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Oral Disease Prevention—its Implications and Applications: Summary of Proceedings
C U R R EN T C O N FER EN C E
Oral disease prevention— its implications and applications: summary of proceedings George S. B eagrie, DDS, FDSRCS (Edin), FRCD (C)
Methods of im plem enting preventive dental care program s w ere discussed, problem s and successes encountered in various countries w ere reported and compared.
D e n t a l researchers, educators, and practitioners know what modern pre ventive dentistry can do to improve oral health. The Colgate-Palm olive Company and Kao-Colgate Products Company of Japan have recognized the need to explore further the topic of prevention of dental disease and have continued sponsorship of these Oral Biology Conferences. This conference was designed to provide an interplay between basic knowledge (new, experimental, and well-tested) and applied knowledge (individual, group, community, na tional, and international). From this, it was hoped, new goals for the future would emerge.
T h e 1 9 8 0 co n fe re n c e On June 1 to 3, the Eighth International Conference on Oral Biology was held in Tokyo. Three years earlier, at the 1 9 7 7 co n fe re n ce in C op en h agen , Davies1 stated that “the central prob lem w hich faces us both in public health and private practice is the prob lem o f m ak in g d e c is io n s on th e priorities that should be given to the prevention of disease as distinct from the treatment or control of the conse quences of disease.” Working from conventional preven tive methods, the 1980 conference ex amined new developments alongside established procedures, both sepa
rately and combined. To plan sensible change in dental health care, it is important first to es tablish that w hich is known and then to examine possibilities for the future. Only then can techniques be explored to transfer this technology to the bene fit of the public. Although oral dis eases are multiple in definition, the papers submitted at this conference re lated overwhelmingly to prevention of dental caries, w hich rests at present in the use of fluorides, the control of bac teria, the strengthening of the tooth surface, and the modification of the diet.
Fluoridation Water fluoridation was again recog nized for its sim plicity and efficacy; however, its very sim plicity becomes a weakness because it is subject to a va riety of political pressures. The politi cal and psychological groups against water fluoridation still prevail in many areas. Because of the difficulties of water fluoridation, other methods for the de livery of systemic fluoride have been sought. Fluoride drops and tablets are available to the individual, but present other problems: self-discipline, m oti v atio n , u n d ersta n d in g , and o v er dosage or under-dosage. M ilk may have possibilities in the future, and salt is another vehicle that has been widely used; however, the im plica tions of toxic and systemic side effects from salt must not be disregarded, even though there are successful re ports on such use. Although much has been presented against fluoride, the reports remain unsubstantiated, and Y. E ricsso n , PhD, D rOdont, made strong mention of its value in the man agement of some bone pathology, pos sibly including alveolar bone. Although the mechanism of fluoride action, particularly its effect on the early caries lesion, needs to be studied further, H. S. Horowitz, DDS, MPH, showed the value in long-term studies of several topical vehicles, including tablets and rinses, which are sim ple to use in school programs w here the JADA, Vol. 101, November 1980 m 809
CURRENT CONFERENCE
On June 1 to 3, the Eighth International C onference on Oral Biology was h eld in Tokyo. The co n feren ce was designed to provide an interplay betw een basic and applied know ledge. From this, it was hoped, new goals fo r the future would em erge.
problems of self-discipline and under standing are removed. When used in combination with fluoride dentifrice at home, impressive reductions in caries prevalence can result, particu larly on approximal surfaces.
Oral hygiene Tooth cleaning has long been held by the dental profession to be an im portant means of preventing dental caries; however, J. Ainamo, DrOdont, although fully supporting toothbrushing in the control of gingival disease, challenged its value in the reduction of decay. Antimicrobial agents are poten tially useful in the prevention of both decay and gingival disease, particu larly in high-risk groups—and the de velopm ent of effective screening mechanisms to detect such people is an important priority. Indeed, the positive approaches of this method were more than ade quately supported by D. Bratthall, DDS, who clarified the term high risk. Although acknowledging that Strep tococcus mutans is not the only or ganism that can induce caries, he nevertheless presented a simple sam pling technique for this organism that may be an effective method of identifi cation of patients at risk. The identifi cation of mothers who might transfer S mutans to their offspring presents the possibility of controlling caries on a family basis. The work of Ellen and Gibbons2 has shown the importance of bacterial adherence in the phenomena of dental plaque diseases; the identifi cation of mechanisms of immunology is used to explain other findings. M. A. Taubman, DDS, PhD, presented the immunochemical approach to the pre vention of dental caries and showed its effectiveness in animal studies. More will be heard of this approach in the fu ture, but wide acceptance of this method may be hindered by the impli cations in all work associated with vaccines and immunology as treat ments. Current work in Japan points to the possibility of modifying the tooth sur 810 ■ JADA, Vol. 101, November 1980
face in the fight against disease. S. Takuma, DDS, PhD, examined the u ltrastru ctu ral changes of tooth enamel in the demineralization and remineralization processes. In vitro studies support the theory of invasion of the enamel surface via enamel rod sheaths and also that the same route can be capitalized on for preventive treatment of surface enamel by a re mineralized process. H. Yam am oto, DDS, PhD, also suggested the use of laser modification to render the tooth surface more resis tant. It is clear that research in Japan is combining originality with advanced technology; these skills and charac teristics offer exciting possibilities for the future. The same technological innovation was shown by T. Yamada, DDS, PhD, who reported a technique to evaluate pH of dental plaque in situ and, through this, to assess the cariogenicity of various new sugars. Al though previous workers have exam ined plaque pH, none has been able to monitor the plaque as it grew. Such a technique, coupled with the findings of Brudevold,3 will add greatly to fu ture knowledge of in situ testing of cariogenic foods, an observation that leads directly to the consideration of diet and nutrition in the control of den tal caries.
Importance o f diet Much emphasis has been placed tradi tionally on the role of sugar as a cause of dental caries, but M. C. Alfano, DMD, PhD, suggested that other dietary implications in oral disease have been underestimated. He stressed the complexity of nutrient interaction at the cellular level and suggested that these problems of micronutrition can affect not only growth, development, and occlusion, but also caries and periodontal disease. The critical periods of development and growth are times of great vulnerability. The cariogenicity of food was recognized but so too were means of modifying eating behavior by altering taste so that
these foods were less attractive to the consumer. Modification of epithelial permeability by nutrition promises to be another challenging area by which to investigate and treat periodontal disease. The application of the basic knowl edge implicating soluble sugars in dental caries occupied the remainder of the proceedings. Major influences were commercial and political pres sures. Alfano pointed out that some countries, for instance, Switzerland and the Netherlands, now have to dis play warning labels on food that is cariogenic, just as tobacco must carry a warning as a cancer agent. Implica tions of this are widespread, and there fore it was important that the experi ences of the Director of the Bureau of Food and Drug Administration of the United States were carefully noted. S. A. Miller, PhD, explained that it was possible to control food additives through legislation, but not the food it self. Until recently the US government was not much interested in dental dis eases that are not life-threatening. However, society is becoming more aware of dental disease. The need was shown for the dental profession to be come sensitive to the new public awareness and to produce sensible and effective educational program s, whereas government must continue to press for accurate and honest advertis ing. A. Sheiham, BDS, PhD, further emphasized this approach, claiming that poor advertising had no place in modern society. Unfortunately, the strategy of the sugar industry is to pre sent its product as though it were vital to good health. Sheiham asserted that a policy that enabled healthy dietary products to be readily available to people for the lowest price and social cost is the only acceptable goal. A coordinated action by all health pro fessionals needs to replace the apathy shown in the past to advertising claims made by industry. L. J. Okholm, Dr Techn, MS, showed that industry can take a responsibility for the health of the public and still
CURRENT CONFERENCE
Health care costs cannot go on climbing. The n e e d fo r self-care health program s has b een well documented. There has been a reduction in caries in m any o f the developed countries in the world, but a rapid rise in the developing ones.
profit. The average consumer cannot evaluate whether commercially pro duced foods are harmful, so producers must pursue a policy aimed at better nutrition by displaying a clear state ment of the levels of possible harmful substances, including soluble sugars. Industry is well able to maintain the acceptability of foods while reducing the sugar content. Indeed, there was agreement that the goal was to reduce sugar consumption, not to eliminate it, and that it was important to impart a message acceptable to all health pro fessionals so that the public would not be confused. All foods, however, are not industri ally produced; many “natural” foods are consumed, and one cannot help but reflect on Zen, with its specific health practices by behavior modifica tion: in nutrition, enough is the mea sure, never excess.
Dental health education The application of scientific findings in the public health field needs to be as rigorously tested as the original dis covery. Local conditions can substan tially modify the effect of accepted procedures, and the planning and de livery of health care must take this into account. M. A. Lennon, BDS, PhD, suggested that planning needs to be viewed as a dynamic learning process. Sequential planning allows several alternatives to be tested simultaneously using cost value analysis, so that the public is given value for money in the shortest time possible. The studies Lennon presented were from England and were clear examples of inappropriate selection of target populations, but the process of planning was demon strated. The planner has to remain open-minded, with a system suffi ciently receptive to new methods to be ready to reassess a program in time to avoid the massive costs of an ineffec tive system. O. Sakai, DDS, showed how the cor rect amalgamation of method and target group can have a significant ef
fect. His incremental dental care pro gram, including the use of fluoride rinses and supported by strong com munity involvement, was highly cost-effective. However, the accurate transfer of basic preventive measures to im plementation is not always so straight forward. J. B. Silversin, DMD, Dr PH, showed the clear need to understand the factors influencing acceptance or rejection of proved public health mea sures. Using fluoride mouthrinse pro grams as a model, he explored these in fluences among school administrators. Not only is it necessary to gain accep tance but it is also equally important to ensure that the transfer has been made accurately in the community. In such transfers, simple language as well as simple methods will increase the probability of success. Although schools were identified as ideal for the transfer of knowledge, lit tle use has been made of schools for studies of diffusion of preventive health practices, either in dentistry, medicine, or other health sciences. There can be resistance to the use of schoolteachers for this type of work, and it is valuable to know in this con text that several administrators of the rinse program voiced commitment to the program and found it minimally disruptive to usual school activities. So much for school programs, but most dental services are delivered through private practice. M. K. Nikias, DDS, PhD, MPH, examined nine pri vate dental offices in New York that exemplified several important con cepts. She put in balance enthusiasm and skepticism—or applications and implications. The sample consisted mainly of patients of higher social class, with probabilities of high com pliance. Even within this group, inter esting variations in adoption of plaque control programs were found. The dentist was important in enhancing both the skill and knowledge required for the home care regime. It was not surprising that the percentage of pa tients who used dental floss was so low, considering the dexterity it re
quires. Similarly, the finding that only a few patients were prepared to use disclosing tablets and change their diet was not unexpected. Our educa tional approaches to convince people to adopt preventive habits are not yet effective enough to make a great im pact on the public, and we must de velop research technology and include a wider representation of social class to discover how best to assist patients in oral self-care. The problem of evaluation formed the final section of the conference. All the material gave evidence of change for the better. J Hefferren, DDS, ob served favorable long-term trends in populations exposed to water fluorida tion; the results suggested a reduction in periodontal disease and caries. Comparisons are said to be invidi ous and that may be true. However, there is no better way to stimulate the actions of authority than to show unfa vorable data for one system compared with another. Thus, the characteristics of the international collaborative study on dental manpower systems forced comparative data into the open for deliberation and debate, and from such data stemmed much good for preventive dental services in the world. Both L. A. Heloe, Dr Odont, and P. B. Hunger, BDS, MDS, attested to that for countries as far apart as Norway and New Zealand. Heloe’s analysis of the growth and development of a national dental care program was an example to all public health dentists. A. J. Bonito, PhD, showed a diversity of thinking and characteristics in dental practices from one nation to another. Although similar goals for education of patients were identified, end-results were somewhat different. Each national sample disclosed a different set of c h a r a c t e r i s t i c s p o s s e s s e d by prevention-oriented dentists, and it may not be possible to generalize across cultures in the field; each coun try may need to define for itself those factors that must be emphasized in order to encourage a preventive ap proach among the practitioners. Beagrie: ORAL BIOLOGY CONFERENCE ■ 811
CURRENT CONFERENCE
There was agreem ent that the goal was to red u ce sugar consumption, not to eliminate it, and that it was important to im part a m essage acceptable to all health professionals so that the public would not b e confused. H elôe show ed the value of the school system to benefit the popula tion as a whole in prevention of dental disease, and, at a time when one hears many people talking of a dental man power excess, Helôe showed that de mand could be stimulated by an in creased awareness. It should be noted that, although a drop-off occurs in the use of dental services after patients leave organized public dental care, there is a reentry later. Also of impor tance for the conference was his report that preventive services doubled be tween 1973 and 1979. Hunter, presenting data for New Zealand, showed how evaluation can influence authority enormously, the more so because that country prides it self on the effectiveness of its treat ment service. Why or how could this be? The implications were profound, and the remedy was réévaluation of the School Dental Service. Both Nor way and New Zealand are moving away from first aid and repair to a pol icy of prevention. From New Zealand has come a deci sion to change the level of caries diag nosis requiring restorative treatment, to improve preventive services, and to set a target of 10% reduction of fillings. To have achieved a 27% reduction of caries treatment after one year of the new regimen, and 41% after two years, has to be one of the most encouraging signs in any dental system and points the way for other countries. Surely the implication is a reexami nation of service patterns in the light of a changing society. Health care costs cannot go on climbing. The need for self-care health programs has been well docum ented. Barm es4 has re ported a reduction in caries in many of the developed countries of the world, but a rapid rise in the developing ones. Can the message from one group be
812 ■ JADA, Vol. 101, November 1980
transferred to the other and be effec tive? Conferences such as this can cer tainly help in this direction. The philosophical changes occur ring in New Zealand and Norway at test to the application of nationally successful preventive programs. It is also apparent from data from other studies given at this conference that p reventive program s will provide benefit in the control of other oral dis eases, notably periodontal disease. Dentistry has been acknowledged to be of great significance to the mainte nance of and improvement in the qual ity of life.5 Helôe showed that with im proved socioeconomic conditions and improved preventive services more teeth are being saved— and the more teeth in the population, the more den tists are kept employed. Furthermore, even though the treatment time per adult has been reduced by 50% in Scandinavia, 1 ,000 dentists a year graduate and the profession there re mains busy. Demand for preventive services is increasing in Norway with the addition of 1% of the population to the system as regular attendees. Nikias showed “regulars” were better preven tive performers and Bonito found that the dentist giving preventive therapy and oral health education feels less overworked. The dentist’s quality of life will, therefore, also change. The treadmill service of the past is disap pearing. Are members of the profes sion able to recognize the changing face of society as it affects them? Im plications of applications of oral dis ease prevention are much wider in scope than previously realized. There are many pitfalls and much has to be recognized as incomplete. What has happened in one country may take a long time to be applied in another. Exam ples, however, help to effect change.
Summary It would seem that “tried favorites” are currently the preferred application methods, not that the futuristic tech nology is unimportant. Pragmatism must prevail, however, and simple self-care, associated with high quality organization, is the order of today. Iso lation and treatment of risk groups will becom e com m on courses and test methods of Brathall and others will come into their own. Immunization, la se r beam tre a tm e n t, and o th er sophisticated methods will develop and future conferences will probably hear of their use. It would appear pertinent, because of the importance of oral health pro motion, to recognize the weaknesses shown in that area and suggest a re search conference to examine the sub ject of oral health education of the den tist and the public. Could this be the subject for the Ninth conference?
Dr. B e a g rie is p rofesso r, o ral m e d icin e , and dean , F a cu lty o f D en tistry, U n iv ersity o f B ritis h C o lu m bia, 3 1 2 -2 1 9 4 H ea lth S c ie n c e s M a ll, V an co u v er, B C , C an ada V 6 T 1W 5 . A d d ress req u ests fo r re p rin ts to th e au tho r. 1. D av ies, G.N. S u m m ary o f th e p ro ce ed in g s o f th e 7 th In te rn a tio n a l C o n feren ce o n O ral B io lo g y . C o p en h a g en , D en m ark, M a rch 2 8 - 3 0 ,1 9 7 7 . J D en t R es (S p e c ia l Issu e C) 5 6 :1 6 0 -1 7 0 , 1 9 7 7 . 2. E lle n , R .P ., an d G ibbo n s, R .J. P a ra m eters a f fe c tin g th e a d h e re n c e an d tis s u e tr o p is m s o f S tre p to co ccu s p y og enes. In fe ct Im m u n 9 :8 5 -9 1 , 1974. 3 . B ru d e v o ld , F .; B a k h o s, Y .; a n d G o lsh a n , K. T ow ard a n in tra -o ra l ca r io g e n icity test. J D en t Res 5 9 : a b stra ct no. 6 5 ,1 9 8 0 . 4 . B a r m e s , D .E . O r a l h e a l t h
s ta tu s o f
c h ild r e n — a n in te rn a tio n a l p e rsp e c tiv e . D en t J 4 5 :6 5 1 - 6 5 8 ,1 9 7 9 . 5. T ra n sa ctio n s o f th e 6 5 th W orld A n n u a l D en ta l C ong ress h e ld in T o ro n to , C anada, O ctob er 1 9 7 7 . In t D en t J 2 7 -2 8 , 1 9 7 8 .
Oral disease prevention— its implications and applications: summary of proceedings George S. B eagrie, DDS, FDSRCS (Edin), FRCD (C)
Methods of im plem enting preventive dental care program s w ere discussed, problem s and successes encountered in various countries w ere reported and compared.
D e n t a l researchers, educators, and practitioners know what modern pre ventive dentistry can do to improve oral health. The Colgate-Palm olive Company and Kao-Colgate Products Company of Japan have recognized the need to explore further the topic of prevention of dental disease and have continued sponsorship of these Oral Biology Conferences. This conference was designed to provide an interplay between basic knowledge (new, experimental, and well-tested) and applied knowledge (individual, group, community, na tional, and international). From this, it was hoped, new goals for the future would emerge.
T h e 1 9 8 0 co n fe re n c e On June 1 to 3, the Eighth International Conference on Oral Biology was held in Tokyo. Three years earlier, at the 1 9 7 7 co n fe re n ce in C op en h agen , Davies1 stated that “the central prob lem w hich faces us both in public health and private practice is the prob lem o f m ak in g d e c is io n s on th e priorities that should be given to the prevention of disease as distinct from the treatment or control of the conse quences of disease.” Working from conventional preven tive methods, the 1980 conference ex amined new developments alongside established procedures, both sepa
rately and combined. To plan sensible change in dental health care, it is important first to es tablish that w hich is known and then to examine possibilities for the future. Only then can techniques be explored to transfer this technology to the bene fit of the public. Although oral dis eases are multiple in definition, the papers submitted at this conference re lated overwhelmingly to prevention of dental caries, w hich rests at present in the use of fluorides, the control of bac teria, the strengthening of the tooth surface, and the modification of the diet.
Fluoridation Water fluoridation was again recog nized for its sim plicity and efficacy; however, its very sim plicity becomes a weakness because it is subject to a va riety of political pressures. The politi cal and psychological groups against water fluoridation still prevail in many areas. Because of the difficulties of water fluoridation, other methods for the de livery of systemic fluoride have been sought. Fluoride drops and tablets are available to the individual, but present other problems: self-discipline, m oti v atio n , u n d ersta n d in g , and o v er dosage or under-dosage. M ilk may have possibilities in the future, and salt is another vehicle that has been widely used; however, the im plica tions of toxic and systemic side effects from salt must not be disregarded, even though there are successful re ports on such use. Although much has been presented against fluoride, the reports remain unsubstantiated, and Y. E ricsso n , PhD, D rOdont, made strong mention of its value in the man agement of some bone pathology, pos sibly including alveolar bone. Although the mechanism of fluoride action, particularly its effect on the early caries lesion, needs to be studied further, H. S. Horowitz, DDS, MPH, showed the value in long-term studies of several topical vehicles, including tablets and rinses, which are sim ple to use in school programs w here the JADA, Vol. 101, November 1980 m 809
CURRENT CONFERENCE
On June 1 to 3, the Eighth International C onference on Oral Biology was h eld in Tokyo. The co n feren ce was designed to provide an interplay betw een basic and applied know ledge. From this, it was hoped, new goals fo r the future would em erge.
problems of self-discipline and under standing are removed. When used in combination with fluoride dentifrice at home, impressive reductions in caries prevalence can result, particu larly on approximal surfaces.
Oral hygiene Tooth cleaning has long been held by the dental profession to be an im portant means of preventing dental caries; however, J. Ainamo, DrOdont, although fully supporting toothbrushing in the control of gingival disease, challenged its value in the reduction of decay. Antimicrobial agents are poten tially useful in the prevention of both decay and gingival disease, particu larly in high-risk groups—and the de velopm ent of effective screening mechanisms to detect such people is an important priority. Indeed, the positive approaches of this method were more than ade quately supported by D. Bratthall, DDS, who clarified the term high risk. Although acknowledging that Strep tococcus mutans is not the only or ganism that can induce caries, he nevertheless presented a simple sam pling technique for this organism that may be an effective method of identifi cation of patients at risk. The identifi cation of mothers who might transfer S mutans to their offspring presents the possibility of controlling caries on a family basis. The work of Ellen and Gibbons2 has shown the importance of bacterial adherence in the phenomena of dental plaque diseases; the identifi cation of mechanisms of immunology is used to explain other findings. M. A. Taubman, DDS, PhD, presented the immunochemical approach to the pre vention of dental caries and showed its effectiveness in animal studies. More will be heard of this approach in the fu ture, but wide acceptance of this method may be hindered by the impli cations in all work associated with vaccines and immunology as treat ments. Current work in Japan points to the possibility of modifying the tooth sur 810 ■ JADA, Vol. 101, November 1980
face in the fight against disease. S. Takuma, DDS, PhD, examined the u ltrastru ctu ral changes of tooth enamel in the demineralization and remineralization processes. In vitro studies support the theory of invasion of the enamel surface via enamel rod sheaths and also that the same route can be capitalized on for preventive treatment of surface enamel by a re mineralized process. H. Yam am oto, DDS, PhD, also suggested the use of laser modification to render the tooth surface more resis tant. It is clear that research in Japan is combining originality with advanced technology; these skills and charac teristics offer exciting possibilities for the future. The same technological innovation was shown by T. Yamada, DDS, PhD, who reported a technique to evaluate pH of dental plaque in situ and, through this, to assess the cariogenicity of various new sugars. Al though previous workers have exam ined plaque pH, none has been able to monitor the plaque as it grew. Such a technique, coupled with the findings of Brudevold,3 will add greatly to fu ture knowledge of in situ testing of cariogenic foods, an observation that leads directly to the consideration of diet and nutrition in the control of den tal caries.
Importance o f diet Much emphasis has been placed tradi tionally on the role of sugar as a cause of dental caries, but M. C. Alfano, DMD, PhD, suggested that other dietary implications in oral disease have been underestimated. He stressed the complexity of nutrient interaction at the cellular level and suggested that these problems of micronutrition can affect not only growth, development, and occlusion, but also caries and periodontal disease. The critical periods of development and growth are times of great vulnerability. The cariogenicity of food was recognized but so too were means of modifying eating behavior by altering taste so that
these foods were less attractive to the consumer. Modification of epithelial permeability by nutrition promises to be another challenging area by which to investigate and treat periodontal disease. The application of the basic knowl edge implicating soluble sugars in dental caries occupied the remainder of the proceedings. Major influences were commercial and political pres sures. Alfano pointed out that some countries, for instance, Switzerland and the Netherlands, now have to dis play warning labels on food that is cariogenic, just as tobacco must carry a warning as a cancer agent. Implica tions of this are widespread, and there fore it was important that the experi ences of the Director of the Bureau of Food and Drug Administration of the United States were carefully noted. S. A. Miller, PhD, explained that it was possible to control food additives through legislation, but not the food it self. Until recently the US government was not much interested in dental dis eases that are not life-threatening. However, society is becoming more aware of dental disease. The need was shown for the dental profession to be come sensitive to the new public awareness and to produce sensible and effective educational program s, whereas government must continue to press for accurate and honest advertis ing. A. Sheiham, BDS, PhD, further emphasized this approach, claiming that poor advertising had no place in modern society. Unfortunately, the strategy of the sugar industry is to pre sent its product as though it were vital to good health. Sheiham asserted that a policy that enabled healthy dietary products to be readily available to people for the lowest price and social cost is the only acceptable goal. A coordinated action by all health pro fessionals needs to replace the apathy shown in the past to advertising claims made by industry. L. J. Okholm, Dr Techn, MS, showed that industry can take a responsibility for the health of the public and still
CURRENT CONFERENCE
Health care costs cannot go on climbing. The n e e d fo r self-care health program s has b een well documented. There has been a reduction in caries in m any o f the developed countries in the world, but a rapid rise in the developing ones.
profit. The average consumer cannot evaluate whether commercially pro duced foods are harmful, so producers must pursue a policy aimed at better nutrition by displaying a clear state ment of the levels of possible harmful substances, including soluble sugars. Industry is well able to maintain the acceptability of foods while reducing the sugar content. Indeed, there was agreement that the goal was to reduce sugar consumption, not to eliminate it, and that it was important to impart a message acceptable to all health pro fessionals so that the public would not be confused. All foods, however, are not industri ally produced; many “natural” foods are consumed, and one cannot help but reflect on Zen, with its specific health practices by behavior modifica tion: in nutrition, enough is the mea sure, never excess.
Dental health education The application of scientific findings in the public health field needs to be as rigorously tested as the original dis covery. Local conditions can substan tially modify the effect of accepted procedures, and the planning and de livery of health care must take this into account. M. A. Lennon, BDS, PhD, suggested that planning needs to be viewed as a dynamic learning process. Sequential planning allows several alternatives to be tested simultaneously using cost value analysis, so that the public is given value for money in the shortest time possible. The studies Lennon presented were from England and were clear examples of inappropriate selection of target populations, but the process of planning was demon strated. The planner has to remain open-minded, with a system suffi ciently receptive to new methods to be ready to reassess a program in time to avoid the massive costs of an ineffec tive system. O. Sakai, DDS, showed how the cor rect amalgamation of method and target group can have a significant ef
fect. His incremental dental care pro gram, including the use of fluoride rinses and supported by strong com munity involvement, was highly cost-effective. However, the accurate transfer of basic preventive measures to im plementation is not always so straight forward. J. B. Silversin, DMD, Dr PH, showed the clear need to understand the factors influencing acceptance or rejection of proved public health mea sures. Using fluoride mouthrinse pro grams as a model, he explored these in fluences among school administrators. Not only is it necessary to gain accep tance but it is also equally important to ensure that the transfer has been made accurately in the community. In such transfers, simple language as well as simple methods will increase the probability of success. Although schools were identified as ideal for the transfer of knowledge, lit tle use has been made of schools for studies of diffusion of preventive health practices, either in dentistry, medicine, or other health sciences. There can be resistance to the use of schoolteachers for this type of work, and it is valuable to know in this con text that several administrators of the rinse program voiced commitment to the program and found it minimally disruptive to usual school activities. So much for school programs, but most dental services are delivered through private practice. M. K. Nikias, DDS, PhD, MPH, examined nine pri vate dental offices in New York that exemplified several important con cepts. She put in balance enthusiasm and skepticism—or applications and implications. The sample consisted mainly of patients of higher social class, with probabilities of high com pliance. Even within this group, inter esting variations in adoption of plaque control programs were found. The dentist was important in enhancing both the skill and knowledge required for the home care regime. It was not surprising that the percentage of pa tients who used dental floss was so low, considering the dexterity it re
quires. Similarly, the finding that only a few patients were prepared to use disclosing tablets and change their diet was not unexpected. Our educa tional approaches to convince people to adopt preventive habits are not yet effective enough to make a great im pact on the public, and we must de velop research technology and include a wider representation of social class to discover how best to assist patients in oral self-care. The problem of evaluation formed the final section of the conference. All the material gave evidence of change for the better. J Hefferren, DDS, ob served favorable long-term trends in populations exposed to water fluorida tion; the results suggested a reduction in periodontal disease and caries. Comparisons are said to be invidi ous and that may be true. However, there is no better way to stimulate the actions of authority than to show unfa vorable data for one system compared with another. Thus, the characteristics of the international collaborative study on dental manpower systems forced comparative data into the open for deliberation and debate, and from such data stemmed much good for preventive dental services in the world. Both L. A. Heloe, Dr Odont, and P. B. Hunger, BDS, MDS, attested to that for countries as far apart as Norway and New Zealand. Heloe’s analysis of the growth and development of a national dental care program was an example to all public health dentists. A. J. Bonito, PhD, showed a diversity of thinking and characteristics in dental practices from one nation to another. Although similar goals for education of patients were identified, end-results were somewhat different. Each national sample disclosed a different set of c h a r a c t e r i s t i c s p o s s e s s e d by prevention-oriented dentists, and it may not be possible to generalize across cultures in the field; each coun try may need to define for itself those factors that must be emphasized in order to encourage a preventive ap proach among the practitioners. Beagrie: ORAL BIOLOGY CONFERENCE ■ 811
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There was agreem ent that the goal was to red u ce sugar consumption, not to eliminate it, and that it was important to im part a m essage acceptable to all health professionals so that the public would not b e confused. H elôe show ed the value of the school system to benefit the popula tion as a whole in prevention of dental disease, and, at a time when one hears many people talking of a dental man power excess, Helôe showed that de mand could be stimulated by an in creased awareness. It should be noted that, although a drop-off occurs in the use of dental services after patients leave organized public dental care, there is a reentry later. Also of impor tance for the conference was his report that preventive services doubled be tween 1973 and 1979. Hunter, presenting data for New Zealand, showed how evaluation can influence authority enormously, the more so because that country prides it self on the effectiveness of its treat ment service. Why or how could this be? The implications were profound, and the remedy was réévaluation of the School Dental Service. Both Nor way and New Zealand are moving away from first aid and repair to a pol icy of prevention. From New Zealand has come a deci sion to change the level of caries diag nosis requiring restorative treatment, to improve preventive services, and to set a target of 10% reduction of fillings. To have achieved a 27% reduction of caries treatment after one year of the new regimen, and 41% after two years, has to be one of the most encouraging signs in any dental system and points the way for other countries. Surely the implication is a reexami nation of service patterns in the light of a changing society. Health care costs cannot go on climbing. The need for self-care health programs has been well docum ented. Barm es4 has re ported a reduction in caries in many of the developed countries of the world, but a rapid rise in the developing ones. Can the message from one group be
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transferred to the other and be effec tive? Conferences such as this can cer tainly help in this direction. The philosophical changes occur ring in New Zealand and Norway at test to the application of nationally successful preventive programs. It is also apparent from data from other studies given at this conference that p reventive program s will provide benefit in the control of other oral dis eases, notably periodontal disease. Dentistry has been acknowledged to be of great significance to the mainte nance of and improvement in the qual ity of life.5 Helôe showed that with im proved socioeconomic conditions and improved preventive services more teeth are being saved— and the more teeth in the population, the more den tists are kept employed. Furthermore, even though the treatment time per adult has been reduced by 50% in Scandinavia, 1 ,000 dentists a year graduate and the profession there re mains busy. Demand for preventive services is increasing in Norway with the addition of 1% of the population to the system as regular attendees. Nikias showed “regulars” were better preven tive performers and Bonito found that the dentist giving preventive therapy and oral health education feels less overworked. The dentist’s quality of life will, therefore, also change. The treadmill service of the past is disap pearing. Are members of the profes sion able to recognize the changing face of society as it affects them? Im plications of applications of oral dis ease prevention are much wider in scope than previously realized. There are many pitfalls and much has to be recognized as incomplete. What has happened in one country may take a long time to be applied in another. Exam ples, however, help to effect change.
Summary It would seem that “tried favorites” are currently the preferred application methods, not that the futuristic tech nology is unimportant. Pragmatism must prevail, however, and simple self-care, associated with high quality organization, is the order of today. Iso lation and treatment of risk groups will becom e com m on courses and test methods of Brathall and others will come into their own. Immunization, la se r beam tre a tm e n t, and o th er sophisticated methods will develop and future conferences will probably hear of their use. It would appear pertinent, because of the importance of oral health pro motion, to recognize the weaknesses shown in that area and suggest a re search conference to examine the sub ject of oral health education of the den tist and the public. Could this be the subject for the Ninth conference?
Dr. B e a g rie is p rofesso r, o ral m e d icin e , and dean , F a cu lty o f D en tistry, U n iv ersity o f B ritis h C o lu m bia, 3 1 2 -2 1 9 4 H ea lth S c ie n c e s M a ll, V an co u v er, B C , C an ada V 6 T 1W 5 . A d d ress req u ests fo r re p rin ts to th e au tho r. 1. D av ies, G.N. S u m m ary o f th e p ro ce ed in g s o f th e 7 th In te rn a tio n a l C o n feren ce o n O ral B io lo g y . C o p en h a g en , D en m ark, M a rch 2 8 - 3 0 ,1 9 7 7 . J D en t R es (S p e c ia l Issu e C) 5 6 :1 6 0 -1 7 0 , 1 9 7 7 . 2. E lle n , R .P ., an d G ibbo n s, R .J. P a ra m eters a f fe c tin g th e a d h e re n c e an d tis s u e tr o p is m s o f S tre p to co ccu s p y og enes. In fe ct Im m u n 9 :8 5 -9 1 , 1974. 3 . B ru d e v o ld , F .; B a k h o s, Y .; a n d G o lsh a n , K. T ow ard a n in tra -o ra l ca r io g e n icity test. J D en t Res 5 9 : a b stra ct no. 6 5 ,1 9 8 0 . 4 . B a r m e s , D .E . O r a l h e a l t h
s ta tu s o f
c h ild r e n — a n in te rn a tio n a l p e rsp e c tiv e . D en t J 4 5 :6 5 1 - 6 5 8 ,1 9 7 9 . 5. T ra n sa ctio n s o f th e 6 5 th W orld A n n u a l D en ta l C ong ress h e ld in T o ro n to , C anada, O ctob er 1 9 7 7 . In t D en t J 2 7 -2 8 , 1 9 7 8 .