COMMUNITY DENTAL PREVENTIVE PROGRAMS

The dental diseases and problems that pose the greatest burden to most communities are dental caries (tooth decay), periodontal (gum) diseases, oral cancer, and trauma. These can be largely prevented through a combination of community, professional, and individual strategies. Community preventive programs, particularly community water fluoridation and school-based dental sealant programs, have proven highly effective in reducing dental caries. The effectiveness of programs to prevent other oral health problems has not been demonstrated, but common sense and indirect evidence indicate that continued efforts to develop and implement such programs are warranted.

The first use of fluoride for caries prevention occurred in 1945 in the United States and Canada, when the fluoride concentration was adjusted in the drinking water supplies of four communities. This public health approach followed a long period of epidemiologic studies of the effects of naturally occurring fluoride in drinking water. Observation of dramatic declines in dental caries in the cities conducting the studies, compared to similar cities with low levels of fluoride in the water, led to fluoridation of water supplies in many other cities. The Centers for Disease Control and Prevention (CDC) has recognized water fluoridation as one of the great public health achievements of the twentieth century, since it provides an inexpensive means of substantially improving oral health that benefits all residents of a community, without regard to their interest in, or ability to receive, dental care.

In spite of its well-documented effectiveness and safety, 100 million persons in the United States remained without fluoridated water at the beginning of the twenty-first century. Adoption of water fluoridation can require political processes that make institution of this public health measure difficult, and opponents often make unsubstantiated claims about adverse health effects of fluoridation in attempts to influence public opinion. These barriers present serious challenges to expanding fluoridation in the United States.

Fluoride prevents tooth decay by making tooth surfaces more resistant to the demineralization caused by the acids produced by bacteria in dental plaque as they metabolize carbohydrates. It also remineralizes the enamel surface of teeth weakened by the decay process, reversing the cavityproducing process. Through these effects on the surfaces of teeth, fluoride prevents dental caries in both children and adults. The success of fluoridation led to the development of other fluoride-containing products, most notably fluoride-containing dentifrices (toothpastes) and high strength gels for professional use. Promotion of regular use of fluoride dentifrices by their manufacturers and the dental profession through commercial advertising and health education in schools has proven to be another effective community intervention. By the year 2000, drinking of fluoridated water and the self-care habit of regular use of fluoride toothpaste by most persons had reduced dental caries markedly compared to levels that existed at the middle of the twentieth century.

Dental sealants are plastic coatings that can be professionally applied to pits and fissures, primarily on the chewing surfaces of molar (posterior) teeth, to protect them from dental caries. Without sealants, as much as 90 percent of all dental caries in schoolchildren occurs in pits and fissures. To be most effective, sealants should be placed on teeth soon after they erupt, but they can be applied across a wide age range. Community programs generally target vulnerable populations less likely to receive private dental care, such as children eligible for free or reduced-cost lunch programs (or from low-income families). These school-based programs select classes of schoolchildren at high risk and seek parental permission for referral to an off-site private practice or clinic, or for receipt of services provided in the school by dental professionals using portable equipment. School-based sealant delivery programs are strongly recommended on the basis of strong scientific evidence of their effectiveness in reducing caries on the chewing surfaces of permanent molars.

Other community dental-disease prevention and oral-health promotion efforts include those directed toward the public, practitioners, and policymakers to create a healthy environment, reduce risk factors, inform groups at risk, and improve knowledge and behaviors. There is evidence that comprehensive application of community approaches can reduce the use of tobacco, which is a risk factor for both oral cancer and periodontal diseases (gum infections and the inflammatory reaction that leads to loss of bone support for the teeth). Periodontal disease is a significant cause of tooth loss among adults, and approximately half of the cases of periodontal disease in the United States are attributable to cigarette smoking. Oral cancer is diagnosed in 30,000 Americans each year, and it causes about 8,000 deaths annually. Detection of oral cancer at an early stage is believed to improve the likelihood of successful treatment, but the success of community-based interventions for early detection of oral cancers has not been demonstrated. Nevertheless, it is prudent for all persons to seek regular oral examinations and for health practitioners to be particularly proactive in assuring that tobacco users receive annual oral examinations.

The promotion of oral hygiene by manufacturers of toothbrushes and dentifrices is likely responsible for improvements in oral hygiene practices, including the current common practice of brushing teeth at least twice per day and the regular use of dental floss by many persons. The extent to which this has reduced periodontal diseases is not clear, but many people who attend to these daily practices are able to maintain their teeth for a lifetime.

Finally, the use of mouth guards and face guards while participating in contact sports is prudent practice, and is mandatory in many amateur sports and professional boxing. Examples of community-based interventions to prevent sportsrelated trauma include the development of rules and regulations; efforts to alert players, parents, and officials to the potential for injury; and better product designs.

William R. Maas

(see also: Caries Prevention; Community Water Fluoridation; Dental Fluorosis; Dental Sealants; Oral Cancer; Oral Health; Tobacco Control )

Bibliography

Centers for Disease Control and Prevention (1999). "Achievements in Public Health, 1900–1999: Fluoridation of Drinking Water to Prevent Dental Caries." Morbidity and Mortality Weekly Report 48 (41):933–940.

—— (2001). "Strategies for Reducing Dental Caries, Oral and Pharyngeal Cancers, and Sports-Related Craniofacial Injuries—A Report on Recommendations of the Task Force on Community Preventive Services." Available at http://www.thecommuntyguide.org.

National Research Council (1993). Health Effects of Ingested Fluoride. Washington, DC: National Academy Press.

Tomar, S. L., and Asma, S. (2000). "Smoking-Attributable Periodontitis in the United States: Findings from NHANES III." Journal of Periodontology 71 (5): 743–751.

U.S. Department of Health and Human Services (2000). "Community and Other Approaches to Promote Oral Health and Prevent Oral Disease." In Oral Health in America; A Report of the Surgeon General. Rockville, MD: National Institute of Dental and Craniofacial Research.