Paper 111 Disc

International Journal of Paediatric Dentistry 1999; 9: 81±91

Preventive oral health care and health promotion provided

for children and adolescents by the Municipal Dental Health
Service in Denmark

POUL ERIK PETERSEN & ANA MARIA TORRES

University of Copenhagen, Faculty of Health Sciences, Department for Community
Dentistry, Copenhagen, Denmark

Summary. Objective. To describe the current organization of health promoting and

preventive activities within the Danish Municipal Dental Health Service and to assess
how the service has chosen to comply with the directives as formulated by the National
Board of Health.
Design. A cross-sectional survey of the municipal dental health services was carried out
on a national scale. Postal questionnaires were used to collect information on active and
passive preventive care activities and community-orientated health promotion.
Setting. The survey was conducted to aid the reorientation and adjustment of the
Municipal Dental Health Services in Denmark.
Subjects. All municipal dental health services in Denmark were considered relevant for
the survey and 141 services (71%) responded to the questionnaire.
Outcome measures. Quantitative methods were used to measure recall-intervals for
children and adolescents, passive and active prevention, identification of and care for
individuals at risk, and health education. Qualitative methods were applied to record the
organization of community health activities.
Results and conclusions. The majority of dental services stated that preschool children
are called at regular intervals (every 3, 6 or 8 months); school-children and adolescents
are most often recalled according to individual needs. Chairside assistants, dentists or
dental hygienists give oral hygiene instructions systematically to children of grades 0
through to 3. Fluoride is frequently administered through topical application by
dentists; fluoride tables are not used. Permanent molars are sealed when this is
indicated. Clinical and socio-behavioural criteria are used to identify children at risk.
Half of the services reported school-based health education, and in one-quarter of the
municipalities community health activities took place. Adjustment of the services should
consider population-directed activities and greater use of ancillary personnel.

Introduction improvements in oral hygiene, changing patterns of

Over the past two decades there have been dramatic
declines in the dental caries experience of children in
several industrialized countries [1]. The widespread
use of ¯uoride, especially ¯uoride in toothpastes,
Correspondence: Professor Poul Erik Petersen, University of
Copenhagen, Faculty of Health Sciences, Department for Com-
munity Dentistry, 20 NoÈrre Alle, DK 2200 Copenhagen, Denmark.
sugar consumption, changes in diagnostic criteria,
and preventive and restorative e€orts by dental
health services are often considered the main
reasons for the decline in dental caries. The possible
role played by broad socio-economic factors has
also been highlighted and in macro-ecological
studies of caries reductions the limited impact made
by dental services has been indicated [2,3]. However,
systematic information about the various types of

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82 Poul Erik Petersen & Ana Maria Torres
activities employed by the dental services is needed
to analyse further the reasons for changing dental
caries patterns.
In Denmark, oral health care for children and
adolescents is provided by the Municipal Dental
Service, and according to the Act on Dental Health
consolidated in 1986 [4] the system provides health
promotion, systematic prevention and curative care
free of charge. The programme is essentially school-
based and as a result of outreach activities, the
participation rate is nearly 100%. The Act on Child
Dental Care in 1972 created the ®rst concrete
framework for preventive and health promoting
activities in relation to children and adolescents
[5,6]. A health information system was established
to evaluate the development in oral health status
nationally, regionally and locally [7]. Since 1972, the
reporting system of the oral health care for children
and adolescents has made it possible to monitor
changes in the prevalence of oral disease and oral
health. From an overall perspective, considerable
improvement has been registered [8,9]. The prevalence
rate of dental caries, the average experience of caries
(defs/DMFS) and the number of children with
particularly severe caries pattern (zone 4) have all
decreased substantially. In parallel, improved oral
health attitudes and the self-care practices of children
and parents have been observed [10]. Since the 1970s
the dental health service has gradually included more
and more children and according to the 1986 Act on
Dental Health [4] in force today, all children are
o€ered preventive and curative care free of charge
from birth to the age of 18 years. Moreover,
municipal dental services may o€er dental care to
certain adult groups, e.g. nursing home residents or
old-age pensioners, however, most working hours
(4 90%) are allocated to child dental care.
The aim of the dental health service is, by oral self
care at home and a coherent prevention and care
system, to develop oral health habits in the
population so that teeth, mouth and jaws can be
maintained and function for life. The objectives,
therefore, include aspects of behaviour, systems of
care and health. The means used to reach the goals
of the Municipal Dental Health Service remain
health promotion, prevention, regular recalls and
dental treatment of oral disease [4]. Great impor-
tance is also attached to individual needs and
contact with key persons associated with the care
of children. The directives regarding the content of
the Municipal Dental Health Service for children
# 1999 BSPD and IAPD, International Journal of Paediatric Dentistry 9: 81±91
Paper 111 Disc
and adolescents are relatively clear [4,11]. However,
there is sparse information about how the munici-
palities have actually chosen to comply with the
directives. The purpose of this article is to describe
the current organization of health promoting and
preventive activities in the Danish Municipal Dental
Health Service.
Methods
The study centres around the following principles
[12]. Prevention aims to detect signs of disease and
symptoms as early as possible and prevent a
condition developing further. Preventive activities
should either be directed at an increase in the
resistance of the individual or a decrease in the
impact of harmful factors. Most preventive activ-
ities take place in the municipal clinics. It is the aim
of health promotion to `keep healthy people healthy'.
Health promotion includes measures that can be
taken at a community level, e.g. taxation, policies,
legislation, service planning, etc., which enable
people to adopt healthy choices and improve their
health. Health promoting activities also depend on
people's own participation, the aim being a reduc-
tion in the amount and impact of health-threatening
factors related to lifestyle and behaviour. Health
promoting activities mostly take place in the
children's own surroundings, i.e. school and local
community. The organization of health promotion
and preventive oral care refers to the structure,
administration and division of tasks as well as to the
decision-making on strategies and management in
relation to the implementing of health care work in
clinics and local communities.
According to the 1986 act [4], the municipal
administration establishes and maintains the public
dental services for children and adolescents. In 201
of the 275 municipalities public dental clinics are
now established, whereas in 74 municipalities
private dental practitioners provide care on a
contract basis. The target population for the present
study comprised all Danish public dental health
services. Questionnaires were sent by mail to the
ocial addresses of the dental health services, who
were asked to report on their actual activities. A
total of 141 (70%) services responded. It was the
intention to obtain information on:
1 recall-intervals for children and adolescents,
2 passive prevention (use of different forms of

Preventive oral health care and health promotion
fluorides, fissure sealing practices and profes-
sional plaque control),
3 active prevention (e.g. instruction in oral hygiene),
4 programmes to identify children at risk,
5 health education activities aimed at different
target groups of children (preschool children,
school-children, 16±17-year-olds),
6 content, structure and duration of health education,
7 division of tasks between health care personnel
and the incorporation of key persons,
8 local health activities and interdisciplinary work.
The questionnaire was structured, but also con-
tained qualitative questions to obtain information
about the organization of clinical work and the
work carried out in the local community. Before
launching the study, the questionnaire was tested in
four pilot municipal dental health services.
All data were transferred to diskette in order to
enable electronic data processing by the Statistical
Analysis System. The description and analysis of the
hard data were based on frequency distributions,
whereas the qualitative answers were submitted to a
content analysis. No statistical tests were applied
because the study focused on the target group of all
public services in the country.
Results
Appointments for dental visits
Eighty-eight per cent of the municipal dental
health services stated that children are called for
their ®rst dental visit at age 2±2‰ years, 7% said
that they call children from age 1±1‰ years, 2%
that they see the children before they are 1-year-old;
only a few dental services did not reply to this
question. Table 1 shows the percentage of municipal
dental health services who stated that they recall
children at certain intervals. Approximately 7 out of
10 dental services indicated that children aged 2‰±5
years and in school grade 0 (6 years) are recalled at
regular intervals, approximately every 3, 6 or 8
months. Most dental services stated that they recall
older children according to individual needs.
Instruction in oral hygiene
Systematic instruction in oral hygiene is most
often given to children in school grade 0 and the
®rst three grades (Table 2). Ninety per cent of the
municipal dental health services stated that chair-
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Paper 111 Disc
83
side assistants participate in the instruction; 75%
reported that instruction is carried out by dentists,
while 50% said that a dental hygienist is responsible
for this task.
Oral hygiene instruction takes place in special
preventive care rooms (88%) and/or in the clinic
(79%). In addition, 23% of the municipal dental
health services reported that they have classroom
instruction, 46% answered that they organize the
instruction according to needs or individually
planned prevention programmes, while the remain-
ing dental services organize educational sessions
two to four times a year. Instruction in how to
brush one's teeth is often organized in a group
(75%), but individual instruction is also provided
(97%). Instruction in how to use dental ¯oss (96%)
and tooth picks (31%) is normally carried out on an
individual basis. The criteria for individual instruc-
tion in oral hygiene are as follows: high level of
caries activity/initial caries (46%), educational
criteria/motor function (21%) or a high plaque
index/poor oral hygiene (19%).
Eighty-one per cent of the municipal dental health
services stated that they give individual nutritional
instruction according to need; 70% reported that
they evaluate the need for this kind of instruction
based on the following criteria: poor oral hygiene,
high caries activity, initial caries, risk situation or
evaluation of general health. Information is given on
sugar and sweets (90%) as well as on unhealthy
(69%) and healthy food (71%) in general. Ninety-
two per cent of the dental services answered that
dentists are involved in the oral health instruction,
52% that chairside assistants are involved and 46%
that dental hygienists are involved.
Passive prevention
Table 3 shows that in most dental services
¯uoride is administered topically in the form of
varnish (Duraphat) or by topical application of 2%
NaF. Fluoride rinsing programmes for children
from grade 0 and upwards exist in more than one-
tenth of the municipalities, while ¯uoride gel (1%)
and ¯uoride tablets (5 1%) are only rarely used;
62% of all municipal dental health services stated
that they have stopped all ¯uoride rinsing pro-
grammes during the last 10 years. According to the
replies, ¯uoride varnish (92%) and topical applica-
tion of ¯uoride (63%) are mostly administered by
dentists. More than 40% of the dental health
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84 Poul Erik Petersen & Ana Maria Torres

Table 1. Percentage of municipal dental health services who stated that they recall children at certain intervals (related to age/grade), and
the percentage of dental health services calling children according to individual needs.
0±2‰ 2‰±5 Grade Grades Grades Grades 16±17
years years 0 (6 years) 1±3 4±6 7±9 years
Approx. every 3±4 months 3 14 16 16 17 17 15
Approx. every 6 months 4 23 20 11 9 10 8
Approx. every 8 months 6 31 35 43 45 43 40
Approx. every 10 months 1 6 9 13 15 16 14
Approx. every 12 months 6 4 6 8 9 9 8
Other 5 3 4 4 4 4 3
According to individual needs 38 77 77 77 77 78 83

Table 2. Percentage of municipal dental children with high caries activity. The answers given
health services who offer systematic oral
in connection with ®ssure sealing are shown in Table
hygiene instruction to children related to
age/grade. 4. The permanent molars (91%) and premolars
Age/grade Instruction
(31%) are the teeth most frequently sealed. Criteria
for ®ssure sealing are ®rst and foremost deep ®ssures
0±2‰ years 23
2‰±5 years 40 combined with poor oral hygiene and previous caries
Grade 0 (6 years) 75 experience (49%), as well as high caries activity in
First grade 65 high-risk children (37%).
Second grade 66
Third grade 61
Fourth grade 57 Control of oral disease in high-risk children
Fifth grade 37
Sixth grade 31 In total, 10±15% of children are typically identi®ed
Seventh grade 33 as at high risk. A large number of criteria are used to
Eighth grade 25
Ninth grade 25
identify high-risk children. Most of these are based
16±17 years 11 on a clinical evaluation, but social, family and
behavioural conditions are also used (Table 5). Table
6 shows which actions are taken by the municipalities
services said that chairside assistants are responsible with respect to children at high risk; both active and
for this task and approximately the same number of passive preventive activities are used.
dental health services answered that they have a
dental hygienist who, among other things, is respon-
Oral health education
sible for topical ¯uoride administration. A change
from population to individual use has also taken Most of the municipal dental health services o€er
place with regard to ®ssure sealing. Fissure sealing is health education to preschool children and children
o€ered in most municipal dental health services and in grade 0, Table 7. Approximately half of the
most often to children in grades 0, 1, 6 and 7. municipalities organize health education activities
The choice of method in passive prevention is during the ®rst school years, less frequently in later
made on the basis of a number of criteria. Fluoride school years, especially among 16±17-year-olds.
varnish is typically administered according to need Table 8 shows the frequency of cooperation between
when examining the children (62%), or every 3±6 the dental health services and key persons such as
months (16%). The most frequent indication is that visiting nurses in homes and schools, teachers and
of initial caries (34%) and/or a high caries activity child-minders. Table 9 gives an overall view of
(22%). Similar criteria are used for topical ¯uoride typical health education activities for speci®c target
application. Fluoride rinsing is primarily used in groups of the municipal dental health services.
children undergoing orthodontic treatment and by
dental health services using ¯uoride brushing. It is
Local health activities
most often o€ered three to eight times a year on an
individual or group basis. Only a few dental health More than a quarter (29%) of the municipal
services recommended ¯uoride chewing gum to dental health services stated that they had been

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Preventive oral health care and health promotion 85

Table 3. Percentage of municipal dental health services who stated that they use different fluoride methods and fissure sealing in children
with regard to age/grade.
Topical
fluoride
Fluoride application Fluoride Fluoride Fluoride Fissure
varnish 2% NaF rinsing brushing chewing-gum sealing
0±2‰ years 46 14 ± 8 1 1
2‰±5 years 78 25 ± 17 4 23
Grade 0 78 36 12 28 4 82
First grade 76 38 14 26 4 84
Second grade 76 43 14 29 4 53
Third grade 74 43 14 27 4 45
Fourth grade 74 44 13 26 4 47
Fifth grade 73 45 13 24 4 60
Sixth grade 72 47 14 21 4 75
Seventh grade 72 50 13 19 5 72
Eighth grade 72 50 10 16 4 51
Ninth grade 72 51 9 15 5 44
16±17 years 71 49 6 15 6 44

Table 4. Percentage of municipal dental services who stated that Table 6. Percentage of municipal dental
they use fissure sealing (percentage of children in the target group). health services who stated that they make
different kinds of efforts in connection
No children provided with fissure sealing 7
with children at high risk.
1±30% of children provided with fissure sealing 25
31±50% of children provided with fissure sealing 20 More frequent dental visits 99
51±80% of children provided with fissure sealing 17 Intensive instruction in:
More than 80% of children provided with fissure sealing 31 Toothbrushing 94
Use of dental floss 76
Use of tooth picks 17
Contact with parents 92
Table 5. Percentage of municipal dental
Professional removal of plaque 86
health services who stated that they use
Fissure sealing 85
different criteria to identify children at
Intensive fluoride prophylaxis 83
high risk.
Dietary counselling 82
High caries activity 99 Interdisciplinary contact with key 55
Poor oral hygiene 92 persons around the child
Gingivitis 77
Sickness in general 36
Family conditions 28 Table 7. Percentage of municipal dental
Social conditions 26 health services who stated that they have
Nutrition 25 health education programmes for children,
Behaviour of the child/low 3 and by their age/grade.
degree of acceptance
0±2‰ years (parents included) 82
Aplasia of teeth 2
2‰±5 years 80
Sister or brother with high 2
Grade 0 84
caries activity
First grade 48
Saliva/bacteria test 1
Second grade 48
Handicap 1
Third grade 46
Fourth grade 56
Fifth grade 42
recently involved in local health activities (promo- Sixth grade 38
tional campaigns, exhibitions, etc.). Fifty-eight per Seventh grade 48
Eighth grade 35
cent of municipalities answered that interdisciplin- Ninth grade 64
ary activities had been greatly expanded over the 16±17 years 19
last decade and external contacts had become more
frequent. The establishment of prevention or health
councils shows that, in the course of time, these Interdisciplinary contacts are mainly initiated by the
contacts have been supported and formalized. dental health service. In schools, this contact is

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86 Poul Erik Petersen & Ana Maria Torres

Table 8. The percentage of municipal informal cooperation between the di€erent groups
dental health services who stated that
of the dental health personnel. In larger municipal
they collaborated with various key per-
sons with respect to health education dental health services, it seems to be the rule that the
of children. whole dental health service team is represented
Midwives 11 during the planning stage through to the establish-
Visiting health nurses 89 ment of a project and prevention groups/commit-
Personnel of day care centres 36 tees. These committees hold meetings on a regular
Child minders 80
Kindergarten staff 82
basis (monthly) to discuss, adjust and evaluate the
School teachers 84 implementation of programme activities. A number
School psychologists 37 of municipalities also stated that they organize
School health nurses 68 theme days or conferences to lay down overall
School doctors 43
Family doctors 34
objectives for the municipal dental health service
Social workers 46 and plan programme activities. Detailed planning
Others 29 and responsibility for implementation are usually
delegated to the individual clinics who have `artistic
freedom' and responsibility according to the objec-
mainly based upon daily personal contacts with key tives and strategies laid down in the preventive
persons, such as teachers and health nurses. health care plan. Most municipalities answered that
In open-ended questions the municipal dental normally each clinic is responsible for making a
health services were asked whether local and preventive plan for the scholastic year. This is done
regional interdisciplinary activities were possible. to improve participation in the decision and
Several factors have an encouraging e€ect on implementation phases of the project. However,
participation in these health activities: there was a great diversity in the reports on the
implementation of health promotion activities and
. common objectives of participants,
preventive oral care in many municipalities, owing
. openness, involvement and interest of partners for
to the fact that these activities depend on the
health,
attitude, motivation and personal involvement of
. technical preparation by the dental health service
the local dental health care personnel. Only very few
and production of good health educational
municipal dental health services have established
material,
structures to evaluate results and working processes.
. acceptance and support by local politicians and
In most cases, an exchange of experience takes place
authorities,
during seminars and joint meetings. A few munici-
. outside input and inspiration from other dental
palities used the municipal dental health services
services.
epidemiological tables as part of the control and
It was stressed that the following conditions have supervision of long-term programme activities.
a restraining e€ect on the development and im-
plementation of local activities: Discussion
. time constraints/work load, The health information system for the Danish
. scarce economic resources for dental services and Municipal Dental Service allows outcome evalua-
insecure employment conditions, tion and monitoring of the oral health status of
. poor working conditions/ambience in the dental children, whereas no systematic data are available
health service, on programme activities and processes. The public
. lack of motivation among dental health personnel dental services cover approximately 90% of all
and key persons to the collaboration, children in Denmark and the purpose of the present
. negative attitude of local authorities/local politicians. study was to describe the system with respect to
preventive oral care and health promotion activities.
Organization of projects ± qualitative data To do that, it was decided that the target population
should comprise all municipal dental health services
With regard to small municipal dental health in the country, i.e. the total population; the
services, planning and evaluation take place as an participation rate of the survey was satisfactory

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Preventive oral health care and health promotion 87

Table 9. Typical oral health education program activities in relation to target group.
Target group Contents/topic Materials, etc. Time spent Setting
0±2‰ years Information to parents about Picture books, posters, ‰±3 hours Day care centres
dental health care, teething, slides, video, model of Groups of mothers
toothbrushing, breastfeeding, secondary dentition, Library
comforters/feeding bottles, nutrition, foam teeth, food.
caries, medicine, tooth trauma.
Pamphlets, macromodels. One to six Dental health care clinic
Drawing/colouring sheets. times a year Play meetings in clinic
2‰±5 years Puppet theatre, role playing,
songs.
Grade 0 Six-year-old teeth Picture books, slides, video, 1±9 hours Classroom
Oral hygiene puppet theatre, foam tooth,
Nutrition/food pyramid fishing game, food, jigsaw Once a month
Shape and function of puzzle, drawing/exercise to once a year
different teeth sheets
Grades 1±3 Dentitions, function and Slides, video, fishing game, 1±2 hours Classroom
structure of teeth, caries food.
process, body/oral Pamphlets on nutrition. Once to twice
consciousness, hygiene. a year
Trauma Macromodels
Grades 4±6 Body, nutrition when to Slides, video, overheads, 1 hour Classroom
eat sweets, caries process, picture books.
dental plaque. Role playing
Bacteria Bacteria cultivation Once to twice
Hidden sugar and types of sweets. Worksheets, recipes. a year
Caries registration, self- Macromodels
examination.
Grades 7±8 Health, well-being and oral Overheads, slides, video, 1±2 hours Classroom ± eventually
health in general. pamphlets. in collaboration with the
Structure of the tooth and X-rays health nurse at school or
supporting tissues. Newspaper articles Once to twice the teacher
Initial caries and oral Worksheets a year
hygiene. Music
Approximal caries. Dental floss
Health and lifestyle. Nutrition, computer
Tobacco and nutrition. programme.
Sweet drinks Statistics
Hidden sugar
Grade 9 Gingivitis/periodontitis. Slides, video, pamphlets, 1±2 hours Classroom ± or dental
16±17 years Change to adult dental newspaper articles. clinic.
health care. Quality-of-life game. Once a year
Computer programme

(71%). Data were collected on the basis of a
relatively comprehensive questionnaire with both
structured and open-ended questions. This sort of
questionnaire was necessary to ensure the validity of
the study, both with regard to the possibility of
analysing the range of preventive activities and to
show past and present methods in oral health care
work. The unit of the study was the municipal dental
health service. Most of the questionnaires were
answered by the chief dental ocer or the dentist
responsible for the preventive care department. These
individuals also provided valuable information on
# 1999 BSPD and IAPD, International Journal of Paediatric Dentistry 9: 81±91
policies related to prevention and health promotion
in their municipal dental health programme.
For several years, a number of methods of
prevention have been available for use in public
health dentistry [13]. As in other countries, informa-
tion on the application of speci®c preventive care
methods within the framework of the Danish
Municipal Dental Health Service is limited. A
national study [14] has shown that, during recent
years, professional administration of ¯uoride to
Danish children has changed from mass prophylaxis
towards administration according to individual

88 Poul Erik Petersen & Ana Maria Torres
need. This trend is con®rmed by the present study
and probably re¯ects the fact that dental health
services have tried to adapt ¯uoride prevention to
the disease pattern of the target group. In a
Copenhagen suburb, an evaluation study has shown
that the e€ect of ¯uoride rinsing is poor if a well-
established dental care system exists and appro-
priate dental habits are developed in the population
[15]. Previous studies [16] have shown that ¯uoride
tablets and ¯uoride chewing gum are seldom
indicated in dental health services, the present study
con®rms this. Indications for ®ssure sealing have
only been described in a few reports [17,18]. On the
basis of the present study, it is evident that this
preventive technology is now used extensively at the
relevant age/grade. However, contrary to practice
towards the end of the 1970s, ®ssure sealing is no
longer provided on a general or systematic basis.
A similar development can be observed with
regard to the intervals between recalls for children.
The ®xed intervals that children were called for
examination or control previously, have been
replaced by more ¯exible routines and calls accord-
ing to need. However, it seems that there is a
reluctance to surpass 10-month intervals, and from
a Scandinavian perspective this seems a somewhat
conservative practice [19,20]. Particular initiatives
are taken where high-risk children are concerned. In
addition to the clinical evaluation of high caries
activity, poor oral hygiene or gingivitis, social,
family and behavioural criteria are also taken into
consideration in the identi®cation of children at risk
for caries. This practice is thus in accordance with a
modern approach to the identi®cation of children
with high caries risk [21]. The e€orts in connection
with caries risk in children comprise an intensi®ca-
tion of known passive and active preventive
methods combined with more frequent control.
Moreover, the answers to the questionnaire also
indicate that contacts are often made with other
professional key people with a view to creating
interdisciplinary cooperation.
Nine out of 10 municipalities said that small
children are called for their ®rst examination at age
2±2‰ years. In the light of recent observations
regarding the increasing incidence of caries in young
children, it can be expected that an increasing
number of municipalities will call children even
earlier in the future. Answers given showed that in
many areas, health promotion activities were being
directed towards groups of small children. The
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Paper 111 Disc
study showed how visiting nurses, day care mothers
and kindergarten personnel play a very central role
in oral health in these age groups.
Contrary to the case for small children, external
oral health activities for school-children were more
limited. At a time when local activities, consumer
involvement and external health work have been
given a higher priority, it is surprising to see that
about half of the Danish municipal dental health
services do not have any systematic oral health
promotion programmes for school-children, parti-
cularly since the value of health education activities
has been demonstrated in relation to this group
[22,23]. The overall impression is that health
education activities in these municipalities are based
in the clinical environment, so that the individual
instruction and motivation, for instance, take place
as an integrated part of the clinical examination and
treatment. This could be explained by scarce
economic resources and the dental health person-
nel's lack of interest and faith in the use of external
health education. Only a very few municipalities
stated that they include more general health topics,
such as alcohol and tobacco abuse. This study
shows that a relatively high number of municipa-
lities, with a low average price for dental health
services and a large number of children per dentist,
have not established systematic health education
programmes. This could be an indication that cuts
in resources to dental health services have put external
health promotion activities at particular risk.
The interdisciplinary cooperation and participa-
tion of municipal dental health services in local
activities have been strengthened during the last
decade, and this has happened concurrently with the
setting up of local prevention and health councils.
These councils have been established on a municipal
basis as part of the WHO `Health for All' strategy,
both with a view to obtaining a coordinated health
policy and to creating structures that can initiate
and support concrete health activities. The munici-
pal dental health services play an important role in
the work of the health councils. Health councils/
groups exist in more than one-®fth of the munici-
palities [24], thus the results of the present study
indicate that the municipal dental health services
play an active part in the existing local health
councils. Also, it has been indicated by some of the
other municipal dental health services that they
have initiated or been involved in local activities,
even if there is no health council in their munici-

Preventive oral health care and health promotion
pality. The probability of implementing projects
depends partly on local practical and political
conditions and partly on motivation, will and
involvement of the dental health care personnel
and potential partners. Almost all of the active
municipalities in the area said that project work
demands solid professional preparation and compe-
tence in the dental health service.
In conclusion, the study shows that modern
municipal dental health services in Denmark com-
prise a diversity of `hard' and `soft' health activities.
The study has indicated that resources ± economic
and personnel ± as well as political support at the
local level improve the conditions for developing
community health work. However, good internal
dental health service conditions are also of great
importance; factors such as positive working con-
ditions, a good ambience in the dental health
service, sources of inspiration, the dental health
care personnel's motivation and involvement as well
as a visible management have a constructive impact
on the organization of health work.
Concurrent with the expansion of Municipal
Dental Health Services, oral diseases in Danish
children and adolescents have been controlled.
During recent years oral health care e€orts have
become more focused on prevention and health
promotion. However, in the future it may be more
appropriate to apply population-directed strategies
to improve the oral health of children still further.
Presently, most of the preventive work is carried out
by dentists, this is primarily due to structural
conditions. It must be expected that the Municipal
Dental Health Service will go through a process of
reorganization to adapt to the changes in oral
disease patterns and higher standards of health. A
redistribution of tasks resulting in greater involve-
ment of ancillary personnel would be of value. The
e€ect of the redistribution of tasks could be analysed
more precisely through experiments or alternative
delivery models. Moreover, health systems research
aimed at the evaluation of community-based pre-
ventive care programmes is badly needed.
ResumeÂ. Propos. DeÂcrire l'organisation habituelle
des activiteÂs de promotion et de preÂvention de la
sante du service danois municipal de sante dentaire
et eÂtudier comment ce service a choisi de se conformer
aux directives du Comite National de SanteÂ.
MeÂthode. EÂtude transversale des services de santeÂ
dentaire municipaux sur une eÂchelle nationale. Des
# 1999 BSPD and IAPD, International Journal of Paediatric Dentistry 9: 81±91
Paper 111 Disc
89
questionnaires ont eÂte envoyeÂs par la poste pour
reÂunir les informations sur les activiteÂs de preÂven-
tion actives et passives et la promotion de la santeÂ
dans la communauteÂ.
But. Cette eÂtude a eÂte conduite pour aider aÁ la
reÂorientation et aÁ l'adaptation des services munici-
paux de sante dentaire.
Sujets. Tous les services municipaux de sante dentaire
ont eÂte consideÂreÂs comme relevant de cette eÂtude et
141 services (71%) ont reÂpondu au questionnaire.
Mise en oeuvre. Des meÂthodes quantitatives ont eÂteÂ
utiliseÂes pour mesurer les intervalles de consultation
de rappel des enfants et adolescents, la preÂvention
active et passive, l'identi®cation et le traitement des
individus aÁ risque et l'eÂducation aÁ la santeÂ. Des
meÂthodes qualitatives ont eÂte utiliseÂes pour enregistrer
l'organisation des activiteÂs communautaires de santeÂ.
ReÂsultats et conclusions. La majorite des services
dentaires ont arme que les enfants d'aÃge preÂ-
scolaire sont convoqueÂs aÁ intervalles reÂguliers
(chaque trois, six et huit mois); les enfants d'aÃge
scolaire et les adolescents sont convoqueÂs le plus
souvent selon leurs besoins individuels. Les assis-
tants au fauteuil, les dentistes et les hygieÂnistes
dentaires donnent des conseils pour l'hygieÁne orale
de facËon systeÂmatique aux enfants de la classe 0 aÁ 3.
Des ¯uorides sont prescrits freÂquemment pour
application topique par les dentistes; les comprimeÂs
¯uoreÂs ne sont pas utiliseÂs. Les molaires perma-
nentes sont scelleÂes si neÂcessaire. Les criteÁres
cliniques et socio-comportementaux sont utiliseÂs
pour identi®er les enfants aÁ risque eÂleveÂ. La moitieÂ
des services ont mentionne qu'une eÂducation aÁ la
sante avait lieu aÁ l'eÂcole et dans un quart des
municipaliteÂs sont organiseÂs des programmes pour
la santeÂ. Une ameÂlioration de ces services devrait
prendre en compte des activiteÂs de prise en charge
de la population et l'emploi plus important du
personnel para meÂdical.
Mots-clefs. Services de sante dentaire, promotion de
la santeÂ, besoin en personnel dentaire, changement
des modes de distribution des maladies orales.
Zusammenfassung. Ziele. Beschreibung der aktuel-
len Organisation der Gesundheits und Prophylax-
eaktivitaÈten innerhalb des munizipalen daÈnischen
dentalen Gesundheitsdienstes, und zu beurteilen wie
dieser, die Anweisung des nationalen Gesundheits-
rates ausfuÈhrt.
Design. Ein Kreuzstudie der munizipalen Dienste
wurde national erfasst. Mittels brie¯icher Umfragen

90 Poul Erik Petersen & Ana Maria Torres
wurden Informationen gesammelt uÈber aktive und
passive Prophylaxemassnahmen in den verschiede-
nen Gemeinden.
Setting. Die Erhebung wurden durchgefuÈhrt zur
Reorientierung und Anpassung der munizipalen
dentalen Gesundheitsdienste in DaÈnemark.
Subjekte. Alle dentalen munizipalen Dienste des
Landes wurden angefragt und 141 davon (71%)
beantworteten den Fragenbogen.
MasstaÈbe. Quantitative Methoden wurden ange-
wendet um die Recallintervale fuÈr Kinder und
Jugendliche, passive und aktive Prophylaxe und
dentale Erziehungsmassnahmen zu messen. Quali®-
kative Methoden, wurden fuÈr die Beurteilung der
Organisation angewendet.
Resultate und Schlussforderungen. Die meisten der
Dienste behaupteten, dass Kinder im Vorschulalter
in regelmaÈssigen AbstaÈnden (alle 3; 6; 8 Monate) fuÈr
einen Recall aufgeboten werden. Jugendliche hinge-
gen nur nach den individuellen BeduÈrfnisse, Zah-
naÈrzte, Gehil®nnen und DH'S geben systematisch
orale Gesundheitsinstruktionen fuÈr alle Kinder bis
zum 3.Grad an. Ober¯aÈchen¯uoride werden heu®g
von ZahnaÈrzte appliziert, Fluoride-Tabletten wer-
den nicht abgegeben. Bei gegebener Indikation
werden bleibende Molaren versiegelt. Klinische
und soziale Kriterien wurden zur Bestimmung von
Kinder mit hohen Risiko, angewendet. Bei der
HaÈlfte der Dienstellen wurde angegeben dass die
dentale AufklaÈrung in den Schulen statt®ndet und
bei einen Viertel, im Rahmen der Gemeiden. Bei
einer neuen Anpassung sollten die AktivitaÈten mehr
direkt an die Einwohner gerichtet werden, und dies
mittels vermehrten Einbezug von Hilfspersonal.
Resumen. Objetivo. Describir la organizacioÂn actual
de la gestioÂn sanitaria y actividades preventivas en el
Servicio de Salud Dental Municipal daneÂs y valorar
en que medida el servicio ha escogido ajustarse a las
directrices formuladas por el Consejo Nacional de
Sanidad.
DisenÄo. Se realizo a escala nacional un estudio
transversal de los servicios de salud dental munici-
pales. Se utilizaron cuestionarios enviados por
correo para recoger la informacioÂn sobre activi-
dades de cuidados preventivos activos y pasivos, asi
como de la promocioÂn de la sanidad orientada hacia
la comunidad.
Marco. El estudio se efectuo para ayudar a la
reorientacioÂn y ajuste de los servicios de salud
dental municipales en Dinamarca.
# 1999 BSPD and IAPD, International Journal of Paediatric Dentistry 9: 81±91
Paper 111 Disc
Sujetos. Se consideraron relevantes para el estudio
todos los servicios dentales municipales del paõÂ s y
141 servicios (71%) respondieron al cuestionario.
MeÂtodo. Se usaron meÂtodos cuantitativos para
medir los intervalos de visita para ninÄos y adoles-
centes, prevencioÂn activa y pasiva, identi®cacioÂn y
cuidado de individuos de riesgo y educacioÂn
sanitaria. Se emplearon meÂtodos cualitativos para
registrar la organizacioÂn de las actividades sanitar-
ias de la comunidad.
Resultados y conclusiones. La mayoria de servicios
dentales indicaron que los preescolares se citaban a
intervalos regulares (cada tres, seis u ocho meses);
los escolares y adolescentes se citaban maÂs a
menudo seguÂn sus necesidades individuales. Asis-
tentes, odontoÂlogos e higienistas dentales daban
instrucciones de higiene oral de forma sistemaÂtica a
los ninÄos, que se valoro seguÂn una escala de 0 a 3. El
¯uÂor se administraba por los odontoÂlogos con
frecuencia en aplicacioÂn toÂpica; no se usaban las
tabletas de ¯uÂor. Los molares permanentes se
sellaban cuando estaba indicado. Para identi®car
ninÄos de alto riesgo se usaron criterios clinicos y de
compartamiento social. La mitad de los servicios
informaron de una educacioÂn sanitaria basada en la
escuela y en una cuarta parte de los mismos tenian
lugar actividades de salud comunitaria. En el
reajuste de los servicios debarõÂ an considerarse
actividades dirigidas a la problacioÂn y una mayor
utilizacioÂn del personal auxiliar.
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