e++ecti"eness o+ sc,ool--ased re"enti"e dental care. m " Pu4lic Health, %'9=(>-;:.
(<. U.S. Deartment o+ Healt, and H/man Ser"ices 7:;(<8. National Instit/tes o+
Healt,. Detection and Prevention of Periodontal Disease in Dia4etes, NIH )/-. No.
(<-::&(. 1et,esda, MD9 U.S. Go"ernment )rintin* O++ice.
(%. )atton, .. .., ),elan, #. A., !amos-Gome@, 3. #., Nittayananta, 4., S,i-oski, C.
H., g M-/*/ye, 5. .. 7>$$>8. )re"alence and classi+ication o+ HI6-associated oral
lesions. +ral Dis, ( S/l >9;(-:$;.
((. 2ocaelli, H., Haltirik, M., Har*ic, .. I., g O@-as, H. 7>$$>8. Al@,eimerCs disease
and dental mana*ement. +ral Sur$ +ral %ed +ral Pathol +ral Radiol !ndod,
;=7'89'>:-&.
(;. S,i, #. A. 7:;;>8. Oral ,ealt, o+ atients wit, Al@,eimerCs disease. " m Dent
ssoc, :>=9'=-'(.::
;$. Antc@ak, A. A., 1ranc,, .. G. 7:;('8. )ercei"ed -arriers to t,e /se o+ dental
ser"ices -y t,e elderly. 0erodontics, :9:;&-;(.
;:. Gil-ert, G. H. 7:;(;8. FA*eismF in dental care deli"ery. " m Dent ssoc,
::(9'&'-&(.
;>. Co,en, .. A., g Grace, 3. G. 7:;;$8. In+ection control ractices related to
treatment o+ AIDS atients. " Dent Pract dmin, %9:$(-:'.
;=. Strayer, M. S. 7:;;'8. )ercei"ed -arriers to oral ,ealt, care amon* t,e
,ome-o/nd. Spec Care Dentist, :'7=89::=-(.
;&. 1r/nelle, #. A., g Carlos, #. ). 7Marc, :;(;8. !ecent trends in dental caries in
U.S. c,ildren and t,e e++ect o+ water +l/oridation. International Fl/oride Symosi/m,
)ine Mo/ntain, Geor*ia.
;'. 1ell, !. M., 2lein, S. )., 1o,annan, H. 1., et al. 7:;(&8. Treatment !ffects in the
&ational Preventive Dentistry Demonstration Pro$ram, Santa Monica, CA9 !andD !-
=$%>-!4#.
;<. 1o,annnon, H. M., g 1ader, #. D. 7:;(&8. F/t/re imact o+ /-lic ,ealt, and
re"enti"e met,ods on t,e incidence o+ dental caries. " Can Dent ssoc, '$9>>;-==.
;%. 1r/nelle, #. A., g Carlos, #. ). 7:;(>8. C,an*es in t,e re"alence o+ dental caries
in U.S. sc,oolc,ildren9 :;<:-:;($. " Dent Res, <:9:=&<-':.
;(. 1ryan, 3. 5., Collier, D. !., Howard, 4. !., g 6an Clea"e, M. .. 7:;(>8. Dental
,ealt, stat/s o+ sc,ool c,ildren in 5ennesseea >'-year comarison. " Tenn State
Dent ssoc, <>9=:-==.
;;. De)aola, ). F. 7:;(=8. 5,e Massac,/setts ,ealt, s/r"ey. " %ass Dent Soc,
=>7:89:$-:, >=-'.
:$$. Glass, !. .. 7:;(:8. Sec/lar c,an*es in caries re"alence in two Massac,/setts
towns. Caries Res, :'9&&'-'$.
:$:. H/*,es, #. 5., !o@ier, !. G., g !amsey, D. .. 7:;($8. The &atural History of
Dental Disease in &orth Carolina, CHD92DD, D/r,am, NC9 Academic )ress.
:$>. 1/rt, 1. A. 7:;('8. 5,e +/t/re o+ t,e caries decline. " Pu4lic Health Dent,
&'9><:-<;.
:$=. 1ea@o*lo/, 5., 1rown, #., g He++ley, D. 7:;;=8. Dental care /tili@ation o"er
time. Soc Sci %ed, =%9:&<:-%>.
:$&. Friedman, #. 4. 7:;%%8. A cons/mer ad"ocateCs "iew o+ comm/nity dentistry. "
Dent !duc, &:9<'<-';.
:$'. Federation Dentaire Internationale 7:;((8. 5ec,nical !eort No. =:. !e"iew o+
met,ods o+ identi+ication o+ ,i*, caries risk *ro/s and indi"id/als. /nt Dent ",
=(9:%%-(;.
:$<. Stamm, #. S., Disney, #. A., Gra"es, !. C., et al. 7:;((8. 5,e Uni"ersity o+ Nort,
Carolina caries risk assessment st/dy. I. !ationale and content. " Pu4lic Health Dent,
&(9>>'-=>.
:$%. Gala*an, D. #. 7:;%<8. Some comments on t,e +/t/re o+ dental /-lic ,ealt,. "
Pu4lic Health Dent, =<9;<-:$>.
:$(. D/nnin*, #. M. 7:;%;8. G/est editorial9 t,e stone wall. " Pu4lic Health Dent,
=;9:%'-%<.
:$;. Instit/tes o+ Medicine 7:;((8. 5,e +/t/re o+ /-lic ,ealt,. 4as,in*ton, DC9
::$. Mil*rom, )., g !eisine, S. 7>$$$8. Oral ,ealt, in t,e United States9 t,e ost-
+l/oride *eneration. nn Rev Pu4lic Health, >:9&$=-=<.
:::. Glass, !. .. 7:;($8. 5,e /se o+ +l/oride denti+rices9 a /-lic ,ealt, meas/re.
Community Dent +ral !pidemiol, (9>%(-(>.
::>. Healt, Care Financin* Administration 7>$$$8. &ational Health !xpenditures
CHHF, 4as,in*ton, DC9 Healt, Care Financin* Administration.
::=. Niessen, .. C. 7:;;$8. New directions-constit/encies and resonsi-ilities. "
Pu4lic Health Dent, 7Sec Iss8D'$9:==-=(.
::&. Ga/, ). G. 7:;;$8. New initiati"es +or ad"ocacy in national maternal and c,ild
oral ,ealt,. " Pu4lic Health Dent, 7Sec Iss8D'$9=;<-&$:.
::'. U.S. Deartment o+ Healt, and H/man Ser"ices 7:;($8. Promotin$
HealthLPreventin$ Disease6 +47ectives for the &ation, 4as,in*ton, DC9 )/-lic
Healt, Ser"ice, '&.
::<. U.S. Deartment o+ Healt, and H/man Ser"ices 7:;;:8. Healthy People <:::6
&ational Health Promotion and Disease Prevention +47ectives, 4as,in*ton, DC9
::%. American )/-lic Healt, Association 7:;;:8. Healthy Communities <:::6 %odel
Standards, 4as,in*ton, DC9 American )/-lic Healt, Association.
::(. U.S. Deartment o+ Healt, and H/man Ser"ices 7:;;>8. Healthy People <:::6
Pu4lic Health Service ction, 4as,in*ton, DC9 Go"ernment )rintin* O++ice.
::;. U.S. Deartment o+ Healt, and H/man Ser"ices. 7:;;>8. Healthy People <:::6
State ction, 4as,in*ton, DC9 Go"ernment )rintin* O++ice.
:>$. U.S. Deartment o+ Healt, and H/man Ser"ices. 7:;;>8. Healthy People <:::6
Consortium ction, 4as,in*ton, DC9 Go"ernment )rintin* O++ice.
:>:. American F/nd +or Dental Healt,. 7:;;>8. Proceedin$ of the &ational
Consortium %eetin$6 +ral Health <:::, C,ica*o, I.9 American F/nd +or Dental
Healt,.
:>>. U.S. Deartment o+ Healt, and H/man Ser"ices. 7>$$$8. Healthy People <:C:
7>nd ed.8 -ith understandin$ and improvin$ health and o47ectives for improvin$
health, > "ols. 4as,in*ton, DC9 Go"ernment )rintin* O++ice.
:>=. U.S. Deartment o+ Healt, and H/man Ser"ices. 7>$$>8. profile of older
mericans6 <::C, 4as,in*ton, DC9 Administration on A*in*.
:>&. 1/rt, 1. A. 7:;(>8. New riorities in re"ention o+ oral disease. " Pu4lic Health
Dent, &>9:%$-%;.
:>'. Hand, #. S., H/nt, !. #., g 1eck, #. D. 7:;((8. Incidence o+ coronal and root
caries in an older ad/lt o/lation. " Pu4lic Health Dent, &(9:&-:;.
:><. Stamm, #. 4., 1antin*, D. 4., lmrey, ). 1. 7:;;$8. Ad/lt root caries s/r"ey o+
ssoc, :>$9:&=-&;.
:>%. U.S. Deartment o+ Healt, and H/man Ser"ices 7:;;<8. O++ice o+ Insector
General. Children?s Dental Services Under %edicaid, ccess and Utili1ation,
4as,in*ton, DC9 O++ice o+ Insector General.
:>(. U.S. General Acco/ntin* O++ice. 7>$$$8. +ral health6 Dental disease is a
chronic pro4lem amon$ lo32income populations, 4as,in*ton, DC9 U.S. Acco/ntin*
O++ice.
:>;. A*ency +or Healt, Care )olicy and !esearc, 7:;;>8. National Medical
30endit/re S/r"ey9 nnual !xpenses and Sources of Payment for Health Care
Services, !ock"ille, MD9 A*ency +or Healt, Care )olicy and !esearc,.
:=$. .oe, H. g Dr/ry, 5. F. 7:;;$8. F/t/re NID! Initiati"es in !isk Assessment. /n6
1ader #, 3d. Proceedin$s of the Conference on Ris* ssessment in Dentistry, #/ne >-=
:;(;. C,ael Hill, NC9 Uni"ersity o+ Nort, Carolina Dental 3colo*y, =:'-<.
:=:. U.S Deartment o+ Healt, and H/man Ser"ices. 7Set :;;>8. Healt, !eso/rces
and Ser"ices Administration. Health Personnel in the United States6 !i$hth Report to
Con$ress, CHHC, DHHS )/-. No. H!S-)-OD-;>-:.
:=>. Goodman, H. S., g 4eyant, !. #. 7:;;$8. Dental ,ealt, ersonnel lannin*9 a
re"iew o+ t,e literat/re. " Pu4lic Health Dent, '$9&(-<=.
:==. Interim St/dy Gro/ on Dental Acti"ities 7:;(;8. /mprovin$ the +ral Health of
the merican People6 +pportunity for ction, 4as,in*ton, DC9 U.S. Deartment o+
:=&. Mac,en, #. 1. 7:;(;8. 3d/cation and dental en"ironment9 t,e +/t/re +or dental
sc,ools. " m Coll Dent, '<9==,&>-&&.
:='. U.S. Deartment o+ Healt, and H/man Ser"ices 7:;;:8. !e"iew o+ +l/oride
-ene+its and risks. )/-lic Healt, Ser"ice. 4as,in*ton, DC9 Deartment o+ Healt, and
H/man Ser"ices.
:=<. National Instit/tes o+ Healt,. 7A/* ><->(, :;;:8. 5ec,nolo*y assessment
con+erence statement9 e++ects and side e++ects o+ dental restorati"e materials.
Deartment o+ Healt, and H/man Ser"ices.
:=%. Co,en, .. A., Grace, 3. G., g 4ard, M. A. 7:;;>8. Maryland residentsC attit/des
towards AIDS and t,e /se o+ dental ser"ices. " Pu4lic Health Dent, '>9(:-('.
:=(. McCart,y, G. M., 2o"al, #. #., g MacDonald, #. 2. 7:;;;8. Factors associated
wit, re+/sal to treat HI6-in+ected atients9 t,e res/lts o+ a national s/r"ey o+ dentists
in Canada. m " Pu4lic Health, (;7&89'&:-'.
:=;. Ciesielski, C., Marianos, D., O/, C-H, D/m-a/*,, !., 4itte, #., 1erkleman, !.,
Gooc,, 1., Myers, G., ./o, C. C., g Sc,oc,etman, G. 7:;;>8. 5ransmission o+
H/man Imm/node+iciency 6ir/s in a dental ractice. nn /nt %ed, May :'D::<9%;(-
($'.
:&$. 1arnes, D. 1., Ger-ert, 1., McMaster, #. !., g Green-latt, !. M. 7:;;<8. Sel+-
disclos/re e0erience o+ eole wit, HI6 in+ection in dedicated and mainstreamed
dental +acilities. " Pu4lic Health Dent, '<7&89>>=-'.
:&:. American Dental Association 7:;;>8. In+ection control recommendations +or t,e
dental o++ice and t,e dental la-oratory. Co/ncil on Dental Materials, Instr/ments, and
3?/imentD Co/ncil on Dental 5,erae/ticsD Co/ncil on Dental !esearc,D Co/ncil on
Dental )ractice. " m Dent ssoc 7S/l8D:>=9:-(.
:&>. Centers +or Disease Control 7:;(<8. !ecommended in+ection control ractices
+or dentistry. %%-R, ='9>=%-&>.
:&=. U.S. Deartment o+ .a-or, Occ/ational Sa+ety and Healt, Administration
7:;;:8. Occ/ational e0os/re to -lood-orne at,o*ens, 5itle >; CF! :;:$.:$=$.
'ed Re$ Dec <D'<9<&$$&-<&:(>.
:&&. 3"ans, C. A., g 2leinman, D. 6. 7>$$$8. 5,e s/r*eon *eneralCs reort on oral
,ealt, in America9 oort/nities +or t,e dental ro+ession. " m Dent ssoc,
:=:9:%>:-(.
reser"ed.
Chapter 17. Dental Public-Health Programs - %ar* D, %ace* and Harold S,
0oodman
Objectives
:. .ist t,e core +/nctions o+ /-lic ,ealt,.
>. De+ine dental /-lic ,ealt, and relate t,is de+inition to dental /-lic-,ealt,
ro*rams.
=. Comare t,e met,ods o+ /-lic ,ealt,-care ractitioners and ersonal ,ealt,-care
ractitioners.
&. Descri-e t,e se"en-ste model +or assessin* oral-,ealt,-care needs and relate t,is
model to a lannin* cycle +or /-lic-,ealt, ro*rams.
'. O/tline t,e scoe o+ traditional dental /-lic-,ealt, ro*rams.
<. Descri-e recent c,an*es in t,e United States t,at are rele"ant to dental /-lic-
,ealt, ractice.
%. .ist t,e "ario/s or*ani@ations t,at maintain and s/ort /-lic ,ealt, ro*rams.
(. Descri-e ,ow t,e S/r*eon GeneralCs reort on oral ,ealt, in America ,as imacted
dental /-lic-,ealt, ro*rams.
Introduction
In :;;&, t,e Core 'unctions of Pu4lic Health Steerin$ Committee, co-c,aired -y Drs.
),ili !. .ee 7Assistant Secretary +or Healt,8 and M. #oycelyn 3lders 7S/r*eon
General o+ t,e U.S. )/-lic Healt, Ser"ice8, rod/ced a consens/s statement o/tlinin*
t,e essential ser"ices o+ /-lic ,ealt, in t,e United States.
:
5,e new statement
ro"ided a "ision +or /-lic ,ealt,Healthy People in Healthy Communitiesand
de+ined its mission9 Promote physical and mental health and prevent disease, in7ury,
and disa4ility, 5,e consens/s statement also ro"ided -roader descrition o+ t,e core
+/nctions o+ /-lic ,ealt,assessment, policy development, and assurance,
>

Accordin* to t,e statement, t,e purpose of pu4lic health incl/ded9 :8 re"entin*
eidemics and t,e sread o+ diseaseD >8 rotectin* a*ainst en"ironmental ,a@ardsD =8
re"entin* inA/riesD &8 romotin* and enco/ra*in* ,ealt,y -e,a"iors and mental
,ealt,D '8 resondin* to disasters and assistin* comm/nities in reco"eryD and <8
ass/rin* t,e ?/ality and accessi-ility o+ ,ealt, ser"ices. 5,e practice of pu4lic health
incl/ded9 :8 monitorin* ,ealt, stat/s to identi+y and sol"e comm/nity-,ealt,
ro-lemsD >8 dia*nosin* and in"esti*atin* ,ealt, ro-lems and ,ealt, ,a@ards in t,e
comm/nityD =8 in+ormin*, ed/catin*, and emowerin* eole a-o/t ,ealt, iss/esD &8
mo-ili@in* comm/nity artners,is and action to identi+y and sol"e ,ealt, ro-lemsD
'8 de"eloin* olicies and lans t,at s/ort indi"id/al and comm/nity ,ealt, e++ortsD
<8 en+orcin* laws and re*/lations t,at rotect ,ealt, and ens/re sa+etyD %8 linkin*
eole to needed ersonal-,ealt, ser"ices and ass/rin* t,e ro"ision o+ ,ealt, care
w,en ot,erwise /na"aila-leD (8 ass/rin* a cometent /-lic and ersonal ,ealt,-care
work+orceD ;8 e"al/atin* e++ecti"eness, accessi-ility, and ?/ality o+ ersonal and
o/lation--ased ,ealt, ser"icesD :$8 researc,in* +or new insi*,ts and inno"ati"e
sol/tions to ,ealt, ro-lems.
In :;%<, t,e American Dental Association adoted a de+inition o+ dental pu4lic
health, statin* t,at it was9
. . . t,e science and art o+ re"entin* and controllin* dental diseases and romotin*
dental ,ealt, t,ro/*, or*ani@ed comm/nity e++orts. It is t,at +orm o+ dental ractice
w,ic, ser"es t,e comm/nity as a atient rat,er t,an t,e indi"id/al. It is concerned
wit, t,e dental ed/cation o+ t,e /-lic, wit, alied dental researc,, and wit, t,e
administration o+ *ro/ dental care ro*rams as well as t,e re"ention and control o+
dental diseases on a comm/nity -asis. . .
=
.
Gi"en t,is de+inition, dental pu4lic2health pro$rams re+er to or*ani@ed e++orts t,at
stri"e to re"ent and control oral and cranio+acial diseases at t,e comm/nity le"el.
Dental /-lic-,ealt, ro*rams are ,i*,ly "aried and incl/de acti"ities t,at co"er a
wide sectr/m, +rom small-scale local roAects to lar*e-scale national and
international "ent/res. Gi"en t,at a comm/nity is t,e +oc/s, dental /-lic-,ealt,
ro*rams m/st satis+y t,e criteria o+ racticality, +easi-ility, acceta-ility, sa+ety,
e++ecti"eness, and e++iciency.
Historic Perspective
,istory.
<
1etween :(<> and :(<&, loss o+ teet, was t,e +o/rt, most +re?/ent ca/se +or
reAection o+ yo/n* men +or dra+t into t,e Union Army d/rin* t,e Ci"il 4ar.
%
In :;:(,
military dra+tees +or 4orld 4ar I were reAected-eca/se o+ de+ecti"e and de+icient
teet,at a rate t,at e0ceeded :$E in some states.
(
D/rin* t,e conscrition eriod o+
4orld 4ar II, t,e U,S, -ar Department %o4ili1ation Re$ulation re?/ired t,at a
recr/it ,a"e a minim/m o+ t,ree ser"icea-le, nat/ral anterior and osterior teet, in
oosition, er arc,, to -e acceta-le +or military ser"ice. Fi+teen ercent o+ recr/its
were reAected, -eca/se t,ey co/ld not ass t,ese rat,er li-eral criteria.
<
D/rin* t,e
:;>$s, t,e Metroolitan .i+e Ins/rance Comany cond/cted one o+ t,e earliest
eidemiolo*ical st/dies o+ t,e dental condition o+ a lar*e, ,etero*eneo/s, ad/lt,
ci"ilian o/lation.
;
Oral e0aminations o+ more t,an :>,$$$ ad/lts re"ealed t,at,
amon* >$- to >&-year-olds, more t,an ,al+ o+ t,e teet, ,ad -een a++ected -y dental
caries, and t,is roortion increased steadily in older a*e *ro/s.
D/rin* t,e ne0t se"eral decades, t,e n/m-er o+ eidemiolo*ical s/r"eys cond/cted
amon* ci"ilians increased dramatically.
:$-:'
It was not s/rrisin* t,at t,ese st/dies
re+lected t,e ,i*, dental caries re"alence le"els noted in earlier st/dies and
cond/cted amon* military recr/its. 5,e s/r"eys s,owed t,at dental caries was a
serio/s ,ealt, ro-lem amon* yo/n* ad/lts, and o+ten res/lted in toot, loss. 5,e
st/dies also s,owed t,at dental caries -e*an early in li+e and a++ected yo/n* c,ildren.
1etween :;== and :;=&, t,e U.S. )/-lic Healt, Ser"ice 7US)HS8 sonsored a s/r"ey
cond/cted amon* t,o/sands o+ <- to :&-year-old c,ildren in >< states across t,e
United States.
:<
5,e st/dy re"ealed ,i*, dental caries re"alence le"els in c,ildren, as
well. In :;=%, t,e classic Ha*erstown, Maryland, st/dy,
:%
w,ic, introd/ced t,e
Decayed, Missin* and Filled inde0 +or teet, 7DMF58 and toot, s/r+aces 7DMFS8,
s,owed moderately ,i*, caries re"alence le"els amon* t,e e0amined c,ildren. 5,e
st/dy also s,owed t,at c,ildren wit, t,e ,i*,est dental-caries inde0 scores recei"ed
only >E o+ t,e treatment time rendered -y dentists.
5,e dental-caries e0erience o+ c,ildren and t,e ro*ression o+ t,e disease in ad/lts
ro"ided t,e rationale +or t,e alication o+ dental /-lic-,ealt, ro*rams to address
t,e ro-lem. 5,e e++orts, cooeration, and interactions o+ a n/m-er o+ indi"id/als and
a*encies led to one s/c, dental /-lic-,ealt, ro*ram, t,e imlementation o+ adA/sted
water +l/oridation.
Fl/oridationA Mon/mental )/-lic-Healt, S/ccess Story
Fl/oridation is t,e rincial dental /-lic ,ealt, re"enti"e ro*ram a"aila-le in t,e
control o+ dental caries in t,e o/lation. D/rin* a national ,ealt, con+erence in :;<<,
+ormer S/r*eon General Dr. ./t,er .. 5erry stated, FControlled +l/oridation is one o+
t,e +o/r *reat mass re"enti"e ,ealt, meas/res o+ all time. 5,e +o/r ,orsemen o+
,ealt, are9 t,e aste/ri@ation o+ milk, t,e /ri+ication o+ water, imm/ni@ation a*ainst
disease, and controlled +l/oridation o+ water.F
:(
5,e Centers +or Disease Control and
)re"ention recently listed +l/oridation amon* t,e to ten /-lic ,ealt, tri/m,s o+ t,e
>$t, cent/ry.
:;
5,e ,istoric de"eloment o+ +l/oridation in t,e United States ser"es as an e0amle o+
t,e contri-/tions o+ indi"id/als o+ "aried -ack*ro/nds reresentin* ersonal and
/-lic se*ments o+ t,e ro+ession. For e0amle, Dr. H. 5rendley Dean, considered t,e
F+at,er o+ +l/oridation,F ,ad a rominent role in t,e early de"eloin* story o+ t,e
imortance o+ +l/oride to toot, enamel.
>$
Dean was an o++icer in t,e US)HS w,o led
e0tensi"e st/dies t,at later esta-lis,ed t,at : art er million 7m8 o+ +l/oride in a
comm/nity water s/ly red/ced dental-caries re"alence.
>:
As imortant as t,e contri-/tions o+ Dean and t,e US)HS were to t,e s/-se?/ent
imlementation o+ comm/nity +l/oridation, one s,o/ld not lose si*,t o+ t,e roles
layed -y Dr. Frederick Mc2ay, a ersonal ,ealt,-care ractitioner in Colorado
Srin*s, Colorado, and Dr. G. 6. 1lack, a ractitioner and rominent dental ed/cator.
Mc2ay and 1lack cond/cted n/mero/s in"esti*ations o+ Colorado 4ro3n stain, a
condition indicati"e o+ e0cessi"e amo/nts o+ nat/rally occ/rrin* +l/oride ion d/rin*
toot, de"eloment, and +o/nd t,at dental caries was less re"alent amon* t,ose
a++licted.
>>
In addition, one s,o/ld consider t,e in+l/ence o+ an ind/strial c,emist, H.
6. C,/rc,ill, w,o de"eloed t,e analytic met,od t,at co/ld detect min/te ?/antities
o+ +l/oride in water, a critical ste necessary to esta-lis, t,e link -etween t,e le"el o+
+l/oride ions in water and t,e dental caries e0erience o+ t,e o/lation cons/min*
t,e water.
>=
At t,e same time, Smit, and Smit,,
>&
a*ric/lt/ral researc,ers, also linked
mottled enamel wit, water +l/oride concentrations. Followin* t,ese and ot,er
st/dies,
>'
indeendent researc,ers cond/cted controlled trials o+ t,e e++ect t,at
+l/oride ion in a comm/nity water system mi*,t ,a"e on dental caries e0erience in
c,ildren. 1e*innin* in :;&' and roceedin* t,ro/*, t,e mid-:;'$s, researc,ers added
+l/oride to t,e water systems o+ +o/r test comm/nities 7Grand !aids, Mic,i*anD
New-/r*,, New HorkD 3"anston, IllinoisD and 1rant+ord, Ontario8 and o-ser"ed t,e
dental caries e0erience o+ t,eir residents. 5,ese trials s/ccess+/lly demonstrated t,at
adA/sted water +l/oridation, at concentrations o+ :.$ to :.> m, co/ld dramatically
red/ce dental caries e0erience in c,ildren.
><->;
Accordin* to t,e most recent national data a"aila-le, aro0imately :<> million
ersons, or aro0imately <'.(E o+ t,e total U.S. o/lation, drink adA/sted or
nat/rally occ/rrin* +l/oridated water.
=$
Howe"er, t,is reresents a nearly &E increase
since :;;>. 3++orts to increase t,e roortion o+ t,e world o/lation drinkin*
+l/oridated water still ,a"e -een t,warted, in art, -eca/se o+ t,e contin/in* olitical
acti"ities o+ t,e anti-+l/oridation mo"ement. S/orters o+ t,is mo"ement contin/e to
oose adA/sted +l/oridation +or many reasons, t,e "ast maAority o+ w,ic, are
e?/i"ocal.
=:
Desite t,e e++orts o+ oosition *ro/s, comm/nity-water +l/oridation contin/es to
recei"e widesread s/ort +rom -ot, t,e ersonal and /-lic ,ealt,-care sectors.
N/mero/s ,ealt, ro+essional or*ani@ations, cons/mer and ad"ocacy *ro/s, and t,e
S/r*eon General contin/e to endorse comm/nity-water +l/oridation.
=>-='
AdA/stment
o+ water +l/oride concentrations to otimal le"els is an e0amle o+ a s/ccess+/l dental
/-lic-,ealt, ro*ram*ro/s workin* to*et,er to re"ent and control oral and
cranio+acial diseases in t,e comm/nity.
Current Problem
1/rt and 3kl/nd
=<
de+ine a pu4lic2health pro4lem as meetin* two criteria9 a8 a
condition or sit/ation t,at is a widesread act/al or otential ca/se o+ mor-idity or
mortalityD and -8 an e0istin* ercetion t,e condition is a /-lic-,ealt, ro-lem on
t,e art o+ t,e /-lic, *o"ernment, or /-lic ,ealt, a/t,orities. A n/m-er o+ oral and
cranio+acial diseases and conditions reresent /-lic ,ealt, ro-lems in t,e United
States today, and are -rie+ly disc/ssed -elow. 5,ese are t,e rincial concerns t,at
need to -e addressed -y -ot, t,e ersonal and /-lic ,ealt,care sectors to imro"e
oral ,ealt, at t,e comm/nity le"el.
Dental Caries
Dental caries is one o+ t,e most re"alent diseases in t,e United States. A-o/t :%E o+
c,ildren a*ed > to & years ,a"e ,ad a cario/s lesion in a rimary toot, d/rin* t,eir
li+etime, and t,e re"alence A/ms to &;.%E amon* c,ildren a*ed ' to ; years.
=%

Amon* ermanent teet,, ><.$E o+ c,ildren a*ed ' to :: years ,a"e ,ad a cario/s
lesion and <%.=E o+ c,ildren a*ed :> to :% years ,a"e ,ad a cario/s lesion.
=%
Dental
caries is also ,i*,ly re"alent amon* U.S. ad/lts, as aro0imately ;&E o+ dentate
ad/lts a*ed :( years or older ,a"e ,ad a cario/s lesion d/rin* t,eir li+etime.
=(
Dental-caries re"alence and se"erity also is associated wit, raceBet,nicity and
socioeconomic stat/s 7Fi*/re :%-:8. Certain minority c,ildren e0,i-it a ,i*,er
re"alence o+ rimary toot, decay t,an do t,eir eers, as =&.>E o+ non-Hisanic
w,ite c,ildren a*ed > to ; years ,a"e ,ad a cario/s lesion, w,ereas =(.(E o+ non-
Hisanic -lack c,ildren and '=.$E o+ Me0ican-American c,ildren ,a"e ,ad a cario/s
lesion.
=%
Amon* adolescents a*ed :> to :% years, lower o"erty stat/s is associated
wit, ,i*,er mean dental-caries e0erience scores and a *reater ercenta*e o+
/ntreated disease.
=;
)eriodontal Diseases
Gin*i"itis, one o+ t,e eriodontal diseases, is moderately re"alent in ersons a*ed :=
years or older. On a"era*e, <>.;E o+ ersons in t,is a*e ran*e e0,i-it *in*i"al
-leedin*, and :>.$E o+ sites are in"ol"ed.
&$
Gin*i"itis, as meas/red -y *in*i"al
-leedin*, is also more re"alent amon* Me0ican-Americans t,an it is amon* non-
Hisanic -lacks and non-Hisanic w,ites a*ed =$ years or older.
&:
Calc/l/s, a
contri-/tin* +actor in *in*i"itis, is resent in (;.;E o+ ersons a*ed := years or
older.
&$
Alt,o/*, most ersons wo/ld not consider *in*i"itis a serio/s t,reat to oneCs
,ealt,, it recei"es a *reat deal o+ attention in t,e aearance-conscio/s United States,
*i"en t,e conditionCs e++ect on est,etics and *in*i"itis recedes, -/t does not
necessarily ro*ress to eriodontitis.
)eriodontitis is t,e second o+ t,e eriodontal diseases and is associated wit, *reater
mor-idity t,an is *in*i"itis, and as s/c,, is considered a more serio/s /-lic-,ealt,
ro-lem. On a"era*e, >%.$E o+ males and :%.'E o+ +emales a*ed := years or older
,a"e at least one site wit, 'Kmm loss o+ eriodontal attac,ment.
&$
5,is *ender
di++erence is statistically si*ni+icant. 5,e re"alence o+ attac,ment loss is also
si*ni+icantly ,i*,er amon* minority *ro/s, as >&.;E o+ non-Hisanic -lacks and
:%.:E o+ non-Hisanic w,ites a*ed := years or older e0,i-it t,e condition.
&$
Oral and ),aryn*eal Cancer
5,ere are aro0imately =$,>$$ cases o+ oral and ,aryn*eal cancer detected in t,e
United States eac, year, and t,is n/m-er acco/nts +or some >.&E o+ all cancers. O+
ersons wit, oral and ,aryn*eal cancer, aro0imately %,($$ die eac, year. 5,e
o"erall '-year s/r"i"al rate +or ersons wit, oral and ,aryn*eal cancer is '>E, w,ic,
is lower t,an t,at +or cancers o+ t,e rostate, -reast, -ladder, laryn0, cer"i0, colon,
and rect/m.
&>
)ersons dia*nosed wit, oral and ,aryn*eal cancer at an early sta*e
,a"e a m/c, -etter ro*nosis t,an do t,ose dia*nosed at a later sta*e, as t,e '-year
s/r"i"al rate is (:.=E +or early-sta*e dia*nosis and >:.<E +or ad"anced-sta*e
dia*nosis. Only ='E o+ indi"id/als wit, oral and ,aryn*eal cancer are dia*nosed at
an early sta*e o+ t,e disease.
&>
Cranio+acial 1irt, De+ects
Oral cle+ts are amon* t,e most common classes o+ con*enital mal+ormations in t,e
United States. On a"era*e, t,ere are :.> cases o+ cle+t li 7wit, or wit,o/t cle+t alate8
er :,$$$ li"e -irt,s and $.'< cases o+ cle+t alate er :,$$$ li"e -irt,s in t,e *eneral
o/lation 7Fi*/re :%->8.
&=
5,ese de+ects may a++ect +acial aearance t,ro/*,o/t
li+e. Cle+t alate occ/rs more +re?/ently in +emales, w,ereas cle+t li or cle+t liBalate
occ/rs more +re?/ently in males.
&&-&%
5,e oral cle+t incidence rate +or w,ites is more
t,an = times t,e incidence rate +or -lacks.
Intentional and Unintentional InA/ries
It is ass/med t,at inA/ries to t,e ,ead, +ace, and teet, are relati"ely common, ,owe"er
t,e maAority o+ o/r knowled*e re*ardin* t,e n/m-er o+ inA/ries comes +rom
emer*ency deartment data and more se"ere inA/ries. 5,e leadin* ca/ses o+ s/c,
inA/ries incl/de +alls, assa/lts, sorts inA/ries, and motor-"e,icle collisions.
&(-'$

Accordin* to data collected in :;;= and :;;&, t,ere were aro0imately >$ million
"isits to emer*ency deartments er year +or cranio+acial inA/ries. Falls and assa/lts
eac, acco/nted +or a-o/t =:E o+ "isits and sorts-related inA/ries acco/nted +or
aro0imately :;E o+ inA/ries.
':
InA/ries res/ltin* +rom -icycles and tricycles
acco/nted +or 'E o+ ,ead and :;E o+ +ace inA/ries.
'>
O"erall, >&.;E o+ ersons a*ed
< to '$ years ,a"e ,ad an inA/ry t,at res/lted in dama*e to one or more incisor teet,.
'=
Accordin* to data collected in :;;:, ersonal ,ealt,-care dentists treated more t,an
'.; million cranio+acial inA/ries.
'&
Fi*/re :%-: Disarities in re"alence o+ /nrestored dental caries e0ist -etween
oor and non-oor. 7From U.S. Deartment o+ Healt, and H/man Ser"ices. +ral
Health in merica6 Report of the Sur$eon 0eneral, 1et,esda, MD9 U.S.
Deartment o+ Healt, and H/man Ser"ices, National Instit/tes o+ Dental and
Cranio+acial !esearc,, >$$$7='89<=.8
Fi*/re :%-> Incidence o+ selected con*enital de+ects. 7From Sc,/lman et al.,
:;;=.
&=
8
Dental Public-Health Methods
)ersonal oral-,ealt,-care ractitioners ser"e t,e oral ,ealt, needs o+ indi"id/al
atients, and t,e ersonal ,ealt,-care deli"ery system re?/ires a one-on-one
interaction -etween ractitioner and indi"id/al atient. )/-lic-,ealt, dentistry
+oc/ses on t,e comm/nity and, as s/c,, does not necessarily re?/ire a one-on-one
interaction -etween ractitioner and indi"id/al atient. 4,en a dental /-lic-,ealt,
ro*ram s/c, as water +l/oridation is s/ccess+/lly imlemented in a comm/nity, a
m/c, -roader cross section o+ t,e comm/nity -ene+its m/c, -roader t,an co/ld -e
e0ected -y ersonal ,ealt,-care ractitioners, alone.
2n/tson
''
contrasted t,e met,ods emloyed -y ersonal and /-lic ,ealt,care
ractitioners. 3ac, consisted o+ si0, se?/ential stes t,at ermit a lo*ical ro*ression
+rom identi+ication o+ a ro-lem to its sol/tion 75a-le :%-:8. For t,e indi"id/al
atient, a ersonal ,ealt,care ractitioner initiates treatment wit, a care+/l
e0amination and ,istory, w,ic, leads to an acc/rate dia*nosis o+ t,e ro-lem.
A+terwards, t,e ersonal ,ealt,care ractitioner lans a co/rse o+ treatment. Once
treatment ser"ices ,a"e -een ro"ided, and +ees aid, s/-se?/ent "isits ro"ide +or
e"al/ation and +ollow-/. 5,e met,ods emloyed in /-lic-,ealt, ractice arallel
t,ose o+ t,e ersonal ,ealt,-care ractitioner, -/t in"ol"e t,e total comm/nity instead
o+ an indi"id/al atient. Dental /-lic-,ealt, met,ods are disc/ssed in *reater detail
-elow.
30amination "ers/s S/r"ey
4,en a ersonal ,ealt,-care ractitioner -e*ins t,e e0amination rocess, ,e or s,e
collects s/-Aecti"e in+ormation +rom t,e atient and o-Aecti"e in+ormation, s/c, as
"is/al and tactile data, radio*ra,ic ima*es, and ot,er si*ns o+ disease. 1y contrast,
w,en a /-lic ,ealt,-care ractitioner assesses t,e e0tent o+ disease in a comm/nity,
,e or s,e m/st rely on descriti"e in+ormation, s/c, as e0istin* s/r"ey data or ot,er
eidemiolo*ical assessments.
Question 1
A. As a *eneral r/le, c,ildren wit, t,e *reatest oral-,ealt, treatment needs are also t,e
c,ildren w,o recei"e riority care.
1. 5,e o"erw,elmin* maAority o+ Americans die wit, at least one cario/s or restored
toot,.
C. 5,e incidence o+ oral cle+ts is ,i*,er amon* -lacks t,an it is amon* w,ites.
D. Core +/nctions o+ /-lic ,ealt, incl/de assessment, olicy de"eloment, and
ass/rance.
3. Dental /-lic-,ealt, ro*rams do not necessarily re?/ire a one-on-one interaction
-etween ractitioner and indi"id/al atient.
Some descriti"e s/r"ey data ,a"e -een collected and reorted re"io/sly. At t,e
national le"el, s/r"eys s/c, as t,e National Healt, 30amination S/r"ey, National
Healt, and N/trition 30amination S/r"ey, National Healt, Inter"iew S/r"ey, and
s/r"eys cond/cted -y t,e National Instit/te o+ Dental and Cranio+acial !esearc,
'<

,a"e ro"ided assessments at t,e comm/nity le"el re*ardin* t,e distri-/tion o+
diseases, s/c, as dental caries and eriodontitis, as well as oral ,ealt, knowled*e and
-e,a"ioral ractices. At t,e state le"el, s/r"eys s/c, as t,e 1e,a"ioral !isk Factor
S/r"eillance System or cancer re*istries ,a"e ro"ided /se+/l descriti"e in+ormation
re*ardin* oral ,ealt, care /tili@ation ractices and incidence o+ oral and ,aryn*eal
cancer. Selected states ,a"e also administered s/r"eys to assess t,e oral-,ealt, stat/s
o+ t,eir citi@ens 7Fi*/re :%-=8.
For t,e dental /-lic-,ealt,-care ractitioner, t,e +oc/s o+ t,e s/r"ey ste is to
comile all o+ t,e descriti"e in+ormation t,at e0ists in a state, co/nty, re*ion, or local
area. 4,en descriti"e data do not e0ist, t,e dental /-lic-,ealt,-care ractitioner
m/st +ind a way to collect /se+/l in+ormation. D/rin* t,e mid-:;;$s, romted -y t,e
newly de+ined essential +/nctions o+ /-lic ,ealt,, t,e Association o+ State and
5erritorial Dental Directors 7AS5DD8 de"eloed a model +or t,e collection o+ oral
,ealt, data at state and local le"els,
'%
re+erred to as t,e Seven2step %odel for
ssessin$ +ral Health &eeds, 5,e se"en stes incl/ded9
:. Identi+yin* artners and +ormin* an ad"isory committee.
>. Cond/ctin* sel+-assessment to determine *oals and reso/rces.
=. )lannin* t,e needs assessment.
Cond/ct in"entory o+ a"aila-le rimary and secondary data
Determine need +or rimary data collection
Identi+y reso/rces
Select met,ods
De"elo work lan
&. Collect data.
'. Or*ani@e and analy@e data.
<. !eort +indin*s and /tili@e t,e data +or ro*ram lannin*, ad"ocacy, and ed/cation.
%. 3"al/ate needs assessment and ret/rn to +irst ste, as necessary.
AS5DD intended t,at t,e collected data -e /sed as art o+ a lannin* cycle 7Fi*/re
:%-&8 t,at wo/ld lead to t,e imlementation o+ necessary dental /-lic-,ealt,
ro*rams. #/st as a ersonal ,ealt,-care ractitioner wo/ld not consider initiatin*
treatment on a atient wit,o/t s/-Aecti"e and o-Aecti"e data at ,and, t,e /-lic ,ealt,-
care ractitioner wo/ld not consider initiatin* a dental /-lic-,ealt, ro*ram wit,o/t
descriti"e data re*ardin* t,e needs o+ t,e comm/nity.
Dia*nosis "ers/s Analysis
Once a ersonal ,ealt,-care ractitioner ,as *at,ered s/++icient s/-Aecti"e and
o-Aecti"e in+ormation +rom t,e atient, ,e or s,e /ses ro+essional A/d*ment and
e0erience to dia*nosis a disease or condition, i+ one e0ists. Once a /-lic ,ealt,-care
ractitioner ,as collected s/++icient s/r"ey data, ,e or s,e analy@es t,e in+ormation in
order to answer seci+ic ?/estions. Is t,ere a dental /-lic ,ealt, ro-leme I+ so, w,at
is t,e e0tent o+ t,e ro-leme Are t,ere aroriate sol/tions a"aila-le to address t,e
ro-leme
5,e analysis ste ,els t,e /-lic ,ealt,-care ractitioner assess w,en a ro-lem
e0ists and ,els to ?/anti+y its e0tent. )/-lic ,ealt,-care ractitioners rely on standard
statistical met,ods to s/mmari@e s/r"ey data +indin*s d/rin* t,e analysis ste. For
e0amle, state-seci+ic s/r"ey data may s,ow t,at &'E o+ sc,oolc,ildren ,a"e
/nrestored dental caries, and t,at t,is ercenta*e is si*ni+icantly ,i*,er t,an wo/ld -e
e0ected at a national le"el. 5,e si*ni+icant di++erence in ercenta*es may oint to a
dental /-lic ,ealt, ro-lem in t,at state. In addition, s/r"ey data may s,ow t,at oral
and ,aryn*eal cancer incidence in one co/nty is si*ni+icantly ,i*,er t,an is t,e rate
in a nei*,-orin* co/nty. One wo/ld e0ect t,e +irst co/nty to recei"e secial attention
or a tar*eted dental /-lic ,ealt, ro*ram. 4it,o/t t,e analysis ste, ,owe"er, t,e
di++erence -etween t,e two co/nties mi*,t -e less o-"io/s.
In order +or a /-lic ,ealt,-care ractitioner to comare analytical +indin*s to ot,er
s/r"ey data, or transmit analytical +indin*s to ot,er /-lic ,ealt,-care ractitioners, ,e
or s,e /ses standard meas/rement tools and descriti"e */idelines, called dental
inde0es. A "ariety o+ dental inde0es ,a"e -een de"eloed +or seci+ic oral and
cranio+acial diseases and conditions. Some o+ t,e more common inde0es are listed
-elow.
Dental Inde0es
An imortant tool /sed in e0aminations o+ a o/lation *ro/ is a dental index, a
n/meric score t,at ?/anti+ies t,e ma*nit/de o+ t,e disease meas/red. A n/m-er o+
inde0es ,a"e -een de"eloed +or t,e /rose o+ ro"idin* t,e o-Aecti"e meas/rement
o+ t,e oral ,ealt, stat/s o+ a o/lation *ro/. 5,e n/m-er o+ teeth t,at are decayed,
missin*, or +illedt,e DMF5 inde0
:%
is a total score o+ all a++ected teet, and
ro"ides a dental caries e0erience score +or an indi"id/al. A co/nt o+ tooth surfaces
t,at are decayed, missin*, or +illed is a DMFS inde0 and ro"ides *reater recision
re*ardin* t,e dental caries ,istory o+ an indi"id/al or o/lation. 5,e mean DMF5
score +or a o/lation *ro/ is t,e total a"era*e dental caries e0erience at a
artic/lar time. Dental caries e0erience in t,e rimary dentition is denoted -y t,e /se
o+ lo3er case letters to reresent t,e n/m-er o+ decayed, e0tracted, or +illed rimary
teeth and surfaces8 deft and defs,
'(
5,is inde0 ,as recently -een modi+ied to dft and
dfs, -eca/se o+ t,e di++ic/lty in distin*/is,in* a rimary toot, t,at ,as -een e0tracted
+rom one t,at ,as -een lost to t,e nat/ral rocess o+ e0+oliation.
5,e stat/s o+ eriodontal tiss/es ,as -een e"al/ated /sin* se"eral inde0es. 5,e
0in$ival /ndex 7GI8 o+ .oe and Silness
';
is artic/larly s/ited +or assessin* c,an*es in
*in*i"al ,ealt, t,at mi*,t -e o-ser"ed d/rin* t,e e"al/ation eriod o+ an oral ,y*iene
ro*ram. Se"eral la?/e inde0es ,a"e also -een de"eloed to assess t,e stat/s o+ oral
,y*iene in o/lation *ro/s. 5,e Pla5ue /ndex 7)8 o+ Silness and .oe
<$
?/anti+ies
t,e e0tent o+ la?/e on de+ined areas o+ seci+ic toot, s/r+aces. 5,e +ral Hy$iene
/ndexSimplified 7OHI-S8 o+ Greene and 6ermillion
<:
meas/res oral de-ris and
calc/l/s on seci+ic toot, s/r+aces.
5,e Periodontal /ndex 7)I8 o+ !/ssell
<>
and t,e Periodontal Disease /ndex 7)DI8 o+
!am+Aord
<=
were once /sed +or assessin* t,e se"erity o+ eriodontitis, -/t are no
lon*er considered "alid. 4,en t,ese inde0es were de"eloed, it was -elie"ed t,at
*in*i"itis and eriodontitis were on a contin//mD as *in*i"itis -ecame more se"ere,
eriodontitis res/lted. Conse?/ently, t,e )I and )DI were de"eloed as comosite
inde0es, assessin* *in*i"itis and eriodontitis to*et,er. 5oday, it is well esta-lis,ed
t,at *in*i"itis does not necessarily lead to eriodontitis, and t,at t,e two diseases are
/ni?/e. Alt,o/*, t,e )I and )DI are no lon*er /sed, t,e )DI le+t -e,ind a
meas/rement comonent t,at is "alid +or assessin* tiss/e destr/ction. 5,e s/r"i"in*
meas/rement comonent, sometimes re+erred to as loss of attachment or (+,
calc/lates t,e loss o+ eriodontal attac,ment t,at ,as occ/rred adAacent to a toot,. 5,e
Community Periodontal /ndex of Treatment &eed 7C)I5N8 is not an inde0 o+
eriodontitis, -/t a meas/re o+ t,e necessity +or eriodontal treatment.
<&
5,e C)I5N
,as -een /sed -y nations aro/nd t,e world.
4,en /-lic ,ealt,care ractitioners emloy a dental inde0 d/rin* t,e analysis ste,
t,ey m/st ay artic/lar attention to t,e trainin* o+ e0aminers. Consistency in t,e
alication o+ scorin* criteria is aramo/nt to t,e "alidity o+ inde0 scores. A
comarison o+ DMF5 scores +rom one co/nty to anot,er wo/ld -e o+ little "al/e, +or
e0amle, i+ t,e e0aminers in t,e two co/nties alied t,e scorin* criteria in di++erent
ways.
5reatment )lannin* "ers/s )ro*ram )lannin*
Once a ersonal ,ealt,-care ractitioner ,as identi+ied a disease or condition, and
assessed its e0tent, ,e or s,e is ready to transmit t,e in+ormation to t,e atient and
lan a treatment strate*y. Once a /-lic ,ealt,-care ractitioner ,as identi+ied t,e
e0istence o+ a dental /-lic-,ealt, ro-lem and assessed its e0tent, ,e or s,e is ready
to transmit t,e in+ormation to concerned indi"id/als and comm/nity artners.
5o*et,er, t,e /-lic ,ealt,-care ractitioner and artners de"elo a /-lic-,ealt,
ro*ram t,at is tailored to t,e needs o+ t,e comm/nity.
D/rin* t,e treatment lannin* and ro*ram lannin* stes, decisions m/st take into
consideration s/c, +actors as a"aila-le time, +inances, knowled*e, e0erience,
attit/des, and willin*ness to comlete t,e lan. #/st as an indi"id/al atient m/st
consider ,is or ,er ersonal circ/mstances w,en selectin* treatment otions,
comm/nity leaders m/st consider comm/nity reso/rces and riorities w,en selectin*
aroriate /-lic ,ealt, ro*ram otions.
5reatment "ers/s )ro*ram Oeration
Once t,e atient and ersonal ,ealt,-care ractitioner ,a"e decided on an aroriate
treatment lan, treatment o+ t,e disease or condition -e*ins. Once t,e comm/nity and
/-lic ,ealt,care ractitioner ,a"e decided on an aroriate ro*ram lan, t,e /-lic
,ealt, ro*ram is set in motion. )ro*ram oeration /s/ally incl/des t,ree +eat/res,
incl/din* ,ealt, ed/cation, disease re"ention, and ro"ision o+ ser"ices.
<'
Gi"en t,at
administrations c,an*e, reso/rces s,i+t, and attit/des and moti"ations e"ol"e, t,e
ro*ram oeration ste is ne"er static. Comm/nity inter"entions are *enerally more
di++ic/lt to orc,estrate t,an are lans t,at address an indi"id/al, -eca/se more +actors
m/st -e taken into consideration at t,e comm/nity le"el.
Fi*/re :%-= S/r"eys desi*ned to esta-lis, t,e oral ,ealt, needs o+ c,ildren
+re?/ently take lace in a sc,ool settin*. 7Co/rtesy o+ Dr. Art,/r 1enito,
!esearc, 5rian*le Instit/te, Nort, Carolina.8
Fi*/re :%-& Dental /-lic-,ealt, ro*ram lannin* cycle.
Question 2
A. Treatment plannin$ re?/ires t,e in/t o+ t,e ersonal ,ealt,care ractitioner and
in+ormed consent o+ t,e atient, w,ereas pro$ram plannin$ re?/ires t,e in/t o+ t,e
/-lic-,ealt, dentist and in+ormed consent o+ in"ol"ed comm/nity leaders.
1. Indi"id/al State Healt, Deartments oerate /nder t,e administrati"e control o+ t,e
C. 5,e examination ste o+ ersonal ,ealt, care is analo*o/s to t,e analysis ste o+
/-lic ,ealt, care.
D. Comm/nity-water +l/oridation camai*ns o+ten +ail -eca/se o+ olitical
iss/esnot -eca/se o+ ,ealt, deartment decisions.
3. 5,e Community Periodontal /ndex of Treatment &eed 7C)I5N8 is a "alid meas/re
o+ eriodontal tiss/e destr/ction.
)ayment +or Ser"ices "ers/s Financin*
For t,e indi"id/al atient +acin* a treatment lan, t,e scoe and e0tent o+ treatment
ser"ices deend on ersonal reso/rces andBor t,e e0istence o+ t,ird-arty ayment
lans. For t,e comm/nity lookin* +orward to t,e initiation o+ a dental /-lic-,ealt,
ro*ram, t,e scoe and e0tent o+ t,e ro*ram deend on t,e e0istence o+ a"aila-le
/-lic and ersonal ,ealt,-care +/nds. In most cases, /-lic ro*rams are +/nded "ia
t,e +ederal *o"ernment or t,e state. )ro*ram administration and +/ndin* tyically
ori*inate +rom state-le"el ,ealt, deartments, or co/nty-le"el or local area-le"el
,ealt, deartments, w,en t,ey e0ist.
3"al/ation "ers/s Araisal
4,en a ersonal ,ealt,-care ractitioner comletes an indi"id/al atientCs treatment
lan, ,e or s,e e"al/ates t,e indi"id/al d/rin* eriodic inter"als, to ass/re t,at t,e
oral ,ealt, is maintained and any arisin* treatment needs are identi+ied and met. 5,e
resonsi-ilities o+ t,e /-lic ,ealt,-care ractitioner are comara-le. D/rin* t,e
araisal ste, t,e /-lic ,ealt,-care ractitioner +irst needs to assess w,et,er t,e
ro*ram ,as ade?/ately addressed t,e needs o+ t,e comm/nity. As s/c,, all /-lic-
,ealt, ro*rams s,o/ld ,a"e a meas/ra-le set o+ o-Aecti"es a*ainst w,ic, s/ccess or
+ail/re may -e araised. I+, +or e0amle, a dental /-lic-,ealt, ro*ram were
initiated to red/ce t,e oral-cancer incidence in a co/nty e0eriencin* /n/s/ally ,i*,
rates, t,en t,e ro*ram s,o/ld contain a tar*et incidence rate t,at wo/ld si*ni+y
s/ccess. Once t,e /-lic ,ealt,-care ractitioner ,as assessed w,et,er an o-Aecti"e
,as -een met, ,e or s,e m/st monitor t,e e0istence o+ a /-lic ,ealt, ro*ram on a
re*/lar -asis. I+ new s/r"ey data are re?/ired, t,e /-lic ,ealt,-care ractitioner
s,o/ld sec/re t,em. I+ t,e standard a*ainst w,ic, s/ccess is A/d*ed s,o/ld c,an*e,
t,e /-lic ,ealt,-care ractitioner s,o/ld reassess w,et,er t,e ro*ram wo/ld -e
considered a s/ccess.
For -ot, t,e ersonal and /-lic ,ealt,-care ractitioners, t,e e"al/ation and araisal
stes reresent t,e link -etween t,e end o+ a treatment lan or /-lic-,ealt, ro*ram
and t,e -e*innin* o+ a new lan or ro*ram. As lon* as indi"id/al atients ,a"e
treatment needs or comm/nities ,a"e /-lic-,ealt, ro-lems, t,e si0 stes o+ t,e
ersonal and /-lic ,ealt,-care ractitioner can -e alied.
An 30amle o+ a Dental )/-lic-Healt, )ro*ram
A dental sealant is a lastic material t,at is alied to t,e it-and-+iss/re s/r+aces o+
t,e teet, -y oral ,ealt,-care ro+essionals. Dental sealants +/nction as a rimary
re"enti"e a*ent a*ainst dental caries -y o-str/ctin* t,e it-and-+iss/re s/r+ace +rom
-acteria. Dental sealants also may ser"e as a secondary re"enti"e a*ent a*ainst
dental caries w,en alied to inciient lesions. Dentists and dental ,y*ienists aly
dental sealants in ri"ate ,ealt,-care +acilities, ,owe"er t,is means o+ ro"idin* t,e
re"enti"e a*ent is limited -y access to t,e +acilities and t,e ersonal circ/mstances
o+ t,e atients in need.
5,is section o+ t,e c,ater resents a dental /-lic ,ealt, ro-lem in a +ictitio/s
comm/nity called .ourto3n and roceeds t,ro/*, t,e si0 stes o+ t,e /-lic
,ealt,care ractitionerCs met,od, in order to ill/strate ,ow a dental sealant camai*n
mi*,t -e emloyed as an e++ecti"e dental /-lic ,ealt, ro*ram 7Fi*/re :%-'8.
Alt,o/*, t,is e0ercise descri-es a seci+ic ro-lem and ro*ram sol/tion, t,e
rinciles may -e alied more -roadly to ot,er ro-lems and sol/tions.
Survey
5,e s/r"ey ste o+ t,e rocess encomasses t,e se"en-ste model o+ assessin* oral
,ealt, needs. Dr. Sally Sealem, t,e co/nty ,ealt, o++icer in Ho/rtown, -e*an t,e
rocess -y identi+yin* artners and +ormin* an ad"isory committee o+ interested
arties. Dr. Sealem asked administrators +rom t,e sc,ool -oard to Aoin ,er, as well as
sta++ mem-ers +rom t,e ,ealt, deartment, t,e director o+ t,e dental ,y*iene trainin*
ro*ram at Ho/rtown Comm/nity Colle*e, t,e state dental director, and t,e
administrator o+ a nonro+it ,ealt,-care +acility.
D/rin* t,e ad"isory committeeCs +irst meetin*, t,e mem-ers disc/ssed t,eir reso/rces
and limitations. Dr. Sealem knew t,at t,e most cost-e++ecti"e dental sealant ro*ram
wo/ld in"ol"e sc,ool-a*ed c,ildren. 5,e sc,ool administrators ass/red t,e ,ealt,
o++icer t,at a dental sealant ro*ram wo/ld -e welcomed into t,e local sc,ools. 5,e
administrators also said t,at t,e rincials, teac,ers, and sc,ool n/rses wo/ld -e
willin* to coordinate comm/nication wit, arents and st/dents. Dr. Sealem also
reco*ni@ed t,at oral ,ealt,-care ro+essionals wo/ld need to articiate in t,e
ro*ram. 5,e dental director told ,er t,at ,e wo/ld disc/ss t,e roosed ro*ram
wit, t,e state and local dental society. He was +airly s/re t,at t,e dental society wo/ld
em-race t,e ro*ram and ro"ide t,e names o+ a +ew retired ractitioners w,o mi*,t
-e interested in "ol/nteerin* t,eir time to t,e ro*ram. 5,e director o+ t,e trainin*
ro*ram in dental ,y*iene also o++ered t,e assistance o+ ,er +ac/lty and st/dents.
5,e dental director also said t,at t,ere was little money in t,e -/d*et +or a dental
sealant ro*ram. Uon ,earin* t,at t,e dental directorCs -/d*et did not allow +or a
dental sealant ro*ram, t,e administrator o+ t,e non-ro+it ,ealt,care +acility said t,at
t,eir treatment clinic wo/ld -e willin* to donate some money and s/lies to t,e
ro*ram and t,e attendees +rom t,e ,ealt, deartment said t,at t,ey wo/ld look into
t,e e0istence o+ *rant money +rom ri"ate cororations, comm/nity *ro/s, and t,e
+ederal *o"ernment.
)rior to t,e meetin*, Dr. Sealem comiled demo*ra,ic data +or Ho/rtown and all o+
t,e rele"ant data re*ardin* dental caries and re"enti"e oral ,ealt, ro*rams. S,e
disco"ered t,at t,e comm/nity contained aro0imately :$,$$$ sc,ool-a*ed c,ildren.
Most o+ t,ese c,ildren li"ed wit,in :$ miles o+ t,eir resecti"e sc,ools, ,owe"er a
+ew were transorted "ia -/s +rom nei*,-orin* r/ral areas. 5,e socioeconomic stat/s
7S3S8 ro+ile o+ t,e comm/nity was relati"ely low, wit, aro0imately '<E o+
c,ildren ?/ali+yin* +or +ree or red/ced meals at sc,ool. Dr. Sealem also learned t,at
Ho/rtown did not ,a"e access to +l/oridated comm/nity water. Dr. Sealem ,ad no
data descri-in* t,e dental caries re"alence or t,e re"alence o+ dental sealants in
Ho/rtown, ,owe"er s,e did ,a"e access to data +rom se"eral national s/r"eys.
5,e ad"isory committee reco*ni@ed t,at s/r"ey data +rom Ho/rtown wo/ld ,a"e
ro"ided a more comlete ict/re o+ t,e oral-,ealt, conditions in t,eir comm/nity
t,an t,e national data, -/t t,ey also reco*ni@ed t,at in order to collect s/c, data, t,ey
wo/ld ,a"e to cond/ct a s/r"ey +or w,ic, t,ey ,ad limited reso/rces. Gi"en t,e
circ/mstances, t,e ad"isory committee /ltimately decided t,at t,ey wo/ld rely on t,e
national data to draw concl/sions a-o/t t,eir comm/nity.
nalysis
From st/dies o+ national data,
=;
Dr. Sealem knew t,at dental caries re"alence was
,i*,er amon* oor c,ildren t,an it was amon* t,eir non-oor co/nterarts. S,e also
knew t,at t,e ercenta*e o+ /nrestored disease was ,i*,er amon* t,e oor c,ildren.
In addition, national st/dies s,owed t,at only :(.'E o+ c,ildren a*ed ' to :% years
,ad one or more sealed teet,.
<<
Gi"en t,at t,ere was a si@ea-le roortion o+ oor
c,ildren in Ho/rtown and *i"en t,at national s/r"ey data s,owed t,at oor c,ildren
,ad *reater needs, t,e ad"isory committee concl/ded t,at t,ere was *ood reason to
initiate a dental sealant ro*ram in t,eir comm/nity.
Pro$ram Plannin$
D/rin* t,e ro*ram-lannin* sta*e, t,e ad"isory committee listed all o+ t,e ossi-le
ways to imlement a dental-sealant ro*ram in Ho/rtown. Some o+ t,e otions
incl/ded /se o+ a mo-ile dental "an, "isits to c,/rc,es and ot,er meetin* laces,
e0ansion o+ ser"ices at t,e ,ealt, deartment, e0ansion o+ ser"ices at t,e nonro+it
,ealt,-care +acility, and a sc,ool--ased ro*ram. In decidin* on t,e -est aroac,, t,e
ad"isory committee considered a"aila-le reso/rces and otential ad"anta*es and
disad"anta*es o+ eac, otion. Gi"en t,at sc,ool administrators ro"ided ready access
to sc,ools, and -eca/se t,is was w,ere t,e maAority o+ c,ildren co/ld -e +o/nd, t,e
ad"isory committee decided t,at t,ey wo/ld /se a sc,ool--ased dental-sealant
ro*ram. 5,ey also decided t,at t,ey wo/ld /se st/dents +rom t,e dental-,y*iene
trainin* ro*ram at t,e comm/nity colle*e to ed/cate arents and teac,ers a-o/t t,e
-ene+its o+ t,is re"enti"e oral-,ealt, meas/re, and t,ey wo/ld /se t,e retired dentists
+rom t,e comm/nity to administer t,e dental sealants.
In reco*nition o+ t,e -/d*etary constraints, t,e nonro+it ,ealt,-care +acility ro"ided
disosa-le *lo"es, masks, dental mirrors, and ton*/e -lades to t,e ro*ram. In
addition, sta++ mem-ers +rom t,e ,ealt, deartment were a-le to roc/re *rant
+/ndin* +rom a local ,ilant,roic or*ani@ation and dental sealant materials +rom a
national dental s/ly distri-/tor. 5,e ad"isory committee /sed t,e *rant +/nds to
/rc,ase a orta-le dental c,air, *enerator, and li*,t so/rce.
Pro$ram +peration
A+ter t,oro/*, consideration o+ t,e ro-lem and analysis o+ its se"erity, care+/l
lannin*, and roc/rement o+ +/ndin*, t,e sc,ool--ased dental sealant ro*ram was
/t into oeration. In rearation +or t,e initiation o+ t,e ro*ram, in-ser"ice trainin*
ro*rams were cond/cted +or all articiants to a++irm *oals and standardi@e treatment
rotocols. 5,e alication o+ dental sealants to t,e sc,ool c,ildren ro*ressed well,
-eca/se t,e ad"isory committee ,ad aid s/c, care+/l attention d/rin* t,e re"io/s
sta*es.
'inancin$
Alt,o/*, t,e ad"isory committee was a-le to solicit t,e necessary +/nds +or t,e +irst
year o+ t,e dental sealant ro*ram, t,ey reali@ed t,at in order +or t,e ro*ram to ,a"e
a lastin* imact, t,ey wo/ld need to roc/re new +/ndin* o"er time. 5,e *reat
s/ccess o+ t,e ro*ram made t,is ste relati"ely easy. 5,e ad"isory committee created
ress releases and *a"e t,em to t,e rint media. Dr. Sealem asked t,e local tele"ision
stations to inter"iew ,er d/rin* F,ealt, sotsF on t,e local news. 5,e ad"isory
committee caitali@ed on t,e o/larity o+ t,e ro*ram amon* arents and
comm/nity leaders -y askin* t,em to re?/est additional +/nds +rom t,eir le*islati"e
reresentati"es +or t,e stateCs ,ealt, -/d*et. Sta++ mem-ers at t,e ,ealt, deartment
wrote new *rant alications and contin/ed to solicit +/nds o+ ot,er a*encies and
or*ani@ations.
ppraisal
5,e ad"isory committee /sed national data to determine w,et,er t,eir comm/nity
wo/ld -e a *ood candidate +or a dental sealant ro*ram. 5,is aroac, was
satis+actory +or t,e initiation o+ t,e ro*ram, -/t it wo/ld not s/++ice d/rin* t,e
araisal sta*e. In order +or t,e ad"isory committee to e"al/ate w,et,er t,e dental
sealant ro*ram ,ad -een s/ccess+/l in red/cin* dental caries e0erience in
Ho/rtown, t,ey wo/ld need new dataD a -aseline assessment and eriodic assessments
o+ dental-caries and dental-sealant re"alence amon* t,e sc,ool c,ildren.
5,e araisal sta*e is ar*/a-ly one o+ t,e most di++ic/lt comonents o+ a dental /-lic
,ealt, ro*ram. It re?/ires care+/l delineation o+ meas/ra-le *oals and o-Aecti"es and
a detailed lan to collect e"al/ation data o"er many years. 5,e araisal sta*e m/st
take into consideration t,e -ene+its o+ t,e ro*ram and wei*, t,em a*ainst t,e cost. It
m/st also consider alternati"e re"enti"e and treatment re*imens as t,ey de"elo, and
assess w,et,er t,ese new strate*ies mi*,t -e a -etter otion.
3nt,/siasm and e0citement +re?/ently dri"e t,e +irst +ew years o+ a new ro*ram,
,owe"er +/ndin* a*encies and le*islators will e"ent/ally demand t,at t,eir reso/rces
are -ein* alied to an e++icient and e++ecti"e ro*ram. 4it,o/t a "alid araisal lan
in lace, t,e a-ility +or an administrator s/c, as Dr. Sealem to demonstrate e++iciency
and e++ecti"eness is all -/t imossi-le.
Alt,o/*, t,is may -e t,e most di++ic/lt comonent o+ a dental /-lic ,ealt, ro*ram,
administrators ,a"e a n/m-er o+ reso/rces at t,eir disosal. Healt, deartments
tyically ,a"e eidemiolo*ists and s/r"ey researc,ers a"aila-le +or cons/ltation.
AS5DD and t,e Di"ision o+ Oral Healt, at t,e Centers +or Disease Control and
)re"ention also ,a"e cons/ltants a"aila-le.
Fi*/re :%-' Sc,ool--ased dental sealant ro*rams ,a"e -een +o/nd to -e an
e++ecti"e aroac, to red/cin* dental caries in it-and-+iss/re toot, s/r+aces.
7Co/rtesy o+ O,io Di"ision o+ Dental Healt,.8
Levels of Dental Public Health Operation
5,ere are n/mero/s international and national or*ani@ations t,at ,a"e as a rimary or
secondary +oc/s, t,e re"ention and control o+ oral and cranio+acial diseases at t,e
comm/nity le"el. At t,e international le"el, t,e 4orld Healt, Or*ani@ation 74HO8
,as acceted t,e resonsi-ility o+ coordinatin* t,e e++orts o+ all mem-er or*ani@ations
in de"eloin* and imro"in* oral and medical ,ealt, ro*rams t,ro/*,o/t t,e world.
4HO ,as se"eral re*ional o++ices located t,ro/*,o/t t,e world t,at aid in
administerin* ro*rams on a local le"el.
1ased in 4as,in*ton, D.C., t,e )an American Healt, Or*ani@ation 7)AHO8 is one
s/c, re*ional o++ice +or t,e Americas. Mem-er States o+ )AHO incl/de all ='
co/ntries in t,e Americas and )/erto !ico is an Associate Mem-er. France, t,e
Net,erlands, and t,e United 2in*dom o+ Great 1ritain and Nort,ern Ireland are
)articiatin* States, and )ort/*al and Sain are O-ser"er States. 5,e mission o+
)AHO is to stren*t,en national and local ,ealt, systems and imro"e t,e ,ealt, o+ t,e
eoles o+ t,e Americas. It works in colla-oration wit, Ministries o+ Healt,, ot,er
*o"ernment and international a*encies, non*o"ernmental or*ani@ations, /ni"ersities,
social sec/rity a*encies, comm/nity *ro/s, and many ot,ers. )AHO tar*ets t,e most
"/lnera-le *ro/s, incl/din* mot,ers and c,ildren, workers, t,e oor, t,e elderly, and
re+/*ees and dislaced ersons. It +oc/ses on access iss/es and a )an-American
aroac,, enco/ra*in* nations to work colla-- orati"ely on common iss/es.
5,e 4orld Dental Federation 7FDI8 is an indeendent, ro+essional or*ani@ation +or
dentistry. 5,e acti"ities o+ t,e FDI co"er all asects o+ ersonal and /-lic oral
,ealt,care and take lace all o"er t,e world. Amon* its "aried resonsi-ilities, FDI
contri-/tes to t,e de"eloment and dissemination o+ statements re*ardin* olicies,
standards, and in+ormation related to oral ,ealt, care. In addressin* t,is resonsi-ility,
FDI rod/ces t,e statements "ia its Scienti+ic Commission or in colla-oration wit,
ot,er ro+essional or*ani@ation t,ro/*,o/t t,e world.
At t,e national le"el, t,e U.S. Deartment o+ Healt, and H/man Ser"ices 7DHHS8 is
t,e Ca-inet-le"el -ranc, o+ t,e +ederal *o"ernment t,at is resonsi-le +or t,e lannin*
and imlementation o+ a -road array o+ ,ealt, ro*rams, +rom s/ort +or and
rotection o+ Americans o+ all a*es, to aid +or ersons wit, disa-ilities, as well as
assistance and new oort/nities +or t,ose in need. In s,ort, DHHS is resonsi-le +or
/-lic ,ealt, in t,e United States, s/ortin* t,e worldCs lar*est medical researc,
e++ort, ass/rin* t,e sa+ety o+ +oods and ,ealt, care rod/cts, and +i*,tin* t,e ra"a*es
o+ dr/* and alco,ol a-/se. )lannin* -e*ins in 4as,in*ton, D.C., wit, o-Aecti"es
e"ol"in* as ,ealt, needs s,i+t. For e0amle, at one time t,ere was a need to +inance
new dental and medical sc,ools to increase t,e o/t/t o+ ,ealt, ro+essionalsD more
recently t,ere ,as -een a need +or seci+ically +oc/sed ro*rams to accelerate
de"eloment o+ control meas/res +or eit,er caries or eriodontal disease, and
contin/ally t,ere are e++orts to re+ine ro*rams o++erin* -etter access to, or less cost
+or, medical and oral ,ealt,care. DHHS resonsi-ilities in t,e United States are
di"ided into :$ *eo*ra,ic re*ions 7I to G8, eac, one ,a"in* a central o++ice. 5,ese
o++ices +acilitate administration -y ro"idin* cons/ltation and monitorin* e0ertise
+or re*ional and local ,ealt, ro*rams in"ol"in* +ederal +/nds.
DHHS o"ersees :> maAor or*ani@ations, eac, wit, a di++erent in+l/ence o"er /-lic
,ealt, iss/es and dental /-lic ,ealt, ro*rams 7Fi*/re :%-<8. 5,e dministration for
Children and 'amilies 7ACF8 is resonsi-le +or n/mero/s ro*rams t,at ro"ide
ser"ices and assistance to needy c,ildren and +amilies, administers t,e new state-
+ederal wel+are ro*ram 7Temporary ssistance to &eedy 'amilies8, administers t,e
Head Start ro*ram, ro"ides +/nds to assist low-income +amilies in ayin* +or c,ild
care, and s/orts state ro*rams to ro"ide +or +oster-care and adotion assistance.
5,e Health Resources and Services dministration 7H!SA8 ,els ro"ide ,ealt,
reso/rces +or medically /nderser"ed o/lations, s/orts a nationwide network o+
comm/nity and mi*rant ,ealt, centers and rimary care ro*rams +or t,e ,omeless
and residents o+ /-lic ,o/sin*, works to -/ild t,e ,ealt,-care work+orce, maintains
t,e National Healt, Ser"ice Cors, works to imro"e c,ild ,ealt,, and ro"ides
ser"ices to ersons wit, AIDS t,ro/*, t,e !yan 4,ite CA!3 Act ro*rams. 5,e
$ency for Healthcare Research and Euality 7AH!j8 s/orts in"esti*ator-initiated
researc, desi*ned to imro"e t,e o/tcomes and ?/ality o+ ,ealt, care, red/ce its costs,
address atient sa+ety and medical errors, and -roadens access to e++ecti"e ser"ices.
5,e Centers for Disease Control and Prevention 7CDC8 administer a ,ealt,
s/r"eillance system desi*ned to monitor and re"ent o/t-reaks o+ disease. It also
*/ards a*ainst international disease transmission, maintains national-,ealt, statistics
and ro"ides +or imm/ni@ation ser"ices and s/orts researc, into disease and inA/ry
re"ention. 5,e CDCCs Di"ision o+ Oral Healt, maintains and reorts on national and
local oral-,ealt, s/r"eillance data, cons/lts wit, states and local ,ealt, deartments
re*ardin* oral-,ealt, assessments and s/r"ey tec,ni?/es, administers t,e 4ater
Fl/oridation !eortin* System, and /-lis,es olicy statements re*ardin* control o+
in+ection. 5,e $ency for Toxic Su4stances and Disease Re$istry 7A5SD!8 works
wit, states and ot,er +ederal a*encies to re"ent e0os/re to ,a@ardo/s s/-stances
+rom waste sites. 5,e S/-stance A-/se and Mental Healt, Ser"ices Administration
7SAMSHA8 stri"es to imro"e t,e ?/ality and a"aila-ility o+ s/-stance a-/se
re"ention, addiction treatment, and mental ,ealt, ser"ices. 5,e dministration on
$in$ 7AoA8 ro"ides and s/orts om-/dsman ser"ices +or elderly, and ro"ides
olicy leaders,i on a*in* iss/es. 5,e 'ood and Dru$ dministration 7FDA8 ass/res
t,e sa+ety o+ +oods and cosmetics, and t,e sa+ety and e++icacy o+ ,armace/ticals,
-iolo*ical rod/cts, and medical de"ices, incl/din* t,ose /sed in ersonal oral ,ealt,
care settin*s and dental /-lic ,ealt, ro*rams. 5,e Centers for %edicare and
%edicaid Services 7CMS8, +ormerly Health Care 'inancin$ dministration 7HCFA8,
ser"es t,e needs o+ Medicaid and Medicare -ene+iciaries. 5,e /ndian Health Service
7IHS8 o"ersees and s/orts a network o+ ,ositals, ,ealt, centers, sc,ool--ased
,ealt, centers, ,ealt, stations, and /r-an Indian ,ealt, centers t,at ro"ide ser"ices to
nearly :.' million Nati"e Americans and Alaska Nati"es. 5,e &ational /nstitutes of
Health 7NIH8, t,e worldCs remier medical researc, or*ani@ation, s/orts researc,
roAects nationwide in diseases like ,eart ailments, dia-etes, cancer, HI6, Al@,eimerCs
Disease, and ast,ma. 5,e &ational /nstitute for Dental and Craniofacial Research
7NIDC!8, one o+ t,e NIH instit/tes, s/orts intram/ral and e0tram/ral researc,
re*ardin* dental caries, eriodontitis, oral and ,aryn*eal cancer, +acial cle+ts, oral
,ealt, disarities, and re"enti"e oral ,ealt, t,eraies. 5,e Pro$ram Support Center
7)SC8 ro"ides, +or a +ee, sol/tion- and c/stomer-oriented s/ort +or administrati"e
oerations, +inancial mana*ement and ,/man reso/rces t,ro/*,o/t DHHS, as well as
ot,er deartments and +ederal a*encies.
5,e US)HS encomasses t,e Commissioned Cors, t,e /ni+ormed ser"ice o+ t,e
DHHS. Dental o++icers in t,e Commissioned Cors ser"e t,e oral ,ealt, treatment
needs o+ Nati"e Americans and Alaska Nati"es as art o+ t,e IHSD acti"e d/ty
mem-ers, deendents, and retirees o+ t,e U.S. Coast G/ardD and ersons incarcerated
/nder t,e Federal 1/rea/ o+ )risons. 5,e S/r*eon General leads t,e Commissioned
Cors o+ t,e US)HS.
3ac, state ,as a ,ealt, deartment t,at may or may not incl/de an oral-,ealt,
di"ision. O+ t,ose states wit, an oral ,ealt, +oc/s, many di"ide t,eir A/risdictional
oeration into re*ions to -etter administer and monitor state-administered oral-,ealt,
ro*rams. 5,e re*ional ro*rams incl/de oeration o+ clinics +or needy o/lations,
state rison systems, and in some cases, sc,ool systems. Cons/ltations wit,
comm/nities desirin* to esta-lis, or to imro"e comm/nity oral ,ealt,, /-lic ,ealt,
ed/cation ro*rams, and +l/oride initiati"es recei"e maAor em,asis.
4it,in eac, state, o/lo/s co/nties and cities may administer comm/nity oral ,ealt,
treatment clinics t,ro/*, local ,ealt, deartments. 5,ese clinics /s/ally oerate in
sc,ools, economically /nderri"ile*ed areas, or amon* o/lation s/-*ro/s t,at do
not ot,erwise ,a"e access to ro/tine ersonal oral-,ealt, care. Federal, state, and local
ta0 +/nds are intermi0ed in t,e deli"ery o+ care at all le"els.
Fi*/re :%-< Or*ani@ational c,art +or t,e U.S. Deartment o+ Healt, and H/man
Ser"ices.
Dental Public Health Programs
Healt, )romotion and Healt, 3d/cation
Healt, romotion and ,ealt, ed/cation are inte*ral comonents o+ most s/ccess+/l
dental /-lic-,ealt, ro*rams 75a-le :%->8. Health promotion consists o+ any lanned
com-ination o+ ed/cational, olitical, re*/latory, and or*ani@ational s/orts +or
actions and conditions cond/ci"e to t,e ,ealt, o+ a comm/nity or *ro/ o+ indi"id/als
in a de+ined *eo*ra,ic location 7<%8. )roAects desi*ned to -e administered in sc,ools,
s/c, as +l/oride mo/t,rinse ro*rams and dental-sealant ro*rams, ,a"e -een
artic/larly s/ccess+/l, -eca/se dental caries is re"alent in c,ildren and t,ose wit,
t,e *reatest needs may reside wit, arentsB*/ardians w,o are ot,erwise /na-le to
ro"ide +or t,eir treatment needs in ersonal ,ealt,care +acilities. Sc,ool--ased ,ealt,
care ro*rams are disc/ssed elsew,ere in t,is te0t-ook. Healt,-romotion acti"ities
do not re?/ire acti"e articiation o+ its reciients, ,owe"er. )/-lic sanitation
meas/res, +or e0amle, romote ,ealt, amon* ,/mans aro/nd t,e world, yet most o+
t,ese ersons enAoy t,e -ene+its wit,o/t action or awareness. Conse?/ently, ,ealt,-
romotion acti"ities are "itally imortant to dental /-lic-,ealt, ro*rams, -eca/se
t,ey do not /s/ally deend on reciient awareness or cooeration +or s/ccess.
Question 3
A. 5,e American Dental Association is /nder t,e a/sices o+ t,e 4orld Healt,
Or*ani@ation.
1. 5,e ,ealt, olicies o+ t,e U.S. Deartment o+ Healt, and H/man Ser"ices are
administrated +rom t,e :$ !e*ional O++ices o+ t,e Centers +or Disease Control and
)re"ention.
C. Aro0imately :&& million ersons in t,e United States drink +l/oridated water.
D. Healt, romotion +re?/ently yields more immediate e++ects on t,e /-lic t,an does
ed/cation o+ t,e /-lic.
3. 5,e S/r*eon GeneralCs !eort on Oral Healt, in America, released in >$$$, was
one o+ many s/c, reorts dedicated to dentistry.
Health education incl/des any com-ination o+ learnin* e0eriences desi*ned to
ena-le t,e "ol/ntary adotion o+ -e,a"iors or actions t,at are cond/ci"e to ,ealt, and
,ealt,+/l li"in* 7Fi*/re :%-%8.
<(
4,ereas ,ealt,-romotion acti"ities do not re?/ire
t,e acti"e articiation o+ its reciients, ,ealt, ed/cation does. For t,is reason, dental
/-lic-,ealt, ro*rams t,at rely ,ea"ily on ,ealt, ed/cation are s/-Aect to t,e
attit/des, -elie+s, and ot,er moti"atin* +actors o+ t,e reciients. In addition, alt,o/*,
knowled*e is an imortant element o+ emowerment, knowled*e does not */arantee
t,at aroriate actions or -e,a"ioral c,an*es will +ollow.
<;
Healt,-romotion
acti"ities in dental /-lic ,ealt, ro*rams +re?/ently incl/de ,ealt,-ed/cation
comonents, -/t ,ealt,-ed/cation, alone, is not s/++icient to re"ent oral diseases or
conditions.
Comm/nity-4ater Fl/oridation
Comm/nity-water +l/oridation, or t,e addition o+ aroriate concentrations o+
+l/oride como/nds into water systems to re"ent dental caries, is a ,ealt, romotion
acti"ity wit,in a dental /-lic ,ealt, ro*ram. As -ene+icial as water +l/oridation is in
t,e -attle a*ainst dental caries, t,e addition o+ +l/oride to water is not an a/tomatic
condition, ,owe"er, and +re?/ently re?/ires t,e sa""y and care+/l coordination o+
dental /-lic-,ealt, ro+essionals, water en*ineers, le*islators, and or*ani@ed
dentistry. In order to cond/ct a s/ccess+/l +l/oridation camai*n, one m/st
/nderstand olitical realities and reco*ni@e a"aila-le reso/rces in t,e comm/nity t,at
can -e /sed to assist in sec/rin* a +a"ora-le o/tcome.
%$
S/ccess+/l camai*ns re?/ire
dedicated and ent,/siastic ersons w,o are coordinated -y an indi"id/al wit, *ood
olitical skills. S/ort +rom all se*ments o+ t,e o/lation, not A/st ,ealt,
ro+essionals, is cr/cial. 5,e -est met,od to ac,ie"e +l/oridation in a small
comm/nity is t,ro/*, city co/ncil action i+ state laws do not re?/ire a re+erend/m.
3ndorsements o++ered -y strate*ic role models, s/c, as a mayor, city co/ncil mem-er,
or ot,er comm/nity leaders, lay an imortant role in t,e rocess.
Coordination o+ acti"ities is also imortant once a water +l/oridation ro*ram ,as
-een initiated. St/dies s,ow t,at water distri-/tion centers +re?/ently maintain
a?/eo/s +l/oride concentrations t,at are lower t,an recommended le"els.
%:
In order to
com-at t,is reality, a/t,ority s,o/ld rest wit, an administrator w,o is dedicated to t,e
dental /-lic ,ealt, ro*ram and w,o is in a osition to mana*e t,e system.
Fre?/ently, t,e dental director o+ t,e state ,ealt, deartment is an ideal c,oice +or t,e
administrati"e osition. 4,en a dental director is /na"aila-le, dental /-lic ,ealt,
ro+essionals s,o/ld assi*n a erson w,o ,as t,e resonsi-ility o+ water +l/oridation
s/r"eillance and mana*ement.
Secial )o/lation Gro/s
Selected dental /-lic-,ealt, ro*rams incl/de roAects t,at +oc/s on artic/lar
o/lation s/-*ro/s. Certain *ro/s, +or e0amle, -eca/se o+ ,ealt, stat/s, osition
in society, attit/dinal -arriers, or *eo*ra,ic location, do not ,a"e ready access to
ersonal ,ealt,care ro"iders and m/st recei"e care in secial clinics, s/orted -y
/-lic or ri"ate +/nds. 5,e oral ,ealt, care needs o+ t,ese *ro/s, w,ic, incl/de
Nati"e Americans and Alaska Nati"es, lon*-term-care o/lations, mi*rant *ro/s,
medically comromised indi"id/als, -ene+iciaries o+ t,e Deartment o+ 6eterans
A++airs, ersons wit, de"elomental disa-ilities, ,omeless indi"id/als, t,e elderly,
and ersons wit, low socioeconomic stat/s, are /s/ally si*ni+icantly *reater t,an t,ey
are +or t,e *eneral o/lation.
'<,%>-('
For e0amle, medically comromised indi"id/als
and ersons wit, Ac?/ired Imm/node+iciency Syndrome 7AIDS8 are +re?/ently
redisosed to raidly ro*ressin* eriodontitis and ot,er oral ro-lems.
(<,(%

Al@,eimerCs disease and ot,er dementias comromise t,e a-ility o+ many older
ersons to take care o+ t,eir mo/t,s.
((, (;
5,e a-ilities and limited e0erience le"els o+ some ersonal oral ,ealt,-care
ro+essionals, as well as t,e conditions wit,in w,ic, t,ey work may stand in t,e way
o+ e++ecti"e ro"ision o+ care +or some o+ t,ese secial o/lation *ro/s.
;$-;>
For
e0amle, ro/tine treatment +acilities are +re?/ently inaccessi-le to a erson w,o is
,ome-o/nd -eca/se o+ ,ysical or mental disa-ilities or limitations. Dentists and
a/0iliaries, trained in t,e /se o+ mo-ile treatment e?/iment and mana*ement o+ t,e
disa-led atient, are necessary in order to ro"ide oral-,ealt, care to t,e
,ome-o/nd.
;=
In t,is e0amle, t,e remo"al o+ -arriers to care is an e0amle o+ an
e++ecti"e dental /-lic-,ealt, ro*ram.
Dental /-lic-,ealt, ro+essionals in /-lic-,ealt, a*encies, local or state ,ealt,
deartments, and academic instit/tions are called /on to ro"ide cons/ltation or
initiate ro*rams +or indi"id/als wit, artic/lar diseases or conditions. 30amles may
incl/de ed/cational ro*rams aimed toward mot,ers and desi*ned to address +eedin*
-e,a"iors leadin* to early c,ild,ood caries, ro*rams desi*ned to rod/ce mo/t,
*/ards +or ,i*, sc,ool at,letes, ro*rams desi*ned to assess t,e +/nction o+
remo"a-le rost,eses in a *eriatric o/lation, ro*rams desi*ned to ro"ide +l/oride
t,eray to cancer atients /nder*oin* ,ead and neck radiation, ro*rams desi*ned to
screen low-income c,ildren +or oral diseases, or ro*rams desi*ned to ro"ide
in+ormation re*ardin* oral and ,aryn*eal cancer re"ention.
Fi*/re :%-% Classroom dental-ed/cation ro*rams are imortant, -/t it is
critical to e"al/ate t,eir e++ect. 7Co/rtesy o+ t,e National Instit/te o+ Dental and
Cranio+acial !esearc,.8
New Strategies Needed
C,an*in* Disease )atterns
D/rin* t,e early :;$$s, ac/te in+ectio/s diseases were more re"alent t,an t,ey are
today and acco/nted +or *reater mor-idity and ,i*,er mortality amon* t,e *eneral
o/lation. D/rin* t,e :;'$s and :;<$s, wit, t,e ad"ent o+ imm/ni@ations and
anti-iotics, /-lic ,ealt, ro+essionals -e*an to s,i+t t,eir attention to c,ronic
diseases, s/c, as ,eart ailments, cancer, strokes, and dia-etes. Dental /-lic ,ealt,
ro*rams ,a"e ,ad to adat to c,an*in* disease re"alence, as well .
One o+ t,e tr/ly si*ni+icant de"eloments in dental /-lic ,ealt, ,as -een t,e decline
in dental-caries re"alence d/rin* t,e ast :' years.
'<, ;&-:$>
!ed/ced s/sceti-ility to
dental caries, artic/larly amon* c,ildren and yo/n* ad/lts, is alterin* t,e oral-,ealt,
stat/s o+ t,e o/lation. NIH estimated t,at t,e United States sa"ed aro0imately
f:$$ -illion in dental e0endit/res d/rin* t,e :;($s as a res/lt o+ t,is imro"ement in
oral ,ealt,.
:$=
5,e c,an*e in dental-caries re"alence reresents a maAor s/ccess +or
ersonal oral ,ealt, re"enti"e and treatment ser"ices and dental /-lic ,ealt,
ro*rams, -/t it also resents new c,allen*es to t,e ro+ession .
D/rin* t,e early-:;$$s, dental caries was ,i*,ly re"alent across a*e *ro/s and
o/lation s/--*ro/s. 3"eryone re?/ired treatment ser"ices.
:$&
5oday, as a res/lt o+
e++ecti"e re"ention and imro"ed treatment re*imens, dental caries is concentrated in
a s/-stantially smaller roortion o+ t,e o/lation. 5,e c,allen*e to dental /-lic-
,ealt, ro+essionals is to concentrate on identi+yin* ,i*,-risk indi"id/als and
e0andin* ser"ices +or t,ose w,o ,a"e not ,ad access to care. C/rrent trends to
decrease sendin* +or /-lic ro*rams as well as red/ce ,ealt,-care costs s,o/ld
+a"or re"enti"e ro*rams t,at are tar*eted to t,ose w,o ,a"e ,i*,er /nmet le"els o+
oral disease.
:$'-:$<
C,an*in* )/-lic-Healt, )ractices
Dental /-lic-,ealt, ro*rams s,o/ld -e or*ani@ed to meet t,e needs o+ t,e
o/lation. As needs c,an*e, dental /-lic ,ealt, e++orts s,o/ld e"ol"e to address
t,ese c,an*in* needs.
:$%
An acceted c,aracteristic o+ a ro+ession is t,at it s,all -e
willin* to resond to c,an*in* needs as a res/lt o+ its own s/ccess+/l re"enti"e and
treatment acti"ities.
:$(
Concern o"er t,e c/rrent a-ility o+ t,e /-lic-,ealt, ro+ession
to adat to c,an*e is addressed in an Instit/te o+ Medicine reort, entitled The 'uture
of Pu4lic Health,
:$;
5,e reort contends t,at /-lic ,ealt, in t,e United States is
disor*ani@ed, slintered, and /nreared to accommodate and address +/t/re
c,allen*es. 5,e reort *oes on to state t,at t,e means to maintain and e0and /-lic
,ealt, ro*rams and meet t,e demands o+ a c,an*in* en"ironment is "ia assessment,
olicy de"eloment, and ass/rance .
Contrary to t,e reortCs recommendations, olitical and economic +orces in t,e United
States ,a"e ser"ed to red/ce or discontin/e many dental /-lic ,ealt, ro*rams. 5,e
decline o+ dental /-lic ,ealt, ro*rams at t,e national, state and local le"els is, in
art, a res/lt o+ t,e ercetion t,at oral ,ealt, is not a maAor concern.
::$
Nei*,-or,ood, r/ral, mi*rant, and ,omeless ,ealt, centers ,a"e s/++ered se"ere
c/t-acks in +ederal o/tlays +or oral ,ealt, care ser"ices, ersonnel, and scoe o+
ro*rams.
::$
)/-lic-,ealt, dentistry c/rric/la in many sc,ools o+ /-lic ,ealt, are
e0eriencin* maAor red/ctions or dissol/tion. Many comm/nity-dentistry ro*rams
in dental sc,ools are only modest in scoe, relati"e to t,e concentration o+ reso/rces
de"oted to t,ese ro*rams w,en +irst initiated .
4,y ,as t,e downsi@in* o+ dental /-lic-,ealt, ro*rams ro*ressed wit, relati"ely
+ew c,allen*ese One answer may -e t,e lack o+ an or*ani@ed constit/ency or
ad"ocacy *ro/ +or dental /-lic-,ealt, iss/es. A artners,i -etween t,e /-lic and
ersonal ,ealt,-care dental sectors is essential i+ oral ,ealt, concerns are to -e
e++ecti"ely romoted. O+ten t,e aims o+ ro+essional *ro/s wit,in dentistry tend to
-e comartmentali@ed and narrowly de+ined. )/-lic dental ro*rams may also -e seen
as cometiti"e wit, ersonal ,ealt,care ractitioners. )re"enti"e aroac,es are at to
-e erroneo/sly classi+ied as /-lic sector or ersonal ,ealt,care sector ro*rams. Het
t,e e++orts o+ -ot, s,o/ld rein+orce common *oals. Fl/oridation, +or e0amle, may -e
seen as an e++ecti"e /-lic ,ealt, meas/re -/t t,e romotion o+ +l/oride denti+rices
may not -e. Het t,ey comlement eac, ot,er and -ot, are /-lic-,ealt, meas/res.
:::
Cooeration -etween dental /-lic-,ealt, or*ani@ations, s/c, as, t,e American
Association o+ )/-lic Healt, Dentistry 7AA)HD8, t,e American )/-lic Healt,
Association 7A)HA8 Oral Healt, Section, and t,e American Dental Association
7ADA8 co/ld ,el resol"e t,e di++erin* ersecti"es o+ t,e ersonal ,ealt,care and
/-lic sectors. Cooeration co/ld also +oster an in+l/ential alliance in local and
national camai*ns addressin* dental /-lic ,ealt, iss/es. Colla-oration wit, a
m/ltit/de o+ national and local "ol/ntary non-dental ,ealt, and ed/cational
or*ani@ations, s/c, as, t,e C,ildrenCs De+ense F/nd, American Association o+ !etired
)ersons, or t,e National Healt, 3d/cation Coalition is e?/ally imortant to romote
oral ,ealt, as essential to o"erall ,ealt, and to inte*rate oral ,ealt, iss/es wit,in t,e
,ealt,, ed/cational, and olicy directi"es o+ t,ese or*ani@ations. 1y workin* to*et,er
on certain -road--ased o/lar iss/es 7i.e. access to ,ealt, ser"ices8, t,ese searate
artners,is can e"ol"e into a coalition, s/c, as t,e National Oral Healt, Alliance t,at
can -e recr/ited to acti"ely s/ort seci+ic oral ,ealt, iss/es .
In :;;(, '=.( -illion dollars were sent on oral ,ealt, care ser"ices, reresentin*
a-o/t &.%E o+ t,e total ,ealt, e0endit/res -/d*et +or t,at year.
::>
30endit/res +or
oral ,ealt, care ser"ices increased -etween :;;% and :;;( at aro0imately t,e same
rate as e0endit/res +or medical ,ealt, care 7'.= "ers/s '.<E8. Alt,o/*, t,ese +i*/res
s/**est t,at oral ,ealt,-care ser"ices were ade?/ately +/nded, comarisons wit,
+/ndin* le"els +rom earlier decades aint a di++erent ict/re. In :;<$, +or e0amle, >
-illion dollars were sent on oral ,ealt,-care ser"ices, -/t t,is reresented %.=E o+ t,e
total -/d*et.
='
4it, red/ctions in +/nds to s/ort oral ,ealt,-care ser"ices, /-lic-
,ealt, ro*ram administrators will ,a"e to -ecome more oort/nistic and adati"e in
order to cond/ct e++ecti"e ro*rams .
Ot,er ad"ocacy meas/res t,at can -e /rs/ed in s/ort o+ dental /-lic-,ealt,
ro*rams may -e ad"anced t,ro/*, re*/latory and le*islati"e ro/tes. An area o+
acti"ity o+ten entered wit, some rel/ctance is t,e olitical arena. 5,ose in dental
/-lic-,ealt, ro*rams c,aracteristically *o a-o/t t,eir d/ties ?/ietly, content to li"e
wit,in t,e constraints imosed -y citi@ens w,o, +or e0amle, "ote a*ainst +l/oridation.
Niessen -elie"es t,at t,ere are comm/nity re*/latory roles +or dental /-lic ,ealt,
re*ardin* comliance wit, +l/oridation and in+ection control standards.
::=
I+
s/ccess+/l, e++orts to ed/cate and ers/ade ot,ers o+ t,e imortance o+ t,ese iss/es
co/ld ay -i* di"idends. 5,e re"enti"e -ene+it ro"ided to a comm/nity -y initiatin*
andBor monitorin* +l/oridation or a ractice act t,at addresses in+ection control may
-e *reater t,an t,e -ene+it attained +rom a li+etime o+ ractice -y a do@en dentists .
S/ccess+/l /-lic-,ealt, workers need to -e oinion leaders and comm/nity decision
makers re*ardin* oral ,ealt, ro*rams and ser"ices. Ga/ e0ands t,is notion w,en
statin* t,at, FIt is oort/ne +or t,e oral ,ealt, interest *ro/s to strike o/t on t,eir
own -y workin* toward a national, comre,ensi"e, oral ,ealt, -ill.F
::&
!eso/rce
de"eloment co/ld also -e e0edited i+ dental /-lic-,ealt, ro*rams attained
in+l/ence in t,e re*/latory and le*islati"e arenas .
&ational +ral2Health +47ectives
5,e US)HS reco*ni@es t,at an e++ecti"e means to e0and ad"ocacy and re*/latory
acti"ities and *enerate s/ort +or oral-,ealt, ro*rams is "ia t,e settin* o+
meas/ra-le and ac,ie"a-le, national ,ealt, o-Aecti"es. In :;($, t,e +ederal
*o"ernment esta-lis,ed a ro*ram, entitled Promotin$ HealthLPreventin$ Disease6
+47ectives for the &ation, CHH:,
::'
to identi+y and monitor a "ariety o+ ,ealt,
o-Aecti"es, incl/din* :> t,at addressed oral ,ealt, and +l/oridation. Alt,o/*, t,is
ro*ram ro"ided an early oort/nity to romote oral ,ealt, alon*side ot,er national
,ealt, riorities, it did not ade?/ately address t,e means -y w,ic, states and localities
co/ld meet t,e o-Aecti"es. S/-se?/ent national-,ealt, o-Aecti"es +or >$$$
::<
-/ilt
/on t,e re"io/s +ramework, -y ro"idin* strate*ies t,at wo/ld -e ,el+/l in
meetin* t,e new o-Aecti"es. 5oward t,at end, t,e US)HS o/tlined twenty-nine
meas/ra-le oral ,ealt, o-Aecti"es and indicators in anot,er doc/ment, entitled
Healthy Communities <:::6 %odel Standards,
::%
and called +or eriodic reorts
::(->$$
and consortia
:>:
to romote t,e national ,ealt, o-Aecti"es +or >$$$ .
In >$$$, t,e US)HS released national ,ealt, o-Aecti"es +or >$:$, w,ic, incl/ded an
oral ,ealt, +oc/s area
:>>
75a-le :%-=8. 5,ese oral ,ealt, o-Aecti"es di++ered +rom
re"io/s ones, in t,at t,ey incororated a F-etter t,an t,e -estF standard +or settin*
*oals, as oosed to settin* disarate *oals +or certain o/lation s/--*ro/s. For
e0amle, t,e -est "al/e attained +or any sin*le o/lation s/-*ro/ in >$$$ was /sed
to determine t,e *oal +or all o/lation s/--*ro/s in >$:$. 5,e rationale -e,ind t,is
standard-settin* met,od was to esta-lis, a sin*le ,i*, *oal +or all *ro/s, rat,er t,an
to eret/ate disarities o"er time .
Special Populations
D/rin* t,e last two decades, t,e United States ,as e0erienced an increase in t,e
n/m-er o+ secial o/lation *ro/s, incl/din* ersons in lon*-term care,
%&
medically
comromised indi"id/als,
%(
and t,e ,omeless.
(:,(>
Hi*,er /nmet needs in t,ese secial
o/lation *ro/s ,as -een ,amered -y limited +inancial reso/rces at t,e +ederal and
state le"els. 5,e roortion o+ older ersons in t,e o/lation ,as also increased
:>=
and will contin/e to increase, as t,e F-a-y--oomF *eneration a*es. 5,e increased oral
,ealt, care needs o+ older Americans co/ld ,a"e dramatic e++ects on t,e oral ,ealt,-
care deli"ery system
',:>&-:><
and t,e a-ility to meet t,e national ,ealt, o-Aecti"es +or
>$:$ i+ ersonal and /-lic ,ealt,-care ro*rams are not de"eloed to address t,e
demand .
.imited access to oral ,ealt,-care ser"ices +or t,e secial o/lation *ro/s also
co/ld a++ect t,e a-ility to meet t,e national-,ealt, o-Aecti"es +or >$:$. Only a small
roortion o+ t,e secial o/lation *ro/s ,a"e ersonal dental-ins/rance co"era*e,
and oral ,ealt,-care -ene+its "ia /-lic ro*rams ,as not ket ace wit, c,an*in*
demands.
:>%,:>(
Medicaid e0endit/res +or oral ,ealt,-care ser"ices ,a"e decreased -y
almost =$E since :;(%, +ar more t,an any ot,er ,ealt,-care ser"ice.
::>,:>;
In :;;(,
Medicaid e0endit/res +or oral ,ealt, care reresented only :.=E o+ t,e total
Medicaid e0endit/res -/d*et.
::>
+ther Trends ffectin$ +ral Health
Ot,er trends co/ld in+l/ence t,e attainment o+ national-,ealt, o-Aecti"es, incl/din*
ad"ances in tec,nolo*y, ersonnel re?/irements, and ro+essional ed/cation.
Ad"ances in imlant materials, restorati"e met,ods, c,emot,erae/tic a*ents,
*enetics, and t,e identi+ication o+ risk markers +or disease,
:=$
+or e0amle, s,o/ld
a++ect ersonal and /-lic ,ealt,care deli"ery systems well into t,e +/t/re. Ad"ances
in com/ter tec,nolo*y s,o/ld lead to de"eloments in all areas o+ -iomedical
researc,, inno"ati"e ways to mana*e and retrie"e data, and t,e ro"ision o+ ,ealt,
care ser"ices .
H/man reso/rces are a critical +actor in any dental /-lic ,ealt, ro*ram. C,an*es in
t,e distri-/tion o+ oral ,ealt,-care ersonnel certainly co/ld imact meetin* t,e
national ,ealt, o-Aecti"es +or >$:$. !ecent data ,a"e s/**ested t,at t,e n/m-er o+
dentists will decline d/rin* t,e ne0t :' to >$ years,
:=:
,owe"er t,e rediction models
/sed to determine FaroriateF le"els o+ ersonnel +re?/ently ,a"e s/++ered +rom a
lack o+ data and *enerally ,a"e -een /na-le to acco/nt +or eidemiolo*ical, social,
economic, and olitical "aria-ility o"er time.
:=>
Conse?/ently, w,et,er t,e nation as a
w,ole +aces an /nders/ly o+ oral ,ealt, care ro+essionals remains /nclear,
,owe"er, /nless actions are taken to address t,e lack o+ ersonal and /-lic ,ealt,care
ro+essionals in desi*nated Fdental ,ealt, manower s,orta*e areas,F
:==
it is +airly
certain t,at t,ese arts o+ t,e co/ntry will +ind it di++ic/lt meetin* t,e national-,ealt,
o-Aecti"es .
5,e ro+essional ed/cational c/rric/la is e"ol"in* contin/o/sly, as a res/lt o+
-/d*etary constraints and redistri-/tions in enrollment, distri-/tions o+ disease,
treatment and ,ealt,-care deli"ery systems, in+ormation trans+er, and demo*ra,ics.
C,an*es in t,e c/rric/la *enerally re?/ire additional interdiscilinary researc,,
re"enti"e modalities, and comm/nity--ased initiati"es.
:=&
!mer$in$ Pu4lic Concerns
)/-lic and ro+essional reactions to ercei"ed risks in t,e oral ,ealt, care deli"ery
system a++ect treatment modalities, ser"ice /tili@ation, and /ltimately oral ,ealt,
stat/s. 4ell /-lici@ed reorts o+ indi"id/als contractin* a n/m-er o+ conditions +rom
+l/oride, and amal*am restorations ,a"e romted t,e dental researc, comm/nity to
re"iew t,e risks associated wit, t,e /se o+ t,ese +/ndamental comonents o+ dental
re"ention and treatment.
:=',:=<
O+ e"en *reater t,reat to t,e ractice o+ dentistry and
t,e recr/itment o+ +/t/re dental ersonnel is t,e +ear o+ contractin* an HI6
in+ectionBAIDS in t,e dental o++ice -y -ot, ,ealt,-care ro"iders and atients.
:=%,:=(
4,ile dental /-lic-,ealt, ro+essionals ,a"e -een at t,e +ore+ront in ens/rin* access
+or atients in+ected wit, t,e AIDS "ir/s, many dental ractitioners are still rel/ctant
to treat known AIDS atients. On t,e ot,er ,and, t,e re"elation o+ t,e ro-a-le
occ/ational transmission o+ t,e AIDS "ir/s +rom a dentist to +i"e o+ ,is atients ,as
*enerated a ,i*, le"el o+ concern and an0iety a-o/t recei"in* dental care amon* t,e
/-lic.
:=(-:&$
Dental /-lic-,ealt, acti"ities ,a"e -een directed at re"entin* transmission o+
in+ectio/s diseases in t,e dental o++ice -y re?/irin* dentists to comly wit,
recommended ADA and CDC in+ection control */idelines and t,e Occ/ational
Sa+ety and Healt, Administration 7OSHA8 1lood-orne )at,o*ens Standard.
Howe"er, imlementation o+ t,ese edicts is already dramatically c,an*in* t,e scoe
and cost o+ deli"erin* oral ,ealt,-care ser"ices in ersonal and /-lic ,ealt,-care
settin*s.
:&:-:&=
Surgeon General's Report
In :;;%, Donna S,alala, t,en Secretary o+ DHHS, commissioned t,e O++ice o+ t,e
S/r*eon General to create a reort to, FDe+ine, descri-e, and e"al/ate t,e interactions
-etween oral ,ealt, and *eneral ,ealt, and well--ein* 7?/ality o+ li+e8, t,ro/*, t,e
li+e san, in t,e conte0t o+ c,an*es in society.F
:&&
D/rin* t,e ne0t t,ree years, /nder
t,e direction o+ t,e National Instit/te o+ Dental and Cranio+acial !esearc,, )roAect
Director Dr. Caswell A. 3"ans s/er"ised an imressi"e list o+ contri-/tin* a/t,ors
and content e0erts. On May >', >$$$, at S,e,erd 3lementary Sc,ool in
4as,in*ton, D.C., Assistant Secretary +or Healt, and S/r*eon General, Da"id
Satc,er, released +ral Health in merica6 Report of the Sur$eon 0eneral,
='
t,e
+irst-e"er S/r*eon GeneralCs reort e0cl/si"ely dedicated to oral ,ealt, iss/es. In ,is
resentation to t,e Nation t,at day, S/r*eon General Satc,er s/mmari@ed key t,emes
o+ t,e reort9 :8 oral ,ealt, means m/c, more t,an ,ealt,y teet,, >8 oral ,ealt, is
inte*ral to *eneral ,ealt,, =8 sa+e and e++ecti"e disease re"ention meas/res e0ist t,at
e"eryone can adot to imro"e oral ,ealt, and re"ent disease, and &8 *eneral ,ealt,-
risk +actors, s/c, as to-acco /se and oor dietary ractices, also a++ect oral and
cranio+acial ,ealt, .
5,e S/r*eon GeneralCs !eort was di"ided into +i"e arts, eac, relatin* to a artic/lar
?/estion. )art One asked 3hat is oral health, )art 5wo asked 3hat is the status of
oral health in merica, )art 5,ree asked 3hat is the relation 4et3een oral health and
$eneral health and 3ell24ein$, )art Fo/r asked ho3 is oral health promoted and
maintained and ho3 are oral diseases prevented, and )art Fi"e asked 3hat are the
needs and opportunities to enhance oral health, In answerin* t,ese ?/estions, t,e
S/r*eon GeneralCs !eort listed se"eral +indin*s t,at re+lected t,e +o/r rincial
t,emes 9
Oral diseases and disorders, in and o+ t,emsel"es, a++ect ,ealt, and well--ein*
t,ro/*,o/t li+e .
Sa+e and e++ecti"e meas/res e0ist to re"ent t,e most common dental
diseasesdental caries and eriodontal diseases .
.i+estyle -e,a"iors t,at a++ect *eneral ,ealt, s/c, as to-acco /se, e0cessi"e alco,ol
/se, and oor dietary c,oices a++ect oral and cranio+acial ,ealt,, as well .
5,ere are ro+o/nd and conse?/ential oral ,ealt, disarities wit,in t,e U.S.
o/lation .
Additional in+ormation is needed to imro"e AmericaCs oral ,ealt, and eliminate
,ealt, disarities .
5,e mo/t, re+lects *eneral ,ealt, and well--ein* .
Oral diseases and conditions are associated wit, ot,er ,ealt, ro-lems .
Scienti+ic researc, is key to +/rt,er red/ction in t,e -/rden o+ diseases and disorders
t,at a++ect t,e +ace, mo/t,, and teet, .
5,e S/r*eon GeneralCs !eort s/mmari@ed dramatic c,an*es in oral ,ealt, iss/es
d/rin* t,e last cent/ry, and it also -ro/*,t to li*,t some serio/s c,allen*es +or t,e
+/t/re. It stated t,at, alt,o/*, oral ,ealt, ,as imro"ed in t,e United States,
disarities in ,ealt, still e0ist. Seci+ic o/lation *ro/s, s/c, as in+ants and yo/n*
c,ildren, t,e oor, t,ose residin* in r/ral locations, t,e ,omeless, ersons wit,
disa-ilities, racial and et,nic minorities, t,e instit/tionali@ed, and t,e +rail elderly,
contin/e to e0erience a *reater -/rden o+ oral and cranio+acial diseases. 5,e S/r*eon
GeneralCs !eort also stated t,at t,ere were *reat disarities in access to oral ,ealt,
care and /tili@ation o+ re"enti"e ser"ices, eac, cr/cial to t,e esta-lis,ment and
maintenance o+ otimal oral and *eneral ,ealt,. Finally, t,e reort reco*ni@ed t,at
t,ere were ins/++icient data to descri-e t,e o/lation s/-*ro/s in *reatest need +or
oral ,ealt,-care ser"ices and dental /-lic-,ealt, ro*rams. 5,e lack o+ data will
make t,e de"eloment o+ rele"ant and e++ecti"e dental /-lic ,ealt, ro*rams a more
di++ic/lt task .
1y /-lis,in* t,e S/r*eon GeneralCs !eort, t,e O++ice o+ t,e S/r*eon General ,as
made a"aila-le imortant and timely in+ormation to ,ealt,-care ractitioners, /-lic-
,ealt, ro+essionals, olicy makers, and t,e /-lic. For access to t,e reort, t,e
O++ice o+ t,e S/r*eon General ro"ides an electronic "ersion o+ t,e doc/ment and
o++ers a +ree ,ardcoy o+ t,e reort to all w,o re?/est one .
Summary
5,e core +/nctions o+ /-lic ,ealt, incl/de assessment, olicy de"eloment, and
ass/rance. 5,ese +/nctions are also essential comonents o+ dental /-lic ,ealt,,
w,ic, is de+ined as t,e science and art o+ re"entin* and controllin* dental diseases
and romotin* ,ealt, t,ro/*, or*ani@ed comm/nity e++orts. It +ollows, t,en, t,at
dental /-lic-,ealt, ro*rams are any or*ani@ed e++orts t,at stri"e to re"ent and
control oral and cranio+acial diseases at t,e comm/nity le"el .
,istory. Ar*/a-ly, one o+ t,e most s/ccess+/l dental /-lic ,ealt, ro*rams e"er
created to address t,ese ro-lems ,as -een comm/nity water +l/oridation. As
s/ccess+/l as +l/oridation ,as -een, ,owe"er, new dental /-lic-,ealt, ro*rams need
to -e de"eloed to meet t,e needs o+ o/lation s/-*ro/s w,o ,a"e s/++ered +rom
,i*,er -/rdens o+ disease and ,a"e ,ad oorer access to timely re"enti"e and
treatment ser"ices. 5,e S/r*eon GeneralCs !eort on Oral Healt, in America
,i*,li*,ted some o+ t,ese concerns and laced t,em in t,e conte0t o+ e0istin*
ro*rams and olitical realities. In addition, t,e +ederal *o"ernment reco*ni@ed t,at
one way to address some o+ t,e oral ,ealt, disarities t,at e0ist is to esta-lis, realistic
national ,ealt, o-Aecti"es +or >$:$ .
5,e initiation and imlementation o+ any dental /-lic-,ealt, ro*ram +ollows an
esta-lis,ed lannin* cycle, t,e +irst sta*e o+ w,ic, in"ol"es assessin* t,e oral-,ealt,
needs o+ t,e comm/nity. Once a ro-lem is tentati"ely identi+ied, it is addressed
t,ro/*, t,e /se o+ si0 se?/ential stes o+ t,e /-lic ,ealt,care ractitionerCs
met,ods/r"ey, analysis, ro*ram lannin*, ro*ram oeration, +inancin*, and
araisal. AS5DD esta-lis,ed a se"en-ste model +or needs assessment w,ic,
+/nctions well d/rin* t,e +irst ste .
4,en traditional dental /-lic-,ealt, ro*rams ro"e ine++ecti"e, t,ey m/st -e
relaced -y more cost-e++ecti"e aroac,es. 5,e com-ination o+ less disease, more
e++ecti"e /se o+ ersonnel, and imro"ed tec,nolo*y and re"enti"e met,ods,
artic/larly dental sealants, ro"ides oort/nities to create dental /-lic-,ealt,
ro*rams +or t,ose w,o ,a"e -een traditionally ne*lected. In order to +/l+ill t,ese
oort/nities, ,owe"er, a constit/ency o+ /-lic and ersonal dental and non-dental
ad"ocacy *ro/s is re?/ired .
Dental /-lic-,ealt, ro*rams lay a critical role in t,e romotion and maintenance
o+ oral ,ealt, in America. 5,e c,allen*e +or dental /-lic-,ealt, ractitioners is to
de"ise ro*rams t,at are e++ecti"e, yet incororate t,e rinciles o+ so/nd lannin*
and imlementation. 5,e oral ,ealt, o+ t,e /-lic deends on it .
: . 1, D, and 3correct .
Aincorrect. C,ildren wit, t,e *reatest treatment needs are /s/ally at t,e -ottom o+
t,e economic scale and ,a"e +ewer reso/rces a"aila-le. Until access to care +or t,ese
c,ildren is imro"ed, t,ey will contin/e to -e in *reat need o+ oral-,ealt, treatment
ser"ices .
Cincorrect. In t,e United States, t,e incidence o+ oral cle+ts is t,ree times ,i*,er
amon* w,ites t,an it is amon* -lacks .
> . A and Dcorrect .
1incorrect. 5,e State Healt, Deartments are /nder t,e administrati"e control o+
State *o"ernment. 5,ere is o+ten cooeration -etween t,e U.S. Deartment o+ Healt,
and H/man Ser"ices and State Healt, Deartments, ,owe"er, -eca/se many ,ealt,
ro*rams are +inanced -y t,e +ederal *o"ernment .
Cincorrect. 5,e examination ste o+ ersonal-,ealt, care is analo*o/s to t,e survey
ste o+ /-lic-,ealt, care .
3incorrect. 5,e C)I5N is a "alid meas/re o+ treatment need. A "alid meas/re o+
tiss/e destr/ction is an assessment o+ loss o+ eriodontal attac,ment 7.OA .7
= . C and Dcorrect .
Aincorrect. 5,e American Dental Association is not /nder t,e a/sices o+ t,e
4orld Healt, Or*ani@ation, ,owe"er it is a mem-er o+ t,e 4orld Dental Federation
7FDI .7
1incorrect. 5,e ten !e*ional O++ices are o+ t,e U.S. Deartment o+ Healt, and
H/man Ser"ices, not t,e CDC .
3incorrect. 5,e S/r*eon GeneralCs !eort on Oral Healt, in America was t,e +irst
e"er reort o+ its kind .
: . 5,e core +/nctions o+ /-lic ,ealt, incl/de iiiiiiiii, iiiiiiiii, and
.iiiiiiiii
> . 1y de+inition, dental /-lic-,ealt, ro*rams are .iiiiiiiii
= . Accordin* to :;;( estimates, aro0imately fiiiiiiiii was sent on oral ,ealt,-
care ser"ices in t,e United States .
& . D%'S reresents decayed, missin*, and +illed toot, s/r+aces, w,ereas, iiiiiiiii
reresents a caries e0erience inde0 +or rimary teet, .
' . 1y de+inition, a /-lic-,ealt, ro-lem is one t,at meets t,e +ollowin* criteria9
iiiiiiiii and .iiiiiiiii
< . 5,e +ollowin* are comarati"e met,ods /sed in ersonal and /-lic ,ealt,care
ractice 9
Si0 stes o+ ersonal-,ealt, care Si0 stes o+ /-lic-,ealt, care
30amination S/r"ey
iiiiiiiiiiiiiiiiii iiiiiiiiiiiiiiiiii
5reatment lannin* )ro*ram lannin*
5reatment iiiiiiiiiiiiiiiiii
)ayment +or ser"ices Financin*
iiiiiiiiiiiiiiiiii Araisal
% . 5wo dental /-lic-,ealt, ro*ram strate*ies +or rimary re"ention o+ oral and
,aryn*eal cancer are9 iiiiiiiii and .iiiiiiiii
( . .ist t,ree national oral ,ealt, o-Aecti"es +or >$:$9 iiiiiiiii, iiiiiiiii, and
.iiiiiiiii
; . .ist t,e +o/r rincile t,emes o+ t,e S/r*eon GeneralCs !eort on Oral Healt,9
iiiiiiiii, iiiiiiiii, iiiiiiiii, and .iiiiiiiii
:$ . Healt, romotion consists o+ any .iiiiiiiii 9
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Rep, <'9:&$=-( .
>% . Ast, D. 1., Finn, S. 1., g McCa++rey, I. 7:;'$8. 5,e New-/r*,-2in*ston caries-
+l/orine st/dy. I. Dental +indin*s a+ter t,ree years o+ water +l/oridation. m " Pu4lic
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Res, >%9>%;-(< .
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+l/oride on ,ealt,. " m Dietetic ssoc, :$$9:>$(-:= .
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),iladel,ia9 4.1. Sa/nders Co. . =&-&> .
=% . 2aste, .. M., Selwit@, !. H., Oldakowski, !. #., 1r/nelle, #. A., 4inn, D. M., g
%'7Sec Iss89<=:-&: .
=( . !ies, .. A. G., 3isner, M. )., 2osary, C. .., Hankey, 1. F., Miller, 1. A., Cle**,
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=( .
&$ . 1rown, .. #., 1r/nelle, #. A., g 2in*man, A. 7:;;<8. )eriodontal stat/s in t,e
United States, :;((-:;;:9 re"alence e0tent, and demo*ra,ic "ariation. " Dent Res,
%'7Sec Iss89<%>-(: .
&: . Al-andar, #. M., 1r/nelle, #. A., g 2in*man, A. 7:;;;8. Destr/cti"e eriodontal
disease in ad/lts =$ years o+ a*e or older in t,e United States, :;((-:;;&. "
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Needs, de"eloment, +ield testin*, and statistical e"al/ation. Gene"a, Swit@erland9
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%$ . Faine, !. C., Collins, #. #., Daniel, #. 7:;(:8. Isman, 1., 1oriskin, #., Ho/n*, 2. ..,
g Fit@*erald, C. M. 5,e :;($ +l/oridation camai*ns9 a disc/ssion o+ res/lts. "
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%& . American Dental Association 7:;(>8. Oral ,ealt, stat/s o+ 6ermont n/rsin* ,ome
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and related -e,a"io/rs o+ U.S. n/rsin* ,ome residents, :;;'. 0erodontolo$y,
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%< . 4ool+olk, M., Hamard, M., g 1a*ramian, !. A. 7:;(&8. Oral ,ealt, o+ c,ildren o+
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%% . 3ntwistle, 1. A., g Swanson, 5. M. 7:;(;8. Dental needs and ercetions o+ ad/lt
Hisanic mi*rant +armworkers in Colorado. " Dent Hy$, <=9>(<-(; .
%( . .ittle, #. 4., g Falace, D. A., Miller, C. S., g !,od/s, N. .. 7>$$>8. Dental
mana$ement of the medically compromised patient, St. .o/is9 C6 Mos-y .

Engineering Books
www.allislam.net
%;. Niessen, .., g D/nlea"y, H. A. 7:;(&8. Meetin* t,e oral ,ealt, needs o+ t,e a*in*
"eteran. In 4etle, 5., g !owe, #. 4., 3ds. +lder veterans6 (in*in$ = and
community resources, 7. =<;-&$%8. Cam-rid*e, MA9 Har"ard Uni"ersity )ress.
($. U.S. Deartment o+ Healt, and H/man Ser"ices 7:;($8. Special Report6 Dental
Care for Handicapped People, DHHS )/-. No.7)HS8 (:-'$:'&. 4as,in*ton, DC9
U.S. Go"ernment )rintin* O++ice.
(:. Gel-er*, .., .inn, .. S., g !osen-er*, D. #. 7:;((8. Dental ,ealt, o+ ,omeless
ad/lts. Spec Care Dent, (9:<%-%>.
(>. Gi-son, G., !osen,eck, !., 5/llner, #. 1., Grimes, !. M., Sei-yl, C. .., !i"era-
5orres, A., Goodman, H. S., g N/nn, M. 3. 7>$$=8. A national s/r"ey o+ t,e oral
,ealt, stat/s o+ ,omeless "eterans. " Pu4lic Health Dent, <=7:89=$-%.
(=. 1eck, #. D. 7:;((8. 5rends in oral disease and ,ealt,. 0erondontol, %9>:->'.
(&. 1eck, #. D., g H/nt, !. #. 7:;('8. Oral ,ealt, stat/s in t,e United States9 ro-lems
o+ secial atients. " Dent !duc, &;9&$%->'.
('. 2lein, S. )., 1o,annon, H. M., 1ell, !. M., et al. 7:;('8. 5,e cost and
e++ecti"eness o+ sc,ool--ased re"enti"e dental care. m " Pu4lic Health, %'9=(>-;:.
(<. U.S. Deartment o+ Healt, and H/man Ser"ices 7:;(<8. National Instit/tes o+
Healt,. Detection and Prevention of Periodontal Disease in Dia4etes, NIH )/-. No.
(<-::&(. 1et,esda, MD9 U.S. Go"ernment )rintin* O++ice.
(%. )atton, .. .., ),elan, #. A., !amos-Gome@, 3. #., Nittayananta, 4., S,i-oski, C.
H., g M-/*/ye, 5. .. 7>$$>8. )re"alence and classi+ication o+ HI6-associated oral
lesions. +ral Dis, ( S/l >9;(-:$;.
((. 2ocaelli, H., Haltirik, M., Har*ic, .. I., g O@-as, H. 7>$$>8. Al@,eimerCs disease
and dental mana*ement. +ral Sur$ +ral %ed +ral Pathol +ral Radiol !ndod,
;=7'89'>:-&.
(;. S,i, #. A. 7:;;>8. Oral ,ealt, o+ atients wit, Al@,eimerCs disease. " m Dent
ssoc, :>=9'=-'(.::
;$. Antc@ak, A. A., 1ranc,, .. G. 7:;('8. )ercei"ed -arriers to t,e /se o+ dental
ser"ices -y t,e elderly. 0erodontics, :9:;&-;(.
;:. Gil-ert, G. H. 7:;(;8. FA*eismF in dental care deli"ery. " m Dent ssoc,
::(9'&'-&(.
;>. Co,en, .. A., g Grace, 3. G. 7:;;$8. In+ection control ractices related to
treatment o+ AIDS atients. " Dent Pract dmin, %9:$(-:'.
;=. Strayer, M. S. 7:;;'8. )ercei"ed -arriers to oral ,ealt, care amon* t,e
,ome-o/nd. Spec Care Dentist, :'7=89::=-(.
;&. 1r/nelle, #. A., g Carlos, #. ). 7Marc, :;(;8. !ecent trends in dental caries in
U.S. c,ildren and t,e e++ect o+ water +l/oridation. International Fl/oride Symosi/m,
)ine Mo/ntain, Geor*ia.
;'. 1ell, !. M., 2lein, S. )., 1o,annan, H. 1., et al. 7:;(&8. Treatment !ffects in the
&ational Preventive Dentistry Demonstration Pro$ram, Santa Monica, CA9 !andD !-
=$%>-!4#.
;<. 1o,annnon, H. M., g 1ader, #. D. 7:;(&8. F/t/re imact o+ /-lic ,ealt, and
re"enti"e met,ods on t,e incidence o+ dental caries. " Can Dent ssoc, '$9>>;-==.
;%. 1r/nelle, #. A., g Carlos, #. ). 7:;(>8. C,an*es in t,e re"alence o+ dental caries
in U.S. sc,oolc,ildren9 :;<:-:;($. " Dent Res, <:9:=&<-':.
;(. 1ryan, 3. 5., Collier, D. !., Howard, 4. !., g 6an Clea"e, M. .. 7:;(>8. Dental
,ealt, stat/s o+ sc,ool c,ildren in 5ennesseea >'-year comarison. " Tenn State
Dent ssoc, <>9=:-==.
;;. De)aola, ). F. 7:;(=8. 5,e Massac,/setts ,ealt, s/r"ey. " %ass Dent Soc,
=>7:89:$-:, >=-'.
:$$. Glass, !. .. 7:;(:8. Sec/lar c,an*es in caries re"alence in two Massac,/setts
towns. Caries Res, :'9&&'-'$.
:$:. H/*,es, #. 5., !o@ier, !. G., g !amsey, D. .. 7:;($8. The &atural History of
Dental Disease in &orth Carolina, CHD92DD, D/r,am, NC9 Academic )ress.
:$>. 1/rt, 1. A. 7:;('8. 5,e +/t/re o+ t,e caries decline. " Pu4lic Health Dent,
&'9><:-<;.
:$=. 1ea@o*lo/, 5., 1rown, #., g He++ley, D. 7:;;=8. Dental care /tili@ation o"er
time. Soc Sci %ed, =%9:&<:-%>.
:$&. Friedman, #. 4. 7:;%%8. A cons/mer ad"ocateCs "iew o+ comm/nity dentistry. "
Dent !duc, &:9<'<-';.
:$'. Federation Dentaire Internationale 7:;((8. 5ec,nical !eort No. =:. !e"iew o+
met,ods o+ identi+ication o+ ,i*, caries risk *ro/s and indi"id/als. /nt Dent ",
=(9:%%-(;.
:$<. Stamm, #. S., Disney, #. A., Gra"es, !. C., et al. 7:;((8. 5,e Uni"ersity o+ Nort,
Carolina caries risk assessment st/dy. I. !ationale and content. " Pu4lic Health Dent,
&(9>>'-=>.
:$%. Gala*an, D. #. 7:;%<8. Some comments on t,e +/t/re o+ dental /-lic ,ealt,. "
Pu4lic Health Dent, =<9;<-:$>.
:$(. D/nnin*, #. M. 7:;%;8. G/est editorial9 t,e stone wall. " Pu4lic Health Dent,
=;9:%'-%<.
:$;. Instit/tes o+ Medicine 7:;((8. 5,e +/t/re o+ /-lic ,ealt,. 4as,in*ton, DC9
::$. Mil*rom, )., g !eisine, S. 7>$$$8. Oral ,ealt, in t,e United States9 t,e ost-
+l/oride *eneration. nn Rev Pu4lic Health, >:9&$=-=<.
:::. Glass, !. .. 7:;($8. 5,e /se o+ +l/oride denti+rices9 a /-lic ,ealt, meas/re.
Community Dent +ral !pidemiol, (9>%(-(>.
::>. Healt, Care Financin* Administration 7>$$$8. &ational Health !xpenditures
CHHF, 4as,in*ton, DC9 Healt, Care Financin* Administration.
::=. Niessen, .. C. 7:;;$8. New directions-constit/encies and resonsi-ilities. "
Pu4lic Health Dent, 7Sec Iss8D'$9:==-=(.
::&. Ga/, ). G. 7:;;$8. New initiati"es +or ad"ocacy in national maternal and c,ild
oral ,ealt,. " Pu4lic Health Dent, 7Sec Iss8D'$9=;<-&$:.
::'. U.S. Deartment o+ Healt, and H/man Ser"ices 7:;($8. Promotin$
HealthLPreventin$ Disease6 +47ectives for the &ation, 4as,in*ton, DC9 )/-lic
Healt, Ser"ice, '&.
::<. U.S. Deartment o+ Healt, and H/man Ser"ices 7:;;:8. Healthy People <:::6
&ational Health Promotion and Disease Prevention +47ectives, 4as,in*ton, DC9
::%. American )/-lic Healt, Association 7:;;:8. Healthy Communities <:::6 %odel
Standards, 4as,in*ton, DC9 American )/-lic Healt, Association.
::(. U.S. Deartment o+ Healt, and H/man Ser"ices 7:;;>8. Healthy People <:::6
Pu4lic Health Service ction, 4as,in*ton, DC9 Go"ernment )rintin* O++ice.
::;. U.S. Deartment o+ Healt, and H/man Ser"ices. 7:;;>8. Healthy People <:::6
State ction, 4as,in*ton, DC9 Go"ernment )rintin* O++ice.
:>$. U.S. Deartment o+ Healt, and H/man Ser"ices. 7:;;>8. Healthy People <:::6
Consortium ction, 4as,in*ton, DC9 Go"ernment )rintin* O++ice.
:>:. American F/nd +or Dental Healt,. 7:;;>8. Proceedin$ of the &ational
Consortium %eetin$6 +ral Health <:::, C,ica*o, I.9 American F/nd +or Dental
Healt,.
:>>. U.S. Deartment o+ Healt, and H/man Ser"ices. 7>$$$8. Healthy People <:C:
7>nd ed.8 -ith understandin$ and improvin$ health and o47ectives for improvin$
health, > "ols. 4as,in*ton, DC9 Go"ernment )rintin* O++ice.
:>=. U.S. Deartment o+ Healt, and H/man Ser"ices. 7>$$>8. profile of older
mericans6 <::C, 4as,in*ton, DC9 Administration on A*in*.
:>&. 1/rt, 1. A. 7:;(>8. New riorities in re"ention o+ oral disease. " Pu4lic Health
Dent, &>9:%$-%;.
:>'. Hand, #. S., H/nt, !. #., g 1eck, #. D. 7:;((8. Incidence o+ coronal and root
caries in an older ad/lt o/lation. " Pu4lic Health Dent, &(9:&-:;.
:><. Stamm, #. 4., 1antin*, D. 4., lmrey, ). 1. 7:;;$8. Ad/lt root caries s/r"ey o+
ssoc, :>$9:&=-&;.
:>%. U.S. Deartment o+ Healt, and H/man Ser"ices 7:;;<8. O++ice o+ Insector
General. Children?s Dental Services Under %edicaid, ccess and Utili1ation,
4as,in*ton, DC9 O++ice o+ Insector General.
:>(. U.S. General Acco/ntin* O++ice. 7>$$$8. +ral health6 Dental disease is a
chronic pro4lem amon$ lo32income populations, 4as,in*ton, DC9 U.S. Acco/ntin*
O++ice.
:>;. A*ency +or Healt, Care )olicy and !esearc, 7:;;>8. National Medical
30endit/re S/r"ey9 nnual !xpenses and Sources of Payment for Health Care
Services, !ock"ille, MD9 A*ency +or Healt, Care )olicy and !esearc,.
:=$. .oe, H. g Dr/ry, 5. F. 7:;;$8. F/t/re NID! Initiati"es in !isk Assessment. /n6
1ader #, 3d. Proceedin$s of the Conference on Ris* ssessment in Dentistry, #/ne >-=
:;(;. C,ael Hill, NC9 Uni"ersity o+ Nort, Carolina Dental 3colo*y, =:'-<.
:=:. U.S Deartment o+ Healt, and H/man Ser"ices. 7Set :;;>8. Healt, !eso/rces
and Ser"ices Administration. Health Personnel in the United States6 !i$hth Report to
Con$ress, CHHC, DHHS )/-. No. H!S-)-OD-;>-:.
:=>. Goodman, H. S., g 4eyant, !. #. 7:;;$8. Dental ,ealt, ersonnel lannin*9 a
re"iew o+ t,e literat/re. " Pu4lic Health Dent, '$9&(-<=.
:==. Interim St/dy Gro/ on Dental Acti"ities 7:;(;8. /mprovin$ the +ral Health of
the merican People6 +pportunity for ction, 4as,in*ton, DC9 U.S. Deartment o+
:=&. Mac,en, #. 1. 7:;(;8. 3d/cation and dental en"ironment9 t,e +/t/re +or dental
sc,ools. " m Coll Dent, '<9==,&>-&&.
:='. U.S. Deartment o+ Healt, and H/man Ser"ices 7:;;:8. !e"iew o+ +l/oride
-ene+its and risks. )/-lic Healt, Ser"ice. 4as,in*ton, DC9 Deartment o+ Healt, and
H/man Ser"ices.
:=<. National Instit/tes o+ Healt,. 7A/* ><->(, :;;:8. 5ec,nolo*y assessment
con+erence statement9 e++ects and side e++ects o+ dental restorati"e materials.
Deartment o+ Healt, and H/man Ser"ices.
:=%. Co,en, .. A., Grace, 3. G., g 4ard, M. A. 7:;;>8. Maryland residentsC attit/des
towards AIDS and t,e /se o+ dental ser"ices. " Pu4lic Health Dent, '>9(:-('.
:=(. McCart,y, G. M., 2o"al, #. #., g MacDonald, #. 2. 7:;;;8. Factors associated
wit, re+/sal to treat HI6-in+ected atients9 t,e res/lts o+ a national s/r"ey o+ dentists
in Canada. m " Pu4lic Health, (;7&89'&:-'.
:=;. Ciesielski, C., Marianos, D., O/, C-H, D/m-a/*,, !., 4itte, #., 1erkleman, !.,
Gooc,, 1., Myers, G., ./o, C. C., g Sc,oc,etman, G. 7:;;>8. 5ransmission o+
H/man Imm/node+iciency 6ir/s in a dental ractice. nn /nt %ed, May :'D::<9%;(-
($'.
:&$. 1arnes, D. 1., Ger-ert, 1., McMaster, #. !., g Green-latt, !. M. 7:;;<8. Sel+-
disclos/re e0erience o+ eole wit, HI6 in+ection in dedicated and mainstreamed
dental +acilities. " Pu4lic Health Dent, '<7&89>>=-'.
:&:. American Dental Association 7:;;>8. In+ection control recommendations +or t,e
dental o++ice and t,e dental la-oratory. Co/ncil on Dental Materials, Instr/ments, and
3?/imentD Co/ncil on Dental 5,erae/ticsD Co/ncil on Dental !esearc,D Co/ncil on
Dental )ractice. " m Dent ssoc 7S/l8D:>=9:-(.
:&>. Centers +or Disease Control 7:;(<8. !ecommended in+ection control ractices
+or dentistry. %%-R, ='9>=%-&>.
:&=. U.S. Deartment o+ .a-or, Occ/ational Sa+ety and Healt, Administration
7:;;:8. Occ/ational e0os/re to -lood-orne at,o*ens, 5itle >; CF! :;:$.:$=$.
'ed Re$ Dec <D'<9<&$$&-<&:(>.
:&&. 3"ans, C. A., g 2leinman, D. 6. 7>$$$8. 5,e s/r*eon *eneralCs reort on oral
,ealt, in America9 oort/nities +or t,e dental ro+ession. " m Dent ssoc,
:=:9:%>:-(.
reser"ed.
Chapter 18. Preventive Oral Health in Early Childhood - Stephen ", 0oepferd
Objectives
:. Understand t,e rationale +or ro+essional re"enti"e dental inter"ention +or in+ants
and toddlers.
>. 30lain t,e tye and rocess o+ early in+ant caries.
=. )ro"ide aroriate recommendations +or in+ant +eedin* t,at minimi@e t,e c,ildCs
risks +or de"eloin* early2childhood caries 7+ormerly called Fn/rsin* cariesF8.
&. 30lain w,y it is so imortant t,at t,e mot,er and ot,er mem-ers o+ t,e immediate
+amily ,a"e a "ery ,i*, le"el o+ oral ,ealt,, and esecially a low Streptococcus
mutans co/nt +rom -e+ore -irt, /ntil a mat/re, nonat,olo*ic la?/e is esta-lis,ed in
t,e in+ant.
'. Descri-e t,e si0 maAor areas to disc/ss wit, arents d/rin* t,e inter"iew rocess.
<. )ro"ide aroriate co/nselin* on +eedin*Bdiet mana*ement, toot, cleanin*, and
+l/oride mana*ement +or arents o+ in+ants and toddlers.
%. Descri-e t,e timin*, location, ositionin*, and stes +or e0aminin* in+ants and
toddlers.
(. )ro"ide a rationale +or determinin* t,e +re?/ency o+ recall e0aminations.
;. Descri-e t,e rocess o+ anticiatory */idance and t,e a*e-seci+ic in+ormation to
-e disc/ssed d/rin* t,e dental "isit.
Introduction
The dental profession possesses the *no3led$e and technolo$y to assist parents in
raisin$ children free of dental disease, DentistryCs *oal is to ,el in+ants and toddlers
a"oid t,e ain and de"astation t,at accomanies early c,ild,ood caries 7+ormerly
called Fn/rsin* cariesF8, ro"ide t,em wit, a leasant, nont,reatenin* introd/ction to
dentistry, and to esta-lis, and rein+orce t,e +o/ndation o+ re"enti"e dental ,a-its.
Alt,o/*, t,is otential e0ists, the preventive process must 4e$in early in infancy
7-irt, to : year o+ a*e8,
:
to ens/re a s/ccess+/l o/tcome.
As ,ealt, ro+essionals, it is necessary to identi+y t,e otential +or t,e de"eloment o+
disease, and instit/te e++ecti"e meas/res +or re"entin* t,e initiation o+ t,e diseaseD it
is t,en a so/nd and lo*ical ractice to intervene prior to t,e onset o+ t,e disease,
rat,er t,an treat t,e e++ects o+ t,e disease. 30amles e0ist in ediatric medicine wit,
J3ell24a4yJ e"al/ations and imm/ni@ation ro*rams. )ediatricians recommend t,at
t,e in+ant -e e"al/ated +i"e times d/rin* t,e +irst year, and t,ree times d/rin* t,e
second year o+ li+e. Alt,o/*, t,ese "isits are aimed at e"al/atin* de"eloment,
re"ention, or early detection o+ disease, ,ysicians are not trained to ro"ide a
t,oro/*, dental e"al/ation or roer re"enti"e dental ,ealt, co/nselin*. /t is the
dental profession that must 4e proactive and assume the responsi4ility,
Prenatal Considerations
In t,e s,ort eriod a+ter t,e dia*nosis o+ re*nancy, an e0ectant mot,er is e0osed to
a -arra*e o+ in+ormation alica-le to ,er ,ealt, and t,at o+ ,er /n-orn c,ild.
Dentistry s,o/ld -e incl/ded in t,is ro/tine. At t,e time o+ t,e dental co/nselin*
session, a knowled*ea-le dental ro+essional s,o/ld -e t,e so/rce o+ t,e essential
in+ormation.
Dental co/nselin* s,o/ld come early, since t,e +irst trimester o+ re*nancy is a
critical time. All or*an systems are +ormin* d/rin* t,is eriod. 5oot, -/ds -e*in
+ormation at t,e +o/rt, to +i+t, week o+ *estation +ollowed -y t,e initial minerali@ation
o+ -ones and teet, +rom t,e nint, to twel+t, week. Stress e0erienced -y t,e /n-orn
c,ild at t,is time can rod/ce dento-oral de+ormities. For e0amle, a cle+t li or alate
res/lts w,en t,e ma0illae +ail to /nite -etween t,e +o/rt, to si0t, weeks. 5,ese
c,an*es can res/lt +rom a "ariety o+ etiolo*ic +actors a++ectin* t,e mot,er s/c, as
*enetics, stress o+ an inA/ry, se"ere "ir/s in+ection, alco,ol to0icity, or smokin*. An
e0cessi"e stress to t,e +et/s at any critical time in de"eloment can res/lt in a
temorary -/t o+ten irreara-le arrest in cell/lar *rowt,.
)roer n/trition d/rin* re*nancy is essential. Alt,o/*, n/tritional de+iciencies in t,e
mot,er /s/ally m/st -e se"ere to a++ect t,e /n-orn c,ild, a daily -alanced diet
ro"ides t,e necessary roteins, +ats, car-o,ydrates, "itamins, and minerals. 5,is
re?/irement can /s/ally -e met -y t,e ade?/ate intake o+ t,e four 4asic food $roups,
alt,o/*, t,e o-stetrician may desire to rescri-e n/tritional s/lements. 1ones o+
t,e maternal system +orm a lar*e mineral reser"e +or /se -y t,e de"eloin* c,ild.
ll o-stetric ser"ices s,o/ld de"elo a ositi"e re+erral system to ass/re t,at e0ectant
mot,ers recei"e an early dental e0amination, re"enti"e dentistry co/nselin* +or
t,emsel"es and t,e +/t/re c,ild, as well as necessary treatment. 5,e re+erral may -e to
a ri"ate ractice, a ,osital dental ser"ice, or to a /-lic-,ealt, +acility.
I+ a"aila-le, t,e mot,er-to--e s,o/ld -e enco/ra*ed to seek a +le0i-le dental ro*ram
w,ere re"ention, monitorin*, and t,eray is commens/rate wit, t,e se"erity o+ t,e
dental condition. Many women w,o -ecome re*nant are already lon* o"erd/e +or
treatment, and to ostone needed care +or nine more mont,s co/ld ca/se se"ere oral
ro-lems. Dental radio*ra,s +or emer*encies may -e necessary, -/t should 4e
avoided 3henever possi4le durin$ the first trimester, I+ radio*ra,s are necessary,
careful $onadal and a4dominal shieldin$ is re?/ired as wit, all dental atients. All
dental treatment s,o/ld -e comleted -y t,e end o+ t,e second trimester, since t,e
osition o+ t,e -a-y -y t,e t,ird trimester a++ects t,e womanCs ost/re, makin* lon*
dental aointments ?/ite /ncom+orta-le.
>
Once t,e treatment is comleted, t,e
attendin* dentist s,o/ld s/ly feed4ac* to the o4stetrician, indicatin* comletion o+
t,e rimary, secondary, and tertiary re"enti"e dentistry treatment lans.
5,is em,asis on e0cellent maternal oral ,ealt, is re?/ired +or t,ree reasons9 7:8 to
red/ce t,e ossi-ility o+ onset andBor ro*ression o+ caries and eriodontal disease
t,ro/*,o/t t,e re*nancyD 7>8 -eca/se o+ t,e ersonal in"ol"ement o+ t,e mot,er wit,
dental treatment, re"ention, and co/nselin*, t,ere is a *reater ossi-ility o+ -etter
care +or t,e e0ected c,ildD and 7=8 to reduce the num4er of cario$enic or$anisms in
the mother?s mouth,
Question 1
A. Dental co/nselin* s,o/ld -e initiated in t,e +irst trimester o+ re*nancy.
1. )roer n/trition d/rin* re*nancy is not essential +or t,e in+antCs oral ,ealt,.
C. Mot,ers-to--e s,o/ld seek a +le0i-le dental ro*ram.
D. Dental radio*ra,s s,o/ld -e a"oided d/rin* t,e +irst trimester o+ re*nancy.
Dental CariesAn Infectious Disease
3"idence s/**ests t,at dental caries is an infectious disease rocess initiated "ia t,e
transmission o+ S, mutans +rom arents to t,eir in+ants.
=-'
5,e seci+ic la?/e
,yot,esis s/**ests micro-ial seci+icity in dental caries, and lon*it/dinal e"idence
s/orts t,e role o+ S, mutans in caries initiation.
<,%
5,e +ollowin* c,aracteristics o+ S,
mutans are imortant relati"e to dental caries in c,ildren.
)ermanent S, mutans coloni@ation o+ t,e oral ca"ity in in+ants occ/rs only a+ter t,e
er/tion o+ teet,.
(
S, mutans ,as di++ic/lty coloni@in* in an oral ca"ity already coloni@ed -y mat/re
oral +lora.
;
S/crose +acilitates t,e ad,erence o+ S, mutans to t,e toot, s/r+ace.
:$,::
5,e so/rce o+ in+ection o+ t,e in+ant wit, S, mutans is +rom wit,in t,e +amily, most
likely t,e mot,er.
=-',:>-:&
A minim/m t,res,old le"el o+ maternal S, mutans is necessary +or transmission o+
t,e microor*anism to t,e in+ant.
:>-:&
5ransmission o+ S, mutans to t,e in+ant most likely occ/rs durin$ the first year of life,
after the eruption of teeth,
:>-:'
I+ t,e in+ant ,as a ,i*, s/crose diet in t,e resence o+ S,
mutans t,e conditions are +a"ora-le +or t,e initiation o+ caries. The early
esta4lishment of oral hy$iene measures and the adoption of a lo3 cario$enic diet and
lo32ris* feedin$ patterns should 4e$in in infancy,
4it, t,e a-o"e -/lleted oints as a -ackdro, it is ossi-le to de"elo t,e */idelines
t,at minimi@e t,e ossi-ility o+ transmittal o+ a cario*enic +lora +rom t,e mem-ers o+
t,e +amily t,at will -e most closely associated wit, t,e c,ild. 5,e most imortant *oal
is to red/ce t,e -acterial c,allen*e to t,e oint t,at t,e potential for transmission of S,
mutans is minimal, For t,e mot,er esecially, t,is will re?/ire t,e contin/al
maintenance o+ a ,i*, le"el o+ oral ,y*iene. )re+era-ly, s/c, a ro*ram s,o/ld
commence no later t,an t,e si0t, mont, o+ re*nancy and contin/e t,ro/*,o/t t,e
time o+ t,e er/tion o+ teet, and onward /ntil a mat/re, sta-le, nonat,o*enic la?/e
,as -een esta-lis,ed 7"ery low S, mutans co/nt8 on t,e c,ildCs er/ted rimary teet,.
:'
S/c, a ro*ram incl/des aroriately saced ro+essional "isits +or ro,yla0is,
-acterial co/nts, and monitorin* oral ,ealt,. For t,e mot,er, t,e man/al and c,emical
la?/e control roced/res may incl/de, in addition to t,e toot,-r/s,, irri*ation
de"ices and /se o+ s/c, antila?/e rinses as c,lor,e0idine, w,ic, can seci+ically
tar*et S, mutans, For t,e c,ild, t,e most imortant roced/re +rom time o+ -irt, wo/ld
-e a restriction o+ cario*enic +oods, and oral ,y*iene attention, s/c, as disc/ssed later
in t,is c,ater.
Question 2
A. Caries is an in+ectio/s disease transmitted to t,e in+ant mainly -y t,e mot,er.
1. 5,e most imortant -acteria associated wit, caries initiation is Streptococcus
mutans,
C. Streptococcus mutans coloni@ation occ/rs immediately a+ter t,e c,ild is -orn.
D. S/crose +acilitates t,e ad,erence o+ Streptococcus mutans to t,e toot, s/r+ace.
3. Streptococcus mutans can coloni@e any toot, wit, a mat/re la?/e.
5,e Mot,er-at-!isk
A re*nant woman is o+ten at considera-le risk o+ caries de"eloment. 5,e mot,erCs
teet, do not lose calci/m as ost/lated in a n/m-er o+ myt,sD instead, t,e risk o+
dental caries ro-a-ly increases -eca/se o+ c,an*es in eatin* ,a-its. For e0amle, t,e
s/ckin* o+ ,ard candy to red/ce na/sea, dietary cra"in*s, and +re?/ent -etween-meal
snacks o+ re+ined car-o,ydrates can raise t,e caries otential o+ t,e dental la?/e. In
addition, t,e mot,er o+ten experiences na/sea or Fmornin* sickness,F ca/sin*
"omitin* wit, a re*/r*itation o+ stomac, acid w,ic, may ca/se erosion and
deminerali1ation o+ t,e lin*/al s/r+aces o+ t,e teet,. Many times, only a toot,-r/s, or
a s/dsy denti+rice is needed to tri**er a *a* re+le0.
A"oidance o+ a-errant eatin* ,a-its and snackin*, and e0ercise o+ s/*ar disciline can
*reatly minimi@e t,e ossi-ility o+ caries de"eloment. I+ t,e mot,er is li"in* in a
non+l/oridated area, +l/oride s/lements s,o/ld -e considered. 5,ere are +ew reorts
a"aila-le t,at indicate a decrease in caries re"alence o+ c,ildren -orn to mot,ers
takin* +l/oride.
:<-:(
Since t,e s/lement -rin*s t,e le"el o+ +l/oride intake to one art
er milliona le"el in*ested daily -y o"er :$$ million ot,er Americanst,ere is no
dan*er o+ e0cessi"e intake -y t,e mot,er. 5,ere is t,e possi4ility o+ some -ene+it to
t,e c,ild. In addition, t,e e0ectant mot,er s,o/ld -e ro"ided wit, aroriate
treatment and recall aointments d/rin* t,e eriod o+ re*nancy. )ro+essionally
alied toical +l/orides and systemic +l/oride s/lementation can -ene+it +rom t,e
additional daily ,ome /se o+ +l/oride denti+rices and mo/t, rinses. 5,ese meas/res
will -ot, re"ent deminerali@ation o+ t,e teet,, as well as +acilitate reminerali@ation in
t,e e"ent o+ t,e de"eloment o+ an inciient lesion.
Question 3
A. D/rin* re*nancy, t,e mot,erCs teet, lose calci/m.
1. I+ t,e re*nant woman li"es in a non+l/oridated area, +l/oride s/lements s,o/ld
-e considered.
C. 5,e ideal amo/nt o+ +l/oride in water s,o/ld ran*e +rom $.% to : art er million.
D. Fl/oride in*estion -y t,e re*nant woman o++ers t,e ossi-ility o+ some -ene+it to
t,e c,ild.
3. 5,e /se o+ +l/orides -ot, -y mot,er and c,ild re"ents deminerali@ation and
+acilitates reminerali@ation o+ t,e teet,.
Rationale for Early Preventive Intervention
Dental caries can and does occ/r in in+ants and toddlers 3ell 4efore A years of a$e,
3arly in+ant caries ,as -een o-ser"ed in c,ildren as yo/n* as C< months of a$e,
:;->:
One o+ t,e +irst maAor ,a@ards to t,e c,ildCs rimary dentition is early c,ild,ood
caries. 5,is condition ,as also -een re+erred to as Fn/rsin* caries,F n/rsin* -ottle
caries, nursin$ 4ottle mouth, 4a4y24ottle syndrome, 4a4y24ottle tooth decay 7115D8,
and 4ottle2mouth caries, 5,e caries attern o+ t,is condition is ,i*,li*,ted -y
rampant dental caries initially in"ol"in* t,e ma0illary rimary incisors,
<
and
ro*ressin* to t,e +irst rimary molars in later sta*es
>>->',>%
7Fi*/re :(-:8. It is ca/sed
-y contin/al, rolon*ed e0os/re o+ t,e rimary teet, to milk, in+ant +orm/la, +r/it
A/ices, so+t drinks, or ot,er s/*arBcar-o,ydrate-containin* +l/ids laced in t,e n/rsin*
-ottle.
Once teet, er/t, t,e ractice o+ o++erin* a c,ild a -ottle +illed wit, cario*enic +l/id as
a aci+ier or at natime or -edtime s,o/ld -e disco/ra*ed. Once teet, er/t and
la?/e acc/m/lates, t,e in*estion o+ s/*ar-containin* +l/ids durin$ 4edtime or
naptime laces t,e c,ild at considera-le risk +or dental caries since sali"ary +low
decreases d/rin* slee and t,e +l/id ools aro/nd t,e teet,, creatin* a ,i*,ly acidic
en"ironment. 5,is ermits t,e oolin* o+ t,e oral +l/ids aro/nd t,e ma0illary anterior
teet,.
<
Not all rimary teet, are e?/ally attacked. D/rin* s/ckin* o+ t,e nile o+
eit,er t,e -ottle or t,e -reast, t,e ton*/e o"erlies t,e lower incisors, w,ic, directs t,e
sweetened li?/id a*ainst t,e maxillary incisors and to t,e -ack o+ t,e alate. 5,e
mandi-/lar incisors o+ten are eit,er comletely intact or only sli*,tly a++ected, w,ile
t,e ma0illary incisors -ear t,e -r/nt o+ t,e reeated acid attacks. 5,e ot,er rimary
teet, are in"ol"ed to "ario/s de*rees, deendin* on t,e s/cklin* ,a-its o+ t,e in+ant.
5,e caries attack -e*ins wit, t,e aearance o+ w,ite areas o+ deminerali@ation
aro/nd t,e *in*i"al t,ird o+ t,e teet, 7see Fi*/re :(-:8. 4it, time, t,ese inciient
lesions -e*in to t/rn -rown as acti"e caries ro*resses. 3"ent/ally, t,e cario/s lesions
t,at rin* t,e cer"ical areas o+ t,e teet, can res/lt in entire crowns -ein* lost, eit,er -y
+ract/re o+ t,e /ndermined enamel or -y t,e contin/o/s action o+ t,e caries. In eit,er
e"ent, only t,e e0osed root is le+t in t,e al"eolo/s 7see Fi*/re :(-:8.
I+ a -ottle is to -e /sed as a aci+ier, it s,o/ld -e +illed wit, 3ater,
3arly c,ild,ood caries can also occ/r in some -reast-+ed c,ildren w,o are n/rsed
e"ery time t,e in+ant indicates a desire +or +eedin* 7demand +eedin*, wit, :$ or more
n/rsin* e"ents o"er a >&-,o/r eriod8.
><,>%
Fi*/re :(-: Di++erent sta*es o+ early c,ild,ood caries accordin* to Garcia-
Godoy, et al.
>&,>'

Question 4
A. Dental caries may occ/r in in+ants and toddlers well -e+ore = years o+ a*e.
1. 3arly c,ild,ood caries is mainly d/e to contin/al, rolon*ed e0os/re o+ t,e
rimary teet, to milk, in+ant +orm/la, +r/it A/ices, so+t drinks, or ot,er s/*ar-
containin* +l/ids laced in t,e n/rsin* -ottle.
C. Once teet, er/t, t,e ractice o+ o++erin* a c,ild a -ottle +illed wit, cario*enic +l/id
as a aci+ier or at natime or -edtime s,o/ld -e disco/ra*ed.
D. 3arly c,ild,ood caries does not occ/r in -reast-+ed c,ildren.
3. I+ a -ottle is /sed as a aci+ier, it s,o/ld -e +illed wit, water.
5,e loss o+ teet, res/ltin* +rom early c,ild,ood caries can ,a"e +ar-reac,in* e++ects
on t,e c,ildCs e"ent/al +ace *rowt,.
:(
On occasion, t,ere will -e a attern o+ m/ltile, se"ere caries in a toddler wit,o/t a
s/-stantiated ,istory o+ early n/rsin* atterns t,at laced t,e in+ant at an increased
risk. The caries process is certainly multifactorial and at times, a de+inite ca/se may
not -e identi+ia-le. Ne"ert,eless, so/nd rimary re"enti"e strate*ies early on will
ro"ide t,e aroriate en"ironment +or t,e re"ention o+ dental caries.
Disease )re"entionA )roacti"e Aroac,
As ,ealt, ro+essionals can identi+y t,e otential +or t,e de"eloment o+ disease and
,a"e e++ecti"e meas/res a"aila-le +or re"entin* t,e initiation o+ disease, it is a so/nd
and lo*ical ractice to intervene rior to t,e onset o+ disease w,ene"er ossi-le rat,er
t,an to wait and treat t,e e++ects o+ t,e disease. 30amles o+ rimary re"ention e0ist
in ediatric medicine wit, Fwell--a-yF e"al/ations and imm/ni@ation ro*rams.
)ediatricians recommend t,at t,e in+ant -e e"al/ated +i"e times d/rin* t,e +irst year
and t,ree times d/rin* t,e second year o+ li+e. Alt,o/*, t,ese "isits are aimed at
e"al/atin* de"eloment and re"ention or early detection o+ disease, ,ysicians are
not ade?/ately trained to ro"ide a t,oro/*, dental e"al/ation or roer re"enti"e
dental ,ealt, co/nselin*. The dental profession must 4e proactive and assume this
responsi4ility,
)/-lic and )ro+essional Attit/des
1eca/se o+ e"ents s/c, as early c,ild,ood caries, t,ere is a $ro3in$ desire 4y parents
o+ in+ants and toddlers to recei"e an early dental e"al/ation and o-tain in+ormation on
t,e re"ention o+ dental diseases in t,eir c,ildren. Accordin* to arents, t,e maAor
reasons +or t,em seekin* early dental e"al/ations are9
Desire +or in+ormation on re"entin* toot, decay +or t,eir c,ild
Desire to a"oid /nleasant e0eriences t,at t,e arents ,ad s/++ered
Desire to learn w,at t,eir role is in t,eir c,ildCs oral ,ealt,
!ecommended -y t,eir ediatrician or +amily ,ysician.
5,e ed/cation rocess can ro-a-ly -est start wit, t,e o-stetrician and ediatrician
e0lainin* to t,e e0ectant or new arents t,e ca/se and conse?/ences o+ contin/ed
intake o+ s/*ar +l/ids. 5,e ,ysician can +/rt,er aid in red/cin* t,e ro-lem -y
rescri-in* t,ose -ottle +orm/lae t,at contain t,e least s/*ar. For instance, t,ere is a
considera-le ran*e in t,e amo/nt o+ s/*ar +o/nd in t,e "ario/s commercially
a"aila-le -a-y +oods. Finally, t,e dental ro+ession s,o/ld em,asi@e t,e need +or
,i*, sc,ool and comm/nity dental ed/cation ro*rams to alert wo/ld--e arents o+
t,eir resonsi-ilities in dental care +or t,eir in+ant.
3arly Dental Care
5,e new-orn s,o/ld -ecome acc/stomed to oral care early. A+ter +eedin*, t,e rid*es
w,ere t,e teet, will later aear and t,e alate s,o/ld -e *ently wied wit, *a/@e or a
so+t was,clot,. 5,is remo"es le+to"er +ood, and esta-lis,es a ro/tine +or t,e mot,er to
clean inside t,e c,ildCs mo/t,. C,ildren need directly s/er"ised oral ,y*iene care
t,ro/*,o/t c,ild,ood. It was traditionally recommended t,at a c,ild s,o/ld "isit t,e
dental o++ice no later t,an <CL< years of a$e, Ideally, t,e c,ildCs +irst dental "isit
s,o/ld occ/r at 9 months of a$e and no later that at C year of a$e,
:%
5,e /rose o+
t,is initial "isit is to ermit an e"al/ation o+ t,e mo/t, and Aaws +or roer +ormation
and ali*nment o+ str/ct/res. A second o-Aecti"e o+ t,is "isit is to allow t,e c,ild to
-ecome +amiliar wit, t,e dental o++ice and its ersonnel /nder leasant circ/mstances
and +orestall +/t/re are,ension.
In+ant Oral-Healt, 3d/cation
Accordin* to t,e United NationsC Con"ention on F5,e !i*,ts o+ t,e C,ild,F articles >
and >&, all c,ildren s,o/ld ,a"e t,e same ri*,ts and ,a"e ri*,t to ,ealt, and medical
ser"ice.
>(
3arly c,ild,ood caries is a li+estyle disease wit, -iolo*ic, -e,a"ioral, and
social determinants. An early screenin* o+ all c,ildren at aro/nd : year o+ a*e is an
e0cellent oort/nity +or early detection o+ risk +actors and risk indicators t,at may
increase t,e ossi-ilities +or its re"ention. 5,e caries risk e"al/ation s,o/ld +orm t,e
-ase +or aroriate recommendations o+ re"enti"e meas/res.
>(
5,e American Academy o+ )ediatric Dentistry states9 F/nfant dental care 4e$ins 3ith
dental health counselin$ for the ne34orn, 3hich should include a dental office visit
for preventive oral health counselin$ no later than C< months of a$e,
:%
Howe"er, +or
t,ose c,ildren w,o are delayed in er/tin* teet,, t,e +irst "isit may -e ostoned, -/t
s,o/ld occ/r 3ithin 9 months follo3in$ the eruption of the first tooth,F
5,e American Society o+ Dentistry +or C,ildren also recommends in The ns3er
#oo* t,at c,ildren s,o/ld "isit t,e dentist -etween < and :> mont,s o+ a*e.
:(

!ecently, a +ederal ro*ram called F3arly and )eriodic Screenin*, Dia*nosis, and
5reatmentF 73)SD58, w,ic, mandates t,at medical and dental ser"ices -e ro"ided to
c,ildren +rom low-income +amilies, adoted t,e olicy t,at c,ildren in t,e 3)SD5
ro*ram recei"e a dental screenin* -y C< months of a$e, A recent s/r"ey amon* '&
dental sc,ools ediatric dentistry ro*rams s,owed t,at (<E teac, st/dents to see
in+ants at :> mont,s o+ a*e or yo/n*er.
>;
One st/dy e"al/ated an oral-,ealt, romotion ro*ram in"ol"in* ,ealt, "isitors and
mot,ers o+ (-mont,-old -a-ies in order to address some o+ t,e risk +actors associated
wit, n/rsin* caries.
=$
5,e oral-,ealt, romotion ro*ram si*ni+icantly imro"ed
mot,ers recall o+ ad"ice *i"en -y ,ealt, "isitors enco/ra*in* t,e /se o+ a +eeder c/,
-r/s,in* t,eir -a-iesC teet, wit, +l/oride toot,aste and restrictin* s/*ary +oods and
drinks. Si*ni+icant imro"ements were also +o/nd in recall o+ ad"ice re*ardin* t,e /se
o+ s/*ar-+ree medicine and re*isterin* -a-ies wit, a dentist. 5,e ro*ram enco/ra*ed
a ,i*,er roortion o+ t,e mot,ers to -rin* t,eir c,ildren to clinics +or a ,earin*
c,eck.
=$
5,e ad"anta*es o+ t,e in+ant oral-,ealt, aroac, are9
Identi+yin* and modi+yin* detrimental +eedin* ,a-its, red/cin* otential caries risk
Assistin* arents in esta-lis,in* low caries-risk snackin* and dietary atterns +or
t,eir c,ild
30lainin* and demonstratin* toot, cleanin* roced/res +or in+ants and toddlers
Determinin* +l/oride stat/s and recommendin* an otim/m +l/oride ro*ramD
Introd/cin* dentistry to t,e c,ild in a leasant, nont,reatenin* manner
)rearin* arents +or /comin* dental e"ents +or t,eir c,ild 7anticiatory */idance8.
Question 5
A. 5wo maAor reasons +or arents to seek early dental e"al/ations +or t,eir c,ildren
are a desire +or in+ormation on re"entin* toot, decay and a desire to learn w,at t,eir
role s,o/ld -e in t,eir c,ildCs oral ,ealt,.
1. A+ter +eedin* t,e new-orn c,ild, t,e rid*es w,ere t,e teet, will later aear s,o/ld
-e *ently wied wit, *a/@e or a so+t was,clot,.
C. 5,e c,ildCs +irst dental "isit s,o/ld occ/r at >:B> years o+ a*e.
D. Some ad"anta*es o+ an in+ant oral-,ealt, aroac, are9 identi+yin* and modi+yin*
detrimental +eedin* ,a-its and e0lainin* and demonstratin* to t,e arents toot,
cleanin* roced/res +or in+ants and toddlers.
3. 5,e dental ro+ession s,o/ld em,asi@e t,e need +or ,i*, sc,ool and comm/nity
dental-ed/cation ro*rams to alert wo/ld--e arents o+ t,eir resonsi-ilities in dental
care +or t,eir in+ants.
A Protocol for Early Preventive Intervention
5,e Inter"iew
5,e inter"iew rocess and co/nselin* session s,o/ld -e t,oro/*, and seci+ic, yet
concise. 5,e attention san o+ t,e in+ant is limited and once t,e c,ild -ecomes -ored
and seeks attention +rom t,e arent7s8 t,eir attenti"eness to yo/r disc/ssion will -e
limited at -est. 30erience s,ows t,at t,e inter"iew and re"enti"e co/nselin* are
-est accomlis,ed 4efore t,e e0amination o+ t,e in+ant +or t,e +ollowin* reasons9
Seci+ic arental concerns can -e identi+ied and addressed d/rin* t,e e0amination.
S,o/ld t,e in+ant +/ss d/rin* t,e e0amination 7normal -e,a"ior8 t,e arent7s8
/s/ally direct t,eir attention toward t,e c,ild d/rin* t,e ens/in* disc/ssion and not
toward t,e dentist.
5,e c,ild can -e ket -/sy wit, toys, etc., -e+ore t,e e0amination in a
nont,reatenin* en"ironment and t,e arent7s8 will -e -etter a-le to direct t,eir
attention toward t,e dentist.
5,e inter"iew s,o/ld -e*in wit, a disc/ssion o+ t,e arentsC reason +or seekin* care.
Historical in+ormation *at,ered at t,e initial inter"iew wo/ld assist t,e ractitioner in
de"eloin* t,e most aroriate and indi"id/ali@ed re"enti"e ro*ram +or t,e
+amily. Cate*ories o+ ,el+/l in+ormation are disc/ssed in t,e +ollowin* ara*ra,s.
:. G!O45H AND D363.O)M3N5. An a-normal attern o+ de"eloment may -e
disco"ered or s/sected, romtin* a re+erral +or +/rt,er e"al/ation. Also, t,e date o+
t,e er/tion o+ t,e +irst toot, will ro"ide a -aseline +or determinin* dental
de"eloment atterns and assist in answerin* +/t/re ?/estions +rom arents re*ardin*
t,eir c,ildCs dental de"eloment.
>. F33DING HIS5O!H. 2nowled*e o+ t,e +eedin* atterns d/rin* in+ancy is critical
to assist t,e dentist in assessin* t,e c,ildCs risk +or de"eloin* early c,ild,ood caries
-y disco"erin* potentially harmful feedin$ ha4its and to ,el +orm a -asis +or
recommendations re*ardin* roer +eedin* ractices t,at minimi@e t,e otential +or
dental disease.
=. M3DICA. HIS5O!H. A comlete medical ,istory is imortant. 2nowled*e o+
any systemic conditions t,at may ad"ersely a++ect dental ,ealt, will assist in
de"eloin* aroriate re"enti"e strate*ies. For e0amle, lon*-term, +re?/ent intake
o+ s/crose--ased medications may re?/ire additional recommendations +or toot,
cleanin* to o++set t,e increased caries risk +rom t,e s/crose intake.
&. )!363N5I63 ASS3SSM3N5. In+ormation re*ardin* dental de"eloment, dental
,ealt, attit/des, and c/rrent oral ,y*iene ractices will ser"e as a startin* oint +or
co/nselin* arents re*ardin* an aroriate re"enti"e ro*ram +or t,eir c,ild. A
,istory o+ toot, decay in t,e +amily 7Fso+t teet,F8 will ro"ide insi*,t into t,e
en"ironmental in+l/ences as well as arental attit/des re*ardin* dental ,ealt, and
ser"e to */ide t,e dentistCs disc/ssion re*ardin* re"enti"e strate*ies.
'. F.UO!ID3 SU)).3M3N5A5ION. It is imortant to know i+ t,e c,ild ,as access
to +l/oride in drinkin* water. It is not s/++icient to esta-lis, t,at a +amily li"es in a
+l/oridated comm/nity. On occasion, t,e +amily may drink -ottled water, w,ic,
contains an /nknown ?/antity o+ +l/oride. On t,e ot,er ,and, a +amily drinkin* well
water may or may not -e recei"in* systemic +l/oride deendin* /on t,e
concentration o+ +l/oride in t,e water. 1e+ore any +l/oride s/lements are
rescri-ed, t,e water s,o/ld -e tested +or +l/oride concentration and s/lements
rescri-ed accordin*ly. Some +amilies li"e in r/ral settin*s wit, well water, -/t t,e
c,ild sends t,e maAority o+ t,e day in a location wit, +l/oridated water s/c, as a day
care +acility or sc,ool. 5,ere+ore, an acc/rate assessment o+ all otential so/rces o+
+l/oride intake s,o/ld -e e0lored -e+ore makin* any recommendations re*ardin*
+l/oride s/lementation.
I+ t,e daily intake o+ +l/oride is ins/++icient, arents s,o/ld -e in+ormed t,at small
daily dosa*es are -ene+icial to a c,ildCs teet,. Aendi0 :(-: will aid in determinin*
t,e amo/nt o+ +l/oride s/lementation needed. 5,is can initially -e -est
accomlis,ed -y t,e /se o+ fluoride drops, Aro/nd t,e a*e o+ =, t,e dros can -e
relaced -y fluoride ta4lets, w,ic, are swallowed. .ater, as t,e c,ild *ains skill in
c,ewin* t,e ta-let, t,e +l/oride-laden sali"a can -e swis,ed aro/nd t,e mo/t, and
t,en swallowed to ro"ide a toical alication as well as systemic -ene+its. 5,e
ractice o+ /sin* a ta-let a day s,o/ld contin/e /ntil t,e c,ild is at least :> years old,
alt,o/*, many -elie"e t,at +l/oride s/lementation s,o/ld -e considered as lon* as
t,e indi"id/alc,ild or ad/lt,as a +l/oride-de+icient intake.
<. O!A. HHGI3N3. An assessment o+ c/rrent toot,-cleanin* acti"ities is imortant
to esta-lis, t,e arentsC role in oral ,y*iene +or t,eir c,ild. Many arents t,ink t,at
allowin* an in+ant or toddler to -r/s, t,eir own teet, is ade?/ate. I+ t,e in+antCs teet,
are -ein* -r/s,ed, it is imortant to esta4lish ho3, 3hen, and 4y 3hom, and in?/ire
w,et,er t,e arents e0erience any di++ic/lties d/rin* t,e rocess.
In one st/dy, almost ,al+ o+ t,e arents inter"iewed ,ad started toot,-r/s,in*
ro*rams +or t,eir in+ants at :> mont,s and %'E ,ad done so -y :( mont,s. 4it,
s/c, in+ant and toddler toot,-r/s,in* ro*rams, only a small amo/nt, aro0imately
t,e si@e o+ a ea, o+ a +l/oridated denti+rice s,o/ld -e /sed in order to a"oid t,e
ossi-ility o+ t,e c,ild in*estin* an e0cess o+ +l/oride. Aro/nd t,e a*e o+ <, daily
+l/oride mo/t, rinses may -e initiated as art o+ t,e total li+elon* oral ,ealt, ro*ram.
Question 6
A. In a re"enti"e oral-,ealt, ro*ram, t,e inter"iew and re"enti"e co/nselin* are
-est accomlis,ed -e+ore t,e e0amination o+ t,e in+ant.
1. 5,e inter"iew s,o/ld -e*in wit, a disc/ssion o+ t,e arentsC reason +or seekin*
dental care.
C. A comlete medical ,istory is not imortant in t,e initial "isit.
D. A ,istory o+ toot, decay is imortant to esta-lis, en"ironmental iss/es as well as
arental attit/des towards dental ,ealt,.
3. It is imortant to know i+ t,e c,ild ,as access to +l/oride in t,e drinkin* water
-e+ore rescri-in* any +l/oride s/lement.
Co/nselin*
1ased /on t,e in+ormation *at,ered to t,is oint, t,e ractitioner is ready to ro"ide
recommendations on ho3 parents can play an active role in re"entin* dental disease
in t,eir c,ild -y ass/min* t,e resonsi-ility +or t,e +ollowin* roced/res.
+ral Hy$iene
)arents s,o/ld -e ed/cated re*ardin* t,e +ollowin* toot,-cleanin* recommendations.
A arent, ot,er ad/lt, or older si-lin* m/st ass/me total resonsi-ility +or toot,
cleanin* in in+ants and yo/n* c,ildren. Many c,ildren are /na-le to er+orm ade?/ate
la?/e remo"al /ntil < to ( years o+ a*e.
5oot, cleanin* s,o/ld -e done in a com+orta-le location and leasant en"ironment.
)ositionin* will -e demonstrated d/rin* t,e e0amination.
A denti+rice is not necessary +or in+ants. In many cases, it may -e a so/rce +or
o-Aection -eca/se o+ t,e taste and +oamin* action.
I+ a denti+rice is /sed, only a ea-si@ed amo/nt s,o/ld -e laced on t,e -r/s, to
a"oid in*estion o+ e0cess +l/oride.
5oot, cleanin* s,o/ld -e accomlis,ed wit, a small, so+t--ristled toot,-r/s,.
5oot, cleanin* s,o/ld -e accomlis,ed at least once daily.
5,e e"enin* toot, cleanin* may -e easier to accomlis, +ollowin* t,e in+antCs last
+eedin* instead o+ waitin* /ntil A/st -e+ore -edtime since a tired in+ant can +re?/ently
-e +/ssy d/rin* t,e roced/re.
Question 7
A. 5oot, cleanin* o+ in+antCs teet, s,o/ld -e done -y a arent, ot,er ad/lt, or older
si-lin*.
1. A denti+rice is not necessary in in+ants.
C. I+ a denti+rice is /sed, t,e entire len*t, o+ t,e -r/s, ,ead s,o/ld -e +illed.
D. In in+ants, toot, cleanin* s,o/ld -e accomlis,ed at least once a day.
3. A lar*e toot,-r/s, is ade?/ate +or cleanin* in+antCs teet,.
Diet %ana$ement
)arents ,a"e control, +or t,e most art, o"er t,eir c,ildCs diet d/rin* t,e early years.
5,e e0cetions incl/de time sent wit, -a-ysitters and in day care settin*s. )arents
can ,a"e some in+l/ence in t,ose sit/ations, ,owe"er, i+ t,ey make t,eir wis,es
known. 5,e +ollowin* in+ormation s,o/ld -e s,ared wit, arents.
In+ants s,o/ld -e weaned +rom t,e -ottle aro/nd :> mont,s o+ a*e.
5,e -ottle s,o/ld not -e /sed as a aci+ier nor *i"en d/rin* -edtime or natime.
Only +orm/la or milk s,o/ld -e o++ered in t,e -ottle.
Fre?/ent, rolon*ed eisodes o+ -reast-+eedin* co/ld -e a caries risk.
Sleein* wit, t,e c,ild and allowin* n/rsin* t,ro/*, t,e ni*,t s,o/ld -e a"oided.
In+ants and yo/n* c,ildren *enerally will eat more +re?/ently t,an t,ree times daily.
1etween-meal snacks s,o/ld consist o+ +oods t,at ,a"e a low cario*enic otential.
5otal amo/nt o+ cario*enic +oods is not t,e iss/e, rat,er t,e +re?/ency o+ in*estion
and retenti"eness o+ t,e +ood are t,e +actors t,at contri-/te to t,e caries risk.
Question 8
A. D/rin* t,e in+antCs oral ,ealt, +irst "isit, t,e arents s,o/ld -e in+ormed t,at t,e
in+ant s,o/ld -e weaned +rom t,e -ottle aro/nd :> mont,s o+ a*e.
1. Only +orm/la or milk s,o/ld -e o++ered in t,e -ottle.
C. 1etween-meal snacks s,o/ld consist o+ +oods t,at ,a"e a low cario*enic otential.
D. Fre?/ent, rolon*ed eisodes o+ -reast- +eedin* co/ld -e a caries-risk sit/ation.
3. 5otal amo/nt o+ cario*enic +ood cons/mtion is more imortant t,an t,e +re?/ency
o+ cario*enic +ood cons/mtion.
5,e 30amination
Once t,e inter"iew and co/nselin* asects o+ t,e "isit are comleted, t,e dentist is
ready to roceed wit, t,e e0amination o+ t,e in+ant or toddler. 5,e dental c,air and
o"er,ead li*,t are neit,er re?/ired nor "ery /se+/l +or e0aminin* c,ildren t,is yo/n*.
Since one o+ t,e rime o-Aecti"es is to ro"ide a dental e0amination in a leasant,
nont,reatenin* manner, t,e roced/re is -est accomlis,ed in t,e *nee2to2*nee
osition +or c,ildren /nder = years o+ a*e 7Fi*/re :(->8. 5,is osition ro"ides a
sta-le, yet com+orta-le en"ironment t,at incororates t,e sec/rity o+ arental
in"ol"ement, w,ic, may rod/ce a calmin* e++ect on in+ants and toddlers w,o lack
t,e co*niti"e a-ility to cooerate. S,o/ld t,e c,ild o++er resistance, t,e dentist can
easily and *ently sta-ili@e t,e c,ildCs mo/t, and ,ead cradled in t,e la w,ile t,e
arent ,olds t,e c,ildCs ,ands and can sta-ili@e t,e le*s -y cradlin* t,em wit, t,e
el-ows. Many o+ t,e in+ants and toddlers accet t,e e0amination roced/res in t,is
osition wit,o/t resistance. It is imortant in t,ose instances w,ere t,e c,ildren resist
or cry t,at t,e arents -e ass/red t,at t,e -e,a"ior is normal 7and e0ected8 +or t,e
c,ildCs a*e and s,o/ld not -e considered F-adF or F/ncooerati"e.F
5,e e0amination s,o/ld -e*in wit, a so+t to/c,, e"al/atin* t,e e0traoral ,ead and
neck conditions +irst, allowin* t,e c,ild to -ecome acc/stomed to t,e dentistCs actions.
5,e e0amination o+ t,e oral ca"ity s,o/ld -e*in -y /sin* t,e +in*ers to alate t,e
oral str/ct/res -e+ore introd/cin* t,e dental instr/ments. Ill/mination can -e ro"ided
wit, a enli*,t or +las,li*,t ,eld -y t,e dental assistant. Access and sta-ili@ation o+
t,e mo/t, can -e o-tained -y lacin* a +in*er on t,e */m ad distal to t,e most
osterior toot, in a ma0illary ?/adrant. Followin* insection o+ t,e oral so+t and ,ard
tiss/es, a dental cleanin* 7la?/e remo"al8 is accomlis,ed wit, a so+t -ristled, moist,
c,ild-si@ed toot,-r/s,. !arely will a r/--er c/ and olis,in* aste -e re?/ired +or
stain remo"al. 5,e toot,-cleanin* rocess is disc/ssed and demonstrated as yo/
remo"e t,e la?/e. At t,is oint, it is "ery imortant t,at t,e c,ild -e reositioned
wit, t,e ,ead cradled in t,e arentCs la and t,e arent *i"en t,e oort/nity to
ractice t,e toot,-cleanin* rocess wit, t,e dentistCs s/er"ision and */idance. 5,is
will ,el some arents *et o"er t,eir rel/ctance to clean t,eir c,ildCs teet,, esecially
w,en t,e c,ild resists. Occasionally, some in+ants and toddlers e0,i-it ti*,t contacts
-etween t,e anterior as well as t,e osterior teet,, w,ic, acc/m/late considera-le
la?/e. 5,e arent can -e s,own ho3 to clean t,ese areas /sin* dental +loss in a
,older wit, relati"e ease. 5,e arents are ad"ised t,at t,ey need to er+orm toot,
cleanin* +or t,eir c,ild at least once er day, -/t re+era-ly +ollowin* eac, meal. 5,e
most critical time to clean t,e teet, is +ollowin* t,e last meal or snack o+ t,e day. It is
em,asi@ed t,at toot,aste is not re?/ired and is /s/ally o-Aectiona-le to t,e in+ant. I+
it is /sed, only a minimal ?/antity s,o/ld -e laced on t,e -r/s,.
It s,o/ld also -e em,asi@ed early t,at w,en t,e c,ild is -ecomin* acc/stomed to t,e
ro/tine o+ ,a"in* a arent -r/s, t,e teet,, t,e toot, cleanin* s,o/ld not -ecome an
/nleasant str/**le +or t,ose in+ants and toddlers w,o initially resist t,e roced/re.
On t,ose occasions w,ere t,e c,ild str/**les considera-ly, t,e roced/re s,o/ld not
-e a-andoned. !at,er, less attention can -e laced on er+ormin* t,oro/*, la?/e
remo"al, w,ile maintainin* a consistent e++ort to esta-lis, a ro/tine wit, t,e c,ild. A
more t,oro/*, toot, cleanin* can -e er+ormed anot,er day w,en t,e c,ild is more
cooerati"e. )arents can -e reminded o+ ot,er ro/tines t,at are accomlis,ed in site
o+ t,e c,ildCs o-Aections, s/c, as was,in* t,e c,ildCs ,air. I+ t,e toot,-cleanin* ro/tine
is esta-lis,ed d/rin* t,e +irst :> mont,s, stron* o-Aections and resistance to t,e
roced/re d/rin* t,e Fterri-le twosF can /s/ally -e a"oided.
Concl/din* t,e Aointment
5,e aointment is concl/ded -y addressin* t,e +ollowin* areas.
)ro"ide t,e arents wit, a s/mmary o+ yo/r clinical +indin*s.
Make aroriate recommendations -ased /on t,e clinical +indin*s.
Solicit and answer any remainin* ?/estions t,at t,e arents may ,a"e.
!ein+orce t,e arentsC role and resonsi-ilities in t,eir c,ildCs oral-,ealt, care.
3sta-lis, an otimal +l/oride ro*ram 7endin* any water analysis8. 7See Aendi0
:(-:.8
Distri-/te ed/cational am,letsB-roc,/res as desired.
)ro"ide anticiatory */idance in+ormation.
3sta-lis, an aroriate recall sc,ed/le.
Anticiatory G/idance
Anticiatory */idance is a rocess +or rearin* t,e arents +or /comin*
de"elomental c,an*es and concerns t,at may arise -e+ore t,e ne0t sc,ed/led dental
"isit in order to minimi@e t,e ne*ati"e e++ects t,at may arise. 4,ere"er ossi-le,
preventive oral health information s,o/ld -e ro"ided to e0ectant arents d/rin*
renatal ed/cation ro*rams. 30amles o+ s/c, in+ormation are ro"ided in Aendi0
:(->, :(-=, and :(-&.
3sta-lis,in* a !ecall Sc,ed/le
5,e recall aointment may -e sc,ed/led +or =, <, or :> mont,s deendin* /on t,e
c,ildCs otential risk +or de"eloin* dental disease -ased /on clinical +indin*s, sta*e
o+ dental de"eloment, and +eedin* or diet atterns. 30amles +or determinin*
aroriate recall sc,ed/les are listed in Aendi0 :(-'.
Fi*/re :(-> 2nee-to-knee e0amination osition.
Summary
5,e otential e0ists today +or dental-,ealt, ro+essionals to assist arents in raisin*
caries-+ree c,ildren. 5,e knowled*e and tec,nolo*y are a"aila-le and t,e re?/est +or
t,is ser"ice is *rowin*. 5,e dental ro+essional ,as t,e oort/nity to accet t,is role
wit, ent,/siasm and contin/e to -e a leader amon* t,e ,ealt, ro+essions in disease
re"ention. 5,e dental ro+ession m/st not i*nore t,e oral ,ealt, needs o+ in+ants and
toddlers /nder = years o+ a*e. 4e m/st instead, take ad"anta*e o+ o/r knowled*e and
tec,nolo*y and -e*in o/r disease re"ention e++orts wit, c,ildren as in+ants and
ed/cate arents-to--e and new arents re*ardin* t,eir imortant role in t,e oral ,ealt,
o+ t,eir c,ildren. 1y doin* so, we can ro"ide a leasant and lo*ical introd/ction to
dentistry and romote t,e ro+ession in a most ositi"e way.
:. A, C, and Dcorrect.
1incorrect. Alt,o/*, n/tritional de+iciencies in t,e mot,er m/st -e se"ere to a++ect
t,e /n-orn c,ild, a daily -alanced diet ro"ides t,e necessary roteins, +ats,
car-o,ydrates, "itamins, and minerals.
>. A, 1, and Dcorrect.
Cincorrect. Streptococcus mutans coloni@ation o+ t,e oral ca"ity in in+ants occ/rs
only a+ter t,e er/tion o+ teet,.
3incorrect. Streptococcus mutans ,as di++ic/lty coloni@in* in an oral ca"ity already
coloni@ed -y a mat/re dental la?/e.
=. 1, C, D, and 3correct.
Aincorrect. 5,e mot,erCs teet, do not lose calci/m. Instead, t,e risk o+ dental caries
occ/rrence ro-a-ly increases -eca/se o+ c,an*es in eatin* ,a-its.
&. A, 1, C, and 3correct.
Dincorrect. 3arly c,ild,ood caries ,as -een reorted in se"eral st/dies dealin* wit,
-reast-+ed c,ildren, alt,o/*, t,e re"alence is lower t,an in -ottle-+ed c,ildren.
'. A, 1, D, and 3correct.
Cincorrect. 5,e c,ildCs +irst dental "isit s,o/ld -e at < mont,s o+ a*e and no later
t,an :> mont,s o+ a*e to ermit a comlete e0amination o+ t,e c,ildCs mo/t, and
Aaws, to allow t,e c,ild to -ecome +amiliar wit, t,e dental o++ice roced/res /nder a
leasant sit/ation, and to ro"ide arents wit, early re"enti"e ad"ice.
<. A, 1, D, and 3correct.
Cincorrect. A comlete medical ,istory is imortant as some systemic conditions
may ad"ersely a++ect dental ,ealt,.
%. A, 1, and Dcorrect.
Cincorrect. I+ a denti+rice is /sed, only a ea-si@ed or smaller amo/nt s,o/ld -e
laced on t,e -r/s, to a"oid in*estion o+ e0cess +l/oride.
3incorrect. Alt,o/*, a lar*e toot,-r/s, may -e care+/lly /sed to clean anterior
teet,, a small so+t--ristled toot,-r/s, ro"ides easier access to all areas o+ t,e teet, as
well as more com+ort to t,e in+antCs mo/t,.
(. A, 1, C, and Dcorrect.
3incorrect. 5otal amo/nt o+ cario*enic +ood is not t,e iss/eD rat,er, t,e +re?/ency
o+ in*estion and retenti"eness o+ t,e +ood are t,e +actors t,at contri-/te to t,e caries
risk.
:. Dental co/nselin* to re*nant women s,o/ld start iiiiiiiiii.
>. Dental radio*ra,s s,o/ld -e a"oided d/rin* t,e iiiiiii trimester o+ re*nancy.
=. 5,e em,asis on e0cellent maternal oral ,ealt, is re?/ired +or t,ree reasons9
iiiiiiiiii, iiiiiiiiii, and iiiiiiiiii.
&. 3"idence s/**ests t,at dental caries is an iiiiiiiiii disease.
'. Dental caries is mainly rod/ced -y t,e -acteria iiiiiiiiii.
<. 5,e main so/rce o+ transmission o+ Streptococcus mutans to t,e in+antCs mo/t, is
mainly +rom iiiiiiiiii.
%. C,ildren o+ mot,ers takin* +l/oride at t,e time o+ t,e c,ildCs -irt, re"ealed less
caries iiiiiiiiii.
(. 5,ree ot,er terms t,at descri-e early c,ild,ood caries are iiiiiiiiii,
;. 5,e caries rocess is iiiiiii and at times a de+inite ca/se may not -e identi+ia-le.
:$. !ecently, it is recommended t,at a c,ild s,o/ld +irst "isit t,e dental o++ice at
iiiiiiiiii o+ a*e.
References
:. Garcia-Godoy, F. 7:;(=8. Oral ,ealt,9 )art o+ t,e sociali@ation rocess. " Pedodont,
%9>':-'&.
>. Croll, 5. ). 7:;;&8. A c,ildCs +irst dental "isit9 A rotocol. Euint /nt, :'9<>'-=%.
=. 5,orild, I., .inda/-#onson, 1., g 5wetman, S. 7>$$>8. )re"alence o+ sali"ary
Streptococcus mutans in mot,ers and in t,eir resc,ool c,ildren. /nt " Paediatr Dent,
:>9 >-%.
&. .i, H., 4an*, 4., g Ca/+ield, ). 4. 7>$$$8. 5,e +idelity o+ m/tans stretococci
transmission and caries stat/s correlate wit, -reast-+eedin* e0erience amon*
C,inese +amilies. Caries Res =&9:>=-=>.
'. 2o@ai, 2., Nakayama, !., 5edAosason*ko, U., 2/wa,ara, S., S/@/ki, #., Okada, M.,
g Na*asaka, N. 7:;;;8. Intra+amilial distri-/tion o+ m/tans stretococci in #aanese
+amilies and ossi-ility o+ +at,er-to-c,ild transmission. %icro4iol /mmunol, &=9;;-
:$<.
<. !ia, .. 4. 7:;((8. #a4y 4ottle tooth decay (nursin$ caries)6 comprehensive
revie3, Dental Healt, Section. 4as,in*ton, DC9 American )/-lic Healt,
Association, :-:=.
%. 5an@er, #. M., .i"in*ston, #., g 5,omson, A. M. 7>$$:8. 5,e micro-iolo*y o+
rimary dental caries in ,/mans. " Dent !duc, <'9:$>(-=%.
(. 1erkowit@, !. #., #ordan, H. 6., g 4,ite, G. 7:;%'8. 5,e early esta-lis,ment o+
Streptococcus mutans in t,e mo/t,s o+ in+ants. rch +ral #iol, >$9:%:-%&.
;. 2rasse, 1., 3dwardsson, S., S"ensson, I., g 5rell, .. 7:;<%8. Imlantation o+ caries-
ind/cin* stretococci in t,e ,/man oral ca"ity. rch +ral #iol, :>9>=:-=<.
:$. Oos,ima, 5., Mats/m/ra, M., Hos,ino, 5., 2awa-ata, S., So-/e, S., g F/Aiwara,
5. 7>$$:8. Contri-/tions o+ t,ree *lycosyltrans+erases to s/crose-deendent ad,erence
o+ Streptococcus mutans, " Dent Res, ($9:<%>-%.
::. S,ei,am, A. 7>$$:8. Dietary e++ects on dental diseases. Pu4lic Health &utr, &9'<;-
;:.
:>. Ca/+ield, ). 4., Dasanayake, A. )., .i, H., )an, H., Hs/, #., g Hardin, #. M.
7>$$$8. Nat/ral ,istory o+ Stretococc/s san*/inis in t,e oral ca"ity o+ in+ants9
e"idence +or a discrete window o+ in+ecti"ity. /nfect /mmun, <(9&$:(->=.
:=. Ca/+ield, ). 4., C/tter, G. !., Dasayanake, A. ). 7:;;=8. Initial ac?/isition o+
m/tans stretococci -y in+ants9 3"idence o+ a discrete window o+ in+ecti"ity. " Dent
Res, %>9=%-&'.
:&. .i, H., g Ca/+ield, ). 4. 7:;;'8. 5,e +idelity o+ initial ac?/isition o+ m/tans
stretococci -y in+ants +rom t,eir mot,ers. # Dent !es, %&9<(:-'.
:'. 1ram-illa, 3., Felloni, A., Ga*liani, M., Maler-a, A., Garcia-Godoy, F., g
Stro,men*er, .. 7:;;(8. Caries re"ention d/rin* re*nancy. !es/lts o+ a =$-mont,
st/dy. " m Dent ssoc, :>;9(%:-%%.
:<. Casamassimo, ). S. 7>$$:8. Maternal oral ,ealt,. Dent Clin &orth m &'9&<;-%.
:%. Moss, S. #. 7:;((8. 5,e Hear >$$$ Healt, O-Aecti"es +or t,e Nation. Pediatr
Dent, :$9>>(-==.
:(. Her-ert, F. .., .enc,ner, 6., g )ink,am, #. !. 7:;;&8. In Starkey, ). A, 3d. The
ns3er #oo*, C,ica*o9 American Society o+ Dentistry +or C,ildren.
:;. Dimitro"a, M. M., 2/kle"a, M. )., g 2onde"a, 6. 2. 7>$$$8. A st/dy o+ caries
olari@ation in :-, >- and =-year-old c,ildren. 'olia %ed 7)lo"di"8 &>9''-;.
>$. Dimitro"a, M. M., 2/kle"a, M. )., g 2onde"a, 6. 2. 7>$$$8. Seci+icity o+ caries
attack in early c,ild,ood. 'olia %ed 7)lo"di"8 &>9'$-&.
>:. Dimitro"a, M. M., 2/kle"a, M. )., g 2onde"a, 6. 2. 7>$$$8. 3arly c,ild,ood
cariesincidence and need +or treatment. 'olia %ed 7)lo"di"8, &>9&<-;.
>>. 1e,rendt, A., S@ie*oleit, F., M/ler-.essmann, 6., Iek-O@demir, G., g 4et@el,
4. 3. 7>$$:8. N/rsin*--ottle syndrome ca/sed -y rolon*ed drinkin* +rom "essels
wit, -ill-s,aed e0tensions. SDC " Dent Child, <(9&%-'$.
>=. )etti, S., Cairella, G., g 5arsitani, G. 7>$$$8. !amant early c,ild,ood dental
decay9 An e0amle +rom Italy. " Pu4lic Health Dent, <$9:';-<<.
>&. #ones, D. .., Mo-ley, C. C., g Garcia-Godoy, F. 7:;;<8. 6alidation o+ a clinical
se"erity inde0 o+ n/rsin* caries in a resc,ool Hisanic o/lation. " Dent Res, %'9:&
7A-str. =&8.
>'. Garcia-Godoy, F., Mo-ley, C., g #ones, D. 7Set :;;'8. Caries and +eedin*
ractices in So/t, 5e0as resc,ool c,ildren. Report to the Centers for Disease
Control and Prevention,
><. 6alaitis, !., Hesc,, !., )assarelli, C., S,ee,an, D., g Sinton, #. 7>$$$8. A
systematic re"iew o+ t,e relations,i -etween -reast+eedin* and early c,ild,ood
caries. Can " Pu4lic Health, ;:9&::-%.
>%. Dini, 3. .., Holt, !. D., g 1edi, !. 7>$$$8. Caries and its association wit, in+ant
+eedin* and oral ,ealt,-related -e,a"io/rs in =-&-year-old 1ra@ilian c,ildren.
Community Dent +ral !pidemiol, >(9>&:-(.
>(. 5wetman, S., Garcia-Godoy, F., g Goe+erd, S. #. 7>$$$8. In+ant oral ,ealt,. Dent
Clin &orth m &&9&(%-'$'.
>;. Mc4,orter, A. G., Seale, N. S., g 2in*, S. A. 7>$$:8. In+ant oral ,ealt, ed/cation
in U.S. dental sc,ool c/rric/la. Pediatr Dent, >=9&$%-;.
=$. Hamilton, F. A., Da"is, 2. 3., g 1link,orn, A. S. 7:;;;8. An oral ,ealt,
romotion ro*ramme +or n/rsin* caries. /nt " Paediatr Dent, ;9:;'->$$.
reser"ed.
Chapter 19. Oral Health Promotion in Schools - lice %, Horo3it1
&orman +, Harris
Objectives
:. 30lain w,y *eneral and oral-,ealt, sc,ool ro*rams are needed.
>. Disc/ss w,y many teac,ers are concerned a-o/t t,e rosect o+ teac,in* oral
,ealt, and o+ cond/ctin* daily toot,-r/s,in* as a rimary re"ention meas/re.
=. 30lain w,y sc,ool--ased ,ealt, clinics 7S1HCs8 o++er t,e otential o+ ro"idin*
access and +/ndin* +or re"ention and treatment ro*rams.
&. Descri-e an e++ecti"e rimary re"enti"e ro*ram t,at can -e accomlis,ed -y
existin$ sc,ool sta++ ersonnel.
'. Identi+y t,e reasons t,at sc,ool--ased sealant and +l/oride re*imens s,o/ld tar*et
F,i*,-riskF st/dentsD e0lain ,ow a dental ,y*ienist can contri-/te to a re"enti"e
ro*ramD and +inally, state t,e -ene+its t,at a dentist can add to t,e sc,ool ,ealt,
team.
<. #/sti+y t,e need +or a sc,ool to-acco inter"ention ro*ram to ,el re"ent st/dent
/se o+ smokin* and smokeless to-acco rod/cts.
%. Descri-e t,e role o+ +oot-all ,elmets and intraoral mo/t,*/ards, as well as w,at to
do i+ a layerCs toot, ,as -een knocked o/t.
(. 30lain ,ow an e0ansion o+ a sc,oolCs mission to incl/de teac,in* a-o/t -road
societal ro-lems can -e cometiti"e wit, teac,in* a normal academic c/rric/l/mD
s/**est a sol/tion to t,is dilemma.
4e need to do a -etter Ao- o+ wea"in* a sa+ety net o+ /nderstandin*, areciation and
*/idance in t,e +amily, in t,e comm/nity and sc,ool. 4e need to start t,inkin* o+
,ealt, and ed/cation as interlockin* s,eres.
C. 3"erett 2oo, MD, S/r*eon General
Introduction
5oday we ,a"e t,e a-ility to re"ent or control most oral diseases or conditions o+
sc,ool-a*e c,ildren. 5,o/sands o+ c,ildren and yo/t,s in t,e United States ,a"e
-ene+ited +rom t,e /se o+ t,ese re"enti"e roced/res. For e0amle, dental caries ,as
-een red/ced dramatically amon* U.S. c,ildren ' t,ro/*, :% years o+ a*e.
:-=
In +act,
recent data s,ow t,at nearly ''E o+ t,ese c,ildren are caries-+ree in t,eir ermanent
dentition, alt,o/*, t,e ercenta*e decreases dramatically wit, a*e. In addition, an
o"erall imression is t,at most st/dentsC mo/t,s are cleaner wit, little noticea-le
e0o*eno/s stain and reasona-ly ,ealt,y *in*i"a. Un+ort/nately, re"enti"e roced/res
,a"e neit,er -een a"aila-le nor a++orda-le -y all c,ildren. 5,is ine?/ality likely
e0lains w,y aro0imately ($E o+ caries lesions are +o/nd amon* one ?/arter o+ t,e
U.S. c,ild o/lation.
:-=
Moreo"er, s,ar disarities still ersist in oral ,ealt, stat/s
and /se o+ dental ser"ices.
:
)oor c,ildren are more likely t,an non-oor c,ildren to
,a"e a hi$her proportion of decay and are least li*ely to receive treatment,
:-=
Daily more t,an <,$$$ U.S. yo/t,s :( years o+ a*e and yo/n*er try t,eir +irst
ci*arette.
&
It is well esta-lis,ed t,at t,e /se o+ to4acco productssmokin* and
smokeless to-accois t,e rimary risk +actor +or oral and ,aryn*eal cancers.
'
Het,
t,e /se o+ FsitF to-acco 7c,ewin* to-acco and sn/++8 amon* U.S. yo/t,s is on t,e
rise and is not limited to lower socioeconomic *ro/s. )/rortedly, some yo/t,s
-elie"e t,at FsitF to-acco is a sa+e alternati"e to smokin*. Moreo"er, w,en yo/t,s
/se sit or c,ew to-acco t,ey are likely to switc, to ci*arettes. 3?/ally or more
disconcertin* is t,at smokin* ci*arettes remains ,i*, and is increasin* amon* t,e
yo/n*.
<
One reort s,owed t,at in :;;(, =$E o+ ,i*,-sc,ool-senior *irls reorted t,at
t,ey ,ad smoked in t,e ast =$ days.
&
Also it is notewort,y t,at +ew ,ealt, ed/cation
te0ts incl/de in+ormation t,at t,e /se o+ to-acco and alco,ol rod/cts are rimary risk
+actors +or oral cancers.
%
5,e *ood news is t,at in"estin* in comre,ensi"e to-acco control ro*rams, w,ic,
incl/des sc,ools, does 3or*,
(,;
5wo maAor contri-/tin* +actors incl/de9 re"entin* t,e
initiation o+ to-acco /se amon* yo/t, and romotin* ?/ittin* amon* yo/n* eole
and ad/lts.
(,;
3?/ally imortant is t,e +act t,at lar*e n/m-ers o+ yo/t,, esecially minorities, do not
comlete ,i*, sc,ool.
:$
And, many -ecome arents at an early a*e. 5,/s, ,ealt,
literacy is esecially imortant +or yo/t,s w,o dro o/t o+ ,i*, sc,ool. It is imortant
t,at t,ey *ain t,e knowled*e and skills to attain and maintain *ood ,ealt,, incl/din*
oral ,ealt,, +or t,emsel"es and ot,ers w,o may deend on t,em. For t,ese reasons,
romotin* oral ,ealt, in sc,ools is not only desira-le -/t also a necessity.
1eyond t,e +amily, no ot,er instit/tion in o/r society can do more +or c,ild and
adolescent ,ealt,.
::
In todayCs +ast-aced society in w,ic, c,ildren o+ten li"e in sin*le-
arent or d/al-career +amilies, t,e sc,ool may -ecome t,e only -astion o+ constancy
in a c,ildCs en"ironment. 1/t, oral ,ealt, ro*rams in sc,ools cannot 4e considered in
isolation +rom t,e maelstrom o+ con+lictin* needs and riorities o+ o"erall medical,
dental, and social needs o+ c,ildren and yo/t,.
Definitions
For m/t/al /nderstandin* t,e +ollowin* de+initions are ro"ided +or /se in t,is
c,ater.
Diet re+ers to t,e oral inta*e of all foods and 4evera$es,
&utrition is t,e st/dy o+ meta-olism t,at occ/rs follo3in$ the in$estion of foods and
4evera$es,
Pro$ram is an or$ani1ed *ro/ o+ roced/res desi*ned to sol"e a de+ined ro-lem.
Health education is any com-ination o+ planned learnin$ experiences desi*ned to
+acilitate "ol/ntary actions cond/ci"e to ,ealt,.
:>
Healt, ed/cation m/st -e an inte*ral
art o+ any sc,ool ,ealt, ro*ram. Healt, ed/cation is /sed to in+orm, ed/cate, and
rein+orce re"io/s ,ealt, messa*es. It is essential to ed/cate a -road sectr/m o+
indi"id/als and *ro/s to *ain accetance and /se o+ ,ealt, meas/res. Healt,
ed/cation alone cannot +/nction as a re"enti"e met,od.
:=,:&
Still, acc/rate
in+ormation and knowled*e are imortant -eca/se t,ey ena-le indi"id/als, *ro/s,
and a*encies or instit/tions to make informed decisions re*ardin* oral ,ealt,.
:=,:&
Health literacy is t,e caacity o+ an indi"id/al to o4tain, interpret, and understand
-asic ,ealt, in+ormation and ser"ices and t,e cometence to /se, or not to /se, s/c,
in+ormation and ser"ices in ways t,at are ,ealt, en,ancin*.
>
Health promotion is any planned com4ination o+ ed/cational, olitical, re*/latory,
and or*ani@ational s/orts +or actions and conditions cond/ci"e to t,e ,ealt, o+
indi"id/als, *ro/s, or comm/nities.
:>
5,is de+inition di++ers +rom a more common
/se o+ romotion t,at is *enerally re*arded as /-lic relations or marketin* acti"ities.
Alt,o/*, t,ese kinds o+ acti"ities +re?/ently are a art o+ ,ealt, romotion, t,is
de+inition re+ers to actions intended to modi+y an indi"id/alCs en"ironment in a way
t,at will imro"e ,ealt, re$ardless of individual actions or to ena-le indi"id/als to
take ad"anta*e o+ re"enti"e and treatment roced/res -y remo"in* e0istin* -arriers.
For e0amle, one ,ealt, romotion strate*y to in+l/ence oral ,ealt, mi*,t incl/de
ro"idin* a comm/nity--ased +l/oride re*imen s/c, as +l/oride mo/t,rinse or ta-lets
in sc,ools t,at incl/des aroriate ed/cation +or arents, st/dents, and sc,ool
ersonnel. Anot,er e0amle, /sin* a re*/latory s/ort, mi*,t incl/de t,e
prohi4ition o+ any to-acco rod/cts on sc,ool roerty. 5,is tye o+ re*/lation alon*
wit, aroriate ed/cation a-o/t t,e ,ealt, e++ects o+ to-acco /se as well as an
increase in t,e state?s to4acco tax wo/ld constit/te a ,ealt, romotion strate*y.
Comprehensive school health education is a planned, systematic, and on*oin*
learnin* oort/nity t,at ena-les all students 72-:>8 to -e rod/cti"e learners and to
make well-considered ,ealt, decisions t,ro/*,o/t t,eir li"es.
Comprehensive school health pro$ram is an or$ani1ed set o+ olicies, roced/res, and
acti"ities desi*ned to rotect and romote t,e ,ealt, and well -ein* o+ st/dents and
sta++, w,ic, ,as traditionally incl/ded ,ealt, ser"ices, a ,ealt,y sc,ool en"ironment,
and ,ealt, ed/cation.
Who is Responsible for Teaching Oral Health?
Sc,ool a*e c,ildren, esecially yo/n*er st/dents, lar*ely deend on arents andBor
sc,ool--ased ro*rams +or oral-,ealt, in+ormation or +or incl/sion in re"enti"e
dentistry or treatment ro*rams. Many teac,ers -elie"e t,at oral-,ealt, instr/ction
s,o/ld -e t,e resonsi-ility o+ arents and ,ealt, ed/catorsnot teac,ers o+
academic s/-Aects. 5,is -elie+ mi*,t -e le*itimate i+, /ni"ersally, arents were a-le to
care +or t,eir c,ildrenCs oral ,ealt,. 5o ill/strate, Mandel ,as ointed o/t t,at t,ere
,as -een a ro+o/nd dro in caries +or :%-year-olds, wit, '$E -ein* +ree o+ decayD at
t,e same time ,e e0ressed concern +or t,e '$E still e0eriencin* caries.
:'
In
addition, t,e contin/ed *rowt, o+ n/m-ers o+ c,ildren li"in* in o"erty, co/led wit,
cuts in pu4lic health pro$rams, may not -ode well +or t,e /nderser"ed o/lationCs
access to dental ser"ices.
:<,:%
In +act, recent reorts indicate t,at t,ere is a ,/*e
disarity -etween low-income c,ildren and t,eir ,i*,er-income co/nterarts.
:,>
A
c,ild reared in a ,ome w,ere t,e arents are s/-Aect to economic and ed/cational
disad"anta*es is o+ten dentally ne*lected. In t,ese ,omes, arental intercession in t,e
oral-,ealt, care o+ a c,ild +re?/ently -e*ins wit, seekin* ,el to relie"e ain, o+ten a
di++ic/lt task -eca/se access to dental care is not easy +or t,em. 5oo many workin*
mot,ers and sin*le arents +ind it "ery di++ic/lt to take time o++ +rom work to tend to
t,eir c,ildrenCs ,ealt,, esecially w,en t,ere are additional -arriers to access. Ot,ers
may -e aat,etic or so o"erw,elmed wit, ,ow to +eed t,eir +amily t,at oral ,ealt,
simly is not a riority in t,eir li"es.
3"en wit, ,i*,ly moti"ated and ed/cated ad/lts, t,eir knowled*e a-o/t oral ,ealt, is
o+ten minimal.
:(->:
In addition, -e,a"ioral c,an*e may -e more di++ic/lt to in+l/ence at
,ome /nder arental */idance t,an /nder t,e t/tela*e o+ a teac,er. In ot,er words,
many arents t,emsel"es do not know ,ow to ,el t,eir c,ildren ,el t,emsel"es and
need t,e s/ort o+ a sc,ool ,ealt, ro*ram. Still, w,ene"er ossi-le, t,e arent m/st
-e incl/ded in a sc,ool--ased, oral ,ealt, ro*ram. )arents can ro"ide stron*
ositi"e rein+orcement, eit,er t,ro/*, role-modelin* or "er-al messa*es t,at s/ort
t,e attit/dinal and -e,a"ioral c,an*es rom/l*ated in t,e sc,ool settin*. Ideally,
arent ed/cation s,o/ld arallel c,ild ed/cationD in t,is way, arents can learn to
imro"e t,eir own oral ,ealt, as well as ,a"e t,e */idelines to assist t,eir c,ildren.
5,is ed/cational rocess o+ arents is o+ten necessary to ,el o"ercome t,e -arriers
raised -y their ast ad"erse e0eriences wit, dental treatment and its +inancial
,ards,is.
5,e -ottom line is t,at all c,ildren ,a"e the ri$ht to a $ood education to ena-le t,em
to -e knowled*ea-le, rod/cti"e ad/lts. A ,ealt,y c,ild is -etter a-le to learn.
Sc,ools and ,ealt, are ine0trica-ly linkedD t,/s, sc,ool ,ealt, ro*rams are t,e
/nderinnin*s o+ romotin* ,ealt, and re"entin* diseases amon* o/r c,ildren.
>>,>=
5yically sc,ool ,ealt, ro*rams ,a"e ,ad t,ree maAor comonents9 ,ealt,
education, ,ealt, services, and a ,ealt,+/l environment, More recently some ,a"e
e0anded t,is triad to an ei*,t-comonent model t,at incl/des ,ealt, ed/cation,
,ysical ed/cation, ,ealt, ser"ices, n/trition ser"ices, ,ealt, romotion +or sc,ool
sta++, co/nselin* and syc,olo*ical ser"ices, a ,ealt,y sc,ool en"ironment, and arent
and comm/nity in"ol"ement.
>=
5,ose w,o ad"ocate t,e ei*,t-comonent model
-elie"e t,at it is more comre,ensi"e to ,el sol"e comle0 ro-lems now +aced -y
comm/nities. No indi"id/al model is -est. !at,er, sc,ool--ased ro*rams, like ot,er
,ealt, ro*rams, s,o/ld -e comre,ensi"e and 4ased on the needs of the population
t,ey are desi*ned to ser"e.
Roles of Oral-Health-Care Providers
)ro+essional 6ol/nteerism
In addition to arental s/ort, professional involvement in sc,ool ro*rams is
desira-le. 5,e l/0/ry o+ ,a"in* salaried dentists or dental ,y*ienists 7or -ot,8
emloyed -y sc,ool systems, ,owe"er, is rare. 5,ere+ore, oort/nities a-o/nd +or
dentists and dental ,y*ienists to "ol/nteer in sc,ool--ased ro*rams. )ro+essional
in/t is "al/a-le +or identi+yin* teac,in*-learnin* reso/rces, seakin* to st/dents,
+ac/lty, and arent *ro/s, ro"idin* in-ser"ice trainin* o+ +ac/lty and administrators,
and +or assistin* t,e sc,ools on secial occasions, s/c, as career day and ,ealt, +airs.
5,e s/ort o+ t,e ro+essional comm/nity en,ances a ro*ramCs credi-ility,
imro"es t,e ima*e o+ dentistry and dental ,y*iene, and may -e a practice 4uilder
+or articiatin* ro"iders. A more consistent resence o+ t,e oral ,ealt, ro+essions
t,ro/*,o/t t,e academic year is needed to ,el stren*t,en sc,ool-comm/nity
relations,is.
Dentists, dental ,y*ienists, and st/dents o+ eac, ro"ider *ro/ can and s,o/ld lay
maAor roles in sc,ool ,ealt, ro*rams.
>>
5,eir in"ol"ement may ran*e +rom takin* t,e
lead in lannin* a comre,ensi"e oral ,ealt, ro*ram and imlementin* it, to
articiatin* -y ro"idin* ed/cation to st/dents, treatment or re"enti"e ser"ices, or
in-ser"ice trainin* +or mem-ers o+ t,e +ac/lty. Or, t,ey may simly lay a role o+
-ein* s/orti"e o+ an aroriate roced/re t,at is -ein* recommended in a local
sc,ool. 4,ate"er t,e role one lays it re?/ires t,at t,e ro"ider -e knowled*ea-le
a-o/t t,e needs o+ st/dents in t,e sc,ool7s8, w,ic, necessitates cond/ctin* a needs
assessment. And, it re?/ires c/rrent scienti+ic knowled*e a-o/t ,ow to re"ent oral
diseases and conditions identi+ied amon* t,e c,ildren in t,e tar*et sc,ool7s8.
>>
Healt, care ro"iders s,o/ld s/ort t,e /se o+ "alid roced/res. 5,at is, one s,o/ld
recommend, /se, and ro"ide acc/rate in+ormation a-o/t only t,ose roced/res
known to -e e++ecti"e -ased on researc,.
>>
For e0amle in a sc,ool in w,ic, st/dents
,a"e ,i*,-caries rates in c,ewin* s/r+aces o+ osterior teet,, dental sealants s,o/ld -e
recommended in addition to re*/lar /se o+ a re*imen o+ +l/oride 7Fi*/re :;-:8.
Most imortant, oral-,ealt,-care ro"iders m/st work wit, ot,ers w,o are in"ol"ed in
sc,ool-,ealt, ro*rams. 5,ese *ro/s incl/de sc,ool n/rses, ,ealt, ed/cators,
,ysicians, n/tritionists, sc,ool administrators, leaders o+ local reli*io/s
or*ani@ations, mem-ers o+ t,e local and state ,ealt, deartments, arent-teac,er
associations, arents, st/dents, and oliticians. Ideally, oral-,ealt,-care ro"iders
s,o/ld ,a"e solid comm/nity or*ani@ation and comm/nication skills.
Fi*/re :;-: A lea+let e0lainin* w,at sealants are and w,o needs t,em is
a"aila-le +rom t,e NIDC! 7: NOHIC 4ay, 1et,esda, MD >$((;>-='$$8.
School-Health Programs Past and Present
Sc,ool-,ealt, ro*rams 7SH)8 ori*inated aro/nd t,e -e*innin* o+ t,e >$t, cent/ry to
,el cope 3ith conta$ion, screenin$ needs +or ,ysical disa-ilities, nutritional
deficiencies, and first aid ministrations. Since t,eir incetion, sc,ool-,ealt, ro*rams
,a"e "aried in ?/ality and content -y state and comm/nity. In t,e :;=$s and :;&$s,
c,ildren were ro"ided n/tritional s/lements, eye e0aminations, ,ealt, ed/cation,
smallo0 "accinations, and in some cases oral-,ealt, ser"ices. In t,e early :;'$s,
sc,ool--ased +l/oride re*imens were introd/ced in t,e +orm o+ m/ltile alications
o+ oerator-alied, ne/tral sodi/m +l/oride and sc,ool water +l/oridation. In t,e
:;<$s, t,e o/tstandin* s/ccess o+ raid imm/ni@ation o+ total sc,ool o/lations
a*ainst olio-myelitis, and t,e almost /ni"ersal esta-lis,ment o+ n/rsin* ser"ices
wit,in sc,ool systems to deal wit, day-to-day accidents and illnesses, is a le*acy to
t,e attainment o+ early sc,ool ,ealt, o-Aecti"es.
1/t, t,e concets and re?/irements o+ sc,ool ,ealt, ro*rams ,a"e -een *reatly
-roadened o"er t,e last t,ree decades. At t,e onset o+ t,e >:st cent/ry, school2health
services no3 include or attempt to address ma7or societal health issues t,at ,a"e
in"aded t,e sc,ools. 5,ese incl/de9 alco,ol, dr/*s, and to-acco /se 7smokin* and
FsitF8D sa+e-se0, HI6, AIDS, ot,er se0/ally transmitted diseasesD *an* "iolence and
c,ild a-/seD and sel+-esteem, deression, ,omicide, s/icide, and terrorism. In addition,
,ealt, ro-lems o+ dys+/nctional +amilies, mi*ratory workers, and t,e o"erty
stricken are o+ten addressed.
>&->(
4,en t,ese ro-lems are mi0ed wit, t,ose o+
et,nicity, race, reli*ion, and olitics, lannin* sc,ool-,ealt, ro*rams -ecomes a
comle0 and c,allen*in* e0ercise.
>;
F/rt,er, w,ile attemtin* to address more iss/es,
most sc,ool systems ,a"e ,ad a s,ar red/ction in ,ealt,-related ersonnel. 5oday, it
is a l/0/ry +or a sc,ool to ,a"e a +/ll-time n/rse or ,ealt, ed/cator on t,e remises.
Alt,o/*, dental ,y*ienists ori*inally were trained to work in sc,ools to imro"e
c,ildrenCs oral ,ealt,, relati"ely +ew sc,ools today ,a"e access to t,is tye o+ oral-
,ealt,-care ro"ider.
5,ere is little do/-t t,at sc,ools, esecially /-lic sc,ools, m/st -ecome more
in"ol"ed in a wide ran*e o+ ,ealt, ed/cation and romotion to ,el coe wit,
o"erw,elmin* societal ,ealt, ro-lems. 5,is need is en/nciated clearly in two
doc/ments, Healthy People <:C: and Healthy Schools <:::,
>,=$
Aendi0 :;-: s,ows
t,e oral-,ealt, o-Aecti"es related to sc,ools contained in Healthy People <:C:, Many
states ,a"e t,eir own ,ealt, o-Aecti"es t,at incl/de oral ,ealt,. 3ac, state deartment
o+ ,ealt, ,as at least one erson resonsi-le +or directin* ,ealt, ed/cation.
Un+ort/nately, t,ese state2level health educators and the state dental directors rarely
3or* to$ether to ac,ie"e oral ,ealt, o-Aecti"es. Some states e"en re?/ire ,ealt,
ed/cators in attendance in elementary, A/nior, and senior ,i*, sc,ools. F/rt,er, some
states ro"ide written */idance in t,e +orm o+ c/rric/l/m */idelines +or ,ealt,
ed/cation. Only a +ew states, ,owe"er, ele"ate t,e stat/s o+ ,ealt, ed/cation to
incl/de mandated testin$,
=:
In con+lict wit, t,e e0andin* ,ealt, role o+ t,e sc,ool system is t,e +act t,at the
primary mission of schools is educationnot conservin$ health or preventin$
disease, Sc,ool administrators are sensiti"e to any c,an*e or e0ansion o+ t,eir -asic
mission. 5,ere are limits to A/st ,ow +ar sc,ools can contin/e to ass/me *reater
teac,in* resonsi-ilities.
=>
)ro-a-ly t,e most imortant +actor is t,e lac* of time in t,e
c/rric/l/m +or new teac,in* re?/irements. Unless sc,ool days or years are e0tended,
any e0anded ,ealt, ro*ram -ecomes competitive wit, -asic ed/cation needs. 5,is
cometition is e0acer-ated -y le*islati"e mandates t,at re?/ire additions o+ seci+ic
sc,ool ,ealt, workloads wit,o/t allocatin* additional seci+ic ,ealt, +/ndin*.
==
It is
little wonder t,at, at times, teac,ers consider t,emsel"es dedicated, -elea*/ered, and
/nderaid ro+essionals w,o are -ein* called on to disc,ar*e d/ties 3hich JsocietyJ
itself cannot solve,
=&
5,e needs o+ a comm/nity and its sc,ools are intricately interwo"en. 5o +oster
cooeration -etween t,e two, Sc,ool Healt, Co/ncils o+ten are de"eloed to ,el
mo-ili@e t,e ,ealt, reso/rces o+ a comm/nity. In sc,ools, n/rses, ,ealt, ed/cators,
,ysical ed/cation teac,ers, */idance co/nselors, +ood-ser"ice directors, rincials,
st/dents, and arents s,are resonsi-ility, w,ile t,e *reater comm/nity tas t,e
e0ertise o+ e0istin* ci"ic or*ani@ations, ,ealt, a*encies, and -/siness and
ro+essional leaders.
='
A recent trend o+ Sc,ool Healt, Co/ncils ,as -een to
recommend imlementation o+ school24ased health clinics (S#HC) -ot, wit,in and
o/tside o+ sc,ool ,o/rs.
>&,>(,>;
5,ese S1HC are now in &' states and t,e District o+
Col/m-ia. 5,ey ,a"e *rown +rom >$$ in :;;$ to :,=($ in >$$$.
=<
5,ese clinics are
now oerational rimarily in ,i*,-risk /r-an and r/ral areas wit, ,i*,er le"els o+
o"erty w,ere t,ere is a lack o+ access and +/ndin* to con"entional ,ealt, care.
=%

Some o+ t,e ser"ices ro"ided incl/de9 at,letic and re-emloyment ,ysicals,
la-oratory and dia*nostic screenin*s, rescritions on a limited -asis, +irst aid, +amily
lannin*, renatal and ostart/m care, dr/* and alco,ol co/nselin*, n/trition and
o-esity co/nselin*, and dental care 7Fi*/re :;->8. Sonsors,i o+ S1HCs may
incl/de comm/nity or*ani@ations, ,ealt, deartments, medical centers, ,ositals,
ri"ate not-+or-ro+it or*ani@ations, and sc,ool systems.
=(
F/ndin* may -e +rom
ri"ate +o/ndations, local +/ndin*, ins/rance, or *o"ernment so/rces s/c, as
Medicaid. S,o/ld t,is trend contin/e, it is concei"a-le t,at sc,ools o+ t,e +/t/re will
need an assistant sc,ool s/erintendent +or ,ealt, a++airs.
Mem-ers o+ Con*ress and many ,ealt, ro"iders incl/din* oral-,ealt, ro"iders, are
interested in t,is S1HC aroac, to ,ealt, care +or c,ildren and yo/t, as it wo/ld
make %edicaid and other appropriated funds availa4le for this use, 5,e Deartment
o+ 3d/cation and t,e Deartment o+ Healt, and H/man Ser"ices ,a"e +/ndin*
mec,anisms in lace to romote researc, and de"eloment +or t,ese tyes o+ clinics.
Accordin* to roonents, t,e de"eloment o+ t,is nontraditional comonent o+ a
sc,ool ,ealt, ser"ice will9 7:8 ermit t,e sc,ool n/rse to ret/rn to a more traditional
/rose o+ t,e n/rsin* ser"ice to s/ort t,e classroom teac,er as well as actin* as a
liaison wit, t,e S1HCD 7>8 ret/rn to teac,ers t,e resonsi-ility +or classroom teac,in*
o+ s/-Aects t,at matc, t,eir academic trainin*D and 7=8 provide a method of access and
fundin$ +or all ,ealt, care +or sc,ool-a*e c,ildren and yo/t,.
5oday t,ere is a national concern +or ac,ie"in* -ot, e0cellence o+ ed/cation and +or
imro"ed ,ealt, +or c,ildren. Sc,ool--ased ro*rams aear to -e a nat/ral site +or
addressin* -ot, concerns. St/dents can stay in class, arents can contin/e at work,
and cost-e++ecti"e, comre,ensi"e sc,ool ,ealt, ro*rams, includin$ those for oral
health, can -e made a"aila-le.
>(,=(
It is imortant to note t,at one o+ t,e oral ,ealt,
o-Aecti"es in Healt,y )eole >$:$ is to increase t,e n/m-er o+ S1HC t,at incl/de
oral ,ealt, 7Aendi0 :;-:8. A consens/s e0ists t,at a st/dent w,o is imaired -y
dr/*s or alco,ol is as ,andicaed in learnin* as an indi"id/al w,o s/++ers +rom a
si*,t or ,earin* de+iciency. 5,/s, t,ere is a need +or sc,ools to ,el s,ae social,
syc,olo*ical, and ,ysical well -ein*all in the name of school health,
Fi*/re :;-> A st/dent recei"es dental care in a sc,ool--ased ,ealt, clinic.
Question 1
A. Oral ,ealt, ed/cation, romotion, re"ention, and treatment can -e -est ro"ided
wit,in t,e +ramework o+ an o"erall sc,ool medical-,ealt, ro*ram.
1. 5eac,ers are well reared academically and t,ro/*, contin/in* ed/cation co/rses
to act as +acilitators in sol"in* societal ro-lems.
C. 5eac,ers are well reared academically and t,ro/*, contin/in* ed/cation
ro*rams to act as +acilitators in teac,in* oral2health education,
D. Sc,ool--ased ,ealt, clinics 7S1HC8 t,at incl/de oral-,ealt, ser"ices, are no3 in
oeration.
3. Aro0imately ($E o+ caries lesions are +o/nd in aro0imately >'E o+
sc,oola*ed c,ildren.
Creating Effective, School-Based Oral-Health Programs
5o in"ol"e comm/nities, +amilies, or indi"id/als in ass/min* resonsi-ility +or t,eir
own oral ,ealt,, many in*redients are necessary. 5,ese incl/de -/t are not limited to9
knowled*e, skills, moti"ation, access to re"enti"e a*ents and treatment ser"ices, and
a sa+e, ,ealt,y en"ironment. F/rt,er, decision makers and teac,ers m/st -e willin* to
incl/de ,ealt, ed/cation and ,ealt, romotion in sc,ools. Finally, policy is imortant.
For e0amle, smoke-+ree sc,ools are a res/lt o+ a olicy t,at -ans t,e /se o+ to-acco
rod/cts-y allon sc,ool cam/ses. S/c, olicies ,el deter st/dents and +ac/lty
+rom /sin* t,ese rod/cts.
It is imossi-le +or t,e aro0imate :'>,$$$ acti"e dentists
=;
and o"er :$$,$$$ dental
,y*ienists
&$
in t,e United States to ass/me t,e tremendo/s task o+ imartin* essential
oral ,ealt, ed/cation to t,e /-lic and enco/ra*e aroriate -e,a"iors t,at are
re?/isite to otimal oral ,ealt,. M/c, o+ t,is ed/cation can -e accomlis,ed t,ro/*,
schools, mass media, and industry,
)lannin*2ey to S/ccess
A s/ccess+/l sc,ool--ased ro*ram does not A/st ,aen. An inte*rated lan o+ action
+or seci+ied *rades is essential, as is a clear delineation o+ ro*ram resonsi-ilities
and o-Aecti"es.
>$
It s,o/ld -e noted t,at, alt,o/*, incl/din* all *radeskinder*arten
t,ro/*, *rade :>is desira-le and ideal, it rarely occ/rs re*ardin* oral ,ealt,. 4,en
oral ,ealt, is addressed in a sc,ool settin*, it is more o+ten con+ined to kinder*arten
t,ro/*, *rade <.
#/dicio/s lannin* /ltimately will res/lt in meanin*+/l, tar*et-seci+ic ro*rams t,at
are inte*rated t,ro/*,o/t t,e sc,ool years. )lannin* m/st incl/de a comm/nity needs
assessment, esta-lis,in* riorities, de"eloin* a -/d*et, and a stron* comonent o+
e"al/ation. De"eloin* a written lan o+ action is necessary +or a "ariety o+ reasons.
5,e lan can ser"e as an ed/cational tool to in+orm indi"id/als and *ro/s, esecially
t,ose t,at are needed to F-/y inF as a artner in t,e endea"or. A written lan also can
-e /sed to solicit +/nds to ,el /nderwrite t,e roosed ro*ram. And, o+ co/rse, t,e
lan ser"es as a */ide +or all w,o are acti"ely in"ol"ed to ,el maintain +oc/s on t,e
o-Aecti"es.
>>
A di"erse and committed work *ro/ ,els to ens/re a *reater "ariety o+ in/t, a
reresentati"e a/dience, and a -road--ased sense o+ owners,i. It is essential t,at
cooerati"e workin* relations,is -e esta-lis,ed in t,e initial lannin* sta*es amon*
arents, comm/nity leaders-ot, -/siness and oliticalteac,ers, sc,ool
administrators, and oral ,ealt, ro+essionals. dental representative should 4e a
mem4er of all state or local school advisory councils to ensure professional as 3ell
as political input,
::
3d/cational Considerations
5raditionally, /-lic sc,ools ,a"e acceted t,e resonsi-ility o+ teac,in* oral-,ealt,
as a art o+ *eneral ,ealt,. Committed, knowled*ea-le teac,ers are t,e cornerstones
o+ all e++ecti"e, sc,ool--ased oral-,ealt, ed/cation. Howe"er, t,e dental s/-Aect
matter contained in many te0ts /sed in teac,ersC colle*es relates mainly to t,e
anatomy and ,ysiolo*y o+ t,e teet,, t,e s/ortin* tiss/es, and sali"ary *lands. S/c,
a -ack*ro/nd ena-les sc,oolteac,ers to teac, and romote -asic in+ormation a-o/t
t,e oral ca"ity. Teachers cannot 4e expected to possess expertise in a constantly
c,an*in* ool o+ scienti+ic knowled*e relatin* to re"ention and dental treatment
otions. As a res/lt, t,ey may -e rel/ctant to teac, w,at co/ld -e incorrect or o-solete
in+ormation in t,ese areas.
)eriodic in-ser"ice trainin* to /*rade teac,er ,ealt, knowled*e, incl/din* oral
,ealt,, wo/ld *reatly ,el t,e +ac/lty to de"elo *reater cometence and con+idence.
&:
5o ,el attain t,is o-Aecti"e t,e state o+ Uta, s/lies t,eir teac,ers wit, a -iann/al
/date o+ ad"ances in dentistry.
&>
5eac,ers and t,e dental ro+ession alike ,a"e ?/estioned t,e riority *i"en to sc,ool
oral ,ealt, ed/cation ro*rams. Sometimes t,e ?/estions are asked -y t,e ed/cators
-eca/se t,e time taken +or dental ed/cation cometes wit, t,e time needed +or ot,er
s/-Aects. Is oral ,ealt, instr/ction more imortant t,an, +or instance, mat,ematics or
"ocational trainin*e Healt, ro+essionals also ?/estion t,e time de"oted to sc,ool
ro*rams t,at +eat/re mainly in+ormation transmittal, rat,er t,an a com4ination of
education and preventiveLtreatment re$imens, 3d/cation, alone, rarely s/++ices. For
e0amle, it is ointless to ro"ide la?/e remo"al instr/ction i+ toot,-r/s,es are not
ro"ided and t,e instr/ction is not racticed in t,e classroom. Indi"id/als, w,o are
not ro"ided assistance in s,ain* ,ealt, attit/des, -elie+s, and ,a-its early in li+e, are
likely to s/++er t,e conse?/ences o+ red/ced rod/cti"ity in later years. Healt,-related
knowled*e and skills ac?/ired in /-lic sc,ool may -ecome more meanin*+/l in ad/lt
li+e w,en t,e imortance o+ *ood ,ealt, -ecomes more aarent.
5,e amo/nt and ?/ality o+ oral ,ealt, ta/*,t in sc,ool is o+ten too little to -e
assimilated -y st/dents, and not lon*-term eno/*, to -e amena-le to *ood e"al/ation.
A national sc,ool ,ealt, e"al/ation cond/cted -y t,e U.S. )/-lic Healt, Ser"ice
7US)HS8, re"ealed t,at c,an*es in ,ealt,-related knowled*e, ractices and attit/des
increase wit, t,e amo/nt o+ instr/ction. 5,e ossi-ility o+ securin$ that needed
additional time is minimal considerin* t,at in :;;&, t,e ann/al a"era*e n/m-er o+
,o/rs sent on ,ealt, ed/cation, incl/din* oral ,ealt,, was CA,F ,o/rsk
&=
3d/cational )rinciles
Oral-,ealt, ed/cation in"ol"es t,e /se o+ many comm/nication and or*ani@ational
skills and rocesses. 5,ese incl/de cond/ctin* a needs assessment, listenin*,
lannin*, +acilitatin* *ro/ and indi"id/al articiation, in+ormin* all rele"ant
indi"id/als and *ro/s, leadin*, writin*, seakin*, ro"idin* +eed-ack and
rein+orcement, and ro"idin* in-ser"ice trainin*. 5,ese acti"ities enlist t,e ,el o+
ot,ers and +oster cooeration and t,e adotion and maintenance o+ e++ecti"e ,ealt,
meas/res and ro*rams -y indi"id/als, instit/tions, or*ani@ations, and comm/nities.
3d/cational rinciles necessary +or oral-,ealt, ed/cation incl/de9
Healt, ed/cation m/st -e an inte$ral part o+ any re"enti"e or restorati"e ser"ice or
re*/lation or le*islation rele"ant to a ,ealt, ro*ram. 5,is ed/cation +/nctions to
introd/ce and rein+orce /nderstandin* and accetance o+, and articiation in,
w,ate"er t,e ,ealt, ro*ram consists o+.
3d/cational materials can -e /sed e++ecti"ely to *ain attention on seci+ic toics and
to rein+orce or clari+y a roced/re or re*imen. 1/t, educational materials alone do
not constitute an oral2health pro$ramD t,ey can -e /se+/l aids.
3d/cation materials s,o/ld -e accurate and consistent wit, c/rrent scienti+ic
knowled*e.
3d/cational materials m/st -e aroriately desi*ned +or seci+ic a$es, level of
literacy, and cultural $roups +or w,om t,ey are desi*ned. One lea+let, +or e0amle,
cannot -e e0ected to -e s/ita-le +or all racial-et,nic *ro/s in a *i"en comm/nity.
3d/cational materials s,o/ld -e e"al/ated prior to t,eir +inal rod/ction and /se
wit, t,e intended tar*et *ro/.
Interacti"e teac,in* in w,ic, t,ere is acti"e participation and involvement on t,e
art o+ learners is essential +or all a*e *ro/s and content areas.
>>
Aroac,es +or Healt, 3d/cation
M/ltile c,annels o+ comm/nication s,o/ld -e /sed to ,el ens/re reac,in* as many
o+ t,e tar*et o/lation as ossi-le +or /roses o+ in+ormin* and ed/catin* as well as
+or rein+orcement. Oral ,ealt, ed/cation s,o/ld incl/de more than one o+ t,e
+ollowin* aroac,es.
+ne2to2one communication s/c, as disc/ssin* t,e need +or an oral-,ealt, ro*ram
wit, a sc,ool s/erintendent.
0roup presentations o+ in+ormation and ed/cation, and demonstrations s/c, as at
arent- teac,er meetin*s, in-ser"ice trainin* +or teac,ers, or or*ani@ational meetin*s.
Use of mass communication s/c, as newsaers, radio, tele"ision, we- sites, and
sc,ool newsletters to in+orm all *ro/s a-o/t t,e need +or an oral ,ealt, ro*ram and
lans to initiate a ro*ram, to solicit artners, and to ro"ide +eed-ack and
rein+orcement a-o/t t,e ro*ramCs "al/e and e++ecti"eness.
Community or$ani1ational strate$ies, s/c, as coalitions, artners,is, co/ncils, or
committees to sol"e local ,ealt, ro-lems, *ain commitment o+ reso/rces, and
cond/ct needs assessments.
>>
St/dent )articiation
Philosophically, all children should 4e entitled to receive maximum information and
primary preventive oral care, )ro"idin* ma0im/m oral ,ealt, treatment +or all
c,ildren, ,owe"er, is not +easi-le. )oor c,ildren ,a"e a ,i*,er ercenta*e o+ /ntreated
decayed teet, t,an nonoor c,ildren.
:
Hence, a sc,ool--ased ro*ram, ot,er t,an
classroom ed/cation, +l/oride mo/t, rinses, or ta-let ro*ram, s,o/ld -e selecti"e in
tar$etin$ the children most at ris* as eli*i-le +or a ,i*,er le"el o+ care. Once criteria
are esta-lis,ed de+inin* F,i*, risk,F all st/dents meetin* t,e ,i*,-risk criteria s,o/ld
-e eli*i-le +or t,e same re"enti"e and treatment -ene+its. For e0amle, some states
-ase eli*i-ility +or sealant ro*rams on w,et,er a c,ild is eli*i-le +or +ree sc,ool
l/nc,es. 5,e economic stat/s o+ indi"id/al st/dents, ,owe"er, should not -e t,e only
consideration -eca/se oor oral ,ealt, occ/rs amon* t,e a++l/ent as well as amon*
t,e oor. O+ imortance in one st/dy, it was +o/nd t,at +ollowin* a +ew years o+
articiation in an intensi"e caries re"ention ro*ram, indi"id/als were trans+ormed
from hi$h ris* to lo3 ris*,
&&
5,e e0tent o+ st/dent in"ol"ement in ro*ram acti"ities is an imortant iss/e.
)ersonal in"ol"ement and articiation tends to ,a"e a *reater e++ect on -e,a"ior,
attit/des, and -elie+s. Acti"e articiation likely en,ances interest in oral disease
re"ention meas/res and ,a"in* a ,ealt,y mo/t,.
One oort/nity +or inno"ati"e st/dent articiatory learnin* comes d/rin*
Children?s Dental Health %onth held annually in 'e4ruary, 5,is acti"ity, sonsored
-y t,e American Dental Association 7ADA8 and t,e American Dental Hy*ienistsC
Association 7ADHA8 was initiated in :;&: to ro"ide an ann/al +or/m +or oral ,ealt,.
Historically, -ot, t,e dental and dental ,y*iene associations ,a"e articiated in t,e
ro*ram. C,ildrenCs Dental Healt, Mont, ,as de"eloed into t,e ro+essionsC most
3idely supported and media2reco$ni1ed oral2health event, It is a time w,en sc,ools,
in cooeration wit, dental man/+act/rers, local dental and dental ,y*iene sc,ools and
associations, and ot,er sonsors, or*ani@e oral ,ealt, +airs +or t,e /-lic and +or
st/dents. As a art o+ t,ese ,ealt, +airs, st/dents en*a*e in entertainment e"ents,
recei"e screenin* e0aminations, toot,-r/s,es and toot,aste, watc, demonstrations
related to seat -elt and air -a* rotection o+ t,e +ace and -ody, articiate in
disc/ssions a-o/t t,e deadly e++ects o+ ci*arette smokin* and c,ewin* to-acco or
sn/++, and learn a-o/t ,ealt,-romotin* -e,a"iors 7Fi*/re :;-=8.
&',&<
D/rin* t,is time,
st/dents o+ten de"elo *ro/ osters and e0,i-its, disc/ss n/tritional in+ormation, and
learn t,at dentistry is not a ro+ession to -e +eared. 5,e in+ormality o+ t,ese
occasions may en,ance st/dent interest and +osters learnin* and de"eloment o+
desira-le attit/des toward sel+-care and sel+-ima*e.
Fi*/re :;-= St/dents learn ,ow to remo"e la?/e d/rin* Children?s Dental
Health %onth,
Question 2
A. I+ t,e len*t, o+ t,e resent sc,ool year is maintained, any additional time
commitments +or teac,ers to ade?/ately teac, comre,ensi"e ,ealt, ed/cation and to
address societal iss/es must come from the teachin$ time used for other su47ects,
1. 5eac,in* oral-,ealt, sel+-care is one o+ t,e most e++ecti"e means +or red/cin* oral
disease.
C. Aro0imately CA,F hours a year is t,e a"era*e time de"oted to oral2health
teac,in*.
D. 5,e ann/al C,ildrenCs Dental Healt, Mont, is sonsored -y t,e American Dental
Association, and t,e American Dental Hy*ienistsC Association.
3. Usin* m/ltile met,ods o+ comm/nication is a -etter aroac, t,an /sin* only one
met,od in ed/catin* a-o/t oral ,ealt,.
What To Teach?
5,e needs o+ st/dents in a artic/lar sc,ool or district co/led wit, a"aila-le
reso/rces,/man, e?/iment, and +inancialwill dictate necessary re"enti"e and
treatment ser"ices, ed/cation, and olicies. Aendi0 :;-> ro"ides a list o+ toics
t,at st/dents s,o/ld -e ta/*,t re*ardin* re"ention and early detection o+ oral
diseases and conditions.
Dental-Caries )re"ention
'luorides and Dental Sealants
St/dents need to learn t,at dental caries is an in+ectio/s disease wit, a m/lti+actor
etiolo*y. And, t,ey need to know t,at t,e disease can -e prevented, arrested and,
reversed and ho3 to do so, St/dents s,o/ld -e ta/*,t t,at t,e aroriate /se o+
+l/orides and it-and-+iss/re sealants are o/r -est de+ense a*ainst t,is disease.
&%
5,ey
also need to know a-o/t systemic fluorides, t,at is, +l/oride intended +or
in*estioncomm/nity-water +l/oridation, sc,ool-water +l/oridation, and dietary-
+l/oride s/lementsas well as topical fluoridest,ose +l/oride rod/cts t,at are
not intended to -e in*estedtoot,astes, mo/t,rinses, and oerator- alied
+l/orides. 3"eryone needs to know t,at +l/oride works -ot, re-er/ti"ely and ost-
er/ti"ely, -/t t,e rimary ways t,at +l/orides work are to inhi4it deminerali1ation
and to facilitate reminerali1ation,
&(
Pit2and2'issure Sealants
!e*ardin* dental sealants, st/dents need to know ,ow sealants rotect occl/sal
s/r+aces o+ t,e teet, +rom decayD t,e a*es at w,ic, teet, s,o/ld -e sealed and t,e need
+or ossi-le realication o+ sealant material. F/rt,er, and "ery imortant, st/dents
and arents need to know t,at teet, t,at ,a"e -een sealed s,o/ld not need to -e
restored wit, a +illin* 7see C,ater :$8.
Diet and &utrition
5,e United States Deartment o+ A*ric/lt/reCs +ood yramid 7see C,ater :'8 makes
it clear t,at s/*ars s,o/ld -e cons/med only in moderation. Sweets not only are
/n,ealt,y +or teet, -/t also are o+ten in +oods 7cakes, ies, cookies, etc.8 t,at are laden
wit, /n,ealt,y +ats. 1asic in+ormation on diet and n/trition s,o/ld -e a art o+ all
,ealt, ed/cation. St/dents need to /nderstand t,at cons/mtion o+ car-o,ydrates,
esecially s/*ar is a *ey comonent o+ t,e caries rocess and t,at s/*ar m/st -e
resent +or caries to occ/r. Ideally, w,en disc/ssin* diet in relation to oral ,ealt,,
in+ormation s,o/ld -e ta/*,t wit, a arallel em,asis on t,e re"enti"e -ene+its o+
+l/oride and ,ow t,ey reminerali@e inciient lesions, w,ic, re"ent t,em +rom
-ecomin* o"ert, and on t,e /se o+ it-and-+iss/re sealants and oral ,y*iene meas/res.
In t,e United States, esecially in recent years, more em,asis ,as -een laced on
makin* t,e toot, more resistant to decay wit, t,e /se o+ fluorides and dental
sealants, )er,as t,e -est messa*e a-o/t sweets is t,at if you must consume su$ars,
do so at meals and in moderation, It is imortant t,at in o/r e++orts to enco/ra*e
cons/mtion o+ nonsweet snacks t,at we do not enco/ra*e t,e /se o+ ,i*, +at and
,i*, sodi/m +oods.
O+ten, a+ter a teac,er ,as ta/*,t t,at s/*ar is one +actor t,at ca/ses toot, decay and
s/**ests t,at t,e c,ild a"oid e0cessi"e and +re?/ent in*estion o+ re+ined
car-o,ydrates, t,e c,ild t,en *oes to t,e ca+eteria. 5,ere, t,e c,ild is con+ronted wit,
attracti"e, s/*ar-laden desserts. 5,e ?/estion t,en is, F4,at messa*e do st/dents
really *ett,e messa*e t,ey ,ear in t,e classroom or t,e messa*e t,ey see, smell,
taste, and enAoy in t,e ca+eteriaeF
Sc,ools s,o/ld ro"ide an environment t,at romotes a"oidance o+ an e0cessi"e
intake o+ s/*ar cons/mtion. One imortant met,od o+ meetin* t,is o-Aecti"e is +or
t,e school dietitian to red/ce t,e n/m-er o+ days a week in w,ic, con+ections are
a"aila-le. Instead, desserts s/c, as +res, +r/its can -e o++ered t,at are n/tritionally
so/nd and limit t,e amo/nt o+ s/crose cons/med.
A second strate*y +or red/cin* st/dent s/crose intake is +or t,e school principal or
superintendent to remo"e all "endin* mac,ines t,at disense candy and A/nk +oods
and so+t drinks. 3ssentially, the income from these machines uses the teeth of the
children to su4sidi1e non4ud$eted school expenses,
&;
Many sc,ools ,a"e remo"ed
t,ese kinds o+ mac,ines or ,a"e s/-stit/ted more n/tritional snacks, incl/din* milk,
+r/it, and A/ices. Still, t,ese mac,ines remain a ro-lem -eca/se sellin* sweets
ro"ides a maAor income +or most sc,ools in t,e United States. !ecent e"idence
s/**ests t,at t,e cons/mtion o+ +r/its and "e*eta-les may ro"ide a rotecti"e e++ect
a*ainst oral cancers 7like se"eral ot,er cancers8 and ,eart disease.
'$
F/rt,er, se"eral
"ery s/ccess+/l '-DAH ro*rams ,a"e -een initiated and e"al/ated.
'$
5,ese sc,ool-
-ased ro*rams are desi*ned to increase st/dent cons/mtion o+ +r/its and "e*eta-les
to at least +i"e-a-day. Dietitians and sc,ool administrators can act as *atekeeers to
-etter st/dent ,ealt, -y e0ercisin* control o+ t,e men/ and t,e items in t,e "endin*
mac,ines resecti"ely.
)re"entin* Gin*i"itis
Classroom Tooth4rushin$
5,oro/*, mec,anical la?/e remo"al on a ro/tine -asis will essentially prevent and
reverse $in$ivitis, 5,/s, it is imortant +or c,ildren and yo/t, to know ,ow to remo"e
la?/e /sin* a toot,-r/s, and dental +loss wit,o/t inA/rin* t,eir so+t tiss/es. For some
c,ildren daily toot,-r/s,in* in t,e classroom may -e -ot, needed and desira-leD -/t,
in most cases, it is impractical, Desite t,e need +or em,asis on toot,-r/s,in*, some
-asic ro-lems arise. Many teac,ers are willin* to teac, t,e mec,anics o+
toot,-r/s,in* so lon* as t,ey do not ,a"e to demonstrate t,e /n+amiliar details o+
la?/e control. In +act, t,e iss/e o+ toot,-r/s,in* is o+ten layed down since too-
+re?/ent reetition can -e considered -orin* -y st/dents.
':
Ot,er t,an resc,ool teac,ers, "ery +ew teac,ers are willin* to incororate daily
toot,-r/s,in* into t,eir classroom sc,ed/le. 5,e daily need +or ,y*ienic stora*e and
contin/ed relacement o+ worn-o/t and lost -r/s,es also oses ro-lems +or a teac,er.
Unless relacement toot,-r/s,es are made a"aila-le to t,e c,ildren wit,o/t cost,
dedicatin* classroom time +or acti"ities in w,ic, se"eral st/dents may not -ene+it d/e
to economic or ot,er +actors is resisted. Finally, +ew classrooms ,a"e t,e water s/ly
and t,e sinks necessary +or con"eniently sc,ed/lin* daily -r/s,in* as a classroom
acti"ity.
Desite t,ese ro-lems, some classroom -r/s,in* ro*rams ,a"e -een a s/ccess. 7See
Aendi0 :;-= +or a s/**ested met,od o+ teac,in* toot,-r/s,in*.8 Alt,o/*, little or
no e"idence s/orts toot,-r/s,in* alone as a means o+ re"entin* caries,
over3helmin$ evidence supports the fact that tooth4rushin$ 3ith a fluoride dentifrice
is 4eneficial, 5,/s, one o-Aecti"e o+ toot,-r/s, instr/ction is to enco/ra*e c,ildren to
/se a +l/oride denti+rice w,en -r/s,in* teet, and not simly to teac, toot,-r/s,in* as
an e0ercise.
Some "ol/nteers *o into sc,ools to teac, la?/e remo"al wit,o/t ro"idin*
toot,-r/s,es and toot,aste +or t,e st/dents to ractice. 5,is aroac,, w,ile well
intended, may send "ery oor messa*es, esecially amon* lower socioeconomic
c,ildren w,o cannot a++ord toot,-r/s,es and toot,aste. 5,at is, t,e imortance o+
t,is roced/re will -e lost i+ t,e c,ild does not own a toot,-r/s,. I+ toot,-r/s,in*
instr/ctions are ro"ided in a classroom, it is critical not only to demonstrate proper
procedure 4ut also to provide 4rushes and toothpaste so that students can 4e
o4served practicin$ to help correct inappropriate methods,
Question 3
4,ic, o+ t,e +ollowin* ?/estions, i+ any, are correcte
A. 5oical +l/orides can only -e alied -y a dentist or dental ,y*ienist.
1. Sealants are most e++ecti"e in re"entin* -ic/sid and molar occlusal s/r+ace
caries.
C. S/*ar is t,e rime so/rce o+ ener*y +or cario*enic -acteria.
D. Daily toot,-r/s,in* in t,e classroom is not ractical.
3. 5oot,-r/s,in* alone does not si*ni+icantly red/ce t,e risk o+ cariesD ,owe"er, t,ere
is o"erw,elmin* e"idence t,at -r/s,in* wit, a +l/oride denti+rice does red/ce caries
incidence.
Oral-Cancer )re"ention and 3arly Detection
5,e /se o+ to-acco rod/cts and alco,ol can -e +o/nd amon* U.S. st/dents as yo/n*
as ( or ; years o+ a*e.
'>
!ecently t,ere ,as -een an increase in /se o+ ci*arettes and
FsitF to-acco rod/cts amon* yo/t,s. 1ot, +emales and males tend to smoke w,ile
t,e /se o+ smokeless to-acco rod/cts is /sed rimarily -y males. Ho/n* w,ite
+emales smoke more t,an yo/n* -lack +emales, o+ten as a means o+ wei*,t control.
'=-
''
Inter"ention ro*rams, t,ere+ore, need to -e imlemented at early $rade levels and
s/orti"e re*/lations m/st -e in lace t,ro/*,o/t all sc,ools. 5,at is, all schools
should 4e smo*e2 and dru$2free, Use o+ to-acco rod/cts s,o/ld not -e allowed on
sc,ool remises or at any sc,ool e"ents. F/rt,er, state and local re*/lations re*ardin*
t,e sale o+ to-acco rod/cts or alco,ol to minors s,o/ld -e stron*ly en+orced -y all
comm/nities.
;,'&
St/dents m/st -e ta/*,t a-o/t t,e risk +actors +or and si*ns and symtoms o+ oral
cancers 75a-le :;-:, :;->8. Also, t,ey need to know t,at an oral cancer e0amination
e0ists and t,at t,ey s,o/ld ,a"e t,e e0am i+ t,ey smoke or c,ew to-acco or cons/me
alco,ol. In addition, st/dents s,o/ld -e ta/*,t ,ow to look in t,eir own mo/t,s +or
a-normal lesions, esecially i+ t,ey are at ,i*, risk. ny oral or facial lesion that
does not heal 3ithin < 3ee*s should 4e seen 4y a health professional,
'<
To4acco voidance and Cessation
5o-acco /se inter"entionsa"oidance, re+/sal skills, and cessationm/st -e
incl/ded in t,e c/rric/l/m o+ any comre,ensi"e sc,ool--ased oral-,ealt, ro*ram.
30erimentation wit, smokin* is occ/rrin* at earlier a*es t,an e"erD most /sers -e*in
e0erimentation rior to adolescence.
<
Aro0imately <,$$$ c,ildren and yo/t,
initiate smokin* eac, day. 5,irty t,o/sand new cases o+ oral cancer are reorted
ann/ally, wit, (,$$$ eole dyin* remat/rely eac, year. )eole w,o /se
to-accosmoke or smokelessare at several times $reater ris* +or oral cancers t,an
are non/sers.
','<
The Healthy People <:C: o-Aecti"es, >%->, >%-=, >%-&, >%-%, and >%-:: 7Aendi0 :;-
:8 address youth and to4acco, 5o resond to t,ese o-Aecti"es, sc,ool--ased ro*rams
in elementary, A/nior, and senior ,i*, sc,ools m/st incl/de smokin* and smokeless
to-acco /se inter"entions and ro"ide st/dents wit, to-acco-+ree en"ironments.
A recent S/r*eon GeneralCs !eort states t,at ed/cational strate*ies, cond/cted in
conA/nction wit, comm/nity- and media--ased acti"ities, can ostone or re"ent
smokin* onset in >$ to &$E o+ adolescents.
&
5,is in+ormation is artic/larly imortant
*i"en t,e c/rrent decreasin* a*e o+ smokin* initiation esecially amon* yo/n* *irls.
1y delayin* t,e onset o+ smokin*, sc,ool ro*rams ,a"e t,e otential to 7:8 re"ent
some st/dents +rom e"er startin*D 7>8 red/ce t,e ossi-ility t,at yo/n* st/dents will
-ecome re*/lar ad/lt /sersD and 7=8 make it easier +or t,ose w,o do start to-acco /se
to sto. 5,ese same rinciles t,at aly to smokin* also can 4e applied to JspitJ
to4acco inter"ention ro*rams. 5,e National Instit/te o+ Dental and Cranio+acial
!esearc, and t,e National Cancer Instit/te ,a"e rod/ced a */ide +or ?/ittin* sit
to-acco 7Fi*/re :;-&8.
C/rric/l/m content m/st recei"e si*ni+icant attention. Ideally, t,e toics o+ smokin*
and /se o+ FsitF to-acco s,o/ld -e introd/ced in primary school wit, contin/in*
rein+orcement t,ro/*, middle or A/nior ,i*, sc,ool wit, ma7or reinforcement
sessions in senior hi$h school, 5o-acco s/-Aect matter may -e inte*rated into
ree0istin* c/rric/l/m /nits on dr/* a-/se re"ention andBor incororated into ,ealt,
or ,ysical ed/cation classes. Coaches can 4e very influential in ers/adin* sc,ool
at,letes to cease /se o+ to-acco o+ any kind as art o+ t,eir trainin* ro*ram.
Anot,er i"otal in*redient +or s/ccess is incl/sion o+ content on refusal s*ills,
C,ildren and yo/t, m/st -e ta/*,t ,ow to resist eer and media ress/re -y
de"eloin* decision-makin* and ro-lem-sol"in* skills t,at +acilitate re+/sal o+
/ndesira-le ,a-its and in+l/ences.
'%
C,ildren and yo/t,s also m/st -e ta/*,t to reali@e
t,at to-acco /se is not the norm and ,as -ot, immediate and lon*-ran*e ad"erse
,ysical and aest,etic e++ects.
A stron* s/orti"e network amon* st/dents, arents, and teac,ers romotes ro*ram
s/ccess. St/dent in"ol"ement is aramo/nt. Alt,o/*, a teac,er, ,ealt, ed/cator, or
sc,ool n/rse s,o/ld lead sessions, st/dents can assist in ro*ram deli"ery. St/dent
role-layin* and modelin* e0ercises en,ance st/dent articiation. )arental s/ort is
anot,er critical comonentD t,e arental "al/es oosin* to-acco /se and +a"orin*
anti/se ro*rams en,ance ro*ram credi-ility.
'(
Finally, teac,ers, ,ealt, ed/cators, or
sc,ool n/rses m/st -e roerly trained and committed to t,e ro*ram.
30amles o+ s/ccess+/l ro*rams are mentioned -rie+ly to ro"ide */idance to +/t/re
ro*ram lanners.
Fre?/ently smokin* and FsitF to-acco /se is related in a ositi"e way to star at,letes
w,o o+ten ser"e as role models to adolescent males.
';
Aroriately, in :;;=, maAor
lea*/e -ase-allCs e0ec/ti"e co/ncil, t,e *o"ernin* -ody o+ t,e sort, anno/nced an
on-t,e-+ield -an o+ all to-acco rod/cts +or e"ery /ni+ormed emloyee o+ minor
lea*/e -ase-all. Under t,is olicy, /se o+ to-acco rod/cts o+ any kind is not
ermitted in any team area. 6iolators are s/-Aect to +ines ran*in* +rom f:$$ to f=$$
and +ace *ame eAections.
';
Un+ort/nately, t,is -an does not e0tend to t,e maAor lea*/e
le"el o+ t,e sort. 5,e /r*ent need +or esta-lis,in* e++ecti"e to-acco a"oidance and
cessation ro*rams early is iterated -y Glynn9 FToday, as in every other day of the
year, more than A,::: adolescents 3ill smo*e their first ci$arette on the 3ay to
re$ular smo*in$, Durin$ their lifetime, it can 4e expected that of these A,:::
children, a4out <A 3ill 4e murdered, A: 3ill die in traffic accidents, and nearly D>:
3ill 4e *illed 4y smo*in$2related disease,F
<$
An o/tstandin* article ,as -een /-lis,ed t,at lends e"en *reater ur$ency to
ac,ie"in* smokin* a"oidance and cessation -y relatin* ad"erse c,an*in* in t,e -odyCs
imm/ne system ca/sed -y smokin*, to t,e onset, se"erity, and treatment o+
eriodontitis 7see also C,ater :=8.
<:
Fi*/re :;-& Sit to-acco a */ide +or ?/ittin* is a"aila-le +rom t,e NIDC!
7:NOHIC 4ay, 1et,esda, MD >$(;>-='$$8.
Preventive Dentistry in Sports
Sorts are an imortant morale in*redient +or -ot, st/dent at,letes and t,e st/dent
-ody. D/rin* t,e :;(; to :;;$ sc,ool year, in *rades ; t,ro/*, ::, t,e O,io Hi*,
Sc,ool At,letic Association, w,ic, is t,e *o"ernin* -ody +or ,i*, sc,ool at,letes in
t,e state, listed :<%,$$$ -oys and ;,>$$ *irls as cometin* in or*ani@ed at,letics wit,
to/rnament lay.
<>
In many o+ t,e sorts, t,e oral str/ct/res o+ t,ese at,letes are
,i*,ly "/lnera-le to dama*e. 5,e ca/sati"e a*ents mi*,t -e a ,ockey /ck or a
-ase-all seedin* at %$ to ;$ m,D a -one-cr/nc,in* tackle or a t,rown -ase-all -atD
or an el-ow +ollowin* a sectac/lar -asket-all slam d/nk. Het, in a recent s/r"ey,
res/lts indicated t,at +oot-all was t,e only sort in w,ic, t,e maAority o+ yo/t, /sed
mo/t,*/ards and ,ead*ear.
<=
In eac, session o+ cometition, at,letes +ace a :$E c,ance o+ oro+acial inA/ry, and a
== to '<E ossi-ility o"er a layin* career. )rotecti"e e?/iment, r/les, and
re*/lations ,a"e -een de"eloed to red/ce t,is toll. For instance, rototye leat,er
+oot-all ,elmets wit, addin* came into *eneral /se in t,e -e*innin* o+ t,e >$t,
cent/ry, alt,o/*, were not re?/ired /ntil :;=;. 1y t,e :;'$s, leat,er ,elmets ,ad
-een relaced -y a more rotecti"e ,ard lastic. Helmets rotect t,e crani/m and t,e
ears, ,owe"er, more t,an t,e lower +ace and mo/t,.
In :;<$, t,e American Dental Association and t,e American Association o+ ),ysical
3d/cation iss/ed a reort t,at ,i*,li*,ted t,e +act t,at w,en ,i*, sc,ool layers did
not wear mo/t,*/ards >:; of all foot4all in7uries occurred in and around the
mouth,
<&
5,e ADA Ho/se o+ Dele*ates soon assed a resol/tion /r*in* t,at all
at,letes articiatin* in contact sorts wear intraoral mo/t,*/ards. 5,is o-Aecti"e
came to +r/ition in :;<>, w,en se"eral sorts or*ani@ations mandated t,e /se o+
mo/t,*/ards. It is estimated t,at as a res/lt, +rom C::,::: to <::,::: oral in7uries to
foot4all players are prevented annually,
<&
Foot-all is not the only school sport +or w,ic, oro+acial rotection is needed. At t,e
amate/r le"el, sorts t,at now mandate t,e /se o+ mo/t,*/ards d/rin* ractice
sessions and in *ames are 4oxin$, foot4all, ice hoc*ey, lacrosse, and field hoc*ey, It is
interestin* t,at t,e Academy o+ Sorts Dentistry ,as listed &$ di++erent sorts,
incl/din* soccer, -icyclin*, skate -oardin*, and -asket-all in w,ic, cranial or
oro+acial rotection s,o/ld -e considered.
<&
A mo/t,*/ard is constr/cted o+ so+t lastic t,at is laced -etween t,e ma0illary and
mandi-/lar dentitions. 5,ese de"ices ,el to re"ent "iolent contact -etween t,e lis,
c,eeks, and teet,, and -etween t,e /er and lower teet,. It red/ces t,e ossi-ility o+
+ract/red Aaws as well as lessenin* t,e likeli,ood o+ neck inA/ries, conc/ssion,
cere-ral ,emorr,a*e, /nconscio/sness, serio/s central ner"e dama*e, and deat,.
Alt,o/*, (%E o+ Di"ision I colle*es ,a"e team dentists, it is t,e team trainer t,at
/s/ally selects t,e mo/t,*/ards.
<'
In +oot-all, +or e0amle, rior to a *ame, it is t,e resonsi-ility o+ *ame o++icials to
c,eck wit, coac,es to ens/re t,at layers are /sin* re?/ired rotecti"e e?/iment.
<'

4,en mo/t,*/ards and ot,er rotecti"e e?/iment are not worn, enalties are le"ied,
ran*in* +rom a red/ction in t,e n/m-er o+ time o/ts to '-yard enalties. It is t,e
?/arter-acks w,o are least comliant.
<'
In t,e ast decade, t,e t,r/st +or rotecti"e
e?/iment ,as -een em,asi@ed in an e++ort to red/ce t,e ossi-ility o+ 4leedin$
in7uries, In some states, any -leedin* inA/ries are ca/se +or o++icials to remo"e a
layer +rom t,e *ame d/e to t,e increased ossi-ility o+ transmittin* HI6.
4,en a mo/t,*/ard is not worn or +ails, one o+ t,e most +re?/ent oro+acial inA/ries
re?/irin* emer*ency treatment -y t,e dentist is t,e avulsion of teeth, Ma0illary teet,
are t,e most "/lnera-le. 4,en a"/lsion occ/rs, a reco"ered toot, s,o/ld -e ,eld -y
t,e crown to rinse and t,en $ently replaced at the site of ori$in, I+ t,e toot, cannot -e
easily reinserted, it s,o/ld not -e allowed to dry. Milk is a *ood transort sol/tion on
t,e way +or emer*ency treatment at a dental o++ice. A+ter relacement, a minim/m %-
to :$-day slintin* eriod is ad"ised. All a"/lsed teet, wit, +/lly +ormed roots
eventually need endodontic treatment,
<<
Question 4
A. 5,e -est *rade le"el to introd/ce disc/ssion o+ t,e ,ealt, dan*ers o+ to-acco
smokin*, cessation, and a"oidance is in senior hi$h school,
1. 5,e on-t,e-diamond /se o+ to-acco rod/cts 7esecially c,ewin* to-acco8 -y
minor lea$ue -ase-all layers ro"ides a role model +or asirin* ,i*, sc,ool at,letes.
C. More eole die +rom to-acco-associated diseases in t,e United States t,an +rom
"iolent crimes and tra++ic accidents.
D. Fi"e or*ani@ed amate/r sorts t,at mandate t,e /se o+ ,elmets d/rin* ractice and
*ames are +oot-all, -o0in*, ice ,ockey, +ield ,ockey, and lacrosse.
3. Mo/t,*/ards are more imortant t,an ,elmets in re"entin* a"/lsion o+ teet,.
3?/ally or more imortant to re"ent serio/s +acial inA/ries is t,at t,e /se o+ seat -elts
s,o/ld -e stron*ly ad"ocated across all a*e *ro/s -/t er,as esecially amon*
yo/t,s w,o tend to -elie"e t,ey are not "/lnera-le. Car accidents in"ol"in* yo/t,s
+re?/ently res/lt in oro+acial, ,ead, and neck inA/ries, w,ic, co/ld -e reduced 3ith
t,e aroriate /se o+ seat -elts.
Oral-Health-Programs for Preschool-Age Children
In :;<', Head Start, a national resc,ool ro*ram t,at ro"ides early learnin*
oort/nities to oor and /nderri"ile*ed c,ildren, was initiated /nder t,e 3conomic
Oort/nity Act o+ :;<&. Healt, care and ,ealt, ed/cation, incl/din* a dental
comonent, ,a"e -een a contin/al art o+ t,is ro*ram. 5,e dental care comonent
incl/des annual examinations, preventive services, follo32up care, and classroom
instruction, Het a+ter +o/r decades o+ e0istence, t,ere is e"idence t,at many Head
Start centers do not comly /ni+ormly wit, t,e U.S. )/-lic Healt, Ser"ice Standards.
As it now +/nctions, Head Start is meetin* t,e needs o+ only a fraction o+ t,e eli*i-le
o/lation.
<%,<(
Howe"er, some states ,a"e e0cellent Head Start oral ,ealt, ro*rams.
5oday many ot,er ri"ate and /-lic resc,ool ro*rams e0ist, wit, t,e n/m-er
e0ected to increase dramatically i+ a national day care olicy is esta-lis,ed. 5,e
*reat maAority o+ resc,ool ro*rams will -e /nder t,e a/sices o+ ri"ate indi"id/als
or or*ani@ations wit, limited e0ertise in ,ealt, ed/cation, seci+ically in oral ,ealt,
o-Aecti"es and re"enti"e ractices.
Academically, resc,ool ro*rams m/st incl/de o-Aecti"es, lesson lans, and t,e
e"al/ation instr/ments needed to meas/re o-Aecti"e attainment. 3"en at resc,ool
a*e, t,e imortant re"enti"e dentistry related words, concets, and skills can -e
introd/ced to yo/n* c,ildren to -e rein+orced later at ,i*,er *rades. At resc,ool a*e,
c,ildren are especially ea$er to learn and articiate. Unlike most /-lic sc,ools,
Head Start centers /s/ally ro"ide toot,-r/s,es and toot,aste and t,e time to /se
-ot,. Some Head Start ro*rams t,at are located in comm/nities wit,o/t otimally
+l/oridated water also o++er +l/oride ta-let ro*rams.
1ri*,t F/t/res is a ,ealt, ed/cation inno"ation de"eloed -y t,e U.S. Deartment o+
Healt, and H/man Ser"ices w,ose mission is to romote and imro"e t,e ,ealt,,
ed/cation, and well--ein* o+ c,ildren, +amilies, and comm/nities.
<;
It o++ers e0ert
*/idance +or ro"idin* ,ealt, ser"ices to c,ildren and t,eir +amilies. 5,is roAect
incl/des an e0cellent section on oral ,ealt, entitled, 1ri*,t F/t/res in )ractice9 Oral
Healt,.
%$
Helping Teachers Teach
In a sc,ool c/rric/l/m, teac,in* mat,ematics -ecomes more so,isticated as a c,ild
ro*resses +rom *rade-to-*rade. In +irst *rade, t,e c,ild is ta/*,t to add : and :D yet at
t,e ,i*,-sc,ool le"el t,e yo/n* ad/lt is a-le to er+orm ro-lems o+ calc/l/s. In many
co/rses, s/c, as c,emistry, t,e didactic in+ormation is rein+orced -y la-oratory
assi*nmentsD t,e com-ination o+ in+ormation and e0erience ,els de"elo st/dent
/nderstandin* and motor skills. 5,is same aroac, co/ld -e /sed to teac, oral
,ealt,. Oral-,ealt, ro*rams s,o/ld -e lanned so t,at eac, ,i*,er-*rade le"el
recei"es a *reater di"ersity and comle0ity o+ s/-Aect matter and ractical e0erience.
For e0amle, elementary sc,oolc,ildren ,a"e less de0terity t,an A/nior-,i*, st/dents.
Flossin*, t,ere+ore, is more easily ta/*,t and racticed in t,e /er *rades.
At t,e ,i*,-sc,ool le"el, st/dents s,o/ld ,a"e an ad"anced lay knowled*e o+
terminolo*y, anatomy, and +/nctions o+ t,e oral ca"ity and t,e etiolo*y and
conse?/ences o+ oral diseases. 5,ey also s,o/ld ,a"e t,e /nderstandin* to accet
resonsi-ility +or 7:8 re"entin* and controllin* oral diseases, 7>8 identi+yin* t,e
resence o+ t,eir own oral diseases at an early sta*e, and 7=8 seekin* treatment once
oral disease is s/sected or identi+ied. In ot,er words, students should 4e tau$ht to
open their eyes 3hen they open their mouths in front of a mirror,
5,e 5attletoot, II Inte*rated )ro*ram
5o constr/ct an inte*rated c/rric/l/m +or oral ,ealt, t,at is alica-le to a contin//m
o+ *rade le"els, it is +irst necessary to consider w,at in+ormation is rele"ant +or eac,
*rade le"el. One e0amle o+ a comre,ensi"e *rade-to-*rade ro*ram de"eloed +or
teac,in* dental ,ealt, is e0emli+ied -y Tattletooth //, &e3 0eneration pro$ram,
developed 4y the Texas Department of Health,
5,is comre,ensi"e oral ,ealt, c/rric/l/m tar*ets st/dents +rom preschool throu$h
$rade C<, In :;;=, wit, +/nds aroriated -y t,e state le*islat/re, t,e 5e0as 1/rea/
o+ Dental Healt, Ser"ices emloyed aro0imately >$ dental ,y*ienists and dental
assistants to romote t,e ro*ram statewide. Ann/ally, t,o/sands o+ c,ildren are
ser"ed -y t,is ro*ram wit, aid +rom t,e 5e0as Dental Hy*ienistsC Association.
3ac, *rade le"el ,as +i"e core lessons and two enric,ment lessons. 1ack*ro/nd
in+ormation for the teacher is ro"ided as art o+ t,e lesson. 3d/cational strate*ies are
descri-ed +or inte*ratin* oral ,ealt, toics into disc/ssions in"ol"in* ot,er s/-Aects,
s/c, as lan*/a*es, arts, mat,ematics, and science acti"ities. 5o +acilitate -ilin*/al
ed/cation, t,e ro*ram ,as -een translated into Sanis,.
In addition, t,e c/rric/l/m incl/des scoe and se?/ence c,arts, a /nit test, -/lletin
-oard s/**estions, a/dio"is/al lists, and s/**ested letters to -e sent to arents. A
"ideotae ill/stratin* t,e aroriate tec,ni?/es o+ -r/s,in* and +lossin* is a"aila-le
on loan to sc,ools. 5,e c/rric/l/m and trainin* materials were desi*ned, tested,
e"al/ated, retested, ree"al/ated, and a*ain re"ised. 5,is ro*ram matches su47ect
matter 3ith $rade level, ro"ides teac,ers wit, */idance in+ormation, and is a"aila-le
in two lan*/a*es to tar*et maAor minority *ro/s o+ t,e state. 5o o-tain t,e ro*ram
+or t,eir classroom, teac,ers m/st attend in-ser"ice trainin* ro"ided -y a state
re*ional dental ,y*ienist w,o /ses a m/ltimedia aroac, in t,e trainin* sessions.
5,e ro*ram is coyri*,tedD ,owe"er, out2of2state educators may secure it $ratis and
reproduce it at their o3n expense, 1eca/se t,e ro*ram ,as -een in /se +or some time
and still is, some o+ it will -e relaced o"er t,e ne0t +ew years wit, newer materials.
Putting it all TogetherComprehensive Oral Health Programs
5reatment is not t,e answer to sol"in* c,ildrenCs oral ,ealt, ro-lemsD rat,er primary
prevention is the *ey, From an economic "iewoint, t,ere is little rationale +or treatin*
a disease at *reat e0ense, w,en t,e disease can -e re"ented at a m/c, lesser cost.
From a ,/mane "iewoint, t,ere is e"en less reason not to de"elo stron* re"enti"e
ro*rams s/orted wit, treatment ro*rams w,en re"ention +ails. !esearc, ,as
s,own t,at inciient dental caries can -e lar*ely controlled -y tec,ni?/es now
a"aila-le, s/c, as sealant placement and reminerali1ation therapytec,ni?/es t,at
are little /-lici@ed and /nder/sed -y t,e ro+ession.
%:
0in$ivitis also can 4e
controlled 4y a com4ination of oral hy$iene practicesprophylaxis, chemical, and
manual pla5ue control,
Many states and comm/nities are +oc/sin* on ,ow millions o+ /nderri"ile*ed
c,ildren can -e ro"ided wit, ,ealt, care. As a keystone o+ t,is e++ort, care m/st -e
accepta4le, e5uita4le, afforda4le, and accessi4le to all, It is critical t,at t,e dental
ro+ession, ,ealt, ed/cators, and /-lic ,ealt, a*encies take t,e stes necessary to
ens/re t,at oral ,ealt, is reresented in t,e lannin* and imlementation o+ s/c,
national e++orts. State dental directors must play a ma7or role in ensurin$ that
dentistry?s share of funds 3ill 4e availa4le, Un+ort/nately, some states c/rrently do
not ,a"e state dental directors, and do not intend to +ill t,ese ositions. At t,e same
time some re"enti"e acti"ities ,a"e -een c/rtailed or eliminated.
%:
5,ere are se"eral ad"anta*es to a comre,ensi"e, sc,ool--ased ro*ram9 7:8 st/dents
are a"aila-le +or re"enti"e or treatment roced/resD 7>8 sc,ool--ased clinics may -e
less t,reatenin* t,an ri"ate o++icesD 7=8 sc,ool dental ro*rams +acilitate and increase
t,e e++ecti"eness o+ teac,in* oral ,ealt, s/-AectsD and 7&8 dental ser"ices s/lement
t,e sc,ool n/rsin* ser"ices -y ro"idin* total ,ealt, care +or sc,oolc,ildren.
A com-ined ed/cation, romotion, and re"enti"e ro*ram in t,e sc,ool wo/ld
*reatly red/ce t,e amo/nt o+ classroom time lost in tra"elin* to a treatment +acility.
Comre,ensi"e sc,ool ro*rams also wo/ld o-"iate t,e loss o+ st/dy time d/e to ain
and are,ension -e+ore and a+ter treatment. 5,is lost time can -e considera-leD +or
e0amle, c,ildren missed more t,an ': million ,o/rs o+ sc,ool in :;(; -eca/se o+
ac/te dental ro-lems.
:
Com-ined sc,ool--ased ed/cational and re"enti"e dentistry
ro*rams +or all sc,ools s,o/ld -e +easi-le and cost-e++ecti"e in terms o+ sta++in*,
money, and material. Most imortant, wit, comre,ensi"e sc,ool ro*rams t,e
decayed, missin*, and +illed teet, 7DMF58 o+ st/dents should demonstrate a
su4stantial and steady decrease over time, A +ew o+ t,ese kinds o+ ro*rams ,a"e
-een esta-lis,ed. Ot,ers co/ld -e esta-lis,ed at di++erent le"els, deendin* on
a"aila-le +/nds as descri-ed -elow and s,own in Aendi0 :;-&.
.e"el :
.e"el : s,o/ld incl/de t,e /se o+ a comre,ensi"e oral-,ealt, c/rric/l/m s/c, as t,e
Tattletooth // pro$ram, )ro"idin* s/c, a c/rric/l/m minimi@es t,e need +or teac,ers
or ,ealt, ed/cators to locate and or*ani@e lessons in an /n+amiliar +ield. In addition,
the teacher 3ith the help of a school nurse and or adult volunteer can cond/ct weekly
+l/oride mo/t, rinses or administer daily +l/oride ta-let re*imens. 5,e n/rse mi*,t -e
resonsi-le +or rearin* t,e mo/t, rinses or makin* t,e ta-lets a"aila-le on a
sc,ed/le aro"ed -y t,e teac,ers. Health educators, i+ a"aila-le, ,el coordinate and
inte*rate all ,ealt, ed/cation acti"ities. 5,ey ,a"e e0tensi"e trainin* in ed/cational
rinciles and ,ealt, and are acc/stomed to workin* wit, sc,ool +ac/lty. Fl/oride
mo/t, rinse or +l/oride ta-let re*imens are easy to accomlis,, economical, and
e++ecti"e. 5a-le :;-= comares t,e two sc,ool--ased +l/oride re*imens. &either o+
t,ese sel+-alied, sc,ool--ased +l/oride re*imens s,o/ld -e /sed i+ comm/nity or
sc,ool water +l/oridation is a"aila-le.
School -ater 'luoridation
Fl/oridatin* a sc,oolCs water s/ly is similar to comm/nity water +l/oridation in t,at
no direct action is needed 4y individuals to accrue its 4enefits ot,er t,an cons/min*
t,e water or +oods reared wit, it. Sc,ool water +l/oridation is /sed only w,en t,e
sc,ool ,as an indeendent water s/ly, /s/ally in consolidated r/ral sc,ools.
Consolidated r/ral sc,ools are ideal +or t,is aroac, -eca/se all *rades +rom
kinder*arten t,ro/*, :> are ,o/sed in t,e same comle0 /sin* one water so/rce. In
t,e ast, t,is re"enti"e meas/re was /sed in o"er <$$ U.S. sc,ools in many states.
5oday, t,e need +or t,is re"enti"e meas/re ,as diminis,ed -ot, -eca/se t,e water
s/lies o+ many r/ral sc,ools ,a"e -een incororated into maAor comm/nity water
systems t,at are otimally +l/oridated and -eca/se t,ere are n/mero/s ot,er so/rces
o+ +l/oride a"aila-le incl/din* denti+rices and mo/t, rinses. 5,e recommended
concentration o+ +l/oride +or sc,ool water s/lies is B,> ppm,
%>
Sc,ool water
+l/oridation was de"eloed and tested in t,e United States in t,e :;'$s and :;<$s.
!esearc,ers +o/nd / to a &$ ercent red/ction in dental caries a+ter :> years.
Installation costs are relati"ely e0ensi"e and workers m/st -e trained to oerate,
monitor, and maintain t,e +l/oridation /nit.
Dietary 'luoride Ta4lets
5,e /se o+ +l/oride ta-lets in sc,ools is a met,od o+ administerin* systemic +l/oride
to c,ildren. 5,is sel+-alied +l/oride re*imen is +or /se only in comm/nities in w,ic,
t,e water s/ly is +l/oride-de+icient and has 4een used in the United States and
a4road for over B: years,
&%
All c,ildren w,o articiate in sel+-alied +l/oride
ro*rams m/st ,a"e arental consent. Us/ally, a classroom teac,er w,o ,as -een
trained to s/er"ise t,e roced/re +irst disenses t,e +l/oride ta-lets to articiatin*
st/dents. St/dents are t,en instr/cted to /t t,e ta-let in t,eir mo/t, and to c,ew it +or
=$ secondsD t,e res/ltant sol/tion is t,en "i*oro/sly swis,ed -etween t,eir teet, +or
anot,er =$ seconds -e+ore t,e articiants are told to swallow t,e sol/tion. Usin* t,is
aroac,, 4oth systemic and topical 4enefits will accr/e. 5,e roced/re is easy to
er+orm, re?/ires little time, and t,ere are no waste rod/cts to disose o+. St/dies
cond/cted in t,e United States s,ow t,at sc,ool--ased +l/oride ta-let ro*rams
ro"ide a-o/t a <: to A:; red/ction in new caries lesions. A daily +l/oride ta-let
aears to -e more effective t,an a weekly mo/t, rinse, as well as -ein* re+erred -y
teac,ers.
%=
5,e maAor draw-ack is t,at it is a daily roced/re and some teac,ers o-Aect
to it +or t,is reason.
It is imortant to note t,at caries re"enti"e e++ects o+ sc,ool +l/oride re*imens may
not -e ermanent. A+ter an ::-year +ollow-/ st/dy in Norway, it was concl/ded t,at
t,e resid/al -ene+its o+ sc,ool--ased +l/oride ro*rams decrease as t,e len*t, o+ time
-etween re"io/s articiation and +ollow-/ increases.
%&
It s,o/ld -e ointed o/t,
t,at st/dents s,o/ld -e ed/cated to /se a +l/oride containin* denti+rice d/rin* and
+ollowin* t,e sc,ool--ased +l/oride re*imens. In contrast, 2o-ayas,i and coworkers
+o/nd *ood ost treatment -ene+its a+ter :: years.
%'
'luoride %outh Rinsin$
Fl/oride mo/t,-rinsin* ro*rams are the most 3idely used sc,ool--ased +l/oride
re*imen in t,e United States and /s/ally are supervised 4y classroom teachers or
ot,er ad/lt "ol/nteers. Caries red/ctions ran*e +rom <: to <>;, alt,o/*, +ew recent
st/dies ,a"e -een cond/cted.
%<
Fl/oride mo/t, rinse re*imens as ori*inally concei"ed
consisted o+ mi0in* a rewei*,ed acket o+ +l/oride owder wit, a seci+ied amo/nt
o+ water in a container wit, a lastic /m cali-rated to disense ' or :$ m. o+
sol/tion t,at wo/ld yield a $.> ercent ne/tral sodi/m +l/oride rinse. A+ter mi0in*, t,e
sol/tion is disensed into aer c/s +or /se -y t,e st/dents. 5oday, most sc,ools
order remi0ed sol/tions t,at come in indi"id/al containers. 5,is latter aroac, is
somew,at more e0ensi"e -/t it simli+ies t,e roced/re +or /se in classrooms. Usin*
remi0ed sol/tions reduces the time re5uired o+ aid or "ol/nteer sta++ to simly
disensin* a container and nakin to eac, st/dent and t,en s/er"isin* t,e rinse
roced/re. St/dents are re?/ested to /t t,e sol/tion in t,eir mo/t, and to rinse
"i*oro/sly +or <$ seconds 7Fi*/re :;-'8. 4,en instr/cted, st/dents are asked to emty
t,e contents o+ t,eir mo/t, -ack into t,e c/s and -lot t,eir lis wit, t,e nakin. 5,e
waste rod/cts are t,en /t into a lastic -a* +or disosal. Fl/oride mo/t, rinse /sed
in sc,ools is a"aila-le in eit,er a +la"ored or non+la"ored and sweetened or
nonsweetened "arieties. Generally, t,is roced/re is not recommended for children
4efore first $rade /nless e0tensi"e trainin* is cond/cted wit, t,e c,ildren to ens/re
t,at t,ey do not swallow t,e contents o+ t,e c/. 5,e weekly sol/tion, i+ swallowed
o"er time may contri-/te to +l/orosis amon* c,ildren < years o+ a*e or yo/n*er
-eca/se some o+ t,eir ermanent teet, are still de"eloin*. 7See Aendi0 :;-' +or
details on cond/ctin* a mo/t,rinse ro*ram.8
.e"el >
.e"el-> ro*rams include level2C activities plus the addition of a dental hy$ienist to
t,e sc,ool ,ealt, sta++. 5,e incl/sion o+ a dental ,y*ienist in a comre,ensi"e sc,ool
,ealt, ro*ram is critical. A dental ,y*ienist is ed/cated to lan and articiate in
sc,ool ro*rams t,at incl/de oral ro,yla0es, /se o+ a "ariety o+ met,ods o+ +l/oride
alication to +oster reminerali@ation, teac,in* oral ,y*iene roced/res, co/nselin*
on diet, lacement o+ it-and-+iss/re sealants, and screenin* and re+erral +or s/sected
oral at,olo*y +or de+initi"e dia*nosis and treatment. A dental ,y*ienist also ser"es as
a sc,ool-reso/rce erson.
Many sc,ool districts or /-lic-,ealt, a*encies ,a"e dental trailers t,at are used to
provide prophylaxis and screenin$ pro$rams +or st/dents. Ot,ers /se orta-le
e?/iment t,at is set / in a room desi*nated -y sc,ool a/t,orities. Older, teena$ed
students are more li*ely to present 3ith $in$ivitis and calculus, A eriodic
ro,yla0is -y a dental ,y*ienist d/rin* t,e sc,ool years may ,el a"oid t,e onset o+
eriodontitis later on. In addition, t,e ersonal contact wit, a dental ,y*ienist can
,el moti"ate teena*ers to de"elo satis+actory la?/e remo"al tec,ni?/es and to
/nderstand t,e need to seek ro+essional care w,en needed.
Dental trailers also may -e /sed -y ,y*ienists for placement of dental sealants, Dental
sealants are ,i*,ly e++ecti"e in rotectin* occl/sal s/r+aces and lin*/al and -/ccal its
and +iss/ressites w,ere up to H:; of all caries lesions occur, In t,e :;(( to :;;:
5,ird National Healt, and 30amination S/r"ey, ,ase : 7NHAN3S III8, less than
CH; of U,S, children and adolescents 4et3een > and CD years of a$e had one or more
sealants placed,
%<
In contrast, in Finland, so many o+ t,e occl/sal s/r+aces are co"ered
wit, sealant t,at t,ese s/r+aces are o+ten e0cl/ded in decayed, missin*, and +illed
s/r+aces 7DMFS8 st/dies.
%%
5,e marked -ene+it o+ sealant lacement in red/cin* caries incidence was reorted -y
Sterritt and Frew in a st/dy cond/cted in G/am.
%(
Some %',$$$ teet, o+ :',$$$
c,ildren in *rades : t,ro/*, ( were sealed -y CD preventive dentistry technicians, In a
eriod o+ > years t,e a"era*e n/m-er o+ cario/s lesions er c,ild dropped from >,A>
to <,H<, 5,e +irst year retention rate +or t,e sel+-c/rin* sealant was ;&E +or +irst
molars, ;%E +or remolars, and %'E +or second molars. In one state ro*ram, it was
demonstrated t,at, dental sealants red/ced oral ,ealt, disarities amon* sc,ool-a*ed
c,ildren.
%;
Sealant lacement, w,en co/led wit, a follo32up $el application of
fluoride ,els ro"ide rotection to t,e 3hole tooth,
($
!ia and collea*/es ,a"e
correctly ointed o/t t,at t,e com-ined /se o+ sealants and e0os/re to a +l/oride
re*imen in sc,ool can result in a virtual elimination of dental decay in elementary
schoolchildren,
(:
Cost er c,ild +or sealant lacement "aries deendin* on w,et,er dentists, dental
,y*ienists, or dental assistants are /sed. A :;(; estimated cost +or sealants ran*ed
+rom f:=.$% to f>(.=%.
%:
In contrast, t,e restoration o+ an occl/sal lesion a"era*es
a-o/t f':.$$.
(>
Most imortant, it m/st -e reco*ni@ed t,at once a restoration is laced
it will contin/e to need to -e relaced w,ic, +/rt,er weakens and comromises t,e
toot, -eca/se t,e restoration -ecomes lar*er at eac, relacement.
A */ide, FSeal America9 5,e )re"ention In"ention,F ,as -een de"eloed +or /rc,ase
at a nominal +ee. It was s/orted -y t,e Maternal and C,ild Healt, 1/rea/ o+ t,e
Healt, !eso/rces and Ser"ices Administration. 5,e kit was desi*ned +or /se in
de"eloin* and imlementin* dental sealant ro*rams in comm/nities.
.e"el =
A le"el-= ro*ram consists of all of levels C and < re5uirements plus the addition of a
treatment delivery option, 5,is le"el o+ a comre,ensi"e sc,ool oral ,ealt, ro*ram
incl/des t,e a-ility to identi+y and re+er all at,olo*y +or treatment as early as
ossi-le. 5o ac,ie"e t,is le"el, an ann/al screenin* is indicated +or all c,ildren and a
semiann/al screenin* +or c,ildren classi+ied as ,i*, risk.
State ractice acts ermittin*, tria$e wit, ossi-le referral to a treatment +acility can
-e accomlis,ed -y a dental ,y*ienist.
(=
D/rin* ro/tine ro,yla0is roced/res and
sealant lacement, a dental ,y*ienist can identi+y early at,olo*y and re+er t,e
st/dent +or e0editio/s de+initi"e dia*nosis and treatment.
All too o+ten, t,e resent met,od o+ mana*in* sc,oolc,ildren wit, oral ro-lems is
+or t,e teac,er or sc,ool n/rse to send ,ome a note indicatin* a need +or treatment and
recommendin* t,at a c,ild -e taken to a dentist. 5,is aroac, assumes t,at t,e
arent immediately seeks a ri"ate dentist or *oes to a /-lic-,ealt, clinic. In t/rn, it
is assumed t,at w,en t,e dentist comletes treatment, a ostcard is ret/rned to t,e
sc,ool ,y*ienist or n/rse indicatin* t,at t,e re+erred at,olo*y ,as -een treated.
5,eoretically, t,is tye o+ system ,as t,e ad"anta*e t,at it /ses t,e ro+essional
deli"ery systems e0istin* in t,e st/dentCs comm/nity. Un+ort/nately it does not
always work. Not all arents resond ositi"ely -eca/se o+ lack o+ money or
ins/rance, aat,y, or lack o+ a"aila-le time to take t,e c,ild to a dentist. 5,is +orm/la
o+ Fno money, no riority, no dentist, e?/als no careF is an elementary e?/ation
reeated co/ntless times eac, year in o/r sc,ools.
(&
Anot,er otion +or re+erral in"ol"es contractin$ 3ith local practitioners to o++er
seci+ic roced/res +or redetermined +ees. In t,is case, t,e re+erral can -e a direct
transaction -etween t,e sc,ool system and dentist7s8. 5,e -ill s/-mitted -y t,e dentist
+or comleted work constit/tes "eri+ication t,at t,e c,ild recei"ed treatment. A t,ird
otion o+ten adoted is to 4us children to a pu4lic health clinic, Or, in some
comm/nities dental societies ,a"e or*ani@ed t,eir dentists to "ol/nteer to treat needy
st/dents.
5,e o-Aecti"e o+ w,ate"er le"el o+ re"enti"e care ro*ram is selected is t,at it -e
a++orda-le, and accessi-le to all3ith a priority for hi$h2ris* students, +nce the
primary preventive dentistry procedures have reduced the incidence of oral disease to
that of the annual treatment 3or*load, the num4er of extractions for a school
population should approach 1ero,
Fi*/re :;-' St/dents rinsin* <$ seconds wit, +l/oride /nder s/er"ision o+ t,eir
teac,er.
Foreign School-Based Programs
Sometimes we can learn ot,er aroac,es to sol"in* similar ro-lems -y lookin* at
models in ot,er co/ntries. For e0amle, t,e New Iealand Sc,ool Dental Ser"ice reads
like an e0emlary le"el-= ro*ram. It is accessi4le to all, -ein* -ased in t,e sc,ools,
e5uita4le, wit, all c,ildren -ein* a-le to enroll, afforda4le -eca/se t,ere is no c,ar*e
+or ser"ice, and accepta4le, wit, ;<E o+ t,e /ils -ein* enrolled. 5,e Ser"ice was
+ormed in :;>: as a res/lt o+ ress/re on t,e *o"ernment 4y the dental profession to
,el coe wit, t,e oor state o+ c,ildrenCs teet,. Ori*inally, yo/n* women were
trained to accomlis, +illin*s and simle e0tractions. 5oday, -ot, men and women are
trained as dental t,eraists w,o can ractice only in state institutions, 5,ey are not
licensed +or ri"ate ractice. S/er"ision is ro"ided -y /-lic ,ealt, ser"ice o++icers
and senior dental n/rses. 5,e Ser"ice is -ased in clinics located in lar*er sc,ools and
takes care o+ all resc,ool, rimary, and intermediate st/dents -etween a*es ' and :=.
C,ildren are e0amined ann/ally, alt,o/*, t,ose considered at hi$h ris* are examined
semiannually, 5,e */idelines +or ,i*, risk are9
:. O"er < and /nder ; years o+ a*eFo/r or more decid/o/s teet, wit, +/ll occl/sal
or como/nd +illin*s or new cario/s lesions ot,er t,an -/ccal or lin*/al its in
ermanent or decid/o/s teet,.
>. O"er ; years o+ a*e 7ermanent teet, only8A +/ll occl/sal restoration or cario/s
lesion on a +irst ermanent molar, an interro0imal ca"ity -e+ore a*e ;, or a new
lesion in t,e re"io/s :> mont,s ot,er t,an a -/ccal or lin*/al it.
5,e re"enti"e ro*ram focuses on hi$h2ris* children, A $.> ercent +l/oride mo/t,
rinse is /sed to re"ent deminerali@ation o+ Fw,ite sots,F w,ile +l/oride "arnis,
7D/ra,at8 is /sed +or reminerali@ation t,eray o+ interro0imal, enamel-limited
l/cencies. Finally, fissure sealants are placed on all ne3ly erupted vulnera4le
permanent molars to prevent occlusal caries, 5,is re"enti"e em,asis and a"aila-le
treatment ,as res/lted in a drop o+ DMF5 o+ :$.% in :;%= to :.(( in :;;> 7Fi*/re :;-
<8, and a arallel dro in e0tractions +rom :(.>$ er :$$ in :;<<, to &.$$ in :;;>.
('
Denmark also ,as an e0cellent and comre,ensi"e sc,ool--ased oral ,ealt, care
ro*ram. 5,ere ,as -een a lon* tradition o+ ro"idin* oral ,ealt, care to Danis,
c,ildren, in +act t,e +irst sc,ool dental clinic was esta-lis,ed in :;$;. 5,e C,ild Oral
Healt, Care Act o+ :;%: is t,e -asis /on w,ic, t,e c/rrent Danis, c,ild oral ,ealt,
care ser"ice was esta-lis,ed. 3ssentially, t,is le*islation mandated comm/nities to
ro"ide +ree dental care +or c,ildren < to :< years o+ a*e. 5,e rocess was an
incremental one wit, em,asis on rimary re"ention and oral ,ealt, ed/cation o+ all
arties. Concomitantly, national eidemiolo*ic data was esta-lis,ed and maintained,
w,ic, ,as ro"ided t,e scienti+ic e"idence o+ t,e s/ccess+/l red/ction o+ dental caries
amon* Danis, c,ildren -etween :;%> and :;;>. In :;(<, a new national law was
introd/ced to relace t,e :;%: Act. 5,e lon*-ran*e *oal o+ t,e re"ised national law
was stated as9 F5,e *oal o+ t,e dental ser"ice is +or t,e o/lation to o-tain ,ealt,y
teet,, mo/t, and Aaws, and to reser"e t,em, in +/nctional condition t,ro/*,o/t li+eD
t,is s,o/ld -e accomlis,ed t,ro/*, a s/++icient ,ome dental care re*imen, and a
comre,ensi"e re"enti"e and c/rati"e dental ,ealt, ser"ice.F A maAor c,an*e in t,e
:;%> Act was to incl/de all c,ildren :< years o+ a*e and yo/n*er. A*ain, t,e
em,asis was on t,e /se o+ +l/orides, dental sealants, at least ann/al e0aminations and
e0tensi"e ed/cational inter"entions. )re"enti"e re*imens ,a"e -een modi+ied as new
researc, ,as -ecome a"aila-le. 5,e treatment o+ oral diseases and maloccl/sion also
was incl/ded in t,e new le*islation and -y :;(% t,e system incl/ded all c,ildren. 5,e
law mandates oral ,ealt, ed/cation +or all c,ildren, arents and teac,ers. 3d/cation in
sc,ools is a art o+ t,e re*/lar c/rric/l/m and, t,/s, is adA/sted +or a*e
aroriateness and at t,e same time to maintain interest. Oral ,ealt, instr/ction also
is ro"ided to *ra"id women and oral ,ealt, instr/ction is incl/ded in ,ome "isits +or
new-orn and yo/n* c,ildren. Older c,ildren are ta/*,t ,ow to make dental
aointments so t,at t,ey can contin/e t,eir oral ,ealt, care as ad/lts. 5,e dental
teams w,o ro"ide t,ese ser"ices incl/de dentists, dental ,y*ienists and dental
assistants. Danis, sc,ool c,ildren enAoy one o+ t,e lowest caries re"alence in t,e
world.
(<
Fi*/re :;-< New Iealand Dental Ser"ice. A"era*e DMF, a*es :>-:& years,
:;%=-:;;:. Caries in ermanent teet, ,as declined %(E in :( years. 7From
internal data o+ t,e Deartment o+ Healt,, New Iealand, *enerated +rom ann/al
ret/rns reared -y rincial dental o++icers.8
Question 5
4,ic, o+ t,e +ollowin* statements, i+ any, are correct e
A. )re"enti"e care +or all Head Start c,ildren is a/t,ori@edD as a res/lt, re"enti"e
ser"ices are now ro"ided to t,e ma7ority o+ Head Start c,ildren .
1. 1ot, inciient caries and *in*i"itis can /s/ally -e prevented, arrested, or
reversed ,
C. No +l/oride ta-let ro*ram s,o/ld -e cond/cted in a sc,ool ser"iced -y a water
system containin* otimally +l/oridated water .
D. .e"els :, >, and = sc,ool oral-,ealt, ro*rams ro"ide ,i*,ly e++ecti"e dental care
otions ran*in* +rom ed/cation- re"ention to ed/cation-re"ention- treatment .
3. An a-r/t dro in occl/sal caries incidence can -e detected 3ithin a year a+ter t,e
initiation o+ an occl/sal sealant ro*ram .
Research and Evaluation
5,ere are aro0imately &( million st/dents in ::$,$$$ elementary sc,ools in t,e
United States.
(%
Many o+ t,ese c,ildren c/rrently -ene+it +rom re"enti"e re*imens
re"io/sly descri-ed and s/orted -y researc,. Many ot,er c,ildren are not so
+ort/nate, esecially c,ildren +rom oor +amilies. !esearc, is needed to e"al/ate t,e
s/ccess o+ c/rrently /sed pro$rams as well as t,e feasi4ility and cost2effectiveness of
future strate$ies to romote oral ,ealt, ed/cation, re"ention, and treatment. 5oday,
t,ere is a need +or researc, and e"al/ation on t,e -est aroac,es to romotin* oral
,ealt, in sc,ools wit, a +oc/s on sc,ool--ased clinics. 5,e rimary o-Aecti"e o+ s/c,
researc, ro*rams m/st +oc/s on t,e = MCsmanpo3er, money, and material, l/s
t,e amount of classroom time it will take +rom con"entional classroom ed/cation .
5o imro"e cost-e++ecti"eness and oral ,ealt, +or all, t,ere is a need to de"elo
validated techni5ues to identify hi$h2ris* students +or -ot, dental caries and *in*i"itis.
5o sec/re s/c, in+ormation, researc, and e"al/ation is necessary. Finally, t,e /se o+
standardi1ed methods of recordin$ data includin$ the use of computeri1ed recordin$
is necessary to ermit a comarison o+ data +rom st/dies to accelerate administrati"e
decisions .
Summary
A lar*e se*ment o+ o/r c,ildren and adolescents are at risk +or droin* o/t o+ sc,ool
-e+ore comletin* ,i*, sc,ool as a res/lt o+ a wide ran*e o+ ,ealt,, economic, and
-e,a"ioral ro-lems. Moreo"er, a lar*e roortion o+ o/r sc,ool-a*e c,ildren do not
,a"e access to -asic re"enti"e and rimary dental and medical care. 4it, t,e
c,allen*es osed -y o"erw,elmin* need and limited reso/rces, c,ildren deser"e to
recei"e in+ormation and ed/cation t,at ena-les t,em to make in+ormed c,oices a-o/t
t,eir ,ealt,. Also, t,ey deser"e t,e oort/nity to learn skills and de"elo attit/des
t,at ena-le t,em to ractice aroriate -e,a"iors to en,ance t,eir oral and *eneral
,ealt,. Finally, t,ey deser"e to recei"e ser"ices t,at re"ent andBor treat oral diseases.
4e ,a"e t,e a-ility to essentially eliminate most oral diseases amon* c,ildren. .ess
o-"io/s are t,e olitical and administrati"e means needed to make t,ese cost-e++icient
meas/res a"aila-le to t,e c,ildren. Sc,ool--ased oral-,ealt, ed/cation and romotion
ro*rams *i"e c,ildren and adolescents a c,ance to learn a-o/t t,eir oral tiss/es in
,ealt, and disease. Comre,ensi"e, sc,ool--ased oral-,ealt, re"ention and treatment
ro*rams ro"ide a means not only to learn a-o/t disease, -/t also to maintain t,e
,ealt, o+ t,e oral tiss/es and str/ct/res. Dentists, dental ,y*ienists, and st/dents o+
eac, disciline ,a"e an oort/nity and t,e resonsi-ility to ,el make s/c,
comre,ensi"e ro*rams a"aila-le .
5,e maAor s/ccesses o+ sc,ool--ased oral-,ealt, ro*rams ,a"e -een ac,ie"ed w,en
ed/cation ,as -een com-ined wit, acti"e re"ention andBor treatment ro*rams .
Un+ort/nately, too +ew sc,ools ,a"e ro/tinely incl/ded acti"e re"enti"e dentistry
re*imens+l/oride mo/t, rinses and ta-let ro*rams, sealant alications,
reminerali@ation t,eray, and a stron* em,asis on t,e /se o+ +l/oride-containin*
denti+rices w,ile -r/s,in*all o+ w,ic, can red/ce t,e DMFS o+ a sc,ool
o/lation. 5,is red/ction can -e accomlis,ed wit, only a minimal c,an*e in sel+-
-e,a"ior or comliance re?/ired o+ t,e st/dent. A +ew sc,ool systems ,a"e emloyed
dental ,y*ienists as reso/rce ersonnel to aid in t,e teac,in* ro*rams andBor to
ro"ide rimary re"enti"e ser"ices. 5,e a"aila-ility o+ a dental ,y*ienist ro"ides an
e++ecti"e and economic means +or sc,ools to lan and articiate in ,i*,er-le"el
re"enti"e ro*rams. Hy*ienists can +/nction on t,e sc,ool sta++ as oral-,ealt,
ed/cators, cond/ct re"enti"e ro*rams, accomlis, tria*e, and arran*e +or re+erral
and +ollow / to ens/re comleteness o+ treatment .
5,e /-i?/ito/s a"aila-ility o+ s/crose-laden desserts and snacks can -est -e
controlled -y t,e sc,ool dietitian red/cin* t,e a"aila-ility and +re?/ency o+ +oods and
desserts wit, ,i*, s/*ar content. 5,e sc,ool administrator also can aid in t,e
o-Aecti"e -y ro,i-itin* t,e on-cam/s lacement o+ "endin* mac,ines to disense
,i*,-s/crose snacks .
)rotectin* t,e oral ,ealt, o+ +/t/re *enerations is a commitment t,at m/st -e s,ared
-y arents, teac,ers, sc,ool administrators, and all ,ealt, ro+essionals. 5,is s,ared
resonsi-ility is esecially rele"ant now t,at national ,ealt, o-Aecti"es +or total c,ild
,ealt, care are esta-lis,ed. )ossi-ly t,e time is roitio/s to t,ink in terms o+ a
national sc,ool oral ,ealt, olicyone t,at endorses /ni"ersal access to oral-,ealt,
ed/cation, ,ealt, romotion, re"enti"e re*imens, tria*e, and treatment re+erral
caa-ilities +or discerned at,olo*y .
As a +inal note, i+ oral-,ealt, romotion is to -e accomlis,ed t,ro/*, t,e sc,ool
systems, it m/st -e inte*rated wit, t,e *eneral medical ,ealt, ro*ram. In order not to
detract +rom t,e teac,in* o+ t,e classic academic c/rric/l/m, t,e sc,ool year m/st -e
len*t,ened roortionate to t,e increased time demands o+ romotin* ,ealt,, and t,e
sc,ool systemCs -/d*et m/st -e increased in order to meet t,e re?/irements +or
additional +acilities, manower, and materials .
: . A, D, and 3correct .
1incorrect. 5eac,ers are certi+ied -y academic s/-Aect to -e ta/*,t3n*lis,,
mat,ematics, science, etc., -/t definitely not in in-det, comre,ension o+ societal
iss/es .
Cincorrect. Same answer as 1D teac,ers are not trained or certi+ied to imart oral-
,ealt, ed/cation .
> . A, D, and 3correct .
1incorrect. S/-stit/te FleastF +or FmostF and t,e answer -ecomes correct .
Cincorrect. 5,e :=.( ,o/rs +i*/re is +or t,e total amo/nt o+ ,ealt, ed/cationD o+ t,is
time, one cannot e0ect s/++icient time will -e allowed +or oral ,ealt, ed/cation and
romotion .
= . 1, C, D, and 3correct .
Aincorrect. 3"ery day, millions o+ eole sel+-aly toical +l/orides /sin* +l/oride
denti+rices .
& . C, D, and 3correct .

Engineering Books
www.allislam.net
Aincorrect. 5,e ,ealt, dan*ers o+ to-acco s,o/ld -e started at t,e elementary
sc,ool le"el in order to intercet t,e /-licity and eer ress/re to /se ci*arettes and
smokeless to-acco at an early a*e
1incorrect. On-t,e-+ield minor-lea*/e -ase-all layers and emloyees are not
ermitted to /se to-acco rod/cts.
'. C, D, and 3correct.
Aincorrect. 5,e +irst art o+ t,e statement is correctD t,e second art, w,ic, is t,e
most imortant, is incorrect and s,o/ld -e corrected. In ot,er words, re"ention is
a/t,ori@ed -/t not imlemented.
1incorrect. Since aro0imately ;$E o+ t,e total lesions in t,e mo/t, occ/r on t,e
occl/sal s/r+ace, t,e red/ction o+ caries incidence on t,is s/r+ace can -e detected soon
a+ter t,e initiation o+ a sealant ro*ram.
:. 5,e e0anded ei*,t-comartment model +or sc,ool ,ealt, ro*rams incl/des, in
addition to ,ealt, ed/cation, ,ealt, ser"ices, and a ,ealt,y en"ironment, at least two
additional ,ealt, attri-/tes w,ic, are9 iiiiiiiiii and iiiiiiiiii.
>. Gi"e +i"e ,ealt, tasks w,ic, mi$ht -e ass/med, or are assi*ned to a sc,ool--ased
,ealt, clinic9 iiiiiiiiii, iiiiiiiiii, iiiiiiiiii, iiiiiiiiii, and iiiiiiiii.
=. It is estimated t,at ($E o+ cario/s lesions in a sc,ool o/lation are +o/nd in only
iiiiiiiiii E o+ t,e st/dents.
&. 5wo nations wit, comre,ensi"e sc,ool dental ro*rams are iiiiiiiiii and
iiiiiiiiii.
'. 5,e two most imortant e0lanations +or t,e cariostatic roerties o+ +l/oride are
t,at it in,i-its iiiiiiiii, and e?/ally 7or more8 imortant, +acilitates iiiiiiiii.
<. 5,e two most imortant sc,ool-system o++icials w,o are in a osition to limit t,e
in*estion o+ s/*ar-containin* +oods, desserts, and snacks d/rin* sc,ool ,o/rs are t,e
iiiiiiiiii and t,e iiiiiiiiii.
%. Gi"e t,ree reasons w,y daily classroom toot,-r/s,in* is imractical9 iiiiiiiiii,
(. Smokeless to-acco ed/cation incl/des9 iiiiiiiiii tec,ni?/es and iiiiiiiiii
tec,ni?/es.
;. One state sc,ool system t,at inte*rated an oral ,ealt, teac,in* ro*ram t,at
incl/des all :> *rades is t,e 5e0as iiiiiiiiii 7name o+ ro*ram w,ic, may -e
o-tained *ratis -y o/t-o+-state ,ealt, deartments and maAor ,ealt, ro"iders8.
:$. Ass/min* t,at yo/ are t,e coac,, and an anterior toot, is a"/lsed -y a ,ockey
/ck, descri-e ,ow yo/ wo/ld ,andle t,e sit/ation iiiiiiiiii.
::. One ro*ram t,at ,as -een +o/nd to increase t,e n/m-er o+ +r/its and "e*eta-les
cons/med -y sc,ool-a*ed c,ildren is t,e iiiiiiiiii ro*ram.
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&(. New-r/n, 3. 7>$$:8. 5oical +l/orides in caries re"ention and mana*ementD A
Nort, American )ersecti"e. " Dent !du, <'9:$(=-((.
&;. Meskin, .. H. 7>$$:8. 3ditorial o/tra*eo/s II. " m Dent ssoc, :=>9:$-::.
'$. )otter, #. D., Finne*an, #. !., G/inard, #-G, et al. 7>$$$8. > Day for #etter
Health Pro$ram !valuation Report, 1et,esda, MD9 National Instit/tes o+ Healt,,
National Cancer Instit/te. No"em-er >$$$D NIH )/-lication No. $:-&;$&.
':. .at,o, M., Nyssonen, 6., g Milan, A. 7:;(=8. 5,ree met,ods o+ oral ,ealt,
ed/cation in secondary sc,ools. Scand " Dent Res, :$9&>>->%.
'>. OCMalley, ). M., #o,nson, .. D., g 1ac,man, #. G. 7:;;'8. Adolescent s/-stance
/se. 3idemiolo*y and imlications +or /-lic olicy. Ped Clinics & m, B< 7>89>&:-
<$.
'=. Fa/lkner, D. .., 3sco-edo, .. G., I,/, 1. )., et al. 7:;;<8. !ace and incidence o+
ci*arette smokin* amon* adolescents in t,e United States. " &atl Cancer /nst,
((7:<89::'(-<$.
'&. Centers +or Disease Control and )re"ention 7:;;&8. G/idelines +or sc,ool ,ealt,
ro*rams to re"ent to-acco /se and addiction. %%-R, &= 7No. !!->:89:-:%.
''. U.S. Deartment o+ Healt, and H/man Ser"ices 7>$$:8. -omen and smo*in$6 a
report of the Sur$eon 0eneral, !ock"ille, MD9 U.S. Det. o+ Healt, and H/man
Ser"ices, )HS, O++ice o+ t,e S/r*eon GeneralD 4as,in*ton, DC.
'<. Ord, !. A., g 1lanc,aert, !. H. 3ds. 7:;;;8. +ral Cancer The dentist?s role in
dia$nosis, mana$ement, reha4ilitation, and prevention, C,ica*o9 j/intessence
)/-lis,in* Co, Inc.
'%. Simons-Morton, 1., Haynie, D. .., Cr/m, A. D., 3itel, )., g Saylor, 2. 3.
7>$$:8. )eer and arent in+l/ences on smokin* and drinkin* amon* early adolescents.
Health !d #ehavior, <F 7:89;'-:$%.
'(. Moss, A. #., Allan, 2. F., Gio"ino, G. A., g Mills, S. .. 7:;;>8. Recent Trends in
dolescent Smo*in$, Smo*in$ UpdateLCorrelates and !xpectations a4out the 'uture,
Hyatts"ille, MD9 U.S. Deartment o+ Healt, and H/man Ser"ices, )/-lic Healt,
Ser"ice, National Center +or Healt, Statistics.
';. OC2ee+e, 2. 1ase-all sn/++s to-acco in minors. San Antonio, 5G9 San ntonio
!xpress2&e3s, #/ne :&, :;;=, :1.
<$. Glynn, 5. #. 7:;;$8. Sc,ool )ro*rams to )re"ent Smokin*9 The &ational Cancer
/nstitute 0uide to Strate$ies that Succeed6 Smo*in$ To4acco and Control Pro$ram,
4as,in*ton, DC9 NCI, USDHHS, NIH )/-. No. ;$-'$$.
<:. 1ar-o/r, S. 3., Nakas,imak I,an*, #. 1. 7:;;%8. 5o-acco and smokin*9
3n"ironmental +actors t,at modi+y t,e ,ost resonse 7imm/ne system8 and ,a"e an
imact on eriodontal ,ealt,. Crit Rev +ral #iol %ed, (9&=%-<$.
<>. !analli, D. M. 7:;;:8. )re"ention o+ cranio+acial inA/ries in +oot-all. Dent Clin
&orth m, A> 7&89<>%-&'.
<=. NowAack-!aymer, !. 3., g Gi+t, H. C. 7:;;<8. Use o+ mo/t,*/ards and ,ead*ear
in or*ani@ed sorts -y sc,ool-a*ed c,ildren. Pu4lic Health Rep, :::9(>-(<.
<&. #o,nsen, D. C., g 4inters, #. 3. 7:;;:8. )re"ention o+ intra oral tra/ma in sorts.
Dent Clin &orth m, A> 7&89<'%-<<.
<'. !analli, D. M., g .ancaster, D. M. 7:;;'8 Attit/des o+ colle*e +oot-all coac,es
re*ardin* NCAA mo/t,*/ard re*/lations and comliance. " Pu4lic Health Dent,
''9:=;-&>.
<<. Cam, #. 7:;;<8. Secial !eort. 3mer*ency. Dealin* wit, sorts-related dental
tra/ma. " m Dent ssoc, :>%9(:>-:'.
<%. NowAack-!aymer, !., g Gi+t, H. C. 7:;;$8. Contri-/tin* +actors to maternal and
c,ild oral ,ealt,. " Pu4lic Health Dent, ';7Secial Iss/e89=%$-%(.
<(. 2/iet@ky, A. 7:;;=8. 5eac,in* kinder*arten and elementary sc,ool c,ildren
dental ,ealt,9 A ractical resentation. " Clin Pediatric Dent, :%9>''-';.
<;. Green, M., 3d. 7:;;&8. #ri$ht 'utures9 0uidelines for health supervision of
infants, children and adolescents, Arlin*ton, 6A9 National Center +or 3d/cation in
Maternal and C,ild Healt,.
%$. Casamassimo, ). 7:;;<8. #ri$ht futures in practice9 +ral health, Arlin*ton, 6A9
National Center +or 3d/cation in Maternal and C,ild Healt,.
%:. Horowit@, A. M. 7:;;'8. 5,e /-licCs oral ,ealt,9 5,e *as -etween w,at we
know and w,at we ractice. dv Dent Res, ;9;:-;'.
%>. U.S. Deartment o+ Healt, and H/man Ser"ices, )/-lic Healt, Ser"ice, Centers
+or Disease Control 7May :;;:8. -ater fluoridation, manual for en$ineers and
technicians, Atlanta9 Centers +or Disease Control, Setem-er :;(<.
%=. Driscoll, 4. S., NowAack-!aymer, !., Selwit@, !. H., .i, S., Hei+et@, S. 1. et al.
7:;;>8. A comarison o+ t,e caries-re"enti"e e++ects o+ +l/oride mo/t,rinsin*,
+l/oride ta-lets, and -ot, roced/res com-ined9 Final res/lts a+ter ei*,t years. "
Pu4lic Health Dent, '>9:::-:<.
%&. Ha/*eAorden, O., .er"ik, 5., 1irkeland, #. M., #orkAend, .. 7:;;$8. An ele"en-year
+ollow-/ st/dy o+ dental caries a+ter discontin/ation o+ sc,ool--ased +l/oride
ro*rams. cta +dontol Scand, &(9>'%-><=.
%'. 2o-ayas,i, S., 2is,i, H., Hos,i,ara, A., Horiik, 5s/ts/i, A., Himeno, 5.,
Horowit@, A. M. 7:;;'8. 5reatment and ostreatment e++ects o+ +l/oride mo/t,rinsin*
a+ter :% years. " Pu4lic Health Dent, ''9>>;-==.
%<. Selwit@, !. H., 4inn, D. M., 2in*man, A., et al. 7:;;<8. 5,e re"alence o+ dental
sealants in t,e US o/lation9 Findin*s +rom NHAN3S III. :;((-;:. " Dent Res, %'
7Secial Iss/e89<'>-<$.
%%. Se, A. I., Ha/sen, H., g )ollanen, ., et al. 7:;;:8. 3++ect o+ intensi+ied caries
re"ention on aro0imal caries in adolescents wit, ,i*, caries risk. Caries Res,
>'9=;>-;'.
%(. Sterritt, G. !., g Frew, !. A. 7:;((8. 3"al/ation o+ a clinic--ased sealant
ro*ram. " Pu4lic Health Dent, &(9>>$->&.
%;. Center +or Disease Control and )re"ention 7>$$:8. Imact o+ tar*eted, sc,ool-
re"alence amon* sc,oolc,ildrenO,io, :;;(-:;;;. %%-R, '$9%=<-=(.
($. Calderone, #. #., g Da"is, #. M. 7:;(%8. 5,e New Me0ico sealant ro*ram9 A
ro*ress reort. " Pu4lic Health Dent, &(9>>$->&.
(:. !ia, .. 4., .eske, 1. S., g Sosata, A. 7:;(;8. 5,e s/r+ace seci+ic caries
attern o+ articiants in a sc,ool--ased +l/oride mo/t, rinsin* ro*ram wit,
imlications +or t,e /se o+ sealants. " Pu4lic Health Dent, &(9=;-&=.
(>. 1/rt, 1. 7:;(;8. )roceedin*s o+ t,e works,o9 Cost-e++ecti"eness o+ caries
re"ention in dental /-lic ,ealt,. " Pu4lic Health Dent, &;7Secial Iss/e89>'$-=&&.
(=. 4an*, N. 7:;;=8. S/-stit/tion o+ dentists -y dental ,y*ienists in c,ild dental care.
" Dent Res, %>7Secial Iss/e89:%>, A-str.'':.
(&. Casamassimo, ). S. 7:;;'8. Sc,ool oral ,ealt,. c3ditorial.d Pediatric Dent,
:%9:%$.
('. )eterson, M. 7:;;=8. )ersonal comm/nication. Dental 5,eraist. Comm/nity
Healt, Ser"ices, Ota*o Area Healt, 1oard, D/nedin, New Iealand.
(<. Friis-Hasc,e, 3. 7:;;&8. C,ild oral ,ealt, care in Denmark. Coen,a*en
Uni"ersity )ress Coen,a*en.
(%. 2ann, .., Collins, #. .., )ateman, 1. C., et al. 7:;;'8. 5,e sc,ool ,ealt, olicies
and ro*rams st/dy 7SH))S89 !ationale +or a nationwide stat/s reort on sc,ool
,ealt, ro*rams. " School Health, <'9>;:-;&.
reser"ed.
Chapter 20. Preventive Oral Health Care for Compromised
Individuals - Roseann %ulli$an Stephen So4el
Objectives
:. 30lain w,y atients wit, t,e same ,andicas can resond di++erently, -ased on
comm/nication and atient treatment tec,ni?/es /sed -y t,e dentist.
>. Disc/ss ,ow "is/al, a/ditory, seec,, and co*niti"e de+iciencies can -e identi+ied
and at least artially comensated +or in re"enti"e dentistry lannin* and
imlementation.
=. Ill/strate ,ow some +/nctional de+iciencies can -e identi+ied t,at re?/ire
consideration in rescri-in* re"enti"e dentistry tec,ni?/es and de"ices.
&. Name and descri-e ,ow new or modi+ied de"ices or aids can -e /sed to sta-ili@e or
aid atients wit, ne/rolo*ic or ,ysical disorders.
'. Cite at least t,ree e0amles o+ ,ow +l/orides, it-and-+iss/re sealants, and s/*ar
disciline can -e inte*rated into t,e re"enti"e dental ro*ram +or comromised
indi"id/alsD also list ossi-le e0cetions.
<. Disc/ss t,e need to ed/cate dental and dental-,y*iene st/dents, dentists, dental
,y*ienists, and lay ersonnel to aid secial atients in t,e ,ome, in t,e o++ice, and in
instit/tional settin*s.
Introduction
A comromised indi"id/al is a erson w,o ,as one or more ,ysical, medical, mental,
or emotional ro-lems t,at res/lt in a limitation o+ t,e a-ility to +/nction normally in
+/l+illin* t,e acti"ities o+ daily li"in* 7AD.s8. More t,an =< million indi"id/als in t,e
United States are comromised.
:
4,en a atient resents +or care, t,e clinicianCs A/d*ment o+ t,e atientCs caa-ilities
may -e -iased. Unrealistic e0ectations o+ t,e ra"a*es o+ a seci+ic disease may ,a"e
-een +ormed in ad"ance +rom readin* t,e scienti+ic literat/re or +rom +irst,and
treatment o+ anot,er atient similarly a++licted. 5,ese e0eriences may rod/ce
/nconscio/s and inacc/rate *enerali@ations a-o/t a ersonCs caa-ilities. S/c,
la-elin* can /ndermine a atientCs re"enti"e oral-,y*iene ro*ram, -eca/se it does
not consider t,e indi"id/alCs act/al caa-ilities.
5,is c,ater resents in+ormation on ,ow to assess t,e caa-ilities o+ a atient o+ any
a*e wit,in any disease cate*ory and o++ers s/**estions on t,e de"eloment o+
indi"id/ali@ed oral disease re"ention ro*rams. Oral-,y*iene aids and tec,ni?/es
alica-le to a re"enti"e ro*ram +or t,e comromised atient, as well as secial
mana*ement tec,ni?/es, are incl/ded.
Sensory Capabilities
Comm/nication is comromised i+ t,e atientCs ,earin*, "ision, or seec, is imaired.
Comm/nication is a critical +actor in any attemt to en*a*e t,e atient or care*i"er in
a -e,a"ioral c,an*e s/c, as t,at re?/ired to imro"e t,e stat/s o+ t,e atientCs oral
,ealt,.
>
6is/al De+icits
A n/m-er o+ +actors, +rom ,arm+/l renatal and erinatal en"ironments to t,e normal
a*in* rocess, can alter "is/al ac/ity. 5,ese c,an*es may ran*e +rom correcta-le
de+iciencies to total -lindness. Ot,er common "is/al de+icits incl/de a loss o+
eri,eral "ision as occ/rs wit, *la/coma
=
or "is/al +ield c/ts res/ltin* +rom a
cere-ro"asc/lar accident.
&
A atient wit, a si*ni+icant "is/al disa-ility may -e carryin* a w,ite-tied cane or
may arri"e wit, an escort. I+ t,e indi"id/al re?/ests, t,e nondental sta++
escortw,et,er ,/man or */ide do*s,o/ld -e allowed to accomany t,e atient
into t,e treatment room. 5,e escort may t,en -e ermitted to stay i+ sace is a"aila-le
in t,e treatment area and i+ t,e resence o+ t,e escort contri-/tes to t,e atientCs
com+ort. An escort w,o +/nctions as an attendant may -e in"ol"ed in any oral ,y*iene
instr/ctions and demonstrations, and t,is erson may -e t,e cr/cial element necessary
to a s/ccess+/l ,ome care ro*ram.
Instr/ctional materials to -e /sed wit, atients w,o ,a"e decreased "is/al ac/ity
co/ld incl/de commercial rod/cts t,at ,a"e -een de"eloed +or ediatric dentistry
ro*rams, -eca/se s/c, rod/cts ,a"e lar*e ict/res. Ot,er commercially reared
am,lets +or sel+-instr/ction and in+ormation ,a"e limited "al/e -eca/se t,e si@e o+
t,e rint /sed in s/c, am,lets is too small +or t,e "is/ally imaired to see
com+orta-ly. C/stom-made instr/ctional s,eets may -e rod/ced -y t,e dental o++ice
/sin* lar*e -lack letters o+ at least :>-oint tye on o++-w,ite or w,ite aer.
'
4,en
aroriate, c,airside instr/ctions o+ toot, -r/s,in* and +lossin* s,o/ld -e
demonstrated on o"ersi@ed models o+ t,e dentition wit, a *iant-si@ed toot,-r/s,
7Fi*/re >$-:8. 5,ese lar*e models allow t,e atient wit, limited "is/al ac/ity to see
and to /nderstand some o+ t,e more s/-tle asects o+ toot, -r/s,in*, s/c, as t,e
correct an*/lation o+ t,e -ristles into t,e *in*i"al cre"ice. !ed +loss can ,el w,en
demonstratin* +lossin* to t,ose wit, "is/al imairment w,o ,a"e di++ic/lty seein*
w,ite +loss. Green +loss is also a"aila-le and can -e /sed, -/t red is easier +or t,e
a*in* eye to see.
<
Once t,e +lossin* tec,ni?/e is /nderstood and "is/al ac/ity ermits,
t,e atient may switc, to w,ite +loss +or re*/lar ,ome /se. 5,is allows t,e atient to
c,eck t,e color o+ t,e +loss +or ossi-le *in*i"al -leedin*.
5o demonstrate -r/s,in* and +lossin* tec,ni?/es in t,e o++ice, an ine0ensi"e
ma*ni+yin* mirror s,o/ld -e emloyed to assist t,e atient in o-ser"in* ,is or ,er
own er+ormance. A similar mirror s,o/ld -e recommended +or t,e atientCs /se at
,ome. 5,ese mirrors, commercially a"aila-le, are /s/ally /sed +or alyin*
cosmetics. 4it, attac,ments ro"ided, t,ey can -e adated to -e ,/n* aro/nd t,e
neck, a++i0ed to a wall, or laced on a co/nterto, t,/s allowin* atients to kee t,eir
,ands +ree +or er+ormin* oral ,y*iene and still /se t,e ma*ni+yin* mirror to en,ance
"ision. Many also +eat/re a li*,ted mirror, anot,er aid +or en,ancin* "ision. Some
atients w,o ,a"e e0erienced a cere-ro"asc/lar accident lack t,e satial-ercet/al
skills necessary to /se a mirror. For t,ese eole, /sin* a mirror ca/ses con+/sion and
t,ere+ore is contraindicated. I+ a atient ,as "is/al ro-lems so si*ni+icant t,at a
mirror cannot -e /sed, ,e or s,e m/st -e sensiti@ed instead to t,e F+eelin*F and
FsmellF o+ a clean mo/t, to attest to t,e s/ccess o+ oral ,y*iene meas/res.
%
For indi"id/als wit, "is/al +ield c/ts or decreases in eri,eral "ision, -e s/re t,at
demonstrations are wit,in t,e atientCs "is/al +ield. 5o c,eck t,e limits o+ a atientCs
"ision, er+orm a "is/al assessment -y ositionin* yo/r ,and in "ario/s locations
aro/nd t,e atientCs +ace w,ile ,oldin* / one or more +in*ers. For eac, osition, ask
t,e atient ,ow many +in*ers can -e seen, and note w,et,er t,e atient mo"es t,e
,ead rat,er t,an A/st t,e eyes to see yo/r +in*ers.
Many atients wit, "is/al ro-lems e0erience an increased sensiti"ity to li*,t or
*lare. Indiscriminate ositionin* o+ t,e dental li*,t so t,at it s,ines in t,e eyes o+ a
atient can res/lt in si*ni+icant discom+ort +or s/c, a atient. 5,is can -e a"oided -y
care+/lly +oc/sin* and ositionin* t,e oeratory li*,t. Also, it is ad"isa-le to ,a"e
s/n*lasses a"aila-leD t,ese can -e disin+ected a+ter /se.
4it, loss o+ or-ital +at d/rin* a*in*, t,e eye -ecomes Fs/nkenF wit, an increase in
t,e /er lid +old and a decrease in eri,eral "ision. 30tra-oc/lar m/scle weakness
-y t,e a*e o+ %$ in,i-its t,e a-ility to rotate t,e eye /ward *reater t,an :' +rom t,e
,ori@on.
(
Since art,ritic c,an*es in t,e cer"ical sine occ/r +re?/ently amon* t,e
elderly,
;
it may -e di++ic/lt or imossi-le +or some atients to ti t,e ,ead -ack. 5,/s,
to en,ance comm/nication wit, all atients, it is -est to con"erse +rom a sittin*
osition directly in +ront o+ t,e atient so t,at t,e clinicianCs eyes and t,e atientCs
eyes are at a-o/t t,e same le"el.
Hearin* Disa-ilities
Hearin* ro-lems can occ/r in all a*e *ro/s. 5,e so/nd o+ dental e?/iment in
anot,er room, -ack*ro/nd m/sic, and street noises can ,inder comm/nication wit,
t,e ,earin*-imaired, as t,ese so/nds o+ten mask t,e so/nd o+ seec,. 5,e most
common ro-lem in comm/nicatin* wit, t,e ,earin* disa-led, ,owe"er, occ/rs w,en
t,e seaker is not directly in +ront o+ t,e atient, at t,e same eye le"el, +ace to +ace.
:$
Most atients wit, ,earin* disa-ilities do some seec, readin* 7+ormerly termed li
readin*8, -/t e"en t,e -est seec, reader is a-le to deci,er only a-o/t one +o/rt, o+ a
messa*e con"eyed entirely t,ro/*, t,is met,od.
::
5,e ,earin*-disa-led atient also
relies on t,e comm/nicatorCs +acial e0ression and -ody lan*/a*e.
:$
Seakin*
distinctly and sli*,tly slower, wit,o/t e0a**eration and in a well-mod/lated "oice,
+acilitates comm/nication.
:>
5,e ro*ressi"e loss o+ ,earin* o+ ,i*,-+re?/ency tones
t,at commonly occ/rs amon* t,e elderly may make a +emale "oice more di++ic/lt to
,ear t,an a male "oice. A"oid -ack li*,tin*
:=
t,at laces t,e seakerCs +ace in a
s,adow. S,o/tin* at a ,earin*-disa-led atient is not recommended, -eca/se lo/d
so/nds are act/ally more di++ic/lt +or t,e imaired ear to comre,end.
:$
4,en
seakin* to a atient, ot,er t,an w,ile doin* a roced/re, lower or remo"e yo/r +ace
mask.
)antomime and demonstration may -e necessary w,en workin* wit, t,e ,earin*
disa-led. 4,en writin* in+ormation, /se a cli-oard and a red +elt-tied en. A+ter
ro"idin* oral-,y*iene instr/ctions, ,a"e t,e atient demonstrate t,e s/**ested oral-
,y*iene skills on models or in ,is or ,er own mo/t, to assess ,ow well t,e messa*e
was comre,ended.
Hearin* aids are -ecomin* more di++ic/lt to detect, as new tec,nolo*ies allow +or
decreasin* si@e or ositionin* entirely wit,in t,e ear canal. .on* ,air may mask t,eir
resenceD t,ere+ore, a conscio/s e++ort s,o/ld -e made to look +or s/c, aids 7Fi*/re
>$->8. I+ re"enti"e instr/ctions are to -e *i"en to a atient wit, a ,earin* aid, -e s/re
t,e atientCs aid is in lace and t/rned on. O+ten atients t/rn o++ or remo"e t,eir
,earin* aids in anticiation o+ dental treatment, -eca/se t,e ro0imity o+ t,e seakerCs
-ody to t,e aid may ca/se it to emit ,i*,-itc,ed s?/eals called F+eed-ack.F )ro"idin*
dental care wit, t,e clinician seated in t,e :> oCclock osition laces t,e oeratorCs
arm nearly in contact wit, t,e atientCs ear, and t,e clinicianCs slee"e may accidentally
dislod*e an o"er-t,e-ear ,earin* aid. Handieces can also ca/se many tyes o+
,earin* aids to rod/ce +eed-ack. S/**est to t,e atient t,at t,e aid -e remo"ed or
t/rned o++ rior to treatment and relaced or t/rned -ack on rior to recei"in*
instr/ctions.
Hearin* aids are e0ensi"e de"ices, and indi"id/als w,o wear t,em /s/ally re+er to
remo"e t,em t,emsel"es. Once remo"ed, t,e aids s,o/ld -e laced in a sec/re sot,
s/c, as t,e atientCs ocket or /rse, rat,er t,an on t,e -racket ta-le w,ere t,ey co/ld
-e +or*otten or *at,ered / and discarded. Indi"id/als w,o ,a"e -ot, ,earin* and
"is/al de+iciencies may ,a"e t,eir ,earin* de"ices constr/cted as art o+ t,e +rame o+
t,eir *lasses. In s/c, cases it is recommended t,at t,e *lasses -e le+t in lace -/t wit,
t,e ,earin* de"ice t/rned o++.
For atients wit, "is/al or ,earin* de+iciencies, kee distractions to a minim/m 7it is
ad"isa-le to ,a"e o++ice -ack*ro/nd m/sic t/rned o++ at t,is time8. 5,is incl/des any
interr/tion o+ t,e clinician at c,airside as well as t,e distraction created -y a/0iliary
ersonnel enterin* and lea"in* t,e room.
Seec, and .an*/a*e Disorders
Se"eral conditions a++ect t,e motor or t,e co*niti"e comonents o+ seec, or -ot,.
5,e atient wit, cere-ral alsy may ,a"e seec, imairment -eca/se o+ ro-lems o+
t,e central ner"o/s system a++ectin* t,e m/sc/lar mo"ements needed +or seec,.
:&

4it, ractice, a clinician w,o listens care+/lly and atiently to s/c, seec, can
-ecome adet at /nderstandin* m/c, o+ it. 5,is is t,e same sort o+ tec,ni?/e many
dental ro"iders ,a"e already ac,ie"ed in learnin* to /nderstand atients w,o attemt
to seak wit, a r/--er dam in lace. Indi"id/als, s/c, as t,ose w,o are mentally
retarded, e"en t,o/*, ,ysiolo*ically caa-le, may not /se lan*/a*e -eca/se o+ t,eir
le"el o+ intellect/al or emotional +/nctionin*. 5,ose wit, ne/rom/sc/lar diseases may
,a"e a weakness so se"ere t,at t,e m/scles necessary to artic/late so/nds are /na-le
to +/nction. Deterioration o+ seec, t,at once was normal may -e d/e to ro*ressi"e
,earin* loss. Indi"id/als w,o are /na-le to ,ear t,e ran*e o+ +re?/encies o+ t,e seec,
sectr/m may de"elo a monotone "oice. In addition, s/c, a erson o+ten loses t,e
a-ility to reco*ni@e ,ow lo/dly ,e or s,e is seakin*.
5,e atient w,o ,as s/++ered a stroke is artic/larly rone to lan*/a*e disorders. One
tye o+ disorder common to stroke atients is a,asia. In a,asia, t,e recetion,
inte*ration, and e0ression o+ lan*/a*e are imaired. 5,e a,asic atient, t,ere+ore,
,as di++ic/lty +indin* t,e ri*,t words to comm/nicate,
:'
and t,is ina-ility may -e so
rono/nced t,at t,e atient may -ecome "ery +r/strated. 5,is is esecially tr/e +or
t,ose indi"id/als w,o are ot,erwise co*niti"ely intact. 4,en dealin* wit, t,ese
indi"id/als, +rame ?/estions so t,at t,ey can -e answered wit, Fyes,F Fno,F or A/st a
s,ake or nod o+ t,e ,ead.
5,e a,asic indi"id/al may also omit or s/-stit/te so/nds +or words. 5,e words t,en
may -e meanin*less -y t,emsel"es -/t con"ey intent -y t,e way in w,ic, t,ey are
e0ressed. 5,e seec, may consist only o+ no/ns, "er-s, or a +ew adAecti"es. An
e0treme e0amle o+ an a,asic atient was a woman w,o s/++ered a stroke so se"ere
t,at ,er "er-al comm/nication was red/ced to two e0clamatory words t,at were
always said to*et,er. 4it, t,e ,el o+ ,er +acial e0ression, -ody lan*/a*e, and t,e
+orce and intonation /sed in sayin* t,ese words, dental aointments were comleted
to t,e satis+action o+ t,e atient and t,e ro"ider.
Dysart,ria is a seec, disorder res/ltin* +rom a motor dys+/nction o+ t,e seec,-
rod/cin* elements. 5,is dys+/nction may -e ca/sed -y lesions in t,e central ner"o/s
system, t,e eri,eral ner"o/s system, or in t,e m/scles t,emsel"es. 5,e sym-olic
lan*/a*e is intactD ,owe"er, t,e coordination necessary to rod/ce seec, is imaired.
5,is tye o+ dist/r-ance occ/rs in atients wit, amyotro,ic lateral sclerosis 7A.S8,
)arkinsonCs disease, tra/matic -rain inA/ry, myast,enia *ra"is, m/ltile sclerosis, and
stroke.
:<
5,e s/-stit/tion o+ written +or "er-al comm/nication is a ossi-le otion +or
indi"id/als in w,om t,e reco*nition o+ lan*/a*e is still intact. Un+ort/nately, many o+
t,e ca/ses o+ seec, disorders res/lt in sli*,t or rono/nced aralysis or tremors t,at
re"ent t,e atient +rom writin* le*i-ly. One sol/tion is to ro"ide t,e atient wit, a
la-oard containin* rerinted letters, common words, or ict/res. Indi"id/als wit, a
knowled*e o+ lan*/a*e -/t an ina-ility to seak or to ,a"e t,eir seec, or writin*
/nderstood can oint to t,e letters or words or ict/res to comm/nicate. Anot,er
met,od is a so,isticated, small tyewriter-like de"ice in w,ic, a key-oard is /sed to
tye o/t a tickertae messa*e. j/adrile*ic atients may -e o/t+itted wit, a ton*/e
control t,at ermits "ery s/-tle mo"ements o+ t,e ton*/e a*ainst a to**le switc,. 5,is
action ca/ses letters to -e rinted on a tele"ision monitor mo/nted to a w,eelc,air or
-ed.
5odayCs society laces *reat imortance on "er-al comm/nicationD t,ere+ore, an
indi"id/al wit, oor "er-al skills is sometimes incorrectly ercei"ed as ,a"in* oor
co*niti"e and intellect/al a-ilities. 5,is is not necessarily t,e case.
Alt,o/*, non"er-al comm/nication, s/c, as smilin*, ,and ,oldin*, and s,o/lder
to/c,in*, lays a role in t,e clinician-atient interaction, it -ecomes e0tremely
si*ni+icant w,en t,ere is no alternati"e. In s/c, a case, t,e clinician needs to enlist
eit,er t,e atientCs attendant or a +amily mem-er w,o ,as -ecome att/ned to Freadin*F
t,e atientCs needs. Us/ally, t,ese constant comanions can ,el interret t,e
/nderlyin* messa*e o+ s/c, non"er-al actions as a rollin* o+ t,e eye-alls or a +i0ed
stare.
Most a/tistic atients are known to -e /na-le to /se lan*/a*e aroriately, and many
resent si*ni+icant mana*ement c,allen*es. 6is/al eda*o*y was /sed +or a *ro/ o+
a/tistic c,ildren in Sweden. )ict/res o+ t,e location and t,e acti"ities to -e anticiated
were s,own to t,e a/tistic atient incl/din* t,e dental o++ice, o/tside and inside, t,e
dental c,air, a wide-oen mo/t,, a mo/t, mirror, and a toot,-r/s,. 5,e ict/res were
s,own to t,e atient at ,ome -e+ore t,e aointment and e0lanations were *i"en
t,/s +amiliari@in* t,e atient wit, w,at was to come. 5,e tec,ni?/e ro"ed ?/ite
s/ccess+/l +or clinical care and can -e /sed +or re"enti"e acti"ities as well.
:%
In s/mmary, -ot, "er-al and non"er-al tec,ni?/es lay roles in t,e comm/nication
rocess -etween a dental-care ro"ider and a comromised dental atient. Seakin*
directly to t,e atient +rom a sittin* osition in +ront o+ t,e atient in a well-
mod/lated, well-artic/lated "oice and rein+orcin* eac, ste o+ t,e comm/nication
wit, non"er-al c/es are all tec,ni?/es t,at s,o/ld -e /sed to rod/ce a s/ccess+/l
relations,i wit, a atient w,o ,as imaired comm/nication skills.
Fi*/re >$-: .ar*e dental models and a ,elin* ,and are needed to er+ect
toot,-r/s,in* ,a-its in t,e "is/ally imaired.
Fi*/re >$-> 4,en lon*er ,air is com-ed o"er t,e ear, t,is ,earin* de"ice can -e
"ery inconsic/o/sand "/lnera-le to ,andiece noise.
Question 1
A. Many seciali@ed re"enti"e tec,ni?/es alica-le to one ,andicain* condition
are alica-le to ot,er ,andicain* conditions.
1. D/rin* eriods o+ atient-dentist comm/nications, it is -etter t,at t,e dentist -e
a-le to clearly see t,e atientCs +ace t,an "ice "ersa.
C. An a,asic atient is one w,o ,as di++ic/lty in artic/latin* ersonal t,o/*,ts and
o-ser"ations.
D. 4,en a atient is /na-le to +orm words -eca/se o+ a motor dys+/nction ro-lem,
t,e condition is known as dysart,ria.
Cognitive Capacities
5,e +/nctional caacity o+ a atient is o+ +ar *reater imortance t,an intelli*ence
?/otient 7Ij8 test res/lts in determinin* t,e caa-ility o+ -ene+itin* +rom re"enti"e
dentistry instr/ctions. For e0amle, a atient w,o is mentally retarded is e0ected to
,a"e a low Ij, s,ort attention san, and di++ic/lty in /nderstandin* oral-,y*iene
instr/ctions. Het many o+ t,ese atients, w,en roerly ta/*,t and moti"ated, can
s/ccess+/lly er+orm oral-,y*iene roced/res. 5o -e s/ccess+/l, one m/st +irst
determine t,e atientCs le"el o+ co*niti"e a-ility and t,en direct all instr/ction to t,at
le"el. !at,er t,an attemtin* to analy@e intelli*ence test scores, ask t,e atient a +ew
simle ?/estions to determine ,is or ,er +/nctionin* le"el. j/estions o+ t,e tye t,at
mi*,t -e asked o+ t,e atient, not t,e +amily mem-er or attendant, co/ld ertain to
s/c, e"eryday con"ersational toics as 7:8 4,at do yo/ do in sc,ool 7or at work, or in
retirement8e 7>8 4,at ,o--ies do yo/ likee 7=8 4,y do yo/ like a +a"orite tele"ision
s,owe or 7&8 4,at ,as -een t,e most di++ic/lt task yo/ er+ormed latelye One
mentally retarded atient w,o resonded to a similar series o+ ?/estions con+ided t,at
,e enAoyed ,is Ao- as a +ile clerk in a s,eltered works,o en"ironment, -/t ,e was
sometimes con+/sed tryin* to remem-er t,e order o+ letters in t,e al,a-et. He added
t,at t,e most di++ic/lt Ao- ,e +aced was ayin* t,e rent at t,e +irst o+ eac, mont,.
3"en t,o/*, ,e knew ,e ,ad s/++icient money, t,e resonsi-ility o+ ens/rin* t,at t,e
+/nds reac,ed ,is landlord in time ca/sed ,im a *reat deal o+ an0iety.
S/c, in+ormation +rom t,e atient o++ers insi*,ts into le"els o+ resonsi-ility,
/nderstandin*, attention san, /s/al le"el o+ de0terity, and memory +or details. 5,ese
+acts *reatly assist t,e dental-care ro"ider in selectin* t,e aroriate "oca-/lary,
le"el o+ comle0ity o+ instr/ction, and reward system +or ad,erence to a c/stomi@ed
re"enti"e dentistry ro*ram.
I+ it is determined t,at t,e atient is intellect/ally or co*niti"ely imaired, t,e
traditional ed/cation ro*ram +or oral-,y*iene tec,ni?/es m/st -e modi+ied. 1r/s,in*
t,e teet, is a comle0 task t,at needs to -e -roken down into "ery simle, discrete
stes. 5,is allows t,e imaired atient to +ollow t,e instr/ctions and to s/cceed at
eac, ste toward t,e +inal *oal, t,ere-y inte*ratin* t,e simle tasks into a +inal
comle0 task.
::
At t,e +irst aointment it may -e ossi-le to address only t,e
-r/s,in* o+ t,e occl/sal s/r+aces o+ t,e teet,. 5,is acti"ity s,o/ld -e monitored and
rein+orced /ntil a le"el o+ satis+actory comliance and incororation into t,e atientCs
daily ro/tine is ac,ie"ed. Clinicians, in t,eir ?/est to *et t,e messa*e across to t,e
co*niti"ely or intellect/ally imaired atient o+ten tend to do and to say too m/c,. It
is imortant to kee instr/ctional eriods s,ort wit, +re?/ent reetition o+ t,e
in+ormation. Usin* a le"el o+ lan*/a*e t,at is /nderstood -y t,e atient wit,o/t -ein*
ins/ltin* is key. 4ritten or tae-recorded reminders can -e *i"en +or ,omework. At
eac, aointment, t,e atient s,o/ld -e asked to state or s,ow w,at ,e or s,e ,as
-een doin* since t,e last "isit. 5,is ro"ides +eed-ack a-o/t t,e e++ecti"eness o+ t,e
re"io/s instr/ctional eriod and t,e atientCs memory and mastery o+ t,e tec,ni?/e.
::
O+ co/rse, one m/st /se A/d*ment and an /nderstandin* o+ t,e atientCs co*niti"e
+/nctional le"el in assessin* t,e "alidity o+ t,e atientCs answers.
Demonstrations o+ aroriate -e,a"ior -y any dental atient, esecially t,ose wit,
decreased co*niti"e +/nctionin*, s,o/ld always -e +ollowed -y immediate and
ositi"e +eed-ack.
:;
!ein+orcement t,ro/*,o/t t,e learnin* eriod s,o/ld -e
s/lemented wit, -ot, "er-al and non"er-al rewardsD +or e0amle, a smile or a *i+t
o+ a new toot,-r/s, is o+ten moti"atin*. De"eloment o+ raort aids in red/cin*
stress, w,ic, can -e detrimental to an indi"id/alCs a-ility to learn. For t,is reason all
learnin* s,o/ld occ/r in an en"ironment in w,ic, t,e dental sta++ can re+lect warmt,
and +riendliness.
Family mem-ers or */ardians, teac,ers, or ot,er care*i"ers m/st ass/me
resonsi-ility +or oral ,ealt, care ro*rams o+ atients wit, little co*niti"e a-ility.
>$

5,e selected indi"id/als s,o/ld -e t,oro/*,ly instr/cted -y t,e dental sta++ in t,e
roer tec,ni?/es +or t,at atientCs oral ,ealt,.
Functional Performance
5oot,-r/s,in* and +lossin* re?/ire t,e +ine-motor skills or de0terity o+ t,e small
m/scles o+ t,e +in*ers and ,ands as well as t,e *ross-motor skills o+ t,e lar*er m/scle
*ro/s in t,e /er e0tremities.
>:
5,e +/nctionin* o+ n/mero/s m/scles and ner"es o+
t,e ,ead, neck, and /er e0tremities are all in"ol"ed, as is t,e ran*e-o+-motion
caa-ility o+ t,e Aoints, esecially t,e s,o/lders and el-ows. In many disa-ilities, one
or more o+ t,ese elements may -e ad"ersely a++ected or limited. Art,ritis, +or
e0amle, is a disease rimarily o+ t,e Aoints and t,ere+ore o+ten restricts t,e ran*e o+
motion o+ t,e Aoint. Cere-ral alsy is a central ner"o/s system disorder. 1eca/se o+
a-errant ne/ral si*nals transmitted to t,e m/scle +i-ers, +ine-motor skills are imaired.
M/scle contract/res also c,aracteristically a++ect -ot, t,e ran*e and motion o+ t,e
Aoints. A ne/rom/sc/lar disease s/c, as myast,enia *ra"is a++ects t,e ner"e
transmission rocess itsel+, res/ltin* in a m/sc/lat/re so weak t,at de0terity, *ross
motor skills, and ran*e o+ motion may all -e a++ected.
An acc/rate assessment o+ a atientCs a-ility to er+orm oral ,y*iene deends on t,e
e"al/ation o+ eac, comonent o+ t,e task. Once a di++ic/lty ,as -een identi+ied, eit,er
a de"ice or a erson is needed to comensate +or t,e atientCs ina-ility. Gross motor
skills s/c, as *rasin* a toot,-r/s, ,andle can o+ten -e imro"ed -y orthotic
a

aliances 7Fi*/re >$-=8. !an*e-o+-motion limitations may -e altered -y ,ysical
t,eray, esecially in t,e early sta*es o+ inA/ry or disease, or in some cases -y
s/r*ery. De0terity necessary +or t,e rod/ction o+ t,e small "i-ratory strokes
recommended in toot, -r/s,in* /s/ally cannot -e en,anced t,ro/*, ,ysical
medicine, s/r*ery or ort,otic remedies. For certain atients, an electric toot,-r/s,
may ro"ide e++ecti"e comensation +or t,is lack o+ a-ility.
a
Ort,otic aliances are de"ices, s/c, as slints and -races, t,at are /sed to ro"ide
s/ort to de+ormed or weakened lim-s.
Assessment
Seci+ic ,and +/nction tests emloyed -y occ/ational t,eraists to e"al/ate a
atientCs a-ility to /se ,is or ,er ,ands can ,el dental clinicians assess a atientCs
otential a-ility to accomlis, oral-,y*iene tec,ni?/es. I+ t,e atient s,akes yo/r
,and w,en +irst *reeted, ay attention to t,e stren*t, o+ t,e atientCs ,andclas.
Indi"id/als wit, a weak *ras s,o/ld -e asked to +irmly *ri t,e inde0 +in*er o+ t,e
clinicianCs ,and. I+ t,e *ri is weak, t,e atient s,o/ld a*ain -e asked to *ri t,e
+in*er Fas ,ard as yo/ can.F !eeatin* t,is roced/re se"eral times /sin* two, t,ree,
and +o/r +in*ers o+ t,e ractitionerCs ,and in lace o+ t,e one +in*er ena-les t,e
ractitioner to decide at w,at diameter t,e atient ,as t,e stron*est *ri
>>
7Fi*/re >$-
&8. I+ it is determined t,at t,e atient wo/ld -ene+it +rom a man/al toot,-r/s,, t,e
,andle will need to -e increased in diameter to matc, t,e n/m-er o+ +in*ers at w,ic,
t,e atient ,ad t,e stron*est *ras.
5,e ran*e o+ motion o+ t,e el-ow and s,o/lder can -e determined -y ,a"in* t,e
atient e0tend and +le0 t,e lower arm, or rotate t,at arm a-o/t t,e s,o/lder. 5,is
in+ormation may -e more ?/ickly o-tained -y askin* t,e atient, FCan yo/ +eed
yo/rsel+eF Indi"id/als w,o are a-le to do so, e"en i+ t,ey /se ort,otic slints or ot,er
adati"e aids, are ro-a-ly a-le to er+orm oral ,y*iene roced/res. )atients w,o /se
secial de"ices to aid in sel+-+eedin* s,o/ld -rin* t,ese de"ices to t,e dental o++ice so
t,at toot,-r/s,es and ot,er oral ,y*iene aids can -e modi+ied to +it t,em. 5,e -est
way to assess w,et,er a atient ,as s/++icient de0terity and co*nition to er+orm
ade?/ate oral ,y*iene is to o++er t,e atient a toot,-r/s, and to directly o-ser"e ,is or
,er s/ccess in la?/e remo"al. 5,is accomlis,es two o-Aecti"es9 :8 5,e clinician can
assess t,e atientCs c/rrent le"el o+ a-ility and /nderstandin* rior to any inter"ention.
>8 5,e clinician can esta-lis, a -aseline le"el o+ ac,ie"ement a*ainst w,ic, +/t/re
imro"ements or modi+ications can -e meas/red.
Noticin* t,e ease or di++ic/lty wit, w,ic, eac, mo"ement is accomlis,ed 7*rasin*
t,e -r/s,, an*lin*, and mo"in* it8 and t,e care needed to sync,roni@e t,ese actions
into /rose+/l motion *i"es t,e dental ro+essional insi*,t into t,e caa-ilities,
trainin*, and ed/cation o+ t,e atient to date. An /nderstandin* o+ t,e atientCs c/rrent
a-ilities allows t,e ,ealt, care ro"ider to determine t,e tye and n/m-er o+
ed/cational inter"entions to -e introd/ced. )atients wit, comromised motor skills
o+ten comensate +or t,eir de+iciencies in in*enio/s ways. 5,ere+ore, t,eir a-ility to
er+orm t,eir own oral ,y*iene s,o/ld not -e reA/d*ed, and t,ey s,o/ld -e *i"en
oort/nities to demonstrate t,eir ro+iciencies. Many atients w,o aear /na-le to
,andle a toot,-r/s, or +loss, -eca/se o+ de+ormed +in*ers or decreased motor
+/nctions, can comensate and +/nction reasona-ly well.
Fi*/re >$-= An ort,otic de"ice t,at ermits a +irmer *ras on a modi+ied
toot,-r/s,.
Fi*/re >$-& 5,e m/sc/lar stren*t, o+ a atientCs ,and can -e assessed -y
,ands,ake or -y a *ras o+ t,e clinicianCs +in*ers.
Question 2
A. It is an in"iola-le r/le t,at as t,e Ij decreases, so does t,e ossi-ility o+ attainin*
cooeration +rom a mentally ,andicaed atient.
1. As an indi"id/alCs disa-ility increases, t,e need -ecomes *reater +or s/ort +rom
ot,er indi"id/als.
C. 30lanations on rimary re"enti"e dentistry *i"en to ,andicaed indi"id/als
s,o/ld -e detailed.
D. 5,e ,and stren*t, and a-ility o+ a atient to /se a toot,-r/s, can o+ten -e
determined -y a ,ands,ake.
3. 5,e -est way to +ind o/t w,at a ,andicaed atient can do is to ask t,e erson to
accomlis, a stated task.
Attendant Care
5o ens/re dental care and comliance wit, ,ome sel+-care re"enti"e ro*rams,
comlete cooeration m/st -e esta-lis,ed amon* t,e +amily or care*i"ers, t,e ,ealt,
ro"ider, and, to t,e e0tent ossi-le, t,e atient.
>=, >&
Many comromised indi"id/als
are /na-le to ,andle t,eir own ,y*iene d/e to sensory, co*niti"e, or ,ysical de+icits.
For t,ese indi"id/als, an attendant or +amily mem-er s,o/ld -e instr/cted in t,e
roer oral-,ealt, care +or t,e atient.
>'
I+ lon*-term comliance wit, instr/ctions is
t,e *oal, t,e com+ort o+ -ot, t,e care*i"er and t,e atient in er+ormin* t,e oral
,y*iene ro*ram is aramo/nt. For t,is reason, a n/m-er o+ ositions ,a"e -een
recommended +or t,e care*i"er to ass/me w,en ro"idin* oral ,y*iene care to t,e
atient. Facts to -e considered incl/de t,e atientCs si@e and stren*t,, t,e attendantCs
si@e and stren*t,, and t,e amo/nt o+ control t,at needs to -e e0erted o"er t,e
intentional or /nintentional mo"ements o+ t,e atient. One osition t,at ,as ro"en to
-e s/ccess+/l w,en t,e atient is an ad/lt is +or t,e attendant to stand -e,ind t,e
atient, w,o is seated in a strai*,t--acked c,air or a w,eelc,air. In t,is osition, it is
easy to sta-ili@e t,e atientCs ,ead -y restin* it a*ainst t,e -ody o+ t,e attendant.
1r/s,in* t,en roceeds wit, t,e attendant /sin* t,e same kind o+ arm and -r/s,
ositionin* as w,en cleanin* ,is or ,er own teet,. )er+ormin* t,is oeration in +ront
o+ a mirror takes +/rt,er ad"anta*e o+ t,e attendantCs own -r/s,in* ,a-its, alt,o/*, a
mirror is not a necessity. Ot,er recommended ositions incl/de ,a"in* t,e atient lie
on a so+a or -ed wit, t,e ,ead in t,e care*i"erCs la or sittin* on t,e +loor in +ront o+ a
c,air in w,ic, t,e care*i"er is seated 7Fi*/re >$-'8. As deicted in Fi*/re >$-' 1,
note t,at t,e care*i"erCs le*s are /sed as an additional restraint to t,e arms o+ t,e
atient. Care*i"ers and atients s,o/ld -ot, -e ad"ised t,at t,e -at,room is not t,e
only location in w,ic, to -r/s, teet,. In +act, it is o+ten t,e least con"enient room in
t,e ,o/se -eca/se o+ its sace limitations and t,e need to s,are its /se wit, ot,er
mem-ers o+ t,e +amily. 4ater is not always necessary +or toot,-r/s,in*, as sali"ary
+low is stim/lated -y -r/s,in* and t,/s ro"ides moist/re. I+ a atient ,as tender,
+ria-le *in*i"al tiss/e t,at can easily -ecome dama*ed -y an initially dry toot,-r/s,,
t,e -r/s, can -e moistened -e+ore,and to so+ten it. 4,en no toot,aste is /sed,
r/nnin* water may not -e needed. 5,e elimination o+ t,e toot,aste increases
"isi-ility and decreases t,e ossi-ility o+ *a**in*. In many cases, it ,as -een +o/nd
t,at w,en water and toot,aste were re?/ired, attendants or +amily mem-ers
discontin/ed or decreased t,e n/m-er o+ toot,-r/s,in* sessions. Normally, a +l/oride
toot,aste is an imortant comonent o+ an oral-,y*iene ro*ram in an
/ncomromised o/lation. In comromised atients, ,owe"er, i+ one m/st omit
+l/oride toot,aste +rom t,e ro/tine, it can -e comensated +or -y /sin* +l/orides in
ot,er +orms.
5,ose atients w,o enAoy t,e taste or areciate t,e aest,etic "al/e o+ toot,aste can
/se a non-+oamin*, in*esti-le toot,aste
-
7ori*inally de"eloed +or t,e astrona/ts8.
1eca/se t,is toot,aste does not +oam and can -e swallowed, it is not necessary +or
t,e atient to -e near a -asin to e0ectorate.
I+ a atient likes to rinse wit, water or a mo/t,was, a+ter -r/s,in*, a two-aer-c/
tec,ni?/e can -e /sed. One aer c/ ,olds t,e rinseD t,e ot,er is +or t,e e0ectorate
a+ter t,e atient rinses. 1eca/se t,e c/s are li*,twei*,t, atients can o+ten ,old -ot,,
-rin*in* eac, o+ t,e c/s / to t,eir lis as needed. 5,is two-c/ tec,ni?/e ro"ides
a means o+ controllin* dri--lin* or droolin*, and it is "al/a-le +or an indi"id/al w,o
is /na-le to lean o"er t,e -asin, s/c, as an art,ritic atient, or +or an indi"id/al w,o
cannot /rse t,e lis to e0el t,e +l/id, as is t,e case wit, m/sc/lar dystro,y
atients.
-
NASAdent, Sc,erer .a-oratories, Inc., Dallas, 5G.
Fi*/re >$-' 5,ree di++erent ositions +or a care*i"er to /se in aidin*
toot,-r/s,in*. 7Co/rtesy o+ lonya Smit, !ay and Gayla Hill 5aylor.8
Specialized Equipment for Patient Management
Mo/t, )ros
Se"eral tyes o+ mo/t, ros can -e /sed to assist in oenin* and ,oldin* oen t,e
atientCs mo/t, +or oral ,y*iene roced/res 7Fi*/re >$-<8. A simle, e++ecti"e mo/t,
ro can -e easily +a-ricated wit, two or t,ree ton*/e -lades wraed to*et,er,
added on one end wit, > > *a/@e s?/ares, and sec/red in lace wit, ad,esi"e
tae.
><
5,is ro can -e /sed wit, atients w,o are /na-le to /nderstand or to
cooerate d/e to decreased co*niti"e +/nctionin*, as seen in mental retardation,
mental de+iciency, senile dementia, or in atients e0,i-itin* ne/rom/sc/lar
dys+/nction, s/c, as occ/rs in cere-ral alsy or m/sc/lar dystro,y. 5,is ro may
-e /sed initially to ,el oen t,e atientCs mo/t,. I+ necessary, it can t,en -e relaced
-y a c/stom-made +in*er co"er
>%
or se"eral di++erent tyes o+ commercially
man/+act/red ros, w,ic, wo/ld t,en -e laced on t,e oosite side o+ t,e arc,
+rom w,ere t,e ori*inal *a/@e wraed ro is initially laced and t,en remo"ed once
t,e more comact ro is in osition. Not only is t,e *a/@e and ton*/e--lade mo/t,
ro /se+/l +or initial e0aminations and screenin*s, it is economical and disosa-le as
well.
Commercially a"aila-le intra-oral mo/t, ros are +re?/ently a"aila-le in di++erent
si@es to accommodate ad/lt and ediatric atients, or as a one-si@e-+its-all /nit
desi*ned to accommodate a ran*e o+ mo/t, si@es. 4,en /sin* a ro o+ t,e +ormer
desi*n, t,e correct si@e m/st -e c,osen and laced +ar eno/*, -ack in t,e oral ca"ity
to -e ,eld in lace -y t,e +orce o+ t,e Aaws attemtin* to close. Ot,erwise, on clos/re,
t,e ro slides +orward alon* t,e occl/sal s/r+aces o+ t,e teet,. It is not as likely t,at
t,is will occ/r wit, t,e second tye o+ ro -eca/se t,e serrations and *rad/ated si@e
o"er t,e len*t, o+ t,e ro -etter resist slia*e. 4,en /sin* eit,er o+ t,ese ro
tyes, one s,o/ld tie +loss t,ro/*, t,e ,ole in t,e ro and allow t,e +loss to e0tend
+rom t,e atientCs mo/t,. I+ inad"ertent swallowin* o+ t,e ro occ/rs, an occl/ded
airway res/lts. In s/c, an e"ent, t,e ro can -e retrie"ed -y means o+ t,e +loss
li*at/re.
5,e most critical asect o+ lacin* a mo/t, ro is to rotect t,e care*i"erCs +in*ers.
5,ose ros t,at re?/ire t,e +in*ers to cross t,e occl/sal lane as art o+ t,e
lacement rocess ose t,e *reatest Aeoardy o+ -ein* -itten. 5,ere+ore newer de"ices
t,at ,a"e ositionin* conca"ities may -e o+ ,el 7Fi*/re >$-< C8. Anot,er de"ice is
similar to a lar*e t,im-le wit, +lan*es t,at +its o"er t,e t,/m- or one +in*er o+ t,e
care*i"er, +reein* t,e ot,er +in*ers and ,and to sta-ili@e t,e Aaw d/rin* toot, -r/s,in*
or a ro,yla0is 7Fi*/re >$-< 18. 1eca/se t,e atientCs Aaw mi*,t s/ddenly sna
closed /on remo"al o+ a ro, /se o+ t,e *a/@e-wraed ton*/e -lades d/rin*
remo"al o+ any mo/t, ro s,o/ld -e considered.
An alternati"e to t,e *a/@e-wraed ton*/e -lade is a disosa-le, ,and,eld,
Styro+oam mo/t, ro wit, *rad/ated notc,es 7Fi*/re >$-< A8 t,at can -e laced and
controlled e0tra-orally. Anot,er de"ice controlled e0tra-orally is t,e Oen 4ide

4raaro/nd Mo/t, )ro wit, an e0tra-oral ,andle t,at can also -e /sed wit, a
s/ction de"ice 7Fi*/re >$-< D8. It is ossi-le to ,yere0tend t,e mandi-/lar m/scles
wit, an o"ersi@ed mo/t, ro or t,e o"er@ealo/s lacement o+ one. 5,is can ca/se a
m/scle sasm, res/ltin* in considera-le discom+ort to t,e atient. 1ite -locks m/st -e
/sed wit, ca/tion, as t,ey ,a"e -een known to ca/se ,yo0emia.
>(
5,e smaller t,e
atient wit, re*ard to ,ei*,t and wei*,t, t,e *reater t,e risk t,at o0y*en desat/ration
will occ/r w,en -ite -locks are /sed, artic/larly w,en t,e -ite -locks are too lar*e.
Headrests
5,ere are n/mero/s ways o+ s/ortin* and sta-ili@in* t,e ,ead and neck o+
comromised dental atients. For t,ose indi"id/als w,o remain in t,eir con"entional
w,eelc,airs t,ro/*,o/t treatment, a commercially a"aila-le w,eelc,air ,eadrest may
-e /rc,ased and ket in t,e dental o++ice. 5,is ,eadrest attac,es to t,e ,and *ris o+
t,e w,eelc,air and adA/sts to comensate +or di++erent c,air widt,s and sittin* ,ei*,ts
o+ atients.
>;
Ot,er tyes o+ ,ead sta-ili@ers can -e attac,ed to t,e ,eadrest o+ t,e
dental c,air wit, 6elcro stras t,at e0tend aro/nd t,e -ack o+ t,e c,air to sec/re t,e
sta-ili@in* de"ice. )illows desi*ned +or neck s/ort are commercially a"aila-le in
retail stores. 5,ey can -e /sed, wit, modi+ications i+ necessary, +or atients wit,
cer"ical sine de+ormities. A cere-ral alsy ,ead s/ort consists o+ a -lock o+ +oam
wit, a deression in t,e center to sta-ili@e t,e atientCs ,ead.
=$
)illows sold to airlane
tra"elers t,at contain -/ckw,eat ,/lls as t,e +illin* material and are s,aed as
enlar*ed neck collars can also -e /sed to sta-ili@e t,e ,ead and neck o+ a atient
d/rin* re"enti"e roced/res.
So+t 5ies
So+t ties, w,ic, are clot, or so+t leat,er stras, may -e /sed to s/ort and sta-ili@e
any art o+ t,e -ody, incl/din* t,e ,ead.
=:
Most commonly, so+t ties are /sed to
sec/re t,e /er and lower lim-s to an aroriate le* or armrest. 5,is re"ents t,e
lim- +rom sasmin*, +lailin*, or ,an*in* o++ t,e ed*e o+ t,e rest, a osition t,at can
comress ner"es and lead to ne/ral dama*e. So+t ties are not meant to -e /niti"e or
restrainin* de"ices. 5,ey are intended to ro"ide ositi"e s/ort, sta-ility, and
sec/rity to t,e atient.
1ody 4ras and Ot,er .im- Sta-ili@ers
F/ll--ody wras, s/c, as edo-wras and aoose -oards, are o+ten /sed to
immo-ili@e smaller ad/lt atients d/rin* dental treatment.
=:
A lastic el-ow sta-ili@er,
t,at -e*ins as a +lat s,eet and is c/rled into a t/-e aro/nd t,e arm, kees t,e atient
+rom -ein* a-le to -end t,e el-ow to /s, away a care*i"er 7Fi*/re >$-%8. 5,ese
de"ices ,a"e limited /se+/lness in re"enti"e ro*rams w,ere /rose+/l attemts are
-ein* made to acti"ely in"ol"e atients in t,eir own oral ,y*iene. 1ody wras and
sta-ili@ers s,o/ld -e considered w,en ot,ers *i"e care, and t,e atient is /na-le to
cooerate. For some comromised atients +/ll -ody wras are welcomed as a so/rce
o+ sec/rity and com+ort.
=>
Some de"elomentally disa-led atients e0,i-it sel+-inA/rio/s -e,a"ior ca/sin*
si*ni+icant eri-oral tra/ma. Mana*ement o+ t,is -e,a"ior is o+ten di++ic/lt as
restrainin* de"ices alied e0tra-orally are only aroriate d/rin* acti"e treatment
eriods and may not re"ent intra-oral c,ewin* o+ t,e ton*/e andBor lis t,at may
occ/r at any time o+ t,e day or ni*,t. In selected cases, oral aliances can -e
e++ecti"e in re"entin* tra/ma -y de+lectin* tiss/es +rom t,e occl/sal lane.
==
Mo/t, ros, so+t ties, wras, and el-ow sta-ili@ers are all considered +orms o+
restraint, and comm/nities contin/e to str/**le wit, t,e iss/e o+ t,e aroriateness
o+ restraints.
=&
5,e /se o+ restraints is contro"ersial, and eac, A/risdiction may
interret w,at constit/tes restraints di++erently. )ractitioners and care*i"ers s,o/ld
researc, t,eir state and local */idelines -e+ore emloyin* s/c, restraints.
='
5,e intent
to /se any o+ t,ese items s,o/ld -e incl/ded in t,e in+ormed consent ro"ided to t,e
atientCs */ardian.
Fi*/re >$-< A. Oen 4ide
Disosa-le Mo/t, )ro.

c
1. Dental S,ield.
d
C. C-
s,aed mo/t, ro wit, ositionin* conca"ity.
e
D. Oen 4ide
4raarand
Mo/t, )ro
+
wit, e0traoral ,andle and oenin* to accommodate s/ction de"ice.
c
Seciali@ed Care Co., Hamton, NH.
d
At,ena Nordic, Fal/n, Sweden.
e
.o*i 1loc, COMMONS3NS3 Dental )rod/cts, N/nica, MI.
+
Fi*/re >$-% A. !ain-ow 3l-ow g 2nee Sta-ili@er
*
-ein* rolled to +it aro/nd
arm. 1. Formed sta-ili@er in lace.
*
Oral-Hygiene Devices
Modi+yin* 5oot,-r/s, Handles
In *eneral, t,e rinciles and tec,ni?/es o+ toot, -r/s,in* /sed +or a comromised
o/lation are t,e same as +or anyone else. In comromised indi"id/als, ,owe"er,
*ood oral ,y*iene is m/c, more di++ic/lt to ac,ie"e and maintain.
:(
I+ it ,as -een
determined t,at t,e atient ,as ade?/ate de0terity to rod/ce t,e small strokes needed
to -r/s, roerly, a man/al toot,-r/s, may rod/ce satis+actory res/lts. 5oot,-r/s,
man/+act/rers are now ro"idin* a "ariety o+ di++erent con+i*/rations
=<
o+ -r/s,es
wit, increased ,andle dimensions, ,andles modi+ia-le wit, ,ot water 7Fi*/re >$-(8,
an*led -r/s, ,eads, m/ltile -r/s, ,eads, and c/r"ed -ristles, all o+ w,ic, can -e
-ene+icial +or secial needs atients 7Fi*/re >$-;8. One tye o+ -r/s, marketed +or
toddlers is desi*ned wit, a lar*e o"oid ,andle t,at re"ents o"er insertion and
otential intra-oral inA/ry w,en a c,ild is +irst learnin* to -r/s,. S/c, a de"ice may
,a"e alication +or an older comromised c,ild 7Fi*/re >$-:$8. 3"en i+ t,e atient
,as a weakened ,and *ras or /ses ort,otic slints or ot,er adati"e aliances, a
man/al toot,-r/s, can -e modi+ied to +acilitate /sa*e.
=%,=(
In a well-controlled st/dy
o+ c,ildren wit, cere-ral alsy w,o recei"ed modi+ied toot,-r/s,es, la?/e remo"al
was increased -y >( to ='E o"er t,at ac,ie"ed w,en con"entional toot,-r/s,es were
/sed.
=;
Fi*/re >$-:: ill/strates di++erent met,ods o+ ?/ickly a/*mentin* toot,-r/s,
,andles +rom commonly +o/nd materials. 5,ese incl/de +oam wrain*s +rom
ackin* materials, acrylic tray or -ite re*istration material, t,e center +oam iece +rom
a ,air c/rler, a -icycle *ri wit, laster anc,orin* t,e toot,-r/s, inside, or a A/ice can
wit, a slotted -all inside to ,old t,e toot,-r/s,.
>>
Ine0ensi"e, cylindrical, closed-cell
+oam can -e o-tained +rom ort,otic or medical s/ly stores. 5,is +oam cylinder ,as
si*ni+icant ad"anta*es o"er ot,er tyes o+ +oam materials -eca/se it is comosed o+
closed lastic cells t,at s,ed water. 5,is eliminates t,e increase in wei*,t and t,e
need to s?/ee@e o/t a-sor-ed water on comletion o+ a ,y*iene roced/re.
Handles a/*mented wit, +oam can -e /sed -y a wide ran*e o+ comromised
indi"id/als. 5,ey can -e easily adated to ort,otic aliances s/c, as slints. Handles
modi+ied wit, ,ea"ier materials, ,owe"er, s/c, as t,e -icycle *ri or t,e A/ice can,
s,o/ld not -e /sed wit, art,ritics or t,ose wit, ne/rom/sc/lar weaknesses. 5,ese
latter two tyes o+ modi+ications are more aroriately /sed wit, mentally retarded
indi"id/als, incl/din* t,ose wit, Down syndrome, and wit, cere-ral alsy atients
w,o tyically ,a"e stron* *ris and lim- m/sc/lat/re 7see Fi*/re >$-::8.
)atients w,o are /na-le to +le0 t,eir el-ows -eca/se o+ Aoint in"ol"ement can -e
*i"en a toot,-r/s, wit, an e0tended ,andle. 5,is can -e +a-ricated -y insertin* a
-icycle or w,eelc,air soke into, and arallel to, t,e ori*inal toot,-r/s, ,andle and
+a-ricatin* a new acrylic ,andle o/t o+ ort,odontic resin or a similar material. 5,e
,andle may -e +/rt,er modi+ied i+ t,e atient ,as *ras di++ic/lties. Ot,er simle
modi+ications incl/de res,ain* t,e lastic ,andle o+ t,e toot,-r/s, -y ,eatin* it in
warm water and -endin* to t,e desired con+i*/ration or *l/in* t,e ,andle o+ a
nail-r/s, to t,e toot,-r/s, ,andle.
Se"eral de"ices ,a"e -een de"eloed to assist indi"id/als wit, limited +/nction to
ac,ie"e indeendence. O+ten, rod/cts /sed to assist in +eedin* can -e adated +or /se
in -r/s,in* t,e teet,, s/c, as almar c/++s or acti"ities o+ daily li"in* 7AD.8 c/++s.
n
n
An AD. c/++ is a *eneric term +or any kind o+ aliance adated to t,e /er
e0tremity to w,ic, "ario/s imlements can -e added, as, +or e0amle, a toot,-r/s,,
so t,at t,e atient mi*,t er+orm ,is or ,er own daily li"in* tasks wit,o/t assistance.
Fi*/re >$-( Commercially a"aila-le toot,-r/s, wit, ,andle t,at can -e
modi+ied -y immersion in ,ot water.
,
,
S,ae It 5oot,-r/s,, #o,n O. 1/lter Co., C,ica*o, I..
Fi*/re >$-; Commercially a"aila-le toot,-r/s,es desi*ned +or secial needs
atients. Clockwise +rom /er ri*,t9 C/r"ed -ristle -r/s,,
i
small trile -r/s,
,ead,
A
do/-le -r/s, ,ead,
k
and lar*e trile -r/s, ,ead.
l
i
Collis-C/r"e toot,-r/s,, Collis-C/r"e, 1rowns"ille, 5G.
A
SU)3!-1!USH
#/nior, Denta-Co., 1er*en, Norway.

k
action >. Action Hy*iene )rod/cts, Inc., 5oronto.
l
SU)3!-1!USH, Denta-Co., 1er*en, Norway.
Fi*/re >$-:$ 5oot, -r/s, wit, lar*e ,andle to re"ent o"erinsertion.
m
m
INFAN5-5ODD.3! SAF35H 5OO5H1!USH
, )re"enti"e Dental
Secialties, Inc., !ot,sc,ild, 4I.
Fi*/re >$-:: !eadily a"aila-le +oam t/-es, -icycle ,andles, cans, or dental tray
material can -e /sed to modi+y t,e si@e o+ toot,-r/s, ,andles.
Question 3
A. Denti+rices are essential to maintainin* *ood oral-,y*iene care amon* t,e
,andicaed.
1. 1ot, mentally ,andicaed and indi"id/als wit, ne/rom/sc/lar dys+/nction may
need mo/t, ros.
C. 4,en it is necessary to constrain a ne/rom/sc/larly ,andicaed atient, it s,o/ld
-e a non/niti"e action.
D. 5,e aroriateness o+ /sin* -ody wras or edo-wras deends on t,e atientCs
si@e and stat/re.
3. A 1/nsen -/rner +lame is needed to modi+y a toot,-r/s, ,andle.
3lectric 5oot,-r/s,es
3lectric toot,-r/s,es are "al/a-le aids in assistin* comromised atients.
&$
5,ey are
esecially /se+/l w,en t,e atient ,as t,e stren*t, to *ras t,e ,andle and lace t,e
-r/s, in t,e mo/t, -/t does not ,a"e t,e man/al de0terity needed to er+orm t,e +ine
mo"ements necessary +or t,e cleanin* +/nction. 5,e len*t, and diameter o+ t,e ,andle
o+ an electric toot,-r/s, aro0imates t,ose o+ man/al toot,-r/s,es t,at ,a"e -een
modi+ied +or indi"id/als wit, comromised ,and +/nction.
!ecent models o+ electric toot,-r/s,es dislay onBo++ -/ttons t,at are /ser-+riendly.
Unlike re"io/s models, w,ic, ,ad switc,es t,at were di++ic/lt to mani/late,
&:
most
now ,a"e ress/re lates t,at acti"ate t,e -r/s, ,ead and are easy to /se. 5,e wei*,t
o+ t,e electric toot,-r/s, is still a ro-lem +or some indi"id/als to mana*e, esecially
atients wit, oor /er e0tremity m/scle control or stren*t,. 5,is can -e
comensated +or -y ositionin* t,e atient at a ta-le and demonstratin* -r/s,in*
w,ile t,e atientCs el-ows on t,e ta-le are /sed to s/ort t,e increased wei*,t. I+ t,e
atient is in a w,eelc,air, a co/nterto can -e /sed to s/ort t,e toot,-r/s, ,andle
w,ile acti"atin* it 7Fi*/re >$-:>8.
For atients a-le to er+orm t,eir own oral ,y*iene, t,e e++ecti"eness o+ electric
toot,-r/s,es in la?/e remo"al ,as -een well esta-lis,ed. M/c, less ,as -een
accomlis,ed in attemtin* to esta-lis, t,e e++ecti"eness o+ electric toot,-r/s, /se in
comromised atients. Howe"er, one st/dy did comare t,e Interlak
to man/al
toot,-r/s,es in a o/lation o+ ersons wit, mental retardationBde"elomental
disa-ilities 7M!BDD8. 5,ose /sin* t,e Interlak
s,owed si*ni+icant imro"ement in

t,e Gin*i"al Inde0 o"er t,e twel"e mont,s o+ t,e st/dy.
&>
5,e +ew ot,er st/dies
in"ol"e care*i"ers w,o are tyically in t,e dental +ield deli"erin* care to n/rsin*
,ome atients. In one o+ t,e st/dies, la?/e and *in*i"itis le"els were comared a+ter
/se o+ a man/al and an electric toot,-r/s, o+ a co/nter-rotational desi*n wit, t,e care
-ein* deli"ered -y a dental ,y*ienist or dental assistant.
&=
5,e res/lts a+ter t,e /se o+
t,e owered toot,-r/s, were si*ni+icantly imro"ed o"er t,e man/al toot,-r/s,. A
second st/dy comared la?/e remo"al and *in*i"al in+lammation in a *ro/ o+
n/rsin* ,ome atients a+ter /sin* an electric rotary -r/s, wit, a sin*le t/+t o+ -r/s,es
and a man/al toot,-r/s,. 5,e care was deli"ered -y dental st/dents.
&&
5,e electric
toot,-r/s, a*ain e++ected a statistically si*ni+icant imro"ement in t,e two arameters
meas/red.
3"en t,o/*, electric toot,-r/s,es seem to -e indicated +or /se in a mentally
,andicaed o/lation, 1ratel and coworkers
&'
were /na-le to demonstrate clearly
t,e s/eriority o+ electric o"er con"entional toot,-r/s,es w,et,er /sed indeendently
or aided. It may -e t,at electric toot,-r/s,es are -ene+icial +or t,is o/lation,
-eca/se atients and care*i"ers +ind t,em easier and more leasant to /se.
&<
It remains to -e seen w,et,er +eat/res s/c, as smaller -r/s, ,eads, sonic cleanin*
ower, recirocatin* -r/s, ,eads, or a co/nter-rotational desi*n may ,a"e /ni?/e
e++ecti"eness +or t,is o/lation 7Fi*/re >$-:=8.
In selectin* w,ic, toot,-r/s, is -est +or a artic/lar atient, one s,o/ld consider
ali*nment o+ teet, in t,e arc,, constriction o+ t,e arc,es, and w,et,er an e0a**erated
*a* re+le0 is resent.
One additional note o+ ca/tion s,o/ld -e considered -e+ore recommendin* an electric
toot,-r/s, +or a comromised atient. An o"er@ealo/sly /sed electric toot,-r/s, can
ca/se considera-le dama*e to t,e ,ard and so+t tiss/es in a s,ort time.
Floss-Holdin* De"ices
Dental +lossin* is not recommended +or all comromised atients. Unless t,e task o+
toot,-r/s,in* can -e learned, it is /seless to s/erimose t,e more comle0 task o+
+lossin*. 5o do so can -e so disco/ra*in* t,at all attemts at oral ,y*iene are
a-andoned. 5,is is tr/e w,et,er t,e atient or t,e attendant is er+ormin* t,e
ro*ram. Flossin*, t,ere+ore, s,o/ld -e introd/ced on a selecti"e -asis +or t,ose
atients or attendants w,o ,a"e mastered toot,-r/s,in* and consistently s,ow low
la?/e le"els on toot, s/r+aces.
An ade?/ate assessment o+ t,e atientCs de0terity and a-ility to /nderstand t,e
tec,ni?/e m/st -e determined -e+ore +lossin* is introd/ced.
For some comromised atients, +lossin* can -e er+ormed re*/larly i+ a +loss-
,oldin* de"ice is /sed. 3i*,t s/c, de"ices were e"al/ated -y eole wit, /er-
e0tremity limitations.
>:
5,is *ro/ rated one de"ice si*ni+icantly ,i*,er +or its ,andle
dimensions, ease o+ t,readin*, and a-ility to kee t,e +loss ta/t.
r
Alt,o/*, some
comromised atients ,a"e learned adati"e tec,ni?/es allowin* t,em to t,read +loss-
,olders t,emsel"es, t,e maAority o+ comromised atients ,a"e *reat di++ic/lty in
accomlis,in* t,is roced/re. One atient wit, "ery limited /se o+ ,is ,ands
descri-ed ,ow ,is wi+e ket +i"e +loss-,oldin* de"ices t,readed on t,e kitc,en
co/nter +or /se as ,e needed t,em. I+ one -ecame /nt,readed d/rin* a +lossin*
ro/tine, ,e simly o-tained anot,er. An alternati"e to m/ltile +loss-,olders is to
create a laster o+ )aris -ase +or t,e +loss-,oldin* de"ice, so t,at it can -e sta-ili@ed
-y one comromised ,and w,ile t,e ot,er comletes t,e t,readin*. 5,e ,older can
t,en -e /sed wit, or wit,o/t t,e -ase, deendin* on t,e atientCs stren*t,s and
desires. 5,ere are c/rrently on t,e market se"eral -rands o+ +loss ,olders claimin* to
-e sel+-t,readin*. 5,ere ,a"e -een no comarati"e st/dies to determine i+, in +act,
t,ey o++er ad"anta*es to a comromised o/lation. 5,ere+ore, mani/latin* t,e +loss
wit, or wit,o/t a +loss ,older contin/es to -e a -arrier +or t,is o/lation.
r
Floss-Aid Co., Santa Clara, CA.
Interro0imal 1r/s,in*
In older atients, *in*i"al recession is a common e0erience. O+ten t,e recession is so
rono/nced t,at t,e /se o+ re*/lar dental +loss is not e++ecti"e in cleanin* t,e lon*
e0anse o+ e0osed root str/ct/re. In t,is sit/ation some recommend S/er Floss,
s
as
it is considera-ly t,icker at one end. I+ t,e *in*i"al recession ,as occ/rred to t,e
e0tent t,at t,e ailla no lon*er +ills t,e interdental sace, an interro0imal -r/s, may
-e -ene+icial.
&%
Indi"id/als w,o ,a"e ne"er /sed +loss or w,o ,a"e di++ic/lty
mani/latin* t,e dental +loss or t,readin* a +loss ,older seem to adat more readily to
t,e interro0imal -r/s,.
Interro0imal -r/s,in* may -e introd/ced near t,e -e*innin* o+ t,e re"enti"e
ro*ram. 1eca/se ,andles o+ interro0imal -r/s,es are lon* and st/rdy, t,ey can
easily -e modi+ied in t,e same manner as t,e toot,-r/s,. Many interro0imal -r/s,es
re?/ire t,e assem-ly o+ t,e roer -r/s, ,ead to t,e ,andle. 5,is is an intricate task
and re?/ires +ine-motor skills. Additionally, some atients ,a"e se"erely constricted
arc,es re?/irin* /n/s/al access and an*/lation o+ t,e -r/s, ,ead into t,e
interro0imal sace. 5,ere+ore, t,e newer reassem-led interro0imal -r/s,es, t,ose
wit, sna on -r/s, ,eads and t,ose w,ere t,e an*le o+ t,e -r/s, to t,e ,andle can -e
c,an*ed +rom ;$ to :($ are recommended +or comromised atients 7Fi*/re >$-:&8.
Demonstrations o+ assem-ly and /se are de+inite re?/irements.
s
Oral-1 .a-oratories, Inc., 1elmont, CA.
)rost,esis Hy*iene
Comromised atients w,o wear +/ll or remo"a-le artial dent/res may need
assistance wit, maintainin* roer ,y*iene o+ t,e aliances, w,ic, m/st -e remo"ed
+or t,oro/*, cleanin* o+ t,e oral so+t tiss/es and any remainin* nat/ral teet,. 5,e
aliances also m/st -e cleaned aroriately and s,o/ld -e le+t o/t o+ t,e mo/t, +or
< to ( ,o/rs er day. Modi+ications to dent/re-cleanin* de"ices as well as
modi+ications to t,e dent/res may aid in ,elin* comromised atients ro"ide t,eir
own dent/re ,y*iene.
&(
Oral ,y*iene care -y n/rsesC aides in instit/tional settin*s
s,o/ld incl/de remo"al o+ all +/ll or artial dent/res and scr/--in* and soakin* o+
t,ese aliances, as well as t,e care o+ t,e so+t tiss/e and teet,. Dent/res are o+ten lost
in instit/tions -y t,e sta++, as well as -y t,e atients t,emsel"es. As a res/lt, residents
may e0erience di*esti"e comlaints, inade?/ate n/trition, and seec, di++ic/lties, all
o+ w,ic, can contri-/te to a oor sel+-ima*e. 5,ere+ore, it is imortant +or t,e dental
cons/ltant to set / dent/re-identi+ication ro*rams to mark rost,eses wit, t,e
atientCs name, Social Sec/rity n/m-er, or ot,er means o+ identi+ication. 5,en any
mislaced aliances can -e readily ret/rned to t,eir owner.
Ot,er 5yes o+ Oral Hy*iene Aids
From time to time ot,er oral ,y*iene aids are romoted +or /se wit, atients w,o are
in some manner comromised 7Fi*/re >$-:'8. Fre?/ently, t,ese de"ices ,a"e not
/nder*one any testin* rior to t,eir marketin*, -/t are romoted on t,e -asis o+
otential wort,. 4,en or i+ s/c, testin* is accomlis,ed, claims are not always
/,eld. An e0amle o+ s/c, a rod/ct is t,e disosa-le F+oam on a stickF de"ice. In a
st/dy -y Addems and collea*/es,
&;
a-le--odied s/-Aects s,owed marked increases in
la?/e and *in*i"al inde0 scores d/rin* t,e week w,en t,e +oam sticks were /sed
7comared wit, a week w,en con"entional -r/s,in* was er+ormed8.
Anot,er st/dy
'$
+o/nd some e?/ality in remo"in* la?/e wit, t,e +oam sticks in
comarison to a re*/lar toot,-r/s,, -/t it was clear t,at t,e toot,-r/s, was more
e++ecti"e in retardin* la?/e acc/m/lation. Cotton swa-s
0
are +re?/ently /sed +or oral
,y*iene in instit/tionali@ed settin*s. I+ swa-s are /sed t,at contain citric acid,
si*ni+icant dama*e to t,e dentition can occ/r in t,e +orm o+ irre"ersi-le erosion o+ t,e
enamel.
':
In anot,er st/dy -y 2am-,/ and .e"y,
'>
+o/r de"ices were comared +or e++icacy
w,en /sed on a sim/lated deendent care o/lation -y a nonro+essional care*i"er.
An /n/s/al toot,-r/s, wit, c/r"ed -ristles,
y
as well as an electric toot,-r/s, wit, ten
di++erent rotatin* t/+ts o+ -ristles,
@
were more e++ecti"e at remo"in* la?/e t,an a
con"entional toot,-r/s,. A +oam stick de"ice came in a distant +o/rt, in t,e st/dy.
5,e s/-Aects rated t,e c/r"ed--ristle toot,-r/s, as t,e most com+orta-le, and t,e
care*i"er rated it as t,e easiest to /se.
Anot,er de"ice incororates t,ree di++erent sets o+ -r/s, t/+ts an*led aro/nd an arc
into one toot,-r/s, ,ead.
'=
5,is allows t,e +acial, occl/sal, and lin*/al s/r+aces o+
eac, toot, to -e -r/s,ed at t,e same time. Alt,o/*, no di++erence was +o/nd in
la?/e and -leedin* indices w,en t,is -r/s, was /sed in comarison to a re*/lar
man/al toot,-r/s,, it seemed to -e easier to teac, its /se to mentally retarded
indi"id/als. Howe"er, t,is -r/s, con+i*/ration does not work in cases o+ se"ere
*in*i"al recession.
0
Moi-Stir, 2in*swood .a-oratories, Inc., Carmel, IN.
y
Collis-C/r"e 5oot,-r/s,, Collis-C/r"e, 1rowns"ille, 5G.
@
IN53!).A2, 1a/sc, g .om- Oral Care Di"ision, Inc., 5/cker, GA.
Disclosin* 5ec,ni?/es
4,ate"er t,e atientCs a*e, disclosin* rod/cts s,o/ld -e s/**ested to "is/ali@e
la?/e w,en a atient ,as di++ic/lty in la?/e remo"al. Disclosin* sol/tions are
readily a"aila-le o"er-t,e-co/nter in m/ltidose -ottles. !ecently, sin*le-dose
acka*in* o+ disclosin* sol/tion wit, its own cotton-swa- alicator ,as -ecome
a"aila-le and may ro"e ractical +or weekly la?/e remo"al e++ecti"eness c,ecks in
instit/tional settin*s 7Fi*/re >$-:<8. S,o/ld t,e rice o+ disclosin* sol/tion ser"e as a
deterrent t,e cost +actor can -e minimi@ed -y /rc,asin* commercial +ood colorin*,
/s/ally a"aila-le in t,e -akery section o+ any *rocery store. 5,e +ood colorin* can
t,en -e /sed in lace o+ t,e disclosin* sol/tion to stain dental la?/e. 5,e color
s,o/ld -e c,osen on t,e -asis o+ w,ic, is easiest to see in t,e mo/t,. For e0amle,
yellow is di++ic/lt to detect on teet, -eca/se t,e color is too close to t,at o+ nat/ral
toot, color. 1l/e and *reen, alt,o/*, s/ita-le +or teac,in* la?/e control to c,ildren,
are more di++ic/lt +or t,e a*in* eye to see. !ed +ood colorin* is t,e easiest to "is/ali@e
+or all a*e *ro/s. A o/lar color, it can -e +o/nd acka*ed in a n/m-er o+ di++erent
containers, incl/din* indi"id/ali@ed lastic -ottles t,at are m/c, easier to /se. 5wo
dros o+ +ood colorin* s,o/ld -e laced on t,e ton*/e and t,e atient ad"ised to /se
t,e ton*/e to wie t,e +ood colorin* aro/nd all t,e s/r+aces o+ t,e teet, rior to
-r/s,in*. An alternati"e tec,ni?/e w,en t,e atient is /na-le to +ollow t,ese
directions is to ,a"e t,e care*i"er aly t,e +ood colorin* to a cotton swa- and *ently
da- it on t,e teet,. 5,e la?/e is well stained wit, eit,er o+ t,ese met,ods, and, as t,e
"ol/me o+ li?/id /sed is minimal, little droolin* or s/-se?/ent stainin* o+ t,e
indi"id/alCs clot,es occ/rs.
Fi*/re >$-:> A ress/re-acti"ated toot,-r/s, 74ater-)ik8 -ein* /sed -y a
se"erely disa-led indi"id/al.
Fi*/re >$-:= 3lectric toot,-r/s,es. 5o9 m/ltile recirocatin* -r/s, ,ead.
o

Center9 sonic cleanin* -r/s,.
1ottom9 co/nter-rotational desi*n.

?
o
IN53!).A2
, 1a/sc, g .om- Oral Care Di"ision, 5/cker, GA.
Sonicare, ),ilis Oral Healt,care, Sno?/almic, 4A.

?
O!A.GI3N3 USA, Inc., C/l"er City, CA.
Fi*/re >$-:& Interro0imal -r/s, ,andle t,at can accommodate -r/s, at ri*,t
7;$8 or strai*,t 7:($8 an*le.
t
t
)ro0ident ,older. At,ena Nordic, F/lan, Sweden.
Fi*/re >$-:' Oral ,y*iene aids. From to9 swa- on a stick,
/
+oam on sticks o+
"aryin* si@e 7mini+oam stick,
"
+oam sticks wit, lon*er ,andles.
w
8
/
Moi-Stir
, 2in*swood .a-oratories, Inc., Carmel, IN.

"
5OO5H3553
, Hal-rand, Inc., 4illo/*,-y, OH.

w
M3DI-C.3NI
, Seciali@ed Care Co., Hamton, NH.

Fi*/re >$-:< Sin*le dose disclosin* sol/tion wit, cotton swa- alicator.
aa
aa
DISC.OS3
1e/tlic, ),armace/ticals .), 4a/ke*an, I..

Preventive Therapies
Dietary Considerations and Alternati"e !eward Systems
For many comromised atients, +oods ,i*, in s/*ar are distri-/ted t,ro/*,o/t t,e
day as a reward +or ,a"in* -een comliant. S/c, a reward system enco/ra*es
-etween-meal snackin* and increases t,e cons/mtion o+ ,i*,ly cario*enic +oods.
:(

4it, atients w,o ,a"e decreased ne/rom/sc/lar coordination or decreased sali"ary
+low, it may -e di++ic/lt to ade?/ately clear t,e mo/t,.
>$
Food may remain in t,e
-/ccal "esti-/le and -etween t,e teet, /ntil t,e ne0t -r/s,in*. 5o red/ce t,e
cario*enic otential, it is necessary :8 to restrict -etween-meal snackin* and >8 to
limit t,e /se o+ ,i*,ly cario*enic +oods.
>$
I+ sweets are to -e cons/med at all, t,ey
s,o/ld -e resented at mealtime and t,e teet, -r/s,ed immediately a+ter eatin*.
1edtime snacks s,o/ld -e disco/ra*ed.
An alternati"e to a reward system -ased on s/*ary treats
>$
is to resent tokens +or later
redemtion +or ri@es, s/c, as toys, noncario/s +ood, or o/tin*s.
Sealants and Fl/orides
In site o+ t,e normali@ation o+ ,andicaed indi"id/als into t,e mainstream o+
society, it aears t,at t,e non-instit/tionali@ed ,andicaed do not ,a"e as ,i*, a
le"el o+ oral ,ealt, as t,e rest o+ t,e o/lation. 5,e F 7+illed8 "al/e +or t,e DMF
7decayed, missin*, or +illed8 scores is o+ten lower in t,e comromised o/lation,
w,ereas t,e D and M "al/es are ,i*,er t,an in t,e *eneral o/lation.
'&, ''
Alt,o/*,
-ecomin* more common, re"enti"e strate*ies t,at wo/ld really -ene+it t,is
o/lation *ro/ are o+ten not a"aila-le on a re*/lar -asis. 5,e /se o+ sealants and
+l/orides s,o/ld -e considered imortant re"enti"e tec,ni?/es to assist in caries
control +or comromised atients.
''
Sealant alication may -e more di++ic/lt in comromised atients, -eca/se it may -e
more di++ic/lt to control moist/re contamination. Sali"ary oolin* is o+ten seen in
cere-ral alsy and m/sc/lar dystro,y atients, -eca/se t,ey ,a"e swallowin*
di++ic/lties. For t,e s,ort time needed to aly sealants, antisialo*o*/e medications
are /s/ally not indicated. Instead, t,e sealant may -e alied in t,e con"entional
manner /sin* t,e tec,ni?/es to control sali"a +low indicated in C,ater :$. 5o aid in
moist/re control t,e atient s,o/ld -e seated /ri*,t rat,er t,an in a reclinin*
osition.
In a =$-mont, st/dy o+ a readolescent o/lation wit, Down syndrome li"in* in a
,ostel-like *ro/ settin*, t,e alication o+ dental sealants was :$$E e++ecti"e wit, a
sealant retention rate o+ ;%E in re"entin* caries o"er t,e term o+ t,e st/dy.
'<
!e*/lar toical +l/oride alications -y t,e dental sta++ are ,i*,ly imortant +or t,e
comromised dental atient. A new +l/oride-containin* "arnis, de"eloed +or
dentinal ,yersensiti"ity is now a"aila-le as a /nit-dose alication and can -e /sed
as a +l/oride s/lement. It is s/lied in two doses9 >' m. +or rimary dentition and
&$ m. +or mi0ed dentition 7Fi*/re >$-:%8. 5,e two may -e com-ined to +orm a <'
m. dose +or t,e ermanent dentition. Fl/oride "arnis, can -e ?/ickly ainted on and
is e++ecti"e e"en in a moist +ield, a artic/larly imortant c,aracteristic +or some o+
t,e de"elomentally disa-led and mentally retarded o/lation w,o ,a"e a disordered
swallowin* mec,anism and are t,ere+ore /na-le to e++ecti"ely clear t,eir mo/t,s o+
sali"a. For t,e yo/n*er atient, water +l/oridation or ta-lets are essential.
'%
3?/ally
imortant +or t,is o/lation is a ,ome sel+-alied +l/oride ro*ram. Se"eral
e++ecti"e tec,ni?/es are now a"aila-le +or ,ome +l/oride alication, ran*in* +rom
mo/t, rinses to +l/oride *els alied wit, c/stom-made trays. !inses are
contraindicated +or comromised atients w,o cannot e++ecti"ely swis, t,e sol/tion
aro/nd t,eir mo/t,s. Some indi"id/als wit, m/sc/lar dystro,y and some ost-stroke
atients ,a"e an incometent or ,yotonic li seal and cannot kee sol/tions in t,e
mo/t, +or t,e re?/ired eriod. O/r e0erience wit, o++ice-alied +l/oride treatment
deli"ered in a tray re?/irin* t,e atient to kee t,e tray in lace +or a minim/m o+ &
min/tes ,as demonstrated ,ow di++ic/lt it is +or many comromised atients to
cooerate t,at lon*, artic/larly i+ t,ere is an acti"e *a* re+le0. A *el-+illed tray also
stim/lates t,e +low o+ sali"a, w,ic, is o+ten di++ic/lt to con+ine. Neit,er t,e atient
nor t,e care*i"er likes t,e droolin* t,at occ/rs. 5,ere+ore, ,ome-+l/oride treatments
/tili@in* a tray-deli"ery met,od will ro-a-ly not -e s/ccess+/l. An alternati"e ,ome-
+l/oride deli"ery met,od /ses a +oam alicator. In a n/rsin* ,ome o/lation,
Sa/nders and collea*/es
'(
demonstrated t,at t,e le"el o+ +l/oride in sali"a was ,i*,er
= ,o/rs +ollowin* deli"ery -y an intra-oral alicator w,en comared to t,e +l/oride
le"els in sali"a a+ter residents rinsed wit, a +l/oride mo/t,rinse. More indeendent
o/lations may +ind -r/s,-on +l/oride *els easier to /se, -eca/se t,eir alication
takes ad"anta*e o+ an already learned toot,-r/s,in* -e,a"ior. Fl/orides ,a"e -een
s,own to red/ce deminerali@ation and en,ance reminerali@ation.
';
5,ere+ore, -r/s,-
on *el +l/orides s,o/ld -e considered +or /se -y elderly comromised atients,
artic/larly t,ose wit, *in*i"al recession. Fl/orides s,o/ld not, ,owe"er, -e
indiscriminately *i"en to atients +or /ns/er"ised /se i+ some ?/estion e0ists as to
t,e atientCs a-ility to /nderstand and +ollow instr/ctions. Alt,o/*, C,an and
OCDonnell
<$
+o/nd little risk o+ to0icity w,en a +l/oridated toot,- aste was /sed
indeendently -y a o/lation o+ mentally ,andicaed c,ildren, one m/st still
e0ercise ca/tion w,ene"er recommendin* +l/orides.
C,emical )la?/e Control
It ,as -een reco*ni@ed t,at treatments need to -e de"eloed to mana*e la?/e control
t,at are less deendent on t,e man/al de0terity o+ t,e atient.
<:
5,e e++icacy o+
alyin* c,lor,e0idine 7CHG8 -y swa--in* +or eole wit, disa-ilities ,as -een
esta-lis,ed. In one st/dy
<>
CHG was alied -y a care*i"er once daily, +i"e times er
week, +or ten weeks /sin* +oam sticks.
cc
4,en comared wit, alyin* a lace-o -y
swa--in*, t,e CHG *ro/ s,owed consistent and si*ni+icant imro"ement in lower
la?/e le"els, *in*i"itis, and ocket det,s. A s/-se?/ent st/dy
<=
demonstrated t,at
CHG swa--in* was e++ecti"e at a red/ced +re?/ency 7twice er week as oosed to
+i"e times er week8 and was well tolerated wit, rolon*ed /se 7&> weeks8.
Alication o+ s/stained-release "arnis,es o+ CHG and ar*inine also rod/ced
red/ctions in la?/e, calc/l/s, and ocket det,s in a mentally retarded o/lation.
<&

5,e e++ecti"eness o+ a "ery low concentration 7$.$<E8 o+ CHG sray deli"ered -y
care*i"ers was e"al/ated in de"elomentally disa-led atients,
<'
and res/lted in
si*ni+icant imro"ement in la?/e scores. 5,/s, +or se"erely disa-led or mentally
retarded atients, a care*i"er can ro"ide CHG alications -y "ario/s means and
imro"e t,e eriodontal condition. Howe"er, it may not -e ossi-le +or t,ese atients
indeendently to ac,ie"e t,ese ositi"e res/lts as demonstrated in a st/dy comarin*
CHG and an essential oil mo/t, rinse.
<<
cc
5OO5H3553, Hal-rand, Inc., 4illo/*,-y, OH.
Imlant Care +or Comromised )atients
)atients w,o ,a"e -ecome incaacitated s/-se?/ent to ,a"in* dental imlants laced
are at si*ni+icant risk +or oral ,y*iene ro-lems.
<%
Once t,e atient or t,e +amily or
t,e instit/tional sta++ ,as demonstrated t,e le"el o+ oral ,y*iene t,at is attaina-le,
e++orts s,o/ld -e made -y t,e ractitioner to modi+y t,e imlant comle0 to ens/re
cleansi-ility. 5,is s,o/ld not -e done /ntil a+ter a re,a-ilitation ro*ram, i+
warranted, is comleted and it is clear t,at t,e le"el o+ a-ility ,as latea/ed. D/rin*
t,e interim eriod more deendence s,o/ld -e laced on c,emot,erae/tic e++orts to
maintain *ood oral ,ealt, t,an wo/ld -e aroriate to do o"er t,e atientCs remainin*
li+e san.
Ot,er comromised atients may -e well ser"ed -y imlants i+ t,e imlant desi*n
allows +or easy cleanin*. In a case reort o+ a erson wit, cere-ral alsy, t,e /se o+
ma*netic keeers ro"ided a ,i*,ly cleansa-le s/r+ace.
<(
Fi*/re >$-:% Unit-dose alicators o+ +l/oride-containin* "arnis,.
--
--
Ca"ityS,ield OMNII Oral ),armace/ticals, 4est )alm 1eac,, F..
Periodic Preventive Maintenance
Many comromised indi"id/als ,a"e a ,i*,er incidence o+ caries and eriodontal
ro-lems t,an noncomromised atients and, t,ere+ore, t,ey s,o/ld -e seen more
+re?/ently.
<;
5,e timin* o+ re"enti"e maintenance aointments s,o/ld -e
indi"id/ali@ed and s,o/ld re+lect t,e atientCs or care*i"erCs a-ility to er+orm oral
,y*iene roced/res. O+ten, comromised atients are eit,er on +i0ed incomes or ,a"e
limited reso/rces a"aila-le to +inance t,eir dental care. Ot,ers w,o are enrolled in
*o"ernment or ri"ate ins/rance lans may ,a"e more +le0i-ility in roc/rin* dental
care on a re*/lar -asis. Doc/mentation -y t,e dentist o+ t,e atientCs disa-ility and t,e
s/-se?/ent oral ro-lems o+ten assists t,e atient in o-tainin* a more *enero/s
interretation o+ t,e ser"ices co"ered -y t,e t,ird-arty ro"ider. 5,is is artic/larly
tr/e +or *o"ernment lans. For some, t,e cost o+ dental care is ass/med -y t,e
atientCs +amily, w,o reali@e t,e imortance o+ re"enti"e oral care and are ea*er to
see t,e atient -ene+it +rom s/c, treatment. In *eneral, t,e comromised atient ,as
limited reso/rces to e0end on dental care. For t,ese atients, t,e dental clinician may
wis, to consider some inno"ati"e +inancial arran*ements to ay +or re"enti"e
roced/res. For e0amle, it mi*,t -e desira-le i+ a contract co/ld -e esta-lis,ed
w,ere-y t,e atient is -ro/*,t in on a re*/lar ?/arterly sc,ed/le +or ro,yla0is.
3ac, aointment a+ter t,e +irst one is er+ormed +or a red/ced +ee i+ t,e atient
comletes t,e entire series o+ sc,ed/led "isits. Conc/rrent treatment contracts s,o/ld
also -e ne*otiated +or restorati"e care.
Provider Availability
Alt,o/*, comromised c,ildren are /s/ally welcomed in most ediatric dentistry
ractices, it is o+ten di++ic/lt +or t,e similarly a++licted ad/lt atient to +ind dental
ersonnel wit, t,e trainin*, emat,y, and atience needed to deal wit, t,e atientCs
disa-ilities. In reco*nition o+ t,is ro-lem, many dental sc,ools are now ro"idin*
trainin* in secial atient care to c/rrent st/dents as well as to racticin* dentists in
contin/in*-ed/cation co/rses.
%$
5,ese actions s,o/ld increase t,e n/m-er o+ dental
clinicians wit, t,e e0ertise and willin*ness to render secial care.
Dental Care in an Institutional Setting
Many instit/tionali@ed ersons ,a"e oor oral ,ealt,.
%:
It is o+ten conAect/red t,at t,is
is -eca/se residents o+ instit/tions are likely to ,a"e more se"ere disa-ilities t,an
t,ose w,o are disa-led -/t li"e in t,e comm/nity, or t,at t,e oral care o+
instit/tionali@ed o/lations is o+ oorer ?/ality t,an t,ose not instit/tionali@ed. A
recent st/dy e0amined t,e oral-,y*iene ,a-its, *in*i"al -leedin*, +ood diaries, and
oral microor*anisms o+ moderately or se"erely mentally retarded ad/lts -e+ore and /
to >: mont,s a+ter relocatin* into t,e comm/nity +rom an instit/tional settin*.
%>
O+ t,e
oral-,ealt, arameters meas/red, none worsened and some imro"ed, demonstratin*
t,at t,e instit/tional en"ironment does lace t,e comromised atient at *reater risk
+or oor oral ,ealt,.
5,e most common role +or t,e dental ro"ider in an instit/tional settin* is t,at o+
cons/ltant. In t,is caacity, t,e ro"ider ad"ises t,e administration a-o/t t,e dental
needs o+ t,e residents and recommends t,e tye and +re?/ency o+ oral ,y*iene care to
-e deli"ered.
%:, %=
5,e dental clinician s,o/ld e0ect to ro"ide in-ser"ice re"ention-
oriented ed/cational trainin* ro*rams +or t,e n/rsin* sta++. 5,e administration and
t,e sta++ m/st -e ket aware o+ t,e imortance o+ ro/tine oral-,ealt, care.
%&
5,e
administrator o+ a +acility may a*ree to a ro/tine dental-care ro*ram, ro"ided t,at
t,e dentist or dental ,y*ienist trains t,e sta++. 5,is re?/ires an on*oin* trainin*
ro*ram -eca/se o+ +re?/ent t/rno"er o+ n/rsesC aides in s/c, +acilities. 5rainin* aids
may incl/de "ideotae recordin*s o+ t,e imortant asects o+ re"enti"e care. 5,e
dentist s,o/ld articiate in sta++ meetin*s w,en needed. )eriodic e"al/ation o+ t,e
residentsC oral ,y*iene /sin* an esta-lis,ed oral ,y*iene inde0 ,els determine i+
additional in-ser"ice trainin* is needed. A more in+ormed sta++ relati"e to t,e
imortance o+ oral ,y*iene ,as -een s,own to res/lt in -etter oral ,ealt, care +or t,e
residents.
%&
4,en aroriate, t,e residents o+ t,e "ario/s instit/tions s,o/ld -e enco/ra*ed to
articiate in t,eir own oral ,y*iene e++orts. Instr/ction in oral-,y*iene met,ods,
+ollowed -y sta++ s/er"ision and enco/ra*ement, can res/lt in imro"ements in
"ario/s eriodontal indices.
%'
3"en t,e totally disa-led or comatose atient w,o is no lon*er takin* +ood -y mo/t,
-/t is -ein* no/ris,ed "ia a *astric t/-e or intra"eno/s line is s/-Aect to intra-oral
la?/e and calc/l/s acc/m/lation and s,o/ld ,a"e daily oral-,y*iene roced/res
er+ormed. Ironically, it ,as -een s,own t,at, alt,o/*, la?/e acc/m/lates at a-o/t
t,e same rate in t/-e-+ed and normally +ed atients, calc/l/s acc/m/lates +aster in
t/-e-+ed atients.
%<
5,e o-Aecti"es +or oral ,y*iene roced/res +or t,ese atients are
-asically t,e same as +or all atients e0cet t,at more care m/st -e taken, incl/din*
s/c, stes as l/-ricatin* t,e lis o+ t,e atient rior to t,e ,y*iene treatment.
)etrole/m Aelly is an e0cellent, ine0ensi"e l/-ricant t,at kees desiccated lis +rom
-ein* inA/red -y mo/t, ros.
5,e teet, o+ comatose atients s,o/ld -e -r/s,ed in t,e con"entional manner wit, a
so+t--ristled toot,-r/s,. 3dent/lo/s areas s,o/ld -e wied *ently wit, *a/@e or a
disosa-le +oam son*e on a stick, -ot, o+ w,ic, can -e li*,tly moistened. I+ a
mo-ile or central asiratin* system is a"aila-le, a toot,-r/s, can -e /sed t,at ,as
-een man/+act/red wit, an asiratin* t/-e
dd
as a art o+ t,e -r/s, ,ead.
><
S/c, a
de"ice is an aid to controllin* t,e sali"ary secretions in t,e de-ilitated or comatose
atient.
dd
)lak-6ac, 5rademark Medical, Fenton, MO.
Question 4
A. O+ten, t,e intake o+ cario*enic +oods can -e -etter controlled -y a */ardian t,ro/*,
A/dicio/s cookin* t,an -y a comromised atient.
1. Dry-+ield oeration and atient cooeration are t,e two salient re?/irements +or
sealant lacement.
C. Fl/oride denti+rices s,o/ld -e /tili@ed -y all comromised atients.
D. )re"enti"e care, e"en t,o/*, more economic, /s/ally ,as a lower riority t,an
treatment.
3. 5,e n/rsesC aides in instit/tions +or comromised atients are /s/ally well trained
to take care o+ oral-,ealt, needs.
Summary
Indi"id/als wit, ,ysical, medical, mental, or emotional ro-lems o+ten ,a"e a
*reater need +or dental care t,an t,eir ,ealt,y co/nterarts. 5,is may -e -eca/se t,e
disa-ility itsel+ ,as oral mani+estations, -/t more commonly it is -eca/se o+ 7:8 t,e
limited caa-ilities o+ t,e indi"id/al or t,e +amily mem-ers to /nderstand and to
er+orm imortant oral ,y*iene tasks, 7>8 a lack o+ /nderstandin* o+ t,e imortance o+
re"enti"e dental care, and 7=8 an ina-ility to +inance dental care. 4,en a
comromised atient does resent to a dental o++ice, t,e clinician s,o/ld de"elo a
treatment lan t,at em,asi@es re"ention. Assessments s,o/ld -e made o+ t,e
atientCs sensory, co*niti"e, and +/nctional a-ilities and -e /sed to c/stomi@e a
re"enti"e lan. 4,en t,e atient is /na-le to ro"ide ,is or ,er own care, t,e +amily
or an attendant needs to -e ta/*,t t,e aroriate tec,ni?/es.
Seciali@ed e?/iment and easy-to-accomlis, modi+ications o+ con"entional oral
,y*iene de"ices may -e emloyed to ro"ide oral ,y*iene care. Strate*ies s/c, as
s/-stit/tin* a noncario*enic reward system to decrease caries incidence are o+ten
s/ccess+/l. Dental re"enti"e roced/res, s/c, as sealants, +l/orides, and c,emical
la?/e control, s,o/ld -e considered +or eac, atient as art o+ any treatment lan.
5,e raort o+ t,e comromised atient and ,is or ,er +amily wit, t,e dental ,ealt,
ro"ider and t,e entire o++ice sta++ is critical to t,e com+ort and comliance o+ t,e
atient. All mem-ers o+ t,e o++ice sta++ need to con"ey a warm, receti"e attit/de to
t,ese secial atients.
Most instit/tionali@ed indi"id/als ,a"e *reat oral ,ealt, needs. 5,e dentist can lay a
si*ni+icant role in assessin* t,ose needs -y comm/nicatin* recommendations +or a
daily oral care ro*ram to t,e instit/tional administrator. Dentists and dental
,y*ienists can o++er trainin* to t,e n/rsesC aides w,o ro"ide t,at day-to-day care.
For many comromised indi"id/als, t,e retention o+ teet, in a ,ealt,y mo/t,
imro"es mastication and di*estion, as well as ,els maintain an ade?/ate n/tritional
stat/s. 5,e leasin* aest,etics a++orded -y *ood oral ,ealt, ,el eole wit,
disa-ilities to -e more welcomed -y ot,ers. Good re"enti"e care en,ances oneCs sel+-
esteem. For some atients w,o are se"erely comromised, secially adated
aliances may -e re?/ired to maintain oral ,ealt,. Many indi"id/als, -eca/se o+
ne/rom/sc/lar ro-lems, ,a"e di++ic/lty +/nctionin* wit, any tye o+ oral rost,esis.
1eca/se t,e nat/ral dentition ass/mes s/c, an imortant role in t,e total li"in*
en"ironment o+ t,e comromised atient, it is o+ /tmost imortance t,at t,e atient,
care*i"ers, and t,e dental team work to*et,er to ac,ie"e an e++ecti"e re"enti"e oral-
,y*iene ro*ram +or s/c, an indi"id/al.
:. A, C, and Dcorrect.
1incorrect. 5,e atient s,o/ld -e a-le to see t,e dentistCs +ace to -etter /nderstand
and to note t,e dentistCs -ody lan*/a*e.
>. 1 and 3correct.
Aincorrect. !emem-er, do not *enerali@e on w,at a atient mi*,t do -eca/se o+ a
,andicain* conditionD t,ere are always e0cetions to t,e r/le.
Cincorrect. Directions *i"en to t,e ,andicaed, esecially mentally ,andicaed,
s,o/ld -e as simle as ossi-le to *et t,e Ao- done.
Dincorrect. A ,ands,ake can determine ,and stren*t, -/t does not assess de0terity
or co*nition necessary to er+orm oral ,y*iene.
=. 1, C, and Dcorrect.
Aincorrect. It is t,e -r/s, -ristles t,at dist/r- t,e la?/enot t,e denti+rice.
3incorrect. 6ery ,ot water is s/++icient to so+ten a toot,-r/s, ,andle rior to
modi+ication.
&. A, 1, and Dcorrect.
Cincorrect. Fl/oride denti+rices are desira-le +or t,ose w,o ,a"e control o+ t,eir
oral m/sc/lat/reD ot,erwise, /ndesira-le droolin* or swallowin* o+ t,e denti+rice
occ/rs. Ot,er met,ods o+ alication o+ +l/oride, ,owe"er, s,o/ld always -e
considered.
3incorrect. 5,e ,i*, t/rno"er o+ n/rsesC aides does not ermit t,e de"eloment o+ a
*ood teac,in* ro*ram.
:. A de+inition o+ a comromised indi"id/al is iiiiiiii. 1e+ore initiatin* any
re"enti"e ro*ram, it is necessary to e"al/ate a ran*e o+ +/nctional, iiiiiiii.
intellect/al, and iiiiiiii caa-ilities.
>. A atient may ,a"e a simle decrease in "is/al ac/ity, w,ic, can -e noted w,en t,e
atient -e*ins to iiiiiiii. I+ a ,/man */ide or */ide do* accomanies t,e atient,
t,ey 7s,o/ld8 7s,o/ld not8 -e allowed in t,e treatment room. Ot,er "is/al ro-lems
are iiiiiiii and iiiiiiii.
=. 5,ree reca/tions t,at s,o/ld -e taken to ens/re t,at instr/ctions are resented wit,
ma0im/m e++ecti"eness to a erson wit, loss o+ ,earin* are iiiiiiii, iiiiiiii, and
iiiiiiii. 4,en a ,i*,-seed ,andiece is t/rned on ne0t to a ,earin* aid, it is
/ncom+orta-le +or t,e atient -eca/se iiiiiiii.
&. )atients wit, a ,istory o+ re"io/s iiiiiiii o+ten ,a"e di++ic/lty in seakin*. In
)arkinsonCs disease, m/ltile sclerosis, and A.S, t,ere is o+ten an imairment o+
seec,, called iiiiiiii. A se"ere imairment in t,e word se?/ence in seakin* is
termed iiiiiiii. 4,en seec, imairment and -ody aralysis occ/r,
comm/nication can sometimes -e accomlis,ed -y /se o+ iiiiiiii 7de"ice8.
'. 5,e -est way to determine t,e Ij o+ a atient is to iiiiiiii. I+ a ,ome-o/nd
atient cannot comlete a task, t,e iiiiiiii 7erson8 s,o/ld -e *i"en t,e
resonsi-ility o+ ,elin*.
<. A simle test to determine ,and m/scle stren*t, is iiiiiiii. 5o determine
w,et,er a atient ,as t,e co*niti"e and syc,omotor a-ility to /se a toot,-r/s,, t,e
easiest met,od is to iiiiiiii.
%. One osition t,at a care*i"er mi*,t take in -r/s,in* t,e teet, o+ a comromised
indi"id/al is iiiiiiii. 5wo disad"anta*es o+ /sin* toot,aste are iiiiiiii and
iiiiiiii.
(. 5wo mo/t, ros are t,e iiiiiiii and t,e iiiiiiii. O+ t,ese, t,e iiiiiiii
needs to -e sec/red wit, a iece o+ dental +loss to re"ent its -ein* swallowed, w,ile
t,e second, t,e iiiiiiii ro, can ca/se an o"eroenin* o+ t,e mo/t,.
;. At least t,ree modi+ications o+ a toot,-r/s, are iiiiiiii, iiiiiiii, and
iiiiiiii. 3lectric toot,-r/s,es can -e /sed -y se"erely weakened atients -y
iiiiiiii. One ro-lem t,at mi*,t -e e0erienced a+ter comromised atients -e*in
/sin* an electric -r/s, is iiiiiiii. 5,e iiiiiiii -r/s, is o+ten con"enient +or
cleanin* t,e interro0imal em-ras/res.
:$. A *ood s/-stit/te +or commercially a"aila-le disclosants is iiiiiiii.
::. )atients wit, tro/-le in walkin* need eit,er anot,er erson as an iiiiiiii to
,el or a w,eelc,air.
:>. !eward systems s,o/ld not incl/de iiiiiiii. In lacin* sealants, t,e two key
+actors to s/ccess are iiiiiiii and iiiiiiii. In a n/rsin* ,ome, it is t,e iiiiiiii
or t,e iiiiiiii w,o normally cond/cts in-ser"ice trainin* +or n/rsesC aides. 5o a"oid
t,e loss o+ dent/res in a n/rsin* ,ome, it is desira-le to iiiiiiii 7action8.
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=$. Sinykin, S. 7#an-Fe- :;(&8. 5,e dental assistant and t,e secial atient. Dent
ssist, >&-><.
=:. Hylin, D. 7:;(&8. )ositionin* o+ t,e cere-ral alsy atient to +acilitate dental
treatment. Texas Dent ", :$:9&-'.
=>. Skle-inski, G. 7#an-Fe- :;(&8. Di++erent strokes. Dent ssist, '=9><->%.
==. Saem/ndsson, S. !., g !o-erts, M. 4. 7May-#/ne :;;%8. Oral sel+-inA/rio/s
-e,a"ior in t,e de"elomentally disa-led9 !e"iew and a case. " Dent for Children,
9B7=89 >$'-;.
=&. Connick, C., )alat, M., g )/*liese, S. 7>$$$8. 5,e aroriate /se o+ ,ysical
restraint9 Considerations. " Dent for Children, 9D 7&89 >'<-<>.
='. Connick, C., g 1arsley, !. 7:;;;8. Dental ne*lect9 De+inition and re"ention in
t,e .o/isiana De"elomental Centers +or atients wit, M!DD. Special Care
Dentistry , :;7=89:>=->%.
=<. Mandel, I. D. 7:;;=8. 5,e la?/e +i*,ters9 C,oosin* a weaon. " m Dent ssoc,
:>&9%:-%&.
=%. Dickinson, C., g Millwood, #. 7:;;;8. 5oot,-r/s, ,andle adatation /sin*
silicone imression /tty. Dent Update, ><9>((-(;.
=(. Ar-laster, D. G., !ot,well, ). S., g 4,ite, G. 3. 7:;('8. A toot,-r/s, +or atients
wit, imaired man/al de0terity. #r Dent ", :';9>:;->$.
=;. Soncini, #. A., g 5samtso/ris, A. 7:;(;8. Indi"id/ally modi+ied toot,-r/s,es and
imro"ement o+ oral ,y*iene and *in*i"al ,ealt, in cere-ral alsy c,ildren. "
Pedodontics, CA 7&89 ==:-&&.
&$. Grat@er, ). 7:;(>8. 3lektrisc,e @a,n+le*e -eim me,r+ac,-eninderten kind.
Reha4ilitation, >:9%=-%'.
&:. M/lli*an, !. 7:;($8. Desi*n c,aracteristics o+ electric toot,-r/s,es imortant to
,ysically comromised atients. " Dent Res, ';9A%=:.
&>. Carr, M., Sterlin*, 3., g 1a/c,moyer S. 7:;;%8. Comarison o+ t,e Interlak
and man/al toot,-r/s,es in a o/lation wit, mental retardationBde"elomental
disa-ilities 7M!BDD8. Special Care Dent, CD 7'89 :==-=<.
&=. 1la,/t, ). 7:;;=8. A clinical trial o+ t,e IN53!).A2 owered toot,-r/s, in a
*eriatric o/lation. Comp Cont !d Dent, 7S/l. No :<89S<$<-S<:$.
&&. 1la,/t, )., g Heisc,, .. 7:;;:8. Clinical e"al/ation o+ an electric oral ,y*iene
de"ice in a *eriatric o/lation. " Dent Res, %$9=<<.
&'. 1ratel, #., 1er**ren, U., g Hirsc,, #. M. 7:;((8. 3lectric or man/al toot,-r/s,e A
comarison o+ t,e e++ects on t,e oral ,ealt, o+ mentally ,andicaed ad/lts. Clin Prev
Dent, C: 7=89 >=-><.
&<. 1ratel, #., g 1er**ren, U. 7:;;:8. .on*-term oral e++ects o+ man/al or electric
toot,-r/s,es /sed -y mentally ,andicaed ad/lts. Clin Prev Dent, CA 7&89'-%.
&%. M/lli*an, !. 7:;(&8. )re"enti"e care +or t,e *eriatric dental atient. Calif Dent
ssoc, C<7:89>:-=>.
&(. 2amen, S. 7:;;%8. Oral ,ealt, care +or t,e stroke s/r"i"or. California Dental
ssoc, <> 7&89>;%-=$=.
&;. Addems, A., 3stein, #. 1., DamAi, S., g Sinelli, #. 7:;;>8. 5,e lack o+ e++icacy
o+ a +oam -r/s, in maintainin* *in*i"al ,ealt,9 A controlled st/dy. Special Care
Dent, C< 7=89:$=-<.
'$. .e+ko++, M. H., 1eck, F. M., g Horton, #. 3. 7:;;'8. 5,e e++ecti"eness o+ a
disosa-le toot, cleansin* de"ice on la?/e. " Periodontol, <<9>:(->:.
':. Me/rman, #. H., Sor"ari, !., )elttari, A., !ytomaa, I., Franssila, S., g 2roon, ..
7:;;<8. Hosital mo/t,-cleanin* aids may ca/se dental erosion. Special Care Dent,
:<7<89>&%-'$.
'>. 2am-,/, )., g .e"y, S. 7:;;=8. An e"al/ation o+ t,e e++ecti"eness o+ +o/r
mec,anical la?/e-remo"al de"ices w,en /sed -y a trained care-ro"ider. Special
Care Dent, CA 7:89;-:&.
'=. Sa/"etre, 3., !o@ow, A., deMeel, H., !ic,e-e, A., A-i-2,alil, M., g Deme/re, F.
7:;;'8. Comarison o+ t,e clinical e++ecti"eness o+ a sin*le and a trile-,eaded
toot,-r/s,es in a o/lation o+ mentally retarded atients. #ull 0roup /nt Rech Sci
Stomatol et +dontol, AF 7=-&89::'-:;.
'&. .i@aire, A. .., 1orkent, A., g 5oor, 6. 7:;(<8. Dental ,ealt, stat/s o+
nondeendent c,ildren wit, ,andicain* conditions in 3dmonton, Al-erta. Special
Care Dent, 9 7>89%&-%;.
''. Nowak, A. #. 7:;(&8. Dental disease in ,andicaed ersons. Special Care Dent,
B 7>89 <<-<;.
'<. S,aira, #., g Sta-,ol@, A. 7:;;<8. A comre,ensi"e =$-mont, re"enti"e dental
,ealt, ro*ram in a re-adolescent o/lation wit, DownCs syndrome9 A lon*it/dinal
st/dy. Special Care Dent, C9 7:89==-=%.
'%. Swallow, #., g Swallow, 1. 7:;($8. Dentistry +or ,ysically ,andicaed c,ildren
in t,e International Hear o+ t,e C,ild. /nt Dent ", A: 7:89:-:'.
'(. Sa/nders, !. H., Da"illa, C. 3., Hayes, A. .., F/, #., g Iero, D. 5. 7:;;&8. 5,e
e++ecti"eness o+ son*e-tye intraoral alicators +or alyin* toical +l/orides in
instit/tionali@ed older ad/lts. Special Care Dent, CB 7<89>>&->(.
';. S,annon, I. .., g 3dm/nds, 3. #. 7:;($8. !eactions o+ toot, s/r+aces to t,ree
+l/oride *els. &. Dent ", &<9&><, &>(-=$.
<$. C,an, #. C. H., g OCDonnell, D. 7:;;<8. In*estion o+ +l/oride denti+rice -y a *ro/
o+ mentally ,andicaed c,ildren d/rin* toot,-r/s,in*. Euint /ntl,, <D 7<89&$;-::.
<:. Newman, H. N. 7:;;(8. 5,e rationale +or c,emical adA/ncts in la?/e control. /ntl
Dent ", BF7= S/l :89>;(;-=$&.
<>. Stie+el, D. #., 5r/elo"e, 3. .., C,in, M. M., g Mandel, .. S. 7:;;>8. 3++icacy o+
c,lor,e0idine swa--in* in oral ,ealt, care +or eole wit, se"ere disa-ilities. Special
Care Dent, C< 7>89'%-<>.
<=. Stie+el, D. #., 5r/elo"e, 3. .., C,in, M. M., I,/, G. C., g .ero/0, 1. G. 7:;;'8.
C,lor,e0idine swa--in* alications /nder "ario/s conditions o+ /se in re"enti"e
oral care +or ersons wit, disa-ilities. Special Care Dent, C> 7&89:';-<'.
<&. S,aira, #., S*an-Co,en, H. D., Sta-,ol@, A., Sela, M. N., Sc,/rr, D., g
Go/ltsc,in, #. 7:;;&8. Clinical and micro-iolo*ical e++ects o+ c,lor,e0idine and
ar*inine s/stained-release "arnis,es in t,e mentally retarded. Special Care Dent,
CB 7&89:'(-<=.
<'. Steelman, !., Holmes, D., g Hamilton, M. 7:;;<8. C,lor,e0idine sray e++ects on
la?/e acc/m/lation in de"elomentally disa-led atients. " Clinical Pediatric Dent,
<: 7&89 ===-=<.
<<. Mc2en@ie, 4. 5., For*as, .., 6ernino, A. !., )arker, D., g .imestall, #. D.
7:;;>8. Comarison o+ a $.:>E c,lor,e0idine mo/t,rinse and an essential oil
mo/t,rinse on oral ,ealt, in instit/tionali@ed, mentally ,andicaed ad/lts9 One year
res/lts. " Periodontol, <=9:(%-:;=.
<%. 3n*lis,, C. 3. 7:;;'8. Hy*iene, maintenance, and rost,odontic concerns +or t,e
in+irm imlant atient9 Clinical reort and disc/ssion. /mplant Dent, &9:<<-%>.
<(. !o*ers, #. O. 7:;;'8. Imlant-sta-ili@ed comlete mandi-/lar dent/re +or a atient
wit, cere-ral alsy. Dent Update, >=-><.
<;. 4at,en, 4. 7:;(&8. Geriatric Dentistry. Tex Dent ", C:C7<89=.
%$. 5,orton, #. 7:;(=8. Dentistry and t,e ,andicaed c,ild. la " %ed Sci, <: 7:89>>-
>%.
%:. .an*e, 1., Cook, C., D/nnin*, D., Froesc,le g 2ent, D. 7>$$$8. Imro"in* t,e
Oral Hy*iene o+ Instit/tionali@ed Mentally !etarded Clients. " Dent Hy$iene, DB 7=89
>$'-;.
%>. Ga-re, )., 4ikstrom, M., Martinsson, 5., g Ga,n-er*, .. 7>$$$8. Mo"e o+ ad/lts
wit, mental retardation +rom instit/tions to comm/nity--ased li"in*9 c,an*es in t,e
oral micro-iolo*ical +lora. " Dental Research, F:7>89&>:-><.
%=. j/inn, M. #. 7:;((8. 3sta-lis,in* a re"enti"e dentistry ro*ram in a lon* term
,ealt, care instit/tion. 0erodontics, &9:<'-<%.
%&. Fa/lks, D., g Henne?/in, M. 7>$$$8. 3"al/ation o+ a lon*-term oral ,ealt,
ro*ram -y carers o+ c,ildren and ad/lts wit, intellect/al disa-ilities. Special Care
Dent, <: 7'89 :;;->$(.
%'. S,aw, M. #., g S,aw, .. 7:;;:8. 5,e e++ecti"eness o+ di++erin* dental ,ealt,
ed/cation ro*rammes in imro"in* t,e oral ,ealt, o+ ad/lts wit, mental ,andicas
attendin* 1irmin*,am ad/lt trainin* centers. Community Dent Health, F 7>89:=;-&'.
%<. Dicks, #. .., g 1annin*, #. S. 7:;;:8. 3"al/ation o+ calc/l/s acc/m/lation in t/-e-
+ed mentally ,andicaed atients9 5,e e++ects o+ oral ,y*iene stat/s. Special Care
Dent, ::7=89:$&-<.
reser"ed.
Chapter 21. Geriatric Dental Care - "anet , .ello3it1 %ichael S, Strayer
Objectives
:. Descri-e t,e demo*ra,ic c,an*es associated wit, t,e U.S. o/lation <' years
and older since :;$$, and ,ow t,is se*ment o+ t,e o/lation will aear in >$'$.
>. Comare key a*e-related ,ysiolo*ic c,an*es commonly +o/nd in older ad/lts wit,
disease related c,an*es.
=. Identi+y t,e most re"alent c,ronic diseases +o/nd in t,e elderly o/lation.
&. Descri-e t,e co*niti"e imairments *enerally associated wit, t,e older ad/lt
o/lation.
'. Comare ,ow atterns o+ oral-,ealt, stat/s ,a"e c,an*ed since :;%$, and ,ow oral-
,ealt, stat/s will c,an*e amon* older ad/lts -y >$=$.
<. Identi+y t,e t,ree key oral disease rocesses commonly +o/nd in older ad/lts.
Introduction
D/rin* t,e latter ,al+ o+ t,e >$t, cent/ry, t,e a*e comosition o+ t,e o/lation
c,an*ed dramatically, wit, more eole li"in* to older a*es and t,e older o/lation
*ettin* older. 5,is demo*ra,ic c,an*e will ,a"e a maAor imact on t,e deli"ery o+
*eneral and oral-,ealt, care, as well as on t,e ro"iders o+ t,ese ser"ices. Alt,o/*,
some older ad/lts ,a"e ,ysical andBor syc,olo*ical conditions t,at re?/ire secial
attention in t,e dental o++ice settin*, one s,o/ld not ass/me t,at all older eole s,are
t,ese conditions. Het, t,e *reatest c,allen*es in *eriatric care +oc/s on t,e oldest,
sickest, +railest, as well as t,ose wit, m/ltile medical andBor syc,olo*ical
ro-lems.
:
In order to -e -est reared +or t,e +/t/re ractice o+ dentistry, oral-,ealt,
ro+essionals need to -e knowled*ea-le a-o/t t,e *eneral and oral-,ealt, stat/s o+
older ad/lts, t,e ,ysical c,an*es associated wit, a*in*, and ,ow -est to otimally
address t,ese iss/es.
5,e FelderlyF se*ment o+ t,e o/lation is di"erse and ,as -een s/-di"ided into t,e
+ollowin* cate*ories9
:. )eole a*ed <' to %& years are t,e ne3 or youn$ elderly w,o tend to -e relati"ely
,ealt,y and acti"eD
>. )eole a*ed %' to (& years are t,e old or mid2old, w,o "ary +rom t,ose -ein*
,ealt,y and acti"e to t,ose mana*in* an array o+ c,ronic diseasesD
=. )eole (' years and older are t,e oldest2old, w,o tend to -e ,ysically more +rail.
5,is last *ro/ is t,e +astest-*rowin* se*ment o+ t,e older ad/lt o/lation.
Alt,o/*, t,e elderly ,a"e traditionally -een de+ined -y as t,ose o"er a*e <' years,
a*e %' may -e a more aroriate a*e to consider, allowin* +or some +le0i-ility to
acco/nt +or t,e many "ariations +o/nd in t,is o/lation.
Demographic Trends
5,e >$t, cent/ry ,as -een e0eriencin* an /nrecedented F*rayin* o+ AmericaF
75a-le >:-:8.
>,=
5oday, ='K million Americans or one in ei*,t are a*e <' or older,
comared to only =.: million eole at t,e t/rn o+ t,e cent/ry. Since :;;$, t,e
o/lation <'K years increased :$.<E, comared to an increase o+ ;.:E +or t,e
/nder-<' o/lation.
>
5,e older o/lation is also *ettin* older. Comared to t,e
o/lation in :;$$, in :;;; t,e <' to %& a*e *ro/ 7:(.> million8 was ( times lar*er,
t,e %' to (& *ro/ 7:>.: million8 was :< times lar*er and t,e ('K *ro/ 7&.> million8
was =& times lar*er, t,/s makin* t,e ('K o/lation t,e +astest-*rowin* co,ort o+
-ot, older ad/lts and t,e o/lation as a w,ole.
1y >$=$, t,ere will -e a-o/t %$ million older ersons, more t,an twice t,eir n/m-er
in :;;;. !eresentin* :=E o+ t,e o/lation in >$$$, t,e <'K o/lation is e0ected
to *row to -e >$E in >$=$. In addition, t,e n/m-er o+ centenarianseole at least
:$$ years oldalmost do/-led in t,e ast decade.
Alt,o/*, t,is *rowt, attern o+ t,e a*in* o/lation slowed down d/rin* t,e :;;$s,
-eca/se o+ t,e decrease in t,e -irt, rate d/rin* t,e :;=$sC Deression, a raid increase
is e0ected -etween t,e years >$:$ and >$=$, w,en t,e F-a-y -oomersF will reac,
a*e <'. 1y >$=$, t,e <'K o/lation will rise to close to >$E o+ t,e o/lation.
>
3t,nic and minority o/lations are also roAected to increase d/rin* t,is cent/ry,
wit, t,e n/m-er o+ Hisanic-American and Asian-American o/lations to increase
s/-stantially -y >$'$. Minority o/lations are roAected to reresent >'.&E o+ t,e
elderly o/lation in >$=$, an increase +rom :<.:E in :;;;. 1etween :;;; and >$=$,
t,e w,ite o/lation is roAected to increase -y (:E comared to >:;E +or older
minorities, incl/din* Hisanic-Americans 7=>(E8, A+rican-Americans 7:=:E8,
American Indians, 3skimos and Ale/ts 7:&%E8, and Asians and )aci+ic Islanders
7>('E8. 5,ese dramatic o/lation c,an*es will contin/e to alter t,e a"aila-ility and
deli"ery o+ *eneral andBor oral ,ealt, care.
Life Span/Life Expectancy
.i+e san is *enerally de+ined as t,e ma0imal len*t, o+ li+e otentially ossi-let,e
a*e -eyond w,ic, no one can e0ect to li"e. H/man -ein*s ,a"e a li+e san o+
aro0imately :>$ years. .i+e e0ectancy is t,e a"era*e n/m-er o+ years a *ro/ o+
indi"id/als -orn d/rin* t,e same time eriod or co,ort is e0ected to li"e. 1etween
:;$$ and :;;%, li+e e0ectancy at -irt, increased +rom &<.= years to %=.< years +or
males, and +rom &(.= to %;.& +or +emales.
&
7See 5a-le >:->A and >:->1.8 .i+e
e0ectancy also increased +or t,e <'-year and older co,ort, +rom ::.; years in :;$$ to
:%.% years in :;;% 75a-le >:->A and >:->18.
&
5,ese increases in li+e e0ectancy are
rimarily ca/sed -y ad"ances in medical tec,nolo*y, and en"ironmental and /-lic-
,ealt, meas/res. 5,e increase in t,e o/lation %' and (' years and older is o+
artic/lar concern to ,ealt,-care ro"iders, since t,is a*e *ro/ tends to resent wit,
t,e ,i*,est +re?/ency o+ ,ysical and co*niti"e disorders.
As t,e o/lation a*es, t,e distri-/tion o+ older ad/lts "aries *reatly -y *ender. At
a*e '', t,ere are aro0imately :$$ +emales +or e"ery :$$ malesD at a*e <' t,ere are
aro0imately :>> +emales +or e"ery :$$ malesD w,ereas at a*e (', t,ere are >';
+emales +or e"ery :$$ males. 5,/s, as t,e si@e and roortion o+ elderly increases in
t,e +/t/re, +emales will contin/e to o/tn/m-er males in t,e older a*e *ro/s.
Marital Status
Marital conditions and li"in* arran*ements o+ older ersons "ary tremendo/sly -y
*ender. Most men send t,eir later years married and in +amily settin*s, w,ereas most
older women send t,eir later years as widows o/tside o+ +amily settin*s. 5,is
sit/ation is rimarily -eca/se most women marry older men, women ,a"e a lon*er
li+e e0ectancy, and t,/s o/tli"e t,eir so/ses. In addition, widowed or di"orced men
*enerally remarry rat,er t,an contin/e to li"e alone. Older widowed men ,a"e a
remarria*e rate t,at is o"er ei*,t times ,i*,er t,an older widowed women.
'
Living Arrangements
Alt,o/*, aro0imately one-t,ird o+ t,e elderly li"e alone, t,e maAority o+ older non-
instit/tionali@ed ad/lts li"e in a +amily settin*. Howe"er, t,ese +i*/res "ary -y *ender
and ad"ancin* years. Most men %' years and older li"e wit, t,eir so/ses or ot,er
+amily mem-er, comared to less t,an '$E o+ t,e women in t,is a*e *ro/. Alt,o/*,
only a small ercenta*e 7&.'E8 o+ t,e <'K o/lation li"ed in a n/rsin* ,ome in :;;%,
t,e ercenta*e increases dramatically wit, a*e, ran*in* +rom :.:E +or ersons <'-%&
years to &.'E +or ersons %'-(& years and :;E +or ersons ('K years o+ a*e.
<
Question 1
A. 5,e new-elderly today are older t,an t,e new-elderly o+ yesteryear.
1. 5,e oldest-old are dyin* o++ too +ast to -e a si*ni+icant economic and ,ealt,
ro-lem +or t,e ta0ayers.
C. 5,e ercenta*e increase in w,ite o/lation o"er t,e ne0t t,ee decades will
o/tn/m-er eac, o+ t,e +ollowin* et,nic and c/lt/ral *ro/s9 Asian and )aci+ic
Islanders, A+rican-American, Hisanic-American, A+rican-American and American
Indian, 3skimo, and Alaskan Ale/t.
D. At a*e (', t,ere are more sin*le men t,an sin*le women.
3. 5,e maAority o+ indi"id/als o"er (' li"e in n/rsin* ,omes.
Education
5,e ed/cational le"el o+ t,e older o/lation is increasin*. 1etween :;%$ and :;;;,
t,e ercenta*e o+ older ad/lts ,a"in* comleted a ,i*, sc,ool ed/cation rose +rom
>(E to <(E. 5,is *ro/ "aried considera-ly -y race and et,nic ori*in, wit, %=E o+
w,ites, <(E o+ Asians and )aci+ic Islanders, &'E o+ A+rican Americans and =>E o+
Hisanics.
>
In s/mmary, elderly o+ t,e +/t/re will -e older, -etter ed/cated, ,a"e -etter control o+
t,eir +inances, incl/de more +emales, and ,a"e more minorities t,an e"er -e+ore. 4it,
t,ese c,an*es, t,e elderly o+ t,e +/t/re will -e si*ni+icantly di++erent t,an todayCs
elderly o/lation.
Healt, Stat/s
5,e st/dy o+ a*in* incl/des not only diseases t,at ca/se mor-idity and mortality -/t
also t,e conditions t,at ca/se disa-ility and decline in indeendent +/nctionin*. 5a-le
>:-=
%
lists t,e most common ca/ses o+ deat, amon* elderly eole in t,e United
States, and 5a-le >:-&
%
lists t,e most common c,ronic conditions e++ectin* ad/lts in
di++erent a*e *ro/s.
%
5,e t,ree leadin* ca/ses o+ deat, in t,e elderly are9 diseases of
the heart, mali$nant neoplasm 7cancer8 and cere4rovascular disease 7stroke8.
3liminatin* deat,s ca/sed -y ,eart disease wo/ld add an a"era*e o+ ' years to li+e
e0ectancy at a*e <' and wo/ld lead to a marked increase in t,e roortion o+ older
ersons in t,e o/lation.
(
Het, i+ cancer as a ca/se o+ deat, were eliminated, t,e
a"era*e li+e san wo/ld -e e0tended -y less t,an > years.
5,e most common c,ronic conditions are art,ritis, ,earin* imairment, ,yertension
and ,eart disease. 5,e maAority o+ ,ealt, conditions and diseases are t,e res/lt o+ t,e
acc/m/lation o+ onesC li+estyle, *enetic +actors and en"ironmental conditions.
For many older Americans, c,ronic disease is a +act o+ li+eD ,owe"er, most older
ad/lts ercei"e t,emsel"es in a ositi"e manner. Aro0imately ($E o+ t,e elderly
,a"e at least one c,ronic medical condition. Het, almost %:E o+ non-instit/tionali@ed
older ad/lts descri-e t,eir *eneral ,ealt, to -e e0cellent, "ery *ood or *ood,
comared wit, ot,ers t,eir a*e.
&
),ysiolo*ic C,an*es Associated wit, A*in*
),ysiolo*ic c,an*es ,a"e a c/m/lati"e e++ect as t,ey relate to t,e contin//m o+
-iolo*ic, syc,olo*ic, social, and en"ironmental rocesses o+ a*in*. Many o+ t,e
de+icits traditionally t,o/*,t to -e associated wit, a*in* are act/ally si*ns o+
at,olo*ic rocesses. C,an*es occ/r +or all eole, tiss/es, and or*ans, ,owe"er t,ese
c,an*es occ/r wit, di++erin* rates and indi"id/al "aria-ility. 6ariations occ/r at e"ery
a*e and in e"ery art o+ t,e -ody. Since many internal c,an*es can mimic disease
mani+estations, and normal c,an*es can mask si*ns o+ disease rocesses, it is "ery
imortant +or t,ose w,o care +or t,e a*ed to -e knowled*ea-le a-o/t t,e c,an*es t,at
do occ/r wit, a*in*, rat,er t,an identi+yin* c,an*es eit,er as at,olo*ic or associated
wit, t,e a*in* rocess.
;
5,e +o/r c,aracteristics o+ ,ysiolo*ic a*in* are9 universal,
pro$ressive, decremental, and intrinsic,
5,e determinants o+ a*in* are comle0, and incl/de en"ironmental e0os/res,
*enetics, li+estyle, and ,ysiolo*ic and syc,olo*ical +actors. ),ysiolo*ic a*e-related
c,an*es are not m/t/ally e0cl/si"e -/t rat,er syner*istic and imact eac, ot,er. In
*eneral, as t,e -ody ad"ances in years, it tends to -ecome less adati"e to stress.
),ysiolo*ic c,an*es associated wit, a*in* can modi+y e"ery system in t,e -ody, and
imact t,e style and manner in w,ic, dental care is deli"ered.
5,e maAor res/lts o+ t,e a*in* rocess are9 a8 a red/ced ,ysiolo*ic reser"e o+ many
-ody +/nctions 7i.e., ,eart, l/n*s, kidney8D -8 an imaired ,omeostasis mec,anism -y
w,ic, -odily acti"ities are ket adA/sted 7i.e., +l/id -alance, temerat/re control and
-lood ress/re control8D c8 an imaired imm/nonolo*ic system, as well as related
increased incidence o+ neolastic and a*e-related a/toimm/ne conditions.
:$
5,e loss o+ eldersC a-ility to +/nction to caacity incl/des a decline in resiratory
+/nction and t,e ina-ility to accommodate to temerat/re c,an*es. It is imortant +or
t,e dental team to -e aware o+ t,ese c,an*esD in artic/lar w,en older ad/lts are
c,allen*ed -y tra/ma, ac/te illness, or e0ternal temerat/re e0tremes. In eac, o+ t,e
incidences, older ad/lts tend to -e less a-le to maintain a sta-le, internal ,ysiolo*ic
state. As dental ractitioners tend to maintain t,eir o++ice at a cool temerat/re, t,e
decline in an older ersonsC -arorecetor +/nction may ca/se t,e erson to +eel cold,
w,ic, can imact t,eir ost/ral re+le0es, ca/sin* t,e atient to -e s/sceti-le to
ort,ostatic ,yotension.
:$
In addition, it is ,el+/l to kee a -lanket in t,e o++ice to
kee atients com+orta-le.
5,e cardio"asc/lar system o+ older ad/lts tends to -e more likely to de"elo isc,emia,
arrt,ymias, and ,eart +ail/re, esecially w,en conc/rrent illness is resent. 4it,
increased e0ercise andBor stress, t,ere is an increase in cardiac o/t/t. For older
ad/lts, t,e work o+ t,e ,eart is increased as -lood is /med t,ro/*, a less comliant
arterial system.
Sli*,t increases in systolic -lood ress/re are not /n/s/al +or t,ose in older a*e
*ro/s, ,owe"er, one m/st ens/re t,e ress/re stays wit,in acceta-le "al/es
7<:<$B;' mm H*8 Systolic ,yertension is a stron* risk +actor +or stroke and ,eart
+ail/re, and warrants treatment i+ it remains consistently ele"ated o"er :<$ mm H*,
re*ardless o+ a*e. Diastolic -lood ress/re is not known to c,an*e wit, older a*e.
Alt,o/*, -ot, -lood ress/re la-ility and t,e re"alence o+ Fw,ite coat ,yertensionF
are increased in t,e elderly, t,e clinical si*ni+icance o+ t,ese ,enomena is
contro"ersial.
::, :>
N/trition de+iciencies are common in t,e elderly atient. In comm/nity-dwellin*
elderly, anore0ia and micron/trient de+iciencies are common.
:=
Anore0ia is
m/lti+actorial, a++ected -y c,an*es in taste and smell, li+estyle, ,ysiolo*ic, and
syc,olo*ical c,an*es. M/lti"itamin s/lementation can o+ten imro"e n/tritional
stat/s and imm/ne +/nction in t,is o/lation o+ older ad/lts.
:&
.oss o+ s/-c/taneo/s +at and decrease in elastic tiss/e in t,e dermis render t,e skin o+
older ad/lts more s/sceti-le to tear-tye inA/ries. In addition, wo/nd ,ealin* is
imaired in older ad/lts.
:'
InA/ries +rom minor tra/ma, loss o+ t,e skinCs e++ecti"eness
as a -arrier, and a decrease in imm/ne +/nction renders t,e older erson skin rone to
in+ections.
:<
A*e-related eye c,an*es are common in older ad/lts. 5,e maAority o+ older ad/lts
e0erience res-yoia, or a*e-related c,an*es in t,e lens and iris o+ t,e eye. )ersons
wit, pres4yopia ,a"e di++ic/lty +oc/sin* on near o-Aects, o+ten re?/irin* t,e /se o+
readin* *lasses. In addition, t,ose wit, res-yoia e0erience a *reater loss o+
dynamic "is/al ac/ity 7"iewin* o-Aects in motion8 t,an in static ac/ity. 5,e a-ility to
adat to s/dden c,an*es o+ li*,t and darkness also diminis,es wit, a*e. An e0amle
o+ t,is c,an*e is e0erienced w,en mo"in* +rom a -ri*,tly lit area to a darkened one,
as w,en enterin* a mo"ie t,eatre +rom t,e snack area. Hellowin* o+ t,e lens and
acc/m/lation o+ insol/-le rotein in t,e center o+ t,e lens +i-ers e"ent/ally de"elo
into cataracts, w,ic, not only red/ce "is/al ac/ity, -/t also ca/se increases in li*,t
scatterin*, renderin* t,e older ad/lt wit, oor "ision and a sensiti"ity to *lare.
:%
Hearin* imairment is common o"er t,e a*e o+ <$D wit, a re"alence o+ >' to =$E
amon* comm/nity-dwellin* elders and close to %$E in residents o+ lon*-term care
+acilities. Pres4ycusis is t,e most common tye o+ ,earin* loss in older ad/lts and is
ca/sed -y -ot, at,olo*y and, in some cases, a/ditory rocessin*.
:(
)res-yc/sis
ca/ses *rad/al, ro*ressi"e 4ilateral hearin$ loss, redominantly in t,e ,i*,er
+re?/encies, as well as decline in seec, discrimination. 1ot, at,erosclerosis and
c/m/lati"e noise e0os/re may contri-/te to res-yc/sis. Comm/nication wit, an
indi"id/al a++ected -y res-yc/sis is en,anced -y slow, distinct "ocali@ation at a low
itc,. S,o/tin* can act/ally -e ain+/l to t,e atient and does not imro"e t,e a-ility
to /nderstand w,at is -ein* said.
Question 2
A. 5,e elimination o+ ,eart disease as a ca/se o+ deat, wo/ld res/lt in a *reater
increase in li+e e0ectancy +or t,e total o/lation t,an i+ cancer were t,e +irst to -e
eliminated.
1. 3ac,, and all o+ t,e +ollowin* are maAor si*ns o+ t,e a*in* rocess9 7a8 red/ced
,ysiolo*ic reser"e o+ many -ody +/nctionsD 7-8 imaired ,omeostasisD 7c8 imaired
imm/nolo*ic systemD 7d8 increased n/m-er o+ neolastic conditionsD 7e8 ,eart
conditions, and 7+8 stroke.
C. 4o/nd ,ealin* o+ t,e elderly +ollowin* oral s/r*ery wo/ld -e e0ected to -e
slower t,an amon* t,e yo/n*.
D. )res-yoia and res-yc/sis are -ot, common ro-lems amon* elderly atients
enterin* t,e dental o++ice.
3. In co/nselin* an older indi"id/al, it is ad"isa-le to e"al/ate i+ ,eBs,e can +/lly
comm/nicate and /nderstand, as well as -ein* a-le to consent and articiate in a
roosed treatment re*imen.
1one remains meta-olically acti"e t,ro/*,o/t li+e. A*e-related -one loss is e0tremely
common, re+lectin* an im-alance -etween -one resortion -y osteoclasts and -one
+ormation -y osteo-lasts. +steoporosis, a common ro-lem in t,e elderly, is an a*e-
related disorder c,aracteri@ed -y a decrease in -one mass and -y an increased
s/sceti-ility to +ract/res. .osses in -one mass wit, ad"ancin* a*e are m/lti+actorial,
incl/din* inacti"ity, estro*en de+iciency, n/tritional de+iciencies and a*e-related
c,an*es. Clinically, ad"anced osteoorosis can resent wit, c,ronic -ack ain, +rom
mec,anical strain ca/sed -y ky,osis or "erte-ral comression +ract/res. !ecent
st/dies indicate t,at c,an*es in al"eolar -one as a res/lt o+ osteoorosis may
contri-/te to t,e ro*ression o+ eriodontal disease.
:;
Also, a si*ni+icant decrease in
-one mass o+ t,e mandi-le may lead to +ra*ility and increased resortion, risk o+
+ract/re, and +ail/re o+ osseointe*ration o+ imlants. )re"ention, rat,er t,an treatment,
is t,e key to t,e mana*ement o+ osteoorosis. 30ercise, "itamins, a -alanced diet,
dietary calci/m, and estro*en lay a role in t,e treatment and re"ention o+
osteoorosis.
Desite e0tensi"e ne/ronal loss, co*niti"e +/nction in t,e a-sence o+ at,olo*y is well
reser"ed +or t,e most art. Certain ne/rosyc,olo*ic a-ilities do s,ow decrement
wit, a*e.
>$
Di++ic/lty wit, 3ord2findin$ is a common comlaint o+ ,ealt,y older
ad/lts, and a common symtom o+ co*niti"e disease. Howe"er, as most older ad/lts
do not e0erience co*niti"e diseases, wit, s/++icient time older ersons do +ind t,e
desired word as s/ccess+/lly as t,ose in yo/n*er a*e *ro/s. Processin$ speed is also
slower in older ad/lts. 5,/s, comle0 tasks t,at re?/ire ?/ick resonses, esecially in
t,e conte0t o+ distractin* stim/li, can -e ,ard +or t,e elderly to er+orm. 5,e central
ner"o/s system /nder*oes si*ni+icant c,an*es d/rin* t,e co/rse o+ a*in*. Decreased
resonse time is o+ten seen in t,e elderly o/lation, -/t t,ere is a wide "ariation
-etween indi"id/als.
5,e imm/ne system -ecomes less cometent wit, a*e. Howe"er, t,e de*ree o+
de+iciency is not se"ere eno/*, t,at oort/nistic in+ections occ/r commonly in t,e
elderly o/lation.
It is t,e resonsi-ility o+ t,e dental team to -e aware and to address t,e commonly
seen a*e-related c,an*es o+ a*in*. 1ot, modi+ications o+ o++ice desi*n and atient
mana*ement tec,ni?/es are -est incororated in t,e dental ractice addressin* t,e
F*rayin* o+ America.F
Co*niti"e +/nction in t,ose a*es ($ years and older is in+l/enced -y t,e ,i*,
re"alence o+ dementin* illnesses.
>:
See section on Co*niti"e F/nction.
Functional Status
F/nctional stat/s is a critical indicator o+ ,ealt, and well--ein* in t,e older erson,
and is one o+ t,e most c,allen*in* iss/es in ,ealt, care o+ older ad/lts. F/nctional
stat/s is o+ten a -etter descritor o+ an indi"id/al t,an t,e resence o+ seci+ic
diseases, as imairments in ,ysical and co*niti"e +/nctionin* redict mortality,
instit/tionali@ation, and t,e tye and amo/nt o+ ,ealt,-care ser"ices needed.
Identi+yin* oneCs +/nctional stat/s re?/ires a comre,ensi"e health assessment,
incl/din* an assessment o+ t,e indi"id/alCs functional a4ilities, health status,
physical, psycholo$ical, and oral2health status,
A +/nctional assessment e"al/ates oneCs a-ility and limitations to comlete -asic tasks
o+ daily li+e.
%
F/nctional stat/s is de+ined in terms o+ Acti"ities o+ Daily .i"in*
(D(s) and Instr/mental Acti"ities o+ Daily .i"in* (/D(s). Acti"ities o+ Daily
.i"in* are t,ose a-ilities t,at are fundamental to independent livin$, s/c, as -at,in*,
dressin*, toiletin*, trans+errin* +rom -ed or c,air, +eedin* and continence.
Instr/mental Acti"ities o+ Daily .i"in* 7IAD.s8 are more comle0 daily activities
s/c, as /sin* t,e telephone, preparin$ meals and mana$in$ money, 5,e indi"id/alCs
a-ility to comlete AD.s and IAD.s will a++ect t,e ersonCs a-ility to access and
maintain t,eir oral ,ealt, care re*imen.
F/nctional limitations ser"e as key indicators o+ an older ersonCs a-ility to remain
indeendent in t,e comm/nity, t,eir ?/ality o+ li+e and acti"e li+e e0ectancy.
Aro0imately %>E o+ t,e o/lation a*ed <'K years reorted ,a"in* no di++ic/lty
wit, AD.s and IAD.s, w,ile a-o/t :$E ,ad di++ic/lty wit, = or more AD.s.
>>
As
a*e increases, t,e ercenta*e o+ t,e o/lation ,a"in* no di++ic/lty wit, AD.Cs or
IAD.s decreases. 5,e two most common IAD.s identi+ied -y t,e elderly are
difficulty 3al*in$ and $ettin$ outside,
>=
5,ese common conditions may re?/ire dental-
,ealt, ro+essionals to modi+y t,e indi"id/alsC treatment lan, and to consider
sc,ed/le times t,at are otimal +or t,e atient.
Cognitive Changes Associated with Aging
Inacc/rate ass/mtions and +alse -elie+s a-o/t mental ,ealt, and t,e co*niti"e
c,an*es o+ a*in* ,a"e res/lted in an o"erem,asis on decrements o+ten associated
wit, older ad/lts. !ecent st/dies o+ t,e a*in* -rain s,ow t,at maAor co*niti"e declines
do not occ/r in t,e a-sence o+ disease, tra/ma, or stress. De"elomental transitions,
li+e e"ents and en"ironmental c,an*es may inter+ere wit, older ad/ltsC a-ility to
concentrate and to t,ink clearly. !esearc, ,as ascertained t,at oneCs intellect does not
decline as an o/tcome o+ a*in* -/t rat,er, as a res/lt o+ many conditions incl/din*
oor n/trition, disease and ,ormonal c,an*es.
>&
An older erson /s/ally takes lon*er
to learn t,e same in+ormation as a yo/n*er ad/lt, -/t w,en *i"en s/++icient time, t,e
end res/lt is similar +or -ot, indi"id/als. In *eneral, more time is needed +or an older
erson to encode, t,at is, to retrie"e or to recall t,e in+ormation. In later li+e, mental
,ealt, is meas/red -y t,e caacity to coe e++ecti"ely wit, relations,is and
en"ironment and -y t,e satis+action e0erienced in doin* so.
1eca/se o+ t,e m/ltilicity o+ +actors t,at relate to t,e treatment o+ t,e elderly, it is
imortant to e"al/ate t,e a-ility o+ t,e atient to comm/nicate and to /nderstand,
consent to and articiate in t,e treatment. 5,e ractitioner m/st determine, eit,er
t,ro/*, an inter"iew or t,ro/*, ro+essional ser"ices, t,e caacity o+ t,e indi"id/al to
resond to treatment.
5,e most common type of dementia in t,e elderly is senile dementia o+ t,e
l1heimer?s type (SDT), acco/ntin* +or aro0imately ($E o+ all dementiaCs seen in
t,e elderly. 5,e second most common ca/se o+ dementia in t,e elderly is m/lti-in+arct
dementia or vascular dementia, acco/ntin* +or :' to >'E o+ cases.
>'
Al@,eimerCs disease is a ro*ressi"e, de*enerati"e, dementin* illness t,at attacks t,e
-rain and leads to t,e loss o+ memory, intellect/al caacity, t,inkin*, and -e,a"ioral
c,an*es. SDA5 is c,aracteri@ed -y t,e acc/m/lation o+ neuro2fi4rillary tan$les and
senile pla5ues wit,in t,e cere-ral corte0.
Al@,eimerCs disease ,as an insidio/s onset t,at mani+ests as loss o+ recent memory,
imairment o+ A/d*ment and ersonality c,an*es. 5,ose wit, SDA5 may e0erience
con+/sion, ersonality and -e,a"ior c,an*es, imaired A/d*ment, di++ic/lty +indin*
words, +inis,in* t,o/*,ts or +ollowin* directions. 4,en e0eriencin* t,e early sta*es
o+ t,e disease, t,e indi"id/al *enerally maintains *ood social skills and is o+ten a-le
to Fdis*/iseF t,e resence o+ t,e disease. In its early sta*e, t,e disease is o+ten "ery
di++ic/lt to assess, and is *enerally denied -y +amily mem-ers.
5,e ca/se o+ SDA5 is not known and c/rrently t,ere is no c/re +or it. Alt,o/*,
SDA5 ,as -een +o/nd in yo/n*er a*e *ro/s, it a++licts aro0imately :$E o+ t,ose
o"er t,e a*e o+ <' and BD; of those over a$e F>, 5,e disease ro*resses +rom > to >$
years, and resents as a comle0 ict/re o+ o"erlain* symtoms, re+lectin* a
contin/o/s decline in memory, t,inkin*, and -e,a"ior. Co*niti"e skills and
cometency in li+e skills decline. 5,ere is loss o+ memory, lan*/a*e, intellect/al
rowess, concentration, emotionality, and altered satial motor er+ormance. 1ot,
"er-al and non"er-al comm/nication is a++ected.
5,ere are n/mero/s re"ersi-le ca/ses o+ t,ese symtoms in older ad/lts incl/din*
in+ection, de,ydration and "itamin de+iciencies. Attenti"e ,ealt,-care ro+essionals, in
artic/lar oral ,ealt,-care ro+essionals may -e one o+ t,e +irst care*i"ers to detect
some o+ t,e early, s/-tle c,an*es associated wit, Al@,eimerCs. It is inc/m-ent /on
t,e ,ealt,-care ro+essional to assist t,e indi"id/al to o-tain a comre,ensi"e
assessment to correct t,e re"ersi-le ca/ses w,ene"er ossi-le and to assist t,e
indi"id/al and +amily in t,e oort/nity to address t,e care and mana*ement o+ t,e
indi"id/al.
Oral-Disease Patterns
D/rin* t,e ast '$ years, one o+ t,e maAor c,an*es in oral-disease atterns in t,e
United States ,as -een a steady decrease in the rate of edentulism, It is likely t,at +or
t,e +irst time in recorded ,istory t,ere are now more older ad/lts wit, nat/ral teet,
t,an wit,o/t teet,. In :;(<, almost =$E o+ t,ose <' to %& years were edent/lo/s,
w,ereas in >$>& it is redicted t,at only :$E o+ t,is *ro/ will -e edent/lo/s.
><
5,is
decline in edent/lism aears to -e t,e res/lt o+ water +l/oridation, increased /-lic
awareness o+ re"enti"e aroac,es, imro"ed access to ser"ices, and a decrease in
early toot, loss.
>%
Alt,o/*, t,e re"alence o+ edent/lism increases in t,e non-instit/tionali@ed older a*e
*ro/s 7:$E o+ &' to '& years, >(.&E o+ <' to %&, and '>.'E o+ ('K years8, t,ese
rates ,a"e steadily decreased o"er time.
><
5,is decline in toot, loss res/lts in more
nat/ral teet, at risk +or caries 7coronal, rec/rrent, and root8 and eriodontal diseases.
As t,ese trends contin/e more restorati"e and re"enti"e ser"ices will -e needed in
+/t/re dental ractices.
!ecent reorts ,a"e +o/nd t,e re"alence o+ coronal caries is decreasin* +or c,ildren
and yo/n* ad/lts o+ middle to ,i*, socioeconomic stat/s. Alt,o/*, dental caries ,as
not traditionally -een ercei"ed as a ro-lem +or t,e elderly, decay rates ,a"e -een
+o/nd ,i*,er in some ad/lt *ro/s t,an in c,ildren. As lon* as teet, are resent,
indi"id/als remain at risk o+ dental caries.
>(
Un+ort/nately, many older ad/lts do not
lace a riority on oral ,ealt, care, and "iew seein* a dentist only to relie"e ain and
discom+ort. For t,ose not recei"in* ro/tine dental care, and as a res/lt o+ increased
deosits o+ secondary dentin and a red/ced sensory a-ility, many older ad/lts tend to
seek care only w,en t,eir decay is in a late sta*e. A s/r"ey o+ IowaCsC o/lation
+o/nd =$E o+ dentate elderly ,ad /ntreated coronal decay, wit, %%E ,a"in* eit,er a
new coronal or root lesion in t,e last = years.
>;
!oot caries is common and +re?/ently occ/rs in t,is a*e *ro/. !oot caries ,as -een
+o/nd in <'E o+ t,e males and '=E o+ t,e +emales in t,e :;('-(< NID! st/dy.
=$
4it,
t,e /se o+ new re"enti"e aroac,es and restorati"e materials, t,e dilemma
associated wit, restorin* root-cario/s lesions is e0ected to diminis, in t,e +/t/re.
Contrary to many lon*-,eld "iews, eriodontal disease is not an a*e-related disease.
Alt,o/*, t,e re"alence o+ eriodontal disease aears to increase wit, a*e, t,is is
likely d/e to t,e lon*-standin* c/m/lati"e nat/re o+ t,e disease, wit, its onset earlier
in ad/lt,ood. In addition, m/c, o+ t,e a"aila-le data re+lects cross-sectional st/dies
t,at do not resent a *enerali@a-le "iew o+ t,e o/lation. .on*it/dinal s/r"ey data is
needed to doc/ment t,e ro*ression o+ t,e disease. It is estimated t,at H:; of adults
9>Q years need eriodontal treatment, wit, :'E needin* comle0 treatment.
=:
4it,
t,e rate o+ eriodontal disease ro*ression artly related to t,e mass and comosition
o+ t,e oral micro-iota and t,e ,ostCs a-ility to resond to t,is micro-ial o/lation,
researc, ,as +oc/sed on new dia*nostic and treatment modalities, s/c, as DNA
dia*nostic ro-es, en@ymatic assays and -acterial analyses, t,e /se o+ lasers, new
,armace/tical rearations and s/-traction radio*ra,y. 4it, new dia*nostic
met,ods comlementin* traditional clinical tec,ni?/es, earlier identi+ication o+
eriodontal disease and risk +actors will -e ossi-le, as well as early treatment to ,el
red/ce disease ro*ression and its s/-se?/ent loss o+ teet,.
Question 3
A. Determinin* t,e a-ility o+ an indi"id/al to er+orm t,e Acti"ities o+ Daily .i"in*
7AD.8 and t,e Instr/mental Acti"ities o+ Daily .i"in* 7IAD.8 is a -etter means to
e"al/ate a ersonCs +/nctional a*e t,an /sin* a*e alone.
1. )eriodontal disease is associated wit, t,e older indi"id/alD ,owe"er, eriodontal
disease is not ca/sed -y a*in*it is ca/sed -y oral ne*lect w,ile a*in*.
C. 5,e +o/r *eneral key admonitions to retainin* teet, +or a li+etime are9 7:8 ,a"e
+re?/ent recalls and dental e0aminations, and 7>8 ,a"e early dia*noses +or disease and
disease risk, +ollowed -y aroriate 7=8 early re"enti"e andBor 7&8 restorati"e
treatment.
D. Aro0imately &%E o+ indi"id/als o"er (' are a++licted wit, dementia o+ t,e
Al@,eimerCs tye.
3. )res-yc/sis, -/t not res-yoia, are ,ysical ro-lems o+ many seniors w,o will
"isit a dental o++ice.
.ike most cancers, oral cancer occ/rs rimarily in t,e older a*e se*ments o+ t,e
o/lation, wit, t,e maAority o+ cases dia*nosed a+ter a*e <' and more t,an ;'E
occ/rrin* a+ter a*e &$.
=>
5,e key iss/e related to oral cancer ro-lem is t,e need +or
early and effective dia$nosis, Alt,o/*, t,e rimary risk +actors +or t,e de"eloment
o+ oral s?/amo/s cell carcinoma ,a"e traditionally incl/ded alco,ol a-/se and /se o+
to-acco rod/cts, t,ese risk +actors do not ,a"e to -e resent +or a lesion to de"elo.
5,/s, it is inc/m-ent /on t,e oral ,ealt, care ro+essional to ro"ide oral cancer
e0aminations to all atients on a re*/lar 7at least ann/al8 -asis. As t,e m/lti+actorial
etiolo*y o+ oral cancer -ecomes e"ident, ot,er +actors incl/din* alterations in cell/lar
onco*enes, as well as micro-ial and "iral in+ections may -e +o/nd to lay a role in t,e
at,o*enesis o+ remali*nant lesions and oral s?/amo/s cell carcinoma.
==
Gi"en t,at
early dia*nosis o+ oral cancer *reatly imro"es t,e ro*nosis o+ t,e disease, and t,at
many +actors in+l/ence t,e timin* at w,ic, oral cancers are dia*nosed, i.e., lack o+
access to care and atient delay in seekin* treatment,
=&
oral-,ealt, ro+essionals m/st
ro"ide w,en aroriate, ro/tine comre,ensi"e intra- and e0traoral e0aminations o+
t,eir atient o/lations.
It is essential to reco*ni@e t,at no -road, *enerali@ed decremental c,an*es in oral
,ealt, occ/r simly wit, a*e. Healt,y older eole can e0ect to kee t,eir teet,,
t,ro/*,o/t t,eir li+etime. Howe"er, in t,e resence o+ one or more medical conditions
andBor t,eir treatments, oral +/nctions may -e altered w,ic, can t,en imact /on t,e
atientsC *eneral and oral ,ealt, stat/s.
5,ro/*, +re?/ent recall "isits and re*/lar ro+essional e0aminations, ad/lts will -e
-etter a-le to maintain t,eir dentition t,ro/*,o/t t,eir li+e. )re"ention o+ oral disease
is t,e critical comonent +or oral-,ealt, maintenance. In addition to romotin* and
monitorin* t,e -asic oral-,y*iene ractices, t,e ractitioner needs to -e aware o+ t,e
c,an*in* ,ysical, syc,olo*ic, socioeconomic, and medication stat/s o+ t,eir older
ad/lt atients. In addition, t,e ractitioner needs to -e ready and willin* to inter"ene
and make necessary modi+ications to treatment as well as re+errals to comm/nity
reso/rces. Older ad/lts and t,eir care*i"ers need to -e ed/cated and ,a"e t,eir
ed/cation rein+orced so to en,ance t,eir knowled*e o+ oral care rotocols.
Long-Term Care
.on*-term care re+ers to ,ealt,, social and residential ser"ices ro"ided to c,ronically
disa-led ersons o"er an e0tended time.
='
.on*it/dinal st/dies in t,e United States
s/**est t,at ersons <' years and older ,a"e a &$E c,ance o+ sendin* some time in
a lon*-term care +acility -e+ore t,ey die. O+ t,ose w,o enter n/rsin* ,omes, ''E will
send at least one year t,ere, and o"er >$E will send more t,an +i"e years t,ere.
5wo o+ t,e most common symtoms t,at lead to n/rsin* ,ome lacement are
incontinence and -e,a"ioral ro-lems s/c, as wanderin* or disr/ti"e actions o+ten
associated wit, dementia and Al@,eimerCs disease.
=<
5,e maAority o+ t,e <'K o/lation li"es in t,e comm/nity, w,ile only &.'E are in
n/rsin* ,omes.
>:
O+ t,ose instit/tionali@ed in :;;$, :E were <' to %& years, <E were
%' to (& years, :;E were (' to (; years, ==E were ;$ to ;& years, and &%E were ;'
and older. Gi"en t,e *rowt, o+ t,e ('K o/lation, a s/-stantial increase in t,e +/t/re
/se o+ n/rsin* ,omes aears ine"ita-le.
=%
5,e deli"ery o+ oral-,ealt, care to residents in lon*-term care +acilities or +or t,ose
w,o are ,ome-o/nd resents secial c,allen*es +or t,e ro+essional. In addition to t,e
mode o+ care deli"ery, t,is atient o/lation tends to -e +rail, +/nctionally deendent
and o+ten lackin* any le"el o+ sel+-interest in t,eir oral ,ealt,. Co*niti"e declines,
lack o+ moti"ation, ,ysical imairment, and c,ronic medical ro-lems all contri-/te
to a decrease in sel+-care a-ility and increase risk o+ oral disease. 5,is o/lation ,as
-een c,aracteri@ed as ,a"in* ,i*, le"els o+ edent/lism, coronal and root caries, oor
oral ,y*iene, eriodontal diseases and so+t tiss/e lesions.
=(, =;
For t,e +irst time, t,e ro"ision o+ oral-,ealt, care is mandated in lon*-term care
instit/tions. 5,e Omni-/s 1/d*et !econciliation Act 7O1!A8 o+ :;(% 7)/-lic .aw
:$$->$=8 re?/ires all n/rsin* +acilities Fm/st emloy comre,ensi"e assessments to
determine seci+ic ,ealt, care needs o+ t,ose residents w,o articiate in Medicaid or
Medicare )art 1 ro*rams. 5,e assessment m/st -e cond/cted not later t,an :& days
a+ter admission and can -e amended / to =$ days a+ter admission. N/rsin* +acilities
m/st re"iew t,e residentCs condition +or any c,an*es in ,ealt, stat/s e"ery = mont,s
and er+orm t,e comre,ensi"e assessment ann/ally. 5,e assessments are cond/cted
-y a re*istered n/rse, wit, in/t +rom a ,ysician or ot,er ,ealt, care ractitioner7s8
as necessary.F 4,ile t,ese assessments are not re?/ired to -e comleted -y a dental
ro+essional, dentists andBor dental ,y*ienists need to -e identi+ied as art o+ t,e
,ealt,-care team o+ t,e lon*-term care +acility. Gi"en a raidly *rowin* o/lation o+
dentally aware older ad/lts, +/t/re o/lation *rowt, atterns and tec,nolo*ical
ad"ances in orta-le and mo-ile dental e?/iment, oral-,ealt, care ro*rams in lon*-
term care +acilities will -ecome +easi-le and common locations +or ro"idin* dental
care.
One maAor in+l/ence on dental /tili@ation is ,a"in* dental ins/rance. Since dental
ins/rance is *enerally ro"ided as an emloyee -ene+it, t,e elderly tyically do not
,a"e t,is -ene+it. Accordin* to t,e :;(; NHIS
><
, '$E o+ t,e =' to '& year, =%E o+ t,e
'' to <& years and :'E o+ t,e <'K o/lation ,ad ri"ate dental ins/rance. Dental
-ene+its are not incl/ded in Medicare, and "ery +ew states ro"ide dental ser"ice to
ad/lts t,ro/*, t,e Medicaid ro*ram. In :;;$, nearly %'E o+ edent/lo/s ersons ='K
years did not ,a"e ri"ate dental ins/rance comared to a-o/t ,al+ o+ t,e dentate
o/lation.
&$
Since edent/lo/s ersons are less likely to ,a"e "isited a dentist +or t,e
ast ' years, ro/tine e0aminations +or and early treatment o+ oral so+t-tiss/e diseases
are recl/ded. 5,/s, t,e elderly edent/lo/s o/lation may -e identi+ied as one o+ t,e
maAor /nderser"ed o/lations o+ t,is co/ntry.
Question 4
A. 5,e two most common ca/ses o+ cancer are e0cessi"e cons/mtion o+ alco,ol and
smokin*D t,e two most imortant ways to ins/re reco"ery +rom cancer are early
dia*nosis and early e++ecti"e treatment.
1. 5wo o/t o+ e"ery +i"e 7&$E8 o+ Americans o"er <' will send time in a n/rsin*
,ome -e+ore deat,.
C. 5,e maAority o+ instit/tionali@ed indi"id/als /s/ally ,a"e ri"ate dental ins/rance.
D. 5,e two most common ca/ses +or n/rsin* ,ome attendance are incontinence and
osteoorosis.
3. Dental care is a/t,ori@ed +or t,e elderly /nder Medicare.
Summary
4it, more older ad/lts and more teet, er older ad/lt, t,e comosition o+ ser"ices
rendered to t,is o/lation will c,an*e dramatically in t,e ne0t decade. 5,e oral
,ealt, ro+essional o+ today and o+ t,e +/t/re will -e called to treat an e"er-increasin*
n/m-er o+ older ad/lts. 5,e +/t/re elderly will -e di++erent t,an t,e c/rrent co,ort
seen today. 5,e +/t/re elderly will ,a"e more teet,, "isit t,e dentist more o+ten, ,a"e
a ,i*,er le"el o+ ed/cation, -etter +inances and a dramatically di++erent ersecti"e o+
needs. 5,ey are and will contin/e to -e a ,etero*eneo/s mi0 o+ indi"id/als wit,
"ario/s le"els o+ +/nctional, socioeconomic and oral ,ealt, stat/s. Ad"ances in
materials and tec,nolo*y in com-ination wit, t,e c,an*in* atterns o+ oral diseases
will contin/e to ,a"e dramatic e++ects on t,e ractice o+ dentistry.
5,e role o+ t,e oral ,ealt,-care ro+essional will +oc/s more on t,e dia*nosis and
treatment o+ oral diseases and disorders, /sin* new aids and de"ices s/c, as lasers,
CADBCAM, and molec/lar ro-es. As diseases o+ t,e ,ard tiss/es are resol"ed, more
em,asis will -e laced on t,e dia*nosis and treatment o+ so+t tiss/e lesions. 4it,
new and imro"ed dia*nostic skills, t,e older ad/lt, t,e *ro/ identi+ied as ,a"in* t,e
,i*,est risk o+ oral cancer may no lon*er re?/ire t,e e0tensi"e and o+ten dis+i*/rin*
s/r*ical remedies c/rrently in lace. )re"enti"e oral-,ealt, aroac,es need to -e
maintained t,ro/*,o/t t,e li+esan.
In order to ro"ide otimal care to t,e a*in* o/lation, one m/st remain c/rrent on
oral medicine, ,armacot,erae/tics and c,an*in* tec,nolo*ies. Oral ,ealt,-care
ro+essionals m/st address ,ow t,is a*in* o/lation will mana*e in t,e dental
+acility, and, at a minim/m, ,a"e accessi-le o++ices, lar*e-si@ed tye medical ,istory
+orms a"aila-le, as well as easy-to-read si*ns, ,ealt, literat/re, and aointment
cards.
:. Acorrect.
1incorrect. 5,e elderly are li"in* lon*er as a *ro/, ,ence -ein* t,e oldest, t,e
sickest and t,e +railest, t,ey constit/te a maAor ,ealt, 7and olitical8 c,allen*e.
Cincorrect. 5,e tr/t, is t,at -etween :;;; and >$=$, t,e w,ite o/lation is
roAected to increase -y a tremendo/s (:ED ,owe"er t,is will -e draw+ed -y t,e
estimated =>(E -y Hisanic-Americans, >('E -y Asian and )aci+ic Islanders, :&%E
-y American Indians, 3skimos and Ale/ts, and :=:E -y A+rican-Americans.
Dincorrect. 5,ere are more older widows -eca/se women marry earlier t,an men,
,ence o+ten o/tli"e t,eir so/se.
3Incorrect. MaAority means o"er '$E. 5,e correct ercenta*e o+ indi"id/als o"er
($ li"in* in n/rsin* ,omes aro0imates :;E.
>. A, 1, C, D, 3correct.
=. A, 1, C, Dcorrect.
3Incorrect. 1O5H res-yc/sis 7,ard o+ ,earin*8 and res-yoia 7+ar si*,tedness8
are ro-lems +or t,e dental o++iceD atient mo-ility and atient comm/nication are
Aeoardi@ed -y t,ese two imairments.
&. A, 1Correct.
Cincorrect. 5,e answer is t,at many n/rsin* ,ome residents do not ,a"e dental
ins/rance. )art o+ t,is ro-lem is d/e to t,e +act t,at many ,a"e dent/res and do not
-elie"e t,ey need ins/rance. Ot,ers do not ,a"e t,e money +or ins/rance t,at -/ys
access to ro+essional care, nor do t,ey ,a"e t,e moti"ation or ,ysical a-ility to
desire to maintain sel+-ima*e.
Dincorrect. Incontenence is one o+ t,e two maAor ro-lems. Osteoorosis is notD 7it
can -e coed wit, in ,ome en"ironments8. 5,e second maAor reason +or
instit/tionali@in* indi"id/als is t,e dementia c,aracteristic o+ Al@,eimerCs disease.
3incorrect. Medicare does not s/-sidi@e ro/tine dental care.
References
:. Ha@@ard, 4. !. 1ierman, 3. .., 1lass, #. )., 3ttin*er, 4. H., g Halter, #. 1. 7:;;&8.
Principles of $eriatric medicine and $erontolo$y, New Hork9 McGraw Hill.
>. 5,e American Association o+ !etired )ersons 7>$$$8. profile of older americans,
4as,in*ton, D.C.
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mericans6 United States, CHHB, DHHS, 6ital and Healt, Statistics, Series =, No. =$,
:;;'.
&. National Center +or Healt, Statistics 7:;;;8. Health6 United States CHHD, )/-lic
Healt, Ser"ice.
'. U.S. 1/rea/ o+ t,e Cens/s 7:;;:8. %arital status and livin$ arran$ements CHH:,
U.S. 1/rea/ o+ Cens/s, C/rrent )o/lation !eorts. )->$, No. &'$.
<. Ga-rel, C. S., g #ones, A. 7>$$$8. The national nursin$ home survey6 CHHD
summary, 6ital g Healt, StatisticsSeries :=9 Data From t,e National Healt,
S/r"ey, 7:&%89 :-:>:.
%. Adams, ). F., g 1enson, 6. 7:;;$8. Current estimates from the &ational Health
/ntervie3 Survey CHFH, 6ital and Healt, Statistics, Series :$, National Center +or
Healt, Statistics.
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Pro7ections, U.S. Deartment o+ Healt, and H/man Ser"ices.
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Clinical 0eriatrics 7>nd ed.8 7. ::=-::<8. ),iladel,ia9 #1 .iincott.
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Ford, 3ds. n approach to common pro4lems in the elderly, ),iladel,ia9 41
Sa/nders.
::. Glen, S. 2., 3lliott, H. .., C/r@io, #. .., .ees, 2. !., g !eid, #. .. 7:;;<8.
4,itecoat ,yertension as a ca/se o+ cardio"asc/lar dys+/nction. (ancet, =&(9 <'&-
'%.
:>. Myers, M. G., !ee"es, !. A., O,, ). I., g #oyner, C. D. 7:;;<8. O"ertreatment o+
,yertension in t,e comm/nity. m " Hyperten, ;9 &:;-&>'.
:=. Morley, #. 3., Mooradian, A. D., Sil"er, A. #., He-er, D., g Al+in-Slater, !. 1.
7:;((8. N/trition in t,e elderly. nn /ntern %ed, :$;9 (;$-;$&.
:&. C,andra, !. 2. 7:;;>8. 3++ect o+ "itamin and trace element s/lementation on
imm/ne resonses and in+ection in elderly s/-Aects. (ancet, =&$9 ::>&->%.
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Uni"ersity )ress9 New Hork. . =$;.
:<. Fenske, N. A., g .o-er, C. 4. 7:;;$8. S*in chan$es of a$in$6 Patholo$ical
implications, &'9 >%-='.
:%. .iesen*an*, 5. #. 7:;(&8. Cataracts and cataract oerations. %ayo Clin Proc, ';9
''<-<%.
:(. #er*er, #., C,miel, !., 4ilson, N., g ./c,i, !. 7:;;&8. Hearin* imairment in
older ad/lts. New Concets. " m 0eriatr Soc, &=9 ;>(-='.
:;. !ose, .. F., Stein-er*, 1. #., g Minsk, .. 7>$$$, Octo-er8. 5,e relations,i
-etween eriodontal disease and systemic conditions. Compendium Continuin$
!ducation in Dentistry , <C 7:$A89 (%$-%.
>$. Ciocon, #. O., g )otter, #. F. 7:;((8. A*e-related c,an*es in ,/man memory9
Normal and a-normal. 0eriatrics, &=9 &=-&(.
>:. Flemin*, 2. C., Adams, A. C., g )eterson, !. C. 7:;;'8. Dementia Dia*nosis and
3"al/ation. %ayo Clin Prac, %$9:$;=-:$%.
>>. National Center +or Healt, Statistics. 7:;;=8. Health Data on +lder mericans6
United States, 6ital and Healt, Statistics, Series =, No.>%. Centers +or Disease
Control and )re"ention.
>=. 2art, C. S., Metress, 3. 2., g Metress, S. ). 7:;((8. $in$ Health and Society,
1oston9 #ones and 1artlett.
>&. #ar"ik, .. 7:;((8. A*in* o+ t,e -rain. How can we re"ent ite 0erontol, >(9%=;-
&%.
>'. 4,ite, .., Cartwri*,t, 4. S., Cornoni-H/ntley, #., g 1rock, D. 1. 7:;(<8.
Geriatric eidemiolo*y. nn Rev 0erontol 0eriatr, <9>:'-=::.
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5oot, loss in t,e United States. " Dent !duc, &;9=<(-%(.
>%. 1loom, 1., Gi+t, H. C., g #ack, S. S., Dental Services and +ral Health, CHFH,
=ital Health and Statistics, Series C:, &ational Health /ntervie3 Survey, :;;>.
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coronal and root caries in middle-a*ed and older ad/lts. Caries Research, ><9&';-<'.
>;. Hand, #. S., H/nt, !. #., g 1eck, #. D. 7:;((8. Coronal and root caries in older
Iowans9 =<-mont, incidence. 0erodontics, &9:=<-=;.
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Ad/lts9 National +indin*s. &/H Pu4l, No. (%->(<(.
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In 5,e Second Fi+ty Hears9 )romotin* Healt, and )re"entin* Disa-ility. 4as,in*ton
D.C.9 National Academy )ress.
=>. 1erkey, D. 1., g S,ay, 2. 7:;;>8. 0eriatric dental care for the elderly, In 1a/m,
1. +ral and Dental Pro4lems in the !lderly, Clinics in 0eriatric %edicine,
),iladel,ia9 41 Sa/nders.
==. Greer, !. O. 7:;;=8. Recent clinical and molecular 4iolo$ical advances in
dia$nosis and treatment of oral cancer, in Scientific 'rontiers in Clinical Dentistry,
n Update, National Instit/te o+ Dental !esearc,, 4as,in*ton, D.C.
=&. Sadowsky, D. C., 2/n@el, C., g ),elan, #. 7:;((8. DentistsC knowled*e, case-
+indin* -e,a"ior and con+irmed dia*nosis or oral cancer. " Cancer !d, =9:>%-=&.
='. Doty, )., .i/, 2., g 4einer, #., 7:;('8. Secial !eort9 An o"er"iew o+ lon*-term
care. Health Care 'inancin$ Rev, <9<;-%(.
=<. O/slander, #. G., Osterweil, D., g Morley, #. 3. 7:;;%8. %edical Care in the
&ursin$ Home, >nd ed. New Hork9 McGraw-Hill.
=%. 1rody, #. A., 1rody, D. A., g 4illiams, 5. F. 7:;(%8. 5rends in ,ealt, o+ t,e
elderly o/lation. nn Rev Pu4lic Health, (9>::-=&.
=(. 1erkey, D. 1., 1er*, !. G., 3ttin*er, !. .., g Meskin, .. H. 7:;;:8. !esearc,
re"iew o+ oral ,ealt, stat/s and ser"ice /se amon* instit/tionali@ed older ad/lts in t,e
United States and Canada. Special Care Dent, ::9:=:-=<.
=;. Strayer, M. S. g I-ra,im, M. 7:;;:8. Dental treatment needs o+ ,ome-o/nd and
n/rsin* ,ome atients. Community Dent +ral !pidemiol, :;9:%<-%%.
&$. Sc,o/, .. 7:;;'8. Oral ,ealt,, Oral ,ealt, Care and Oral ,ealt, romotion amon*
older ad/lts9 Social and -e,a"ioral dimensions. In Co,en, .. 2. g Gi+t, H. C. Disease
Prevention and +ral Health Promotio, Coen,a*en9 M/nsk*aard.
reser"ed.
Chapter 22. Preventive Dentistry in a Hospital Setting - &orman +, Harris "effery
(, Hic*s
Objectives
:. Disc/ss t,e scoe o+ dental ser"ices a"aila-le at comm/nity, +ederal, and lar*e
metroolitan ,ositals.
>. .ist at least ei*,t cate*ories o+ atients seen on a ,osital ser"ice w,o -ene+it +rom
a ,osital dental ser"ice.
=. Name or descri-e t,e ersonal oral-,y*iene items t,at, at a minim/m, eac,
,ositali@ed atient s,o/ld ossess at time o+ admittance, and t,at s,o/ld also -e
stocked in t,e ,osital store.
&. Cite se"eral ad"erse side e++ects o+ c,emot,eray and radiation t,eray +or cancer.
'. O/tline t,e resonsi-ilities o+ t,e oral s/r*eon, t,e seec, t,eraist, t,e
ediatrician and t,e ediatric dentist in t,e e++ort to make li+e as near-normal as
ossi-le +or a cle+t-alate indi"id/al.
<. Orient st/dents a-o/t t,e administrati"e +/nctions o+ a ,osital and e0amles o+ a
,osital dental and medical ser"ice in action.
%. Comare eritoneal dialysis wit, ,emodialysis.
(. 30lain w,y dentists +a"or re*nant women ,a"in* +olate d/rin* t,e +irst +o/r
mont,s o+ re*nancy.
;. 5ell anot,er st/dent w,at reca/tions yo/ are *oin* to take wit, t,is a+ternoonCs
,i*,-risk cardiac atient.
Introduction
5,e idea o+ ro"idin* +or t,e deli"ery o+ dental ser"ices in a ,osital settin* is not
new.
:
5,e +irst dentist to ractice in an American ,osital was !ic,ard Co/rtland
Skinner, w,o immi*rated to ),iladel,ia in :%((.
>
.ater, ,e was t,e +irst dentist to
ask +or and recei"e an o++icial aointment to a medical instit/tion. In t,e :%;$s,
Skinner created t,e +irst ,osital dental clinic in t,e Disensary o+ t,e City o+ New
Hork to treat t,e indi*ent. It was not /ntil t,e middle o+ t,e :;t, cent/ry t,at
Garretson and H/lli,an laid t,e +o/ndation +or t,e ractice o+ ,osital dentistry.
=

Aro0imately >$$ years a+ter Skinner, in :;(%, it was reorted t,at a-o/t &$,$$$
dentists ,ad ,osital ri"ile*es.
&
In :;$:, t,e ),iladel,ia General Hosital
de"eloed t,e +irst dental-intern trainin* ro*ram. In site o+ t,e +act t,at a-o/t <$E
o+ all ,ositals ,a"e dental ro*rams, not all ,ositals e0tend sta++ ri"ile*es to
dentists. )resently, t,e admission o+ dentists to a ,osital sta++ and t,e e0tent o+ dental
privile$es is a determination made 4y each individual hospital and is re+lected in t,e
,osital -y-laws.
5,e +ollowin* artial Ao- descrition ill/strates t,e tyical daily tasks o+ a ,osital
dentist9 F5,e ,osital dentist +oc/ses on ser"in* t,ose w,o cannot recei"e dental care
t,ro/*, t,e traditional deli"ery systems. )atients w,o are medically andBor mentally
comromised 7e.*., wit, cancer, ,eart disease, HI6BAIDS, Al@,eimerCs Disease8,
o+ten s/++er +rom a de-ilitatin* an0iety towards dental treatment. In addition, t,e
ser"ice ro"ides care +or "ictims o+ emer*ency and tra/ma to t,e ,ead and neck
re*ions, o++ers cons/ltation ser"ices +or ot,er ,osital ser"ices, and +/rnis,es dental
care to atients residin* in t,e +acility. Hosital dentistry renders t,e +/ll ran*e o+
s/r*ical, restorati"e, cons/ltati"e, maintenance and re"enti"e o/tatient roced/res
o++ered in ri"ate ractice settin*s. 5,e ,osital ractice also o++ers ser"ices +or
restorati"e and s/r*ical roced/res comleted /nder *eneral anest,esia.F
'
5,e maAority o+ t,e dental care rendered in many ,ositals is +oc/sed on t,e
dia*nostic and treatment care necessary to support the recovery o+ medically
comromised atients or atients admitted +or serio/s ,ead and neck diseases,
in+ection, or tra/ma. 5,e U.S. ,ealt,-care system reco*ni@es t,at t,e trainin* needed
-y dentists and dental ,y*ienists +or ,osital ractice can -e incororated into a
teac,in* ,ositalCs mission. 5o s/ort t,is need +or trainin* dental ersonnel,
teac,in* ,ositals s/ort trainin* ro*rams +or $raduate students, and rotate t,em
t,ro/*, a dental deartment and ot,er aroriate deartments s/c, as emer*ency
medicine, internal medicine, and anest,esiolo*y. 3"ery year more t,an :$$$
American dentists recei"e trainin* in ,ositals. At t,e same time, dental ,y*iene
st/dents and dental assistants ,a"e ro"ided dental ,y*iene ser"ices +or am-/latory
and nonam-/latory atients. 5,e scoe o+ t,e dental ser"ices wit,in a ,osital "aries
*reatly, -ein* deendent on s/c, +actors as -ed caacity, economic s/ort, le"el o+
secialty e0ertise, and ro0imity to medical and researc, centers.
As a res/lt o+ t,e in+l/ence o+ t,ese needs and limitations, dental ser"ices o+ ,ositals
can ar-itrarily -e laced in one o+ t,ree cate*ories9
:. Smaller non+ederal ,ositals 7ri"ate and comm/nity8 t,at ro"ide care to only
support recovery o+ t,e atientCs rimary comlaint +rom t,e time o+ admission. 5,ese
,ositals /s/ally ,a"e only a short2term commitment to t,e atient +or a eriod d/rin*
w,ic, care is -ein* rendered +or a rimary comlaint. Accordin*ly, t,e dental ser"ice
a"aila-le is *enerally concerned wit, deli"erin* ma0illo+acial care res/ltin* +rom
accidents. 5,e oral s/r*eon may -e on-call +or cases arri"in* at t,e emer*ency
roomor t,e ro-lem may simly -e ,andled -y an attendin* s/r*eon. In t,ese
smaller ,ositals, it is ass/med t,at any atient re?/irin* dental care, ot,er t,an t,at
ertainin* to t,e rimary comlaint, will "isit a ri"ate dentist +ollowin* t,e eriod o+
,ositali@ation.
>. Military and ot,er +ederal ,ositals t,at ro"ide total oral-,ealt, needs +or t,eir
acti"e d/ty or eli*i-le ersonnel. 5,ese ser"ices incl/de dia*nosis, treatment
lannin*, re"enti"e and treatment ser"ices, co/nselin* and ro*rammed recalls.
Similarly, 6eterans Administration and U.S. )/-lic Healt, Ser"ice Hositals ro"ide
comlete care to eli*i-le in-and-o/tatients.
D/rin* war years, military ,ositals are o+ten at t,e +ore+ront in inno"ati"e oral and
*eneral s/r*ery.
<
5,e e0ertise *ained in con+lict is t,en -ro/*,t -ack to t,e
eacetime world. For instance, in 4orld 4ar I wit, its trenc, war+are, co/led wit,
"iolent c,ar*es across -attle+ields -lanketed wit, ,i*, e0losi"es and a contin/al ,ail
o+ ,i*, "elocity small arms +ire, rod/ced de"astatin* wo/nds o+ t,e +ace and -ody at
a rate ne"er known -e+ore.
It is o+ interest to know t,at in :;:&, t,ere was no *eneral concet +or reconstr/ctin* a
destroyed mandi-le. It was -etween :;:& to :;:( t,at t,e translantation o+ -one
emer*ed as t,e -est aroac, to restorin* t,e lower Aaw. 3"en t,en, t,ere was a
/@@le as to w,y one translant wo/ld -e a s/ccess and a +ail/re in anot,er. It was a
Dr. Carl )artsc,, a German Army S/r*eon, w,o is credited +or ointin* o/t t,at t,e
s/ccess o+ +ract/re ,ealin* and -one translantation deended on t,e ti$ht contact
-etween /ndama*ed s/r+aces, or -etween st/ms and translantation ieces.
%
=. .ar*e metroolitan and /ni"ersity teac,in* ,ositals ,a"e e0anded t,eir scoe o+
dental ser"ices to incl/de treatment +or atients wit, serio/s systemic diseases
associated wit, a hi$h ris* for life2threatenin$ emer$enciess/c, as ,eart disease.
For t,ese atients, w,en crises occ/r in t,e ,osital, li+e-sa"in* dr/*s andBor
emer*ency teams are immediately a"aila-le. Also, many atients are acceted w,o
,a"e a ,i*, risk +or transmittin$ of disease, s/c, as AIDS. Finally, to s/ort
ad"anced-de*ree ro*rams, dental clinics are a"aila-le to t,e /-lic. Grad/ates +rom
t,ese de*ree ro*rams o+ten remain in ,osital dentistryD ot,ers enter academia,
w,ile ot,ers *o 3ell prepared into ri"ate ractice.
Dental Needs of Hospitalized Patients
Dentists as well as ot,er ,ealt, ro+essionals reali@e t,at oral ,ealt, cannot -e
di"orced +rom t,e *eneral ,ealt, o+ t,e ,ositali@ed atient. Many oral conditions are
intimately related to systemic diseases. Otimally, total ,ealt, care re?/ires t,e
com4ined e++orts o+ t,e medical and dental ro+essions.
Se"eral reorts indicated t,at lon*-term ,ositali@ed or c,ronically ill atients ,ad
many si*ni+icant dental needs. 5o "eri+y t,ese reorts, t,e American Dental
AssociationCs Co/ncil on Hosital Dental Ser"icesC s/r"eyed :,<=& indi"id/als. It was
estimated t,at a-o/t ($E o+ all atients admitted to a ,osital ,ad some +orm o+ oral
at,osis t,at re5uired treatment. 5,e maAority o+ t,ese atients was /naware o+ dental
ro-lems and tyically did not ,a"e a +amily dentist. 5,e si0 *reatest dental treatment
needs were t,e same dental needs as o+ t,e *eneral o/lationdental caries,
eriodontal disease, la?/e or calc/l/s deosits, nonrestora-le teet,, artial or
comlete edent/lism. 5,ey also disco"ered t,at ade?/ate, +/nctional, +i0ed, and
remo"a-le rost,etic de"ices were nearly none0istent and t,at t,e le"el o+ dental care
re"io/sly ro"ided was "ery low. )oor oral ,y*iene, *in*i"al in+lammation, and
aillary ,yerlasia were t,e most re"alent eriodontal ro-lems. Almost all o+ t,e
dent/res e0amined were inade?/ate, wit, *ross amo/nts o+ materia al-a resent on
t,e dent/re and in t,e -/ccal "esti-/le. A-o/t '%E o+ atients wit, ac/te dental ain
,ad not recei"ed alliati"e care.
5,ere are se"eral cate*ories o+ ,osital atients, eac, wit, secial needs +or dental
ser"ices. Amon* ot,ers, s/c, atients incl/de9 7:8 ,ead and neck cancer atientsD 7>8
cle+t-alate cases, 7=8 AIDS atientsD 7&8 renal, li"er, and ,eart-+ail/re atientsD 7'8
atients in need o+ ro,ylactic anti-ioticsD 7<8 comatose atientsD 7%8 arale*ics,
?/adrile*ics, and am/teesD 7(8 osts/r*ical atientsD 7;8 dia-etic atientsD 7:$8
syc,iatric atientsD 7::8 o-stetric atientsD and 7:>8 or*an-translant candidates and
reciients. 3ac, indi"id/al in eac, o+ t,ese *ro/s re?/ires seciali@ed care and
co/nselin*. No treatment lan +its allk
Administrative Requirements
I+ a dentist or a dental ,y*ienist is to -e /sed in a ,osital re"enti"e dentistry
ro*ram, t,e ,osital administrator must 4e receptive to t,e idea. 4,ile dental
,y*ienists may -e emloyed -y a ,osital t,ro/*, normal emloyment c,annels,
dentists m/st -e admitted to t,e ,osital sta++ and -e privile$ed to provide specific
ser"ices. Hositals ,a"e well-de+ined re*/lations +or t,e admittin* and ri"ile*in*
rocesses. 5,e e0istin* medical sta++ and n/rses m/st s/ort any additional ward
dental acti"ity t,at ,as to -e mes,ed wit, t,e ot,er ro+essional time re?/irements
associated wit, atient care. Un+ort/nately, t,e s/-Aect o+ dental care is not
em,asi@ed in t,e +ormal trainin* o+ t,e maAority o+ nondental ,ealt, ro+essionals.
Some medical ro+essionals w,o ,a"e -een trained in ,ositals t,at sonsored ost-
doctoral dental-ed/cation ro*rams may -e more knowled*ea-le a-o/t ,osital dental
care. Howe"er, t,is ed/cation usually m/st come t,ro/*, contin/in* ersonal
relations,is -etween dental and medical sta++ ersonnel and t,ro/*, contin/in*
ed/cation ro*rams.
The Hospital Dental Department
Accreditation and !e*/lations
A ,osital is administered -y 7:8 a $overnin$ 4ody entr/sted wit, t,e resonsi-ility
+or t,e o"erall or*ani@ation and cond/ct o+ t,e instit/tion. 5,is -ody may -e a 1oard
o+ Directors, mana*ers, or tr/stees and t,is -ody will esta-lis, olicies t,at are in
accordance wit, doc/ments written -y t,e Fo/nders, t,e ,osital administration and
-y t,e laws o+ t,e state and nation in w,ic, t,e ,osital is located. Hositals will
aoint a 7>8 chief operatin$ officer w,o ,as t,e day-to-day resonsi-ility o+
maintainin* administrati"e str/ct/re, decor/m, ?/ality o+ ,osital care, lannin* and
+iscal olicies. 5,e 7=8 medical2dental staff o+ a ,osital is t,e t,ird comonent o+ t,e
,osital administrati"e str/ct/re and is comosed o+ its aointed C,airersons and
elected reresentati"es.
Hositals, in order to -e ermitted -y t,eir resecti"e states to deli"er care and to
recei"e reim-/rsement +rom +ederal ayors, m/st articiate in a +ormal accreditin*
rocess. Most, i+ not all ,ositals in t,e United States are accredited -y t,e #oint
Commission on Accreditation o+ Healt,care Or*ani@ations 7#CAHO8. 5,e we-site o+
t,e #CAHO lists as its mission9 F5o contin/o/sly imro"e t,e safety and 5uality o+
care ro"ided to t,e /-lic t,ro/*, t,e ro"ision o+ ,ealt, care accreditation and
related ser"ices t,at s/ort performance improvement in ,ealt, care or*ani@ations.F
In addition, teac,in* ,ositals in t,e United States and Canada t,at sonsor
ostdoctoral dental ed/cation ro*rams are periodically assessed and accredited -y
t,eir resecti"e national dental associations, In t,e United States, t,e accreditin*
a*ency is t,e Commission on Dental Accreditation o+ t,e merican Dental
ssociation, Goals and o-Aecti"es +or -ot, U.S. and Canadian ostdoctoral dental
ro*rams are similar. )ostdoctoral teac,in* ro*rams e"al/ate a "ariety o+
ro+icienciesro+essional skills and ractice mana*ement, restorati"e dentistry,
rost,etics, endodontics, ort,odontics and ediatric care, oral at,olo*y, oral s/r*ery,
eriodontics, ,armacolo*y and ,osital +/nctionin*. 5o add to t,is list may -e
emer*ency care, sedation anest,esia, and some asects o+ /-lic ,ealt,.
(
Dental Department Administration and Sections
5,e Dental Deartment is t,e administrati"e and clinical ,/- +or all dental oerations
in t,e ,osital. 5,e Deartment C,airerson is selected -y t,e Hosital 1oard -ased
on ,erB,is demonstrated leaders,i and ro+essional cometence, and ,as e?/al stat/s
and resonsi-ilities as t,e C,airs o+ ot,er deartments. 30amles o+ t,ese
resonsi-ilities incl/de a re?/irement +or interdeartmental cooeration and
cons/ltation, maAor and minor oral s/r*ery, oeration o+ a /-lic clinic, clinical and
-asic researc,, 4ard dental care o+ dental in-atients, recr/itment o+ deartment
manower, and +or -/d*et rearation to meet e0ected deartment needs and +or
+/t/re instit/tion e0ansion. 5o accomlis, t,ese tasks, many o+ t,e d/ties are
dele*ated to t,e Section C,ie+ss/r*ery, rost,etics, eriodontics, *eneral ractice,
ediatric dentistry, and researc,.
5,e m/ltic,air dental clinic w,ere t,e maAority o+ ro/tine dental care occ/rs, /s/ally
accets an o/tatient atient load as art o+ t,e ostdoctoral trainin* ro*ram. Many
times, t,is atient load consists o+ t,e indi*ent, wit, or wit,o/t *o"ernment or
ins/rance s/ort. 5,is *eneral ractice s/er"ised teac,in* ro*ram is essentially a
ri"ate-ractice en"ironment, and it is a slendid trainin* -ack*ro/nd -e+ore enterin*
ractice. It also ,els ro"ide t,e dental manower to meet t,e ,ositalCs re?/irement
+or a +/lly +/nctionin* dental ser"ice.
5,e Dental DeartmentCs ma0illo+acial team is an essential comonent to a ,ositals
mission. In a lar*e metroolitan ,osital w,ere emer*ency s/r*ery is a daily ro/tine,
t,e oeratin* room d/ties +or maAor cranio+acial s/r*ery are /s/ally s,ared -y teams
o+ #oard2Certified medical and dental ma0illo+acial s/r*eons. Oral s/r*eons treat
"ictims wit, maAor so+t and ,ard tiss/e dama*e o+ t,e +ace and ,ead. 5,ese inA/ries
arise +rom many so/rcesa/tomo-ile accidents, kni+e and */ns,ot wo/nds,
;
and
societal and domestic "iolence.
:$
5,e oral s/r*eons also ro"ide ort,oedic and
lastic s/r*ery to correct +acial skeletal dis,armonies and developmental defects s/c,
as cle+t li and alate.
::
Some oral s/r*eons seciali@e in more e0tensi"e plastic
s/r*ery, w,ile oral cancer sur$ery is anot,er maAor task +or a well-trained oral
s/r*eon.
5,e s/ccess+/l o/tcome o+ any minor or maAor s/r*ery is determined -y w,et,er t,e
atient +eels as t,o/*, ,eBs,e can sociali@e wit,o/t imediment, w,et,er t,ere is
acceta-le seec,, and w,et,er dental aearance and oral +/nction is satis+actory.
:>
5,e dental deartmentCs ma0illo+acial prosthetic section is an essential comonent o+
t,e ma0illo+acial team. 5,e a-sence or loss o+ so+t andBor ,ard tiss/e res/ltin* +rom
de"elomental de+ects, or +ollowin* tra/ma or s/r*ery, o+ten is too $reat for
corrective sur$ery alone. 4it, trainin* -eyond t,e /s/al rost,odontics *rad/ate
ro*rams, some rost,odontists and la-oratory tec,nicians -ecome ro+icient in
sc/ltin* c/stomi@ed dental or cosmetic rost,eses.
:=
O-t/rators are needed at times
to -rid*e alatal cle+ts.
:&
Some ,ositals ,a"e esta-lis,ed rost,etic centers
seciali@in* in t,e +a-rication o+ eyes or +acial arts lost -y tra/ma or diseaseD
:'
ot,ers
,a"e seciali@ed in constr/ctin* ears lost -eca/se o+ tra/ma or con*enital a-sence.
:<
In t,e ast, t,ese e0ternal and intra-oral rost,eses /s/ally 3ere ,eld in lace wit,
ad,esi"es.
:%
Now, w,ene"er ossi-le, t,ey are ma*netically connected to imlants
t,at are inte$rated into 4one +or more ermanent +i0ation.
:(
Once inserted, a ma*e2up
artist teac,es t,e atient ,ow to aly di++erent s,ades o+ creams and owders to
camo/+la*e t,e rost,esis.
Intra- and Extra-hospital Cooperation
Many times t,ere is a need +or cooeration -etween t,e ,ysicians o+ ot,er ser"ices
and t,e ersonnel o+ t,e dental deartment. For e0amle, t,ere ,a"e -een needs +or
endoscoic toot, e0tractions +rom t,e nasal ca"ity re?/irin* t,e skills o+ a nose and
t,roat ro+essional.
:;
),ysician inter"ention is o+ten indicated to coe wit, seemin*ly ro/tine tasks o+ a
dental ser"ice t,at t/rn into emer*encies. A +ew e0amles are9 near-+atal -leedin*
+ollowin* o"er sel+-medication wit, ?/inine,
>$
treatin* o+ eriodontal disease to ,el
control dia-etes mellit/s 7and ossi-ly "ice "ersa8, red/cin* t,e ossi-ility o+ a
-acteremia o+ oral ori*in -ecomin* a ro-lem o+ cardio"asc/lar at,olo*y, or in
recei"in* ,el in remo"in* a dent/re t,at ,as lod*ed in a t,roat.
>:
Some o+ t,ese
ro-lems can -e anticiated +rom a atientCs ,istory record, many cannot.
Daily t,ere are re?/ests +or clinic cons/ltations and e0amination o+ newly admitted
atients. 5,ere are also many re?/ests +rom t,e ri"ate sector +or e0tractions /nder
anest,esia, or +or dental care o+ ,i*,-risk ersons. Some are re+erred -eca/se o+
atient +ear and anticiated di++ic/lt e0tractions, w,ile still ot,ers are re+erred -eca/se
o+ mental ,andicas, moderate-to-se"ere -e,a"ioral ro-lems or a ,istory o+
sei@/res.
>>
Cons/ltations -etween aroriate ,osital ser"ices and ri"ate re+errin* ractitioners
is enco/ra*ed, -ot, as a +orm o+ co/rtesy to t,e re+errin* ro+essionals and to ens/re
t,at atient mana*ement is aroriate.
Preventive Dentistry
In most smaller ,ositals, t,ere are no dental deartments, ,ence no ro"isions +or an
acti"e rimary re"enti"e ro*ram. In one st/dy o+ s,ort ,osital stays, 7at least one
week8 all == resondents to a ?/estionnaire indicated t,ey were /na-le to carry o/t
t,eir sel+-care as well as t,ey co/ld at ,ome.
>=
5,is +indin* wo/ld ro-a-ly ,a"e -een
di++erent i+ t,e ,osital ,ad ,ad a olicy o+ askin* eac, sel+-s/++icient atient
admitted, to -rin* a small kit wit, a toot,-r/s, and +loss to carry o/t daily sel+-care
roced/res. In addition, t,e ,osital store s,o/ld stock ,i*,-demand dental rod/cts
incl/din* +l/oride denti+rices, +loss t,readers, disclosants, +l/oride mo/t,was,es, and
dent/re cleaners. 5,e ,armacies s,o/ld -e in a osition to disense rescritions +or
c,lor,e0idine.
In t,ese ,ositals, n/rses or n/rsesC aides m/st ro"ide essential ost-oerati"e dental
roced/res in"ol"in* t,e oral str/ct/res.
>&
An e0amle mi*,t -e t,e daily +l/oride
sray-cleanin* o+ t,e mo/t,s o+ mandi-/lar +ract/re atients 7w,ere t,e interdental
wirin* makes mec,anical la?/e control di++ic/lt8.
For military ,ositals, t,e task is m/c, easier. All essential dental items are stocked in
t,e ,osital e0c,an*e +or atient /rc,ase. A re"enti"e dental o++icer is desi*nated
-y t,e C,air to ins/re t,at t,e needs o+ 4ard and clinic atients are ser"ed. Us/ally a
"isit to t,e clinic is sc,ed/led +or an e0amination as soon as is appropriate +ollowin*
admission. At t,is time, a dental e0amination is accomlis,ed to determine re"enti"e
and treatment needs. Since, -y olicy, a military atient is ,eld +or rec/eration
-e+ore -ein* ret/rned to +/ll-d/ty, t,ere is o+ten slack time +or accomlis,in* needed
dental ser"ices -e+ore -ein* ret/rned to ,isB,er /nit. D/rin* t,is time, co/nselin*
s,o/ld -e directed to t,e need and met,ods o+ sel+-caremec,anical la?/e control
7-r/s,, +loss, and irri*ation8, and c,emical la?/e control 7/se o+ +l/oride mo/t,
rinses +or ac,ie"in* limited reminerli@ation8, and c,lor,e0idine 7+or temorary
s/ression o+ caries and *in*i"itis micro-iota8. Also, d/rin* t,is time, more
intensi"e reminerali@ation roced/res can -e instit/ted +or interro0imal radio*ra,ic
l/cencies t,at are wit,o/t si*ns o+ o"ert ca"itation. Since ad/lts do de"elo occl/sal
caries, sealants s,o/ld -e laced in any dee its and +iss/res.
For t,e clientele o+ t,e clinics o+ lar$e and university hospitals, re"enti"e dentistry
takes on a more /r*ent and omino/s tone. Many o+ t,ese atients are ,i*,-risk
atients w,o ,a"e serio/s c,ronic diseases t,at ,a"e -een treated at t,e instit/tion or
elsew,ere. For t,ese atients, re"enti"e dentistry means re"entin* t,e occ/rrence
o+ li+e-t,reatenin* emer*encies as well as rotectin* t,e oral str/ct/res +rom disease.
5,e same roced/res s/**ested in ot,er c,aters aly +or t,ese atients, e0cet t,at
7:8 all t,e re"enti"e actions and risk assessments are monitored at s,orter inter"alsD
and 7>8 all emer*ency reca/tions +or eac, condition m/st -e in lace -e+ore
treatment -e*ins.
In total-care ,ositals, a re"enti"e dentistry cart s,o/ld -e a"aila-le to t,e dental
o++icer, dental ,y*ienist or desi*nated erson makin* t,e ward ro/nds. S/c, a cart
s,o/ld -e stocked wit, items s/c, as disosa-le lastic mo/t, mirrors, a +las,li*,t, a
,and mirror +or atient "iewin*, sterile ton*/e -lades, cotton alicator sticks, mo/t,
ros, and sei@/re sticks 7do/-le ton*/e -lades wraed in *a/@e and taed sec/rely8.
Additional aids can incl/de a sray /nit and ,i*,-"ol/me, low-"ac//m s/ction /nit,
asirator tis, *a/@e s?/ares, and disclosin* ta-lets. Mo/t,rinses can -e made / in
?/antity -y t,e ,armacy +or 4ard /se.
Question 1
A. 5,e +irst ,osital dental ser"ice in America was esta-lis,ed in New Hork only a
+ew years a+ter t,e !e"ol/tionary 4ar.
1. 5o -ecome a ro+essional mem-er o+ a ,osital sta++, a candidate m/st -e
ri"ile*ed.
C. A ,osital dental ser"ice m/st -e accredited -y medical and dental r/les and
re*/lations esta-lis,ed -y t,e olitical and ro+essional entities le*ally claimin*
A/risdiction.
D. 5,e C,airman o+ t,e "ario/s deartments o+ a ,osital only "ote on roositions
ertainin* to t,eir resecti"e ser"ices.
3. )it-and-+iss/re sealants s,o/ld -e considered +or ad/lts wit, dee occl/sal +iss/res.
5o t,is oint, ,osital administration ,as -een em,asi@edD t,is ermits t,e -/siness
and ro+essional asects o+ a ,osital to +/nction ,armonio/sly. From t,is oint on,
examples o+ t,e ro+essional resonsi-ilities and atient ro-lems o+ a ,osital
o/lation will -e disc/ssed. 5,e diseases selected +or -rie+ disc/ssioncancer, cle+t
alate, HI6BAIDS, cardio"asc/lar disease, renal disease, and dia-etes mellit/s are all
at,olo*ies t,at will -e enco/ntered -y dentists and dental ,y*ienists o"er a
ro+essional li+etime. 5,ese enco/nters will occ/r re*ardless o+ w,et,er t,e ractice
is a dental o++ice, military +acilities, academia, /-lic ,ealt,, or ,osital clinic. 5,e
main +oc/s s,o/ld -e in reco$ni1in$ imendin* or act/al emer*encies and
immediately initiatin$ a pro$rammed and already rehearsed response,
Xerostomia
Many 0erostomia 7Fdry mo/t,F8 cases t,at are seen in a ,osital clinic are a com-ined
,ysician-dentist concern. 5,is ,yo-secretion o+ sali"a is seen in se"eral medical and
dental conditionsSAo*renCs syndrome, intake o+ 0ero*enic dr/*s, dryness o+
syc,o*enic or idioat,ic ori*in, dia-etes, candidosis, and e0cessi"e alco,ol
cons/mtion.
>'
Gerostomia is esecially tro/-lesome w,en it res/lts +rom radiation t,eray /sed in
t,e treatment +or cancer w,en t,e *land/lar tiss/e o+ t,e maAor and minor sali"ary
*lands are /s/ally destroyed. A drastic decrease o+ sali"a +low occ/rs, and an in"erse
increase in salivary viscosity soon +ollows. 5,e 0erostomia +ollowin* radiation is
*enerally irreversi4le, alt,o/*, some researc,ers ,a"e reorted modest reco"eries in
some atients 7Fi*/re >>-:8. Gerostomia diminis,es t,e sali"aCs -/++erin* caacity
res/ltin* in a ma7or increase of cario$enic or$anisms s/c, as m/tans stretococci and
lacto-acilli.
><->(
Cario*enic acti"ity -ecomes ramant and accelerated /nder t,ese Fdry
mo/t,F conditions. A radiation-ind/ced caries, termed radiation caries, is esecially
destr/cti"e, dislayin* a cer"ical and incisal redilection on t,e teet, +or, +irst la?/e
and t,en caries t,at can raidly am/tate t,e crown. 7Fi*/re >>->8. It s,o/ld -e
em,asi@ed t,at t,e caries is not ca/sed -y t,e radiation, -/t is a res/lt o+ t,e
0erostomia t,at allowed /nrestricted *rowt, o+ t,e cario*enic la?/e -acteria.
1eca/se t,e sali"ary c,an*es +ollowin* radiation are permanent, t,e t,reat o+
radiation caries e0ists +or all teet, throu$hout the reminder of the patient?s life,
)re"enti"e t,eray in"ol"es metic/lo/s attention to daily sel+-care consistin* o+ oral
,y*iene, a low-car-o,ydrate diet, +re?/ent dental c,eck/s 7at least e"ery = mont,s8,
toical +l/oride *el, and c,lor,e0idine rinsin*. Con"ersely, t,e 0erostomia t,at occ/rs
+ollowin* t,e intake o+ 0ero*enic dr/*s and c,emot,eray /s/ally re$resses to
normal +ollowin* discontin/ance o+ t,e o++endin* ca/se.
Sali"ary stim/lants and sali"a s/-stit/tes are otions to ro"ide some relie+ to t,e dry
mo/t,. Generally, sali"a s/-stit/tes consist o+ a wettin* a*ent
7car-o0ymet,ylcell/lose or sor-ital8, electrolytes, +l/oride, and +la"orin*. Howe"er,
sali"a s/-stit/tes are oorly acceted -y atients -eca/se o+ t,eir s,ort d/ration o+
action 7:$ to :' min/tes8. As s/c,, t,e maAority o+ 0erostomic atients re+er +re?/ent
sis o+ water to t,e sali"a s/-stit/tes.
>;
S/*arless lemon dros and c,ewin* */m, are
recommended as met,ods +or increasin* sali"ary o/t/t.
><,=$
A rescrition +or
ilocarine, a sali"a stim/lant, ,as also s/ccess+/lly increased sali"ary o/t/t in
st/dies in"ol"in* a "ariety o+ 0erostomic o/lations.
=:
Fi*/re >>-: Mean +low rates o+ stim/lated w,ole sali"a in &> atients wit,
cancer -e+ore, d/rin*, and a+ter radiot,eray. 7From Drei@en S, 1rown .!, Daly
53, et al. )re"ention o+ 0erostomia-related dental caries in irradiated cancer
atients. " Dent Res, :;%%D '<9;;-:$&.8
Fi*/re >>-> Se"ere radiation caries in t,e ma0illary and mandi-/lar anterior
re*ion o+ an ad/lt treated +or ,ead and neck cancer. 7Co/rtesy o+ t,e late Dr.
Simon 2at@, Indianaolis, IN.8
Head and Neck Cancer
Cancer treatment is /s/ally centered at maAor medical centers ,a"in* -ot, t,e
+acilities and ersonnel to contin/ally seek new and -etter aroac,es to cancer
t,eray. 30amles are t,e MD Anderson Hosital in Ho/ston, 5e0as, and t,e
Memorial Sloan-2etterin* Cancer Center in New Hork City. For t,e year >$$: t,e
American Cancer Society ,as estimated t,at t,ere will -e aro0imately >$,$$$ new
cases o+ oral cancer in t,e United States. 5,is same roAection indicates t,at
aro0imately %,($$ will die o+ t,e disease.
=>
5o-acco is t,e ca/se o+ an estimated
=;$,$$$ remat/re deat,s in t,e United States ann/ally. Desite t,e +act t,at t,e
incidence of cancer is increasin$, early dia*nosis and si*ni+icant ad"ances in t,eray
,a"e res/lted in a much lon$er and more productive life +or t,e cancer atient.
==
Most ,ead and neck cancers are not dia*nosed early. In e0aminin* t,is ro-lem wit,
dentists in Maryland, w,ere t,e mortality rate +or oral and ,aryn*eal cancer is
se"ent,- ,i*,est in t,e nation, +oc/s *ro/s +o/nd need +or contin/in* ed/cation to
correct9 7:8 inacc/rate knowled*e a-o/t oral cancer, 7>8 inconsistency in oral
e0aminations, 7=8 lack o+ con+idence in w,en and ,ow to alate +or a-normalities,
and 7&8 lack o+ time to ro/tinely cond/ct oral cancer e0amination. Most cancers o+ t,e
mo/t, are easy to see, w,ile t,ose o+ t,e +loor o+ t,e mo/t, can -e easily alated.
=&

5,e tyical early intraoral lesion is /s/ally an indurated ulcer, Any /lcer t,at ersists
+or A 3ee*s should 4e 4iopsied,
=&
5,e early detection, and early re+erral leadin* to a
more +a"ora-le o/tcome o+ t,eray, is a cr/cial resonsi-ility o+ t,e $eneral dentistR
Cancer )re"ention
A tra*edy associated wit, many ,ead and neck cancer deat,s is t,at in most cases t,e
disease could have 4een prevented, 5,e *reat maAority o+ ,ead and neck cancers arise
+rom three so/rces9 7:8 smo*in$ and t,e /se o+ smokeless to-acco, 7>8 e0os/re o+ t,e
lis and +ace to t,e sun, and 7=8 e0cessi"e cons/mtion o+ alcohol, 5o-acco rod/cts
acco/nt +or three2fourths o+ all intraoral mali*nant 7s?/amo/s cell8 cancer cases
7Fi*/re >>-=8 in t,e United States.
='
#asal cell carcinomas o+ t,e +ace are o+ten ca/sed
-y an e0cess e0os/re to t,e nat/ral sun or to Ftannin$ devices,F !xcess alcohol
consumption is also a maAor contri-/tory +actor to t,e de"eloment o+ oral and
,aryn*eal cancer
=<,=%
wit, alco,ol aearin* to syner*i@e wit, to-acco as a risk
+actor +or all t,e /er aerodi*esti"e tract cancers.
=(,=;
3"en +or t,ose i*norant o+, or w,o i*nore t,e admonitions -y t,e American Cancer
Society concernin* smokin*, s/n e0os/re and alco,ol, t,ere is +re?/ently a second
c,ance. Us/ally, t,ere are early non,ealin*, precancerous c,an*es in t,e oral ca"ity
or on t,e +ace t,at s,o/ld alert an indi"id/al to immediately seek ro+essional care.
Cessation o+ t,e /se o+ to-acco, a"oidin* e0cessi"e e0os/re to t,e s/n, and
cons/min* alco,ol in moderation 3ill help ret/rn t,e tiss/es to normal. Finally, i+ t,e
cancer is dia*nosed in t,e early sta*es, immediate treatment is /s/ally +ollowed -y a
Fclinical c/re,F ro"ided t,ere is not a ret/rn to t,e ori*inal ,a-its.
5,e )ro+ile o+ t,e Oral-Cancer )atient
5,e a"era*e oral cancer atient is o"er &$ years o+ a*e, wit, men a++licted more o+ten
t,an women. 5,e most common intraoral cancer is a s5uamous cell cancer t,at mi*,t
,a"e -een receded -y leu*opla*ia,
=&
A+ter a atient ,as -een con+ronted wit, an
o+ten terri+yin* dia*nosis o+ ,ead or neck cancer, t,e scene -ecomes one o+ crisis. 5,e
atient will ?/ickly /nder*o a series o+ e0aminations and tests -y t,e "ario/s ,osital
ser"ices t,at will -e in"ol"ed in t,e treatment ,ase, incl/din* dentistry.
&$
Followin*
t,ese e0aminations, t,e serio/sness o+ t,e cancer is desi*nated -y a T&%
classi+ication system 7sta*in*8 wit, scorin* assi*ned in t,ree areas o+ clinical
assessment9 (T)/mor si@e, in"ol"ement o+ t,e lym, (&)odes drainin* t,e area and
resenceBe0tent o+ (%)etastasis. 5,e *reater t,e scorin* n/m-ers +rom $ to & in eac,
o+ t,e cate*ories, t,e more serious t,e ro*nosis.
As a res/lt o+ t,is w,irl o+ acti"ity, t,e atient is o+ten le+t comletely -ewildered as
to w,y teet, ,a"e s/ddenly -ecome so imortant. Many o+ t,ese indi"id/als are in
t,eir +i+t, or si0t, decade o+ li+esome wit, a ,istory o+ e0cellent oral ,y*iene, and
some wit, a ,istory o+ dental ne*lect. In addition to t,e imact o+ t,e dia*nosis o+
cancer or t,e secter o+ ossi-le +acial m/tilation and s/++erin* +rom t,e cancer
treatment, t,e atient is con+ronted wit, a ossi-le +/ll-mo/t, e0traction. 5,e res/lt is
additional stress to t,e atientCs sel+-esteem and morale. 5,en, too, t,ere is t,e +ear o+
a +amily economic disaster as a res/lt o+ medical e0enses and loss o+ income, as well
as +ear o+ deat,. At t,is time, it is imortant to -e co*ni@ant o+ t,e psycholo$ical and
physical strain laced on atients -y t,eir dia*nosis and roAected treatment. As s/c,,
atients may not -e receti"e to care and t,eir ain reaction t,res,old may -e
deressed. 3d/cation, atience, and a comassionate demeanor will ,el esta-lis,
raort and +acilitate care +or most atients. Howe"er, in some cases t,e +ear,
economic, and social ress/res are too *reat to coe wit,D in t,ese cases
,armacosedation s,o/ld -e considered.
><,&:,&>
5reatment o+ Oral Cancer
1e+ore treatment -e*ins, all concerned deartments comrisin* t,e Hosital 5/mor
1oard con"ene to contri-/te o+ t,eir e0ertise. Sin*, at t,e 3astman Dental Instit/te
,as ointed o/t t,at w,en t,e oncolo*y team incl/des a dentist, t,e risk o+
de"eloment o+ serio/s comlications, s/c, as osteoradionecrosis 7to -e disc/ssed
later8, are si*ni+icantly red/ced in t,e cancer atient. Ot,er ersonnel s/c, as +amily
ser"ices workers and a c,alain may -e incl/ded to contri-/te to iss/es t,at are not
directly treatment oriented, yet imortant to a atient and +amily. In t,ese meetin*s,
t,e roAected treatment details are disc/ssedc,emot,erae/tic a*ents to -e /sed, t,e
de*ree o+ anticiated imm/nos/ression, t,e total radiation dose, and t,e tiss/e
+ields 7or orts8 to -e irradiated. 5,ro/*,o/t t,e t,eray, t,e ro*ress o+ eac, atient
will -e e"al/atedall wit, t,e o-Aect o+ ac,ie"in* a -etter end res/lt. O/t o+ t,ese
meetin*s comes a consens/s as to t,e -est retreatment, treatment and ost-treatment
re*imens to -e /sed +or eac, atient.
5,e treatment +or cancer o+ t,e oral ca"ity in"ol"es a c,oice o+ sur$ery, radiation,
chemotherapy, or com-inations t,ereo+. S/r*ery is /sed to excise smaller cancero/s
lesions or to de4ul* lar*e t/mors 7remo"e as m/c, as ossi-le o+ lar*e "ol/me
cancers8. As a co-t,erae/tic modality, chemotherapy or radiotherapy can -e an
otion follo3in$ s/r*ery. 5,e addition o+ radiot,eray adds two "ery disconcertin*
ro-lems to t,e treatment re*imenmucositis
&=
and osteoradionecrosis (+R&), 1ot,
are d/e to dama*e to t,e end arteries s/lyin* t,e m/co/s mem-rane o+ t,e mo/t,
or to t,e -one.
C,emot,eray and radiation rod/ce t,eir own comlicationsD c,emot,eray in"ol"es
t,e /se o+ lant alkaloids, and t/mor anti-iotics to *ill cells under$oin$ mitosis, o+
w,ic, cancer cells are t,e most raidly di"idin*. It is d/rin* mitosis t,at e"en a
normal cell is most sensiti"e to c,emot,eray.
5,e o-Aecti"e o+ /sin* radiation ,as t,e same o-Aecti"e as c,emot,erayi.e., to *ill
raidly *rowin* cells. Una"oida-ly, in -ot, cases ot,er normal di"idin* ,ost cells are
also destroyed, s/c, as hemopoietic cells 7-lood-+ormin* cells8 o+ t,e -one marrow,
epithelial cells o+ t,e oral m/cosa and *astrointestinal tract, and endothelial cells o+
terminal arteries are also killed. Host dama*e -y radiation is /s/ally locali1ed to t,e
+ield o+ irradiation, w,ile t,e side e++ects o+ c,emot,eray are systemic,
Fi*/re >>-= Intraoral s?/amo/s cell carcinoma. 5,e atient was seen in a
Hosital Dentistry Deartment +or a comlaint o+ oral ain. His social ,istory
re"eled to-acco and e0cessi"e alco,ol /se +or many years. A -iosy -y t,e
*eneral dentist re"ealed s?/amo/s cell carcinoma. Desite aroriate re+erral
+or treatment, t,e atient died wit,in < mont,s. 7Co/rtesy o+ Dr. #e++ery ..
Hicks, Uni"ersity o+ 5e0as Dental Sc,ool, San Antonio, 5G.8
Question 2
A. 5,e 0erostomia t,at o+ten +ollows radiation t,eray is ermanentD t,at +ollowin*
t,e /se o+ 0erostomic dr/*s is /s/ally con+ined to t,e eriod o+ dr/* /se.
1. An /lcer t,at does not ,eal in two mont,s s,o/ld -e care+/lly insected and
ossi-ly -iosied -y a ro+essional.
C. 5,e ca/ses +or most oral and oro+acial cancers are sel+-in+lictedsmokin*,
drinkin*, and tannin*.
D. A lar*e cancero/s *rowt, may -e de-/lked -y s/r*ery rior to radiation t,eray.
3. 5,e dama*e +rom radiation t,eray is localD t,e dama*e +rom c,emot,eray is
systemic.
M/cositis
5,e m/cositis res/ltin* +rom dama*e to t,e m/co/s mem-rane is c,aracteri@ed -y a
mo/t, t,at ,as a raw, /lcerated, and ain+/l m/co/s mem-rane t,at o+ten makes
eatin* and swallowin* very ain+/l.
&&
5,ere is o+ten a rel/ctance o+ a atient to eat
+ollowin* t,e onset o+ m/cositis. )atients will selecti"ely eat cool, so+t, ,i*,-
car-o,ydrate +oods t,at romote caries de"eloment. )atients m/st -e enco/ra*ed to
take "itamin s/lements and eat -alanced and creati"e diets t,at minimi@e m/cocitic
ain, yet romote t,e desire to eat. Ha"in* t,e atient consult a dietician is salient to
s/ccess+/lly mana*e t,is side e++ect.
&'
Since t,e e++ects o+ chemotherapy are systemic, t,ere are se"eral systemic
comlications. Aside +rom m/cositis t,e comlications incl/de imm/ne s/ression
7ne/troeniaa low-ne/tro,ile co/nt8, ,emorr,a*e, and in+ection secondary to ot,er
+oci o+ in+ection s/c, as dental a-scesses and eriodontal in+ection. 5,e /se o+
c,emot,eray, does s/ress mitosis. Howe"er, it does not res/lt in a marked
decrease in saliva 70erostomia8 rod/ction or in a rolon*ed m/cositis s/c, as seen
+ollowin* radiation t,eray. 1ot, t,e m/cositis and any 0erostomia tend to eak and
to re$ress 3ithin one or t3o 3ee*s after treatment,
&<,&%
C,emot,eray does not ca/se
osteoradionecrosis 7to -e disc/ssed later8. Howe"er, c,emot,eray is a si*ni+icant
so/rce o+ mor-idity and mortality. Systemic infections resultin$ from the
immunosuppression are responsi4le for D:; of deaths follo3in$ chemotherapy,
Fort/nately, m/cositis occ/rs in only a-o/t &$E o+ t,e atients.
Osteoradionecrosis 7O!N8
Many serio/s comlications res/lt +rom radiation t,eray. 5,ese incl/de a ermanent
0erostomia wit, an accomanyin* accelerated caries and eriodontal disease
de"eloment, altered smell, dys,onia 7seec,8, maln/trition, trism/s, and
osteoradionecrosis. 1/t -y +ar, t,e most serio/s comlication is t,e otentially
dis+i*/rin* occ/rrence and treatment o+ osteoradionecrosis,
Osteoradionecrosis is ca/sed -y a destr/ction o+ t,e end arteries to the 4one that 3ere
in the radiation 4eam, 5,ere is a se"ere reduction or cessation o+ osteocyte and
osteoclast acti"ity.
&(
A ro/*, */ideline de+ines O!N as Fan area o+ e0osed necrotic
-one t,at ,as ersisted three months 3ithout si$ns of healin$F 7Fi*/re >>-&8. A more
otimistic "iewoint o+ osteoradionecrosis is t,at only :$E o+ all cases treated wit,
radiation de"elo t,e conditionD a more essimistic o/tlook is t,at t,e risk o+ O!N is
eret/al and contin/es to increase wit, t,e assa*e o+ time -eca/se t,e -lood s/ly
to t,e a++ected area never imro"es. As t,e total a-sor-ed dose o+ radiation to -one
increases, so does t,e likeli,ood o+ O!N de"eloin*. Any s/-se?/ent s/r*ical tra/ma
to t,e area, i.e., dental e0tractions, increases t,at risk. 1eca/se o+ t,e density and
red/ced -lood s/ly to t,e mandi-le, one st/dy +o/nd t,at t,e mandi-le was a++ected
more t,an t,e ma0illa -y a ;' to 'E mar*in.
&;
Since t,e conse?/ences o+ s/r*ical treatment o+ osteoradionecrosis are so de-ilitatin*,
prevention is the crucial therapy, 5,e conservative treatment consists o+ anal*esics,
anti-iotics, irri*ation and de-ridement 7remo"al o+ necrotic tiss/e8 and occasionally,
,yer-aric o0y*en t,eray.
'$-'>
Hyer-aric o0y*en t,eray 7H1O8 increases tiss/e
o0y*enation o+ t,e tiss/es -y administerin* :$$E o0y*en to t,e atient w,ile in a
ress/ri@ed c,am-er 7>.& atmos,eres8. Under t,ese conditions, tiss/e o0y*enation is
increased, w,ic, in t/rn romotes t,e ,ealin* rocess -y enco/ra*in* t,e +ormation
o+ a connecti"e tiss/e matri0 and capillary 4uddin$, Un+ort/nately, H1O is not
e++ecti"e as a sin*/lar t,erayand it is time-cons/min* and e0ensi"e.
4,en t,e necrotic -one o+ osteoradionecrosis is e0tensi"e, a**ressi"e s/r*ical
excision o+ t,e necrotic areas o+ten -ecomes necessarya s/r*ery t,at can -e
,ysically disfi$urin$ and disa4lin$,
5,e initial si*ns and symtoms o+ O!N incl/de constant, t,ro--in* ain, alon* wit, a
so+t tiss/e -reakdown o"er t,e necrotic -one. .ater si*ns and symtoms incl/de
s//ration, a +etid oral odor, ossi-le at,olo*ic +ract/res and oroc/taneo/s +ist/lae.
Attention to s/-tle oral c,an*es is re?/ired +or an early dia*nosis.
Dental Inter"ention, Cancer
I+ ossi-le, all needed dental s/r*ery +or t,e newly dia*nosed cancer atient s,o/ld -e
accomlis,ed prior to radiot,eray. All teet, wit, a ?/estiona-le ro*nosis s,o/ld -e
e0tracted, s/c, as t,ose wit, moderate-to-se"ere eriodontal disease, e0tensi"e caries,
imacted t,ird molars and irre"ersi-le /litis. In makin* a decision to e0tract or
retain teet,, consideration s,o/ld -e *i"en to t,e ast e"idence o+ t,e atient ,a"in*
maintained a +astidio/s le"el o+ la?/e control, o"erall ro*nosis, attit/des and
e0ected comliance wit, written and "er-al re"enti"e dentistry instr/ctions.
A+ter e0odontia t,ere s,o/ld -e a >:-day waitin* inter"al 4efore radiation since t,e
risk o+ de"eloin* O!N increases wit, a s,orter inter"al elasin* -etween s/r*ery
and radiation t,eray.
'ollo3in$ radiation, all dental care s,o/ld -e conservative, em,asi@in* endodontic
and ot,er toot, retention meas/res instead o+ e0traction. Un+ort/nately, re*ardless o+
t,e ade?/acy o+ sel+-care o+ t,e reser"ed teet,, t,e risk o+ O!N is perpetual, e"en
t,o/*, t,e risk e0ists only +or t,e osseo/s tiss/e t,at was wit,in t,e +ield o+ radiation.
!eco*ni@in* t,at atient comliance wit, oral care instr/ctions +ollowin*
radiot,eray is reorted to -e less t,an '$E, +re?/ent recalls are essential.
'=
!esearc,
to date ,as clearly s,own t,at ro/tine sel+-care ,y*iene meas/res com-ined wit, /se
o+ +l/oride t,eray l/s re*/lar dental monitorin*, si*ni+icantly red/ces t,e incidence
o+ ostradiation caries and t,e ro*ression o+ eriodontal disease.
'&
Fi*/re >>-& Massi"e mandi-/lar osteoradionecrosis secondary to ,ea"y 0-ray
irradiation +or eidermoid carcinoma in t,e Aaw. 7Co/rtesy o+ Dr. !o-ert ).
#o,nson, San Antonio, 5G.8
Cleft Palate
Cle+t alate is one o+ t,e most common o+ all -irt, de+ects, -/t "ery little is known o+
its ca/se.
''
Anatomically, it may in"ol"e eit,er t,e ri*,t or le+t, or -ot, t,e le+t and
ri*,t sides o+ t,e em-ryonic incisal -one and li, as well as t,e ,ard and so+t alates.
At t,e "ery minim/m t,ere mi*,t -e e"idence o+ only a sli*,tly -i+id /"/la. Genetics
,as -een -elie"ed to -e an imortant +actor in t,e de"eloment o+ cle+t liBcle+t alate
+or t,e ast <$ years, -/t no *enes ,a"e -een yet isolated.
'<
Se"eral en"ironmental
+actors ,a"e -een st/diedci*arette smokin*, alco,ol cons/mtion, or*anic sol"ents,
and anticon"/lsant dr/*swit, no concl/sions.
'%
5,ere is considera-le interest t,at /se o+ "itamin s/lements d/rin* t,e +irst &
mont,s o+ re*nancy mi*,t ,a"e a rotecti"e e++ect.
'(
Anot,er st/dy s/**ested t,at a
+olic acid de+iciency may -e resonsi-le +or di++erent mal+ormations t,ro/*, a
common mec,anism t,at inter+eres wit, em-ryonic de"eloment.
';
In 3/roe, : o/t o+ every D:: 4irths a cle+t alate is resent.
';
In t,e United States t,e
Centers +or Disease Control and )re"ention ,a"e listed it as aro0imately : in :,$$$
-irt,s wit, cle+t alate alone, and : in >,'$$ wit, cle+t li.
<$
As soon as ossi-le a+ter
t,e -irt, o+ t,e c,ild wit, t,e cle+t, t,e arents, t,e oral s/r*eon and a selected
ediatrician m/st -ecome in"ol"ed in immediate decisions relatin* to t,e roAected
lon* series o+ rimary, secondary and tertiary treatments t,at will -e needed to
ro"ide t,e c,ild wit, a li+e as near-normal as ossi-le. Co/nselin* s,o/ld incl/de a
-rie+in* wit, t,e arents a-o/t t,e +/t/re needs +or s/r*ery and re,a-ilitation
roced/res.
S/r*ical cle+t-li clos/re /s/ally commences as early as a*e = months, and cle+t alate
reair at C year, 4,en seec, -e*ins, t,e ad"ice and correcti"e actions o+ a ?/ali+ied
seec, t,eraist is essential to modi+y t,e ,yernasal seec, o+ a cle+t alate
indi"id/al as well as to ins/re t,e intelli*i-ility o+ t,e c,ildCs seec,. 5,e ne0t maAor
s/r*ery is at aro0imately H to C: years o+ a*e, w,en -one *ra+tin* may -e
emloyed to restore t,e ma0illary anterior al"eolar rid*e. A+ter t,e ,ealin* o+ t,e
anterior al"eolar rid*e s/r*ery, t,ere s,o/ld -e orthodontic corrections o+ t,e
mali*ned teet, and Aaws. Prosthetic aointments are needed to relace t,ose teet,
t,at are still missin*, or to -rid*e t,e cle+t +or -etter eatin*, -reat,in*, or seec,.
D/rin* t,is +irst decade o+ contin/al monitorin*, it is t,e resonsi-ility o+ t,e
ediatrician to ass/re t,at t,e c,ild remains well no/ris,ed and ,ealt,y. For e0amle,
ear in+ections are a ersistent ro-lem +or t,e c,ild wit, cle+t alate. On t,e ot,er
,and, t,e ediatric dentist is similarly c,ar*ed wit, contin/o/sly monitorin* risk +or
oral diseases, and takin* t,e necessary re"enti"e actions to a-ort onset o+ t,e la?/e
diseases.
<:
5,e cost o+ care o+ a cle+t alate case is considera-le and re?/ires o/tside ,el.
';
In
)isa, Italy, +or t,e ($$ c,ildren -orn wit, cle+tin*, t,e cost is ($ million 3/ros 7:
3/ros h KB- : dollar8, or f:$$,$$$ er c,ild. 5,is s/m is not e0,or-itant, w,en it is
considered t,at t,e +ollowin* mem-ers make / t,e li+etime Cle+t )late 5eam
resonsi-le +or t,e care o+ eac, cle+t alate -irt,9
An a/diolo*ist 7to assess ,earin*8
A s/r*eon, /s/ally a lastic s/r*eon, or an oralBma0illary s/r*eon, or a ,ead-and-
neck s/r*eon, or a cranio+acial s/r*eon, or a ne/ros/r*eon, 7to er+orm correcti"e
s/r*ery8
A ediatric or *eneral dentist, 7to re"ent and treat dental ro-lems8
A dental ,y*ienist, 7to ro"ide ro+essional dental re"enti"e care8
A rost,odontist, 7to ro"ide seciali@ed rost,eses8
An ort,odontist 7to ali*n t,e remainin* teet, rior to rost,etics8
A *eneticist, 7to screen atients +or cranio+acial syndromes and cons/lt arents
a-o/t t,e risk o+ ,a"in* additional c,ildren wit, cle+ts8
An otolaryn*olo*ist, 7to treat ear, nose, and t,roat ro-lems8
A ediatrician, 7to monitor o"erall ,ealt, and de"eloment8
A syc,olo*ist or ot,er mental ,ealt, secialist, 7to s/ort t,e +amily and assess
any adA/stment ro-lems8
A seec,-lan*/a*e at,olo*ist 7to assess and correct seec, and -reat,in* w,en
swallowin*8
A sc,ool co/nselor 7to aid in c,ildCs inte*ration into sc,ool and ed/cational
ro*rams.8
A social ser"ices e0ert 7to aid t,e +amily in sec/rin* +inancial ,el +rom
*o"ernment, ser"ices and +raternalBc,arita-le or*ani@ations8
Question 3
A. A c,ild -orn wit, a cle+t o+ t,e li and alate s,o/ld ,a"e -ot, s/r*ically corrected
a-o/t = mont,s a+ter -irt,.
1. 5,ere are more cle+ts o+ t,e li t,an o+ t,e ,ard alate.
C. Gerostomia is one o+ t,e symtoms o+ radiation dama*e to t,e sali"ary *lands.
D. 5,e identi+ication o+ a re- or early cancero/s lesion is mainly t,e task +or *eneral
ractitioners.
3. 5wo maAor ro-lem se?/ellae o+ radiation t,eray are osteoradionecrosis and
m/cositis.
Aids
Ac?/ired imm/ne de+iciency syndrome 7AIDS8 is a symtomatic in+ectio/s disease in
w,ic, lym,ocytesD seci+ically T helper lymphocytes (CDB cells8 are in"aded and
imaired -y a retro"ir/st,e ,/man imm/node+iciency "ir/s 7HI68. 5,e s/-se?/ent
$radual decline in t,e n/m-er o+ rotecti"e CD&-lym,ocyte cell o/lation res/lts
in an immunosuppression 7loss o+ e++ecti"eness o+ t,e -ody imm/ne de+enses8 t,at
laces t,e ,ost at risk +or opportunistic infections and cancers, Anot,er commonly
re+erred to lym,ocyte is t,e T2suppressor lymphocyte (CDF), 5,e two lym,ocyte
cell o/lations may act in s/ressin* HI6 in+ection until they can no lon$er
contain the virus,
5,e AIDS "ir/s is transmitted -y -lood and se0/al contacts and t,e rincial
contri-/tin* -e,a"iors are male-to-male se0/al acti"ity and arenteral dr/* a-/se.
Initially, t,e disease was con+ined mainly to t,ose articiatin* in t,ese acti"itiesD
,owe"er, t,e disease incidence is now increasin* in t,e ,eterose0/al o/lation
en*a*in* in /nrotected se0 wit, +emales at *reater risk o+ in+ection t,an males.
<>

HI6BAIDS was roAected to in+ect -etween ' and < million ersons worldwide -y t,e
year >$$$.
<>
)atients in+ected wit, t,e "ir/s are termed HI6-ositi"e 7HI6
K
8.
Followin* initial in+ection, HI6 atients may remain asymtomatic +or years d/rin*
"iral dormancy. Nearly all atients eventually de"elo symtoms t,at classically
consist o+ oort/nistic in+ections s/c, as ne/mocystitis carinii ne/monia,
a

Candida eso,a*itis, to0olasmosis, myco-acterial in+ections and
cytome*alo"ir/s.
<=,<&
)atients are considered to ,a"e ro*ressed +rom HI6
K
7H/man
Imm/node+iciency Syndrome8 to AIDS w,en t,e CD& lym,ocyte cell co/nt dros
-elow '$$ cells er milliliter o+ -lood.
-
Crossin* t,is t,res,old res/lts in atients
-ein* at increased risk o+ oort/nistic in+ections.
AIDS atients are at risk +or de"eloin* certain cancers and t,e de"eloment o+ t,ese
cancers si*nal a relati"ely poor pro$nosis for survival, 5,e most common cancer-like
disease de"eloed -y atients as a res/lt o+ HI6 in+ection is )aposi?s sarcoma 7Fi*/re
>>-'8,
<&
)atient mortality attri-/ta-le to AIDS is nearly C::; and is most o+ten t,e
res/lt o+ an opportunistic infection,
<=
.on*e"ity ,as -een increased -y t,e /se o+
Hi$hly ctive nti2Retroviral Therapy, a--re"iated HAA!5. HAA!5 is a treatment
w,ere a com-ination o+ anti-HI6 dr/*s/s/ally t,reeare administered e"en -e+ore
t,e symtoms o+ AIDS de"elo.
Some o+ t,e oort/nistic in+ections and cancers a++ectin* AIDS atients are
mani+ested orally, allowin* dental practitioners to lay a maAor role in dia*nosis,
atient monitorin*, and mana*ement. 5,e most common oral in+ection is
candidiasisa yeast infection, w,ic, a++licts %'E o+ all AIDS atients at least once
in t,eir disease co/rse. 5,e aearance o+ hairy leu*opla*ia, is anot,er mani+estation
o+ AIDS. It is a corr/*ated, w,ite, raised lesion located on t,e ton*/e.
<'
5,e
le/kolakia cannot -e wied o++. 5,e resence o+ t,is lesion aears to -e an acc/rate
predictor o+ ro*ression +rom -ein* HI6
K
to AIDS. Approximately FA; o+ atients
w,o de"elo ,airy le/kolakia are dia*nosed wit, AIDS 3ithin A: months, 5,is
-eni*n lesion does not re?/ire treatment and can /s/ally -e dia*nosed -ased on
clinical aearance wit,o/t t,e need +or -iosy.
<'
phthous ulcers are also common in
AIDS atients ran*in* +rom small, discrete lesions to lar*e den/ded areas. 2aosiCs
sarcoma aears as a +lat or raised, /rle to -rown lesion and occ/rs orally in >:; o+
all AIDS atients. 5,e lesions are most commonly seen on t,e hard palate and w,en
indicated, -iosy is s/**ested +or de+initi"e dia*nosis. 5reatment o+ t,ese lesions is
needed only w,en t,ey inter+ere wit, atient +/nction.
<&
Oral Non-Hod*kinCs
.ym,oma 7NH.8 is anot,er cancer w,ic, is increasin*ly seen in atients wit,
AIDS. NH. occ/rs as a so+t tiss/e mass, commonly on t,e alate or *in*i"a and may
e0,i-it /lcerations. 5,e occ/rrence o+ NH. si*nals a relati"ely poor pro$nosis, HI6
K

dental atients w,o de"elo oral candidiasis, ,airy le/kolakia, 2aosiCs sarcoma, or
NH. s,o/ld -e instr/cted to noti+y t,eir ,ysician. De"eloment o+ t,ese
comlications may indicate a need +or a c,an*e o+ medical treatment.
cute periodontal infections are common in AIDS atients. HI6 *in*i"itis aears as
an eryt,emato/s -and o+ in+lammation on t,e mar*inal *in*i"a t,at will not imro"e
wit, oral-,y*iene meas/res. HI6 eriodontitis is a raidly ro*ressi"e in+ection
c,aracteri@ed -y so+t tiss/e /lceration and necrosis, and loss o+ eriodontal
attac,ment. Clinically, t,e disease mimics acute necroti1in$ ulcerative $in$ivitis
7ANUG8. )resent treatment recommendations incl/de a**ressi"e scalin* and root
lanin* com-ined wit, c,lor,e0idine t,eray and anti-iotics. !arly treatment o+ t,e
HI6 *in*i"itis may re"ent t,e de"eloment o+ HI6 eriodontitis.
<<
5,e imm/no-comromised stat/s o+ t,ese atients re?/ires t,e same a**ressi"e
preventive aroac, to caries and eriodontal disease s/**ested +or cancer atients.
)otential so/rces o+ -acteremia s,o/ld -e de+initi"ely treated to re"ent t,e
de"eloment o+ an oral in+ection t,at t,reatens t,e atientCs systemic ,ealt,.
<%

Gerostomia is a common +indin* in HI6
K
atients. 5,e decreased sali"a rod/ction
may -e ca/sed -y HI6-associated *land disease or as a side e++ect o+ HI6
medications.
a
5,ere is no need to memori@e t,e names o+ t,ese diseases. 5,at will come in
)at,olo*y. #/st remem-er t,at an HI6 atient -ecomes more s/sceti-le to
oort/nistic diseases as t,e disease ro*resses +rom HI6 to AIDS.
-
5,e normal CD& co/nt ran*es +rom a-o/t <$$ to :<$$.
)ersecti"es, !esonsi-ilities, )atientCs and DentistCs !i*,ts
5,e AIDS eidemic t,at came to t,e +ore+ront in t,e :;($Cs ,as -een a "ery serio/s
disease c,aracteri@ed -y a "ery ,i*, deat, rate. In t,e +ield o+ dentistry, all dia*nostic
or treatment roced/res +or HI6BAIDS indi"id/als is frau$ht 3ith some de$ree of
dan$er for the dental team,
<(
5,e reort o+ se"eral years a*o t,at a Florida dentist ,ad transmitted t,e AIDS "ir/s
to si0 ersons ele"ated t,e in+ection-control roced/res o+ dentistry to /-lic
de-ate.
<;,%$
M/c, o+ t,e contro"ersy was ro-a-ly d/e to media reortin* t,at +a"ored
sensation o"er rational disco/rse.
%:
Howe"er, t,e de-ate -ro/*,t to t,e +ore+ront t,e
moral and le$al resonsi-ilities o+ t,e dentist to the patient, and vice versa, t,e
resonsi-ilities o+ t,e HI6BAIDS atient to t,e dental team. Anti-discrimination laws
restricted t,e a-ility o+ t,e ractitioner to control admittance o+ new atients, w,ile
t,e Occ/ational Sa+ety and Healt, Administration 7OSHA8 ,as +orced an /*rade in
t,e in+ection-control re?/irements o+ t,e dental o++ice.
%>
5,ere ,as -een worldwide concern o+ t,e /-lic t,at *oin* to t,e dentist is -eset wit,
t,e ossi-ility o+ transmission o+ t,e "ir/s ca/sed -y incomlete sterili@ation o+
instr/ments. 5,is concern ,as -een e0a**erated, -/t is not entirely -aseless. In Hon*
2on*, teac,ers and secondary-sc,ool st/dents were olled to determine risk
ercetions. Aro0imately one-,al+ o+ eac, *ro/ was concerned a-o/t contractin*
HI6 in+ection d/rin* dental "isits, w,ile <'E o+ t,e st/dents and '%E o+ t,e teac,ers
-elie"ed t,at a dentist did not ,a"e s/++icient knowled*e to identi+y AIDS atients.
%=
A mail ?/estionnaire st/dy was comleted in Denmark to determine t,e time, steam
and temerat/re settin*s /sed -y Danis, dentists to sterili@e instr/ments. At t,e end o+
t,e st/dy, it was concl/ded t,at =.&E o+ t,e a/tocla"es ,ad not oerated roerly.
%&
4it, t,e o/t-reak o+ a worldwide eidemic, dentists -e*an to /se additional disease
-arriers to rotect t,emsel"es and t,eir atientsoeratin* /ni+orms, *lasses, masks,
and *lo"es. Het t,ere aears to -e di++erences amon* t,e secialties in /se o+
rotecti"e de"ices. For instance, *eneral dentists o/ter+orm ort,odontists in /se o+
*lo"es 7;> to ('E8, masks 7%' to =(E8, eyewear 7(& to <$E8, *lo"es 7;> to ('E8 and
,eat sterili@ation o+ ,andieces 7(& to '%E8. Additional reca/tions were increased in
-ot, *ro/s w,en t,e atients were *no3n to ,a"e HI6BAIDS.
%'
It is not known ,ow many atients disclose t,eir HI6 stat/s in t,e atient ,istory
+ormone st/dy set t,e +i*/re at %$E. 4it, t,is =$E /ncertainty, dentists m/st
ro"ide ma0im/m recommended -arrier tec,ni?/es and sterili@ation roced/res on
t,e ass/mtion t,at any atient co/ld -e HI6 in+ected.
%<
One o+ t,e omniresent ,a@ards o+ dentistry is li"in* wit, t,e ossi-ility o+ needle2
stic* andBor cut inA/ries. 5,e act/al inA/ry ales in concern to t,e Fterror +actor,F real
or ima*ined, o+ contractin* a otentially let,al inA/ry.
%%
5,is syc,olo*ical e++ect is
imortant considerin* t,at <$E o+ t,e dentists in a Denmark st/dy reorted ,a"in* at
least one needle-stick or c/ttin* inA/ry d/rin* t,e re"io/s year.
%&
5,ere is a 4ias -y many dentists +or carin* +or HI6BAIDS atients.
%(
At times t,e -ias
,as -een ca/sed -y t,e concern o+ losin* non-HI6
K
atients w,o disco"er t,at
HI6BAIDS atients are -ein* treated in a ractice. At ot,er times it is ca/sed -y
socioc/lt/ral -iases. In a st/dy in #aan, %:E o+ t,e dentists s/r"eyed +elt as t,o/*,
t,ey ,ad a moral responsi4ility to treat HI6BAIDS atients, -/t only :<E were
3illin$ to treat HI6BAIDS atients.
%;
In se"eral st/dies it was -elie"ed t,at additional
ed/cation is needed to imro"e knowled*e and attit/des relati"e to t,e treatment o+
HI6BAIDS atients.
($
In a s/r"ey o+ dentists in .ot,ian, Ireland w,ere care is
mandated, t,e dentists considered t,at t,eir ro+essional -ack*ro/nd allowed t,em to
coe wit, disease transmission ro-lems in treatin* AIDS atients.
(:
As a +inal note +or t,ose worried a-o/t contractin* t,e disease +rom dental
ro+essionals, mit is wort,w,ile to ?/ote +rom an a-stract +rom a aer -y !o-inson
and de 1lienk9 F5,e risk o+ ac?/irin* ,/man imm/node+iciency "ir/s 7HI68 in+ection
+rom a ,ealt,-care worker is >,$$$ times less t,an t,at o+ dyin* +rom a car accident. It
is %$$ times less ro-a-le t,an eris,in* +rom -ein* str/ck -y li*,tnin* or s/++erin* a
+atal +all. Desite t,e rarity o+ t,e risk o+ ,ealt,-care-worker-to-atient, t,e
transmission o+ t,e disease in t,e worklace ,as -een t,e +oc/s o+ in"esti*ation -y
con*ressional, +ederal, state, and local a*encies. I+ all HI6 transmission +rom ,ealt,
care workers to atients were re"ented /sin* c/rrent */idelines and le*islation, t,e
eidemic o+ AIDS wo/ld -e red/ced -y $.$$$<E.F
(>
Fi*/re >>-' 5,is HI6
K
atient is e0,i-itin* a 2aosiCs Sarcoma on t,e ,ard
alate. 5,is lesion was treated wit, radiation to re"ent its enlar*ement.
7Co/rtesy o+ Dr. #e++ery .. Hicks, Uni"ersity o+ 5e0as Dental Sc,ool, San
Antonio, 5G.8
The Patient with Cardiovascular Disease
Cardio"asc/lar disease 7C6D8 is a term t,at em-races a varied array o+ cardiac
at,oses. Generally, C6D atients can -e s/-di"ided into 7:8 isc,emic ,eart disease
7IHDoor -lood s/ly to ,eart m/scle8, 7>8 myocardial in+arction 7MIscarred
,eart m/scle +rom re"io/s ,eart attack8, 7=8 ,yertension, 7&8 "al"/lar and con*enital
,eart disease, 7'8 dysr,yt,mias, 7irre*/lar and erratic /lse8 and 7<8 con*esti"e ,eart
+ail/re 7CHF-+ailin* ,eart m/scle8.
5,e +ollowin* t,ree sections on cardio"asc/lar disease, renal disease, and dia-etes
mellit/s is not meant to ro"ide a detailed acco/nt o+ t,e dr/*s and detailed treatment
modalities /sed in t,eir treatment. Instead, it is anot,er series o+ snas,ots o+ w,at
,aens in di++erent deartments o+ a ,ositaland are alica-le +or /se in a ri"ate
ractice.
3ac, year, more t,an ='$,$$$ ad/lt Americans die eac, year o+ s/dden cardiac arrest.
5,e +atal e"ent is /nredicta-le and can occ/r in atients wit, no ,istory o+ cardiac
disease or cardiac symtoms.
(=
C6D is t,e leadin$ cause o+ deat, in t,e United States
and is resonsi-le +or twice as many deat,s as cancer. Irresecti"e o+ t,e /nderlyin*
cardio"asc/lar ro-lem, all dental practices s,o/ld -e reared in case t,at a +atal
e"ents t,reatens or occ/rs in your office, and to one of your patients, 4aters and
ot,ers ,a"e laid o/t a at, t,at s,o/ld ,el reare +or s/c, a catastro,e. 5,e
reliminary reca/tions -e*in on t,e initial contact wit, t,e atient. At t,is time an
assessment is made o+ t,e stress tolerance o+ t,e atient. S/c, a tentati"e assessment
is made +ollowin* an inter"iew t,at e0ands on t,e in+ormation contained in t,e
atientCs medical and dental ,istory. S/c, details incl/de t,e rosecti"e atientCs
narration o+ ,ealt, stat/s, dr/*s -ein* taken, any ast ,eart attacks etc., +ollowed -y a
ossi-le cons/ltation wit, t,e atientCs cardiolo*ist. For dental le*al record /roses,
an in+ormed consent +orm s,o/ld -e comleted o/tlinin* t,e e0ected treatment, and
t,e e0ected comliance -y t,e atient.
(&
)rearin* +or an O++ice 3mer*ency
5,e dentist s,o/ld maintain a dr/* ca-inet stocked wit, c/rrent +res, dr/*s. All o++ice
ersonnel s,o/ld -e incl/ded in an emer*ency lanone t,at esta-lis,es w,o is to
call 3MS i+ necessary and w,o wo/ld sec/re t,e emer*ency dr/*7s8. It is ass/med
t,at t,e dentist wo/ld accomlis, t,e initial cardio/lmonary resc/sitation, i+
necessary. A mane/"er in"ol"in* t,e o++ice team s,o/ld -e re,ersed at inter"als to
ens/re an e++icient oeration i+ it is e"er necessary to initiate an act/al resc/e lan.
5,e 5yical Aoinment
All aointments s,o/ld -e shortless t,an an ,o/r i+ ossi-leand re+era-ly in
t,e mornin*.
5,e atientCs c,art is re"iewed to re+res, t,e memory a-o/t details o+ t,e atientCs
medical and dental -ack*ro/nd.
5,e treatment ,ase s,o/ld -e receded wit, t,e takin* o+ t,e atientCs -lood
ress/re. I+ it e0ceeds t,e systolic and diastolic limits s/**ested -y t,e cardiolo*ist,
t,e aointment s,o/ld -e terminated /ntil t,e -lood ress/re is wit,in t,e
esta-lis,ed limits. I+ t,e treatment is o+ emer*ency nat/re 7e0traction8, cons/ltation
wit, t,e cardiolo*ist is recommended.
3++ecti"e stress mana*ement may incl/de reoerati"e sedation wit, t,e decision
-ein* deendent /on t,e expected stress tolerance in,erent in t,e roosed
oeration. Stress tolerance is a $au$e of the heart?s a4ility to sustain additional
stress, )atients wit, oor stress tolerance 7and ,i*, risk8 incl/de t,ose wit, se"ere
,yertension, /ncontrolled cardiac ,eart +ail/re, se"ere dysr,yt,mias 7tac,ycardia,
a-normally +ast ,eart -eat and -radycardia, a-normally slow ,eart -eat8, or
,emodynamic insta-ility 7erratic -lood ress/re8, /nsta-le an*ina 7new onset o+ c,est
ains, ain at rest, ain t,at is oorly controlled wit, medication, or ain t,at ,as
recently c,an*ed c,aracter8. Se"ere ,yertension is c,aracteri@ed -y a diastolic
ress/re *reater t,an ::' mm o+ merc/ry, and a systolic -lood ress/re *reater t,an
>$$ mm. 5,ere are an estimated '( million cases o+ ,yertension in t,e United States,
wit, +ewer t,an 'E ,a"in* a c/ra-le ca/se. Many do not know t,ey ,a"e ,i*, -lood
ress/re, or its conse?/ences, 7/s/ally ,eart attack or stroke8 ,ence t,e term, Fthe
silent *iller,F
At t,e end o+ t,e aointment, i+ t,e atient ,as -een sedated, s,eB,e s,o/ld not -e
allowed to deart t,e o++ice /nless accomanied -y a care *i"er w,o can ,el t,e
atient in acti"ities s/c, as dri"in* or crossin* streets.
On t,e Day o+ t,e 3mer*ency
3"eryt,in* is *oin* alon* +ine, /ntil s/ddenly t,e atient comlains o+ a c,est ain.
5,e dentist immediately and correctly ceases t,e dental treatment. It is now / to
,imB,er to immediately assess t,e ro-lem and react to t,e emer*ency. 4,at is to -e
donee Not all c,est ains are a serio/s ,eart attack.
('
Not all ,yer"entilation ,eralds
a ,eart attack. 5,e dr/*s in t,e emer*ency ca-inet may -e s/++icientD ,owe"er, i+ t,e
dentistCs dia*nosis is t,at t,e ain is considered more serio/s, t,e 3MS s,o/ld -e
immediately contacted -y t,e o++ice ersonnel. 5,is is a time t,at t,e dentist stands
alone and m/st demonstrate decisi"e leaders,i as lanned in ast mane/"ers. In a
worst case scenario w,ere t,e ,eart ,as stoed, 7cardiac +ail/re wit,
/nconscio/sness8 cardio/lmonary res/scitation 7C)!8 is a-sol/tely necessary. It
m/st -e initiated immediately, wit, t,e stark reality t,at i+ t,e ,eart is not restarted in
a-o/t & min/tes, cere-ral ,yo0ia Aeoardi@es li+e contin/ance.
(<
Addin* to t,e crisis
is t,e +act t,at t,e c,ance o+ s/ccess towards *ettin* t,e ,eart restarted is red/ced -y
:$E +or e"ery min/te t,at asses. 5,ere is not s/++icient time to wait +or t,e arri"al o+
t,e 3MS to aly ad"ance res/scitation ossi-ilities, s/c, as t,e /se o+ t,e a/tomated
e0ternal de+i-rillator. 4it, its /se, an electrical s,ock to t,e ,eart m/scle o++ers a
m/c, -etter c,ance to restart ,eart action. Alt,o/*, dental o++ices do not /s/ally ,a"e
a need +or a de+i-rillator o"er t,e li+etime o+ t,e ractice, its early /se instead o+ C)!,
can mean t,e di++erence -etween li+e-or-deat,. )assen*er lanes carry de+i-rillators
+or assen*er emer*encies. 5,ey are /s/ally a"aila-le in lar*e *at,erin* areas s/c, as
sorts arenas and ind/strial clinics.
(=
Criti?/e
5,ere are se"eral ?/estions t,at can -e asked. 5,e most critical wo/ld ?/estion
w,et,er t,e dentist ,as t,e c/rrent le"el o+ trainin* needed to correctly assess t,e
se"erity o+ t,e case. A second ?/estion wo/ld -e, FS,o/ld all dental o++ices stock
de+i-rilators desite t,e +act t,at "ery +ew dentists e0erience a li+e-or-deat, sit/ation
d/rin* t,eir entire ro+essional careers.F 5,e t,ird ?/estion wo/ld -e, FI+ in t,e
estimation o+ t,e cardiolo*ist t,e "ictim is considered to -e a "ery ,i*, risk atient,
w,y was s,eB,e not re+erred to a ,osital wit, a dental cliniceF In s/c, a +acility,
monitorin* d/rin* t,e treatment is ro/tine, all emer*ency dr/*s are a"aila-le, and a
crisis team is a"aila-le wit,in min/tes o+ -ein* s/mmoned +or any emer*ency.
(%
3d/cation Needs o+ t,e Dentist
In t,e United 2in*dom, in :;;;, senior o++icers in oral and ma0illo+acial s/r*ery
e0ressed dissatis+action in t,eir trainin* in res/scitation.
((
5,ese were ro+essionals
wit, *rad/ate trainin*, workin* wit, daily ,i*, risk oerations. Het, o/r a-o"e dentist
was con+ronted wit, t,e same kind o+ critical decisions learned in a lect/re ,all some
ten- or- +i+teen years a*oor morein dental sc,ool. HeBs,e ,ad t,e leaders,i, -/t
not t,e academic -ack*ro/nd or e0erience to make t,e e0editio/s and in+ormed
decisions t,at were necessary. In "iew o+ t,e rarety o+ a li+e-or-deat, e"ent in any
dental o++ice, t,ere is a need +or an intensi"e re+res,er co/rse, m/c, as *i"en -y t,e
airlines to selected crew mem-ers to ro"ide de+i-rilator res/scitation o+ airline
assen*ers s/++erin* a ossi-le ,eart attack. Incl/ded in s/c, a co/rse s,o/ld -e a
re+res,er session on C)!, mainly -eca/se FAll ,ealt,care ro+essionals are e0ected
to -e cometent in cardio/lmonary resc/sitation.F
((
A Final TopicAntibiotic Prophylaxis
Once t,ere is an in"asi"e roced/re in"ol"in* -lood and ossi-le -lood -orne
-acteria, t,ere is t,e -asis +or a de-ate as to w,et,er anti-iotics s,o/ld -e
administered to at risk atients 7ro,ylactic anti-iotic co"era*e8. 5,is cate*ory o+
atients incl/des imm/nocomromised atients and end-sta*e or*an disease 7kidney,
li"er8, atients wit, certain cardio"asc/lar mani+estations 7,eart m/rm/r, rost,etic
"al"es8 and atients wit, rost,etic Aoint relacements. 5,e /rose o+ t,e anti-iotic
co"era*e is meritorio/s i.e., to *et t,e anti-iotic into t,e -lood stream to eliminate t,e
microor*anisms -e+ore t,ey reac, t,e tar*et or*anD and secondly to *et t,e anti-otic
into t,e tar*et or*an to eliminate any in"adin* or*anisms. Actin* on t,is common
sense -elie+, anti-iotics were /sed -e+ore all in"asi"e roced/res to re"ent in+ection.
Howe"er, wit, t,e e0tensi"e /se o+ anti-iotics, it was soon noted t,at se"eral strains
o+ -acteria -e*an to aear t,at were resistant to anti-iotics. It was not lon* -e+ore t,e
American Heart Association drew / some */idelines 75a-le >>-: and >>->8 listin*
seci+ic conditions +or w,ic, anti-iotics s,o/ld de+initely -e /sed, wit, ot,er
conditions le+t to t,e A/d*ement o+ t,e clinician. 5,ere are minor disa*reements wit,
t,ese */idelines, -/t +rom a ractical "iewoint 7t,e medicole*al "iewoint8 t,ere
aears to -e a consens/s to ro"ide ro,yla0ic anti-iotic co"era*e to at risk
atients /nder*oin* oral sur$ery, periodontal treatment, and implant placement,
Question 4
4,ic, o+ t,e +ollowin* statements i+ any, are correcte
A. )atients are considered to ,a"e deteriorated +rom HI6 to AIDS stat/s w,en t,e
la-oratory co/nt o+ t,e CD& lym,ocyte ,as decreased to less t,an '$$ cells er
milliliter.
1. As a sa+ety reca/tion, -arrier tec,ni?/es 7masks, *lasses, r/--er *lo"es, etc.8
s,o/ld -e /sed w,ile treatin* all atients on t,e common sense ass/mtion t,at all
atients are HI6BAIDS in+ected.
C. One o+ t,e -est indicators o+ atient risk, is t,e atientCs medical ,istory.
D. Anti-iotic ro,yla0is is re?/ired +or all cardio"asc/lar atients.
3. A de+i-rillator is more e++ecti"e t,an C)! in restartin* t,e ,eart a+ter ,eart +ail/re.
Renal Disease
!enal disease a++ects t,ree ercent o+ t,e United States o/lation, o+ w,ic, :>>,$$$
indi"id/als re?/ire ro/tine renal dialysis and aro0imately &$,$$$ ,a"e -een
reciients o+ kidney translants. !enal disease is di"ided into acute 7A!F8 and
chronic renal failure 7C!F8, t,e ca/ses o+ w,ic, co/ld incl/de ,yertension, dr/*
reactions, renal o-str/ction and dia-etes. 1eca/se A!F is an ac/te medical
emer*ency, atients wit, t,is ro-lem are not commonly enco/ntered -y dental
ractitioners and dental ,y*ienists in a ri"ate ractice settin*. C,ronic renal
+ail/realso called end2sta$e renal failure (!SRD), is /s/ally t,e res/lt o+ a
ro*ressi"e loss o+ renal +/nction t,at $radually destroys t,e ne,rons, 7w,ic,
accomlis, t,e "ital *lomer/lar +iltration8 and e"ent/ally ca/ses irre"ersi-le kidney
dama*e. Few symtoms are mani+est /ntil / to %' ercent o+ *lomer/lar +iltration
caa-ility is lost. 5,is loss o+ e++iciency o+ -lood +iltration and increased -/ild-/ o+
waste in t,e "asc/lar system a++ects every or$an in t,e -ody.
(;
5,e two treatments +or C!F are dialysis and *idney transplantation, One or t,e ot,er
is re?/ired or deat, ens/es. 5,e remo"al o+ wastes can -e accomlis,ed -y
hemodialysis and periotoneal dialysis, Dialysis is a alliati"e t,eray t,at maintains
li+e o"er a lon* and o+ten demorali@in* time as a atient waits till ,eBs,e reac,es t,e
to o+ a list to recei"e a donor kidney.
Hemodialysis in"ol"es a re?/irement to s/r*ically create a shunt w,ic, ser"es as a
ermanent access to t,e arterial and "eno/s "asc/lar systems. 5,e /s/al sites o+
lacement o+ t,e arterioB"eno/s s,/nt is in t,e forearm or upper arm, 1y connectin*
t,e ,emodialysis mac,ine to t,is access, t,e atientCs -lood can -e circ/lated t,ro/*,
a dialy@er /nit t,at acts as an arti+icial kidney and e0tracts t,e wastes +rom t,e
atientCs -lood 7Fi*/re >>-<8. &ine to C< hours o+ ,emodialysis is re?/ired each 3ee*,
/s/ally di"ided into t,ree sessions on alternatin* days 7M-4-F or 5-5,-S8.
Continuous am4ulatory peritoneal dialysis is a "ia-le otion +or atients wit, oor
"asc/lar accesses +or ,emodialysis, or w,o re+er t,is met,od o+ dialysis. In
contin/o/s am-/latory eritoneal dialysis, dialysate is laced into t,e a-domen
t,ro/*, a s/r*ically laced ermanent cat,eter and t,en drained a+ter & to < ,o/rs.
New dialysate is introd/ced a+ter t,e old is drained, so t,at dialysis can -e
contin/edi+ desired, t,ro/*,o/t t,e day and ni*,t,ence t,e term continuous, It
also ermits t,e atient to -e am4ulatory d/rin* t,e dialysis eriod t,at can -e
accomlis,ed at ,ome wit, less risk o+ in+ection.
;$
It is estimated t,at aro0imately
one t,ird o+ t,e Canadian c,ronic dialysis atients are on eritoneal dialysis.
;:
In contrast to dialysis, *idney transplants are t,e only means to normali@e kidney
+/nction. 5,ey also ro"ide a m/c, -etter oort/nity +or s/r"i"al t,an lon* term
,emodialysis.
;>
5,is em,asi@es t,e need +or early translantation once t,e dia*nosis
o+ 3S!D is made.
;=
5,e ro-lem is t,at t,e n/m-er o+ indi"id/als needin* dialysis is
*rowin* -y :$E to :'E er yearand t,ere A/st are not eno/*, donors.
;&
5,e donor so/rce +or renal translants can -e eit,er +rom an immediately deceased
corse 7cada"eric translant8, or +rom a li"in* donor 7allo*enic translant8. Allo*enic
translants are m/c, more s/ccess+/l. Once a s/ccess+/l kidney translant is in lace,
a life2lon$ imm/nos/ression dr/* re*imen is re5uired to minimi@e t,e ossi-ility
o+ or*an reAection.
Fi*/re >>-< )atient and Hemodialysis Mac,ine. An 3nd Sta*e !enal Disease
)atient is recei"in* dialysis treatment w,ile connected to a dialysis mac,ine. 5,e
atient is connected to t,e mac,ine "ia t/-in* laced into a s,/nt in t,e atientCs
ri*,t arm. 7Co/rtesy o+ Dr. #e++ery .. Hicks, Uni"ersity o+ 5e0as Dental Sc,ool,
San Antonio, 5G.8
Salient Systemic Signs and Symptoms of ESRD Anemia
DorlandCs medical dictionary de+ines anemia as FA red/ction -elow normal in t,e
n/m-er o+ eryt,rocytes er c/-ic mm., t,e ?/antity o+ ,emo*lo-in, or t,e "ol/mn o+
t,e acked cells er :$$ ml. o+ -lood.F 5,is de+inition so/nds innoc/o/sD ,owe"er,
one researc, *ro/ s/**ests a more omino/s connotation alica-le to t,e anemia o+
a dialysis atients, "i@., F4e s/**est t,ere is a trian*/lar relations,i, a "icio/s circle
-etween c,ronic ,eart +ail/re, c,ronic kidney ins/++iciency, and anemia w,ere eac, o+
t,ese t,ree can -ot, ca/se and -e ca/sed -y t,e ot,er.F
;'
5,ere are se"eral imortant contri-/tin* +actors to t,e de"eloment o+ an anemia o+ a
,emodialysis atient9 7:8 Many red cells are destroyed -y t,e ,emodialysis /nitD 7>8
t,ere is a de+iciency o+ erythropoietin 7a rotein t,at stim/lates red cell rod/ction8
and res/lts in a reduced output o+ eryt,rocytes8D and, 7=8 a lack o+ eryt,ooietin
needed +or normal +ormation o+ hemo$lo4in, A c,ronic or se"ere ,emo*lo-in
de+iciency is ,i*,li*,ted -y t,e res/lts o+ a st/dy o+ a *ro/ o+ ,emodialysis atients,
w,ere F5,e relati"e risk o+ deat, and ,ositali@a- tion are inversely associated wit,
,emo*lo-in le"els.F
;<
5,e loss o+ eryt,rocytes is increased -y 4leedin$, 5,is is a latelet ro-lem since t,ey
are essential in t,e clottin* rocess. )latelets can -e destroyed d/rin* ,emodialysisD
t,eir +/nction to a**re*ate 7clot8 can -e ne*ated -y t,e ,i*, -lood /rea content, or
clottin* can -e re"ented -y t,e resid/al resence o+ ,earin t,at is /sed d/rin*
dialysis.
!enal Osteodystro,y
!enal osteodystro,y
c
is a disorder o+ -one seen in t,e endsta*e o+ renal disease.
6itamin D is normally man/+act/red in t,e kidney, a so/rce t,at is lackin* in
ad"anced kidney disease. In its a-sence t,ere is a de+iciency o+ calci/m a-sor-ed
+rom t,e */t +or essential -ody +/nctions. 5o comensate, t,e arat,yroid *lands
secrete a ,ormone t,at ca/ses a wit,drawal o+ calci/m +rom -one. Howe"er, t,is
secondry ,yerarat,yroidism res/lts in any remodeled -one -ein* dystro,ic and
o+ten s/-Aect to sontaneo/s +ract/re. !enal osteodystro,y disease -e*ins relati"ely
early in t,e de"eloment o+ c,ronic renal +ail/re.
;%
It is a c,allen*e to t,e ne,rolo*ist to adA/st t,e medications to sim/ltaneo/sly
control t,e anemia, t,e de+icient mineral meta-olism o+ t,e 3S!D atient, and ot,er
emer*ency medical needs as t,ey arise. 5,e lac* o+ s/ccess is ,i*,li*,ted -y t,e
e0erienced mortality rates in atients wit, 3S!D t,at are :$-:$$ times t,ose wit,o/t
3S!D.
;(
c
Dystro,y h not normalD osteodystroy h dystro,y o+ -oneD renal osteodystro,y h
-one dystro,y o+ renal ori*in.
Hypertension
Hi*, -lood ress/re is considered a si*ni+icant risk +actor +or t,e de"eloment o+
3S!D. Also, ,i*, -lood ress/re ,as -een looked at as a ossi-le redictor o+
mortality +or ,emodialysis atients.
;;
Closely arallellin* t,is risk +actor is anot,er o+
interest +rom a dental "iewoint, namely t,at /ric acid mi*,t ,a"e a at,o*enic role in
t,e de"eloment o+ ,yertension, "asc/lar disease, and renal disease.
:$$
A +ew
decades a*o, American dentistry Aoined in t,e camai*n a*ainst ,i*, -lood ress/re
-y takin* t,e -lood ress/re o+ all atients -e+ore ro"idin* dental care.
Un+ort/nately, only an estimated 'E o+ t,ose w,o are in+ormed o+ t,eir ersonal ,i*,
-lood ress/re take acti"e stes to red/ce it as an important ,ealt, ,a@ard.
:$:
In+ection
In+ection is a constant comanion o+ t,e 3S!D atient. 5,e s,/nt t,at is a-sol/tely
necessary +or ,emodialysis is "/lnera-le to in+ection +rom -ot, wit,in 7-lood -orne
-acteria8 and +rom wit,o/t 7-acteria aro/nd t,e s,/nt8. As m/c, as '$E o+
,ositali@ation costs +or 3S!D is related to access ro-lems.
:$>
5,e in+ections t,at
occ/r are not a matter o+ A/st mor-idity, -/t also o+ ossi-le mortality. 5,e sol/tion is
to /se anti-iotics to coe wit, -lood -orne at,o*ens, and e0?/isite cleanliness and
,y*iene aro/nd t,e s,/nt area. A clinician s,o/ld make e"ery e++ort to a"oid
tra/mati@in* or in+ectin* t,is "ital arterioB"eno/s access str/ct/re. For instance, t,e
-lood ress/re s,y*nomometer c/++ s,o/ld never -e laced on t,is arm.
/nfection of dialysis patients 3ith hepatitis # and C viruses ran*es +rom >$-=$E. 5,e
ro-a-le so/rce o+ t,e in+ection is ro-a-ly +rom contaminated e?/iment and
nosocomial transmission.
:$=
1eca/se o+ t,e risk o+ transmission o+ t,e "ir/ses, a
cons/ltation wit, t,e atientCs rimary care ,ysician is recommended to determine
t,e atientCs in+ectio/s stat/s -e+ore -e*innin* dental care. Howe"er, 3ith
appropriate vaccines and universal infection control measures, the ris* to health care
3or*ers is minimal,
Anti-iotic )ro,yla0is
Anti-iotic ro,yla0is rior to any dental treatment +or a ,emodialysis atient t,at
ca/ses -leedin* 7calc/l/s remo"al, scalin*, and lanin*8 may 4e recommended to
a"oid in+ection o+ t,e s,/nt -y at,o*enic -lood -orne -acteria. 5,e decision
concernin* anti-iotic ro,yla0is s,o/ld -e 7ointly made -etween t,e dental
ractitioner and t,e atientCs ne,rolo*ist. Howe"er, anti-iotic ro,yla0is to re"ent
endocardidtis in t,e dialysis atient is no lon*er specifically recommended -y t,e
American Heart Association, t,/s lea"in* t,e decision / to t,e A/d*ment o+ t,e
ractitioner andBor t,e ne,rolo*ist.
Oral Manifestations of ESRD
5,ere are se"eral si*ns and symtoms o+ 3S!D t,at are -ot, o+ interest and imortant
to t,e dentist and t,e dental ,y*ienist. Most are d/e to t,e hi$h level of urea in the
saliva, 7Under normal circ/mstances, t,e /rea is +iltered o/t in t,e /rine -y t,e
,ealt,y kidney8. 5,e c,an*es in ,omeostasis t,at are attri-/ta-le to /rea are9 7:8 taste
c,an*es and -reat, malodor 7,alitosis8 d/e to t,e /rea in t,e sali"a -reakin* down to
ammoniaD 7>8 a ,i*,er sali"a H and -/++erin* caacity, also d/e to t,e ,i*, alkaline
/rea. Additional si*ns and symtoms o+ 3S!D incl/de9 a lower +low o+ stim/lated
and /nstim/lated sali"a, d/e to t,e e0cess loss o+ +l/id t,ro/*, t,e diseased kidneyD
-one dystro,ies seen in 0-rays, s/c, as a missin* lamina d/ra aro/nd t,e roots o+ t,e
teet, and a-normal tra-ec/lae 7t,e +ramework o+ -one8 t,at can -e traced to t,e
secondary ,yerarat,yroidismD allor o+ t,e oral m/co/s mem-rane, wit,
ecc,ymosis and etec,ia
d
t,at are all ca/sed -y t,e anemia.
d
3cc,ymosis h Area -leedin* -eneat, t,e m/co/s mem-rane or skinD )etec,ia h
)inoint -leedin* -eneat, t,e m/co/s mem-rane or skin.
Chronic Renal Failure and the Plaque Diseases
5,ere is a consens/s t,at t,ere is a lower re"alence o+ caries in a 3S!D o/lation.
N/nn et al +o/nd t,e re"alence o+ caries to -e low in t,e 3S!D atient.
:$&
It is
-elie"ed t,at t,e lower caries re"alence t,at is c,aracteristic o+ atients wit, 3S!D,
is d/e to t,e ,i*,er concentration o+ sali"ary 7alkaline8 /rea nitro*en. O-ry +o/nd t,e
/rea le"el in sali"ary analysis to -e ':= KB- >:$ m*B:$$ml prior to atient dialysis.
'ollo3in$ dialysis, t,e sali"a le"el droed to >&: KB- (> m*B:$$ ml. 5,ese +i*/res
are in contrast to ::$ KB- &( m*.B:$$ ml. +or t,e control *ro/.
:$'
It s,o/ld -e noted t,at in one st/dy a+ter t,e la?/e was e0osed to car-o,ydrate t,e
con+i*/ration o+ t,e Ste,an c/r"e +or -ot, 3S!D atients and t,e control *ro/
aralleled eac, ot,er, -/t -eca/se t,e H o+ t,e 3S!D *ro/ -ein* initially ele"ated,
t,e dro did not as o+ten reac, t,e critical le"el re?/ired +or deminerali@ation.
:$<
Miscellaneo/s Factors !elatin* to t,e Care o+ 3S!D )atient
Any ro/tine dental aointment +or a c,ronic renal +ail/re atient s,o/ld -e sc,ed/led
+or t,e day -e+ore, or t,e day a+ter ,emodialysis. 5,is olicy a"oids t,e ossi-ility o+
t,e atient comin* to t,e dental o++ice +rom one stress+/l aointment, to anot,er
e?/ally or more stress+/l e0erience.
I+ onset o+ t,e renal +ail/re -e*ins 4efore t,e de"eloment o+ t,e teet, is comleted,
t,ere is t,e ossi-ility o+ enamel hypoplasia and intrinsic stainin$ ca/sed -y t,e ,i*,
-lood le"els to /rea and relati"e calci/m de+iciency.
:$&,:$%
5,ese a-normalities
ro-a-ly date +rom t,e time o+ t,e onset o+ t,e 3S!D.
5,e intrinsic stain o+ any teet, ca/sed -y /remia cannot -e remo"ed wit, scalin* or
ro,yla0is 7t,e same as +or intrinsic stains o+ +l/oride and tetracycline8. 5,is is
-eca/se d/rin* t,e +ormation o+ t,e teet,, t,e stain comletely ermeates t,ro/*,o/t
t,e enamel.
I+ anti-iotic co"era*e is desired in order to re"ent in+ection o+ t,e s,/nt or ca/se
+/rt,er kidney dama*e, t,en t,e American Heart AssociationC recommendations
75a-le >>-:8 s,o/ld -e +ollowed. A simle way o+ ac,ie"in* anti-iotic co"era*e is to
,a"e t,e ne,rolo*ist administer intra"eno/s "ancomycin 7an anti-iotic8 at t,e time o+
dialysis. For dialysis atients, t,e d/ration o+ co"era*e o+ "ancomycin is
aro0imately '-to-% days, *i"in* t,e dental ractitioner amle time to er+orm any
needed dentistry.
:$(
)ost 5ranslantation Dental Concerns
A s/ccess+/l translant ,els normali@e daily acti"ity. Howe"er, t,e atient is
e0c,an*in* one ro-lem +or anot,er. In+ections are emer*in* as ca/ses o+ mor-idity
and mortality -eca/se o+ t,e li+elon* re?/irement +or daily imm/nos/ressi"e dr/*
t,eray to re"ent reAection o+ t,e kidney translants.
:$;
Followin* t,e kidney
translant, all dental treatment e0ected to cause 4leedin$ s,o/ld -e receded -y
anti-iotic ro,yla0is 7accordin* to t,e American Heart Association */idelines8.
Anot,er ro-lem *enerated -y t,e imm/nos/ressant dr/*s is hyperplasia o+ t,e
*in*i"a 7Fi*/re >>-%8. 5,ere is a =$ ercent incidence o+ *in*i"al ,yertro,y +or
atients takin* t,e s/ressi"e dr/*, cyclosorin A. 5,is side e++ect can -e minimi@ed
wit, scr//lo/s oral ,y*ieneD ,owe"er, i+ necessary, a *in*i"ectomy or *in*i"al +la
is o+ten needed.
::$,:::
O+ interest, in one st/dy t,e data s/**ested t,at +ollowin* a s/ccess+/l translant,
wit, t,e restoration o+ normal kidney +/nction, t,ere was a*ain an increased risk o+
caries.
:$<
5,ere are "ery +ew st/dies t,at oint o/t any seci+ic eriodontal ro-lems in
translant atients not enco/ntered -y normal indi"id/als. Once t,e dia*nosis o+
3S!D is made, it s,o/ld -e t,e resonsi-ility o+ t,e ne,rolo*ist to coordinate t,e
atientCs ,emodialysis sc,ed/le and medical care. 5,is sc,ed/le s,o/ld also incl/de
ro"isions +or an aroriate e"idenced--ased dental recall sc,ed/le to maintain as
,ealt,y eriodonti/m as ossi-le. 7C,ater >=8.
5,is need is well ointed o/t -y Na/*le et al. w,ere :$$E o+ 3S!D atients on
dialysis ,ad some +orm o+ eriodontal disease. Si0ty +o/r ercent dislayed a se"ere
*in*i"itis 7>(E8 or early eriodontitis 7=<E8. Na/*le also ointed o/t t,at t,ese two
eriodontal conditions reresent a -acterial +oci t,at can contri-/te to a -lood
in+ection t,at can increase a atientCs risk to mor-idity or mortality.
::>
As a +inal note, not all s/ccess+/l translants end ,aily. 5,ere are reorts o+
translants -rin*in* wit, t,em ro-lems t,at were art o+ t,e donorCs le*acy. 5,is
ossi-ility is co"ered in a sel+-e0lanatory article entitled, F!isk +or t/mor and ot,er
disease transmission -y translantation9 a o/lation--ased st/dy o+ /nreco*ni@ed
mali*nancies and ot,er diseases in or*an donors.F
::=
Fi*/re >>-% Se"eral imm/nos/ressi"e dr/*s taken to re"ent reAection o+ an
or*an translant, and some taken to s/ress sei@/res, rod/ce t,e same *in*i"al
o"er*rowt,. S/r*ery is indicted to remo"e t,e e0cess tiss/e, and atients m/st
e0ercise e0cellent oral ,y*iene to re"ent or delay re*rowt,. 7Co/rtesy o+ Dr.
#e++ery .. Hicks, Uni"ersity o+ 5e0as Dental Sc,ool, San Antonio, 5G.8
Diabetes Mellitus
Dia-etes mellit/s 7DM8 is a common endocrine disorder. It is estimated t,at
aro0imately C9 million Americans are a++licted wit, t,e diseasea n/m-er t,at is
roAected to dou4le -y >$:$. 5wenty ercent o+ U.S. citi@ens o"er <$ ,a"e DM.
::&
An
estimated '.& million o+ t,e :< million do not reali@e t,ey ,a"e t,e disease. 5,is is
/n+ort/nate, since early and contin/ed treatment ,els re"ent some o+ t,e disastro/s
conse?/ences o+ DM. 5,ese conse?/ences can ran*e +rom -lindness, to am/tations
o+ lim-s, eriodontal disease, renal +ail/re, ,yertension, ne/roat,y, cardio"asc/lar
disease and a $reat red/ction in t,e ?/ality o+ li+e. A+rican Americans, Hisanics and
American Indians are esecially s/sceti-le to dia-etes.
::'
Dia-etes mellit/s is ca/sed -y an ins/++icient s/ly o+ ins/lin -eca/se o+ eit,er a
lack o+ rod/ction -y t,e islet cells of the pancreas, a de+icit o+ ins/lin recetors, or
an error in ins/lin meta-olism 7ins/lin resistance8. Ins/lin is t,e key t,at allows t,e
-lood *l/cose to enter t,e -ody cells to provide for ener$y needs, 4it,o/t it, t,e -ody
cells are literally star"in* +or t,e ener*y-*i"in* *l/cose, w,ile A/st o/tside in t,e
-lood s/ly t,e needed *l/cose contin/es to -/ild / to to0ic le"els in t,e -lood and
sill o"er into t,e /rine.
5,ere are two main s/- classi+ications o+ DM, 5ye :, and 5ye > 7-ot, wit, Ara-ic
n/merals, not !oman n/merals8. 5ye : is o+ten t,e res/lt o+ *enetic omission, or as a
res/lt o+ an a/toimm/ne destr/ction o+ t,e ancreatic -eta cells early in life, 1y t,e
time t,e disease is identi+ied / to ($E o+ t,e -eta cells ,a"e /s/ally -een destroyed.
Aro0imately '-:$E o+ t,e cases o+ dia-etes are in t,is cate*ory.
For *lycemic control o+ 5ye :, exo$enous insulin is a4solutely necessary to
maintain life, 5,is ins/lin is sel+-inAected -y t,e atient t,ro/*,o/t li+e, or is
a/tomatically disensed -y a straed-on ins/lin /m 7Fi*/re >>-(8. 5,e /m
a/tomatically senses a c,an*in* le"el o+ *l/cose in t,e -lood, and adA/sts t,e dose
accordin*ly.
5ye > /s/ally de"elos later in life and is o+ten associated wit, over3ei$ht and
relati"ely inactive individuals, Aro0imately ;$-;'E o+ t,e cases +all into t,is
cate*ory. O+ten 5ye > DM can -e controlled -y a com-ination o+ e0ercise, diet
andBor oral ,yo*lycemic a*ents.
::<
1ot, tyes can -e reco*ni@ed -y t,e resence o+
t,ree clinical si*ns9 polyuria 7+re?/ent /rination8, polydipsia 7+re?/ent /r*e to drink8,
and polypha$ia 7+re?/ent /r*e to eat8. A ositi"e dia*nosis o+ DM /s/ally +ollows a
,ysicianCs clinical e0amination t,at is "eri+ied in ro/tine -lood tests as an e0cess o+
*l/cose, or in /rine tests wit, t,e resence o+ *l/cose. 5ye : is increasin* slo3ly in
n/m-ers. On t,e ot,er ,and, t,e n/m-er o+ 5ye > dia-etics is escalatin* rapidly and
is e0ected to dou4le -e+ore >$:$.
::&
Many in t,e news media and /-lic ,ealt, call it
an epidemic,
5,e !elations,i o+ Dia-etes Mellit/s to t,e C)I5N
I+ t,ere is a relations,i -etween t,e le"el o+ -lood ser/m *l/cose and eriodontitis,
t,en a ,i*, *l/cose le"el +or an indi"id/al s,o/ld ,a"e a si*ni+icant arallel ,i*,
C)I5N score. 5,ere are two st/dies t,at "eri+y t,is ass/mtion.
A lar*e-scale st/dy in"ol"in* :$,';$ s/-Aects in Israel c,arted a-normal -lood
*l/cose 7le"els o"er :>$ mlBdl8 wit, ele"ated C)I5N scores o+ a-o"e &.'.
::%
In t,e
second smaller st/dy o+ &$ s/-Aects>$ wit, dia-etes, and >$ control s/-Aects. It was
+o/nd t,at t,ere was a steady increase in -lood ser/m *l/cose 7:&>-:%= m*Bdl8 t,at
aralleled t,at o+ an increasin* C)I5N score 7:=.'-:;.:8.
::(
)eriodontal Disease and Dia-etes Mellit/s1i-Directional Diseases
In re"iewin* t,e literat/re, t,ere is a consens/s t,at eriodontal disease ,as an ad"erse
e++ect on t,e se"erity o+ DM, and "ice "ersa t,at t,e se"erity o+ DM ,as an ad"erse
e++ect on t,e se"erity o+ eriodontal diseasea 4i2directional relations,i 7Fi*/re >>-
;8. 5,e -i-directional etiolo*y si*nals t,e need +or cooeration -etween t,e medical
and dental ro+essions, as ec,oed in t,e +ollowin* statements.
::;
Statement: Poorly controlled dia4etics ,a"e a $reater incidence o+ se"ere
eriodontal disease comared wit, t,ose atients w,o are well controlled or ,a"e no
dia-etes mellit/s.
:>$
Statement: )eriodontitis is a common ro-lem in atients wit, dia-etes. 5,e
relationsi -etween t,ese > maladies aears -i-directionalinso+ar t,at t,e resence
o+ one condition tends to romote t,e ot,er, and t,at metic/lo/s mana*ement o+ eit,er
may assists treatment o+ t,e ot,er.
:>:
Statement: New e"idence s/**ests t,at ad"anced periodontal disease may interfere
3ith dia4etes mellitus control and t,e ,ysician s,o/ld -e made aware o+ t,e atientCs
eriodontal stat/s.
:>>
Statement: Not only does dia-etes a++ect t,e eriodonti/m, -/t eriodontal in+ection
can ad"ersely imact *lycemic control in dia-etics.
:>=
Statement: 3?/ally imortant is t,e +act t,at t,ere are no st/dies o+ acceta-le desi*n
t,at re+/te t,is -i-directional relations,i -etween eriodontal disease and DM.
:>&
In :;;; and a*ain in >$$$, t,e American Academy o+ )eriodontolo*y iss/ed osition
aers a-o/t t,e relations,i o+ dia-etes and eriodontal diseases.
:>',:><
5,ese two
osition aers oint o/t t,at t,ere is a relations,i -etween t,e two diseases and t,at
all atients s,o/ld -e in+ormed o+ t,at relations,i, esecially w,ere eriodontal
disease mi*,t increase t,e risk o+ DM comlications and "ice "ersa.
Caries
5,eoretically, t,ere is a -asis +or either a decreased or increased caries re"alence +or
5ye : dia-etics. Normally, i+ t,ere is a *ood sel+-care 7wit, an e++ecti"e mec,anical
and c,emical la?/e control re*imen8, t,ere is a lower co/nt o+ cario*enic or*anisms
and a lower DMFS. I+ t,ere is a diet wit, minim/m car-o,ydrate t,ere is a lower
caries incidence. Anot,er moderator is t,e +low o+ sali"a, wit, an in"erse relations,i
-etween +low rate and caries de"eloment. A look at se"eral st/dies is necessary to
determine w,at +actor7s8 are most determinant +or t,e caries.
5wetman et al. a+ter a t,ree year st/dy wit, adolescents o+ (-:' years o+ a*e,
concl/ded t,at t,e main most influencial determinants for hi$h caries development
over the period of the study 3ere meta4olic control, oor oral ,y*iene, re"io/s caries
e0erience and ,i*, le"els o+ lacto-acilli. lso there 3as a hi$her $lucose in the
restin$ saliva,
:>%
Ot,er researc,ers ,a"e eit,er con+irmed or added to t,ese +indin*s. For instance9
Statement: Poor control of dia4etes was +o/nd to -e associated wit, caries.
:>(
Moore et al. con+ined t,eir st/dies to t,e +low o+ sali"a, and reorted t,at dry mo/t,
70erostomia8 was more re"alent in dia-etics t,an in t,e control s/-Aects, wit, more
comlaints +rom dia-etics wit, poor meta4olic control,
:>;
Gerostomia in dia-etic atients is /s/ally secondary to t,e de,ydrational e++ects o+ t,e
disease rocess itsel+. Greater amo/nts o+ +l/ids are eliminated "ia t,e /rine 7oly/ria8
and less is a"aila-le +or t,e sali"a. 5,/s, t,e aroriate t,eray +or 0erostomia o+
DM ori*in is to restore insulin 4alance,
:=$
In anot,er st/dy, ,ome care ractices were similar, and all s/-Aects ,ad recei"ed
similar re*/lar dental treatment. In concl/sion, it 3as poor meta4olic control of
dia4etes that 3as found to 4e associated 3ith caries,
:=:
5akin* all re"io/s statements
into acco/nt, it is oor *lycemic control t,at acco/nts +or t,e e0cess re"alence and
se"erity o+ t,e la?/e diseses.
First Aointment
3"ery dental o++ice will treat dia-etes atients.
:>>
Uon admittance, t,e atient will -e
asked to +ill o/t a ersonal medical and dental ,istory +or t,e /se o+ t,e dentist and t,e
dental ,y*ienist
5,e +irst aointment s,o/ld ,a"e two maAor o-Aecti"es. 5,e +irst s,o/ld -e to
esta-lis, raort wit, t,e new atient, and t,e second is to learn more a-o/t t,e
dia-etic -ack*ro/nd o+ t,e atient. As t,e inter"iew /n+olds, any critical in+ormation
s,o/ld -e added to t,e medical and dental ,istory record. 5,is wo/ld incl/de
in+ormation on dosa*e, time sc,ed/les, met,od o+ administration, re"io/s ad"erse
e0eriences wit, ins/lin control, n/m-er o+ ,ositali@ations, and ,ysician
recommendations.
At t,is time, t,e dentist s,o/ld care+/lly e0lain t,e relations,i -etween DM and
eriodontal disease. Accordin* to an article -y S/nd-er*, (=E o+ t,e DM atients
were not aware o+ t,e linka*e -etween t,e systemic and t,e oral disease. It is
necessary t,at t,e atient s,o/ld know in t,e -e*innin* t,at t,ere will -e many "isits
to t,e dentist +or ro,yla0es, monitorin* and ossi-le eriodontal treatment, t,at in
t/rn will ,el maintain meta-olic -alance in t,e medical treatment.
:=>
Anot,er salient ed/cational item is t,e s/-Aect o+ smokin*. I+ t,e atient smokes or
/ses smokeless to-acco, cessation is re?/ired i+ eriodontal ,ealt, is to -e maintained.
In comarin* t,e e++ects o+ smokin* on dia-etic and non-dia-etic men, it was +o/nd
t,at t,e arameters /s/ally assessed +or eriodontal diseasela?/e inde0, *in*i"al
inde0, -leedin* score, ro-in* det,, loss o+ attac,ment, and missin* teet, were all
*reater +or t,e dia-etic men.
:==
It is co/nterrod/cti"e and ridic/lo/s +or a eriodontist
to treat a disease, i+ at t,e same time t,e s/-Aect is racticin* a ,a-it t,at is 4loc*in$
t,e e++ect o+ t,e treatment. 7See C,ater := +or a +/ll disc/ssion o+ t,e ad"erse e++ect
smokin* ,as on t,e eriodonti/m.8 Anot,er reality is t,at i+ smokin* contin/es, t,ere
is an increased risk +or cardio"asc/lar disease t,at is one o+ t,e serio/s conse?/ences
o+ dia-etes mellit/s. 4it, t,e a-o"e ed/cation and co/nselin* comlete, ro/tine
treatment aointments can -e made.
!o/tine Aointments
4,en t,e known DM atient arri"es +or any aointments it is wise to determine
w,et,er s,eB,e ,as ,ad t,eir rescri-ed ins/lin dosa*e and w,en t,e ne0t dosa*e is
d/e. 1e+ore treatment -e*ins, t,e -lood ress/re needs to -e recorded. I+ any s/r*ery
is contemlated, cons/ltation wit, t,e atientCs ,ysician is desira-le since t,e
ossi-ility o+ in+ection is omniresent. 5,ere is always an increased suscepti4ility to
infection o+ so+t tiss/e as well as a delayed healin$ of 3ound sites, 5,is increased
,a@ard is ro-a-ly d/e to t,e ,i*, content o+ *l/cose in t,e so+t tiss/es t,at is ideal
+or -acterial *rowt,. It is -eca/se o+ t,is increased risk o+ -lood -orne -acteria t,at all
oral s/r*ery 7incl/din* eriodontal treatment8 s,o/ld -e accomlis,ed wit, anti-iotic
ro,yla0is.
:>>,:=&
5,e First DM 3mer*encyt,e Hyo*lycemic 3isode
5,e most common emer*ency is t,e Hypo$lycemic !pisodean /ne0ected decline
in t,e -lood *l/cose le"el. 5,is is mani+est -y t,e atient +eelin* weak, e0,i-itin*
mood c,an*es, inco,erence, sweatin*, and tac,ycardia. All oerati"e roced/res
s,o/ld cease, and t,e atient immediately $iven a fast actin$ oral car4ohydrate from
the emer$ency ca4inet*l/cose ta-lets or *el, candy, A/ice +ollowed -y a
determination o+ t,e *l/cose le"el.
e
5,is can -e determined easily wit, a relati"ely
economic electronic *l/cose monitor, w,ic, is ?/ite acc/rate. I+ t,ere is no aarent
ro*ress a+ter :$ min/es, reeat in*estion o+ t,e +ast actin* car-o,ydrate. /f there is
recovery, t,e atient s,o/ld eat a snack or a meal to re"ent a re-o/nd to t,e
,yo*lycemic state. I+ t,ere is no aarent ro*ress, t,e ;:: ,one call s,o/ld -e
made, since wit, +/rt,er delay, t,e symtoms -e*in to -ecome
omino/s/nconscio/sness, low -lood ress/re, ,yot,ermia, sei@/res, coma and
deat,.
:=',:=<
e
Dia-etic mellit/s atients o+ten carry a s/ly o+ +ast actin* car-o,ydrate a*ents o+
t,eir c,oice. A so+t drink 7not a dietetic drink will o+ten s/++ice.8
A Day in t,e .i+e o+ a Dia-etic
.ike +or any ot,er disease dia*nosis, comliance wit, an attendin* ,ysicianCs ad"ice
can -e e0ected to ran*e +rom +/ll to minimal cooeration. For t,e dia-etic, *lycemic
control and ,isB,er *eneral ,ealt, stat/s directly deend on t,is comliance. And w,at
does t,is comliance entaileeee
3"ery mornin*, it will in"ol"e a fin$er stic* to sec/re a dro o+ -lood to determine t,e
-lood *l/cose le"el, /sin* an electronic *l/cose monitor. I+ t,e -lood *l/cose le"el is
low, a decreased ?/antity o+ ins/lin is necessary. I+ -reak+ast is to incl/de
considera-le more car-o,ydrate t,an normal, t,e amo/nt o+ ins/lin m/st -e increased.
From & to ( +in*er sticks a day is re?/ired to determine i+ *l/cose le"els are remainin*
wit,in re esta-lis,ed le"els. A well controlled dia-etic attemts to maintain a -lood
*l/cose le"el o+ %'-:>' m*Bdl. Additional +in*er sticks are necessary -e+ore e"ents
s/c, as dri"in* a car 7sa+ety8 or -e+ore aointments 7dental8 to maintain a reasona-ly
normal *l/cose -lood le"el o"er t,e time to -e in"ol"ed. For some F-rittleF dia-etics
w,ere t,e ins/lin le"els are erratic and /nredicta-le, ni*,t +in*er sticks may -e
necessary. Fin*er sticks and ,yodermic sel+-administration o+ ins/lin -ecome a
monotono/s way o+ li+e. Howe"er, t,ey are a4solutely necessary day2in2and2day2out
over the remainin$ years of life, 4,en t,e enormity o+ t,is daily task is +/lly reali@ed,
t,e /nceasin* s/ort o+ a so/se, o+ t,e +amily, ot,er dia-etics, and t,e attendant
medical comm/nity ,els to 4rid$e the discoura$ement of the unendin$ tas*s
necessary to preserve life,
For t,ose dia-etics w,o ,a"e an ins/lin /m, t,e dosa*e is re-ro*rammed -y t,e
endocrinolo*ist to inAect ins/lin se"eral times a day into t,e a4dominal cavity. 5,ere
is s/++icient ins/lin in t,e /m reser"oir +or at least t,ree days. 5,e wearer m/st
release additional ins/lin +or any increased intake o+ car-o,ydrates or emer*ency. In
addition, e"ery t,ird day, t,e atient m/st re+ill t,e /m reser"oir, accomlis, skin
,y*iene o+ t,e entry oint, and relace t,e small cat,eter connectin* t,e /m to t,e
a-dominal ca"ity.
For any dia-etic, t,e ,oly *rail is a c/re t,at will eliminate t,e need +or t,e reetitio/s
+in*er sticks and sel+- or /m-administered ins/lin. 4orld-wide researc, ro*rams
to ac,ie"e s/c, a c/re a-o/nd. As reorted in an e0cellent article in t,e New Horker
ma*a@ine, ancreatic cells ,a"e -een imlanted into ,/mans t,at rod/ce t,e needed
ins/lin.
:=%
Howe"er, to o++set t,is o/tstandin* ac,ie"ement, ,as -een t,e +act t,at t,e
a"aila-ility o+ donor islet cells 7+rom ancreases8 is minisc/le in relation to t,e
tremendo/s need.
:=(-:&$
Het, it is a "ery romisin* -e*innin*, e"en t,o/*,
imm/nos/ressi"e dr/*s are still re?/ired.
5,e most romisin* re"enti"e ro*ram t,at is immediately a"aila-le as well as
a++orda-le +or all a*es is a ersonal cr/sade o+ healthy eatin$, daily physical exercise,
and maintainin$ a normal 3ei$ht.
Fi*/re >>-( Ins/lin )/m. 4orn -eneat, t,e clot,es, t,is ins/lin /m is dri"en
-y an internal com/ter t,at can -e ro*rammed to inAect seci+ic amo/nts o+
ins/lin at seci+ic times. More acc/rate *l/cose control is ossi-le wit, t,e
/m t,an wit, t,e tyical > or = man/al inAections er day. 7Co/rtesy o+ Dr.
#e++ery .. Hicks, Uni"ersity o+ 5e0as Dental Sc,ool, San Antonio, 5G.8
Fi*/re >>-; )eriodontal disease as art o+ t,e Dia-etes Mellit/s ro-lem.
30amination and -lood *l/cose testin* o+ t,is atient wit, Dia-etes Mellit/s,
5ye >, re"ealed se"ere eriodontitis and ,yer*lycemia. 5,e atient admitted to
o-ser"in* oor *l/cose control and to -ein* c,ronically ,yer*lycemic.
7Co/rtesy o+ Dr. #e++ery .. Hicks, Uni"ersity o+ 5e0as Dental Sc,ool, San
Antonio, 5G.8
Question 5
A. 5,e sali"a /rea content o+ t,e a"era*e 3S!D atient -e+ore ,emodialysis is a-o/t
twice as ,i*, as a 3S!D atient /nder*oin* ,emodialysisD in t/rn, t,e sali"a content
o+ t,e atient /nder*oin* ,emodialysis is ro/*,ly twice as ,i*, as a non-dia-etic
control.
1. Dental +oci o+ in+ection can dama*e eit,er t,e s,/nt /sed +or ,emodialysis, or t,e
translant t,at relaces t,e need +or ,emodialysis.
C. Dia-etes mellit/s is c,arcteri@ed -y an ins/++icient amo/nt o+ *l/cose wit,in t,e
cell mem-ranes, and an e0cess o+ *l/cose in t,e -lood s/ly o/tside t,e cell
mem-ranes.
D. 4it,o/t a relati"ely contin/o/s *lycemic control in DM, an /ncontrolled
eriodontitis can -e anticiated.
3. 5,e s/ccess+/l translantation o+ islet cells still re?/ires imm/nos/ressi"e dr/*s.
Summary
5,e +irst art o+ t,is c,ater ro"ided an o"er"iew o+ t,e o-Aecti"es and t,e
administration o+ a ,osital. 5,e second ,al+ related to some o+ t,e diseases t,at are
-ein* treated daily in a ,osital. Most +r/stratin*, in many cases re"ention racticed
-e+ore admission co/ld ,a"e a-orted t,e onset o+ t,e rimary comlaint. 5o cite a +ew
e0amles9 7:8 in t,e case o+ +acial cancer 7-asal cell8 t,e etiolo*y ro-a-ly was
e0cessi"e e0os/re to t,e s/n in earlier days 7and still contin/es wit, a *eneration t,at
-etter /nderstands t,e conse?/ences8. 7>8 For many, t,e more deadly intra oral cancer
7s?/amo/s cell8 co/ld ro-a-ly ,a"e -een a"oided -y reAectin* t,e earlier /se o+
to-acco rod/cts 7smokin* and c,ewin* to-acco8. 7=8 Anot,er +ail/re in cancer
re"ention occ/rred w,en t,e indi"id/al +ailed to seek ro+essional ad"ice +or t,at
small m/cosal /lcer t,at wo/ld not ,eal, -/t only enlar*ed in si@eD or, 7&8 t,e lesion
co/ld ,a"e -een missed -y t,e dentist in t,e last dental e0amination 7i+ t,e erson ,ad
access to a dentist8. Anot,er e0amle o+ t,e need +or close cooeration -y
Deartments in t,e ,osital is ill/strated -y t,e need +or *lycemic control -y t,e
dia-etic atient. 5,is control re?/ires t,e com-ined e++ort -y kidney secialists,
endocrine e0erts, t,e eriodontist. and ot,er secialists to care +or t,e comlications,
i+ and w,en t,ey are dia*nosed. 5,e end res/lt o+ t,is cooeration, is -etter ,ealt,,
and a -etter li+e +or t,e dia-etes mellit/s atient. DM is tr/ly an e0amle o+ a -i-or-
m/lti directional diseasek
In dealin* wit, diseased, tra/mati@ed, and mental and ,ysically ,andicaed
atients, t,ere is always t,e concern +or t,e /ne0ected. All ,osital ser"ices ,a"e
lans to react to most emer*encies, ran*in* +rom /se o+ emer*ency dr/*s to crisis
teams t,at resond immediately w,en ad"anced res/scitation roced/res are re?/ired.
In all o+ t,ese resonses, someones li+e is o+ten in -alance. 3"en /nder t,e -est o+
circ/mstances, t,e o/tcome is ne"er */aranteed. In ri"ate ractice, it is only a rare
e"ent s/c, as t,e ,yo*lycemic eisode t,at arises. Occasionally +or some dentist in
t,e United States a more serio/s emer*ency occ/rs. HeBs,e is resonsi-le +or
dia*nosin* and reactin* to t,e emer*ency. 5,e reaction m/st -e immediate and
correct. .ike +or t,e crisis team, it is an awesome resonsi-ility, and t,e conse?/ences
can also -e catastro,ic, e"en t,o/*, t,e resonse mi*,t ,a"e -een correct.
For re"ention o+ t,e la?/e diseases in systemic disease, t,e */idelines o/tlined later
in C,ater >= aly. For sel+-care +or most caries or eriodontal atients, it is t,e
/s/al need +or mec,anical la?/e control wit, t,e F-r/s,, +loss, and +l/s,F ro/tine,
co/led wit, c,emical la?/e control+l/oride mo/t,rinses and aroriate /se o+
c,lor,e0idine 7or ot,er antimicro-ial a*ents8 to red/ce t,e ossi-ility o+ caries and
*in*i"itis. It is not di++ic/lt to +i*/re w,at is to -e done, -/t instead, ,ow to moti"ate
indi"id/als to do t,em. 5,e main "aria-le e0erienced in contin/in* care o+
c,onically ill atients, is t,e time inter"al -etween recalls +or ro,yla0es and
monitorin* to a"oid t,e need +or secondary and tertiary re"ention roced/res. A
second c,allen*e is t,e ?/estion o+ ,ow to -est deli"er re"enti"e care to indi"id/als
w,o need ,el wit, sel+-cares/c, as t,e arm am/tees, t,e /nconscio/s, +acial
+ract/res, w,ere t,e mandi-le and ma0illa are wired to*et,er, and t,e mentally
,andicaed.
It is not lon* -e+ore a dentist in a ,osital en"ironment learns t,at dentistry does not
end at t,e t,ird molar. 5,is c,ater ,as ointed o/t ,ow systemic disease can
mod/late oral disease, and "ice "ersa. In t,e case o+ renal disease, t,e accomanyin*
/remia can e"en -ene+it caries controlk
Hosital dental ractice is now -ecomin* an alternati"e dental career to t,e resent
otions o+ ri"ate ractice, academia, t,e military and /-lic ,ealt,. It is an e0citin*,
c,allen*in* ro+essional career o+ contin/al learnin* +rom collea*/es and ersonal
e0eriences. It is also a maAor contri-/tion o+ t,e ro+ession to ins/re -etter dental
care +or t,e disa-led and diseased as well as +or t,e ,ealt,y.
Finally, as a sta++ mem-er o+ t,e ,osital, t,ere are +o/r areas w,ere t,ere is a need
+or yo/r articiation in re"ention9 Ho/r atient needs to -e rotected +rom -ody
,arm 7Hiocratic Oat,8D yo/ need to rotect yo/rsel+ and yo/r co-workers +rom t,e
transmission o+ diseases o+ atientsD yo/ need to rotect yo/rsel+ and yo/r instit/tion
+rom malractice s/itsD and i+ yo/ are in a non-,osital en"ironment 7ri"ate ractice8
w,en an emer*ency occ/rs, yo/ need to remem-er t,e n/m-ers ;::.
:. A, 1, C, 3correct.
Dincorrect. 5,e Deartment C,airersons +/nction as an 30ec/ti"e 1oard and act
to*et,er +or t,e *ood o+ t,e instit/tion.
>. A, C, D, 3correct.
1incorrect. A non-,ealin* /lcero/s lesion s,o/ld -e care+/lly e0amined and
ossi-ly -ioied a+ter a eriod o+ a-o/t = weeks, not t,ree mont,s.
=. C, D, 3correct
Aincorrect. At = mont,s o+ a*e, only t,e s/r*ical correction o+ t,e li s,o/ld -e
considered. 5,e correction o+ t,e anterior al"eolar rid*e s,o/ld await /ntil t,e atient
is a-o/t :$ years o+ a*e.
1incorrect. 5,ere are more cle+ts in"ol"in* t,e ,ard alate t,an in"ol"in* t,e lis
and ,ard alate. D/rin* t,e em-ryonic eriod t,ere is a cle+t -etween t,e ma0illary
-ones t,at +/ses +rom t,e li -ack towards t,e /"/la. At times t,e +/sion will roceed
normally and +or /nknown reasons, lea"e a normal li. 5,is artial +/sion acco/nts
+or t,e lis sometimes -ein* sared and t,e alate -ein* in"ol"ed.
&. A, 1, C and 3correct.
Dincorrect. Since a cardiac emer*ency is ro-a-ly t,e most serio/s occ/rrence t,at
can ,aen in a dental o++ice, ro-a-ly t,e sa+est ro+essional and sa+est le*al osition
is to cons/lt wit, t,e atientCs cardiolo*ist as well as re"iew t,e c/rrent
recommendations o+ t,e American Heart Association. I+ still in do/-t, empirical
propylaxis 7ro,yla0is co"era*e -eca/se t,e oerator wants to -e on t,e sa+e side8 is
a lo*ical resonse.
'. A, 1, C, D, and 3correct.
:. A dentist 7and ot,er ,osital ro+essional sta++ ersonnel8 m/st -e iiiiiiiii to
indicate cometency to ractice in a ,osital dental ser"ice.
>. 5,e accreditin* a*ency +or dental ,osital ser"ices in t,e United States is t,e
iiiiiiiii 7or*ani@ation8.
=. 5,e rost,etic de"ice /sed to -rid*e a alatal cle+t is known as an iiiiiiiii.
&. 5,e more scienti+ic term +or Fdry mo/t,F is iiiiiiiii.
'. 1one necrosis t,at +ollows cancer radiation treatment is known as iiiiiiiii.
<. An HI6 case -ecomes an AIDS case w,en t,e CD& lym,ocyte dros -elow
iiiiiiiii lym,ocytes er milliliter o+ -lood.
%. !elie"in* a atientCs iiiiiiiii is one o+ t,e -est means to ass/re an /ne"ent+/l
aointment wit, a ,i*, risk cardiac atient.
(. A -i-directional disease is one w,ere -ot, can ,el in+l/ence t,e o/tcome or t,e
se"erity o+ t,e ot,er.
;. A systemic disease t,at red/ces t,e incidence o+ caries is iiiiiiiii.
:$. I+ yo/ ,ad a atient ,a"e a cardiac arrest in yo/r o++ice, wo/ld yo/ ,a"e a -etter
c,ance o+ res/scitation wit, 7C)!8 7a de+i-rillator8. Circle yo/r selection.
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%ed, :>&9>''-<.
%:. 5,omson, 4. M., Stewart, #. F., Carter, M. D., g Sencer, A. #. 7:;;%8. )/-lic
ercetion o+ cross-in+ection in dentistry. ustral Dent ", &>9>;:-;<.
%>. )/lick, C. 7:;;<8. 4as,in*tonCs teet,9 atientCs ri*,ts and dentistsC ri*,tsw,ere
are we ,eadin*P nn R ustral Coll Dent Sur$, :=9>>:-=<.
%=. C,/, C. S., C,an, 5. 4., H/i, ). M., Samaranayake, C. !., C,an, #. C., g 4ei, S.
H. 7:;;'8. 5,e knowled*e and attit/de o+ Hon* 2on* secondary sc,ool teac,ers and
st/dents towards HI6 in+ection and dentistry. Community Dent Health, :>9::$-:&.
%&. Sc,e/t@, F., g .an*e-ack, #. 7:;;'8. Dental care o+ in+ectio/s atients in
Denmark. Community Dent +ral !pidemiolo$y, >=9>><-=:.
%'. McCart,y, G., Mamandras, A. H., g MacDonald, #. 2. 7:;;%8. In+ection control
in t,e ort,odontic o++ice in Canada. m " +rthod Dentofacial +rthop, ::>9>%'-(:.
%<. 1arnes, D. 1., Gar-ert, 1., McMaster, #. !., g Green-latt, !. M. 7:;;<8. Sel+-
disclos/re e0erience o+ eole wit, HI6 in+ection o+ dedicated and mainstreamed. "
Pu4l Health Dent, '<9>>=-'.
%%. Da"id, H. 5., g Da"id, H. M. 7:;;%8. .i"in* wit, needlestick inA/ries. " Can
Dent ssoc, <=9>(=-<.
%(. Greene 6. A., C,/, S. H., Dia@, 5., g Sc,a-le, !. 7:;;%8. Oral ,ealt, ro-lems
and /se o+ dental ser"ices amon* HI6-in+ested ad/lts. S/lement to HI6BAIDS
S/r"eillance )roAect Gro/. " m Dent ssn, :>(9 :&:%->>.
%;. Ai@awa, F., Honimi@/, M., Ai@awa, H., Hanada, N., g Akada, H. 7:;;<8. A
s/r"ey on in+ection control ractices, knowled*e and attit/des towards AIDSBHI6
amon* dental racticioners. &ippon )oshu !isei @asshi, &=9=<&-%=.
($. 2ita/ra, H., Adac,i, N., 2o-ayas,i, 2., g Hamada 5. 7:;;%8. 2nowled*e and
attit/des o+ #aanese dental ,ealt, care workers towards HI6-related disease. " Dent,
>'9>%;-(=.
(:. Gi-son, 1. #., g Freeman, !. 7:;;<8. Comment. #rit Dent ", :($9'=-'<.
(>. !o-inson, 3. N. #r., g de 1liek, !. 7:;;<8. 5,e colle*e st/dent, t,e dentist, and
t,e Nort, Carolina senator9 risk analysis and risk mana*ement o+ HI6 transmission
+rom ,ealt, care worker to atient. %ed Dec %a*in$, :<9(<-;:.
(=. Ale0ander, !. 3. 7:;;;8. 5,e a/tomated e0ternal cardiac de+i-rillator9 li+esa"in*
de"ice +or medical emer*encies. " m Dent ssoc, :=$9(=%-&'.
(&. 4aters, 1. G. 7:;;'8. )ro"idin* dental treatment +or atients wit, cardio"asc/lar
disease. +nt Dent, %>9>&-<, >(-=>.
('. Gar+/nkel, A., Galili, D., Findler, M., I/sman, S. )., Malamed, S., F., 3lad, S., g
2a/+man, 3. 7>$$>8. C,est ains in t,e dental en"ironment. Refuat Hapeh
=ahashinayim, :;9':-';.
(<. 2aeler, G., Da/-inder, M., Hinkel-ein, !., g .i, M. 7:;;(8. j/ality o+
cardio/lmonary res/scitation -y dentists in dental emer*ency care. %und )iefer
0esichtschir, >9%:-%%.
(%. 4oods, !. G. 7>$$$8. Imro"in* sa+ety o+ dental roced/res wit, ,ysiolo*ical
monitorin*. nn R ustralas Coll Dent Sur$, :'9>%<-;.
((. 1assi, G. S., Co/sin, G. C., .awrence, C., 1ali, N., g .owry, #. C. 7>$$>8.
Imro"ed res/scitation trainin* o+ senior ,o/se o++icers in oral ma0illo+acial s/r*ery.
#rit ", +ral %axillofac Sur$, &$9>;=->;'.
(;. Matt,ew, Ca,ill, 30ec/ti"e Director. 7:;;%8. >nd 3dition, Diseases, Renal
Urolo$ic Disorders, Srin*,o/se, )A9 Srin*,o/se Cororation, . :>>&.
;$. )/ttin*er, H., g 6yc,ytil, A. 7>$$>8. Heatitis 1 and C in eritoneal dialysis
atients. Semin &ephrol, >>9=':-<$.
;:. )ere@, !. A., 1lake, ). G., #indal, 2. A., 1ado"inac, 2., 5reski, .., Fenton, S. S.
7>$$=8. Canadian Or*an !elacement !e*ister3)!3G St/dy Gro/. C,an*es in
eritoneal dialysis ractices in Canada :;;<-:;;;. Perit Dial /nt, >=9'=-%.
;>. Medin, C., 3linder, C. G., Hylander, 1., 1lom, 1., g 4ilc@ek, H. 7>$$$8. S/r"i"al
o+ atients w,o ,a"e -een on a waitin* list +or renal translantation. &ephrol Dial
Transplant, :'9%$:-&.
;=. Meier-2riesc,e, H. U., )ort, F. 2., OAo, A. O., !/dic,, S. M., Hanson, #. A.,
Ci-rik .eic,tman, A. 1., g 2alan, 1. 7>$$$8. 3++ect o+ waitin* time on renal
translant o/tcome. )idney /nt, '(9:=::-%.
;&. 2lassen, #. 5., g 2rasco, 1. M. 7>$$>8. 5,e daily ,ealt, stat/s o+ dialysis atients.
" Can Dent ssociation, <(9=&-=(.
;'. Sil"er-er*, D. S., 4e0ler, D., 1l/m, 1., g Iaina, A. 7>$$=8. Anemia in c,ronic
kidney disease and con*esti"e ,eart +ail/re. #lood Purif, >:9:>&-=$.
;<. O+st,/n, N., .a-rec?/e, #., .acson, 3., 2een, M., g .a@ar/s, #. M. 7>$$=8. 5,e
e++ects o+ ,i*,er ,emo*lo-in le"els on mortality and ,ositali@ation in ,emodialysis
atients. )idney /nt, <=9:;$(-:&.
;%. Ho, .. 5., g Sra*/e, S. M. 7>$$>8. !enal osteodystro,y in c,ronic renal +ail/re.
Semin &ephrol, ><9&((-;=.
;(. 1lock, G., g )ort, F. 2. 7>$$=8. Calci/m ,os,ate meta-olism and
cardio"asc/lar disease in atients wit, c,ronic kidney disease. Semin Dial, :<9:&$-%.
;;. ./ca, M. F., j/ereda, C., 5er/el, #. .., Orte, .., Marceen, !., g Ort/no, #. 7>$$=8.
3++ect o+ ,yertension -e+ore -e*innin* dialysis on s/r"i"al o+ ,emodialysis atients.
7In )ress8 m " )idney Dis,
:$$. #o,nson, !. #., 2an*, D. H., Fei*, D., 2i"li*,n, S., 2anellis, #., 4atana-e, S.,
5/t, 2. !., !odri*/e@-It/r-e, 1., Herrera-Acosta, #., g Ma@@ali, M. 7>$$=8. Is t,ere a
at,o*enic role +or /ric acid in ,yertension and cardio"asc/lar and renal diseasee
Hypertension, &:9::(=-;$.
:$:. .ittle, #. 4. 7>$$=8. 5,e imact on dentistry o+ recent ad"ances in t,e
mana*ement o+ ,yertension. +ral Sur$ +ral %ed +ral Pathol +ral Radiol !ndod,
;$9';:-;.
:$>. Anel, !. .., He"@lin, A. S., g I"anoic,, ). 7>$$=8. 6asc/lar access and atient
o/tcomes in ,emodialysis9 ?/estions answered in recent literat/re. rtif +r$ans,
>%9>=%-&:.
:$=. Iacks, S. .., g Fried, M. 4. 7>$$:8. Heatitis 1 and C and renal +ail/re. /nfect
Dis Clinic &orth m, :'9(%%-;;.
:$&. N/nn, #. H. S,ar, #., .am-ert, H. #., )lant, N. D., g Co/lt,ard, M. G. 7>$$$8.
Oral ,ealt, in c,ildren wit, renal disease. Pediatr &ephrol, :&9;;%-:$$:.
:$'. O-ry, F., 1elco/rt, A. 1., Frank, !. M., Geisert, #., g Fisc,-ac,, M. 7:;(%8.
1ioc,emical st/dy o+ w,ole sali"a +rom c,ildren wit, c,ronic renal +ail/re. SDC "
Dent Child, '&9&>;-=>.
:$<. )eterson, S., 4ood,ead, #., g Carall, #. 7:;('8. Caries resistance in c,ildren wit,
c,ronic renal +ail/re9 la?/e sali"ary H, and sali"ary comosition. Pediatr Res,
:;9%;<-;.
:$%. 4ol++, A., Stark, H., Sarnat, H., 1inderman, I., 3isenstein, 1., g Dr/kker, A.
7:;('8. 5,e dental stat/s o+ c,ildren wit, c,ronic renal +ail/re. /nt " Pediatr, <D:>%-
=>.
:$(. 1erns, #. S., g 5okars, #. I. 7>$$>8. )re"entin* -acterial in+ections and anti-
micro-ial resistance in dialysis atients. m " )idney Dis, &$9((<-;(.
:$;. O*/@, H., 1/l/c/, F., Oktenli, C., Do*anci, .., g 6/ral, A. 7>$$>8. In+ectio/s
comlications in :=' 5/rkis, renal translant atients. Cent !ur " Pu4lic Health,
:$9:'=-<.
::$. 5,omason, #. M., Seymo/r, !. A., g 3llis, #. 7:;;&8. 5,e eriodontal ro-lems
and mana*ement o+ t,e renal translant atient. Ren 'ail, :<9%=:-&'.
:::. )ern/, H. 3., )ern/, .. M., 2n//ttila, M. I., g H/tt/nen, 2. !. 7:;;=8. Gin*i"al
o"er*rowt, amon* renal transort reciients and /raemic atients. &ephrol Dial
Transplant, (9:>'&-(.
::>. Na/*le, 2., Dar-y, M. .., 1a/man, D. 1., .ine-er*er, .. 5. g )owers, !.
7:;;(8. 5,e oral ,ealt, stat/s o+ indi"id/als on renal dialysis. nn Periodontol, =9:;%-
>$'.
::=. 1irkeland, S. A., g Storm, H. H. 7>$$>8. !isk +or t/mor and ot,er disease
transmission -y translantation9 a o/lation--ased st/dy o+ /nreco*ni@ed
mali*nancies and ot,er diseases in or*an donors. Transplantation, %&9:&$;-:=.
::&. 6aron, F., g Mack-S,iman, .. 7>$$$8. 5,e role o+ t,e dental ro+ession in
dia-etes. " Contemp Dent Pract, :9:->%.
::'. .alla, !. 6., g DC Am-rosio, #. A. 7>$$:8. Dental mana*ement considerations
+or t,e atient wit, dia-etes mellit/s. " m Dent ssoc, :=>9:&>'-=>.
::<. Matt,er, C., 30ec/ti"e Director. 7:;;%8. In Diseases, >nd 3d. Srin*,o/se, )A9
Srin*,o/se Cor., . :>>&.
::%. 2at@, #., C,a/s,/, G., g S*an-Co,en, H. D. 7>$$$8. !elations,i o+ -lood
*l/cose le"el to comm/nity eriodontal in t,e treatment needs and -ody mass inde0
in a ermanent Israeli military o/lation. " Periodontolo$y, %:9:'>:-%.
::(. Almas, 2., Al-ja,tani, M., Al-Hami, M., g 2,an, N. 7>$$:8. 5,e relations,i
-etween eriodontal disese and -lood *l/cose le"el amon* tye II dia-etic a*ents. "
Contem Dent Pract, >9:(->'.
::;. 1ell, G. 4., .ar*e, D. M., g 1arclay, S. C. 7>$$$8. Oral ,ealt, care in dia-etes
mellit/s. SD", ''9:'(-<', ?/i@ :%'.
:>$. Mattson, #. S., g Cer/tis, D. !., 7>$$:8. Dia-et/s9 a re"iew o+ t,e literat/re and
dental imlications. Comp Cont !duc Dent, >>%'%-<$, %<>, %<&.
:>:. Mealey, 1. I. 7>$$=8. Clinical e0erience t,at many eriodotists ,a"e ,ad w,en
treated as oorly controlled dia-etic atients. " Compend Continuin$ !duc, >&9((.
:>>. !ees, 5. D. 7>$$$8. )eriodontal mana*ement o+ t,e atient wit, dia-etes
mellit/s. Periodontol, >=9<=-%>.
:>=. Mealey, 1. .. 7>$$$8. How does dia-etes alter treatment in t,e dental o++ice.
Compend Contin !duc Dent, >:9;&=-<.
:>&. 5aylor, G. 4. 7>$$:8. 1idirectional interrelations,is -etween dia-etes and
eriodontal diseases9 an eidemiolo*ic ersecti"e. nn Periodontol, <9;;-::>.
:>'. American Association o+ )eriodontolo*y. 7:;;;8. Dia-etes and )eriodontal
Diseases. " Periodontol, %%9;='-&;.
:><. American Academy o+ )eriodontolo*y. 7>$$$8. )arameters o+ eriodontitis
associated wit, systemic conditions. American Academy o+ )eriodontolo*y. "
Periodontolo$y, %9(%<-;.
:>%. 5wetman, S., #o,ansson, I., 1irk,ed, D. g Neder+ors, 5. 7>$$>8. Caries
incidence in yo/n* tye : dia-etes mellit/s atients in relation to meta-olic control
and caries risk +actors. Caries Res, =<9=:-='.
:>(. 2arAalainen, 2. M., g 2n//ttila, 2aar, M. .. 7:;;%8. !elations,i -etween
caries and le"el o+ meta-olic -alance in c,ildren and adolescents wit, ins/lin-
deendent dia-etes mellit/s. Caries Res, =:9:=-:(.
:>;. Moore, ). A., G/**en,eimer, #., 3t@el, 2. !., 4eyant, !. #., g Orc,ard, 5.
7>$$:8. 5ye I dia-etes mellit/s, 0erostomia, and sali"ary +low rates. +ral Sur$ +ral
%ed +ral Pathol +ral Radiol !nd, ;>9>(:-;:.
:=$. Greensan D. 7:;;<8. Gerostomia6 dia$nosis and mana$ement, Oncolo*y
7H/ntin*t8, :$9%-::.
:=:. 1Aelland, S., 1ry, )., G/ta, N., g Hirsc,t, !. 7>$$>8. Dentists, dia-etes and
eriodontists. ust Dent ", &%9>$>-%, ?/i@ >%>.
:=>. Sand-er*, G. 3., S/nd-er*, H. 3., g 4ik-lad, 2. F. 7>$$:8. A controlled st/dy
o+ oral sel+-care and sel+-ercei"ed oral ,ealt, in tye > dia-etic atients. cta
+dontol, ';9>(-==.
:==. 1rid*es !. 1., Anderson, #. 4., Sa00e, S. !., Gre*ory, 2., g 1rid*es, S. !.
7:;;<8. )eriodontal stat/s o+ dia-etic and non-dia-etic men9 e++ects o+ smokin*,
*lycemic control, and socioeconomic +actors. /" Periodontol, <%9::('-;>.
:=&. Mealey, 1. I., g !et,man, M. ). 7>$$=8. )eriodontal disease and dia-etes
mellit/s. 1idirectional relations,i. Dent Today, >>9:$%-:=.
:='. 1a"it@, #. 1. 7:;;'8. 3mer*ency man*ement o+ ,yo*lycemia and
,yer*lycemia. Dent Clin &orth merica, =;9'(%-;&.
:=<. #owell, N. I., g Ca-ot, .. 1. 7:;;(8. Dia-etic ,yo*lycemia and t,e dental
atient. #rit Dent ", :('9&=;-&>.
:=%. #erome Grooman. 5,e 3dmonton )rotocol. The &e3 .or*er, Fe-. :$, >$$=.
:=(. !yan, 3. A., .akey, #. !., !aAotte, !. 6., 2or-/tt, G. S., 2in, 5., Imes, S.,
!a-ino"it, A., 3lliott, #. F., 1i*am, D., 2neteman, M. N., 4arnock, G. I., .arsen, I. g
S,airo, A. M. 7>$$:8. Clinical o/tcomes and ins/lin secretion a+ter islet
translantation wit, t,e 3dmonton rotocol. Dia4etes, '$9%:$-;.
:=;. 3meric,, D. F. 7>$$>8. Islet translantation +or dia-etes9 c/rrent stat/s and +/t/re
rosects. !xpert +pin #iol Ther, >9%;=-($=.
:&$. !o-ertson, !. ). 7>$$>8. Islet translantation9 tra"els / t,e learnin* c/r"e.
Curr, Dia4 Rep, >9=<'-%$.
reser"ed.
Chapter 23. Rationale, Guidelines, and Procedures for Prevention of the Plaque
Diseases - &orman +, Harris %arsha , Cunnin$ham2'ord
Objectives
:. Descri-e t,e two re"ersi-le sta*es t,at occ/r -etween ,istolo*ical normalcy and
de"eloment o+ o"ert lesions +or eac, o+ t,e la?/e diseases, i.e., caries and
eriodontal disease.
>. 30lain w,y t,e initialBann/al dental e0amination is so imortant to t,e resent and
+/t/re dental ,ealt, o+ a atient.
=. Name se"en caries-acti"ity indicators 7CAIs8, and +o/r eriodontal-acti"ity
indicators 7)AIs8 and e0lain w,y t,ey s,o/ld -e incl/ded in t,e initialBann/al
e0amination.
&. 30lain ,ow t,e CAIs and )AIs t,at are incl/ded in t,e initialBann/al dental
e0amination can -e /sed as an aid in rearin* t,e atientCs ed/cation, treatment,
re"ention, and maintenance lans.
'. Disc/ss two dia*nostic scenarios in w,ic, t,e /se 7or mis/se8 o+ an e0lorer +or
caries dia*nosis can res/lt in t,e insertion o+ many /nneeded occl/sal and smoot,
s/r+ace restorations.
<. )roose a +le0i-le recall sc,ed/le -ased on a atientCs le"el o+ treatment /r*ency
7risk8, and e0lain ,ow risk determination can -e /sed to c,annel atients into a more
closely monitored caries andBor eriodontal maintenance ro*ram.
%. Criti?/e t,e ad"anta*es and disad"anta*es +or t,e de"eloment o+ national
*/idelines +or re"enti"e dental care.
(. State +i"e 7o/t o+ t,e si0 listed8 clinical en"ironments in w,ic, a @ero-or-near-@ero
dental la?/e disease re"ention ro*ram can -e +/lly imlemented wit,o/t maAor
c,an*es o+ resent clinic +acilities and mannin* ersonnel.
;. Contrast w,at yo/ t,ink can 4e done to prevent the pla5ue diseases 3ith 3hat is
4ein$ practiced,
Introduction
In t,e ?/est +or a @ero or near-@ero incidence o+ t,e la?/e diseases, i.e., caries, and
eriodontal disease7s8, t,e critical re?/irement is t,at t,e si*ns and symtoms o+
imendin* disease -e identi+ied at a time w,en ro*ression toward o"ert ca"itation
andBor eriodontitis can -e prevented, arrested, or reversed, 5,ree salient +actors
make t,is re"enti"e o-Aecti"e +easi-le9 7:8 -ot, dental caries and eriodontitis are t,e
res/lt o+ a rolon*ed resence o+ at,o*enic la?/es a++ectin* t,e enamel, cement/m,
andBor conti*/o/s *in*i"aD 7>8 in most cases, -ot, diseases can -e controlled -y
mec,anical and c,emical la?/e control re*imensD and, 7=8 -ot, o+ t,e la?/e
diseases m/st *o t,ro/*, a contin//m o+ two reversi4le interim sta*es +rom
,istolo*ical normalcy to clinical at,olo*y.
5,e earliest sta*e o+ t,e la?/e diseases is in situ in"ol"ement. For caries, t,is sta*e is
marked -y t,e microscopic deminerali1ation o+ t,e crystalline str/ct/re o+ t,e enamel
rods.
:
For eriodontal disease, it is t,e early infiltration of inflammatory cells -eneat,
t,e s/lc/lar eit,eli/m.
>
Neit,er t,e early deminerali@ation o+ caries nor t,e early
cell/lar in+iltration o+ *in*i"itis can -e directly seen. Howe"er, t,ese microscoic
-e*innin*s o+ imendin* la?/e disease can -e suspected on t,e -asis o+ nonin"asi"e
caries and eriodontal risk assessment tests and indices t,at are no3 a"aila-le to
dental and dental ,y*iene ro+essionals.
An in situ in"ol"ement, /nless arrested or re"ersed, mer*es into t,e ne0t sta*e o+
ro*ression o+ t,e caries rocessthe incipient lesion, For caries it is mani+est -y t,e
clinical aearance o+ a F3hite spotF on t,e enamel t,at is d/e to a more e0tensi"e
s/-s/r+ace rod deminerali@ation.
=
Inciient lesions can occ/r on any s/r+ace as a
precaries lesion,
a
5,ey may occ/r 7:8 interro0imally, apical to t,e contact oint, 7>8
as cervical 3hite spots, 7=8 on t,e 3alls o+ t,e dee occl/sal +iss/res, and 7&8 on
4uccal and lin$ual surfacesw,ere"er t,ere is la?/e sta*nation. 5,ese recaries
lesions can -e easily seen on dry, well-li*,ted -/ccal, lin*/al, and *in*i"al enamel
s/r+aces.
&
5,ey are more di++ic/lt to detect on t,e occl/sal s/r+ace w,ere FstickyF its
and +iss/res s,o/ld always -e ,i*,ly s/sect as ,a"in* inciient or e"en early
/ndetected cario/s lesions.
'
5,e resence o+ Fw,ite sotsF on t,e smoot,
interro0imal s/r+aces are /s/ally +irst identi+ied in radio*ra,s.
<,%
In eriodontal
disease, t,e inciient lesion is an in+lammation o+ t,e *in*i"a, i.e., $in$ivitis wit,
*in*i"al -leedin* -ein* one o+ t,e +irst noticea-le mani+estations.
(
5,e inciient
lesions o+ 4oth caries and *in*i"itis can -e re"ersed to ,istolo*ical normalityw,ic,
-y de+inition, reresents a c/re.
5,e t,ird and +inal sta*e o+ t,e la?/e diseases is t,e overt lesion. For caries, t,is
sta*e is ,eralded -y cavitation wit, -acterial in+iltration. For eriodontal disease, it is
c,aracteri@ed -y nonreversi4le c,an*es in t,e eriodonti/m s/c, as an aical
mi*ration o+ t,e eit,elial attac,ment and -one loss 7eriodontitis8. At t,e o"ert
lesion sta*e o+ t,e la?/e diseases, treatment is /s/ally indicated. 5,ere are two
ossi-le e0cetions w,ere nonin"asi"e re"enti"e re*imens may ossi-ly -e /sed to
re"erse o"ert caries, namely t,e /se o+ anti-acterial a*ents andBor reminerali@ation
t,eray to arrest root decay, and t,e /se o+ sealants to arrest early it-and-+iss/re
caries.
;,:$
Not all in situ lesions ro*ress to t,e inciient sta*e, nor do all t,e inciient lesions
ro*ress to t,e o"ert sta*e o+ caries andBor eriodontitis.
::
Howe"er, it is e0tremely
imortant to note t,at no o"ert la?/e disease lesion occ/rs at any site wit,o/t +irst
-e*innin* as an in situ mani+estation, and t,en ro*ressin* to an inciient lesion
-e+ore -ecomin* o"ert. Thus, any prevention pro$ram must focus on identifyin$ and
reversin$ the in situ and incipient sta$es of the pla5ue diseases 3ith the same, or
$reater dili$ence than is no3 $iven to searchin$ for and treatin$ overt disease, It is
t,e /rose o+ t,is c,ater to s/mmari@e ,ow t,e dentist, t,e dental ,y*ienist, and t,e
ot,er mem-ers o+ t,e o++ice team can realistically accomlis, t,is *oal. S/c, an
ac,ie"ement will allow t,e ro+ession to mo"e +rom a traditional em,asis on
secondary and tertiary re"enti"e dentistry, to a primary preventive focus and
commitment,
a
)recaries lesionD Since an inciient caries lesion can, in many cases, -e
reminerali@ed, it s,o/ld not -e considered in t,e same cate*ory as an o"ert lesion
w,ere a restoration is /s/ally indicated.
The Initial and/or Annual Dental Examination
5,e initialLannual dental examination is a most imortant e"ent in t,e entire oral
,ealt, ro*ram o+ a atient. At t,is time, a erson seekin* dental care ,as t,e
oort/nity and expectation to ,a"e ,is or ,er c/rrent oral stat/s care+/lly assessed -y
a ro+essional, a treatment lan reared, restorati"e care accomlis,ed, and a
comprehensive preventive dentistry pro$ram initiated t,at will ,el +orestall +/t/re
la?/e disease. 5,is -aseline e0amination is one a*ainst w,ic, all +/t/re
e0aminations s,o/ld -e comared to e"al/ate time-+/nction de"iations +rom -aseline
oral ,ealt,.
5,e +irst ,ase o+ t,e initialBann/al e0amination -e*ins in t,e recetion area o+ t,e
dental o++ice. Here t,e atient is asked to comlete t,e /s/al aerwork t,at incl/des
t,e atientCs medical and dental ,istories. Incl/ded in t,ese ,istories s,o/ld -e a
car-o,ydrate-intake ?/estionnaire and ?/estions relatin* to systemic +actors and
-e,a"ior atterns t,at mi*,t a++ect ast, resent or +/t/re oral disease de"eloment.
1e+ore t,e clinical e0amination, t,e dentist and ,y*ienist s,o/ld care+/lly scr/tini@e
t,e atientCs ,istory, -ot, +or e"idence o+ transmitta-le disease, as well as +or
conditions indicatin* a relations,i o+ systemic conditions to oral disease. For
e0amle, a atient takin* anti-,yertensi"e medications, tran?/ili@ers, or many ot,er
dr/*s, o+ten ,as an accomanyin* 0erostomia and an increased caries risk. 5,e
medical ,istory also ,els identi+y conditions s/c, as Cro,nCs disease
:>
or dia-etes
mellit/s
:=
t,at are -ack*ro/nd systemic +actors t,at raise t,e risk +or caries and
eriodontal disease, resecti"ely.
5,e initialBann/al e0amination s,o/ld -e di"ided into two sta*es9 7:8 a clinical and a
roent$eno$raphic ,ase to locate, dia$nose, and to record sites o+ inciient and o"ert
la?/e diseaseD and, 7>8 la4oratory tests and indices to ,el identi+y t,e ris* o+ in situ
andBor inciient la?/e disease. 5,ese are /ltimately t,e resonsi-ilities o+ t,e
dentist
:&,:'
-/t t,e la-oratory ,ases can -e er+ormed -y t,e dental ,y*ienist. 5,e
e0amination s,o/ld incl/de as a minim/m9
A "is/al e0amination o+ all t,e intraoral and cranio+acial tiss/es +or diseases, ot,er
t,an t,e la?/e diseases 7cancer +or instance8
A set o+ -itewin* and eriaical radio*ra,s as art o+ t,e e0amination +or
interro0imal enamel radiol/cencies and loss o+ al"eolar -one
A visual and mo/t, mirror e0amination o+ all t,e teet, +or inciient and o"ert
coronal and root caries, and an e0lorer e0amination +or s/sected +ract/red
restorations, and secondary 7i.e., rec/rrent8 caries
A record made as to w,ic, occl/sal s/r+aces need sealants
A record made as to w,ic, Fw,ite sots,F 7interro0imal radiol/cencies 3ithout
e"idence o+ ca"itation8, and root s/r+ace caries t,at re?/ire reminerali@ation t,eray
and,
A eriodontal ro-e e0amination o+ all *in*i"al s/lci
5,e final phase of the initialLannual e0amination can -e accomlis,ed -y a dental
,y*ienist as art o+ t,e +irst ro,yla0is aointment. 5,is ,ase s,o/ld incl/de9 a
la?/e inde0, a calc/l/s site recordin*, a sali"a +low rate notation, and aroriate
la-oratory tests to esta-lis, caries risk. All can -e easily accomlis,ed in t,e dental
o++ice to +/rnis, "al/a-le -aseline in+ormation on t,e -ack*ro/nd o+ t,e atientCs
la?/e diseases. 5,e indices also +/rnis, "al/a-le in+ormation needed to ,el
esta-lis, t,e le"el o+ re"enti"e treatment re?/ired.
A la?/e inde0 is -ot, an indicator o+ caries andLor eriodontal disease acti"ity.
Howe"er, it does not discriminate as to w,ic, la?/e disease is in"ol"ed. As t,e
la?/e score 7C,ater :=8 increases o"er :$E t,ere is an increasin* ro-a-ility t,at
t,e la?/e -acteria are ca/sin* dama*e to t,e teet, or to t,e eriodonti/m. 5,e la?/e
inde0 also ro"ides a means o+ e"al/atin*, at se?/ential aointments, w,et,er
re"io/sly recommended la?/e control meas/res ,a"e -een imlemented. 5,e sites
o+ calc/l/s acc/m/lation can -e recorded at t,e same time, t,/s ro"idin* a +/rt,er
means o+ identi+yin* areas o+ sali"a sta*nation w,ere la?/e control met,ods s/c, as
toot, -r/s,in*, +lossin* and irri*ation ,a"e not -een ade?/ate.
Micro-iolo*ic caries acti"ity tests ro"ide a *ood assessment o+ caries risk, esecially
i+ t,e res/lts are comared wit, re"io/s -aseline res/lts. Di-slide
-
kits are
commercially a"aila-le +or e"al/atin* t,e sali"ary le"els o+ m/tans stretococci and
lacto-acilli, resecti"ely 7Fi*/re >=-:A and :18. Any increase in t,e n/m-er o+
cario*enic -acteria -etween ann/al e0aminations s,o/ld -e "iewed as indicatin* an
increased risk +or diseaseD t,ere+ore, it is r/dent to take action to red/ce t,e -acterial
co/nt. Micro-iolo*ic test scores w,en considered alon* wit, t,e car-o,ydrate intake
score, ser"e as tools +or assessin* atient comliance wit, re"io/s dietary and oral
,y*iene co/nselin* intended to red/ce t,e -acterial c,allen*e.
Stim/lated sali"a s,o/ld -e collected in a cali-rated t/-e in order to determine +low
rate er min/te. 5,is latter dat/mesecially i+ t,e +low rate is -elow one milliliter
er min/te 70erostomia8is o+ten imortant in ,elin* to identi+y t,e ca/se o+ an
indi"id/alCs caries. 5,ere is little di++erence -etween t,e data collected +or treatment
lannin* and t,e data needed +or re"ention ro*rams. )er,as t,e *reatest contrast
-etween t,e two is in t,e decision-makin* rocess o+ w,at to do wit, t,e data. 5,e
dentist makin* t,e initialBann/al e0amination s,o/ld ,a"e t,e knowled*e and
e0erience to identify -ot, inciient and o"ert lesions in t,e clinical and radio*ra,ic
e0am- inations, and t,e 3isdom to di++erentiate -etween t,e two in selectin*
aroriate treatment otions. A treatment-oriented decision o+ caries /s/ally res/lts
in an in"asi"e treatment roced/re res/ltin* in dama*e to t,e toot,, w,ile a
re"enti"e-oriented decision /s/ally lea"es t,e toot, intact.
:<
A second maAor di++erence -etween t,e treatment and re"enti"e asects o+ t,e
e0amination lies wit, o++ice-time riorities. In t,e /s/al treatment lan, time
commitments em,asi@e disease eradication. In an ideal re"enti"e ro*ram, otimal
time is allowed +or 4oth rimary and secondary re"ention. Anot,er critical di++erence
is t,at t,e treatment lan ends w,en t,e recorded at,olo*y is s/ccess+/lly treated. In
t,e re"enti"e lan, t,e in+ormation *ained in t,e initialBann/al e0amination can -e
arrayed in a manner t,at ermits t,e de"eloment o+ reasoned atient -e,a"ior
modi+ication and monitorin* strate*ies t,at can -e /sed to re"ent +/t/re la?/e
disease de"eloment.
-
Di-slide kits +or o++ice co/nts o+ m/tans stretocc/s and lacto-acill/s are a"aila-le
+rom I"oclar 6icadent, Am,erst, NH, :&>>(.
5,e Com/ter A*e
5,e ercenta*e o+ dental ractices /sin* com/ters at t,e -e*innin* o+ :;;; ,as -een
estimated at (;E.
:%
Articles are -e*innin* to aear in t,e literat/re on t,e ad"anta*es
o+ ,itec, dental o++ices.
:(->:
5,e initial /se o+ com/ters was +or administrati"e
/roses-illin*, recall aointments, electronic ins/rance claims, ayroll and
in"entory control. Howe"er, wit, t,e assa*e o+ time, so+tware -ecame a"aila-le t,at
directly s/orted clinical needs. For instance, t,ere are cosmetic ima*in* ro*rams,
interacti"e atient ed/cation CD-!OMs, sel+-administered atient ,istories, diet-
analysis ro*rams, so+tware to determine t,e indications, contraindications, and
incomati-ilities o+ a"aila-le dr/*s, on-line ro+essional in+ormation and e"en remote
cons/ltations o"er t,e internet.
>>
3"en more -ene+its are comin*.
>=
Howe"er, t,ree o+
t,e most c/rrent and romisin* areas +or com/ter s/ort o+ t,e dental clinical
e0amination are9 7:8 computeri1ed chartin$, 7>8 the use of the intraoral videocamera
(/=C), and 7=8 (filmless) di$itali1ed roent$eno$raphy (DGR),
Com/teri@ed c,artin* ro*rams are now commercially a"aila-le +or recordin* t,e
resence o+ o"ert or inciient la?/e disease lesions 7Fi*/re >=->8. Ot,er arts o+ t,e
com/ter so+tware o+ten ermit recordin$ the presence and severity of selected caries
and periodontal activity indicators t,at are t,e -asis o+ risk assessment at the time of
testin$, Commonly /sed e"idence--ased caries-acti"ity indicators 7CAIs8 are t,e 7:8
la?/e inde0, 7>8 ?/anti+ication o+ cario*enic or*anisms, 7=8 sali"a +low rate, 7&8
+re?/ency o+ intake o+ re+ined car-o,ydrate 7s/*ar8. 3?/ally imortant are t,e 7'8
n/m-er o+ FstickyF occl/sal its and +iss/res, 7<8 coronal and root caries, 7%8 inciient
-/ccal and lin*/al smoot, s/r+ace lesions, and t,e 7(8 n/m-er o+ interro0imal
l/cencies 7inciient lesions8 3ithout cavitation, For eriodontal disease, t,e
eriodontal-acti"ity indicators 7)AIs8 are t,e 7:8 la?/e inde0, 7>8 calc/l/s, and 7=8
*in*i"al -leedin* indices, and t,e 7&8 )eriodontal Screenin* and !ecordin* system
7)S!8 +or ocket det,.
>&,>'
5,ese la?/e disease indicators can -e entered into t,e
com/ter at c,airside -y /se o+ a key-oard, mo/se, to/c, screen, or "oice acti"ation.
Note t,at t,e la?/e inde0 is /se+/l as a risk indicator +or 4oth caries and eriodontal
in"ol"ement. Ot,er indicators +or eit,er o+ t,e la?/e diseases can -e added or
s/-stit/ted in a com/ter +ormat. For instance, t,e +low rate o+ *in*i"al cre"ic/lar
+l/id mi*,t e"ent/ally ser"e as a )AI +or dental o++ices ,a"in* t,e necessary
e?/iment.
><,>%
Howe"er, t,e a-o"e +o/r )AIs are now well known, easy to
accomlis,, and resently /sed -y dentists and dental ,y*ienists in caries and
eriodontal control ro*rams.
Fi*/re >=-: A A+ter &( ,o/rs, m/tans stretococci -ecome "isi-le on test stri.
5,e two le+t slides ,a"e less t,an :$$,$$$ colony +ormin* /nits 7CFU8 er
milliliter o+ sali"a and constit/te a relati"ely low risk +or caries. 5,e two samles
to t,e ri*,t indicate a ,i*, risk wit, more t,an :$$,$$$ CFUBml.
Fi*/re >=-: B A small con"enient o++ice inc/-ator +or rocessin* Caries !isk
5est slides. 1ot, ill/strations co/rtesy o+ I"oclar 6i"adent, Am,erst, NH :&>>(.
Fi*/re >=-> )eriodontal Com/ter Assisted !ecord Form. A eriodontal
com/ter assisted record +orm t,at, alon* wit, ot,er otions a"aila-le wit, t,e
accomanyin* so+tware, ermits easy comarison wit, t,e details o+ re"io/s
eriodontal e0aminations. 4,en t,e ro-in* is accomlis,ed wit, t,e Florida
)ro-e ill/strated in Fi*/re :=-<, entries can -e a/tomatically made on t,e record
+orm. Color codin* cnot ossi-le on t,is -lack and w,ite ,otod allows easy
detection o+ di++erences in *in*i"al s/lci ro-in* det,s o+ :-& mm 7-lack8,
*reater t,an ' mm 7red8. Note t,e ot,er arameters t,at are art o+ a comlete
eriodontal e0amination, s/c, as )S!, la?/e inde0, mo-ility, +/rcations, and
recession. Co/rtesy o+ t,e Florida )ro-e Cororation, Gaines"ille, F..
Question 1
A. Inciient Fw,ite sotF lesions are +o/nd only on t,e +acial and lin*/al s/r+aces o+
teet,.
1. F4,ite sotsF in t,e enamel indicate t,at t,e cario/s rocess ,as assed t,e
inciient sta*e.
C. 5,e in situ sta*e o+ *in*i"itis is c,aracteri@ed -y s/lc/lar -leedin* /on *entle
ro-in*.
D. 5,e resence o+ dental la?/e is an imortant e"idence--ased indicator +or -ot,
caries and eriodontal disease.
3. 5,e CAIs and )AIs are more acc/rate in indicatin* present vulnera4ility, t,an o+
predictin$ +/t/re caries andBor in+lammatory eriodontal disease.
5,e Intraoral 6ideocamera 7I6C8 and t,e Di*itali@ed G-!ay 7DG!8
5,e recent introd/ction o+ t,e intraoral "ideocamera 7I6C8 and t,e di*iti@ed dental 0-
ray 7DG!8 ro"ide two ower+/l ,i*,-tec, instr/ments, t,at w,en co/led wit, a
com/ter, "ideo recorder or color rinter, +acilitate a more acc/rate identi+ication,
c,artin*, and /nderstandin* o+ t,e sites o+ -ot, inciient and o"ert la?/e disease.
>(
5,e I6C, w,ic, is a miniat/re camcorder, ro"ides a /ni+orm li*,tin* at all sites
-ein* e0amined 7Fi*/re >=-=8. It ermits ma*ni+ication o+ ?/estiona-le areas to
improve t,e ossi-ility o+ locatin* inciient and o"ert lesions, as well as sites o+
la?/e acc/m/lation, calc/l/s deosition, de+ecti"e restorations, and eriodontal
ro-lems. 5,e I6C ,as t,e ad"anta*e o+ allowin* an area to -e +ree@e-+ramed to st/dy
a ?/estiona-le site -etter, or i+ desired, to make ,i*,-?/ality color ,oto*ra,s -y
o/t/ttin* t,e ima*e to a ,i*,-resol/tion color rinter. Cracked or +ract/red
amal*ams are easy to identi+y. A later relay o+ t,e e0amination tae on t,e ,i*,-
resol/tion tele"ision screen is an o/tstandin* means o+ ed/catin* and moti"atin*
atients.
>;
Administrati"ely, t,e modem o+ t,e com/ter can -e /sed to transmit t,e
necessary ima*es +or immediate ins/rance "eri+ication o+ anticiated treatment and
re"enti"e costs, or to send treatment in+ormation to remote sites.
5,e di*itali@ed 0-ray 7DG!8 /tili@es intraoral +ilm-si@e electronic sensors, w,ic, are
connected to t,e com/ter 7Fi*/re >=-&8. 5,e e0istin* o++ice 0-ray /nit ro"ides t,e
so/rce o+ ener*y. No li?/id rocessin* is necessary as t,e ima*e is rocessed
electronically wit,in t,e com/ter.
=$
5,e di*itali@ed ima*e is more /ni+orm in
contrast t,an is now ossi-le wit, +ilm. 1y /se o+ com/ter control, it is ossi-le to
@oom in on small details, and to /se en,ancement tec,ni?/es to li*,ten or darken
areas o+ t,e screen +or -etter dia*nosis.
=:
An imortant ad"anta*e o+ DG! is t,at it
only re?/ires >:; or less ioni@in* radiation t,an is necessary in con"entional dental
radio*ra,y.
=>
5,is imro"ed sa+ety +actor res/lts in a -etter -alancin* o+ t,e
indi"id/ali@ed need +or more +re?/ent radio*ra,ic monitorin* a*ainst t,e et,ical
resonsi-ility to minimi@e atient e0os/re to ioni@in* radiation.
==
.ike t,e I6C, t,e
DG! ima*es can -e downloaded +or atient ed/cation and st/dy, ins/rance
"eri+ication, or +or /se in treatment or re"enti"e ro*rams. 5,ere is no deterioration
o+ t,e stored di*itali@ed ima*es wit, time. Finally, a most imortant oint is t,at t,e
dia*nostic "al/e o+ t,e ima*e is considered e?/al to traditional -itewin* radio*ra,y
w,en downloaded to a hi$h2resolution monitor or rinter.
=&
Fi*/re >=-= A ,i*,-tec, mer*in* o+ electronics and otics to make an intraoral
"ideo camera. Note t,e small camera lens at t,e end o+ t,e camera s,a+t. 5,e
ima*es o-tained are seen on t,e oeratory monitor d/rin* t,e e0amination as
well as -ein* transmitted o"er t,e o++ice ,ardwirin* to t,e -/siness center w,ere
it can -e stored or rinted, or i+ necessary sent o/t as an e-mail +or ins/rance
/roses.
Fi*/re >=-& 5,ree di++erent intraoral +ilm-si@e sensors-itewin*, anterior, and
ediatric/sed +or DG!. 6ariations in ener*y recei"ed -y t,e sensor are
transmitted -y t,e attac,ed wire to t,e com/ter +or electronic rocessin*. 5,e
res/ltin* ima*e can -e resented on a ,i*, resol/tion monitor, stored, rinted or
treated as e-mail i+ needed.
Caries and Primary Prevention
30lorer Misdia*nosis and Mis/se
5,e ,i-tec, ad"ancements to dental dia*nostic science disc/ssed a-o"e, ,a"e arri"ed
at a time w,en t,e traditional e0lorer is comin* into ?/estion as o+ten -ein* an
accessory to iatro$enic dentistry, 4it, t,e millions o+ e0lorer dia*noses o+ caries-
or-no caries -ein* made e"ery day in dental o++ices t,ro/*,o/t t,e world, it is
essential to look at any e"idence t,at mi*,t indicate otential or act/al atient ,arm,
as well as ossi-le sol/tions.
5,e /se o+ t,e e0lorer to searc, +or cario/s lesions is -ein* ?/estioned in 3/roe
='

and t,e United States.
=<
5,is concern is *enerated -y t,e +act t,at e0lorer
e0aminations can ossi-ly ca/se irreara-le dama*e to t,e s/r+ace o+ immat/re
enamelD
=%-=;
carry cario*enic -acteria +rom one in+ection site to ot,er "/lnera-le dee
its and +iss/resD
&$
and most important, explorer catches have not proved to 4e valid
indicators of the presence, or a4sence, of 5uestiona4le occlusal caries,
&:,&>
5,e
dia*nosis o+ it-and-+iss/re caries wit, con"ol/ted +iss/res is recario/s -y eit,er
"is/al or e0lorer tec,ni?/es. 5,e dia*nostic "al/e o+ an e0lorer e0amination o+ t,e
occl/sal s/r+aces decreases as t,e FstickinessF o+ t,e +iss/re increasest,is at a time
w,en the need for validity increases, For instance, t,e sensiti"ity o+ an e0lorer
e0amination can decrease +rom ($E +or wide +iss/res to '>E +or t,ose t,at are
narrow.
&>
)ennin* and coworkers emloyed an e0lorer to e0amine t,e occl/sal
s/r+ace o+ :$$ e0tracted teet, t,at ,ad no visi4le cavitation, and w,ic, were later 0-
rayed and sectioned. Only >&E o+ t,e caries lesions t,at were e"ent/ally +o/nd were
disco"ered -y /se o+ t,e e0lorer.
&=
./ssi cond/cted a st/dy in"ol"in* =& dentists
w,o serially e0amined <: e0tracted teet,. A ,istolo*ical st/dy o+ t,e teet, was
accomlis,ed to ro"ide t,e FcorrectF dia*noses. 5,e res/lts demonstrated t,at t,e
dentists were more likely not to treat decayed teeth than to JrestoreJ sound teeth,
Forty two ercent o+ t,e teet, were correctly dia*nosed, only one toot, was correctly
dia*nosed -y all, and two were ne"er correctly dia*nosed.
&>
As a res/lt o+ t,e lack o+
"alidity o+ t,e e0lorer--ased e0amination o+ occl/sal s/r+aces, several clinical
researchers have su$$ested that the explorer is no more effective for locatin$ pit2and2
fissure caries than is a visual examination coupled 3ith professional 7ud$ment,
&&,&'

5,is concl/sion ar*/es +or t,e /se o+ an explorerless mo/t,-mirror-only 7or
re+era-ly t,e /se o+ t,e I6C8 in dental e0aminations, 7Fi*/re >=-'8 -/t rele*ates t,e
e0lorer to s/c, tasks as locatin* calc/l/s, c,eckin* t,e mar*inal inte*rity o+ newly
laced restorations and sealants, and in searc,in* +or secondary caries. 3"en t,is latter
/se ,as -een s/-Aect to ?/estion.
&<
An e0amle o+ o"ertreatment ca/sed -y misuse o+ t,e e0lorer is t,e case o+ t,e
inciient caries lesion. In a caries e0amination, Fw,ite sotsF on t,e -/ccal and
lin*/al s/r+aces can -e easily seenD w,ereas, interro0imal enamel l/cencies 7Fw,ite
sotsF8 are /s/ally +irst detected -y radio*ra,y. +nce incipient lesions are identified
and recorded, there is no need to pro4e this precarious site, 5o do so will o+ten
con"ert t,e inciient lesion into an o"ert lesion re?/irin* a restoration. .esions o"er
$.: to >.$ mm. can -e created in e0tracted teet, -y s/c, mis/se o+ t,e e0lorer.
=%

4it,o/t t,e ro-in* penetration o+ t,e s/r+ace @one t,at allows a s/-se?/ent -acterial
in"asion, reminerali@ation t,eray o+ t,e Fw,ite sotsF can "ery o+ten -e s/ccess+/lly
imlemented wit, no e"ent/al dama*e to t,e toot,.
As a *eneral s/mmari@in* concet o+ dia$nostic errors, Downer
&%
and 1ader
&(
,a"e
-ot, ointed o/t t,at in ro/tine caries e0aminations, w,et,er as a res/lt o+ t,e 0-ray
dia*nosis or +rom t,e /se o+ an e0lorer, t,ere is a ,i*, ro-a-ility o+ false2positive
and false2ne$ative dia*noses. As t,at line o+ delineation -etween disease-and-no
disease is aroac,ed, it -ecomes e"en more di++ic/lt, in +act imossi-le, to ositi"ely
identi+y a toot, as cario/s-or- noncario/s. In t,is *ray area t,e toss o+ a coin can -e as
acc/rate as t,e e0lorer. 5,ese dia*nostic errors are t,e res/lt o+ ercet/al and tactile
"ariations -etween e0aminers, di++erent criteria +or treatment decisions, lack o+
recision o+ dia*nostic tec,nolo*y, and di++erences in dili*ence to searc, +or
at,olo*y and impendin$ disease. 5,is +alli-ility ,as -een reco*ni@ed +or years, and
se"eral met,ods ,a"e -een, or are -ein* tested to ro"ide more "alidity to caries
dia*nosis. Some o+ t,e more romisin* met,ods /sed are -ite win* and di*itali@ed
roent*eno*ra,y 7t,e latter wit, its caa-ility o+ ima*e en,ancement8D +i-er-otic
transill/mination 7FO5I8, "is/al e0amination esecially w,en /sin* a "ideo intraoral
camera, disclosin* dyes, electrical cond/ction 7or resistance8 and ,i*, intensity
+oc/sed li*,t. In t,e latter cases, t,e re+lectance +rom t,e toot, s/r+aces o+ t,e
/ltra"iolet, +l/orescent, laser, or in+ra red li*,t are -ein* meas/red -y a li*,t meter.
&;

Until a -etter sol/tion is de"eloed, enetration o+ t,e s/r+ace @ones o+ inciient
lesions or +alse-ositi"e dia*noses +or caries can -e as dama*in* to t,e teet, as is
-acterial-ind/ced ca"itation, since in a clinical sit/ation t,e end res/lt is t,e insertion
o+ /nneeded restorations
30erience and st/dies also indicate t,at restorations are not-+or-a-li+etime.
'$-'=
5,e
,i*, +ail/re o+ amal*ams +rom mar*inal de+ects, o"er,an*s and rec/rrent caries ,as
-een noted +or many years.
'&,''
More contemorary st/dies s,ow an imro"ement in
lon*e"ity o+ restorations, -/t still t,e cycle o+ lacement and relacement is stron*ly
e"ident. MAor et al., in a recent st/dy o+ <,%<: restorations, +o/nd t,at t,e a"era*e
lon*e"ity +or an amal*am restoration laced in ad/lts 7> or h :; years o+ a*e8 was ::
years. !esin--ased comosites a"era*ed ( years, *lass ionomers & years, and resin
modi+ied *lass ionomer, > years.
'<
3ac, s/ccessi"e relacement in"ol"es a *reater
loss o+ toot, str/ct/re and a *reater dan*er o+ e"ent/al toot, loss. Thus, preventin$
one ne3 cavity results in a multiplier effect of preventin$ several recurrent lesions
over a lifetime, For t,is reason, t,e resent treatment o+ o"ert, and arrest, or re"ersal
o+ inciient lesions, must 4e accorded an ur$ent priority of preventive care,
)ro-a-ly t,e two most e++ecti"e and economical dental-o++ice re"enti"e roced/res
a"aila-le to raidly red/ce caries incidence, and o+ten t,e least /sed, wo/ld -e t,e
early lacement o+ sealants in all dee con"ol/ted 7FstickyF8 occl/sal +iss/res, and t,e
timely /se o+ reminerali@ation roced/res +or all nonca"itated inciient smoot,
s/r+ace lesions. 5o eitomi@e t,e otential o+ t,e com-ined /se o+ sealants and
reminerali@ation strate*ies, !ia concl/ded t,at caries co/ld ractically -e eliminated
in U.S. sc,oolc,ildren -y t,e com-ined /se o+ sealants to rotect t,e occl/sal
s/r+aces, and +l/oride rinses to rotect t,e smoot, s/r+aces.
'%
Fi*/re >=-' 4it, a atient watc,in* t,e monitor d/rin* t,e e0amination, m/c,
atient ed/cation can -e accomlis,ed.
Question 2
A. 5,e I6C camcorder doc/mentation o+ t,e dental e0amination can -e watc,ed on a
monitor screen -y -ot, t,e atient and t,e dentist.
1. 5,e main disad"anta*e o+ DG! is t,e +act t,at it re?/ires more 0-ray ener*y t,an
-itewin* +ilms.
C. Se"eral clinical researc, st/dies ,a"e demonstrated t,at e0lorer catc,es are not
"alid indicators o+ t,e resence or a-sence o+ occl/sal caries.
D. Accordin* to se"eral clinical researc,ers, an e0lorer e0amination o+ FstickyF
occl/sal s/r+aces res/lts in many +alse-ositi"e and +alse-ne*ati"e dia*noses.
3. A +alse-ositi"e recordin* o+ caries stat/s +or a toot, /s/ally res/lts in t,e
lacement o+ a restoration in a non cario/s toot,.
Sealants
5,e lacement, relacement, and retention o+ a sealant in FstickyF caries-rone its
and +iss/res can prevent andBor arrest incipient occlusal lesions 7C,ater :$8.
'(-<>

Sealants ro"ide a er+ect solution to t,e dilemma o+ coin* wit, t,e +alse-ositi"e
dia*noses o+ occl/sal caries. 5,eir lacement in dee con"ol/ted +iss/res o+ occl/sal
s/r+aces ne*ates t,e ossi-ility o+ wron*+/lly restorin* t,e many teet, t,at wo/ld
,a"e recei"ed inad"ertent +alse dia*noses +or caries. 5,e sealin* o+ a +iss/re also
se?/esters t,e cario*enic or*anisms to re"ent t,e seedin* o+ ot,er areas in t,e
mo/t,. Sealin* o+ t,e +iss/res can -e accomlis,ed easily, ?/ickly, ainlessly and
economically.
5,e sealant ser"es to interdict t,e n/trient s/ly to t,e +iss/re microor*anisms,
leadin* to t,eir e0tinction, and t,e ,ardenin* o+ t,e /nderneat, dentin.
<=
5,e
lacement o+ an occl/sal sealant is ro-a-ly t,e most conser"ati"e sol/tion to
re"entin* or arrestin* t,e early caries rocess 7i+ resent8, t,ere-y a"oidin* t,e
ro-a-ility o+ +/t/re rimary or rec/rrent lesions and t,eir se?/elae.
<:
Sealant
lacement s,o/ld -e +ollowed -y a toical alication o+ +l/oride alied at t,e dental
o++ice, as well as a daily ,ome e0os/re to a +l/oride denti+rice andBor mo/t,rinse to
,el rotect t,e w,ole toot,. 5raditionally, t,e maAority o+ sealants were laced on t,e
occl/sal s/r+aces o+ c,ildrenCs teet,. Howe"er, t,e anatomy o+ t,e occl/sal +iss/re and
t,e ris* assessment of the patient, not t,e a*e o+ t,e indi"id/al s,o/ld -e t,e */ide to
any decision to lace or not to lace a sealant. (est 3e for$et, 7:8 for every occlusal
restoration seen at any a$e, a sealant 3as indicated previous to the development of
the overt lesion and 7>8 for every smooth surface lesion seen at any a$e,
reminerali1ation 3as pro4a4ly indicated previous to the development of cavitationR
Tooth, Heal ThyselfRemineralization
5,e microscoic loss 7deminerali@ation8 and re*ainin* o+ mineral 7reminerali@ation8
on t,e surface o+ t,e teet, occ/rs continuously in a ,/man en"ironment.
<&

!eminerali@ation can -e a short2term de+ense resonse to t,e daily microscoic loss
o+ mineral +rom +ood a-rasion and in*estion o+ acid +oods and condiments s/c, as
oran*es, ineale, cola drinks and "ine*ar. O+ e?/al imortance is t,e -odyCs a-ility,
/nder lon$er2term +a"ora-le conditions, to reair radio*ra,ic l/cencies t,at are seen
in radio*ra,s e0tendin* +rom t,e enamel s/r+ace into as +ar as t,e o/ter :B= to :B> o+
t,e dentin. 5,e re,ardened s/-s/r+ace lesions are /s/ally micro-iolo*ically inacti"e
wit, a ,ardness t,at aroac,es or e0ceeds t,at o+ t,e ori*inal enamel or dentin.
<'
5,e e?/ili-ri/m -etween de- and reminerali@ation can -e *reatly -iased in +a"or o+
oral ,ealt, -y9
:. !ed/cin* t,e o/lation o+ cario*enic -acteria in t,e oral en"ironment -y
mec,anical and c,emical la?/e control meas/res. 5,is is accomlis,ed -y +re?/ent
atient /se o+ toot, -r/s,in*, +lossin* and irri*ation 7F-r/s,, +loss and +l/s,F8D it is
also aided -y t,e eriodic /se o+ t,erae/tic mo/t,rinses s/c, as c,lor,e0idine and
+l/oride.
>. A drastic red/ction o+ re+ined car-o,ydrate 7s/*ar8 intake.
=. Initiatiation o+ reminerali@ation and rotecti"e strate*ies t,at en,ance and
s/lement t,e cr/cial sali"a-dri"en toot, reminerali@ation.
<<,<%
30amles incl/de
m/ltile e0os/res to +l/oride +o/nd in comm/nity-water s/liesD o+ professional
alications o+ +l/oride "arnis,B*els, ,y*ienist /se o+ +l/oride ro,ylactic astesD and
t,e home use o+ +l/oride rod/cts s/c, as +l/oride denti+rices and mo/t,rinses.
&. Stim/latin* t,e +low o+ sali"a wit, its minerali@in* constit/ents. 5,is can -e
accomlis,ed -y c,ewin* non-s/*ar containin* c,ewin* */m, esecially a */m
+la"ored wit, 0ylitol, a non-acido*enic and non-cario*enic olyol
<(
7C,ater <.8
!eminerali@ation o+ teet, is not a new concet. In :((&, one o+ Dr. #. D. 4,iteCs
FtisF in Dental Cosmos ointed o/t t,at Fmany teet, comin* t,ro/*, t,e */ms ,ad
an e0ceed- in*ly de+ecti"e lookF. For t,ese teet, ,e s/**ested t,at t,e +in*er s,o/ld
-e /sed to r/- c,alk on t,e teet, twice a day. As m/c, o+ t,e c,alk as ossi-le s,o/ld
-e allowed to remain. .imewater was to -e /sed to rinse t,e mo/t, instead o+ re*/lar
water.
<;
D/rin* t,e eriod o+ :;:$ to :;>$s, Head, a ,ysician resented con"incin*
e0erimental e"idence t,at teet, co/ld -e ,ardened.
%$
In one aer ,e wrote t,at ,e
and se"eral ot,er dentists ,ad seen 3hite spots disaear, a+ter w,ic, ,e asked, FI+ t,e
sot disaears, wo/ld not t,is ro"e t,at t,e enamel is not a dead, inert s/-stance
t,at we are s/osed to consider iteF
%:
1y t,e :;>$s, t,ere was considera-le a*reement t,at recalci+ication 7reminerali@ation8
co/ld occ/r, -/t still considera-le de-ate as to w,et,er Fcalci+ication and
recalci+icationF was ,ysiolo*ical "ia t,e /l, or a c,emical ,enomenon +rom
addition o+ constit/ents +rom t,e sali"a.
%>,%=
It was not /ntil t,e :;'$s t,at t,ere was more ositi"e roo+ o+ caries arrestment.
M/,ler in ,is e0tensi"e researc, o+ a stanno/s +l/oride denti+rice 7Crest8 +o/nd t,at
t,e end-o+-t,e-year e0aminations, many o+ t,e ori*inal c,arted lesions no lon*er
e0isted. 5,ese ,e termed re"ersals.
%&
Followin* t,e initiation o+ water +l/oridation, it was -elie"ed t,at t,e caries
decrement t,at +ollowed was ca/sed -y t,e +ormation o+ a more resistant +l/oraatite
crystal on t,e enamel s/r+ace, w,ic, to some e0tent was tr/e. Howe"er, it was not till
Sil"erstone descri-ed t,e cario/s lesion as comrised o+ a s/r+ace @one, t,e -ody o+
t,e lesion, and t,e dark and transl/cent @ones, t,at it was demonstrated t,at wit,
aroriate +l/oride t,eray, t,e s/-s/r+ace cario/s lesion co/ld -e reminerali@ed.
::

5oday it is reco*ni@ed t,at +l/oride acts to 4oth re"ent deminerali@ation and en,ance
reminerali@ation. 7C,aters = and ::.8
!eminerali@ation t,eray to arrest and re"erse inciient smoot, s/r+ace lesions is
o+ten mentioned in research Ao/rnals, less mentioned in practice2oriented
/-lications, and rarely emloyed routinely in clinical ractice. Het, t,e
reminerali@ation o+ inciient lesions wit, no e"idence o+ ca"itation is an essential
noninvasive re"enti"e otion to maintain a li+etime caries-+ree dentition. As early as
:;%$, "on der Fe,r and coworkers in a st/dy in"ol"in* m/ltile daily s/*ar
mo/t,rinses, visually o-ser"ed t,e de"eloment o+ Fw,ite sotsF wit,in >= days.
!eminerali@ation o+ t,ese Fw,ite sotsF was s/ccess+/lly accomlis,ed -y /se o+
dental ,y*iene and +l/oride mo/t, rinses.
=
It was a-o/t > years later t,at a similar
st/dy was reorted, only in t,is case, t,e st/dents also /sed a $.>E c,lor,e0idine
mo/t,rinse twice-a-day to s/ress t,e cario*enic or*anisms. 5,ere were no si*ns o+
early caries. The chlorhexidine had made a difference,
F4,ite sotsF are not rare occ/rrences. MeAare and collea*/es "is/ally insected ';(
s/r+aces o+ remolars e0tracted +or ort,odontic reasons as well as t,e adAacent
s/r+aces o+ nei*,-orin* teet, and +o/nd t,at ':E ,ad inciient lesions, o+ w,ic, only
'E demonstrated ca"itation.
%'
MeAare and Malm*ren in anot,er st/dy +o/nd t,at at
a*e :<, t,e mean n/m-er o+ inciient lesions er indi"id/al was =.$
%<
In a Scottis,
st/dy, >,;:% inciient lesions were +o/nd "is/ally on t,e -/ccal and lin*/al s/r+aces
o+ t,e teet, o+ >,('&, :=-year-old sc,ool c,ildren. At t,e end o+ > years,
aro0imately three 5uarters o+ t,e lesions ,ad remained static or re$ressed,
F/rt,ermore, w,ere inciient lesions were ori*inally identi+ied, t,ere was a *reater
amo/nt o+ la?/e, as well as a *reater ossi-ility o+ locatin* ot,er inciient lesions.
&

The identification of one incipient lesion can 4e a 3arnin$ si$n of a more $enerali1ed
caries status re5uirin$ attention,
5,e extreme importance o+ considerin* all radiol/cencies +or reminerali@ation is
ill/strated -y a st/dy in Denmark. 5,e interro0imal l/cencies o+ :,$($ preoperative
radio*ra,s were e0amined follo3in$ lacement o+ restorations. Most l/cencies +o/nd
were t,ose demonstratin* deminerali@ation -/t not ca"itation. Only :$E
demonstrated ca"itations, meanin* t,at H:; should have 4een considered for
reminerali1ation in lieu of restoration, As a res/lt, it was concl/ded t,at t,e ori*inal
dia*nosin* dentists needed to -etter reco*ni@e lesions amena-le to reminerali@ation.
%%

5o +/rt,er em,asi@e t,is ro-lem o+ inaroriate o"er-treatment, 5,ylstr/ and
coworkers, in a roent*eno*ra,ic st/dy o+ interro0imal caries, estimated t,e only
one out of four patients receivin$ restorations, needed restorations,
%(
Un+ort/nately,
many -elie"e t,at oerati"e inter"ention is necessary to restore minimal interro0imal
l/cencies desite a let,ora o+ in+ormation t,at reminerali@ation is a re+era-le
noninvasive otion +or toot, lon*e"ity. For e0amle, in a ?/estionnaire st/dy in
Scotland, it was +o/nd t,at &&.>E o+ Scottis, dentists wo/ld +ill an aro0imal lesion
con+ined to t,e enamel o+ a ,yot,etical :>-year-old prior to ca"itation.
%;
Anot,er +actor to -e considered w,en an interro0imal s/r+ace o+ a toot, is
remat/rely restored is t,e iatro$enic dama$e ca/sed to t,e ro0imal s/r+ace o+ t,e
adAacent so/nd toot,. In one st/dy, more t,an '$E o+ s/r+aces adAacent to aro0imal
restorations were dama*ed, o+ten resentin* wit, radio*ra,ic c,an*es.
($,(:
!very interro0imal radiol/cency not sho3in$ cavitation, s,o/ld -e considered +or
reminerali@ation t,eray and lon*it/dinal monitorin*D only w,en a lesion
demonstrates ca"itation s,o/ld it -e considered irre"ersi-le. )itts and !immer, in
e0aminin* :,'(( teet,, +o/nd t,at C::; o+ t,e teet, wit, only Fw,ite sotsF ,ad
so/nd enamel s/r+aces wit, no ca"itationD e"en (;.'E o+ t,e enamel l/cencies
e0tendin* to t,e dentinoenamel 7unction ,ad no ca"itation. Howe"er, all l/cencies
e0tendin* into t,e ro0imity o+ t,e /l did have ca"itation.
(>
5,e New Iealand Sc,ool Dental Ser"ice s/ccess+/lly /ses +l/oride "arnis,
7D/ro,at8 to en,ance reminerali@ation o+ t,e teet, o+ c,ildren ,a"in* an
interro0imal l/cency t,at is not more than half3ay throu$h the enamel and no
cavitation,
(=
Ot,ers /se t,e dentinoenamel A/nction as t,e t,res,old.
(&
For instance,
3lderton -elie"es t,at a radiol/cency s,o/ld e0tend into t,e dentin or sho3 cavitation
-e+ore oerati"e inter"ention.
('
Dodds ,as s/**ested t,at e"en dentinal l/cencies
3ithout apparent cavitation s,o/ld -e considered +or ossi-le reminerali@ation
t,eray since +/rt,er caries ro*ression is o+ten -locked -y sclerosin* or secondary
dentin.
(<
Clinicians in 3/roe and *lo-ally are -e*innin* to t,ink conser"ati"ely.
(%,((
5,e
+ollowin* :;;; aer +rom Scandina"ia ill/strates t,is trend. 5,e st/dy -y MaAare et
al. is entitled FCaries assessment and restorati"e t,res,olds reorted -y Swedis,
dentists.F 5,e st/dy incl/ded t,e resonses o+ <': 7o/t o+ ;>=8 dentists w,o indicated
t,at +or an adolescent wit, low caries acti"ity and *ood oral ,y*iene, ;$E wo/ld not
a/tomatically restore an aro0imal l/cency i+ its radio*ra,ic aearance did not
s,ow o-"io/s ro*ression to the outer CLA to CL< of the dentin, Moreo"er, <%E wo/ld
only consider immediate restorati"e treatment o+ an occl/sal s/r+ace i+ o4vious
cavitation andBor i+ radio*ra,ic si*ns o+ dental caries co/ld -e o-ser"ed. Ot,er
interestin* +indin*s were t,at t,e yo/n*er, more o+ten t,an older dentists wo/ld
ostone restorati"e treatment, and t,at dentists in ri"ate ractice wo/ld restore
aro0imal caries at an earlier sta*e o+ ro*ression t,an dentists in t,e )/-lic Healt,
Dental Ser"ice.
(;
5,ere are no U.S. reorts a"aila-le +or comarison.
5,e !eminerali@a-le !oot Caries .esion
4it, an a*in* o/lation retainin* t,eir teet, lon*er, t,ere is an increasin*
re"alence o+ root caries.
;$,;:
Aro0imately >(E o+ t,e o/lation seekin* treatment
w,o are /nder <$ years o+ a*e ,a"e root cariesD
;>
o"er <$ years o+ a*e, t,e estimate
increases to aro0imately &$ to <=E.
;=
Fi+ty-t,ree ercent o+ t,e root lesions are on
t,e facial s/r+ace, +ollowed in order -y t,e distal, lin*/al and mesial s/r+aces.
;&
.ike coronal caries, root s/r+ace caries occ/r in distinct and imortant
sta*esinciient, arrested, o"ert, and restored. 5,e inciient sta*e t,at recedes +rank
7o"ert8 ca"itation is descri-ed as a Fwell-de+ined so+tened area, yellowis, or li*,t
-rown in color, -/t 3ithout ca"itation /on initial insection, t,at is, /ndist/r-ed
4efore ro-in*.
;'
5,ere is no Fw,ite sotF or s/-s/r+ace lesion as +o/nd in coronal
caries. 5,is so+tened mass can o+ten -e reminerali@ed -y daily la?/e remo"al wit, a
toot,-r/s, and a +l/oride denti+rice, l/s aroriate saced ro+essional alications
o+ +l/oride.
;<-;(
As a art o+ s/r+ace re,ardenin*, t,ere is also a redistri-/tion o+
mineral wit,in t,e lesion.
;;
5,/s, like inciient coronal caries, t,e easily "isi-le root
caries site s,o/ld not -e s/-Aect to e0lorer mani/lation i+ contemlatin*
reminerali@ation roced/res. 5,e in+l/ence o+ +l/oride on root s/r+ace caries is t,e
same as +or coronal caries, i.e., red/cin* deminerali@ation and en,ancin*
reminerali@ation.
Se"eral c,emot,erae/tic aroac,es ,a"e -een /sed to arrest root caries lesions.
1illin*s and associates,
:$$
and Markit@/i and collea*/es /sed topical fluorides,
;

Ny"ad and FeAersko"e +o/nd t,at w,ere root lesions were accessi-le 7mainly facial
s/r+aces8 to -r/s,in* wit, a fluoride dentifrice, it was ossi-le to con"ert '&E o+ t,e
acti"e root caries to an inacti"e stat/s. Only (E o+ t,e aro0imal lesions re"erted to
inacti"e stat/s.
:$$,:$:
Sc,aecken et al. +o/nd t,at t,e /se o+ c,lor,e0idine and +l/oride
ca/sed a hardenin$ o+ root caries as well as markedly s/ressin* t,e m/tans
stretococci o"er se"eral mont,s.
:$>
Followin* a ,istoat,olo*y e0amination o+ e0tracted teet, wit, root caries, Sc,/ack
and associates concl/ded t,at reminerali@ation deended on 7:8 t,e de*ree o+ acti"e
sclerosis o+ dentinal t/-/les /nderlyin* t,e lesion, 7>8 t,e de*ree o+ t,e -acterial
in+ection o+ t,e dentin, 7=8 t,e de*ree o+ ro*ression o+ t,e lesions, and 7&8 t,e
location o+ t,e lesions at t,e "ario/s root s/r+aces
:$=
5,e alternati"e to preventin$ acti"e root s/r+ace caries is t,e insertion o+ restorations
t,at soon -ecome t,e sites o+ secondary caries. FeAersko" e0ressed t,is t,o/*,t -y
statin*, F5,e more +illin*s inserted, t,e more likely is t,e risk o+ de"eloin* more
caries lesions.F
:$&
!eminerali@ation t,eray o+ root caries, esecially o+ t,e +acial
s/r+ace, aears to ,a"e an e?/al or -etter ro-a-ility o+ s/ccess in restorin* an
inciient or early o"ert lesion to inacti"e stat/s, t,an does t,e insertion o+ a
restoration.
Fluorides and Remineralization
!e*imens to ma0imi@e t,e otential +or reminerali@ation as well as to minimi@e
deminerali@ation consist o+ t,e /se o+ ,ome and o++ice c,emical and mec,anical
la?/e control tec,ni?/es, m/ltile +l/oride t,eraies, and a se"erely limited intake o+
s/*are0actly t,e same tec,ni?/es as /sed to re"ent t,e de"eloment o+ t,e
inciient lesions in t,e +irst lace. 5,e m/ltile +l/oride t,eraies incl/de +l/oride
denti+rices and mo/t, rinses, o++ice alications o+ toical +l/oride li?/ids, *els, or
/se o+ a +l/oride "arnis, or reminerali@in* aste at seci+ic sites, and e"en t,e
ossi-le rescrition o+ +l/oride ta-lets in +l/oride-de+icient areas, re*ardless o+
a*e.
:$'
Once reminerali@ation ,as -een s/ccess+/lly accomlis,ed in t,e resence o+
+l/oride, t,e reminerali@ed areas o+ten are more resistant to future acid attac* than
previous to deminerali1ation,
5,e two times w,en a toot, is esecially "/lnera-le to deminerali@ation and caries are
7:8 immediately a+ter er/tion and -e+ore mat/ration o+ t,e enamel, and 7>8 at any
time d/rin* li+e +ollowin* rolon*ed -acterial acid-ind/ced deminerali@ation. 5o meet
t,e +irst o+ t,ese two c,allen*es, se"eral professionally applied fluoride alications
s,o/ld -e made +rom t,e time t,e +irst ti o+ t,e er/tin* c/s aears /ntil t,e toot,
is in occl/sion. 3"en a+ter +/ll er/tion is attained, +l/oride s,o/ld -e alied se"eral
times ro+essionally d/rin* t,e +irst year o+ intraoral mat/ration.
In t,e second instance, t,e many daily cycles o+ de- and reminerali@ation at di++erent
eriods t,ro/*,o/t li+e are /s/ally s/-clinical and are not ossi-le to detect.
::
One o+
t,e -est ways to ens/re enamel rotection +rom caries ro*ression d/rin* s/c,
eriodic ne*ati"e mineral -alances, is -y t,e daily e0os/re o+ t,e teet, to +l/oride,
s/c, as +l/oridated water and -y /se o+ o"er-t,e-co/nter rod/cts s/c, as +l/oride
denti+rices and +l/oride rinses. 7Fi*/re >=-&8.
5,e )otential
5,e s/ccess+/l sealin* o+ all dee its and +iss/res and t,e reminerali@ation o+ all
inciient lesions wo/ld -y de+inition, res/lt in re"entin* all cario/s lesions 7e0cet
+or t,ose ca/sed -y dia*nostic error and e0lorer mis/se8 +rom ro*ressin* to t,e
o"ert sta*e re?/irin* restorations. Any concern o+ ossi-le /nnoticed caries ro*ress
d/rin* reminerali@ation t,eray or -eneat, a sealant can -e allayed -y s,orter
indi"id/ali@ed recall sc,ed/les to ermit lon*it/dinal monitorin*.
:$<,:$%
5o +/rt,er
allay concern, t,e slow ad"ance o+ t,e re-caries +ront is seen in a reort -y MaAare et
al., w,ere '$E o+ t,e l/cencies at t,e dentinoenamel A/nction re?/ired an a"era*e o+
=.: years to ro*ress into t,e dentin.
:$(
5,is ro"ides amle oort/nity to later
s/-stit/te in"asi"e oerati"e treatment, i+ necessary.
:$;
5o rein+orce t,ese re"io/s
+acts, )itts, in a =-year st/dy o+ re*/lar adolescent attendees, +o/nd t,at ($E o+ t,e
ori*inal radiol/cencies aarently re*ressed or arrested sontaneo/sly.
::$
5,/s,
nonin"asi"e aroac,es o+ sealant lacement and reminerali@ation t,eray are "ia-le
and a re+erred aroac, to maintainin* intact teet,. Dental caries is a preventa4le
disease 3here even esta4lished precaries lesions can 4e arrested or reversed3ith
appropriate patient cooperation,
:::
Question 3
A. Sealants -ecome more cost-e++ecti"e as t,e +iss/res on t,e occl/sal s/r+ace
deeens and -ecome more con"ol/ted 7FstickyF8.
1. Sealants s,o/ld -e laced o"er all FstickyF +iss/res w,ere t,ere is t,e ossi-ility o+
a +alse ositi"e or a +alse-ne*ati"e dia*nosis.
C. F4,ite sotsF res/lt in a ermanent c,an*e in color and s/r+ace too*ra,y o+ a
toot,.
D. Us/ally, more Fw,ite sotsF re*ress or remain static t,an t,ose t,at ro*ress to
o"ert lesions.
3. Caries o+ -ot, coronal and root s/r+aces can only occ/r w,en deminerali@ation
e0ceeds reminerali@ation o"er time.
Periodontal Disease and Primary Prevention
A !ational Aroac, to )re"entin* Gin*i"itis
5,is s,ort section will -rie+ly re"iew a +ew +acts aroriate to t,is c,ater t,at were
learned +rom C,aters & and :=.
:. A ,i*, la?/e-inde0 score andBor t,e resence o+ calc/l/s /s/ally ortends a
*in*i"itis.
>. Gin*i"itis /s/ally can -e re"ersed -y o++ice-instit/ted and ,ome sel+-care ,y*iene
meas/res t,at remo"e or se"erely dist/r- t,e dental la?/e. Since t,e eriodontal
tiss/es ret/rn to ,istolo*ical normalcy, t,is ,ome and ro+essional care reresents a
cure,
=. Once t,e *in*i"itis is s/ccess+/lly treated, t,e ne0t recall inter"al s,o/ld -e -ased
on t,e resent treatment /r*ency, t,at is, t,e ,i*,er t,e aarent ris*, t,e s,orter t,e
time inter"al s,o/ld -e -e+ore t,e ne0t aointment.
)eriodontal-acti"ity indicators 7)AIs8 and */idelines +or aroriate therapy,
counselin$, and recall schedules can -e de"eloed in t,e same way as re"io/sly
disc/ssed +or caries-acti"ity indicators 7CAIs8. A*ain, t,e +o/r e"idence-de"eloed
indicators are t,e la?/e inde0, calc/l/s se"erity, n/m-er o+ -leedin* sites on
ro-in*, and t,e )eriodontal Screenin* and !ecordin* system 7)S!8 +or ocket det,
7see C,ater :=8. 5,e )S! was introd/ced in :;;= -y t,e American Dental
Association and t,e American Academy o+ )eriodontolo*y as a met,od to screen all
ad/lt atients :( years o+ a*e and older +or e"idence o+ eriodontal disease.
>&
Only ' min/tes is needed to accomlis, t,e )S! screenin* 7ro-in*8. 5,e @ero-to-
+o/r codin* system /sed +or eac, o+ t,e se0tants o+ t,e atientCs mo/t, ro"ides a
n/merical -asis to s/**est t,e eriodontal treatment /r*ency as well as atient
mana*ement */idelines commens/rate wit, t,e atientCs eriodontal stat/s. 5,e )S!
s,o/ld -e recorded at all initialBann/al e0aminations, and at all recalls, esecially
w,ere t,e re"io/s eriodontal treatment /r*ency was o+ concern. A color-coded,
-eaded ro-e ti is /sed to meas/re s/lc/s det, ena-lin* t,e )S! to -e ?/ickly
accomlis,ed.
5o increase t,e acc/racy o+ determinin* t,e det, o+ t,e eriodontal ockets, as well
as to +acilitate t,e ease o+ recordin* ocket det,, a com/ter-co/led eriodontal
ro-e was de"eloed to a/tomatically si*nal a com/ter to record t,e ocket det, o+
a toot, a+ter enco/nterin* a *i"en resistance at t,e -ase o+ t,e *in*i"al s/lc/s.
Unlike t,e CAI la-oratory tests in w,ic, caries risk is related mainly to m/tans
stretococci and lacto-acilli le"els, no arallel la-oratory Fscreenin$ testsF are
a"aila-le +or eriodontoat,o*ens. A n/m-er o+ dia$nostic la-oratory tests +or
ctino4acillus actinomycetemcomitans, Porphyromonos $in$ivalis, and Prevotelle
intermedia and ot,er s/sect eriodontoat,o*ens are /sed to aid in makin* treatment
decisions, -/t t,eir cost--ene+it as ro/tine micro-iolo*ic screenin* )AIs ,as not -een
ade?/ately assessed. Howe"er, m/c, researc, e++ort is now -ein* de"oted to +indin*
some *enetic marker +or identi+yin* resent and +/t/re risk +or eriodontal disease.
)la?/e and )la?/e Control
Dental la?/e is al3ays resent at t,e inter+ace -etween t,e sali"a and t,e toot,
s/r+ace. Any site wit, more t,an a minimal amo/nt o+ la?/e s,o/ld -e considered an
infected area in need o+ constant and e++ecti"e daily disr/tion or remo"al -y /se o+ a
toot,-r/s,, dental +loss, and irri*ationD andBor -y t,e s/ression o+ at,o*enic
-acteria wit, antimicro-ial a*ents. Initially, a mar*inal *in*i"itis o+ local ori*in
occ/rs as a res/lt o+ -acterial meta-olic end rod/cts in t,e s/ra*in*i"al la?/e. 5,is
early eriodontal in"ol"ement 7*in*i"itis8 is /s/ally t,e +irst si*n aarent to t,e
atient in t,e +orm o+ Fink toot,-r/s,F ca/sed -y -lood on t,e toot,-r/s,. Startin* at
an early a*e, it is essential t,at a erson s,o/ld learn to /se la?/e-control meas/res
t,at remo"e or se"erely dist/r- la?/e at least once a day. 5,e toot,- -r/s,in*,
+lossin*, and irri*ation t,at are accomlis,ed -y t,e indi"id/al w,ile t,e
eriodonti/m is ,ealt,y is intended to prevent the onset o+ *in*i"itis. Any e"ent/al
*in*i"itis may or may not ro*ress to eriodontitis. I+ it does, it was t,e s/ra*in*i"al
la?/e t,at ro-a-ly ser"ed as t,e initial seedin* loci o+ t,e microor*anisms +o/nd in
t,e s/-*in*i"al la?/e. I+ /ns/ccess+/l in maintainin* *in*i"al ,ealt,, t,e re"enti"e
e++ort s,o/ld immediately -e directed to ro+essional inter"ention to arrest t,e disease
rocess -e+ore an entrenc,ed s/-*in*i"al la?/e ca/ses additional dama*e to t,e
eriodonti/m.
)eriodontal maintenance care can red/ce 4oth t,e n/m-er o+ root caries and t,e
n/m-er o+ ockets.
::>
C,lor,e0idine Gl/conate
In A/*/st :;(<, t,e U.S. Food and Dr/* Administration 7FDA8 aro"ed t,e
prescription sale o+ )rocter g Gam-leCs )eride0, a $.:>E c,lor,e0idine *l/conate
sol/tion as a mo/t,-rinse. 5,is action was soon +ollowed -y t,e American Dental
Association 7ADA8 also aro"in* t,e rod/ct as /se+/l in t,e control o+ *in*i"itis.
Since t,at time, it ,as -een +o/nd t,at c,lor,e0idine not only ro"ides a otent
adA/ncti"e a*ent +or t,e treatment o+ eriodontal disease7s8, -/t also is ,i*,ly
e++ecti"e +or s/ressin* cario*enic la?/e -acteria.
::>-::<
C,or,e0idine is considered t,e F*old standardF +or e++ecti"eness as an oral
antimicro-ial a*ent. 4it, t,e e0cetion o+ +l/oride, it is considered t,e most e++ecti"e
dr/* a"aila-le in t,e war a*ainst m/tans stretococci.
::%
5,e e++ecti"eness o+
c,lor,e0idine stems +rom its s/-stanti"ityD t,at is, 7:8 it adsor4s to t,e in+ected tiss/e
in t,e tar*et area, 7>8 it is released slo3ly, and 7=8 it is released in an active form,
5,e dental /ses o+ c,lor,e0idine are imressi"e.
::(
For so+t-tiss/e t,eray it is /sed to
treat *in*i"itis, eriodontitis, stomatitis, ,eres simle0, /lcers, and -e+ore and a+ter
oral s/r*ery.
::;
For caries control, it ,as -een emloyed wit, s/ccess in mo/t,rinses,
*els and "arnis,es. It ,as -een com-ined wit, +l/orides in "arnis,es to s/ress
Stretococc/s m/tans, and wit, +l/oride to accelerate reminerali@ation.
:>$,:>:
One
t,ree-year st/dy o+ :> to :& year old ,i*,-risk st/dents wit, >:$
<
Streptococcus
mutans t,at /sed :E c,lor,e0idine *el e0erienced an (:E red/ction in caries
incidence.
:>>
5,ere ,a"e -een relati"ely +ew comlaints, and t,ese ,a"e ,a"e mainly
tar*eted toot, stain 7%%E o+ t,e comlaints8, transient -itter taste 7:>E8, e0cess
calc/l/s, and dry mo/t, 7<E8.
::;
5,e small amo/nt o+ toot, stain t,at occ/rs
+ollowin* contin/ed /se o+ c,lor,e0idine rinses can /s/ally -e easily remo"ed at
,ome -y some o+ t,e rotary owered toot,-r/s,es, or certainly -y a ro,yla0is.
Some st/dies now -ein* cond/cted indicate t,at w,en c,lor,e0idine is com-ined wit,
ero0y-orate, an antio0idant, t,e res/lts are claimed to -e s/erior to c,lor,e0idine
alone, yet wit,o/t t,e ro-lems o+ taste and stainin*.
:>=
In controlled mo/t,rinse ro*rams, c,lor,e0idine ,as -ot, prevented a -/ild/ o+
la?/e and reduced la?/e acc/m/lations, i+ /sed alon* wit, -r/s,in*.
:>&
Once
*in*i"itis is dia*nosed, c,lor,e0idine rinses l/s ot,er sel+-care oral ,y*iene
meas/res are /s/ally ade?/ate to ret/rn t,e in+lamed *in*i"al to normal. Once t,e
s/-*in*i"al la?/e -ecomes in"ol"ed, s/-*in*i"al irri*ation wit, c,lor,e0idine
-ecomes an otion.
:>'
5,e irri*ation instr/ment can -e a owered /lsatin* Aet stream,
or as simle a de"ice as a lastic can/la attac,ed to a lastic s?/ee@e -ottle.
(=
5o -rie+ly s/mmari@e its *reat /tility in la?/e disease control, c,lor,e0idine ,as
-een /sed wit, toddlers,
:><
wit, ,i*,-risk sc,oolc,ildren,
:>%
wit, ,i*,-risk elders,
:>(

wit, t,e ,andicaed,
:>;
and wit, t,e mentally ,andicaed.
:=$
It ,as +o/nd /se in
ort,odontics,
:=:
in eriodontics,
:=>,:==
in caries-control +or o"erdent/re atients,
:=&
and
wit, ost-radiation atients.
:='
FScorecardsF and G/idelines
)ro+essional ethics and t,e la3 mandate t,at ,ealt,-care ro"iders resent atients
wit, a disclos/re o+ full and accurate information 7in+ormed consent8
:=<
a-o/t all
contemlated in"asi"e or nonin"asi"e treatment roced/res, as well as t,e likely costs
and -ene+its o+ eac,.
:=%,:=(
O+ten missin$ +rom t,ese disc/ssions are science--ased
re"enti"e re*imens t,at o++er otions to -ot, t,e atient and dental ro+essional +or
t,e non in"asi"e control o+ t,e la?/e diseases.
:=;,:&$
In #/ne :;;', The "ournal of the
merican Dental ssociation s/lement, entitled FCaries Dia*nosis and !isk
Assessment,F atly de+ined in narrative style t,e c/rrent needs +or oral-re"enti"e
strate*ies and mana*ement.
:&:
3arlier, Anderson et al. concisely ointed o/t t,e same
stes were re?/ired +or a comre,ensi"e re"enti"e dentistry lan.
:&>
Needed is a
way to -rin* all t,e narrati"e in+ormation into a worka-le aradi*m at t,e time o+ t,e
initialBann/al e0amination.
G/idelines, or standards tar*et seci+ic diseases, ,el esta-lis, a atientCs le"el o+ risk
and s/**est aroac,es to dia*nosis, treatment and maintenance to meet t,at le"el o+
risk. 5,e */idelines are intended to ,el in decision makin*, as well as ac,ie"in* a
le"el o+ consistency o+ treatment t,ro/*,o/t a o/lation.
:&=
5,ey s,o/ld also
increase t,e n/m-er o+ otions to atient care, red/ce atient costs, and imro"e t,e
redicta-ility o+ ac,ie"in* desired o/tcomes.
:&&
They should also leave room for
professional 7ud$ment, 5o accomlis, t,ese o-Aecti"es, t,ere are now e++orts to
de"elo nationwide ro+essional */idelines o+ ractice +or -ot, medical roced/res
:&=-
:&'
and +or dentistry.
:&<-:&(
As new researc, ad"ances e"ol"e +or controllin* or con?/erin* t,e la?/e diseases,
any /*radin* o+ standards s,o/ld reresent a consens/s o+ t,e *eneral ractitioners,
secialists, ed/cators in dental and dental ,y*iene sc,ools, researc, /nits, ins/rance
ser"ers and cons/mer *ro/s. All */idelines s,o/ld -e s/-Aect to continual revie3
and chan$e as accomlis,ed -y t,e eriodic /dated recommendations -y t,e
American Heart Association,
:&;
t,e American Cancer Society and t,e American
Academy o+ )eriodontolo*y.
:'$
As t,ese */idelines contin/ally e"ol"e, arallel e++orts
are needed to ed/cate t,e /-lic and t,e ro+ession a-o/t t,e new -ene+its res/ltin*
+rom /se o+ new roced/res and tec,nolo*ies.
Putting it all TogetherExamination, Treatment, Prevention
In t,e +irst edition o+ t,is te0t 7:;(:8, Harris introd/ced t,e concet o+ caries-acti"ity
indicators 7CAIs8 to de"elo a atientCs oral-,ealt, ro+ile 7FscorecardF8 at t,e time o+
t,e initialBann/al dental e0amination, and to link it wit, t,e treatment, re"ention,
atient ed/cation lans, and recall sc,ed/le.
:':
5,is was +ollowed in t,e second
edition 7:;(%8 -y Harris and Sc,eirton
:'>
s/**estin* t,at t,e same aroac, co/ld -e
/sed +or eriodontal disease. 5,ese atient la?/e disease ro+iles 7FscorecardsF8 can
-e /sed to matc, t,e se"erity o+ t,e e"idence--ased disease indicators wit, rimary
re"enti"e dentistry resonses commens/rate wit, t,e se"erity o+ t,e la?/e
disease7s8. 5,is aroac, acknowled*es t,at all indi"id/als ,a"e di++erent dental
disease rocli"ities. 5,ose at ,i*,er risk re?/ire more a**ressi"e and closely
monitored rimary re"enti"e t,eraies. 3"idence--ased indicators s/c, as t,e la?/e
inde0, t,e -leedin* inde0 and semi ?/antitati"e micro-iolo*ical testin* s,o/ld -e
emloyed to ,el esta-lis, w,et,er a atient is at ,i*,, moderate, or low riskand to
adA/st treatment and monitorin* sc,ed/les accordin*ly.
:'=
As an e0lanatory note, t,e CAIs and )AIs are not 4ein$ used as predictors o+
imendin* la?/e disease in terms o+ sensiti"ity and seci+icityD
:'&-:'<
instead t,ey are
-ein* /sed to estimate the patient?s present vulnera4ility and to take t,e necessary
actions to ret/rn any indicator scores to as near @ero as ossi-le -e+ore t,e ne0t
aointment. A s/**ested aroac, to a */ideline t,at /ses t,e FscorecardF o+ t,e
initialBann/al e0amination to aid in selectin* indi"id/ali@ed treatment otions is
s,own in 5a-les >=-: and >=->.
5,e +irst ste +ollowin* t,e entire e0amination is to sec/re a rinto/t o+ t,e
FscorecardF listin* t,e oral ,ealt, ro+ile o+ t,e atient and t,e treatment /r*ency o+
eac, o+ t,e CAIs and )AIs. 5a-les >=-: and >=-> list t,e selected CAI or )AI clinical
+indin*s, la-oratory tests, or indices considered imortant in t,e de"eloment o+ t,e
la?/e diseases and indicate t,e relati"e treatment /r*ency 7risk8 o+ t,e se"eral
indicators on a scale o+ $ to &. For e0amle, i+ t,e +indin* +or any o+ t,e caries
indicators is ne*ati"e, t,e @ero in t,e aroriate col/mn o+ t,e @ero treatment
/r*ency rows is circledor entered into t,e com/ter. I+, ,owe"er, inciient or o"ert
lesions are identi+ied, circle t,e F: or >:F listin* +o/nd +or eac, caries cate*ory in t,e
5reatment Ur*ency & row. cNote9 5,ere is no intermediate ossi-ility -etween
5reatment Ur*ency $ and &eit,er a toot, is at risk d/e to inciient or act/al lesions
and s,o/ld -e *i"en riority treatment, or it is at no riskd. In t,e e0amle o+ 5a-le >=-
:, a 5reatment Ur*ency o+ & is circled -eca/se o+ one inciient -/ccal lesion 7Fw,ite
sotF8 and two dee 7FstickyF8 +iss/res-ot, wit,o/t ca"itation. 5,e le"el-& ratin*
will -e retained /ntil t,e two +iss/res are co"ered wit, sealant, and reminerali@ation
t,eray comleted +or t,e Fw,ite sot.F I+ t,e two entries ,ad -een $, t,e treatment
/r*ency score wo/ld ,a"e -een = -eca/se o+ t,e la?/e inde0 score. In t,ese
e0amles, t,e indicator "al/es ori*inally entered in t,e com/ter as art o+ t,e
initialBann/al dental e0amination are now ,i*,li*,ted 7circled8 in t,e aroriate
col/mns and rows. 5,e o"erall treatment /r*ency listin* in t,e last col/mn is -ased
on t,e most /r*ent 7,i*,est n/m-er8 entry in any o+ t,e col/mns, in t,is case, a*ain &
-eca/se o+ t,e inciient lesions and FstickyF +iss/res. 4it, t,is 5reatment Ur*ency o+
& esta-lis,ed, a second rinto/t is made t,at links t,e atientCs FscorecardF to care+/lly
considered indi"id/ali@ed rimary re"enti"e dentistry s/**estions 75a-les >=-= and
>=-&8. 5,/s, t,e CAI and )AI FscorecardsF ro"ide ro+iles o+ eac, atientCs caries
and eriodontal ,ealt,, resecti"ely. As a s/mmary listin* o+ riority needs, t,ey are
/nderstanda-le to t,e atient +or disc/ssin* in+ormed consent +or treatment and
economic otions. For t,e ractitioner, t,ey are "al/a-le in ,elin* to ro"ide
*/idelines s/**estin* t,e treatment +or eac, o+ t,e le"els o+ treatment /r*ency listed
on t,e Fscorecard.F 5,/s, wit, t,e inte*rated caries and eriodontal e0amination
FscorecardsF, t,e dentist and t,e dental ,y*ienist can /se t,e ori*inal e0amination data
as a atient-moti"ation instr/ment -y ,i*,li*,tin* specific atient oral ,ealt,
ro-lemsand sol/tions.
Once FscorecardsF and */idelines ,a"e -een comleted +or t,e o++ice records, a coy
o+ eac, s,o/ld -e *i"en to t,e atient as art o+ t,e in+ormed consent, ed/cation-
co/nselin* rocess, and to em,asi@e t,e commitment t,e dental o++ice ,as to
re"ention. 6ice "ersa, it identi+ies t,e areas re?/irin* atient cooeration. I+ desired,
a rinto/t can -e s/lied t,at lists t,e ro*ress 7or retro*ression8 o+ anyBor all o+ t,e
indicator scores recorded o"er t,e ast se"eral e0aminations.
Question 4
A. 5,e )eriodontal Screenin* and !ecordin* system 7)S!8 aids in dia*nosis and
s/**ests treatment otions commens/rate wit, t,e se"erity o+ t,e atientsC eriodontal
stat/s.
1. C,lor,e0idine is /sed to s/ress 4oth cario*enic -acteria and
eriodontoat,o*ens o+ t,e la?/e.
C. Disease */idelines attemt to standardi@e disease dia*nosis and to s/**est
treatment otions -ased on disease se"erity, yet allow +or ro+essional A/d*ment.
D. A nationally acceted */ideline, i.e., one acceted -y t,e American Dental
Assocition, -y state dental societies, -y researc, a/t,orities, dental sc,ool +ac/lties,
and -y ractitioners, wo/ld aid in imro"in* /ni+ormity o+ care and en,ance t,e
redicta-ility o+ o/tcome o+ a disease rocess.
3. Com/ter stora*e o+ data contained in t,e initialBann/al dental e0amination record
ermits con"enient downloadin* o+ a atientCs oral ,ealt, ro+ile 7FscorecardF8 -ased
on disease se"erityD wit, anot,er keystroke, a */ideline +or s/**ested treatment,
atient ed/cation, and re"enti"e dentistry otions can -e dislayed.
5,e !ecall Aointment
5,e recall aointment ro"ides an oort/nity +or lanned screenin*s and
ro,yla0es -etween ann/al e0aminations wit, t,e time inter"al -ein* -ased on CAI
and )AI +indin*s at eac, s/ccessi"e recall. ),iloso,ically, t,e recall eriod o+ ,i*,-
risk atients s,o/ld not e0ceed t,e time necessary +or a at,o*enic la?/e to re+orm
and to a*ain allow its micro-ial o/lation to dama*e t,e enamel, cement/m, andBor
*in*i"a. Once t,e at,o*enic la?/e is remo"ed -y ro,yla0is, se"eral st/dies ,a"e
doc/mented t,at it re?/ires at least = mont,s +or t,e la?/e to re*ain its disease-
ca/sin* otentiale"en t,o/*, t,ere may -e minimal comliance wit, ,ome care
la?/e control ro*rams.
:'%,:'(
Since pla5ue and time are t,e key +actors in t,e
de"eloment o+ -ot, inciient caries lesions and *in*i"itis, eac, ro,yla0is, -y
remo"in* t,e at,o*enic la?/e, essentially resets the time cloc* of pla5ue
patho$enicity 4ac* to near 1ero,
5,ere is a need +or a +le0i-le recall inter"al, -ased on the level of treatment need, as
s/**ested in 5a-les >=-= and >=-&. Ot,ers ,a"e indicated t,at t,e same eriodic oral
,y*iene roced/res and monitorin* are e++ecti"e in red/cin* t,e incidence o+ 4oth
caries and eriodontal disease.
::<,:';
I+ ossi-le, t,e eriodontitis and t,e caries
maintenance "isits s,o/ld -ot, -e ket in sync,rony on t,e same =- to <-mont,
inter"al recall. In t,is way, a re?/irement +or a =-mont, recall +or caries wo/ld aid in
la?/e re"ention control +or *in*i"itis, or "ice "ersa, e"en t,o/*, t,e ris* o+ t,e
ot,er mi*,t -e low. For e0amle, +l/oride alications +or coronal caries wo/ld aid
re"ent root caries w,ere t,e cement/m is e0osed. C,lor,e0idine "arnis,es are
e++ecti"e in ,elin* s/ress 4oth the cario$enic and periopathodontic 4acteria,
Finally a ,i*,-la?/e inde0 can ro"ide a warnin* si*n +or either caries or
eriodontitis. 5,e inde0 s,o/ld ideally -e :$E or less. 4,en t,e la?/e score
increases markedly, it s,o/ld ca/se ro+essional concern. Additional ed/cation and
co/nselin*, la-oratory tests and indices, s/c, as -acterial ?/anti+ication +or caries,
andBor t,e -leedin* inde0 +or *in*i"itis is indicated. 5,/s, t,e accomlis,ment o+ a
la?/e inde0 at eac, recall can alert t,e ,y*ienist a-o/t t,e ossi-le e0istence o+ in
situ and inciient lesions +or either or 4oth o+ t,e la?/e diseases, w,ile t,e
accomanyin* ro,yla0es can *reatly aid in a"ertin* t,e initiation and ro*ression
o+ in situ and inciient lesions +or 4oth diseases. !ecall ro*rams can -e easily
,andled -y /se o+ com/ter ro*rams. 4it, "ery little trainin*, an o++ice mana*er or
dental assistant can enter c,an*es in aointments and *enerate ro*rammed recall
notices t,at are a/tomatically rinted o/t +or re*/lar mailin* or e-mailin* aointment
reminders. S/c, timesa"in* and imro"ed administrati"e ractices are essential, e"en
in small dental ractices.
Car-o,ydrate Intake
5,e car-o,ydrate intake inde0 ro"ides an easy met,od to assess a atientCs intake o+
re+ined s/*ars, esecially i+ t,e intake is ,i*,. 5,is s/*ar intake score is -ased on t,e
atient +illin* o/t a car-o,ydrate intake s,ort +orm administered -y t,e dental o++ice
ersonnel. As t,e +re?/ency o+ intake, and t,e retenti"ity o+ t,e di++erent s/*ary +oods
increase, so does t,e car-o,ydrate intake score 7Aendi0 >=->8.
5,e Dental Hy*ienist )rimary-)re"ention Secialist
As a rimary dental re"ention secialist in t,e dental o++ice, t,e dental ,y*ienist is
salient in ins/rin* em,asis on re"ention. Academic dental-,y*iene ed/cation
ro"ides a comre,ensi"e c/rric/l/m t,at incl/des, amon* ot,er re?/irements,
clinical articiation in alyin* it-and-+iss/re sealant /se, reminerali@ation t,eray,
+l/oride alications, atient ed/cation and oral-,ealt, romotion, dietary co/nselin*,
ro,yla0is, root scalin*, root lanin* and s/-*in*i"al irri*ationall areas o+
e0ertise t,at are needed +or an otim/m la?/e- disease re"ention and control
ro*rams.
Under a total immersion approach to prevention, t,e Ftoot,-cleanin*F aointments
re?/ired +or ,i*,-risk atients s,o/ld not -e ercei"ed as ro,yla0es er+ormed
mainly +or aest,etic /roses, -/t rat,er as art o+ a caries andBor eriodontal disease
re"ention and maintenance ro*ram w,ic, will re?/ire lon*er aointment eriods.
S,all,orn and Snider
:<$
and )+ei+er and )+ei+er
:<:
+o/nd t,at it took aro0imately '=
and '% min/tes, resecti"ely, to comlete a recall aointment. 5,e m/ltile
aointments o+ indi"id/als in t,ese more intensi"e re"enti"e ro*rams will re?/ire
additional ,y*ienist time and resonsi-ilitiesand compensation, Additional
,y*ienists will ro-a-ly -e re?/ired as well as an assistant d/e to t,e increased atient
+low.
:<>
In t/rn, to administrati"ely s/ort t,e increased enrollment o+ atients in
re"enti"e ro*rams, t,ere s,o/ld ro-a-ly -e one +ront desk indi"id/al w,o can act
as an aointment coordinator to ens/re t,at recall "isits are sc,ed/led, and +ollowed
/.
I+ atient comliance wit, ,ome mec,anical and c,emical la?/e control instr/ctions
+or caries and eriodontal in"ol"ement ,as -een ade?/ate -etween "isits, t,e
treatment /r*ency le"el +or t,e a"era*e atient s,o/ld dro and remain at a low score.
5,is ossi-ility will ermit additional atients to enter t,e re"enti"e ro*ram to
maintain a +/ll and e0andin* sc,ed/le +or t,e o++ice dental-,y*iene sector.
)atient 3d/cation
5raditionally, dentistry ,as -een considered a treatment-oriented ro+ession. 5,e
concet o+ *oin* to t,e dentist to re"ent disease is mainly associated wit, a twice-a-
year ro,yla0is and t,e /se o+ +l/orides. )ro-a-ly t,e -est way to start in t,e
c,an*eo"er +rom a treatment to re"ention orientation is to cond/ct a searate
aointment +or dental education and promotion devoted to the patient?s o3n
pro4lems as identi+ied at t,e initialBann/al e0amination 7Aendi0 >=-=8.
:<=
.ike t,e
ann/al medical e0amination and e"al/ation, t,is eriod s,o/ld ,a"e a +ee. It is
essential to enlist t,e atient as a Fco t,eraistF i+ a ,ome re"ention ro*ram is to -e
a s/ccess. For atients to ass/me t,is role, t,ey need to know 3hat is e0ected, ho3 it
is to -e accomlis,ed, 3hy it is necessary and ho3 much it will cost. 5,is is t,e same
in+ormation as is re?/ired as art o+ in+ormed consent
At t,e end o+ t,e session, t,e atient s,o/ld +/lly reali@e t,at ,e or s,e is at risk, -/t
t,at t,e la?/e diseases can o+ten -e re"ented or re"ersed as a res/lt o+
recommended t,eray. As a art o+ medicineCs Fone t,ird r/le,F one t,ird o+ all
atients wit, c,ronic disease can -e e0ected to comly wit, instr/ctions, one t,ird to
comly erratically, and one t,ird not to comly at all.
:<&
It is also necessary to in+orm
t,e atient t,at all treatment e"ent/ally +ails wit,o/t a w,ole,earted and e++ecti"e
sel+-care commitment. Only t,e atient can decide w,et,er ,e or s,e wants to ay to
re"ent diseaseor to accet disease and ay +or more e0ensi"e treatment. I+ t,e
atient contin/ally +ails to comly wit, instr/ctions, it is e0edient to doc/ment a
warnin* ad"isory in t,e dental record to co/nter any ossi-le +/t/re le*al
reerc/ssions.
:<'
One indi"id/al +rom t,e dental o++ice s,o/ld -e selected to carry o/t t,e main t,r/st
o+ t,e ed/cation ro*ram. 5,e erson selected s,o/ld -e a dental ,y*ienist or a ,ealt,
ed/cator. 5,e main attri-/tes desired are t,at t,e erson -e mat/re, intelli*ent, and
comassionateD ,as leaders,i a-ilityD likes eoleD is ers/asi"eD ,as t,e a-ility to
imro"e on t,e daily resentationsD and ,as t,e +le0i-ility to adat resentations to
meet eac, atientCs needs and attit/des. 5,e entire ed/cation session can -e +acilitated
-y +oc/sin* on t,e FscorecardF listin*s +or t,e CAIs and )AIs, esecially w,en t,e
5reatment Ur*ency le"el is a-o"e >. At t,is time, t,e imortance o+ la?/e control
can -e introd/ced, /sin* edited ortions o+ t,e "ideo camera tae to s,ow t,e location
and e0tent o+ la?/e in t,e atientCs mo/t,. 5,e car-o,ydrate-cons/mtion
?/estionnaire re"io/sly +illed o/t, -ecomes m/c, more meanin*+/l w,en disc/ssed
in conte0t o+ t,e acid-rod/cin* caa-ility o+ t,e -acteria in t,e atientCs la?/e. 5,e
need +or la-oratory tests to determine t,e n/m-er o+ acid-rod/cin* -acteria in t,e
atientCs sali"a -ecomes e?/ally conse?/ential w,en it is made clear t,at t,e risk o+
decayed teet, increases as t,e n/m-er o+ acido*enic -acteria increases. As stated -y
2rasse, F5o r/n a caries re"enti"e ro*ram wit,o/t /sin* micro-iolo*ical met,ods is
like r/nnin* a wei*,t control ro*ram wit,o/t a scale.F
:<<
Finally, t,e relations,i o+
t,ese CAIs to in situ, inciient or o"ert caries lesions can -e related to t,e
deminerali@ation t,at occ/rs -etween t,e times o+ toot, ,ealt, to toot, ca"itation.
5,is -ackdro t,en ro"ides t,e -asis +or introd/cin* and disc/ssin* t,e F*/idelinesF
+or c/stomi@ed re"enti"e strate*ies +or t,e atientCs own treatment /r*ency le"el.
At t,is oint, ro-a-ly t,e two most imortant s/-Aects related to caries re"ention
and re?/irin* disc/ssion wit, a atient are9 7:8 t,e need and ad"anta*es o+ ,a"in*
sealants laced in all FstickyF +iss/resD and 7>8 t,e need to consider all inciient
smoot, s/r+ace lesions 7wit,o/t e"idence o+ ca"itation8 +or reminerali1ation therapy
and care+/l monitorin*not restorations. 5,e ad"anta*e o+ t,ese two e0ceedin*ly
imortant re"ention actions are not *enerally known and /nderstood -y t,e /-lic,
nor acti"ely romoted -y t,e ro+ession.
)la?/e-ind/ced *in*i"itis is t,e most common +orm o+ eriodontal disease.
:>=
All
atients s,o/ld -e co*ni@ant o+ t,e +act t,at Fink toot,-r/s,F is an imortant warnin*
si*n o+ *in*i"itis t,at can -e sel+-dia*nosed. I+ not cleared / wit,in a week -y more
"i*oro/s sel+-care e++orts at ,ome, an immediate "isit to t,e dental o++ice is indicated.
A com-ined ro+essional and sel+-care ro*ram is /s/ally all t,at is necessary to
ret/rn t,e *in*i"al to normal. On t,e ot,er ,and t,e ne*lect o+ t,is critical early sta*e
o+ *in*i"itis creates an en"ironment in t,e *in*i"al s/lc/s t,at +a"ors a more
at,o*enic +lora. Intermittent eisodes o+ *in*i"itis at a yo/n*er a*e increase the ris*
o+ a later eriodontitis.
:<%
5,e data ac?/ired as art o+ t,e initialBann/al dental e0amination as s/mmari@ed in
t,e FscorecardsF and */idelines can +orm t,e -asis +or indi"id/ali@in* t,e ed/cational
resentation. 5,e inte*ration o+ all t,ese s/-Aects s,o/ld make t,e ed/cational ,ase
+or eac, atient m/c, more moti"ational and lon*er lastin* t,an an a-stract
disc/ssion o+ re"enti"e dentistry.
3d/cation o+ t,e )ro+essionals
5,ere is a need +or t,e dental ro+essionals to mana*e caries to t,e ma0im/m e0tent
ossi-le -y /sin* non-in"asi"e re"enti"e meas/res. 1ot, smoot,-s/r+ace and it-
and-+iss/re lesions are re"enta-le and re"ersi-le. Certainly, t,e restorati"e aroac,
to caries control ,as not -een s/ccess+/l, esecially +or t,ose indi"id/als wit,o/t
+/nds nor access to dental care-ot, in t,e United States and esecially in nations
wit,o/t t,e reso/rces o+ t,e United States.
In t,e ast, +ew dental sc,ools ro"ided co/rses in primary re"ention t,at ri"al t,ose
o+ secondary and tertiary re"enti"e dentistry in terms o+ time, money, sta++ and
commitment. In :;(;, in an editorial in t,e "ournal of Dental Research, 5,ylstr/
identi+ied two maAor reasons t,at t,e -ene+its o+ re"ention are not /ni"ersally
a"aila-le. First, dental sc,ools do not yet inc/lcate in t,eir st/dents t,e imortance o+
re"entin* disease. Second, and ro-a-ly, most imortant, no re3ard is *i"en +or t,e
re"ention or re"ersal o+ on*oin* la?/e diseases w,ic, ,a"e -een ro"ed
re"ersi-le.
%(
An/sa"ice ,as added anot,er reason t,at aears as innoc/o/s as it is imortant, "i@.,
F-e do not examine for, or monitor incipient pla5ue disease,F
((
Until t,e smoot,
s/r+ace and occl/sal sites o+ inciient caries are identi+ied and recorded for priority
care, little non-in"asi"e remedial action will occ/r +or t,ese re-caries lesions. Until
CAIs and )AIs as well as s/mmari@in* FscorecardsF +or caries and eriodontal disease
aear as art o+ t,e clinical record, t,ere is no or*ani@ed +ormat to resent eac,
atient wit, indi"id/ali@ed in"asi"e and non-in"asi"e re"enti"e and treatment
otions.
5wo ot,er reasons mi*,t -e cited. 5,e +irst is t,e +act t,at many o+ t,e older dentists
+ind it difficult to accept the concept of reminerali1in$ pre2caries lesions seen as
radiol/cent areassites t,at in +ormer dental sc,ool days were considered as diseased
tiss/e t,at m/st -e restored. Conc/rrent wit, t,is "iewoint is t,e +act t,at once a
Fw,ite sotF de"elos, t,ere is an over2estimation o+ t,e "elocity o+ caries ro*ression
t,ro/*, t,e enamel and dentin.
:<(
Now it is reali@ed t,at caries ad"ances o"er a *reatly
"aried time san t,at can ran*e +rom mont,s, years or to re"ersal.
:$(
3?/ally
imortant is t,e +act t,at t,e ad"ancin* +ront o+ t,e inciient lesion can ro-a-ly -e
reminerali@ed /ntil it ,as, accordin* to Scandina"ian st/dies, ad"anced to ,al+ way
t,ro/*, t,e dentin, i.e., i+ ca"itation ,as not occ/rred -e+ore re"ersal takes lace.
:$(
In e"al/atin* 5,ylstr/Cs c,ar*e t,at t,e re"enti"e care c/rric/l/m in dental sc,ools
is tr/ncated, t,e ADACs S/r"ey o+ C/rric/l/m Clock Ho/rs o+ Instr/ction is
enli*,tenin*. In t,e :;;%-;( sc,ool year, U.S. dental sc,ools de"oted a mean o+ <<
,o/rs o+ c/rric/l/m time to re"ention. Didactic instr/ction on prevention incl/ded
mean o+ ;= ,o/rs o/t o+ a mean o+ '>>( ,o/rs in U.S. dental sc,oolsC c/rric/laor
aro0imately >E o+ t,e time.
:<;
In addition, t,e ADACs Accreditation Standards
re?/ire t,at F*rad/ates are cometent in ro"idin* oral ,ealt, care wit,in t,e scoe o+
*eneral dentistryincl/din* ,ealt, romotion and disease re"ention.F
:%$
In a :;;; ?/estionnaire, Horty et al. detailed some o+ t,e on*oin* re"enti"e
initiati"es -ein* cond/cted in t,e dental sc,ools. Forty-two o+ t,e +i+ty-+i"e dental
sc,ools 7%<E8 resonded to t,e ollin*. Not all t,e ?/eries were answered /ni+ormly.
3i*,ty-one ercent reorted ,a"in* +ormal ris* trainin$ pro$rams, wit, =(E ,a"in*
criteria +or low-, moderate-, and ,i*,-risk atients. Si0ty-two ercent ,ad de"eloed
seci+ic recall sc,ed/les -ased on t,at risk. 5wo-t,irds o+ t,e resondents 7:%B>'8
consider t,e otion o+ reminerali@in* or sealant lacement +or early rimary
7inciient8 lesions. 5,irty-se"en o+ t,e sc,ools indicated t,at t,e le"el o+ enetration
o+ t,e caries +ront -e+ore restoration, was t,e o/ter one-t,ird o+ t,e dentin.
:%:
Clearly,
t,is st/dy ortends a trend towards a more conser"ati"e 7re"enti"e8 aroac, to
clinical dentistry.
:%:
3conomics can -e a otent +actor in c,an*in* ,ealt, attit/des +or -ot, a atient and
t,e ro+essional. 5,ere is an ac/te need +or a reasona4le reim4ursement to dentists
and dental hy$ienists practicin$ preventive dental care, t,e same as is e0ected +or
dental treatment. 5,e idea o+ /rc,ase o+ *ood oral ,ealt, is alien to Americans w,o
,a"e traditionally acceted restorations, e0tractions, and rost,etic de"ices as a means
to coe wit, dental disease. 5,e /-lic expectations and demand +or re"enti"e dental
care m/st c,an*e i+ t,e ro+ession is to mo"e into an era in w,ic, re"ention relaces
a need +or restorations. In t,ese oenin* years o+ t,is new millenni/m, t,e ro+ession
m/st reare t,e pu4lic and itself +or t,eir new roles o+ dental re"ention and +/ll
dent/lism.
Clinical met,ods no3 e0ist to identi+y, arrest, or re"erse t,e inciient la?/e disease
lesions t,at are rec/rsors to o"ert lesions. It s,o/ld -e so easy to mo"e t,e +oc/s o+
dentistry to t,e ractice o+ dentistry in t,is direction. 5,e di++erence -etween
re"ention and treatment is simly an intact toot,, a restored toot,, or no toot,.
Imlementin* )re"enti"e )ro*rams
5,ere are si0 maAor treatment en"ironments in w,ic, t,e a+orementioned intensi"e
re"enti"e ro/tines can -e imlemented immediately9 7:8 ri"ate ractice
en"ironments, 7>8 military dental ser"ices, 7=8 /-lic-,ealt, clinics, 7&8 /-lic sc,ool
dental ro*rams, 7'8 ind/strial work sites and 7<8 dental-,ealt, maintenance
or*ani@ations. In eac, instance, t,e strate*ies +or red/cin* t,e incidence o+ -ot, o+ t,e
la?/e diseases, in"ol"e +ew c,an*es in clinical ,ysical +acilities or in daily
oeratin* ro/tine. Only a demonstration o+ leaders,i and a commitment to rimary
re"ention is needed to identi+y and re"erse t,e risk +actors o+ imendin* la?/e
disease, rat,er t,an limitin* t,e e0amination to a searc, +or and treatment o+
at,olo*y.
In t,e military, t,e economics o+ c,an*e +rom treatment to re"ention s,o/ld ose no
maAor ro-lem since aroriated +/nds are already a"aila-le +or dental care. In ot,er
dental settin*s, additional ins/rance and ersonal or /-lic +/nds are initially
re?/ired. Howe"er, a drastic red/ction o+ later e0endit/res +or t,e restoration o+
rimary and secondary caries lesions, toot, +ract/res, eriodontal treatment,
endodontics, e0tractions, -rid*es, and dent/res wo/ld soon comensate +or t,e
increased o/tlays +rom any o+ a+orementioned so/rces. In ri"ate ractices, it co/ld
lead to contracts to prevent, rat,er t,an treat dental disease
5,e Imm/nity Factor
In :;<$, 2eyes
:%>
and Fit@*erald and 2eys
:%=
demonstrated t,at S, mutans ca/sed
caries in rodents. Once it was esta-lis,ed t,at caries was an in+ectio/s disease, it was
reali@ed t,at caries mi*,t -e controlled -y /se o+ "accines. Se"eral instit/tions in t,e
United States and 3n*land were already accomlis,in* "accine researc,. 5,ere was
t,e prediction t,at a "accine wo/ld -e a"aila-le wit,in = to :$ years.
:%&
In :;%;
Co,en reorted on a ;-year st/dy w,ere two actively imm/ni@ed monkeys ,ad @ero
and a small lesion resecti"ely, w,ereas t,e t,ree s/r"i"in* control animals e0,i-ited
'<,<; and %= decayed s/r+aces.
:%'
5,e =- to :$-year time-ta-le was not reali@ed +or one maAor reason, "i@., it was
s/**ested t,at wit, acti"e imm/nity, t,ere mi*,t -e a cross reaction wit, ,eart
m/scle.
:%<
4it, t,at ossi-ility, 7:8 e"en i+ a "accine was de"eloed, t,ere was no
ass/rance it wo/ld -e acceted -y t,e Food and Dr/* Administration 7FDA8. 3"en i+
aro"ed -y t,e FDA, otential man/+act/rers were wary o+ ossi-le ,/*e laws/its.
:%%
1esides, caries was on t,e wane in de"eloed co/ntries and t,ere aeared to -e no
/r*ency to risk maAor ro-lems since caries was not a li+e-t,reatenin* disease. M/c,
o+ t,e researc, stoed or slowed. Anticiation t/rned to disaointment. Howe"er, in
G/ys Hosital in 3n*land, t,e searc, was contin/ed to de"elo a toically alied
passive vaccine a*ainst Streptococcus mutans, 5,is wo/ld -y-ass t,e maAor ro-lem
o+ cross-reactions.
3"ery dentist s,o/ld read t,e deli*,t+/l easy-to-read article -y #2-Ma.
:%(
It is a
+ascinatin* acco/nt citin* some o+ t,e ro-lems and s/ccesses t,at were enco/ntered
-y t,e G/yCs Hosital *ro/ o"er t,e ast >$ years on t,e way to a rototye dental
caries "accine. 5,e test "accine ,as already s/ccess+/lly assed animal and a small-
scale ,/man tests. It is now in a Sta*e II test ro*ram wit, a lar*er n/m-er o+
s/-Aects. 5,e initial test answered two cr/cial ?/estions, "i@, 7:8 it is ossi-le wit, t,e
"accine to suppress Streptococcus mutans 7SM8 and 7>8 to prevent caries. 5,e "accine
is toically alied to t,e teet,, a rocess called local passive immuni1ation, t,/s
eliminatin* t,e ossi-ility o+ in"ol"in* t,e -odyCs imm/ne system. 5,e anti-ody t,at
,as -een de"eloed -y *enetic en*ineerin* ,as tar*eted t,e adhesins resonsi-le +or
t,e attac,ment o+ Streptococcus mutans 7SM8 to t,e toot,.
5,e de"eloment o+ t,e anti-odies is a +ascinatin* story in itsel+. In assem-lin* t,e
desired anti-ody -y *enetic en*ineerin*, it re?/ired +o/r s/ccessi"e critical s/ccesses
to de"elo t,e +inal anti-ody wit, t,e correct con+i*/ration to d/licate t,at o+ t,e
,/man anti-ody. 5,e ama@in* art o+ t,e *enetic assem-ly rocess was t,e +act t,at
eac, ,ase o+ t,e more-and-more comle0 anti-ody, was accomlis,ed /sin* t,e
lowly to-acco lant t,at cannot ordinarily -e ind/ced to rod/ce mammalian
anti-odies. Once de"eloed, t,e contin/al ,ar"estin* o+ t,e lant seeds ins/red t,e
eret/ation o+ +/t/re cros o+ to-acco lants, wit, eac, *eneration d/licatin* t,e
ori*inal created anti-ody con+i*/ration. 5,is lant -iotec,nolo*y s/lied an
economical and relia-le so/rce o+ anti-odies needed +or t,e st/dy.
5,e rearation o+ t,e mo/t, +or alication o+ t,e "accine was also in*enio/s. A
two-week mo/t, rinse ro*ram /sin* c,lor,e0idine was s/++icient to clear t,e mo/t,
o+ most Streptococcus mutans, I+ no +/rt,er action was taken at t,is time, t,e mo/t,
was ?/ickly reo/-lated wit, SM. Howe"er, i+ t,e "accine was alied to t,e
ac?/ired 7sali"ary8 ellicle o+ t,e teet,, t,is reo/lation did not occ/r. It is estimated
t,at t,is assi"e imm/nity wo/ld ossi-ly last +rom t,ree mont,s to a year. 5o
increase t,e /ni"ersal "al/e o+ t,ese anti-odies, st/dies are -ein* cond/cted as to t,e
+easi-ility o+ incororatin* t,em into denti+rices and mo/t,rinses.
:%(,:%;.
A ossi-le dental caries "accine +or t,e +/t/ree !emem-er, we are now in t,e
-e*innin* o+ t,e >:
st
Cent/ry.
Question 5
A. 5,e twice-a-year ro,yla0is is ade?/ate in ,elin* to re"ent, arrest, and re"erse
t,e ro*ress o+ eit,er o+ t,e la?/e diseases.
1. 5,e la?/e is an etiolo*ic +actor +or -ot, caries and eriodontal diseaseD t,ere+ore,
a ro,yla0is at aroriate inter"als and recorded o-ser"ations +or )AIs and CAIs
s,o/ld *reatly ,el to re"ent, arrest, or re"erse -ot, la?/e diseases.
C. !eminerali@ation o+ o"ert cario/s lesions is a common ractice in Scandina"ia.
D. 5,e cost o+ rimary re"ention to re"ent one o"ert la?/e-disease lesion can sa"e
a m/c, *reater cost o+ later s/ccessi"e secondary- and tertiary- re"ention roced/res.
3. Mammalian anti-odies can -e d/licated in lants.
Summary
1y de+inition, i+ all inciient caries and all inciient eriodontal lesions co/ld -e
re"ented, arrested or re"ersed in t,e inciient sta*es, t,ere wo/ld -e no o"ert lesions
to treat. In order to aroac, t,is *oal +or all eole, it will ro-a-ly re?/ire an acti"e
/-lic-,ealt, imm/ni@ation ro*ram o+ t,e immensity and intensity t,at c,aracteri@ed
smallo0 elimination. 4e ,a"e not yet reac,ed t,at oint o+ dental disease
s/ressionD ,owe"er, t,e comletion o+ t,e H/man Genome )roAect does *reatly
en,ance t,at ossi-ilitynot only +or dental disease -/t +or all in+ectio/s and *enetic
diseases. At t,e resent time, t,e ra"a*es o+ t,e dental la?/e diseases can -e *reatly
minimi@ed +or t,ose indi"id/als w,o ,a"e access to a dental +acility, and t,e
commitment to comly wit, a dental re"ention and treatment ro*rams esta-lis,ed
-y a dentist. G/idelines wo/ld ,el esta-lis, a le"el o+ e0cellence and /ni+ormity +or
-ot, treatment and re"ention inter"ention. 4,en called /on, it is t,e resonsi-ility
o+ t,e dentist to e0amine, detect and er+ormor dele*atet,e necessary rimary
and secondary roced/res necessary to ass/re ma0im/m atient dental ,ealt, in t,e
resent and in t,e +/t/re. 5,e initialBann/al e0amination is a most imortant e"ent in
attainin* t,ese o-Aecti"es. Here it is ossi-le to sim/ltaneo/sly identi+y and record
treatment and re"enti"e needs, esta-lis, resent risk le"el, seci+ically +oc/s
co/nselin* and ed/cation addressin* atientsC seci+ic needs, as well as makin*
recommendations +or ,ome care. 3mirically, t,e ,ome care in"ol"es daily oral-
,y*iene roced/restoot,-r/s, 7wit, +l/oride toot,aste8, dental +loss, irri*ation and
s/lemental mo/t,rinses recommended or rescri-ed -y t,e dentist. 5,e two most
/se+/l mo/t, rinses in t,e dentistCs armamentari/m are +l/oride to increase toot,
resistance and en,ance reminerali@ation, and c,lor,e0idine to s/ress Stretococc/s
m/tans, ,el c/re *in*i"itis, and as an adA/nct +or treatin* eriodontitis. I+ a s,ort-
time assi"e "accine does -ecomes a"aila-le, it will -e a maAor ste towards a
li+etime o+ intact teet, +or t,ose w,o ,a"e ro/tine access to dental care.
1y t,e end o+ t,e initial treatment cycle, all o"ert lesions s,o/ld -e restoredD all
inciient smoot, and root s/r+ace lesions s,o/ld -e /nder*oin* reminerali@ation
t,erayD all necessary sealants s,o/ld -e in laceD and, all *in*i"itis s,o/ld -e /nder
maintenance control. Also, -y t,is time, t,e atient s,o/ld ,a"e t,e knowled*e and
/nderstandin* to articiate wit, t,e oral-,ealt, ro+essionals in a team e++ort o+ sel+-
care. 5,e o/tcome o+ s/c, a comre,ensi"e, inte*rated, and ersonali@ed la?/e
disease re"ention ro*ram in"ol"es t,e articiation o+ t,e entire o++ice team l/s
t,e comliance o+ t,e atient. As a res/lt o+ s/c, a controlled re"ention and
monitorin* ro*ram, t,ere s,o/ld -e an early dramatic red/ction in t,e incidence o+
t,e la?/e diseases and t,eir se?/elae. 5,is is as it s,o/ld -et,e ,allmark o+ t,e
dental ro+ession s,o/ld -e oral-,ealt, maintenance and en,ancement, not A/st
disease treatment.
:. D, 3correct.
Aincorrect. A Fw,ite sotF can occ/r on any s/r+aceD ,owe"er, it cannot -e "is/ally
o-ser"ed on e"ery s/r+ace. For instance, it cannot -e seen at t,e -ottom o+ its and
+iss/res. It is /s/ally +irst o-ser"ed as a radiol/cency in 0-rays o+ t,e interro0imal
s/r+aces.
1incorrect. 5,e inciient sta*e -e*ins as a Fw,ite sotF and contin/es /ntil t,ere is
s/r+ace ca"itation, w,ic, -y de+inition is an irre"ersi-le o"ert cario/s lesion.
Cincorrect. 5,e in situ sta*e o+ *in*i"itis is c,aracteri@ed -y an in+iltration o+ -ody
de+ense cells -eneat, t,e s/lc/lar eit,eli/m.
>. A, C, D, 3correct.
1incorrect. 5,e oosite is tr/e. M/c, less 0-ray ener*y is re?/ired +or t,e DG!
ima*es t,an wit, t,e intraoral +ilm.
=. A, 1, D, 3correct.
Cincorrect. 4,ile Fw,ite sotsF are a transl/cent w,ite, once reminerali@ed, t,ey
/s/ally take on t,e ,/e o+ t,e enamel.
&. A, 1, C, D, 3correct.
'. 1, D, 3correct.
Aincorrect. 5,e twice-a-year ro,yla0is is ade?/ate +or t,e maAority o+ eoleD
,owe"er, t,ere are many w,o co/ld -ene+it +rom a more +re?/ent sc,ed/le. In ot,er
words, t,e inter"al -etween ro,yla0es s,o/ld -e +le0i-le and -e -ased on risk.
Cincorrect. !eminerali@ation can only occ/r 13FO!3 t,e o"ert caries lesion sta*e.
:. 5,e two sta*es o+ caries de"eloment, rior to t,e o"ert lesion de"eloment are
iiiiiiiii and iiiiiiiiiD t,e two sta*es o+ eriodontal disease rior to
eriodontitis are iiiiiiiii and iiiiiiiii.
>. 5,ree ad"anta*es o+ t,e intraoral "ideocamera are9 iiiiiiiii, iiiiiiiii, and
iiiiiiiii.
=. 5,ree ad"anta*es o+ t,e di*ital G-ray are9 iiiiiiiii, iiiiiiiii and iiiiiiiii.
&. .ist +i"e reasons +or ,a"in* t,e ro-lem o+ +alse-ne*ati"e or +alse-ositi"e
dia*noses +or caries9 iiiiiiiii, iiiiiiiii, iiiiiiiii, iiiiiiiii and
iiiiiiiii.
'. How does a sealant prevent caries on t,e occl/sal s/r+acee iiiiiiiii. How does a
sealant arrest early caries on t,e occl/sal s/r+acee iiiiiiiii.
<. De+ine su4stantivity6 iiiiiiiii. Gi"e an e0amle o+ t,e a*ent in a mo/t,rinse
wit, t,is attri-/te9 iiiiiiiiiii.
%. Gi"e t,e reason w,y atients are not demandin* reminerali@ation t,eray instead o+
restorations 7HOU! e"al/ation8.
(. 4,y do yo/ -elie"e, or not -elie"e t,at a "accine can -e de"eloed +or eriodontal
diseasee
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ro0imal cario/s lesions at t,e time o+ oerati"e treatment in yo/n* ermanent teet,.
Scan " Dent Res, ;&9:;-><.
%%. 5,ylstr/, A., 1ille, #., g j"ist, 6. 7:;(<8. !adio*ra,ic and o-ser"ed tiss/e
c,an*es in aro0imal caries lesions at t,e time o+ oerti"e treatment. Caries Res,
>$9%'-(&
%(. 5,ylstr/, A. 7:;(;8. Mec,anical "s. disease-oriented treatment o+ dental caries9
ed/cational asects. " Dent Res, <(9::='.
%;. N/ttal, N. M., g )itts, N. 1. 7:;;$8. !estorati"e treatment t,res,olds reorted to
-e /sed -y dentistry in Scotland. #r Dent ", :<;9::;-><.
($. Medeiros, 6. A. F., g Seddon, !. ). 7:;;%8. 5,e re"alence o+ iatro*enic dama*e
adAacent to restored aro0imal s/r+aces. " Dent Res, %<9 :$%$ 7A-s. &:&8.
(:. j"ist, 6., #o,anessen, .., g 1r/nn, M. 7:;;>8. )ro*ression o+ ro0imal caries in
relation to iatro*enic rearation dama*e. " Den Res, :%=9>:$->.
(>. )itts, N. 1., g !immer, ). A. 7:;;>8. An in vivo comarison o+ radio*ra,ic and
directly assessed clinical caries stat/s o+ osterior aro0imal s/r+aces in rimary and
ermanent teet,. Caries Res, ><9:&<-'>.
(=. Mac2en@ie, M., g )eterson, M. 7:;;'8. 5,e New Iealand Sc,ool Dental Ser"ice.
In Harris, N. O., C,risten, A. G., 3ds. Primary Preventive Dentistry, &t, ed. Norwalk,
C59 Aleton g .an*e, <$:.
(&. 3selid, I. 5"eit, A. 1., g SkodAe, F. 7:;;%8. !estorati"e treatment decisions on
aro0imal and occl/sal caries in Norway. " Dent Res, %<9:$;; 7A-s. $=;8.
('. 3lderton, !. #. 7:;;=8. O"ertreatment wit, restorati"e dentistryD w,en to
inter"ene. /nt Dent ", &=9>$-&.
(<. Dodds, M. 4. #. 7:;;=8. Dilemmas in caries dia*nosisalications to c/rrent
ractice and need +or researc,. " Dent !duc, '%9&==-(.
(%. )itts, N. 7:;;=8. C/rrent met,ods and criteria +or caries dia*nosis in 3/roe. "
Dent !du, '%9&$:-:&.
((. An/sa"ice, 2. #., 3d. 7:;((8. j/ality e"al/ation o+ dental restorationsD criteria +or
lacement and relacement. C,ica*o. Euintessence, &:>-=.
(;. MeAare, I., S/nd-er*, H., 3selid, I., g 5"eit, 1. 7:;;;8. Caries assessment and
restorati"e treatment t,res,olds reorted -y Swedis, dentists. cta +dontol Scand,
'%9:&;-'&.
;$. S,ay, 2. 7:;;%8. !oot caries in t,e older atient9 si*ni+icance, re"ention, and
treatment. Dent Clin &orth m, &:9%<=-;=.
;:. #ones, #. A. 7:;;'8. !oot caries9 re"ention and c,emot,eray. mer " Dent,
(9='>-%.
;>. De )aola, ). F., Searkar, ). M., g 2ent, !. .. #r. 7:;(;8. Met,odolo*ical iss/es
relati"e to t,e ?/antitation o+ root caries. 0erodontolo$y, (9=-;.
;=. Miller, A. #., 1r/nelle, #. A., Carlos, #. )., et al. 7:;(%8. Oral Healt, o+ United
States Ad/lts. NIH )/-lication No. (%->(<(, :-:<(.
;&. .eske, G. S., g !ia, .. 4. 7:;(;8. 5,ree year root caries increments9 An
analysis o+ teet, and s/r+aces at risk. 0erontolo$y, (9:%->:.
;'. Feat,erstone, #. D. 7:;;&8. Fl/oride, reminerali@ation and root caries. m " Dent,,
%9>%:-&.
;<. 3milson, C. G., g 1erk,ead, D. 7:;;=8. 3++ects o+ a :>-mont, ro,ylactic
ro*ram on selected oral -acterial o/lations on root s/r+aces wit, acti"e and
inacti"e cario/s lesions. Caries Res, >%9:;'->$$.
;%. 4allace, M. C., !etie+, D. H., g 1radley, F. .. 7:;;=8. 5,e &(-mont, increment
o+ root caries in /r-an o/lation o+ older ad/lts articiatin* in a re"enti"e dental
ro*ram. " Pu4l Hlth Dent, &=9:==-%.
;(. Hoen-ro/wers, ). M., GroenendiAk, N., 5awarie, N. !., g Driessens, F. C.
7:;((8. Imro"ements o+ caries resistance o+ ,/man dental roots -y a two-ste
con"ersion o+ t,e root mineral into +l/oridated ,ydro0ylaatite. " Dent Res, <%9:>'&-<
;;. Ny"ad, 1., ten Cate, #. M., g FeAersko", O. 7:;;%8. Arrest o+ root caries in sit/. "
Dent Res, %<9:(&'-'=.
:$$. 1illin*s, !. #., 1rown, .. !., g 2aster, A. G. 7:;('8. Contemorary treatment
strate*ies +or root s/r+ace dental caries. 0erodontics, :9>$-%.
:$:. Ny"ed, 1., g FeAersko", A. 7:;(<8. Acti"e root s/r+ace caries con"erted into
inacti"e caries as a resonse to oral ,y*iene. Scand " Dent Res, ;&9>(:-&.
:$>. Sc,aecken, M. #., 2elAens, H. M., g "an der Hoe"en, #. S. 7:;;:8. 3++ects o+
+l/oride and c,lor,e0idine on t,e micro+lora o+ dental root s/r+aces and ro*ression
o+ root s/r+ace caries. " Dent Res, %$9:'$-=.
:$=. Sc,/-ac,, )., G/**en,ein, 1., g ./t@, F. 7:;;$8. Histoat,olo*y o+ root
s/r+ace caries. " Dent Res, <;9::;'->$&.
:$&. FeAersko", A. 7:;;&8. !ecent ad"ancements in t,e treatment o+ root caries.
c!e"iewd. /ntl Dent ", &&9:=;-&&.
:$'. Horowit@, H. S. 7:;;$8. 5,e +/t/re o+ water +l/oridation and ot,er systemic
+l/orides. " Dent Res, <;7Secial Iss/e89%<$-%.
:$<. )itts, N. 1. 7:;;:8. 5,e dia*nosis o+ dental caries9 dia*nostic met,ods o+
assessin* -/ccal, lin*/al and occl/sal s/r+aces. Dent Update, :(9=;=-<.
:$%. 2idd, 3. A. M. 7:;(&8. 5,e dia*nosis and mana*ement o+ FearlyF cario/s lesions
in ermanent teet,. Dent Update, ::9<;-(:.
:$(. MaAare, I., 2arlestral, C., g Stenl/nd, H. 7:;;;8. Incidence and ro*ression o+
aro0imal caries +rom :: to >> years o+ a*e in Sweden9 A rosecti"e radio*ra,ic
st/dy. Caries Res, ==9;=-:$$.
:$;. 3kanayake, .. S., g S,ei,am, A. 7:;(%8. !ed/cin* rates o+ ro*ression o+ dental
caries in 1ritis, sc,ool c,ildren. A st/dy /sin* -itewin* radio*ra,s. #r Dent ",
<=9><'-;.
::$. )itts, N. 1., g Deery, C. 7:;;%8. !adio*ra,ically monitored lesion -e,a"ior in
Scottis, adolescent re*/lar attenders. " Dent Res, %<9><$ 7A-str. :;%<8.
:::. 3lderton, !. #., g Osman, H. I. 7:;;:8. )re"enti"e "ers/s restorati"e
mana*ement o+ dental caries " Dent ssn S fr, &<9>:%->:.
::>. Al"es, M. 3. A. )., Allen, 5., g Al"es, M. C. 7:;;%8. 3"al/ation o+ lon* term
eriodontal maintenance t,eray. " Dent Res, %<9'& 7A-str. =><8.
::=. 4allman, C., 2rasse, 1., g 1irk,ead, D. 7:;;&8. 3++ect o+ c,lor,e0idine
treatment +ollowed -y stanno/s +l/oride *el alication on m/tans stretococci in
mar*ins o+ restorations. Car Res, >(9&='-&$.
::&. .ind?/ist, 1., 3dwards, S., 5orrell, )., g 2rasse, 1. 7:;(;8. 3++ect o+ di++erent
carriers on re"enti"e meas/res in c,ildren ,i*,ly in+ected wit, m/tans stretococci.
Scand " Dent Res, ;%9==$-%.
::'. 5wetman, A. 7:;;;8. Interdental caries incidence and ro*ression in relation to
m/tans stretoccci s/ression a+ter c,lor,e0idine-t,ymol "arnis, treatment in
sc,oolc,ildren. cta +dontol Scan, '%9:&&-(.
::<. ./oma, H., M/rtomaa, H., N//*a, 5., Nyman, A., N/mmikoski, )., Airamo, #.,
g ./oma, A. !. 7:;%;8. A sim/ltaneo/s red/ction o+ caries and *in*i"itis in a *ro/
o+ sc,ool c,ildren recei"in* c,lor,e0idine-+l/oride alications. Car Res, :>9>;$-(.
::%. 3milson, C. G. 7:;;&8. )otential e++iciency o+ c,lor,e0idine a*ainst m/tans
stretococci and ,/man dental caries. " Dent Res, %=9<(>-;:.
::(. ./oma, H. 7:;;>8. C,lor,e0idine sol/tions, *els and "arnis,es in caries
re"ention. Proc 'inn Dent Soc, ((9:&%-'=.
::;. Al-andar, #. M., GAermo, )., g )re/s, H. !. 7:;;&8. C,lor,e0idine /se a+ter two
decades o+ o"er-t,e-co/nter a"aila-ility. " Periodontol, <'9:$;-:>.
:>$. )etersson, .. G., Ma*n/sson, 2., Anderson, H., Alm?/ist, 1., g 5wetman, S.
7>$$$8. 3++ect o+ ?/arterly treatments wit, a c,lor,e0idine and a +l/oride "arnis, on
aro0imal caries in caries-s/sceti-le teen a*ers9 a =-year clinical st/dy. Caries Res,
=&9:&$-=.
:>:. 5wetman, S., g )etersson, .. G. 7:;;;8. Interdental caries incidence and
ro*ression in relation to m/tans stretococci s/ression a+ter c,lor,e0idine-t,ymol
"arnis, treatments in sc,ool c,ildren. cta +dontolo$ Scandinavica, '%9:&&-(.
:>>. Iickert, I., 3milson, C. G., g 2rasse, 1. 7:;(>8. 3++ect o+ caries re"enti"e
meas/res in c,ildren ,i*,ly in+ected wit, t,e -acteri/m Stretocc/s m/tans. rch
+ral #iol, >%9(<:-(.
:>=. Gr/ndemann, .. #., 5immerman, M. F., IA@erman, H., "an der 6elden, 6., g
4eiAden, G. A. 7>$$$8. Stain, la?/e and *in*i"itis red/ction -y com-inin*
c,lor,e0idine and ero0y-orate. " Clin Periodontol, >%9;-:'.
:>&. Al"es, M. 3. A. )., Allen, 5., g Al"es, M. C. 7:;;%8. 3"al/ation o+ lon* time
eriodontal maintenance t,eray. " Dent Res, %<9=><7A-str. (&8
:>'. Stein, M. 7:;;=8. A literat/re re"iew9 oral irri*ation t,eray. 5,e adA/ncti"e
roles +or ,ome and ro+essional /se. Pro4e, >%9:(->'.
:><. 5wetman, S., g Grinde+Aord, M. 7:;;;8. M/tan stretocci s/ression -y
c,lor,e0idine *el in toddlers. mer " Dent, :>9(;-;:.
:>%. Sliet,, C., Ste++en, H., !osin, M., g 4elk, A. 7>$$$8. Caries re"ention wit,
c,lor,e0idine-t,ymol "arnis, in ,i*, risk sc,ool c,ildren. Community Dent +ral
!pildemiol, >(9&:;->%.
:>(. Clark, D. C., Mor*an, #., g Mac3ntee, M. I. 7:;;:8. 3++ects o+ a :E
c,lor,e0idine *el on t,e cario*enic -acteria in ,i*,-risk elders9 a ilot st/dy. Spec
Care Dentist, ::9:$:-=.
:>;. Martens, .., Marks, .., g 2int, #. 7:;;;8. 5,e /se o+ c,lor,e0idine as a
re"enti"e and t,erae/tic means o+ la?/e control in t,e ,andicaed. !e"iew o+ t,e
literat/re and de+initi"e ad"ice +or alication. Rev #el$ %ed Dent, '>9>%-=%.
:=$. 1/rtner, A. )., Smit,, !. G., 5ie+en-ack, S., g 4alker, C. 7:;;<8.
Administration o+ c,lor,e0idine to ersons wit, mental retardation residin* in an
instit/tion9 atient accetance and sta++ comliance. Spec Care Dentist, :<9'=-%.
:=:. #enatsc,ke, F., 3lsen-er*er, 3., 4elte, H. D., g Sc,la*enka/+, U. 7>$$:8.
In+l/ence o+ reeated c,lor,e0idine "arnis, alications on m/tans stretococci
co/nts and caries increment in atients treated wit, +i0ed ort,odontic aliances. ",
+rofac +rthop, <>9=<-&'.
:=>. Cor-et, 3. F., 5am, #. O., Iee, 2. H., 4on*, M. C., .o, 3. C., Mom-elli, A. 4.,
g .an*, N. ). 7:;;;8. 5,erae/tic 3++ects o+ s/er"ised c,lor,e0idine mo/t,rinses
on /ntreated *in*i"itis. +ral Dis, =9;-:(.
:==. )iccolomini, !., Di 1ona"ent/ra, G., Catamo, G., 5/rmini, 6., Di )lacido, G.,
DC3rcole, S., )er+etti, G., g )aolantonio, M. 7:;;;8. Micro-iolo*i"al and clinical
e++ects o+ a :E c,lor,e0idine-*el in /ntreated eriodontal ockets +rom ad/lt
eriodontitis atients. &e3 %icro4iol, >>9:::-<.
:=&. 2eltAens, H. M., S,aeken, M. #., "an der Hoe"en, #. S., g Hendriks, #. C. 7:;;$8.
Caries control in o"erdent/re atients9 :(-mont, e"al/ation on +l/oride and
c,lor,e0idine t,eraies. Car Res, >&9=%:-'.
:='. 3stein, #. 1., Mc1ride, 1. C., Ste"enson-Moore, )., Merilees, H., g Sinelli, #.
7:;;:8. 5,e e++icacy o+ c,lor,e0idine *el in red/ction o+ Stretococc/s m/tans and
.acto-acill/s secies in atients treated wit, radiation t,eray. +ral Sur$ +ral %ed
+ral Pathol, %:9:%>-(.
:=<. S+ikas, ). M. 7:;;(8. In+ormed consent and t,e law. "D, :>;9:&%:-=.
:=%. .eake, #. .., Main, ). A., g 4oodward, G. .. 7:;;<8. !eort on t,e !CDS-
CDHS!U works,o on de"eloin* clinical */idelinesBstandards o+ ractice. " Can
Dent ssoc, <>9'%$-%.
:=(. S/ra-ian, S. !. 7:;;<8. In+ormed consent or re+/sal. " Calif Dent ssoc, <9':-&.
:=;. D/ckwort,, !. M. 7:;;=8. 5,e science -e,ind caries re"ention. c!e"iewd. /ntl
Dent ", &=97< S/l A8D '>;-=;.
:&$. Horowit@, A. 7:;;'8. 5,e /-licCs oral ,ealt,9 5,e *a -etween w,at is known
a-o/t re"entin* oral diseases is o+ten e0tensi"e. dv Dent Res, ;9;:-><'.
:&:. #ADA Co/ncil o+ Access, )re"ention and Interro+essional !elations. 7#/ne
:;('8. Caries dia*nosis and risk assessment.
:&>. Anderson, M. H., 1ales, D. #., g Omnell, 2-A. 7:;;=8. Modern mana*ement o+
dental caries9 5,e c/ttin* ed*e is not t,e dental -/r. "D, :>&9=;-&&.
:&=. Field, M. #., g .o,r, 2. N. 7:;;$8. Clinical 0uidelines6 Directions for a &e3
Pro$ram, Instit/te o+ Medicine. 4as,in*ton DC9 Academic )ress.
:&&. .o,r, 2. N., 3lea@er, 2., g Ma/sko+, #. 7:;;(8. Healt, olicy iss/es and
alications +or e"idence--ased medicine and clinical ractice */ide lines. Health
Policy, &<9:-:;.
:&'. Hayward, !. S. A., g .awacio, A. 7:;;=8. Initiatin*, cond/ctin* and
maintainin* */ideline de"eloment ro*rams. C%, :&(9'$%-:>.
:&<. An/sa"ice, 2. #. 7:;;'8. 5reatment re*imens in re"enti"e and restorati"e
dentistry. c!e"iewd. "D, :>9%>%-&=.
:&%. 1aker, #. D., g S,/*ars, D. A. 7:;;'8. 6ariation, treatment o/tcomes and
ractice */idelines in dental ractice. " Dent !du, ';9<:-'.
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Heart Association. Circulation, ;<9='(-<<.
:'$. G/idelines +or )eriodontal 5,eray. 7:;;(8. 5,e American Academy o+
)eriodontolo*y. " Periodontol, <;9&$'-(.
:':. Harris, N. O. 7:;(>8. 5,e clinical alication o+ rimary re"enti"e dentistry
roced/res in t,e control o+ t,e la?/e diseases. In Primary Preventive Dentistry, :st
ed. !eston, 6A9 !eston )/-lis,in* Comany, Inc., &'&-($
:'>. Harris, N. O., g Sc,eirton, .. S. 7:;(%8. In Primary Prevention Dentistry, >nd
ed. Norwalk, C5B.os An*eles, CA9 Aleton g .an*e, '==-%=.
:'=. Frame, ). S., Sawai, !., 1owen, 4. H., g Meyerowit@, C. 7>$$$8. )re"enti"e
dentistry ractitionerCs recommendations +or low risk atients comared wit,
scienti+ic e"idence and ractice and */idelines. m " Prev %ed, :(9:';-<>.
:'&. De"eloin* Clinical 5eac,in* Met,ods +or Caries !isk Assessment. 7:;;'8.
Symosi/m )roceedin*s " Dent !du, ';9%-:'.
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Uni"ersity o+ Nort, Carolina Dental 3colo*y.
:'<. .e"erett, D. H., )roskin, H. M., Feat,erstone, #. D. 1., Adair, S. M., 3isen-er*,
A. D., M/ndor++-S,rest,a, S. A., S,ields, C. )., S,a++er, C. .., g 1illin*s, !. #.
7:;;=8. Caries risk assessment in a lon*it/dinal discrimination st/dy. " Dent Res,
%>9'=(-&=.
:'%. 1arrin*ton, 3. )., g Ne"ins, M. 7:;;$8. Dia*nosin* eriodontal disease. "D,
:>:9&<$-&.
:'(. Greenwell, H., 1issada, N. F., g 4ittwer, #. 4. 7:;;$8. )eriodontics in *eneral
ractice9 )ro+essional la?/e control. "D, :>:9<&>-<.
:';. A0elsson, )., g .ind,e, #. 7:;(:8. 3++ect o+ controlled oral ,y*iene roced/res
on caries and eriodontal disease in ad/lts. !es/lts a+ter si0 years. " Clin Periodontol,
(9>=;-&(.
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:$=9>>%-:<:.
:<:. )+ei+er, M. !., g )+ei+er, #. 7:;((8. Dental re"ention9 5,e oral ro,yla0is.
Clin Prevent Dent, :$9:(->&.
:<>. Solomon, 3. S. 7:;;%8. !es/lts o+ t,e 5e0as Dental AssociationCs Dental Hy*iene
Needs S/r"ey. Texas Dent ", ::&9:%->>.
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:<&. .e"ine, !. A., g 4ilson, 5. G. 7:;;>8. Comliance as a maAor risk +actor in
eriodontal disease ro*ression. Comp Dent !du, :=9:$%>-;.
:<'. 4ilson, 5. #. #r. 7:;;(8. How atient comliance to s/**ested oral ,y*iene and
maintenance a++ect eriodontal t,eray. Dent Clin &orth mer, &>9=(;-&$>.
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+or t,e treatment and re"ention o+ dental cariese " Can Dent ssoc, '$9>>:->=.
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7Sec.8 &:-&'.
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selected asects o+ dia*nosis, re"ention and restorati"e dentistry. " Canad Dent
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reser"ed.

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, 1a/sc, g .om- Oral Care Di"ision, 5/cker, GA.

Sonicare, ),ilis Oral Healt,care, Sno?/almic, 4A.

, 2in*swood .a-oratories, Inc., Carmel, IN.

, Hal-rand, Inc., 4illo/*,-y, OH.

, Seciali@ed Care Co., Hamton, NH.

1e/tlic, ),armace/ticals .), 4a/ke*an, I..

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