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Effectiveness of a preventive dentistry delivery system
A p re v e n t iv e dentistry d eliv e ry system was d e v e lo p e d f o r m a x im u m e ffe c tiv e n e s s in p riv a te p ra c tic e . F o u r n e w p it or fis s u r e ca rio u s lesio n s d e v e lo p e d in 2 0 p a tien ts who w e re 10 to 2 0 y e a rs old at the start o f a tw o-year exp lo ra to ry test; th e re w e re n o n e w lesions o f smooth s u rfa c e s . O f the in c ip ie n t lesio n s that w e re u n d e r observation, n o in c r e a s e was o b s e rv e d in 2 3 o f 26 p it o r fis s u re lesions, 24 o f 25 p ro x im a l a n d all o f 26 b u c c a l o r lin g u a l smooth s u rfa c e lesio n s. In 33 p a tien ts 21 to 3 0 y e a rs old at the start o f the test, no n e w lesio n s a p p e a r e d a n d grow th o f th e 142 in cip ien t lesio n s a p p e a r e d to b e a rrested . A low le v e l o f gingivitis was m a in ta in e d in all p a tien ts who w e r e tested.
Effectiveness of a preventive dentistry delivery system Carl A. Ostrom, DDS, MSD, Birm ingham , Ala
umerous investigators have reported vari ous benefits from each of the principal com ponents of preventive dentistry practice— topical fluoride, dietary habits, and plaque control. Any of these factors, under closely controlled test conditions, can be highly effec tive, but the results of clin ica l experience have been inconclusive. As a result, the credibility and practicality of preventive procedures in the clin ical practice of dentistry have long been viewed with skepticism . To paraphrase H ein ,1 the dental practitioner is not w holly re sponsible for this less than spectacular record. The fault should be equally shared by those in research who have published conflicting in formation and, as a result, have failed to pro vide dentists in practice w ith unequivocally effective control and preventive m easures. For dental faculty, students, and practitioners, a further com plication may arise from the differ ences betw een the pu blic health approach and the optimum treatm ent for the individual pa tient. An inexpensive, convenient public health m easure that yields a partial reduction
of caries in thousands of ch ildren is a trem en dously valuable contribution to society, but this is not enough for the practicing dentist and the patients who rely on him for the best available dental care. T h is report describes the exploratory test of a preventive dentistry de livery system; the results indicate that the practitioner can adopt this system w ith con fi dence.
Methods PHILOSOPHICAL APPROACH. C lin ical preven
tive dentistry should be organized as a service that can be performed principally by auxiliary personnel under the d en tist’s supervision. A step-by-step procedural m anual, devised for the preventive dentistry program, can be used as a guide for a su ccession of dental hygienists or assistan ts.2 T h is system w ould enhance cost-effectiveness and perm it the dentists to devote them selves more fully to the dental procedures that only they are qualified to per form. JADA, Vol. 97, July 1978 ■ 29
ATTITUDINAL APPROACH. This program was based on the positive approach to success3,4 and the desirability of life-long health. A steadily decreasing gingivitis score makes the patient aware of his return to gingival health, a direct result of effective plaque control. Im proved oral hygiene coupled with the accep tance of sound dietary counseling quickly re duces the Snyder test score. These factors, as well as the comfort and pleasure of a clean m outh, encourage the patient to m aintain oral hygiene habits. Repeated improvement gives patients a sense of personal achievem ent be cause, through their own efforts, they have ac com plished the change. It is safe to predict that the patient who meets the criteria of suc cess at each appointment will have a reduced dental caries increm ent and no gingivitis. A less certain but reasonable anticipation is the arrestm ent and possible remineralization of m ost enam el-only, interproximal carious le sions and gingival white-spot lesions. Thus, both short- and long-term benefits motivate the patient. In most instances, the dentist and the hygienist can sincerely congratulate the patient at nearly every appointment. ELEMENTS OF HABIT CHANGE. Of the three principal components of preventive dentistry, only the topical application of fluoride that is performed in the dental operatory is under the dentist’s control. Effective use of fluorides at hom e and control of dietary sugars and plaque, w hich are necessary for m aintenance of oral health, depend on changes in the habits of the patients. Therefore, the following essential ele m ents of changing habits have been incorpor ated in the program: recognition of undesir able conditions, understanding why such con ditions have occurred, learning how to con trol them , experiencing personal success in this control, and reinforcing the new habits until they have become well established. A goal is set to achieve success in the first four of these elements during a sequence of five weekly visits. Because continuity and frequent encouragem ent sustain interest and en thusiasm of the patient, these visits are set up for consecutive weeks on a day and hour that are m utually convenient to the patient and the dental facility. The fifth of the essential ele m ents of changing habits, reinforcem ent of new habits, is emphasized by a gingivitis re view that is scheduled six weeks after com ple 3 0 ■ JADA, Vol. 97, July 1978
tion of the original sequence of visits. Thereaf ter, recall visits will coincide with the semiannual topical fluoride treatments. TOPICAL FLUORIDES. Of the many methods of topical application of fluoride, only two have consistently reduced the occurrence of new carious lesions by 60% or more. These are acidulated fluoride phosphate (AFP) applied by the method of W ellock and Brudevold,5 and stannous fluoride (SnF 2) applied by the method of Bixler and M uhler.6 Because AFP is more acceptable to the patient and has a long shelf-life, semiannual application of AFP was adopted as the preferred method for routine use in this program. For its proved cariesarresting features,7 SnF 2 was retained in the program for use in certain circum stances, such as treatment of a posterior tooth with a broadsurfaced buccal or lingual lesion that had an intact but chalky surface or application to all posterior teeth of the occasional patient who had several lesions in which carious exposure of the pulp appeared imminent and immediate operative treatment was unfeasible. Daily use of fluoride in either a mouthwash or a gel in a tray has also been highly effective.8' 10 These impressive results were obtained in children whose parents were highly motivated or in children who were under direct supervision of a teacher in school. Other investigators have reported that fluoride mouthwashes used at home under casual supervision are less effec tive. Therefore, semiannual topical application of AFP solution was adopted as mandatory for all patients in this program and use of topical SnF 2 and fluoride mouthwash was reserved for additional (not substitute) treatm ent in selected cases. NUTRITION AND DIETARY HABITS. For many years, the members of the dental profession have been aware of nutritional influences on oral health and of the effects that frequency, time of consumption, and consistency of in gested sugars can exert on the carious at tack.11,12 An illustration of the acidogenic capability of the patient’s oral flora is tele scoped by the Snyder test into a three-day period.13 This test provides an immediate demonstration of the effects of dietary-sugar habits that might actually require several years to culminate in caries. The normal delay in experiencing these effects tends to cloak the
inevitability of the potential damage of sugar consum ption and lulls the patient into a sense of false security. The Snyder test presents con crete evidence that can influence the patient to alter his dietary habits to the extent necessary to minimize cariogenic attack. To impress pa tients with the importance of diet and plaque control, nutrition and dietary counseling by the m ethod of Nizel14 and monitoring by the Snyder test were incorporated in the current preventive dentistry program. PLAQUE CONTROL. Although the dental pro fession has long credited microbial plaque with an essential role in dental disease, numerous clinical trials failed to demonstrate significant benefits from personal oral hygiene practices. More recent reports 1518 indicated that com plete plaque removal once a day rather than more frequent, superficial oral hygiene led to effective control of both caries and gingivitis. These reports justify the in terpretation that mature plaque is pathogenic, and that m eticulous plaque removal once a day prevents the development of mature plaque. Loe’s Plaque Index (PI) and Gingival Index (GI) provide definitive means for record ing these relationships.19,20 These concepts were the basis for plaque control in this clini cal preventive dentistry delivery system.
Procedural outline A t the first appointment, the patient’s com plete GI and PI are recorded. These records serve as baselines for future com parison and as an educational device for the patient. A t most subsequent appointments, only a locally mod ified pair of indexes is used. The GI-6 and PI-6 methods of monitoring progress are highly ef fective for educating and encouraging the pa tient during his series of appointments. In these abbreviated indexes, gingivitis and plaque scores are recorded for any six teeth (usually a pair each of m axillary molars, man dibular incisors, and m andibular molars) that had the highest indexes at the first appoint ment. The sum of the six scores for each pair of teeth gives high whole numbers, in com parison to the decimal fractions that are used in Lo'e’s original system. The whole numbers are m uch easier for the patient to understand. Recorded and discussed at each appointment, the meaning of the steadily declining scores is
easily understood by the patient. Such prog ress prompts most patients to strive for a GI-6 score of zero (Fig 1). Reduction of these re flects the degree of the patient’s success in achieving plaque control and gingival health by personal practices of oral hygiene. At each appointment, the Snyder test is taken to monitor the acidogenic potential of the patient’s oral flora. A five-day diet diary begun at the first appointment is analyzed and used along with counseling and successive changes in the Snyder test results (Fig 2) to demonstrate to the patient the influence exerted by dietary habits in controlling his cariogenic attack. The Bass method of sulcular brushing21 is used in conjunction with unw axed dental floss. The patient is advised that com plete re moval of plaque once a day is the m inim al fre quency for preventing plaque from maturing on the teeth. Methods for plaque removal are introduced at the first appointment, extended at the second, and reinforced at each succes sive appointment. The patient is told that, for the first week, he should use a disclosing tab let each night after brushing and flossing. He is provided with a dental mirror to use at home so that he can detect remaining plaque and remove it by additional effort. Beginning the second week, the patient is instructed to continue use of disclosing tablets as often as necessary (not less than once a week) to ensure that he is maintaining his new, successful oral hygiene habits. Removal of calculus and polishing with pum ice are performed profes sionally at the third appointment, or after the patient has shown significant success in per sonal daily plaque control and has observed the associated reduction in gingival inflamma tion and edema that has occurred solely as a result of improved personal oral hygiene. After polishing with pum ice, a topical ap plication of AFP is made. To ensure a daily resupply of fluoride ion, one of the approved therapeutic dentifrices (ADA Council on Den tal Therapeutics) is prescribed. At the fourth appointment, the dentist per forms a complete examination and reviews the original set of radiographs as well as the four bite-wing radiographs taken at the first pre ventive dentistry appointment. This reexam i nation allows the dentist to appraise the pa tient’s response to the preventive dentistry program. Special attention is given to any Ostrom : PREVENTIVE DENTISTRY DELIVERY SYSTEM ■ 31
2 3 4 5 3 3 2 0 3 3 2 1 1 1 t 0 14 2 2 1 1 2 2 1 1 1 1 1 1 1) 1 2 3 4 5 2 1 1 1 0 0 Ii 1 1 1 0 0 4 2 3 4 5 2 0 0 0 0 0
1 b M L B M L 6 M L
ft
M L
B M I
6 0 1 0
7 0 0 0
0 0 0
0 0 0
6
7
8 9 10 11 12 13 14 15 16 17 18 19 0 0 0 0 2 2 3 3 1 2 2 P 0 0 1 1 2 3 3 1 1 0 0 0 0 1 1 <3 1 0 0 0 0 0 1 1 2 2 0 0 0 0 0 2 2 2 1 0 0 0 0 1 5 8 9 10 11 12 13 14 15 16 17 18 19 2 1 1 0 0
1
0 0
B M L
0 0 0
3 0 0 0
4
5
6
7
8
6
7
8
1
r-L U
2
0 0 2 0
0
0 0 0
0 0 0
20 21 22 23 24
25 26 27 0 0 0 1 1 1 1 4 0 0 0 0 1 0 1 4 25 26 27 o 6 1 1
28 0 2 2
29 0 2 2
30 1 2 2
0 2 2
0 2 2
0 2
31 32 Index Date 1 2 P1 — 1 0 2 1
a
28 29 30 31 32 P1
I
— a
1 0 0 0 0 1 G1 0 1 ■ 2 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 2 0 0 P1 0 1 1 0 0 0 0 0 I 2 0 0 0 0 0 0 0 0 GI 0 0 0 0 (> c 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 0 0 0 1 0 0 1 0 P1 0 0 0 0 2 0 0 0 0 0 0 0 G1 0 0 0 0 1 0 12 13 14|15|16 17|18 19 20 2 1|22|23|24|25|26| 27128(29130, 31 j 32 10
-j »
0
i
2
B M L
0
21 22 23 24 0 0 0 0 2 1 2 1 1 1
j
0 0 0 0 Ô 0
B M L
20 0 2 1
0 0 0 1
0 0
. 3 4 5 6 7 8 9
ro *
ro * I I
Fig 1 ■ Sequential G ingival Index (GI) and Plaque Index (PI) of typical patient. Progressive reduction of the GI during the first five appointm ents resulted from new ly learned o ral hygiene habits. Continuing low indexes dis played at re ca ll sittings ind icate that new habits have becom e established.
Test date
24 hr.
48 hr.
72 hr.
Progress
Probable future caries activity
11/7/74
1
2
3
Original
Moderate
11/14/74
1
2
4
No Change
Moderate
11/21/74
1
2
3
No Change
Moderate
11/28/74
1
2
Improved
Low
12/5/74
0
2 1
2
Improved
Low
3/21/75
0
0
1
Excellent
Low
5 /2 3 /7 5
0
1
1
Excellent
Low
1/23/76 8 /4 /7 6
0
0
1
Excellent
Low
0
0
0
Excellent
Low
2/15/77
0
0
1
Excellent
Low
Fig 2 ■ Sequential Snyder test scores o f typical patient. Changes during original se quence o f preventive dentistry appointm ents reflect changes in dietary habits as well as improved plaque control. Low score at successive re call appointm ents indicates that new habits have becom e established.
enam el-only carious lesions that are to be ob served for arrestm ent and remineralization, as well as to sites with continuing gingivitis w hich m ay relate to open contacts or m alcontoured restorations that also cause a continu ing GI score of 2 or higher. If there is a need, the treatm ent plan is then modified for correc tion of such problems, and the reason for each 32 ■ JADA, Vol. 97, July 1978
modification is explained to the patient. Criteria for terminating the basic program and putting the patient on recall are as fol lows: Snyder test score, in two consecutive samples, of not more than 2 + after 72 hours incubation; GI-6 of not more than a total of 10 for the 18 surfaces of the six teeth scored; no gingival score of more than 1 for any single
site, unless it can be explained by a correctable defect that is scheduled for appropriate treat ment; topical application of fluoride accom plished; and verification of treatment plan ac complished. Patients who m eet these criteria in five ap pointments or less are warmly congratulated on their success and strongly encouraged to continue their newly acquired oral health m aintenance habits. Persons who fail to achieve these criteria in five visits are given additional weekly appointments at which the dentist or the hygienist discusses the patient’s difficulties with understanding, patience, and encouragement. Six weeks after a patient has met the criteria for ending the original sequence of appoint ments, a gingivitis review is scheduled, at which the GI-6 and PI-6 are recorded, a Snyder test is taken, and the patient is appropriately counseled. This usually entails only a fiveminute visit with the dental hygienist. The purpose of this visit is to provide reinforce ment for changes in oral hygiene habits. At subsequent, semiannual recall appoint ments, the Snyder test is taken, and a complete examination is performed, including use of new bite-wing radiographs of the posterior teeth. (There was no radiographic evidence of increase in any of the interproximal lesions after a year; therefore, bite-wing radiographs were taken only on alternate semiannual ap pointments to minimize exposure to X rays.) Special attention is given to the minimal cari ous lesions recorded previously for continuing observation. The GI-6 and PI-6 scores are re corded and necessary counseling and encourgement are given. After removal of cal culus and polishing with pum ice, topical AFP is applied. The patient is later informed by telephone of his Snyder test score and its sig nificance. For a patient who fails to meet the criteria for success at a recall appointment, additional appointments are scheduled as nec essary to help him to again meet the criteria. CARIES DIAGNOSIS. A pit or fissure that felt soft or leathery to an explorer or showed dis coloration indicative of undermined enamel was diagnosed as being beyond arrestment. A pit or fissure that could be wedged with an explorer but was hard and showed no discol oration was recorded for semiannual observa tion. For interproxim al lesions, radiographic
evidence of invasion of dentin or clinical de tection of cavitation with the explorer was diagnostic of the need to excavate and restore the affected area. If the radiolucency was con fined to the enamel, and the explorer was not engaged in the site, a lesion was recorded as incipient caries to be observed at subsequent recall examinations. Continuing observation was recorded for buccal or lingual white-spot lesions, including those with a chalky surface that could be scratched with an explorer. E x cavation and restoration were scheduled for all lesions that showed evidence of invasion of dentin or a collapsed surface. PATIENTS. Many persons whose ages ranged from 2 to 72 years have been treated. To ex plore the effectiveness of this program, records were screened for all patients who had com pleted the original sequence and four sem ian nual recall appointments. To reduce variabil ity, only records of patients who were 10 to 30 years old at the first appointment were analyzed. From this group, four cases were de leted from the review because the patients had acquired fixed orthodontic appliances during the test period. The resulting total of 53 pa tients were assigned to group A, w hich in cluded 20 persons aged 10 to 20 and who were expected to be more caries-active; and group B, w hich included 33 persons aged 21 to 30 in whom fewer new caries lesions would be an ticipated but in whom arrestment of existing m inimal caries lesions might be more dem on strable.
Results The patients’ socioeconom ic backgrounds and previous levels of dental care varied widely. This diversity and the small number of cases precluded realistic analysis of their responses to various factors. Aside from caries experi ence, the only observation that merits report ing is that all but one patient met the preced ing criteria for termination of the original se quence and at the four successive recall ap pointments. The exception was a 22-year-old patient who was unable to achieve an accep t able Snyder test score until his first six-m onth recall appointment. The average age of patients in group A was 14 years when the program was started. The previous caries experience varied widely. As Ostrom : PREVENTIVE DENTISTRY DELIVERY SYSTEM ■ 33
Table 1 ■ Caries experience of 20 patients 10 to 20 years old. __________________________ Carious surfaces______________ __________ To restore
Original examination Mode High Mean Total
To observe
Missing and filled teeth
P it or fissure
Proximal smooth surface
Buccal or lingual P it smooth or surface fissure
0-4 13 3.4 68
0-2 8 1.9 38
0 11 1.9 37
0 5 0.4 7
24-month recall Progressed Percent arrested New lesions
Table 2
Bucal or Proxim al lingual smooth smooth surface surface
0 12 1.3 26
0 6 1.3 25
0 12 1.. 26
3 90
1 96
0 10C
Caries experience of 33 patients 21 to 30 years old. Carious surfaces To restore
Missing and P it filled or teeth fissure Original examination Mode 9 0-2 High 18 6 Mean 11 0.7 Total 354 23
P it or fissure
Buccal or Proxim al lingual smooth smooth surface surface
0-2 11 2.0 63
0-5 5 0.6 20
04 12 2.2 71
0-1 10 1.4 51
0 100 0
0 100 0
0 100 0
24-month recall Progressed Percent arrested New lesions
illustrated in Table 1, the average patient had 3.4 missing or filled teeth, a total mean number of 4.2 carious lesions requiring resto rations, and a total mean number of 3.9 carious lesions that were recorded for continuing ob servation for arrestment or progress. Carious lesions recorded for observation included 26 occlusal pit and fissure, 25 proximal smooth surface, and 26 buccal or lingual sm ooth sur face. Of these, three occlusal and one proximal lesion progressed, so excavation and restora tion were scheduled during the two-year test period. The remaining lesions, w hich ap peared to have been arrested, accounted for 90% of the pit and fissure, 96% of the proxi m al, and 100% of the buccal or lingual lesions. A total of four new pit and fissure carious le sions that required restoration developed dur ing the two-year period; no new smooth sur face lesions developed. The average age of group B patients was 22 years when the program was started. The pre vious caries experience of patients in group B also varied widely, but none was com pletely free of caries as was indicated by the presence of either restorations or existing lesions. As il 34 ■ JADA, Vol. 97, July 1978
To observe
Buccal or Proxim al lingual smooth smooth suface surface 0-1 1 0.1 4
lustrated in Table 2 the average young adult had 11 missing or filled teeth, a total mean number of 2.8 carious lesions that required restoration, and a total mean number of 4.2 carious surfaces that were recorded for con tinuing observation for arrestment or progress. Of the latter, 20 were occlusal pit and fissure, 71 were proxim al smooth surface, and 51 were buccal or lingual smooth surface lesions. None of these lesions showed any recognizable progress, and no new lesions were detected during the ensuing two years.
Discussion A comparison of the results of this study with other reports provides a m easure of this pro gram ’s effectiveness. Children in the area of Birmingham, Ala, m ay expect an average of 3.6 newly carious surfaces per year,22 and a control group of young adult Navy personnel experienced 1.4 per year.23 In this study, about 60% of the reduction in caries increm ent was attributed to topical application of fluoride by the W ellock and Brudevold m ethod.5 There fore, the preventive dentistry program could
be credited with any reduction in caries in crem ent that exceeded 60% of the amount in dicated for that group. Spontaneous arrest ment of incipient carious lesions has been re ported. A study of buccal gingival white spots showed that only 10% progressed to cavita tion.24 In the current study of 77 such lesions, none progressed. Of the enamel-only interproxim al lesions that were radiographically detectable, approxim ately 60% of the lesions exhibited no progress during a period of two years in an untreated control group.25 In the current study, one of 25 such lesions in group A and none of the 71 lesions in group B had a detectable increase in size. This supports the interpretation that this program was highly successful in arresting the growth of existing carious lesions and suggests that continuing observation of arrested lesions may be equally as im portant as the prevention of new lesions. Although it may not be widely accepted for clinical application, published results of re search have shown that partially de mineralized enamel can be remineralized by saliva, fluoride ion contributes to such rem ineralization with resultant reduced solubil ity at the site, and such remineralized enamel is more resistant to future caries attack than was the original enamel.26-28 In more direct clinical application, enamel surfaces as sociated with remineralized lesion but no cavi tation are far superior to any restoration. One might also suggest that such a surface is superior to the original, sound enamel because carious enamel lesions that have been re mineralized and have incorporated fluoride salts are more resistant to subsequent acid at tack than was the original enam el.28 The den tist who adopts this preventive dentistry con cept will succeed in avoiding the need to cut many teeth for two- and three-surface restora tions, w hich involve problems of gingival margin, contour, and eventual failure of resto rations, as well as unequal wear that ulti mately m ay lead to fracture of the cusp. Success in this short-term study does not ensure that this preventive dentistry program would be equally effective with all patients to whom it is offered. In this study, the test pa tients were self-selected, because each one ac cepted the original sequence of appointments, met the criteria of success, and continued in the sem iannual recall system. Thus, results of this exploratory test suggest that a comparably
high rate of success in arrestment of incipient caries lesions, prevention of new cavity forma tion, and m aintenance of a low rate of gin givitis, can be expected for patients who par ticipate in the program. The step-by-step method of m aintaining oral health, which was strengthened by consistent encouragement of a positive mental attitude in the patient, was met with an enthusiastic re sponse from all who participated in the study. This supports the concept that it is practical to teach oral health m aintenance measures in small segments and to reinforce interest by successful progress in specific tests.
Summary The exploratory test of a preventive dentistry delivery system that consists of a sequence of five (approximately) appointments followed by semiannual treatments and exam inations is described. Applied in 20 patients who were 10 to 20 years old, and in 33 patients who were 21 to 30 years old, the program achieved al most com plete prevention of new carious le sions, arrested virtually all minim ally detecta ble carious lesions, and maintained an excel lent level of gingival health during the twoyear test period. T h is report is based on research supported in part by USPHS Grant DE 02670 from the National Institute of Dental Research, Department of Health, Education, and Welfare. The author expresses thanks to Catherine A. Sim s for her edito rial assistance. 1. Hein, J.W. Introduction: dental diseases and therapy. Ann NY Acad Sci 153:3 Dec 23, 1968. 2. Ostrom, C.A., and others. A preventive dentistry demonstra tion program. Ala J Med Sci 12:161 April 1975. 3. Peale, N.V. Power of positive thinking. Englewood Cliffs, NJ, Prentice Hall, 1952. 4. Stone, W.C. The success system that never fails. Englewood Cliffs, NJ, Prentice Hall, 1952. 5. W ellock, W.D., and Brudevold, F. A study of acidulated fluoride solutions. The caries inhibiting effect o f single annual top ical applications of an acidic fluoride and phosphate solution. A two-year experience. Arch Oral Biol 8:179 M arch-April 1963. 6. Bixler, D., and Muhler, J.C. Effect on dental caries in children in a nonfluoride area of combined use of three agents containing stannous fluoride: a prophylactic paste, a solution and a dentifrice. JADA 68:792 June 1964. 7. Mercer, V.H., and Muhler, J.C. The clin ical demonstration of caries arrestment following topical stannous fluoride treatments. J Dent Child 32:65, 1965. 8. Weisz, W .S. Reduction of dental caries through use of a sodium fluoride mouthwash. JADA 60:438 April 1960. 9. Torell, P., and Ericsson, Y. Two-year clin ical tests with dif ferent methods of local caries-preventive fluorine applications in Sw edish school-children. Acta Odontol Scand 23:287 June 1965. Ostrom : PREVENTIVE DENTISTRY DELIVERY SYSTEM ■ 35
10. Englander, H.R., and others. C linical anticaries effect of re peated topical sodium fluoride applications by m outhpieces. JADA 75:638 Sept 1967. 11. W eiss, R.L., and Trithart, A.H. Between-m eal eating habits and dental caries experience in preschool children. Am J Public Health 50:1097 Aug 1960. 12. Gustafsson, B.E., and others. Vipeholm dental caries study; effect of different levels of carbohydrate intake on caries activity in 4 3 6 individuals observed for 5 years. Acta Odontol Scand 11:232 Sept 1954. 13. Sim s, W. T he interpretation and use of Snyder tests and lactobacillus counts. JADA 80:1315 June 1970. 14. Nizel, A.E. Nutrition in preventive dentistry: science and practice. Philadelphia, W. B. Saunders, 1972. 15. Loe, H.; Theilade, E.; and Jensen, S.B . Experim ental gin givitis in man. J Periodontol 36:177 May-June 1965. 16. Fehr, F.R. von der; Loe, H.; and Theilade, E. Experim ental caries in man. Caries Res 4:131, 1970. 17. Greene, J.C., and Vermillion, J.R. Oral hygiene research and im plications for periodontal care. J Dent Res 50:184 March-April 1971. 18. Lindhe, J., and Axelsson, P. T he effect o f controlled oral hygiene and topical fluoride application on caries and gingivitis in Sw edish school children. Community Dent Oral Epidem iol 1:9, 1973. 19. Loe, H., and Silness, J. Periodontal disease in pregnancy. Prevalence and severity. Acta Odontol Scand 21:533 Dec 1963. 20. Silness, J., and Loe, H. Periodontal disease in pregnancy. Correlation betw een oral hygiene and periodontal condition. Acta Odontol Scand 22:121 Feb 1964. 21. Bass, C.C. Effective method of personal oral hygiene. J La State Med Soc 106:100 March 1954. 22. Finn, S.B., and others. T he clinical cariostatic effectiveness of two concentrations of acidulated phosphate-fluoride mouth wash. JADA 90:398 Feb 1975. 23. Scola, F.P., and Ostrom, C.A. C linical evaluation of stannous fluoride when used as a constituent of a com patible prophylactic paste, as a topical solution, and in a dentifrice in naval personnel. Report o f findings after two years. JADA 77:594 Sept 1968. 24. Backer Dirks, O. Posteruptive changes in dental enamel. J Dent Res 45:503 May-June 1966.
*
25. Shiller, W.R., and Scola, F.P. Two-year observation of enamel caries on posterior interproxim al surfaces. Memo Report 66 20 M R005 19 6042.01, Dec 23, 1966, USN Submarine Med Center, New London, Conn. 26. Koulourides, T ., and others. An intraoral model used for studies of fluoride incorporation in enamel. J Oral Pathol 3:185, 1974. 27. Ostrom, C.A., and others. Combined effects of sucrose and fluoride on experim ental caries and on the associated m icrobial plaque. J Dent Res 56:212 March 1977. 28. Keller, S., and others. Enhancem ent of fluoride effectiveness by cariogenic priming of human enamel. J Dent Res 54{special issue A): L77, abstract no. L 308, Feb 1975.
THE AUTHOR
A OSTROM
Dr. Ostrom is a scientist, Institute of Dental Research, and associate profes sor, department of oral biology, School of Dentistry, University of Alabama in Birmingham, University Station, Bir mingham, Ala 35294.
Foley’s Footnotes In 1905, a Baltimore newspaper reported an unusual occurrence under the heading, “ Early Morning Dental Work Disastrous.” A woman with a toothache tried to wake a dentist at 5 AM. His wife threatened to throw hot water on the recklessly motivated visitant if she did not stop kicking at the front door. On her return an hour later, the would-be patient and the dentist's wife got into a physically contested argument that resulted in the former's being fined in the police court for assault. G ardner P. H. Foley
36 ■ JADA, Vol. 97, July 1978
Effectiveness of a preventive dentistry delivery system Carl A. Ostrom, DDS, MSD, Birm ingham , Ala
umerous investigators have reported vari ous benefits from each of the principal com ponents of preventive dentistry practice— topical fluoride, dietary habits, and plaque control. Any of these factors, under closely controlled test conditions, can be highly effec tive, but the results of clin ica l experience have been inconclusive. As a result, the credibility and practicality of preventive procedures in the clin ical practice of dentistry have long been viewed with skepticism . To paraphrase H ein ,1 the dental practitioner is not w holly re sponsible for this less than spectacular record. The fault should be equally shared by those in research who have published conflicting in formation and, as a result, have failed to pro vide dentists in practice w ith unequivocally effective control and preventive m easures. For dental faculty, students, and practitioners, a further com plication may arise from the differ ences betw een the pu blic health approach and the optimum treatm ent for the individual pa tient. An inexpensive, convenient public health m easure that yields a partial reduction
of caries in thousands of ch ildren is a trem en dously valuable contribution to society, but this is not enough for the practicing dentist and the patients who rely on him for the best available dental care. T h is report describes the exploratory test of a preventive dentistry de livery system; the results indicate that the practitioner can adopt this system w ith con fi dence.
Methods PHILOSOPHICAL APPROACH. C lin ical preven
tive dentistry should be organized as a service that can be performed principally by auxiliary personnel under the d en tist’s supervision. A step-by-step procedural m anual, devised for the preventive dentistry program, can be used as a guide for a su ccession of dental hygienists or assistan ts.2 T h is system w ould enhance cost-effectiveness and perm it the dentists to devote them selves more fully to the dental procedures that only they are qualified to per form. JADA, Vol. 97, July 1978 ■ 29
ATTITUDINAL APPROACH. This program was based on the positive approach to success3,4 and the desirability of life-long health. A steadily decreasing gingivitis score makes the patient aware of his return to gingival health, a direct result of effective plaque control. Im proved oral hygiene coupled with the accep tance of sound dietary counseling quickly re duces the Snyder test score. These factors, as well as the comfort and pleasure of a clean m outh, encourage the patient to m aintain oral hygiene habits. Repeated improvement gives patients a sense of personal achievem ent be cause, through their own efforts, they have ac com plished the change. It is safe to predict that the patient who meets the criteria of suc cess at each appointment will have a reduced dental caries increm ent and no gingivitis. A less certain but reasonable anticipation is the arrestm ent and possible remineralization of m ost enam el-only, interproximal carious le sions and gingival white-spot lesions. Thus, both short- and long-term benefits motivate the patient. In most instances, the dentist and the hygienist can sincerely congratulate the patient at nearly every appointment. ELEMENTS OF HABIT CHANGE. Of the three principal components of preventive dentistry, only the topical application of fluoride that is performed in the dental operatory is under the dentist’s control. Effective use of fluorides at hom e and control of dietary sugars and plaque, w hich are necessary for m aintenance of oral health, depend on changes in the habits of the patients. Therefore, the following essential ele m ents of changing habits have been incorpor ated in the program: recognition of undesir able conditions, understanding why such con ditions have occurred, learning how to con trol them , experiencing personal success in this control, and reinforcing the new habits until they have become well established. A goal is set to achieve success in the first four of these elements during a sequence of five weekly visits. Because continuity and frequent encouragem ent sustain interest and en thusiasm of the patient, these visits are set up for consecutive weeks on a day and hour that are m utually convenient to the patient and the dental facility. The fifth of the essential ele m ents of changing habits, reinforcem ent of new habits, is emphasized by a gingivitis re view that is scheduled six weeks after com ple 3 0 ■ JADA, Vol. 97, July 1978
tion of the original sequence of visits. Thereaf ter, recall visits will coincide with the semiannual topical fluoride treatments. TOPICAL FLUORIDES. Of the many methods of topical application of fluoride, only two have consistently reduced the occurrence of new carious lesions by 60% or more. These are acidulated fluoride phosphate (AFP) applied by the method of W ellock and Brudevold,5 and stannous fluoride (SnF 2) applied by the method of Bixler and M uhler.6 Because AFP is more acceptable to the patient and has a long shelf-life, semiannual application of AFP was adopted as the preferred method for routine use in this program. For its proved cariesarresting features,7 SnF 2 was retained in the program for use in certain circum stances, such as treatment of a posterior tooth with a broadsurfaced buccal or lingual lesion that had an intact but chalky surface or application to all posterior teeth of the occasional patient who had several lesions in which carious exposure of the pulp appeared imminent and immediate operative treatment was unfeasible. Daily use of fluoride in either a mouthwash or a gel in a tray has also been highly effective.8' 10 These impressive results were obtained in children whose parents were highly motivated or in children who were under direct supervision of a teacher in school. Other investigators have reported that fluoride mouthwashes used at home under casual supervision are less effec tive. Therefore, semiannual topical application of AFP solution was adopted as mandatory for all patients in this program and use of topical SnF 2 and fluoride mouthwash was reserved for additional (not substitute) treatm ent in selected cases. NUTRITION AND DIETARY HABITS. For many years, the members of the dental profession have been aware of nutritional influences on oral health and of the effects that frequency, time of consumption, and consistency of in gested sugars can exert on the carious at tack.11,12 An illustration of the acidogenic capability of the patient’s oral flora is tele scoped by the Snyder test into a three-day period.13 This test provides an immediate demonstration of the effects of dietary-sugar habits that might actually require several years to culminate in caries. The normal delay in experiencing these effects tends to cloak the
inevitability of the potential damage of sugar consum ption and lulls the patient into a sense of false security. The Snyder test presents con crete evidence that can influence the patient to alter his dietary habits to the extent necessary to minimize cariogenic attack. To impress pa tients with the importance of diet and plaque control, nutrition and dietary counseling by the m ethod of Nizel14 and monitoring by the Snyder test were incorporated in the current preventive dentistry program. PLAQUE CONTROL. Although the dental pro fession has long credited microbial plaque with an essential role in dental disease, numerous clinical trials failed to demonstrate significant benefits from personal oral hygiene practices. More recent reports 1518 indicated that com plete plaque removal once a day rather than more frequent, superficial oral hygiene led to effective control of both caries and gingivitis. These reports justify the in terpretation that mature plaque is pathogenic, and that m eticulous plaque removal once a day prevents the development of mature plaque. Loe’s Plaque Index (PI) and Gingival Index (GI) provide definitive means for record ing these relationships.19,20 These concepts were the basis for plaque control in this clini cal preventive dentistry delivery system.
Procedural outline A t the first appointment, the patient’s com plete GI and PI are recorded. These records serve as baselines for future com parison and as an educational device for the patient. A t most subsequent appointments, only a locally mod ified pair of indexes is used. The GI-6 and PI-6 methods of monitoring progress are highly ef fective for educating and encouraging the pa tient during his series of appointments. In these abbreviated indexes, gingivitis and plaque scores are recorded for any six teeth (usually a pair each of m axillary molars, man dibular incisors, and m andibular molars) that had the highest indexes at the first appoint ment. The sum of the six scores for each pair of teeth gives high whole numbers, in com parison to the decimal fractions that are used in Lo'e’s original system. The whole numbers are m uch easier for the patient to understand. Recorded and discussed at each appointment, the meaning of the steadily declining scores is
easily understood by the patient. Such prog ress prompts most patients to strive for a GI-6 score of zero (Fig 1). Reduction of these re flects the degree of the patient’s success in achieving plaque control and gingival health by personal practices of oral hygiene. At each appointment, the Snyder test is taken to monitor the acidogenic potential of the patient’s oral flora. A five-day diet diary begun at the first appointment is analyzed and used along with counseling and successive changes in the Snyder test results (Fig 2) to demonstrate to the patient the influence exerted by dietary habits in controlling his cariogenic attack. The Bass method of sulcular brushing21 is used in conjunction with unw axed dental floss. The patient is advised that com plete re moval of plaque once a day is the m inim al fre quency for preventing plaque from maturing on the teeth. Methods for plaque removal are introduced at the first appointment, extended at the second, and reinforced at each succes sive appointment. The patient is told that, for the first week, he should use a disclosing tab let each night after brushing and flossing. He is provided with a dental mirror to use at home so that he can detect remaining plaque and remove it by additional effort. Beginning the second week, the patient is instructed to continue use of disclosing tablets as often as necessary (not less than once a week) to ensure that he is maintaining his new, successful oral hygiene habits. Removal of calculus and polishing with pum ice are performed profes sionally at the third appointment, or after the patient has shown significant success in per sonal daily plaque control and has observed the associated reduction in gingival inflamma tion and edema that has occurred solely as a result of improved personal oral hygiene. After polishing with pum ice, a topical ap plication of AFP is made. To ensure a daily resupply of fluoride ion, one of the approved therapeutic dentifrices (ADA Council on Den tal Therapeutics) is prescribed. At the fourth appointment, the dentist per forms a complete examination and reviews the original set of radiographs as well as the four bite-wing radiographs taken at the first pre ventive dentistry appointment. This reexam i nation allows the dentist to appraise the pa tient’s response to the preventive dentistry program. Special attention is given to any Ostrom : PREVENTIVE DENTISTRY DELIVERY SYSTEM ■ 31
2 3 4 5 3 3 2 0 3 3 2 1 1 1 t 0 14 2 2 1 1 2 2 1 1 1 1 1 1 1) 1 2 3 4 5 2 1 1 1 0 0 Ii 1 1 1 0 0 4 2 3 4 5 2 0 0 0 0 0
1 b M L B M L 6 M L
ft
M L
B M I
6 0 1 0
7 0 0 0
0 0 0
0 0 0
6
7
8 9 10 11 12 13 14 15 16 17 18 19 0 0 0 0 2 2 3 3 1 2 2 P 0 0 1 1 2 3 3 1 1 0 0 0 0 1 1 <3 1 0 0 0 0 0 1 1 2 2 0 0 0 0 0 2 2 2 1 0 0 0 0 1 5 8 9 10 11 12 13 14 15 16 17 18 19 2 1 1 0 0
1
0 0
B M L
0 0 0
3 0 0 0
4
5
6
7
8
6
7
8
1
r-L U
2
0 0 2 0
0
0 0 0
0 0 0
20 21 22 23 24
25 26 27 0 0 0 1 1 1 1 4 0 0 0 0 1 0 1 4 25 26 27 o 6 1 1
28 0 2 2
29 0 2 2
30 1 2 2
0 2 2
0 2 2
0 2
31 32 Index Date 1 2 P1 — 1 0 2 1
a
28 29 30 31 32 P1
I
— a
1 0 0 0 0 1 G1 0 1 ■ 2 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 2 0 0 P1 0 1 1 0 0 0 0 0 I 2 0 0 0 0 0 0 0 0 GI 0 0 0 0 (> c 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 0 0 0 1 0 0 1 0 P1 0 0 0 0 2 0 0 0 0 0 0 0 G1 0 0 0 0 1 0 12 13 14|15|16 17|18 19 20 2 1|22|23|24|25|26| 27128(29130, 31 j 32 10
-j »
0
i
2
B M L
0
21 22 23 24 0 0 0 0 2 1 2 1 1 1
j
0 0 0 0 Ô 0
B M L
20 0 2 1
0 0 0 1
0 0
. 3 4 5 6 7 8 9
ro *
ro * I I
Fig 1 ■ Sequential G ingival Index (GI) and Plaque Index (PI) of typical patient. Progressive reduction of the GI during the first five appointm ents resulted from new ly learned o ral hygiene habits. Continuing low indexes dis played at re ca ll sittings ind icate that new habits have becom e established.
Test date
24 hr.
48 hr.
72 hr.
Progress
Probable future caries activity
11/7/74
1
2
3
Original
Moderate
11/14/74
1
2
4
No Change
Moderate
11/21/74
1
2
3
No Change
Moderate
11/28/74
1
2
Improved
Low
12/5/74
0
2 1
2
Improved
Low
3/21/75
0
0
1
Excellent
Low
5 /2 3 /7 5
0
1
1
Excellent
Low
1/23/76 8 /4 /7 6
0
0
1
Excellent
Low
0
0
0
Excellent
Low
2/15/77
0
0
1
Excellent
Low
Fig 2 ■ Sequential Snyder test scores o f typical patient. Changes during original se quence o f preventive dentistry appointm ents reflect changes in dietary habits as well as improved plaque control. Low score at successive re call appointm ents indicates that new habits have becom e established.
enam el-only carious lesions that are to be ob served for arrestm ent and remineralization, as well as to sites with continuing gingivitis w hich m ay relate to open contacts or m alcontoured restorations that also cause a continu ing GI score of 2 or higher. If there is a need, the treatm ent plan is then modified for correc tion of such problems, and the reason for each 32 ■ JADA, Vol. 97, July 1978
modification is explained to the patient. Criteria for terminating the basic program and putting the patient on recall are as fol lows: Snyder test score, in two consecutive samples, of not more than 2 + after 72 hours incubation; GI-6 of not more than a total of 10 for the 18 surfaces of the six teeth scored; no gingival score of more than 1 for any single
site, unless it can be explained by a correctable defect that is scheduled for appropriate treat ment; topical application of fluoride accom plished; and verification of treatment plan ac complished. Patients who m eet these criteria in five ap pointments or less are warmly congratulated on their success and strongly encouraged to continue their newly acquired oral health m aintenance habits. Persons who fail to achieve these criteria in five visits are given additional weekly appointments at which the dentist or the hygienist discusses the patient’s difficulties with understanding, patience, and encouragement. Six weeks after a patient has met the criteria for ending the original sequence of appoint ments, a gingivitis review is scheduled, at which the GI-6 and PI-6 are recorded, a Snyder test is taken, and the patient is appropriately counseled. This usually entails only a fiveminute visit with the dental hygienist. The purpose of this visit is to provide reinforce ment for changes in oral hygiene habits. At subsequent, semiannual recall appoint ments, the Snyder test is taken, and a complete examination is performed, including use of new bite-wing radiographs of the posterior teeth. (There was no radiographic evidence of increase in any of the interproximal lesions after a year; therefore, bite-wing radiographs were taken only on alternate semiannual ap pointments to minimize exposure to X rays.) Special attention is given to the minimal cari ous lesions recorded previously for continuing observation. The GI-6 and PI-6 scores are re corded and necessary counseling and encourgement are given. After removal of cal culus and polishing with pum ice, topical AFP is applied. The patient is later informed by telephone of his Snyder test score and its sig nificance. For a patient who fails to meet the criteria for success at a recall appointment, additional appointments are scheduled as nec essary to help him to again meet the criteria. CARIES DIAGNOSIS. A pit or fissure that felt soft or leathery to an explorer or showed dis coloration indicative of undermined enamel was diagnosed as being beyond arrestment. A pit or fissure that could be wedged with an explorer but was hard and showed no discol oration was recorded for semiannual observa tion. For interproxim al lesions, radiographic
evidence of invasion of dentin or clinical de tection of cavitation with the explorer was diagnostic of the need to excavate and restore the affected area. If the radiolucency was con fined to the enamel, and the explorer was not engaged in the site, a lesion was recorded as incipient caries to be observed at subsequent recall examinations. Continuing observation was recorded for buccal or lingual white-spot lesions, including those with a chalky surface that could be scratched with an explorer. E x cavation and restoration were scheduled for all lesions that showed evidence of invasion of dentin or a collapsed surface. PATIENTS. Many persons whose ages ranged from 2 to 72 years have been treated. To ex plore the effectiveness of this program, records were screened for all patients who had com pleted the original sequence and four sem ian nual recall appointments. To reduce variabil ity, only records of patients who were 10 to 30 years old at the first appointment were analyzed. From this group, four cases were de leted from the review because the patients had acquired fixed orthodontic appliances during the test period. The resulting total of 53 pa tients were assigned to group A, w hich in cluded 20 persons aged 10 to 20 and who were expected to be more caries-active; and group B, w hich included 33 persons aged 21 to 30 in whom fewer new caries lesions would be an ticipated but in whom arrestment of existing m inimal caries lesions might be more dem on strable.
Results The patients’ socioeconom ic backgrounds and previous levels of dental care varied widely. This diversity and the small number of cases precluded realistic analysis of their responses to various factors. Aside from caries experi ence, the only observation that merits report ing is that all but one patient met the preced ing criteria for termination of the original se quence and at the four successive recall ap pointments. The exception was a 22-year-old patient who was unable to achieve an accep t able Snyder test score until his first six-m onth recall appointment. The average age of patients in group A was 14 years when the program was started. The previous caries experience varied widely. As Ostrom : PREVENTIVE DENTISTRY DELIVERY SYSTEM ■ 33
Table 1 ■ Caries experience of 20 patients 10 to 20 years old. __________________________ Carious surfaces______________ __________ To restore
Original examination Mode High Mean Total
To observe
Missing and filled teeth
P it or fissure
Proximal smooth surface
Buccal or lingual P it smooth or surface fissure
0-4 13 3.4 68
0-2 8 1.9 38
0 11 1.9 37
0 5 0.4 7
24-month recall Progressed Percent arrested New lesions
Table 2
Bucal or Proxim al lingual smooth smooth surface surface
0 12 1.3 26
0 6 1.3 25
0 12 1.. 26
3 90
1 96
0 10C
Caries experience of 33 patients 21 to 30 years old. Carious surfaces To restore
Missing and P it filled or teeth fissure Original examination Mode 9 0-2 High 18 6 Mean 11 0.7 Total 354 23
P it or fissure
Buccal or Proxim al lingual smooth smooth surface surface
0-2 11 2.0 63
0-5 5 0.6 20
04 12 2.2 71
0-1 10 1.4 51
0 100 0
0 100 0
0 100 0
24-month recall Progressed Percent arrested New lesions
illustrated in Table 1, the average patient had 3.4 missing or filled teeth, a total mean number of 4.2 carious lesions requiring resto rations, and a total mean number of 3.9 carious lesions that were recorded for continuing ob servation for arrestment or progress. Carious lesions recorded for observation included 26 occlusal pit and fissure, 25 proximal smooth surface, and 26 buccal or lingual sm ooth sur face. Of these, three occlusal and one proximal lesion progressed, so excavation and restora tion were scheduled during the two-year test period. The remaining lesions, w hich ap peared to have been arrested, accounted for 90% of the pit and fissure, 96% of the proxi m al, and 100% of the buccal or lingual lesions. A total of four new pit and fissure carious le sions that required restoration developed dur ing the two-year period; no new smooth sur face lesions developed. The average age of group B patients was 22 years when the program was started. The pre vious caries experience of patients in group B also varied widely, but none was com pletely free of caries as was indicated by the presence of either restorations or existing lesions. As il 34 ■ JADA, Vol. 97, July 1978
To observe
Buccal or Proxim al lingual smooth smooth suface surface 0-1 1 0.1 4
lustrated in Table 2 the average young adult had 11 missing or filled teeth, a total mean number of 2.8 carious lesions that required restoration, and a total mean number of 4.2 carious surfaces that were recorded for con tinuing observation for arrestment or progress. Of the latter, 20 were occlusal pit and fissure, 71 were proxim al smooth surface, and 51 were buccal or lingual smooth surface lesions. None of these lesions showed any recognizable progress, and no new lesions were detected during the ensuing two years.
Discussion A comparison of the results of this study with other reports provides a m easure of this pro gram ’s effectiveness. Children in the area of Birmingham, Ala, m ay expect an average of 3.6 newly carious surfaces per year,22 and a control group of young adult Navy personnel experienced 1.4 per year.23 In this study, about 60% of the reduction in caries increm ent was attributed to topical application of fluoride by the W ellock and Brudevold m ethod.5 There fore, the preventive dentistry program could
be credited with any reduction in caries in crem ent that exceeded 60% of the amount in dicated for that group. Spontaneous arrest ment of incipient carious lesions has been re ported. A study of buccal gingival white spots showed that only 10% progressed to cavita tion.24 In the current study of 77 such lesions, none progressed. Of the enamel-only interproxim al lesions that were radiographically detectable, approxim ately 60% of the lesions exhibited no progress during a period of two years in an untreated control group.25 In the current study, one of 25 such lesions in group A and none of the 71 lesions in group B had a detectable increase in size. This supports the interpretation that this program was highly successful in arresting the growth of existing carious lesions and suggests that continuing observation of arrested lesions may be equally as im portant as the prevention of new lesions. Although it may not be widely accepted for clinical application, published results of re search have shown that partially de mineralized enamel can be remineralized by saliva, fluoride ion contributes to such rem ineralization with resultant reduced solubil ity at the site, and such remineralized enamel is more resistant to future caries attack than was the original enamel.26-28 In more direct clinical application, enamel surfaces as sociated with remineralized lesion but no cavi tation are far superior to any restoration. One might also suggest that such a surface is superior to the original, sound enamel because carious enamel lesions that have been re mineralized and have incorporated fluoride salts are more resistant to subsequent acid at tack than was the original enam el.28 The den tist who adopts this preventive dentistry con cept will succeed in avoiding the need to cut many teeth for two- and three-surface restora tions, w hich involve problems of gingival margin, contour, and eventual failure of resto rations, as well as unequal wear that ulti mately m ay lead to fracture of the cusp. Success in this short-term study does not ensure that this preventive dentistry program would be equally effective with all patients to whom it is offered. In this study, the test pa tients were self-selected, because each one ac cepted the original sequence of appointments, met the criteria of success, and continued in the sem iannual recall system. Thus, results of this exploratory test suggest that a comparably
high rate of success in arrestment of incipient caries lesions, prevention of new cavity forma tion, and m aintenance of a low rate of gin givitis, can be expected for patients who par ticipate in the program. The step-by-step method of m aintaining oral health, which was strengthened by consistent encouragement of a positive mental attitude in the patient, was met with an enthusiastic re sponse from all who participated in the study. This supports the concept that it is practical to teach oral health m aintenance measures in small segments and to reinforce interest by successful progress in specific tests.
Summary The exploratory test of a preventive dentistry delivery system that consists of a sequence of five (approximately) appointments followed by semiannual treatments and exam inations is described. Applied in 20 patients who were 10 to 20 years old, and in 33 patients who were 21 to 30 years old, the program achieved al most com plete prevention of new carious le sions, arrested virtually all minim ally detecta ble carious lesions, and maintained an excel lent level of gingival health during the twoyear test period. T h is report is based on research supported in part by USPHS Grant DE 02670 from the National Institute of Dental Research, Department of Health, Education, and Welfare. The author expresses thanks to Catherine A. Sim s for her edito rial assistance. 1. Hein, J.W. Introduction: dental diseases and therapy. Ann NY Acad Sci 153:3 Dec 23, 1968. 2. Ostrom, C.A., and others. A preventive dentistry demonstra tion program. Ala J Med Sci 12:161 April 1975. 3. Peale, N.V. Power of positive thinking. Englewood Cliffs, NJ, Prentice Hall, 1952. 4. Stone, W.C. The success system that never fails. Englewood Cliffs, NJ, Prentice Hall, 1952. 5. W ellock, W.D., and Brudevold, F. A study of acidulated fluoride solutions. The caries inhibiting effect o f single annual top ical applications of an acidic fluoride and phosphate solution. A two-year experience. Arch Oral Biol 8:179 M arch-April 1963. 6. Bixler, D., and Muhler, J.C. Effect on dental caries in children in a nonfluoride area of combined use of three agents containing stannous fluoride: a prophylactic paste, a solution and a dentifrice. JADA 68:792 June 1964. 7. Mercer, V.H., and Muhler, J.C. The clin ical demonstration of caries arrestment following topical stannous fluoride treatments. J Dent Child 32:65, 1965. 8. Weisz, W .S. Reduction of dental caries through use of a sodium fluoride mouthwash. JADA 60:438 April 1960. 9. Torell, P., and Ericsson, Y. Two-year clin ical tests with dif ferent methods of local caries-preventive fluorine applications in Sw edish school-children. Acta Odontol Scand 23:287 June 1965. Ostrom : PREVENTIVE DENTISTRY DELIVERY SYSTEM ■ 35
10. Englander, H.R., and others. C linical anticaries effect of re peated topical sodium fluoride applications by m outhpieces. JADA 75:638 Sept 1967. 11. W eiss, R.L., and Trithart, A.H. Between-m eal eating habits and dental caries experience in preschool children. Am J Public Health 50:1097 Aug 1960. 12. Gustafsson, B.E., and others. Vipeholm dental caries study; effect of different levels of carbohydrate intake on caries activity in 4 3 6 individuals observed for 5 years. Acta Odontol Scand 11:232 Sept 1954. 13. Sim s, W. T he interpretation and use of Snyder tests and lactobacillus counts. JADA 80:1315 June 1970. 14. Nizel, A.E. Nutrition in preventive dentistry: science and practice. Philadelphia, W. B. Saunders, 1972. 15. Loe, H.; Theilade, E.; and Jensen, S.B . Experim ental gin givitis in man. J Periodontol 36:177 May-June 1965. 16. Fehr, F.R. von der; Loe, H.; and Theilade, E. Experim ental caries in man. Caries Res 4:131, 1970. 17. Greene, J.C., and Vermillion, J.R. Oral hygiene research and im plications for periodontal care. J Dent Res 50:184 March-April 1971. 18. Lindhe, J., and Axelsson, P. T he effect o f controlled oral hygiene and topical fluoride application on caries and gingivitis in Sw edish school children. Community Dent Oral Epidem iol 1:9, 1973. 19. Loe, H., and Silness, J. Periodontal disease in pregnancy. Prevalence and severity. Acta Odontol Scand 21:533 Dec 1963. 20. Silness, J., and Loe, H. Periodontal disease in pregnancy. Correlation betw een oral hygiene and periodontal condition. Acta Odontol Scand 22:121 Feb 1964. 21. Bass, C.C. Effective method of personal oral hygiene. J La State Med Soc 106:100 March 1954. 22. Finn, S.B., and others. T he clinical cariostatic effectiveness of two concentrations of acidulated phosphate-fluoride mouth wash. JADA 90:398 Feb 1975. 23. Scola, F.P., and Ostrom, C.A. C linical evaluation of stannous fluoride when used as a constituent of a com patible prophylactic paste, as a topical solution, and in a dentifrice in naval personnel. Report o f findings after two years. JADA 77:594 Sept 1968. 24. Backer Dirks, O. Posteruptive changes in dental enamel. J Dent Res 45:503 May-June 1966.
*
25. Shiller, W.R., and Scola, F.P. Two-year observation of enamel caries on posterior interproxim al surfaces. Memo Report 66 20 M R005 19 6042.01, Dec 23, 1966, USN Submarine Med Center, New London, Conn. 26. Koulourides, T ., and others. An intraoral model used for studies of fluoride incorporation in enamel. J Oral Pathol 3:185, 1974. 27. Ostrom, C.A., and others. Combined effects of sucrose and fluoride on experim ental caries and on the associated m icrobial plaque. J Dent Res 56:212 March 1977. 28. Keller, S., and others. Enhancem ent of fluoride effectiveness by cariogenic priming of human enamel. J Dent Res 54{special issue A): L77, abstract no. L 308, Feb 1975.
THE AUTHOR
A OSTROM
Dr. Ostrom is a scientist, Institute of Dental Research, and associate profes sor, department of oral biology, School of Dentistry, University of Alabama in Birmingham, University Station, Bir mingham, Ala 35294.
Foley’s Footnotes In 1905, a Baltimore newspaper reported an unusual occurrence under the heading, “ Early Morning Dental Work Disastrous.” A woman with a toothache tried to wake a dentist at 5 AM. His wife threatened to throw hot water on the recklessly motivated visitant if she did not stop kicking at the front door. On her return an hour later, the would-be patient and the dentist's wife got into a physically contested argument that resulted in the former's being fined in the police court for assault. G ardner P. H. Foley
36 ■ JADA, Vol. 97, July 1978