Elements in Oral Health Programs oral health preventive program.^'' The American Dental Association (ADA) also addresses the fact that tooth decay remains the single most common chronic

Elements in Oral Health ProgramsAnty Lam, R.D.H., M.P.H.

ABSTRACT

Demographically, dental caries remains the single

most common disease of childhood. Various cam-

paigns have been carried out to promote and to im-

prove the oral health of children. However, the preva-

lence of dental caries was still more than 50% in many

communities. This article reviews different approach-

es used in dental health programs in industrialized

and developing countries. To build a comprehensive

oral health preventive program, three elements are

essential. They are oral health education/instruction,

primary prevention measures and secondary preven-

tion measures.

Demographically, dental caries remains the single most commondisease of childhood.^ According to the Report of the U.S. SurgeonGeneral in 2000, tooth decay is five-times more common thanasthma and seven-times more common than hay fever. It affectsmore than one-fourth of U.S. children ages 2 to 5 and half ofthose ages 12 to 15.̂ '̂

The World Health Organization (WHO) also considers den-tal caries the most important global oral health burden. And aglobal strategy for preventing oral health diseases was formulated

and endorsed in 2000 by the Fifty-third World Health Assem-bly.*'' Before that, the WHO had partnered with the FederationDentaire Internationale (FDI) to formulate global goals for oralhealth to be achieved by the year 2000.' One of the goals wasto declare 50% of 5- to 6-year-olds free of dental caries. Variouscampaigns have been carried out to promote and to improve theoral health of children to reach the goal. However, the prevalenceof dental caries was still more than 50% in many communities.

It is not only children in developing countries, but those indeveloped countries with low socio-economic status as well whosuffer from a similar pattern of dental decay. For instance, in theUnited States, about half of all children and two-thirds of childrenages 12 to 19 from low-income families have had dental decay.•̂Nevertheless, many reports suggest there was a decline in dentalcaries in the past decades observed in many developed countriesas a result of a number of public health measures, coupled withchanging living conditions, lifestyles and improved self-care prac-tices. However, it must be stressed that dental caries, as a disease,is not eradicated but only controlled to a certain degree.

Oral Hygiene in ChildrenPoor oral hygiene leads to the development of gingivitis. Epidemi-ological studies have found that oral hygiene in children is worsein developing countries and in low socio-economic groups.'''^ Gin-givitis can be prevented by practicing good personal oral hygienepractices, including brushing and fiossing, which are also impor-

2 6 IVIARCH 2 O 1 4 • The New York State Dental Journal

tant in controlling the advancement of periodontal lesions.^ The2001 Grant Makers in Health Issue Dialogue observed that "Oneproven strategy for reaching children at high-risk for dental dis-ease is providing oral and dental health services in school-basedhealth centers....'"

The American Dental Association (ADA) also addresses the factthat tooth decay remains the single most common chronic diseaseof children. Resolution 38H-2010, passed by the ADA House ofDelegates, recognizes the benefits of school-based oral health pro-grams in preventing and controlling dental caries in children andadolescents.^° In fact, a number of community oral health programsfor children have been conducted in school/kindergarten. Some ex-amples are the ones in Milwaukee, WI, Brazil and Ecuador. ""̂ ^ Tofacilitate the operation of these community oral health programs,the involvement of school staff, community clinics, dental hygien-ists and health educators is feasible and appropriate.

Elements in Oral Health ProgramsThere are three main elements in mostoral health programs. They are: oralhealth education/instruction; primaryprevention measures, which can be chair-side and non-chairside; and secondaryprevention measures, which refer to earlydetection and treatment. Frazier and hisco-workers surveyed prevention programsfor children in Japan, Singapore, Swedenand the United Kingdom and concludedthat it is essential to include these threeprogram elements to build a comprehen-sive oral health preventive program.^''

The American Dental

Association (ADA) also

addresses the fact that

tooth decay remains the

single most common chronic

disease of children.

Oral Health Education/InstructionOral health education/instruction usually refers to oral hygieneinstruction and/or oral health education. These instructionalactivities aim to promote oral health practices and to improveawareness and attitudes toward dental health. They target notonly children, but also their parents, teachers and health workers.Oral health education and instructional activities for children,parents, teachers and health workers are commonly carried outin schools and clinics. Reinforcing and teaching toothbrushingis generally accepted to be a main component in oral hygiene in-struction. Oral health education is usually carried out throughpresentations, games or printed materials. Schools are oftenselected because they provide good access to children, parents,teachers and health workers. The WHO supports programs car-ried out in schools.^^ Arguments in favor of promoting dentalhealth through schools include:

3 Students can be accessed during their formative years, fromchildhood to adolescence. These are important stages in

people's lives, when lifelong oral health-related behaviors, aswell as beliefs and attitudes, are being developed.School can provide a supportive environment for promotingoral health. Access to safe water, for example, may allow forgeneral and oral hygiene programs. Also, a safe physical envi-ronment in school can help reduce the risk of accidents andconcomitant dental trauma.The burden of oral disease in children is significant. Mostestablished oral diseases are irreversible and will last a life-time and have an impact on the quality of life and generalhealth.School policies, the physical environment and education forhealth are essential for attainment of oral health and to con-trol risky behaviors, such as the intake of sugary foods anddrinks, use of tobacco and alcohol consumption.Schools can provide a platform for providing oral health care,that is, preventive and curative services.Oral health education is considered important to preventing

and treating oral diseases as evidenced inthe Knowledge Attitude Behavior (KAB)model. The Health Belief Model (HBM)also posits that individuals must perceivethemselves to be at risk before they willtake actions to reduce risky behaviorsor to engage in healthy alternative be-haviors. Through education, people canacquire the knowledge to identify theirrisk and the impetus to practice healthyalternative behaviors.

Kay and Locker reviewed the ef-fectiveness of dental health educationand reported that very few definitiveconclusions about the effectiveness of

oral health promotion can be drawn from currently availableevidence.'* Knowledge levels can almost always be improved byoral health promotion initiatives, but whether these shifts inknowledge and attitudes can be causally related to changes inbehavior or clinical indices of disease has not been established.Although there are studies conducted in China and in Englandreporting that oral health education had an effect in improvingthe dental health of children,'^'^^ several other studies in differ-ent countries, such as the ones conducted in Zimbabwe, Bel-gium and Indonesia, concluded that the involvement of primaryhealthcare personnel and school teachers in providing school-based oral health education had little significant effect on cariesprevention in children.""^'

Primary Prevention MeasuresFluoride agents are commonly used as a primary preventionmeasure. It is generally agreed that the use of fiuorides has led

The New York state Dental Journal • IVIARCH 2O14 27

to a significant decline in dental caries.-̂ '̂̂ ^ Research has shownthat fluoride is most effective in preventing dental caries when alow level of fluoride is constantly maintained in the mouth.̂ ''•^^The provision of fluoride can be through drinking water, salt,mouthrinse or toothpaste, and various forms of professionallyapplied fluorides, such as gels and varnishes. Of these modalities,water fluoridation is considered the most cost-effective way toprevent caries formation. It has been suggested that the most po-tent effect of water fluoridation is not so much preventing new le-sions from appearing, but remineralizing existing carious lesionsand, thus, slowing down or even arresting the caries process.^^

Although there is evidence of merits in water fluoridation,health authorities in many countries still have implementationproblems. The lack of a safe networked water supply system andthe absence of government willingness/support are difficultiesin developing countries. In industrialized countries, worry fromunjustified claims of harmful effects and freedom-of-choice andautonomy arguments from anti-fluoridationists may affect thedecision to add fluoride to the water.

When water fluoridation is not feasible, WHO recommendsconsidering the use of salt fluoridation techniques to preventdental caries.^'' Unlike water fluoridation, which requires a reli-able water supply, salt fluoridation is less dependent on infra-structure and can achieve wide coverage. It is a less politicallysensitive issue that allows for freedom of choice. And it has beenreported to have an effect on preventing dental caries. In someareas of France and Germany, domestic fluoridation salt has amarket share of more than 50%.̂ ^ In Jamaica, the reduction ofcaries in children has been noticed since implementation of saltfluoridation.^' Although there is increased use of fluoridated saltin Europe, Central and South America, the population coverageis still not large.

The most common products for self-application are fluoridetoothpastes and mouthrinses. A review of fluoride toothpaste byCochrane Collaboration, using random effects meta-analyses,found that fluoride toothpaste is efflcacious in preventing car-ies in children.^° The review also found that the effect of fluo-ride toothpaste increased with higher baseline levels of D(M)FS, higher fluoride concentration, higher frequency of use andsupervised brushing. Fluoride toothpaste can be used in com-munity-based preventive programs. A study in China found thatbrushing with fluoride toothpaste for three years arrested 45% ofthe proximal and 23% of the buccal and palatal carious lesionsin primary anterior teeth.^^ It demonstrated that daily tooth-brushing with fluoride toothpaste could be an effective programto control the caries problem in children. Since the use of fluo-ride toothpaste in developing countries like China, especially inrural areas, can be inhibited by its relatively high cost and poordistribution, the development of the fluoride toothpaste marketin these countries presents a challenge to manufacturers and todental public health workers.^^

Although fluoride mouthrinse is not as popular as fluoridetoothpaste for self-application, there are studies that report thatmouthrinse is effective in caries prevention in children. A meta-analysis conducted by Cochrane Collaboration suggested thatthe supervised regular use of fluoride mouthrinse reduced cariesincrementally in children.^^ However, fluoride rinses may notbe suitable for young children, because they are likely to swal-low the solution posing a risk for fluorosis. On the other hand,rinsing appears to have a greater effect in older children aged 10or above.̂ '*'̂ '

Fissure sealant application is another procedure that hasbeen demonstrated to be effective in preventing caries in children.Although the prevalence among U.S. children and adolescents ofone or more sealed permanent tooth surfaces increased about13% during the period 1988-1994 to 1999-2002, it is still wellbelow the objective set by the Healthy People 2010 document,which is 50% of sealant use among this population.

Many states have used government money to initiate seal-ant utilization programs to meet the objective delineated in theHealthy People 2010 document.^* Examples of community-basedsealant promotion programs targeted to high-risk school childreninclude Sealant Saturdays in Salt Lake City, UT, and the Den-tal Initiatives of the Academic Health Center at the Universityof Minnesota; Dental Sealant Program of the Department ofState Health Services, Texas; Seal a Smile Program of WisconsinOral Health Program; Dental Sealant Grant Program of IllinoisDepartment of Public Health; and the Rural School-Based OralHealth Program for South Texas. '̂' School-based dental sealantprograms also have significant accomplishments. Those programsin Arizona, Illinois, New Mexico, Michigan and Ohio have beennamed as successful practices in the Association of State & Ter-ritorial Dental Directors May 2011

Secondary Prevention Measures

Dental screening is the usual strategy used in early detection andtreatment service. A study in Sweden pointed out the importanceof early detection and prevention of caries in the primary den-tition.^' In industrialized countries, dental treatments are oftencarried out in either standing dental clinics or provided througha "mobile dental clinic" housed in a van that travels to variousplaces. These methods are neither available nor affordable in de-veloping countries,''° where the cost of basic sets of instruments,dental materials and infection control products is too high andtraining for primary health workers to undertake basic oral care isinadequate. In these situations, a new approach to oral healthcareis needed.

The Commonwealth Dental Association (CDA) and theWHO held a workshop in 1996 on equity in oral health. Oneof the many challenges addressed at the workshop was how toprovide funding to treat the massive amount of caries in childrenin developing countries."*^ Managing caries through minimal

2 8 IVIARCH 2 O 1 4 • The New York State Dental Journal

invasions and low-cost methods is imperative. Caries-arrestingtreatment that aims to halt or slow down disease progression isa practical solution to minimize children's discomfort and otherproblems due to dental caries.

Studies on xylitol chewing gum showed the effect of the gumon arresting caries in children.''̂ ''*^ Other studies showed similarresults from using chlorehexidine varnish.*''•'*' Moreover, a mini-mal intervention treatment using professionally applied topicalsilver fluoride, followed by stannous fluoride solution, was foundto be effective in arresting caries in primary molars."*' The SchoolDental Service in Western Australia has used a 40% silver fluo-ride solution as the standard treatment for deep carious lesionsin primary teeth with good results.*'' In China and Japan, silverammonia fluoride or silver diamine fluoride (SDF) has been usedsuccessfully for arresting caries in children for many years.**'*' Arecent review found that SDF is a simple and cost-effective agentthat has signiflcant and substantial benefit in arresting and pre-venting caries.^"

Another systemic review by Rosenblatt concluded that SDFappears to meet the criteria of both the WHO Millennium Goalsand the U.S. Institute of Medicine's criteria for 21st century med-ical care."

The use of glass ionomer in atraumatic restorative treatment(ART) is another useful method for treating dental caries in pre-

school children in developing countries. The short treatment timeand simple and minimal armamentarium of ART makes it af-fordable for treating children. An evaluation of ART restorationsplaced in children in China showed promising results.^^ Anotherstudy in Tanzania reported a good success rate with ART over sixyears." The WHO Collaborating Centre performed a meta-anal-ysis and found it appears there is no difference in survival resultsbetween single-surface ART restorations and amalgam restora-tions in permanent teeth over the first three years.̂ *

The advantages of ART sealants and restorations then are: itrequires simple instruments and materials; the cost is low; it isfiexible; and it is user friendly, especially for children. Dr. R.G.deAmorim commented in a journal article that the accumulatingevidence of ART has suggested that it can be as good as or evenbetter than conventional treatment."

ConclusionIn summary, most articles on prevention describe how the pro-grams were run; few studies have proper evaluations. Evidence-based studies are essential to evaluate the outcome of theseprograms. It is difficult to have appropriate study design for evalu-ation; and a randomized clinical trial model may not be appli-cable because of ethical issues. However, as there are a numberof effective prevention methods available, we can provide feasible

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prevention care to children after careful consideration of the cul-tural, social, economic and healthcare settings in which they live. //.

Queries ahout this article can be sent to Ms. Lam at alamiScitytech.cuny.edu.

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