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ThePreventionof
OralDisease
FourthEditiott

Editedby

J. J. Murray CBE
Enaitus Profu:araf Child Dntal Heahhand
Fa,werDeanaf DenT^tûiUniteniry oJNeucattleLPonTjne

J. H. Nunn
Pnfe$ar ofSpecialCaft Dent^r\\ Trinity Callege,D/tbn1l

J. G. Steele
Sen;arLect&rerin RerTolatil'eDe titTrl
Un;NeNi4t af Neuca.ttle Pon Tjne

OX-FORD
l-rNrvnRsrTY rjr{Ess
OX.FORD
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FiN e,lirjonpublished1931
Se.o.d ednton!ùblahed 1939
Thnd edirionPùblished1996
Thls €dition fiBt pùbLshed 20ol

^ll .ighh rsered. No !âft oa tÀis publièno. may Le repolûed,

rored in a rdrieÉl sy*em, or rFnsmirred, in my tôrn or br my neu,
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 to the FourthEdition
Preface
This bæk wd conceivedalmost twenty yeds âso. Its aim wd to
sathertosetherthe scieftific evidencecon.erning the prevention of
denraldis%e. Subsequnt editlors built ot this aim md expa.ded
the scopeof the booL. Now the primary lmpoftoce of prftntiôn
in âll spects of disede is genedlly accepteddd ir is time tur the
boôk to iake a different direction. I m delighted thàt wo col
leâsues, Jm Nmn dd Jimy sreele, have agr€edtô join me in
developingthis fôùjth edirion. They have beeo insÛuûenrâl in
developingthe shapeôfthe book. Many changeshavebeenmadet
son€âurhorsof chaprersir the first edirioû have asreedthtt
othelsshould be glv€n the opportùity ro presett ioformation in
rheir chosen fietd of er"eftise. I m most smtetul to rhem for
enabling this book to dqelop over the rwenty yea. pe.iod.
The mànuscript of this bôôk wès edited. and the proofs
corrected,ât â time ôf pe$onàl difficulty and sadness.This edition
is dedicatedto the memory of valerie Mùtay (28.04.194)-
r9.08.2002) md Professor Gemld lriûter (24 1r'1928-
22.12.2002). :Ihei loae ûd support, friendship md sudance,
sustainedme for over thiny years.
J J.M.
Iebruary2003
Prefaceto the ThirdEdition
whÉd rhe ideâôfth;s bookùs firsr sussesredin rhe early 1980s
Ûateon rhe prevenriorofdenrâI.ârics
and periodonàl dsease.Ore revlewer,ahhoush complimentary
overall,sussestedthar ùe book wôùtd !âve beenimp.oved by
includjrs a chapreron rhe prevenrionof ûauma. I rejectedthis
idealmmediàtel).-as I felt the revi€werhad nor uDderstôôdthe
oa;n purposeof the book.
The se.ondeditlon .enecred.tevelôpmerlsin the field ofpre
vention, chapreB or de.tal heàlth educarjo', rôot ca.;es,and
olher problemsaffectingrhe denritionin niddte dd otd age,ârd
the dificulries in preveDrirsdertal disease
in handicappedper-
h pldûing rhe third edirion it be.ameoblioùs thar ;fmore
.hapterswereio be adde.l,then consi.lehbterev's'onofextrinS
màte.ialwd reqùir€d.ProfesorCdspiaDS.ù1lykirdty agreedto
wite a chapteron the F.evertiônofdiseases of dre oratnùcôsa.A
.hap!e. by Dr Richùd Vetbury on rhe prevenrionof thùma has
beer includedGhereriewerofrhe first edirior, Professor Dennr
Plc.or, obviôùslyhad à clarer ideaof whe.erh€ book shouldbe
developirsthan I djdl), ard ProfessorAubrey Shethd hascor
triburedacbapreror the pieventionôfoml diseùefrom an iorei
nariooal peBpecrive. Di Jimny steete, who nas r€cenûy
.ômpleted a study of the eide.ly in Salùbnrn Dadington, ând
R . ,h û ô a d , \ . e .o . o "a e d - h J p ' , , , r . C p , n è n p F . p e . r . ê
Untbrtunately,Profesôr Enerirùs J.R.E NIiLtsdied in Januùy
199t dftera lonc illness.He susaestedtô me some.ime asô th2r
a ûew âùthor shoùtdreview ihe topi. Prcve..ne o(hodônr;cs.
Dr Peter Go.dor kindly agreedro piepde a châpter or 'The
prevc.rioo oi malo.clu'on'.
A linal secrlonhas beenâdded, iôôklng brielly ar rhe orâl
heâhhneedsir ùe twenty-fiBr century.
In orderto æcohnodale rhese.hanses, my chapteron Deûtal
.aries a gereri. disea€?'hd beenoDi.redfron the.ewedition.
The sectionson diei aûd fluoridesand rheiieffe.t on denratcdies
hale both been.educed,pàftly by edirjDs rhe ter ând parrly by
elininating someof the refereûces. For è fulle. coûsiderationof
rhes€topics rhe reader is refeffed ro Àndrew Rùgg-Gurn: boôk,
Nrtr;tio, akd ùnIdl Àedlîbor ro the drird edition of ou. Lrook,
Fhlaùd6 ;n .dtut lttutnrion.
The ritle of ihe book hasbeen ch^nseà slighiy ro T/k pttueû;an
of Ad DLup ro rcfle.t the wider remit ôf the rhi.d edition.
The IiB. edidon was e$eûti.]ly à Newcastlebôok ln thar a
mj{,rity of confiburors were either workirs in, ôr had wo.ked
àt, NewcastleDenrâl Schoolènd Hosp;rat The presenttisr of
authorscoverseight denralschools.I hoperhar rhis edidoû wjll
beacceple.las a Bdtish contributn,nro our knowledgeaboufthe
prevenrion of orè1disease.
JJ.M
March L99t
 to the SecondEdition
Preface
h the five yers since the first edirion vâs prepared the impetùs
for thepreventionofde.tal disease hasin.reased.Revlewsôfthe
boo! have beengenerally favourable, but in sôme .des poiûted
oùt ùeasthar misht havebeeninclùdedii a text or the preve.'
tloû of de.ral diseâse.Most rcviewef app.e.iat€ddrat the aim
va norrcproride detailsofcli.ical techniquesbuÙather tô.ôn-
centFteon documentedeviderce. This sene.al aim has been
nainaiftd: chapterson deûtal healthedùcation,root cariesand
orlerlroblemsaffectirs the denûtioû in mi.tdle and old ase,and
lhe difiicùltiesinvolved iû preventinsdental diseasejD handi
câlpedpersoûshàve been âdded. The chàpter ôn fissùre sedlants
hs beenexpàndedso thar rhe questionôf cost effectiveûess of
pNertive t€chniqùescaDbe considerediD grealer detail. :fhe
dowNtud trend in dertal caries in develop€d.ouûtries hæ been
Fiewed, togerherwhh a .onside.âriônof.hanges in child àûd
adùlr deDtalhealrhoverthe lasr20 yers, âsfoùnd by resultsfrom
ùtionâl Ns'eys. The jmplicaiions of prôviding à preveûtlv€ly
orlenledserice to deâl with rapidly .hângitg levelso{oral dis
eas€are.oBidered agairst d back arourd ofde.tal seFl.es thât
hàvedevelopedfrom a curative bde.
I d most srateful to Mr J.R. Mcca(hy, chief Dentâl Advlser,
Dentâl EstlnàtesBoùd, for providirs me with detailsfron the
Boards Annual Repôfts,to Ms Dima Scariolt.Under Sedetary
Brir;shDenta.lAsso.iatiôn,for i.form.tioû on the GeneralDental
and mor especiallyro }Iiss SèllyBaldwin,who hasbeen
Services,
responsiblefor the se.rerarialwôrk inlolved in compiljns rhis
J.J.M
Prefaceto the FirstEdition
The Surey of Childrent Denràl Healrh in Enslând and Y/àles iû
1973 showedthat over 90 per cent of our childrcn leaveschooL
with uûÛ@ted dentâ.]disede aod over t0 per cent hive had at
lest one seneral âùes.hetic for dettd treatmenr' This lish level
of dertal disede seemsto have beenæcePtedwirh equnimitv bv
the public ar 1dge, æ though it vere inevitàble It m@ûs thàt iD
adùlt life, at best a ldse moudr ofiePair is .equired !o maintâin
teeth in the mouth, at wost, thât decayedteeth mut be
qÙacted. The qtent of the problem cm be judged by the fa.t
that 30 per cent ofall adults ased 16 yeds ad over in Brjtain
hav€ ûo ûtùJâl teeth at all.
And yet, md yet. Are things changing?
Over the ldt ren yeàs therehd beeûân in.reanA emphds
on sood denrâl health ând a number of en o@sins rePôrts, ûot
oûly flom Britâin, but alsofrom Ame.ica,ÂtsÉlia. S.atdinÈvia.
ànd other European CoutÛies that dentâl cdles is de$edina iû
children. The ided is sÈitjos rôund that d€ntal diseaseis not
inevirâble,but preventâbleand thàt the possibility of keepins
one s teeth for life is not jut for the lucky few but ls po$ible for
I was delighted to be given the opPonunity of trvins to drao
tosethe! some of lhe nain fæto6 involv€d in the Prevention of
dental disede md m most gÉtetul to my colldgùes for agreeina
to .ôntrlbure the aariouschaptes whi.h ûake uP this book
\\/e do rot attempt to cover.ll deoraldisese but cônceûtrâte ôn
the prevendon of dentâ.] cdies and periodontal .li€Àce i. order
ro drâv tosether the avdlable clidcal and ePidemiologi.al iûfor-
marion. Iû many instànceswe hâve referred to Previols Publica-
tioûs and have reprodtced diagràmstion other workers:due
ackrowledsement is mÈde in the text. We would also like ro
thank our pùblishersfor their help ând encoûàsemett If our
presentknowledge.où1d be tddared into pmcticethe iûPact
on dent healthwoù1dbe imme$e a.d the Præticeô{dentlsrry
would changecoNid€mbly.Ire-hoP€rhèt this bôok will hetp iû
some small way to encomge the môvemen! rowdds PreYentot
JJ.M
Janùâry1983
Acknowledgements
I would Liketo tha.l Oxford Universjry Pre$ ibr encoumsirs me
ro develop rhe themeofthe prevenrioûoforàl diseàse. Tl s book
h6 beenlroduced ir line with Oxfo.d Un;ve6ity P!e$' latest
thinking ôtr the produ.tion of books f<x bodr mdergraduate and
psrsFduat€ stùde!$. The runber of refereûcesfor eachchapter
hasbeeûreducedmarkedly; iûstead key referencesare now
ircludedat the endôfeàch.hàpter.Aseriesôfkey çords or bùller
pointshâvebæn buir in to eeh .hapier in ôrder to diieû the
râdtuto themaln lssues.
Pâft ôfùe material on nuodde denr;f.iceswd firsr pùblished in
the thi.d ed;don oî Flsori.ùs in Cdiet Pftre"tion a.d I rh^ak
Bùite$otb-Hei.emâm fôrl)ermission to reprcduceth;s maiedal.
Diâgrds frôm the nrtlonal sùn€ys of .hlld and adùlt dental
healthhavebeenreprodu.edby kiûd permissior of Mlss Jear
Toddard lhe GoverDm€ntsratjsricalserices. Ou. thanks so !o
rlre ed;lorsof A.chivesof oral Biolôgn British Dental JourDal,
CariesResearch, ârd dre \rofld Health Orgânizàtiotfor permis
sio. to reprcdu.eillu$.ariôns.Thanksgo rlso rô EmmaTwende..
Reriew cioùp Co ordinaror,CochÈneOnl Heâldr Group. fô.
pe.mission !o publ;sh summafiesof topi.a.l fluoricLerevieùs.
Fisures 17. 18, and 19 in Chapte. 3 are reprodu.ed by kind
permissionofthe NHS Ceûre fof Reviewsand Disseminât,on.
I ân môst sratetul to Mrs Judy Preece,Aud;o-Vsual Cedt.e.
Newcd e Universityfor the way shehasiûterp.eredmI incom-
prÉhenliblesqùigglesover mmy yea6, particularlyto. drâwlû8
Flsures1.1 add 16.6 in this edirion.
Flnall).,I thank a.l1cônùibuiorsàûd their secre.ari€s
for lheir
help,and ûôr espe.iàllyMrs Helen Cox,who ha beer responsi-
b1efor nost ofthe secretarial wo.k involvedin dre côdpiling of
Taltuùde tbeoppaûu"i4lat eæryan,rafttd;r d hedhlrrf,û.ti/ûa/ dn Otul Hedbù r d ltd"'tad af hedlthof theùal d"d relaîd ti$"" tuhith
tîib" Jt l1fe,.tJ p@dti"s ùhaî it !ft,entàhle d"d I co"rdint"s tbe ddbh dn itdiltdadl to edt, $uh drd tuializ. ùiîlJorl a.îiù àitde,
rwin;,8 'tuedp (ar defarùrt) bt the afli.;!û 6e and di!tuib,tion of di!ûnfû d"d enbdtdsMnt dr'l ahi.h ûîlitata* to gehetulù.ll

A;m ofûe Dental Stntegy Reviewcrôup, Oral Heâhh StrategyG.oup 1994

I|udrd' Bettd De"ldl Huhb I:IMSO r9a7
'rbe
erhû aï l@e,|i,e dest^î0 $arld pftlail i, ewry .liki.dl
Th' ntunrio" thraxsbui tife afd Inîttotbl, aarlt.ri. tur"ràl dal't;an
ofnat hr thdi 20 leetÀGbartekeà àùtdl àr.À) d"à natry"iri"s rear$e
Tbe Firlt Fiù. Yurr,
GeneràlDenral Côun.il 2002
TheGMt aJOMt HMht
wHo r982

.,1t,
Contents

r Oral heahhin the twenry Êrr.efltùry I

J J Mùûay
Specifi. DiseâseIssucs
2 Diet ard dertal cùies 7
PJ Moynirran
I lluorides and dentÀlcaries 3t
J J Muûay
4 Mic.oh;ologicalaspecrs
ofcarjespreveûtiôn 61
R R B Ru$elL
5 Manasinscdies ir erdel 77
EÀMKid.tàndJHNùn
6 Prere.rion ofpulpal Èrd peridpicaldisese 97
J ri wr ,,qor-
7 Tooth weafraeliology,prev€ntlor,clinicâl implicâtion 1 I l
L Shaw
8 The preventiônand conûol ofpedodonraldisease l2l
\rMMJenIlûs and P A Heasnan
9 Prevent;onofdeDtaltrauma r'it
R R Welbury
10 Preleûtionofm2loccluion ltt

tl Prevetrtiorofôrâ.1mu.ôsa.l
disease r6t
C S.ully and A Hesarry
Specitic Envirooments
l2 Prevertionin the Ègeirgdentition 187
JGSreeleddAwc\x/alls
t3 Impairme.t-prevenring a d isabiliry 209
J H Nùnn
14 The preyertion of sociâlifle,lulities in oml health 22I
N M Nuttalt

15 Oral healthp.omorioûard policy 241

A Sheihamand R \lart
16 Developinsthe conceptof preveûtiôn-eviden.e-bâsed
dentisrry 2t9
J J MùÛây
hdex 269
List of Authors

D. P H Gôrdon ProfessorJJMurrayCBE
Cbild Dentai Hea.lth EmeritusProfe$orofChild Dental Heàlth
S.hoôlof DentÈlS.iences Unile6ùy oÊNevca*le
Unive6ity ofNewcastlc
New.6t1e upor TyneNE2 .1BW
NewcasrleLlpoûTyne NE2 4B\r(

ProfessorP A Heasna. Deparmenr ofPublic & Chjld De.t2l Heâlth

RestoratlveDentis!ry Derlal School& Hospitèl
Schoolof Denlal Sci€nces
Univesity ôfNewcasle Triniiy Collese
Dùb]nr
Ne(catle upon TyneNE2 ,18\X/
D.N ùf NuttÈli
Dr À Hegary Rerar.h Unit
Dertè1Health Seryices
Oral Medi.ine & SpeciàlNeedsDentistry Udversity ol Duodee
EastmanDe.tal Institurefof oral Heâ]th CareS.ie..€s
UoiversityColleserondo.
2t6 Gray! Inr Road Du.dee DD1 4HN
Lordon \VCrX 8LD
P.ofessofR R B Russell
Mr v/ M Mjenkins Onl BioloAy
Consùltânrin Periodontology Schoolof Dentâl Scico.es
Glægoù Dentà1Hospttal& School Unive6ity oi Newcdtle
178 Sàuchiehall
Streer
GlâsgowC2 ]JZ Newcastleupon TyneNE2 4B\fl

ProfesorC ScullyCBE
Profesoro{ Cariology
King s ColleaeLondon EâstnènDental Lsriûte for Orâl Health CareScieû.e!
Floor 2t GUI'STower Unive6ity Coll€aeLo.don
Guy's Hospihl 2t6 Gray: tnn Roâd
lonclon SnL 9RT Londo. \rCrX 8LD

Dr PJ Moynihan Dr I- Shaç
Child Dertèl Health Sedor lf,cturer & Coûmltant in PaediaùicDentistry
Schoolof DenrâlSciences
Univeniry ofNewcastle Univesi!y ofBi.minghd
St chad'sQueensway
New.arle ùpon TyneND2 4tsV/ Blrnlnsham 84 6NN
 Dr R Warr
Depturmeût oflpideûiôlôgy & Public Heâlth Deparlmen!ofEpidemioloay& Publi. Healtll
Unlvesiiy CollegeLôndon Uoiv€rsily ColleseLrdon
GôverSÛeerCahps GowerStreetCampus
I 19ToftingtônPla.e 1 19 Toûinglon PLace
lrndon VCrE 68T London\I/CrE 68T

DrJ G Sreele Profesôr R R Welbùry

DepârtmentofChlld Dentàl Health
ot Dental Sciences
Scbool clasSowDental Hôspiûl & School
Univers;tyofNewcdtle 378 Sauch;ehall
Sù€ei
Gldgow G2 Z
Newc4de upoD:fyne NE2 4B\r
DrJ M Vhitworth
Prcfe$orÀ\frG\Y/alls Resto.aiiveDentisûy
S.hoolof Dertàl Scien.es
School
of D€ntalSciences UniversityofNevcasde

Nevcaile upon TyneN!2 4Bw Nes'cdtle upoDTyneNE2.1Bw

r-
ti 0talh ealthin the twentyfirst century
tonn
v,.',,v
I

lniroduction general trincil'lcs of pLcventitn dtrs èpplt thro!.qhour thc

worl(l The Vod,l Hcaidr OrsdLizatioù hù l ornre.l our thc
Thc aim ot tbis book is to dms hAcrhd .urrent epi.lemiôLogi.èL potentiâ]1! disùstfous conscaucncesof a rise ii dûrral cùrics i.
md dinicil l..os'lelge or rl,c l,r1'cnrion ol oml ând denrâl dis develot]rng .o! nûies (Fig. L.1). Thc ptuvisiôù.fdûnàL treatn,..t
ms ii .rdcf ro highlisht rhc rrenredoùs impftrveûent in orùl .o.$n,es c.onomi. rcanù.e\ {rd re.luiies highl! trrincl II.{rn-
h e a l t h ,\ h i . l i N o u l d o . . u r i f . p r v e û t i ' e ! h i i o s o t h l u d c ! ûcl. The only possible \àv lo^ai.d ,n 'mpmvlng ora.latrd dentil
I inncJ o!r it|.oi.h to or2l Jiscas.. ,. .,f.. I r, -,, \. I \ 1., :.r..
The mourh .onrai.s a .un$cr of dillircrt tissoes. v,ne of TLle wllo.ofsl.lc.cJ ùc pLestnr global sitùèùof wirh
shtrh, N.lr rs nlcous nemLrrane, co.n.ctlv. tissuc, trlnd ves rcïe.r ro orll disersesthù occur in ând affc.t rhe orxl.â!n\ rn a
set, neives,ûus.le, âr.t bone, .re foun.l lhrolshout di. bodl. ttacrncnt Oul kdhn fur tb. 2ttt Cent'q ind ils) in a ]e.h .âl
-trr oi tLe* rissuesco *ffer frôù infe.tion, ùâ!ùa, llesef..à R.plsr, Rtunt alut.r ;n ù l hù.tth lt t)t)2J Thcs. .cfots eram-
rioù, or ne.pLasn dhnse Of ove^vhelûiùg inpon)n.e ro rhc i.cd ihr rfe.ds xnd advâr.es ii oral healrh 'cscrr.h, dcliverl oi
tunditbn.irhe nn)urb ùe lrs rùo st'e.iâlize.l tissues rhe teedl otul cif., and thc cdu.arntr of pe^otûel 1ôr oral ca.. rclâtcd io
ând the pefn)donthm. Ind€ed, dent!.l.dies dd peûo(lontal ,lis chânAcsin rhc aritùdes dd dedànds ofûren,bes ofthc omnù-
eàseûe so $idespre.rdrhât lirturlll eler]ùodr i. the wo.U. .cr ril1: lhe.or.lusion $às thar oril heâldr scNi.cs ard edu.âtio! of
ûinlr'$ery rduL, has.irhcronc.. borh ot drcsc.ondrn,ns. pe6onfeL {rll nec,l ro bc râdi..ll-r ûrnsformed. les lechni.rl'
A.on5idrrbl. amoùi is knon'n alreadr about Lrorvto prevent nafnal sl.ills sill bc necded. due in pâit to n$t technoloat. and
horh dcihl.arics a.d pcrndo.tal diseâse,ând this is dftJiled ,o nore stecial skills i. diaEno\is, pâthophrsiologl. diseisc risk.
Chùp.e6 2 l. Th6 woùl(l nor onlr aflcct dranaticalll their $sessûent .nd ùrlasem.nt. 2.d .ommùi.âtiotr will Lre
trc\'ùleD.ebùtilso,,l ths knowledge wrs i1)|licd. dic.c sîuld be required The Lpen Grouf i.lcnriilcd l2 aùidlns pril.iples:
È drdùù]. efect oD the rlte a! whi.h they !rogrc$, {r rhat dre
L. Otul herlth is an e$e.tial pam ofhuran function end the
!Èstùaiortrl ol peopLewolld be able to kery rlri. mouths ir fta-
soùble.oùdûioù for dre whole ofthelr lires. Chatres I I xrc
o , n . l. 'r-. . 2. Ofa.lheâldr $dùa sholldLre nnfrc\td rnd maintaifledinthe
la l.r' { |
Or.r drc lâsr 20 rcâ$ mafkcd rcdu(n,n\ in thr pre!âleù.e ôl môn economical n,2r n.r .onsiscnt $ idr ,tnâlitl dd &c$s.
deniâI.âiier ir.lil.lieù hale beeù observe(l,f Rriràin. a.,l mint
odri iûdusrièlDe.l coùnùies, rnd there rs fos'snong cvidcr.c
dùr thn redu.ùoû in iJries hrs renrLred in improlen,..ts in rhr
d r d : , r ' f 1 , ' , d 1 . . l . - l : r r . r -
klÊrtd n) in Chap.d 15.
Aboùt 2000 rc$ .xscs ot oral.atr.er ocot id Brn.i! eà.h !ear,
aLthough;rlmc cou.tric5. paiti.dxrl.r inÂsia, tlte prerâlen.e ol
rhn lnexsc is mud, highcr. Tcarnrcnr of ora.l .xn.er an.i ôther
od mù..\âl dÀcascsrequnts spe.ialÂt l,ospital serli.es Chàpler
l0.oNidûs the pÉleûrion ofor.l ,nu.osal .liseise rnd highlights
rhe imlonarce of two oÊ rhe rislr factrs, al.oh.l and ()bx..o.
involitd;o orul cù.ce.

A WorldHealthOrganization
persp
ective Figure l.l Hcahhymoùrh! tur.lL by tLÉiei :1002 |â of.
Althoùgh tl,e trevalefce oi.lental Jiscascs:nd rhc pr)visbn of \o'r'"l l ' \\t H. O. ,
ddnilri'iccs !a.i.s i. di*cfcnr .oùntfir\, the sâme undeflying i9s.i.)
I
| | 0 r oh e o i h i n l hwem r fyr l G n l û y
I
3. Prcvenlioûs preferabletô Ùeàtmertasâ generatrul€.
4. lndivi.tùatsshoulddô as mù.h xs po$iblc iàr drcmscrvcs
!o achleveèrd màinrâinôra.lhealtb.
t. Caries and pe.iodontal diseas€scaû be preventedard
/ ror.,n,)n-l d."fD,.' ', ' '.'llb. ,lto .\
of;ndividùal ard pe6onè1câre,
and ir sômeituûons a.e
7. Oral health cafe shoùld bc p.ovid€d in îhe coolext of
côdPrenen$vecare.
8. Oral hcahh careprovi.lersshoùl.l be preparedand mot!
r j , c d o o n . . . r e r B F n el .r. Jl r i . " r d 5 o , r l d p . r . p , r r
the provjsionof seneralheâ1th.are.
9. Thc ry?e,numbeaàrd disÛibùtiônof ôra.lhealrh.afepeF
sônnel should bc mairtai.ed ar levelsconsislent wlth
need,qùâliry,côs. and ac.esrnece$aryto achieredesiLed
oral he th stàtus.
10. Planning, health care practices,and ed(àtionâl pro-
sramDes shoùld be Àppropriatefor rhe popùhrjon ôr
sjtuationir qùe$ior.
rr. !,eseùch,evâlùarion,a.d educarionare essenrlallàr rhe
.ontinued advanceoenrofoml hearh
12. Ledrning mur conriqùe rhroughour lhe câreerof rhe
heâlthprofessioûàl.
Thcse.ecolrmenda.joÀs ùe comprehensive
d.t shôtrldûderpin
an_r..al hcalrhsfa.egir
Resources,
treatment,and prevention
There is à dynâmn relariodship betweco rhe narural hisro.y olany
disede dd the responscbv societyiû t'yins to combat theF'oblen.
As fù âs.teûtâl disede is.on.emed, i. Brirain 2nd in mâ.y orher
o. , e rle . .or .lre|o^'- oi d ".. -ha.- , 1. -' i'.
ThÀ was uua.lly a painiirl ard hazardous procedùre perforûed by
ûûiined ôp€rat(a. Soc;ctys reslonse wa to encolrage lhe devel
ôpmenr ofprofessio.al skiLlsaûd .o Èllow the |ractice of den$ûy to
Figure 1.2 Fa.to6 aftèctirA .lrarg€s rn dcntd trcam.nr rnd prcv.ntior
be llmited tu .hose wiro h.d re.eived âpprôpride raititg. As
k.owledae and skill in.rease.l,ârtentn)n tûned tu the preserâdôn
o{teerh and the Ûextm€nt o{.aries b}.esioratl.,û rarLrerthandÛa.-
!io.. Tbis tLcnd from cxùacrion to rcso.atb. deFn.led notonlyon
drc skill ofrhe de.ral prcËssbnal but alsr on the reacuox oi ilnl
wiih .espe.. ro rhe rconomi. resoù(es rhar irdivi.lnâls .rd goverr
ment were preparedto commn to deftai ûealmenr, ind rhe artiru,le
of irdjliduals !o the advice lrotTered bjr f.ofc$ion2ls. Rcal
imprortn€ûs in h€alth can onll occùr s'h€n bolh the communiry
at larse .nd the health professiorèls share the same objectL!€s,
whi.h sûely should be the primâry preveûrion ofdsede.
Simplisl.a.Uy, rhe ptusress of.lentistrl .an be represenred.s
,n. in ih.h L.r . m-..m nL 1lôm ru* i.û rô renô " .t
T'he
and onwa.ds tu prerentn)n GiA. r.2). main tlùur of thls
book is tu gdher rogÙher infordâtiôû oû dier, lluoridètioû, pre
lenlive meùures for dre i.dividual, a.d oral hygiene, all ofFhich
sluld havc an effe.r on the preventbn of rhe Nr) nrâin denral dis-
eascs.câricsa.d pefnrdontal disease.Itwould beiâ.ile bowevef.ù)
a$une thar these measu.cs alo.. ca. cxcrt a bcn.fi(ial cffect
withoùt eppreciatins ûat they cdo onlr work wjthiû a taloùrâble
framework ègreedbr- sôciety.P.tienis attltùde, dertisfs èftnùde.
remuneration, ùd manpower all hàve è.rùc@L role to play ir the
prelenrion of dertaL drede
Daôjrit'i Lr-È 1'",'\r' o' ô'f::ôr.r\rne.
great sigûificancei for eÈmple, às people retain teeth lbr longer.
rhc_vbccomc cxposcd ro incrcasing wca. ard dris is .ok.ed more
extensivelt in tbls edition. Changing pfnriries, xs s.ell as ln..eae
lo8 !)phlstl.âtb. ln .a.e fo.ùres rtentnrn on more vùlnerdble
sroups ir soci€ly, l;l.e lery old |)eople and diose $i!h a disabilitr
(Chapters 12 ar.L rl).
Clinicalgovernarce,
evider ce-based
dentistry
Astects ôfrFreleùtne àpFro.ch are tô be found ù the in..easirg
attc.tion bcirA tJàid to clinical Sovc.nar.c and cridcn.c-based
mcdl.i.c and dc.tisùI. The UK GovcmnrenCs \\rhi.e Paper
'A
Fi6r Cla$ Scdc. Qualiry in ihc ncw NHS dctiner dinicxl
Del
gove.nance as a f.aFework th.ouah wbich NHS O.ganisations
ateaccouorable for continuouslyimp.ovira the qul;!y of rhei.
sericfs a.d s2feauard;oshigh standardsof careby creatingan
e.vi.oÂnen! ir which excellencein cli.ical carewiu ilourish .
Thedrive to idenri4rbestprâcticemeânsthât unrece$aryûeaÈ
deût is avoided and mo* appropriate .dc is provid€d, redu.ing
theneedfor further intervertion ù.1prolonsirs rhe effe..iveûe$
o r û p !. m p n !C
. h . p r r 1 6 . r m m " n z e .o m e o l ' ( h - , u e . . m p , n g
iry or prevention d â re$lt ot increasing attention beina paid to
elidence-bded denrisÙy.

DentalEducation
Tôday.edùcarion ls evaluated in rerms of knovledge, skills, and
ûititudes.The generaldenta.lcounciiùcs thesetehs to fôcuson
lhe deslrableoùtcomes in lts do.umert on È franework for Figlre r,3 la-ors involvedin improvingoral health
n d eE , , d E ' e d r i ' " r e d u ! - ' , o , T \ e P ^ , I \ e Y e d N.
In the secion on P.eve.tiveDeoris!ryi. the secondedition of the psycholosicala.d socialfâctorsrelevàntto the preventionof
TTF! .he GDC slares

Dedtalstudenrssbouldhe nade awareof the successes and

llmtadons oi p.eveûrivedentisùy, and the polertial tof Conclusions
turtherprosre$. The edrosofp.evertive deûlist.y should Iigure 1.2 çàs fist Lsedalmost lO yeas ago. The ûovemett
prevaiL iû everyctinicaldertal departnert, sothat rewp.e- hom Exûa.tion toResorâtlonto PreventioD wasin pâr meanÙo
veftive dentisûy tech.iquesâretâughr to stude.is as they showthe developmertof dental setrices. pârticulâ.lyiû Britain,
becomeavnllable.Studentsshould be conveBantvirh rhe from the 1940s arçl tos Gtrorg emphasÀ ôn exÛaûion ènd
prtice ofpreventivecareinclùding onl heahhe.tùcctlon coDpietedeniures),onwdds to reroratiot, especlally amalsam
aûd oral heakh promotion.Studentsshould recosûsethe resroratioosin the 1960sand ùowtu in the 1970s,to tbe first
jrcredins elidence-bàsed.pproàch to treatmenr Ànd shoolsofp.evenrioo. no.ed frôn epidemlolosicatstudiesin rhe
shoù1dbe able tu make appropriatejudgenens. The sttr- 1970sând 80s.
dentshoù1dappre.iaterhe ned for the dentlst to collabo- Figùre 1.1 d€pictsthe maio .hrusr of rhis boôk, suggestiûg
iate in prevertbn, diaanosls,ÙÉrment and managehent thàr prâctisirg prevenrjor, applyina evlden.€-based treâtment
of diseasewitb orher health ca.e profe$ionals and with ând improviûa rhe qùality and oraaoizationof seri.es, ûù$ all
laii€ns themselves.The studcnt should be awareof the .ôales.eif betteroÈl healthis to be achiryfd.
economi. and pra.ticâ.I comùaints affeûing rhe prôvisior
ol\e. rh rre References
This book is concerne.twlth sùmmârizlnsoùr krowledse on world Healrh O'sa'izarion (r9a1). Altendli,, û!t^ oI otdl
inportarr toplcs$ch as,for esnple, diet Md mtritlon, fluoride 'lechnical
caft deli!4]. Reporr Se.ies750. Genee.
andplagueand rhe etre.t ôfsmoking oû oml health.It considers wôrld Heâlth OrganizÀrion(1992). Rre"t dd,ancs in oldl
iûpôranr skills relevaûtto the pr*entlon of o.al disese (e.g., tNdhh. F.epoft of à rx/HO Expert ComDilree. Te.hnical
' i , r " ' r i . . n r ' r ' , r " 1 r o l p , p | J , ) . , r d 'n " ' , . r " r i " l
-the Repôit Series826, Geûevâ.
Êeth). a1|1rxd.or the professior and dre public tovard den-
\7or1d Heairh Ofgâni,ation (1991). OM/ heahhfu the 21"
tisrryis dtal ifthe prevalerce(ard severiry)oforâLdiseases arc to
æ,t /r'. Oial Heàlth Unit, Geneva,Switzerlard.
beredu.ed,thâr is why ân appreciâtionofoml healthpromotiôn
aDdpoiicy (Chàpter1i) is esentiàI. If furher progre$ is to be A first ClæsSelvicerQuallty in the New NHS. HMSO com
âchieved, the deûtal professiormust extendits horizoûsbeyond mandPaper3807,December1997.
rhelradlrional.ole ofclinical, diasnosticard t€chûicalexpe.tise ceneral Denrât Côuncil (20a2) The Fi$ F;,e Yw'. Seca\à
for irdivi.tùâl pètients in the sùrsery, md becomenore âwùe of
Dietanddentalcane
s
PauLalvloynihan
lntroduction
D6l)itc a los motrâliry ràte a$ociared sirh lenrâl .ârics. it hâs 1
tûnsidenble impa.r on selt--es.ecm,catùA abili.-v, ùurnur, aro
heùldr.Te{h are imFo.tânr i! eràbfirg con$rmprion ofa vârie,]
dier rnd fÉparirs lhe fôo(l 10' disesrion. ln mode.o society.he
fiost inportant role ol leeth is !o eihance nppeùance an.l faciJ
ùpperrârcen ver! importâûr ir determiùlg àr individuàii inte
grâtiôr intô sô.ierl lteih âlso plar â! impotunr rc1e in spee.h,
being *sentjll for making ceraln v,unds. Dental dirâsÈs mar
tlFÈitre lmpa.t od diet and nutirn)n, facial appearance and
speedr.In xddition, dc.tal.2.ics caùscco.sidcrâblc pain ând an{-
icq. lhe r9t8 Âdùh Detr.al Heahh Sùrver showed rhat 10% ol
aduL$in dr Uùired Kiùg.iôm had experien.ed dental pdin in rhe
p4rycar Aln,osthalfof English children âged il yeas hàvccxfc-
ricnccd dcn.al pa;. and this is 2$ociarcd wirh cryi.a. lo$ ot'
slcc!, solpins plarins ard nor eatins. These ià..ors afe likely ro
be eracerbaredû less deleloped socierieswhere pam control aûd
ûot readily d"ailable. Deft.l de.ây ultimately
resnts ni tooth los, wlich impans quÈlity of life arct re.tucesthe
ab,lity ro eàr â vâried dier, and is iû pdticulâr a$ocidte.l with à
dier lov iû fruirs ân.l regerâbles and non sa(h pô1]sàc.hârides.
Deital caries rs a co$lt, b!rden to health care servrces.Denlil
ûrles ls d1c mof.osrly hùmxn discasc ln rcrDs ot rrearmen.
dud .ardiovâs.nlar di\eâse, o$eôpô.osis or dia
betes Tle.ost ofdeûral feâtdeûr is ûlikel] tô be redu.ed iû
setre.nized .oùnùies desfite imphrements in di\€xse ùends in
r'.ungcr fcoplc. This is bccausccarics is proALc$ivc and rcqùncs
m.rirùd carc; so. rhc t.c.d iôr i.c.cascl ûcnrio. oftccrh inrc
.ld{.8c incrcascsrhc cost ot dcnral ncat.rcnr.
Thesystemiceffect of diet on the
aetiologyof dentalcaries
ln rhe early halfofûe twertiedi .ert ùry, it ivd rhoùght thù pro
rslon oI good nùÛrtlon while the reerh *ere deleloping vas
the prir.ipâl * ây ù prev€ni dentrl .tules. It ls no* knô" n rhâr ihe
topi.al etre.t of di€t ln the moùth. after the t€eth have erupied
plays a du.h more impoftant tule. Hovever. mdernuù]tbn
dd defi.ienciÈsofspe.ifi. ntrùien.s do inflùen.e dredevelopmenr
ofùe teeth and tLrefrûmtn,n, fun.rbn and sc.ttnrn ofrhc sali-
vâq glands, whi.h in rurn inntren.€ suscepribility tu .Lerta.l.arie!.
Itr populxibn! shere oûdernutritionexistsèrd drer€js mod
e.àrecxposu.cro sùgârsin the diet, hirther levelsof càriesare
Ibùndin .onpùlvrn ù' experienefrôûdelelôped coùnÙies.This
has led to rhe sugge$ior dDt unden,uririor may exa.erba.c
'\- roge,'rof ' r/ ,-'.lli.i.,f
d,ât irc undcrgoina nùùitnrn ûansitiod, ie. counùles thèt
ar€moling awayf.om thcir ùaditbnal dierstu adôptthe \esteû
ized diet' rhat s hisher jo iree suga.s2nd fât. It is a cohtuon
dls..û.eptior thar à diet high jn Naar tron,ores grosth. and
rhe ihpoftar.e ôflimidng slgas coDsunFlionin u.dernoudshed
pôpùhrn,nsis ôfteû ôverlôok€d.However,ùere s no e\rd€.ce
tu slùw rhat n hiAh sugâr intèk€ is èsociate.l w,dr grosth
.'ar'rre,\'-,.r.'r\Ê lo.'o -lJe. " ro'.r I
DietondSugor
A toor diet hlgh in sùgùs reruls in dentaL.rnes
Denral .rnes .d reù r ir t@ih lo$
Tooth lo$ rcdù.cs rhe ability ro d aheâlthr Jiet hish ln ftùns ând
e.Âdâbles a.{l llbre ficb aooJs
in many Low rm.de.otrnûies, ùâ1. uûrion .o.xn6 wnb â hlgh
rùgâr iniàke, sù.h.ouûûles âre ar higher ris! oadenraL.r,!s
svsie]nia:nrllriii{rÉiilinllùencesilrl enamel
developrneiltnldeli{:ls
Poor ûuùitn)n is ônlv one ôf ndv .auses ofemnel developnen
iâl deiècrs. An cramcl defe.r rhar i! .ôûdôn iû nnderûôurished
commùnitics is lin€ar enamel hlpoplasia (LEH). This ùsJally
o..urs in pridary iû.iso6 àrd is characreri2edby r horizortil
groove ù$rally folnd on the labial sùdacc rhat be.omer sâ,ned
tos. eruttiveh Sflc.âL ;nrcstiEaûna lnve shosn tirat rhe pres
eûce ot €oamel hyfoflasia is a$ociated wnh ùnde.nuùition ând
its prevàlenie iûcreàseswith dre severitr ol !.de.nur.irio.. How'
ever, the spe.ific mechansn for an eflècî ofdiet oo the delelop
ûeût of eûame1hypoplæiè ras not ùndestood ù.til dr 1980s
when re associ.tion betweeû hypocaLcaemiaand hypoliasia sas
discovered. Hypocalcaemia is common ir ùnd€rnùtririor dnd is
a$ocided with .liùrhoeà.
t0 ? Dielondderlol.ories

Ihe studics oi Lâdy Nldr ùlellânbf in the earll, hJlI of the rour$hed .hildrer hùve been shown !o have 2 t le$ recdi
t$en.icdr ccntu.t showed rirat litamin D deii.ien.r'hàd J erupred.oûp.red to w€ll nourishe.l.h](lren oi rhe san,eage
narked cfticr o. die derlopment ot rlie teeth. Doss reared ôù (fis. 2.1). Srurted chiL.lrer lià\'e been shown !o h2ve,lcla-vc,l
dic$ thâtvere deficielt D ritamin D hJd delayed derelopûent of exlôliâtiôr of priûar) reeth Jld delar.Fe.lerùprionol t,€rmâr€nt
recrh a.d tccth drat were poorly calcited aû.I pôorl)" aligned. teeth.The prevêlerceofdenr.l cèriesasà fùnctiof of!ime occu6
Mdrofrhe reerh shos'cJ sians ofh)pflasiâ. Mellanby ùtriblred approxnnatelrLt n,onrhslrter i. u.lemourishcd .hildrcn oF
lhe improverrenB nr rle reedr of.hlldren i. Brirain bcrs ccr L92 9 parcdnirh r ell-.ouflshed.hlldkn (Flr. 2.2). lhis gsess drt
a.d 19.11!o hrprolemerts h diei xnd the ratus of vitamin D,
includ;rs the iûtrodu.rioû of.heap milk i 1t11, the ftuvisx,.
of lrtdir D ri.h.od llvef oll rcpqjnanr a.d lxcratin.q modi.s,
iûfàns, and ronnA.hild.c.. ànd thc addirio. oÊrirami.s A rnd
D rô margxrlne. More rcccnr sudies have showf rhar srptlemen
t
tdtionwith viramin D to t.cgn2nr molhers fes!kellin higher.ir
.ulating.al.iùm lcvcls in infd.rs ar blfth and Lower nci.len.e of
12
hlpôplâslx in i xnrs at aAc drcc, con,I)2red sirh conrors who
d,d .or receivesupplemenrs
Mellanb). suagcsred that hlpopltstic teedr }ere moie s6.ep
E
tible n) dc.ay and she l)ertôrme.l a chnical Ùial iû which the.tiets
oi child.e. were supplenent erher with côd liver oil (high ir vit-
dnnr A ànd D), olive ôi1(1.,w ln viranrins A a.d D) of trcaclc.
The cod liver ôil suppleme.red .hildrcn dcvclofc.t tc$'cr .,ncs
over the Nô yed rùdy period. In ùr rcccnr trials. .lâ$rooms
0 2 4 6 A 1 0 1 2 1 4 1 6 1 A2 A 2 2 2 4 2 6 2 a 3 A
ir Cânâda *erÉ inraltcd virh full s])ecûùm ligbrirg rhar bN a Age(monlhs)
high UV ourpùr and hcn.c irromotes vitâmin D synrhesis i. rhe
Fisurc 2.1 The mean rumber ot frinrq teeth e.ufted rt vùnrus
skin. Chlldren anending s.hools slrh drc fùll sPc.ûùm lightinA
.ses be.yeen 4.nd lo n,ônrns nr wcll fcd Nigcri.r childrcn (ofr-
scrc tound to delelop iewer cdies over dr€ t$o yeâr rudr, pefioA
mum srcù!) ard n1 urdeqrrlrileged, malflourlsheddril.lkn
.ompaftd s irh chil.lref a!!€odirg cLasrooms with convenriorèl
(Osesercrillase srcup). Àll (hildftn Ne.r rioo i]t YonnL rllJe.
liAhti.U.
(Reprodù.edtlom lDwon$ u 19r l. wnh p{mission of ùe editot
.f t\thiLt' rf 1Ml ts'alarJ )
Ihe studies
of LodyMoylt/lellonby
Shoied drar yirâ'nln D a.li.i.n.f imFiirs ooth d.y.lopmcnr Hypôlh€t
ôâ ôârêssôôrês
Clo..lùdÊd thât rhe imf.ovea (li.r !ltrrirr ih..ùycx6, $i1h rcsF..t
rô viftm,nind.d.i|m inGte *às rÉsforsiblÊ Lr lmlforeJ Jertul

Sho{c.l th2t elrmel htpoplÀù in.reâsedsùs.Élribilitr b denul

\ o . d ! \ , . 4 . n - - . " ' o - t , . i , ,
I
I

LlêÈ! rlrrl f itior dr.rrin!J

ioolll di:-/rloÈnrarni
ir:il rrencl:ijriLlfe (:nrie55Lrlactlrlril;rl/?
Undcrnùùition mry exacerbàtedre de!elopnert of.leDtrt caries
h three ways. Fns, as alfeadr mc.tiorcd, ir.ontribùtcs ù rhc
developmeùt ofht,poplasia whl.h in turn i..ftases .âres r.ep-
tibrlity. Secondly,ù.aNes salivxrl Elan.l aùophr. s'hi.h ftsùlts in 2 3 . 1 5 6 7 3 9 1 0 f 1 21 3
redu.ed saliva flos and altc.ed salila comtos:lion. This €dùces Ageiyearc
rhe btrffcdna .apacity of rhe saliva d.d lnûeas€s rhe acnlosenic l'isurc 2.2 Sde.itr ofdeniil.âries in prinnry afd |e.ndoit
load oftbe did. Thc.c is âko evnle.ce ihat (leUcie.q ol !ildmin A deflrnion as a fun(tlon ofrifre. l-he vnid li.es .efrese.t the
.aùses salir2q' al2nd aùofhy and a co.sellùetrr reduced sdlira well tuurlshe.l .hildier aùd the dotted li.es n nou.ished
Ui,w. Thirdly, undefl,u(itroD delals en,prion and shedding of dril.lÉn. (Reprodu.edÈom Àha'ez ând Nnviâ (1989), wlrh
teedr whi.b affc.ts dr càries exfenence ât a give. rge Poodl F1!rnr issio. of trre editor of ,1ùa tr" -k"t,rl t'[ (.lrrnnl Nrrrja".)
ta-

effed
Potefuplive ofdier
0nrhedeve
opnrenl
0lde,l0l(0,i,,
I

rhc highef i..iden.e of denrâl .lrles in F,rimùr. reeth ol uid€r lor o relotionrhip
[vidence between dieiqnddentol
coties
noùfishrd .hildfen .oùld pxrrlv be explâined bf the dela!&l
conesfiomdifferent typesof studies
$li,liatn,. of these teeth. At âge 12. trndenrournhed .hilJref
àfl)car m hxrc a l.srrprclxlÊn.e ofde.ar intl,epciûrneût teth, . llurar nr.ir.rllon $ull$ (.liri.al û,rlt
bùt rhj\ i\ dùc in fart nr tnÊ delared enLprior oftlÈ permanenr ! Hùmrn obserxronil *o.Ler

. lirirr. s $.ilfrimÉrF
effectol dielondenlcl(0rie5
Ihesystemic
' IjnJÊrnnûirnr G aso.iàtÈd nith ht !û!hvi .a enmrel rvl .h
,nfl ea$.xries sus.etribiLity
' Lrdennûnion r.sul$ ni r,Lirù4 glùnll ù1rofhf, '.lu..J sâlimff
nôB rr&, û.1idr.d br iltrnu.nFn ]'v 'h.s. r'r.r.n rnrasÈ
r,!ri{1ei'rit,lo!lirnl
\rrlorirl-r,r':,k r,:rtur|i:i::1,:rn:rl
. D.fl.ietu r d vnini n I) is dso! irn! { n [ .r,m.l hfl.tl]:]tr âôJ r:frrditrJ
SrgÙ nrnke ard levels ol,lcntal c:rlcs can be coqrared rt a
r Uûdexûnrln r.nLl6 ni dtlrrtd s|.(l.liis o rh. rrinùr teerh xnJ
'lhl5 berweer .ouû(j te'el. Sreebf-r (l9El)..rîlated rL,edenidl cànes
dd.r..1on'!rio. oaiJrt pdùi.nr r..,h. 'niv lntl,,er.É drÉ
.rr\ Preukr.r at a gNcû 4. cxpcricncc ofprimrry .lentLtlon klt,h) ot t ,nd 6 laFolds *ith
! li rrd.niôtrnskd nûFul!l.iù $h.r. .l,.re is e!p. f. ro sugann slgùr i,|lti.s data of 23 .ôutÛies, .ûd d€n.al câtcs crfc.itn.e
1ft ilc(,.nrics pr.ral...c ( high.f drâr ÈxtiÊtàl tr.m.bseNxlons
(l),\'lF f) ol l2 -rcrtsoldsio sùgafmpplLes dtn, ol.1l.ou.ùics. For
lô r'ell'..!risheJ ]'tùlirloff borh age g.oufs, sianifi.Mt (trfehti.ns Nere obseNcJr+0 Jl t(tr
tft prhr.rl denti.io. ,nd + 0 I for tl,É p€rûaDeût (le.tr.io.
ù e ù f i f g r h i t t 2 t ' . o f d r c v , r i a t i û n n i . è r i e s L e l e l s. o u l J b c
$t)hi ncd by drc peF.rpita avrihl:il ,t1_of rgat ! m nr rhct dâta
Post-eTUptive
ellect of diet on the ir $xs.âl.ulftd rhàt for.'ery 2t E.lNsar pefday. oûe tooih Fer
rhlld $ôrld become 1..âr.d. missinr or filled IIr..u.(ies w,di
developmentof dental cafies:is â! inùke ol sùgaf beloç l8kgbeA.n pef )ear {eqrrvrlent to
intakeof dietarysugarsstill an -t0ErpcN,nidxl) erpeiien.e ol .,.i.s sâ5 r,nsistentll belor
DNIIT J. r'he connÛies wrth Ngit ml,ttics in exces of
impofiant causeof dentalcaries? 1.1kgrfcN,n pef reâr (120gipeso.ili)) hàd siAnii.antly hlgher
Thoc is â s'calth ofcridcnLe n) shoù tL,enrle of.lietdrl n,-qà6 in lNcl5 ot {:ific\ (seeIitj. 2.1).
d,c rcri.lo8.r ofd..tal .afics. Thc eri.tÊn.e.omes ftud ùdry dil A lrt.fa.xlrsis ()ndu.ted jn 1991, dil nor tin,l sùth r srtun!
feient tr'!e\ oi ltrveslgâtior\, nrlu.ling h!nù. stu.lies (borh a$o.iarlon bet$eeù Fer .aliirâ ru.sr. aia,l.billti' and me.t
observàtio.àl ria i.re.!enlions), n.in,rl sùdi.s, hllnun plaqùe D I I I T o I l 2 l e r r . l , l s i n d c r c l o p e d ( / = 2 9 ) , 1 n . 1{ l e v e L o f i . a
tH 5tudics, cnù,n.1 slab. and in.ùba.n)n {ùdies of oiâl Lrrcteiià (,=61) corùrtfic\.HosevÛ, the reùsof fof 2. rtrsc..c ol rny
md dictrry sùhsûatcs i, ,;r,. Colle.tively. irùarûâtioù lioû ùll r.ldri.nsbit beN.eenn,gri suppl] dùû rfl n,cxn DùfI'l in
fh. ,llt]èrcnr .yl,cs ofstudicstq'idcs in .aerall pi.(re of the or dereLoL,c,l(ounrrics was trerause*nh sucli very high avrilabil-
r o !r . . P ' . o 'r:F_ . 'lJ ' r'r 'l it) ol s,gar if thcs. ountrics. .hîn!n,g tlle 1e!eLol sùgàr inrikc
ofdre er eûce ,n.rinirâlnrg N.qi4 in rl,c a.rioloEt ofdÊnrd LJf r fes klloAnms l.r ,vci. doÊs not ilù]tren.e the .rnes .h,L
.trrÈs .ones fion rhe 'r!Lripli.irr of rl,. smJics rarhcr rhan the l e n g e .À v r j L ù b i l i r r s t i l l i . . . u . t e d f o r 2 E Z o f v . r i ù t , o . i f l e l c l s
power ofanr' oùe strdl àloDe o i . L e n t a lc d i e s J n d 2 i o f . h . 2 6 ( ) ù n t r i e s w i t l , \ t r f â r s à ! i i L ù b i L
IiJir' ferA rS!, dierr.! is,,es relevanl 10 lo,ral h.âldr lirgclt nr Lrelow t0gj(la) hatl mcân DùIIT lalùes f(tr 12 IeaÈol(k of
foclsed on drelrry mgà. (,n fa,ti.ùla. sù.rosc) rrd alrhn,!], below l. whe..is ..1-r half of.he .outûies \lth nrgaf Nail
Ngars xfc ùndoùb.edlr rhe nù$ sirnificart dÈfury fa.tor i. rhe âbilirv abore thls level h.d ).hieve.l DIlFT..i. The werker
rernnos! of.aries, modeû di€s rlso .onrani an ,rcred,n.q amy a\{).ixtnrn be.veeù per.aprtr sugrr afiilx.r,ilir} ud levels of
of fuarentable carhL,ldnres iûclu.ling highLl relined srr.h.s, .aric\ ln indtr$irlized .o!nries .ra-r fârly bc r..oùnted 1.r
tru(osc sl.u|s, tjlBor |ol,vnrcs. md srntheti. oLitjosâ..h.ri.les. br rh. à(r dnt mrnl su!a6 odier tliaû sùcrose,r..o.ttiburins
IloE i.formarion is rlso availablc about rhe effect ofotLter com r o . o . , l n , A i . s i n r à k c .I o r e x a m P l e ,h d r e U S A ! h e t c i s à s i a n i t -
pncnh of rbc dict .. drc intcractn,n tenreen rgÙs and dent iQfr !s. of hiSh t|u.ù)se .oû ttup (siù]hr !o if\'.rt sùgxr)
.âri.i (ic. frcrc(Îila ià( tuf\ in.hdinA lluorlde) Il this chJpter a.!l i. orbcr i.dusûiallzrd .ounùies the ùse ol Sh,cos. s-rrfs,
dæ refln \!gàs reri.s ro ror,l NEârs in 8cn.ml and tLre term frrr j!ice.on.c.ûârcs. and !lu.ose pôlfûeû is becontng
\ùgâi rctcn b rrrosc
't2
z oier
ond
denrorm,i,,
I

Table 2.1 Consùnprior (s/persorp€r day)of Susàr and FlouF

containinSFoodsin Tristaûda Cutha

l9lri 1966
tt0
0t
J.rn àrJ ..rdense.l diLk

ll0
i0

intake and this is a$ociated wth a marked increasem dental

câries.Exâmplesol su.h populètionsinclùde ihe AlèskanlÂùit,
Sùdarùd Erhiofir, GhaM ànd N'aeriâ, and the Islâ.,]ofT.iraû
da Cunha(seeRugs Gutû l99l for d review).Inhabituntsofrhc
l . ' . , ' T l { d , ' t u r ' r D , i " d , e ! \ . tl rs n ' u e . r t i o , ,
1940 when à trè.ljrs storeopene.ton the Islând.The storesold
imported sugnr ând msaFcontaining foods and the nèrked
inûeasein rhc.onsumptioDofsuch impoftedtoodscanbeseenin
Tàble2.1. :lhc denrâlrecordsor the inhàbitètts from befôreùd
after rhe open;nsôfthe storeshos'rery 1owcaries;r 1937 bùi a
reâdy incr€asein dentâ1càriesletls in all ège grouts be.çeet
1 9 3 7a n d 1 9 6 6( l i g . 2 . . 1 ) .

ûo pcople ',r'liûhabituall] ron3ùfie a hiqh

Susar supply(s/Pêreon/day)
Fignre 2.3 Cdies exFrience (DMIT) of 12 yedrcld children dd
sugar pply (s/pe.sodldayin 47 couflùi€s. (Datd irom Srccbûy
1982.)
r . i , .( l r l | ' i r l r J f ; e \ p . r l l t r ' n . r ' h u r r q rl h l l ' , t ' r i n r l
changes in avnilabilit]/ of dielêrv sugêrs?
Popùlatiôûs !y dudqt rhese.otd
ûat hadredu.ed{gar àvâilabjli
\Xrorld\rèr showeda.cdùdiôn in.teotdl ca.ies,whi.h subse
quendyinùeased aAainwhe. the tsriction on su8a.vas lifte.l.
The ânnual.âriesirûemeû! in dre fiBt mo1èrs belveeûr91r
and l9t8 bâs beenshowDto m;ror annua.lsùgù consumptôn
in manycoudùiesin lùdina Jafan. Nonay, Scètdinavia, Svitzer-
lard, àrd New Zealand.Althoush lhesedatawerecôllecredbcfore
wldespreâdexponte to flùoride,a rcdù.tbn in deitar câreswd
obscred beN een1941 ànd 19:19in deàsofNoith Enalanl with
both hlsh and low wa.er-fluorideconceotratnrns. It shouLdbc
nore.lthd! durira the Se.ondworld \(ra..a.edù.tion in intakeof
sugârwd nor an isolatd diet.ry chanaeand tbar ittàke ol other
caôohydràres, e.s. reined 1]où! wd à1soresricted.
kolared.ommxnitieswidr â primitive way of lii-eand a.otsis
rently low $gâr iotake halc very lorv dentalcarieslcrels.Às such
societiesincreasetrtrd€vidr indu$riâlized countLiesthey shif!
towafdshabitsù.1dies asociatcdwith nodern Living(knownas
','' i o, ' rn.'!o, n l,di :, 'uP.'
-, rr''PJ . -,"
sùg.rrsdiet have lir'gherlevelsoi'.lertal caries?
There js edden.e to show tlut many groups ofpeople wùh habitu
âl1y lish consunption of s!s26 alsô hÈve levels of ca.ies hish€r
than ûe l,opulation average. Etmples inclu,le confe.tioûery
intNry vo|kers dd children with chroric diseasts requûiûs
1ông term sugaF.ontaiûiûA me,.licines. Stuclies have shown ùp to
71% higher.ades in coûfecrioneryindù$ry workcF rh.n fà.tory
vorkcrs from other ln,lutdes. this holds ùùc nen û countrics
s,.h d linland s'hei! there is Aood exposnre to fluoride Sode
nedicàl condiùns su.h d phenylketoneuriÈrequire dicts ttÈt are
high in reûned su8âr\. There have been few stùdies ot su.h srouPsi
yct. eistirg repo.ts do not show ao incteasedlevel ot caries How-
ero..hildren oD longrcm sugùed medicines have beet shown t)
hNe higher.aries expcrien.e .ômpar€d widr healthy chlldren
llo Feople ilho lrabitually cors1]me â lo$
sugarsdiet havc lower levclsof dental caries?
Low deûtal cariesc+erietce has bcen rePôrted 'n grouPs 01
people who havc â habnually low intake ôf djetary sù8arsifor
exdple, childrenof dentists,childtcnln intitùtjôns where$i.r
dietaryregiûens arefollosed ând childret vith here.lilarytrù.-
tose infuLerance(I'IFI). Despite repons by parent dentists of
resrdctedintàkeof susarsb-! their chjldrer, ùe low deotalcaries
€xpedcn.èofthesechildred.aû!ot b€ assumedtô be dxe to lo{
rgr r \' Jor'*oru '. a dlo,le t'.enr,.erei.
likcly b be greâterio thesechil.lret.
tT
Ë . 0
Ezo
1937 1952 1962 1966
Iigurc 2,,1 Carics scvcfty (p.r..rt DNf!T) nr three rge grôùt,s ol irhâbit.rts ofTr'sur
= gllcaemia; hence all foods .ôftainnig ftuctose md N.rose are
Figu.e 2.5 Cariesexfûien.e (DNrfl ) in.hildrn in HoFwood
l]oùse (vith S!Àf) and .hil.lien jn r.re schoolso1Sourh Âu$idlix.
(Dxù from ùIdrnaler, 196r with peûnnsion oftl1e edno. of Câries
Children livins in the llopeçood lloùse childreûs home in
Ncq South \v2les receiBl an.ual denûL Nn'eys between 1947
and 1962. Tbe.hild.cn iolloied â sûiff lacrovcg$âriân di$ thât
vJ lo" I r.. "ndr fr'd l .l ,\ê ,. {r 'r;' , \..\ l
Nallr absert and fllorlde exFosure $d loÙ DeDtè1 .ùies lelels
vere mxch lower than û chil.lren of the sàne ase rn.l socio
econoûic ba.kurôurd arftnding rate s.hools in Ne* Sôùrh
\{rales lFig. 2.t)i 46% of r2-leaFolds lD Hopewood ho$e were
cdiesfree .odpâred $irh r% of the .hildren fmm rare s.noor.
However, dter 12 rexrs ofaEe. çhe. ih€.hildrcns xss).iatn,n
with the home ended, rhc mtc oi .arics in.fcascd ro lcvcls
ôLrservedin.hildren from ihe r.te s.hools.
elledofdier0nlhedevelopmefr
Poneruprive ofderrolo'ies tl
1937 1952 1962 1966 1937 1952 r962 1966
dx ûlnbi ar foù crmnlarlotrs benrar 19ll
À ùeèLnes ofdre data lioû obrn'arions oflofùlârions is rhat
.hèùses ir irtèke ôfnrsàs ar€ olief d$o.l2ted wirh chr.Ecs in
rLre intàke ôf refined floL,r, makjns n jmpossible to atifiburc
.hanljes in denkl .aries solely tô changestr the irûke of sugâ6
A gôod exception ro tbis are rhe .lâtà ion, rudics of.hildkn
with H!1. Hll 's â.ongcûihl dcfl.lency offru(ose-l'phôsphête
aldolare, and.on$mptiôn ôffrtr.tôse results ir nèuseèaùd hlpo
c.xcludcd from dre diet. Pe.pLe wirh HFI therefôre hàle à 1or
intàke ofsuga6 bur, âs Alucorc is ûnc.ared tber âre not re$i.ted
on i.take of siârch. Sùdics havc \lùw. drar subje.6 with HFI
hâle a lov int2kc of sùga.s xnd a hiAher .han werâgr ittâLe of
starch, -veta low ca.ies exFricncc.
L:|1)!s-:n:rL:ûrr.:r; Lr|is .l {' d i r 1 r nL},11:
irofililiirri5 rl I i,rl
airri15lrvei! irr pdllijit;or!
stùlies fiom ma.I
I{uderousùôs sectronrlepnleûrological
.ounÛies, hâve relared sugàs ùtàke *lth derùl cdrs r€!e1sal
T'hose
.nc foint in time. pùblished befoie the eâr1y r990s hale
bccn su.rmâfizcd by Rùss-Gùnn (1991). À11 studies rarlert
widcll ir mcrhodoloal and means of reporing tLre firdings,
making drawing ofolcrall conclùslonr .ompll.âted. Nine ont ôf
21 sulies drai com])a.cd wciAbr of $Aa$ .on{med tu .diies
ir.rcnrcnr Èùnd sis fi.anr âsso.iations dr.l dÉ remriûitg 12
.lid not. Tweûty rlùee oût oldre 17 stùdies rhât i.vestiA2tcd rhc
ùsocLàtion beîween fiquen.y of suga6 .onsumptbn and.afies
lelelsfoùûd signillcan. relationshilx and l.l failcd tu iird an ass!
.iâtiôn. Sôûe ùos se.rioral stùdres have also coostrlered toocb
brLshlng habùs ând exposurero fluori.le rs weLl as $,gas lotake
In nos studies, a.ll dre\e fâ.rors hàve beer $owû io be iûr,orîa.t
dererninants ôf.aries Lelels .n.t in sone, Lelel oI slsars ioldlre
is .o.sidcrcd dre mor impoitant Ia.iôr lor exadple CrJnxth
!i"/. (Gr.narh 1978).ompared the leveLofdentnl.èries i. oler
ra ? D i e r mdde fo t o , i e s
|
500 1-yeaFold Swedish child.c. ro sugâ6 consumFion. Ruo.idc
supplemenrarion and orâl hyAiene l,r2c!ices. lnlake ofsuaâ^ wâs
ihe nùr lmpoûa.t fàftoL a$ociarcd virb den|alca.ies, and dit:
fercnccs i. dcnral caries qp€.ieoc€ oi children çrrh îhe hlshesr
and loie* in'bcNccn meâlsuga6 inldLe could .o! be eTlânred
by diilerence in use of lluoride or oral h-vgicrc pra.ti.cs. \X/hen
d,e eafectsof orJl hygieûe aûd fluoride were kepr .ôn$ânr the
child.en wi.b a low sas lnûke !r berween neàLs hè.t 867.less
buccal and lifsùal cdrjes and 6E% less approximal .aries thar
children Ûth high irtàLes of sugds ir between neals.
The Nâtiôtâ.I Diei ând Nuùitn,n Suney (NDNS) ol young
people aged I 18 years .oue.td inf(nmatn)n oo diet and dental
health ôû à representativesample of.hlld.en ln Edaladd. \.âles.
ând S.otldd in â .rcsvsc.rional su11cl No or.all .clarionship
between dte anoùt of sùsars .on\uned rnd levels of dental
ca.ies we.e obseryed. \rher drildren were divided into high,
ne.liùm, or loq' bands ofsuAâs consumfrion. no signiilcânr .cla'
in nrhlp wâs fouûd bctwccn carics cxpc.icncc a.d bând ofsusa.s
inrake. Howcvcr, i. the It 18 yearold ige group,.he uppe.
band ofir!*e ofsusars were more likely to hère decay thàn those
in the lower ban.t (70% cômpàred with t2%). childreû $ho côn
sùned nrsared confe.tiorert, Gweersrcârdies) drilr were à1so
more likely to have decây rhan rhôsr whô .onùnÈd it Ie$ fre-
quently at.l thôst sith r high frequency of carbonated $ft drink
con$ûption Ùere môre likely thar ûôû coNume6 to have..ries
h drc pfimâry dentirio.. Hoveler, this relâtionshlf wis not
observedfor the permanerr dc.tirior. Thosc rhar consùmcd tnrce
or IÛe cups of ugared tea or .offee daily s'eft more likely t.)
halc cârics cxFttrience(\Valket et dl.2t)U)).
\Yhen considerlos the ltulûs ofthese ûo$ se.tional sùrleys,
it is in,po(an! to cons er that dertàL .àries deveLopsover lnre
and, drerefbre, slmùltaneoùs meanrrenents ol dsease levels anll
dlet may not sive è ùne reflectiôù ofrhe role of.tiet iù the de'el
opmenr ofthe disease.it n the d,et severâl),ea6 eanier dra! md)
be rcsponsiblc tôf .utrcrt .âLics lcrcls. Cfos sc.tional *ùdies
shoutd, therefore, be inrerprered $nh caurion. ThÀ pheùômeûor
is les o1 à problem iû r,o,ûg chil.lier, whose diet mar Dot hùe
chdoged signilicùdy sirce the eruprior ofûe primdry dentitior
àûd several sttrdies of young children have ftnnd asvriatn,ns
bet*een lntaLe ofsugars of hiEh suEarsfin)d\ and lelels of.arles.
The NDNS ot l i-/1.5 year old .blldreû (Hlnds and GreEorI
r9tt) showed rhar rhe stenaest dctcrmina.rs of dcntal bealrh
weft $.iâl fa.ers such âs thc lcvcl ofhouschold incomc ând lcvcl
of educaton of mothers. Howevef, wben $.ixl tà.t(trs s'ere
coitrolLed for, dsoci.\ions $ere rtso fourd betùeer ho!sehold
cxpc.diruLc on confectionery, fiequency oÊ consumption of con
fc.rio.cLv 2.d sofi d.inks, and high average intake oi sugà.
.ontèc.iorery m.l sofi drirks.
L-ongjtudinal
studiesol diet ând câr'ies
ir'rcide$ce
Sûo.ger evidencerôra relationshipbetweendler ènd dennl cdries
is âcqdrcd from *ùdics rhar havc âsc$cd sugas c2tinA h2bi$
over rime in .elarn n ù .hdges ir dertèl cùies experlenceoler
rhâr rimc pdiod. Inls rlpe of rndy is relàtively more cosly
ând rinre .onsLming and in .omparisor to rhe runber ot.ross
section2l sud;cs in rhc literatu.e, this type of study is relttlvely
rârc. Stcckscr-Bli.ks and Gustafsson mea*ted carres mrreorerr
oler one veaf in 8 ând Ll year ô1d .hildrer an.l related it to ,liet
ù ôre timepoinr (StecksenBlicks and Gusdf$on r916). Despite
the shor! perio,l ofobscnâtion, a risnifl.ant relatn)aship betweet
caries develormen! and lntakc of sugars *as tàtLnd for both the
primùr ànd permanent dentjtion. Io a mo.e.ecenr studr (i.c. in
the era ôfexpôsure to flùori.te) ofthe causesofcari€s in lbe rri
mafy dentiriôn, ciirdefjord .r ,/. observed caries levels in ,
.ohoit ôf )ônûg chltdreû ber\eer rhe ages of r to l.t yeaa
(Gdndefjo.d d.//. r996). À sigrificaûr reldtionship beslee! lhe
.on$mptiôn ôf .oûfe.rioûery àrd sugâFcortàining beleràges2rd
.aries i.crement wrs founJ.
Ir a.onrprchenslle rudy of.aries ittâke aûd diet ôfo"er.100
E.AIish adoles.ens (aged l1 L2 !'ears)(Rugg Cnm r,l. 19E.1)
a !.all bur siAnifica.t .elatbnship *as inmd beoeen lntake ot
tottl sùsas and cdries inc.ement ovcr two rca.s (+0.2).
The Mi.hisàÀ Srudy wâs cùried ou! in dreUSA bctFcc. 19s2
Jn.t l98t aûd st!.lled dre rejarjonsl,i! beNeen suga6lntakc and
deûtâ1iàries in.remert ov€r three yea6 in .hildr€o initiaily ated
10 lt reds (Burt d ?1. 1988). Thls stldy also found çeak relâ
tionsliFs benveen tbe amoun! anl tieque.cl ofintâkc ol dictary
suaâ6. Cbildrcn sho .oflsmed a higher propoitlon ol then rotul
dietary enerry a\ {gats had r higher cùies in.rement for àpprox
inm.l .xrles, though drere was no significèrt aso.ratLon between
sugârs i.takc and pitand fisure carles.The freguency ofintakeof
$rsa6 or sugâr co.râinina hods (a.idr > lj% rusars) rvas nôt
F p . ,l o " ' . ' r n ' h ' r , 1 , . " , , , , . , 5 " " I
b€!\'een medls wa rclâtcd ù airplîximal .aries. \Xrhen the .hil'
dreo \aere divnled into lhose s'l,o bad a high, coqwcd with a
low, câriesincrcmmt. a tcrdc..y bs xrds mo.efrequent sna.king
s'as seen lû ihe high ..rles .hildred. Howevei, irtèLe of n,gas
wù geûerally high Ior all subjects in th:s study widr only 2{) out
of 199 chiLdren consuming lc$ rhâr lt g/dâI. xnd rhe averx€e
rûtèke ol rhe lowesrquarrile of.onsumfrion hcing 109s/dav
or 21.1% of erersy inûke. The r&soo Iôr the loç relative risk
of.xries developûenr iû the high sugùs consùmes wasthat snall
varirnces were found both foi ièrles inùemert and rnake of
A rcvles' by Mxithaler (1990) pôinred our rlhr màùv ô]dr
$trdie\ fâiled ro shôw â relatioûdiF benveer suga6 rûtâke an,l
development oa,lentâl càries becàusemâny ofdrcsc wc.c ot po.r
mcdrodological dcrian, ùscd ùnsùliable merhods of dletaq analr
sis. ând vcrc ofi.sufil.ient powef. Corelatiôls between individ
xals' srgas consumfrion and denàl c2.ics i.c.cme.ts may be
w€ak.lue ro rhe llmted range ol sù.qa^ ifldl.e in lhe study l)otu-
l.rior !ùtuion nr $rgàs intâke vilhjn populations is roo ros
ro show M effeû on caries occutrence. Th€.e is morc bctFccn-
.ourtry varlation in ùtèke ofsùgars ûhicli erplajos the strooSer
aso.iàtior between sugàr âlaiLabllit, and deftal caries leveh
foùnd from ànalysisoÊs'orld ('idc dara (Srccbnl L9il2).
 Pon+ruprive0fdier
effect onrhedweopmnr (0 es
0ldenr0l l5
I

[pidemiologirol
studies relotionshipMqincondusions
of thesugors/cories ol theVipeholm
study
. Â Fosili'e r.lrl,onshit.il!s hûsor l.i .il)l.r Igrf irùilrbilir) . Susd rnùr, .vùr $h.i ...sunrd in hrÉ rm.nn6, nxd ftrl..ri.i
ri(l DlitÎ rt à9. rl !.ùs or.rn6 û.i.ûxnr i ir ss ligered ùt i. r mximum ûf6ur
' A mr[e.] ln.rexs. nr rbe tJErÀlÉ..É rf,d ykrtr rinû i ir1 r, metrlrinrÊs.rlt
oi dèn L .ds ha
Lf{ ol'rrved n, poÈrldion5 \1r nov! a}ar ioni nxir n!l,,lotùl . Consunlnûr ûarLg,r nr lJtv.ù, u.trl; nàs ùs..iâted eirh a
{àt ôiê}tlna â.J àJ.tr r{ÊsrÊ$izÊJ dGr. higb nr sùgr$ nirrk.(l in..N ln JennL.ùriÉs
' SuL ritunF! oa rhe popuL:tior slD LrLniiftl[ .ôNum. r l]isr, sûEàn . The in.rease,n derid rrri.s,'...lif,ll:rft.àis on r'lthdf'rwRr oi
J,( hr!. hrr. :howf ro hùr. hiuh.r l.vcls or tl.r.il .r.l.s..nrl*rd
(o 1ù. g.turd PoPrLtr on
. Denul.rries.xF!ricf.. sl,or.J e J. iaJlvidnxl vam.n
. SL,l]-utu!Fsoi rh. Fofulllion rvl,. hàbin,rllt' .onsne â l.n sù!xr
,ll.r LN. b.ù, ;l,on. r. hàv. L.{.r lÂ.ls of J.{al .ârls ..oFred
çiù rhe gÊnerâlFfùltrrl.n Thc signiil.ân.e ûf neâlrlûe coDsurnptio. of n,A2r is al{r
. Gùtôn n neededshen lnrerlredng rhè tnding\ oa !ro$ re.d.!:'l t1ùt sali!a.y Ro{' ratr À Ereate. at me.Jùdes .L!e to nimùhrio.
' l l bt orhe. m.rl componenrs md dreiefot plùque ù.nls n,ir bc
loin,, si,r.e.r.i.s (i.v.l.ts ov.r linrÈ ft màt' bÊ rlt {lie. rveDl nnr .aridly neoûâlized
rerA previonsnnd,jh r responiible ior.rrert dnerso lo. r
Tlie st!d) hr.l i .on,1n i.rtcd dcsigû xnd $bje.rs weÈ ûot rri
. S R l e s n i d r à l . n g l t ù n l n a l , l e s i g f ,d, r a r r É a s u r d r t i n d r e l i r e doûlr â$igncd tu g(ù]x (xs Anrps *Ûe detrûnre(l bl \L,nls to
tr tu.brage,n le\rls.ldentxl.xler over dmc !ftnidr *tunger
setù.are.lierxry rcgimcn\). A pern of !irnnr n,Fple.renrâriof
ô..trûe.l Iôr l.; "vea6frio. o rhc.arboh-rdLare perb.ls d rt tlis
. Hnnm ,nterennon rùd,É\ !ftrdr thr $tunges evi.lere lor û .lme lr was rliôushftb.r dentil.ârlcs mal bt xdcfi.iÊn(' d;ease
Àvnffiûn benveendiet rnd d,*sA. LDrvever,thesed!.liinù 1 10 'lhr
pefnrd of vn.m!r sùpliLemefririon sàs ûnr sln)û n) fn)pefll
tordr.r ftun æ enn.:L md Lùs,ntr Fort ofr,r'v
nonier the effeùs on .arles rl€r.lo|.icrr trnd nxs in.on.l$lve
Thc rùdr was.arie.l oùt on adùltsin, sin,atn,. s'hc.t it wrs
I lulnar ir':ier_va:!ition
s1Ùcliirl poslble ro pres.ribe dieiary reAimcn As idults, drc subie.6 nd
Htrman iflterventbn rudies wl,ere intake oi sugrs hrs beet hrve beo more resivinr ro.xfics (is ûranel ls tully dinetuLten)
alreredâfd ùries develof,nenr n,oniroreJ ,rc m.c. târh dùc n) an,l a norc marked effec nây hr"e beet obserle,l ,fchil,ltcn hid
d! troblûns ifher.r in n)ifA to trcsc.ibc dirrs àf rhe long bccr {ùdied. fhe flnôride.on.enùùrio,, i. thc d.inkinA sxrcr
period ol line necesâry !o mernrfe chùnges in .ârcs dcvclof- was o.:lftm (l(N) ard tLre strdy .vas carierl our ltforc ur of
meùr TL,osethât hâve been repofte.l ùre no$,de.ùles old rnl Ihonde i.,lenrii.i(.s.
w{e ()ndtr.rd in rlrr pie fltrôride erà or highlv rle.le(l Sroùts 'l'be Turkn sugar sndies
.i p{ple. befùe rLe rrông link be$een sugùs r.d .arles çis
 se.ond in,port]nr in(ircntnn sucly was th Tuku sudl.l. This
esxblished Srh rtrdles $odd dor be possible to repeat roda-r'
\as . coûtrolled Lo.giflklinâl studr'.irird otrr h fnLl{rd nr die
be.aù\eol erhnal.onrL?in6 'lhe
I910s ( S . h c i . i n x . l l l a k l n c û 1 9 r t ) . $ ù.1] inv4ti.çien the
Tbe ViPehaln studl cfc.t of a.Lnor (tr.,.I $,Lrritu ti.. ofs,crose in r..rmal dicr sidr
Thr Yipeholm {udy was .ondu.te.l sho(ly aitei the Seconn e i r h e r f r r . t o s e o r $ l i r o l ô n . i . i c \ d c 1 ' r l o p m e n . ,b u t e ! i d e û c e
\j/odd lixr ln an adult nental insirtrtion iû SNeden bels'ee. frorn rhe.of!.ol g'outi.in tr. usrd a\ itrdirert eviden.e for the
lr,ii add l9j3 (Gtrrlfss,n d /. 195.1).The stu.ty rnestl-qar€d imprct oi sr-qar on rh. ,lcr.lof.rcar of LÙles. ThÉe grctrps of
d,c clfccc of.o.nn.i.a ùL8ar' àods of var]lng rl.kires s u b j e . t s( r = 1 2 t n t o r ù l ) i g € d 1 l t l y c r 6 , s i d r 6 i 9 ; b c i n ! i n
(ic ,llitè'enr orâl..rcnrion tim.s)and at dilTerent rimes thnrgLr drelr Nenries,.ôûsuûed ù d,er swe{.fc,l s'idr cithcr r.(se.
. ) o , , , J . . b . fmfuse. or rylitol for r penod ot 2t n,o.rh a.l dcrrxl .xries
in.renen! ir NLrjecs who co.$m.d (l).cti.cd sùsa$ "ùh a in.rcnrc.r wrs moûrôred blLnd ù1 !r no.rh ln.c'!trls b' onc
s L i g hr e f ( l e n . t r o b e r r a l f e l i n r b e . r o u r h i t m c â l r l n r c \ o n l l fcsor dùoulhour rl,e rrdr ùd both .ariols .âviri.s Ù,1 t,.c
(..9 5u.ros. solùrio., .ho.olarc) (2) reUned susâis with a .a'nat]on lesiôùs $ere noritore{l Foodsw.r st)..ixur mxntrh.-
trrons ren.len.t ro be rerâined ni the molrb rt ùe.l ri,nes o.ll rùred for the liu(osc and x-rlitol s(ùps xnd nnke ùfrar.h vrs
(e.s.sùeerene.lbreè.1)(l).elinerl srgaa widr: srons tcndcnc-rt, n o t . e s . i . r c d b ù t b j e . B N r f e a s k É dt o àv o s f e e t l i ! i r s N c h i s
be retaûe.l û the ûroùth, n tretween neùls (e.s. roftic) Th. sùb- dried ftuits si1r.c gxrs in rhese iblds .oul.L not Lre$L\ri(,f€,].
lects rvere cLlvlded nrt! ar gtuups land t.ro grolFs were sùb Th€ xllirol groul' .o.mmcd \rlinn-.ontainnig foods sigtili
dnided lnn) nale xnd femrle); drese âre lsted in Tlbte 2.2. The .drl) 1es lre,lrefrl) thâf rl,c sùcrcsc of ifu.()se lroùps .on
dietar-rreAinresitre giren in.vo perb.ls. The fist c.rbohydnÉ \ûe.t theû sNeerene,ltoo.ls rnd dic.1'crall irtake ofxi,lltol it
f{n)d wa\ berseen 19.1i xnd 19.19ând the se.ont carlrohydtule the xylitol grolt çùs lowcr diin drat of r.nse or fmcov nt
li{ni in sii.h drc ltAinens sere .nanged slightly rân between rhe.rlrÉrlronps An 8t7i.ed!.tlon in .lcnrxl {:a.icss'a\ obseÀed
1t1t âtrd 1r5 r. i'he denral cafies in.rÉhen6 ôfthe 6 groups i.e i! die xylnol .qrolti who h2d rcmovcd gàf Èonr drelr diet
The findinAs irc Rnnmafizcd in lible 2.1 ârd ligure 1.7. The
r6 | ? Diermd
denrot@rie,
I
Tàble 2.2 Suhnary of rhe VipeholmStùdy (cus |aitson eîa/. r9t4)
cnnûot4ô$ \uief,l ûl
su.rose ât mQls. l00g/d redùced t7
io -ltog i. re.ond perid
Sweetbred à! merlsl.1t s àt àticrnôôn.oftle 1l )2
in period L ân,l ibeùat 1meâirlnes inperiod 2
Cho.olarel00g su.rôsetmals ln il^t pernd 4a
ThÊn I l0gat mals rnd 64g.nnôlâre
(l0s sùsdr) rd fou po(ions berseeo m..ls
Cùamel Srâ1.tugar ri.b breù.I during llst
ye& oa 1i6r FrioJ Sc.ond yeâr ôf fi6t pèriod
:: Gsm.Ls (r0g susâr) i. rrô beeÊÊn n1e!
Fitions IIN yeâ. of sè.ond teriod 22 larmels
3 e,ffecs/d liff y*f, ff6i period low
.arbohy{ltute hish 1àr dict Tnen 3 .oaacesr day
1.10s sùsù) rn se.ond yee litsr leriod ù! LrreùfÀt
æd lù.ch onb: Inse.of,d D.nod gnfn tn bcôveen
deals Sùc'lse solurio! wâs raken rr meah so
su.ftxÊ 1nr.kc wd egul ro odrer g.onps
2.1 iof.."rd Ii6. Fùôd 24 -tl""t
Àvâilablcilroqh.ùt aat.
Tofees sropped àt end ol first
.onclusionsof rhe Tùrku study are thàr sùbsrirurior ôf su.rose
widr xylitol resulredjn. ôâfkedly lower denal caflesm.reme'r
rn both cèviriesand at the pre-câlitètiônnaae.
Al]imal expcrilncnts
Animal experihents desigred ro ;nvestigatedrc relàrionshlp
berseendletùy sùgaNan l dentalca.iesmôs .ommorly ùserhe
rat model;hôwever,mice, hamsre.s,and mônkcvshâveâ1sôbeen
ued. Aniûal eryerimens hare eDabledstudy ofdlferenr r',l)es,
concenùarbns. aod fregùenc;esof .arbohydrâtesând susa.s
under specifiedcorditiôns.It $'oùld ror bc po$ibte to test such
<lletùy rÉAimensir hunransdùe to probleûs ofpâlatabililv aûd
The impomnce oi the lo.al effeft of susaf nr the mouth was
cleaflydcmonsûâtedi. srudieswhe.c .ars vere fed a carioged.
diet either convertionallylia rhe stonrâchor by a somacn tùDe
(Tâb1e2..1).The salivar)'slaûds ôf someof the a.imals jo eùh
grôùp had beenrenoved.The resullsdenônsÛâte0) ihe irpo.-
t.nce of the lo.a.lp.eserceôf susa.sir the mourh md (2) ihc
imporar! role of sâlivai! prôrecringagd6r denralcaries.
The precise.onrrol of freguencyof feedinga cariogent.dicr
bec2mepo$lble vhen the Zurich Dental I.srirùte devetoFd
an aùtomaticfeedinADachine.Tirn embled fi)od ro be given ro
Câri.s iturement âlnôr nil. ln.rerse in sùAâ. in
se.ond Grhohydrate period vas a.oùFrmed bt
à snrll bor signiû.â.i in.rede in.aries.
No siAnlaicaûtir.rerses in denial.ûries
,turemenr
'fbo!g!
slishdy hisherdrdr in 19.16.
Srgniû.â.r in.rcÀe n.âries i..reneût in sê.ond
.arbohj'dràre iÉriod sigdli.â.r lor nales ônly.
cdies ir.rÊmenr \'6low iD llrt.ârf,ohrdftF Fertod
but inùeaed slAniilcandy in the se.ond l,eriel. ln
subjcc6,'gêd<10 rhere w6 a ùree lold i..rcàse iù La.ies
DÊ.tâl cari.s was ùn.hÀ.ge! {lLtnrg rhellst yeâr
C.Nrnprlon of.rrineli led ro â signitjcaùi in.reâse
ir.â.ies in.remeni. so nrù.h rhd.anmels {erÉ n,nh
.lh*n in dre tirs. yeù.fse.ond ]tiod. !/rbdh*âl
r.$,I€d in fall in câri.s ii.rement t. p.evioùs Level.
Iirr te.r, û6t pÊrio{l carles iû.rement vÀ lo*
SiAnifi!int in.re6e in.iries in,ll rhfee y.ùs
whcû tofees were co.suùed. cÉatÊs ln d,iRl yerr
À ) É - ,,',.a',e
ai6r period. Consù.rtrion ofbtreesvÀr higherin aemrtÊs
and soqd.!ri.s nrremenr. ktue of tofees çâs mtfel
bcfoi! edd oan6r period (berxrueoa i..reÀod.ûes)
r corsudprôn i. beùecr meals was not rllo(e.].
this led ro marked dec.€se in.ûies in..eoent.
anjnèls .t definedrines ând ùnder f€edinsens red rhat the ânr
mals rte all oi rhe fee.iprôûded. h sùchsrùdicsa cl€arposùtve
F l d ' o a l i p b f l \ e e n . q u a . o i f e e1 . ,à " , a . , ' i ( . . e r - r . , J{ -
sccn(Tab1e2.5). Arim s fe.l ad libirum consuded tt.7s food
per day which \r.s nearll Nice rhe 6s fed io olher grôupsln
whom frequcncywù cônûolled.The resdts rhow drar freqnency
of eèring a c2.iogedc diet is mo.e lmpôrrânr drar the ovehll
Anorh€rimportanr facro.is the âdôùnt ortime betwee.ibod
intakcs.h an expefimen.whereànimals.eceire.i18 po.rio.s of
feedper clay,one group .ecelved3x6 po'fions, wirh .o time
betwe€nconsunpt;onofthe 6 pôrtions.The secôndsroup hada
l0 minute irteral bctweereachof rhe r8 portiors. Cdies devel
opm€ntwasArearerin rhe lâfter group.
Ànimal expedmeDrs haveâlsr beenusedto examinelhe €Fe.r
ofcorcerûation ofsusas ir d1edict. A largenùmberofsxdies
haveshôwndrar djets conrâi ns somesùgù (,10%) causenore
c.ries tha. susù free diets. furrher ir.reasesin .des navenol
àhvaysbecnseenwhen dre sugarconcenr.arion is increased
above
10%. Resuttshale rtuled due !o the type of dier xsed dd also
À.côrd1nAto whether or nor rhe ràs sere super l.fectèd wirh
cd$acnic orgadsms.The mn sugârcoârpo.ertsofthe di€t a(
impor.nrj âs lirde æ 2-5% sugarcènses.arics if rhe bde dier
T 0 reifet so f t 1
P o n e r u p r i v e e l l e d 0 l d i e l o n l h e d edveèflr00pl !m

ËÏ[

i'F
' : [
0

l i r u r " 2 . -l
l l l , l , 1
lesions,
? 4 6

, \ l\ ""'
- \ "
3

, , ' 1 .
1

rr. \.J
0 r

po'
, " ' . n L
dirgnosedboih.lioi.alir andradiosrphrallr',bur nor
2 1 4

rn.Lùdrngsccord.rt.^rics.Âr 2.1months,diffe.e..esbenvee.nll
AroùLrs wercsatisti.all_rslgrifi.â.r (r< 0.01).(schrnrinand
Makiren rrl;, vldr pcmrsl.n of th. .Jnû Aûà où,1rk[itd
1946 1947 194a 1949 1950 1951
l
Periôd v1 câfbohydftrtlcftohyd€Grrl
!_i8ùe 2.6 Ca.iesexF.ien.e (DM|T) I;f dr.otrûol srcùp a.d Table 2..1The meaanumbero1.aioùs lesiorsû rèts fed â
froll, ;l \"o cariogem.dier either corvertion.lly or br, soda.L nttre.The
bctsc.n 1944rrnd l91l Solm line indnatcs dr.t drc sùbiefts rr
sàl,varySlàndsofsoùe ôfthe adhal\ irLra.h gtuup Lra.tbeen
sugd both û.n,1bftseÉ. nerlsr irter.ulred llre nldi.xrcs
rcmoved.Nun,ber ofanimels nr eàchgroup b give! rn
ùtJjeùs È.eived saf onlr' ir mc.ls. (Reptudu.ed riom CuralTlon
d,/. r9i.1, r'rrf pernislofl of the ednû AûnOlûûrhiù

6 . r( 1 1 ) 0 (l])
Tabl€ 2.1 The bÀeline condriols of dre rii sùbjc.$ sho 0c)
.omtlcrcd the 2 year ntrku sugâr rudr

idfe.ted *lrh {.h ba.te.ia are likclr b cxasEcrarcdi*i.cn.es

ndùgq)bL .rrl.u\ Nnn {s
f,ill.,r ."i*
benreen dre .èrciûogeri.ity of n,.rok .ompâr€d *th odrer
. i^ l, ,l ,' .l : , \rr n",'
geri. rhan glù.ose or ftù.n*e, bùt dre diffcrcn.cs{'c.c smill.
ri.9 Thereù6 rô diiferen.eitr the .arinogeni.ir) ofAlu.osca.d ffùc
2t.,1 2-.1 iôsÉ.I. ù)nkeys. lLcroschas bcc. shown !o hav. a lm,Lar cat
12.r .inoAcniciryro AtucosclfiL,crosemiaes,whereastiuctoseNas Les
câfioAcnicdrànsoc.ose.DrinLin.qwatercontajnins207 gIùcôse
)4.2 'yq) (, p.oduct of srârchhydrolysis)hùsLreenshovû to tre les
.arioge.ic îhan 202 srcroseii drnrkiûg s.ter.

ontanr -57. $rr.h vhered dmôs 5 tlm€s xs mù.h sùgaf is

re!uired shen the bascdici 's hiah in fa!. Caries seleriry hns been
Anirnql
studies
haveodded
to theknowledge
of the
où' oi. , r I I r" ,l {c. , o , ô r ' . _ . o rf o . 5ugqr5/ories
relofionship
byshowing:
level ol 10% iD rars srpef infcftcd wiù J ùx1t|nt trDAA.,nù\ùt . Â . l e a r . e h d o . d r i t J b e t s e e nt i e q ! . r . 1 ' o l c o n î r m F r i o n 0 1 .
.ârl.genl. !ier rnrl s.1r'l.tr of lcrlùl .drjcs
Some xnimxl srudies bave shown thàt su.rose l . In.ftisin8 .âriÈ\ iith in.ærsinA sùgrir ..n.enmrio.
grd. dran orbcr.rono ànd disacchàrides:hôweyer, iû dreserùd-
t J-tdr .liaaeièn.e tle.dioseni.iq ofg]o.ose, fru.nxe and mrt.$
ies ânimxls s'ctu ino.ul2te(l with I r/,1r,.,.,)ir ,,tdr. Some strai.s
..d nr.reis.d.d,ogru.ty oasfttur lnlr rvhen aninr! xre rper
of{rcpûrocci urilize sùcrosepreferenrially tu odrer ga6 2nd do lnrid.l \nl.t ,n,r,,l
not rhrlve ir is abscnce. E\perirer6 iù whi.h ânlm.h are
,u I oi..aa.",t*,i,,
I

Tablc 2.5 The meancari€ssercritl, daill fôod intike and s eiEht ganrnr fi'e groupsof rats fè<l:t d ifferentftequeocies
I)er dalr six anlmalsper grolp

croup Earingtcquen.y/ddr

l2 2)
.,1
t
lr (
l0 6
12

Fisufe 2.9 Àn cxxmple ofân ,ùyllc .csnr a!!Li.n.e shôsrns tso

bu..dl illng$ ..ch .ontaining a teryLcnem*h covere,Jslab of
o]mel. (Illu$[ùô. kindl]' sullLied bI E.l.E Pear.errePro!ù.cd
0 1 0 2 0 3 0 4 0 5 0 6 0 vldr permisio. ofrhc editot.lNat zulà,d DûnnlJùûalJ
% Sucroseconcentrârion
Figure 2.8 Incidcûcc o1 .tuious Lesio.s(1S!) in fissur€s(') dûd
smôoth surfà.esC) nr mts fe.l ad libitum, diers contxinns 0, 10,
20, jo, {0, to, and :6 per.ent sucrôs. (R.proda.ed t;on Fleftl rot jBt didose.ic l,orcntial aûd àlso rccounr fir dre Frole(1ve
and S.hmi.l l9r 9, Nnh Frrmnsioo of the ediror C,rr' Âù'd )

siâb€xperimriris
[inér11Êl
Enamel slab experimens ùse orâl 4plian.e\ thât hold slâbs o{
bovine o. hùmân endel. Plaqu€ foms on the tndel slabs rhat
r€main in themouthfor l to 6 we€ks.:fhe slxbs âre erPosedto the
dietèry facror hci.s resied, by either corsumptbn *ùh the slabs
, rirr or bI rcnmval oftlte rpplia.ces scvcral tlDes à clây !o {liP
inro vcseb .ontêiûing the dietafy te{ substètces. ChânAcs in
endel hardnessor,lcgrce of dtmineraltâtion ma-vbe meâsured
at the en.t oi lhe expcdnental periôd. A! exâmflc ofanaPplùnce
dade to fit over manditrular teeth is sliown in lisulî 2.9. Etmel
slab experideûts hale shown rhat \ùgats cÈusedemj.e.aliza.n n,
whilc non-fermettable ûon suAarsweetenetsâld reminemlizatn)n
Increasing rhe côncentration of sùgds, ancLthe fr€quencv of expo-
sure tu sugarsinùeasesdeni.eralizatlon. The âdvantageoic.amel
.t.,.*t-,-. ,l i{..-rn.n o./ / ing medrod rhat involves removirg small smples ofplaque fron
plaguepH experlmenis is rh2t ih€-r medure deminerâlizatbn and
PlaquepH :llidicrt
Pla,tùepH stùdies meanue changesinthe pH ofplaque following
.o$ùn!!io. of a.dbohydrile o..a6ohtdrate.ontâin;ûa food
They measurc a.idolenii potentiâI, {'hi.h is ûken as an indireft
medùre ofca.iog€ni. potentlal, 2ldnrugh acidogeniclty does not
rxkr irto acconnr pqe.tive hctors in ioods .oNumed and, sal!
vaq fâcto^ rh2t mây nodif! the ca.cinoaenicny ofâ lood.
PLàquepH rtrdies usually.mplol one of fou. mcdxdologies
linr, mefu1 probes âLc ùred, (aûtimony. itidium or p.lLàdium).
wbi.h .an be i$eftcd i, ritl into plaque. Sc.ordlr glas trob$,
which.ar be i$erted ir a sidilâr mann€i The ihird method lss
nlniaturc glass electrodes built intô à partjal denture thât sâr'.s
in tbe moudr for seleral lays o enable plaque to gr)w on the
rlæe. Re.ordings ofpH a.c talen from rires coming 1rôm the
nouth or by radio telenetll'. The fotr(h method is rhe hâr!e$
reFrescntatile teeth anl rhc neastemett ol tlaqùe pH ôn àn
 Po\l{ruplirF
eltdoldielolhede,elooment rrie' l
ofdenror rr
I

dæûodeoutsidedre moufh. Each me.bod has ;rs advantases wlth peanuts.It is o{ieo advisedto côtuune susd rich foo.tsat
anddisadvantases. The iDdweLljrseleclrodetendsio sive an all meàttimesûlher than alone,;. beùeen meals.This is be.aùse,
or nothi.g Esporseresulling in a mùimum drop i. pH in th€ when consumedwith oiher foodsthe effe.t ôn pH is mimimized
lresence ofth€ snJiest anount ofsusar.This nakes the method probàbly .tue to (1) a dilulion efïect and (2) the in ieded sàlivàry
wllsuited for testina the ûo. carcinogeûici!yot foodstuffs.Fof flow râte.tùeto nasticatio,rofotherf@ds.A $udy thar exàmited
elntl€, ifaprodùct does.ot redùceplaqùepH ro below 5.7 on the effectoi a three-courebreaLfiston plaqnepH illùstÉt€sth$.
o ù , , m p .o n , l d i ô , 2 0 n r , ' F , i ô o { i l g o r , u n p , o , . ' m d y The breakâ$ .ômisted of s,garconrainina coffee, a boiled eag.
becalesorized às sàfefor teeth'.The hdestlDs nethod oû th€ and a ùisp breÀdwith butrer. The smallestdrop i pH was
otherhaûdis more sùred to rhe ranklns offoodstùfs accordjDsto obseûedwhen à11three i.ems were consumedtoaedrer(Fisure
2.11. cuNe I). The largestdrop in pH was obseFedwhen the
sugaredcolTee vas consumeda1ône(Iigure 2.1r, cùre E). These
Snackfoods,meal patterns,and plaqueptl $udies cl@rly show bow one ftôd .d influence the ècidogedcity
Plaqùe pH stùdiestbat havebeedusedto hnk thÉ didôgeni.ity
of snackfoodshave sbovn rhat boiled sweersSive the lower Plaque pH stud;eshare be€n ùsed to cômpârethe relative
plâquefH (-5.2), sweetenedtea and .offee alsô sive tow âcidogen iciry of dlftèrenrmûno and .lisâcchârides aûd ro compare
!H Elùes, and foods sveetenedwith ron suaar sweerenere the effe.tsôfpH ofdifereDt conce.rrur'onsofsu8a6. Usina the
chewinaaumOH -6.u), diâbericcho.olatesweeG
(e.s.susaf-Êee haFestinAmelhod,Arearertàlls lû pH havebeenobservecL with
enedwith soô;tol) and salivarystimulantssuchaspeanuBgNÉ t0% suc.osecorparcd ro 5% sù.rosesolurion.Howevet $iûg
thehishestpH vÀLues.Fisure 2.10 illusrraresrhe difference;nrhe the in.twelhrs slass elecr.ode,.o differen.e in pH drop wàs
acjdosenicityof mcrosecontainins and sorbitol coDlai rs ôbsenedbetween2.t%, t%, or r0% sucroseand evena very lôw
.ôn.enÛâtion of sucrose(0.02t%) p.oduce,l â f2ll ;n pH of
Stùdiesùsiûs the irdwellirs slass electrode sysrem have 1.5 ùnirs.This demonsrrates rhe all o. nothing' response fiom the
showûstar.hy stàp1efoods such âs sheàt flakes ànd breèd iddwelling e1ecfuôde, md it is therefore impo$ible to state,at
o lro.luce deep pH responses,similâr to those prodùced by presenr,a thftshôld .onceûtratior below which a sucrosesolut'on
mày be cônsi.lere.isàfe.
Eatinghard .he€sefôllowina a suga. snack(peds ,n syrùp) Lactose (10% and t0% solùtion) prôdu.es smâller pH
h6 beenshôwn rô alhosr abôlish the fal1 in pH rhàt usu.11y dec@sesconpa.edwith str.rose,slu.ose,or ftuctos€usjns either
âccompâùessùgar consûptiôn. \xrhen stlgded cotree wæ cor rhe indwelling elecÛodeor hdvestins metho.t.The iDdwell;ng
suned in place of ha.d chæse.rhe pH wd depressedfitther. The electrodenerhod hâs shown that galâ.toseprodncesà sinilâr
elïectofcheese is probabLy due to .he slimulâr;o. of sal;va by this decrese in pH to lactose,and dre acldogÉnicityôf màltôseis
hishlynarouledfood and its Lowcarbohydlate(laciose)contenr. siùilar to sucrose, alucose,and lrucrose.
Ponutsard suga!freechewiûg gum arealso good salivarysrimu-
,n. !l ,! eJ | Ê !l e pH f' I o n r n e J l o , l o r' ' g . r g - -
contaiûinameal of s.ack. Applcs havellrtle beæIit compaftd

1.5
'-"olaeetrc
CHOCOLATE

CHOCOLATE 5.5

1 1 t 1 5 1 9 2 3 2 1

03 t 11 15 19 23 27 Fisur€ 2.ll Stlhm .lNes prodù.ed when sugaredcoffeewa

minutes tak€n alone (l) or tako togethr wnh the other twô non acidogenic
Figure2.10 Stephdncu6ts producedby dark(plain) chocohte fôôds (!). (Rcproduc€dfrom Russ-Gunn, ?l 1981, with lerûis
(contâinl.Asôrbnol).
kontâiningsugàt ùd diàbeticchocolâte siofl of th€ edno. Joùrnal ofDen.aL R$eâ.ch).
 2 Dielmddertolmries
pHstudier
Ploqoe
Medurc a.idoaeri. potunnrl, x. indir.t m!:6rre of.rf,ogen,.trv
Medure the pH oatLaque rsing Èirherxn in.lJe.lli.g ele.ûo.le rhat
ûÉsùres pH r, rr, or bt removing !lqù. srmples and meÀsunrg
^.ido8eni.ny is .{pre$ed as the dea oa ihe rnne/lH g.r'Ê
(Stephù.ùrv.), the ainidud Ftt r.à.bed rnd,ôr dre iime ntr
Rh,.n pH drops below t t (th. c.kicâl pH')
lnrurîtilll] ii{periIiril|5
In.ùbariorstudiesarcsidple;z rirm te*s thetmeæurcifpLaque
ba.teriâ cio mctabolize cèrbohydrare in a r€$ food &, Prôdlce
âcnl. Purc.ultu.es of micro-olsanisns may âlso be u\ed i. fla.c
of sùne phqùe. Rapid a.ld production and/ôr à low ilnal PH is
inrerprered to nean ùat à food is potcntirlly carioac.i., whiLe i
slow fute of ècid produ..n,n or lilghet finil pH 6 llkcll tu be ol
litde clini.al significance. Àll hono and disa..h.rides (r07 vnù_
tlons) frodùce a finaL pH ol belôw'1.t whcn incubate,l s'ith
Iû sooc i..ùbation experiment\, teedi, sectioned ôr Powdcrcd
roôth erdûel. or hrdrotynpatitc aft in.ubaÉ(l widr the test sub
siance ârd rhe p1èqùenicro{xainism in ordcr.o emùrdtc the
c2ricsp.ô.e$. Potentiâl câriogeni.ity is csrimate.lri.û rhecatent
of calcium and phosphorùs releasc f(nlôwiûg n,cubâiiôd Sù.h
srùdies hàve jndi.ared thet nraa^ conttnt ls an imPrtaft deler
minanr ôf the aûount of ftineral dissohed.
ls dentalcâriesrelatedto the
lrequencyof sugârsintakeor the
amountconsumed?
Thc impoitètce offrcqùen.] ve6ùs thc da.l amoùnr ofQgars b
diffl.ult ro evdluate as ihe $vo !'2.iables ar€ har,l ftr di$iùgùish
fron eà.h olher. An in.reàse ofeidrer pùd*er ohen automdû_
calijrSives ânincÉase in thÈ other, a.d likewise â redu.rn)n in he
qùency in intàke ofsugârs id ih€ diet should itù,1t nr a rcdù.ûon
h lhe rotal {gd6 consumcd.
Darâ ftoh âninaL sudie! hate indicatcd tlte imPoftxn.e of
freqû€lcy of Naats intake ir ùe develoPocnt of dettal .aries,
àûd have shô$n thât dental cnries exPerlcn.e ,n.reascs th
'nctcaslng frequeocy of iniâke of$tgi6 eren whe. rh. absôlute
intàke ofsùga6 eat€n br all gtoùps of r.ts js rhc sade. Ânim2l
rudies have also shôwû thd! Icss .aiies develoP as the i.reNxl
between fee.ls i.crcâses. Sone buma! studies also $sses dlar
thc frcauenq, ol suaa. intèke is ù mo.e lmPoftanr aeti{noglcal
factoL n,r caries devcLopmett than ùe totèl consllnptiot of
suAaf. The primary eviden.e fôr the bcliefthat the ])rc!âletce ol
denrâl carits is dt€cdy rclâ.ed to the f.egùet.y and to ùe form,
nr whidl sugâr is eàter..oûes f.om rhe viPeholm sud!
(Gùsiâfsson .r ,/. l9t4) Nlany $udics ha'e show. , ftlxtionslii!
betwcen th€ ûequen.y o1 intake of sugars and sLrgarrich foods
âf.ldcntal cârles,bùr mdnr ofdlcseh!'e.or simulràneousIt me.
surcd the relalio.ship besteen 2mount olsuSùs xn.Lcàtics leveLs.
Stu,lics ofprescbool .lildren halc sùgseste.li rhrtshold ofintake
oÊsugarsof4 timcs a day.\after sùi.h rhe.àLics sererny m2fkedll
i..re*es. Ior .xampte, I lolb.ook t/ ,/. (1915), ti I studr ôf t
yeaÊoL,l.hildreù in Iccland, ibun.lrhât nr chiL,hcn rePôitifg lbur
or norc inù&es oÊ suaaB p€r .lir or i o norc betweef meâr
$ècl<s tcr dar.Û,the .,ties s.ôres mafkedl! inctcased In .hildren
rhar de!€lotcd I or rorc lesiôùs rbc intrke of suÉiarsaveragcd
5.1 tiû€s per dxy dt age 5 ()mPâred lith 21 timcs a dav for
.lildreù who dNeLoped Lessdrad I .arious lesiots (t < 0 0l ) This
confirmed eaLLicrwork bI the s.me i.lcrigàtos rbar slto{€d
cârics leveLs ro markeclly incrcase rt liequencl of intakc above
Ru.oing .ôÀtrury rc the gete.xl pef.ePtio. dr.t lre.luenc-t ot
inrake i! rore imfoitâùt tban rh€ amoù.t of nLgas edre.. \evdal
lonElrù.Liûàl studie\ IFveshos'n the iDount oistrgùs i.tâketo be
morc inrpôrtànt dian fieqùef.y (Burt ./ ,/. r98E, Itugg-Gdû
,r,/. 19u.1).Aûimil stùdies hrve also beeû ùsed rc inve$igatc the
01 susafs .ôtNmed "'l tlre '*(l'
rel.tio.shb be.vee. aùrtt
opne.! ofdentàl carics and ha{e shosn â signiU.ant corelarion
bû*een .hc srLgd conccnÛxtiôû of rhc diet led to n.s dnd thc
ln.ideÀce of dentêl cùrics.
The.c ir, undoùbrcdl-t,a $ont corelâtion bets'centhe âmoùnt
ànd tlequetc) of sulas consumPtiot a.r ùe exPetr c.$enrr
is tbât both a.c ihpôitant (Rùgs Gù.n t9tl) ]i ,n amhsr of
dàta f.om ôver 400 11-12 yeat old.Lildren. Rùglj Cùin
dierary
lolnd the .oûelatôn beû{een fregnency of intake ol sugartich
foods ând tot.l weiEht .ôùnrmed e) be + O.ri (Flg 2 12) (Rùg!
Gun. ,r,/. 198J). Sidil.r oLrsrrvrtions harc beet lbund in â
numbcr ofso!!h Afti.an eùrj. E(trLPs.À vcrr hLgh .oflclxron
between frequercy of consutrllio. of sugarl drirks in Lretscd'
60 30 100 120 140
wê ghr of daiy intâkê(9)
Fi$rc 2.12 Tbc Élatio.sh,p ber{ee. th. ftequen.r, trnd nmount
ofconlecionery rnrale: freqùorcl of dùk. asâifli lint.k6 Pd
Jâ!) mount ôf hake (grd,I) n1 10t l2 t1_yearold Enslish.hll
drcn. (Rep.odd.cd tom Rus Gùm d,l. 1981, $irh Frmission
.f the eduû af Ar.tia ri ttnl Lir,trl:! )

Deats,n.l eount .onsùûed has been found i. A.iÊrl.an {:hil-
r- =-0 -.1ô' ' ir " . q' , i, li ' ',rr "..,
are,lwtrh hLghercùies risk. The odds ratn)s ofhâving aDÀ{ITof
àbovedre 80rh percenrik f.r aAc, in.rcascd |j'om 1.28 fà. rhose
hNing one sôft driùk per dar ro 1.87 ôr Nl.c, and 2.19 i-orrhrcc
or mor i.tâkes l,er.lày.
InsUmm0ry
r llhûè n eiden.e 6 show rbàr bodr drÊ nrquency oainlak. of rdn
dd sLLgariri.h aoodsand dri.ks, ând rbe rôml ànoùnt or sùsa6
.où'aed ùe relaftd ro denral.ariÉs
. Thfle n Èlso.vid.n.e o sliôù nrar rhey N! vùribles âre rrt,.gly
rso.iÈred, me,nils ih.t.froits iô..!ù.1one are liLeLr tû.onrrol
. Ir nlubli. heâkh Foli.y ro r.dtr.d rheanount.fNga^.onsuned
. À..h.l.vel ofthe individuaL,n is more pngnâ . ro rdrÆ r.
qju.e.h. t.(l!.n.J, oa.onsumpriôn
Aresomesugarsmorecariogenic
thanothers?
Man-!ofthc câdie. slu.lies iovestigrtnig the relâtlolship bers een
sig.rs and denrai.dies ta.usrd on suc.ose,\'hich wâsàr rhdr tin,e
the nain diet.iy sugaf. Howeler. mod... dicts of ptulâtio.s
in ni.lùstriJlized .ouûûles .onrain a m;x of fcrmc.tablc suga.s
nduding su.lîrc, glucosc,Ia.ros€, tiÙcror, AlLrcoses!n,Fs, high
iu.tuse .om srn\)s ând otber syrdr€nc oligosâcch.rides (e.s.
ftu.nnniEosa..irâridct O.âl baclena ùetiboliz€ .11 mono àùd
sugârsphyscâly ôcâredwithn
of jr! ts,
thece lu arstructLrè
vegelabes andcereals
Sugarsnâllrâly prese.t n
Iisur. 2.l l Clasifi.atior of sùgùs f.r henlih pu r!ôses:.liasiii.ation ol rhe 1989 Depaftment of Healrh COÀfÀ reloft Dlerary Su.qars
l , , r . t q o . . ' " , r o g .i l , o o l h r . , I 2l
I
dlsa..barid€r n)pn)du.ea.id. Anlmal $trdies hale shôwt ûocLear
cvidc..c rhat rhr .xrn,geni.itr of mono ând disacchari.ledlffes,
widr rhe e'.eprbn ol la.tose. Hô\re!er, plaque pH stu.lles have
shown plâquc baffcriâ ptr)du.e less a.id ftum la.nxe cômp,ùed
with orhcfsugars. Someanimal {ùdits havÉÈpôiie.lat iùcreÀed
.ârlogeni.ity ofn,..osÉ bû in these $udies the ràts were n,teÊ
infecle.l vilh S. n nrlu which urilizcs su.rosc nr prcteren.e nr
o'1".'e. L - ' o\'.' 11 l\,'.r " 'a. , -
ogeric b€câuseit 6 a substrate tor exùa.ellulâr dcxûan slnrhÈsis
by S ,trtat!. Coûsumprion of n,cros€ does, therelore, ledd ro
ir.ieàsed p1àqnevôlume. Howerei, the anoùni ofpld!ùe lbrmed
is nor ne.e$afill, reldrd ro cùiôgeni.iry and high cari€sdevelop
nenr in rhe ab\en.e ôf sigûificâût p1èqne hù beer reported
(Rusg-Cunn 1993). Srudies in lruhars hale alsô nNesigated
rhe.tifereû.e i! the.diogeniciy olsone sùga^; lor exdmfle, dre
âforeme tioncd Tu.kù {ùdv showcd .o ditl.ftnLr Dnwror ur
.afi€s developmenr bd$Éen subjeùs ôn dies sweet€ned wth
sucrose compare,l wnh ftu.tose (Scheidin ând ùtàkirer L9jt).
Invcû susâr (50% ftuctosc+50% slù.ose) bas been shôwn nr be
20 2t% le$ câriogeoic lhan sucrose.
There is no elid€lce liom epirlemiological studics dnr nga*
locatedwrlur rhe cellulù s(ucnùeofa tbod arc ha,lntul tu teerb:
.n.t, rherefore, for.tertal heâlth purposes, rt is iûrof.anr ro dis-
tinguish bet\eer th*e $rgas and $rgas i. rhe tiee fô,1n. The
rern, âdde.l sugà6 is.or ileâlâs it cx.lùd$ sùAz$ in truit jùl.es
âtrd honer The term free $gar' hd Lreenused by the \i'orl,l
HùhL Orga zrtiôû. Iû 1989. rhe UK Côûmittee o. N{e,licâl
Aspects ofFôo.l Poli.y (cOù{À) .làssifie.l su$rs for dental health
furlnNcs ;.to i.trinsic'a.d exûinsi. slLga.i (fig. 2.1l) (Depert
mc.r of Hcalrh 1989). Eiftinric sùga$ were sub-divided ito
'milk
suga6 (as lacrosc nârùauy f.esent i. milk i\ not thoùght
s!ga6 physcaly ocatedoutsde
lhe ce ! ar strùôtLre
ofloôds
Non"milkextrinsicsugars
cois!ner pruss!garsprcse.1
lr iru t jùices,honeyârd
 I
22 | i D i em
! dd e fo l û r i e s
I

ro be hàrmful to rhe reeth) d.t ron-milk exùinsic susa^
(NMES)' Nhich include âtl sùgarsaddedbr minùfi.rurer, .ôok,
or côDsûer, àrd hoûeydd frtrir jui.e!. In rerds ôfdenrâi.dies,
it is the intakeand freguen.yofintâke ofNMEs (,r 'freesuEars)
rhtt ûee.tsto be recLu.ed.
(oriogenicity
of rugor:
' Sn.rose,glu.osè,fru.rôse, add maltose hâve simiLar.ânosemlty
prevenrive meaures su.h as use ol lluofu1e are emploved. a rela-
dônship betweensugâs iûtèke àrd câriesstiLlexis6. Âtler revies'
ing ihe literàûre or decLùes nr .aries Md Nocia.ed lâctos
Marha.ler.on.lùdtd that
wid,ir n,ode.n socicrics shi.h arc as'aft and mxke Ne oi
pftlenrbn, rhe relâtlon bet$een n,gâ6 .onsumprior and
rûies a.tility si11 exis$,

. Lrciose tr les d.l.geni.l.ariôgèni. û d h e a l s o . o r . l ù d e sd r â r

. Physnd lo.ator ofsugds in fôods !ffeùs the,r .eiôgêli.iry
sùsàn lBle be.n.lÀsin.d into irûirsi.'and en ùi.
' Inùi.\i.sùaânâre l.câredwirbi. dre.ellulâr$ru.tùreof
ând Àremt thoùghr ro be hârmful to teÈtir
' nxfinsi. sus,^ are lo.ated ousidè rhe.elluLrr$tr ù,.ê ôrr1,ê finxl
ând ir.ludê lnilk sùgri ând no. mnt Êxûnri. sùÂâK(liee sùsàn)
. Milk su!Ê^, wbe. nàrùrâlly prcs.rt ir nilli o( milk prodù.s,.r.
nor bÀrmaul to tæth
' Non niLL Érûinr. sùs{s (free sùsâs) âfe drÊ suse6 thâr xre
rnd rc.cnr srudics harc dcmo.sùared rhar sutj
wcll âs othcr hcxoscs .onrinùes ù) be rhe mâin dùert foi
nrefoorl dc.tal hcaldr of 1) sh.le fopulat$n in *,me developedand
n,d.y delelotinA countLics 2) for ùc indn'idul in both
, \ , t o . r . , - , , . ! , . . . . , , , . . i , . . - i
pogress mde in using fluôrides rnd improved oful
Àlihoùgh dentaL.âries levels hàve.teclined in nnDl .leleloped
counrrics, a 5ig.ifi.ant .elarn,n\hip betweed ittake ôf dietâfl
suA2a â..1 carics lcvcls pc.si*s dcryire widegead use of fluotide

Doesfluorideeliminatethe ln a s-vs.emaricrcvicw, Burr2nd Pai(Bùit a.d Pai 200r) âided

to derernnre whelher wnh exre.si\rc iluoridc cxfosu.c, indiridù-
sugaïs/
caflesïeraûol'rsnrp
r rls sidr â high level of sùgas inrakc cxpcrien.ed sreater .aries
The evide.cediscu$edi. chàfter I iLlùsrâtesthâl flloride is the scvcrlrr rclâtnk ù dmse s'ith a low€r level ofintake. The tvie{
mor effe..ire piopbyla.ri. aEetriagain{ .aries. irs ùse laraelt .oûsisred of a seJrch of datâbaseslor fetes tublished beNan
a..ouûtinu for the de.line in denralcariesdrat hasbeenobsened 1980 ù.1 2000. The 11.èl d.alFis i.cluded 16 rudics rhr dt
in dereLoped counuiesoverthe pat thrcedecadcs sumûèriz€d rr Tâble 2.6. Over hùll ot dic fafc6 lound a
Much ofthe.lara rhar iliùstruresan associdr;ofberwee.intâLe moderate relarn nshlp and r fufther sixteen, è we.k r€larionsiriti
ordi€ta.y sùsa4 and deolal carieswer€ collecled in dre rre ûo papcr failed o find a relâtionsLip bet$eeû n,gas iùale md
'Ihe.on.lùsn,ns
fluo.ide era. More .ecent rudies of the r€lalioosiil belween .arles. of the !]rehati. review were:
sùsds and cariesare .onfounde.lb\' the presen.eofnùori.le bùt . \irhere drere is good erposure to flÙortrl€, n,ga.s co.sump
shoN that a relarionshipbetweer suga6 inrâke ând carlesst,ll rion is a moderate nsk lâcror tô..irics in most fcoflc: xnd
ciss ir rhc prcscnccof lluoridc. Fo. exàmfle, dre or2l hcâlth so, f.evcntinE .onsumpùoû ot er.ess susds b r ju$iliable
suûey ôf the NDNS of.hildren ased 1.t to .1.t yeâBin the LrK pdr of.dries prelenrior if not dre most .rucial âsFct tbl
(Hn.k àrd Gresorl r99t)foùûd thèt the asso.iationberweenlre
quencyof intake ot sugar-vloodsand dertal .arieswas only par
. Suuàs côrsrmption is likell to b€ a more lros'cdul indicÈ
tiàlly ûegâtedbv the freluent use of fltrori.te. lù nvo naior
tur n,r .isk ôf.aries i ectiôr in persons who .1o no! hare
longitudlnal*udies of tLrerelatn,nshipbetwe€nintakeofdittarr
regular erposute rc lluoride
sugas and dental caies lelels ln .hlldren, the observ€drelatntÈ
ships betweensugÀB intake and deveLopmentof dental .aries
Lcmai.cd cvcn aftff conùouinA foL usc of fluoridc and oraL
Tâble 2.6 Disùiburion oI l6 pàpe6 sl,owing stro.g, modcnt,
h y A i e n ep r a . t i . c r ( B ù r t r , / . 1 9 8 8 .R u g S - G ù n n , r , / . 1 9 8 , i ) .
rûd weù relatioùships b€lseen sugas inrikc and dcnral.ades
we.ver (1950)iepôftedon rhe t.u in.aries leretsbesveenl9il
by t,vte ofstudy dcsiAû (Bù( xûd Pai 2001)
ân{l 1949 in !2 yeâFoldsfrom areâsçith nâtu.allyhigh anl low
wareriluo.ide concenùâriorin Noûh E2srEflgl2nd.Caricslcvcls Sûong Moderate
s'ere loNer iû the hish iluoride a'€d in 1941, bu. followins rbc
war time susèrrestxctior, dertèl .âriesLelelsfel1afùrther t.1%,
r'dr,::,5" '.po ' "il .o,,lFf,IIoô ' ' . J Jo ' 1 . f - 1 "
effectofsugàrsir the diet rnd thàt exposûreto fluoride,.oùpled
t2
ùlth susàs re$ricrlon, hàs addedbeùefirsfor cùies redùùion.
ùlâ(haler (1990),a leâdinsepidemiôlôlisr,revie$edrhe.hâûges
in rhe Frevalerceof.ienûL cariesèr.l corclùdedrhat eleÀ whe.

. $/ùh widespred useol flùori(l€,msâ6 conNnrFnrn *i11
hd a rô1ero p1èyin tlie Frelenîiof ofca.ics bùt rhn nne ls
. 'ltr'',. o'r'1o,'.' lr iJ
Tïe erideû.eôf ù dsôcrâtionbetween,1iet:rysugar and dental
.dies.onesfrom a r!ùLrer oldiftèrenrry?csot cxfefiment.From
d,isbodyofevilence,rhc àllon inA .ondùsn)tutuy be drèwn.
Diehry (orier
onddentol
Jugûrs
. Sug$ â.e rlt m.$.â'l.Aenic l.em ln dre diet
. The .âriogeni.i tl oI sù.tuv, glu.ose, aru.rosè,ad mdhos. ar. sinri
lù bnr drar or Lr.tor n l!*er
! Irtguen.r ofeadng n impodùnr, b!! ri.l!e..y ot Rting Ax( ftLr
looasr.,la'nounr.onnnÊJirÈ highllas..iâred $ drâr eaaoii!to
..nrcl.ne sill.onrmL the oùer
. {" '" r"' , i '.
o ,-1, '. 'd p .
Dostarches
causedentalcaries?
stu.n.onsitures a heteiogereous food groupr it v,rics ir botan-
i.alofigin, it mây be highlv refined or consrned rn rs natutat
*ae: it may be conuned raw or jn a cooked Iom all dtsc 1,.-
tors drould be .onsidered when a$e$ing rhe cxriogcûi.itr of
stir.h$. Son,e ârgue rhar âll .arbohydrates .aùse Aettal .dties
hccaurcsrarchcsare t,rcken dorvn by salivary mylde releasing
glucosc..rahosc. ând nraltoûnxe dht mây bemetebollzed byo.al
ba.leria to produce aci.is. Hoal\'c.. rhe evided.e tu support dils
|oe l' \-IK ' .. ) ,, i . ,,,-'
dierdri,gu elines lor health fromotc i.c.carcd .on mption of
starchrich stàple loods Lr!!.ecomm..d linritinE the xmouût ôi
non ûilk ex(msi. susèrs (liee nrsars) .on$rmcd. It is, rhe.ef{,re,
importàùt ro consi.ler rhe cârioAcni. potcnrial of rar.l! ri.h
trafle iiods ùnd gar\ as sepamte is$es. 1he folloNng prra
!ftph\ will .ônsider the ev ence tom alL r11,csof cpcrinents
Èlâtiûg to dF c.riogenic liotenrial olrarch conraining frnds.
llirnlrn ohsri-/aiiilnill stùdirs
Efidemnnogi.xl sudies hd"e sho*! drar starch is of low .ariÈ
genl.itl People who.onsume high r.r.h/low srgas li.ts AcrcF
âllI hivc los'caries experien.e, *ùereâs peôple \îho.onslme loF
srir.hlhigh Aa$ die.s hale high levels of.rries. l. ihe l lotc
{ood Hoùse sudy, .hildieù .onsumed a hiAh stàrch. lov ga$
ilier in(l ba.l Lo\r levels of.,rics. Childftn rith HfI have beeû
shown to hâvc lon lcvch oi .afies; rhey .ânnôt .ôns ute sucroseol
tiucrose,bur can consunrc u.linriied amomts ôf$arch.lt a lon
gutrdinrl $!d! ofdiet do(l d€.ial .ârics in il r2-learold [ûg
lish childrer, ltùgg GunÀ rr a/. found no corrclaton between
int.ke ôfstùch ù.1 .arles incr€ment whcn.onùoui.g i(tr su!,ts
!nke, and chll.lren wrth ilgh stârcb and los suaaB inrakes
developed significàrtly fe\rer cariols lesions rb2n childrcn slih
low $dr.h'ligh sugùs intake lRuga Gu.r t,/. 1t8l). fù(her
Dosrorthes denlol
muse ories? | 23
I
€lldence drar starh is ôflittle imprtat.c in dre developûent of
.rries comes i-.om {ùdie\ ôf dlet.ry cbangcs during the Second
World Wâr Thc intâkeofstèr.h increded du.inA rhe wû yeà6 in
Nor\ra"! ao<l lâpan, yet the prerèietce of caties wrs reduce.l.
Whû $rga6 intâkc in.Fased dfter the wâr, lcvcls of.aries è1so
,.c.eâscl. Popùlatbns thrt hrbiealiy con$me a high $.rch/Low
sa.\ diet have dlso been rcpolted tu hare 1ôw leteh ofdcûral
.aries, for exaùple, rbc Chinese ù.1viettamer, Eùiopians, xnd
south Àmericd. ln.liàns hare eateû côoke.t $irches in dre f(,rn ôf
.i.e, $hrar, dld r.lze brr h2vc a loa strgars intake and low câries
Thc ccohgnal sudl.oofSreebny (1982). along wùh.oota.ing
sugâf arailabiliry ard level ofcarics. c.nrpared the cerealsavdil
rbility ând lcvels of.dies it t2 -veerold .hildren ftum 17 .lif{er
eni coùntfies. ùsing data fronr the \Xro.ld Health Orgènlzation
Glob.,.l Epidemiology Bânk ând Èod ba.lanceshe€s.omfilcd tôr
die lool ând Àgfi.ùltutul Orgmtation ot rhc llnlted Nêtiôûs.
Cer€dl â!âilâbility sa\ quàttified i. lwo \tys: (1) âs the ProPor
tior of energl rrorided bl .ereâls àrd (2) as drc nunrber ôf cè1o
ries provided by cercâls pcr dxl. Bivâriate corel2rion â.alFls
sho'ed the .orrelâtion bctvcen ttrl .ereàls nvdiLabiliry and
DMI1 to be 0.21(cdlû,l2tc,l as.al/day) dd +0.,1t (calcùlarcda\
propo.fuû of energy) !_or whcar, positive corrFlrrions wc.c
obtained sirh .oefficierts of +0.1t a.d +0.i0 for cat/dav an,l
pef.€nr of energy resfe.tivcly. Ho$ever. whet tbe dârâ aere
exrmined firrthcr, ùsiûg pa(ial.orelation inalr's (ahl.h xlloùs
a. cxxminarnrn of rhe cèries ve6us ccrcâl relatn,nship wlie. lhe
cfiiff of diiferencesir sugù avdilabiliry ir .€môved), the cotrel2
tioûs belvccn ccftx1 xvailabilitr'' atd DùffT wet lôw àn.1 not
signlfrcânt. Whcn dre .oûelâtiôt betweef DùIIT ând tugâs
.vèil.bility (i=0 7 fbm bivrtiate anâllsis) was coniftnled for
cereal avâllabili$. drc.oûelatbt fell only slighrll ù 0.67 ât.l
'Ihese
remdiùe.l highll significant. fnrdinss $rggcst â n .h
.loser tosiln'e relarionshlp benveed .lettal ca.ies ,nd gaf avail
àbiliqr dur betiee!.ere.,.l J!àilùiLity âtd dcntal ,xr c(
Xlrrlan intrl1{:n1i$1!ludie!
I. drc aiàremedtiôred Turkù sugar studies (S.heidn atd Mâki
ren l97t), drar inverl8ated the effect on ca.ics ot (tral nLbritu
tion ol srcrosc $irh iylltul o. frl,ctose, ùany iôods s'e.e spt.iauy
manllnclured rcpl2.ing .rôse with xylnol o. ILu.nxe, but tlt
stùch.onleot remai.cd ùnaltered. The mean 2 yca. ca.ies 'n.fe
meùs for rhe sùcrosc.iru.h\e, â xy1ùol groùts qrc.c 1.2. j.8,
àûd 0.0 resl,ccti\Ély. As intuke of starch s'as not limited
a.d ail srcups ar uùliûrlte(l st2r.b. d'crxry r.r.h .antot bave
()nùil'ured sigrilican!ly to câricsdevelopment iti thls s.ullrr
A irYialcrperii1]înts
À!im.l $ùdies havc sh.in thai nw stù.h is of los .âriogcn1.1tI
regardtess of d,e mcthod of feedhg. Iû sù.lies whc.c cooked
stù.hes have been t:c':t àd Lr't,n. stttcl\es .nrse .atcs but onLy
abôtrt half the anouil! câuscd br $.nN. How€ler, mix.u.cs of
rar.h ard &rcrose à.c more .xrn,geni. thàù stàtch aLo.e ind dre
 ? Djs,ondden'ol(oes
anoùnt oi ca.ies drai develôps is related ro rhe sùcrose.ôncenr.a-
rn)n ln tbe oix. Bàkin8 of suaar corrajning srâich fôods
in.reasestheir cariogenicpô.enrial.AninaL studieshÈveshown
tlat stârch .ich foods su.h as bre2d cause caries bur tô a much
le$cf extent thân ùùôse. A rhc frequercy of irtùe of.ooked
sdch or .ooked starch .onràlnin8 foods increases,rhe lerel of
cèries ircftases. À sûdy usinA ûe iar model ùo{'cd drar n,take
or s$rch èr.t 1âûose vas nor relate.t ù .aries d€velopmen!,
whereashighly signifi.anr correlarlons between intake ofglucose
(r=+0.,i3),reduclnssusars(r=+0.30),and sucrcse
(r=+0.18)
werefonnd.Cautionneeds to be àppliedwhcnexrrapolatins
the
resu16ôf animal yudies o hudans dùe to differencesn roorn
morphology,plaquebacterlalecology,and salivâryilow and com-
pôsittun.The bufferjngcâpâcityofnr s2livais alsoles thân thar
ofhnûans. In ao;malrudies the Ëedsarealsousuajlyprolide.t in
a powderedform .hat diIIe4 in dre wdy in sùl.h *dch is hâbi!
ua.lly.onsumed Lry humàns.Noncthele$, mlmâl sn.lies hare
enabledtic eilect ôr cùies ôf ditrÉ.enrrypes,freqùer.ies,and
dou.ts of carbohydrates ro be stud;ed
{rl:r.[ii]pll slucli.s
PLaquepH rudier of sta.ch conralnirg foôds using rhc hân'esrins
method have indicared rha! cooked sâr.h or s.archy foods ùe less
aciclogeni. than sugâ6 or sùgàB,ri.h foods. Howev€r, stùdies
usiog the indwellinA Alas eleftrode method have shown {archy
fdrds to def'r€$ plàgue pH helow t.i, by â similar exient kl
suga., and hy these criteiià, starch .ânnor be caregorlzed 6 \afe
fôr teerh . Plaque pH stu.lies thâr use an i.dweLling plaqùe e1ec,
ûode do, howevea teûd rôglvean allo. norhjng respo$e. and arc
.ot good n discriôinâtlna drc acidogenic potential ofdifferenr
carbohydrates. Plâ!ùe pH sudies rhar renove plague f.on all
arcasoflhe ûorth ùd rhe. measu.epll (harvesrins merhod) arc
more .liscriminatlnA. ft musr also be considered that plaque pl:I
studies measuieàcid prcdùction froûr a sùbstrareand do nor mca-
sùe .arles derelopmeûr. fhis means flaque pH $udies tuke no
accoùrt of rhe pde.tive lâclors fouû.t in some starch-rich fbods.
En.rmelrlâb ÊllrcfilliirnLs
There havc beer rwo reports of the elïcct of cookecl, rarch dch
fôôds LlPon the deminerâlizarhn of enâmel sldbs unter exper!
dertal condi!ions and both hâve i.dicâred rhar starch .àuses
approximately 252, of the deminc.ali,alion seen *ùh suc<*e.
En@el slab experiments ln humans have shoùn tlur raw rar.h
does nor.aùsc demireralizâtion.
l rtdhir l ion L-iirreri
rrelr'it
Starch is .ot t.anspoited àùôss the .etl membrare of plâqùe
mlcro orsadsmsand sô.arnot be merabolize.t by ordl ba.terlaro
pfoduceacld.Howeler, sâlivaryamylasemèy hvddyze sta(h ro
produceslucose,mâlto\e, â.d mallorrlose,è11of whi.h nay be
taken ur and metdbolizedby bacrerialcelts.T|e rate at which
ya.ch is brokendos'n will dep€odon the narûe of drc srârchafd
rhe aDount of mylae pftscnr.
Sumnarl of stocb and.lertal carks
The UK COMA irânel oD dierarv &Lgds dd hùman d6c2se co.
.ltrded rhar sta(hy sr2ple fàods were à ûeljligible .aùse ofdclral
cafies and that iû or.ler to redûce the risk ofdcnrâl (aries NIIIS
consùmprion should be decrede.i.n i repla.ed wirh fruit. vegeû
bles, and star.hy staple ibods (Depàrtment ôf HÉalth 1989)
Starcbeshàve be.ôme hôre pro.escd a.d rhe fr€quercy ofeâting
may hâve nrreasecl ir soûe .oùnûies. Many highly procsrd
srârchy toods may ako be high ln fats a.d o. susa6 ard salt (eg.
corn snacks,$veetened brcakâs.ereaLs, cakes,ancLbiscùt. ftn
oot intàke ofthese, bur ihc i.c.€ased j.tèLe of srâr.hy sraple foods
thàt is being e!.ouaaed.
Stqrches
onddentol
<ories
. Cooked rç1e $ù.hy foods suô d ri.e, Fraroes, an.] bÈad aF o1
low.àriogerlclry iû humrns
. The .rriogeDi.itv of u.cooked $arc[ is very Lov
. liineLr sroûnd md heat ûÈted s&c! ni.y crusedertal.aries bùr
rhe moût of . ies h le$ dun .ha. .àùsûl by suga$
. The âd,:lit ion .a susan in.riles rhe cârioseri.ny of.oôked sû.hy
toods. Foodscoùtning .dôLed $mh ând sub$r..jal mo!.s of
su.roscapF.d to Lred.drogeri. âs simil{quanrkies ol crcse
N ovel carbohydrates
and dental
cariesrisk
Conmerciâl prôdu.rhn o{polym€rs ol: glucose ànd oligosâ..ha-
rides ôf glù.ose, ftùftose a.d saLa.rose, èn.t theif ùse in food
prôcltr.s i! in.reasi.g. Infô.marioD on the dertal hea.lthetre.tsof
these cdbohyd.âÉs is drerefoie ofinpoft.nce. clu.ose pollne(
and non-diAest;ble ol;gosaccharldes àre fermentahle cârbohy-
drJtes, hôwever piodu.$ drai conrâin them m.y be labelled m
suaàr free (€..q.some.hewable rùgaFfrcc' vitrm i n ràblers co ain
fiu.nxnlg\a..ha.ide0.
Glu.os€ svrUx an,l mâltodeaffiN ùe .ô11ecri!ely krovn ù
glu.osc polymctr aûd are prodùce.i by àcid hldrtysls ofsa(h.
Thcy vâry i. compositior but.ontain a mixrure olmono, di, rrj,
rcùa, penta, hexa, anclheptaaa..barldes ard 2lfha limjr de!ûins
Ghort bmched chèin sà.charider. :rhe dca.ee of comrlexiry is
exrressed as ûe dexfose eqùivalcnr (DE)j rhe less complei ùe
Alucosepolymer, the highe. rhe DE. Glucose synrps hùv€ aDlof
20 or more, whereasmalodexÛins are mo.c .omplex â.d [aye a
DE of less .han 20. Glucose l)olyme6 ùe viftually ra*ele$ ed
odourless ând âre urd to inc.câse die eoergy contert ofa vadery
of foods. Ther are frequenrlv âdded ro iûf:rt food ând drinls,
spôrts dfinks. dc$errs, coofeclionery,àtd energy supplemenrsfor
u\e ln .li.icâl dieierics.
Glu.osc folym€s contain rièces ôfmono. di, a.d ûisacchl
,d, I ' ,..\ he.-alol,/"d L\ p"9r i.ru-o;- '.
Addirionâl\', saljvdy anylde mây hyddyzc the loûSer gly.o
sidl. .hai.s ro mâlrose and glucôse fhe ertenr ofhyd.olysis br

anrla\e s'ill be derermired br the reteûriôû time in ùe oral
lavitl: The.efbre.glu.ose polymer have rhe pôrentièLto câlse
denta.l.âriesbur evideû.€ùdemônsrâte dû ù spùse.Most ddla
.omcf.om an;mal,plaquepH and rr zira laborauy sudies. Glu
.oscsrfùp {nùtb$ hale beeû6und to be less.ariogeûicthan
\uror solurioN;howeler,shenà.tdedto the sotrdcomFo.entol
rhe.rt diet, no difaerence in càrjesle\relofmcnr hasbeensho*û
beNeenrats fe,l glucoscsy.ufs ard mts fcd N.rcse In htrmats,
subsitulionofsuc.oscwidr glucoscsyrupsrewlted in markedly
Êdùcedp]âqxe scores,bùt îhe moùor ol flaquc prcscnris not
n(esârily relatedto.èries dereLoFmen!. Ghrcos€synDs ârctrc-
' rp- o l . ô ! . I o l o| . , ' r o r ' 1 . ! ' . i F o ' " , 1
âboutûe effectofsuch nilks on i art cùies. Plaque!H studics
sl,o$ no signifl.anr differencein {i.lôge c potertrar Lrels€en
sotaiûlèûr forûu1è drd stJndàr.liûfanr milk Iloweler, pl2quc
tH sud'cs do rot ac.oùnrfor rhc los'cf.onreût of pfttre.tlvefa.
bÀ ir soyamilks and rhe eiteùded time ior lvhlch ,nfaotsn,ay
needro reûain ôr this fôrmulà.
 maltodexrin solLrnn (10%) hds beer shown to lower
flaquc fH hut ro a lc$c. crtc.r dran â 10% inuinn ôfsù.rose
(Iig 2 l4). l. rhe âbsc.ceofcvidc.cc r.om hùma. .llni.xl ûiâ1s.
advicefôr dre useot glucose])olymcf shodd bc rh€ sameasdlat
'fo
lor noû mllk €rtriûsic srgars. safeauârddc.tal hc2lth. it Â
lrelerable thar, if consùmed i. berween meals. maltodciûins
ùt âd,lcd orll to loods and dfinks that are clearedftom the
Tlere is àr iûcreasiDsinterest ir the s-vnthesisof novcl
ol,gosa.chùrdes(e.9.preb,otlct and in isolalingrhc transglùco-
s_rlareûzymesdiat enablethenprôduùion, ror ônl! tor econon
i.âl reavrnsbùt alsô due ro porenriâLhealth benefrs. Many
areftslrânr to digesior àn t pùs on ro
srndretl.oliEorâ..harldes
pH
7 1 1 1 5 1 9
lisure 2.1,1 Stphan auvcs (mcan valrcs (1stj) of 11 Nbjects) ol
107a(wiv) solûions ofmaltodcrtrnr. ofNro* x ofwatef
alonc.(Rcprodùc.l]ftôm Nroynil.û 'r,/. 1996, vldr pemission of
the elnot af tn.ndia"dl ./o,nnl al Patdidlti Dt"^\.).
0æs
rrulmuse ories! | 2 5
dentl
I
lhe largc irrestin€ y here rhef encoùragedr€ Arowth ofbifidoba.-
leria, sbicb aft known ro redu.e ûe Sroçlh ofFathoaenic micc
organisms. TheI may, therefore. protec! daâinst discasesof the
bosel. ÀIâny of dre speciesôf bà.t€ria foùld in th€ colo. a(e also
prese.t in de.tal plagùe (e s. bifidobàûeria ârd lacrobacilli). and
drcreftre the dentaLhealth eff€ctofthese.ovelca.bohydrates is ol
Isomoltooligosorchorides
. Isot ltooligosæchârides(lMo).ontiin monôs"ihti.]R nia rP
(,l-6linke,i (b!t inây.onEin dl 4)
. IMos in.Lude i$nâlrôsè GLû.6e dl-6 slL,cose),isooâkulole
Glù.ose dr 6 ûù.rôe shl.h is âlsokno{n 6 pàlà rose)âd pânose
Gh.ose dl 6 gLù.Ge d]-,i llùcose)
t lMOs âre lrodn.ed lircm sàr.h or $.bse by ûi.sglùcosvlalio.
returi.ls usntg rrnsalL'.osylde erztns
.!. arra,Ispccies meiabolizelMOs to amuch lesser exte!. lhan
gLù.oseand sucrose,and plaqu€ pH sudies in hùmàn volùlte€s
hàve èLsoshown lhat IÀIO arc le$ â.idogenic .ômpèred with
glncor or srcrose, bu! mây .cvc(heless rcsùlt in a fài1 in pH to
belos the cfuical pII of t.t. Studics n? 'itfl have showt IMO to
inhibit glucd synthesis riom sucrosc aûd inltbt tht $.rose-
depeDdenrâdherenceof.l. ,rrt 'r
tru(Ioo[g0lo(flonqe5
Fntrroollsosa..hâridÊ!(FoS)ârê âisô resnraùt ro digc*ion rn
ihe qrler ax*roinre*iml tm.t and iturerse the gro{ih of
FOS âre $idely usodin dre lood indu$ry if,Jâpxn xnd in.reÀrdglt
so in the Lrnned Kingdoa
I..ubarior $ùdies show FOS to be d.ariôgeù,. d s,.iose, bej.g
npidLy metabolized aolidsnrg ,.cùbation wilh severâl *Eins ot orâl
$r.!!o.o..i ard indu.nrg llÀque grorvth
T p tFpll .i'. u fol 'le" bc1ù ' i di s i/
lOS to Lrods dci,losenicàsrù.r.se ând rhus loteùally.ariùgen,.
Doesfruit causedentalcaries?
HeaLthrepoits throùghout the wodd encouraseincfeâsed.ôt-
mptionoffrults àrd vegetables with a minnntrm intakeqùôte.l
as.100g per dal or l'ivefoltloûs. The 1989 UK coùIÀ report
.c.ommcûdcdthar in o.der to reducethe rsk of derràl càfics,
consumptfn of non nilk erùnric suaa6 should be decreas€d
and ùat rhesrsqtarsshouldbe repldcedby liesh lruit. vcïctables,
ard sra.chrfoods.The UK Natiôûâ1FôodGùrde The Balaoceol
Good Health .cconrncnds rhât one{hird of dierary vôlume
snoull be !.olidcd by fruits and vegetables(Fesh,.anned,a.d
Èozer).I.esb nuit jdces arelû.hded dôngst fn,it aùl vesera
1., ,' |.Fo','e,Jlc - 1r' -i .a -p,o, r.)
colnr as only ore of rhc minimLm five portiots. The preferet.e
26 | ? Drer (orie5
onddenrol
I
toqa.ds whôle frùirs a.d veserdbles is because these .ontxin
more non stàr.h polt'sacchâ.ides aDd plàrt.ell sall matcrials
rhât beDefit hedth. from a de.!âl Foint ofvie$, it ls als) pftti.
able to constrme wholc nesh liùr d oppôled ro jùlccs. bc.âuse
rheir masticarion piovidcs â goo.l stimnlus ro sâ.h.ary llow. In
addirjo., Iresh fruir jul.es.o.râin no. milk exÛinsi. sùAars.
sin.e liçùidatio. reledsesrhe fnùt suAas lrom rhc celLular srn,.
tùeofthe fruit. \Xrhar is rheeli.lence, rheref(tre,fàfân â$ocidîior
betweer fnLir ând dcn|al cdries?
llun]:ri ob5irûational5lù{'liei
There is little evi.len.efron, €pdemiologi.al sudles ln huma.s
that coNumptbn of lruit is a$o.iared with rhe derclofme.r ol
cariesjdd indeed.ncAarivecoûeldiôrs betwee.iru't .onsùmp
rion afd .lertdl .ariesharc beenreported.
,{ number of cros se.ilonal studics hare cornFùed clenrâl
cariesexperien.eto ]cvelsof fruit .on$mptn,.. Srulies in rhe
USA, UK rnd Scandinaviahare fài1edto Ênd a. 2$ociarion
betweenftequcncyof fruit.ônsmprb. and dcnml ories. Y/her
rhe frùir intakesolchildren *irh high câ.ieshale beer ioûpûed
ù rhoseqidr 1ov cùies. rhe laftcr groùp tend ro havea hi8her
iruit co.surptlon. Lôrgirùdinalsù,lies in lhe UK d!.1USÀ have
lound a negètiveas!).iatio. berweer cùies iû..em€nr and rhc
co.suûption of fruit. Tlre orly epnleùioiogicâlrùdn itr shi.tr
an asociâtion betweenfrult .onsùmttion and dertè1.âries was
denoNûared,.ompred denrrl.ariesexpe.ieD.cof SoudrAft ican
worl<e6ôr appleand ar2fe farmswrh wôrkerson Anin fârms.
The sùbie.s wereased It aod overàrd had livedon rhe fams l:o.
èminimùm oi 8lea6. The.teùtu1.a.i€\expcricnce wd hjgherrn
rhe vrkcf tion, rhe appleurowing farms(DllflT 24) conpared
witb dre arâfe Aro\ring fdms (DIIFT t7). and rh€ cariesexperi
enc€roi borh rhesegrotrpsôf \aorke.svâs sigoiicantly ligher
rbanthâr ofthe gnir wofkers(DMI:a l0).'fhe leleis of intakeôf
frû br drc s'on.e4 were very hishi drc won.e^ o. the Jpple
turms .onsumed on averuge€ighr applespef dxy shcfcas rhe
wo.kc6 on rhe sièpe farms.onsùmcdon averaseihreebunchesof
g.apcspe. da\'.However,rhe hiah DùIIT lerelswerelarge\' dùe
tu mi$ing teerh,the cruseofwhich wasunknown.
l)ried fruit, potenri2lly, n,ay be more cariogenl.t si..e drc
drying prôces b.eaksdow. rhe cellulài sÙu.tuÈ of rhe trùit
releding erÛinri. suAa6 HoR.'er, .onstrmptbn ofdrled tfùir is
generâ]lylow a.d rhc.eare oo ep eûiolôgi. darx ro l;nk it ro
cùies developmcrr
lilunlâninterv(_iiticllsLirrlir!
The of ly intervertiôn rudics off'uit and dentàl.Jrles hâve inves
rjs2!€d ûe efect of apples on the develornent ôf deûtu1 .aries
with equi!ôcal rcsults. I. on€ study, in.hildren\ homes in livc.
Fool. the .hildrcn s'cre Alven è sli.e of an rpple folloving c,ch
meàl of rhe dal a.d âfier any between meal sna.ks. Thrcc age
grotrps were rùdicd: urdei 6lea6,6 L0 yea^ a.d r1 1) ycâ6.
Àt the end of â qo yeâr Ùial, the .xries i..rcmc.t vâs lov in
both the primxrl' and Frmaneùt denritiôns ln a.Uâgc ArcùtJs.tn
i.od,erdietary interleùtio! serdn ôfolder sùbje.is, ân aprlc Fxs
frovided lolloùirg rhe t.st deal ofthedat but no sianiic2nt dii:
iè.e.c€ vas observe.tin câriesnr.reneni .ompaftd s'irh a conûol
AroùF rot receivirg çp1es. Neitber of rhcsc sûdics loun.l rha!
frovnlnrg exùr fn,ir in the form ofapple\ in.ftascd c,rics lNek
A1ïirnai5tu{iles
Higher càriesscoreshave bccn f.u.d in rais tèd ûgs, atples,
banatus,srapes,ând raisins.omp2.cdwiù .a.s ièd cjtrus frùlrs,
peinùs, o. dricd apricots.However,â11Irùits connûe.l ren rd
ln lo$ cr caricsf.er2lencethan sù.ros€.onùmpriôn al.rnr.When
th€ .ariogcricity of 22 $ack Ioo.tsiûcludiûg Lrâûanâr
dd raisins
s'âssco.cdi. relation!o sucrose(which $âs siven r s.oreof 11.
ba.anasscored1.2 ànd raisiN 1.1 irdi.atins rher.aùsed mor
.dles lesnnr rhan sucroseàlone.I. generàl,è mâl $ùdies have
showntlur $trenirùlr is .onsmed tlcaùcnrll (e.a l7 timesaday)
in a mâshedtom (meannrgsomeofdr surarswill be exùinsic),
n causcs caries.Howeler,therearelimùariônsin exû.polati.g dr
findinss of thesesrudiesto hûù!.
Fln{juetfl 5t',rr,jc!
Ânunber ofplaqùepH *udics using rbe haryesrnrgmedro.l hale
found f.ùlr tu be 2.idoscnic (but less so ûèr suùose) although
the dten. oi thn varics â.cord'ng ro lexûùe ànd sugas .oûten.
Plàque FH ùndirs ùsinr the indwclli.g alâ$ cle.ûode m{hod
havc show.2fples !o d€pre$ pH to below 4.5 rn erperments
ùslnA o.c-da)'-old ând iàùr day old plaque. Llsirg ùre sâmeÈ.n-
nlqk, bananashare been shown to depresspH to be1ôw4 and to
.emalf low 1àr àr leàs 90 miûures. Drtes and raisins harc b(o
tb!fd ro resùlt û a loù pH fo. x long pe.bd ofri.rc. shilc dried
apple or apricot led to sm.,.ll .hanses l! pH. It ,s imtoûxit ro
trote lhàr plèque pH studies dea{re â.idoAenic forcnrial anl do
Àot accounr fôi prore.tlve ti.nn thxr arc f.cscnr in fiuir or rhe
." ,l',o',o l'.'lô{ on 'p,. {r','t .i{
lnct])âti'iln e.{!eri nrÈn11
lfcubatior sudies hale been usrd n, Alve f(Dd p&duc$ a dc.ùki
licâtioD score.In a sùdr rhar testcd 96 foods lelaûve ro Ncrosear
fruitonddentol
<ories
' lxrgÊqunrlrles oi !n|Ès rnllatFles hâv. b..n i$so.irtèd ùiri an
n,.È.sed DùIIT, bur onlt in one sùdJ'
.B r ' 1' c_s'èti
' '" \"" '\ ' o
appl.s to.aùe.lertal.arie\. but ùis d.es nor aurÊrr t. hâve
. lruir 'ùl.es conrain non'nilh exÛinsi. ntgri! and.rnnor be..nsid
. Brsed !n presenreviden.Ê,nr.rerslns connrmpriônof\holc ûeslr
amr,norder ro Frla.e non m,lk exùi,$i. susâ6 (ticc sùrm) in rh.
diet, as re.omnended by rhÉ Dqrâftmeor of Hdldr, is llLely .o
dc.rede rhe leveLofdentxl.ùies in thÊp.pùlârior
 r0crùs prored
h ihedie|h0i 0s0ini (0ries
derl0l 27
I

a s(tre of 231, apple Eave rhe lowest s.ôre of.l, tineapple 22.
tea.h 18, peaf 130, banana 180, ând dàte ioj. Vegetables gave

\{rhcn foodr afc mixed sith \xliva ând powdered etrûrel,

banan.s.aùse rliahrly lerr deminerâ.lization that su.rose, ipples
'' ',-, I n ,p hr, l,.r'
much demi.ertrli,ûion as sucrosc.SurPrisinglr', dares only .aùse
ùound onc dri.d of dre dcmi.eralizarn,n .âsed b) suùose. li
l , - , . \ i ' ' " a { d : . , , \ô , . " , '
liuirs nar cause caries. Howeve., as consumcd as part of the
nlxed hùnd.Uet ûere rs little evidence ro show truit () be rn
iùlonàrt fèctor in the developnen! ol.lenràl ca.ics.

l - a c L oIrn: t h e d r e Lt h a Lp r o l e c l
R l n sn g p e r i o d
agarnsr oenrarcanes
Iigure 2.1i Nica. Srcphar.ùnes (rellt o. beiueen pl.!ùc pH
foods ârd food comFon€.ts dràt havc ânri cârn,gcni. p()peitles
and iinrc) for rl rolùnteer subie-s who dtred vth .ows milk
ùe sometlmes relèrred !o as cariostâtic facors . Iluofide is
(b.!nE) hùmân milk,7% lactoseor r? sucrosetôùr rtncs dùrflg
undoubiedly the nost eÉèctive ol lhese tâctofs. Howcvcr, dairr
l5 minutes (Reprollùccilftom Russ Gunn r //. 198t,\'irh
pmducÀ. phnt foods, tea, ard even.hocôl.ùe contd. fdctors rh2t
terDlsrion ofdE ed'tôr of ala,û Àakl, )
prtec again* decay. Below is an overview ofprotecrive ractos
aod rhe impll.atbns of their.onndPtiôù fôr denûl health.

N'li:li .aLics frcc vhen led mi1k, comparea wirh dnrsc ted su.rose or
la.tuse iD wâtei.Iroû this rt wâs cor.lùdcd rhat milk.at be ur(l
Desplre bein.q oùe of dre ,na,f sources of sugiN in drc die. oi
sJfeli by IJàtients$irh I.,w s.livary now as r saliva substiùrc.
sfiill diild.cn. romal nrilk.on mptbn does not .âus€ dentar
Comprcd sith.ow s ni1k, brea$ nilk contâins more la.tu\t
.aricsr x.d a. inverse relatbnship betweer the .onsurnption ol
(-7% vs.4 5%) dd loùei con.entra.ions ofc2lcnur and phos
nilkind cadcs in.rcmenr bas been repôfted. Cow s milkconldils
phare (1.1ûg and ]i mE/1008 iespectively), and so, in drcorl,
LÀctose, which is less dcidos€.ic thân odrcr mono and disd.hà
ûa! be more câriogeni.. How€ver, epidemioiognal $udies b2vc,
rnles,iûd ir also contalns calciùm. phoDhoùr, ând.arein, al1ôf
iû general, ùsociâted brcast feedlng \ïnh low telels of lenàl
whtrh âÉ cariosatic. Calciùm ind fhoThatc afe ffesent ,n.o$ s
' ,,'. lo ù '"' ,, 'li i.
n l l l ! r h i g h c o n c e n ù a l i o n s( 1 2 t m g l l 0 0 m l a . d 9 6 m g / 1 0 0 g
and .oNunprior ol olher vru.ccs of suAxrs is nnknown. breat
i$pectilely) and rre able to pr€re.r enàmcl dcmircmlizxtbn
feediûg provnles no.fforNnlty tu xd.l a.lditionrl m.qr ro milk
Anim,l experimcnrs and ,? |tt" $ùdies hare show! diât rhe
fèedsând brcasÈfe.linfaûts are pedraps lss liLely to ùsc b.bt boÈ
phosphopepti.te, .asein, may prôte.t ngJinst de,ni.erâlizâtioni
iles.onrâilirg e,.qàry Li,luils.:lhcft have beer d feù repoits of
howe!er,.rsein is unpàlarib e 10 hùmansa.l so ih i)m.ti.al va.ltre
.des of severe denràl .âLics arn).iated \rith prolotsed tun,ally
ôler 2 Iea6), on demand brea\t feediris, ofteû wrdr ifânts
severùlstn.lles have show! thdt dÉ fill in plâquc pH nnlow-
fccdldg dtrriûg the night wh€n t.otccrn,n ftom saiiva n ]ov.
int mllk .onsunprbn n negligible. À plaqle fH rudy i.
hùmxn volunieefs rhxr .ompared the èù.LogeDi. potentiâl of
a,ss milk and Lrrman bredst milk with 7Z soiutio.s ot lâcrosc
and sucrcsc sln)ved drat srctose caused e substantlJ .lecteùe Milkqnddentol
cories
i. tlaque pH s'iile toth milks depre$ed pH orl) slightly àn,l
! Mill ( à s!6t"ntlâl s.nre oasùgxs n, rhè.lici ofrou.g.hilJrên
Iâ.rose dr.realed pH to d mucli lesser e:tent rhâ. .ftxe
(Fig 2.it). . Tl,e suÉr nr m,ll r !â.i.se, shi.h is le$ fudogeri.
In cnanrcl slab cxferime.rs, lilk has beeû slto$! o pro.l!.e t Mllk .oomins phosFhorur,.i'l.rLù, nml.6ci. âll otshl.h prre.t
k$ c.amcl di$olution .ompafed with la.tôse or su.rose soLù agâin$ demineraL,zt,!ù
rioûs Sùdr experin€ots hale aho shos'n milk ù redu.e tl,É.,ti . Âf,imal$ndies hrvr i[ô\vr nilk 10 bcâft].ârloÂe.i.
ogeûicpoteûtirl of sugrÊco.taining fàods. . Hùnû bredt niilk is hlgh.r lo là.rosÊa.d lower inphorFlrorus rml
Tliere rs sone evrle.ce fion, ânimâl sudics rhat the addnnxr ..L.itrnr l,o{.!.ii rorn.l brersr leedins dos nor.:used.ntulcâries
ofmilk to a carlogenlc diet reduccs rhc ca.ics pre'âlen.e. Àddi . Ptototlea. dn ILr"n, ûd tu tltnal nt.kling hd!. b..t à$@lrted
tioûxLly,in experimeDtswhere ràts hale had tbeir sâlivary Elaûds wirh in.asen .xries risL
€mo\rd, naLi.g them .àries pronc, drry rnraincd more or less
 I
zB | 2 D i em
t dd e n l o l ( o n e s
I

However, these câsesarc ra.e ard a$ociàte.l with unsùa.l feedlna rwo-ye2.pe.iod in children who ète â ts pieceôf hdd cheer
practice. Therefore, human br€ast milk hd à sftatÉr porenrial ddly, tôllowinA breakfast,comFaredwith a conùôl giôùp shô
rhar cows miik tô.nNe dcnrâlcaries bùt dentàl cdies in hmran did noi co.sune the €xtracheese.
i.fànts due tô b.easr tèedins is rùe èrd is âlw.ys asociated widr
prolonse.t, on-demand feedina. As formulâ feeds .onraln similar Flnnt tbod.i
âmounts oIlàctose, .â1.1ln, a.d fhosphale to breast mi1k, ihr.e ^ l{rwelthan-cxfc.redcarieslevel i. groùpsofpeople krowû ro
ùe no beneilrs to deûtà1heè]dr ôff€eding a formulâ feed. Breast lnve high cùbohydraredie$-su.h ar rhc Bantu Tdbc ofsourh
feeding should bc pronored since ir ptuvides thc bcsr inf2r! Atiica ând sugèr led to an inrercst in dr
preserceofprotectivefâctôrsin fôodsofplanr orig;o. The effecls,
on .âries, ôf fa.ro.s in foods of plânr orisio inclùdins orsadc
l'heeser phosphates. inofSanicpbosth2les.and phyratehar€beenirlesri
Nunrcrous2nnml studiesandexperime.t2l srudieshak indicâted grted. Ir hasbecûpostulârcdthar orsanicphosphates proreft tle
that checseis antlcùiosenic.PlaquepH studieshaveshownrhàr ' F b ) " J ' L b i B U " ' o , l t r " i J i e l . ' o r m , B . p r o ' F, . . , o d .
.onsuminAcheese fô11ôwinga suAarysnacLvtflrally abolishes rhe Borh oraani. and inorAâ.ic phosphareshève been four.t rô be
,,"1 ' ,oll ,5" , d,u ".Js . , E - . o ' , n p , ' o n . effe.rivein animalrudies. but studicsi. huoâns baveproduced
Cheese stinularessah'âry secretionJnl ir.reasesplâqùe.al.,um nrorclusive results.Cdcnû $,.rosephosphatewasmarkered.s
conccnrmdon.The câl.iu .on.cnùario. wirhnr dental plâqùe a cariosrati. food addirive in Australia, bùt its Ne wàs never
*i!.gly inllxercesthe balan.ebetwccnde aod re mineralizarion srLppoited by eddcrce riom clinical rrials.
of enamel.ln experimentalsrudies,cooked,cheese-côftainina Phytâte is anticariogeûicand acs by âdsorbing ônto tbe
n€als hèveâ1sôbeenslrown.o incredeplâquecal.iun .oû.e. ûa, enamelsurfaceto fom â physicâlbarief that pro.e.ts 2Aalnsr
r.o, in \'n"a.or''pF- Pl..t'FJl.,1 .{. '" oNseft plaqùe dcids.v/hen isôlaredfrom foods.phyrareis a. eriècrive
meanred in i6 volùo€eB beforeàrd fô11ôwing consunrF;onof anli carjesfactor but asù inÛinsi. Lôd conponent.;s oor effec-
cheese-.ôntalni.A mealsand cheese freeconÙolnreals.Pl2quecal tjve. Therefôreto be effecrive,phytarewouldneedfo be exrracled
cium.oncentrarionsincreasedsigrificddy on .onsùml)rionol â aron Srù$ rûd then 6ed d a tàod âddldve.Tb;s s'ouu nor be
li g cubeof.heeseand on corntmptlon of meals.ontaininA r5 a dcsiablesl.ce phyratebhds mireruls(.alcilm, i.on, maAne!ùn,
.hcesc, bur dd lot irûease slgniflcarrly on consùmFrior of ând zinc)in ihe ga{rcintcrnrâl ùact.
ch€ese-t.ee co.ùol ûeè1s(Ils. 2.16). Admàl studies hnve shown rhar inorgânic phospha!€sare
Enamelslabexperimentshâveshôwnthar cheesc !.omoresrhe cùlostètic âûd prevenrdeminerallzario. ofcnamel. Howerer, sùdies
rcminerallzarioD of previoù.ly demi.eralizedenmel and, ir d in humrns have produced eqùlvocalresùl$. Sodlû ùheta'
elidemiologicalstudy,.heeseintakevas higher in chilcLren vho phosphareha bcen show. ro be the nost eF{tlve inôrgàûic phoç
remainedcùies free over a two-yeârperiod ûèn in rhosewho phaÈ. bùt its uscwould€suLrin udeslràblyhighsodim inrakes.
developedcàries(Rugg-Gùn. rt,/. 1984).funhermore, d con- Probabh,onc of tlre nain redons why peoplewho cônsûe
trolled clirical ùlal sbowedrhâ! fewer cariesdelelôprd over a dic6 hiAh ir unreihed plant foods hâve fewer cârbus lesbns
is due nr simùlarion ofsâlivaRowlhat occu6 on consumprionôf
fibrousfoôds.Salnr not only helpsto .lcar fàod debrislrom ihe
moùrh, but âlso butfes plaqueacid,èùd therefore,fnvoûs rcm-
ineralizâtiorofroodr enamel.Other foo.tsthât turkedly incÈase
salivailowincludedrewinssùn (sùgàrfree),cheese, ândpearûts

E_^ ^
iià 4 dehtirlcaries?
E z
Mea lype
Fisurc 2.16 plâqùe c"hiùm con.etr&don b€iàrc ard folowinS
.oDsumptiotr of che$e ànd cheese.ontainlng mea.ls.Mar valùcs ôf
16 subj€.6. l, rt g ùbe ofcheesej2, Test mea.l:pasa m cxccsc
sau.erI, Corûol me.l: t,stà in ùushioom sauce;4, Tes mcall
.hnkefl breær snb .he$e and ham nllns; t, Conûol m..1:
chicketrbÉær wnh mùsllôom ând hdh fiLlins.
Do chocolate ard lii{ùoriceprolectrgâinst
In the Vipeholm stù.ly mertiôned prevbùsly. dre S&ùp rc.eiv'nE
.ho.olarc deleloped relatively fewer .arious lesios rhan gnLps
receiving similar amoùn6 of suAas âr sioilar fr€qùercies
(!-is. 2.6). This led to the suggern)n thar chocolaie co.ranred
protectlve factoB. Aniûâ1 sttrdies also shoved drar cocoa may
hàve a prôte.rive effecr. In 1986 cocoa faclor wd extr{te.t froû
cho.olate ârd wâs shown to be etTective7n ?ir". Re.ert $udies
\ " . . r ' s a \ J ' , l - , , b o | d e " l o o , F . r b L F' o I r e ô p , j . .
ral slze in enamel. thus i.creaing lhe .esistanceto acid demineF
allzatlon. In addition to cocoa fàctor' ând rheôbroôidr, milk
cho.ôlate .onhlns .a.l.ium ând casein, ard is high in fdt, which

àidsorxl .lc2.a.cc. Hoçerer rhe higi sùgdr conÉDt oI .hocola.e
, o . .l o ' " - ' - ' , l . l $ . " ' o ' - . 0 1 ' ' .
l ' .
pûedn'c csrc6. drc bene|r ot vhich is olNelghed b_vrts h,gh
Glr.yrhizinic acnl, à nrajor constituent oflùuorlce, has .arlo
rdn |opel1ics. Gh.yfdrizi.ic a.id inhibis b2cÉrirl Slycol)s;
!Élentiûg the formation of rclcl f.on dler.fy strga$, and lt
increasesrhe bùIfelng porential ôf pLaque. H.we!er, ir lbs â
rfong .asej may .ùse $anring of the reedr dr.l li.ltrori.e ûay
alsocaùseele.ùolyte distufban.e\. IB $€ xs rn anti-.afies fa.etr
is rlleiefore$dewhar lim]td.
'lrir
irIri;afirrlirri
TI'rn n in.reased inrcrc* in krodsdixr conràin|ohh.noh, ,s
drimtri r!.1 experimenral rtrdles have shosn that thcsc om-
Fùnds hâve ânril'cterirl p.operties. ÀFples.onrair polypherols
ând ùe a sood stin lùs ro salivâ|]r flow. Tca âlso .o.râi.s
polfpl,erols in addltion b lluoridc a.d ilâv2.oils. Blacl. rca
È\ûads have bccn shown to inhibit salilary dmylase ùcû!,ry and
rcdu.c dcnàl ca.i€s i! ammal $ù.Lles. lpi.lemiologrcâ] rudies
hale reported lower.àries in greer teà.tii.lers û J.lpd ând tea
J.ifke6 in lsrael. llose(er, ir [ng1ùh t yed olds .o differen.e
ii .ùrles levels beiween tea drirkers and non-drinkÉrs $xs foùnd,
,ldroush no account qds raken of the po\sibl€ eilecr of adclecl
{rrosc. Tbe t.otecrive effect ofter ]nay be due to fl!oride or the
dûiba.reriâl a.rôn ot polrphcnols, of bodr.
'lâble 2.7 Bull.
aild iûtenselon sùsas sveeteûeBpermrtte.l1àr{àodusel! the Unlted Kjosdoo
Bull
viru,ll!
Virùxlly non.rrn,g!ni.
o)
A,G**
f 0 . r 0 r s i n r h ehdoi er p f 0 r e d 0 g 0 l n n d e n l 0 l ( 02d9e s
fûdorronddentol(01ies
Prote(iive
. (ôùs.iiLktr non-cdrioSc.l., rln..1lr. froiecrlE frrois t,esÉrt
.ouûrc .l ùry.ùiog.ri. Fo.cn.lil due o nr lâ.rose.o.tÊnt
. Âll itres.aexl,efi.rÊrt, in.ludnrg r.lini.d riaL, have shoNn ûe$e
ro br .xrio$iri. snall luaûiries. rlnr û!rL. r' o.sligiLrl. .onûiLr!
inn 1o li liLâ]i., rr. ette.rivE
. PLanrJoûÀ.onrâin phos!hû6. wlù.h hÀr L4n $o{r ro b. ct..
tive ùr lrleùnrg .rrics in .rlmdl !!ai.sr hur h!màn {ùdies hrve
not Frodù.cn .oorin.ins r.sù]ts
. A ntrr ror ol looas in.nxllrr .o.or, liquorl.e, rnd h.nev.onta,.
Fror..riv. lido$, bur rhelr fm.ri.âl |otÊntial in fedu.,.g.nes a
' Ioods that rre sood iimuLi to \rl,larv norv prutrù I'grùts d.ntùl
.âriesi exanples in.LLde nLga.fi!!.ie'vitg srtr, F.trnùs, a.a
Non-sugars
sweeteners
Sùgarsùbstrt!r€scanbe separaterllnrorwo majorgrcups intcnse
sveeteners (nor cxlori.), and buLksweeleoers' (.2lori.). Somcoi
ûese ère ùàturalll oc.r(nrg conrpou.(lsiboçelcr. drc frcdù.-
rtur ôf synrLresize.l
s$eeteners has Lrcrede.lneidih due ro n.w
re.hnologies.n.l nÛeased denand fôr sugn.sliee trlternâtilrs.
The sweeteners rhar are |ermite,l tor foo,l usc varics bctn'ccn
.où.trics. Thoscpcfnrl(cd ln rhe UK aLî li$ed ir'lltrle 2.7.
mn .d!!!.,.
cxnnù be urd br those
 I
l0 | 2 Dielmddenloorie5
I

lntense srleetirntrs 1Om1

1 5 m 1 1 O % 3%U 15mh0%
InteNe sreeteneB dre !se,l in ibod produ.tr llkt sôft driùs, beer,
co.fection€r)', de$e(s, ice c.cam. nramalade, âûd id. Th€y are pn
dlso used i! dentifrlces ar(l in sweffcn;réi drcps/tablets {or !s€ i.
food, coffee,ted, erc. Currcnrh, abolù J0% ofrlre.dbônated L]ev 7
eragcs .on mcd in rhe USA âre Nleetened \tith rhc intcnse
s$eetener asPaftame
Se.hârn h.d beer ùsed û foo,ls in rhc UK fof dldosr à.en 6
tury. It hâs a bitter tdte ii corcenta.io.s orcr 0.1%, althôqth the
pc(cption of this larie! besveet indilidudls. Sacchâdn it $ldely 5
used in food' su.h as sweetenins tablets. Àcesulfame I otâssiùm is
a chcmi.2lll sFthesized sweetenerthèt is stùle olet â r2.Ae of
pH !âlues ,nd doc' not break dowt ôû heatiÀs. Th€se ptopcrics 4
mâke it a uscful ss'ectenerlr bolled $vees an.l presenes. AspxF
hnre is x dip€ptide .odprisiûg ofrsFafti. acid à.d ph.ûylalanine
Ir is ûrrkere.l under dr. bftnd ûamcs of NrÛcweet'and Crn 3 79 26 313537 mln 5457 6l
dereL'.It is uscd cxtcnsivell ln ffozen foods, desefts, dri.ks. ând
Figurc 2.17 TeLedeÛictrllyrccordcdplaque pH afr{.n$itA vith
guns. Thaumatin. aprotcin eain.ted frôm a plâtt !r \ve$ Âiica
(r) 1t ml of 10.z $(rok solutioo. (b) It ml of r01' m!n.,tor
is d eMmple ol a nrîurally occurina inrense sweetener.lt his a
ilutiôn. (Rcprodù.ed tiom lfrfeld 1997. sldr peûnissiodol the
li tuori.e afteitdte m.l its mdn use is in fhamr.euti.a.l pro.lucts.
editot .f HtlLûnd Oùrr|lùritu A.tn.)
Iood labels m6t declùe ilarrodlct co.t2i.s x s$eetenei d.l,
in the .ase of aspùdme, the label nust âlso sal thât the prô.luù
contai.s a vrt.e of phetylàhnnre, becdùse indn'idùals with a0/55
phenylker,nuria are unable to merabolize dris âmino a.id.
H2O Sucrose HrO PC+U
Irterse sÙeeteneB àre not mctabolized to a.ids by oril
micro ola2nisms a.d drey .annot .use .lettal câries Sa..hafin
has bcc. rcpored nr lihlbit Lrâ.teri.l Srowth à.,1 mctabolirm,
blt animâl studies hâve \Lrowt rhàt its carles inhlbitins cfie.ts
I
ère small. Lnrjtalions ol inrc.sc sweet€nets in.ltr.1e poof !âstc
qudlity, nrûbrlit), d.,.1 lack of rolume. Câutiot is stlll nee,le,l
Y,i
'€ I-or, ' . rr,ir:r" ir pr'e "Fq"'
\
be.ause oth€r ingredjeos, e.g (itfi. or phôsphoric ac s, ,n \
beverages mry.àùse denttrl erosior. In s)n€ foô.1 products,
iûtense s$eetenes arc addcd in addnion tô sugas, e.g. to t.ù1t
\.-
tlù\oùrcd sot. drinks, aûd the naturèLly oc.utrinA sugaB in dle
' ' i ' | ' .r o e . - I ' r ' " r ' , r . ' .

hlenresweeleners 29 31 35 31
Tme lmin)
rrÊ nôt.hemi.ill_r relared to sgrs
Filaure :2,18'lèlem.tuicalLt re.oft1edLrlùlt fil âftd (a) erlng {
âre addèd,d 'es sdr'll !!r.rnies @ àJJ sseetnes xnd not voLid.
hafd sweet.orlnnring lr.6in, (b) rn$lnS wnh Lt nn ol r0%
de hundÉds io thousdrds ot rimet sweeEr rhu N.rosÈ nL.rosesoLurio. lR€rrôdùced fiom Imteld, 1917, Ntrh pcnslon
hâ!. â.egl,giblÊ energvv k (kilo.iLdriet of tft eAitot.t Itth.tùd Odt"î||ùrln ^.!d.)

Eùllt 5!,r{:eteir(lrs
Bulk $veeteres provi,lc sscctness and bulk to è food pro,luct.
Manr de sugd al.ôhols; and, being chcmi.ally slmilâr to susas,
drelr .artusenicny hd beer teste.l in mâny tlpes ofexperiments
and, ln !,me cdes iû cljnnâl irjals Bulk sscetene^ âre wi.lely
ùsed ln .ônfectiôrerr, preservesand sugarfrce gmrs. one of tlie
disadmntagesoftht bulk s$eetene6 is d,ar dicy afc only pdt ly
nb",rbed in the snàlL intestife ând pâ$ b rhc .olon where ùel
mây r.(luce osmorl. diarllôeJ. Bùlk ss'eetcncrt are thereforemt
r€connendcd fof.lildret utder three yea.s of aEeand cde mùsr
be raker wrth sugàtsncc nredi.ines contaimrs bulk s$eetenes
sin.e ligh inûkes cduseaastointe*inal dist!rbance. Thc denûl
healih effe.ts, Iood !scs, and specifi. propertjes of thc bulk
non-Ngàs sweeteneBa.cp.esent€d in T.bLe 2.7.
]'he nôn'acidosenlciîy ofmaû.i.ol and lra$iû is illLrûrtcd iû
Iisufes 2.17 ànd 2.18.
"r- %l d.{hi r , l o l i o n l o o F l o d 0ee0nhl h
0I 3l
I

lulksweetener5 Itr r1t Belize stù(lt, l0 -rcâr .ld.hild,tr, initirllr with ùo.l.l
x.e ù) high..ries lelels, \t.c dividcd inù) t snn,ps. one 01shi.h
. û..Iùni.rll_! snnilùr ro str!rs recelved sugared gum. Scrcn gmups lt.eiled eitlier itlirol o.
. ii {lùn,c ann s!..r.r.$ io r lrrô{lù.t lrt,irol gùms, or glms !hd. .onrii.cd mirrurÉ\ of these t\io
. rrl trom 0.t rmes t! 1.0 nm
ss'eerene$. ore grouf re..ircd .. gùrn. Childi€n.he.ved for

. hrrÊ m Êne'gJ'mlùÊ (kilo.rl.rht

t ûiù,res lrle lmcs i da-1:Àlter 28 ûontLrs. the lo\aes DùIIT
scorcs vcLc obsesed iû gi.ups lsrng l00t/ a,rliRn run. r'l,e
' rndr- r..rtunnl_v founa nr roons
so.binn gùm and the gums conrâininE mixtucs of xllirol aûd
so.birolftsùlted h Liglier DÀ{l'T scorcs.onit2tud widr gnn.on
tainlog onll xllitul. the hilhat ùean D,\l!T sco.cs scft nrnd
ii the tço troufs ùsi.g elthef sugared gùù or no aum. Thc
B e l L z en u , h i s r h c l i N . l i n i . a l Û i â l o f x l l r r o l r h i t c n a b l c s
Doessugarssubstitutionwith a .omFirison of drc .âfleçfrevdtive ùction ol xlllrol b bc
non-sugarssweeteneTs prevent .ômpired \'llh sorbirol and rhe resJts nidi.lte thal {-tlitol is
s u p e r i o ri n r c , l u . i r g . ù r e s .
dentalcaries?Clinicaltrials of À rccent re"ler" of the ele.r of plyols oû d1e prevûtlon ol
polyol-containingchewinggums dentà1cènes .on.lu,lcd rhat dre ftpla.ement ofn,.rose w,th sol
\l 'o .' \i' bitol ènd !Lirol mar signltl.xtrtly de.rersethe inci.lenc. ol
),... o 'P i. ,, ,, "
dertal.àries(Ita]es 2001) This i\ in llne with dÉ.otdùsiof of
nencelrve beer.àfie.l o!r. Sone have coml,rrcd drc cffcct of
ùc 1t8t COIIÀ reFort Drerary SUEârsùnd Humxn Diserr thàt
sivnrg strbje.rs sugù free guû wnh sùgùred gùn, ând somc hxrc
onpæd rL,eeffect ofgivirg n,gù free gùm 10 !ùLing no aùnr.
SomÊot the rudles hâve âiûed ro .onpùe rhe reld.i\'€ cffccttrc- .ùûenr evidelce sùgse$s .bit bùlk ss'eeteneBhale ùegh
ras of dificrcnt non-ugars sveetener. E iblc .arbleni.iry .ompared Fiù sùga.\ ând rhat s,b$nù
'Ihe'lurku.he$lng
gum stùdr coinl,ar,l the eflccn of tn,n ofsugan b} à[eniârilc ssccrcnrr.ould n,Lrtaûtiallt
\ rith thàr oi aylit.l .onrxrnlnssLLn Ln 'lhe
n,ùor.ôtrùiri.g.qum red!.e crries dcvcloÈnctrt grerter gùif would bc
Ioùng aJults Thc mcâû .uie\ in.rement âfter 1 ]ear was \ . ' . 1 ' , , ' 1 . . - - o I
2.9 DNIIT in rhc su.rcse aûd 1.0 in dle x!1itô1grolp. In dr. ioods inlered frequetrtly sùch is sncff s.a.ks, dfn,ks, an.l
Ylivicskâ sûdy, school .hitdren \.ere raûdomlv .llvde.l into
'ù .' ,.o p.. d I
rhdr .heNe.l Do g!Ir. Tlre xylitol Eun afoù|s dereloped ferer
.drles. wlien tie .hild.ef verc .. crâmi.cd
'fbc
2 I reaÀ later, à Non-rugori
rweelener5
ngn,fi.ùt ones re.hrctior was lound. aurhors conchded
. '1he buL[ sft{enerr $nrno], ûirfnnol. lrriol. nonah.ly.a!n,
thtn x.vlitol w6 ànt,.àrio.qeni.. I lowerc.. ncirhcf rlÉ lnntren.e of
and di.ltito '( noi .âfi.geri. .r ..irùxll,v so
the chewing àcrion .o. rhc spc.ii. effe.r of x)"litol o! .èrles
reducrn,n can be neasured ftoû this st!d] ia it .lid .or in.lùdc . Xthtol and the rnton $!..(r.ir rr n.n .xriogÊnn

a.orroL grolP on i lLa.eDo gun, or a 8u,n .ontaonE a {gar ! CheninA gnff sqtetened rvnL, rrl,tol d(lio. s.rbirol fr.te.t
n,b$,t!re orher tia. alli.ol. ft should 2l{, bc trotd that the Àsrif,l den L.rn!s. this dlicr n Jle m dt n.n .xrn,srnrtt oi
thr seetêneB rd thr nnnùlatior olsrlna fl.* rÉ\ult,ng llon
deùra1 etâniûàtLon srs ûot cârried out blind o ùc grorp
llenrity of rhe.hildren.
. 1r r idpûftdr r! rcnrn,hef rhr dr nsètulnes ofr s'gd nùrntrlc
In rhe ùfonûerl rnd], s.hool chil.lren vere a$igned ro onc 01
hrs ro LJclool.n lFm n.r orlr l|on i.ar!losi.d. but rlso lron l
rhreeErnps, $o xr'lirol A(rps lenher 6t7. rylilol or I I % rylid)
nrririonà]. ioxl.ol.gl.xL, e.otu,ni.. md te.!n(al Foiff olyles
ind onc control ArlLlP, whi, .heived nô gun. Clildren cheçed lbr
i mnrtrcs rlùee.imes â dr!: ÂJter L yed the xylitolgroùI,s hâd sig
nitl.andl lo$er.aries iNreûents The groùI, çho ch.s cd rhc 65%
llnol gùm hal le$ carics rhân tlnrse $ho trsed the LiZ xr'Litol
su.,. Howclcr. aiicr rqo ycas the difference besveen the two Politicalissuesin relationto diet
rylitolgroll)s lid .ot rcinain. bot both hd a 1ôwerc.ries incideû.e
.onpùred {rth the control grolt A .cricw of.llni.al ûix1s ôf and dentalhealth
rylitoi (Infel.l 199.1).orclùdes lhir rhe similx.irr rn.ânes rn.rÉ
:l[_.ntî!ii]rlt l1|'rrrnI d{ntirI fitri:rr!
. 1 " . " , . - , . o , , - o 8 ! , 1. , . . . , 1 , 1 . . ,
rile efect wd dùe to chewiDs rarher rha. rhc "l__lid .onr€nr oftLt liir ilir{ inirliir û-i sriiqijr-i
gtrd Hôwevei. rs the sud) .lil nor l.clule â conùol arcup that k is impoftânt to h.ve . marimun, .c.om.icndcd lelel fù intêke
. l r e w e dr t l à . e b o . q ù m , . o l r m . o . c l u s i o n m a l b e d r x * n . of free n,g.s again$ which dr. dcrdl heâlth rlsks ofpôpulàtions
32 2 Dielonddenrolrorie5
hây be assc$cda.d healthpromôrtunsôalsmoni(rcd. The.e;s
evlden.c rhar die relarionshipbeùeen denrxl .arics lerels and
suga6 is a. S{ha]red relationship(Fig. 2.19). Ar los' lcvelsoÊ
sLLAaf intake (10 kglFerson/yed).dies is very low. Ar levelsoI
inrakea(ù.d It k.q/pe6onper yedr,the liûe ofrhc arafh $eepLy
risesand rhe lerel of.âries increases with ir.reasing sugara!âjl
âbilitq A! hlgli levelsof suAarintakc (-lt k.q/tesoû/yeèr)dre
.unc Uattensout a!.1 r sàrûarbn levcl is Lca.bed,so rhnr a fur
rhe. in..câsei! nrgùs côrtent ofthe di$ docsno. ûcreas€cènes
to an appre.ièbleexÈnt. l-be c.vidence for rhe sigûôid relarion-
ship ber{een n,sa6 inrakc ân.l denrâl cùies cones from a
nlmber ofsndies. Dah fronrJaI,ànon carieslevelsfôlloring rhe
SecorclWortd \\rar. rvhenthc arailabilirr'.ofn,gàr *6 resrded
showsar S shapeddosc<fièct .une dut reê.Lessarûtn)n lL'vcl
_1,!
'r t . r ô r p' . . , T , r , | ' r - . I e Ê . " \ " . r , -
rivelr rclarcd s'id, dre ùnual $gâf av2ilib'litl ,n Japàr
t=+ 0.8) w1rn suEari.rakcs we.eber{een0.2 kg n, 15ksber$.
per yeù an.l when lnrakcswereaboveIt kg/persônper yearric
rate ôf câriesinrensificd.
Datx frcm BLitainan l Norùàv during rhc {'ar yea6 alsosrp
por rhescÊn.lings. V/her Nôrweglan.hild.cn consrme.l less
rhan r0.4 kghe4on per year,levelsof dcnr2l .aries were tow.
Childrcnevdcùate.lfromJerseyduring drc war yeas wereexposed
k, hiah i.tâl.es of sugar ( I0 kgi pcson/yeâ, rhan those that
renalned in Jc.sey.Chiklrer in Jersey onsumcd on alerase
8 cr'. t-r'." ,r| | l r À l l - T o8 'p" d., ',
The aforemeùtioreddara of Srcch.v (1982) fouûd thât lo"
carlesrèresùere a$ociarc.lwirh lo* sug.r iûtuke id 12-rcarold
Intakeof sugars
!isere 2.19 sigmoid.une ro illNtuxrc dre relitiofsl,ip b6veen
tuâk. ofsùAâ6 d,d denral.âri€s lckLs. ligùres "r bûrd on data
fiom epidcmiolôg'.rt itud ies.
.hild.e.r iôr drc 2l /.i7 coù,nri€sNh€reNga6 avdllabiljtvwasles
thar lti.2tka/yeâr (-t0 gilay), DMFT levelswere belos l.0,
\ùgaestinarhat dris may be dr€ uppersfe limit for strgatsiùake
I. Jâ],ân, caries levels inùeèse.t ès sugàr iniâkr in.reased
th$uah rhc yca6 u.til â pedk in srsar irtake wâs rea.hedîr
29kglperson per l.eâf nr 1913. The.eafier,the ,ftake ofn,Sàr
decreasedand so .ii.l dre .aries exp€rien.e.The .otrciatior
betweensùgaralaiLabiliryânl ctuieslevelswa hiAh and \igniil-
Theabole sru.ties*ere on popularbns.or cxt)osedro rhe Lren
efits offluoride.Exposuretolluofidc;n soniecoùn!ries hasàltered
the strgd .âries.elarnrnship.It hasbccna.gued!ha! whereflù
orideispresenrlndrinkl nAwatc. âr a con.e.lm.ion of0.l lppm,
.r a\et 9oLt of rurpasrcs avâilable are fllori.tèred, rlie
dose effect.ùrvr shiftsro rhe.iahr and niscs dresàfelimi! oi the
lcvcl ol suAa6consù,nption.
[lfectsof sugors
intokeondfluoride
onrorierexperience
. OveralL,the rùdiÉs $.s rhxr çhe. Ànnul sugâ..onsumFnon (
rbove 15 to 20kglerFd$n per veâI.,,lenEl.rries ln.re6es wùh
in.rc.s ng n,gd int.ke
.l1 , 0 k s n e q u i v ù l . n it o 1 1 - > t s l e i d q
. Â nùmbÊr.i$ndies bàvê shovn.hI.âri.s l.i.ls iû.rersè wtrh
nftkcs ùffree susa6 abo\r fir rlmes â drr
. t{tideslrexd exposurero Uùori{le 'nâv .riÈ dr. rnr.n,old l.veL ofsafe
intùlic, iûd thn I rene.têd in thedietary gùideli.Ês âd.Ited hy
seve l ltullnrializcd .ôtrndes
0.-:riralltf5r]jlnliÊ ir
l"'ûiiiri{ts
difièreri roiû{ri€ri
A nunber of counÛles !are adopted pol'cics/.c.omn,e.dd!iois fol
sugàrs ,ntùke bded o! these .lata (Iible 2 8). In dre UK, vher
drere is wides}read c\rosurc io flLrori.lâle(lroorhpa$e, rheDierâry
Referen.e Valùe frr non-milk cxùinsic suAa6 is 609/dày or
<10% of energl i.take. Similà. rc.omme.ddîions irale been
adoptcd by scvc.alcou.tries inchrdjrg the Scèrdiràvm .onnt.res.
Table 2.8 Policies o! lrtùke ôffree sugûs br a nunrbef of
NÈdrerlânJt, MlnisL.! oT I l.ùlrh
Âutnlx, Deprtmenr ot HÊrkh
irsr !',nla.d, Nûftion Bôard
P!lan.l, Nx.onil lnritùtÉ
ljnlreJ KiiUJon, D.Friimcnr oi rl.rLrl :102
t996 Nordi. Nùrritl.a Re.omm.n(làrlons

rhe Nethedands, a.d Poland. The i990 NIHO repor 'Dje!,
Nuûition & P.ever.ion of Chrodc Disedes' a.lsorecommeûded
ihat free Ngds should conrribute ûô môre thd 10% to ene.gy
ls there an inve6e lelationsltip belrve€n t]te
intal<eof sugarsand làt in the dj{:l?
Theclaimthat totâl sugd intake is commonlyirverselyrelàted
r oL o t Jf . ' . n ' J - t " . b . , ' 6 r d - , n i 8 u n . l ' , o r r o r . a , r c '
recomnendedlimir on sugas conNmptiôn, $ggestinA thar
d(ÉasingdietarysuAa6woùldleadto ù in.rede ln far;.rake or
lice versà.Hôwever, dara available ùe nor sufaiciènt to supporr
thlsârguûent,and drereareloûsitùdinâl dataro showrhat rhe.e
ls no evidence lor sucha (e1a.iorship.The dararhat rheorcticâlly
sulportm inveBerelarionshipuse..o$ seftioùl âralysisôfthe
dieisol populâtions,and arenot bded on longnud'nal sudies of
popolârio$fouowinAchangesi! inrdkesôf$ga6 or fats.Recenr
e!id."n e from a repeatedcros sectiorâl study of EnAlish school
.hildrendoesrot supportthe exisrerceofan iqve.serelarionship
berveeofat and sàs. The study shoved rhar althoùsh fèr
innkesigrificârtly redùcedbetween1990ard 2000,this sd nôr
a(ompaûi€dby ân in.reâsÉin susarsinrake(Flercher,Admson
a , / p q . o n dôl n n ' - , " i o r ' ) L . \ o | e r n . l e ' d r j i 1 ' e nr -
rionstudyaimedat inùeâsiûarhe;.tâke ofdie.ary fibre by dieri-
tims aûd their hoùsehol.ts,a redu.tmn in rhe i.tâke of dded
sngds was dhieved âr the same rime âs reduclng the inrake of
dierârytot. Therels ûo soundevideûcero $rpporr rhe exlren.e of
a tùgditat seesaw',and pernirrins ùnlimited sugds codsump-
tion nray not lead !o a redùctionin diÉtary àr. H@lrh reporrs
havestaredthat aoy deficir iû energy.esultina from a redlcrioo
in intakeof f.e."sùAarsmÀybe met by an lûc.easein ibe inrakeof
huits.veselables, md sàr.h-rich lraple làodsand shoùkl nor be
ner by increasinsln àke of fat.
Recommendations
for preventionof
dentalcaries
. Id the presenc€ofadeqùÀteexposùreio fluofide, rhe inrake
of free sugarsshould be limited to 15 ro 20 ts/pe6on
ter yea.(e{tuivalentto 10-55 s/dây).In dre absenceof tlu
odde,the intake of free sùgarsshouldbe below rt ks/day
(<.i0s/.tay). These valùes equate ro 6 r0% of erersy
i.tâke. Th€ freqùer.y of in.âke of foods contâi.ing fr€e
sùsarsshouldbc I'miled ro à mdimum of fôur rimesa day.
. The poiential fitun.iâl .onsequc.ceof fajlnrs ro prevert
deûtalcùies needsro be hlgliiabred. especiallyto goverr
mentsof côunÛiesrhar cu.rerlly havelow levelsofdisede,
b , d , e I n d .Z o , . i t i r ' o n _ t u t u , , , 'o, " d ô p ' . d d w , -
. The deÛimenrallmpacr oû ,turljry of life thrôughôurthe
life course-dre lonAeFtermnùûitioràl cônsegùeûces of
derûl.aries dd rcoth Io$ need!o be higl ighted.
romruro.s ::
|
The nyth thèt â high sugds inrakels importa.r for ene.gy
inûke ândgrôwth needstô be dispelled.especiauy in devel
oping counùiesNhereunderntrûnionis prevalent
ResÛicting the iftnke of free sùAa6 ro l0% of energy
irtake woutd sti11eùb1e a natained prcdu.tlon of suaâr
.âne6 a cashcrop in low incomecourûies.
Regùlàr môùroring ôf the prsalence and sevcrity of denlal
cariessibùld be en oûaged Bing \X/odd Heahh OrAaniza
tion slobâlguidelines.lndifËrenrcou.t.iesir all asesroups.
More nâtnrnâllnfo.mationon .he diera.y intâke ofsùsars,
sùgârâvailability,and sofrdrink iorak€shoùldbecotlected.
Gôvernûenrsshould support resea.ch;rro preveûiion of
dentalca.iesrhoùgh dietary meâns.
Nùtritioû needsrô be recognizedas an esse.tialpart oi
ùainlnA fo. dentâl healdrprofesionals,àrd dertal health
i*',e'."a iÎp { ', . ,nt oFe, o cdt . ', o'
àrd ôtherheâ1thprcfe$ionals.Tb;s is essenrial
if advicefor
denralbeâlrhis ro be consisrerl!
wirhdie.ùy Àdllcefor gen-
Depâtumentsof EducarioDnlst enNre rhat reachers,
pqrils. and healrhprolèssionals receiveadeqùateedùcàûon
on die! ard dental heatrh isn,es.There shôu1dbe .ross
DepârtmentalAuideliûesfo. rbe useand cortent ofeduca-
tiôna] hare.ials b eûrùe drey are sound,rnd nor bided
towards ûe irterests of the fôod indus.y.
I.ternâ.ional non govermentèlorganizdions(e.9. Wodd
Health Orsanization,Food & Agrictrltuiâl OrgânLauu,',
IDl, IrterûàtiônâiAsso.intiônfô. Dental Research)should
reconmend fisca1pri.ing poiiciesfor food irems rhar are
hish ir nôr'milk exùinsi. suga.s (free susars)and âre
ôtherwiseof quÉrbnable nut.itional value. ârd shoukl
en.ouragegove.nmentsro .dopr morc sringcni codesof
adverthnrgpractlce,espe.iâllythôseaided at.hlldren.
lood nanlfaftuers shoùld .onrlnùe to dcvelopând pro
ducelow sugdysugàs-freeâlrertuiivesto prodù.ts dcb ;.
freesùgars,iûctd.tirg drinks.To enableindividuls to make
infôrûed .hôi.es .esa.dlnasusarsioraLe.rhereis aDeedfor
clear,unblased,and non-mislead;.slabellirs of ibodswirh
respedt) sù8ârsconte.rs.
Conclusions
:fhis chapterhasprovi.ledaû overviewofthe evidenc {or an 6so-
ciarionbe!çeeûdiet and dertal carles.For â morecomprehensive
account.tlre readeris referredto Luss Gunr (1991) ànd Rùgg-
GunD ant Nùûn (1999).To conclùde:cô1iâtive1y. a multipllclq,'
of dlfferert types ôf studies provide .oNin.inA evidenceof a
causàlrelàtionshipbetweenthe ahounr ând f.equencyof free
susarslntàkeàrd dertâ1.àries.
Sùgârsâre necessary for denral .a.ies to occur.Orher facfo.s
such d etposûe to fluôride, oral hygiere pradice, and saliMry
 I
la | 2 D k l o ndde n o l r o r i e j
I

now ratc ard comfositio. modili drc fts}!ûse io sùsars.llùride Hinds, K. and G.eso.y.J. (r995). Nationâlclietùd n!ûit1oo
;s rcry cffcctivc at .cducina dcnral caricsrbut it does not eliminate suNe"-:child'€n dsed 1.t .ri.j ye ts: R4,ùt af tbe D tdl
ca.ics, and manl low incomc.ountfies do dot hxve adequâte Jirzel, Vo]. 2. Londo.. HNfSo.
exlosure to fluoride. In develofe,l .ou.ùics whcrc caposuft nl Holbrook, \v.P, ÀrnadotriL.LB., Takaz)e,I, Birkhed, D.,
tluoridci5 adcqùâtc. drc..ly $'ây to tirltbcr ftdfte.xries is to ard Frosell, G. (199t). Lonsltudinal sudy of caties,
rcsÛl.t sulitui.on mption. Therefoft, drspite excellenr prôgres c2.ioscni. ba.tefi. and dier in childr€i jùst berbrcand
n",l'L,i ' o f l . o ûh. JB. rF ,_'o rôn.'' 'fi "' aiter stdtins s.hooL.t,/rrr,".lr'nzl rf aràl S.jti$, rol,
.aries prevertio! in dr€ twenly 116. cenrury The evidcncc sùa- 1241
sests that in order !o minlmiz€ dentat caries, rhe intakc of frcc InfrLd, T. (1991). ClmicaLcariesstudicswidr fol]'alcohôlsâ
sugùs shonld ûot excee.trt 20kg per person per yeèr.
lircmnre Éview S.tueiz llûtdtrbt Zabnwd. lll\8),
91r 911.
References 'r.
ùIaftnaler, (1990) Chanseslr th€ prevalcnccot denral
c,rics: how n .h .an be atrributed !o cbdngesin did?
B ù t r , 8 â . d P â i , S ( 2 0 0 1 ) k. s u g â .c o n s u m t r ; orni l l a m a j { , f
Cdrit R6ùflt,24,1 It
dererminâniofdental .arlesl Consen s developmert.on
ferer.e où diàgrosh àr,l màragemert of dent)l crries R ug.qann,n, A.J. (L991).r\r?îni," dnàD.ûdl Hdlth. ()rlotl.
throughourlifè, Bed,esd2NlD. USA. Oxiord Medi.al Ptrbli.ètioûs.
B u r i , 8 . , A . .E l . l u n d ,S . A . .N f o € a n .K J . , L â r k i n .E E . . G r L i f t , RusE-Gùnn, AJ , Hrckett, A.r, ArJpleron,D.R., Jenkins,
K.[., Brown, L.O., a \\reintraùb,J.À. (1988).The efticts G.N.. anJ Easû,r, J.E. (r98.i) Itelâtionship benccn
of su$rs intake èrd frequen.yofnrgestrono! dentalcaries d;eraryhabirsand .ariesin.remert àsesed oler No yera
ircrement in à three Ieàr loùgittr.tiiat st!d).J,,,lal ,l in .i0t È.slish adolcs.cnrs.hool.hiidret. Â/.rrla al 0d
Dcktal Rdtut.t , 67 , 1422 1129. Bialasr,29.983 992.
Departmentol Heafth1L989).Dietârysugâsdcl humù .lisease. Rùsg G!nf, A.J ànd Nù.n l.H. 11999).Ntttittu,. tet d\tt
Repoûon heaLthdd sô.lalsubjectsNo 17.I-ondon,HMSO. oul buttÀ. Oxfotd, Oxford UniveBn! Pres.
Gmûaù. L.-E.,Roorzen,H., Liljesren,E, Holst,K.,andKôhler S.heinin,A ar.l Makin€., K.K 1197t). Tù.kù sugarsùdies.
r. (1978).Varidiôn in.dies prevalerceielàtedro conblna I XXl. ;.t Adotolry;ta Standinaùu, ll(Supp1. 70),
tions ôf dietary .nd ôrâl hygiere hâbits aùl chewlng nuornl€ I )49.
(r.Lr (
tablctsin 4-vcrr-oldchildren.Cdrir Rtv ù,12,83 92. r. l.\'1 . .ô \. ra.r,. il b r/ . r' | ,r ip' o.
G r i n d e i l o . d ,M . . D a h l l o l G . , N i l s s o n ,8 . . a n d M o d e e r T
, . arddenral cèries.C,,?,d;4 Dût;ttry d"d ard Lridùniat\x,
(1996) Srcpsiscprcdiction ordcntal .afies ln .hildren up 1 0 ,L 7 .
!o 1.5 yea.sofasc. c,r.j R6tdr.L.lo,216 266. Ste.ksen-BLicks, C. and Gu$af$on, L. (r916). Impâ.t ofoûl
Gùsàfrsor, B.8.. Quc.scl. C.E., Lankc, L.S., Lùndquist, C, hrslenexn.l useoffllorides on câricsin.fcmeni in.hildm
G r a h n e nH, . , B o n o * , 8 . E . , a n d K r N e , B . ( 1 9 t . , i ) .T h e àûlng one yeû. Contnr"tt) Dlrr\îù a"à aMl L.pilùi1lw.
VlpehoLmdenlal .àriesstudl The ealèctof,littÈrcnt lNcls r.i,r8t rrJ9.
of carbohyd rarc ;ntakc on caricsa.rlritr ln 1.16lndividnals \xralkei,Â., Gresor!,J., Brâd.ock.G.. NrLntr,J., and whire,
obscncd for 5 yca$. A.tu Adanl,ga Srdrà;ndrira, lI, D ( 2 0 0 0 ) . N a l i o n â l d i c t a n d n ù ù i t t u n s u r v e y :y o ù n g
232 i61. people qted ,1 to r8 yen$. Reloû af tb, Atul Hullh Sbaq,
h.\F.a : L,l\f."": o l' o r r o a . r , q ! . I c { V.n. 2. London,HMSO.
the preverlior ot deital caries:a review ol dic cvidcr.c. wcâvef, R. (19t0). fluorine atd waÊtimedict. B,ttn, D.,td
JatmdlofDnldt Edt.dlias,6t(10), I 106 l 109. Jûfi ,88,2ar 219.
Fluoride
anddentalcaries
Johnl\,4
urray

oxr€r husks of the grains ôf lvhich it is composed have

introduction l , e e ne l m , , t e d . ' i - i ' ' . o " r " " n o u r ' r y .r " n y m r e . .
Thehistory of fluorides in deDristry;s over 101)yeas old. Si concerned, rhls is esenriallyan àse ofçhile breadaod Ê.e
Jdrs CrichtonBrôwnehrde m lnspiredgues âbôurrhe iûpor floû, and n is an àge therefo.e 'n which we arc no lônger
@nce offluoride in the dier in 1892. I1ùoridews solated from pùtaklng to anylhiûAlike the sameamoùntthat our aûcev
watersuppliesin 1931 ud hâs been inco.poraledrnto wate., iors djd of the b.ao or husky pârts of wheat, and so are
milk,salt,rablets,md drops.lr hasalsobeeniûcludedasar acflve deprivedro a largedegreeoi a chemlcalelemertwhlch they
aseritur the preventlônof dentâ] .ârles in morhpasres, profes rcceivedin Èbùndarce,nmely, fluorine.
sloûâllyâpplied rcpical ftùorlde rgenis dd ûotrth ri$es. The
p - r p o * h i . , h , p r ' I i . , ô n n a - i / " ' h r i l f o , n a r i ô r , 0 1 , Fr - In 1908 rhe British Deolal Joumal. urder the heàding
' ' l ( ' n f i , o , d e i n l h e r J p l r ' . i g , ' e , r - r , l . p " a et o " n
ingtheetrectof flùoridesin ùe prevenrionofdentâl .aries.
absthct fiom a Frcnch pharmaceuticaljournal on iluoride dosages.
The article refeffed to rhe beûeficlal effeff orflùo.ide in the heàllts
Fluoride1890-l 930 ofbore fMtures a.d stâtedthat it was genenlly recogdzed'thât
Ttr useoffluotides for dentalpurposesbesaoi. lhe nirereenrh
ceDtury.The first entirely speculative ided led !o rhe develop-
nent of fluoride-containinspitls io the 1890s.This aspectofilu'
orideaftl deûta1heàlththen iÈy dornaût for ôver40 yeùs.
The first refererce to à prôphylâctic role fôr fluoride may well
havebeer nÈ.Leby Ërhddr in i 874. In à coûtribtrtion io Memom
billâ+ ûônthly publicâtiôn in Gerûm fof rariônàl physf

Âs, for a lonA time, Iron was giver for tbe blood, Cal.ùm
dd Phosphoru for rhe bônes,so hd it been$rccessfulto
add llùori.te to rhe tooth eMnel ln a solùble èo.t
absorbâbleform. Ir is Flùoride thât gives hârdnessand dùrà
b 1 , ' h - ' , i l - n d r . l ' , d p r L ' er d d r , \ ' d , e \ .
Pindborg(196t) ând Hùnsfadbraren bôth rcferro a pànphlet
pùblishedin 1902 bl Cro$ md Co. in Côpennàgen, Denmàrk,
entided lluofidens. How to Rehedy the Decâyof our Teeth'.
The Danish Apôthe.ary Sôriety analysed the râblers ând foùnd
theycortained83.7 per.eni càlcirm fluoride(Fis. Lt).
Tbe lnpoftâûce of tluorine wâs €nphâsi,ed by Sir Janes
CricbtonBrowne;n 2n addre$ to tbe Easter.CounticsBranchof
rbeBrit;sh Dental A$ociadoû in i892:
I would qameto you, as a specificcauseofthe increaseof
dertal caries,a cha.gethat ha takeoplacein a foodsluffof
apa.licuLùkind, aod ofplimary impoftance.ImeaoDreaq,
the staff of life, from which, ir the prosre$ ofcivilisation, Figure 3.1 lront.o'd ôfa leânet, Iluoridens: Ho{ to R.nedy
the coarseeLements-andthe coùseelemerrsconsistorthe the D€cay of Oû Te€th',.. 1902 (Pindborg. l96t).
 I
rB I I fuoflde
onddenrol(oriej
I

'Tdblel.lfl .1
fluorideis necessar-!
fôr drehealrbofreeth.A powd€rFrescribed b! . iI" l)\.lro'.1 Inh' /
A. Robln included magnesiumârd c2lcium .arDolare,ca(,um
t.iphosphate,cal.iû fluoddeand oncgEn oivhi!€ sùgar Flùorine ù itu.ride (ppû)
The man who had the Areâtesimpact on the earlyhisrory of Dc.F \(/dl, tsaufte, ÀrL 11.'
water fluori.lÈtiônwas D. Ircdcdck McKdy who âtrlve.l ir Cô1
oradoS!.ings, ColorècLo in 1901, dre yearfollos'ina his gradul w"f l * Kidd.,5. D"L. I2.O
tlon irom ùe llnive6ity ofPemsyhèûia Derta.lS.hool.He nDn NeLL nerr ll.lgerwood. N. Dxk
noti.ed thnt many of his falienrs, Farti.ulâily thôse who had
lived in the areâall their lives, hdd a permân€rt sr.in ôn drelr
teedr, wh;ch vas knowr to the 1ocàlinLlabirantsas Colomdo
stâin'. McKay checke.this lecture nores,but found rodri.g !o
describesuch markiras, nôr côùld he find â.v rcrère.ceto ir
in any of lhe availablesciertifi. literarùÈ. Hc callcd the srain for.ookins. ÀLCOA mined mo* ofits rlminlum srppLr ftn
'moûled
enamel, charâ.terized br: Bèuxite; if rhe sory ôf rhe rxln ln Bawire sot inb rhc haûds
oa lbose who clalned thn èlùmitium .oôking urensils .ausd
Minùre whitel1e.ks,or yellos'or brownspoa or areas,scat
poi$nlns. ALCOA woùld havc ro reflv ro the .bârse. \\rhr
,, . li . . , l r t )o r . ! - r l - , o . e r \ e . . - " . , . , , . , ,
Churihill re.eived a sample of Baùxlte s'atcf he i.rrùdÊd
ûay be a .ondirion where dre entire tooth surfàceis of a
Mr Â. $r. Petrey, heâd ôf rLlerering divisbn of dre ALCOA lab.
deadpapeFwhireIike lhe colourof a clirà dish.
ordrôr), e, lôok foi ùa.es of mre elcncnrs rhosc not usudll
Ir the forefrônrof his mi.d âllrhe rime wasrhe desiretoderer- te{€d f(tr. PeûcI n. a sfccrroahfhic ânâlysisard ooled thar Ilù
mire rhe caus.-ofmottled e.anel. 1le e$ablishedrhàt the o..rLr- ofide wd prcscnt in Bâuxite vater at d level of ll.l. Churchill
rerce ôf hôûled enamcls'âs locdlizedin definite geographicâi wrore to McKay on 20 lânu2ry l9l l:
a.eas.\Xrlthin these endemic areasa very high prôpoftn,n of Vwe
have discovered rhe prcsen.e of lirhcro ùnsusFffcd
.hildrenwere afrccted:only lhose(ho had beer born and lived all
con$ituens iû rhis wder The high ilùorine contet wN v)
their lives in ù endemi. arcah2d mottled endet; those bôin
unexpected dràt à new sàmFle was tJk€r with extieme tr
clscwhereard brought to the di$l.t when No to rhrceyea6 oa
.aùtbns and xgain dre tcs shovcd flùorinc i. rhe water.
aEewere.ot affected.The cordition wasnot innùen.edby bomc
or environmentalfactors:fdilies whether fi.h H€ also aske.l McIçy !o sen.t sdples of wàter frôû orbù
alTecled.This observâtiôntendedto eliminatcdier asaDaeîiolos erdemic areàs with à ûiriûuû ôf pùbli.lty. II.KaI qùi.Lll
ical factor McKày ôbsered rha. drcc ciries in Arkansd where ùmged for dentists in Brirù)n, Soùdr Dâkota, Oaklcy. Idrho,
motthrs occntred,althoqh sepa.arcdr.om e2cholher bv some ùd Cô1ôradôSprings ro send sanples ofdre mkr,. rhctr âra\
miles, all recelvedrheir wate. suppll f.om one soùrce,fountain The reù1ts of rhe\e ana.lyses a ere ptrblished ln r 9J 1 (Tablc i.l).
Creek.This, tôgetherwlrh manyodrer.eports,led him to believe Chû.hill emphâsizedthe fa.t rhar .o f.ccisc corelarion berNe0
rhat somethirg in rhe warer sùpply was responsiblefor motried the fluori.te .ontent of rher $ateB and rhe motrled enamelhad
been eyablished. All that was sho$n wù ûe preserce of a hith
M.Kty\ resed.h la*ed ovcf 30 yea4. Iû 1928 the US Publi. efto ùnsuspe.ted .ommon .onsrltucnt of thc warcc from dt
HealthServicedked Dr M.Kay to accomfanlDr GromerKempr,
oneoftheir medica.lotrrcers,ro ca.ryour €xamlnarions
in Baùxite.
They foùnd that .o moltlirg occu(ed ln peoplewho grew up on
Bâuite wa.e. prio! to 1909,bùt all nàtiveBduire .hildren $ho
Fluoride
in water
uled .he decp weU warer after thar .iâre hâd mo(led reerh. No lire v,'r)rl({rJll. li?ï.lley l}(:âr:
indlridual vhose €omel deklope.l during residen.ein Benron
l'\' rd'o 'l :.a'or'hrrbq"_q ilrr d, ' r'r 'r '
had mottle{lteeth.They reportedthit rhe rddard wareranalysn
drnrkina vat€r moû1ed enamel, ard denral .ùies was grvend
ot Baulte wârcf throws liûle lighr whèreverôn rhr probable
imFtus by d,e decision ofl)r Clinton ï i\'I€sùer, Heâd ofrhe US
caùsù]àgeri. Anoth€r pie.e ot evidcnceh2d bee. Aathered,bùt
Publi. Hea.lthSerl.e, in l9l 1, rc asian a yoù.8 dcrral .lïcq D,
McK2y seemedro closerrô the sôlutn,n.
H. Treûdley Deat, tô pûsue fùll-time Ésearn on mottiedcnmrl
Deân ùâs respônsiblÉfor rhe .esearh unir wirh;n drc US Publi.
Mottledenameland fluoride Heal.h Scffi.c ard wâs thc lEr dental ofic€r of the s€nice to be
An-cr a.o.'cli.ical asignme.t. His Ursr ldsk wd to coniloue
concentration
in drinkingwater À{.Kayi work and tofind the exten! dnd Aeographicàldistribùtioû
The chief chemistôf ârCOA. ÀrtuH. V Cburchiu, rea.lKempt of mottlcd cnamcl in dre tlrited S!d!€s. lle reported tlrat thûe
m.l ÀfcKat'\ paperand wd Areadv.lisurbed. Certèinpeopleir we.e 97 locali.ies in rbe coùntry wliere mottle.l erdel \16 sâidù
the Urited Stàtes"ere .ondemnlnAdrc useof iluminium vare oc.û a.d dris clâim hâd bccn co.fi.med by ade..aL sùney.
 n*,ia,
i,-"' .n
|

100

9 4 0
,Ë
^"
- Normalorqu€stionable
E
5+o I Moftledenamel

20

Mean annualluoride (F) conlenl (ppm)

Iigue 3.2 Th€ p.€val€nc€ofmoftied emel in a.€aswith dl$e.ins .oncenûâdons ofnuoride i. the wate. supply.(Irôm Deân 1916.)
l\eprc.lù.ed fnm FleîrL drinÉ,j z,tn, edn€d by E J. MccluË, by kind prûission of the US Depafrment of Health, Edù.ation dd

Manyof rheseconfirmarorysuryeysvere catied our by Dean

himseltH€ developeda standardofcla$ilicatioD ofnortlirs in
ordû to recor.lquntitàtively the severityof mottlins withiû a
comnùrity so thât he coù1drelate the fluoride coûcentnfloD rn
thedrinkrngwàtertô the severityof mottling in à givenare..His
âinwd rô findout the mlnimal rhreshô1d' of fluorlne-rhe level
n rvinh flturine begd to blemish the teerh. He showedcoûc1ù
sneiyrhàt the severityof mottllûg ircreasedwlrh lDc.easlûgRu
orlde.o.cerù?tion in the drlnking wâ€r (Fig. 3.2).
Deatrrcnrinùed his studi€s intu dre relâtiônship berween rhe
s*erity of momled enmel and tbe fluoride concenrhtion in wàter
sulllies.He preseoted additionalevidence to shov that mou.$ or
ûloridenot exceedjnsr ppm wereofoo public healthsigniÊcance.
Oo 2tth Octobe.,1918,ir coniunctionwith F.edelicl.McKan he
sunmari,edthe knowledse of notded €nanel in a paper|o .he Epi-
deniolosy Sectior of the Anericàû Pub|c HaLth Àssocjatioû.He
rpofted that in iheU.ited Stâiestherewerercw 37t knownar*,
ir 26 $ates whe.e moûled elrmel of varying degrepsôf severity
werefound.He alsos!àtedrhar rhe prcductionofnottLed enamel
0.5 1.0 1.5 2.0 2.5 3.0
hadbær hal!€da! Oakl€y,ldaho,Bauxj!€,A'kaNd and Andoler. F uoddein watêr(ppm)
SoudrDakota, siûply bv chansing the water sùpplx whjch con
tuftd hish coûcerÛàrionsôf flùôride, tô ône whose fluorl.ie cor Figure 3.3 The relârionbeiweenca.iesexr€ri€nce of72i7 12 to
1.1yeaÊoldwhiie s.hoolchildm of 2r citi€sin the USA ândthe
cenrÈtiondid nôt dced 1ppm. This informtior wd the most
flùoride.ont€ntofthe wate.su!!ly. (Irôm Deânet â1.1942.)
corclNive àrd direct prôofthat fluoride in the domesti. *àter is rhe
priûary .alre of hlman moÛ1edenme1 . \F.epndved frcm Fltutide dti,Èir{ rarar, edited by E J. Mcclu€,
by klnd permlssiofl
of th€ US DepâftûentofHeàlth. Edùcation
The rory of liuoridariôn now enued a new md, from a publlc
he.tthpoirt ôfview, è most importànt phde. Ded wèsawareof
the.eprts from the litemture drât rheremay be ar ,.vese rela-
tlonsiip betweenthe lflel ofmottlina and the prcvalen.eof.diÉs '0 1 . <p p n o n ) i ' r . o t r p er'. rê-e o " "*. O. 'n.
ln a conmunity. He knew ofMcKâys obsenat;oq. fi.sr madein otherhùd, of the I 22 childrenwhô hâd contlûùously useddomes'
1916,lhat nollled enmel vas no moresuscellibiero decaythan ti. wÀtercontaininsr.7 2.t ppm nuoride.27 (22 pei cent)were
.ornal erumel. Dùrins his srùdy to derernire the minimuD
th'esholdoli norllins, Deaû had, in somecri€s, also examined This stu.ly pave.l the way fo. a much la.ger investigàrion of
lhe childrenior d€ntalcùies. TakiDsa selecledsampleof9 year' ' a r " - r p r : e r ' " o f - - ' l- . 4 y e . r o c ' l d e a : o n - i , , e .
old children,he foùnd thèt of 114 chil.trenwho had continùoùsly in n)ùr sûtes. The resùlts(Fia. l.l) showclea.ly dre asociation
useda donestic wat€r supply comparalivelylow in fluoride betweeninùeasirg iluoride corcentniion in rhe drinking wâter
 3 t uoride
onddefrolories

and dedeasing cù]es experien.e in rhe popùhtbn. Iùftherm..e,

this *trdy rlDw€d tha. neaf mdlmal redu.tn,n ln .arie\ experi- N EE n ga n d
en.e o..ured *irh a .on.rnûatbn of 1 ppm I in the drinking
water. At this .oncenùalion nlloflde .aused onll' sporxdi.
lnstan.es of rhe milde* foms of denta.l nùo.osls of no pra.tical
ae$heti. sisnifi.an.e (Deanet al. 1942).

Why I ppm F in water?

Dear's vork làrned the basisoftire decisloÀto 0!or ale at 1
ppm ir the Urite.l Sûtes of Amerna. His orignrèlobserratlons
hàle beer substanriètedby i nnmber of iûvestiaètos. Moller
(196t) shoùe.t thèr dat. from Denhark ùd Swedenfollowed
the sâhe trend âs rhar repôrtedby Dean.t / (1942) (lig. Ll).
In a.ldition,stu.liesin GreètBritèiû, Hurgary,Aùsûi., Spdiû,ând
d,e tJniredSu.essbowâdec.ease n, cariesexFriencesith increas
lng fluoridecontentoftLrervater pplr up t) about2 ppm.
The ielarionshipbenveen.aries experien.Éin rhe decidùôùs
dertitiôn xnd the flùoride .on.enùatn)n in the drinkiûg warer

History
ol fluodde
in dentishy
1874-1942 nL L--------.LI-L
00 0.2 0.5 1.0
1814. role ofÂuoride.s r nùùient i6t reco.deJ i. GÊûâ.y Fluorideconcenlrationin water (pprn)
l9L6,Ic.leri.k ll.Kry notud mottling' of teeth in CoLohdù !_isure 1.5 The reLitionshit beNeen .diÉs er,rû'encc (dcft) in
l9il,Iluorlde idendtieJ in siCdti.Àftâmoùoc ln *rrer ironr ar6 l0l8 5 yeacold .hiidren lilnrg nr fuùr ùcs ofNE lngLad and ùe
flùôfld. con.dtEtion r tlrelr drinkinq water (Rugg Gun. ù,1
r981.) (Reprcdu(edby.outresy.l t\. eànat Bùitli DttùlJnûr.Ll
l9l9,Tiendley Dem denof,{$ted .elâ.lonsh4i bemÊe. iitÊr
flù.fide ârd eninel mottllng

19rir, Deâni sùset demo.r.fâled nrvÊse rlâti.nshb beNeen

!ù{ de xnd dental.ÀriÊs
was ln'e$igared by Rugg Gurn,/ d/. (1981). Thcy c{âùined
10I8 j -yeaf-ôld.hil.tren from foûr ared in dre .orth ean of lnr-
lând and dn)s'edâ ptugressive deûeasein cariesexpedefceNtlr
i'.reâsing .on.enÛ.tiôù offlùoride ,r d,e wârer,ut ro 1.0 ppnr
(!i8. l.i), thùs followina the samcrcnd as rhat reportedfor dt
tc.nranc.r dcftnnrn.

Temperate and tropicalclimatesand

fluorideconcentration
Repofts in dre 19.10'sfrom the Llniled StâtesofÂmc.i.a showed
drat mortlinA indeased çith rhe I conceDtrilion 1. the wa(Êr
nurplier and rhe mem aûmd1 reûperatùre (!-,g.1.6). Cou.rricsin
t.opi.a1 dre.s should reduce rhe F conte.r i. thcif water. Ior
$âmfle, Ho.E Kong nlulda.ed drelr wâter at 0.r ppm ! !ûd
hârc sincc.cdùced this ù) 0.6 ppm E

Engand
0 1 2 3 4
ls artificialfluoridatioraseffectiveas
Fluoricle(ppm) naturalfluoridation?
tigure 3.,1 Cariesexterien.e in 12- ro lJ ye.Fold.hildÉn flor
Denmdrk, S$e.len,anrl dre USA ifl Èlarion to.oncenû2ùon ol Grard Rapids1\,4rrs]<e!J0n
5tutly
'fhe
Uu..ide in Mte. suttljs (Itum l{oller 196i.) lReprcducedNidl ûucial ref sas ro sce if dental caies could be reduced in a
ommùnirr by adding fluôride dt L tpm to à lùoride lei.,.nr
l- bodiliidfluo,dorioî
0!.fledive lh,oidorion
!snorurd l'r
:l

I
1.0

=
908

9oo
E
E

0 0,4 ,0.6 0.8 1.a 12 1.4 16 :13 .2'.4

.Fluordecon.entrâ]onipansperm lion)

Iisurc J.6 Relâiiofsl,ir beN o.n flùond. .on.enû!rio. .f murniral $are.! drd Où.rols ùder tor commu. niesFnh meatrxûflual
tnpentlues ofappnxinrGlr t0'E (Nlldie$) and rl'! (ALizona)

s'arersul,th Tbe LS Pub1i. Health Sen'ic.ûas 'cadt tu eûbrrk

on s!.b an e+eriEett. Ii De.embet 19.12drc servicebegan
tùlks(irh cj.y ofi.ial\ ofôvo.ities in the J-dkeNti(hiaa! xrea,
Crdd ILJ!ids ànd ùIuskegon.Bodi.it\ coùncilsrgrccd ft,.a(y
our astùdl, virh Grand Rxpidsbe.oûnrg dreexpe'iùcrral ù)wn
ùkl ùlxskegon drc .odûôl rowù. tsaselinestrdies showedrhat =
.ârieseiperien.c in the p.imarl d.l perm.Àen! de.rition in
(ifur,l R,lJidsva siDild to that ol Nlusl.cao..1n tddition .hil-
dreû.onriûuôuslr rsideni i. ihc Darumlflùoride areaôfAu.orr ô
Jlltriors(F = 1.1 fpnt $efe exdûiied to pro!,(le fir(bc. bas.llne

On 2t Jaûuaryi1t4i sôdirm fluoride wâsa(lded!o rhc Gmnd

Itrpids waler $,ttll. thls qxr ad hisroric o.casion,be.ausctor
the fisr r,n,e a fermissihle9ùdnrity ofr benefi.ial.Lletarynu.i
ent wrsd(lde,ltodrc.omnunal drn,kitg wèrer.Theellècs ofsia
drd à hall redrs01ûuoridationin Gratd Rapidswereclear:c.rle!
ex!ûience ol 6 -vearold Grând Râpds.hildren w.s dmon bali
thât of 6lcxlold Mùrkegon .iiildien. The ci.,r ofti.iais ot
NftLskelton, .où!nr.ed of the eftlcr.I ol tlùoridâ.n)fl,de.i.lÉdto
fluofulatedier own warcrsùpph ln Julr L951, sô from this dàtr
ùl$keaon could ro Ionscr bc uscdasa controltorvn.
'tL. .,i
o , . r o tt - r , ô . c L , d R . J . . . "
<,mparisonr"ith baselinedàû. Resul!sâlicr l0 yers ofnmrldd
ùnand1iIeâ6qffluor in IiAuft 3.i lhey
a t i o nd . el c c o r d c d
irdi.are ûàr cèrieserperlencein l:-ycaÈold G.and Râpi.ts.lil
dLîo hâd falledfrom 12.t Dùlf leeth !e. moùtlr in lt:11 n) 6.2
DMf ieedr per inouth rn 19t9, r rcdu.rion of app(!'lmrt€ly
t0 ter.eni Fù,th.mofc, .arlcs experlen.ei! rl,e lluori.late(l
5 : 7 9 r r 1 3 1 5
,lge ât Lasl Blrlhday
Figu.e 3.7 Donâ1 .ars in Granil Râpids drildi.n llicr l0 a lt
yer6 .f llùoûdxrlotr {|{an Aûdld ,r,a 196zi.oFlrlihr by tlÉ
Amdican DeDralÂsso.i.tion, RltrinrÉJ br pdmnsion.)
. . . . 1 -, .
.oûûûin! ofGnrd Rôpids vâsrery simrl.r to d,ar oc.uÛna iû
the nà ral Uuoridc irca efÂùrôia. This \aas d,e ea|crimcntal
pnbf ûàt dre pr€riouslr obscr.ed hverse relatiolslrip berFcc.
flnôride in drinl.iia witcf and dental .âries experienceFas â caùlc
trf .l etiicr rclatn)nshlp
 I
a2 | 3 ttuoride
ûfddenlûl(ores
I
'Lhe
feeling\ tha. Tfendlel Dea. and his (Èwofke$ had when
thel rafted the Gra.d Râfids cxpcdnrcrt s'crc rc.alled in an
artnle brJohn KnùN)n ln 1170:
It is rôw 2j yeùs ago thàt rhe lare Trerdlev Deù èrd I
journered by truln from vashnraron, D.C., to Grand
Rapids,Mi.li€an. h bc joincd b PbilDJay Èf a meetins
ùith dÈ m,ùôr ù gain his approva.l iai r * âterflùôridÈtiôû
experiment. ... There were nô sigûs ôf apprehensiô!of
ddirg or of pn neerinA.There *er no impli.ations or
intèfen.csrhat wc s'c.c bcing foolhardy in subjc.ti.s a
fopulation ol 160,000pcoplero â l).occdu.cçhich might
hxrc cidrcr short or lonA .angc hazards.\{rc wcrc merell
Lcpli.,tins nacur€'sbest,base,lon an €xtensilebacksround
.fstlldr daà in nâture! laborarory.2 làborâtorywhich {'as
'\' r Jl,r:. Ua',l<." '"1,a. .i
milLionpeoFl€i. 1,900 comû!ùitles hàd dùougholt lile
use.ldrinl.ingvater which wÀ ûarùrallynuori,laledwiù a
tluorid€ co.centratlon of 0.1 ppm or grea.er.\Ye knew
whàt too much did, we kûew whàr too lftle di.t, we kne\r
wLràtthe optimùm anoùnr *6 and \re lhd dsùâfte tlrat
onr par per millbn flùorldeln rh€ d.inkins 'âier h.ùl the
srme bnnogicaleffectwh€thef it Aot the.e ftuh flo$itg
ovcf rocksor fronr a iècd;ns machinc.
Nevvburgh-Kingstnrl
study
In ddditior ro the crù.iRapids Muskegonstu.ly, two otherllùo
ridàtionstudies$ere cùried otrt ir the USA. On 2n.l À{à} t91t,
sodtumnmride sas addcdo ùe drinking waterofNewburgh,on
tbe Hùdnrn dvcr. Thc bs. ofKi.Éjston, situtcd l1 miles away
frcm Ncwbùrgh. sas choscnas a @nttrn own. BareliDerudies
$crc cafficd out in thc rwo communiricsin 1t.1.1''16.Clidnxl
cxaminarionsâfte. l0 yea6 of nuori,lâtio. wcfc câfficd out ,n
1r51-5j. Tbey rcpoftedthat shlle.a.ies experi€n.ein 10 L2
yeù old King$or .hil.lren h.L.l.hânge.l litde frôrn I9.1t (2LI |er
c c n to f r e e r hw e r ec 2 r i o u tr o l 9 t t ( 2 6 . 1 1 ) c . . c . t )1, . . o . ù a r , n
si.riladl aAcdNcwburgh child.c. ovcr rhc 1ùycaf pernrd,dre
DI\{F ote had laller fiom 2l.t per c€ntto l:1.9l)...c.t.
Evanston-Oal(Park5turly
A !hid Amerlcan t]ùoriddîiof experimenr begân in.J,nuiry t 914)
in rvanson, Iliiroisr ûe neèrby commùmt! ofOak Park acred d
die conÙo1 tow!. The findnigs after 1l yea6 ol fllori.lâtion in
Evi.sto. vere fubl;hed in 1961. Whc.câs rhc DMI rallles of
11-reaFold Evmron children fell fron 1l.r tô 6.0 betweet 19.16
drt 1960 (a reductiôn ôf49 per.ert) no .hèùse w.s obsen'ed ir
dre DrvII vahes ôf 11-yeaÊô1dOak Pârk chil.tren oler dre ûer
Thc stfcnErh ofrhc crpc.inrcnrâl purtof the .arleslnhlbitofy
prcfcry of nùorid c d rinkinA varer l;cs not only in ùe.on.lùsiôr
ofo.c stud-l, bur also in drc facr drxr dre tlùee Àne.i.ân sùdies,
.â..ied our by liftèrenr i.vestisaro6 in diffcrcnt pafs of the
.oùnùI, rca.hcd sinrlla. .on.hNnrns: additbn of r ppm ilùofide
in d,€ drinking s'âtcf ftdu.ed.â.ies experien.e by ipproxindtell
Artifiriolfluoridotion
. riN vtrÊne in Gmnd Rrpds (T) tud Àtûskclon(C), ]r,lt, DMI
r e d u . r i ô rl 2 . t p . r . o r L t . 6 2 F e r . e n r
' Seco.J*tierimentd s.hêne,Nervbursll(T) drd l<,qrn.n (C),
1911,DM! ædu.tn,n,2l ter.ent to 11.9pÛ..nr
. Thlrd exFrimenul s.hemê,Irnns.. (T) àmlOlk Park(C) 1t.1a,
DIII Édu.rion 11.1ler.ent io 6.0 pûc.ôr
Briti5h5ludie5
In rhc UK, rhe rudies by Nreè'er hàd shown that cxrcs
- r p i . - . o , r\ l , e . . , , r . ' , , " . . - t . f
\yas apFro:imaiely t0 pcr .enr lower rhrn h Norih Slields
(û!ori.le conte.t 0.2: ppnt. rhùs ()nilrmiûs Deàù'sfindlns5
in Gâlesbtrrs and ùIonmontb, I{acomb. x.d Quin.y (De.n
tt dt. 1919).
In addirbn, v/eàver(1910) .atrled out a sccondi.vcrisarbn
in 19,'19.i! tlre Nôfth last ofEnglâ.d, i.cluding a sùNeyot
V/csr Harlefool .hlldftn, *here flùor e con!e.! of tbc watd
sùpply wâs 2 ppm. He exrmiied 500 t jreâÊoldcbildrc. and
ftpofte.l rhàt ûe ûeàn .lmfi wù L76 and rhat 5J.6 pef .dni oi
lhe chiuren wcfc .arielffte. A similâr !ùmber of I2 re,Êold
.hild.c. {'crc cramitred:the ûeân DMI wàs 0.96 and !9.8 l)d
ce.t $'crc cadclffte. He .ommeûted: There .at be fèw, it a.l'.
oth€rared !r lhis cou.ùyçhctu the avemg€DI{F figurefor lns
elected12 yearol(lchildren is lcs rha. 1, âsn wasfonn.l to bein
fofest st!.lled 12.1I2 lJ ycaFold.lrildren in odter p.rts of
Brirain ùnh .orcentratronsof tluoridc in the drlnking $aû
larJ,iDgfton, 0.9 ro t.ii ppm. She.onpâredtlte càriesprevèlene
s'irh 2t9 .hlldren of dre srme ige in not fluotid. ,tcas.Cùies
w$ mrrkedly lotr'eiin the high fluoridc rcgbns.
À fufther $ùdy of areaswirh varyira on.enûdiôns ôf lluorde
i. drinkiûg ùâter sâs c:urie.lou. bvj2mcs. stro exxmined102i
ch;ldrenaSed1L-11yeasfrom dneeaÉùsin Èa$ Analiâ:Noml.h
and Yamoùth (Norf.lk) (I = 0.17 {).2 ppm), Chelmslo.d(int!
m;ftc.t llùorlde .onrert), rûd Col.lie$er (F= l 2 2 tpnr. Chil
d.en iiom ColchesÈfs'erefufther divided mto conlinuous'and
'no.
conrirùoui residens.This sudy sho.tedlhrt rhc DMI d
dnrse.hlktr€n .ontituoùsli resdenrif rhe biAh-tiuordex.ea{d
lesstlirn hàlathàr of corcspndins drildtun in die lo$ Iluoride
area.Chil,l,rn âacd I I lJ yea$ çho *ere côntiruoùsresnlenls ol
CoLch€srer hd<lnd.h doublerhe ptupôftiôr of somd lis! rûr!
dert molârsfoun.l û the.o. co.tinuoùsre\iden6
In 1952,the tsritishGove.nmenr sc.tâ missn)ntu ùe USÀ dd
Cânadâtô sudy flùornlallo. in o])ehrio.. Tbe missnn.on.lrded
thar flnôridàtionoI watersutplieswis â râlùablebealtLme.$e,
b r k.onmended rh.t iÀ rh6 coùfûy fluoridcshoùldbeadde.ltu
thr wêtern,ppliesofsomeselecre,l .ommùniriesbetàreits genesl
 thmses
serulor sreosI a:
iûlluo'lde
I

adôpriônwâscoûsi.tered (Repoûof rhellnlted Kiûg.lôm Mission
19j3). The selectedcommlnities chosenwere v.àtfôrd, Kil
nûnock, aûd part ofAislesey. Fluofidcwâsaddedto ûese d'ink
ins warersin r9ti 19i6. Sxttoû, Ayr, and ùe redainins pùt ol
Aflgleseydte.i a the coûtrol towns. :lhe resuits after t yeùs ol
flooridètion(DepartmeDtof Ptrbli. Healrh atd SocialSecu.irl
1962)showedthâr.dies txperien.ein i yeaFoldcbildrcnwd j0
po ccnt lower in the fluoride ùeas tha. rbc non-fluorideueù.
Inspireo{ rhis. fluôridàrionwd dscontnruedin Kllddnock it
1962,on rhe insÛuftnrnsôf rhe 1ôcàlcouncil. However,dentâl
exûiûâtiors continuedro be.adied ôut ir all àreæa.d the find-
iû8sèft€r l 1 y@s l]uofidarnrn were reporte.l h 1969. Thc ftpoft
contrned the main lindinss of 1962, ûat fluorjdationoi water
suppll€sis a highly effeciivc method of recLtuingdeital decal
In additionro dcmonrrntins rhe beûeficialeffectsof lluorida-
'During the
rior, rhe Épo( aiso .o.Jiimed its complcresatèry
eleveryeùsunder.evieq medi.a.lprdtitioûers reportedonll two
ptierts with sympromswhich they felt might hàvebeend$cl-
âred*lth fluordation. Careiul ;.vestigatiôn in both insranccs
failedrô nttribnte the symptomsto dre drinklng of fluorida!€d
yarer' (Depârthent ofPùbllc Health and SociâlSe.ûity, 1969).
Major nùoridâtior schenesb€sa. in drc wes Midlàt.ls in
1964and or Tynesidein 1968.
sù^'eys ol 5-yeaFôld children in l'lùôridàte.tNewc2stle and
'fhe resultsfôr this 1987sudy are
1ownùorideNofthùnberlând.
compare,lwith rhe fiûdinas ofdrc 1916and 198r suryeyssl wn
iû Ilsùre 1.8. Ca.ir! experietcefèll in both deas between1976
ân{ 19E1.but no fûther.tecline wd noted be.veeo l98l and
I987. In all dtee stu.liesthe differencebetweeûthe No.omdu
niries$âs t4 60 ler ccût.
Dàtèfor t , l2-. and Li-yeù old Hatlc?ool childret ùe av2il-
able sirce rhe 1940s (veaver L9)0, Mumay 1969; Murray
d ,1 r 991)àûd ùe summarlzedin TèbleL 2. The.€are.eftèin .Lif
ière..es in epidemiologicalmethô.lsoler the last 20 yeds. It
'i.'d .dl-o,oôFnÀr\ei pl" dorÉ.h'Fe,'l' e\Fty
rendr examitution. Neveftlrelesr.if it .tôùbt about a diagnôsis,th€
surtæe was recordectassoun.l.:rhe sùrveyscùrled out in 1989 90
l- l'lf i ,i,aato.'.gr'^i.rr'l. on\ \r. .En. \,g '
bâ.Llended probe, diameier 0.t mm ;n a.cordance with the
national suFeys. This dillerencc in dre level ofdiagnosis mal be in
part rcspnsible for sone ofrhc dlfferencesbetw€en rhe 1969 an l
1989 sun'eys. Â sliljht shift in d;asnôlis, or reductlot ;. denta.l
disede, can afiècr the per cent cùies Êcc râ1ùe guite markedly. in
thar it only t*es ore dinstôsis of a \dclg fisûe to a canous
cavity to remove an i.dlrldkl from dre cadcÈireegroup.

Artificiol in theljl(
fluoridqtion

I
J
J i:
in fluorideareas
changes
Secular
Agreardealhasbeenwritteû àboùtthe seculardcclinein câriesit
maoy counùiesin the dereloped'\aorld, pâiticulâfly rin.e the Figure 1.8 Cad6 experie.ce(mcân DMIT) ôfi yed ôld.hildrcn
1970s.Th;s se.ularde.line it.ârles in tluoridâtcdâreahasbeet 'n flùoridxr€d (I: datk.olumnt and rcn-fluo.iddted (NF: opefl
Doledio B.itain. in Ansleseyand in Newcdtle (Russ-Gudnd?r .o" I . r - o f ' n \ o ' n I r n ll ' ; . o'|'q d
1988). Russ-Gunn ?t ?, {i988) hàle be€n involved in three 19s7. (!rom Russ Cunn d zl 19ss, with lerFissio..)

in Hartlepoolchildret 19,19 89 (wcalef 19i0; Mùttuy )L)69iN[mrareIdl t99t)

TÀble1.2 Cariesexperience

ùlùrruy Mùrav dr. Vedycr Nlùray Nturay a r/

(1910) (1969) 0991) 0950) 096r) (1991) (r9jrD (1969) (rrrr)
r.1
Per .ent .aries-free 5.i tl 6.j 60 t9 )1 26 19
 3 ttuoride
oiddenrol(ories
ln spire of rhe scculâr chdngesin .lentâl .die! drar havc bccn
relefed tô kr oftenln rhc lâsrlèw yeas,.âriesexperlen.e;nHa(le
pool remainsone of drc los'es .€cor.ledofàr]' pa.t of(}ltat Britain.
Thereis no doubr rha! ;n lhe r960s dd 70s $hcn rhc.c\as a.
'epideni.
of.aries';r B.itai., Eùrôpe,ând Amerl.â. warcriluori
d2rioowas seen.o h.ve a major impact oû the dedtalhea.lttlofâ
.omnùnity. A redlction of t or 6 DMI rccdrir It y€dFoldchil
.lier betweer G.and RnFi.tsàr.t MùskeAor of H2nlelool ard
York wasa! obviousraûglblebenefir.The resùlrsÊoin Angles€y
and Newcasde/Northumberland show drât warer nuoridarionrs
s.lll bcnctcidl, bùt the si,e of the hcneÊr has been re.ttr.e.t
be.aùscrhe total Froblemof.afies hasdimirn|ed.
Ellect of cessatior.r
of fluoridation
Mâûsbiidseshowc,ldiâr àlie. cesationof rhe tlù,fidârior scheme
in Kiln,rmock, ir 1962,the prcvalcn.eofcarlesùûersed in.hlt-
dfen agcd I 7 yeès. By 1968, drc pro])o(ion of.hlldren free
irom decal approximâtedto rhc prc iluofularior le!e1 of 19t6
and !o that ofthe.ônrrcl childr€. in Àyr.
(1987) reporredlhe resuhsôf.linl.at and.adn!
Stephen//
graphic examlnâtb.s of t yedrol.t childrer rvho had beenborn
ard nised in the fluoridâredrosn of Wick, .ompâredwith simi,
lar ùbjeds j l'cas âfter Vick wèrersâs denùofidâtcdln 1979
becaùse of a de.isbn takcr by I lighian.l RegionalCoun.ll. Thc
rcsultsâre sùmmrrize.lin T.ble :j.l a.d shos rhat a sut\rrnridl
riseindentul câLicshd oc.ùûed.TLe authors.on.ludcd rhât dris
locâ.lized.aries incrcae, whi.h is rgair$ a.UÂarn,nal.lo.â1,and
sô.ia1.1assrrcrds, 'enrlte.t frôm the 1977 decisio. ro derj.ile
\Xri.k ;nhabirantsof iluoridaredwatef sumlies.
In 19E0, a compùisôn had been made betweenrhe dertèl
health01l0 yearold childreninSùanrâcr,10 yea6afterrheirtro
ducdo. of water fluoridarbn, and drosein Aûnan, which h&l è
ncAl;Aibleco.cenûationof lluofide in rhc tublic wr!€r slppLy'Ii
1986,ùe opforuniry wastÀker to ex,ûine lGycaFold childrcn
âa2i., emplovingthe sanediaanor'c crire.iarnd ore ofrhe exm
incF involved ir ûe previôùsrtudy (AtNood a.d Bli.l.honl
1988).Only l;fèlime resi.tensrere includedir rhe 2nâlysis.The
.en,ls showthàt $herea!DMIT \'àLues hdd fallenby 16 per ceûr
i. Anûan, rhevhâd rlsenby I per ceorin Straniaerèfterfluoridè
lionhad beer wirhdhwn. Althoush l0 yeù old cliil.lrenin Srrà!
.iere ma! $i11hÈae sône rcsidualbenefirfron earlierfl ûoridatior,
dreir $u.ly {gEered drar der$l healthhad st.rted to.leteriorâte.
Table 3.3 Càriesexperien.eln i ycàÊold\x/jck ch,idrer rn
I979 and 198.1(Srephen d d/. t9ll7)
l93r P e r . e n rl n c r . 6 .
Clini.al an.l n liographi. dnli 412 rt 9l
O.e contrary resuh {ès reporte.t iecendy by Kudzel
Fisch€.(2000),folLoans the cesationof lluoridariodin Cùba,i
1 ,, D\l Tr lF r-É.e|o.er,,lr.dlrdLefo flro,,d"
(1971), dfter 9 "veùsof nuôri.tàtior (1982) ard 7 yèars(1
2rierthe ce$ationof fl uori.tdtiorin 1990.
Thc lafgc$ .eluctio. in ctrries occùred be$e€n 1971
1982. Valtrts tor 1997 were simllaf to drc rcsùlrs (ccorded
1982 Ior 8/9 .n.l L0/Li yeârold .hildren. However,when
flùori.làtlon ceasedin 1990 à foftnighrly mourh rlnsins
granme for al1.hildren Nar insrirùted,ui.A a 0.2 pc. ccnr
ô'Ûô,,,d" , " \ ' , ' f o ' n . c a 1 1( , 1 1 ,
Fluoridation
andthe law
I-e.qislatior
àudbrizing waÛ fluoridarionls of rwo iyps. ft mr
be mandato4,rcqùirinaà Mi,rÀtry ofLlealth or .om mùririesotl
ceitainsizeto flùo.i.latethei. pùblic s'arc. sùppl;cs,of d,c lcgis.
htion mây be permlsive or enablir:j, giv;.9 drc M;njÎry
Healdr'ôf a lo.al:jolcmmcrr thc âu!|o.itI ro jnsli!ùre flùorid&
Inrn. Sù.h lcgisladon does .o! aù.ondtically brjng dboùr flùod
da.ed watcr sufflies, bur pales dr€ way for heèLih officialso
ùnits ol localgove..menr ro dct.
NIàndaloryld$s r€quiringfluori.tatrôrof pùbli. watersulplis
that xrc ilrcrinc dcUc'e.t hà!€ beenera.ted in Brazil, Ilùlgùia
Greece,Ireland,and tive {arcs ofthc Unitcd SàrcsofAmcri.a.
E:!ûples of colntries $ith etubtirg legislation dre severxl
stares of dre USA, a.(l also Àùsirâliè, lsrael, New Zeâland,
Canada.and rhe United Kiûsdom.
Tbe elisting flroridatioû s.hedes id Brirâir were iûpie
mentedin the r960s wher rhe bulk of dre *âtei sùpF1vinduùr
was in plblic ovûeship i-e. underthe hanageûent oflo.al go!'
€rrmerr. Boih privateard stàreosned $ater supplierssÉre!û
sùade,:],èt the time, tô fluoriC"lte iaÙ f.r dre publl. good ùndd
a non Frofir nakirg xûangemeût$herebl rhe $ate met dLlthe
There 8as grat optimism in pulJli. heâhh.lcles \vhenthe 1981
\ Àler(Fhoftlarion) Bill *enr dEush Pârliaûert. The BiLl{A
brousht foN:ud by the then CôBeNntive govennent to reù,fy1
tack of legislative frmÈrvork tu albs. nis fluoridatnn $]Èm8 r
be inûo{tu.ed. This fôllowed a iulln8 by th€ HlAh Coùrt ln S.o.
1ârd ir 1981 that nuoridattuq wô iLlûa vires and rhâr dndig
s.hemes,in S.otland ar least,wse foond ro bc unlastur.
k *âs rh$ .onsideredbl. publi. hcahh pra.rlrn,ne6 rhatir
woùld be ody à matterof rime beforefluoridJtionofpublic Nater
pplics would bc cxrcndc,lthrouahoutthe LIK Thc subseqùmt
A.t wasnot orlr rhe m€chanlsnt nû.du.e nes' s.hemes,bû
â1sôsetôut the respective roler for dre heâlthauthofity,the satr
undefakcr ard rhc Scc.ctalyofsi,te. Go$.y ând Elans 1999)
Hoscr.. no ncw !âter lluo.idario. schemeshavcbeenintù
dù.cd u.der drc I98t (a.d latc! .orsolidaring)lcAislation,butn
was only on Dcccmbc. 1t. 199ti. lollo{'ina a Judicial rc\'ie{
bmushtbINesrâsdeâ.dNordr'fynesjdeHeakh Audrorifi',thd
the lesislationi'as llnâlly p.ovcd i. coùft rc bc hadegùâtc.

Ncwcastlc rnd r\i,rth lynÉside Hedldr Aùthoti!-v hâd.cquc*ed
a iudiciâl .cvi.v of rhe de.i\nD by NorthumLrrià. \X/atcr CoF
l)â.y Ltd ftllos.ing a ftfùsa.l ofrheir originii requcr ro rhc com-
tanr !o€xreûd Uuoridation in 199.i (file yeèrsèlter pr!a. zâùon).
The aim of rhc jlldiclal revlew \aas ro .l.rify tlt respnsibili$ ot
rhc s.tcr.oDpânr in the lo.âl decision maLjna l,.o.c$.
Afû d exrersile pùblicitl ând .oû ltxtion ..mpdi.qn rn
1991 9.1,Newcasrle ând North Tlneside Heâlrh Authorily (s'irh
Èll die otlier heahh autho.irics in .he Nô(hern health resio.)
âskedNorthuûbriù Water !o i.troducc {'ater lluôridàtiot to a
turnef 1.1 hi11iôn peôple, t miLlion leoplc hârinA al.tâdy bete
fitrd from rvater fluoridation nr the Noiih East tu o'er 2t yeas.
'l'be
He rh Àuthority .onter.led that Nofrhumbfiad \\rater was
&tina ùrlawtuUy in de.llniûg the tsIeù]th Aulhoritys rcaft$ ro
extendlluoridttion, ard drdt .he reâsonsgi\rn wcre lllogi.âl. The
He.lth Àlrhorny rrAuel drat rhc rclevanr pdlinûettrry àcts ao\-
cfii18 satcf lluofidarbn $ ere ifterd€.i to en.ouragc it. not merc1y
ciùhlc it n, be lnplemenÈd ifÉluested ro by rhc Heahh Âuthor
i$ Thc mâin a1Éjunrentâgrirst dre Heà]th Aùlhotiry challense to
Nonhumlrriar \rater's dccnnrn was thd ûe waref comFn-! had
âb$ltrte discretion !o t'o.ecd of not {'ith new wtter ihroridarbn
s.heûes,àrd tliar dris di scrction wN $'lde ard ûIettered Thc fre-
sidins judge, MrJùstice Collins. @..luded thàt as a pûratc com-
pany (vhich did not po$e$ Iôs'cr $nely f{r the tùblic Aood),
Noithumbridn Vater hâd ù.ièûeftd dir.retioû for the futxxes of
d,e (tluo.idatbn) *atute. :fhe Jud.qe .ondudcd tlr.t, regreûable
rhoùsh the water .omtany (lecision vas. be.âùse of the existina
lâN,.he appli.Jrion to have.he decisior .hxllenged ûu$ Ià1.
ThcJudiciaL Review hd shown thàt .urcnt leslslâtioD is ]rel:
flcrilc æ far as new water fluôridation schemcsarc 6!cerûed, .s
dreFârcr indu{ry irselfagrees.Heèlth profi$ionâls .aûnor junif!
rny moLc cfnrt nnder exlstitg regùlat,ons. lfrhc fftsent golern
nû,twatrr imtrcrcd dentâl heâlth, Jn.l l]ùori,hrio. is rhc nethod
ofchoicc, rhcn.ew (and etreùive) re.qùlàrionis drc only oûe.
It n âlso po$ible thar exisring s.hemes $ill cone un,lcf
jûcràsing dr.at if s arer .ompdries ère torced rô dcfcr ù share
holdcrs (Lowq and Evans 1999)
progress
Politicol ol lluoridotion
in lheUK
l9r0s l2% oapopulanonil uùiid.td
tt80s Couri.,se in Scôdùnd
L93t wiÛ (flùor àrion)bill
I91l JrLdl.l RevievÂrd: lorisldio. i.àdEqùàF
2000 Yor[ Certuead Reriew\ reue. oacfn.(v a.d etÊty
oaflturdit,or
Why advocatefluoridedietary
<rrnnleynentc?
\xrheninÙodtrced,die!ùrytluo.idc sùppLemens\"ereperceivedto
be x redsoMbleahe.nâtirc s'bcfe rvater iluoriclatronvas not
VlhIodwii,i {juo'i) illsro,yiuul,*.'-r ,ru
|
posibte. Thcy sere reganled as vrluable both for individùals
àn.t às a fùbli. heal.h meènrre. Nfofc re.entlr', it has bccr
.onclLrde,l tha. the .âriôstat,c efÊe.t of suppleûetrts n,â,v bc
1es thxD wâs sugacsted in early ûials. Thc lnitlll dosrge s.hcd_
ù1es were i.rr.dù.cd befôre fl!ori,le toothpa$es lvere widcll
ivâiLable. Thcy vere set to emulâte tbe effecs ol ,Jrirklng
1000 ni of wdter fjuori,lared at I ng ter l1ùc, bur it $ôùkl
appear rlièt chil(lren nrcly drinL Js ûùh as half tlis .moù^!.
More rLlùr oDe sudr has slb*! an asociatn)n bÙ$een lse ol
fluoride strpplemeos a.d cûame1 opèclties. Suptlemtd6 àlso
demand a hitjh desree of (loperation oler à lo.A Period
dnd ir has beed n,ggest€,] that re.oûmendrtions slmuld trôt
only bc reduced but also simfllfied in orlet to cnconrage
]i is rgreed tlur dietnry supfltnetrs ûe nor.qencfalll itâble
as a publlc heahh mcasure add thl th.y sluld Lie dne.ted
to\r,rds childrcn *ùo reqùit rhcm and lvhô lire i. ârc.s sath
$rboltimxl wâ.Éi fluor e lcvcls. Children who st2nd to benefit
in.ludc rhosefir whôt caries .f its tfe.tnett mrv lnsc.n rd.1,
tiondl h2zard. a se11.s cbjldtcn thoulht likely to dcveloP.âûes
for maol of rhese clitdren rhc potenriâl disad!ànra8c of dild
errmel ot,acirics nal, be ollwciahed by th€ benels of tlùoride
supplemerts. It is al$ àgreed tl,r!. whengiveû ds tùblcts. lpPle
menrs should hc dloùed to dissolvc slovlt h the n,outh n) ptu
vde rofi(al as weu as srstemic cffect. Both to rc,lucc dre risk of
ol)a.iries aDd t. mâximizc thelr effeùn'en$s, $plnedeùs should
nor be give. ,t dic same time as teclh aft t,ftshed.
. : l ' - . ' , 1 ' 1 I ' p p i "
dosage sihe.hrle. A summarl of cutrcnt s.hedules ùsed in
(liafc.cn. pÙs ô1 rh€ wo.ld is sivet in lis. l.t. It dar ne€(l
to be ac.cpre.L that eny ,losagc s.hedule Nhich in.lùdes the
criti.âl perbd of enamel tbLmarn,n will .itry somc delreÉ of
risk of mild enamel opàcilies, t)ari.ulady if 1lùon(1. i.ge*rn
ftom .rhcr \tu.es occo6 ât dre sarnetide. The r;k ot oPr.ities
varies with tiûrer rhe aAc ofrhe .hil.l is criri.rl, s'lrh peitJ.ent
teed, ar .isk ùp tu the age ol'6 -vca$, an.l pennn.e.r tn.aors
dnri.A rhc tiN I ler6 ofllfe. Thc.aries iisk stàtrtr of2.hildma!
also.hange\,lth time, so thât rcaùlâr redse$me. ! is nccded P.r
eùts û!s be tull-r invohe.t it lhe dc.isn)n xnd, shere a.l.nri{ or
dô.or wisbcs ro pre\.ribe sùpplen,cnrs, dre risks ànd bcncli6
ûee.l to b€.lea.l-r cxpldded to rllow parcnts o mke rn rrtormcd
The Rrirish Sociclv of Pae.lftû. Deffisùy (BSPD) ûade thc
follow,fa recommerdntiôùs Nitl, rcst)e.t io lluôri.le sul,Plemcrrs
i. â rc.cnt poh.l do.uJnenri
. Diet.ùy lluorid. sùppleûetts ire .ot gcûcmuy a publrc
healtli nea re. They shoukl be recommended onLv tot
iddlvidml .hil(lreû çho aÈ ât xsk and who lile i. àreas
sidr les rlrdn optiûal warer thoride levels.
Each crse sboul<l lt dccided ot its in€.i!s, ând
rhe fisks
and brnefits oI opplemcn6 shoul.t be fùllv cxtlained to
F.cn6 before prescrifrio.. Â flexible àPpro&h shoùld be
adopted ard. cliild\ risk sratus regululy reascscd.
ou I n,'ia,.a
a,n,a
*,iu,
I

m m
0 2 5m g 050n9
m
0.75mg
VM
1 . 0 0m g
I1 5 0 m 9

Brilâin

USA
(uftil 1994)
8 1 0 1 2 1 4 1 6

FigL.e 3.9 Daily flùôriJe suptlement dosâga, liv asr, r(lxxnu,ccd 1or useln low-flùord. rms (<0 li Lrlrn) h dlfûc.t .ôtr.û,s.
(Â1tû Riordân, l99a )

lor.lildren h'inA ir ùred witb varer nrFplies.orr,'n,'s

widr hdide elready piovides an cilàcrlve nears of prerenting
le$ rhù 0.1 pfm flloride ân.l who âre .onsidefedû, bc 2t
goiùc.Iidee.ln las à medi.al pn tirioner .otu€rned with preven-
hisli iisk, dre rc.on,neûdeddosascschedùleshouldbc:
tb. ofAoiûe;r Switzedand stn, ovcr 40 yeus ègo, pbd€ered rhc
additio. oflluori.le tu sah as a ca.iesprelertne mea{ft. Ilùoi
datedsalrhâsbeeo n n s . e j r S w l r z e f l â n l s i n c el 9 t i , d r . l b y 1 9 6 r
r1fee qtrùd3 ol doi.cric salt sold ir S*itzerland sas fluo.i(la€d
ar 90 m.q F/kg *rlr (or 90 ppm F). Sin.e 1981, rhe mlomr of fluô
fidc adle.l !o salt hd LJeen2j0 .ra F/l.g snlt (2t0 ppm F). This is
h rred wirh waler sùpplies .onrain inA illoride xt of âbove 2milable ù 2l Sviss.mtuns $'irh t.t mlllior iûMbitunrs 2nd is
n . 1. l , I J . ' , . . . , , d , ' . . " r .l o r . J . . . , used !otûtdi\' br 70 pcr.en. 01tlie pôpnhtn)n.
Despitethe vidcsP.cad use ol lluôridâied sah in S$'irzerldnd,irs
Alterrotive
syslemi(
0gents:
fluoride
rupplernenfs q - ' , 1 p i . , ,
tres, ôrher pLîrcnrive r.osrarnnes (ftùofidc àblers or llùoride
' OriAlrd doslge reAlmes r. ,nimi.llloridarÊd iat.r l.y.]s
bnahing) hxle bccn o|erdlirg ir m.ny \.hools for orer 20 y€:ùs.
. Àdrenr.tdùo'nl.,oodrpaies redù.ês iosit!. re.ommended (BSP[) Interiû ien .s sefc fublished by ùtr(La.ler !r,1. il..m whrdl
they ....luled drar rLe ..iieçprcrcnûve eifeûileûes\ of 1lùo-
. Pi.s.nbing
Fm.rlrlon.r ndedsbieigh ùt !isks iùd benerr. ri.lized salt ir V,u.l was greàrer than rhc 2t l]e. cent or so redtrc
rior ob\encd lollowinA rhe âdditn)n of90 m.q l/kg in orherS*,^s
. Not &llo.ried âs a t ùbln hcàLb ùenrre .xnrons (Ntartlièler ând s.ne.â1di 1962). The ren s aticr 12.
rcaN âre given in.letail by dc Crousazrirl (r98t). De.tâlcxanl
inario.s ol 100 -200 .hildfen in fou. age groups 8, 10, 12, 2nJ
Fluoridized
salt arîdmilk 11 Icâ6 were côùdu.ted o. an cxaminer blird ba\is i. 1970,
As â di{ùy veL!.le fof e,,nring âdrquatci.ge$ron of flùridc, l9lri, 1978, Jûcl 1982. aldiouah rhe rumbers of.hildrcn â.qed14
domcsricsâlt côhes se.on,lto driûkins *arcr: Sàks eùi.lhent yca.s i. t he .onÛôl ârer $ erc roo smàll to aùrlyse Re\ul. làr Dùl!
 t u o r i d i z e t ' û rm
mkd l4/
I

decli.c in .aries preval€.ce. This is d smàI] srudy .âfied out lD

l98t ând publishe.l iû 1991. and i\ itdnative, râthe. that con
clusilc. ofa long tern benellcial effe.i .lue to sak flùoridâtion
Fluo.idâted ult, when well accepted by the Public. hâs sôme
,9 parallels to v.tei fluoridation in terms of wlde covenge, little
Ô cons.nr a.tior by drc individnàl a.d los'eipense. lt also
q requires systemsofmonitoriûg qùâliry at .he pro.esing Plars
The polidcal atÙa.tiveness of fluoridated sa1t, as opposed rc
t .9 water iluoridation, is it the element of choice for consumers
In dôs plèces using Iluôriddted sdlt, it appears âlongs e non_
à
nuoridated sâli on the supermdket shelv€s. This makes fluor ated
salt more palatàble from the sociè] Folicy vicvpoint, bùt its
commùnity wide carie*p.erÉntive impâc! is clcarly reldted to the
extent ofpùblic aLreptdnce(in Switzerlàtd, l]ùoridaÈd elr .lâimF.l
75 pe. cert ôf d,e nârional doneric sèLrmàtkct ln r98l to L99l)
The nîrodù.rion offluoridated s2lt, drerefoft, teeds to be â..om-
panicd by public edlcârior and prômotio.. \{/hcn only some
donrestic salt is flùoridated. .ôn$mes r€lain more chôice, but
plblic heaLth effectiv€D€ssis dlminùhed. The Swiss .antôn of
197A74 7A A2 191A74 7A A2 Vaùd. i.tcrestiûgly etôugh, remores tbat chôiceby fluoridating â.ll
canlons FF/NE canlors ot vâLd sèlt oo the supe.ma*et shelie d wcll a\ the sÈlt cleliveted in bùlk
zurich
to resauEnls. baleries, f@d proce$o.s, hospitâls, aDd odrcf insi-
Iisuc 3.10 ùIeanDMIT lor 12 ycaFoldSwissdlildien in the nrions. Oral hcâhh shorLl benent d a resùlt, thoùsb consumer
.orùol Canrorsof l.ibourg rnd N{rhârclr r€.eiving salt cLrôiceis cuiiailcd. In Fran.e àtd Germaûy, which only acceF flùo-
to 2j0 mg F/kAin vaudi in flùoridizedBâsleiândnr
tlùoridized rnle ues whi.h perûit con$,mcr choi.e, the flùoridared sali pro
l6..mmùniiics nr Zuri.h Canion.(^iter de Crôùsaz d dr trs>igrmmr is limited to domeri. salt, which is available alôngside
reprcdu.edwirh kind Frmisston af aà|t t, H.fu\i.d Adù tgtu Adà.)
non-fluoridàte,i s2lr. Bu. in both Costa Rica and J.Lfuicè all domcù
tic àr.l irsti$tional salt, excep! that rèr bakeri.a, is Ilxoridârcd
DesPire ûe extensive studies cdried out i! Colonrbia àûd Hùo
siresde aivenin Fis. L 10.Th€ authomcon.lùdedrhât (è)therewas
salt fluori.lâtioo ias no. be.ôde estèblishedin either .ôuntqr
âdedineln.dies dperiencenr childrenir tbe.onÙôlcommunitiesi aary.
Salt fluoridàrion is.or re.onmetcled in countrics where there
(b)a simild de.lire ùrùûed in l2 and I.1-ymrold childreoLlnra
is cxredsir sâter nuoridation. Further resea.cb in salt ntrorida
in the rest.omùnities this wæ not rhe casefô.8 d.l t0 y€aÊ
tion should be it its acceptanccand effectirenes in ùe different
oldss'he.ea low.dies pre!.lencealeadyqisted in 1970,prcbèblv
-ronJe'" coùnûies nôw adoptina rhc meanûe, ènd irrthcr .efinement of
. k ' " " , 1 , 1u o f :.1 , _ Frp,
'w.n rj .ri , r ' r ' " . i . . . \ ' ' J \ ' , ' \ ' r i Ê . r . .I ' '
tently lowerin cbildrenwho cosumed saLtfluoridizcdto 250 mg
Therc is also iittle iùfornation on nùo.osis resùllin8 f.om s t flr
liks conparedwirh clitdre! iû dre conùol .ommuûities.Caries
oridarbn; rhar too requires do.LlmentÈtrôn.
e{cden.e of children in Vaùd in L982 wâssimild tô thoserecord€d
The elidence for the efièctivenessofsèlt flùoridation is bded on
for child.cn in Basle wL1ôhâd consxned vater flùorldit€d èt r.0
rllnited nunrber ofobserlalional studies; rhe ùtùr€ oi thc Prc.t-
ppn I, aûd similar to clildren in Zûi.h C!û!on who hâd benefite.t
dure does not lcnd itsefreèdily !o.adomized, double blind clini-
fom a school bded dental pr.€râûne, which had bcen operadts
cè1 ùials. Odrcr ùses of fluortle 2lso nrake it difficllt to as..ibe
specificeffectsroany one nethod ofusi.s nuoride Positlle.csults
Other studi€sin childrcn bare beet reportedtioo Hunsat',
were è1sorepoffed from stu.tiesin l:lungàry and Spâit in the 1970s
colLûbla and SFnr. Thc stùdies*ere càried out in the lr60s
and | 970s,when .dies levelsiû lurope werevcry dlfferentfrom
whar they de mw !ùrrhermo.e,mo* of thesestu.Ueshavebecn
.afied ôut orer aliDiled periodoftime. one stù.lyofSwissmil- 0therdietsry forfluoride
vehides
iiâry .onsùipts (age 20) sufpof.s tbe hypôthesisof cortinued
e{fcctirenes Menshiûi et rt./J9a5). Àmong consùipts liom
Fcsrch Swûerlandthosewho had not be.eiredfrôû fluôridated Repreff,B 75 pùîent of table saft i! Swnzeddd
sâh had 10.2 DMI (.{ecàyed, missing.or tilled) teeth (, = rtl).
whilc drose fn,h rhe.ànto! of Vaud who had.ônsûed flùori Sig.jtcdnt reductioosnr cariesd4lite bâckgroundfluo.ide
date.lsâlt trem .he ageof t yeâ6 olwa.ds shovedonl-v7.1 DMF
(, = 56). In switzerland as a whole. rhere is a srons sene.al
 3 Fluoride
onddenld.ûries
Flûoridizednlilk
Borh bovine èrd human milk contain low lcvelsor fluo.ide
about 0.01 ppm E Be.a6e nilk is rcommended æ a good food
tor infanrsandchitdren,it wasconsidercd,
ove.30yea6ago,to be
a sùitablevehicle for suppleûenriûg childr€n! lluo.ide inrâke
in area with lluoride deficienrwater supplies.Ericsson(19)8)
showectrhât flnoride wasrbsorbedin the sur jlsr asreadityfrom
milkas from wàter,refuringrhe n$Aesrlon!ha! rhe high cèlciùm
contert of milk wô d renderdre nuo.ide ùnavailable.Howerer
the biûdirs ofaddednuo.ide ro calcilmor protein ûisht Édu.e
the topi.al fluoilde efrecrin rhe noùrh conpùed with flùo.ideln
wèter All the.eporteddals haveshowncùies prevenriveeiïe.B,
espe.iâ]1)'
wben milk coosumpriorbegd beforethÉ enpr;o. of
perdanÈnt reerh.Cli.ical data are stil1 liûite.l, however.Milk
flùoridlzètior requires.onsidefableloAisricellon ard, d yet, it
hasnot bec. inroduc€d oû à comunity b6is, althougns$dies
hàvebeÉn.aùledour in GL4sov m.t Cheshire.
ueveropmenlsll'l Ttuofloe
tônthnâçfe(
Developrlrents
i Bliiahl betvlee* 196i1ônd l99tl
Clinical ùials ofûe effectivere$offlùoride in roothpâslebegan
in Englâûdin thc 1960s.Fourinlependentstu.lieslnro rhecffccr
of stmnousfluoride tuorhpasrcwe.e càr.iedoùr by Jâcksônând
Sulclire,Jènes aû.tAndersôn,Nâylor a.d Èoslie, and Slàckand
co-worke.smd werepublishedin r967. In addirion!o investiga
tjon of stèûnôùsf]ùorlde pasres,Naylor and tmslie, ànd later
Hàrgrewesand Cbesterwere iovolvedir trlals ôfsodiun monô-
fl ùorophôspha.e (ùtIP) toothp{îe
In mrkering terms, two comnerciatprodtr.$ (CôlgateMIP
dd Gibbs F) werelaunchedin the late r960s a.lonssidestandard.
TâbIt 1.,1 DMF i.crementsùd percentigedilïere!.esrcported;n cariesirc.emenrs stù.liesirvolring màinlr sodium
T ô n , l l , r o r . o . r h J , e , e ,, r r . o r d r r - , n r , r e r r i o r ,
214
tt I .il
MitroFlous dra (1934) 1.29 t 1 3t l 16).
212' 1 1 0 . 0 1, 2.29
6.a0
2.J9
nôn-flùôfidetôothparesprodù.edby ùc samccompâ.y.In itially
the idpa.t ofrhe flùoridetooùpasrcswassmall, !h d,es€!rod-
tr.ts captùing onlr 5 pe..enr ofthe marketsharcby 1970.
À fixdrer ûidcâl developmenrir malkeriûsoccur.edir r9l1
when MlP wæ ad.le.l fu the r@drpdte which wa rhe. lhe b@d
lea.ter(Colgàte Midty), virh ôve. 20 pe' .ent of the ma.ket sbar.
Two nlrthe. mâ.ufætlre6 (Beechansaûd Urilever) followed suir,
Élrirerby convcrringdreirmain band to an MlP pNte or by irtm
ducjns a no pastecontainiûs Tluoride.The fourth mjor t@rhp4te
manulàctur€r (Procter aû.t Gmble), enteredthe Brirish ûdket ln
1976, when they laùûcheda ne* toôthpdte (Crest).ônrainllg
Iluoristan (stâmousflùoride).Sàlesof ntrôiide rôôdrpasres had
'l,ro'
. , . r e a ê dr d p , d l 'n d b ' ' f i . , m d uknr. p,"e.
ecoùnted for 7t per cÈnrôf the ha.ket. Ghwdr .ontinued and by
the end of !h€ 1970sthis fisùre b.d lrùeæed ro abour 95 per .tnt.
Y/iih tne in.reascin srles.comper'tio. âmooAthe maoùfac
tùrersbecde irtenseand a wide ranseôf Ilùofidetoodrpdteswas
developedânt màrketed.Prdlù.ts ldied in l:luorldeco.ce.rh-
tlôn ànd in the type offluofide compoundused.Mixed nuollde
systens(NaF and MIP) we.eenpLoyedir sometoothpastes, and
odr$ acive aaenrswere;ocLuded in others.
A ûùmberofclinicâl |rlah $'erecarriedour to iNesigate tle
cffectsofvarying l'luorideconceûtretioûs, with pdres resi€dcôn-
ralnnrAfrom 2t0 to 1000 to lt00 ppm I or hlgher. Resùltsof
rhesearesùmmarjzed;trTàhlc1.4. From fi.dinss in rhesesùdies
ir hasbeeùsuggestedthât i doseiespônseday be seenvirh each
increaseof t00 ppm I abole 1000 ppm F resùltingi! ar addi-
donal reductior in cxies ircremert of6 7 per cenr.
ln srmmary, stùdieshavesbôwn rhar nuoride i. toorhpâsre
at a concenthtion ôf 1000-1500 ppû I resuit ;. .educrions
ir .ùies inùements in 3 year clinical ùlâls of âpproxioarell
l0 per ceÀt .oûpared with .oftrol Sroupsusins qon-iluo.ide
133l ' 2.91
o.rl' 219
1 7 . 1 1' 6.ll
6.a1 I 1 0 . 9 1' t.?l
l 2 7 . s l+ 1.37
fi6.8l ' 2.o2

Incodl.lerlng rhe cuûenrsraru and rhe turùre role offluoride
@, f re. th" folto\ ns i, h. s bf Ji..r..eJ
. low dose/low .oncentrar'on formulatiors;
. fluodde insesior an l the risk of flùo.osis;
. toothpasre delivery syfems, dilpenslng insûucrioff
lab€llirs;
. fluoridetoothpæredd oral clcâra.cel
. fte eifectofflroride roôthpareson roor cariesl
. lhe additlonôfother therapeur;casens.
Lorvdose/lou concentriltion l'orff ûlârons
Toorhpstescontaininalover co.cer.rurionshàvebeendesigned
lrlnarily to redùce rbe .isk of fluo.osls, an.t are therefore,
nost ofteûdireûed rcwa.dschiLd.en.Flowever,fluoride conrenr
in toôthpastes tor childreDvdies ant àhhôugh sône do so, nor
all bavea iluo.ide corcenrratioûbetôw rhe 1000 ppn I fourd
in dre majoriry of slrndàrd pèstes. child.ens pastes may
contai. nuoride in the form of sodiun flùoride of of sodium
nonofluorophosphate.
Iive dinicâl studiesnxo th€ effectivenesofpases wiih lower
lluoridecorcenûadonshavebeenrepo,ted.In [oùr the effect]ve
ne$otpas.escortàinlng 2t0 ppm ôr lÉssvas lnvesrlgarcdand in
rhecde or the tifth rhe tesr pdte contained5t0 ppm (]N/inrcr
'r,/. 1989).Over.ll, thesestudiesshowedrhar cariesinhibilioD
inùeaed vkh iûcieasingI.onre.r ofrhe roolhpasre.
CllnlcalÙiàlsof1ôw coû.entnrion fluoridetoorhpdresvaried
nor orly in the fltrôride.orcenùadon employedbur alsoin rhe
âseofthe children rak;ns parr ni rh€ lrial. Irw flùoride toorh-
ldstesare desiAnedro rcducethe risk of €Danel opâcitiesând
drerewoùl.t dpFearro be liftl€ jusrifi.arioo ror usins then fof
teenagcctrildren when there is nô risk of ll
teth. The study cai,ied ou! bI Wifter ,t ?1 in NôNi.h wâs
Iùge,lnrclvlna moredrar 2000 childrenwho wereinitially aged
\ ) e " r .a \ ' i r e n I n , 1 " ' F . S r o ' p - e d , $ . . , . ( i ' , - i o i
tNre co.laioins tto ppn of flùride, and tbosei. rhe conrrol
groupuseda standard1050 ppm F pare.
The smallditTerence in ned DMIS ar ùe end ofrhc dree lear
tdal s€erbetweenrhesroùpsamountcdro le$ thân 0.1 DMFSper
childper yearin fàvoùrôf the cônûolsand wasnot sianiûcanton
Developmenr
nlluonde
toofipostes
' ÈI --
ç E
ce ^^
0,0
Test Conlro
Figure l,l I Thrcc year low ! toothpâ$e tridl in children aged .wo
I'e.6-follos-ù! sùdy âr.'ne ie,6 ofage.
sfutiti.a.l rering. ft was rhercforc, diÉlcuh ro 'nier rhât tl,ere wd
â difterence between the gronps àt the end of rhe ûi.1. Howerer, a
ô l l o 1r f . ( u J ) s . .(,.dou {\e, 'he -ld lunÊ,:,-)-J,'
and
ol ase (I-iolt r99t)i no fùther rest or cônÛol pasres had bee.
availàble during the four year lnteral. Fi.dinAs ar follow up
sho$ed rhar rhr differen.e between arcups had ircreded wlrh
time. Difference in med DMIS now anrountcd to an averageof
0.8ô 'l ,TJ,) ._ ..f É I I
The sme .esùlt ls appârcrr whe. i.crement is considered in
relation to cèries experien.e nt five I'ears. Iigure 3.12 shovs dre
i.cfe.renr for children who hàd m caries experienced five yeas,
fôr dnxe wirh DMFS orberveen I a.d t aûd for rhose who had
DMFS ofmore rha. 5 ât rh; agc. In borh resr aad conrrol groups
thc number of new carious mrfaces increaed with increasiûg
leveh ofcaries €xp€ri€nceat file yeàs.
low fluoride
toothpostes
t In th! tuÉ? r|ro rro plm
rsk) to lrotect ftuû ôlx.ries .d adiérior eûh
. Dertiss to cônsiderthe bdlù.e beNeô.isk ofcànes
- :
F l r r o r i d (i l' g c r l r o n à n d l l r ( r i \ k , r f l l r r o r . r r i :
The ùial cadcd our ir NoNich .or o.ly p.ovided information
èbour càriesbtrt the fô]lôw{p rudy dso provlded iniormarnrn on
emmel opacltlesin chil.lren ùho hdd usedà low fluoride pasre
(Holr et dl 1991). The authors in the fol1o$-ùp study phô-
tôgrâphedthe upperpernanenrinciso.teedrofthe child.enwhen
thel'we.e nine yeds ol aAe.The rcedrwcrc scorcdusi.A dre Tl
index for fluomsisand dre Modified DevelopmcntulDefectsof
Enmel (DDE) lndex. CoDpâredwidr findinas in rhe sta.dard
.onûols, dre child and iooth prevalenceofopacitiesweresjgnifi
.anily lower iû the childrcn wlro had ued rhe test pasrcwiih a
 3 rluodeonddentol.ûries
6.0 I resr(550ppmr)
50 Klconrro (1050ppmr)
40
3.0
14E
2.0
1.0
0.0
None Low (1'5) High (5+)
Caries at 5 years
tsisurc 3.12 TILre Iea.loù F tootÈpa$e ûi in .hildre. .scd rvo
Ieâ.s follow uf study rt nine years.I.gc.
Lo*er fhorlde content. The ferd sès see! nor oûly siù drc
TI Index btri al$ in rhe cde ôf.{iff6e deIe.s n€isured usins
the modiilcd DDE indca. À drird gtuup *às irilude.l jn îhe
$!d', chil.l.en who had notFti.bared ln iheofilital stu.ty.nd
sone ofwhom mây rhereràrc, havc hecn erposed during tlteir
earll y€is to tdstes co.tainina 100i) 1500 ppm F. TLris l.tter
group hèd dre lilghest proportion ofchildLcn $'irh a l'F1 of TF2
Odrcr workcs havc ftpored on nuoride inge$ion, toothl)]$e
$e. and rhe risk of iluorosis in fluoftle areàs.Osuji cr,l. (1188)
repôfte.t thàr childreû who stafted roothbrush;rét bctûe .he rye
of 22 mônths were eleven rimes more liLeLy ro dcvclop iluo(sis
dra. dDsc .hlldren s'1lo beltaû brushing later. ùlilsom 2nd
Ilitropoùlos (1990).onsidered rLrerelâtiorship between dre asc
of orsct of ntLrbmshing an.L resider.e in a llùoride drea. Nforc
childrc. in rhc lluofide .omnùnity (60 per iert) ha.l enamel
defects comparcd s'ith rhose in the non-fluôiidJted commù.ity
(11per.enr).In rhe fluoridated cômm!rùy more chil,l.c. whosc
pàrens cLaime.l to begin brushirg àt an eaflr age exhibned
Thus. ùe LÀks and benefis oflôw dôse formùLàtioos màr bc
seen to be balanccd in drat dr$e is a higLler risk of dentèl .arjes
asàinst à Lover rlsk ofde.ul fluoros;s (Fis. 3.13). However, fluo
nd.r'9. :o|rib-tron.^ r'o. . w'1. i \ "-.,o''
reported àbove employed ànâlysis .clatcd $lell () ù,thpa$es,
three more recertstudies have incllded mulrilariatc mcdn)ds and
hâve repôite.t od.ls ratios for more diin â singlc lluoride *M.e.
Pen.lrys ,l 11 in\rriaatcd rhc risk tàca,rs for enmel fluorosis in
a urn)ridard .onmùnirr ând reported rhàt nraptroFriare iluofidc
suppbmens (odds ràtio 21.7), soyd bard an,l milL bascd lûIâdr
formulâ use (OR=7.2 and l.l) dnd Fejuenr toodrbrùshins
(OR = 2.S) wcrc sisnifi.xft .i\k fâ.tors. Broè.11"-srmilù fiftlinss
wc.c rcpoftcd bI Ldman.ller ùd Roziei ânl Riodanr dielary
iluoridc sufplcnrcnrs (oR = 6.5). .|geat re sa.t ôf roothbrub ing
(OR = 1.0), ca.ly wcanins (oR = 2.8) atd ssâllowing toodrpaste
(OR = 2 6) {'crc idcnrificd as rnk àctrs bl tLrese àuthors.
Illlofidc kxtrhpas.er are vety rvidell use.l The pote.liaL tôr
Figure l.1J low I toodrtdk fonnùLarioÂs-flsk\ add bo,elits.
inappropriùte usc b rerlt in f]ùôrosis was empharzcd 1n a vùr
receûr rudy, whe.e it was reported dut 11 pe. cett of, rcricsot
.Jsesdiagnosedas nùorcsls weÉ explicèble in terms ofahlsotyof
hâving bNshed more thrn ofce po diy sirh more that a !4
sized nmount ofroorhFsÈ rhrcuEhoùt rhe fi$t elgh! rea6 oflih
from these reports ir may be.ot.luded that rsl< tætor for
dcntal flùiôsis ûèf be rafke.l i. rhc follo$iûg ôrder:
fluorosis
Ri:kfooor:fordentol
! irr'pFtoFriâre tluollde seplements
. \ . - ' r . . r " @ ' 1 .' . i d ' d
. FrÈqùen.r oa brshinc^vdloNing !oorht'{È
''lbo[hpr5tÈ g irlstïuctions,
cielivery,
dispÉnsifl
labelling
tlow toodiFstc ir deliÉred, in terms ol the tl'pc oi F&kaging
and conrainc6 ùscd, the insÛuftions gn'ef lbr its ue and dÈ ùâ!
in whi.h ii ls labelled ire in|o,tani in derefminidg efficæ)L
lhese f.ctos Dày ilso sùonslr affect toodrpaste inge$ion,.nd$
influence rhc i.ge{bn offltrori.le.
'fherc
hâs been nu.h debate æ !o dre quantitl oi pat thÈt
shoui.l be usrd. I.stfù.thns hàre varled, one child.c.s tooth-
pase, sô1.1in I'ance. adriscs one io côver the brùsh. Ad'ernû
herts as posteB or in ncvspapes or mâgàzites often trolilc the
sde me$àge bI imflicatioû ihtuùgh their àrtwork. The Hcath
Edu.ûiôn Àuthorny r€commcnds drat a peâ size.l do!ûr b!
$edi dris lr.ivice hæ becomc widcsprcxd and is tow prlnted on
m.ny toothtdre tubcs and .dbns. Ro.k (199J) sùgAesrcddùt
rhc bùsh shonld be smeared, rarhet rhùn ùsiûA a pea sized
annnnr whi.h mÈ)"be roo o!ch. It is urhe\tul o hale dispùat
bc.ween exhôitàtiôrs to use small ,mounts and the images of
îoothpâsrc gcncr)ùsll applied tô the brush. Rock has pointedour
tha! rhe âmounr $ed.an radicèlly aff€ct toldl Uuo.idc inAe$ion.
As r. examl,lc, a *fip of toothpdte coitaining 1000 ppm I aid
.overi.s dic b.ush h€ad.ontains fifteen tlmes the amount ofllu'
ô r e of. olo ofr"" .r ' rd 'l .n.'h.-' o , . :
of200 fpm ilùofide.
 c oim*+*ii'orns
r,rc, rr
I

Thc amounr ofnnrhpa{e ùsed wiLLbe ! lueù.e(lLrr thc.on

sis(f.r. Pâstc $idr low vis()sitr mât be diffrculi to ue2nr.
(.ura!ch'onto rhc brush heMl before it ilôws bet\ree. thc flh
ûoni }Iorc .orvcnrional irastrs sho\r grerter.oheretce, ùlloû
,ng r m..c a..ùarc c{imatc () be mxde. ù{ôie recentl},.ozr.
dcsisnshare been inûodùre.l whi.h J11owa reau.e,l àmounr ol
toorlrtr$e ro be (lisl,ûre,l fôr r Sivcn lcngrh. Tubcs tu ore .hil
(lansFste hair r sâr sh2t'.1 nozdc dcsign in.orûa$ û r r.ûnd
one iôr e\im1,lr ln th. casc of vDc oùe* currently on tlie
nùler,.ontùrers hrve lery sDùll siTetl 'oùnd nozn$.
0!e.trrot re.oûûen.htion is lbat.hil,l(. undcr rhr aAe of
svenverrsandatlo* riskof.Jriesshoùl(lusealowiLr.i,lc&rtrb-
patre(BritisL So.ietl ofPàedla(n Denrisry). l IoF.vcr, .booslnA
à. xppn)prlxte PNe mrr' LJediffi.ûlt èr presenr be.trusc of dic
\rsÉm of lrbeLLirg ùse.l. Làbe s Jnâ\' giie .o indi.ûnlr 01 the
elel ol fluoride.ont.inc,l, o. rh. amouût ofdùri.te mây LJe.qiven
r . l r i n t h e f { r n o f p e r . e n r â g es o d i L d f l u o . e o r s o d i l m . r o n o
dùtrophosphâte. lhe Nreât û.joritf of coo$rne^ ân.l ot drc
,lcrtal;r,fcssn,n may te11 be uuwâre olthe rmoùnl ot lùofidc
fren. in .irbc. of drcsc tw) flùoride .ompoulds. Or tlie basis
01a\"ilable ifrànnariof it sccm' ùnlikch. drereire, tltât ûrDr
cors,n,e6 coùl.l mâl{. a. i.fo..rcd .hoi.c, o. drxt mxnf.Lentiss
.oùld n.ke srecitlc re.on,men,lûions

;nd r;ral i:lear'ani:c

l[ror]d! tnr)ll1l.rir.!te
Ch&e$ û.,.1. (1992) drew,.ttenrion ro ilt '1c1thit rhc mcdnrd ol
orJ rnising afrer lug Jr roorhpasle, i..l di. ticqùc..r' of t(nth
b tr:-. ,, Lo'l .. ". Fl 'o, I .'l i , ' '
dinlrl rid\ The D}]IIS ln.rement û dxs st!.I! wâs hjghcst (6 9)
thcn a tukerçrs rsed a, ri*eâwE ùodrpJ$e follo\Led bI ting
a hrush (5.t), pùttin! heâd urder tâp' (t.s) ùd i,sins hrn,l'
(i.j.). '1he .arles ln.remenr iar dlre who brushed once per nèr o.
lc$sâs hiShcr (1.0) than rho\e who bnbhe.l*'i.e perday or n,o.€
. i . L ' o ' , l r ' , j
.edu.tion iû t)Ilrs inc.eûreft o..tr6 Fhcn brudrirs at lcar tsne
ll.f lir a.d rnrshg br means of hxn.L mder dre ap (f,9. l.1.1)
Similaf indnrs\ have been ftpoited LJyÀnrlef, /. t999.
LileÊt !L! rû(,t câriÈa
Jr rellewirg rhe (levelo|m..t of ûnrhta{c, drere ha\ bÉer pd
!orlnr.on.er. àboùt flùori,lc ingcsrnlr by .hildren. Hose!ei,
rootlipa$es àlso need to be .orsj(le..d in f.lxrion (, the ne€ds of
the ûi.t.lle aged ànd el(lerlJ. I. drcsc oUcr rgc ErtrLPs.lluoride
roothtisr. miy bc r. imlrota.t mc.Ds ol ftdu.lnu root cafies. A
hiAh prevalen.e ofnû (ûies hâr beetr.eforte.l in rrefuL sttld,cs.
Kâtz d ,l (1981) reporte.l thai .10 60 r,c. c.nt of drc dcntatc
populârioD h.d rt l€rst one rool .aries lesion, ânJ ac(o.ding e)
Bmtinr one in nlne ofexposed tuôr surfà.es s c!rio!s. l(eNlts of
x rc.cnr srLdr by Steele rr al (1996) ilLGtr.te.l r1irt. b denlal
xdùl$ aEcd 60 rears. in Sali\buf)! Dùljngtot, rtd lti.bmofd
shik, the mean nmrberof.ârntu n,ôr surfâ.es wàs aFprorinri.eiy
1.0. Thc adùlt dcntal hcahh {uver ftported a snnil.r fin.l,ng
(lûtd xndLader l911). ft mùr be.r.ogiized rLraftrresesriùâtes
Iigde :1.11 SLr.hcs ofxlteffn.ne ri'sing ûi.ih.ds. (n) ùsing a
t.orhbrsh to .nnsrer wnte. tô rhr ùoùrh (b) !uiti!! rhe nrôudr
under the .iLir:(, ûùsfeûios s'it.r usinA .upped lu.ds (dl un.s r
bcxker ro ûxrsiir w,ier i. th. moùth. (lrom Ch$ers r,a 1991.)
ofnû.dies !r dre ell.dy xfc highei, i! lutena Éûns, rhan
DI{IS vahes ni t re!Êol.l childrcn. t here mrr' $e1l be a.ase fot
itr.rea\itrg dÈ flu.rnle contenr of urhpa*e. speciflcal\,fot use
i r t l È d e r ù r e l a e r l ) ,i n . . d c r n r p r e v e r t i o o t . à i i e s ( F i g . l . l l ) .
o.c rudr br Jenser add Kohour (l98ril rclroltcd on tht be!
I f , n p r l o o r l , , ' l i ' , ô . r - o - r . .
very slntrt (,ne rertperio.l bur drc mo* rpftupri.ùe I .o..e. û2
rion tar prevedtirq root sùrlacesref..( nt cxfosed n$nfe r.ôih
pasrcssuitabic n,r dre elrterlf ûa\ no. o.ly rccd n) hxvt lnLfeded
lluo.iJc but $uLld a1s) require dilletent âb.asirc $'ncms. Pa$es
wirh lo{'ibmsivi$ may be morc att.ofriarc in rh]s .onrett.
Re.ûIlj. Bayser .r,1 (2001) .od.lude.l tliat i defrii i.c co.tain-
iûg ;000ftn, !' sas signltl.ântly beter al ren,i.c.àlizirA |ri-
marï roor surUce cafuns lesioN drat onc .or tùininr 1 r 00 ppm l
A d di t i o n a tl h e r a p e u lai cg e nl s
Scver rypes ôl fluorde toorl,t,âstcsin.ludc otL,Érqrens ni ùddi
rio. n) lluoride. À !âneq olagenc hrs bccn added nrenderl to
cnhancc effectiveres ard afpeal to rhc (onsLmc. ort ddtr,f..
nùcf (Srnlth Klire Beech.rn) hù addcd .xl.iùm glt.erophos
pharc o n notluoopLospliàte. clain,i.E dur this rcsùlt\ n, .
g.cxtr redù.tlor ir .rries. lf the .ârc ol n,nc other ptudùcG.
52 | 3 llomid€
ûnddenh.orie5
I
$diun pyrophoslnrde hd bee. addcd as at ènti câlcùlùs agett
Br..useofis u.pleasant ùste, dris ,gcnÙeqnires comPlcte refôr
ûuhtioo to make iht prodùct dcccprable.
Zinc cilrale is used by one manufacturer (Unilevc, as âÀ
T.i.ldàn has ako been shown to te.lù.e Plaqte
artiplâqle,gc.t.
and Ainaivnn and is used fôr example it ColgateT(ml Chlorhex
idine, use.l for maty ycâs .s a moùdrrnrc of gel, h.s now been
ituorporèred in somc nxtrhpâstes, such as Crest SPecialist Gùm
Ca.e. Môre receody. Fitl.ulady in Scandinaliâ, Pdtes bavc beeû
i.tro.lu.ed ùhich conlai. Xylitô].
Unril re.tntly there vas onll a limited numbef oftôothPastcs
nimed at redù.ing seNilivirI. but wùh è greateLPtuPortion ofibc
popul2tion .erâining dre; rcetb, and ù ioc.eâscd pre!àletce ot
exposed .oot sùrfa.es, there has been a narke,l ir..eae ii the
numbcrs of pastes of rhis tyPe mùketed Pastes desig.e,l nr
re.lu.e sensit'viry may.ontaiû è ririetl of difterent a.ù\î aAents
ln Britâin a new toôthtds.e claimlng to lock in high fluôride
has bee. marketed. Thls product cân o!1I be Pùr.hâse.1 on
prescription. Tnc kJôthp.ste contai.s $dî,m fllo.ide 0.6r9l.
(2800 ppnl) an{l is sâid ro be lde fb. dre maûègement ot high
.isk patietts slclr as thc elderly ùd thosc wlih ramPânr canes,
Addifi ogents
onoltheropeuli(
Crl.nm gly.erophospMrc
XIli.ol
sod'u6 lyrolhosl) nte
Figùre Ll5 Àdveii titr high flùofide toodrt.$c (2800 PPm)
ft.uûe!! .âfles, comp.omised oral healih
(riE.I.rt).
Aretopicalfluorideseffective?
Topicâlfkrûridetherapy
Topicdl ilùofides IàlL inrc ôvo cùteao.ies: tlùse afflied bl' the
dertis in rhe ùrgeryand those ùtplicd bl dte Pètientat hôme ln
iluorlde con
Frdctne those eûploled trl E den.jst a.e ôfhish
.enrâtioû an.l a.e àpplie,l aenerallr'-at Lcaular bùî inhtqtreût
ifltervàls, pe.haps tlice a lcar. Thôse uscd bt the Paricnt de
of lo$ fLùo.idc l€ve1s a.d a.e aPPlied nt lfequett lnrcnârs,
appliedby the dertist
Fhr.)rid€s
Such lluori.le agents mrnrly nrchde simpLe aqucoùs solutionsol
sodnLn fluornle,nd samous tluoride, ard low pH solLrtionsand
gcls ofar àcnlulared phostharc fltrôride systcn Othet aEens
.onjrisc fltroride t.op|ylds Pastes and IlLro.ide-.ôttèiûrog
vaûrishes.little chd.gc ha\ ô.iuûed in this aret i. rhe ]!st hle
yeùs, d.,l ibr that reasontlrir topic vill not be cotsidcftd fùithû
Tôothpastcs .oûrarning flùoride Nerc first iÀûodu.ed over
30l,ea^ a8o. Clinical rixls have demonrm.ed their cftè.tivenss
in redu.ing .àries âtd berruse thcy hâve been so wid€ly uFd in
mâny weste..ized .ôùÀtries tlùoride toodrFstes hale come to
plal rmâtor pa in d€Dtal hcakh.
'tp,.ll'.o'i "-
| ""1",u
dental pia.tice for over fifty yeâs. During this PÊriôd Ln. mii
tyl,cs ofprepara.ions hâve been âdvo.ated: neutrl \ôdi'rnr uùo_
rnle nrlutiots, stànnoù\ fluornlc Rnutioù, acidulated Phosdrt
.ge.ts. and f]ùornle varnishes.
 4,, kpr tdoio. ,f.'u , . ,
|

The minutiac ofihe ftsults ol clinicâl ûials sith toPical tlùo- ollhro.idc laûishes.ln l'fi.trld Durafhrr. s'hi.h yiel(ls 2 26 Per
'1.-lr ',1 ', .1. .'r o r tr'pr 'o'o\'r .ent ! (22.600ppm) Iiom a sùspellon of $dnLm lluotnlc in an
ûother, hâvc bccn .onsidered elses'hcrc (N{ùran Rugg Gunn, alcoholi. dutnû of tarù rl 1'arnishs,bstr..cs It is clùinrc,l drar
diis ûdlerial nnerates war..{cll, $ ùat ir corcn evet nosr ('cdl
Tlie pù.j,osc ol dris se.riot n tu des.ribc bfiefl] some or rhc $nh à ûlm ofmrnlsh. A.omtnfisxr oftotrcàl nùofides, bded on
faJ,ions in bpi.al nuoride thernj'I ovcr dre Ia$ fifty yea6 r.d n) d,e work ofHotuw,tz d.d Ismall 1996 is gircn in T.ble l.t
onside. tLe effe.tivfl,e$ ol this aspe.. ofPrerefrirc dcnûsfy Two srsen,atic .cliews ofthe etl:.tikness ofgels ard vdnishes
Ifl 1940 n {,âs sl,own that invlfo the solùbilit} of enmel.ould hx"e beeÀl,ublished re.entl! i. Thc co.hfure l-ibrârl'lwetry tilc
beredu.ed by ûeating it s'ithâllnori.le sol!tio. Bibbraû.lKn!t , 1 . o , . 1 . . . 1 . , \ o . , l ' ! , , ,
'l'hc
soi sîre among those who .a.riLd out .lini.èl tiùls usina s)ditrm bes estirdic of the màgnit&lc .f rhe .dries i.hihitila ellèG
Unoridcnnù.nr$ Knu6or cofclud.d thatma{iùùù rcdùcùons !i ol llùorlde gel ris i 2l % ftdu.tlon in DI{IS s.ores. As nrd!} as
.ùies sns a.hieved ftuû four rrearmcrrs of 2 per .eit àcquco$ NaI .nc in nvo.hildret s'irh high lereh of rcotlt deùy,2nd one nr
a. $(kh inre^âls tpproxinratcj-v 8000 ppd f) at dr€ as.s.f3. i, Ncnty nù wrth d,e lower levels.çould have les de.a-i
10. âr.l ll yeis, t) oiitide Nith tl,c cnurnt, ôfteetb. Thc Pn)b Nine sturlLesol iluotide vân,ish lppli.ùtio., i.lolving 2109
hm w,rh rhis mednd w.s thal it s'às not e.$y to n,t.gùÈ n !tô .hildrer were co.sidereA. À $n\tintlâl .àties i.hibitury elièci ot
mùrft reûU exrnl.rtions iàf .lildre!. nùormelamish in bofh rlt1lrmmeùt (ri6/. ) an.t tlre P.i nr2ry .let
Iûdre I 9 t 0Satcn.n,n .hèûged !o rxnnoùs fluor e, trccaùscn titi.ns (ilz) \r:a obsc^e.t. The.cvics'ers conclùdcd thât fù1utc
IllLdbeen claimc,l drat this rgeDt vâs sùferntr to sodnnn illù)li.le rirlr shodd be placcbo-tontolled nndomized studics aû.Ishould
in (hievûg fllo.idc absorptiôn nno enxmcl Stâùnuous tluofide i.cludc dte ùse$mcnr of odref rclcvart oul.omc\, inchdrfs
is ùn{able h solùrio. 2nd so it rvd suggestcd that ân I Per ce.t âcceFabilitt ofÛertnrnr xnd i.lormatio. od Po$ible side elleùs
sùnoùs fiuoride solutio. sMùld bt freshly l,.cfxred eâ.h day (I{àrlnho er,l 2002., b)
\',t ,, .rI o,t. | , r,,'1, r.r -.,i ô
m,lvruld be actire for tivc to eilht hous Tbc aAent shouL(lbr
Àplliel Ncq slx months. A dis2dvantalteol sran.ous flùr e is fe\snmals, . irbcf dentiss or hygienis$, to 2PPIÏ ùem. Thcr were
dr|l ir câuscsbtuçr pigme.ùrion ofteetl!.nd .an also.aùse giti exûemet) tot'ulaf espe.lâlly in the Uùit&l Sùrcs ofÂmeri.2 xnd
n, S.anainâvia ln the 191(x. when tbe l,.cvalen.e 01 c cs *xs
h 19.17 B,bbI hâd found thrt lowc.'rs ùe PH of r fluofide very hish an.l sùbst2rtiâl reduftions in Dl'Ils riLR rrf'la bc
solution erablcd more fluor e ro bc abvxbed imo enamcL.In dre a.hieve.l in one.. r$ole.rcL,ni.xl ùiâls. Tis.studles Rer€ okctr
1960s resca..hc$ turned away |l!m {ânnors tlùoridc bxrk to il\o .âtried out in .onjuncrion {'ûh fort.ishdl mouti .i.sinr
$diuû l]loridc in an a.id solûion, 0.1 NI phosPhori. xcid, !l |rcljrdmmes ar schooL.
glvitrg iise to a.i,lùlared phôsphrte (APF) s,ltrtions an.l 8cL\' As .arie\ rates hxrc de.lined. farti.dârlr n rbc Perm.tenr
The\e rgers r-l?icall-v yiel.Led 1.21 per cc.t I (12,100 t|m F) teerh of.hildret and 2dole\.ents, rhc .o{ ellective.css of ùsllg
APF $lurions w.rc appli€d to tlie tecrh s'ith.ottoû vool tof proÊcsn,nrlly aptlieJ ill(tride agens has Lreet llùestioned both
1 minùres, dùrnrg vbich time tLe teeth hr,l ù be isolùted tiom on etièctivcne\\ ând econo,ni. grôuDds, csfe.lxll) s'lre. dre rvâi]
sxliva Sone workc.s inûoduced a geLLingagent (srrlly mcdr-rl abilit-v of another self:afplle.l toticil lluorlde agenr nult
.eLlulôscor hrdtuxy ethyt (cellulosc) $ ùat dn AP! geL..ùld be Fstc in.reâse.l ûom arcund 5 per.eni in 1970 to 9t tcr.cnt ilt
applled iû à Ûùy, {'hi.h sa\ held h pLà.e lor 1 mlnnres. The 1r80. Toar-v it,s re.osùi7e.l dlrt p()fessionâlly aPflied toticrL
patietrr (,sually 2 {nild) is then in$.ùcred nor n) fi e olt lo. l0 nùornle 2acnrs are tôt .ost eÈi.rive d J toPulùrion meante, but
û ltes, iD okl.r b keep tl,e fltror e ùg..t i. .oi''.i wirh thc should bc tarsete.t ùt titlc.r' ât in.rerse.l risk of develotins
cnanel strrfâ.e lor a !.olongcd perb.l oftlme. .afies lor exai.t)le, dlre \tho slnrs' tllite sPo! cn,m€l lesions,
I a d o L'1 | LrJ '" I lo. \a, ,o .fpâtieù$ ùnde'goln8 fixed èppllàncc ûeâtmett, o. due re.ûv
rhc ûtrh nda.e lor as lon.qd possible gale rise to drc dcvelopmeDt irg ndioûerapy ii,r herd aûd ûe.k malisnan.y

Table 3.t Chaft.disti.s oftofical lluorlde agetts (Atic. Hotuwitz iDd Ismâil l1)96)

sd,:
t.ztz t
22I,oo
1,ftqutt.y o1 àf f Li.âtnr. 1rr ]veskl! in1.Âàls rt rglr l, r, l0 & I l

Lr,-.,b1. SRbLe,nFldri...nui.Êr St.Lrl.

Nf
 Aretopkol ethdi!ê?
Il!ordes

The minùriaeof rhe resultsofclinical Ûiâlswilh topicÈlfluo ôffluo.i.le vdnishes,;. pturiculd DùâPhàt, which vields2.26per
dde rhÉrâpy,and po$ible è.lvâtlaae of one preparation over cenrF (22,600ppn) from È susPensiôn of sodium fluoride in d
mother,hàvebeen considere.teisewhere (Mùfay, Rugs-Gunn. alcoholic solùtion of natural !ârûisb sùbstmces lt is cLimed rhât
À J e n k i n s1 9 9 1 ) . rhis mterial tôlerates water well, so that it coves eveûmort teerh
The pùrposeof this sectionis to dcs..ibe briefly some of the with a tilm of vtnlsh. A conParison of tôpicd Ruo.ides, bded on
fasbions ir topicâl llùoride therapyovei the lasr it.y yeds âtd to the work ofHorovitz andIsmail 1996 is given in Table l.t
coNidertbe effe.rirene$ofthis aspectof Preveniive.lentistry T$o systemati. reviewsot rhe etrective.es of gels and tunishes
'Iwetlv Êt
In 1940itwæ showntbat invitrothe solubiliry of€namel.ouLl haae bæn published receotly in The Cochrme Library
bereducedby trad.g n wnh a fluoride solurbn Bibby and Knut siùdies of Ruo.ide gels. involving 77'17 chiLtre., were imluded
sonwereamong those who cairiÉd out cljnical t.iâls 6iDs sodiû The bestestimareôf the masnitudeof the c?riesinhibiting efects
Ilmridesolurions. Knutsooconcludedrhat ndim@ reductions in of nuoridegel wasa 21% reductnrnit DMIS scôres.Às mdv æ
cariesw6 achiryedfrôm ftur tÉâhenB of 2 P{ cent a.q ueoùs NaF oDein ùo child.cn with high levelsof tooth decày,and ône n
arweekly jûrervals (approxjnately 8000 PPm F) at the Àses ot l, 7, twenty iàùr witlr tbe lowest levels,wôùld haveles decay.
10,dd L3 yeas. to côincide with rhe eruPtior of reeth. The Prob' Ni.e srùcLies of fluoride laûbh ÀpPlication.in!o]vi.8 2709
lem with lhis methodw6 that ir vd nôt esy to inregràte it inio chil.lrcn were considered. A substanrièlca.iesinnibitoryeF.tt of
ouli.e re-ca.ll exMlMt'o.s for chiLlret. nm.ide !ârnisb in both tbe pe.manett(46%)âtd the tfinarv det
Id the 19t0saûenrionchmaed to*annous iluoride. becàuse it titiots (31%) ws obsered The rNisÉ6 concllded thar tuture
hadbeerctaimedùat this asentvas superiorto sodit flùorjde trials shoùld be placebo-côntrolled .andônized stùdies md sboulcl
in achievlrgnuo.ide absôrption jnto enânel. Stmnuous flùoride iûclude the dsesment ôf other relevètt ourcomes,iûcludins
is lnstablein solùtionand so it wa suAgestÉd thèt an 8 Per cent a.ceptabjliry of Ûatment ând information on lossiblesideeffects
staDoosl]ùficLe solutiot shôù1dbe liesHy prePâred eâch dÈv (Mdiûho d/ 2002 â, b).
andwouLdbe aûive for Êve b eisht houa. The âsent should be \ I ' h et o 1 a. : f l , o n J e . J ' ' e l ' ' ' l i ' ' I o r r o ' r : r e F o -
âppliedeverysix months.A disadvantaae ofstannôùs fluotide is fcssionàls, eirhefdenristsor hygienisrs,to apply them Thevwete
thàtit causes hrcwn piametradod of teedrmd can also cause 8in- exrenely popular especiatlyin the Uûited StatesofAmericaènd
in Scardinaviain the 1970s.when dre Prevàlence ol carleswas
In 19,17Bibbl had foun t that lowering the pH ofa fluoride very hiah dd substantial re.lùctions in DMÈs values could be
sôlutioreoablednoreflùoride be to absorbed i.to endel lndre achicved inooe or two yeèr cli n i.a.lùièls These rudi€swereofteo
1960sresearchers mrned away fron staonousfluôri.te back ro also .arie.t ou. in .ôûjùnction sith fort.i8hrly mouth rinsing
sodùn flùoride in an âcid solution.0.L M phosphoricèci.l, so programmesat school.
siri.s r^e to acidularedphospha.e(API) solurionsând sels. Às cariesràteshavede.lined. Pa.riculèrlyi the Pernanent
TheÉ agentstypically ylelded r.2l per .Ént | (12,100pPm F) reethofchlldreû ard adolesceûts, the cost efecdveûes or uins
AP! solurionswere applied to the teeth with cottoû wool fo! profe$ionallyàppliedfluoride €etts hâs beenqùestionedboth
4 minutes,dùrina which time the teeth hâd to be isolatedfrom d.t econodicgroùnds.esp{iallywheû ih€ avall-
ôn effectivcness
saliva.SomeworkeGinÙoduceda gellins agert (u$ally methyl abillty of aûother self-appliedtoPi.al flto.idc asent tooth-
.elluloseor hydroxyethyl (cellulose) so thÈt an API gel coul,l be Pdte-in.reæ€d Êom aroutd t Pe' 'ent in L970 to 9t Percentit
'lhe 1980. Today n is recognizedthât ProËsiondlly âPPli€dtoPicaL
alplied lû a ùèy, qhich was held in Pla.e for '1 minutes
paricrt (ùsuâllya child) ls rheû instructednôt to rt.sc out for l0 flùorideâaens de not co* etrective4 â popùla.iondeaure, bùt
ninures. in order to keepthe f]ùorjdeaaenrin contâctwith the shoùld be targetedat patients at iDdeàse.trisk of develoPlng
enmel surfacefor tprolonsed periodof time caries for exadple,thosewho showvhite sPote.adel lesions'
l h p n e e d' , < F - p_ h e l ! r i d ' d g e ,! i 1 e pro)'n') rô orparierts ùrdergôinsfixedapPliàtcetreatment,o. thoserece'v-
the tooth surfa.efôr d lons as po$ible sàv€ .ne tu the .teleloPment ina radiotherapy fôr hea.l and neck malignancy

oftopical flùori.teasents(Âfier Horown, aûd lsnail 1996)

Tablc 3.5 Characreristi.s

ChÀrâ.Frisi. Nar Snr,

t.2)9t I
9,200 19,500 ,r,a.AA
Fiequen.r of âpplication ,i at vee*ly i.renâLsrt rgesl,7, 10 & 1l

SÙbL nr pldti..on!ânrer StabLc

 3 fluoride
onddeniolrories

Professionolly
opplied
topicol
lluorides tccù may be âtre.rcdby iluoiosis,undcf unifom condrions
lluoridea!âildbllitylluorosisren ls e, bca.eâreriû perûanenrteerh
. 19.1GSodiun flùoride 2 ter.ent = g2OOpfm rhânprimdy teeth.Thisdispùirymal hcduero the t&t thxt mu.h
. I r c . c , n , o . u o r i a -" f - , . e r , , .)n!j,
I,
of îhe nireralirârion ofprimdy teethoccùs beforebi.th andche
. . a O . c , a " c l r l ' o p , nt m ' . - . - . p ' , é ' I {OO flacerta sefts as a batrler ro the ânsfc. ofbigh con.entmtions
pkn,a nuorideUlm a fregMrr dother ro her develôpinsfeu,
' .o O sôd'u 1.t.r-n
th$ .onùolln,g to a .erain c{te.t the delik{. of flùorideb rhe
\d,,nh 2-.,0ù
develôpinAprimary dertùnrn.Odicr reso6 m.y bedr2trheperiod
tPm
of endrl fofmârionlor pridary tccrl,is shofterthanià. Frmarenr
tetb md tha! the eûâdel off.inury teethI' rhinoerihan rhârûf
What aboutdentalfluorosis? Iflrerest iû denta.lfluorosis hd in.reascd over rhe par 10 ),eù5
Denra.lfluorosr is a hvpoplaia or hlpomaturatton ôf tutrh cnamel of so. not orly iû ûea\ likc ltulla arcLKenla. Fhere there âk.on.
o , J ' , i É t r o - . 1 - .b,). , l " l r ô , . ri ' E ! . , ' o n o . munities with hlAb lcveLsof lluo(xls âsocialed with ]righ coF
ôffluoddc dùrins thepcriodwhen@rh aredevelopjns(F,s.t. t6). . ," r ' , o n o i ' u ,. i ' , 1 " \ . 1 . , t - ô .. { t o,, .r l 'd.
The najor .2useof.tental flùorosisis the @.sumprionof watcf, clinares vid, optimal or los' iluoridàred ware. suppLieswher
.onra'ningligh levclsoi{luôiide, by inaanrsù.l.hildren dùring flùortrle nprake fio.r orher sources,i. ])anicrtù flùoride sut lle
thè firsr six yeùs of lifc. Àlthough borh primàry ând permmert mens and fluori.le roolhpaste, in eafll infdûcy. have resùltcd ir

tsisure3.16 Desrccsôftluorosls

. . n p " - , ' l - p - r . l - . - o , . . a l ' o , ' -
declûe û cùres, IolloMrs iluornle lherafy. i.c'casi.g
r nov benrg giver !o levels ofdenral tluorosis. In a sense,nirory
tr rurniûg ftr11cir.le, beoùse the hislo't oi war€. uuo.idarion
EalLt stùted wirli âtternprs to ùs.ertain tbe.ausc of col(ndo
s r a i . ' i nd r e e à n t l 9 0 0 s
l , - . . , ' r L r ' " o \ r ,
& dr pô$ibiliry ô{ d nrùede ir dÉ pre"èlen.e ol'(len!âl fl uorc
rs.Ior exanpLe,Ostrji âûd Nikifôruk (r988) presented two cascs
$hi.h cxhibitcd.lâsi.al dc.ral iluo(sis ln rLreperûanert.1ûrt,
ion. bodr ofn'h.m had .c.civcd nnt? flùori.Le sopplemeùt thaD
(coinmc.dcd in thc dosâgc s.hcdùlcs. The fl$t re.eired 0.t mS
Uda,!tiom intàncy and ]10 mg l/day ilom .hc rge o{2 tô 6 yeàs
ir ai ù.ei th2t hès a naiural s'arc. iluo.idc concentratnn of
0.,12]itim. Thc sc.ond .asc fc.civcd 1.0 ng f/1]ây lrom birth to 7
of0 ppm r: l{iodan (1991) calle,l fb' 2 rc.onsidcratbn ofeaisr-
ing recomnerdalions concerning iuoridc supflcnrcn.s in order
to redtrc€the r$k 01 1lùorosis.Ile proposed that iluo.idc $Lp|le-
nedrs shoùld be xined ô y àr idenrifiàble high orles risL indi
riduxls ând shoùld $âft xr 6 ûonrL$ ôf .€e or t.ter. Pans afd
Vnnn (1t92) .lùored an NIDR sponsôre.lintenùrionàL worksholl
oo ù.iging patrcrns ofslsrcmxrl. floorlde ntake , where lt wtts
igreed tbat drc inadrcrcnr insern)n of toorl,pâste .oul.l be ù
can* ofincreased dertal fh,o.osis in.hiLdreû.
1û èn edirorinl €ntitl&l Too n,!.h ol 2 Ao.d drinA? Nlas,n
Th. av2ilablc cvidcn.c foints to an indease in dental fluo
rosis!r both ltuofulated d.d non nùo.idâtcd (o',,","",.*.
]nùease.l flloû.Le etposlre ftom a vari.ty of llùoride-
contàiniig deDrJ prodlc1s is rhe mosr likctr $uf.c.
h sôme iàses, heàlth prolesslorals mâI be lrcsc.ibing
Iluoride dierrq n,ptlements inatprofnàte\', o. fàili.8 û)
a{lv$e Fre.ts to ter.h dreir small .hildrcr b sprt oùt, not
swxllos, lluorlde roorhpare. (In this iegar.l. goveii,Jnenr
regulâtioN and rhe nèrufa.tures ofdentàl frodu.rs nccd
to look .t the làbe1 ûstrù.trons ro see iÊ tirer nccd to bc
more spe.ific.) In.reasesii.tcntâl fluorosis.re ân nr.lj.atlon
drat ûtral Uuorlde expo{te is in.feâsnrg âtd mèy be more
rhan .c.cssafy nr Frevent ûxtrh deLây. Pn,dent plbli.
hcaldr fra.ri.e di.tates ùsing no more diân the àmoùnt
nece$ary !o a.bicvc a dcs;.cd c*c.t.
WaterFluoridation:
â Systematic
Review
 sl$ematlc review of water llùo.i,lario. {'as .ommissn)ne.L
by the Chief À{e.li.al Olli.er oÊd,e Dera,tmcnr of Hcalrh for
nûglard ro cary olr an !p ro date exl,ert scicntiti. Ficw ol
flûi.te ar.l health (Pùa 9.20 Oùr lleâld,ie' N2tion)
A foresrrnot ôfûe bonesù,dl€s(!ls. Llj) showed!hù d,crcnis
ro ùsoci'ationbenlee! \rarer tluoridrtion anJ iiâ.rùrc ln.lden.e.
lr0mrhelioild
Rep0dr H!0hh
0fq0rirorior 55
'lhe
\ . h findi.gs ôfcùn.er sudics s'c.c mixed, *ith smill ld.irtio.s on
atentnrn cirher slde of ûo efe.1. Individùal .on.ents esmine(l werc bone
.ad.er ând diyroi.l ca.ce6, whcrc on.e a1jânrtu deâ. pùltetr ot ass!
ciaron was seen.ClveraLl,ûom tbc Kcardr evideûceFresented.no
aso.iatn,n w6 derectedLretwcorsad Uuoridatjon and moftaliry
fron.ûy cùcer, or Êom bonc or thr'foi.l câû.es s|e.lticrlll
Wirh rcAifd ù .hanges iû càris eyc.,cn.e, flftee! sùdrs
tound â {xrlsrn lr sigtificantl-v grcâtcf nrean clldrge nr dn,tt/
DMIT scofes in the flnôrnlâted area dran dre non lluornhred
.JeaslrJis. l.l8). Stùdier in s4tich fluorida.io. wa5 dis.ôttinued
were è1soDclù,le,l in drc ysremati. reviev (!ig.:j l9), wjth all
bnt oneofthe st!.lics sùtjserin! tlkt $oppnrg w2tc. flùofidrtiôn
hâd le.t to r gred.er in(.casc in dte previolsly flùo.idated areâ
ùxn il re nôÀ flùornldred ,rca.
The sy$enÎic .Nics .on.lLrded that the best 2vxiiable eli
dcnc. sùsscs6 th.t lluoiidrtio. does .cdù.e ffi€s Pre"àlence,
borh $ dedured bl the t.ol,orin)n ofchil.lreù wlio are cirics kee
xnd br the mern drfi,DÀIIT s.ore. Àn effect of\tù!et uuofida-
rion sxs rill elident û sudres comtleted xfter 19r.1 it sfitc of
d,€ dsumcd cxposurt tô fluori.le fiom orhc. soû.es ôf die PoPu
lt|,ons studics. lhe avâilâble evldence on v,.iâl .lxs eifecs of
lvater llùoridatb. in redn.ilrg càries apca.s ù sqlest. benehr
in red!.lrs drc diifcrc..es i! selerity of roorh dc.xy be.veeû
.las$ an,ona t ând l2 -Fn.old .lildren.
Syslemoli(
reviews
S''$.mnd. rwie{s lo.are,âJ)ptuise, and sJtdreslze6idence
lioh s.ienrit. nùrliesln ofde' io fovide l.lormative
ùrwê^ tô s.icrtiJi. resar.h querù.s
l-h.y ârc ralùdrle soùr.€sof if,ôrmtiôn li,r .le.isio. mike.s
S)ncnâil..evier !dhere ro a Ûi.i scicntifl. design,\'irh
L , r m o l ! ! . ô p . n . \ _ m i n
nre . hânc€of liâs ùnd lmFrori.s reLiabiliq,
 sliÉm!!i. reviewnr,ùld.ôntùh r.otrt'eh€tsae
a$essnenra.d sunû]rJ, ôlth. alailableeviden.e
Reportsfrom the WorldHealth
Organization
À .ôderence h 1982 on tbc approprlate use of lluorides for
hùmâ!lre.Jth, !DdertheâuTi.cs of the lûrernùtionâl Dcrrâl led-
erxtio!, dre Kelloag Foundatlon. dn.l the \Vorl,l Hcilth orsdri
zarion. fcâ.hed the following conc!usi.ns and .e.ommendarions
NTHO r986).
l. lhe Inremàtional Co.tercn(c on fluori.les revreve.l .rc
tindinas of rc.€nt experimental, cliai.â1, and epideûiologi
cal rescarch on rhe nse ofilùoriiles in tn)motnrg .leûtàL
' F . ' , s ' q , r , ' - l - F o , 1 . 1 , i . r ' .
exte'iencc i. mrny dereloped coùnùics, jr vas greèdy
con.enie,l ,bour ùc shârp in.rede nr de.t2l cârcs tn sohe
delelofi.g .oùntfies. As there is no 1,o$ibilitl of ùertnrg
56 3 tuorideond
denrolloies
|

É a I f a'r. I H,p I Hubefls I N'o'hi!

I .ion spine E 'où* I

Figùre 3.17 Bone 1ra.nùe iflcidenc€.(Nlcxsùe of effeft siintrte à.d 9t% CL) (NHS Centie fof Reviewsatrd Dlsseminarlon:Repor 18.)
 ReporB lieohh
lromlheW0rld 0rg0iizolion

----l
f-

T-T_.l
gm
'EffiM
Egffil
ËE
m
t
I
-
I
I

Figu.e i.ts M€m diftèrenceofthc .hx+e in dTftIDMFT in rhe expord (flùodde) .ompared with the.otùol srouP oow fluoride),
se!ùatelv bv â8e Gold.oded) for ibc tàù. $udies rePorrits dmft/DMrr. v]th 9t% cls llfteetr $trdies found a $atisticallv siSniÂ'dtlv
âr€âs Th€ rdge ofmm duûse in
sraÈr ûedt ch"ngc in dmft/DMIT scorcs in the fluoridâred areas tlud the .on'fluoridated
dmfi/DMFI scorevæ from 0.t to,i.,l. mc.liat 2.25 teeth (lnrcrqùaftile range 1 28, l.6l teetlt. (NHS CetÛe fÔr Rdi€ws and
Dissedinatio.: RcDort 18.)

I DMFr$dê tr DMFSsco@

Figure L 19 Mean differen.e of the chmge in the dmft/DMFT a.d DM!_S s.oie i. childretr ifl tlle *toscd (fluoride) ArouP comPafed Bith
the conrot sroùp (toN fluoride), in sudies in which flùori.lation vds dnconrinued àfter tb€ bxselinesuryey.(NHS Cenûe for Rcvi€wsdd
Disscmimtion: Report 18.)
 I
58 3 rluo'ide
mddeirol(o'ie5
|
I
somary decayedteerh$irh rhe.lenralresources
èvâjlâblcât
preseûrin the develop;ngcoùrùies. dre oDly hope is to
coûtâinrhe câriesprôblemby prevenrl'cmeaures.
2. Tbe ConlererceaA.cedrhar.ommunny wàtef flùo.idarton
û m ideâl mea$re iàr rhe preve.rion of denral .arjes rn
.ountiies v'th well-developed,.e!ûalize.l pobli. s,arcr
supflies. ft *as in agreementwith dre view of rhe IDI,
NiHO, ar.i the mcdicalèûd de.àl profesionsrhroughoùt
rhevorld that.ommlniry warerfluorjdèrionis an elfective,
sate,and iflexFnsive prevcnlive ne.sùre, whlch hd rhe
vii!ùe ofrcquiriDg no a.tivc complian.eon ltre pù ofrhc
le6ons be.cfired.The Conference recômme.dedrhàt.om-
mùnity watef flxoridarion be intrôdtr.cd aûd natnrâi.cd
whereverpo$ible.
3. Urfonuùrcl)', the vèr lrajo.ity of rhewo.ldI popùtarn,nlivc
in runl ar.l uÈr. âreaswith fN larAesâr€r inrallâtioûs.In
these5iruadoff,comnruritywârertluornhrioûis nor ièa;ble
.nd âlrcrnativest.aregiesreed to be adopred.There is
elidencetioû drrcelong terh srud;esin bôrh develotnrg aûd
;ndusfialized colotries that nuoidized sah .rây be nearly as
cLe.tive âs warerfluoridationi! r€ducjnsrhe inci.tenceof
dentalca.ies.Coosequendl. rhe Conferen.e srressed
lornô, ,n. -rr ll 'd l o r . d l . n , , , r i .i . , . r o n .
TlF. .,or'r'i,,n' oru.,-,r'. \,,o?{..n.
iluoride measureàt any onc rime.
t. Vâ.ioustopl.al luoride nedrods, or cônbi'arioÀs of n,ch
mcdrods, day be beneficial;n commoni.lcs r.d. nèle a
soxrceôfsF.emic flùôridc rhat is 6ed wiae,y.
6. Whereverposlble, when cônbjnariors of flùoride lherapy
ârcconsiclered,
ir is besrtô .hooserhoserh.t ar selt admiû
$tcredorgtuùp-admidsteredbecalserheyde te$ expe$jle.
L Professionallyèppliediluoridesà.e paricularly app(4 are
for iDdividuatssho havebceni.leûtified âs à! hjgh risk of
8. The co eren.cwÀ concerned abolt the problcn,soIdental
uuorors iû âreaswith ligh .o.cerîratiôns.f lluorid€ ir rhe
public wâtc.supplyând u.gedresear.hto dcvelopeffecriv.-,
simple, and econoûi.?l defluoridrth. merhodsfôr warcr
sùppllesoi raq,irg lizes h .ecoùhendcd rhar, in .hildrcn
ùnclerrhc 2se of 6 veas. brushlig i,irh à flùorjde toorh,
J.. .\orl,lbe
o l r F . F l '. \ . . . i \ "
ûgestion. Iôr simila. reàsons,l]ùoride month rinsinA
shouldnot be consi.ter€d fo. childrenùndcf t ye!6 ofage.
9. Cufert knos'ledseof rhe c*èctiveûess ofra.ious nerhods
ofùsirg fluoridesle.t the Conrerer.en,.o.clude thar er.h
couûÙyshould reriew irs own dertal ncedsand râke tee,
islâtlvc acrioû ro adofr rhosemethodsot trsiûgfluo.ides
rhat bcs sùr its necdsin differedr.calons.Ir vie{,of rhe
prôvenvâlxeofnmrides i! proûo.l.a dentà1heâlrh.rhcir
Ne shouldbe exr€.dedçrhôtrt fu.rhe' delèyrô au popula
tronsrlùolghoor rhc world.
\XIHO Llrsider€drhe sùLrieftagainin 1991.The expeftworkinc
ArcuFma.lÈa nùmbe.of recômmendations, inclrding rhefolloviûg
. The effe.tlve.css of all cari€s pfcveûtive prôg.ammes
shouldbe Doniroredo! an ônaoinabasis.
. Comounity watcLfluornlatiônis safcând co$ effe.rivexnd
iniroduced àû.1mainraircd Rherever$.ially âc.epràbte
J,d Jib. l\Fop
eill ûôrmallybe wirhin the ranAc0.: t.0 mgIL.
. Sâft fltro.idi,arioû, at a nrinimum concenùario. oF 200
ûE/r I. shoul.t be .onsldc.edas a prâ.ti.al altenrarivem
ùâte. fluormarioû.
. EncouragingresultshavÉbecnrelorted wtth fluo.idization
oi m;1kbùr more$udies arer€commended.
. Ihôrlde sùfpleûenG havelinrired apFli.âiionas â
]ùblk
healthmeaùe.In â16 wirh medim to lov ctrrl€s experlenc
a .onscrvarivepres.ribingpolicyshoùl.Ibeadopted;a doseof
0.t ms l/day s1iotrLl
bepresc.ibed for at-riskindividuahfrom
rhc âgeol I ylf. In arca s'ith hiAh .dics cxp€lere â reg!
menstanirytû 6 monrhsofage,tuking inro dccôuûrtheflù-
o.ide.ortenr of rhedrlrking wâÈf, shouldbe ùse.l
ûe need . Only one sy$eni. iluornle me6ûe shouldbe lsed at dI
. Bec2usefluorlde boftfa.e is â lishly ciïècrivemeànsof
.ùlcs .onùol, everye$ur .rust be m,Ldetu devclot afford
.1,1,,,.. ooto-.. r.-,r.r"toprrt.,..,r.
Me.suresslnrùld be rak€û to ex.-mprnuori.le toôthpastes
from dùtiesând raxation.
. Ilùôfidc toodipasretubes should contâiû advicc rhar,fo.
childft. u.de.6 yeâBofage,bNshing shoùldbe suFffù&l
dnd onlt a mirimrl dotrnt (lesslhèn 5 ûn) shouldbe
pla.cd on rhebrlsh ôr .heii ng sîick.Toothpa{css,i!h low
e.ed lercls of fluoride,manùiàftured€sFe.iallrlor usebI
childrer, shoùldbe fully stu.tie.L.
. Inrhfasres \aith .àndy-likc Raloùs, èrd ùxtrhl]are con
turnin8 I t 00 pFm ôr môrÉarc not reconnendedfoLusebv
childrcnunder6 yeùs ofagc.
. I. loa tluorlde cômmù.ities, schôolbasedb.ushirs atd
moudrinsing progiammesare r€coûnendcd, bu! rlietr
adoptior shoùl.t be bascdon dr€ côs of implcmenlation
ând lhe cariesstarùsofd,e conmuûity. Iluoride moùthrins
i.g is contrèindl.atcdin childrenunder6 yca.sofage.
. lurhcf.cseâr.h on rhe etre.rircne$offtuôride or nu su.
facecàriesis re.ommen(led.
. Dierarypra.ticesthar inc.edsethe risk oflnlànrs and loùrg
chil.lren being orer-cxpose.lto flù.idc from au sourcs
shoulcL be lde.rified an.l èppropriâtcacrionraker.
. Dertâl flùôrosisshouldbe mônitored
l,eriodicâllytô der{t
incresing of hiAher rhan a..eprablc lelels of flùoross.
Action shouldbe raken$hen nuo.osisis foud tô b€ exce$
sile br djùsing fluori.ie inrakefrom vdrer, sàlt, of odrr

sources.Bnnakers shouldbe usedto dses, whereprætical.
curcnr flùoride er?ôsùe tô pre.ticr funher risk of tlùo.osis.
Conclusions
Tie studyol rhe sysremicard .opica.leffecrsoffluoride hN Fro
dùceda ûemÉndousoùtpoLtring of reseùch, particularly over dre
hs t0 yeds, dd oùr knosle.lge ofdertal epjdemioloay..lini.al
trials, cômdunity dertà1 health, dertal plaque, physiology, and
biochemnrry hâsin.reded enorhoùslyæ à re$dt. This chapterhas
colcenrEredo.vârer fluoridation.fluoridizâtionof saltùd nilL,
flùride supplements,flùfide denrifri.es,ânt dertal flùorosis.
l h en o t o t u i o ' " i n r r d i r ' ' \ " , o , . i o r n ù r ' r i e .
prrye.ljve aAenrfor borh the i.dividul and rhe .ommudty, is ooe
of rbemo* lnpofant àctors responsible for the decreæe i n dental
cùiesin childrenobsen'edin manyindusrrialized.ou!ûres.
References
À Systemtic Reviewof V/at€r lluoridation NHS CenÙefor
Revlewsânl Dissemination.Udve6ity of Yo.k Repor 18.
Anolà,1.A.Jr,et dl. (1962).FjÊeenyearof the Giand Rnpids
flturidatiônstudi.J. Â,. r$1 Arû.,65,1a0 185.
Âshley,PF.,,r,/. (1999) ToodrbrusLrins Hâbits and Câries
ExPedcn.e.c,/tr R6., 33, 401 402.
Ârtwood, D. md Blirkhorn A. S. (l9lJu). :frcnds in
denrdlheà1thofren yearold schoolchild.c. in lruth-wer
Scodandafter cesâtioû of (èter fluor ation. /,,.,t..
; i , 2 6 6 2 6 1.
Balsa.,4., Lynch, 8., Ellwood, R., Dâvies,R., Pete6son.l..
r n J B u o b u . r P , ô 0 1 ' .R e . - r n lo l r r . n . 4 r o o t ' r e '
usira dertifri.es .onrâiûing t,000 àûd 1,100pFm flùoride.
Cdriti R6.,35,4116.
Cheste$.R.K.. HDntinAbn, E., Burchell,C.K., .td Stephet,
K.W. (r922). ElTecrs oforâ1cùe habitson cùies in adoles-
.en e. Cdrit\ R6.,26,299 101.
Churchill,H.V (1931).o..ùûence ôfflnoridesin som€wate.s
ol fhe Un ited S.ates.1,1- Ent!r{. Chtù., 23, 996 998.
Co.ri. ÀJ.. Lorzkaf.S.,Da.by,R., Cdcro, L., Mark, R.G. and
McNeal, D.R. (1988). Â l-year cliûicàl ùlÀ1 to compare
efficacyofdentifricescontainins1.14% dd 0.76% sodnrm
mono-flùorophophâte. C,z ù"ù1 Dekl. Otdl Ept.tntol., 16,
1lt Ll8.
Deaû,H.T., Ar.old, EA.Ji, and Elvore. E. (1942).Donesric
wa!€raD,.lde.talca.ies.V Additioûal studiesofthe relation
of flùoride .tomesticwate6 to denral carieseiperiencein
442i white chlldren aged 12 14 yea6. of 13 cities in,1
st^tes,P,ù1.HLt. Re!.,57,l1tt tttL).
DHSS\1969). Theflaai lrtjon irdie! i, the Un;tuàKin{thi al.l
th. ,rùrl1! a.bidel dft( elaen)et. A ,tort a" 1beConnbl'L a"
Meaù inra fltuti.lé|i,", Depàûmcnt of Hea.lth and Socièl
I
Reh'en(es| 5e
I
Se.ûity Reportsoû Public Health and Medicàl Sùbiec$
No. 122.
de Crôusù, P, ,t ,1. ( I 9Et ). Cariespreva.leûce
in childrenarte.
12 yearsof salt fluo.idatio. i. a Canon of Switzerlatd.
S.bùeiz. ùIr,/. Zdhn,Ed., 95, ao5-al5.
Fosels.H.R., Meade,JJ., Criffith, J., Mirasl'uolo, R.. ând
Canûo,L.P (r988). A clinical investiSâiionôfâ high level
De,r CÀild.,May-Jûe,2ra 211.
flmride dentifrice.-1.
Hoft, R.D. (1995). The partero of cafies in à sroup of
5-year-ôldchildrenandin thesamecohoftar 9 yÉarsofàse.
Co""n.DLnî Hhb.,12,91 99.
Hoh, R.D., l',/. (r994). Enamelopacit;esand dÉntalcdies in
childrenwhô sed â 1o\riluoride roolhpasrcbetween2 ancL
i y e t s ô { ^ g e . I n îD
. uû..J..44,13r a1r.
Ho.os'itz, H. and Isnail (1996). Topicèl fluoride 'n cades
preventiôn.In: reiecsror,O., ErkstEnd,J., and Bart, B. A.
\Eà.) llturiù iî Dtûirrt!, 2n,/ Ed;ù". Copeùhàqen:
Jeûsen.M.E. and Kohôùt, L (r988). The effecrofa l]uorldared
dentirricco. root and côrotulcàriesin atolderâdult popù-
l^tion.J. An. Dox. Ai!ù..,117,429 432-
Kdtz, R.V. Hazen, S.P, Chiltoû, N.N/. ùd Mumma. J.R.
(19iJ2).Pi€va.lenceâlcLintraoruidistributioo of roor caries
in ân âdùlt popùlation Cdrie\Re'..16,26t 211.
Koch, G., Perefson. I'G., Kling, n. and Kl;ng L. (1t82).
rrle!, of '"ànd n00ppn ll ,on.h'rei, li'.con .ri : ,
three yeùclinical stud)...t/,1 D.ît. J., 6, 23a 238.
Kùnzel, \l1, and l;scbef. 1'. (2000). Cuies prevaLence after
cessâtioD oi water flu,.idatlôn in râ Sàlùd,Cuba. Carrr
R a . , 4 , 2 02 1 .
lo$ry, R. ard Evars.D. (1999).the privatisedwa!e. industry
and public health: bâ.k ro s.trùe ot€. BDJ Vol. 186, 12,
591-198.
Mcclure, FJ. (cd.) (1962). rl,a l. Dù.kj,s Uàren, IJs
Defaitment of Health E.lucàtioDaDd Welfarc. Natbral
lnstitute ofDental Retear.h,Bethesdâ, Md.
Mdinho VC.C., Hissins. J.PT.. rosàû, S., atd Sheiham,A.
(2002a).Fluoridegcls tif prevenringdental carjesin chil-
dren and adol€scents(Cochrdnereview). The Cacbturl
I;l'/,l,Issùe 2, Oiford: UpdateSoftware.
Marinho YC.C. Hiaains, J.PT., Logm, S., Md Shciham,A.
(2002b).Iluoride vardshesilorp.eve.tlog dental .dies it
.hildren ar.t adolescer.s (Coc\raae ftv;ew). The Ca.htu"e
Lihu'1, Issue 3, Oxford:UpdateSôf6vare.
Menahini, G.D. l/,/ (r99r). Cariesprevalen.eân.t sinsival
inilanrmarioniû.oùcripts ]n I t)81.S.buLiztrMohaîrtbtill
fnr Zàl)mulizik, roL, rrr'9 I\26.
Milsom. K. and Mkropoulos,C.M. (1990).Endel.tefects in
b y m F o . , l dF l i ' n r o . ' e . . " n o r - - ' r d ; d p , r t
of Chesh]je.C.tie! Ra.,24,21)6 289.
60 I 3 fluo'ideond
denrot0ie5
I
lUitropoutos,C.M. ?t,1 (1t8'1).Relaliveefiicæyôf dentifri.es
cootaidng250 ôr 1000ppmF inprevenringtuies repoftof
d l2 morth ctnna.lùial. Cûrn n. Dni 17[1h., 7, 79) 2OA.
Moller, LJ. (196j). De"rdl Fltutue rs Catie!. Côpenhâsen:
RhodesInrerturiotul SciencePublishers.
Mùûan JJ. (1969).Cèriesexperienc€ of lt-veaf old children
from flnoride and no. iluoride comnudties. Ar D,,r _f..
t27,l2a t1l.
Nturrèy,JJ., Rusg-Gunn.AJ. aodJe.Iins, G.N. (1991).F1,r,
ùridù it1 Cdtitr Preeilior, lrd edn. Wrlghr, Buttcryor.h
Mùûèy, JJ.. Breckon,J.4., Reynolds,PJ., Tabdi, E.D. and
Nunn, J.H. (199r). The effectôfresiden.eand sociâlclss
ôn denral.dies experiencenr 1i L6 yed old .hildrco llvioA
in dùee àreâs(nÀtumlflLloridc,âd,ustedfluorlde dd low
flmiide) ln dre North træt ôflngland. Ë,, DùL J., \7\,
319-422.
Mufây.JJ., Russ GunD,ÀJ., âûdJenkins.c.N. Frro,Ær,?
Cais Pttudra,. )À eàn.London:Wrishr I992.
ossuji, O.O. and Nikiforul, J. (r988). lluorid€ supplenerts
induced deDtal flùorôsis-.ase ÊIiaûs. Pded.Dert.,IO,
.r8 t2.
Paûs.D.T. ând Vmr, $r.L Jr (1992).The ue olRuorid€con
tâinins toodrparesin youngchil.lren:thes.ienrificcvidc.cc
Forrecommendingsma.llquit;ty. Pde'L.Dùt. , L4, )a1 3a1.
Pendrys.D.G. (1991).Risk ôfflùorosis;. â fluoridaredpopula
tion. Implicàtionsfôr rhe denrisrand hysieùr.J. Â2. Ddt
Arù,126,1611-1624.
Pindbôrg,JJ. (r965). E. Dâ.sk FlxoriderinsspjecaFRÂ 1902
Tdndlde&ùldàeI, 69, t5 t t6t.
n o r d . n .P J ' .utpôrFn'\,r i, ô\ p.\r,-
tioo: a literân,re revies' and prcposâl for a new dosège
Ld)
J . P - l t .| t I r D ' l . ç { . 1-"'
Rock, Nr.P (199.1).Yoùns ch;ldrenaDd flloride tôorhpastÉ.
Br Dnt.J.,177,11-20.
Rù8s-Gunn, A J., 'r a/. ( 198 1).Cùies experien.eôf t yed otd
ch;ldren livi.A nr ibùr communities in N.l. England
fcccivins differen! water fluori.te leÉls. B/. De/|t.J.,
150,9 12.
Russ-Gu.o, AJ., Câ.michael,C.r., ard rerrelt, R.S.,(1988).
EfIe.t offlùorldarn,n and scculartrend in cùies in t year
old clildrer living ir Newcarle md Northmberiand. B/
DnL J., 16t, at9 44.
Steele,J.G.,
\Valls,À.wG., Ayaroilàhi,S.M.T.dd Mùûa),JJ.
(1996). I{ajor c1ini.a1findings ffom a dcnral surveyof
êld'r D"ô, ,1 1,,-di. -,' l'.i.| .oinr',p.
Bt: De"LJ., r8o, r1-21.
Srepheû,K.!4r.,Àrlccall,D.R., a.d Tull6,J.I (1987). Caries
pre!èlencein Noiih S.orlandbetàre,andt ycas âtier,wae,
- Bt Dehl.J.,763,324 j26.
detlnotidation
Stepher,.t/ (1988). l-year oEl bealrhdoseresponsesrudy
of so.tirm môrofl trorophospshate denrif.iccs widund
skhont zirc .itratÈi antl caiet rcsl]fs. Coûnrn. DnL Ardl
Llridlu,n..
rc,12r 325.
Todd, J.E. and L^dct. D lt.)91J. Adtlt Deùdl lTedhli 1988
U" tuà K;"!àan. Londan: ]II}'{SO
Trnn, C.\r{r.,Grarcs. R.C.. \Xrebsler,D.B. and Clarke, BJ.
(1987). Anri.âries c*è.r of 14t0 ând 2000 ppm I deûri
frices.J.t?,r ]l.r., 66 (Spec.Issue),216 (Absù. lJ79).
\Ireaver,R. (19t0). lluorine aod wa.tine diet. 6N D,,rJ., 88,
23r-239.
\{rinrer, G.8.. Hotr, R.D. and Wlllians, B.Ii (r989) Cllûical
t.i2l of a Lov flÙoridetoothpastefor young childien. Lr
D e " r . J . . 1 9 , 2 2 72 1 1 .
\rofld Heal.h Orsanizarjoù 11986).Ap!tultjak tu affl,an,l,t
fat ,"nb" Aklth. Geùe\ : wHo.
V.orld Health Ofaanization (r992J Roefltd,bdsa in a%l
,.,rr. l?HO Techni.alRepoit SeriesNo. s26, Crnevâ.
world Health O.sânizâi;on(tL).)4).Fhaùtta akd otdl hùhh.
Geneva:WHO.
 IVlicrobiological
aspectsof cariesprevention
RoyRussell
lntroduction
ùIo,len delelopmen8 in dentistry hwe Aive! ùs è wide rânge ôf
ôptbm 1;r dre efaectivetrearmenr ofdenal d;seâse,but it is only
by ù eistanding the deta'k of ûe everts rhât leâd ùr rhe dis-
eÀ&l stète that we can hope ro design futiôra1 detlùds of
!flefuiô!. Insi8hts into rhe diseasewlll help u ro a.bieve dre
ûLtimarÉaim of preveDrion md â1solead ro merhods ror predic
tiod ol diseaseaDd new apprôâ.hes to ùearmeor. In lhis chaprer
thefefore.we shall fi6t consider whât is known of !h€ way in
vhlch bacte.ia ùe involved in rhe de.tal caf;es proce$ and rhen
hos'this kûowledge cân be exploitcd.
Tne bistory of oral miûobiology can be rraced righr back
to the origins of micfobiology as a s.ien.e.
reeuçerhoek, d seventeenth ceorury Dutch draper whô was
delelopins hs niùoscôpes so .hat he coùld check ûe qùality of
his textiles,exâhined sdapiûss frcn his teerh oùrofcûiôsiry. He
wd fscimted by rhe seetlrins activity he could obseNe. aÂd tuok
gÉar delight i. rhe v2.ie!y of shapes,sizes,dd novement of dre
'liftle
anima.lcules'that he saw. However, ror everyonesharcd hls
enthtslasm for thes€ tiûy fetlôw-Ûavellers and, ;ndeed, m2ny
rverehdrified at the droughr ofsu.h momrers in rheir moùdrs.
From his clrâwinss and dcscriprioûs, we now knôw thât vrn
leeùvcnhoek saw spheres,rôds, dd spimls, which we now.ecoa
nize as sùeptococci, fùsobè.teriâ, ând spiro.haeres. \Ye shall
Êtûn $ thn rhene oi a compter orâ1mi.rôflôra later but some of
vanreeuwenhoeki other obserathns seÙhc sce,iefor subse,luent
do'elolmen$ in orâ1mi.rôbnnosy ibr exampLe,he found that
everyonehe ddired harboùftd a s;milârly diveBe collecrion of
oisanjsms nr the denrâl plaque, bur drar dre mixrure of rlpes wâs
not costàrt. ^r .o rime. hovever. did vàn Leeùwe.nôek èppear
to have màde àny cônnectbn berween vha! he observed ard
deûtal discase. Such discoveries were nor tu come for anothcr
The furdamentals of ou. unde.standns of the pâthoseresis of
cùies date back to rhe period vhen specific bàcteria were being
liiked to specilic dise6es, md resedche4 su.h a5 Pareuf a.d
Kô.h wc.e developing the germ theory ofdisease.Pasteurt A.car
eàt r was Chethez h ntmbl àrd rhe lâtter half of rhe ninctcendr
centuJy sav mpid rdvarces in the quest tu idenr;\. thc c2usarive
orSanlsmsofinfectiols disedes. Over a few de.ades, drc bacteda
responsiblefor diseâsessùch Às èûthrâx, plagùe, dysentery,
cholerà,àûd tuber.ùlôsiswereisolntedand .nltûed in rhe labora-
tory. lt ùd natural, therefore, th.t irteresr wd àrouse.lû cteter-
mnrin8 the spec'ficae.'oloAyofother dneàses,includnrAdentâl
cdies. The fisr repoft thÀt we hale ôfsu.h inverigariônscomes
from the recor.ts of rhe Inrernarional Medi.al Congres held in
Londônin 1881.This wa cleârlya majôr event.asboth Pdteur
add Kocb âteûded lt. Joscphl;stcf. dre pionecrin dre field of
anrisepsis.invited them both m dirne.. pedups tacrtullykeefing
the corvcsation only !o scie.ced lheir coun!.iesvere at va. a!
the tiDe. A! thatsameconsr€$two Londondenlhts.UûdeNood
ând MilLes.presenleda paperdesûibing the microscoFic obsetra
tion of AcmD' in decâyi.g tccth, ând rhc eipcrimentsin vhich
they incubare.l exÛaûed teeth in rer tubes and lôoked fôr
damas€ !o the eramel. They found tha. eramel dissolutior
occurredoDly if there was bolh a sourceof carbohydntÈth€y
usedchewedbreèd-ând ]i!e germs. Killlng gerns ùsirg pheno-
lic solution,inùoducedby Lisrer,preventeddy ddage ro the
enânel.Under*ôôd ândMilies publishedthen wôrk in 1884bùt
nothing more is knôwn of their inverigaiiôns. Their.on ept ôf
the three-wayinteraclon betweer bacteria,carbohydrate,and
teeth was develôpedand firmly einblished by I7. D. Miller an
Àmeri.an workiûg ln the sème iNritù.e as Koch ir Vienù.
Miller pmposedhis .hemi.oparâsiti.rheor)"of ca.iesir a book
publishedin 1890,idenrii'ing the essenrial .oûjunctiônof ba.re-
rià ànd ferhentable .arbôhydrate to eenerate the a.id thd
resultc'd;. dre deminerâtizâtion of emoel. Mill€.s book wd an
importâû! stef ;. lhe descriptionaod cla$;tcâtion ofdre varieqr
ofbâcledafoundin derlalplaque,a.d helpedesrablishtwo oi'lhe
main tbemestlrat havedominaled .esearchiû cariesmicrobio
losy wha! bacreriaareiNolved and how lhey usecarbohydrate.
A third major theme rhât did not emelseuft;l lhe lairer halfof
rhe rwentieth .e.rury .on.erns the is e of how the bacteria
attachto aD.icolodzethe toorh.
Vith the development of bacteriolos'-, it becme posible to
stùdy the propertiesof bacteriÀisolÀtedfrom cârioùsteeth in the
laborarory.Sln.e it was nôw .led thai bete.ial a.id prôdu.tiôn
wd â cenÛa1fratùre ôf enamelarta.k ln the derelopneni of
caries,intere$ wa fô.usedon dros€plaquebi.teria thar pndù.e
a.id. Mlller aôd subseqùcntresearchers favoutd bacteriaùat
produ.edla..i. acidasdre.aùsativeâ8entsofcaries,and for many
 4 Mi(robidl0sk0l
ospeds
of.niesFevenrion

(honging ol roriesmicobiology
conrepts flrel <lrentncncci
. Va. L reù1,ftk(1600t Ilrr mi.rtx.ùli. ù|lslrva.io. ôiod
Taxiilloûly ol orâl struplococct
' Prr.rr, Ko.l, (lrre lNoos) Cdm Ïir.ory o JisÉàse Ofe of dic diffiù,lties lhât hxs bedeville(l ,frcstigxrnÀ nùo dt
conùibutlon of oral srcfrc.o.ri toplâ.tuc àmrtbt lus bec. ùr
. L eNrod md M,ll.s (lsg.t) ^s..iûi!tr be.lecn s.rns MJ
etuû,. n..rr of fesohrng raxononi. iehtionshùs benveeû tl,e d,ftirnr ryPs
Chemi.opansiri. r1[o4 ol .afies obsen'el. In,lccd, mâny .oùrinc dialnosti. rne,li.rt laborâtories
ùi1l lùnf âll rhe or:Ll$rep.ococ.i nrseth€r ùf{lcr thc dÉsùiPtnt
Identi,n ûiai .\ ,tutn'rnat ,r'tt,r
,i. ,. . ,t,.,r
and xs$.irtio. {nL i^irhl.aries 'Ihis
or {I-hâemollsis, fmdù.ed on blood aEar. cLi$iti(2tnin n
a\o.'anon or nuans {fpn,.{.'
rnh .irl.s (sl,(in. thqft hr?oth.sis)
.lcâdr limired, is not âll the orul $rcfrc.o..L âre rx hreNn.rrt,
ind d-hle,nolyli. ltcles such as .1.2ru:zrtz .re nor nornâl
!.ololnd llaqft hvpOthesn
inhât,itatrs ofdre orl .â!itr llore nnl)oltandr, tLterets e{rctrvt
eortnrsizes billtur b..vc.o
kterogeneiq ot |hysnnoli.nl ptorric\ withir the.qrout $ ûn!
$o!ld ânri.ipare diffeÉ.t vi.ùlctr.e ptuteries N1àn-taitdnlts
havc, rherefore, been madc ove. the ter6 ftr dcveloP scheN; li,I
idcntitrln! $refto.oc(i n) dt spe.ies lclcl br'lxbor.tory rArs
\eàts Bûjlhr a.ilollrh dûr,4t;ùt!, r species na.re dtât no Thesc have lxrgely been b,scd on biodremi.2l tn)penies Mh ù
longer hxs any lomal re.og.irbn, wxs the lâvourc,l .ulPrit. rlÉabilirr rc ùiilize J iànge of(afbohydràte substntcs. Stôtyfiig
Rod shxfed lx.ti. acd fro(h.ing ba.terix (now nle.riticd as sûemes hâvc al\o p1âyedù prft in id€ttifiiûg taxo.omr bound
mci.bc$ ofthegetus 1-,.1arlt/1ff) (Nid reâdily be isolatcd fu)m âries,Lrùt.onc.fthe approùch.s basedon bJ.trirl l)hc.otvPe (i e
e r a b l i s b c d . a f i e \ l e s t u n s rb ! 1 i . 1 9 2 / t ( l l â f k e, worLinE ar rhe proferti.s thc br.teria dis|I2-t i. Iabor.tory .ultutl Ir
SL. À{iry s Hospinl ii Loûdon, .lescLibcd a differett affr.,.h ptuled enrirell satisfr.tor!. lt $'rs onlr with dt inmdùdilt of
$'hcrc he examited the bâ.r.tii prcsent it nitlrL whitc-spof ûoie.ulàr mcrlnds brrd o. ba.tcfial se!.tlPe rhât dre hLIliliri
emmei lerons. I Ic idcrtiÊed a Lrâ.teriun, he .amcd .tt4i,ùùa siry of rfeptoco..àl l,ccles crme to be rc.osnDed iist nith
/,r,rj thr n,i.. .f dre (trgaûism tellecs drc f,( t1[t it aLre$ DNÀ DNA hybridizatnn, ef,pein,€nrs and lxtr wrth scqùctu,ng
shrpe depen,linÉt uton die growlh conditions $1ùcf $'2s of fibos.ûul RNA genes. Bl iihc .rid 1980s, n Fas ntrm,Llll
pft\€rt irr à liigli proporio. i. $.h eârlr' leslons ClarkeprôPose.l recognized dnt r group of bx.teria drdt had aU LJeentrelLouJr
!. z,tflJ as rhe iûrportant organism in the nritlftiûr of disease. derribcd N J. Mltdrt. ;i la.r, .ôùtrlretl a number ôf.litli'cnr
v'c now rlriûL that rhe.. is à f().e\s of mr.robhl N..e$bt so stecics. whi.h IÈl \àrlous tr)peities in .on].n)n but, nevnrhe
rbar rhe lâ.tobà.illi m o r . ; n l a t e r . t l i e r p r o l l t . t a r h n b e i n g les. hâd di\tit.t featÙtcs. lhese dre .ollcctirell ftfe(&l ro d
. o r b r ' , l o ' ' ' l ' r t rlie murans AoLp or Mùt2rs Sûepniioc., (À1S).Às a lorollùioi
Clafkes work went lârsch ùrfcsrrdeA until dre lâtc L9j0\, wlien h,vina difeÈnt proFrtics, rhe wûio!s st€.ics have diffûeir hsr
lew rttioà.hcs ro iûimâl models ofcâncs. bascd .i .he sÉLe.rivc and favour diltèrent cnvitordei$. lt âl{r be..me.le,t dmt $ôr
ùsc of ântit,ntrics to Do,lil-v rhc oml mi.roflota, .cta.use.l t]pes rhar h.d beet the oLr'c.r of sn,d\ if r.imals (.t .tn!û.
aûc.tn)n on rlt rÉptococci. Thc intudtr.tion of isolatôn .hâm .!. &rl t $'cre rarel),, ifevc.. àund nr iùn,ans li,ble 1.1 slùss
Lr€rss'hcrc germ iree Jninals.ould be.aise.l and intc{îcd sith $e cùrcnr rdônomic s.antr.fthe humè. oràl sftPntro.ù.
. , r . f q i , . r . . , ,I r ) | l l . ' ' , ) ' l , . ' ' , t ' o : ' . - r
, . . , I o . .
wlù.h vdfious sfc.ies ofsrepto.oc.i could trc ra*e.l rc.oiilina nl nr LJefirnlr estâbli\hed, \'ith gcncril agfeemenl orcr dre sp(trs
dieir abiL,ty ro indù.e.afies in ts or h,m{crs le.l ôûaslgtrr r.lr deflnition. uelo.c xnlone heales â sigh oirÉliel it h,s t(, t'e tot
dier. Àn animdl .rcdcl of.âries .oùld rbus bc developed, and a rhar eren the.on(+t ofâ \Fe.is n,r bâ.teri. has bccn thioM
{reptô.o.cus l.rown ilN rs.t. /,///rr 6rl t (tlrc tifteeitli isolrtc inio .Lispure by tu.rhcr delelotments in oû utdefrandi.r ûl
oa,."1 " '. \,H r / 1l' _ ' f bx.rerial pofulitbn rnLct!res. b(nahr ab.ut by .cw !enoû!
as .!. vôrrzr L'ecamethe to.rN of.ttentio!. \x/hilc .h modd se.lù...irs approrches. F..a lon! riûe we wcrc l:miliu$nh ftr
sr{ems ûe $sefrial for taklnA ftseâJcli IôN'âtd, thert n a neetl i d c a t h r r a U n e r n b c 6 o f a s p e . i e ss ù c h a st , , r z , ù e € t h c v m q
n,r.odrinùàl !,gila..c b cnste thrt rhe vâriolls.omPonef6 ba\cd on our ùndestirditrg ofbinâry ,iilisn)n, so dràt all dAGt
of drc sy*em b.cterum, animrL. diet rrull rcf.tsedt the .lùnrs of a diriding Lra.(rimr are lde.ri.xl rnd di6 Lolncd!
fèiùcs ofthe hnûrn.lsease in nhi.h *e.re i.!e..srcd lLking hon,osenoùs .lone. k nos'sccms tlht tlis is lcry far l.om hei0S
rhe i6t of t|ese, it is .^r.l,l for dre exPloiàtio. of prcvcntlve ô . , , $ i l l l l , " o l
stritcAics thât the ùue rdeftit-t of the câus.tile o.Sani\m(s) of which .onrains tl,e hr.qest number of name,l lccics oforal sttl'
caries is knos.. k is, tlieielôre. n..cssary tu a.l.1res !hc iimbLem ùco..i. Dad Fom rlLNÀ seqùcn.ln! sho\ts d,at.t l,,rrrtm
of ba.rcrial identiil.atioD nn.l clasili.atnn. rlso lies in rhis !ftr,p. thouah irs hal'nrt is .onsidcrt.l ro beIr

TabLe4.1 Human itral {Lerro.o.ci
Pi.neer sF.ies in phqft
aoûrntio..Comû.n.rusarive
âgenho1nne.dousen,locrill.is
ùfuri.s gmùp S. "tetdrt ldte.olonizèrs ùf pL:qft ,
'ûtrtans
sftpro.o..i S. rrrnz, ii.rc6cd nrùbes .$o.,ated
Iound mâif,ly .. ,n!.osàl nrfdes,
Ixvou ânàerobi. enùlnments
f r.!uently isoLrred from
odo !]raryù rèther thân rhe ônI c^!;ry. S. fnex'na,ide ;s .losdy
FJ.lneàto S. nni! ^nà S. 0tu1i, and drere is now a subsranrial bodï
of evidenceshôwins thar rbere ;s exte.sive exchanse ofsenetic
lnformâtion berween rhe specics. This wù fi6r r€ported for à
pelicillir birding protein, when genes in pcnicillin resisrânt
is.tates or S. f"Mna,ide were shoùn to hdve r mo",.. ..".-".,
with selmenrs .leady ;dentical ro g€oes ofs. ,/,lrr. The conmeû
sâl oral sÛepro.o..l rhus o1ïc. a pool oi senetic marerl.l, which
canundergo gene shuffling wrh èn impôftàrt pâthogen and Lrad
to rhc emergeoceofreslstmt sûdins. Other genes show ihe saDe
nosaicisDi so, drere is reæon to thiûkthâr rheie mal beexrensire
m;xinA ofAenetic lmits wlthiû the mitis gtutç. This raises rhe
,luesion as ro whether the curently defined speclescar bc sepa
,"'_Jb/,e- oInl.r'e.o kl F r.Fl,ep,-.n.r.,r'ia-',|
$ \n.,r\ T,,.",.,.^l ,-,J,t,y,,9. n,'t, -oip.opF É.1ô\
ægardedd chùàcteristi. of individual spc.ics. Thc exisreoceof
hetooger€iry anl gene exchùge vithin popùlatbns of bâcrcfiâ
hd impoilart jmpli.Ètiôrs for .ertain prevenrive sÛarcgies rhat
!ûget distinctive feâtu.es.
Whichspeciesâre associatedwjth caries?
Âsshôu1d be .lear f.om dreabovedhcussion,the iech cÀlability
to identiô' and enumc.ârepârricllar specieshàs beer è ûrcièl
factorir àlloving an irverisarion of drei. a$ociàrions'ith carles.
Ithasbeenestiûat€dûàt somet00.lifferenr iypesdbacdia.an
belsolatedtuom dentaLFlaqùe.Thesecompriseôur normdl ôral
fioe, for the mostpar livinsinharnony asconme$àls.The v6t
m.to.ity ofthesearenotdirecdy impli.ared as.âùsatlveâ8enrsof
caries.:Iheynay, nelertheles,inîtrencerhe prope(ies ofplaque
andth€ conditionscontucivero caries.FollowinAPâstcurihun.
thc m;crobeprecept,efficiert methodsfor idenriô.i.s rhc l;kcl),
cuLprjtsareesenriàI.The derÉlopmentofsclcctivemediaslch d
M'tis Salivarn,s àgèr supplemenredwlth bâ.iùacin, s'hich
65
lnhibits rhe grôvrh ofmostoril bâ.teria btrr allôws nutans sÙep-
r,cocci t, gtow and frrm coloûies thai .an bÉ .ounted, was an
impoftant advân.e rhnt led ù dre linding thar presen.e ôfhigh
numbers ofthese oLganismsar a tooth site was assô.iaredwith a
hiah risk ofsubseqùenr developnenr ôf.arles (Loesche1986). A
substèrtial ruûber ôf .rôssaectiorèl àrd torgitudirèl srù.ties
hâve demorsnte.l à stron.qà$ociâtion betweeo muiâns s.epto
cocci âod caries (â rece.t sysrematic .eview fourd 2730 pape6 on
dre ropi.). One linriàtion oi rhese sûdies is that dre selectivc
m€dia used for counrios the $reptococci do ûot allow accu'at€
j.leûiificatior to the species lelel S n"tan! ànà S. Mbrlna!
càmot reliàbly be distinguishe.l by colony morphology alone so
it is stili nor ertirely cleù what the reiatlve contrlbùtion ofthe
two speciesmay be. However .t ,,/zd is by fàr more cômûôn
àrd is cârrled by over 987. ofadùhsj so,lts asociatior wnh caries
is clcar.l. rr,t J shos$ a nngc ofproperties similar to.!. -r,ur
àûd, in iee.t, is even môre.diôgenic in ùimâlûodels. k h.s been
repôrte.i to be fôund in t 3i% of individnâls in ditrereût.onn
',.',b, i nd,. rr Iar shrl \..r... d, .,\e .'iÊ.
o. irs own or is thc major oL m;no. partne. when 't occu6 1n
co-existencewirh -t. ,drru. It hâs been sugaestedrhat ir mây be
morc strongly a$ociâted with smoodr sudace lesions or mpidly
advancns cùies (ard rs ,, ,rt" properties woùld suppo.t this).
Nelertheiess, alL the avaiLùle evidenceindica!€s lhat my p.€ven
tivc sûategy should hâvc.t. zrr,z' as irs ffircbal ta.gct.
k is iôpôftant ro nôte thar rhe eviden e impli.âring ûùtads
sreprococci âs major caùsètive aserts of cèries comes from
studies ofspecitc cariesprore srteson teih. There is a closecoûe
ldtiôû between rhe levels ôf mutàN sÙeptocôc.i ir sâlivd and the
levels inplagùe. Sin.e ir ir mùcheasier r., obrain samplesol saliva
than of pLaqùe, drere ha\ been n .h interer in usinS sahvary
levels as a prôry mèa!ùrÉ ôf dLnbÉrs ofba.teria ln plague. thn ls
dls.ùssed fuithcr in.hc sccthn o. Prcdi(ion but it musr hc
re.ognized thÀt rhe hrre presen.e of nurars *repb.o..i in the
moùtli, or elen hlgh nùmbers of mutans stretroco.ci, .toes not
inerlrabll leâd ro .arlcs as orhc..o.ditiors mùsr bc satisficd fo.
the .lisease pio.ess b advan.e. The inùlnsl. rcs;siân.e of rhe
û)rh enamel Oe.haps st.e.8tbe.ed by thc inco.porario. of
fluoride) is o.e factot ltrur,.€!!mins ro Mille.'s o.isinal concepr,
r€adily fernenr$le carbohydrate is aLsoessential. As a conse
,tuence, many iûdiliduaLs, pa.licllarly thos€ wjth sood seneral
healrh, sood orul hysiene practices,exposùreto tluoride, and suit
àble .tietàry hàbrts car harbour retàtively hish lelels ofJ. ,,r,,r
(> !0r colony formi.g uits/ml ofsâliva), yet bave a liletim€ tee
ofcdies. Nre mùr al$ nore that .he mâjorliy of ihe *ùdies rhar
linked levels ofmutàrs streprococclro cùies risk were caried our
in North Ameiicà or Scàrdinâvià. ft is ûôw àppàrert that rhese
findings .annôr ne.essafily be applied to orher pxr$ of the $orld.
Ior example, in many Afti.ar populatio.s, high lcvcls ofmurâ$
sieptuoc.l tre found boss;bly due to a sta(h-rich dieo but rhe
ugar lntake, and hence rhe carlcs level, remai.s los'. In such
plulations. âttempts to use measuremenrs ol mutans strepto
.o..i to prcdicr futùrc car;cs risk arc doomcd to fâilu.e.
66 4 llkrobioloqi!01 offtriespreveftidn
!sperh

V\vhenhc tiN described.1. ntnt r\, Cl^ùe madc it.leùrhrt 6ï0 tse.ausc of dre greàt varixbiln! ol R|LP trP€s amongn
.rries, so.rdimes, develops in rhe abseDce of anl detectablc ;olares, i! s'âs posible !o a..ept the conclusnû that mat.hing
J. r"/r,L He.ou1d fi td.t,r,r,,f in o!1r' 787. of his ùhite sPot parterns in fltrheG ù,1 (hildret had .or o..uted by .han(
lesions, and dris srLggestst|at othcf spe.ies, or combinâtions of rtr.l rh.t ,,atcrna1 tansmi*n)n ùès rrust bè rh€ sour.e ot
s t e c i e s .c a û p t u d ù . e ù t o u n t s o f a . i d s i m i l i t t o S , t k t . ^ ût .!. ,rrhd in 807. ôfth€ cbildftn. Y/hiLe 2r iniânt ùdy initidlll
'fon .àry onlr one .Lo.rL lnrc of J. ,r?/r,, (identilied bI ribotypi0g
hcrcc cause dmage. Thcse otller mùtr$ fePtoco..r ,
capâble of gerchtina â lôw tl l, halc been identiûed as ati pi.al ôr R!lP), b-v 2dùlthood drere may Lre rt t. seven diffetcnt
$rJiN of.ommon p1âquestecies sù.h a\ J. ,,trl, -1. ,,,sn, and donotr_pes, lhoùgh rhese s.cnr b be renarkabLl *able ona
S. inkhnet t! (\^nl.ù.\\eù e/ r/. 2000). Â.ôrollùy ot dre re.ognl cstablishecl.Thc basis for this sù..esful lons tcfm côlonrzxùûn
flod of srongLl àcidogeni. species odlcr that S nttdnt r rt\!t is not.leâr, b!! ir does illlsrâtc the Perfect equilibri!û rhe
cven lfJ. ,/rrd v.rc n) be erà.li.ated. it is nnliLell tlràt .âries can bc a.hiele.l beNccn â pàrticllâr ba.ûi.l ty|c. its hos, md
risk \u d be re,luccd ûerô its nci€hboùitA b&tcfia rh.t .oinhabit plaque DcsPite the fa.t
rbat mor peôple will have enloy&l a.eitdn amout of ittnn4.
oral .onrâ.r \ïirh orhc. people, it is .lcarly exùen,el-t dlftarLt
for xnod,û teson's .t. z,/,rr to suPeri ect This dso loss
Thelinkbetween ond(o1ie5
mulcnsrtrepfo(o((i a rôûsideriblc .hâlleng€ b pre"entile rmtegies drât ftek
ro retl,.c x .arioge.ic ba.tri.l Potulâtnn, with o.c lcss IileLI
. Ânim'J c$erimentsi nutrns srepio.o..i .rusr.ârlcs r
gnoiôbioti. amnals in the p.escNeof $rgar A va.ict-r ôfmolecùla. rypitg teci.ique\ âre tow dvâihblelô'
. Vnuleocclroperties: mùtâôsnrc!to.o..r fos:ê$ lroPenes rhri hngerydirl.E s. rr/tdrt ^id .hese dre bei.8 aPpiied to sudiesof
conrlbfte to cariogehi.nl. lh.l area.,doseni..rc,.lrùr. and ûaûsmGsion It ls Lre.onring apparent thar to.ial differ€nar it
prôdmc e!ùa.elLularslù.ùrs ard i.i.a.eltdar $orage r'l t"' rl ,' '1 l'- a' ' !
i l e r - ' r ' . r ' " . | ' ' - , ' . . r r , ' i
. crôss{..tionâl *udies h hùmÈns:inÛÊ:LiedlroFortro.oi Idertifi.ation ofthe sôur.e ofinfe.tion wth drc baùeria rcs!0n
mntanssrettuLo..i dc Joùfd ât snesd nrnid.anes leùôns silne tor caries pro! es ur witlt è Pote.tial way oI.lclclopiiS
. Ldsitudinal sudi€s i! ],ùùùrs: high runrbeÀ ôl mùta.s 2 t.cvenrile sÛâtcgt, be.ause, âs wlth âtI inac.tbu\ disûr,
' ' ' ' o r l _ L _ a , Lays o]rcn tht lo$ibiliri
;denti{yitg dic soor.e ol i.li..r,n
. odrer non muta$ nt!to.o(.i rvnh simlld troPerti€snaJ' nlso ot inretrùptinA the .hJii of ransmission. Ic mar not be feÀ\ible
io a(hieve à LiFerimc kte ot S. nt,tnt, bùt (lelaling the age
at wh;ch a .lil.l b.c.nres infe(ed can ie.iu.e drei. subsqùor

Acqùisilionof oral ttreptococcj

The oral calitr is rerile t, zra,, btrr Jthougb dùrlns bifth rhc
nconate is expose.l to âLl the.o,ntler mi.rnlorà of thc bi,th
cam1, these organisms fâii to .olo.ize illusÛâti.a th€ highl-v
\ele.tive enliro.ment ôf tlie n,ourh. À distincrirc ofâl flora is
.apidlr estàblshe(l soon rfiei bifth. Sùcfto.occl are numeri.â.uy
S njtit, and S rdli\. *lli.li
dominant. p.rtrculârl) .!. vlidùr,
c o l o n i z e t h e m u . o s asl ù . i à . e s x n d d o s u m . f t h e t o n g ù e S i n . c t h e
, o ' l l , , ô r ' o" ' i . p . - . ' , \ " b , . i
likelr thât ùe soûce oi thcsc wi11be ân ù(lulr, mor probnbh tle
mothcr or other frimàry .afer Howevcr. {) iar it is onLy in
thc.ase ôfJ. ,rr,'' ùât anl detdiled *ùdt has been made ofthe
sourceof irfc.tbn. Iârller aork baed on bactcfô.in tyPnrg hâ{l
nllicarc,l .hc morher as d,c nrllr.e ofrD ,nià.Cs .!. /r,l/rrJ, Lrlt x
mjor advancewd nè.Le $'hc. Crufield atd his colleâgues(1993)
$ed Restrict;on Ffxgmen! lengib PôlyDo{ùism
n) obtai. gen$i. flûgerprints of .t. ,rrlrrr ivnated frotl
nrother infanr pa1ts. t. ,]tid"! frcfefentiall-v .oli,nizes lianl
sufaces ànd hcncc. its âppeùinc. is .lclâyed unlil tbc eruPtion of
the firsr molar rccth. À n.jo'iry of infana, thercfc,rc, rcqune
S. nùta^ dttir! a ùiùlow of inte.tirny' itôutd the rge of
ol 5.nulonr
Arquirition
. NfuiLdssrc!ro.o.., ùe un.lctectableid!r. dentate,naâns
' Ntôn .triidren be.ônc infe.tedaùùnd rbe aseot 2 yeùs
' th. !inr.l!àl sôur.. ofinÈctiotâplas to be the nr.rher
. ùlothcs vho.aût trigh lenelsols ,*t ,r are h.re likelJ'10
infcct thei..hiLdieû
q ' . . Rcdu.ing murùs l*€Ls if, ûôttrcs can deld) iùfecrlor oathen
Dentalplaqueas a biofilm
'llre
Bioillû co..ept h$ bcone firmly cstablished nr thr lar
(RfI-P) 20 yca$, âùd m xppre.iètion thât tLle !âst nalority of baaon
livc or surlà.es ând itr intimale âss).iation with odrer bæcem,
has inthen.ed o!t ùndestardl.g ofmi.robiàl gm$th ôû sùfacr
d diacse d indwclling crthfte6. oil pilrehres, ând rewâgeiatm!
Th. orâl .nvity has bccn .omFared to a ûoPicàl .o.al reel in lhd
it is wârd, ûroisr, fi.h nr.ùnicna. at.l sr'ftio,ts rn rbùndad
q

o obio'r'nI ur
uertrPoqr
l

vdiet! ol s1'c.ics. fher ùtrditions &und ldllli., b!! .l,allcûst Pl.qù. drer delelo|s botLr Ll growù of tire Piot..r \|c.res to
d orgtrnism .o rcsi! rhe \xglries or'Nrcrr ioù ând to makc dre Iônn ni.()rolonies r.l bI tlt funher:.ftrn,n ol morc bacttritl
.hoi.e berwe.. lifc in rhe flu ph!s. ind .ol{xiizdtion ofi haLd ce ls ofrhc sxde or otircr sPeries This 2..ftrnxi ctt b.dirc.r Lr..
iuifa.e. In onler o.(.trpl x ni.h€ \'id,in rth âr e.os)tr!.m. an tei,ùû bâ.kfiLun bindlns i,i .ô,Lggre.q2tn,rPlirs .l!e to slt.iti.
o4iâniso musr harc evolvrd a $r.reg-t n) ivoid be,ng sashcd re.etto. lisard Lrnrling or na-r be m.li.Èd bI s.l,\'trr'nr.rc
À\ay.|o lna ir s,ne soit ofbâlân.c s'ith odrers, J.,l !o.1Dc \"ith n,olc.ùles whid, noslnrk becùlse rlrcl xre bolnl b! N)re tLrn
rhc oarart !.iiùons in t..rferxrufe aù(l fl I, and rhe rvaiLabr! one Ltreriun ^l(',g wjrh th.sc pL!.e$es, tlâqùt buill ut n
ity of oryger anl .ù.icn6. Dettâl plùluc is. drerefore. no. ù tr.ilirùrea by rhe pro,:lu.tion oi baùeriùl ertn.cllular follmc*.
iri.ertitl but shoùklbc re8xr.le.l .s .onsun rll n,bje.t to lof..s s'li.h se^'c n) erûàF rhc (rus The foL-r,nt$ oi Parti.ùl,r
tirr .hinge--ftf.rmnrg an.l dixngn,g in .om!o!ù.n ân.l pro inr!ftr .re dro&' \lnthested tr)nr sr.ros€ br !afit,ù\ s|e.rei ol
tûtics u.dcf tl,t nifllen.e of cnlirxrmenÙl stic$cs. ft i\ our strc|ùro..i, {'l,idr $iU bt.onsnlcrcd i! the ûex! sc.tion. ù{Jtui€
ù..]e^rrndirg of rlis drta,nlsn drxt helps us !o crtLxln L,ow tlague. witli i1s .limâx .o,nmnnit-t of ù,..obiil sPe.ies, is
pla.tùc bâ.icria .a! .oûtrjb!.c ar crrits. and thc E.ologi.Jl dcpcndert upon rln' .ixtrteùn.e of a iire brlâf.. bctNeen the
Pld!l!e HIl,.rhcsls hâs repln.tul râ.litr ârsulnefls âb.Lû rhe nùfï Teries piesefr. $id, ùetabo!i{: intera.tions ànd f(nrd
sfc.iii.ity oi dliîere.t !lâqùcs r\n).lared with .lis.asc (Ifarnr .hri.\ nkirg rn ,n.rcascd iûPotran.c ortf adhejivc irrtutfuots
'1he It nn,$ be..rcd rhnt tlie rnurans streft..o.ci ârc n.r ro.!.le.cd
lrri) en,thisis on rlre balaû.e beNccn difièrent tr'pes.i
' - r r , r r . . r o l r . , , i , , o r ' " j f l ' I
phlsiologi(al fn)peities of ba.te.ial totùlxtiôùs tnâf simllt nl pro|o1tnn oithe loiâl nùmbÛ ol bâ.rc'ir P,tÈnt, Sen..ill-r les\
dre preser.c o. atrsen.e ôf p.iiicùlat sfcciÊs (KlenrLretg 2l)01) dran l rr. S(h J level p5cs !o probLe.ls so Ldrg .s nrc lil.gue
Irom our kno$'le,lEc ofdre loûpler fro.c$ offlîgk fonnation popularion is mxlnfui.e,l i. a sute of cquiLit,rium, brt ùc
ir is deâr th.t rhere rrc nùmentu poi.s,t whi.h ilteivenl'o. rclarive Frol,.rion\ ofdillerc.Ùtc.ies (ùnJ h.n.c dre prtllologi
nrisl,t .Listurb dre .o..r.l tnrÊs of plù! ùe buiU'up. Irteileren.c .âL pôreDr,al of dre pl!!!el .ân bc rlteÉd ,hrri.alll LrI sliills l.
û xn-r of rhese Foi.6 .oùld be sùfii.Lenr .o pfuvide t rvry rbr enrnonncntal .ondtions Pfcverùot oÊ,lortrl .dûes cù.
ol ftduclng phque, erthcr b] delatltrg th.tue }..m,ûo! or b! onLv betcLrerd br ktepnrg the l6'cls of nn, tùni strcftu.or.i lo'1.
nlrern,g ns con,fosirn'r. iLr {trh ù $r! d]ât it (xtdr losîr oi fiùI, fs orhcr mÊansofftcvûîing !.û tirodùduL
ounber of mutans *reptoco..i of .thcf .afiùlienrc st..i.s The
r.xr scûn)n roûsi.les fhar q'c nov krow rboùr tlrc ùneLulàr
m.(hanisnb of plx!!e lonnarn,.. [ventrin ploque
fomotion
. Pnr,c.r stre.jet(.1 nÀ,5 tràh. Ànnn,tn slr! l.oL')n'zetoodr
(onsequenres
ol thebiofilm of growth
mode
. Pioffe^ inùLtipLyto lom innr).oionl.s rtll onre' sp3!,rs
. Pl\\i.il {abitiz.ûon dùe t. r.rggr.gaiiot and ext.a(ellllrr Lr..omÉesôtnh(l bI.oalgregatn,n ('nh lioreÉI'
. !:rr.ellular p.lysa..hâri.lesheLpto nxbnne lrl]q".
. Fx.lusior .a,n\rdn,!. br.l.ri. (.oLûriAr.n rcsnLat..)
.'rhêrcl.ri\'.ti!ûrtnt,sof .lilfere,t\Frier ni th. .Limax.tnr
. Protc.tior agÙnsrh.st dÊien.Ês nùrirr' is rll(tral by.fri.onmcùLrl û.rotr, r,xrti.ll.rl! Jie.rrl
' Itetiboli. $rbilizlti.n (ni.1ob1ailr.De.i*is) dù. ro hlar.r.f
rlnerql{i. rnd.magonnri. inrenttnnx . Th. ùdoùfu of a. id r..dùl.ri!! ir fhqu. d.lcffr otr
. l,rrreâle.lmeuboli..lfi.lcr.f.he ù (o .Fûiivc cfle.a rhe ruilibllirt ot sùsr.lld ihc Lralan.el,edv.cnr.rilriy of
. Or':!l fn,FÊrti6.irhc b'ioilln a.e deternnùt by nre baLrn.e a. ptud!.ing Èt,l r.id ùÈtrlralizngblt.nr
ofù ririries of djIf.r.ûr s!e.iei fr.sÊnt

Stir j.)tcc|c{:lladh.s;ns
flâqric ilrr'ïrlatior Bc.aùse of drc d,urtnig ùrm|l.rirr 01 dre evcnrllll drqle
C!treft n,od.ls of {,lrlgiùgivâL |hqft ntrrndtion e.\.srsc a nricrofloh, indllidùrl ba.rcrixl sPe.ies.à. onLt be.oûe ùen,brfs
n(ce$i{,r of rare\. erch ol rhem i.volln,s a dlllèr.t raret of or'.1x, .omnuDrtr if tl,r-r a,t pJrtne^ in v,nre sPe.riic Lrinditr!
bacÉriâl spc.irs, but.ll nases bcirg characterized b-v a sct of inrc.r{rion rlirt Fre!..ts rhed lionr b(inA \wept r$ùt trr rhe
spe.i|. Inolcculâr inrera.tnins This n,i.ft)bid su..eslof . vhnh floN ol salil',. ft is probùbl. rhar dÉ nrrù('ofarl irr(rQlxl
is .onùof ro drr frtrmarnti of biotilms i. mlny sjt!ùrions Lrâùeriun, disinî-rs â n!rnb. olditlereût brnlli.E mole!ùles {irh
nr ndrlre. nul b! mmrtized rs lôlloû: in tl,e iùt,al s.i8c. diife.ng s1,ccii.i! and nrengdr ofbitdin.q, bnr s'r. âs vû, ha(
'pnmeer dûii€d inùrmatbt on onlr r iit! oitheses n,olc.ùlcs an.LLveit.
st,f.i.s ofbr.tefia doûize rhc tooth {tfx.e Lrr binlin:i
ro odponefs oÊ dr. sih.ary pe11ic1e.
Ptelo,.inânt mong thesc l.ritirulii t .on.rneA here widr $'har is known ol tlÉ \lr.ies
initi)l colorizcrsar belie!edtobeJ..û'r!?tr,5.,r/li,,r.!1.\,rtrn assûci)re,ls'irh denul.ùnes
6s 4 r[kr0bi0l00jr0l
Npêdsoforiesprwmrion
|
Thecoûiporens oibà.terià rh.t bind ro ie.epror molecul€s.re
cùlled adheslrs ar.t ore nàior fadily of âdlre\iN hrs beeû fouùd
!o be ç espread amoûgr rhe ofu1 strepto.ô..i. The fist. àûd
best c1i,uà.tersed, nenber oidris family rvasidenrified nrdeper
defrl_v b) ûvo reseàr.h groups $ôrking o! â.aries vx..ift nr die
mid 197(\. lt is a major âfrigei ofJ. a//rrr d,at is loù.{lboth
Lrounrt rc the.ell iâU pcptidoslr.xr
me.liûm. To the orisinâl nxme\ of I/II rnd anrlseû B, othef
r€se.Jcher strbseqnertly rdded the slnonlms Pâ.. SPxq SR f{,r
rlt J. /,rr,,r pntrci.. vhilc a iurthc. sct of namcs has bccn
applied n) thc cotrcstûiding froteins fion, orhe. sr.l)rococ.i. A
d i s t i n . r i v c t c à t u r c o f r h c I l I l t ) . o r e i n si s r l , e i r h i g h m o l . c ! l a r
s ' c i E h t ia n d s i n . c t h c . i o n i . g r n . l s e q u e n . i n so f a n n m b e r o f t h c i r
Ec.cs. ir h2s been po$,ble to rlentil!.omnon
tbei rft.rùc (FiA. .1.1a).All hâla â morif.hin.rcrisric
dtchore.l proteins in Grm-posirile ba.terir ar the C{emin$.
A comn,of lrùlure 01 drese froteins is dF tossesion ofstretches
oftândem âmino ncm rerens an.l all llll proteins have one Lrlocl.
ofilùine rich repe.ts àr.l ùorherofptuliùe
reglôrs often are as$.iâted wnh bindlng ând s€veral ftseâr.h
urônps hxve impli.ated dre xhninc-ri.h rïnnr i. bi.di.€ n) a
vlivxry glr.opntrein thât is rcsln).siblc toraAslùùnarlng rrcpù!
.o..i 0cnkinson and Dcmurl, l99l) Tbc imfort2ncc ol I'II i.
adhesnn ias ilrt dcmo.strarcd b-v sl,on'ing dràt a.tibo,lv .xiscd
tgaitr tl,e pûlfied prtreln .ould blo.l aû.hneûr
to sâlrva coùte(lhydroxl,rrJtite, è làboiàror! ûo.lel ofàdhesiof to
c o n f i . m c d i r s i n , l o f t a n c e i . r h i s s y s t e n ,b ù t l o $ o f l / I 1 w i s
not sùl1iciert to prelenr .ç. ,,r,,r becoûing es blshe.l iû
rh€ ûotrrlis of râs. Hôwever, deletnri oi the geûe resulte.l rû
a re.tuced leve1 ôf .âfies. Iuithermore, nùrdr\
sere deleted.re les xble rlrar the sild tr'Pe
I t L t , t=f+.l
!_iaure 1.1 S.bcmati. {Nrùrc of(r) {ùfr.c.rtigcr 1,11ùal
lb) slu.osrlrranstemr, dÉ rwo rn.jor .onlotrenrs ofl. ,rri,r
rsrin\t ùhni trote!rive 4efrs lrnvel)eenfu.gered
Kcy: S, SiAnal pcpridcsnrc vcll.o$cFd itul simlLaf ro those
' I l r r t r ' r I r 1 \ b . , . .
À, Àlar1.. ri.h rttâ6 'ilolrl ir binJirA sâln'tu]'ah.opfotcnl
q PrcLnrcri.h rcpcms:\V \\/â11ri.bor m.ril
V, Vâiablc rcg,on ôlehi.h rFF.ars ro bc ùr,qù. t. crch a;Tf bur
is oJ ùrkm$'n fùn.rion;(i, C.trLrti. donranrn highlt-.onscNcd
nnd simlLaf 1. â11(;TFr ts, tsnrlirA Jonrâir .sscnrâl for uLù.rr
bû]inA. Contans n ltlpLc rnndcm rcpciB oi.mnro a.rd seqùer.e.
tnhrles, anJ this has bccn attibnted to a redtr.e.t ibil,ly to
| . . . . . r , , t .t l d . \ , \ , , . . e
rlù,s trovides a m.io.al basis à. rhe deslgn of nrâregies tlul
,ni.qhr be eai,..rcd rc rcdtr.c. ifnor etrrnely rbolislr, .ùies .aù!d
bt .t. 7,,n7,r. ^nriseû LII \"a dre fi6t pure frotein ùse,l ^ m
ind t-rcc ir rhc.uldre erperimenral .dries va.ci.e in n,o.kcrs r.d sas dcù)nsL?td m
be effe.rne kee rùiof Crri.s Vâccinct. In anorhef linÉ oi âtdk
bde.t upoû.ompetrlion betwe.. ftcc idhcsin an.l \lhole bdÉri..
ir ha\ beer repôiie.l r1rit. slntheric pepli(le ùimicking. {red
ofJùst l9 amino a.i.ts.fLII..D block ù(i.hmefr of.l. ,,t n, t)
x sali!ùr asllurinin xn.l interfere N,th coloni,ario. by S. ,/r,,,
in volùnreers who hâd t1È peÈnle.pplied ro lheir te.rh (KÊllr
leaNres of
of{'âll
of 5.,rutons
Adherion
. Surfi.e lr.t.tu nrh rs rntigcn I/iI biirl ro sâlyâ'y
rich repeas.Itepe.t gry.ôFntre,rs.n ûotn sdflrcc
. Clùorylûân+lrise enztrn.s syrdrcslzesi.tr,v glu.xrs ilol
. Glu.â! bnrdn€ prorcnr !c!r.onsolnlrte plÈgle
. \ i . L t 1 o t - " i \ '
n , "
of.l. ,,t rJ
âdh{:sicn
SrJcrosr-Cîperr{ieit
While anr fi.nicnrablc .arbohrdratt mây LJeutili2€d bt pLùquc
bJcienà ro geûerùle lhe ùci& whi(b arra.k €nmrel strbnùnft.
su.nrcjs recognized ùs being 1ra,ticula.ll i.rgûant ,r rLrt ùns
with rhe pn,.es LJe.a6e lot onl! caf ,. bc t.nncnrcd. bùt t als) seNd6
tô nr'âde deftiûr1 x strbsrâte for extr!.ellÙlar en2,vmcsof flâqù. ba.rerlx, vLi.l'
syûrhesi\e n,.nN .lerived po1!ùe6. These ltly.rcs arc ot €t
ûâl iûport.ûce ,n a.lhesive inrcri.rions in rnxqùe, *lÉre dkl
n,e,l,ate arachmcnr ol bactcfia o the tootl, surfa.e ài(l ro .dtr
bx.terla. lhns tl,e! stàbilise rhe fLùlùe biolilm. sc11c.\ ens!!
rofts âi.llry tlie sur!,val ol tlùque ba.rcfir, ,nd modùlat tht
permerbility ofphque url hetr.e lhe lelrl ol icid ar dre en16el
suilàcc. Thc c.zlmes .âtâlr'znrg formation ol polrn,ds imm
su..os., tâ(i.ùlarlr the llurosr ltrâùsferùes (GTIrl mùl.ing s t!
solublc inl innnùble ghcans. as ÙelL rs rlie gLùcù. binding
prorei.s (GBP), halc rhtrs aftra.rÉ.1.ûnsideràble lrterest d I'orc'.
till rargers ôr i.hibitnlr ofthe pn).e$es rvhi.h..! lead to ùric5
Glu.o\-rltfxnsÈfxses afe exù..e111,1èren7!n,es trôdù.cd bl
sererâl spe.ies of orJ stretroco.., dur syndrcsizt, liom suctot,
poll,nets .of sisri.g solcly ofSh.osc (Alù.nn\). Sûepro....alGTf
Jre càpable o1 srndrcsizing cidrcf o-i.6- or (} 1,1 llnkags
betNÉen the glu.ose ùfuls. rn(l d,c ..latnt pr)ytrrn)ns ot dtr
û!o li*ages and tlÉ degÉe o1brafching ,lcrc..ri.cs drc ultimût
pr4:enies of rLreglLrcar. À glùcan, vhid, is c$cnriallr â linar
o-1.6-liiLked dÀ!, n relerred ro as a tl.xr.r. and 1ss'âter-\olrblr
Ghr ùivi,l mme .Lextrxnm.rase $ olien atflierl ùr GTI $hth
prrture .texûdù iri .onûàst, rnûr. rs r s',rctrinRnublc gluai

Riti à high p.opoftbn ôf ct l,l lj.kaaes. Bôth types of glu.ans
àrebelieved!o be inrportant in dentalplaqùe, with.lexttan medi-
ding bacterial2AAreSationù.1seNing âsa rôrâge Polymer, s hile
nùtd has been shovn tô be rhe matot co.tributor to adherence
In.ddition !o this fùn.tion ofprodùcinA glllcân, GTI at thc sû-
fdeolbacteria, or âdsorbedto dre tooth stfâce, èct to bind ba.te
'.. J. 'F .^ol.l.tef,9r'.C.I 'hu o, tib ', inr'. 'e,y
ofvai's tô pla,tùe fo.nraiion and the.lenlal caLiesprôces atd dre.e
is do{ astrbstàûtial body ofexperimeftal eviden.e tô sùPPo.r thetr
imfortan.e d virùleoc€ detehinânts (Colby and Rù\sell1997).
Vhile mosr ôf the species of sùeptococci tôund ln plèque
p.oduceGTI. attettio! has bec. 6.u\ed ôt those co.sidered to
be most closely âsôciated vith dentâl cùies, vhich belong to the
nntaos sroup (r-. zrt,j, S. j,r/t/i). Blochemical s.udlcs ofGTF
rre grcadr complicated by ihc taci d1e eàcb sFecics produces a
rumber ofdiff€rerr GTI: but the fitdi.g ihat G]'l genes could
be do.ed and expre$ed in E. .,/t .cpreseûte.t a major advaûce, às
it becan,etro$ible to study each ofdre GT! in isolalioû. It is now
kùo{D lhat.t. a,td,r Froduces threc distin.t GTI whilc S r,rt
"'r prodrces foui Each GTI A encoded bI a separâtegene and
a.h enzyme hd distioctive properties, ltryiû8 rû rhe proPoft,ot
ofû-1,6-ando l,l linkâges an.l hence the dcaree of brândrina it
i.rrcdù.És into rhe slucâ., and the totâ] lensth ôf the slucan
chair prcduced. Litd€ is yct kûo$n àbout dre re8ùlntiôû 01 the
propôftiors ofthe differcnt GTI in a single spe.ies, blt drctr
dùtive dciivitl determites dre evettùa.l prôpertles oi rhe slu.ât
prcduced.\Xrithin dental plaquc. the sitùètion will he varly mor€
complex b€.àuse ûe overall propefties of the Alucaû rePresetîs
tle conbincd a.tiôn ôfè.tozen or mo.e different GTI and àlso
of drn inreract;ons. sin.e one GTI may moc{ify the product of
ânother !_urthermo.e, gln.eN çill he modified by drc â.tbn
of dexrànase. whi.h is produced by vaLtns placlue bactcr;a and
shi.h d€gradesthe o- L.6Jinke.t chans.
Às nucleoride seqùences of GTF became tvàihble, n was
p$iblc io .drr ou. muhiple alignmens ofthe dcdù.ed diûo
a.id sequencesin ordcr b identify conseffcd and ùniqle leâûrcs
vhi.h may erylair whi.h âmino acid rcsidues or domâins de
Ésporsible fàr common âctions of all GTF Gu.h ds sucfose
hydrclysis) ùd s'hicb determine .listinc!;\'c a.tiviries Guch as
q'l)e o{linkÈge or chain tcrminâtion). The bâsi. orgadzèrio! ot
GTI could be.tisc€rned as û,n as more than one sequence
becameavailable; but the gcne sequencesol over a dozen srepro
cocc2l G:f4 nn.l seleral lnm L&n,tolIû n4e,îeqid6, ate now
âvailabletô us and dris has.ofltirded the earlief model forabasic
.ommon oraânization fo. all GTL All G:fF arc of hish molc.ùld
veigh! and .ompôsed of dislinct domains, illustr2tcd in ligure
.1.lLr.Iderrifi.âtion ofilie reacriot me.hadsm ànd locariôn ôfthe
rtlle site ;s essential for the Elional drsign of GTF i.hibitors
ûar mimic the susa. rb$ràte and for iargetiûs anlibodies
agâiûstthe catalytic rcaiôn.
The terminâl one{hnd of GTI consisis ofa series of rclated
bùt non-i.{eDljcal randem anito acid tcpears. e.ch about ll
amino âcnls long In ar ledt some GTF', this dodart contnLrùtes
oso biolilm
0enhlploque
tu drest'ndiesis ofthe glucân .hâi! .t.l i t aPpeds to be imPortàtt
id bindnB GT! to prefotmcd o. ûdc€nt glucan, thùs mediatiûg
bâ.reria bacteriaor bacteria surfaceadhesion The mutars $ep
ù)coc.i âtso p.oduce À nxmber o{ôûer glucan-bindiog ft.xeins
besidesGTF. Thc fùn tio.s of rheseFroteins a.e nor yet erùrelv
.1eàr but ir seens prolrabic thât they conûlbtrte in somc wèv to
rhe \tickines' oldental plàqd€ ârd so Provide fu1ther Potenr'al
.role.ùlù targe.s fd inhibilio..
of dentalplâque
Metabolism
On.e the bacrerix have nanaged to become established in dental
plaqùe, they contfibùte to lhe olerallbèlance beReenthe sPccies
- f ' l p r o d e ' T ' F . , FD l ' a ! p , ô p e û , " ' l l r e P _ oo ' i '
of cenral imponance in the .rehbolisn of plaque not only
be..6e they are wtl1 equipped tô survive in the fluctuâtins
.ordilions. bui also becaùscrhey fâciliraie the siNn'al ofother
sri.rly anderobic spe.ies. The \'ârnrùs sPecies ot $eptococcr
differ bôth in dreif âbility to ge.cmte a.i.l fiom dletdy catbohl'-
dr2tc and in rhelr acid tôleraoc€. À conseqùeoceofthis is that he-
quenr cxporue to carbohydrate md the.ô.sequent iall in PH, !o
values vhich dày go as low d pH '1.0 in .drôus levo.s, serveto
eùich lhc popùlètioû ol a.iduri. sPeciesand Pârtlculafly of ûe
mutdns strepn,.ôcci. The produ.tion ofacids by ferDentatiôû of
dietàry carbohydmres has lona been recogûized i{ à .enûal tle
ment ofthc caies proces, but its lmPoran.e in.letermining the
micrcbial composition ofPlâqùe has been.PPreciated only ln rhe
ftcenr yeùs. SF.ifi. à.lhesn'einterâctions ate the ûàjor detefmi_
nanB in selecting which bâct€rià caû establish a toehold in
a
flaque, bùt, oncc âny pafticula. bacteriaLslecies hàs become
menrber of the plaque micioblÀl conrmunity, ils sul1ivâ1dePends
largell ùpôn its met2boli. versalility. lrithit Plaque. it has been
€sinrated thàr ùe alu.ose coicentratn,n mày vary over è 10000-
fold r2rtje. rhe ptsI may shift from 7.t n) 4 0 ànd, vhile orygeo is
freely avnilàble ar dre placlue su.fa.e, cot.lilions are ertlrely
anaerôbic close to the tooth surfa.e. As fècukarive aûerobes, rhe
streptoco..i are vell suired ro floùrishina under ilrl'ing .otdi
!io.s of or.]gen aldlâhility. Y/lth reAad to âcnl, different Plaque
specicsdlffer it the ta.Ae ofPtsl drar.hel.at tolerateS rrl/rtù is
noteble ;n conbitir1g drc properti€s of being extremell âcido
genic and also diduric. As a .ônseqlence, whet thete is a good
supply ol c26ohrdrate,.t. ?r/r,,J ùill Prodù.€ a Làrseamount of
acid (nainh lâ.tic {id) tha. wi111owerthe }rlâgtrePH. J. Æ,t ,r
.onrinues to metabolize und$ the low fH .onditions while
ôther comperiûg species ârc dlsad!Èttaged, with ùe ner .en'lt
that rhc relative prolonnrns ofJ. 4rt,2' inthePlaquc Populatton
increase. This phenomenon has been demonsûated both by
uslng chemostàis in the làborarory and by moni&tr1n9 the Plaqùe
compoiitiot involunÈeA ot a sugaFrich.liet l.eqùett exPosure
to lèrmcntable carbohydrates thus has the effect of reperitivelv
enrichiog ihe proporion ofJ. /rrld,r in plaqûe This. ofcoù6e,
r one of the reasons for the adlice again$ frequent snacking.
Longiludinâl $ùdi€s of plague mic.oblolôgy have shosn drar
the probability of carics o..nrrlng ât a particùl2r ûûh sile
 I
70 | 4 Mkrcbiolosk0l olorierpreention
0spods
I
rises dhmarically oDce .t. nrlan' re clles t0% of rhe ba.terial
pôpùlation-! healthy, ctuiesfre€ sires S. urrrrJ mày be present
àt a level below 0.1% (lôesche 1986). In the èbsen.e of a
.àriôgen;c dietary chàllenge, muraos srreptococci âre hafmle$
commensals in balance with odre. plaqùe bècteria and rhe
host defen.es. The mon stràightforyard {ay ro àvoid a diru!
bârce in.his baiance. vhich may lead ro disease, is drerefore
Preve'nting
infection
Idenri4iins rhe courseof infect;o. is lhe first step in conrrol or
in{ectiousdlseaseèrd â11de.lisrs are fully fâmiliar wlth rhe
conccptsof cros-infe.tion conrrol jn rheir c1inl.s. s'here dr€y
$e.ilise contminàted insÛumentsand use physi.al barie4 in
the form of gloves aDd mâsks to prcvent ffaNmissio!. Since
s'e now have rhe eridence rhat ào urinfecred infanr acquires
.t. rzre iioù their mothef or orher cùer, shai can we do to
reducerhe risk of inJèction?The best ve .an bope for is disin
fècrionof the lrurce. i.e. redùcinsthe 1€velof the bacreriaiû the
nother soa3roreduce,asfùâspôssible,dre.isk ofcrossinfecrnn
That dris approæhis praûi.able wd firs! demônstraredby
reanûA expecran!mothe^ b reducc rhù cùriège oft z,r,r bI
inte$ive proiessional orathygien.",in.ludinA chlorhexidiretreaG
mert, èrd givins dietary âdvicedudng preAnanctand afler ûe
bifh of lhe chil.l. A .edu.tio! in rhe salivàrylevelsof mutâ.s
sùeptococcicoùld be demonsrraredin rhe môrhers and rhis
dramaticaltyreducedthe llkelihood of rheii babiesbeconing
colorized with .t. 7,!rda, so rh.t most did not become infectecL
durins the usMl w;odow ofifectiviry' buÛeoained ùDinf."cted
unril they were ar leâs '1 or t yeds old. More importartln
this resulted ln a reduftion in thelr subseq!€ntcariesètrack
r . ê ' K ô h . , , r J q , r e - . ,. o r , . t , . t o . , r , ' ; t - , , , .
have been demôn$ated in a number of subseqùc.t srudies.
ln microbiotoAicalreims, the results cân be explàinedby the
ftct thàt the denraLplaqùe niùoflo.a thâr becameestÈblished
in the edlr yea6 of ljfe di.l ûôt in.lude cârioseoicspecies;dd
the phe.omeûonofcô]ônizationrcsislaDce makesir in.reasinAly
d f r i t l ' b . . r o . r r F i , , i o . m u r . , . . r F po . o . ' i o . . r r
at a lâre. d!te. Ofcôtrse. ir remai$ esentiàlfor tbe.nlld to
mai.tair soodoral hygieneând dierùyhabits to ivoid conditiolis
tha! woul.t fàvour invâsioû by S. natdîs, hm ae'lns n
Sood srà.r in life by redù.iûA dre risk of infectlon by paying
ètteftio to dre ùorher .aû pay .ich divider.ls (Tholild
Replacement
therapy
Àû €:tensionof the dremeof esrablishinga bencvoler!plaqùe
Ficroflora had led us to an alternàrlve âpproâch ro caries
control thâr is rlll in lhe erlerimental stâgebur has atrrècted
considerable pùblic;ty.Id€ally,we mighr like rc haveno iûfection
wlrh S. nfias\ but, if se cannôt r.bieve rhar, caD we ar
t u n d e rr h " b r e , i \ à , r 1 , . \'.,'i18 :on L\epemr'e
urdesilaLrle speciesin p1âqne pe.form pafticular tuncliors,
approachdependsupôn consûuûi.g good' vdi.ûts of
speci€s,
whlch ùe benign in th€ir ln0uenceard will displèce
ûohâl srdrs from .lentèl plaqùe. Inte.esr ;n rhis area
focused upon the constructioD of mutàrts .{ S. "irîà"' t^.ki
làctàtecLehydrcgeûase,since lack of rhis ûucià1 en,yne
that they produ.elesslâcricacid aûd are,iherefore,lesslikely
prôûore dental ca.ies.Hjllmm ?r u/. (2000) hâvecardedour
seriesol Aenetic maDipulatioûs ro knôck our the lactale d
genasege.e, a! the sde time irûôducing a acre iiom
bacerium encodinsalcoholdehydrogenase
in orde. ro
the otherwisetoxic effectsôfN D-NADH imbalarce.lr
ùr Alve dris outaDt r competitive advdraAe in colo.izina
they a.lsoinùodu.ed dr€ genes for productior ofÀ bæt€rio.ltr
;nhibjrory pepti.le) thar hd a vide sFcctrum of activity agâi
other plaqxe bacteriè. The 60 basic prem;ses of ths
have a iim experimental bâsis.d lacrale dehydroseftse
areles.diôgeni. in ratsand lhereis sùpportfôr the côloûizari
àbility ôf ba.rerlocint.odùciDg strains from ôbserationsi
h,ûâns and moûkcls.
Replâ.ementdrerapyexperimentsùe nôt resÛlctedto
cLehydmAenasemulaûts. Orher researchers have rried a
differenr app.oa.h. inùoduciûs a aere fôr produ.tior ôf
eûzlme ùreaseinto t ,zt?rr. so rhat ir cân generateatkali
. 1 , , : l / - . J d ù r ' l i , ô 1 : ' p r " q u ,R. ' ! o g n ' , , n 8
imponaoce oi suùose derived glucans in plaque cohesi
Japaneseresearchersintroduced aenes {or a dextranæe
ard for an enzyûe that makes cycloisomaltotig
(idribrors of cTF) lnro the plâquebacreriùmS. salr/,,r,
A nuber ôftheserepla.enent srra.esi€shavebeentesd
ànimàl ûodels, aûd rhcrewe.e .eporrsin 2002 rhÀt researh
replacement rhehpy with the lact2re dehydrogemse mutmt
slortly .o move to experimenB with human volunteers. ^s
triâ1sôf odrer anri-cariesageDs.suchtriâls âre likely to bei
tially ir âdults. l'h€ N..ess ofthe sûregycoù1d be monitored
foliowing rhe abiliry or rhe ouranr sffain to become
in plaqùe â.d by measuringthe câpÀ.ity of plaque f.on
rolùnteers to produceacid wheû expôsèdtô sugars.Only
.an lnrcstisâtiors with a caries-prônegrorp (1.e.childrer) be
ùndertake.. The mah areèsof uncertaintyin the replacemenr
therapyapproâchrelate to the ùrpredicrableecolosicalconr
gu€n.eof rhe release ofa geneti.àllyhôdified olgarbnb, ae u
mâny ways the guerions âre dre saùe ù rhoserelaring to dy cM
o.sarisms will rhe mùtant be stableard will ir €:chanseDNÂ
widr the Dormàtmi.rofloraTHow w;ll rhe overallbalanceottbe
bacterièl populâtion be afÈcted? \Irhlle everycarecM be râkenû
the côn$u.rion oi rhe mulaûr, i. À impô$ible tô pftdi.i rhe
dsweB i., rhesequestionsat the ùoment. Fitulln n À ne.€$ary
to re.ôgnizethe widespre2dpublic ùneæedbout cM prodùcts,
sô even a product wirh màny poreûtiâl advanrasesmisht

lnhibitionof mutânsstrentococci
Curcnr means of prevenring plaque-relàted dental diseâsesarc
krgely .on s])ec;fic. rclyioA ùpon mechaûi.èl removal of denlal
tlaque or upor thc usc of aûtlba.teria.l àgens ôr detergentswhich
rt on a ranae of bacteria {Russe11199'i). Althoush 'n some
iNtdrces the prevertlve efl'ect may be duc .o a diÉè.entia.l âctiôt
ulor pârticula. oraanisms. sucb selectn'lty has ùsuâlly onlJ' been
recosnizeda/tr aû asenr hâs cmplricall)' been fôûd to be eftica
, o , . A n - r , r p l e. l e r e , l , z o- , 1 " , n - d ' . ,poo.
shôwexceptlônâlse$itivity tocl orhexidine and tha.t.nlowing d
.ôùse ofûearment, they mày take seveFl months ro re.orer tô
r ' , 1 e ' e . u l . " r e -o \ r y .n o n r o g e ' i t(!ii,i 4e
nù.h vrner. Iven non+pe.ific aûti plaque ageots can rhus trave
a bÈnefi.ial tffe.r in desrâbilising the plaque microflo.a $ thar
nùtdns sûeptococci, poor colon'zes ar tLre best oi times, ùe
rduced ro sù.h a le!Él thÀt they do tot readily rise to â
sdfkientlt hiah proportion ôf rhe p1àqre popùlation to pose
Chl0111 exi d in e
Chlorhex ine is the nos! efrective aûtiha.trlal agent that hd
lour.l ùide èpplicdrion io dentjstry, larricul2fly in ihe ùertûett
ofgingivitis dd às m âdjunci to periodontàl tLrcrâpy.Oral rns
iûg or topicèl apFiicltion of chlo.hc.idine .auses a rtpi.l droF in
rlr viabiliry ofplaque ba.teria, and ns effect or mù.ans sretto'
, l-* b r s, .-d ed. N il"r
beredu.Èd ro underectàble levek, yet will sr&lually.e.uh ù) the
olisiûl levels over a pefiod ofseveràL nôûths, with the occlusal
snrfæesofnoLar teelh (rhe most.afieçprône siB) beins th€ first
'',.,lr'
' t p " , i ' , 1 , , . ' 1 " o o , , , n , o , . buffering by salivaw l ptevc.t plaque PH remainingâr a 1o1v
ÀlplicatioD ofchlorhexid;ne wolld be ne.essaJl tô àchieve lons
rerm suppresion, unles chlodrexidnre treatntdi is being used às
À short term 'neâsu.e to rcdù.e mother-.hild t
being.ombùed vith some odrer ûeâtme!!. Chlorhc{idine
vùnishes hàre the potentlal !o h2ve a lonS{erm eflè.t, dd there
h.ve bee! mixed reports of theû cfica.y iû reducing salivary
lelels of mùtans streplococcj. Only a ièw paptn bave described
Ésearh rhat loôked both at the mnrobiological mafker ard at dre
etrecron ca.ies, ànd àgùn mixed resùlls hale been obtained. It
seemsùâr this !ùiùle experienceis due to praciicaL diffi.ulties
inachierlna add haintaining àdequate covenge oi reeù with rhÈ
vamish. The conccpt has bèen demonsÛeted to be vàlid. but
lxperimenlcl to tonholS.nutont
opprocches
lnhibilion
ofmLrrofs
treprorc(ri
rranslâringreleârchresuhsinto â n)bst procedlre thar can b€
applied in praûi.e ûirh good rcliability is ProrinA dlffi.ult
(Io,aie d,l. 2000).
Xylitol
'fhe và1ùe non
of sùAar sveeteûe^ in caries prelenûon 1s
addre$edin Chaptr 10. Xylitol s'âslntroduce.lù a oon-\ùgar
sweetcneron rhe bæis ol the fact rhar it û tot Detabolizedby
baclcrlasu.h asJ. ,zrrrr. Tlris o. its .wn is cl€adyadvantageôus,
bùt an addedbooù\ is thât xylitol hasan antlbàfterialettècr'This
is becèùsethe xyl;tol dôlecule, a sraaf alcohol,is stmctùralll
sinil.r to f.uctosc. It ls thùs ûànspored by the Phostho-
Ûdsferase srsremsrespônsiblefor uprakc of frtrctôse,md is
phosphorylatedas it crossesthe menbrâne. However, in the
abserceofenzymcse, take it further along metabolicPèdrways.
xylitol phospharea.cùtulares iûside the bactetium vhere it
exertsâ toric ellect. Somewill be .lephospl,orylated in â fùtlle
.y.le thàt is a drai. on eûergyàûd theretoreslowsErôwth.T|e
overall effe.t is a sel€ctiveanrlbâ.terlÀ]efièct o. ba.teriÈthat
can cmnsportry1lto1but not utilize it (Tdzer r99t). The efect
on mu.ansst.eptôcôccihs beet bestdo.ùdeûted, riroush other
rlaque bactcda (pà.ti.ùlârly s.repro.ô..i rûd lactobacilli) are
èlso subject to dr Éffect.Resuiar conNmption of xyLilol has
been demonsrraiedto result nr â rcduction of numbers o{
S. aatar. and alsohare a cariesprotc.rive effect(Sodedingdzl
u , o M o . o t' t p . , d . l , ' \ , d F \ . e l ) . o r " , , . L n i É , _
, . I v , , ! B ' T - ' , 1 " T , - ' r o \ . . e ' o .' d ' r ' , , d o ' t u 'i '
irg sorbrtolis ius! d etfe.tive,rÀisnrgthe questbn âsiô whethcr
rhc benÈfiscone ftom the suE'r substltuteor |fom thÈbeneficial
efièc$ of sriûulâtms salivary no$. Of co!6€, rhe in.reâsed
valuc and so in.lirecrly is likely tô result lo a.edù.tiôt in
numbers of J. ,/,r,ri by stopp;.4 selectlvecoodirions f.ôm
Elochingof adhesion
Considerùleresearch hâsbeen.driedoùton idendrylns àdhesiN
on rhe sufà.esofpla,tue bâc|erirât.l chùac!€.izi.g the receptor
noleculcsb$hi.h they bind. TheserecePtuBmay eithcr be host
macromolc.ulesadsorbe.lto lhe tooth sùrfde in salivaryPelli.ie
or componcntsofthe surfaces of othef bafteria.Charactc.izatlôn
of dre bindirs feàctioû opensup possibiLitiesfor inte.fering
rvith the blnding eirhd by the use of nnùble aûàLogùes of the
receptor or by Ûeàting with exccrs ftee âdhesin.Thc.c ha
beenone prelimi.ary repon of usitg d exce$ 01 a re.ePùr to
b1o.k èttàchment:,'1.rju,,/r'ùrttpe 2 fimbriac re.ôgniz€salivary
dolecùlesconraini.s P-llnked G.lNAc and it hasbeenrepo.ted
rhâr,in volunteerswho had .insedtheir nolths vith GâlNdpl
lcâlcrl-O-ethy1, there ws a rcdù.tiôt iû the lotal nmber of
,1rrlraz1ærasre1l c a redu(ion in totâl plÈqueDa$. Labôrâtory
srudieshaveâ1sôshowDdiepo$ibility of the alte.nâtivcapproâch
of using an exces of adhesin,and a shôrt peptde ol 20 anino
.l.,,. , l r r l r ' o r h "L I l r ' g o ' o i \ . 2 , . " r . i . e r
72 | 4 Mkrob (01
ojoq prwmlion
sperh0iories
I

LII has been tcstcd in experlme!ts where lt Fds xtiplicd ba.teriè aDd hosr .cs )nse mrnitùre.l in caùillbrnd? On tht
to the leeth of volunrccrs (Keur rr //. 1999). Th€ lrlcls ot orher hèrd, .herc is no$ strbst.ntial evidcn.t thât d sroigll
S. nttdû htd l,rcliously beeû fÉdtr.ed to ùndelecrablc lclel\ enLrdn.ed resp.sc itrdtr.ed br nnn,unizâtn)n or b\ Pa$L*
bl chlorhex ûe treai,nenr,a.d dre topi.al âppli..tiot ol pefridc appli.âtion 01 antibodl .an itfluet.e d,eit âbilitl ù .oLotize
Nd repeakd elcry othcf day tàr 2 *eeks. All cont.ol subic.rs ard/or càusediseàsc(Kosa ri,l. 2002).
becrmc rc(noDized to the origiùàl leleL oler thc ncxt J to l{sei(h irn, a dertal .arres M..i.r hâs beet càrie! oùt,û
i nonrhs but of rhe four tcsr bjc.6 $ho ft.eile.l the mirr latorârories aroù.,] dic suld in the lùst drûtl yeùs d
peptide. o!ll, one became rrcolonizcd wirhin tlle tiùe perio.l. moLe. rnd tLrere is co.ri..iûs e"iden.e rhat ir is posiblÊ o
Lnder these experimetrtdl con,Jitio.s, whi.h lveie simiLat !o âchicve a high level ofl).orc.rn)tr agàiûst cdries in capefiûflnd
thosc used o rest pà$ive aFpLication of a.rihodl (ste below) a.imils b]' the use ol laccincs \4ri.h reLy u!,on 'ntlù
it 2p])ca$ rhar there ûay be r cr,rclal $rge âr vhi.h interleretce -t ,,rr7,I is immunôuet. ln .ommon s'idr the ùetd i. rhc detl
$irh rhc atta.hmenr ofJ. /rr,rr to recetroE cân hav€ a lotg otment of othcr hnm.ù laccines, .onslderalrle effon has bctr
rcrm bcncficial effe.t in.le.reasing ns rbilitl k, be.ode elpended on dcinirg dre proteclivc (ompontt6 oI.l. /trr,''.i0
establishcd âs a najor plx.lue ôrg. sm. Thete clcarLy rcmrins the erpecrâtn r drât a pùrified e,butit vacclne *outrl ,n,luc r
mù.h tu be.Lone in resol"in.q nrcb rste.s as rhc ber t(trmnlâtion mof..onsisteût imtute restonsc. ând woùld be les likcll ùt
ôf the petrnle for easydclivcry ù dre tuoth site aù.1the fre,tuet.-t whole bn.reria ro caùsc aDr adre6e snle reicti.ns. Àlthoush i
oÊ ,tflicarbn needed for a strstètie.l etlect. Ncrcrthele\s, range of cellùilf.omPonets hdvc bccn inve$ig.te(1,n6t
the .csulrs .cinfof.e the vallcLny of an âpfroâdi diar âinN to progres hâs bcen made rvlth GTF pLqraratbns ènd .ell wdl
rop.t. ,rra,r gxininE a ftothôld, râth€r than attempting r, proreins. There is good evideDce that a GTf-ba\ed !.ccrne o0
re.tuie èlreadt hisb lelels. pntre.r iâs ngaiist .a.ics .a$ed br' J. trlirrj. $'idr mo$ ofth.
pnrc.ilve efie.ts being limited tô sûooth m.aâcc lcsx'r.0t
hiibitio ol' specillc.nz,vnrereactions snnrh surf!.es, G'flr .icdiated glLrcat fotmation is likelr to be
of majd inpoitdDce IoLddhcsion ofl vrfnl,r. çhich.,n exPLdr
Uslns metalJôli. inhibirors du! blod. faûi.ùlaf rex.tiôN unntùe
ùc uccess of .iTF v:ccincs in .his e:te.mc.tâL m!d!r'
tu d,e rarget speciesis, in theorl, a tmmLsrn! approê.h to tn e.â!-1
Hose!ei, expe.imcnB h ihi.L mà.rqùe mo.kcvs were rnnù
Althoùgb a .umbcr of spc.ifi. fm.tiols h oràL br.te.ia .rn be
.i7e.l wirh GTf Èom.t ,,rrlr shos'cd ûo ptute.tne eatèct. lt i\
f.ofoscd xs poten.iâl tdgets for inhibi106. atc2tc{ attention hàs dre ût
rl,us nc.cs\rry tô eiàùn,e .itciilll-t dte relelan.e of
bccn pâid r., the sh.osylûanslèrases (GTI). Benrfi.ial effefts 'l
animal models to liunan ,liscisc. he rât hès toolh mo.fhnùgl
night hc erpected frcm either prerercing dre ftrûâtiôD 01
Jn.l a t,dffeff ofd€.ar differeût liom drc hMut àtd s not tàtu-
g l L r c a n so r , l i g c s r i n g r h e m o n . e f o i n e d . K n o w n i n h i b i n r s o f
râ11y.oloni,€d by t. ,,,rzrr. Iû monLeys. as in ludâùs. dt mrifl
CTI' llclùle sûu.rural malogùes ôf mcrose Nhich .omfctc f(tr
poins ol aiiack xrc itr ô.cl$al fts!.es ând inte|Proxinal sltc5,
ûe àclive sire ând 2.c likeLy rc be relatively specific fôt cnzymes
ùith S. ,r//a,J bcina rhe prin.lpdl ofgtrnism as..iâre.i {i!lr di5'
$hich hile slcrose ,s a substnte. Ekmples oINch comfctiri'e
eâse progressionr f(tc.tn,n agèirrt snooth *uface acack (
iûhibitoB are 6 âmino dcrila.l'es ofru.rose, a.arbose. 6 dc.at-
therelore of rclati"el-r little imtorti..c. Ftrfthermor, iYnt
suùosc, dcoxynoilrimy.in, ând ribo.iÛn,. Odrcr agcnts $hidi
crficsva..itre experiùenrs usirs n.s hare eûPlo!e,l.t fl,rrd
have been shôwr tô inbibir GT! ir.llldc ûatuâl prod!cts ù(b as
rl,e.hêlleûge orgrnisnr; and it mu$ be remcmbcfed dktJ. rrl
polyphenols tà!n,l in rca..o.oa, or fnits, dd a nlmbe. ofsmâll
kr is .onmonl]' i-oùnd in les t1i!n o.e third ot the Luûùn Fot'
m o l € c l l e s i i c h i n g Z n r n r n r , l r i s , p l r i . L i û e .a I u a r i L , r rl,. s a L \ .
nlûjon and is conùibùtiôn to .iries in hunrads is unda,
Àmorgr the wide ranse of subsrancestt*ed. none lu yet bccn
Nlonkey erperim€ls n,x) offcf a nnft suLtable.lisc,sc nn)del btr
identlfied thât .ù be reganl€d âs bcinéi bodr a poteDt inhibilot
2rd hiahlr spe.ifi. for GTE :rhese a.c fupefties tltat are desir
able ifa subrâûce is to supfre$ GTF sùffl.lentlr atd to hale 2
benctlcial effe.i çhi1e haliûg to a.lvese sidc cftc.s bl inhibiting Denlol(oriesvo(dfle
. Ra6, mi.e, rnd honL.r,s hrve beer prtelted agùinsr cùies hr
imduniz.rioo virh ninnÊ baltèria ôr Fdrc ptoteins deri\ed fsn
Caries
vaccines
Àntibodies û the orùl streptococci .ân bc detected û salira liom . Nô adrff eltds ofinn niz.tion have been rèp.ited
an c2rll 2ae. dn)rgh tLIepJttern ol responscto diftirent attigeù . Diti.ùLrles remain over the itÛôdù.tior oia.linl.rl ûiùl ol ùn
sl,o\5 Arcar rariablli.!: Despite n!metous studlcs. Lrowever,to intcdable.ar,es ra('ne
convincinE eviden.e has emeig€d that !l,is immunc ftsponse.oû . ReseÈr.h has den.nsrarcd ùe feasibility .aalternrti!. allroadB
trols rhc dclclofing ni.roflorr. Ths reùalns onc of the greàt ùsnrg recomblnr.t vù..nrùs. orallt adminbÉied vrùin6, or p6!\t
fùzles. ùtr Ju{ fù the oral .wit} bùt lbr othct tcflnantndr
<nonized mù.osal sites hoN is the bâlâncc bctieen.omdeûsal
 wdnes ?3
corres
I

presentcorsiderabletLohlems in terms of husbandrr'ân l cost and the resuLt s'ar a resrrsencc in itcidence o{ diseèse ir
sirh .onseqùentially small exFerimental groups. Therefore,
alrhotrghit may be,lcs;rable to rest èny proposedvâ.cine ot Seriousconsidcntion wâsglver,arcund l9St, ro the iniiatio.
nod-hùdânprimâtes,ruts âre 1lkely tô be more convenientfor of tfiaLs in hùma.s of vaccinesùrilisinA .t. ,/rrr wall-dsoclâted
pieliminaJy experlm€.s so lona ascutiot is exercnedin exùÈP pLoteins in dre UK and other counÛles. Some quesn,ûs aboùt
oLarlorofresults.o humans. rhe exten! of dre availàble experimentâl da!â fcmlined r. be
àNwered, but dre overtidin8 concern wàs rclnte.l to the Place
Bâfiier\ to introductirrnol a caric. raccirre ofa carlesld.ire in natbnal rdcine poli.ies. This,.ogerhc. with
a pe(eptiot û.t olhcf anticàries 'nedùres were a'iequare, va
The fi6r p.omising resù]ts widr cafie\ vâccine trials 1n nôn-
a decisive fa.tor in the dcciliôt tot to Prc.eed with resea..h
hùnmp.;maÉs s'ere obrâined it rhe lt70s. Twô wail a$ociated
leadins to rrials ôf ù lnjeclable m.cite at lhat time The decision
proteirs ot'S. urr,ur were tested as vaccires. one, referred ro as
âltered lerccptnrns of what !,.t of caries vaccine night be
A ' g q . A " " a c n r i _ r e f- : r | ?1'.-J";.È io qd.
à.ieprable, hut the fèct renrains rhat exPerjmenral elidetce shows
fported ro protect both rats ùd mookeys â8aln$ .âriFs ân(l was
that d immunologic.l apptoach tô .dies co.t.ol is vâlid, and
theDtèkeû through.he subsequeût$âg€s ofresriûg fôr toxici!-v in
re pri.citlc of immule inrcn'ention to conûol caxes rematns
aniû"ls and hùmar âdu1rvolunteers. The other, the major suda.e
biahly attrnctive. Reseâr.h has .onlnrucd along a numbcr ol
- h . i r 1 1 ô \ n . { ' _ ' F p ,I l l . J ' o 'fq' ro. | ", | ,i'' or
lines to fird ihc ber ântiget and dre be$ way of indtr.itg an
nonkeys. Desfirc promising test results, nelther protein bas
.dvancedto the sâge of hûânclinnal tdals ând lt mÈy be ùseful
ù consider some of the .easons.QuesioDs can alway\ be raised
Novelantigens
rbour the vàli.tity ofanimal daû(es. toothstr!cture in nrs,smèll
sizcof e{perimetrral groups ofmonkeys, ecologlcaLconscquences Tmditn,nally,the wallsofcrm posir;vcba.teriàIDv€bee. .epre-
lor otherplague bacterla), bur pfoposals to introduce a novel vâc se.red d beins f"tly simple in stnrclu.e (.omPâredto the wa.llsof
disede also iûùldu.e à whole ratac oi eth-
r r ' n - . g d '\ e nr ' hcr ' rr".1to'. r ae
cineag2i$t a hûd
icâl .nd politi.ô e.oromic i$ues that extend fât berond nos beiry re.ôgdzed and tht recen dereminatiot of the entire
laboratoryfiû,]iûgs. These apply toany tovel vàccine but demànd gcnome sequenceofj. zzrarr hs provid€d neN âveouestor er?lo
pdrtlcuLa.ly close atentiot whet the ProPosâl s to vacc,nate rarion.Thereis no dorbt lhar turùer kûosledgeofùe suifaces of
plaque bacteriaÙill presentnew Potenliâl .arges for lmmune
€anr! câr;es.Principàl mona lhesc is dre questlon of.isk ben-
eii becausc,fof n nôûlife threat€nins disease$hich is r€sa.ded as ageû.s.There is â]so increaslngemphdis on defining sPecific
â miûor (aDd avoidable) âffti.tion in medical terms, no adve6e drigenic efitope! sithit eachanrigeû,md of definitg the type
reaftioff ca! be lolemtcd. Pdticulù concern has been ràised with ofinmùne response rhÈtûey would induce.
regardto sreptococcal va..ines, becàrse ol rhc kûosn phenome
non ôf dtigenic cro${ea.tion benveet $reptococ.âl protelns and
Novel immlrnizationstrutegies
\.."i-'-.\,,e\.'. *-,_r r.nb"req I r.,, r o . " i^ Àn àlternative to an injectable va..ine is one vhich n adminis
an.theaft tssue has beeû dtsùibe.l, the.aûre otthephetomenon tered orally, {'nh rhe àdded âttE rion ûtt srimulation of the aut
' J 1 , , , " ' r ô . h ' ! t . ^ l , " 1 ' n n ! e ' ' , r u m mucosal imûune reTonse may also bc manifested ln drc oral
flerely exphiied a.d. though it ûow alpearc that no hèzàrd mu.osâ, giving ân id.rede.l lerel of r.retory lg aûtlbodt in the
exis6, it is difficul! to allay all fe.6. oral cavity. An inûaûdàl .outc of immùtlzation lras a.lsobeen
Ir shôuld be noted that ihe inÛôdùctiorl ol-,4 norÉ1và.cne is explore.t n 6ice and recerdt humans. Stratesies being iNestl
lhught wlth difficultles, .or lcast becanseof cotce.n that dûr si'aôonedi o,o ' \,nBo_o- \ e r . r e L o ' li n l ' n '
mishaps(ofntwspàper scares.oties).an hale a d$as.ous ere.t on LesponseinclLrdethe 1ilsn n ôf antise.s to.hô1erè toxnr B sùbuni,
s.hemes thc in.orpômtioo ofantigens into Ljposomes d.l the clo.ing dd
tlblic artitudes èt.l pailicipation in immùlizâiiot
evenfor uorelated but well establishcd va..ines srch as rhose for ex!.ession ofmtiseûs in alirulent Salzaral/a An undersanding
pûtu$is. polnr. ùd diphtheria. :fhe saf€ry requlreoents for à ' r o rp o r \ ' P ô e v ' J ' i E r '
vaccine isainst à.lisease that is ûot life tlùealenirg mùst be has led a nùmber of resed.h groups to ut fnsion ProÈiûs thèt
vdrr $rirsent, nor jùst becaùseof dre .isL benefit equàtion fôr are constructed of frèsnents of Gfl iûcor|oratins the active
protectio! against caries, but because of concerns that fubli. sre and/or glucèt bfidirg dodain togethef with the bjoding
' F So ' o l d , , d ' , l l l . , . t d 'o.q 'Jt.l D,i-ri'ee'Do^
confideûce in nrasvvaccitation camfa;:ins .ôn1.t be damâ8cd
The lulnerabilny of such .ampàlgns to advc$e publlcrty has âg.irst two majôr èntis€.s. On.e àn immunosen hâs been
been vividly lllusrared by rhe erperience with whooPita selecre.t,the srases of research inlolve first, the denônstrètion
.oùgh vâccine in the 1980s and. môre receody. meâsles,mnmPs, of the induction of d immuoe resporse, ùen an effect on
rubel1à(MMR) \'accine. In both cdes pùblic .t. ,rr,rr, and Ênally àû lnfluence on the.tev€loPment of.aries
paiti.ùlar vâccire hd â kro.k{n effec! o. up.ake ôf other A nunber ol laboran,ries àroùDd rhe wôr1d, PrinciPauy in the
vaccides. As a co.sequcn.ei many children wcût ùnProtected USA drd Jàpar, are iûroh'ed i. .his work anrl have .ePôfted
 4 tttri(r0bi0losnol
0sp€rBof(0rksp'eventior
n'cces rn expcrim€ntswirh rats or m;ce.À na,or châlleûseis to
.lelelôp immunizarionregiûes thar lea,lro a e6tèine.lhigh level
ofartibody sccrerion.
Passiveiffmùnization
 differentappoâch !o thàr ofindù.inA an immùDerespo$ebt
racc'n2tionis to âpply rcady fo.me.l ùribôdies rcpi.ally. tkjng
nùDoclonaldriibodies di.ectcd aAaûsi Artigen I/II, Mâ cr ,1.
(1998) havereporte.tthat rhey havebeenàb1etu.odr.ol reim
plantation ofs. zrtz,r on cleanedtooth surfacesi. moDkeys hctor. And n, wÉ comefull ci.cle back!o van LeeuwemoeK
and in hûd rolunreers.À{ono.1ôna1 a.ribodies are, however
extremelt expensivero prodûcear presenr;so aireflratile cheâp
sourcesof ântibodyfor tasjve immunlzâtionhaveb€er sotrght.
The rolk ôf egss irom imnuni,ed hc.s coolains subsraftiâl . Dental câries is a Lrac.erlatdise6e, môdlfied bI enliron-
amourts ôf immunoglolrùlir; atrd two Amùps of wo.kes hàve
reportedd,ar artibody l-.omdr's source,*hen in.orpo Lco,rLod . Maoy
sù.rôse-.onrainina dier, re.iucesthe lffel ofcarjesin ratsinfecr€d
with J. ,zt?r'. Anorherreadysoùr.eof anribodvis coroMum rtne
fir$ ûilk yictd alter bifth) ftom immxnizedcors, ând rhls allr
hasp.oved promising in i?r cxperimen$.In rials wirh hum2n
roluntees, ùsirg r bovnreanribodymouth{inse, howevef.dr€re
ùas no elf€cton rhe toûl nuobers ofs. ,zrra bur a shifr io rhe
type of S. n,\d/t.\ a.cùtted, with a smâl|.ôlony type replacjDs a
rype wlth large .olonies.This hlghlights a porenriâl dimculty
with troceduresbaed on specificantibodies,whl.h Day be ,rt
spe.ifi.. Ifâ varidDtofj. ,/rrrr, wlich hæ dillererr epiropesliom
thèr orisinally ued to rèisethe ârtibody is presert ir rhe ôral
carity, then h Fill evadelmmùro1ôAicalclea.ance.Ir ls rhrs
essenrialrhar ro be effectire.d1epro.ectiveèûtibodieshust be
dlre.tcd agaifftartigens wbich showro variètiônandâreunivc!
sallyconse^edthroùghoùtall lhe mrge ofs ,,r/,r rypess'h;ch . Thc application of 'nod€rn molecdèr biôlogy techniqd
dre naruraLLy presert ln rhc ppulatjon. from anôrhefpoinr of
view.vhen sele.ringan.l. zrrarr antigend a targcr tor pre\Én
rive st.are8ies,the possiblli.y of cro$ reâctiônswirh other orâl
sreptôco..i mus be bômr in mind, ar inhibirion of hdrmles
IJeciescould be.oùnrcr prodlcrive.
Microbiological
prediction
of caries
The d;scu$ionrelèresnj mcrhodsro preventcàries.Ifwe.ânror
pievcnt the .lisede, can we âr leasrpredlct the risk ôf irs oc.ur
.enceard uke stepsto hinimise rhe impàcr ôn identified h;ah-
risl<irdjvidMls? In i9lt, it vas fisr reportedthar bv mcâsu.ing
ihc numbersof mrtans *.cptococci jn sè1i!àit was posslblcro I o r g i e , . { . H . , P a r e K ) n ,M . , P l n c , C . M . , P i r t s , N . 8 . , a n d
ideniily high ûsk indivi.tuals.The results'ndicaleddut over 106
colony-fôrmingmirs per ml of sdlivawas a strong pr€dicrorof
risk ofsùbsequeDt caries.l:_oràny predicrivete{ ro hc ol Fracrlcal
!è1ùe,itisesscnriaL!o kno\r irs sensirivlryândsp€cificiry, rhe pro
poitn)n ol ùue an.t false pôsltirc ând negatile resu6, âno Hillndo, J.D., Broohs,T.4., Michalek, S , Harmoo, C.C.,
vhetber;t hasgereralàppli.abillry ro â raûgeofdlfferentpopulâ-
tion grcùps.:fhecoDseNus now ls rhâr.excepri! youngchil.lren,
di.rob;ological testson.heif own do nor hèvesuffi.ient .eliabll-
iiy to pick oùt high-risk indi\-iduâls for r pôpulation groùp
(Powcll 1998).Microbiolosicaldatâc.n, hôwevef.be valuble
oole compl€x risk dsessûent schemes rvbere odrer lnli
such aspdr caûes experlence,s.livâry properties, and dierar
iacto.€d in. The conmerciâl .Llairside tèsrs desisrco Lu ru,
murâns $.eptococci frôm sâlivd also have a ùse ln parienr eduo-
rn)n ârd morilarion, as well às provi.iins an ôbjeftlve way
modtorirg .omplian.e wi.h dicrary advice.V/hile soûe ol
nay be.tetishtedby beingshown.hatwc hâLbou.aLl lhesesems
in oùr mouths,the revùlsiônôfothersca. bc 2 s.oûs norivari
Conclusions
hentâ.Ifa..os sucl, âs die. aûd condliions ir the ûoùrI
of dre preventive $âtegies alreâdy availâble ro
dc.tisris'ork becNse they i lûence the bacteriâl.hâ.llenge
ro rhe susceptibl€ tooth sùrfâce. Iôr elanplÈ, fissùft
...a "br.. r.rin;rur .rimr
eJ. '(. mrk- | b..
lates sati!è flow aod atrÈ.rs pH levels ;. pl2que. chlorhexi
.l.,ed,,ruo', rFbdd, . bd\,. 'hi.,! J .|e,F.
. l{esearch lnro the ûi.robbloay of ca.ics has show. rhat
J. /,ru,r js the majù. bur.ot dre onlv, speciesdsociared
. Uûdcniandi.S of the àcqùisiion ofJ. artTrr h6 provided
the oppôrdnity b preve.t o. delày i.irial infectioD while
oùr kûo"ledge of the e.rironmcrral condilions thar favoùr
in.reâse in J. nxld$ 1t1 pldgne can be èpplied in pètieùt
ro thc sûdy oi S. ,rt rr hæ preserte.l à ràlge of novel
approaches!o prelentlon ofdental cùies.
Referen
ces
Cduii€ld, P.\f/., Curter, RJ., and Daânayake, A.P (i991)
I.irial æqusition of mùtàrs sÛepto.oc.l by lnf.ntt
evidence for à dis.rete whdaw of in{ecri\ity .larndl af
De,tdl Rtûdr.h,72, 37Jt.
Colby, s.M. and Russell,R.R.B. (1997). Susar me.ùolisû
by mûans srpto.o..i. /,trdl af Atu!iedtlimbiokst,SS,
80s-88S.
Nuje.t, JJ. (2000). A rdrdomised.ônùolled Ùial of ùe
. d r ' : f , . , | \ ! , f l . ' ) o r ' , l l o . . e "1, , , eo n G n . -
rdnish i. h;ah-car;elrisL^,Ldes.ents. Cdtt! Rdkt,h,34,
132!!.)t).
Snoep,J.L., an.t vd.ter Yreijden, c.C. (2000).
Corsructlon and chèr.cterizàrionof ân effe.etr sÛainof
Stteptaùûu ûrld/ {ot rcplacedent rheiapy ofdenral ca.ies.
Isk.tion d"l tnn,hitl, 68, t4a-149.
I
Jenkinson. H.F. and Dcmuth, D.R.(199j)- Stru.ture,Â,n.rion
and immuroacnicit).oi sftcprococcal anrigcnI/II po\"ep-
ti.les.ltù.alàr Mnar U!, 23, r8l-190.
K c l l y ,C G . Y o u n s o nJ. . S . , H ; k m a r . B . Y . b d r y k , S . N L .
Czis.h.M., Haris, PL. Fllndâll, LR., Newby, C., Mallet,
À.L, 1,{a,J.K.C,a Lehrer, l1 (1999).Asyftheti. peptide
adhesionepitope as a.ovel antiûicrob'rl âgent N"t,,r,
Bjak.hnalaS!, 17, 4241 .
Kleinberg,l.(2002).A mixe,l$acterialecologicalâfproaclrrc
under$ardnrsùe role of the onl bâcterjain denralcàries
.ârsètlor: an àltermtive to Sl/epla.aùa tta^ rnrt rne
spe.ifi. plùltre hypôrhesis. Ct1li.dl Rditur i, Otdl Biolog
anl ùI ititt, 13,IOA l2t.
Koga,T., Ohô, T, Shimazàki.Y, ÀûcLNèkàno, Y (2002).
Immunizètiorèg.nBt deDtùIcnties-Vdîlre, 20. 2027 2I)41
Kohlef. B. ard Andfccn, L (r99.i). f.ilùcn.e oi.ariev
prerentivemean,resin ûotheB or cùiogeDi. b.cteriaàrd
carieserperier.e ir their childten. tu.hir5 rf Otzl Biùlost,
19.907-91r.
rosche, \XrJ. (1986). Rolc ot .t//d1t.,..1\ nnta$ tn btrnàn
denût ae.^y.Mifubiotas Rùie!.50, )5J-18o.
M.. J.K C.. Hikmat. B.Y. \(/ycoff. K., Vine. N.D.,
Charg€l€gue, D., Yu, L., Hein, À{.8 , andrch.$,'r'. (1998).
Charucteriationof a recombinâ.tj)lânt monoclonal se.reofy
artibody ùd preveitive in,munodreqT in hmrd. Àr.rrr
Mk/i.;ke,4,601 6a6.
rvlùsh,PD. (199.1).llticrobialecology of denta.lplagueân l its
signifi.ânce in health .nd disease./\Caà"at in DLnîdl
R a t u t . b , 8 , 2 6 ] 2 7t .
Powetl,L.V (1998).Ca.icspredictôn:a reviewôfthe lirerèture.
An"utnir- Dnt^îry arà ot'/ Efllaùalûg!, 26, aa(ti l | .
Russell.R.R B. (199.1).Corrrol of sp€cilc flâque ba.te.iâ.
AàrdnLr!ii Dù|tdl Rtudrh, a,2at 29O.
Sodcflina.E., I$k.qtd, P, PienihèLkirer, K., T€lovuo, J.,
ând Àlancn. P (2001). Influeûce of maternal xylilol
co.sumfrion on mo.her-.hild ùàûsmission oI mlta.s
s.reftococci:6-yeaff(nlow-ùp. Cdù! Ilad$, 3i, 11) l/1.
Tan,er,J.Nl. (1995). Xrllrol ches'lns gùû ard .lert.] .àries.
Inkndri'ndl DoûdlJl,nn/, 45 (Suppi.1), 6t 76.
Thorild, L, Lindau Jonson. ts., ând Twctmân. S. (2002)
Prevdlenceof sal;vary .tt"l,/,.,a?J r,,trur it ûorhers ènd in
dreir freschool .lril.lren. t,tonaîj|,dl Jotrtul af Paedidtti.
D e r 1 r t r y , 1 2 , 2L
vân Rnylen nO., I-ins$.om P., va. Houte J.. and Kenr R.
(2000).Rel.tiooshipamongmutanssrrcptococ.i."low-pH
bâcteriâ,ù.1 iodophiljc tolysaccha.idcl&dù.lna ba.reri.
in dertâl ptaqre an.l ear\' emmelca.iesi. humâns./,n,z/
of Dtntal R4e.t4,79,778 781.
lVlanaging
cariesin enamel
E d w i nKai d da n dJ u n eN u n n
lntroduction-what
is caries?
It is iml)oûn! to unde6tù.1 whtt cariesls, b f(nlos' rhe lo8i. of
its suggesed nrânaAcme.t. Dental câries is â Fro.es whi.h mry
takeflace on arl tooth nda.e in rhe oml .avirt s'hcrc â m icrobial
bioulm (deataLplaqùe) is â1lo* ed tô develop ovef â pcfod ofrimc.
Ionatjor of the biofilm is â naùal physidoAlcal procc$ Gcc
Cheprer.l).lr is important ro rcmcmbe. rbar ù€ ltrionln is not à
tr.pheùd colle.tnrn ofm;cLo oisanisûs, bur a comûuity wrh è
collecrivephysnnoay,which can soh'erh€ specllicphysico chemi.al
problemspôs€d by rhc cnvironmerr ar the site. The bafteda lr the
biôÂlm xft âlways metàbolically ætlve, cèusing minure flù.tu-
tions in pH. Ihese mâI câusca n{ loss oiûineral fron the tooth
$hqr ùepH is drôpping. Ihis is.âlled dcmlncmlizatio.. Àkei,ra
tivell'. rhc.e may be a oet gàin ofmiûerâl whed the pH is in.reas
ing. This ;s callcd .emnleûllzation. The cumulati"e result ôf rhese
de-and Eninerullzation pmcessesnày be â ftt lds ofminerâl and
a carioùslesion thèt cd be seÉn.Akernatn'eh, rhc changcsnray hc
soslisht thât a.â.iôus lesrn nser be.omesapparcnt (lis. t.l).
From this .lesûiptiôn ir be.omes oblions thar rhc ca.ious
procss ls d ubigùirous. nâtùral p.occ$. The formarion of rhe
Iigù.e t.1 The ùppe. anteflor teeth ofa yoùl1sùlÙft. In drc ùppcr
pi.tue,, dis.losins asenr kveals dre plaqùe,*hll€ in the rovel
picrue, the plàque h6 beenremov€d.\X/hlr€ spor lesiotrstuc lisible
oi the.anlnes,bui nor on orhef roodr sufâ.6, âlthôùsh plaqùc n
bioillm and its metaboli. a.rillty .annot be prevented, but
diseâsctfoare$ion ca. bc corùolled so that a clinl.ally v]sible
cûamel lcsion ûcler loms.
Logi.ally, mù.rgement .lepends on àppre.iating thà! tl,e de
2nd remineralization procc$cs .ar bc moditicd. For inrm.e, if
drc biofilnr is fariauy o..otalh rcmoved. mineral lo$ may be
stopFd or ever revesed towards mincnlgain.
Iactors which inlluence the masMrde of rh€ r,H ilucruarions
ère also lerr impoftant dd many ofihese can b€ nûuenced. For
inrance, the compositior ânt thickre$ ofdr€ oic.obial deposits,
the dier, the flnoride iôr corceûtrètior, and ùe salivary secretioD
rare. These biôlogicàl f.ctos cd ir rrn be l hence.l by various
sociologi.al pardetes such às a p€son! behav,our, attiru.les,
drcir k.o$tcdgc ard bclicli and rhei. afnùen.e or povdry.
Ine caflou5process
an0 Tnecanous
lesion
Carnrs l€sbns can form on oy rôoth surtuce expose.l ro the
mouth; rhùs rirey .an fdm on rndel, .eûertrm, or denûre.
Tbis .|aprer will .on.e.n rhe enamellesbn; but the reader shotrld
appre.ide rhd the prir.iples ôf mrùgemeni of the process are
rhe saùe, itrespective of dre ioorh tôsuc invol\îd
I. ir pe.haps unfortunate that rhe wor.l .diet is use.l ù
detute bodr the .afbû pio.ess thât o..urs ir rhe bioÊlm ù the
tooù orcavitysurfaceand thr.arnNs leslon thâr foid\ * nL1iûthe
loodr !;$!e a a .esult of the !.occ$. :lhc .afious lesbn .an be
lhousht oa d a r€necrion of the cârious frocc$. Thc mctaboli.
dcriviry jo rhe biotln, (rheprocc$) carnor bc sccnrir is dre refle.-
tior, orconseqùence,ol thisprocess rha! lhe dentis..an see.Thus
ûe dertist is workina ora retleclio. ofreility ând ihô may cause
confusion d to whcLc ihc a.tion'is. Pleâseraûd in froni ofthe
miûoi ând look at rôur refle.tion. Do you like shàr yoù see?Il'
yôu do not whÈt might lor do? Maybe yoù colld set some .ew
clothes, lôse sone weisht, cha.ge yoùr hairstyle, or eveo see a
plâstic su.8eon. Y(r are, ôf.ôùBe, seûsibly .on.ertiàtiùg on the
real Ioù a.d lt piobably soùld not oc.û , yôu to pick up a bri.k
and smasb rhe mif(tr] Now plede !ô inro ihe.linic. All rhe clen-
risrs who aft fiUlnE hôles in teèrh de, in â sàn smdhing the
m;roLr unlc$ drcl bare,l', coûcenù?t€d oû ta.ting rhe pâtient
fu.oûùn rhe netaboli. a.iivity in the biofilm.
eo I s llonooino
mriesin
enomel
t " -

You ù,ght also lik. r0

Theconceptof activity
Tlrus fâr dÈ ..iiôùs pro.css hrs beer pieseDtedrs !r lbùt{tiloùs,
larùal pheûomeûo! ar dre cryra1 level. The pro.es s spread
ovef rime bùt lt does nor have tu prôgres. Lesiôtrs..t àr! stàge ol
dieir Jctivirr, .û be rGsted Lr) ûnpro!edlila(l!e.onrroL, se.siblc
dictâry d,inacs. r.l Jùdi.iors $c of Uùrfidc. \rhilc exâminifl!
p.ticnrs, yoù ma_rdet.r enxnrel.afnù lesnrnsard it is posible tô
gt â lery Aood idea ofdreif depth ofpen{tuttut iito ilÉ tnsues.
Hos cv( r. it is tust xs i,.fo,tânr to dc(idc shcrhd rhcseL\ions are
a.tive ind l,.ogre$ing or alrca.ly aff.stcd. This jùdScmcnt i\
esef!iùl for logi.al n,rfrgen,e.r becà!s. activc Isions rcquiLc
,. ,i,€- ,1t.-' .. '..t.'o,J.,.
' l l , , . \ "
' , , 1 . r r l - - r F ' o ' . l o ' . . . , 1 ' . )
Lo n,al.e like rlling bLàd( fion, {'hiÉ. Lr.fàtrunarcl}'. rhn is nor
rhc.iscr bc.aùsc, sc xrc dcalhs {'lth a.onrinùum of.hMges and
rhe shrdes ofgrey dre llso relevùt. Thus !n ùctire leson mr)' bc
rùpxlll, or slo$lr progre$ing ând farts ol â leson n,i) b. a.rivc
while other.rers .ie Jrreste.l.
(orieso(tivity
regùive diagnosis in tcrms of krtmert.
cons er dre sùme r..ârio t1om the poi ôiliew ofdæ,le.rir,
rJdier r1iâr the ttrti..t. This is a pal1l.uld1! rholght lrorokiig
exer.ne. where oDe de.ision rcaps more rervard. fiùncirllt', dmr
âlother. I{àybe this ev.. jicltain\ n) yotrr sudent clnri. whcÉ,
Frhaps, foifs rfc isided tu rerôiâti!e ûetrtn,ens, but ded'6
âfc ror siven tu preventile care. \i'e liE.c$ 'ro cth1.\
k ls Lftûft dràt derrisrs scc txricnrs on re.dl.:fhus, a.lû&
noriL decisiôù.rn be É .'aluitcl on a$bseqftnt o..dion 5m(
qid, di. .ii.2gcnenr.l rbe
fxricnrs x.e n) inrimâtely con.erned
.a.ious tro.c$, they mur .eit.iil! be dorn,el ot dic dia8.osili
rna should t2lti.Date ln dls.u$ion 01 ù€ùûne.t otrions. iler
dll, thc tccth bclonS n' d,e pâtieft, but the .esl]ofsibilirr' .t rhe
prolèsio.rl is ro 8ivc adli.c basedo! t1t besi ettlence.
Cariesriskassessment
The trelious scctions concenrated on n ividual esiors, bur
th$e lelons are.lusr..cd i. individMls lt is importat! to ùt{
dn irdni.luJl pètrerti Ns.el,ribiliry rc.arnns lesnri foûuio!
aid phlres\ior Thrs n ar imirofta.r far .t .oûedtûlr!

. Th...ries pio..$ mar orùal

not bc progr.$iv.
. J.{sionsùrf b. r.li!.
. lesl.ns my be arerÊd bt,l,er. oraLhtgirne, md N- oanknd.s
Ine va 0lrv an0 re a0IIry or
diagnosticdecisions
Ifthùs atpeas rhar (liagfosiic de.isions ârc madc i. .orditn,ns oi
!n.ertainl! V/ilL rhe denlisr rlwa_vsb. cotrc(Î in drc diaAnoslsol
the presence01 r les,on and its aclivjryf \rrc .o{ conic h a verr
impoitàût ponr rbout diagùosis iL should aLwr-r'sbc.onsidcfcd
if tern,s ofi$ vilidirr ind icli2biliry: Vàlidit-v meâns\ahether dre
di.snosls fttle.rs rhe ûue.ondnion. Reli! LJilny.on.ei,, s $4,fl her
the result \'ôuld be repro.lù.lble €id,er br rh. sani. rcnùr..
diferenr o.cùslon or Lryâ (lil'lè.en!,le.tist
It is roù âppropriâre to.oos er rhe.o$eq!e.ce of cr.o.s of
diaEno\is ofr..ivitr Sùpposex denrisr jùdges.n ertnel lesion ro
bc a.rivc when t is in fa.r airere.L. The ùnsequencesol the enol
.ll b | .ll -" . - \ , , o , o i- r . ,
i.carmcnr 2nd dris $'xs nor rcqùiftd. Sùppo\inA, ot dÈotherhàûd,
d,cdc.ri{ jL Acsalcsn)n ro bc inadive, rnd .lôesnot nstitutefre
veflrive ûeârnenr, \rher h 1&t tLe lesior is J.rive. Now rh. t,ro
Sre$io. ofrlt lsion is Lrkeh ro .ô.tinuc ù..hc.kcd. The flr{ of
lher ls'o ei106 is c,llc.l a tàhc fositn'c, thc sc.ond â tr.lseleijative.
lÊroù were rhe F.ienr. bcâri.g i. nind lmc erors ùiLI aLwâls
be ûrde. wlii.h eiror would you prelèr to be rrearcdunncccssar-
i1! or nôr be reftd when rction ùas re.tùi.&l? Please.o.sidcr dris
frôm tLrepoint ofliew ofàû enrrnel carlols Leson r.,l d,cn ,kcf
)ôur peBpe.rive so rlut lreùrmeni tus imtLies son,. i(rcffiblc
x.rbn e.s nntrh exûx.tlon or a fi11ûg Your pe6t,ecrive mighr
.hânge dependhg ôù tft .orse(luef.s of lùGe Fsitirc ,nd làlsc
ffx.ti.e fù the folloNing r€ùsons:
. 1r makes e.o!.mrc seûseto rarger l)rcvc.ùvc ltdmÈùs d
drc appnrpriâte rÀk grouf
. deDtrl care.eirh{ b.Eins noL ends with r single coraeoi
.cânrcnt, bùr is otrlonrg. \Vheû..o!6e of.lcttâl ùcrtnenr
is..mdere. dre denrnt atrd rh€l,atienr Jc(idcwhcn it $or d
bc *ise r, check dut a1l s rvell This tccâll i.È1aal is bded
' ' \ ' i r ' " ! e i n
. pdrients sh.ùld be mrde rware of ùeir .sl. srtrrùr. 'lhn
l..owl.lgc cn.oùr,êes tiLed tô keeF rpprof.inrc .Édl
.tpoinrmcnrs ind b be.ome irt!olle.lnr thet own ftr\tn'
iire car r.,1, ifdrcl |xy àr thi\, mây helF th€,n bulgû i,tr
a Lù âssessn'rertof caics fisk
I'actors r_É:ievanl
The tæro.srclcm.t n) .ariesrisk .re outhnedif T2Lrlc
5.1md
rll.
dncusedsuLrr,tuef
Social historl
I{ân! $u.lies hale slrown rhat dcntxl.aries is nô$ .oû€rt.rcdn
srixlly depri'e.l peofler an(l o.lrr d iscisc\,su.h assôft .ùre4 ,,d
.ofotuy xfter) drede, rre si.ri larll .on.enùated. The loLLoNiûs ù
tLres oflhe socialhisio$ mir xlv, bepÉrùt ni high risitftn(
' Cxrles in silrlnrgs mi] be hi.sh
. ihe pârient po$e$es lirrlc looslcdgc ofdent.rl dnea*.
. Dcrdl aftrndan.e is ûregùl.r an,l dcntâl 2sfimrn)n\ lN.
. l'hc prri€nas use ôi!i..Ls s hi.sh.
llcdi.allr ()mptudise.L èûd disable.l|..tlc mxl be xt à hfr
fi\k oi â!.1 frod .àries LJse6 of lona rcm rnedi.nrs d ba
TÀble5.1 lactos relevânrro càriesrisk
HICH RISK
rov krcwL.dgc ol<le.!al aise6e
Rsd) 1!,,tsb,t,q,É.n,LLs
xerôstomia.Patjentsvith rhcùmarôidàrthritis may also have
Sjôgrels syndron€, which aftècB the sâlivùy atd Lac.imal
LOW RISK glânds, leàdng to a d.y nrourh and dry eyes.Inrâ]Iy, many
nedicderts, sùchasantjdefre$ants,antipsychôtics, trmqùiLr?
eB, dtihyperteûsives,and diureri.s, .nuse.lry moùth. V/hen a
practitior€r is i. doubt as nr whether à pàtienr! medicâtionn
likely b .a$e À drr mouth, a forûulâry drar notess,.h compli
Deni,lly rvàre
.arbns should be consù]ted.One tuûber srôùp of pàtientswho
nay haver dry môùth is rha! with eatinadlsôrdeB.Hyposaliva
w r k d l A n u ri t u r r s u l , r \ n ( L s
rion, combinedwith dietarychæs,cancausedentalprcbleûs.
The medicalhistory ôneôf the fâctorsio a cariesrisk assess-
men! lhat câr chanAe.À vigilànt denral prac!:tionef ideauy
detecs tlr;s chânseand lnforms the pètient ap!.opr;2telybefôre
too much dù,aae is done.

x;;*;i; Pkqae cqnttol

Ldg terû .ùiogen,. heili.inè
No lloride s,ppleùens
Inarquetrt inetre.tive.le.n,ng
H,gh S. mùiins md Lîtoba.iLLus
Ant.rior .ûies or reno.rùors
Hiso.y of 'rlate.l re*ogdors
N.l.ng{erm meil,.anon Dental plaqueis dre nrostimpoitmi risk fâctorfor dentalc2ries.
becaùse cariesis dre rcsùlt of metabôlicdtivities in this bioillm.
ù.t unle$ jt is prescnt,cariesdôesnor ôccùr,resardless of any
orher fàctors. All palients $'ith poo. plaque conÛol do nor
inerltnbly developcaries,but oral hygie.e wirh a flùoridetoodr
pasteis the bedrockof cùies control in all patients.Il for ùy
Flùornt.suFFt.n.û6 usea rasod, oral hygieûebecomesdiilicult, perhapsbecause ôf hàûdi
FlùoriJe oôrhpâ*e ùsed
cap.a8e,or lllness..dies risk iûcreùes.Thus,patic.$ who.lean
rhei. reerh infrequeûrlydrd inefectively or hare poor hanuèl
conrol may be at high risk. The ability to.leat the molth effec
rÈquent eale.tive.leaùiù! lively may also.hângewith tiûe.Iâmily d€ntisrsand hyaienists
areio â. idealposiriônro detectthis charse.
Dietary babits
Hish susariotal.ecanbc a carlesrisk fâ.tôr Âs ùith all fèclors,i!
is rot po$ible !o stateu.equivo.a.uyrhat àll pàtientsqho havea
rnN S dtrtùs ùd ldtobdillds
high Ngâr intake developde.ral decny,md somedent$ts nter
pret this âsnegalingthe valueofdlerary analysisând àdvice.k is
ùDusual.howevcr,to find a patienr with mùltiple actrvecàûous
Iesbnswho do€snor havea high sùgarnnake.Dictary habirs.d
alsochèrge\aith !ine, pâ.ricularlywlth llferyle chàtge,sùchas
Nô exùrtioff aor .arics stèrtlng work, re!iremenr,and bereavedentiÈgèit, â lisildt!
prdritiorer idedly noticessuchchanaes.
Useoffluoridc
Re$..âti.os iosefted lan ago
flùride cLelàysthe progr€$io. oi dental cafies;rhùs parients
who dô not usea flùorde conlainjna toodrpdte may be àt risk.
Numebus studieshâve shown warer nuoridâtion n benefi.ial
in .a.ies prevertior, particularly in arcasot deprilarlon (see

problem, if rhe nedi.lnes dè sugdsbâsed. Todày, màny sùgùs
ftee medicinesare avâil2ble,bu. denristsshould always.he.k
ihe suaare co.rent of âny medicât;o.s rheif fatiedB hkt
Perhapstbe most releva.t factof ir a mcdical hlstor_vis a
dry nouth. Palieotsvho havehad rudiorherapyi. rhc .esbn of
d,e salivaryalaods for â heâdand ne.k maliAnan.y ffer from
Salitn
ùtâry featu.esofsalivaaffcc|the risk ofdevelopinAcaries.Xeros
tomiàhd è]reèdybeendiscu$edd âprcdrsposing facto. Nnmer
oùs reseàrchstù.Ueshavealso suagesreddrat salivarycoùns of
mùtans$reptococciard Laclobacilliarc predicitrs ôf cariesrisk.
This hnge volùûe ot work appeaGrc showthar l{)w .ôuns ôften
predidlôw iisk well ond irdividual pâ.ient basn.bùÙhe ôppô-
site is not necesùily !rue.
so | 5 llonooino
mriesin
enomel
t " -

You ù,ght also lik. r0

Theconceptof activity
Tlrus fâr dÈ ..iiôùs pro.css hrs beer pieseDtedrs !r lbùt{tiloùs,
larùal pheûomeûo! ar dre cryra1 level. The pro.es s spread
ovef rime bùt lt does nor have tu prôgres. Lesiôtrs..t àr! stàge ol
dieir Jctivirr, .û be rGsted Lr) ûnpro!edlila(l!e.onrroL, se.siblc
dictâry d,inacs. r.l Jùdi.iors $c of Uùrfidc. \rhilc exâminifl!
p.ticnrs, yoù ma_rdet.r enxnrel.afnù lesnrnsard it is posible tô
gt â lery Aood idea ofdreif depth ofpen{tuttut iito ilÉ tnsues.
Hos cv( r. it is tust xs i,.fo,tânr to dc(idc shcrhd rhcseL\ions are
a.tive ind l,.ogre$ing or alrca.ly aff.stcd. This jùdScmcnt i\
esef!iùl for logi.al n,rfrgen,e.r becà!s. activc Isions rcquiLc
,. ,i,€- ,1t.-' .. '..t.'o,J.,.
' l l , , . \ "
' , , 1 . r r l - - r F ' o ' . l o ' . . . , 1 ' . )
Lo n,al.e like rlling bLàd( fion, {'hiÉ. Lr.fàtrunarcl}'. rhn is nor
rhc.iscr bc.aùsc, sc xrc dcalhs {'lth a.onrinùum of.hMges and
rhe shrdes ofgrey dre llso relevùt. Thus !n ùctire leson mr)' bc
rùpxlll, or slo$lr progre$ing ând farts ol â leson n,i) b. a.rivc
while other.rers .ie Jrreste.l.
(orieso(tivity
regùive diagnosis in tcrms of krtmert.
cons er dre sùme r..ârio t1om the poi ôiliew ofdæ,le.rir,
rJdier r1iâr the ttrti..t. This is a pal1l.uld1! rholght lrorokiig
exer.ne. where oDe de.ision rcaps more rervard. fiùncirllt', dmr
âlother. I{àybe this ev.. jicltain\ n) yotrr sudent clnri. whcÉ,
Frhaps, foifs rfc isided tu rerôiâti!e ûetrtn,ens, but ded'6
âfc ror siven tu preventile care. \i'e liE.c$ 'ro cth1.\
k ls Lftûft dràt derrisrs scc txricnrs on re.dl.:fhus, a.lû&
noriL decisiôù.rn be É .'aluitcl on a$bseqftnt o..dion 5m(
qid, di. .ii.2gcnenr.l rbe
fxricnrs x.e n) inrimâtely con.erned
.a.ious tro.c$, they mur .eit.iil! be dorn,el ot dic dia8.osili
rna should t2lti.Date ln dls.u$ion 01 ù€ùûne.t otrions. iler
dll, thc tccth bclonS n' d,e pâtieft, but the .esl]ofsibilirr' .t rhe
prolèsio.rl is ro 8ivc adli.c basedo! t1t besi ettlence.
Cariesriskassessment
The trelious scctions concenrated on n ividual esiors, bur
th$e lelons are.lusr..cd i. individMls lt is importat! to ùt{
dn irdni.luJl pètrerti Ns.el,ribiliry rc.arnns lesnri foûuio!
aid phlres\ior Thrs n ar imirofta.r far .t .oûedtûlr!

. Th...ries pio..$ mar orùal

not bc progr.$iv.
. J.{sionsùrf b. r.li!.
. lesl.ns my be arerÊd bt,l,er. oraLhtgirne, md N- oanknd.s
Ine va 0lrv an0 re a0IIry or
diagnosticdecisions
Ifthùs atpeas rhar (liagfosiic de.isions ârc madc i. .orditn,ns oi
!n.ertainl! V/ilL rhe denlisr rlwa_vsb. cotrc(Î in drc diaAnoslsol
the presence01 r les,on and its aclivjryf \rrc .o{ conic h a verr
impoitàût ponr rbout diagùosis iL should aLwr-r'sbc.onsidcfcd
if tern,s ofi$ vilidirr ind icli2biliry: Vàlidit-v meâns\ahether dre
di.snosls fttle.rs rhe ûue.ondnion. Reli! LJilny.on.ei,, s $4,fl her
the result \'ôuld be repro.lù.lble €id,er br rh. sani. rcnùr..
diferenr o.cùslon or Lryâ (lil'lè.en!,le.tist
It is roù âppropriâre to.oos er rhe.o$eq!e.ce of cr.o.s of
diaEno\is ofr..ivitr Sùpposex denrisr jùdges.n ertnel lesion ro
bc a.rivc when t is in fa.r airere.L. The ùnsequencesol the enol
.ll b | .ll -" . - \ , , o , o i- r . ,
i.carmcnr 2nd dris $'xs nor rcqùiftd. Sùppo\inA, ot dÈotherhàûd,
d,cdc.ri{ jL Acsalcsn)n ro bc inadive, rnd .lôesnot nstitutefre
veflrive ûeârnenr, \rher h 1&t tLe lesior is J.rive. Now rh. t,ro
Sre$io. ofrlt lsion is Lrkeh ro .ô.tinuc ù..hc.kcd. The flr{ of
lher ls'o ei106 is c,llc.l a tàhc fositn'c, thc sc.ond â tr.lseleijative.
lÊroù were rhe F.ienr. bcâri.g i. nind lmc erors ùiLI aLwâls
be ûrde. wlii.h eiror would you prelèr to be rrearcdunncccssar-
i1! or nôr be reftd when rction ùas re.tùi.&l? Please.o.sidcr dris
frôm tLrepoint ofliew ofàû enrrnel carlols Leson r.,l d,cn ,kcf
)ôur peBpe.rive so rlut lreùrmeni tus imtLies son,. i(rcffiblc
x.rbn e.s nntrh exûx.tlon or a fi11ûg Your pe6t,ecrive mighr
.hânge dependhg ôù tft .orse(luef.s of lùGe Fsitirc ,nd làlsc
ffx.ti.e fù the folloNing r€ùsons:
. 1r makes e.o!.mrc seûseto rarger l)rcvc.ùvc ltdmÈùs d
drc appnrpriâte rÀk grouf
. deDtrl care.eirh{ b.Eins noL ends with r single coraeoi
.cânrcnt, bùr is otrlonrg. \Vheû..o!6e of.lcttâl ùcrtnenr
is..mdere. dre denrnt atrd rh€l,atienr Jc(idcwhcn it $or d
bc *ise r, check dut a1l s rvell This tccâll i.È1aal is bded
' ' \ ' i r ' " ! e i n
. pdrients sh.ùld be mrde rware of ùeir .sl. srtrrùr. 'lhn
l..owl.lgc cn.oùr,êes tiLed tô keeF rpprof.inrc .Édl
.tpoinrmcnrs ind b be.ome irt!olle.lnr thet own ftr\tn'
iire car r.,1, ifdrcl |xy àr thi\, mây helF th€,n bulgû i,tr
a Lù âssessn'rertof caics fisk
I'actors r_É:ievanl
The tæro.srclcm.t n) .ariesrisk .re outhnedif T2Lrlc
5.1md
rll.
dncusedsuLrr,tuef
Social historl
I{ân! $u.lies hale slrown rhat dcntxl.aries is nô$ .oû€rt.rcdn
srixlly depri'e.l peofler an(l o.lrr d iscisc\,su.h assôft .ùre4 ,,d
.ofotuy xfter) drede, rre si.ri larll .on.enùated. The loLLoNiûs ù
tLres oflhe socialhisio$ mir xlv, bepÉrùt ni high risitftn(
' Cxrles in silrlnrgs mi] be hi.sh
. ihe pârient po$e$es lirrlc looslcdgc ofdent.rl dnea*.
. Dcrdl aftrndan.e is ûregùl.r an,l dcntâl 2sfimrn)n\ lN.
. l'hc prri€nas use ôi!i..Ls s hi.sh.
llcdi.allr ()mptudise.L èûd disable.l|..tlc mxl be xt à hfr
fi\k oi â!.1 frod .àries LJse6 of lona rcm rnedi.nrs d ba
TÀble5.1 lactos relevânrro càriesrisk
HICH RISK
rov krcwL.dgc ol<le.!al aise6e
Rsd) 1!,,tsb,t,q,É.n,LLs
xerôstomia.Patjentsvith rhcùmarôidàrthritis may also have
Sjôgrels syndron€, which aftècB the sâlivùy atd Lac.imal
LOW RISK glânds, leàdng to a d.y nrourh and dry eyes.Inrâ]Iy, many
nedicderts, sùchasantjdefre$ants,antipsychôtics, trmqùiLr?
eB, dtihyperteûsives,and diureri.s, .nuse.lry moùth. V/hen a
practitior€r is i. doubt as nr whether à pàtienr! medicâtionn
likely b .a$e À drr mouth, a forûulâry drar notess,.h compli
Deni,lly rvàre
.arbns should be consù]ted.One tuûber srôùp of pàtientswho
nay haver dry môùth is rha! with eatinadlsôrdeB.Hyposaliva
w r k d l A n u ri t u r r s u l , r \ n ( L s
rion, combinedwith dietarychæs,cancausedentalprcbleûs.
The medicalhistory ôneôf the fâctorsio a cariesrisk assess-
men! lhat câr chanAe.À vigilànt denral prac!:tionef ideauy
detecs tlr;s chânseand lnforms the pètient ap!.opr;2telybefôre
too much dù,aae is done.

x;;*;i; Pkqae cqnttol

Ldg terû .ùiogen,. heili.inè
No lloride s,ppleùens
Inarquetrt inetre.tive.le.n,ng
H,gh S. mùiins md Lîtoba.iLLus
Ant.rior .ûies or reno.rùors
Hiso.y of 'rlate.l re*ogdors
N.l.ng{erm meil,.anon Dental plaqueis dre nrostimpoitmi risk fâctorfor dentalc2ries.
becaùse cariesis dre rcsùlt of metabôlicdtivities in this bioillm.
ù.t unle$ jt is prescnt,cariesdôesnor ôccùr,resardless of any
orher fàctors. All palients $'ith poo. plaque conÛol do nor
inerltnbly developcaries,but oral hygie.e wirh a flùoridetoodr
pasteis the bedrockof cùies control in all patients.Il for ùy
Flùornt.suFFt.n.û6 usea rasod, oral hygieûebecomesdiilicult, perhapsbecause ôf hàûdi
FlùoriJe oôrhpâ*e ùsed
cap.a8e,or lllness..dies risk iûcreùes.Thus,patic.$ who.lean
rhei. reerh infrequeûrlydrd inefectively or hare poor hanuèl
conrol may be at high risk. The ability to.leat the molth effec
rÈquent eale.tive.leaùiù! lively may also.hângewith tiûe.Iâmily d€ntisrsand hyaienists
areio â. idealposiriônro detectthis charse.
Dietary babits
Hish susariotal.ecanbc a carlesrisk fâ.tôr Âs ùith all fèclors,i!
is rot po$ible !o stateu.equivo.a.uyrhat àll pàtientsqho havea
rnN S dtrtùs ùd ldtobdillds
high Ngâr intake developde.ral decny,md somedent$ts nter
pret this âsnegalingthe valueofdlerary analysisând àdvice.k is
ùDusual.howevcr,to find a patienr with mùltiple actrvecàûous
Iesbnswho do€snor havea high sùgarnnake.Dictary habirs.d
alsochèrge\aith !ine, pâ.ricularlywlth llferyle chàtge,sùchas
Nô exùrtioff aor .arics stèrtlng work, re!iremenr,and bereavedentiÈgèit, â lisildt!
prdritiorer idedly noticessuchchanaes.
Useoffluoridc
Re$..âti.os iosefted lan ago
flùride cLelàysthe progr€$io. oi dental cafies;rhùs parients
who dô not usea flùorde conlainjna toodrpdte may be àt risk.
Numebus studieshâve shown warer nuoridâtion n benefi.ial
in .a.ies prevertior, particularly in arcasot deprilarlon (see

problem, if rhe nedi.lnes dè sugdsbâsed. Todày, màny sùgùs
ftee medicinesare avâil2ble,bu. denristsshould always.he.k
ihe suaare co.rent of âny medicât;o.s rheif fatiedB hkt
Perhapstbe most releva.t factof ir a mcdical hlstor_vis a
dry nouth. Palieotsvho havehad rudiorherapyi. rhc .esbn of
d,e salivaryalaods for â heâdand ne.k maliAnan.y ffer from
Salitn
ùtâry featu.esofsalivaaffcc|the risk ofdevelopinAcaries.Xeros
tomiàhd è]reèdybeendiscu$edd âprcdrsposing facto. Nnmer
oùs reseàrchstù.Ueshavealso suagesreddrat salivarycoùns of
mùtans$reptococciard Laclobacilliarc predicitrs ôf cariesrisk.
This hnge volùûe ot work appeaGrc showthar l{)w .ôuns ôften
predidlôw iisk well ond irdividual pâ.ient basn.bùÙhe ôppô-
site is not necesùily !rue.
 I
82 | 5 fiûrosrns
o'iesrnenomej
I

Clinical erùlence
Cll.icâl evidencehasbeensbown!o be rhe bestpredl.ro.of
caries risk. Thus, pètieûts $irh rhc fbllowirg char.cteri$ic arcat
high risk:
. Mùltitle new lesioûs
. Ilistorl ôfprema.ùrc cxùâctiors for..ries
. Mùltide restoratioûs
. Àntefio..aries of resroratiôns
. l'. !o er',,n q,l, rfltrFnlrrer' .ri{.
Mùch ofd,is nifôrmâtjÔn can bc elicired from a ûew parient bv
a .d€fùl hisrory. The clini.al and râdiographic exâhination of
dean, dry reeth is ofgreat lmporr2nce and revealswlrther lcsions
âre prescrr and ùherher they arc likcly !o be èctile or drered.
A prâ.ririo.cr who knows his or hcr |âtients car hône this Figurc 5.2 Âr SlM pntùre ôfa nevly e.ufred eDamels ee
initial asesmeft b near pcrtiction ard dete.r a chaûsc i. risk âfter renolal ofihe Lrellide.The rrefklmara ârd ToÙes proæ$
*atus bciore too much dmase hâs been doDe. In sôme paricnts. cxr bc seen.Origi.dlrr !rblished iD nxîbrok afCli"tnlCdflkn
placlnA an appliànce, su.h as a t2rial dentùre ôr àn oithodontic (MùnksAùrd) 1994 ènd .eprodu.rd wirh pernission. (ScePLaa
âftllance, in the mourh can drange rnk $arùs sùch rh2t caries
derelops. The reau fo. rhis js thàr rhe applja.cc lâvoùs plaqùe
I o e . e . o r b . . 1- \ ' l J ' , , n F r o r d . \
.tefe.s, .âlled f(,.aIholes(Fia. t.2). Lr vivo, all rhesefeâtuies
S mtuary
A! experien.edprâcririo.eris èb1etoassess.arlcs
risk in les rime On.e rhecnamrl cruptsinto rhe oral càviry,irs.overedby
rh2nit takesro reâdt]ùough rhe Frelious a..oùn. ofdrc proce$. metùbo1icallra.rive bn)ilm and is corrinùally nodified by
ResetuthconlÛ6 logi. and har dnrsn drar a Fractitlonersber altcmatinAde and remireièlizarionsofthe.tunùs tro.es.
sues  â sood a$esor of risk status. Ir,t,., i. ', ' '1o(" ! _'ie.ll'e'oo.- Tflè,
over a nùmber oi months. :Ihe partly erupted rôotn doer
pari.ifate in masticalion dd it is diffi.ùlt tu clea.. lor
)tle preole(Itonlot lne (qfle5pl0(e55
rcasons, ûicrobial èccrmulàriôr is enhan.ed. and duLing
dDe rh€re are many eFisodesofde- xnd rcminemlizatio.. Thi5
rhc cùioùs proces at a sub clini.al level.
The .leeper pèrts of the fissure sysrcm are tarric
prorcctel fiom removalofthe biofilm and vlslblc s'gnsoi
may develop wbcfc bâûerial deposirs remain for the

A siollar sirùation exisB âpproxima.Uy bccausc

Histopathologicaj
leaturesof
enamelcaries
Enamelre*ctions during eruplion
When a.oo!h erup6 intô the orai caviry,the enamelis fully min-
eralized.Normal aÀdsouûdermel.o$ists orcrystàLs of hy.trôx
yàperite $ ti8hrly Facke.t rhât rhe enanel lrâs a A1â$ like
appearan.e.k is translucenrand the dentineshinesthrcuAh to
gilc ayelLowwhite co1ôù b rhe roodr.
Thc eoamelc4,stâ1s ùe afmnscd in rod (!rism) an.t intefod
eramel.tset$eenthe crystalsa.e mnute spees filled wirb watef
and orgè c mnerial. Thesespaces form è fine nùwork of diffu-
sjon pathwàysor pores;r the enamel.
The outermosrenamcl is rarherporo6 wirh the openingsof
the $iàe ofRerziuso. rhe surfaceard rheft perlkymatasrooves
àc! d largerdiffùsbn pâdrs'âys.The rlmerous piis of the Tonrcs
protecle.l beneath the cortâù point aûd aloos
margin,ùhere plagk.onr.ol mal ako bc l,oor.
Irom this desùiptior ir ls obvlousdrâr drereis no sudrth
æ a cariesnsceprib]t slte bur drcre âre sireswhere
depositsàre likely to remainund;s!urbed.These{ea,
, or , i9, . l-_T .l ) i ) Nell .r-'FloF , , , n 1)
lesiors.k û intererlns kr know drat it wâsG.V illack {ho
polnredth's out i. I908, so we âreror dealinssn! nes'knoûl
Ultrd sti"ucturalchangesilr enamel
relâtedto the biofilnl
{ , . t e s , . - r * o fr . . . . r . \ p -nr e , , . . , . t , . s , dd, t , .
of rh. inirial iesioûtormed unter d ûdisrùrbed biofilm.
, o r J , r , o ,q . " e J F / b \ , I n a . , - b " , t . o 1 , o , e e l
wcrc Nlxcquerdy e{trà.ted for orthodontl. pu.poses.The
P1êtct The upper antnôr t.cth ofn yôu.g àdult.In the uptler
pi.ture adis.lo\ing aAent rerals the llaqùe shite ln thc tô\'cr
prcurc dr. plâque hrs bee. renored. Whire spot lesionsaie vlsible
on rlæ cmnrcs but nor ô. ôthe. tôodi surfi.es ahhough pt;Lqueis
pr*nt. (!'gure t l, f. 79.)
Plète 3 À clinl.al afld SÈM pi.nùc ofa vhit sPor lcsio. fonn.J
',. orloJo". L, .i.r s"pl'of1 1:. .9','on
Clnna.lly rft leslotris ôprqù. wilh r ùtt sùrftr.e.
UlûdtN.tùft.llr drere f dissolù1ô. ôIdre terikymrt,
ovûlaplinss md dissolutlor ofrlr. sùrfaceenâmel.Origiidly
pùhlnhed 1n TeûkaÈ af alj"t l (.d,nrp (Mtnksgaatd) 1994
i.d .eprodr.ed with pemnsior. (figùr. 5.i, p. sa.l
Plnrc 2 An SENIli.rue ofa newh enrl]tedenamelsu.la.eariù
. n . 1 , È tI ,. L | ' ) n , d b n o . " . j | '
be re.. Origindlrrpubrishedin n!bûp ,lali,itàl a:ànlrrJ
(Munksgdard) I99.1a.d eproducedwnh t]erni$ion.
(IisuÈ t.2, ! 82.)
Ptatc .1 Â diûical afld SEM pldure ofa white spot lesion turme.l
ùnder an odrodontic bx after remoral of dre bioÊlm. The leslon
rfacc is nos'$nrl' and ha as a rcsult of abruior o. polÀhins of
thc patb drsolvcd sù|fæe ofthe a.rire leslor OrisnalLy
pnblishe] 1nnnhrh afchrtrnl Cdt os (NItDksEûtJ) 11)1)4
atd rcprodùccds'nh pcrmissiôn.(ligurc t.,1, p. 81./
Plate 5 Longitùdin l gmùrd s€.tion drough â smâtl white slor
leslon in e.âmel exâmi.ed in wâter wkh phrized 1ighr.The body
ofihc lesion slro\a as ân àreâofpositive birefringen.e beneatha
relatirell intxct, neaatlvely bircfrlngeft sùfacc zor(
(ligure t t, f. 8.1.)
Plare 6 Longimdinal ground r.tioû though a snlll whne spot
lesionin e.amel eumnrcd in qùifloliû€ with polarizedlight. The
ûndù.ent 2ônc is at dre advm.ins fiort of tlÉ lesioô âid the ddk
zone is sup€d.ial to this. The $rjae ofReùius are well marked
wi.hi. the body ofdre lesion. (Iigùrc t.6, p. 8i.)

Plate 7 ronAnudi.âl groùrd sc.rior of a mrual .arious elrmel

lesion i. d tooth e{tn.t€d from a paticnt âged 70 y.-ds, examined
in wàter in t)olariz€dlighr. Tlris tcron wd dreied and simild iû
afpeannce to the lesio. nr Figùrc 1.20. V/ell-mine.âlized
Itrninations Ie obvioùs within ihe bôdy ofthe leslor, parii.uldly
or its ocdBal âspecr.(Fisùe 5.7, p. 8t.)

Plaie 8 The sâmese.i'or âs 'n ligùre t.7 (Pl.tc 7) cxamrnedn

Plare 9 Loûsnùdiral grôùnd r.tion ofâ ùtùral ôcclusa.l.arioû
gùnroline wnh polarized light. wide, well deleloped d.rk zoncs
lcsion eanifled in quinoli.e i. tolâri2ed iisht. Thc lesiot ford id
,re obv'oùs "t the âdvan.ing front ôfùe lesion,wnhln the lesiotr,
rhrce dir€ctions,gllded by lisn dire.tion âsùmits dre drapeot!
ànd at rhe sùrfa.eofthe les'or. (liAùrc t.s, p. st.)
.ore wlih its b.se tôwards the e.amel dentinc jutction. The
ùnderminins shee of this lesio. is purely a fùnctiot ofaûatony.
Plârc 10 Âctive smoodr $.facc .cdcal lesiors. Th$e are mât â.d Plate rr Àre$ed smooth sùrf&e cefllGl lesions.Noti.e the
visibleon a wd tooth surfà.e. Cav'ties cà. be seenon some hcaldry snrgirxl marsins il1dicatins sood plaque removal. The
lesions.Thes€l€sios cm bc âtrcrcd by pl.qùe.ônùol àlône. - r o n , r \ I r , r o , " . r ; l r l i o r . q n r l . m. " ! , , , , i ' .
(Fit:juÊ5.1 I, p. 86.) licked up tiom .he douth (IiAure 5.12. p 86.)

-rhis
Plate 12 e.uliting molèr àppedrs.àries iree but it is not.
ligùrc by.ôùrrcsy of D'r,/ I\rLù.lFlsLtc t.ra. p. a1.)

'fhe
Plate 13 su (e hN nôw been dis.losed,bnNhed ro Émole
all srined flâ{.tue,and thôroughlr dried. Â whlre spot leyon 6
now obrious at rhe enû.n.e to r]1efÈsurcs.Ilgùr€ br.oùftesy of
Dertàt Uttldk. \r\Bnrc t 14,ï al.)
Pldtc 14 The srcr dls.olourarion ofthis ocdusdl surF,ceis câused
bi demine.dlized,.liscolouieddentine shining through lelatively
iDta.t enamel.This leslon wa visible itr.lenrine or brew,ng
rudio.s.|]!h.liguÊ tJJ,.ou esyafDrtal Urdak (Iigùre5.1t.p.87.)
 i::':
Platc I i There is r ni.roctrlit! nr thc whnc spot lenoû Ln rhrs
o.llùsxl $llfn.e. ft loots like r slighrly sidc.cd nsùrc of a smalr
hole lelt bt a wood$orm. Hl$ologi.rll! this lÉsi.n n iclL nîo
dcntnrc atul ]t nar be vlsible ln.lentiiÈ on r bit.ving ra.liosrxph
!,Âùrc by coùtcsy of D!,r,/ Lil/ n. (fig!rc t.16, t 8s.)
Plare 17 Clea ns a pânlr en'ried tooth Nith r roodrbflsh The
f.1trr sLroùldsxnd behnd the.l,ll{l r.d bring tlt brNh h t
nÂbr ^nglcs to dre ar.h. Firure br (ouiiesr .J Dt,tl lrllt.
Pllte l6 A.iriratcd lcsion e$oslng dentitc. This levûn rr
nr de.rire or i bncvins rellogtuph ligùre bI.oùfr6]'ol
Ul&r. (IiSU.et ls, f. ss.)
Plate 18 Âr ôfthodoûri. nighrhùeL llùk,plc $hite r|ol Le$or
r,ive lo.nrcd on rooth {ûa(es rrou.J rl,c orhodonri. bB.kes
Rorlr fl,guc.ontolând diei wet u.ia6ùrôLc.

Iigure 5.3 A.llniGt andSIM licture ofd whitespotlesjoiformed
utderan orhôdontic bmd afto .1weeksot'pla,tue*a.qnadon.
Clinicdlb,ùe lesionis opaqre Nitb a mac sùridce.Uhratructu.àlll.
thereisdissolutionrftleperiktnàtr ove.lntpings iûd dissolrtidnof
rhesùJtu€ mmÈl. Ofisinallr p\bllsbe,l  nnb\r€ 0f Cli";.dl Cdti0/09
(Mùhlsgdd) 1994lnd reprodùcd witlr ldmissioû. (Ste Plate 3 )
preverledmechanicaldjsturbanceof the plâque.Aitef varyi.:i
period,oftjûe, the baodswere removeda.d replicd ofdrc sùF
fæeslakenfor scarûing€lecroo microscopy. The teetlrwererhcn
lehurcoveredandmecharicalplaqù€coolrolwasiesumed,furdrer
rpllcas shonins how the surfacereà.red àfter bioÊlû removal.
AËe.one weel.orundisturbedbioÊlm rormârio., no chanses
id th€ enamelvere seen.lini.ally, eren after .areful air drying.
Ho{e!er, at ûe ultrèsrûctrral tevel, there were sisns of di.ect
d{solutioû of lhe outer eMn€l mrfa.e. This
enlârsemertofthe intercrystàI]inespèces.tue to partial dissolu
tion ôf dre iddividuâlcryrâi peripheries.
ÀfrÉr h'o weeks wirh .omplerÉly ùndlsturbed plâ.tue,the
enûel chânA€swere visible .linl.a.lll after airdrying. The $ hite
ttof lesionwâs nos'visible. À{ter dùee and four sreks, drese
ûangescouldbe seeowitbuÛ aiFdrying. theltsn,n beingopaque
with a daû nûa.e. Ulfasùù.tura.lly, there was complere disso
Lutio.of rhe thin pedkymataoverlapfj.gs, mùked ,ljssolutioo
.ofLespondirAto developmertal ircAularitics sucb as Tomes'
firocc$es,pits and focalholes,and cootinuedenla.Aemc.tol the
int€rcrystalhrespaces (fis. t.l).
Thrs, the sùfècepdricipètesin the enànel reactiontrom the
very begiining of lesior formètion by .tirect dissolùtion oi
lhe outermostmicrosùrfæean.t enlarsementof iotercrystallire
diffusiônpàthwèys.This direcr surfâ.e erosiôr is môst llkely
lartly resFonsible for rhe nàtt sùrfàceôf ihe actlvelesioo.
Histopdh0losk0l
[e0lur€s (0ries
0{en0mel 83
Figure 5.,1À dinical andSEMli.trft ô1a $ lite sporlesion
fo.med underân odhodonri. band afrd iemoval of rhe biofilm. The
potnhins of rh€ ldtly dissolved$'.face or the ftlve teson.
Origlodry published in TAlùark rfa/i,'.d/ Cdidas lMtnksaaatd)
1994rnd reprodu.cdwùh permissiofl. (SeePlare4.)
\xrher the orùodonîic bandswcrc rcmovÉd,ail.,wingdistùr
banceof the biofilm, dre white zfpeârancedimlnishedand the
sûfa.e becàmehàrd ard shiny aaâir. Uhrast.ucturâ] studies
showedwed of the externalmicrosu.face(Fis. j.4). Thus the
rctlrn r) n shiny,hardsûfècewæ a resuhofabEsjonorpolishing
ôf the partly dissolved$ria.e ofrhe acdvclesion.This lnportant
serjesofexper'mentsshovs ihe pft.tu reldionship ofthe lesrod
to dre bnfilm, and showsthài resùlardistu.barceofrhc biofilm
will d.rr rhe lesionby removingthe acid ploducjogorAaûisms.
Thc white spot lesion
The samcseriesof experinerts àlso eltracled te€lb 2t varyi.S
rimesro allow ddalled exaûinâtionofsectionsin polarlzedlight.
AfterooLyonewcekof undisturbedbiôfi1n fornàlion, tiris ext
inarjonshos'eda sliaht in.rede in enâmelporosityaD.lthe lnsue
bcncathrh€ po1utsouier microsurfJ.ewù morepo.ousthan dre
dicrosurfè.e i.self- :fhis so called subrùia.e demineralizatiot
be.âmemoreobviousa! wccksis!, thrce,andfoùr ûd the cldsi
cèl hislolosicalzoresof rhe wbitè spot lesbn in pol.rized light
.oùld be idenrifie.t.Thes€,onesare tbe surfacezoneand body of
the lÉshn,bestseerafrerlmbibltjon ofsec.iorsin w2tc. (lis. 5.5)
ând thr dârk zôneârcLprlnàry traslucent zooeseenafrcrimblbi-
ton of\ectiônsis quiûoline(Iis. t.6).
Scvcralmodels hâve beer proposedto explain dre relativc
pûe.tior ofihe ourer L0 l0 micrors ofen2melagâinstirrthel
u,r r m*ori,o
.,i.,i,**a
I
tsisrù. t.t LonsiNdnrâl srcurd sc{ror drroùsh i smilt *lare spor
lesiô. in e.rnel exrnined in wârer Nirh |,olfized light lhÉ b.dl
ofthc lcsiôn slross s,. àeà.fpositive bireûinge.cÉ b4eâLh r
iclat'lcly inn.t, regâtilely bireirnrgent suface zonÊ.(scc PLâtct.)
!_igure 5.6 longnùlLinal ljroùnd rction through a small vhire spot
lesioùln etunel exxminedin quinoLinewith pohri,ed light. the
tÈ.slu.e.r zone is a he advnn.lnS Éont ofnr lesnrr rn! the d,n<
'lhe
zoneis su!ùtl(iâi ro rhis. $iæ ofReùn,s aÉ well ù,èrled
wirhifl the bodr ofthe lesion. (SeePlate 6.)
,l .,,",,.A p l . . i, . - \ T , , . pl,r'i{ -n.iilo ''
Dnvnùtn,n is caused by an rndersanuatbn with iespect to
emmel aparlte aûd a f(rmatn,n of fluoraprtitt in the endel
s,r{ê.e câuse.lby d n,peBatûdiôn vùh respectto fluoriparite. A
frotecti\rc roLeof sâli\'rry froline rich f.otcirs and odrcr salirdt
'lhese
inh;bids. such as stadrc.i.. has also bccn cnrphasized.
'I
iahibit dcminc.âlizarion and p.cvcnt crrsal :t()wth. htr de
macronolecùles aod .annot peieffate the deeter farts ol the
erùrel, thùs their stablltiÀg role is lnriled .o rhe surlàcc
enmel. h is aisopô$ible r1iàt the orter erdmel is stecial in tc..it
of (s llrra$rùctùre an.l.hemical composilio!.
Reûo!â1 of rhe orthô.iôrtic bèùds an.l resrmption oÊ loorh
cleaning resuhed nr redu.ed porosiry ot the leeter fâ16 ot
lesiors.A gradùalretu.n ofcnamci1luidsrc superatuaron
respe.rto àpètrtescausesa shiii in cqùlibfnLm ofmiûeslsat
sires ôa.lemineral,zation. Atrc*cd lcsn)nsshowed d wdeD
É d , \ / o , " n l . I n S , l 'r ' t . 1 ' " ' , F r \ { ' .
rLe nûtu e ôf rhe lesion'nay be.omcha.dard shinr aûdthe
somc b-nùtà.e porosirris rill Fresert.It shouldbenotd
rhese dresrd lesioN ùe àftualiy more .esist.nt to a
a.id attack thâû sourd enanel.
' Lf .r'lr \1, l ,o,r. q.rn "Jh.'r
burion of rbc bioillnr and rhe diiecriôr ôf ûe enamel
Tirùs, on â. âfrrorinrâl sùi{a.e,rhe lesionforned ben@rh
bioilD is a l.idncy'shapeda.er betweeûthe cotîactlact
dÉ Sirgival ûargin Y/idr;r the enamel,spre!.1of
tùkes !làce âlong thc cramel prlsnù. h se.tiot, tlt !n@rh
'fhis
1:.c lcsbn ls .oni..l (Figs i.5 and i.6). connal shapeÀ
resulr of systematicvariarionsin dissnùrbn alotg the
prisms. The oldest o. mosr â.tive pxit ol the lelon 6
àlong the centraltrav€.se.The con;callysbxpedlesioû
o '- ,a ,'ê 1a 14è' or l- o' Frosi b n ùt€
disnnùrbn ar the ulûasn,cturâl level at the edge ol the
This cnrphxsizes thât the lesiôn s drlve. by, rnd retle6,
ryecific cnrin,nmentrl .onditioùs ir the ovûlj"i.g
Figuresi.7 ând i.8 showhi$ologi.dl sections tlrougban
.arbùs le\bn, similâr to rhèr sliown .linic,lly in Figùe
Aûested lesiotuàre chàracrcrizcd by mùlriple .larkzoæs,
exanloedif qui.olirc indl.atins ft'depôsitionofnincml.
a ù s . n t r r o L . l ù v t \ u r i : t r . r s . ' 1 , oa l o . , l r - e T p h e
the deepest par! ofthe.qroolc tassasrsteh. {here the
n..ùmulâtions rec€ile lhe bes f.otcctnlr aSxin$ fuùctional
lhe 1e\ioû fôrms ir three dimcnsbns, âgxln guided br
dir€.inû The lesion rhus a$umcs rhc rhapeot..one
bxseexlard\ the enanel dentne Junftio. (IiE. j 9).k
thâr d,e â.tive biofilm is abo\E dicc.tran.e ù) the ûdiov
èûd grooles LjLùarru.rùal rùdies show that the dæ|e{
'1, ..'| F,ll rr'" ro' |I d lr.
lar impoftânt .linical impli.dtions crflxi.inE sby
Ie\n)n fitrmarion c.n be prevented of c.upti.E mold
removal of drc bn)ilm with â fluor e tootirtdle.
Usingpolosityin diagnosis
TLreporosiry oi the s!bsu.à(c lcsbn .an be turnedto
advaûrageby the cliniciin. F'isr ir cxplains whr tl]e ql,i
l€sion looks whitc ând s'h-r . dentist, lôoking a! a ddt
r f - . r ' ir ; . , i { . ' r . , ' F - ' ) 1 .
.he dèpth oi penetrèrion of tbe lesion Thc lesiôûth.t
'lslble od â dry tôodr srrtdce is !.obably in thd outt
mo$ of dic s'ây rhhgh dt etdel rnd malbe itto the
This rclarcsro the relatlve Éiia.rile iû.li.es of emmel,
air E.âmclha' a refrâ.iivei!.ter of 1.62.In thesub{u"-"
dre pores a.e fillcd {'itlr â watert' me.liû of refoctl\t I
The diûtrcn.c nr reÊetlve index bet$teû waler rnd the
 Dûsmrl
olsmel,ores 05
I

Figù.e 5.7 lôngirudlnal groutul se.rlofl ofa naturul .dnous
enmel lesion in x tooih erttu.ted trom r Fdl.ft.gcd 70 lea6.
exÈûi.ed in \'àter in t)olirized liAht. Tbis lesion was a.rese.l d..l
sjniLdriû dppea .ce to the lesior 'r !_isùe t.19 V/ell mineralned
lminations are ôbvious within the bodl'ofùc lcsion, pdticularly
on its o.clùsal aspe.t. (Set Plate 7.)
Figùre i.9 Longitudinal 8roùnd se.tior of a mturÀl d cl unl .ârioùs
lesionexuri.e! nr qùinoline in poladzedlight. Thc lcnofl fo.ms in
tlll* dire.tions, Aùidedby prlsm directiot, À$ùnins the shdle of,
.oft wlth is bùscrôs'dds the en,ûel .lenrinc lmdion The
mddminiûg shale oftbn ksion n purely d fu.{io. ôfânatomt:

when used or a loogitudinal basis, ther potentially all(^v the

dc.tist n, follow lesion progre$ion orâftst.
Before .oû.lu.llng the section on ub*urface porositn a word of
cauriôn is, hovekr. atprcpriate. The .lentist must be .areful when
ùsnrg à shary ptube. It is very ùsetul rc gcndy drâ$ thepoi.t2cto$
dre lcsôn ùr dere.t à matr sllface irdnating d a.tive lesion. It is,
howclcr. mo$ utwise to iab rbc sharp probe itto the lesion to see
whether it n ldcky. The probe is lllrely to .aùse a càvity and lhis
r,l',o : 9 " h i l i r J 1 ' r , o n '. ' _ ' o , r " , il

lerion
Shqeof theroriour
. De eln,nedb! a !ur' ' rJr oj ,tc '. ,t

'|i. " FÈy., dD^. ' o,,r--,',i

liglrr€ t.il Thc sam€rction as itr ligùtu i.r exaûntd in qù1no'

lin."\enh plârized light. vidc, well develope.l,dùk Tofesrre . u , J . : . e o _ , , H
olNiousnt the âJlancnrg frort ofthe lesion, wirhin tLÈ l4i.n. and
1r rhe sùrfâcoôfthc lcslotr (Se€I'late 8.)
Diagrosisof enamelcaries
a$c.ts the liaht naftering dd mêkes the lesion l@L ofaqùc. If the It ir impoitdrto re.oAni ze acrive enmel cdies al the staAeof ihe
surfa.eis roù dried,air, reftâctivenrdcx 1.0. repla.esthe wêter Th€ Nhite spot lesion so ùat preveniive treârmcnt ha a.hatce to
diference!r reùactive indcx bcNeen tbe dr aûd the enânel s nov drest 'cror P()gfts,on.
grearer thm th belveen thc ware. dd the e'jdel. This neans, lbr earlydiagnosis
Prerrquisites
rhelesiônbecones nore obvioùs or à. eàt;cr lesion.an be detect&I. Caries cliàgrosis reguires
Ponxir!' is dÉ bàsis of ûraoy lechniqucs .hat det€.t cdiotrs
lesbns; fôr iNtàrce, râdiograph', ùd tvo quxntitative tech
nigua, qtrantirèrlve light induced tluorcscc..e add ele.tricèl
'l'hese .
iesntan.e. rechnhues allorv quaotitarion of thc desree of a rhree ir one sy.inac !r drd teeth .an be liewcd boih wet
pôrôsity $rher used once they çill letecr dcmineralizatioû, but
 5 Monosins.orie5
inenomeL

. ùarp etes wlth vision aided by maa.ificarion. This is lnacliveles;o.smay be furtherf.om thc ai.aival maryin,whieû
pdtlcùlârly ne.e$aryfof oldcr dcntis$ who arcunlikely ro brownjn colourvith ashùy surtæe(lis t.l2).
beabl€e) seea5vell asrhci d;d in drdf youdr.
Occl sal sûrfaces
. Rep.oduciblcb;tcving radiogfaphs
visùàl ermnration ard exmi.atio. ol the bitewing nd ioSmph dt
The white spôt lesbn, although .aused by plaque. is also bodr imlort2nt. The acrn-c,u.cariratcd lesio. is wbite, often wirh
obscùredby it. A 1ogi.r1 wây tô pro.eed is fôr the dentist to a mdr sûia.e (Iigs 5.rl and j f.i).'Ihe.oûespoûdiûg in(tive
examlncdrc tecdrbodr beforeand arte. removalofplaqu€.Maûy lesior ûày be browr. These emel leslons ùe oot vriLrle ooâ
- . 1 , , a . d . . i i o , , . . l o o . F , o , i oi ,, , , h p - e " - , , b L o ,bitewing râdiogrâph. The endel lesion that r only visibLe on a dry
immcdiatclyafterlhe pali€ot hd seenth€ hysienjst. t.,ôth sûfa.e is tLre ôurer el]del lesion The lesion vrible on a net
The dùee jr oDesyrinseis invalLÈblein the.Uâsrôsisofthe ruria.c is all tbe wal thn)ugh endel and may be intô dettift Cav
deprhofpenetràtionof the white spotlesion.A whùe spôt lesior itatcd lcsions mal prcsent a\ mi.m.aviries wlih ôrwithôùt agtr
lhat s vsibte onll wher the enâmelhd beenthoroushly dried ish discolomrlon o{ the enam€l (fi8s 5.rt and t.16) The
has penetrètedabour hàlfsdy rhrôtrsh the Énme1. A white or micfocality is easill misscd on visual examination, unLes the
brown spot lesiônrhar is vÂibl" on a wer tôoth nrta.e haspene- sudace is pcriicdy clcar ard d$. Careftl exâmlnâtbn of bieùing
lr2red I the way throush the efuael, drd rhe .temiûerèlizàrior radnrskph is inportdt and serves d r useful sâfery ûet o aloid
mar be in dre dentine.Demincnlizarior may be i. dc.rine bcfôrc
calitÈtior occuB, btrt the lesbn .an rill be arested ll plâgùe
.ortrôl cù be established.
Iinalh. good bitewina radioArryhsa.c e$ential fo. rhc diâg
.o'is orâpproximallesionsvherea cootactponr! jsrresenî.A liln
holder â..1 beamanniûs deviceshoùldalqaysbe ùsedto ensure
drc.otrect2nsularionofrhe bem atuld an aid û reprodùcjnsrhe
sameSeometryir aûysùbseqùertrèdiogrèph(Iig. 5 .10).Where è
lcsion is ro be moûnored for progresion or èrest, this repro
dù.lbllity ol licw is c$cnrialrodreryise.ân àppàre.tchârAein dre
lesloû mdr simply be ân aftitrt ofgeomei.y.

Diagrlosisof âctiveând arrestedlesr'ons

on
individ1laltooth surfaces
'r'hese
Free smaatl: szrfaces !'isue t . t 1 Â.tive smooth surldce.eNnal leslois. rre mdt
Visions thesalientdiasmsict@1.Uncèvitat€.i,
etire lesionsare . vslble ofl avet tooth suda.e. Cayities.dt be sen oû sone
closeto th€ gingivalmùgir ùd hwe à mrt suif..e(Iig. 5.rl). l€sio$. Thse lesions.afl be arrcstedbr' plaqre.ont.or nLone.

Figure t.lo À bne\'lng ftdiograFb r bcnrg r.ker. Tb. tlm n in

a lilm hold€r ând a rod.omcs oùt ofthc môùû ^r.isiÎ anAlcsro Figure 5.12 ÂtrGtcd smooth rfacc .cFical lesions.Notice rhe
dr tilm. The.one ofthe x-ray nxchinc n liftd up wirh i.n.ùhl h€rhl,y gnrglv.l mxrAns irdlcatnrs sood plaqùe removxl. The
aûa.hmert to thn rcd. Tlis .nsùes â reprodù.lble ser ùp w'th thc P o, , l , J , l r ' l r h j b ô ç ' i ô ' \ " : 'i o ' 'n
X{ar beam pdsing ar ight æsles ro dre frlm. pick.d up ftom drc moùdr (SeePl.r€ ll )
 a7

t P , r . : . i I l . . l , . , . r , , . 1 , .
ligurc t.Il This cftpring molù r!!..s.u,cs ftcc but,t r nôr
fig!.É hr .ouftesr ot Drrt,l ll!l./n lsee T,lùe I 2.) .xrsed bI dem neanized,dis.olûtr.d dcntnrc shnnn! drro!.qi
reLlivelr irllcr .ùmcL. Tlrir Lenor vè vls ble in aÉf.n. ôn
btr.rei.g râillognFb. llgùft bJ ( or r tesy of Dar.l Irlzit.

ùisiDg ùlcro.ùliti.s. A l(5n,r drxr ha\ bee! trissed on llNrl

eurrinùûo. bù1 loùn,lon.a,lùEmfh has been La.lledLrnklef .ati6
llig t I I ). -ùloreùdlafce.l lcsions mal |Bcnt âs .a! nies erpos .g
deûirr (fis. t.l8). Crvilâ1ûl L(iiô.s irc ù{xlll rislble nj dentite
o! a biteNing tu.liog'qtr Caliùted oLduel Lesions.$'hedtf
miù..aritis of.il]ties do$n to deûtnre, ùe uiùrlL! (tila bc.iuse
rbc patienr cuu,ot cleo ph!!e où1 ofrh..ù'iri:

Approximal stfuces
Somctimcs an cnxnrcl lcsn,n i\ visible Lre.aùserhe ùlja...t nntll
hrs bce..xnâ.tcJ This is often !n ûere.l lelon (F_it : 19) Its
n,fl;ce is shinl and rhr lcsnrn is LrnNn be..!s€ rt has ti.kcd ùp
Iigure t.l.t l l,e Ùt!.e hls n!$ beendisdord, bnlslre.fto yr,n tiom rl,c moudr. Hoçerer. $ùâUr ù adjacent û)th
Èmolr all{rined rldqùe aDd rhoroùgh\ driÊd. À *ùite rlror
trec u,les a ,lirrcr lisuxl caanrimrion rrd roÈ tlre b;tesrng
l e s i ô rl \ r , ù . b \ i , , ! s f n , e e n û , . . e . o r l i e i i s $ f t s I g u r e b y '.J ,. | _
| 0
.aùr6\i .f Dùtrl rltlàL (S.. Pl.i. I i )
\rr L. ,t r.

Rodiogl0phi(
inlerpret0tion: poinlt
imporl0nt A definingmomentclinically
. Ai rt:,pror,ûr'l .nrrncl ndr,.. tlùt iDp(( io L..in.s h.. Ùrf h is iml,oita.t û, dis.ùs wherl,er progie$ion inlo nefri.{, o.
Lre r I.riof nlntr.|orùsl1r ls i,!, nr il.i.., ro slh* or i,tull.S.rfll .avilario. r..l.tlni.g mont.ts rhLi.aliy.s hr rs leson man
. 1 l$l.n ii dr..rànrel .r ù bli.slng ,itll.g!trI)1, i hn..l.!l.rllt ln .genetrt is.on.enre,l. ft his xl.cadl bcc. rred dirt the dnirfs
dr dentine. Tlre hri.f, i. nnllkelr ft be.RrinÉd lesion in ihe
for.e ibr frog.c$n,n is rtrc metxboli. â.ti!it\
. lL lsro.1isibl.r.iraC.lh. t.,r,,y.1,h.1{jio. i.,n tslngl. bi.ÊLn, l. thc un.avitared le\nxr, tlis LJioiln rs oi rhc ùnth
birN,rg ndogJxph.Ir is illi n.t |oslble o tnoN \rtrlthe. r Lesion sufa.e. wlit in rhe.a!i) the biomtr$ |luEs rhc hole Às tli !s
n.rvntr1ùl toù ns rFp.d,n( d idiorjtuFli manlueùeDtis.on.efl,e,IFhÎn,iftcNnrùcdrÈrthepdieût.rn
' ' ' I o . l - ' o r' D r . ' t ,
.etrir.J ro lù!e lsloi t,,.Af.sl.n or àn.sr I. it .s.rr Ll .. lte iû.l.vmt. On â smoorh .er!i.àl s, rli.e. r looiiùhsh {a. rcmove
ilm lr.lJ.s ùrlL b.rnr rlFlig (l.vl..t s. .hrr an i.vs 3e
reFoJn.ibtÈ Sli!hr xlrer,otrs ir rhÉ irÊ"n anAle slll xiÊ.r flxqùc fr)nr a .avit] (fig. i.l1). Oû rt âtittoxin,il Nià.c .rcn
drc inost àridnft of tlos\ers .àùûot rtren r lsion b,r tlaque
. L,Lreop.. ûrtr,lllLmnir!û
,onùrn rlonc t,Ê.lu\r rlrt flos \ill nor ûxer rhe calirl This ls
is tut LrÈLttuln, d{rrtn,g û rppturnt,L
.raûr 6,0., Lrt.ù L. r(n ro.l.r!.r L.rûÉ n, dûri". wh.rc ôt)..xr n'c dcnrÀrry ls c$eûriâi to r$ore rhe,fregntv of dr.
ftrth suda.e, $ that.he prtiett.rD deù..
 5 Monoging.nies
inenomel

Fisurc 5.18 À cdvndtedlesion.xposnrs dentifle. Thr re$ot {

tsisue t.l6 There h a mi.ro(avi.r in tbe white s|ot lesionnr tbis visible ifl dentine or a bite{nrA ndiogmph. lisue by.ourtsyof
o.dusal ruf{e. It looks like a sll8htly wide.ed ftsùre ôr â vn.lr Dt,tàl tJfddk. \see Ptûe 16)
hole left br â voodworm. Histologic.lly. ihn Lcsionis *rll iflto
derttrc ard it may b€ vislbl€ in defltlne on a bitewing ràdiogrtrph.
!isù.€ br court€sr of Ddt / Ul&re. (SeePldte I 5 .)

Figure t. 19 Àfl d.ere.l sûooth srrtace approximal leson on tlie

mcsia.l sujice of the lô$Ù seco.d mol.r Thr lesion lrobably
stotlcd prcsrcsing aftefexûætio. ofthe nst molar

Fi$ùe t.17 A bnewifls radiosrapLrshowing ocdùsal câri€sln dcntal ream may frnd usefùI. The tem pftlentivt ûeatmert
d(n,tu,a,,. {( ', ..r '.\", ,5 ., n ll 'o' ,. i usrd becàusethis implics a.tlre inteNentiot by the dentâl
ble on the râdiograplr. thàt ls skilful. timc-consùmins,ù.1 worthy ofpavmcnr.ft n
ù obse6'e'ora vair ând warch àpproach.
Àll p.tiens should be put i.$ a .dies risk category, ei
Cariesmanagement hiEh or 1ow$ith all orh€s desianated asmednm risk
lher'r.!,T.r ", i\. " ,., \"
menr, and i. casesld whlch câviries precltr.le plàqx€ cont.ol. Palientinvûlverîent
op€rat;ve æâtment n also needed. Flsùre 5.21 piolldes a car;es Tbc.afbùs ptu.e$ c.n be arcsled by nretl.uloùs plaque
conùol che.klir thar prn ritioners dd other menLrers of rhe dietary modification, judicious use of flroride, and sr
 ( , * ' ^ r , s * . 18 9

Figùre 1,20 À blie$ing radiogralLrshoving .ârious re!ons 'n

{xnelon drÊ distrl sù {e.lithÊ t^t ùôlarmd thL xrcid s,F
fâceofihe sÉco.d mohr. thtôlog'iâIly, rhcr l.slons wlll bc in
deftiù bùt dry âre frobâbly .ot c,!ir,1ed.

.{ l" " '.',p'- ' 9'r'_rl 4 i \F oôp'rr

tion of rhc fat;cnt. Thc Fticnt is in .onûol of his or her
ow! dmral deriûr be.âuse it is the patient, loi the dentist, whô
influen.e! the.arious prô.es. lor this ieâson, it ls ùbsolulely
srnlial to i.voht rhe |âtienr tiom dre ousct. and the parient
must æknoFlcdgc drc problcm ard harc nxne scûseot .onÙol

One ofthe best (àts to ernE actile Falient cooperârio. is to

nûn the pàtienr ùtô 1is ôr her o$n pe6o!èL detrlis!, so dràt dre
pùiert cd perform ècheck upelery dây. Thedentist should give
ûe pâtient a mûior ùd shôw rhe pment his or her own caious
Lesiô6.The dertist shôu1dsho$ the pâtient the white sFot and a
rcd ùnd swotlen gingivÀl nârsin tha! bleeds on trobina. DirloÈ
in8 snution should bc applied b demonrEte dre plaqu€ in t]Ét
spe.ific posirion. The dertût shôr1d explrin ho\t FLàqle causes
caries ànd shôw the pètiert his or her orn radiographs. The Figure t.2l À .dies .onùol .he.kli$
denrisr should explain thâr rhe pâtienr is ]ôokrns at decay eûd
thar tbe causemu* be found v, tbat the pro.ess can be .rreste.t.
It shoùld bc .'{flaincd thar onll rhe patieni .in .rûy ont this
pan of rhc rcatmcnt. Tbe abilitl of dre pxiienr tu ùnderstàûd
\ryhythe patielrt is a câries sk
his or her e$entiâl role in discâscconùol A.cady idflùen.es tht The.ientisr needsto de.ernin€ drc.cla.ive impoitance ô{the !èr
ntu .dies promoting l:aclos for rhc indn'idùal patient. Unles
Âbove a.U,rhe dentlr mùr besin ù, determine Ie pètients rhe prâctitiorer an,l rhe tJâticrt.an work ûgether tô find the
wishes with resFect to the caries problen,. whàr eftoû is rirc cause ol ùc prcblem. relevâtt solutioûs cùnnot be tôu.d. Thc
involved pâiient begins to lnderstand the rclcva..c ofth€ paft-
!ùîien! prepâred îo mak€ i. cariesconnol? Fillings havc d impoF
tùri role !o llay in reslorirg cavtries and thus fâcilitarina the neship apprôa.h èr.l oft€n ent€6 i.ro rhc dctc.rlve work of
pâtierfs pl.que conÙol, brt they ùe only part ofthe treatm€nr. detc..ri.ina dre.aùsÉ with ldnirèble gusto.
'fhe
Dire.t qùestioriûg ôr àttitn.les mày nôt be helpfll, how€v€r, fèllowi.a sln)ùld alwrls be checked for their relaiive
becausea patienr may teûd tô âr$ver à quesior in à way !hat, nntoltance in rhc hiÉjhjlsk patient:
'pleàses' .
the deûtist lt cd tàke È 1ôrs rime before ûe paîi€nrr Pld.t&..0"î01: Aài\.losits âgent shoul.l be ùsed so drat rhc
airtùdes are revea.led.:fhese ftùùdd de iûportàût in dsesing palienr can scc drc rclatn)nship ber* een plèqùe an.l carious
po,o^.,,.1 |l-- na.lr'.J r rer'11. ' 'r-e
 (oriesin
eo I s llonooino momd
l " -

Dtu All Fticn.s designd.cd2\ Iigli.isl. sln)ul.lkeef 2 dier ' q , . 1 . r r " l r ' I r o r o b
.or maru.l dertdirr'..
\ " . , 1 , . . . , l , . ' e ' l o J b o " d
I L]atjlt l)inry: Tl\e F.ttotiar.onrettol d,c {'aÉr, tootbln*e,
occlusal s uriùe of eruPtnrg tcctl, Tlie e.ùPting îoorh \
and dl ûoudrva\h the t,atic.r ùes shotll bc.he.ked sh mL€$
lifc of tlle arch an.1 will bc nisse| b-v tlte b
SahLaryfluL: Both stimùlated a.d ùn{intLhted salivarv brcught rn at risht ènglcs tu tlie r..h (Iig t 22) It
flon' shouldbe mosurecL. noted rhÎ ar o.cLusâLstiàce ( mor nN..Fible 10Flâqùt
Sone rislr là.&)a n,ch as plique .ottrol, dict. rnd Ihotidc ùse ùàtion dùrnrg erulir]ot ànJ rceth càn take ûonthr t
xre anenrble o 2ltefttion b-! tllc pâtient. Odrcf risk ia(o6. {.h T'here
erùpt. s buEe indilidùal lrrlarion rn eruPùoû
as x dir ûoùrh, atc tcss .neûablc (, xiterùtion ror instâf.c' x NIo1.6.akc longer io cflpt than Pftmolds but Nnhinâ
Fricnt snh Sjôgtens sr''ndrometay alwàls be at high risk and ûntrhtype rhÊfeis greârvùiâtion tlom peson roPeso'
ùaI als Àrs hàte to maLc sùentrous ttcventive eftorts. vcnrion proarâmmemust. th€retotc.be tuilorôdto the
A dcnrâl piùtilio.c. is also utlil.cly tô be rblc n, mo.liii'of rhc in.lilnlual. The paticût anclparcntshouldbeseeooo
èlleviarc wiâl deprivdrion inâ partlc! la. Ftieût, bur inat be able 1 l . " l , l e ' I 1 ' L l " r r P
ro obscne locidl li.rors .hdge ove. tine, sonerimes tôr bettcl after hon,e.lca nS. Iadris n.onsisttfltly not xthieved
.ûd sometiû,es for Rtse. trtiof shoùld be Aircû to fissutc seâliûg th. rLrfdæt rhl
blo.k the Aroorc-fosù s-vsrcmthùs ridinlj !La!ùÊ.ômml
l\,iechanic:rl plâqueeontr.,l \r{ihere a bire$,ing rà,liocfaph shoq\ dn allmxiûa fl1
R r ' " , l a r ' l " i h " o ' r d r r ' À rhc ontr eMmcL..he Pd.ic.t. ôr dre târert nr !|Éùtof '
liuoride *ili prcvcnt the lorn,,tn,n of lisiblc lesbns ând iill shoul,l be dto.r. ho$ to ùse dcntal flo$
affcst le\iols dra. ha'c âlre..ly lb..rcd.
The delrist should.he.k ûherhcf rhe prtletis nnthPa$. coû- Piofessi0nâl propi:.yla;(is
tains nuoride. It is sugEestedtliat s.rau.Lliklr€n shôù1d ùse rhc I..afies icrn'c pâtients who do not maser Pl.que ùnûol,
adulr. fani\ pasre but a smàLLl,câiized Potrio. ot toothlastc in pârients s'ith seve..l-t decredrd sa.li!trrys.dûrn, rt
shoulcl lt use.l. Snrâu .Iild'en .annot stiit and wi11, dretcàfe nece$rry tu $,ppon rht pitrie.t sith Profc$iondlroth
svdLlo.! rhc lrâre atd dris pre.aution witl aloi.ti!ù.fôns :fhe pro.e.hre is des.ribed ;û lig i.2J
The deniisr sL\on](lshow rhe Pttienr, and tLreParent ln ihe car
ôfàchild. rhe *hite spor lcsioûs dnd rlrcn dls.lose lhc tee.h Thf
wilL deûonsirarc ùe r€l.tionsh4r ôf the biofild to lhc lÈsion
Useol fluoride
T
Nos'\,ât.h theFriÈnt in actlon wnh àtoodrbrsh to remole tlte he denri\. rhôùld che.k rhdt the Pètiolt ir ùlng '
plaque, helpnrg inrpruve te.hnique $heÉ neccsary' tuôrhpdsrc. Some fodu.ts to.mùlâte.l to. sensrtrrÊ
T sode herbâl toôthpa$es dô no. rcntaiù 1luoride The?dt
hepÀtieû! should beencoumacd to feel drc shnr), tldque-free
ufacc *itLr dreir tongre r'nh drc aim of achiclitrg tliis fccl at bc used n icc and cleâred uom the nroùrl bv sll
da111.d
home The denrnt shouLd norc s'hedier thc Paûent .r, rcmove only, furhcr tlnt {igoriMh rinsing

ligure t.22 Cleafling à |ardl erlfted rôodr witr . r"rhbnrnr'

The px.e.i d,oùld $d!d beh,nd the.liild Ùd bri.g drc bNsLr r. 2r
rshr â.gla ro dre ar.h. (By comesy ot Dattult-tllaL)
!_iguÉ 5.21 Ptotesiôml Piothylitn
 9l

rc 'onhne sugar
A reasonableain lor tirf fatient \!oÙld be n) Û!

5èliYan/ l'lc\,!
'fâ'ry doutLl
sâlirdy flo\ slx la be r eânte'l be'rut tlicllng
mav be subic.tive rther ùxn i'tuJl
'hc$ifg
When the salivarr glands are 'iPdblc of sc'rerins
gÙln \ùh ân 'ltif ial
rùm {in,uldes saLn'a{ flo$' A.hewrng
in to a
'.eceneL (s.rbid onïLitol) should b€ 'hosen i"eferen'e
x-vlitol
sLgr..ontainlng gùm Of thc two âiiLll{:iaLsweeteners'
scems the bctter is this pro,lu.t maI $ll)Pres
a.idoncni. mi.roor gaùisnb
I n' |'| |\
" r ' . ' ' i
l o " l l '
be'nuse th'r dte
L'ao's parier6 who aie alreaJ-! !t higli risk to 'Ùies
Fisure 5.21 Àn oittrodo.ri. nig|rmatel NtÙLriflcshit' sfot
r,,* r,*mcA o. tootb srfaces nroù.d ùe oitho'lonti' Lrru'Lc6 Boih
P]licns with lcr-I,lrl foutLrs mar' bctreli' fdn ârtrti'i'l
ùnlàuùable (SeePlxre l s' )
Fli.lùe .orûol ân.l d ier * ere 'I'hesc
ûrdl be bxsed on caLboxrmetbvl 'eLlÙl(ae ildr
srlilas.
product is also
ùtl.led.âl.iùû. phos]tDlc. ând uoriJe Lons A
A flnoride ûouthlnsc (0 0i97 sodiûr Èùornlc) nsetlcverydxr rrailable base,l ot for.inc mucilr bÙt titis nolld oblidrl! be
ilthoùgh
is a ùsefùl lluori,lc n,Pfleme.t h a ligh risk Patieût una..ePtable to sote rctrgron\
, " . . . o , ' r I . , 1 . . . | | . l \ 1 ' , " "
no! be used in drildÉn utdef 6 {'ln 'dnnot
T|esc rinrs shoùld Iit5il11: 5tniin!l
thtre is I tisk Ôl tluorosi\ if rhe rôhtron 1\
rinr atrd ryit À is tissurt
are r scnsrLrrc n À. i.lùùnal t'fe'enriae Lool to halt 'âries lfl)gÉssnxr
$lxlldved. flùofide mouthrinses PrecxlLtron or crflnol nnLlv Pre!Ûtr dÉ
scaling. If rhc Patictrt Pùrcnt
.hil.l.en werrits aicd onho.lônri. dPtliarces' fbesc aPtlian'es rhe b,ofilt in pits âtr'l fi $ùres ot tbe crLF! ûs ot
cràb lidû,ctrt ot
nxle flqùc dtrol mofc difiLcul. àn'i verr ùt\igbtlr white stot sc ûecd to loo! ât Jtcrtutnk ûc2 of
errDrc.l tccrh. then
resMs on forn u-n.l the br,.kets if oral h]lrienc is 1'oor and sites O"lùiûs tlle or tissÙrc
proie<tilg these luifcmbl€ tit
,liet urfarourable (!ig. I 2'l) tsolb .hLl'l'en 'nd Pàticnts wiù'l|!'
.ie.hrni.rlll is onc {r.n meù's'
ù,uths ràvoùr ninnnally asûingenr Pro'lù's
l*r"," t"4"". xre mxterial\ that aÉ 'heûi'o ùc'hrni'1111'
Surgc{ rlfli..tion of Uuori.l. vâmish is r Ùselul Pre{cnrn'e tngfcs or
.ckn,€d sithin thc pn of il$uft, ù'd dN Pret'nr tlrc
Dcdur€, rnd tarticularly valurblc h 'h'se unLikeL-vnr 'omPL-v the sealatl maÉrial is rctaincd i' i6 e'riret!
'lhe s bn)fih,. Prori.led
$'ith è tlài]y nutrh\tish regime. mctlrod of 'ttli"lion s ù L h r ' r l n e r a b L es l t e s
ànd thàt rh.re is n o n r â + i n a l l e a k â g e
given i. Figùrc 5 ?l
reûrin ftee 01 .afics

Size ul tbr f1Ùt'tcnt

DieLilll âalvl':e âo'r
21 shos's We Lno\, tloû .Pldemi{nogic.r1studies dùt dre Ùold tis
Dietàr' xdvice shoùlL.]bebasedon a dicr sliecr ligure i O"l$nL 'anes
kept by â nlan \tith dan,! rpPoxiûal fisures at tlue mosr likel-v tu Lrccoûe 'diou\
o.e.lay l" a Ait shect voung bûlcn rr
'fhe
o"LÙsrl hâs been slio$'t to ,..où.i fo' sltl of th' nnl cÙLes
tc,i.ns i" outt ena,..l on bitewirg mdiogmPLr good e{idet'€ tÉo
\er€ âlrei ll' fiLLe'l' children beNcen: rnd lr reà6 ofàg' Ihe'c is
r'isures oimolir teedr 'lûlts to indl
ot .itioDal ep cmiologi.Èt datt on boù 'liil'lEt 'n'l
The sùgdr ârxcks hale bcet hi8ltlighted, an'l ihc rumber st'c'illc sites
been ntitlc' ât rhe toli Tiris sn'es the catc tha! the Ptcdilectn,n tàf..rics to'lcreloL' oùthcse
in,li'icluai anacks bas ùlÙlt liic'
'ùNe ànd rre .ontinùcs tlùoqlt f.om tbc time oferuPrion iflto eitlv
Jcntnt the ol,Portùnit) to cxPlain dr€ Stelhcn b1
tlt liequenc-' ofsùaar inràke Tlre den- S!,.c t|€ a.tvenr ôf a.ld .t'hing of e1râdel as desctibcd
i-po.r'c .idec*^ng rcllablc meàns
b ger rhe to sÙlsest 'llinges Thrs Buoto.otc il thc r9:0s, Nc ha!e hâd in'ltrsinsll
osi 'Lrould uy txrient ihis dÈ
rhe m set fcallsti' go'ls 'n'l 'Mbles rhe ol .ûâi.ins resin Dateriat in Fis dd tissÙrcs Dc5Pite
ÀrD()dh helDs Frriûtr Émâins lo\r'
" reLdtiotuhil b{$cen dict àrd 'dies hd provision of seaixûts. espcciallv ir -voung adnlts
,1"',lt to sc. '"lctL'et tt r a l i n g 1n
T
hedcntis! shoull 'he'k thrt the c : t l n ; . i " n , t u " " c o n c c r n sa b o u t t h e l ) o s s l b i l i t ! o f
beenundenrrdbr rLe r,arien! is 'lifficÙlt Otc
àrd a list oÊf(!trls that rrc \afe f(tr te'th .aries, snrcc .he .icteùion of s'hnr sPoG lesiont
mù,n nerls àre rdcqùte, into lcfltn'
be {ùd1' nr thc Nerherlùn.l\ bas dem'nstrtrted i'sions
n.r Lre heb{d hcft Thc nesotiaÉd 'Lietary change shodd Fof thc most
p,p"., sô thar the pâtien' can tâke this rFav and ,letected ra,llo.qraphicrllv, bclù{ seâle' {rrÈ'4
*.ord"a o. incifL-v or itcitlent Lcrons
aEree'1rn Daii. or rhecviden.e.l'âilxbl€, seùling
D.ù(lcf at lei{ft. The d€ntist shoul(l rc'ord the .soiLs hd
b e m a d e a t i h e n cxt visit i.". *" oto". () 1eâd to.àries ttugrcsiÔn rltis tremi\e
ibe "ues v' tLut.r*c,ti..nquiry.ân
92 (oriês
5 Àlonoginq inenûme

( 1Y0 '
THUFISDA

7:15 M k shake

3.30
2 pàcketsot
!!.93!
1 0 . 0 0 Coifee/suoar
MORN]NG
Colfee/s!qar
Twx.ârdy

1 23 0 Pieceol cake
M!!1
1 53 0 Coiiee/suaar
AFTEÊNOON Tealsuoar
1 70 0
Evenng
19.30 Brlele

EVENiNG Aalc
22.30 G âssôl

! i$re t .2i ()ne dry our oi a diet sheer.Thc sù$r ârtâds htrvetred, unded ired rid ilt number of rdildùaL atra.Ls ( l0) hs bænrrir.

bccn tered .linicèlly In s)me tfiak. r.erh schedule(l for oftho
donnc extm.tiôrs $here thcrc sâs clinical evi.leûc€ of Jcrive
câfies, hù'e beer seâ1edprior ù cxùacrion. ltistolognJ exJmhâ
tion of theseteeth dfter exûa.rio. i.di.ared ce$ation ofthe.dies
froces. Other Ùials have rakcn enàmel Lriopsiesèrd tesrd fof
mi.mbial acliliq L:eforesealantplaccmcnr an,J âfier eariaûion of
,I. .. I i.,,. { q - ' \ e . l d . .e . - Ln m r . q | ,
Points
to remenber
. Oc.llsxl.&i.s r..ounrs aor 3lt;.1rhe.âfies 6unl$ oft-lr
. , ,1.D- " lla ,\,.\ 1: \d,
ll% in tnslând, ll4 ln $r.l.s, t2É in S.odrnd,4i% i. Northem
. Àlter l0 yeas ofrcc. mear number of.ari.rls reerb sigriJiln,ll
o s ' I ' d . .
. 1993ÂlùlrDenràl lioLlSurver: 5,i.jxllxdnlnhàu rautr5,
21,1 .{ 16 21 ye^t.k)s
I ndicat ians .for sea lant s
As in cadi€.discuslons in rlis.nafrer, scalanrfldcenûrr needs
ro he coff eredn the contert ofrislr factors,both for the indi
rldùâlparient and for irdiyidna.lteerh.It is riràl rbàr seara.sare
rna.ed iùeft rhc.c âre solrd cliùi..] tndt.arn,nsftr dolna so.
$rpprted by appropriaÈ râdbgraph\. in rhis.a\e bitesi.Es.dd
Nith .oûsideratiôn for the nedl.al, dental, and $.ial hisoq 0l
the pètieùt. TLe Biitish So.ietr of Pa€diâri. Dcnris ry hys do\r
criteri.Ior se!1ûr pLa.enenr, ând rheifAùidcli.cs arc curcndtii
As fâr ùsprtieût sele.tioû is.oû.emed, the esseûrla.lelenem0f
.hosc suidclincs 2.c diû scâlân6 rre i.]!ised wher a driLdû
J r'oullg peBon ls .onlpromi\ed in !)mc way. and in {bom rht
developmeù of.dles âDdn)ilB ûkatnrnt is a rnk. This is themdi
caregoryofprriedrs in s'hom scala.rs ii,. dic ti.imarytlenri.or mr
ycd- be xdvisablc.Thc.dicr cârcgori.s ofl]arie.rs for whoùs.ùhocs@
adrlscd ak rhoscwho bave expe.ienceotcaries m triùa$'eerh
If rhc risk t&ro6 ourlined above dre rleùified !r a Fùft'r
thcn ir is pùlent to sealall srsceptible srtesor pernârent teeÏ,
as soon âfier eruftion âs is trù.ticalrle. v/h€re c.rÈs hÀ rfe.trd
one or more pcmranc.t.rolar rccù, dre rernâi.ifg soùn,lti6md
lrss!re shoul.l be se.led.
Proredure
to odoplforlherpplirotion
ol seolonts
D - l - r r " ' , 1 e - o ' , . 1 " ô ' l " .
De.ide pftienrs deff rnk.âregor (lN - les drân 2 orherlesi.s
D.(rn,r. jl pdnlr iiÉ pr rld fis{tres thar anÀrlnl.àl\
trÊdisFse rô Jêvel.lrn,cnr oasrgn,!i.n ar.xs
 9:l

Efficiencyanrt effeaiaenessof fi: sare sealanîs applying fisrùc sealûs it cômbimtlof widr ilùorid€s and, it
Iftedrr a ûerhôd is efficient or e{leftive, that is, does ir do rbc some cases. chlorhe'ldine, is superlor io ternN oi pntre.tiôt
job foi leâst côn ànd .toes it è.hieve dre stated obj€ctive, is a aAalfs câLicsthan ù\iqj these ûôdâlilies alonc.
mdù of nal ùn.ern û .liri.ians. Mareti.rls
simihrly, .liùiciùs ûeed to be confidert t|at sealântswill bc
lhe most suc.e$tu I màte.iak asflssu! sea.lds, iû terms ofreten
(ûiied ânJ thàl cr.es ofthe tirtiâl or nôr scàlcd$rta.c. ahi.h
tio. and rbus cadcs pftrention, are dre bjs CiIIA rcsins. These
naJ'to ùndet.ted, riU not result.
h2vc bccr in ùse \in.e tLre 1970s iod ha\t nor bccn stLperseded,
The firr lonAltùdinal *rd1 rc repon on the 6e ôf fi$lre
àlrhough nei€f marerials eûJoy â vogue urr;l lonEevitr rudies
suLants empl,yed a self-curinEresin rhxt sâs âpplied ôdr oùce ùd
iodlcare drât thcr do nôt.onpère well with drc convenrhnxl
nortot)])cdry ât rny timc subscquc.dir Af.ef 15 leârs, 28% of the
resûs. There has bccr .oncern in receùt Ieârs oler lhe porcnùal
rùlantsse.e totally retài.ed rnd lt% vc.cpaftiatly rerained.Slg-
ôe$roseni.ltl ol.csi. bascd sealaDtûâterièls. tsls GN{A is s-vn-
nitic2rd_L, more of dre se2le,l tccth rcmâi.cd .aricr lree: 682 6
thsized lrom Bisfbcrol À (BPÂ) âû.1,theoretictlh, resi,lualBPA
.où!aÉd witlr l7% nr .he non sealânt g.ouf. Â similù ùia.l ln
.otr1d mnic lhe role of.atufal stetuid hôrmon$. This risk is
Sw&lei look ihe opprtunity to repair ibe sc,lan6 on fiN mola$
negligible ànd sl,ould .ot dcùâ.i from die very psnive heâlrh
sb.n thc sc.ond mol2s scrc scalcd.Dx.a tum thls ûia.l indi.êted
giin to. a t.fsdcd sealantprogidme.
r h . t d i i r 2 0 ) e a A , 8 7 2 ô f t h e s r i f r . e s w e r e e i t h e r t u l l )o r t ] f r i i l l y
sok,lar,l only ll% ha,l ac.ive ci.ies or hal bccn .cstorcd.
Moteriols
usedosfissure [qrlvmoieritls
seolcnl$
given
leosons qgrirstth€useol Jeolonts (r904-r950)
bydinitions
! Nor ette.iiv+serlart .,rterlÀl lo*
' DmgÊioasÊÀling
in dent .âries zin. rhosÉate,æralgû ( PrôFbrlac.ic
o,lorrot.mr)

. Not eli.iert ,erLnort teethth?nvonld evèrbe.ote.arious

' À.nle..hrnr 1.,'.s ihc r.nùin.l.r !f rlrcs!rtà.evùl.enblÊ
Newermcteriol:(1966-preient
doy)
Thn tuûospe.tive analFis.,fdata ftod dre publi. dental heallh
' cyanoa.ryLxteÉsins
ptugrimmr in Sweden wôuld sugges thàt rhe systemalic place
nerr ofsealantsto the occlusalnL.Fa.t\ ofpernaûent molar teeth,
sooi after erufrio.. is a.ost cfièclircpùbli. hnlth medtrre.
\Vh ile eUi.tn'c.e$ is nor. rhcrcibrc.in dispùte. .o{-eÉi.ien.y of ! Gi6s i..oner.emen6
Falans isaconccm ofclinicians and is ânothdftas)n why this pre . Resinnûdited glas ionomerccmcns
!ei!l!e meNre is no. in norevidesfre2d uc. Ccftai.ly. the lndls-
ûinimte at]I)licârion of scalâû6 ro cvc.l pir and fisste, of every
In Aù$âli., g1à$ ionomer cemcors (GIcs) afe ùsed as sealètt
ftntrhlfl a.ll patients n not a.osGeÉl.ient app.oa.h. As with otlEr 'l
ûneriàLin rhe School Den.xl Servi.e. hesemJterials ùe 2s etËc
tudlres,seùlaùts need to be targeted ar tboseteeth 2nd indilidùa]s
rilc as resin-tased darerirls in preventira ca.ics. Hos'eler, ln
thr! ".e a! high isk oi.2nd tiom. rhc dclclopmcnt ot deûtal cdits.
Anolher feature i. the argumcnr suitoundin8 .or i! who Ss'cden. ihe erideû.e or co$ effecîlvenes is ic$ dexr: pla.ement
oflhc matc.ial ls ûore effiiient ifthe cLinicia. is â$istedi bùt, it
âppliesthe seàlant. h mrûI coùDtries s'her€ .herc âLc aùiliary
progmmes, fisnre seâlâns be.ome more co$ etticie.t. Ffticu- takes Lonse. ro pla.c rhan re\in-based nèteials an.l lbis 2dds û,
the cos of the f.o.cduft.
ldly, wLren.arefully tùgered.
Glùs ionomcr.cments have the dvùtage draî tl,ey relcdciiùo-
Iûpli.ir in bôth argumerts on elficiency and elièctivenc$. is
ri.lesi resiû modifie,l GICS .heoreti.âilr, from , ,r/r, labora.ory
rhe issue ofmalnrenan.€. Rrudar rerieùs èrd top ups of los or
parilâllr retained seâ1âûtsde importàrt.In Swe.len. loraiiudi.al based stùdies releascmorc ]]ùoride intô the èdiacent enamer â..1
lhus have drc t)otcniial tu prevent .aries in drese si les com|â.cd wlth
stldies over 20 yeàs hale shown thât mâinrained sealants pro-
flùoride-.oftaiûirs resn, based mircLial. The latter .lsô nffer t|€
dù.c a ldrAlarlng .afies pfeventive effe.t. S.dly, à Scottish
dis.dvùtage thàt flùoride .el6c nral.omptudise dt jùegnly of
trcTe.rive rudy nr lnverigâie a srstem for è$*snig ûe qlality
rhe ûàteri.l:nd ns 'e.€r!io. musr. therefi,re,be i! sone dolbt.
" , . . ' r . J , s J _ r I l a , . b Ê , , d F -q ' , , ' ' t n
one dlrin.t âdvàriage 01 GICS is diar rhc nrâterlxl .at be
of covera.qeor caries prevenrio.. Th;s scFes nr emphasize the
placed on.he...lLÉal surf.ce ofpàrtlalh erufrcd tcctlr that aÈ
rmportanceot marntenân.c
notoLnrsLy di*ior1t to isol.te. and lhus seâl well, ùug .onven-
C am?re hen sile P re,e nt ite îa,. rional resin marerixls. Elen if orl"v Fartiaily .etaincd, slrile i,rt
llssure sealinA should not be viewed ir isolàtion from other rhey acr as a {luoLlde resenoir âûd there is evnlence ro shos trrat
prevenrive measures such ês dietrry co!rseLlnr.q, ordl h)A1enc mâtcrixl may be retuited $elL nitu the.lej'dr ofdic fisurc explain-
iistrùct,or, ând toFi.âl fluorile âac.s. Sùdics slhr that ing rhe.ùies pro.eclion otien itlôrdcd despite appdent los.
ea | (rjesinenome
5 [ionoûino
t ' "

Thc co.rcntn)nal resin-basedûateiidls ùry be eilher tillcd o. to (onridel

bsu€s ol seolonlt
in theoppliotion
!.filled, â.d liAhÈ or selfTolymerizhg. IrteNive trlals have bccn
co.ductcd on .hese âltrnate\. and diere is no good eri,lcncc rc . k lrophvlùis re!ù,rcl?

$r.qgestdrar onc is mor rùtc tr in ieds ôfretentlot ûd cafics ' \(hi.h $oldioû nedro,l t. ùse?
flevc.tio. drar another AfiUedresirsillhàvemorebulLànd rhus ! \VberbÉr t. ùse gel or Lignd !t.hair?
nray ftquift $me iinishing iferces is appl,ed, àlthouAh rhis n tue
. Whr'i mI.i.l t. ùsel
,fL'ûllel.e ' f e l l e l .', \ 1 " , ' , , ' i ' d "
. lchl.h .urin:i syn..i ro.o.siJer,
Ilowever, more liscous m,rcdab ma_r not penetrâte rto the sFce
.reat€.Iby acid ercbi.g to cnsu.c that there i\ agood mùgiml seal.
The choice ofùaterial ârd lhus drc mod c .f polrmerizâtion is
more â ûatter fôr pe^onal choice, since drc.c is no siEnill.anl
Ildn.tge7rent af cd1';esinto enamel and clenrine
.Lliferer.e h rerenrior rates betwee. rbe diffc.cnr modalirles. In the se.tior or diùgnosis of a.rive alll atested lsions, Ne
Vlsible ligLrt .urins of resins or ûodifie,l GlCs for that natter, des.ribe the cliûical io,l râdioÉinphi. diâgnosis of occlusnlcaries.
more corÛol over the se(in.q of rhc mate.ia.l. Thc cafly Lestun.àr be itrestel by mc.hani.a.l plaque conircL(s(
Eives rhe .lini.id
\\.hile .liniciàrs workins l. n,o$ ofthc dclaiopcd .oùtrùie\ will Se.tbn: ùfechJûical plâqu. contd), but if good plaque co.mli\
b,ve reàdyacccs ro.urhA lights, the sâne ls not ùue iu delelot consitently not adricvcd, a fisùre sealant should be plâtd
ing.ounûies whe.e self Pôlymerizins ùnerials mal bc prcfcmble. H.na{cf. s'here .le.al.ificnlion is .otcd and the pàtiett is ii n
h;ah{irk .aregor} s describc,l aborc. it ls deemed setsiblco
invcsrigare rhe fissure {ith du smallcst rund bu. Prov ed dt
Vcriolions
in lhetypeof moteriols
thrt moybe
lesion is .onraincd çirLû eùnel, îhe ,lefcct .an be dàde sood
uredoi seolonts with an dcid etch dalned .ômposite, $rpl'lcmcnrcd by a con
pètible sealanrmarcriâ]. k mnst be borne in mi.d, bowevdr,the
J signihcan. pro])ofth. ofrhese sites will be n,inimâlll xffcûe,1,
Chemi.il or Light .ured resins
irdeed will irave no .adnnù.ency on bite{,nq r2diogrxlhs dd
lint d.lQr or opâqueresi;s
shou (l pe.hâF bc.onsld€fed for seàlanl af'flic2tioû alone.
Resi , CICS or revn m.diflld GlCs On.c r.xvity ispieseùt on rn occlùsal {tt..e, are$ Lryllaqu
FluorlJÊ*lasif,g .r flmride ûee .onûôl aLoneis Àot normalll po\rible. Àt tlis $age d,c lcsb. is

Ap p Ii catian consider.t t ians (linicol

presenlclion
ondprocedurer
lo cdopl
 rcxcd qùcrion ln fthin,n r., rhe prepùètion lor sealantl)lacc-
. No scala.s bùt mo.nor aor
mc.r is drc .eed for professional prophylaxis frlo. io cnâmcl
conditionina. Thc .o.sennLs is tlbr dù is ror recesary ù.lc$
diere is g.o$ dcbfis on the su.fa.e, snrce rcid etchnrg vill clc2l No nedi.rl r*/dnrbiLirr
d1e sùrfâ.e b be sealed. l(her Fiophylaris ,s used, sonrc matcfi- Cno! (lic.âryâ plaqre.ontol
als )Fpeàr to in.reàse rererrion râtcs. ât lcas nl"rt, For exdFle,
N. l(stonss!$.n Lrireçnrg
solium bica.bo.atc or lluofide-.onraining roorhp.st€, :a comFrcd
with tumicc.:rhis.onirns the.ure.rll held vi€w lhat drcrc it . Demrnenlizêd !trrn$! rc . InsuF serlxrt drd moniior
no conrrtodi.ation ro usc of topi.âl fltrôrides prior to sedlanl
. rÊ$ thd.vô dilÉi lcsiofs i.

Âs well :s alterMrile mate.iak. many diftèrent xpprôa.hes to

. Qûsionahle d ietdâque .onùol
dre èpplic.tion olsealan.s hav. bccn advo.atcd. fof exddple, the
. No d.rtif,e involvemenrson
Ne ôflasers àûd.ir èbrdron in comF.ison virh conlentbral âcid
Biiewi,rg Edin,Amths
er.hing of the enamel prlor to seâlànt âftlicâtnn, of ev€û lder
.urinq oldre resin. \vhilc rhc r,nirT sùdies on ihtse alteniàtives DeminenLizel Dlttissùre

àrc v,metimes ptumiring, there is no goôd scienriû( evidcn.c n) More rhrn rro otlr( lcsions lmmel Lropsy..,1 rÊplrÊ
da.e n) suppoit re iûcôrporatlon oI ûese r.to cli.icalAuldelines rnh .onrFsite ro defe.tind
and they msr, as yer, remèiû nolel aftroaches drar feqtrife QL,e$io.able dier/plaqk Lonûol
occlusàlll$ùre Fnrûsnft
N. lenrlne nrvohement on
Orher i$ucs su.h as nreù.ds of innâtion {.otton rool rollan,l
sdlivà etecto. vcrsls ruhbcf dam l$nattun), ftiuid or gel eîchà.ts
,,. ',,e 1.' o olzqr.dd",_. '1"",o -.'Fn ' '
call\'.lltlèr$! resùls in rc.ms of'updn)r rxhnt fttentiot whe'e
one aff.oâch has bcen adopred in preieren.e to àùother.

ùsualllvisible in deftine on a radioa.aph and Dow oper.tive
intefre.lior is reqùired.The prefered melhodol resrorarionis à
In lhjs rechnique,the cavlty ;s enla.sedwjrh a small bur to
rccess ùe soft,i.fected dentlûe,which is nov removedwirh slow
round bu6 ând excavàtors.The .avity is rcsrored wirh âdhesiv€
fillln8natdials (.omposiiebond€dro erdel ùd denrineor (]IC
to eplee the denriÂe. topped oiï with conpôsite resir rô replee
lheelrûel). Â fissu.eseala.ris Dov use.lto protecrrhe remrin-
In the shoit term, the lonselity of suchresrorado.s,d judsed
by compl€teseal2nrretentlonàrd nô caries,would appearro be
good.Thls is not alwaysthe.de ir rhe lonA tem. However,a
significxntp.opoftio! of màreriâ.Iis uNally parr;ally o. fully
n.ined,.aries prevalen.eis lo\ àrd thesererorarionsefficicntly
conseûe toorh tissue.It is, ofcourse.betoldenôù the ciini.id to
tview andmaiûrajnsù.hrestoratiôns. Liftle or no dieaseimplies
nofe.not less,visilaDce.
Conclusions
Thn drapte.d€tallsthe contempôraryvlewson rhe ea.ly carioxs
lesiorsir €nmel, from the tine oferufrion ro rhe esrablishnert H o l m c n . 1 . . T h y l s û u p , 4 . , a n d  n u n ,
ofa biofilm. An ùndeBtandinsofrhc proce$,ar rhe histopùûo
lôgi.al level, is vital to ùndeBtanding .he potential fo. iorer
ruption of the .ontinùum and rhu; prevenrlor of progression
ofdenlal.tiseae.The drnamic narureoi the process,of de md
lemireralis.tion,is exploredas is the mrjonalefor the currert
appomhro diaAnosis.
Thereare a multitude of facroB to take intô a.count whc.
considerinsan ind;vidual's risk for the developmeûrof denral
cùiesand paft oi dre chaprerhaslookedàt rhe nost sisniicarr,
1ûrexample,medicaland so.idl background,.lier and nuori{.le
e*po$re.The rcmai.der oi rh€ chapteris devôtedto corsidera- IejersLov.O..2nd Kidd, E.A.M. (eds).DenlalCaries(inpres).
dor ol: the mûdgement ol caricsnr enâmeLthrough eviden.e
baedrmregiesrfo. eMmple,pdient and individual oEl hy8iene
h.tors, tbe role orfluorides md thàr offisùre seâ.lanrs,bur in a
References
C d v a l h o ,I . C . , T h y t s Û u p , . , â n d E k s r m . d , K ( 1 9 9 2 ) .
Resultsâfier I yeàs non-ôperative o.cll6al cariesûeâtneût
oi etupdns permaûentfiBt nôlûs. Conn"nb Dlnùûry
Otdl Epi./ùi0los,2o, rul 92.
Iurlhn Rcoding
Disney J.4., Grales R.C., Stamm,J.w', ,r d, (1992). Ttre
U.ilersny of Nordr Carolina Rjsks Assessn€ntStudy:
tufthe! developmentsin cariesrjsk llediction. c,uaMtr,
Ddlûtry OtulEldeflrialop,20, & 7t.
E k s t m n dK , . N J . , a . d K i d d . E . A . M .( 2 0 0 1 ) .
, . R . , R i c k e t t sD
O.clùsa.l cades: patholoAy. diagnosis and loAi.â.I manaae-
meû- DentalUp./ak,24,)aO a7-
FejerskoiO., and Manji, F. (1990).R€actorpaper:risk æsess
meDrin denial cùies. lo: I^h AsÎvneil j, Deùûry. J.D.,
Bà.ter,(ed).Chàpe1 Hill,N.C.: UniversityôfNofth Cârolinà
Dentâ1Ecolôgy.pp. 215-217.
Feierskov,O. (1997).Cônceprsofdertâ1câriesànd their conse-
quencesfôr ûdèrstanding rhe di,se^se.
C\nnrn'ry Duiittt)
Oral Llridùrjalls, 25, i -12.
H o l m c n , 1 . . T h y l s û u p , 4 . , O g ù r d . 8 . . â û d K r a A h .F A .
(198i). S.anninsele.tronmi.tuscopi. rudy ofprcaressive
st.gesôf endel cdies in vi\ô. Cdri6 Rutur.h, 19,3tt-61.
Holmen. r., Thylsùup, À., @gaard.8.. and K.agh, F.A.
(19851 À polar;zedliabt m;croscropicsludr of prosreÈ
slve sfaaesof eramel câriesin vivo. C*ie! Raedrh. 19.
348 54.
J . ( 1 9 8 7 ) .S u r f a c e
.hanSesdurlng.he drest ofaftive e.amel cafiouslesioosir
vivo. A s.dning ele.ûon mictoscope snày. Axa Odontolog-
td Scdûlt"dlia,45, )8) 90.
H o l m c n . L . . T h y l s t r u p .4 . , 2 n d À f f u n , J . ( l 9 8 7 ) . C l n r i c a l
and hisrolosical featuresobsered dùrins arrestnert oi
active enmel cùioùs lesionsin \iô- CatiÆ R6,atA, 21,
t46 t4.
E ' ' - + 1 " - . .' - - À i - -
I u, (,,!, !ov,,,9
Blackwell, Oxfdd.
Brnish Socieryof Paediatric Den.istry: fÀnùe sealans in
paediafficdenrÀrryra policy àacùmeùt.I"t. J. Pded.DdL
2 A A A ,L O , 1 7 41 .
British Societyof Pæ.li.tric DentisÛy.UK Nàtiônâ1Clini.àl
Guidelines in Pàediàùic Dentistry: Mânagemenrof d1e
stèined fissure in the first petû nent ûolâi Int. J. Pdùl.
DûL 2aoa,r0,79-84.
 Prevention
of pulpalandperiapical
disease
John
Whitworth

lntroduction ri,sxe, tlasnânr' bôdy flui&, àtd periàpicâ.l inidmation. Sù.h

h o l l o ù, b - , l F o , ,r e g n d e d r " r u p l p . , " . - p d , " i n
^!i.al pe.iodontitisis à term to drs.rlbe i lammaroryco.di which tissùefluids from the periàpexwould nov and dinsl€ sirh
tionsol the pe.bdoûtal r;sues thar àrecâusedbt' iûitants ir dre deaddssùeto form â. irritant cock@il,whosesùbseqùent per.o
pùlpcarâl system.wlile the majoriry of rheselesiors develop lation bàck through rhe apicalfdâmen would tuigaerpe.iapi.al
arcufld.oot apices,aplcÈ1periôdônrnis.ao occù. larerullyor in breàkdosr. The first sùgse$iônrhar agenEorherrhandâmaaed
tucal r€sions, asocine.t with ûy nâtunl or parholosical com hos tissuesmay be involvedin periâpicalirdtàtion ir facr came
1 ù n. . û o , L ' e ' ( e F 1 ' \p, " l p . t d ! e ' r d t h p p - r o . l o n , r û . much earllef rhan drar, when M;ller (1890) djsc@eredmicro
A!;câl periôdôntjtisand rhe pulpjtjs from whl.h ir ùsua11y oraanismin necroticpu1ps.Saûpling, culture,m.t ider.ificatioo
develops de seriôuscondirionsar an iûdivi.tùal ànd populâtiôn techniqucsvere rher rather crude, ard jt was mary decè.tes
Iflel dd shouldror be rrilialized in an ase of improveddenral beforescienrincaûd nicrobiolosjcalûethods wereÀbleto estàb-
hertn. TheI remain â promjDentcèùseof pâin dd lôssof onl l;sb â clearercauseand effect relàtioûship betweer miùôbial
tunctlonin âll côùniries th â hiah prevalence of dentai .dies, ide.tlon and dheasei. drepub ârd periapex.
d" rl _..,m.. .nd ôp. d .- a.,' Jl j' d ,\e' !rp. nen ,.
Somekey dd nqrisingly re.enrmileson€sin.tùde:
.oslr of time. financialresoùrce,ùd denral rissù€.Unùeared.
. ' \ e d . . o r e r )L , yK J < - l - h . . ' , / . , n 1 . 6 ' ' h - | sermireê
theyday prcAres to life threateningsepsis,dd evensymprom-
a.imaLs.pulp rissuecould toleratewi.te exposùrerc the
é l h r c i ( l " . i o n . . û \ r h FL t , - , ' . l l ' F - L f o r . ) { e ' i
moùrh for mdy monthswithour âdlerseetre.rs.Pù1prissue
e r û r d \ ' n h , " r d , Ê p r" ' , \ e a l f r b ' r i . q , n
This chaprerwill rerlew the aerioloayând €pidemioiosyof
conmô y 1àid down d*pire the impa.tion ôf halr and
rpicalperjodoftiris,before.ônsideri.a hov denrisrscar prevent
f@ds.uffs into the open woùnds. By .onÙa-!r. the pulps o{
o ub J nl p e n . p rJ b ' _ r l d s i , p . . ' - . { l l o f . l " - p r e v .r ' "
n o r r , l , r r " . s h , , ' , n , - N . , ' , r r , d r i ' o . o r g "' . n '
masuresaredefinedby the Eu.olxan Socieryof Endodoûtology
predictâbly die.l âfter expô$re ro rhe dôûh, wlth ihe
(199.{)as endodooticrrstment; pro.eduresdesiare.rro mâ,nrâin
derelopmentotper'apiol inflammètionàrd boûelos;
the healdrof all ôf paft of rhe pulp, or to preserveperiapi.al
healthwher à pulp hd died. . the câreful mi.robiôlôgicâl ,tudies of Sundqvlsr(1976)
or humân teeth devitalized by ùnumà, whi.h re'eal€d
Apkolpeliodonliti5 thàt teerh with decroric, inf(red pulp canal conreors
developedap;calperiodo.titis, vl1;le leeth wirh ûecrot;c
pùbs but .o cuhivâble microfloraremajD€dir periapicèL

. rhe prim2te sudy of Moll€. at,/. (1981) nr which pù]ps

Aetiologyof apicalperiodontitis
Â!icè1periôdônritisùsuauyâfecrsreelhcontaidng neciori. pùlp
tissue,and trèdniôtuI texrs madc l;nks b€rweennon vital pulp
wereme.hanicallydsitalized, either unde! neptic condi
tions or allô$ing inË.ted laliva nr enrcr.O.ly the animals
i. whjch mjcro orgmismshad beer èllowedtô erterdevel
opedapicaLperjodoûlitis.Teethvith sterilene.rotic pdps
had no deteclableperiapicallesjons.
Nuneroùs clinical ârd leboratory rùdles have b€en built or
thesefoùndàtiors,.nd fev çoù1dmw.hall€n8e theorerlelm-
lûs body of evidencelin]{ins pù1pbreakdô"n and ùe develop-
meût of âpicàlperiôdônritû wùh ûi..obial lnaection.It is clear
pulp rissùedd sragnâncri$ùe ftùids i. rhepub c2!al
thàr.teècL
spæe are rot sùfflciendy irritânt in themselvesro provoke a
roo peroprtoldseose
r n*.r0, otrubolond
I
respnse in rhr pcriâfi.al rissucs drat soùld iniùatc of {sta,n
. " l ' i l , i ' i \ l $ ' . ' , ' , -
.nù and defen.cless .i.hc f-or nriciobial infcûn,n a, becone
crhblisbcd, ând ir is dic inûoduction of dris non hosr a.tigcni.
nrarefixl snri.h is drc kcy ro drc dcvcl.t.rcnt oi fadnnosi.al
.harges ii ùe perirpex. A sraphi. exrnpl€ is provlded bI tl,e
c l i n i c n l s c e n a r i oi n { h i . h a p l l t l o s e s" i t a l i t y f o l l o \ r i n g a , f u u
maric in.idcnt rhit cardsrrophi.trliy.lisùI,s irs à|icrl bloo,l
. l ) A l , o ( € l " o o , l' . \ . . F ,' li-o'
to thernal an.l electicâl pnlp rernrg, the Fùtrent reports ro
:ùlrese slmptoms; ard ra.liôgraphs provide no eliden.e of pen
àpical iûfldm.tion Su.ldeû,, ôfre! reùs 1âtei. ard after the nost
n , o , ' . h , o r ' É ' ô\ L ' o n a , I
itely pai ul to biteon andcla$]. sisns ofperiapl.xl inflxmmdiot
appear The explandrior is thar tlÈ .lefeùceles, stenle, necrotrc
|ùh rc{tc bc.anrc 'nficicd. Fdra$ bI, si.gle mi.robial ccll,
whi.hgâined a..e\\ thnrsh aû exposeddentinxl tubule or in.om
plere eùânelldenrine .rx.k Exponentlai gn)wth rapidlr .onrefte.l
rvell-rneratrd, *erile canal.onre.rs inb a hitjhll irrirâ.t bôdy.f
marc.ial, caphlc ofcliciting 2 signiiicanr i.nammatory rcstxnrsc.
Thcrc arc of co!4e e:ceprions, lnclu(ling gia.r cell fo.cig.
b o d y . c a c r i o n s t o m a r e . i a l ss ù c h d s ! € g e t è b l e m a t r € r , r â l . u m
pw.leq orefdodontic paperpoints. \ahichgaln a.ce$ to dreperi
ate: rl,rough rhe oten .anù1 slatem, ùnd occasio.âl feo!,last,c
Icsiors ti.cscrri.S âs infli,nmàtory diseise Comn,on lcsions àrc.
however, common and signs ot periapi.al dlsea\eùjmlly med d,
ide.ted, ûecroti. ptl1p spa.c.
Penèpi.rl c1ièrgesùe ùiggered prir.ipJlly b! rlie by pro.l!c$
of micrcbial metabolism and t,xins *rch as 1\r4rnlsrcchtldes
irom ùe .ell wall5 of drintj Granr{rcAativc mi.(lorgânsms.
Diffusn). inrc thc pcrifadi.ula. tisNcr hcralds dcfe.sive inflam-
mânI' a.d imnùnc rcTonscs. shosc dama:jinÉt .onseqùe..€s
i..hdc bonc rcso.l,riof Ii is imptrânt to .otc rhâr ni.R!
orsanisms rhemsch'cs mrcll mlAr2rc ftum rhc nr .xnal s_riem,
d.l rlut dre periapi.al lesion is nor dre fooB ofdisense, i.ùher i
i s r b c . c s l ) o . s co f h o $ t i $ ! e s t o . o . t à i n , f t è c t i o n â n d t r c r c n r i r s
r , . , ' r . \ . ' r r , l , -
- { , l l ) ' r r '
ipicâl rissucsbIsu,Aic2l mea.s or!rescribing âf ribiotics wiU nor
caùserhe Lesior to heel, sûce irs c.use s cofuained i! the ilasc!
lar en\lronûent of rlie ptl1p sp.ce Lesiôns.rnonll b€ prevûrted
Lr! proteftùg pulps àg.inst iûfe.rior.r bv ûeèting rnfe.ted p!lp
syrems befôre chânges.âr afie.r rhe pein.di.ulàr tisn,es.
Similarlv, e*ablished lesions .ân only be expected to heJ lf
ûllodonri. nnè.rior is elirninJted rnd preveDtedfro,n recutri.g,
cirhcr bI crùâcring rhc otL.,li.g roorh. or bl.onilncrirs nnr
.xnâl ùextmelr ihi.b nranaAeslnfe.rn)n xs $ell. ln bnnogi..,.l
terms, âs an err.r.ùon woùLd.
and naiwr .ll'1he r:ndodonl.ie
S(lLrlce microflorâ
Endo.lonlicintèctior n !$ralhderired liom the nom,l oDl florâ.
which gainsefûIto lhepult sFacedvongh carlouslesio.s,fubal
exposrrebJ ûaumà or operativedenristr),or tlnoûgh nr.omtLete
cnân,el/dfl,rinecra.Ls. Bloo.l boi,,e spreâ.Iol micro ola.nisms
fron r di\rart site (tù.horeslt is now .onsidcredmllleLf ar
.au\e ofpnlp cânalnrfeftion.
vhile the oral I]oru retresenlsà dn'cnc, mixcd llora ofnot
rhant00.ultlw$le spe.ies,the ne.rotictu\, c2nali5a sF.idizd
eûvironmert,ÈLe.riry r nàtrowermiûodora. Bx.rcrixaft ûMlh
impli.Jr.l. though teùts 2rco..rsnnrâllyrepofted.Spe.ies {hi.lt
Gri.r forlrive orlanisd, but in tiùe, tlese givc wal o m
incrcasi.tjll anaetubi.Grâm negètnellora, typically
ol 2 .o E sF.ics in a.y .anal. ùfixed .ollectiots of ol(obitl
specreshale been shown rc intcn.t ntrùitnxld1lr...!,ppoitjng@.I
odrer i. the g.o\rh ând cv.llrbn ol a matue hi.roblalclimd
com,nunity (Sn..lqvist 1992). ft is not knôwn ifthere s sùd,d
enritr- .\ à liealthl roor .,.a1 non, or if mr infe.tnnL ôt ilt !ùlp
sta.e refresen6 â i)xdrologi.al entitr Periodôttis$ hale loq
dcbi.cd spe.ifl. and non spe.ifi. pla.lue hypth$es in thc rtri0l
ôgy of mdgiûà1 tleriodofritis. lc$ rcscâr.h is avâllableto itdidt
wherher à sFec,licnras of2ny mi(rlofEx.isnr of lf \pe.ifl. stdes
ôr cônbiû.tiors ol speciesâre rece$ary hr apicâl teri.dontiri! o
'lhe.e
develop i\, Iro$ever, some eli(lence thrt !.glc-\p{ts
infcctons arc j*ras capableofprodùcnrg pe.iapical lnllammltioi
is mixcd htè..bns. thongh dre l.tter are qpicâlly 2$o.iâtrd Nirh
lâ,gcrlcsions.This mxy kfle.t lotljeÊesdblnh€dnrlècrions
hà!. hâd grcatcr rime tu deElop h.oûplexitr èÀd pookr
tn'c.hanses in rhe periâper, ôr rlie se ect,of oaeï'eciâlllvi,ù\ti\
orgn sms d ri.robirL .omn,ù.iilcs c'olve.
Specilc sfecics ha!c. hoierer, been âso.iâte.t with tlie de\el
oprnent of s-v,rptoms. and wlile pre.ise mechrnisns iale not
beeû elucrlèred, tr is likely dixr viùlm.€ ta.nE, nL.h d prce
ollri. eùzyûes, xnn nogenlc cal)sul,f.iarcflâI, or xbilitr- to
.omrrrômise hos.lefence n,echani!.s may bc fts})mslble The
Grad legàrive, aûùeroblc P.evorcllà. Polphltumônâs, iod
Fu{)ba.rerlum specieshrve sFeciala$ociarions in drn kgard.
Fôr now, ù must be consideredrhât a.y mi.mblal i.Jeùion of
d,e t!lf stice ( ùnvclonc and.apable ofitdùcing tulp intlxm-
nrâtn,n, breakdo$h, âùd rhe dele opn,enl of âfi.rl fcfbdonriti.
Denri\À slxndd work ro à!oi(l ù.t ex1'osrc of drc pùh sldet
microfloro
Indodontic
. Pubids.nd api.xl periodon!ù ùe di.tuLral nncÀ.s,.!u;e,l br
member .fthe orxl non
. Prlpnn r pn{ir..lby,lÊrrif,g inl.b oLganisnaenûy tothe pult
' Àpi.aL !eri."l! nùt is is p'.'.nrûlby treicdng !ùbâl be,hh o.
.l.trning th.t,u\i rynen 6Êa.reml.robl tox,n! dn afe.t ih.
t Ihe sF.iàl enimnnenr oarh! Fûlp.aùl strplotrs.rlr.a intèdioil
sbi.b âr |r.gressivelt anaerùtrr. Grim-n !aùv., dr.l .!rtltlooalll
. There is.ùftrtlf no N.h.,rlr) 4 rbeàldrtllùb.xnâl tLdr
Àny ùi.roLrinl nrL..io. ô (orsldûen ùndesinble rnd shouLdLe
 0i0piolpêriodonrilk
tpidemiolosy

periodortitjs is 1âr more prevalent ln lrerern sôcietiesthèn

of apicalperiodon
Epidemiology lilis à.tvance.t formsof periodo.t2ldisease, wirh lmpticaûons,t terms
X ododti.sis oneofrhc most rcch.icallyexaÛingdiscid;nesin of resoùrce auocario. ror iis co.seffarive ûeatment,risksofàcùte
de.tistrylor dris reâson,much of dre.esearchand mos. oi dre flùe ùp or the need tor exr.action.
srddardtexs havelocùsedon mechanical âsFcts ol cl;rical rcch- The risk of acuteflare up in ch.onic api.al periôdôntnishæ
nique,ratherrhan rhe biology and epi.lemiologyof the disede been e$imâredâst% pe. year.inotherwords,S0%overa 10 yea.
bei.srcated.This coDtrasts stronsiywith the relèreddisciplln€s perbd. of srearerconcerûto somels lhe sile.t damâgewhl.h
ofcadologyand periodontologXfo. which rherear€ subsrmdal may result from ùntreatedor in&lequatell ùeated periapi.al
pùblished dataon prevalence ard ff€atnent need. disede. In â homeopathic.ge, when many acceptdrat ùnqùd-
DeûtàLcariesis mderstôod to be the single most common tifiably sma1l amountsof âsentsâre able to exert be.eilcial or
ouseofpùlpdeàthàrd rpicàl periôdonritis,but quite how much deletctuus effects on the bôdy,and links de beins madebetwee'
dÀearitcaùsesis nôt knôwn. SômeùnderùaûdingôfscÈ1e is pro chro. ic i.nammâ(try .onditionsand sy$emicmalaise,mùry U.d
lidedby counÛieswùh ùriôtulized heâlthcaresyrems, suchâs lhe frospect of harbouring nsymptomatic,chronic jniectious
theUK, in which it is known that môrethan r mlliôn root.anal lesio.s as undesirable as dre specÙe ofân dtrte episôde.Thereis,
treatmentsare undeftaken or permàreût teeth eè.h year,tt è cost howevef, no ci€a. eviden.e âr rhe present rimerosùpportor r€fute
in ex.ssofl .10 millioo. This ligure takesno accountofûc nany N.h sy$emic li.Is (Mùrùy md Saunders 2000).
ieethexÛà.redir preferen.eto beingrerainedby nr cmal rear :fhe qualny of endodontic ûeatment hd beenthe s,bject of
ûent,dd simild nûbers of reetbwirh nôû-viralpuips whi.h rume.ous invest;aations iû â range ôf.ôunÛies dd heaithcare
ùe srûptom-free. or episodicallyuncomfo.tablefor which no sysems. Evaluations are usully bded on â hdiôsrnphic judgemeût
ùatme.r is sought.Thecostof rcot canÀL reatmeot alsotakesno ôf the techdol stmdard of treatmen!, usins cr;teriadtu.iated with
accounr ofrhe p.ice to be pdd for coronalrestoûtionofdamased, suc.ess, which ère pùbl$hed by Elropean and Âmelcan
pù\ne$ teedr,o. ofany rem€diaLcùe reqxlrednr the fulxre for Endôdonti.âsoiiètiors.Alnost all haveconcludedthat staûddds
rhemanasenent of treârment failure. ôf seNlcedeliveryiû prà.ricearedisappoinriDg, d Ljkelyro resulr
A .umbe. ofstldies hav€attempled ro qumdfy pulp death and in high levels ôf ûeatdent tui1ûe àrd peslslen! periapicâldisse.
de€lopmentol apicalper;odontiiisin response to operadvede.ral Tâbie6.2 sumrizes quality evaLuations Êom a mnge of .oùÛies.
pmedures.Mary ôf rhese,su.h d rhe prôvisionof ûowns, m6t
plesùmablyhave fottowe.i eùlier episo.tesôf deûû1 .tisede ù.t Table 6.1 Prevalence ot seriousmarainalperlodonritismd
Epair mch ù caries m.t cèvity restoration. k sæms evi.lent thàt àplcÀ]perio.tontjrisin Europe
ûownpiepârariôn is aso.iatedwirh lû.reasinglevelsof endodonric
breakdown asobseratrn pedodsincrease. App.oximat€ly,2J% Disc$e Age s.oup 0eùs)
ofpûlpsmy losevitâlity widrin the firsr 5 yearsofc.ow..emenrâ- 20 10 l0 -10 {0-i0 t0-60 60+
dôn,a figûe whlch.ises to âlmost 20% at 20 ro 25 yearrecall
ll 62
(IaldefiâùA,' /1 1997).:fhis hâsseriouspâdroloaicâland cco-
todi. iûpli.arions in popùlatbnsvith high lltè epectan.l, and
2t 26
denands serlousthoughtbefôreembarkirsor àssresivecousesof
ft$omriv€ùearment,evenin patientsenteinA middleage.
Setri.e pla.ninA ftquires somc k.owledae of diseasep.eva- (ca,urt$r' Blalkvcll &io.6)
tencein thc commuûiqrro be setred.Levelsofapical periodoori
rishaveseldomb€eDinvestisèie.lircdries screeoinsstudies,sjùe :table 6.2 Endodônticûeètmentsconsjd€red technic2lly
radjosræhicexpoNresare needed.Hô*erer, stùdieshâvebeer sarisiàcrory and likely ro pÉvenr or heàlèpicalperiodootitisin
urderiàLento quàrtlfy àpicàl periodontitisas è .listincr disease
eûlty. All sùveys frôm developedcôunûieshâverevealedsub
stdrtiàirormètive ûeâtment need,in lùding the matugemert ôf
rê.bni.âIy saiislàcrory
!rcliously urrreatedperiapical.tisede,and retreàrmenroflesions
vhl.h fail€d to healaftef initial carc. 1990 l0
A cohprehensir sùmnary of preralence data for aplcal perr 1991 21
odonriris,1dge1ybasedôn S.ândinâvianand Eùrôpeanstudies r99a
was made by Er;ksen ;. 1998. T2b1e6.1 shovs drat 33% of IISA r991 42
20-30 yearolds haveat leas.oneleriapical lesion.a ilAurewh;ch
I"J
r6es ro 62% ibr thoseover 60. h is s.rikinA to com!âre apicâl
periodonriris(iniectedpub canalspacerequirinacomplei inter
vrniion) vilh data fo. marsjDalp€riodootitjs(r CPITN scoreof
:i, denotinArhc .ced iôr complexinren'eniior).A.gu2bl)'.apical
I02 | 6 P i s m l i o0nf p l l p o i opnedr r p i od i s t u ç
I
The clcar me$age from all of this is that pdP intècrion,
breakdown, and the.tevelopmenr ofafi.al pefiôdottrtls is betrcr
trevented tha. allôùed to develot. Prcventbn begins by undcF
starding how pulps .nn be protecled nom injù! atd ûlection,
afd by s'ofkin€ with nàtûal deÊencesto presene pulpal health.
tpidemiology
ondcornplicotions
. Api.àl perio,lontitis is probably nore Fr.vùlent thân dvân.ed lnrns
ofm.rgiml Dei.donrnn in \ve*erù communiries
. Tbe lecbri.âl qùÀLiryofend.dotric (earment lres.ribtd t. ûert
iLli.âl leriodonftis n d,srtpôittirg ln '@$.ounûies
. The risk oarute eM.crbùlion i5 âppn,ximâtely to|n ov.r3l0 veâl
!Én.d, bùr dF trehd'ioùrofindivldùxl lesiors n ùnpr.dlcrâhle
. Côn..nN are amslng xbont posibLe Li.ks bÊtveen.hrcni. rpi.aL
periodontitis rnd svslmic n,rlaise
. AFicàl Friodontitis tr beterpr.ltnre.l drân alloied t! deyeloFa.J
reqnire dia6.ult, .o$ly rca.me.r
againstthe
Naturaldefences
oralenvironment
Enâftel
In pristine heahh. the dcnial pulp is protected ftom itiùrl- by det
.ne, enamcl, aûd r sound iûvesti.g leriodonttum. lhe majority of
rh.càts tu pu]pal heâldr cone tlùou8h rbe ouvû âfter los o. damaEe
ro cnanrel.Enâdel, whi.h is 2.t mm dri.k over cusp tlps and hasrhe
bldûess of mild steel, a.ts d è slmple fbysicâl bûier agânst tbc
orà1env;onoenr. Chemnally, it is.ompsed oi 96% minerâl with
4% oisanic mattc., but no .ells. Its capâcity m kmineralize nfîer
àc ic chall€lge is s.ell-dô.trmented, bù! it is in.apable of t€$'
rrowth âfter iirâctureoLloss.For this rèdon, suspicious,early etmel
lesionsdreno lonSd pobed a theÉ is a risL of <nNeltlng at:ùea oi
suLr sùf..c deninerèlizdrioÀ .apàble oi phlsiolosi.ai repair inro xû
aÉr ôfcâ'itètion vhich cannot be rerored {ithout oFmrive rtteÈ
vertiôn. Simrlarll. conscnadve dentists now lNour mlûimally !t!1
si!e, enameLpreservi.g ftsin-bônde.t resîotations nther than
cnamel dd dertin€ særilici.s âltcrnàtives.
Pfeservaiiôt ôf enantl is important. dn.t no dentist shoùl.L
forgct their primary role in f.cvcntlnlj and llDit,ng c.2mer
desrroyinS .âries, ùàumq and roodr wcari or thi.I dre restomùve
ftânncnts ùer prôlide .re better thân ùndamtged tùNe ArI
rhi.kness of eramel prorecrs thcùnderlying tissues,and fcs pùlps
die ànd be.ome 'ntc.tcd in the presen.e ofintâct cnamel.
Dentin€/puiD
cornpler
Bfta.L1 ôfprotectile enamel (\'erage opens .1entl.e to rhe hôuth
ând pla.es rhe pllt at risk. :fhc .onseqùen es.lepen.l on thc erteût
ofri\sue injù!, the ûdlure ofanr hrù6 $hich come ro bcar, atd
tbe ùnderlrirg .ondilion of rhc pùlp. These.an ra.Ae t.om mLnor
dcntine \ensitivity to pulp nec.os;s and serions sPrea,.linAnne.-
rbn. Deûthe àÀd pùlf a.c anatumi.auy âtd lunctioûally llnke.{
èDd should be.orsde'e,l roacther û.,t ttu lxry Iùtptù
Deûtine cn.ases ând provnles fhlsi.al Protection fot dr€ bodl of
dre fulf and the cytoplasmic fo.eses of its Perifhcral .donto
bldrs, whi.h criend deep into its ùbdar stntclure. Thc PUlp,it
tùn, providcs .i$ùe flu vhich hydrâts dentn,e. rnd may pb
vide some degree of toushncss. ùfoveûent of den tiûe/pdP fltld is
al$ resFonsible àr dentine sensiriliry ldlo*ing €namel lGr
Rapid I1ùùl n,orcment utder drynia. rhefmxl, or osmoùc stinu
larioû, excjtes sc.sry te^e endings in iht body of dr€ fùlf, to
warn ôfrissue injùq. Pùlp nerles are also bclieved to be inrolvÊd
in nic.hanoreceptire fccdha.L tu rhe mdticàhry syrem, whi.h
n,ay limn.Lrewing Forcesand potentiàLll ddmâ8ing llexurdLovû_
loâd of teeth (Rândlow and Glanz 1986). Thc absen.e of sù.b
protecrion, ln additron to the tissue los often aso.iâted wich
pu\ness teedr probably cxplain\ tLreirvulne.abillry to fnctùe
'1he is sft.tll .omtrom iscdifn
defeùivc .apa.ity oftheluh
loses its dentine coverage,nd is exPosedd,recdt' b rhe hoùô
Similârly. dentine oflè6 ùc body little or no dcfen.e âgÀnrt
microbial infeûÉû rithont dre helP of a funcloniùg PUL!
Expôsed d€ntinc sln d, thereforc. bc Ûeate.t wth resF.t d !
iivirg tis$r€, a.d cffùs made to limit iùitherlos ètd P.cYÊnrrs
asault by chflnicâ], phFicèl, æ,1 mi.rcbia.l aget$, qhich ûâI
lnflme ùd lhreatcn srLrvivàlofthe tub.
Pb)sical l,rotect;on
So{t tissres ârc damasecLbl, hed!, whidr cat disrùFt blood llo{
ând .leratÙre t(tein .ompotû,6. Dentite is a good them{l
i.sularôr, .n.t is cil,able of prote.tlra thc pulp from dan2sitg
tempcrarure changes pmvld€d dÉt I zmm thi.knss of tnsùr
remaln\ Ifn is thinned ro lmd or les, ds nrâv hxpPet iû a hovl
crovn pfep.ratroni its dcfensive câptcirl is tefnusly.omtû
nised. and rhe cellùla' co.Pnens ofûe pu$ may be at lskol
Renridionol dilfusion
Ëxposcddentiûe surlàccsare porous. !lùnl Êllcd tubules commù-
nicatc frcm the exærnaLsufa.e to the Fuh, ffuvidits avenuolû'
€xrernauy applied agens ro injure pùlP tissuc.-lùbtrLesete nd'
rower and more widell' spâccd in peripheràL d,an .ir.ùdPuL!!l
2 ofden.i.c at thd ânelG
dentnre, virh !)me Li000.ubulcsmn
'at the
dentnal jun.ton as opposed ro 65000 tubùl€smm luD
.hânber roof (Fis. 6.1). Deeper la-vds of.tentite are ùùs ndt
porôus drà. nu)cdicial 1àt,es,and rhe relative risks ofdcef tÀ$!
\rhen ch€ûicâlaûd mi.robial itritâns are apPlied to dentine,
rber m.y be dilutcd by .he.o$tant oùNard flôN oftnsuÉilùd
f()m rhe pxlp .bmu8h opete.l denrinâl tubules. In a,.llitionù
simflc dilûion, d€niinal nuld hæ buftèring. and posibly even
humoral imôune actilitr. () lidlt the peneûatn)d o1 irftoti
The nanue ofmbular fluid app€arsto chanse aftcf deûtâl lniut
\Vidi;n hou^ ofcùtti.g dcntin€ fôr è.avity ot cmvn, disrupro
of the odon(,blaù lâ!er allows plxsûâ Prot€ins indtrding albu-
min. iibrinogen, and lsc dcfived frôn the fùb las.ulâtut, o

!igtr.c b.l Ih. ,nLreisd f!o\
con.o,tra( in dcntinâl rubulcs. incrcase ùe riscosity oftubular
flùid aDd redlce derrlne permeability ro cxtcrnxl agc.6. fhe
l u n r o n o f d i e s e . h a n g e si s n o t k n o w r .
Dilrtion mc.hanienr are asâln depen.Lentot .lentine thicl
n$ oûe ûillimeùe ofremanriûg dentûe redùcesthe eilècs of
toii. màterlal.o 107. of dre origioal lev€1,while 2 mm ot dcnthc
pElen6 dy toxlc action on the p!Lp.
longeFtem lûltntbn, fù e&ûple, àsô.iated with a slowly
advan.ing .afn)ùr le\n)n or ûtrh wear rimnlates haRl tissle
deposlt(,n. Pe.i{ldrra)-tubular dtntine is laid dosn withrn de.!i
nal tùbules tu narov ihei. iùmeûa ând É.toce the ùea o1 an
cryoseddcntinc sùrfa.c s'lrich ]s pofuus. Opened dentnul tLrbules
ue invr]xbLl sealedofffurther ât their pulprl extent b) teiiiary
rdrùtio.' dentine, whose tubulâr srructùrc is mofc spare xnd
haphxz.rd,and dison.inùoùs $nh drat ofprimdl or physiol.gr
dl sc.ondaq deûtine. lbese.hanges gererally seèLofftubular
communications widr rhe pub. and litde, if ân,v,dentine sensi
.ivily or pùlp inlaomâtion is notcd in ca5csot lonE-râdditq,
noDProsre$'Ye denûne $Fosure
Whenerer defline suràces d.e cur sirh btr6 or hard in$u-
rerts, ù sme.r layer n generated, corsisring of tlnc dc.t;ne
I,tricles aDd !ùiàb1e mo!nts ofsaln'ary con,poncno an,r mrcLrr
orgrnisms This m,re.i,l is rrpi.all_v fùdrcd l-t mr.rons xtro
denriml rubules tu torm snear plùgs , wli.h càn redlce dentine
pûûealJiliry by d mu.h as lE%. Y/hiLe dris ca.not stricdr bc
.orsi.tered a nànûâl process,lt r a helplirl a.cj(l€ot oin,nl.c rhat
h.rd tissue pfepa.a.n,n restrfts ln tissue chùges, which nay be
Àli of thcsc pm.esses suk ro spare rhe sofr rissue ofthe pllp
fton majof irrliatx,n and lnjqr In reerh with viral pdps, bdcîe
rir mâr e.te. dcnrinc. hùt drcy do nor enrer ùe pulp in siglifi
cart nunbcrs unless .arles advances to withiû 0 t mm of the
o u o l d e t 'r5aL ! - o n s r t. h
,,',**' ,0,
|
As periphera denl ne is secreled
odonloblaslsoccupya broad
circumierenceard t!b!les are
spaced.Tub! es are re alve y
narcw ard are f!dherdiminished
by intra-tubùlârdenllne.
As c rcumpLpa dentineis
secreled,
odontobaslsare
crcumferenôe.TubLes are
c oselypackedandwide.
Deepdenlne s lhusmore
permeab
e thanperipherâ
iJ ofJ..t J.nt ne
.bambcf. inlades irritàtion .lenli.e, o. drcfe i\ dire.t erposùre of
pùlrr tissuc to rhe môtrth (R€eres rod Sta.lcy 1966).
like odrer soft côùrectrve !i$ucs in dre body, thep!Lt resto.ds n)
ifitàtio. by mou.ting an inumdâtory responsc.Intlamnntion
.àÀbe obseffcd i. tbe pulp whetever deniinâl rubùle\ âre ôpete.l,
but the conscqllen.es ùe not nece$arily sctious. Infiâmmatôry
responses.re helpful ir killinu o..â\iôûâl ûicro organisms whi.h
s.ry iùo rhe pult, and in .fcâting inflammatory eaudaics t.l
dilûe ôther ifitant dAef6applicd tudettite. \VliiLe û is ttuc.hat
rhe pùlp ôc.upres a riajd,,a, .,Æll,,r sprce which does nor snell
rc deonpre$ iûfleed tjssue, it slnuld not be thoush! lhât tub
ri$ue is lielple$ in drc È.c ofi$ùh. Earlier coicefts ol rhc inùa-
pul|âll,.c$ùrc risins during in1]ànnalion to o\tr.ome the pedu
sn)n pft\ùe of the lrrerioles fccding it ùere dnpro\td bv Vat
Ha$el nr 1971. S!dr responscssoùld lead to e!dc!lat tec.osn ol
infar.tn)n. which is rot aconrmon câuseofpùlpdeath. D€spile rhc
rigid casc.pùlp is a surprisnrgLl comlrlia.t tissue. prôvicle.l iûler
nàlly h_r2 ri.h ()n.dûâtion ol tro.€o.qllcarr in it\ grôutd sùb
sancc. whi.h are .ompressibLeand physicalh .ùshlôn tiset i.
rred a,.ljaccrt ro rcsn,n\ of itflammatjon a.d h.âlll ln.reded
presure, prorcctinA then ftom drm€e. Ll.usual aiternlrenons
sbuns are also .€Feseûted in the fub,2llos'ing ùe di\esion of
blood ilo$ a{ay ftom ârcâs ot in.rease.l Fre$ure, prevcûùns
vasc!lar stasis and aras.ular ne.rôsis lmDunoloalcal prresses
àre also acrive in drc pùip. These can hile bencilciâl ar well as
dânàgins elècts on pub cclls.
Inlladmriory respo.ses rcp.esent the finà1 1èyer of ,lcicn.e
âsains dre enùl oI micro organisnÈ 1tun the orâ1 .arry and
pdpâ1 bre.kdo\rn. \{rhen rhc pu\: i overcome. nrflarnnxro.t
changesmay .o ne ùicrobial i.fccrbn n) the peripheq oF fhe
pùlp, sùbjâ.eùt to rbe rreâ .f mi.()bial enÛr. before chingcs
104 5 Prc!€nlmi ondpùiopko
0fpLrlp0 diserc

Figure 6.2 Prog.essivebrcak do$11of the pùlp. PùLpdc.th s nol immedirte dd toin.lnllahrûorr,.hnn!!es sptu!1 tiom a leripb{dl
1
Font oi infe.tion (a), \preadinA n6t ccÂû.lh (b), .nJ rhÉr :rticâlly (.), ufrjL the .ûrre luLp is oveshelmed (d). The Êsht ro rrord
.sâi.* ùiùobirl invAion thefl nor€s to drc Fcrl.pcx. Pr.gressivÊb.Éik doùn rllovs the su..dsful appli..rlotr ofamtrtarion gûlloromt
rcdrniques whi.h ex.ir lntècrd risnr xnd Drcsctr. dr healih! tissuebe.eùrh.

progr€ss.enûally 2nd rhen àtically as,lefercesare over*h€lmed
(Fig. 6.2). This resilien.eofpùlp tlsùc tfovilcs an of|orrùo,ty
in speciallydefire.l cû.uûsan.es n, prcsdvcpa,t of drc rub in
heal!h after ampùtètiôr of disea\ed,mi.hbialh conraminatrd
tjs$reGeesectnn PreseFi.s inju.ed pulFs').
ApicalpcrioCt'ntiùr
I nln nnat ion
wher hfefted pnlps brc*.Iown, (xic microbiil merabohes (llf
t u . . , l o u É l ' t ' 1 .J ' e , , l d r f , , - p i o \ ' ' in" ' i',i
inflme the aso.iatcd iJe.'odontâlltsùes.It is iûFoitdnt tu ûdù
$à!.t that the âreaôf perihdi.ùlar ;nflam matio. does nol represert
the locùs ôf infection. Inflmmabry.harAcs a.c simfly d,e oea.s
by which the body seeks|oprolide aoodr€' layer ofdelèrce èsàinst
tlsa,cnn',si.r, ânl st' crd of mioobiàl iriranrs throughou!àlv+
'l
1.r bone drd Lrqo . he .aùse of rhe lesion renmins dre rnteùrd
root .ùà1 sl $eû witli few miùo organisn$ digrarnu beyon,li$
codiÀes.[||e.ti!e Ùeètûenr of e$ablishedapi.aLperiodoùnr
nur, therefore, be targetedar dr€ iniècrcdfub .anal.onrcnts, Dot
the reetive.hang€sin thc pedradi.ula.rissucsrhcnnch'6.
Preventing
pulp injuryin operative
dentistry
Despne the be* etrrrts ofprimary preventn)n, fcw peoplenÂii.
'"p ''" r""rll'-!'l L.o,g.,' f-.\lôr..f1 " o_.
desree oftrsùe danase by dentai..ries, rooth *e.r ôr ûdumimd
reqûire th€ Àppli.àriôr of ierorâtile materials, usûLlf âier
me.hdicâl or.hrmi.xl hard.issùe prepxratn)n.

l{oturol
delences opirolperiodontitir
ogoinsl Local dnaesthet;.s

.
Hrslily peifusedtisstres.reoftenù e11plâcedtô suûive iûju4àûd
Iterh po$.$ sophisù.atedlaye oadeaen.etopr.te.t rhemsehÊs
. . 1 r ' \ 1 1l t l o 'f 1 ' ô i '. .1,.' r'" r
. Fêw !ùlls
vâsocorsricror,which is a(l(ledro enhàncerhedepthànd.lùnnon
bnomc itfe.rd md die in rhe presen.e of nrÀd erânel
of pain .onûol, aûd rc linrlr blccdinAln .cnain .pcrarvc limft.
. fxiùsed dentide m.l lntp sork rogÊrherÀsâco,nplcx ro rcdu.c
dures.One adverseconseqùen.e is thât ther.xn lxre a ptufoûd
dcnrine peimeJrhtv in rhe 6.e oa exrÊrnallyâlflieJ irniàns
effe.r ôn pù1pb1ôodflô1v,dependenton rhe agenrand tuuteof
. t - . u p . , , p . . " , , n , t , , b . , . b " , . " , â d n r i . i 5 r k t h n . P c f i o d o . r â l i g a m c n ti . i i l t m t i o n o f l i d o o i n !
'l
his r.silicr.o opeN oppôrunnies tu presed? pâft oadrÊ lùllr ln
healrh evenafter njcrobldl nrju4
widr l:100000 cfincphri,ie, fôr ex2n,de, redùc€stulpal bLood
flow by lt% s'idrin t minures,reon,in.q !o normal ollv af.e'
' No defthr shoùld lorger drùtinùy rol. ni Frereùùng md
" . o , 1 , \ , 1 " , o ' . .
r 1 r r , , .I o , t , : r o , o . , , . . . o | o o n . ,I
l i ' 9 d r ! - - , l - r " " l '
ùedmen. drey prollde e berrer rhân ùndamagca lissl l:80000 epi.ephrine.€ducespùlp blood flow bl l0% for ùoe
dran oûc hoùf. s'hiht Ncr infe.ior 2lveoiârblo.k wi!h rhesm!

solutionreducescànlneblood flow by 4l%. Takenin isolàtiot,
theseeffectsprobJ:ly present no sreàt threât to pulp tissùe,
vhichcaûtulerareischa€miaformorethm onehour by switching
to anae.obicmerâbolisn. However,reductionof blood flôrv, in
d'ê,pôi - y 6arr\*\t.o\FrlF.r'i ô d"
don may theoretically compflrmise d tlssùe wiih relatively loç
, , , r d , o ' " , J" - r _ c i .r b g Jt.,) r' i,g i ,ei' \
dd even rupture ôf rhe periph€.al v2scùla(ft with bLeedita into
dre pùlp chamber ând dettite. A fllp wirh reduced terfùiôû
may also s€nerate LesstisNe nu , and rhe prorectile oudlov o{
deûrinà]fluid nay be cùrtailed.
Tn6eo.,e^ro,,", i" - orthet.^
ftee local anaes.hetics during lenathy opcmtile pro.e.lùres o.
F ldvedental tissues.TheI dô, hoùever,.aise awa.ene$ ùat all
sp{ts of denlzl câre .m .onspire to in,ure rhe Pn1p, aod rhat
olentive inte. entions shoùld be jùstified, d ûi nâl âsPossible,
and.onducted wlth càre.
Hardlissuepreparation
MâùglDg deniine.aries ùd prepa.;.g Éeth for crowff .equlres
hard tissùe removai. \x/hile tissue lo$ is inevitable, the manner
in rhich it is removed may be open to debate,and there is geneial
agreement that healthy tissue shoul<l be preserved as far as
Area oJPreqarariorl
Derral tubulcs affectedby cuies are often naûowed by inùa-
(peri)tubulardentine, àûd ù411€doff at dreir PdPal extent by
Mùive tertiùy deût;ne.Excavàtiotof cadesiusi to the lat€ral
limir of rhe leslonis unl;kely to openfreshrubules.which arerel
ativelyedy pàûways ofi..itâns to ûe pùlp. The dàysof cavily
'exredslôn for preveotion'hare now pased in favourof morecoo
rNarlve .pproèches;n vhi.h artempts a.e mâde to simPly
Émôvecariesar,l unsupportedtistue,and meetthÉbàsicthysical
needsof ihe bulk restôntive mâtcria.l.Etn sô, i! is ûor a.lways
easyù) identify precsely,.he *tent of affectedtissueidd ia(o
geûi. ddège is easl cspeciallywith hlgh Teed rotàry tools.
!fforts have been nade to;dentify àffectedtissue by the ùse
oi dyes.bur nost heveresultedin oveFe$imatlonoi the extent
ofca.ies.Alrernarive,and posibly mo.e .ôûservative,methôdsof
cariesremova.linclu.te the use of lasets, aûd ûe afplicarion of
microabrasion,ln which cavnjes afe effectively sand'blasred
free of diseascdtissue. The carieedis$lving àae.r Carisnv
(MediTeam,Gôtebôrs,Swede.)offersa morecorsetrarive,ùe!è
peùricàpproæhto cadesremovàI,whidr is kind ro PU1Ptisuc
(Young and Bonaenhielm 200r). Crovn Prepùâtion.arcly
irvolvesthe removâlôfdiseaed tjssue,and the lârgeareaofpre-
vioùsly nnopenedtubules which ùe exposedto rhe nouth by
crowdprepMtion canbepaiti.llady damaaina.
De,rb of PrcParation
Depth of preparatioois significant in .elarbn to the Pororty
of deepdenrineand the reducedcapacityof thinned den.inc ro
pulp dmriirv
i'ilrvinopst0live
Prevenrirq r 05
I
ptuvide the.mal p.ôrection and dilution ol irritants lt addir;on,
pfeparèrion into deep .tetrjre risks traosecring odottoblast
pio.esses close to the cell body, s hi.h ineljtably re{rlh in .don-
roblast death. Provided that dre pulp remàids heâlthn lost celh
will be reptæed br new odoftoblaGlike cel]s, but ùe detd tract
which immediately ren,lts is ân open Pàthwal tôr miciobltl i.ra-
In Nmmary, !he.c is sôûtd scjetrifi. râtionale thar di.tàtes
ha.d{lsue preparation shonld be d minimàld lo$ible to eradi
cat€ diseaseand è1loç adeguate properties ôf ûe ùose. ÉstôrÀ
Heat generatiott
HardtissueprepùationseûeraresfrictjonalheàtThis is a sPecidl
hsueif dentineis prcpârcdwith largebursÛavellinaât high
afl€ular velocny, wirh hervy pre$urc and withoui wâier .ôolitg.
Most dee| deûtine prepanrion ir .ureotly undertaken ûith hiah-
speed hurPapplied virh light, inleûitteni rouch and with
focùsed çarer spmy lrom mot than ooe dûe.tiôû This, added to
relètively minimal dentine preparâtion çherever posible, means
thar severe thermal pulp damage is avo ed in mor càvity and
Dessi..ltion
lurther injù.y ùn comefrom the ojudicn,ùsuseof thc air
syrirA€ dùing dre exâminatiot and PreParationof dentinenû
fdes. Strears ofairare èbleto for.e flui.l flow thouah.tpilltry
like.teotinal tùbùles,which .an Pluck odontoblastsfrom the
pùlp,lo.tsirs then in .tenlinaltubules,wherethey ràpidly breâk
down. Deûtlre sùrfaces shouldnot be fuily dried unlessesential
for rcrorative plrposes.The dvet! ofh).drôPhilicbo.ding reslûs
and impre$ion naierials mke this 2 rarenecesity
Dentâi materiaisa1ldthe pulp
h is togicùLio coffider whethef rerorative de.tal mèterials
dppliedio dentaltissuescânhard the PulP Con.ernshavermdl-
tlorâlly focùsedôn acidsand monome6.s'hl.h werebelievedto
diffùse through fresl y cur dentiûe surfacesto iriflme and kill
pù1ps.li is not long sincethe useof bde ètd linina ûàterièlswas
rhe norm ;r cavity restoratioûto ad d Prolectileând insùlating
bdriers to sarèEEd the clenlinepùlP.omPlex.
Evidencehd skdùlly beenamassedfrom 8e.m-freeàûind
studiesàn.t from surfaceseàli.s studies(Iis. 6 3) rhat dentaL
mterials are aenerallyton toxi. tu rhe dent2l tÙlp, and ca. be
place,Lin di.ect contâcrwlth pùlp tissuewirhout ProvokinAseri-
,nd p rlo 'e o.i..
repâ.aiivehàr.t tjssucbturie6 are lâid dôwn in r€sponse tô such
taàitianally ùlte ddndti,{ mÀterials as mônômer contarnrng
composireresinsand acidi. zinc PhosPhâte.ement (Cox aûd
Hafez2001).
The key isue is wherhc. mi.ro oraa.;smsde preseotin the
d | I o r ' o ' . i l e r e m . ' ' I d ' f . - r ' i " , ( y D ( t q r , , ' ôo nr e , . F
ing the cavlty by microleakageat the rcsktraùon ma.a'ns
106 6 Preùenliof
ofp!lpol0nd
periopkû
dise0se

a. Germ-iree
anirnalstud
es

ffi
nnY)

b. Sudace-sealng silcl es
r a s g e n e f lay
N o r m a l âm
havepup nflarnriration,
oilenpLp necross wth
and

cavles prepared //rA\

trâ Feslôralion
surface-sea ed
S!riaceseaed resloralons
gènerâlyhâveno microba
i n n o , m èè n i m a r s / / \l to keeptheoralfloraoui entryandno âdversepulp
ândrestorative l/ !
materials placed,

conradwilhpulp
tissue. l\:^'lJ
\i,.'-,R generally
lel bactèriâin.
Pups areollen nilamedor
///'\\\\
( / \

Fiaure 6.1 Geh-f.€€ alimrl md sùrfac€ràling $ùdres to tesr the lrirâûcr oa.lental narerials (â)(Èrm i.eeanlmâlsùdies(b)Surtuû

Aaai.st this ba.kAround,rhè physicalpiopèftiesoFdentalmate- preparàrbnsbeto.e remporiz.tio. hâs been .tisctrssed,

rhough
rlâls and theiiâbiliry ro create2nd mainrainmafginatseè1àgainf wrthoùt clear.o.sensùs.
theo.al eNirodmenrare.riti.al rc success. Probablydsimpôrtanr
is the skill ând thoroùghness ofrhe.tenrisrtn crealinsÈLJ1ôod
and Dimcrsional stabilitl daring vtting
sâli\'2free enrlrorment for mareriala.tdpratnrnand in e$uring Làbôrarortstudieshâve slnrwn drii ûàry .ontemporaq;denûL
proper mârAinâladaptariorofresù.arions The retelanrtèarùres materièlsiorm sm.g boùds wirh deûral hài.l tisstes.Mxnyol
of deûtalmarcriaLs ù termsofpulp hea.itharc discùse.lbelow. thesc$udies tukelide â.counrofrhe re.liriesofniârerialbelâr
iôff and hâûdlirg ir drÉ.linic2l sefthg. ùfos nratcLiâls
conrtur
Ablli4t to band to ar seal interfdces uirb .tenral to $Dc degreedrrinA sering, and the desfec ro which thir
bard tissrcs impactson performa.cccan be greàdr influcn.ed by rhe ûâni{
Materialsprovidins àlonare.mfluid dd hacrerlatight jnreface i. which rhe maredal is apptied and tie conilsùrâtion of the
with denral lissuesare likely ro be well-roleraredby ùe pulp. ,\ !) ep,'- i, ' I. n | ) on|o .. i{
Mùginal scaLinAis a p.ope.!y dsociatedwjrh hvdrôphitjc resnl whjch are expeûedro bond we11,mar develor shrinkâgefo(er
bonding sysremsand ala$ iôDomef cem€rts, atrhoùgh lheir which overcomcbondsrergrhs wirh.aviry wa1k,bringinSaboul
Longterm scaliogability is le$.eitàin. AmalAamrestôrarn,ns do margjùl fâilûe and ofl)o(ùnnl, for leakageÊom rhe momrnl
not form cheml.albon.lswith de.tine, aû.idre rclarivecoûôsion rh€ ftroration is plac.d. Curira coûrrdriôn is ùsulLy comlen
resisa.ceof cônremporary nor-gâmma2, high-copperamatgams sâte.lby larcr hygroscopicexpansionoi polymeri. nrateriahin
may .ompromiserheir abjliry tô fom right margtnsby mdterjât contactwirh salivd.This may imprcle ûùAinâl adaprarior,bur
.orrcsion.Càviry larnishes,or increasinsly,primina an.l seâtins will not .c establishbroke. adhesivebonds.
amalgam càvirieswlth resin boadirg a8enrs.ûav repftsenr Fo. comFositerelins. dre .jsks of pollmeriza!ior inducd
a wise pie.aution beforeresto.aiior virh Do.{catiûS mÈteria.ls. mafainalbreak.lôwnde conlrolledby inùemÊ.ral buikl ù! atd
Poor adèprâtio. is pàrti.ulârly asoci.red w;rh provisionât .ùfios ofoaterièlthe lamellârbuil.l ùp of restom!;oos with flo$-
crownànd bridgework,in which va$ àreasofÊeshly cut denri.e ablc naterièl whi.h is able ro nove tô omfcnsale tor shrinkâge
are toteûtially ar risk. ]'h€ po.entiàl ûeiit of.esiû sealingau in die d€epestlayeF hcfàre buildlng stitlàr mtrre.iàlsmort

supûÊ.iâllr;xndbr di.cfting cu.iog light ir rhe knowleduethat
rhemateriâiwill.ùre rowa.dsir.
GlæsiônomerGmentscnjoysrearerdiûeùsionalsabilirv ând
reducedrisk of polynrerizarionlndùced marginal breakdown.
Dentâlmralsâmstôm .o bonds \rith .Jvity ddgins, bur mal
atæd slighd] ôn serirg ro cûhanceûarginùl à.iàpfutiôn.
Cleff;c;e'û af rberrn.tl expans;on
The hoùrh is a ha6h e.vironûenr, with many, irreAulaf crclcs
oi tbûm.l er.bange €lery .lèy. Thermxl flux b.ings 2bour voLù
netuic dunse. and mâterials whl.h do not hà\E coelilcler$ of
drm,âl expârsion comp.rable s'ith dc.t2l rnsues ma! ùrdergo
ndgnral breakdown $ith time. Mor compsite resins dernon
stmtemarsiral breàldown and pc(olârion ol oral flùids bene.th
thersonlion s'lth tiûe. \rrhether drc prior seiling of(lenthe b)"
the bonding agert sFares ûe Fulp lion injlùr is not known.
Àgrin, problems of this $rr a.c les pronour.ed $itl glas
AmalAam rerorâriôn\ lare .rarkcdly difterent erpdnsion
belraviourro tôoth r}rucs, bu! have probâbly been able r.,.om-
pensâtefôf sù.h changes b_vdynamic coffôlive evenrs xt drc
resorarbnhoorh i.tc.iàce.
The pn)perics ot all derlal ùateriâls n r be .onsidc.cd in
tlatn,n t., fub heàhh. Ellderce on bai. bn).ompatibiliry is cer
tÀilly lmportanr. si.cc dre develotnenr of turerials bxl. b ho*
.sus caùôt be $pported. Thc fhysical prot€ities ofmaterials,
indûdinA cliûical ûetho.ls of se.ùrlns and f.cscn'i.g lors term
mdEi.al scal are Jùst d impôrtdr if dre re*oration is ro .lo is
uldmatcjob ofprotectng thepù1p aswellas intac! enanelwoxld.
operolive
dellirtryondprevenlion
! op{âtnr denrâl ûeàln.nr .ùn côn!rom,* the ninml deae..es of
€eù, and mLe them m.re nl.e.trbl. ro ùi.rôbial ,!!tê,!!
. Tooth!rllârâ.].i sholkl rhvrys be jLrriûed rnd À minlmxl nr arÊr
rnd dqrh as posibLe
' The dÊntjne4iùb .omplc{ sbô d be ûeated ô i sensirive.llyi.s
ri$ue. rvoding okrheârinA, rnll or ryin!, rnd i'krng $eps û seaL
n frdû .ônuminâio. by dre onl ûoru
. l).nr.l reiôorivê mareriah h.vÊ llttl.lllrecr Fulpal tuxi.iry.Iùt4
oI ûi.ro'oigrnnns ft .rvitrrrs..âri.n lnierfæ.s is rh. k.r.ause of
lJo$ofendlc pulp inflmdarion and br$]rdoin
. The trhFlcal Fropcftiesoa rêsbntive mareriÀh a.d.âreiu!
nmipùlatior to enhrnc. lont-i.rù drgimL çxlxre nore
i , p J ! ù ' " ' 1 " ,r . , , , I o o o ,
g injuredpulps
Preservin
The \itmrn)ns ir which pulps âre ln à.nte dâûger and in shi.h
denrirs .an 2.ti\-cly inle^'ene ro pr€serve healih are ln rhe
' pulp exposufe br a..idcnrâl or iarroged. tièuû,"
P ' " ci q r ' tr " , j l l ro/
I
Dental.ades is stlll dre.omnnrncst causcoffubal injuq. Thc
.linlcxl manxscmrnr otdcntal .x.ics cmphasizcscomplcrc cxcisio.
of.xrnrs deflt;ne nr el;nrirarc infcctior and frcrcnr discasc
pfos.c$ion. Tbe p.cF.ed cari!yis dr€nseal€d lunlard bacreria
riahr ro u.crnt new infec.ion or lhe reac.ivalio. oaany micro
orsanisnN drar seft inadvcftc.dl lcii.
l!ldirect p,rlp crpfjflg
O.câsiôtâlly, r pâ(l.ularly deep.arioùs lcshn in a vital,
rt'mpknn-ircc rooth f.cscnts the .li.ician wi!1, a dilennd.
Should rbc lcsio. be tully excisedin lhe krovl€dge that the pulp
v;ll bccomc dire{ly exposed rc the nou.h, or slioll.l sone dis
cascddcntine be lefi io order to dlo direct pulp erponù€/
Compleæ excision of.aries from the periphery ôfthe cèvùy is
ûot ncaotiablc, ànd rhis must be n,eriû,lonsly con,flered Lrefore
attemptitg to mdnage disearedtlsnr on.he pùlpal salts. ^.lcxn
workinA enviro.neot shoùl.l aLsobe secùred,ideè11ywirh à well
scâling n,bber ddû, Lrùl at leNt witli èppropriâte strction .nd
cottoû wool isol.ùion. Côrvertionâl reâ.hiûg is drer basedôn rLre
vieù thJt the âdvâtrciûg frôni ofâ.a.bùs lesbn.ontâi.s dcm'
iteràlized bùt r€rlle dentine, whi.h .an bc saièli lcit in dic
depths ôf rhe .avity pfeparain)û. Ii ls .ùren.lt' impo$iblc ro
judge wlth a..ûa.I $hcr dris condition h,s bccn .câched, and
pfu.ti.r is hilhlr vtuiable and sùbic.rivc. Whcn 2 comtorable
degr€e ofexc.utiôù hd been a.hlev€d, the .lenrinerpùlp .omplex
is ûcarcd s'idr â wound dre$in.q described d ar'irdneft Fulp
.âp , ù ally a sc(i.g calcium hyl.oxile cemenr, befôre restorins
dre.xriq agai.st rhc oral cnri.on.rcnr. The purpose ofdre cal
cium bldroi e cemen! is to .reare a bacteiicnlal, high pH ervi
ronment, nr which the pllp car la! .lowr further dentift to wa.l1
itsell oB liorn tlrther niùr\'. ft hd beeù cldned that ..J.iun
hy(lo{nle aclively promotes rhe deposition ôfrepùàrive dentine,
bui there is rô elider.e that it hrs any spe.ial po'ers rn rLrrs
Lcaârd.other thin 10 secùre a cl€an èrenè for rhe pulp tô get or
with its ûarùal x.ririty in thc la.c ofiffirâtior. Thcrc âre no.leâr
data on the su..ess ôf su.h prô.edùres, rhoùgh a.Uexperien.ed
de.tisrs hale witnese.l re.urent cèries .ùd pulp inyôh,emeni
5ie!i!:!e e1{:a',irtiorl
Wirhout objcctivc criteria and âny d$ùrance îha! remaioing
ca.ies will harc aflested, some deitists a.llocate è $epwLseexcè
vâtion frocedufe ro dllov more lhoroù.qh cari€s removal. llere,
s)ft denrift in rhc dcfrhs ofrhc prcpâration is tLcarcdwidr a cal
'livo
cium hrdroxide .emeùr, bû tlr caviry is sedledteûpôrùily
montlrs later, by wlilch trme rt is hoFe.l drù the putp witl hâ"e
lù down reactive dentlre aD.l retreate.t fron th€ carlous frort,
the câvity is re-entered for .onplere .afir\ removal.
Sit.e the degree ofi tial dlsease.ltlssue ftmoval and ùc.fiG
ical ûrss iar a.rivirr is ùnknos'n. md sln.e it is knos. rhar most
restôrâtiôns teak, *ep\'lse €x.avâtn)n appea$ rarional, and drc
limit€d nùmbcr of stùdics s'ould confi.m rhis borh in frimâ.y
and permrnent teeth.
108 ofpulpolond
6 Prevenri0n periopi(o|
dke0se

Nôvel approachesâre required tô de.l with rhis .linl.al p()b- Ssitzerland) havc drcif advo.atcs. Radi.ai .cs' box.nn
lem, and suk continles oD mèrerials which may b€ bettefpla.cd appfoa.lrcs. such 6 rhc applicarnnr of hu.ia. aronth iæt<rs lir
to indù.e nard'ri$ue .lepositlon ard to $erilize and haden any indù.cddentinc bridSc tôrmadon arc alsoùndcr dcTrcxd i.vsti'
.ârnrusly afiècted d€ntine. Ore esmple i\ an anil-nrl.rcbial resin gatio.. Ii is. however,im])otànt to cmfhaize once,Aâin th.t ùe
polrmer, which cân impregnate softened dentine ln a conparabLc ùrdcrlyi.g condidor ofthcpub is cf,tical ro succc$. Evo bioadnt
m.ûrer o *od bardcncrs used ro treàt are$ ôf timber de.a': mole.ùld approtuhes will be lnetre.tile in the .ase ofa dyitrg pnp.
Another irloLves the fnmisatbn of.arirt prcFr2rions sirh bac
ter;cidal ozone. Sù.h èpproa.hrr mar opc. rcw managcn,enr
Ptury am.?'tt.1.tian
opùors 1n rh€ yeds to.ome. Simfle tulf cappinA of ca.ious and lo.g s.andifg (>2,1 hou{)
taùmalic expnues carnot be reconnen.led. In immatLrreteedr,
where dF pdp hd ûôt yet complered its tdk ôfroot formdtion,
IJirectpulp cappr'ng àùd wLrererôôr cddl Ûeâtmenr souid be ditrr.ulr. advxntxge.âr
' '.
Despùe.arelui cxca!,rion, tults ire freqtreûrlyexposedtu dre '^|1 ô Ép, lp :,-"' '.. r-,1 1.lr **o
hotrth dùfing .2!i!y preperatior. The] âre als) .ommonl)' pulp mputatnn js advocated, in çhl.h an attenpt ls madeto
exposedln .omplicâte,Jcorofal tooth fia.tures 'l-heker deiermi excÀe all of the atrected tissue ând leave the rerile, hea.lthy iddi.
ûarts ofôur.ome aft the ù.dcfll'inA condir,onof the denrdlFulr) ùlar pulp ro coûFlete tôorh .tevelor,ment.
ud rhc abiliry ofthe deùtisttô preventtis e infc.rn,n.Thc c.n Workiûs ùndef arepti. ondirn)ns, rhc iûÈ.rcd (ftn.I
dùn,n ofrhcpub mavoc.ùiona11y beeasyoassessby the hi*ory 2 3 mm ofpulp tlssue de removed mder refile rxline irfigatioi
ôfs)'nrpromso. br dre olrcome of sensirivb rers befift ûeâc with a high speed didmond bù. Àû irdi.atn)n ofthe ùndedling
mcnr. However,ùe histôlogi.dl ratu\ of rhc fub beas li..ie pùb .o.dirh. is pn'idcd hy rhc dcs.cc of blccding from rhe
relâ.ion to reportedsympr.,ms,â.d conrcnrio.al pùlF resiog, s ' o u . d . B l c c d i . a s h o u l d b . s l i g h r i n d r € a d i l j r c o n l r o l l e di n
eveDifit sas dore beforelo.âl a.âcsthcsiâând caviryprerarat,on, hcalrhy rissue, 2n.l sodium h}?od,lorire mar be washed oq rhe
$'ou.d ib. lird,e. disinfection. No a(e'nr. shoukl Lremadero
\ \ l . d F 1 ' . ,' , ,orl-p.r r. rr ", r mæk îhe coldilioD oldre pllp by àt.ainilg ]iæmostasis $'i!hd
exlosùre, the pulp is inlècted iidr m;cro orgânisms,and bùs â s r r i r g c n t . 1 l h a e m o s â s i si s n o r â c h i e v e l , r h e n t L r r t h e rt i s s u e
I I,1,',.or ,.'.'.. -n a'l ,rd ,..fj , i, ,' 1,' shoùtd be ftmoved The sxrne mnse ot no,nd dresv4s na!
Similarlr,a ûamxric duosure leti ol]ento the môuth for 21hoûs agànr be èppliedi rrè.liriôra1is6 favouriig crlcium hydrox,de
is contaminard s'lth micrc o.gânisms,ard hù ltde chèùceof cen€fîs, while odres faloùr resl$, MTA, or biolosicaL
ndival ifrhe.arity is simply r€sored. approadres.In ary elent, the tooû shoul.l be restoredtrghdl ùd
Thc bcst frogrosis is for trèumàri. ptrlpa.leaposùres. ûeâtcd kept under review. This apptuâ.h wa iûltlall!' âdopted by Cvek
ar $on as pssibl€ after rhe event.The ùxtrh shoùld bc l$nâtcd id 1978 for the mxnâgenent of ramatic pdp exposures,andhis
with â well seaLingrutrber dam, rhe ptrlp wound.leaûcd. and long-teim su..esseswere in ex.essot 807. Ho$ eve., rhe ùrlliqoi
h a e m o s . a s i s e . u r e d * i t h s o d i u m h r p o . b l d i r c s o l u r i o . . rhe appn)a.h is reinf{red by re.ent rtrdies showing high levelsot
Hacmosiâsisis critical for the su..essofany di.e.t pùh .afpinE s,c.ess in ihe marasement of.afbùs pù]p etPo\uô u yuuB
pro.edure. Fallllfc to âchieveade.luàtehaemo*dsisprobôlr permrnert molùs (Novn arclNosrar r998).
reflec$greâterdrd ânri.ipatedpubâl irflàmn,inon. ànd â con Thc bc.c|ts oi cxcisiûA inficrcd tissuc a.c wcll rc..grizcd t
scqucndv poorprognosis.Clàsicâllv.the pùlp woùnd is drcn.ov- pa€dlnû]. dentlrs, who hnve shunned sinple pùlp .apting s i
cftd wirh setti.A calcnrmhydroxidecemrnt iô fùrdrer disinfc.r high{isk pro.edure for rhe preseryarlon of expôsed priner
the exposedpù]p and encouragerhe .lcposirionol a rcpararive pùbs. Apicalp$iodon.itis i. drc yours cânies dre samedanged
dentin€ bri.lge. Hôçelef, rhcrc is.o.vinc:ng evrlence thàt ot pain 2nd sct)sis,bur hâs âdded dimcnsions in tern,s ofdânùgr
briclgesinducedby calclumhyd.oxidcâreincompleteard toroùs ro subj2.enr ])cmunetr reeth, risks â$o.iâted s'idr emoscn.r
an.t do not provide l{,na{cfln pulp trorecrior, especiâlLyif rooth cxùâciio. and orthodontic conseque..es tôllosiûg
rerorârnn! leak at a latc. srâse(Cox'r,/. 1996).ln recenryeàrs, unplanned iooth loss. lldintenance of healthy r!]p trsue is lheF
considerable interer has fo.ùsc,l on lenrine bor(led .oûFosir€s fo.e in,toftânt, ând coronâl fulpotomy is tl,e rcceftel norn fo,
d n,]lerlalsableto se.urerhe .lean, s'cu-scalcdmvi.onmcnr fô. the decply .afioùs pfimxry molar. This n idcâlly done ùndû
more prcdl.tablc ârd compl€rep!lpè1 repair these +proa.hes rubbei dan ùrh â shèrp excèvrtôr or trur, ûkirs car€ to fteethe
de now a..epred ârd wi{lely praftlced, rhough 1ôrg rern our .oronal chanber of sofr tissle an.l clt track to heàlth) radiclllr
known. Calcium hy.lroxlde nô lorger hô1dsa pulp srumps. A woùnd dresing s ûeû applied ro the radicùh
posirionol glory asaùn(ue pnlp regenerarive asenr,ând rhc rcal- puLp, before re$oring the rooth ba.tÉria and ntridilghr. clini.d
izationdra! i! is the .on.litiôN .reatd by rhe reromrirc marcrial tesearchLrasfocused tn,ngly on ih€ .hoi.€ ofnrdi.ament ândnr
that âllow healinsro take plàcehdsôpeneddre searh fof alrcrna' impa.t on ..ess. In reality, otrt.ome asain is ptubâbly mot
tivc atfroaches.A variety of mrterials. in.luding ala$ ionomc. dependent on rhe .ordi.nrn of the rxdi.dxr pqr rirrùe and rhr
cements,and the exceptionally*ell seâlinAard biocomFrihle abiliry k, eliminrtc and cx.lùdc irlc.rbn than on dre pfe.ne
Mnlcml Trioxide Aggresate (M.illeferlDenrsply, Ballaisùes. .odposition of.heni.a.ls âpp1ied. In .aretilly sele.ted .ars. ir

hasb€er sho\û rhat èpproximately80% of cèrjouslyexposed
pdtuy molas ùi]l be preservedwrhont eridenceof apicalperi
ùloûtltis,whetherûe pùlp $umps àre treètedwirh lormocr€sol
or calcùn hydrôxide(v.dterhonse,t rl 2000). Attemps hàve
beguûto ùses the con.litiôr ofpulp tissuemôre objectivelyby
meaurin.qinflammno$ mediatorsin blood lrom cut suriæcs,
md relatinAthis b .linl.al oùt.ome. High lerels of PGE, have
bæna$ociaredwith higher levelsôfpù1p brenl dôwn ànd àpicè1
periodontitis, regddl"ss of rhe wound dressing(v.iterhôuse ll a/.
2002).Etroftsto apply ast.insentssucha feû1. sùbhateù con-
toi blced;.8 may appeârlogical, bui may oot hcb rhc clinl.al
ourcomc. BleedinS.which is difficuk to co.ùol may nrdicarethat
rherissueis in ân itreve6iblestaleof inI]âmmâtion2nd will brcak
dos'nFhareler DedicameD.is sùbseque.dyapplie,r.
This is an cxcirina arcafor aduh ard pacdiaùicdeorisr.y,and
oneh whi.h môle.ùld biology will makegrearinroads.o suF
portdiâgnosisa.d rreatûent in the decades !o coDe.
Iniured
pulps
Prevenlion I periodontilis
of apica
afterpulpalbreakdown
Clssi.a.lsignsofiûevetsible pulp innadmrion in.lu.le sportè
neolspanr, aûd prolorsed pain on thernal stjnùlario.. In rhe
ea'ly staaesof pulp breakdown,pulpal nrfeclion ca. be quirc
superficièl(Iis. 6.2),ànd thereùe freqùendyno sisnsofperiapi
câl involvemenr.As degener.tionproceeds,deeperareù of the
pulp ând adjâ.enr denrine becôme infectecLand chânses exterd
o the api.al periôdôntiû. The bestprognosisfor conlentionàl
môr.analùeatment0..ù6 {'ben âpù1p canalsystemis nanàged
befoft there is exrensire infection and api.al periodôftitis
dsrlops. Measres $hi.h dsist in the elimimtion of inlectior
ând thc p.eve.rion of its recurercc are cenrral to lonA-t€rm
Creating
a cleânenviron|nerit
Rùbberdam isolatiooofrhe working teld is maûdalo.y,no. jus
to p.o.ectpatientsrrom lhe dansersof droppedj$troûents, bur
to cortrol asatut the influ: of mjcro orsanjsms,and allov
the ùse of stroûs .Uslnfectants.It ls rot sufrciert for th€ dam
to bc in placeiir must seâI.All câriesând plâquesbouldalsobe
periùdofrilis
Prwefri0lopirol 0llerpulpol I I os
breokdown
I
thoroushLrremovedbeforeâry attenpt is nade to enierrhc fub
Enteiing the syslem
Ir is essenriairhar the pnlp system n tully u.roofcd rc open the
.ôrôna1enÙancesofaLl canâls fbr enr.y. Standad tertbôoks shoù
.Ld$ical câvit). outlincs fof âll teeth at.t ot.e the chamber is
foun,l, blunrnded endodonti. d.es burs allow lhe chamber io
be quickh a.d safelr ùnroôfed tô its fnil exrent. Koowledse ot
pdp a!àlomy is e$e. tial fof predi.rablÉ .are, inclùditg common
"nr'ôrrrl v.û.nra\.l r_!'r.n..si l"rb I 11:'ef prlp
tissue and glle rjse to aFical periodon.itis. The benefits ofmâgni
fi.Àtio! Àrd sùpplemeDlrry liaht carnot be orere*rmatea rn
endodortics, ard the operâtiog microrotc has .evealed lninite
ànatomical variarion in câoal sys.ems. Howev€r,.ommody
misscd anâtomy coû.lnues ro be dre lin.quèl canals of love.
in.iso6 ard cdires ard the mesiopalatal cânal ot upper molars.
The opere.{ chanber sholld be filled from ùe outset wnh an
anrlmi.rôbiâl àûd trsue solvent irrisaot, of which sod;um
hrpochlorlte iîmalns rhe gô1d stddàr.i.
Reiùovalof tissre
Bulk removalofavital p p û still most efiiciendyrchievedçidr
bdbed brôa.hes,whi.h ère a!Àilabl€in a .dngeof diameieF tôr
e"eù fine ànd c!ffed cànâls.lt is important b rcnùle lùge por
rions ofrihl tlssuebeforc.ommencingcèrâl Freparèrion,since
fiLescan compactsoft tissuein rhe canàl,whereit will rbrm an
obsrruct;onto irll idsÙûenrâtion àrd becone necroticunder
bèclerialjDleclio. !o câuscapicâlpern)dontitis.
Dcterminingthe levelol'1heuound
Root câna1treâtment inlohes dre removâlof pulp ti$uc, dre
prcpdarionôfthe cùâl to aFre determinedlevel.ând drc instal-
lâtiôn ofa sealingroot l'illira, whicb will sere d a woud dre$
ina âAains rh€ .ùt $fr tis$te Nifa.e.
The length ofprepârètior, and therefore.the levelof the soft
tlssuewound is rhe working lenath. lt js impotant that dre lerel
dctc.mined doesrôr 1eâveà pulp stùmp which canûot be sus
rained by anr residual aplcal perfnsioû. nqda11y,the woùrd
shouldnor bcplacedoùt inù) the periâpicàlrissues,*hich to this
pojnt havenot bec. involvedin a diseâse process. h reè]ity,r is
' " r y r l t i . r o e r e r n r , c ' " o r ". d ; p l ' u ' r " 5 e r e p ' b "
rarionexrendsto;. relarionb rhe api.â.Iforder, àûd greèthope
is pla.ed in new-genr.arionele.ûonic apex locato^ wh,ch cer
tàiûly àppearto maketheF
Redsurinsly,it hasbeenshoçn dra.ifpulp Insueis.ompletely
remotedunderstrjctly dettic conditio.s.pedapicalhealthwill be
maintained by root fillings extended!o withir 2 mm of Ladi-
osraphi. rôôr end (rriednàn 1998). Preservatiorof vorking
lenath is importanr, but lengrh s frequ€Ddylost durina thc
preparatiônôf.urved cdâls bi the seneratior of obstructions.
Thesearegenerallyblockages caused by dertire chrppiogsa.d due
rô itudequ.te iûigètion, or ledges(stept creàtedon canalwalls by
tt0 I ordperi0pko
D Prevenronofpllpû disem
I
inilcxihlc i.srrumcn8. I'he advert ofn&tionèl .ùtling an,l llcxi'
ble nickcl tiàniu.r allots titr in$rtrmenr màùtlficn,re hd irniosr
coml,lctcl)' cli.rinated tbe o..ûren.e of these proc&luraL ctrott,
illowinA f..dictâblc a.d rafid.anal preparatiot tô letgth
'1
.l,l^ ., L I a . . , ' ô ,i o 1 L .- ' n . i o {
.ânals .on.enùl.a.ur', iiddirg them ofpllf f$ùe.nd i.tc.ted
dertine, ûd allosi.g e.ùI ol firrhcf ûrigant tu the deep F.rts of
the cùaj sysrem. AÊcr a,10 lcaf pe.n)d oiinsnûett naDdâi.l
lzatron, erldfgi.g rools ,rc now arailable in a rânge offupes and
designs, offering .ànal fr€paritiofs which a.c la.8e rpi.alLy at.1
miniôall} flàred, smà11rpna t an(l gready flirc,l, a.d anyd,iûg
itr beôvren There is curenriy Do cofse.eN on whi.h appr,â.h or
prepùdtiôrslreû deli!ers ûe mo$ tr€dictablc .csults invital ôi
nor-lital.ares. Whâr is de.r is r1iàt àn! oIlhe Ntrendt arailable
ni.kel ritadum systems \ril âllow beiicr conûol aûd ieduùio!
i. frocedur2l crrof dùrins rhc shapin! oi root.ùrls (Glùs.n
tl d/.2AorJ.
: i r r , I l l { } t l t i r - t l l li u
f - \ / i r ' i.l i ru
The adv€.t of.al,id ca.al prcpamin)n tt.hniqÉs mrke Lt lechni
.ally possible lbr mos dcnrisr5 tu .omplete root.atâl Ùeâtments
À à sinsle visir. Cli.ical .cscarh cliden.e La n,ggere.l thâr a
single sesion ofinsnrmen.âtion and disinfi.tn)n is im.leqûte to
pioper\' c1eàn,Ifecte,l cas.s,a.d so rhc xppll.âtior ofrn Jltirni
crobial inn2 .rnal drcsinA hxs be€n rdvo.âtd for.ises oi afical
'lhe
sitùarion is .liffereÀt 1ôr cùseswidrour âfi.al peftudoûtitis
$ùefe there is litrle r ection in dre,lcc])cr fx \ ot the.dnJl
s_vsrcm.lor rhese.ases, drere ^ .ôùsensùsrhat sinsle visir ûcaG
menr is prcfcrcd. pmvided thâr tlis does not lead to coml).omlsc
in mcchanicxl in\rfùmeniarlon dd nse of artioic.obial and
ti$ue soh'cnt irrigânt.'lhi.tl mitutes of.rnal .ontact vith trc-
qùeûtly eychàngcd.27 sodium hrpo.hlôrite soLution is generally
co.sidcrcd âdcaùate àr disinf€.tion ând.leansing.
! f e 5 : t i. ' , ' j n I t h . r l r J ï i]'luifr'i'iiùi:lrl
Alier mechrni.âl insûmrcntatn,n, si.es ûeJted for tetiodonrâl
diseaseère lorilled on a mai.tc.a..e ptugrâdûe for periodic
plaque cortiol lDdodonln si.es câ.not br rcpeatedly re eûtered
1ôr plaque.ortrol, so the ervironmenr musr bc prese^ed by odrer
meâns. The pulp caDàlspace is, d,e.ciôrc. obliteraÈd with niert,
, . . . _ , \ i r . r , " r , t - r . , , , o t p , r , t . , ) , f , ,
en6 thtuush apical, Iaterrl, orco.onâll)orals h mi.rlorgxni\ms
left àfter treatnent, a..l t.ercnt drc crûy ofne* n e.tioD lloù
dre moudr. Gùm pef.hâ and sealerrenxnr the con,moncst mxre-
fials Èr rhis pùrpose, ard.an be adapted ro dre c2nâl intcfnr br
cold ()nrpa.rn)n ô. âfter softeniig \anh soh'c.6 or heat.
Thermotlasti. obtumtio. te.nniques are ùore liLely !o dtilc
ùaterials lfro secondârya.ak,nrr, and have been hdled ds beûc.
aûd n,ore comtlcrc fiUing te.hnlqùes thân cold Fetl,o,ls.
Ilowever, no s}'5rcm bas bccn shosn tu preserle periàplcal he2ldi
better drar cold laleral condcnsatnn. vhi.h iemriùs the mos!
wùlely raugbt and l,.x.ti.cd fllling te.hnntL,e world*nle.
Regrettèbl]', i, /t! srùdier hâve shown thùr ,ll root tiiliry
lexl and rhàt .ll ire lulncr2ble ù) mafgitàl percoldrior by uuidr
xnd di.ro orgènisms Ê.om the mouù ifthey are nor f ûeded bt
a sell-sèaliûg ioronal resro.xrtrn.
Cùeiul\' cordùcte,l roor .anal ùeâtmeùt is $(csstirl in pt
veûting àpjcâl t,c.iodontitls ln 8l 1007. of câscs.B! Loitdt,
rcarnrcnr ofe*ablished apical FriodonrnÀ is su..e$fùL ii @Ll
46 937 of.ases. Clearh, rbcsc iigures, taket from ù mnseil
dinical rùdies, preser! dive$c picùfts ôi n,c.es. bùr thc nR.
sige is clcar prevtrtiôù is better thàn .urc.
Prevention periodontitis
of 0pi(01
. ir is orsie|o trevenr âti.àl !Érildo ntnn tlùn.o h.àl lron.etr'r
! Èiicine ffnÉrti.. in the irrevcs,bll tull.iric o.th if,volva
nl{].ùlons FmovrL of m,.o-orsrnnins ând sub*nte ftoù nr tÙLP
sl*Ên, and senlitg n agàins nÊv inli.rôn
. I.aÊ.rn,n r.nûôl sliôtrLl ùn.le{,ln every à.n!nat êvlry siÈgeolmd
' corEmForùrl levi.es sù.h Àsmxgniar.ation,.l..ronl. â|d
lo.nion, nlckel riradùm i tiûentrtio., r.d dre'mofLri'l
oLnn.lo. nrat e.bàf,.e inletio! ontioL Ihey nr.uld nDt,hô{ô(,
trket'r.eJetue over ùê.non.onrol bàsi.s,srh^ r seLl-nrli,,g
'oo', r'\ '' ')r'r"'-n,"",
PrevertingapicalpeTiodontitis
aftel
root.canal
treatment
The root canal ûcated n,ôth hrs Doie of drc .omplex PhysitlL
ard respo.svr b2rricf\ nr protct the aficnl ])crnr.fnL n Jron
dre oràl flo.x. ft hxs al\o been shown diat .orcnaur uûseùLed td
iillings xfe ùd!e6&l b)' r.nrnotile ni.io or.srnisns sirhû
.1 .10 dits. l{oot cxnal ûexted posterior tecrh arc also dr ftkot
cuspàl liùc.urc. whi.h may iûloLte the .oots aûd re{'li rn û4c
nert fàil![e. It is, rhcrcture, .ritical to resro.c .oor .âûâl treated
te€rh d soon ùs po$iblc âftcf dre rôot fill,ns is conpleed l0
mola$, dis cm be as sinidc ar â cusp.l .oversc xùâl!âû ù
.omposlte restorèrion. extcnded 2-lmm iito all .oot.ntuls, dd
oticn supplemented by a resi. bondinaaseùt (Nèyya r,1 1980)
Root .ùal ûeàted premolxis aûd anterior teeth irc clled|lli
rulnerable if $ey arc Lcst,red with prohsionil posr ûo\ùj.
shich 2rc n.unùslr ill fittiÀg i.,l âllos la+e's.ale Leùlo8.il
ea.lr .cstorarn)n is ùot po$iblc, drcse ieeth shoùld r,lerlly bt
sealcd Fith r.oft,û re$otation 2nd ore.laid $nh i Émovôt
partlal de.!u.c Àltcmarively. .oronal scal cân be se.uredwtrh!
dlrect po$ cen,c.tcd inù) rhe nesly fille,l c2nâ1,xnd r pldri. ot
miterial. llbre l)osis and .ômposite cores f.cscnt x pûtnùhdt
ex.nnrg inn,cdiatc resntration. nrFpore,l nos tr Lolu ert
.lni.âlelrden.e (Fer.ad rrzl 2000). atd easily tcù ietd f.r ùùl
 Tbe pla.ement ôf lnÛâcânàl posts is rot without its .isks.
notrbLyroot perfi,ratbn during post chènrei pr€paralion, and
compromiseofthe api.a.l roôr filling by over dtension. IaùoAcni.
conmunicadons berween rhè canal sy$em ù.1periodootium arc
uullya$o.lâted with rhe development ôf àpical pe.iodo. titis âs
nioo-orgùisms from the moudr gair eaùy ro thc .anal and
norod. ApicalLy, at lost'1mm of r.ntr filling mdteri.l mus
emain after post channel pfeparaiiôn to sâfegnarcl perjapical
heahh.Borh ofdrese erro6.ân be prevenred by fist mellins ou.
mot n ins marerial ro rhe desircd lcvcl before shapinu the post
.haûûellith appropriate twjst driLls. Bettc. still, inûa.ana] posts
shouldbe âvoided vherever rh€y are noi e$cntial n) retain the
Final$ pnlples teeth ùe incapable orsensâtion and will not
alefttk hosfto carlesor otherdâmâae wbi.h may e+ôse d1eroot
ûlling ro rhc o.al micrcflora. Roor filled reeth should, therefore.
be exûiûed wùh ekreme cùe dxrnrA clinicâl revicw; and pen-
odicdlll,radiogrâphed to con(ol for coronalcaries, or the develôp-
ûent ôf api.al periodortitis.
Root(onolheotedleeth
Conclusions
' Pulfitis ând apicâl periodontltis are mi.robiâl diseases
caucd hymembers ofthe oral mi.roflôrè. They ère commoo
disordersir dtl developed coundies a.d âre responsible for
substaûrial pain and sufterina, and if inadèqutely treèted,
canprog.e$ !o seriou, disseminatina sepsis.
. Teerh Md their supportiog structu.es contain $phisticàted
defences àgains ertry of dre o.!l microilorâ. Dentists
shoù1d nnderstan.t these defences, and be 2sarc that the
rerôrative solutiors they provide lor dentaldisofders are no
mat.h for intncr dental ris$,e.
. The dentire/Fx]! comflex is ablc to surive .onsidenble
'nsul., and apprm.hes are available to sàfeguùd the heâkh
ofall or pait ofûe pulp ifit is injured. Molecula. b;olosy is
likely tu offer new solL,tiors for the presetralion and regen-
eErion of pu\r tissues, s'hich hâve not bee! overwh€lmed
by microbial iosult.
. Apical pe.iodontitis .an be pftvenred fron developirs if
ireve$iblepu\r injury is managedgùickly ètd well by root
canal tr€atoent. Cli.ical pro.edùres should be bàseclon
souod principies of infe.tbn .onûô1.
. The root canal rcared rôoth is vllnerable to periâpical
breèL.tovn, if it is not adequttelyprorectcd.Root filLe.t
teeth shouldbe .esued gui.kly wilh s€lL'scaling.ôrotul
restônrions,taking carcnot tô.ompromise.be roor iilling
ot ùeate new ponah ofcomnuticàtioo vith drc perjradi.
References
Cox. C.F.,ând HÈfez,A.A. (2001). Blôcoûpositiooatd rea.-
tion ofpùlp risNesto restorativcûeatmens DerldlC|i"ic!
of NortbAmùu, 45, )r4a.
Cox,C.F.,SùbânR.K., Ostro.8., Sùuki. S.,.nt Suzùki,S.H.
(1996). Tùmel defe.tsin den.i.e bddses:their formation
fouowingdûecrpulp capfing. Old-d1;*Dùttitt!,21.4 Ir.
Cvek. À{. (L9lti). À clinical retort or pârtial pulpôtomy ànd
câtpi.g with.alcium hydroxide;. permanentin.nôs wlth
complicared crôwn ffl.we. .ltLt"àl 0f E,laJDntû, 4.
2)2 2)1.
Iriksen, H.M. (1998). Epideniolosy of apicalperiôdôûtnis.
In Eîe"îidl E"àdrnllkrJ: Pftrefltion d"d Tftdrtt"t af
ApMl Peiadnnùit, Chàpter8 (ed. Orstavik, D. and Pitt
Ford,T.l{.), pp. 179-191. Blâ.kwell Sciencc: Oxrord.
EuropeaoSo.ietyôf Erdodonrolosy (1994).consensusrepor!
of the EuropeanSocieryofEndodontôlogyon quàliry8ùide-
liûes for endodonti. ûearûent. Irkfldlio"dl Endodorlit
Jùrrrdl,27,115 r2.t\.
Feûdi, rvl, Vichi, 4., ùIano.hi. E, ant Mason,P.N. (2000).
the clinicàl performanccof fiber
' ReÛôspectlvestùdy of
pôsts. Anînd, JûMàl of De"t^î\, l3(Spec;al lsrùe),
lB-t B.
Frledman, S. (1998). Treârmcrt out.ome an.Lprognos'sot
endodortic therâly. In btrn|tul l.r.loloîtalag!: Prde"Iur dn.r
nùhent afAritul Prtolùntni, Ch2prcrlt, (ed.otstdvik, D
and Pift Ford, T.R.), !p. 167 -40i . Bl&*sell S.ieocerOxtàrd
clukir, 4.H., Brown. D.C., and Buchanàn,L.S. (2001). À
rcconsÛù.tedconpurerised tomogrâphic comparisonof
\ i . i , . d l u | , l F r F - u . | . ' : { J , ' m " , r i. l
c2nâlsshapedby nolice opet,tots.lntunaîiùtu| Erda'loûîi
.Jart"dl a4.476181.
Kak€hashi.s., Sanlen H., and Fifzgcmld, R. (r96t). The
eftic. ofsu.gi.al expos!r€sofdentâl Pùlpsin germ freernd
conventionâllaboraiofy nts. Aral Srryeô. Arat lleùci*,
otd[ Pdîbolog 20. 340-449 .
Moller, AJ.R.. Iabri.ius, L., Dahleo,G.. Ohnan, A.[., aod
Heyden, G. (1981). Influetce on pe';apical iissues of
r d s " ' o uo . l ' . . , i ' " ' d r . r o ' o t,*.! aô1.
keys.S.d"dituria" Ja'nàl of Dektdl Raurch 89. 415J81.
Mumy, C.A., and Sau.ders,L.P (2000). Root ca.al Ùeât
nenr èûd general healrh, a review of th€ literarùre.
tttuflùltonalE",/odr"1tJ,nmal 33, I ta.
112 o{pulp0lond
6 Prevenlion peri0pir0l
dise0se
\-,r P\R ^1 ' \1i.l2.r,d"'r'.. o
encounier betwccn Loot canaLinfectn,n md hor
Peio'lanlakg!2000 14, r2r-144.
Naylar, A., \Irâhon. R.E.,ând Leonard.L.^. (1980).At dâl
aam .orooâl-radi.ùlâr dowel aûd .ore techû!ùe for
endodonri.àily ùeded posreiot reeth. Jotmdl af Pndret;.
Derl^tu!43,5l) 5tt.
Nosnr, LV. and Nosrat. C.A. (1998). Repdative hùcl rissùe
formatioo folloving calcium hydro{idr applicatiôt Àfter
pèftùl pulpotomyin cariorslyexposedpu\x ol pehanent
' p e t h . t a . . . a . o a a ' E a J a, ..Jùa " - . . /\ t t ..
Rmdlow, K., and Glanz,PO. (r986). On cant;leveroreioad-
irg ôf vital èrd non vltal teeth: an experimental clinl.al
' . à t n . b O J a o l o " . . a l\ ' a , d t a a d 4 1 '
Reev€s, R., and Stanle], H.R. (1966). The reldtionshilr
betweer bæterial Éelerra.lon and pulpal parhos; ,n .alous
teeth. Otdl Srtsol 22, t9 6t.
Sundqvist,G. (1976) Bacteriolosicât
stùdlesof n
pù1ps.odontolôsi.âl cLissertàtion
nùmber 7. Unive6iry oi
Umeâ:Umea,sweden.
Sundqrist,G. (1992).Aso.iÈtiôN betweenmjcrobial slccies
in denral .oot .aûal infe.rions. Otdl Mittùbjolag drd
Innxn1lag 7,251-262.
vâlderhaùs,J., Jokstad,4., Ambjornsm, E., and Norheid,
P.\{r.(t 99TFAsscsmentof periapi.a.lând cliticàl statùsof
crowûcd tecdr <itet 21 years.J\Ltndl rf Deninlr! 2t.
97 t0t.
Va! Hasel, HJ. (197r). Physioloarofrhe hunan dentalpulp.
AdS uery,O,z/ t'\edù"e,A/d/ Pdtltolry!J2,126 r11.
Watefhouse,P, Nunn, J., atd Yrh;ù'orth, J. (2000).
r v e \ r j 3 a r i ù n ô f r h e r e L avr e c f l ' j . n . y " f B
Iormo.resôland câlclumhydroiidc in primarymolât
pùtp rhetapy. Britilh DentalJotmd{ 188.32-46.
\ d ' " t r' . l J \ ' n n .J l l " , ' \ x r \ r q u r ' \ .J v
Prosaglùdin E,ànd ùcarmenroutcoôe inluLpt
primary molar with.diors expas\tes. Ltdndî ndl
ol Pdedid*i.Dt"Iitîr 16,rt6 )23.
Y o u . s , C . , a r d B o n g e û h i e l mU , . ( 2 0 0 1 ) .Â
c o n t r ol e Jr n J b t n J d h i s t o L o g r carnL. l
ical irvesisatior of Carisolv on pulp tissue.J
Dentu\ 29,215 2al.
Furtherreading
Kim, S.. T&wbrldge, H., èrd Sùda,H. (2002).Pùlpdl
tions ro .aries and dentàl procedures.In: Côheû,S.,
BurDs,R.C. (Eds.).PrrTl,j,t af ûe P'b, ChapretIt
edn.)S! I-oujs,Mosbr pp. j7l j60.
Spàtsbers,L.S.W (1928).Endôdoûtictreatmentofteeth
oùt âpical periodo.titis. Ini Orstèvlk, D., atd Ptt
T.k. (tià.J Ewiùal E"d,à,n1i|s: P@d)ron a,J li
Apnnl Peiodaûi|t, Ch^prer r0. Blèckwelt Science:
pp.2ll 241.
Pashley, D.H. (1996). Dynami.s ôf the
.otuplex. Cûnal Re,;N\ ;r atul Biùlag)
10,1-131.
\rhlùorth,J I}L (2002). Rdt;o"dl roat.d,dl t rdtltnl,l
PublishinaCo. Ltd. pp. L 1ll
Londoû,Quintessence
 prevention,
Toothwear:aetiology,
implication
clinical
Linda
Shaw

c€nerto enamel junction. A{iâl forces ot the tooth tend to con-

lntroduction certràre st.es i. lhis reg;on, and.dse miùofnctùres aod tooth
Tôôthwed is a relntively .ommon probled an.t the sour.e of rissue lo$. :lhis is somerimes confused $ith cerllcal abrasion ând
naDypâ.ient complâins. It is rôt a new pbenonenon,bur has ' 'q ' i . i u ' r , , \ - { ' r , i o , o F . l l'_ ^", r "',i'.
r.eivedmoreaûentionin recentyeârs. The tlPe oi tntrh wed, its
disribùrn)n.preva.len.e.and aetiolôAyvdie\ * ide1yàcrôs popu Types
ol too wear
lationsard age rdAes. Hôwerer. dre re.enr emph.sison rooth
{er ând its p.evenrion is prohably due to a combination of
factors;we have ar aa€ing popuLation widr iocfeasi.g life
exlectaDcy, who remair dentatefor loûaer,and who h2vearearer
exlectations of dental cù€. Àt the other end of the age tange,
rheieis a cohortofyouûs peôplewho,possiblybecause orl;fevyle
factos,experlence qùit€ exleûsivetooth wetr

Definitions
of tooth wear
Tooth seâr is utuàlly due rô a combiùtion of proce$es, the
trlumvih.e' of abnsion, ârùitbd, and e.ôsiôn. ft is ùnùsuàl for
near ro be solely amrlbured to one ofrhese. Rather, tooth *ear is
dueto âll three proce$ess'ith perhâpsone of thesep.edômindting.
,Arl,jà, ;s Io$ of toodr substance lrom dre fri.tnrn ofa foreisn
bodl often a toothhrush. The.e arc case repoits o{ many quite of tooth weaT
Epidemiology
bizaûe.auses,in.ludins o.cupariotul haztuds.,{ttnd is à 1ôs of
There has beeûsub,ectlvei.formation pDbllshedin the 1990s
ooth substàrce dûe to tooû to toolh contact. hwds very mârkcd
suggesring thar rooth vear, parti.ulàrly from erosion, has
in lredlnasric Eayprians, pfio. to 3000 8., and .oûsidered ro be
increâsedconsidernbly. The s.iertific basisfor this is somes'hat
due to tlre sand content of the dlet, and therefore, could be
u.ce.ûi.. Undoubtedly,very differentiyp€softooth tissueloss
tegafded as partly arrrjtior and partly ab.asiod. Pârafùnctiônal
areobsetrediû the oldcf âduLtpôpulariôntlÈt it children.It is,
activilies such d noctùmal bruxjsn ar€ probablya morc common
therefore,ess€olialro co.sider them separàtelybut to r€gard
caùs€with the type ofdie! jD th€ twenty fi6t c€otury AD. E/ai,,
roorh weèr as a conri.uum rheuahour life with very differeût
6 lery difererr from these lvo physjcal lypes of.oorh w@ri ;t is
aetlologicalfactorsat the endsoi dre aaespe.Ûuû.
the lossof tooth str(tùre by chemical mems, ùsldlly acidic, a.d
nor asôciâte.l wrh mechanicàl or tmlnàric factors, o. de.ral
Prevalence
in âdults
Althoùgh rhese dree terms de well known and in cômmor Thc dataavailable€fy enôrûously,but a generalesiimatchdi-
usâge,there de other rerûs des.ribing non cùioùs destruclive câtesihar up o 97% ôf the adùlt populationâLeafre.ted;only
pro.e$es invotved in tôoth weàr btrt these a.e much les well abour7% exhibit wh.t corl.l be coûsideredasFtholoaical wed,
k.owd and not udlversauy a.cepted. These are demasticàtiôt which lequircssomeform of dàmsement or treatmert.
anl ^EÎtær;o . Dardù.dùaz is a term used frr wearing away of Àhhough rhc.c a.e a few eâilr câserepôrts or looth wear,
tooth substa.ce duri.8 masricarion. Tbis .ould be spe.ifi.âlly the lirs! larse surveywas published iû 1972; thls coosidered
afplied to the type ofwear shosn by tbe ancieûr Egyptians, dd 10000 extractedteeth io Califôrnià.Other sùbseqxentlypub
would depend on the abras;viry of thc food consumed. Â{,zrrzr lished suNeysconside.edRoman and Anslô-Sdon skùlls, atd
has been defined as ùe $€dae+haped defect observed at the èlsotoundâ hiah prcvalenceof tôôth wear Howeler,toneofdrese
116 / Toûùll/êor:0eliology,
prevenlion,
diikol implir0lion
investisatlonscoùld be .o.sidercd âs beins represertarileof â
The consisteûtfinding from very.lisparar€
publishedstrdiesis
'5Jr !oo.h qF" :r' r' In, s, l '9".. ,J d ead ' do-1, ., ..{ -
sidered!o ire È nornél physioloAic'agenrgproces. An ârrempr
hâsbeer mâdeto deteimine th.eshold'levels.which ùe regùded
as acceptable l€velsof wea. for a giver age.More rcent studies
usins the Toôrh \rrdr l.dex (TWI) ôf Smith ând Knisht bare
irdjcate.tthât yoms âdulrsar€ showiûga.celerared wear,which
may poseap.obletr fo. rhe furûe.
PTevalence
in children
Thereareûtof€r€tiÀbledit, od rhep.€valence ofrooù weàrin rhe
child ând adolescent pôpùlarion,As with adiilrs,therehavebeen
mihy càscreportsand severâl.aseônrol studies,bur there is
now d incÈâsin8 ahount of infôrmarionfrod well-.ondùcted
,lrr, !flJ' " rdtu ioir.{,ne\, Oreolrheno.. mporr"rLs
the United Kirsdom Child Dedral H€â]th Sùney of 1993, in
which è râÀdohly lelefted sample of 17 061 .hildre! âgedfrom 5
tô 1t yeas was€'âtrir€d.Ii wasfoundthàt t0 per centorchildren
ryed 5 and 6 ycarshadevidenceôftôûth w&4 ldraelydrlriburedro
efosion.ritb allnosr 2t per ceût hâviig denrinè 'hvolvemeû!.
ôrer bâlf of palâtal surfâcesof prihary upper incisorsshowed
erôsioùin rhis âge groùp. At ê1evenyèaNof d8e,2 p€. c€nr of
children were fôrdd to hàveerosionir théir perdaftnt tect!.
Arr æsesmentof dental erosioûwas also includedin the oral
healrh examjnntions,which we'e pâft or rh€ Nariondl Diet ârd
NùÛirion Sùrveysôfp.e-schoolchiLdreûjn 1992-91 ânt school
âse.hildren in 1996. Asrin, rheseù€ very impôrtant epidem;o-
losical studiesand involle largêpopùlarionsrmple si,es.Tbey,
roô, cô#irfted rhe h;Sh lev€lsoftooth w€âr,âtributed predoûi-
Ddntlyro denrâlefosion,in childrenand yonngpeople.
Thesesudies arecmsssecriôrâlinverigarionsand do nor give
informèrionabout id.idcnce,of rhe possiblechanginspÈra]èn.e
ôi tooth sùrfâcelossinchlldren. Hôweve..idrerchces canbe.trawn
âs rhe Narioml Chil.l Detuàl Heàlrh Susey sds b$e.] oh dâra
colle.ted 2 ysrs bclèrc rhe Nârionàl Diet and Nrrririon SuFey
dàtd.The preûlenceofany €rosionin bôthprlmâ.yandpermanent
Tâble 7.1 Prevalence
ofdentèl efôsiônin.hild.ex
Nûûirior Sùtrey(19t1) [l]ùds ùd 6egùiy 199,11 ri-1+
Millwâd, Shâ\',àndShnh (199.1)
UK child DÊffàl Hdlrh Sùreet(1991) 1,6
11-14
Nuûiljon Sùivey(I996) tvàlkd d aa 20001
Miloselic âhd l-,ûnon 11994)
1,é
I4
denrtioôs war Afe2re. ;n rhe larer srudyi fo!
4-6 yeâ.olds l8Z, ofthe labialsurfaces of upper
*âs affe.red in 1991, comparedwi.h l8Z in
difïcrencesate lessmarkedin the pernmerr
Ùetd ro i(redina levelsoferosionls corsistent.
li1ble7.r Aiver $me of dre data from the UK
. e y . r , w " l l . r o o f - r e p d . n , o l o r i" l i \ À ' l
BirmiDahamand Lilerpool. Althôush rhereare
encesnl rbe measu.enentm.t càlibrâtlonof ùosior
Ëom the epid€miolosicâ1srudies sùggestsrhat
pre-schoolchildren ând a half of reerâse.s have
sûfde loss,which cm ldrgely be â{.ribed ro denial
oor, èsyet, the ptrbticheâlthproblen rhardenral
to be, bùrvigllân(é is reqùiredto tuod tor whelheithe
Prevolence
ol toolhweor
. **orit
rt"!:lidï
.;.:.i
-inql
Assessment
Meârufementof toorh wea.;n €eûerâI,aod erosiorl, ur
Lrâsbeeôfraught with difÊcuhies.Therehavebæn
trsédr, /t'd which plainly cdhnorbeffanslared
ro rheclj
rcnment.Theseirclude physicaland chenicaLsystems
\ a a , . r 8 e e ! , r o n I c r o * o p ) .l g . r d l . m r g -' ) , i
r.a$nogrâphy, l-D{omognphy, lâser scânning,
neric resomrce imdgil1g, miùo-&diogrâphy, and
dissolurion.Many oi rheseaDalyliGl sysremsùe
reproducible, but can ooly be Dseàeithet )" uûa, iÈ
extrenelytine consùnjDsaDdimpræticableto apply
2A L4
r7
t2 t3
tl
1o
t

Tablc7.2 bodr wcar i.dex cri!e.ia
Sùrlac€s Criteria
B]LOrr Nù Lù$ ùf {rf.are .hau.teristi.s
lo$ of cnam.l rurli...l,r.r.r.ris1is
Lo$ oa enrnel. dentine exriûyd lor les
drm onÈ dltit ofruttr.e
los ot emmel iùsr Êr!.sing denrloe
Dentn,è Èxpôsuretor mûre than ône
sub{rtr l"s ùaderur
Co'nllerclos oi.nàncl, or FùLF
ext).r!re.t se.onrlart!lertln.
PùD Êxrosùreôr e+omre ot
Iùdicestu meâsulî both wea. n /;/a were lrs! describ€din
. , n , l o J t . . , , . s e F p l , , 1 Ê - o r . " , h "r r , ! , o r , o
co.scious childrer. ùlaN of the scal€sèùd irdi.es sùbsequertly
sùs8cste.l lor hunar clinicàl studieshàvehdd diversediàgno$ic
cit.ia. The numberaùl compleiity ôf theseindi.esdemôn$àres
tha!uhù b€eû.tifilcuhtô delised ideàLindd for u!è in alL.lini-
olcirumsrances.Thereis no !nilersalty èccepted,.deÂlirive
iûdex
ind i appkablc rc ihc divc6c needslor eseàrchinto tl,e âetioloAy,
!releùior, matugement,ând epidennnoAyof bodr seâr, a.d
ûonilorlngofaû irdividûl p.rirnr. In adùhs,rhe T\{.I ofSnith
md Kniljht ha prôb.rblla.bieled rhc g.catcsrcli.ical acccprancc;
ir dtusûes qtrh wcaf tionr 2ll sourcesa.d doesnor dlfereltid!€
bdryrenûÛition. abruion.and erosio..ii is rhls iùlex, wth some
ôodifi.atnns.rhar hashccnscnemllyusedin children.The manr
ditflaarS;vcn i. TabLe7.2.The T\Vl]iâs seleralù.tvmtèges
oler
ûh{ pnbllshedi.di..s; ir hâsthe rbility to disringùishbesveen
îormJ and abnormallevelsof ûrh s'ca.Àsâc.ct)tahlclcvclsof
toorhwcù h2vebeenpùblishedfor à11the differirg àgegrôups;ir
is,imflc to usctô. i.lividual or ld.g€popùLatlo!$xdiesèrd saris
Iâ.toryexaminc.rcfrcducibility hdsbeenshowr to be èchievable.
Ii die tlK a sjnple, qùalitèt1v€indeN.largelyusirg the ùite-
'iâ in dr€ TV/t but or iûdex teeth,hd beenùse.tin ihr nxtn)nxl
Jeital slFeys. ft shoùldbe notedthârthe câlibiarbDôfd1en.n!
examnrers mvolve.tir ûese ]ùge surveysprôvedehewhar difÊ-
cult. The .tàràfor the ftprod(lbility ofdiagnosisindi.ared drât
lhe resùitsshouldb€ lnr€rpreredsnh .urion.
Aetiological
lactors
Therer no.toubi tbxi the.aùsesof toorhicù arc multifacrofial;
thedifferentrypcsofrooù wearseldon exisrasa sinsleentry and
ihe.aùscsalsoare lcry sel,loDsiûgle or sinrple.lr s a.ontlex
inrn rn,n otfhysical a.d chemicaL torcesor abiolognâl sJ,stem.
It n. rhcrcforc,soncvba! arbi!.a$ îo co$ er eàch!r'.peof rooth
weù individuàlh, asthoùAhthey wereseparate entitieswirh dis
tlnd indilidùxl .ausâtk fâctos.
iocrors rru
n*ohsiro
I
Asiessme[t
ol tooihweor
. l, ,,t /, rt ststems 6e phrsi.al nelhoJs sùdr 6 scàr.,ns
ele.Ûon di.roscoty, dignd imsc aoalysh, Frolilonerq',
rsonrn.e inla re. rnJ m ft. rx!,'!mphl
. Chcmicnl merhodsuse,li&re iinlùde â.id solubiliq sudies,
.âl.iun Àn.l Fhosrrhorus ,lisotLtiûn and lqdùxya!.t;e .tnsolùtloD
' 1, r,:, aninâl $ùdiès baveLeen tnff.o.sumins, sùbjecr o
.ônsidrbble erbr àtd ùot rppmpririe lor.tu$lftio. ro hùman
. TlÈ ûinr publish.d cLinicaliodl.es mAse$ dû lr has h.""
d,fli.!lt rolevise â. i'laL lndex lor !sè in al1.linl.ât.ir.ùmsance:
. IheÏooib \fearl.dexofsnlthândKnishr(19s1)nrqLaRuve
.lini.âl index ?d hâs lrobrblt dhievêd rhe riieares senorâl
e..ptân.c. lt is in{.dc.l for boih.r,jdedl.losi.âl sturli.",-l
lnJividùaL!Àrienr 1ir long Èrh ûôniioring ùf t!.th wed
. toor rcprodu.ibiliry oJ di,snsis of ooih weàr if, lârse suftrs sldr
maoy e$.riiets indi.àre dràr the æsLi6 ôa*udir! shoutd be
in.erp.ete {ith.rùtloo
Abr" sioil
ùIo5t xbE\nh is lo.à.ed in ihe .eNi.al areà of teeth drd Àsocialed
wldl rooth brùshins. In.lreft or over vigoroùs brùshirg wirh an
ibrÀive toothpâ$e ls ùsùàlly thepdme retioloaicâl tà(or. Thcre has
beenâ ùend to ùc.cdrttion inabnsivirl of.ommer.iâlly âvèiLàble
ro.thfdÈs. Thcsc arc.ompl{ for'1ùlations dd rhere fteds to be a
balâncebetwccn onl hcalth benefi8 and porertiâl dânaue to teeth
and soti rssù€s.k s nor jlst dre ab6nr co.renr ot rbe tÈthpak
dEis importnntr dre abrasive!ype. pdfticle sizca.d sùrâ.c, xnd d1e
clienical ellec$ of die other cons.itue. ts s'ill âlso xlt.t the ann,ùlt
ofâbrasior. For exùrple, most 01 lhe hyd'arcd silica hasc'.It.xnh-
p.$es hà"e good cle.ùlùg valu€s wilh d low to modcErc dcntinc
âbrùivitl Obviously. othe. tactos alch âs brBhlns nre. brirLe
slÈnes\ dd pâft1.ùldll rhe fre,lùen.! ôf aû.I time sFeût o. toodr
bnshnlg de ver! imporûrt iû encouragin.qdenral 2bnsior. Thcrc
is sûong eridenceto show that dbrÀion increâsesc.ornrcùslr ifthe
tdth de fist €xposed o ar ..i.lic eroslve chnlleûs€, and ùen toorh
brushlng 15ûndertâLen shôftLy âftersûds. Slmilarly, tlt rcngle dnd
orhefonl $ir tissuesdal play â siûilù role.
Ihefe ait hâny.à!e repôrts ofàbidioû related to differen! lbr
cign ohjccrs and subsrancesrÉpeaÈdly ntrrô.iùced nto the moùth
and.onra.tinA the reerh. Ihese in.lu.le su.h things as pipe-
sûoking, prn and pin chevirg, èùd elen bag pipesl
Attrition
\flear causedb-v rooth toroorh contact durlng the normal func
rior ofeatirs shoùld be nininal unless tbe dlff a kq abrasive
sùch asthat of rhe Àûcient Egl ptlaos. (This a.qàinsbo$s rhc inter
relàtion offactors.) Ho\1e!er, there cin be conrâ{ ol rhc rcdh i{r
reasoûsother thd elringi oral liabits, such a paraiunftio., mal
tunûlbute sigû]fi.aûtll, to dertdl dmage. r'1tu:sm is co.sidere,l
ro be one ôf the most slgnitcan! parafun.tion àctilitics ol rhe
tt8 ,,veor:oeliol0gy,
/ Toolh prwmli0n,
difkolimplkolion
ùomâtugnxthi. syrem. ft ls ùsMUr defiftd âs.he habnùâlarlnd-
intr,.len.hlnE, sfittins, and anasbing ot redh dùrln8 rhe day of
tight for non-fundn)dal pûllses. Borh.ons.n)ùs and b.on-
s.i{trLsSfi.dinA nrat' occu.. but rhc a$idoay is nor $cll ù.dcr
$ood. It has been shosn n, be relared ù) sereml {fts tà.i(trs and
o..lusrl dis.repaù.ies, aithough sôûe ôf rhe ptrblislred infôrûa
tion rclarinA ro dreseta(o,s is que$io.able.
It is u.ccr,in ahcthcr o.clusâl inreilèrences lausc u'( urux
ism ahich .csults in arrririon, or whed,e. lhe wea. has resulted in
lhe occhsdl interlèrences. wear faces rre louncl on ure ocusar
sxrlacesofFosterior reeth and the in.isùl e.tgesôfèrteiior r€eth
These ùe I]ùt ùûd flùs1i sirh dÉ opposirg rood] in.onract. There
is ofteû èr erosile elemenr.lsô tô the tôoth se.i an.t then the
oFposing roôth surfacesdo ûor.orta.t eâ.li orher everly
Evnlen.e fror lloFaro Britisli skulls ànd pàiti.ularly fro'n
exhùmed skulls. $herc thcrc nxs aû ac.urarc rc.ofdins of drc ase
. .1'" '. -g ',
ù .._lê
ân.iert popnhtiôrs. Hoùever, very few ôftheh lived tô re âver
àge life erpeftxncy thxt \,È have in ûe Nenrt'-firr.emw:
pâfterns ofsear on o..lllsal su.faccsand a$c$mcnt.fisland5
denrnrc and crai.cl arc uscd tor dctc.mi.ina rhe aAc of i.dn'idu
a l s i . t o r c r s i c . a s c s k. s h o u l d b c . c r l i z c d r h 2 t d r i s i s l i k c l y t o b c
.clâtilcll inâccuete (he ro fte dbsenceof reliabl€ longtrldinal
dara ând va.iablcs such as dier. {'hid, mây h2ve tlayel ân imfor
iant pal1 in dre developmcnr ofwcar
Erù5k)n
No. onl-v is toodr vear a multilactoial co!.litioû bù! erovon
rself hd a muritactoiial aern 1Ôtjq Figùre i.L indi.âres sôme ôf
Ficur€ 7.1 lûùaft,ôn.f nrùft1pl! r.tlôlôgi.al fr.l.s
the faao* inrolvtd. Obviouslf, è nsceptible toolh d..l riinc
'lhere
ftqtrlred afe fa.ro6 wirhm the nxlr' ùal, retèûe,l ro
inûln\i. fa.(ûs, ard exÉrûâ1inflùen.es,relefed !o âs
iàcios. wli.h aft dl ftlevânr. TLere âppe.6 to Lrea hùge i
$nh rhe à.ruàLanàton,t of the moudi, srln'ary uos rxres
butliri.a cai),ciry,and minemlizarnrflof the tuotlt ris$És
l)layiflg a par. Fof cxanrdÊ ln ùeas su.h as dt lower tuM
regio.. whc.c drc.c is po.li.g ofsaliva xdd .eLati\e protecùor bl
dre toûsue, lhe preval€.ce of c.osion is lo$'cr.
0t acid
llrIrilrsicaioLrlri:s
Atl aii.ts, whetherIroù extriffic or inûnsi. sou(cs, a.c
ôfdeûiùerdiznrg tooth rissue and, therefôre. of caurng oosioo
lntrinsic sour.es of àci,l ârc .$cnriùlll gistri. ()orÊntu, shnù
eûtef rhe noùdr a a re$1t of reflu: and loùirlig. Thûe !
âLsô sôûe o..èsior.l .ise repor$ of rumiflàrio. dclib.n,rh
brirgiûg fôod bè.k nrto tlie moùtl, ro re chew shich hÀ ltd
Ihe ù) exr€nslv€ etu\ion. GdÙi. reflu s mtrch connorer thu i6
of on.c dnùAhr. Relatlvely, recent resea(h has showt that, in (t
dcvclopcd wofld, l% of the adrlt pôpnlation hJ'e gdrc
ocsophaAcal rcilux on a daily basis and môre thèt 107, e!ût
'lhc
lew days. matorit,v ot rhis is asrnrpn)mari., bnt rtur n r
sidc stl.ùum of disexsead sererlt' of ftflnx ittô the noùr
Sornetimes dre derelopmert of.lenrrl erosion rs the ntrr jigr
drat relhr is occùring. r.,l indi.xrcs rh2r inrcrig.tnrn ol rhr
gasro oesofhâEeal .c|ùy nra-v t,c rcqùned. Geoe.âl a$o.i.td
synproms are hearburn. rcrustcrnaL discomfttt and dlsphagu.
Peôple *ith neurolosi.al impa;n,ents su.h as cc.cL,ml pilsl
alo 1we significmdy hgher lerels ofreilur. Sonc of thc pot+
rial.aùses of reftm ère showr in Tdble l.l. OlFri.ul.r lisnill-
.ân.e is ex.esile dl.ohol intake:u rhis s a porenr causcof Letlu
bùt al.oholl. dri*s h themsehes ûra! be a. e{ûinsic ridir
v.miri.g, cirhcf spoflran€ousor selfin.lu.ed. û.! be dsd
ated sirh â va.ieg ôf ûedrcal Froblem. Son,e of rhc nor
.ommôn ôres ûe gileÀ in Tùle 7..:1.This fhe.omenon mù{oF
tinue over a Long period to cause srgnllicanr erosloo, and agaln.
Table 7.3 P.i..itial causc\ ofsasÛores,phageal reflux
ln.rexsed gr*rr presnre
lmrerse.t sÀû,. v.luûr.
NÊùr.inu:.ùlxr, e g .erÉbnl pil,1
rcl.td to
 Àelioloqktl
lodor I 119
I

Table7.,t P.;ncipalcauses
ofrômitits Table 7.5 Eros$n potentialofsome.ônmoû]y wail2ble drinks

Stre$-induced psy.hogeni. vomiting pH Tiù?rable Erosiot

2t

).2

Gaùo inie{inrl disôiil.s Peltlc ùl.er, ga*ritir

r.i
1.3 1 i High
Neroùs t{tem dn.rdes
1.9 0.6
4.1

Se.onaary o Ââsrri. irritatlon

e g. âl.ohot, mpirin, non nemidrl
mii inÂdmnorr druÂs
1 2

Dflg jndu.t.l xetusomir ov.r ù

eftenderl DÛlo,l 'nây âlso intlùÊn e

rhe;. riùatabieâ.idity is nuch reducedand thex thetefore,havea

reducede.osirepôteûtlal.
ùqe ;s a mnge in sùs.epribility. Cuûeo! reseatch shows an
increasinsprevalen.e of ù.h cônditions as bùlimia a.d anofexia l,ilestyleinfluences
nffosa, bodr of whi.h may be asocidted vith selt iodu.ed
Therehasbeena welcomeempbasisin re.ent times on â bealthy
lomiting.
lifestylc.s'ith a heàithy'diei asi$r a Pait ofi!.
En.ouràgementto take regulàr exercne may also lead to
Extrinsicsourresof âcid increàsed consu,nprhnofdidic drinksl someof the sponsdrinks
TlÉre ar€ maDy sourcesofacid from ôurside the body, which may .re roi only ac;di.. brLt Ètsocontai. a.onsidenbl€ amount of
afe.t the deûtâ.I tissùes. À seri€s ol cdc fciports have relatecl ero simpleNgars.Both competitiveswimneG atd .yclistshavebeen
sio. rc conrtut wùh fenilizes, dynmite, ând varnrus industrlal reportedash.vins hisher levelsôf.tental etosion.
pro.e$esùsing acids. Recently, ar hc.eased prFâlen.e and sever Conversely,there are unhealthy lifesryles that may be
ity of eosion has beeû shown lD people with dire$e work ân l impli.ared in denral erosion.The ùseof dre drug ecstàsy'(1,4-
hisure âctivities $.h as wine tâsting and comfetitive swmdrng, medrllcnedioxymethmphetamine) redùcessâlirary flow The
whi.h er?osesùe denritionto reteate,l corra.t witha.ids. Ho\î . r ) i u u ' f ô r " , e s , l d . r \ d t . , o n r o ' \ ' s . r o r 'F v P ( _
i
ever it Noùld b.. fdir to sây ihar these types of expônde are fàr Ie$ and exce$ivecon nption of low !H drinks hd àlsobeer linked
common rhafl the extrinsi. a.i.l sourcesthat a.e tclated b dietaiy
intake.Dierary prdri.es ùe changng ftom dre ûadiriônal rhree
mfllspe.day ro hibirs of gnzing'md inackinA'. There has been
m qromous increasein $fr drink .ôNmptio!, aûd dr;s is ûo
lonserconfined to children bùt is being cùried foNdrd intoâduli
llfe. Â sisriÊcâ.t dsoclâton has been shôwn beiwee. sott driûk
coNrmplioo and dental ercsion, pdticulù]y, the bed time con-
slmptlon of fruit based drioks. There æ a.lsoà.idic foods and
lnctices drai may he implicnted su.h as high consumption of
ftuii. pickles, dd sàu.es.
I i, I o o, .y _hpl _rol e foo. . 'c dirl ,.i .,iporr,.! '
the.tevelopmert oferosior, but also tbe tlÛatable àcidlty. Thjs is
tbe anôunt of âIkr]l that needs !o be added to an a.id to britg jt
ùp to a neùÛa1pH. Ir, therefore, represers rhe amoùnt ofavàil
able a.ld. and is d indication ofstrenslh and erosive pôtentiât.
Table 7.i gives the pH and the titratable acldity oi sôme.om
monly consmed drinks. Mmy proprietary bra.ds ofdrinks hâve
bùSersadded iô rhem so thèt, àlthoùsh theû pH remains low,
rzo r roorh
weur:
mriohor, dini(o|
rl".vêntior implko
oû
I
How canwe preventtooth wear?
Exce$ivetoodr wear is riu not a puhlic denlal health problem
that dentalcùies ùd pefiodoqtald;seaseâre.Howeveafôr à !ig-
ri|cânt aDdhûeâsing nùmberofiodividuals, lr is a seriousorât
,.aJ,o,-\'h.., ..veJ,ôecF"r- .F-
m€nt.Ir is vihl rhar theexjslerce oftoorh wÉdis ldentlfied eâfly
ùr.1 appropiiate prerentivc measures pùr into plâce.
Abrasion
Preve.tion oiabrasionis lârgely.ommon serse.Iflhe màiû aeri
oloay]s incorcct toothbrushingdùo. rhe useoran overlyâbrn-
siveroolhpaste,then the te.hnigucând drepase canbe chànged.
Odrer âeriolosicalfactoô needro be iderrified and ûer èppro-
priar advi.c an-en.Tiris .èr oc..{iona.llybe quitc trcblematic if
the causeof the èbmslônis rclaredto prolesiordl âctivities,$.h
a;r wid instrùmentplayers.
Abrusilefoo.tsareû.ômmon ln dcvelopedcouûtrles,but mÀy
be sjsnilicàût factorsln certain afeæ of the developingwo.ld.
Howevet thereareusuallynaûy healrhùd sô.ial problenrsrhat
mày render tooth wear somewhatinsignifi.ant .ompa.ed s'i.h
theseôtherpublic heakhcoûcerns.
Atldtion
Ifàftritior relatedto paralirnclioùl aftlviry is found ro b€ pro-
Are$ing to un.cceptablelevels,rhe. Freven.ioDof fùrrhei tôorh
suriaceloss must b€ coûsidefed.ALlhoush ndles consisrerdy
showmoreâtÛirioo tiiao iemaies,rh€yerperienietd fewersymp-
tohs of rempoo-mandibulardysfurctiônôr myofarcialpai. rha.
'the
femâ.les. sevc.ity of attrltior hàs rot been showo to bc
stronglya!$clâtcdvi.h rhe developmertofsigns ûd symptom.
It hasprolcd to be impo$ible to rotâlly sropnoctural bruxn g
r.tivity; although d.uA lherapy such d ùicycli.s s'ill rcduce . Give appropriatedietàrycou$e11ing
REM (RaFidEyeMovem€noslceF.whicb is whenthemâtôrity of
thÀ acrility takesplace.The môr realisi. meùod ofconrrolLnra
aûrltn n is not in .he preventionof rhe parafur.tiosal acrivity
irsell but .ather ir the prevertiôû of the dâmaae't câuses.
occlusaL splin! (moùhgùdd) can be conrûucled,wliich wlll pre
vent the toorh to tooth conta.rwbich resullsiû arrrjrloû.Fôr long
,er. , e.r,,l o r.,ôn,ia ? , l € . n o u , c o ' l , r u rn g : , ' ' r ' y .
a hard occiùsàlgnard ro col$ dre mdillary teeth such às â
'lUichigd
SplinCis an option to corsider This, mày re,lùirethe
ue of a ta.e bow so rhar the nodels cân be coûecily anicùl.ted,
dd the o..lusâl suriacesconsructedtu a pr€determircdocclusâl
Thereis nô pùblishedevidenc€i;om clini.âl ûia.lsrô showrhrr
âlterationof ihe occLusjonwill elimjnàte blLxisn, bur ir may
havean ctrcc!on rh€ site ofthe arÙirbn. Occlusâlmanâgemeû!
(ad)ùstne.o aims to direct the fôr.esgene.aieddurios bruxism
throuah af@softhe reetha.cl resrôrarbnsrhar are besrsuiredro
a.cept then. This vil1, rherefore,rcducc mecharical fiilLrre,
Ërosion
:fhc ii.s. sef in the pr€ven.io! oferosior is mâking r di
Once suspicionslravebeenoise.l, ir is esential tô re.ord
je y _ 1 . - . e \ " r . r y' n d e " - 1 ' T l I r . a'"b.i.l ' - : i
baselineso rhàt a.y FroAression
cèn be dsessed,Àrd rhe
of prevertire mearues nonnored. k mâI âho be nece$a.y
!ûdeftale these pro.edures in parierts with ma.ked abrsio.
. Recordthe clinicà1sirùdtiôn
r l-ôr .hildrer, in the permane.r denririon. and aduhs,
tèkeiûpressionsfor rheprodùcion ofAoodqualilysrone
r Clirica.lph.,rographsmay be hebtul.
r CÈtrestly, the no$ ùsefu1diègnoric index is the Tôorh
\i7earIndex, but dris is probablynot sufficie.dy rosi
' \, o/r'e,' .TJ d! o.r" f,r{
r À silicôûeindex.an be piepded Gcelare.).
. Try to det€mlne rhc aetiologicalfâc!o6
r Take an i.-dcprh history to irclude a detailed.tietary
history nedical hisrcry.dertaLhygienehablrs,andsen-
siin'e iNesrisarioûaboutlifes.ylefactors.
r À rhree-daydler history ro lrclude everyrhi.g lhd
pases the pùtierts iips is iûpoftant. The pefiodi.ltyot
eâtinaand roorhb.ushinsis aLsormponèrt. Sùcl habits
as .ontinuoussippira or 'fio!hi.s' of dri*s shouldbe
ooted.,(Iiodrlog is the h.bn of holdirg carbomted
driÀksir the moùrh èrd su&ins thed in dd oùtofrhe
teeth to make frôth. Ths teûds b add the dûdônic
eFectofthe bùrstirg bulrblesto the erosiveeffe.s ofrhe
acid It â]soexterdscônt&t rime.)
r 'rhis .m only b€ slven aftcr a thosugh ânâlysis
of rhe
dret ard iduercing fà.rôB. ft dus b€ tailoftd rô the
irdiridùal, beàrirg in mind the .ôn$niûs that de
^n op€ratirg oû them. It needsro be given in a })osnNe,
individulized wav to mdioize compliance.
. Limit acid nrds and dri.ks ro mcahimes.
r Red(e freqûncy.
r Avoid eidi. subrân.esla{ rhina at ni8hr.
r Finish meaLswiih somethirg dlkâline Nch d â sûalL
pie.e of.hccseor milk.
. Àvoid toôrhbrushin8for at leasr a. hour âftef acidic
r Check thc fomuLationso. constitùentsoi any medi@-
r Che{'in8 gùm hasbcenshovn to stimulatesaLilary flo{
and locreæebuffering capaci.y,bùt may .lso caus
ln.reas.daastricsecretion.
lt shouLdnot be r€commended

for .hiidrn, p!ôbably below Àe .se of I years,ard is not
$rgesed for those with è history ofsdstri{ .el'lux.
. Inrinsi. à.id sour.es
r If there is an) eriden.e or susp!.ion oi gastri. .cr]ux,
rheù refeûèl to the generaL medical p.â.t'!oûcr aûd
orward ro a gastro enterologisr or ps-v.hiaùi\t may be
reguired. If€dl.arb! Day be helpful, b{t this obvjoudy
fl eerls medl.a.l slpeNisiôn.
r If.eflux or rôûiting a.e occrrrirg, then rinsins dre
mouth snh wâref Ând r)dlum bicxrbôoârc helps ro n€ù
idize the oral cnrirormcût. People who lhve !ônir€d
oÊc. rush off to .leao their teerh. This is qtrite the
vrcrs rhins to do ard sloul,l be advlsed agains. It has
tJec!show. drat iftccrh have beer sùbiecÈd rô ar Jcidic
arack and :ue then btushed, up to five .ims ù nuch
endoel ,s removed. lf renux ir occuring duri!8 sleep
rhe! ao occlusal Auârd conr,inioS ydius br.arbonète
can be ued i! âdul6 of.eeraÉters.
. When the pari€lt retuns làr r fevicw. drcû compllin.e
vith all ihe &lvice sjven should bc cl4kcd. Perhaps
more impoiiand], rhe slate of !h," dent;!io. mu't be
exinired veiy carefùlly.
| Â locâliæd silico.c indcx should bc taken ot dre ofigital
$udr G$s in rle ar.ê ofûost.on.ern. This can be cut
throlgh sith à shrrp scàlFel o\'€r the areè (ottc. thc
pâlatal dpect ofthe opper lrcisors). J. is dre. transicrrcd
tube fit on rô rhe pâtieft.Ifdrere is àrr- sàp beN€eo dr€
silicone inderâ!d rhe surfâ.e ô{dre tooth, rheù rliere nds
beeq fufther rrth surface lôss Hôwever, rhis woùld
indicate faifly crtensiae sùrfa.e lôs
Gcnerxl conrparinro with rhe rudr .ars ard the.liùi.ai pho
tugnphs is i.lso nrcessdy. These recor.ts have ù ûlrber of errôrs
rilereûr ,n their nedrods, but.a! be usclul i. showina aûd edn-
ori.g flticûrs ab.ut rheif enxioD ptubleds. There ère more
acouar methods su.h as repli.a te.lniques e$mined un ler rhe
ranninÉj elccûon oi.loscope, bur dresehnve verl limited ùse i!
geisal den.al practice.
Prevenfion
. ALa irr: s..a ôt.l t\yEen. insru.tion reLarnrg to.o.rhbrushiry
I . e ) , - , r , t ' . - ô i , m ' h l - . , c R .m
, ,,, et"b"!
' ldlt ir,: it ls lnnGsibteo pr-€.r tà6furdi.ml r.virv. bùr
dre.oÂseqe!! da@sr mr br mnimùed bv prôriding ô..1 ù1
'"..\ l. r n..t,o
ôarrimry aedlLgi.al aa.tôrs
. Ânr eflua adivity
. DictaryÀse$n.nt lnd.ouns.lll.S
. ÂdequakLilo{{p ro.n(k {hedre! tlt d.ntlrion n rBble.l
rlinkomelrdrbis rrr
I
Clinicalimplications
If there has been eèrly diasnosis ôf tooth wear, ân.l frNcrtlve
mcâsures are controllirg lhe sitùatbn. rLlet symptons will bc
nlnimal ard ùeatme.r, drercÊfe. should be unnece$ary Thcrc
h.y be cas€s,thouAh. vhe!€ parietts ere tot coml)lianr $irh pre-
'.1-\e.n'go,r''l bd ô nilin/'s
dietarl a.ld jnrake Hoùei€r, lhe âctidosi.al fdtors Àeed .o tre
addrcsscdfir*, before proceedins with complex re$orètrve r€.h-
niques, Fidr all rhe ioplicâtiolls for expens;vc mainienaÂ.e thàr
th€se ircu!. The cx.cptnia tu this miy be wilh vomiting bulimia
_ ' - l o r'
1. r-r t ,-l',o d''' il . \
iemtunts oljlhe deffirior.
The eff€crs ottoorh $ca! rhar ray require û€dûncnr arc æe
nretl.s. r@th scnsitl{ny, p.ertntion ofpult 4psùrc, lradùftd
tceù and resroidtlôùs ..d, oc.â5ion!llr', ùe inp.ovemett otro$
Treètmen! oa toodr scrsitl'itr .!n be a cll lengi.g ptoblcm if
dtrh ùeâr is proaressins. A uriery of âgetts thàt tue lsed !o ffeat
dcnrlne hypeAeûsitnity is girer in TâbLe7.6. Sôûe dentàt mèreri.
ak atu rhemselvesnôre sùsceptjbleto vca. rhan oùes. lor ekn
plc, câ.h ompôsite m2teûal has ia ort wear reslstance,*hiclt is
iDproEd br in.Èains the inorsanic lllcf f.acton ând de.reaed
by rcdu.ing the âleftge fi11erpàrticle size. However, it should be
nored that z,tt testlng ofde.tâl mâteria.lsdù\ tot dsats show
Àdditiotùlh aldrouAha oF
goo.l cotreldrionwidr .]ni.a.l vâ.Lues.
posite miaht appca! ro h.ve doptlmal wear ntc.lts fillefpdti.les
mi-! i.crcâsc thc $eâr on opposing eodmel aid dcnti.e s|lrf&es,
ardlea.ltoanin rcasl.g lossoi vÉrticàldime$ioû. Adhcsivc m!re-
rials bàs€don (r/j slycid-vl'mcdraelylate) ,n GIIA resirs 2rc âlso
$s.eptllne to chemi.âl dis$lurn)fl and tuy tot ha\t goo,l lorg-
rerm surviv.l in si.ùarjons d high â.i.ti. .hàllenge. Howevcr,
restorarion $rh.onposjre or cooponer materlals may be usetul
$ âû hterim .reatm€.r s'lrh proSresiôn to èdh€siveûetal car-
irgs 2nd pf..laia reneers if ftcesàrt.
Tabl€ 7.6 lieatmert for se$itiv€ denrirc
. ..odrl'rsfl, wirh or$nhour iôntoFhorcst;i (nirh l.s âbEsiviry)
.rDr.orhoÉsiÊN oia rDill lLnûn.liian ro rmdo.e so.luo flurid! aDdrq
 I
122 I ( inko mpl(orion
7 Tooh w{r oetoloqyFewnl|on,
I

An extensive.lis.ussn)nof ferorarn-. rcchniqucsis outsidc

the s.opeofthis.hâprer, bùr it necdsto bc cml,hisizcdrbar !ear slndd be mtre.essa.-v.
mûrt ofrooû wear$ill be iûeffe.rivenr rhc linrg tc..r, unlc$ rl,c Mmufacnren hâve a respoùsibilnl to eûsure that
aeriologicâlfâ.n8 aft .ontdlcd or climin,re.l. ]rrodu.tr (dentifri.es, soft drinkl are ûnrinally den

Tleolmenl
of loofi weor
. Â.lnie$ ûe ædologi.al aa.ior fist
. rt.liâsÂosis n mtrd. c.rlf andlièvrmon r eaae.rive,then ûeftnenr
References
vill nor ho rc.csaiJ, ftiôLogr. me.Lranisrs àrd implnèrions ol cleotal erosion
. I " t è i , , ' , . " . , . o , I o r o . 11996).Lxrr J. Oul s.i. Ia!-,Prtt IL
Hirds, K.,.rd Giegory,J (t991). Natio,alDiel dnj Nûttrut
! Ren.tutire ireftmenr mrl' be rÊ.Ê$ùt tor sxtuq:.tjliÈ" a! t tù 1)ùît. v|l'M,2:r,pÉt af tlx l$tdl
&n,,r. Her ù{ajestysSrarioneryOlli.e.
I toorh s.nsiinrv lderùne htpe6ensnivnl)
K e l l e h e rN, l , a n d B i s h o | .K . ( 1 9 . 1 9 )T o o d rs ù L à . cl 6 s m
orervieu nr Ddrr J., 186, 61 66.

I arrturdiÊili.g
Ililos€vi.,,{., Yoùng, PJ., aû.1Lenroû, M.A. (199.1).Thc
rÊ$ontiois
prevalerce.f rooth wearin 1.1y€arô1.1schoolchildreniû
Li'etqoal. Cqm. DûL HLh., Ll,At 86.

Conclusions Mlllrxfd. 4., Shaw,L., and Smith, À. (1t91). DentuLerosior

Tooth weâr ha\ been x lona fcco.qnize.l rn,enomenoû in adùlls and backsrounds../. Dar Cb'|d., 61. 263 266.
asùibe.L n, rhe ùillnrvi.arc ofibrasio., arrrirror, and erosion. The
o Brien, ùf. (rrt1). LhildM1't Dûndl HdtL i th lirihl
aetiôlogv ôf tooth weaf is muliifâ.ûia.l. afthouah one ry|e ot
K723l,,/ -i99J, Loûdon:OÉi.e ôi Popllatior Censsesrnd
rooù s'er ind ole spe.ifi. æriologi.al fâ.tof nar pFdoninare.
Surveys.tslNlSO
Padnnogi.âl roorh wer is.ow be,rg seer moie commoûl)" in
ou aEeina popùlation, who are re!ùilinS their teeth lorger. k is Pi.dbors, J.J. (11).jo).Pdt,,lryt 0f tit dutdl hatl 1i\"û
atso bccomirA more prevâlent in r r,ourger pôpuhrnxr. prôbxlrlr CoFnbagcn| ùfunksgâard.112 l2 r.
la.gely relaled to erosiôù. r.- | -,.5a. AJ , ,,|).,. i.r , b.
AIthoùSh chric.l meàslremenr ofixtrh weaf is dltli.ùlr, widr lem anf some l]r2.ti.2l solurions. b De"t. J, 186,
.o !trn'e^ally â.cepte.i .liùi..J dixgnosn ln.lex, there is eriden.e lti I tE.
lhar lelels.re rising and .eftâlnll pâticn rr' as a.c.c$ of drc frob' S n i i t h ,B . G . N . ,a n . l K . i s h t , l . K . ( 1 9 8 . i ) A
. n i.dcx t.LftÈ
lem is in.reasnig. DertÈ1 p.oleslonds ùul.l-$ ide need i) m,ru suri.a dic s'c2f of tccrh. D1: Dlnt. 156,13)-i)8.
J.,
rhat asarcnc$ and be ûrore vi.qilânr.
feù câre J.IL, rùd Iûfeld, T. (r(liros) (1996) Eriolosl',
ft is e$ertid drat early diagnosir ard rccoAniri.. of drc frob
n,echi.isn,sànd imtlicâtiors ofdcnrxl crosn.. Ë,oJ 0&/
len is mà.1esô thât the relevânt pfeve.tivc nrcânùcs .a. bc in'li-
. t i . , r 0 4 : P â 1 It I . 1 1 1 2 4 1 .
luted. Tlie retiolôuicâl fa.(trs need nr be add.crred il.!, $ rhar
the prôgressnrn of k!trh acar to fâi. and desrrucrion .df be Vralke', À., Gresory',J., B.âdnock. G., Nu.n. J.H.. and
,\ô d-d D \. V\vliite.D. (2000).Nrrir/dl Dkt rrl Nûti|ja, Jhr): )thtt
!ù!h.!tl l tt I8 )tdtJ. lohne 2: l{epo.i ofdre onl hoth
iftbere has bccn ân eaily <liasnoss oftooth wear ù.1 Freven su^ej,:The Sûtiorary Oft;ce2000.
.lve mcasu.cs hàve been su..esfllly rpplied, rhen coûpler
 Theprevention
and controlof periodontal
disease
B i l l J e n kai nnsdP e t eH
r easman

lntroduction
PûiodoitrL disease,ôûce esablÀhed, ls oËcn rime consuming
âûd(o$lr to ùcar, wh'ie unÛeated or unù,..esÊr ly ûeated peri-
odortaLdiseâseis a significaûr .aùsc ofioorh loss. Approximately
0 r \ , o r , h ê p ô p , , " , i , n , , , , d r ç r - t/ e J o , , r . . F . . É
aIïectedby senerâlized severecnronic periodonritis, an l evidence
srggsB .hat it may oftc. have irs onset durirg adolescenceaûd
eùly adrlthood. luithe.more, Aingivitis, whi.h àlwâys precedes
t',odor' i, i.s.c) pF\.lenr.n La,e, pF\r, i\r{,-'e-
OE
gieswhlchâ.e târaeted at chil.tren, âdolèicents,and yoDng adulrs
f;,-;refde'edure!l"."eo or ro' ".-dard.rp .'-rr," -
nent of erablished disede.
The aims of r s chaprer ars ro des.ribc.he nâture, occutrence,
ahddistribulion ofperiodoûtàl diseasedd rhen ro review diffcf-
ent aslects ot managemeDi health edûcarioni proËssnrnal clean-
i.gi plaque conûo]; md suppôrtjve perlodonral care. Prevenrive
esines rhât have been applied ro adulis ând cbiLd.er will also be

Howdoesperiodontaldisease

Thc struc.u.eof normal heàlrhyperiodonttumis lllùsÙaredin

Fi8ù.e8.1a.The oûl epitheliùmis kerdtidzedbùt rhe creviculâr
JE
(sulcula.)epjtheliumaûd the junctlonâlepitheliû arenot. the
jurcrional epithelium is dta.hed to thc enamel surfaceand
ùndedyirg conrectiveri\sùe by a basallaminaând heoi desmo
somes, an.tlts freesurfâ.e(from whi.h des.tuamâiion tâkesplâce)
forns rhe botrôm ôf rhe sl.sival c.evice.The crevicejs orly Kôy:AB, aveolarbone;c, cem€nlum;
CE,cr6viculâr
ôpith6ium;E,enameLj
about0.t dm deep+s seenin histologicâlsecÎion.Cii.icalLX plaque/câlcu
JE,rundoôalôptheriumjOE,ôrâ êpithêlium:Pc, us;
PE,pockelephheium
hovever,ûe.revice depth is.onsidered to b€ the disrâ.ce to
shl.h a blùor prcbe vill peneùateùd, becàuseit will readily Figùre I 1 (a) Periodontrl health, (b).hrônn glngn'ids (late
disrùpt rhe fraslle jùnctional efirhelium, lhe probnrs depih of phasc).(c) chroni. pcriodontitis, (d) repair fôllowhs deb.idem€rt.
rheheâlrhyginAiv.l crcvice.@ches abour2mm.
nyhenplaqueis alloved ro accùùlate freely,thereis m (ute chaûses of chronic sinsivjtis can row be detectedr redDess,
eedar;ve ;nflammatoryresponse within 2 -.i dâysin the conne.- swetting, reduce.t resistènce to probing, àrd an rncreæed rer
iive tissueunderLyinsthe cororàl pôrtioû of junctbnal epithe- dercy of rhe gingivâ to bleed oû probing or wher dre t€edr are
lium. Afic. l0 21 days of persistert p1àqtreàc.uûtrlation,
na.k€d collaseo.tesÛuctionàrd a denseinfilÛate of .hroni. Ba.teriâl depôsits dô rot exteûd below rhe ginaivàl mèrgir in
innamm2rorycells can be observedin rhis zone :fhe.]ini...l the sùbcllnicàl sages of .levelopirg girgilitis. The p.oce$ of
 I
I26 | I Theprwmtion
mdontolofperiodonto
di5eûq
I

gingivalenlùgement,howcver,helpsto.reÀteasubginSilal no.a
and,gm.luâlly,Àpicaladva.cenenrofsùbgingivâl plaqueoccus
by periodontal
Who is aflected
(lig. 8.ib) asrhe jùn.riooal eFilhellum sepàrâtes ftum rhc roodr disea
se?
surlâce to becône pocker epithettum', chara.terizedhy rhe tl ,.leflolos' "l ' d e' ,,- ',,i d L" ', dflcrÎne
fo.mation and lateral extensionof rete pegs, and b). areâsof lr€ndsin the occuûencean.l disûibtrrn,nof periodor&r
mlcro ulcefù1or. However,dre interpretùtior ù.t .omparisonôfdâtu de
As.hrcnic AinAiviris.leve1ôps, aneqùilibriun, is usùallyesrâb with ditTi.uliles. Fuodamcntall). there has beeoa
lishe.t berween the increasedmâss ôf ba.ie.la and rhe hos! ùnifordly tPplied diagnosi. crireda. Inread, epidemi
defences, ûaintaining a sraleof chrodc gingiviris indcnnirely.If sùrveyshâveuseda s ide ra.iery of disease ma.ke6.Thes
anclwhen pe.iodoûririsdoesn,pervene,it is drough! !o be pre i , \ ' 1 . . I o b ' É d e p r \ . 1 . r
' . l . ( -| n"n(
di1"i.i
cipltatedeirhe. by a propoftionâlin.fesc in parhogenicmlcrô- ând.âdioAraphically a$e$ed aheolar bore 1o$, èll
orsanismsvithin the subsirgival bacre.iaLRorà, by impâired va.iety ofdiiÏe.ent w2ys. Attachment 1o$ with giûgivrl
L o . . i 1 c o L , y b o '; l' ô . i u,'h,..'on may occuLdue ro trauna from oral hyaiene derices
As soonù the desû(rive p.ocessexrerdsapicâ]lytô àtre.rûe inflammâtoryproce$€s,mâkiûg âttùhnenr lossônâci.L
alveolârboneand fibre àttachmenrofdre.oor su.face,Feriodorti, diffl.uh b nrrcrt.et. Pârtiâl recordirs systemsvhlch
tis is sdd ro havc developed(Iig. 8.1.). Thu. periodo.titis is reflectfull ûoùth .ondnions are .ommonly cmployed.
.haracterized by 1os of(conne.tivetissue)a(achnenr. Jun.ttr,nal nol er'.sre'r\.i. ,on | \ o r ' o ' f À h o l de l r -
eplrheliumproliferètesàpi.alll. to nrâinlainan epjrheliàlbaûier a$iso ar ;ndividual subjecrasa c6e', thÈt is, d sutrei
at thc baseoI the deepeninE pocker,ard rhe denùded.enentLn finally, the periôdôntâld$ase
Friodontal disease.
becomescontdinated br mic.o orsmrns ànd drelr p.oducts. older populèriors with Nbrântia.l both Io$ hasbæn
Periodortitis is derectedmosr reÀ.lily wirh a probe. a blood bùt jàlsely, bâsedon theifsùrivi.g healdrier reedr.The
saineclor pùrulent cxudalebeins eliciredbl. p.obi.g rc rhe bae wlich follows shoùld br kad virh dresemerhodological
o f , l ,o o I b r u i . , l " M e i o , " a e n j - r ' , ' . lyti.al cônsidÈ.ariônsin mind.
Choni. AioAivilisis a con lition rhar.ar be lâ,Aelyrev€sedbJ,
plaquecônûol. O. rhe orhe! haid, rhe 1ôssoffibre artachmenr,
whid, is ûe priû.ipal fearùc of Ieri odonriris,is virtully ife- PeriL,donlal
discasein çhillren and adol
versible.Desrrocrionmây occùrar a linea. rare.procee.lingvery This lj.erature hès been revieved by Jenkinsand
\ o $ 1 , , r ' . e ' ( q , , h ô o , . , a i . " t .o r 1 ' o A - . . . n i9o É (2001)who reache.tûe followirg .ônclùsiôns:
gùlckly, leadlnAeventuâ11y ro toorh lo$. Arrachmentloss mây Gjngivitls is common.Its prevale..e.severiryand
also occur ar à côntinùous.bur qpon€riial rate. Afternatirely, lnûeâsewith age,beAlnnlnsin rhe primarydenrit;
prog.eslon màr be epi$dic, acureepisodesbeiûg interspeised re-\.Â"p."\ '.p,ba,) llo\,.h) ' i,i,e.o([
wi.b periodsofremissn)no. rcpâir Diferenr pàtternsôfprogres- -
adol- en... l ir1.u .,,t.,., n ol.. .i.l f o\iTJ
sion my âffe.t the samcsire ar differert rimes, and prclo.sed faces,Aenerâlly.are most irequenrLy affected;
reoissior màr nôt be uncommon Funhermore,rhe raie ofperi
The leiy tinired dgra àvdlabie on perndoftitis in
odonraldesructior m.y vary ar dlffcreoi slagesof rhe .tisede,
m J q J . n r ' r ' o ' f o , f r ! o J 5 u h r e c fp r e \ i l e n L eo f
be$veensingleroorhsurl2ces èrd betweenirdivlduals.
mètely t% in .hildfen of EuropeanoriAi.. Usully,
Periodontirisis t.eared by .emoval of p1àqueand .al.ùlùs,
sites âre âffeùed and the amount of anachnenr
togetherwith pathôloAlcallyahe.edcementum,.ndby erablisb-
ing effective,daily plaquecootrol. lollo"ing rrcarmenrofperj
odonritis, .epair proceses rèke piàcÉin vhich the juncrional vrt DrÈl), à aencDl zcd seiere Ierio,lo.! !is may
epitheliùmls .e esrablished by irvolùtion ofpockcr epirhelirm, priDa4. dentition, po$ihly resulling in prematuft
dd sùppo..cdbI new Singivâl connÈ.rivetissue.co,isislingof ', '. | , . ., " i( r., ',,,. o, "-. .., ,. ..,o:
fun.rlo.âlly o.ientate.t(but not toorh-aftâched)co àser fibres ly;.A sysremic diso.derl
(Iig. 8.1d).More advarcedlesiônsmay ûor fcspondto rrealmenr P i"d I i I i., ' ,\e fern le' r Jen
\'lthout surgi.a.linkrcntion most teeûagepopL,lations, but usully only minor
oiaftâchment lossor boDe loss àre foùrd (seeTable8.
A few tcenagepolulatiors have been errified
Periodontol
diseose
progresion p e r o r o ' r ! , - . f r . . r o r . . r l . ' " , , d l l JL ' " o o ' b "
:Ihese differencesâre ÈtÛibuted tô h.e, ethni.iry, dd
rion nr ûe avàilability ù.1 uptâke ôfpÈvenrjve dentil
In borh the primary ant permdent dentitions,the
nal sùrfacesof the first môlâis âre rhe slrs most
âttèctedbI periodortitis dd by progresivedg
 't27
Whois byp"iod0nlûl
0l{edÊd diseo5e?

Tàble 8.t Prevale.ce, severity, and extent of ioss ofaffacbnent
on mesio-buccalsurfacesof first molas, tiN premolaB, ard
.n,l ' o^| 1 6 B r i i . ' ' É . 1 d g e.r\' a r ' d ô e r
-) |
periodat ages f i, 16, and 19 yeûs. (Irom Clcrehugh et dl
Tabl. 8.2 Prevalcn.e.severiq'.and exteû!oflos ôffttachment
in rhc Unùed KinAdoD in 1998.Adâptedfrom the ONS
sû\ey. Aral Hedhh i" th U,'ted Kindin ,t t 998 (wÀlket a1ld
Coopercds,2000). (Reprodu.edwith kind Permissn)n ofthe

Jornal tfclinral Ptn'{,nt'tq, 17, 702 Tos Publlshed vi.h Controllerôf HùISO and th€ Quecûr Pritter rbLS.orlâtd )
kind perûissio. ofBlekwelt ScienccLrd.)

AsÉ1yea6) PEInn e (Z subÊdn

>4 mm >6 mm

26
0.i jj 4t le j s r
1.1 ti
n
6t+ 3 0 t
' Â severeâgg.e$ive form ôfp€riodontitis (juvetile Pef!
odonritis)af€c.s approximètely0.I % of white Potulâtions
'rablc 8.3 Nxmb$ ofdentate individtàLsof ea.h âgeand the
andup iô 2.6% of bla.k populàtiots.Lim;tcd evidenc€sus-
gestsdrar ûe disease susccptibilityofthesesùbjê.n hâsiB percc.ragedistrjltruriona.cordingto leventy ot perodootar
fi6r manlfestatio!in the primary clentilio.r .ilsede (Ircnr Hùsosonet al \1998)Jrntal ofCltuiral
. A! a populariônlerel, pl2que and calcùlusdepôsûon and Pùtathnto|,$,25, t12 54t.)
l p \ . r . o! : r ' i .' o l - e - o 1 , " ' d , I ' \ r , e " ' r i n
boi's dlan ir girls; PÛiododt,l discasesrôups
. Withi. drc lâr 40 yeàs, improvem€nBit ortrl hlgiene in
chlldhoodand âdolescencc. matchedby reductbûs i' sin
gn'itis,havebeenobsetvedin $de develoFd .oùntries h
l0 t02
ôrhe6, oral hygienehd deterio.a.edàtd ginai!1ùs levels ' 4
"_ |a |.',gc ''\' 9) 1 1 2 8 1 2
l-d\',rF.e. lr,F, noe.
10 23 40 l,i i
tÈvaienceand scverityof perlodorriris.
rt r- 44 rl 6
disease
Periodontâl in adûlts ro 1 5 1 2 61
Gnglvitis in aduls is coûmot and exists at the levelsobservedi. i:u 22 13 21 rA )
oldcr adolescers. Lerels of periodo.ritis ha'€ beet estimat€d
fron proximal radbsraphlc bone lcveL and from Probina attach
nenr lossdata. and, sin.e prevalen.e e$imâtes of tcrnrdoûtitis are
Ahhoùgh a high propoftion of older peoplemay hare one or
â fuûcrion of ùe .riterià ùsed for dlagûosis, rt.es ol almost 100
oorÉ reeth affectcdbv è.lvancedattachmcntl{rs, as shon'n't
pû.ent ère frequc.tly ôbtàiûe.{ when assignaeot of a diagûôsis
Table 8.2, a snallcf ProPortion xre aff€cted by gen€ralized
ofpefiôdoniitis depcndr ot attèchme.t loss or bone loss of on\'
advanceddestrucrionas deûonstraredit Talrle8 3 The d 2fo.
1mm. By selectjna hiSher Èttèchnent loss rhresholds, as shown
tt2 dentateàduLtsubjects,lllustrâtediu Tdblc 8.1, de from an
in TabLe8.2, the fblloving is àpp.rel!l
epidemiolôgicàL su'vel in 1991 of 58/r ran'lomlv sÉlectedind;
. The pre!àlence ând extent of cliûically significan! 2tta.h- ridu2ls. evtnty .lis.ribù.editto agc levels,from a medium sized
menr los àrc los' in youtg adults and increases'ith age tos'û in Sùeden(Hùgosôn'l ,/. 1998).IollowinS n detâlledciin-
. Only n mitority of teeth, âffected by attâchmet! lo$, i.ai èDd râdôgraphicàl cxanitation, these individuals were
pn,gre$ eventùally to ù a.lvètced staae. âsslsnedrc ore of ive pe.iôdontaLdisea\esrouts. a.(trdits !o
\xrhile rhepârîer. ofatttuhment los denônsntedi. Table 8 2 their do.rinant disease chara.teris!icsl
is conlirmed by mny orhct studies, the lisures gùôted should not cmùp 1 negligiblegingn'j.is and ûô boneloss:
be regarded as definrive, sin.e probing vas carie.l out onll ât Grcup 2 A;rairitls bnt no bo.e l.\si
mesio-bù..al ùûfaces nr the upper jaw and disnllinsùà] surfaces ea.lybonelo$;
Grôup I
in the lose. jâw. Sùch apaftiâl recordina system is likely to hale
croùp 4 nodcmrelr severebone1ôs;
ùûdererinated bôth the proporiion ofsùbjects dd the Nmbcr
ofteeih atrected bI severeatta.hmet! lo$. Grout t advan.e.lbonclos.
12u ! Theprevedi0n
ûrd!ofrr0lolp".riodoni0l
dÈeo$

Trblc E I shows rhal, olr ofift ertne sùnple, l2tz $ere esen
rixll-vfhe oÊlrerio(lontùldis&ae(Group l), while â 1iûther lSta Liad
Singillrn (Gron| 2). Farlr ùargùral bone los (Croup l) Jle.ted
27r';, {hi e onll otl ùD.l lta ofrhc enrire srnlrle suffered iion
i..rcur.l_v scve.e (crouf .1) Nd àil!.n.ed bone loss (Crûup t),
respc.tnrlr: Thc prN'il.nl:. r.l sc!ûiry 01 bo.e Lo$ in.reiseJ
wnh iJr.iersirr-qrge. lârlr Lroft 16, affe.ted onll iT of lùrcaF
olas. i\loaerare r selere booe lo* *rs conmor orll rr olcler rgr
l.'els aliè.lhg Llta, l8ti, dd 26ti ôfj0 ,60 , al|l 7o'yexrold\.
respe.rivel) Àdv{,.ed tronr loss was not diaanos.d bcùrc di. itjc
ôi10 Iea$ md $xs u..omnn)n at ill a8.s rhcrafi(
I! exùapolariûs drc rsulB ol dris S$'clish sml! m.rl,cr t)ars
ôf drr wofld, n mtr* bc rci...rbc(.1 drât rl,s. !,.a F.'. (ol
le.ted lrom a potùlatn,r iidr a hiEh lNcl ot|.rful âFire.e$.
Ne!eithetes, ditfe ls good xsltemrnt Fith .rcs-sc.tnDil srùd,.s
ot riri.ùs odrcr àJùli I,ojLlrtlons rhdr r|e risk olmultitte roôtlr
t(ss (dft () senemljzcd .ndcri(tr s.r... ôr i.h,f.ct bone to$)
i s . o n f i r e d n ) r 0 15 ? o f r h . n ' k n c r d l l r ] { | u h . i o f . O Ê c o l r c ,
a l d r d g h r b a r s r Î i s r i . i s F i ( l e l _ va c k n o v l e d g d , n i s . e l a r l l e L t ,
m.àningl.$i i,.riodonrilis is r progre$i!e.liseae $ thâr. flr
i.rln'lllals who nrnne lIo o1.l 1Lge,rheie n â mud, hisl,er fi\k
of.\'cfrurL loor h Los lioù peiodonr.l .lseâse
11shoul.lalso be àPpre.lrted drar rl,e xsi!Dment oi ca.h sub-
ted ,o one of llve .drglries, br*erl or d,e dominrnt a,seasecrrr-
â{r{,.isi. is someFhtrl .oniri\ell tTable a.l). \\7hile it is I uÈfu1
mr{È olillL,{mrlnr lros'ditïcrclrr inioù.F ot l,crolonrrl lis.rsc
àre disriLtrted n,l popdxrn)n. rhn apfrc'.h nri\ks rhc {însidcf
ase (years)
able direnitv ofdisease prttem in indnidual ùNnsi u c\a.l
lle, sevcr gingivitis or s.r.rc 1,..iodo.riris ma_vbe vi(l€sPler(l in b liLâ.1ù.lcbfn .nd inllammarion ,n dril.lren
v,nrc.ntuh\, but lo.trll2cd in orhe6. ot(lhlllL.ns Dorral Hcaldr, Itr-1, sl. an.l 'lji.

rhc wcll-re()gûized rÊlxtnn*hif br.reer plxqk dtrd infl.tula

Howcomnon
is reriodonlsl
disecse? (Fl!. S.2b). Â vet getrerxl !\erview oJ tlt
rnrn ls also obrnr
. sn{iûÀ n LishLf prevalenrboth in .hildÉr R.,l rdnltr dtree ses ofdafu. Iiôweler, srggeis thù ther {ere .,or.r,iL.rr
. rhroni. periodonriù mt' bÉ idùritiÊd ir teentrAe': sid, fhqùcânJ l.brn.n thci. rccdr,r L9r)i.ompiftd n)pftvi
otrs ]câ^r fu hcrn.rÊ, the rse+lared "ul,ject prevrletce oigrr
. tlr f'.!tr1.n.. ria s.r.rnr ôf.|ro.r Fenldlrùii: n,.rer:e \trh rsr
liviris ln .hiktrÊn in.relsed Éom r9t; io leâk û tlz ,û L98l
a . t î r c n ) 6 a r . 6 ) ' X i r l 9 r l . I h i s s l L E t e s sx d e r e r i ô f u t i o inn
.hc gifgÀ'rl h.âlrl, .f _v.u.acr .hildr.n .!cr rhc 10 rÊ16,
Trends,outcomes,
ard influences rl.hoùgh rh. l,'.\'âl.n.c oiEi.8i!ùl i.nainnùrnlr in 11-reâFoLdi
f.nain..l viitùrll_v r..h,rs.l .vcr drc simc fcriod (fig 8.2b)
[)?fiùa]ûrlii di!eâie Lriûrlri The Àdrh Denrrl I lealth Sùffe_lsof 1988 r..l l99U (ïd,l rnd
'Ihe
drdnAins pircrn\ olucri.donrâlIis.âs. treyil.f.. o\'.r |.f I - r ( l e r1 9 9 1 , \ i â L l i e r r n . l C o o t , . . 2 0 0 0 ) r l ! r d . n u r n â t c a n 1niÉF
o.ls oftide âJedifi.ùh n, emlmre ...ûxrc\'. bc.aùsc rhr mcrh- cfi.s ùcnd àr |cfbdonrxl dis.a\. nl rhe UK. In 1188, plrtts
ols x.,l .rrcrâ ol a$e$n,ent n,ù) rLso vrrr iioÙ oûe $!d! to rhe > .1 mm *ere fouûA ii t1,z of.leùirte ù.IlLrs be$vefl, l6 ùl 2l
ncyr. Ncrcrhcl$s, ùr, serslion, n,..esive nùional s!rvevs !e6 ù nr 762 oi rliose tr the tt 6:t age ringe ln 1998. dr
an.$ n).r' r,hrâhlc obrNùt,ons \aith resre.r ro brr..Lseùse respe.trle Êsures were l.iz rDd 62tt. h 1988, pockets > fr Dn
.en.ls ro be nùde. t:oi erdrple in the UK, ChiL.Lrer's Derrâl \rdc tao.d in 2tZ of 16 û .l.i-redFolds rùd ni 161 ôf tt to 6.1
'1'bese
I l e r l h S ù ( e ! s w e r e u r d e ( â k e n i r L1 9 1 1 , r 9 8 1 , m d L 9 t l . ImFolds. I. 1rts. rhr pftvaler.e râÈ\ hxd.le.rc$e.l tu Itz lnd
show thm lhe I uùber .f.Llildred $nh dxqùe ân.l debr; on rheir 97 rrnrc.tivrl-r: ft appexrs thxr at lexsr itr tuLults,.lrtfe ddr hÀe
rr{h nrcraierl $erdilr benveen die a!e\ of 5 d.d S rerÀ. read} bccn a. olcrau i.rFl\'ement ln perbdontal diseAe sxtus
ing ù Fldre.u before decreasins slllhdl ro rhc xgc of 1t v.is b. N ccr I 9Uil ând l r)ts. l lnidru.itclr, h.vcveL. .llni.al rûxdt
(Fic ii.2il. Thrs re.lietr.! Nith iL-qe ls seenirall thfee suve$ md nrrt ldÊls weE me$u,td onh ln ti,e r9r8 surr+ {ù so ldiNc
 p'nodo''ol
w ortou+, oi'ro+I I r 'q
I

.oûtarison of rhc gold srândârd'for delermi.ing pe.iodonral
disede$ârN overthc l0 ycarperio.lcanrot be made.
Toothmortality
Il{e is greatvadâtion in roorh moit2liry $alisrics in differen!
plis of ùe world, evi.lendr rcUe.rins prsenrivc hexlth behav-
ioù ard the availabilityand elTectivenes of dentàl services.
The
denrisrrandFiientt altitùde,tosetherwith .echnicàldifficrlties
associated\';!h p.ovisioû oi rrealnent, may èlso be significanr
t(to6 detemioing ûe rimirg ôfextrà.rions. While .âriesand
pdodonral dseèseùe the fu adult rnh
erÎnctioû,periodontâldiseæerssumeslessimpofance æ a cause J e " ^ h e ' h e r r l n ô , o . , - ' - o û ' . ( ( r - b r ( . b L e
ofloolh lossln popùlÈtiôûswirh â high cariesexperlence. ]'his i\ etrectofrde, oris a fùûftion ofco.Jourdins tactors.Smokins,10.
illùstrate.l
by fig. 8.3, which denù'$ares ihar pefbdontâ.Idiç
.'eeJrh ' e q 'e ' , . r F o
older age groups. Io rhis Scofthh stùdy, caries ànd its sequel2e
a.coùntedfor i5% ofexrrâ.tions ovemll an.l pe.bdontal dlseas€
wd resforslble for o y L7% (M.Caul ?t,1 200r).
Iactorsafiectirg the prcvalenceand severiLyof'
periodontaldiseâses
spccific padlrgens witbln rhe sub8ingival ml.rôflôrade responsts
blc fo. proare$ivc pc.iodo.titis.
Popùlation srùdies have identified a v.rietr of côûelÈres
(determinanrs) of pc.iodo. tiris, a few ofwbi.h may be risk fa.-
'lhus,
to$, cxpo!ùe io {'hi.h in.rcases rhe fnk ofdiseae severe
periodôniiris has been pôsitively asocièted with ôl.ler ège grolps,
male aend€r bldck race, diâbetes, osteoFrosis. Iow cducarional
*atus, smoking, inflequent dcndl attcndm.e, and.erain ba.te-
rial padioge.s. A.ron8 dris lis oi corelaÉs, evidedcei(r a.aù\al
role is sreèrest lor sûoknrs. Althoùsh sone sru,lies hâve shown
\d' p.r o,lon,. , -û, , iJ ..l8roul . , . io
exdple, côuld be a cônfourdirg factor in mary cro$ seftiondl
st!dies, which ha!€ soùght to tink periodo.ritis wirh demo
amphic variablcs. W|ile old people hare bstanrlallr nor€
atu.hûenr los dEr yonng peôple, this is thoûghr ro reflect th€
.luration ôf expôlre to âetiôlogicèl ageo6, ràther ûan lhe ag€ing
prôces itsell NeveftLreless,sin.e bio.hemicèl and lmmùnolosical
processes of permdontal tis$es dè tubje.t rô ase asociâted
cha.Acs, ;t is po$iblc drar the increasedattachment lxs of older
pcople is a fu.ctlon of aaeinA as well as time.

ft is {ell esrablished rhat. tôr AinAivirisro occùrand teriodo.!i

tisto beinitiated,plaqùemùst bcpfcscnt.Irdeed.thereis âAood
coreLation betweeûsràndùdsof o.al hBieneând rhe preralen.e
andscvedryofgingivit's. Ilowever, the àbseûceofnàior differ
en.Êsin p.cvaLcrceârd extent of severeperiodontitis between
FoFular;ons with dilïerent s.andardsol Flaqùecoûtrol ggess
i , . r ol ] . n . l lr n o ' , \ o p 4 t . i , F t . , , e r r o , , i , p , , -
o,lortitisir a $ceptible patienran.l, ôû.e iniriared,prôgressive
dstluctjonis ]ùgely lndepenlentôfthe pariencsôra.lhrgiene Ir
s believe.t, insteè.i,rhàr hostrespônse factôrsând the presen.eof
}nplications l'0r prevenI ion
Since ginAilitis ls .aued by supraginslral plaque e.umulàtiot,
ard sinL! gingivitis is è Frereqlisire for th€ d€ktolmen. ofperi
odonritis, bodr dseasescan be t'evenled by an àde,lute standa.d of
plaqùe contrôl. Howeve4 the standùd 01!oo!h cLeanlioess rc,tuired
b maintan periodôntal heâlth will be subjeft to sreat !:ulation
according to lndivldual rs.eptibiliqr ldeâlln irdivi.lùèls at high
risk of developing the more aggre$ive forms of perlodontitis
should be singled out for priô.itl preventive care. In e èbsenc€
of.eliable p.edi.rive rers, rhis mar ônly be posible by reperted
dôûnoring of regul.r .lertâl attenders to €nt,fy r.flrn,mâtorl
changesât a. eârly ard .cvcsiblc *aae.

Trends, ondinfluenres
ouftomes,
t :fhcpr.vÀlenæof si!s,ûÀ ûronss It JreFoldtl. thÊtJK qDas û
havechogeJ very litde ove. the lÀ* 20 tràs. {hile borh r leÊnlinss

. lr'"d-.", h . ' D - t r d J" d .nL !,1 .pr ê.po

, o.l. -,l "oo. .o

. l , p ù F " . r ' " 1 ' o k , s T " Ê '

\Ai l!trnd\ rhe \l_.l|,eLioJ.nn tl \eÀe

ase sroup(yearc) periodontal

Whatcauses disease?
WcatiT WPdo nonho EPre- norhs Dental p1àqùeoccupiesthe c€ntral.ole a .he m2jo. âetiolosical
Prosih factôi ir the pèûogeresisof perio.lonraldis€dse.It is, however,
Fisurc 8.3 Reæonsfor crùiction ôfloeth. recognlzeddrnt a nunbe. of lâcto6 which mav frcdisposeto
t30 I fte prcvenlior ofperiodonl0l
ond.onlrol dke0se

plaqùee.nmulÀtion or whicb modiry the host'sresponse,also and sûive !n a low o{ygen environm€nr. Thus the cômPositionot
'd,rol".nl.ç.e r"r- i^r .rJpros' ror subsingival plaque d;ffers from plaque on rhe adjàcett visible
il,)" i.r,r
turh ndace. Io. example, in subalDgival plaqÉ, Gld positir

Dentalplaque bacteila de foû.t iD Lower p.opôftions; md Gmm-nesative bacre

ria in higher propodons thd itr stpragin8ilal pla,tue. The sub_
D - ' l p l " q ' - i r L . 1 ô nm , n . 1 , e d h . , ' i . l , ; À , - s , i o , o '
giûgi!Èl llora compdse a lâyer oflooih-âira.hed plÈque4 vell6â
the teeth àrd other solid sùu.rùes in d1emôuth, which 6 so
loosely adk.enr .ompon€nr in dire.i dsociation wiih the poclet
tenacjously âdhcrcntto the nlrfdes thÈt it resjslstemovâlbI sali-
erirheliun (lis. 8.4). The toorllaita.hed plaqle co.shts tuinly of
vary nov or a gentlesprayof wèterâcros its surtâcc.
Gmùposliive rods and cocd. $ hile rhe ùnartachedplâqÉ comls$
Approximately70% of the volume of plaqxe is composedof
predomi.aûdy ôf GEm n€Aalile organûms itcludita dotlle
bæterlal cells. The rema;nder comprisesproteit àùl exrrucellular
forns. Many diferent bâcterial species de thonght to be of slgnil-
polysæchdl.tes, which acr âs2 mat.ix fôr the cellularcomponent.
icarce ;r the aeriology of periodontâl disease.
In â.l.lition,plaquecontâinssmallnmben ofepithelialdn,l white
Th€ mechannm!by which bac.eriamay Prôvokean intlmtÈ
blôod cellsthat are deriled from the ctvicular fluld. Tbe exact
tory responsea.d .ause tisste darage a.e .omplex. Bacterld
sru.tûâI, bacteriological, and bioch€micalcômpositlotof plâque
ifitoccu4 at all. is thought to be relatldl
irldion of thc rissues,
ls subjectto gre2tvariatlondependingôn: the coûce.tanonor bac-
unimpotunt. INtead, iissùe dâmage ù sustained mâinly by po_
Èria in saliva;rhe site ard durarion oftlaqùe fôrmdoni the mûre
etrutiôr ofthe tissuesby vdious solublcsùb$ances Produæd
of.ompetitive resilen! flo@j ort'gen and .uÙient âvàllàbiljtyi the
the bècterja.Thesetôxins hale wide ra.sins effecs: rn
côûpositiorôf the di€trand the prcsen.eof periodôntaldisede.
ànd eùym;c degradàtionof tÀsue
tô roxic €ffeclson host ce11s
The earliestdepositto form on a cLeaned roodr surfaces the
'acqùrcd pelli.le. ft is À str(ftrele$ fiLm ofsalivary glycôpro cbemorâ.tic md at!;Aeoic effects occur as vell ,\ â.iivâtl.n
ândsi
supprssiônofinflanmarory and immûe mechânisms.
reinsselecrively adsôrbedto the sùrfaceof hydroryapariie.rystèls,
u l r r i , n ô f b ô n er e s o T ro r .
and isvisiblewithin minùtesfoltowinga poljshvirh punice. The
formatjooofpellicle is a..ohpmied by bacleriàlcolonizatn,nàs
micro-o.gânismrin sa.livaddsorbto the pellicle.Aiter I oi 4 h à Denlâl cêlculus
'hiF "l-r o 1"lu'. ompoe n.'r') n {,rra-po'r.i' o MineralizÈtionwiihiû plaqueretults in câlculùsnrmârlôn
(priûcipallyst.eptococci)vill be esablished.Theseremain the ino.saniccoûtentôfcàlculus(70 90%) is mo$iy crystalllne
predominanrmicro-oraanismr for apprôximtely 7 ,lâIs althoùg]1, morphous .alciùm Fhosphare. The ôrgàniccomPo.e.t
durins rhis tioe, thec is aproportiôml increase in GraD-posldve
rodsand inGrm 'esarive cocciand.ods.Âfrer 7 daysfilanents,
fùsoba.teriÈ,ànd spirllla are found ln greater nùmbes. Âs
rhe p1âquemâtùres fùrther. spi.ochâetesând vibrios âppe2r.
and filanentôus bècteri., €sp€cially,1ri,,21.4 may become

Thereappeù to be mâny mechanisms for bà.terlaldhercnce:

Sîep1oû.et tu"8ù is ad+ted for adherenceto hydrort'aPatit d.l
is anong rhe pioûeerbàcteria!o be rouûdln rhe deepe$tay€rsol
plague;someorgdisms iû.erac!virh salivarycônstitùettswbich
sene æ the blnding materiali and lhe occuûencein plaque of
Sîeplaeaûun"tu$ ls àepenàenton $rcrosefiom vhich it synthe
sizesthe exùacellùld polysacchùides to nediate its atta.hment.
The synthesisof surfa.Épôlymersmay alsoaccountfor dre ability
of bacteriaofooe speciesto bind to one anotheror to bacteriaof
molher spec;es. Corn-.ob sÛuftûes, filànentousbacte.iacoated
wirh .oc.i, representan exmple olsuch i.tcap€.ier binclitg. Iu
ad.tition to the ext.acellulaf polysac.harides,plaqùe contains
intncellùlar polysacchârides ln the form ofstorag€aranuiessln-
theslzedfron dieta'y susafs.
Ba.tefiôlôgicà] studiesofdenlal plaque dûing rhe delelopmen.
ofAingivitis$ggest rhat therearemo.c tln.200 differentspeoes
ln matûe plaque.Gingivitis is believedto resù]rfron quàttitatjve
clansÉsin p1àqueràrh€r than r'rcn the ove.grôwthof specj|c
micro-o.8anilms. Perio.lônritlsls oued by the sùbgingivàldowD
s.owth of those bafteria that are hcst able to *ade hos defences Ficure a,4 Dental fldque
 F!(rûsrhorinnm* rhe,kk0fpe,i0dmtdl
dismç II I
|

lorein,.ârbohydhtes,lipid, and variou nôn-vitâ.Imi.ro-organ,

isms,predôminaÂdy filanenrous ores. The râte of calcuLus
fomationbetweenindividuaLsis very vàriàble,and .hildren fo.m
le$calculs rhanadulrs.Catci{icàrionmay cômmencelD ooe day
oldllaque but th€ exaci mechanismfor .alcdù fbrma.,on s nor
known.lnsupragingivallocarions,however,formàdonis drought
tu resulttiom interactiors beùeen saliva.toolh surfaces,àr.t
plâçûe;s'h€rcasin subsingivàllocârbns.dre innâmmaloryexu
dârevithin pocketsis the fltid medirm involved.Subsinsivai
elcrnu tormsmoreslowlydd is uually no.€ dificùlt toremôve
by drtue of the intimàte relationshipwhich it forms with the
rcugherroorsùrfâce.Câ1cd$ itself;s ror causàtiveof periôdonrâl
disose,but js alwèyscoveredby plaqueard reràirs tôxic bdreG

Fisu!. 8.5 Roùshsùrhceofrerorationàndgi.giràl inflàmûarioû.

Stains
Sra;ns
arecè$e.i by fùd substances sxch s teà, côiTee,
aid red
.e, b)'tobacco,by the producrsofchromogenicbaûeriao. by . n,bgingivâl rerorarlon margios vhich lead to gr€ater
meiallicpùticles. The p;sments becone absorbedby plaque or plâgueaccumulation,and .es!]t in poorergingival heâlth
drar do restoratjonma.si.s thèt ùe ir lelelwith, orremâin
abovethe sinsival crest;
. removablepartiat dentùreswhich often leÀdto m rndease
i. th€ accxmulatlonof p]àqùeôn the àburûenr teedr.Cov-
eraaeof8inAival mùgins mày alsoleadto denture-indù.ed
gingivâl overgrowthi
. fixed orthodortic âpplidces, whi.h are very difti.uh to
keepclem ard, lû pMicùlâr, when brackers,bands,wiies.
or elasricsùe very .lôseto the gingival hargin.
Factors
that iùcrease
the riskof Clearly,è11Ùetment shôuld be .detully plaûred a.d unde.
taken tô the highest srandfudiû a maûnerwbich l;mirs plaque
penooonla0
t lseaSe æcumulatiôn.Y.hen pârtial denrùresor ofthodonticapplia.ces
A nùnber ôf facors car iù']ùencerhe risk ofdlsede delelopirg ùe indi.àred,explicirinst$ctlons shouldbesivenwirh respecrro
eitter or à sire l€vel by predisposirgto 1ô.alplaquea..ùmula their lona term.de wnh nview b maintâini.8 a levelofplaque
tio.. or by modifying the inflamnrâtoryresporseof rhe hor. 'o',ro _\'r'. ompJ,.bL wF, r i D e ,o r ô ,r . l l a l '

Factorspredisposingto plaque accumulation Factorsmodjfying the inflammatoryresponse

Localàccùmùlarlonand r€renrion ôfplâque is enbancedby a Host defenceûe.hdnms appear ro he borh prorecrlve ard
ntmberofçell recognized mâtômi.al and laftoseric (deDral)âc desÛù.tive, but l. most cdes, lhe tissu€dmage susràinedis minor
totswlich, .herefore,mày hâven profoundenecron periodonral relatire to the Ërotectioû provjded. AD intaft aûd normà1fuûction-
health.A.2tomical fàcto6 such as toorh mâlalignment,crowd inA host responsevould appear !o be compatible {ith, àt wôst,
ing.and tipp€d orrotatedteerhnay beverydifiiculr to eliminàte slowly p.osre$ive periodoDtaldisease.However, subtle chàngesin
andrhemosrappropriÀte Ûeârme.r is.op.ovide the pâtienrwith rhe capacity of vùious components of the ho$ respônsero d€â.I
aneff€.tivemethodto lmprôveplaqueconûol.Iar.oaenlcfactos, vith the bacterialchaue.Aemay oxse m inùeæecL nsceptibility
howeverare often a rcsuh of poor qualiry dental ùeaùnent or to periodonialdisese. In âddirion,a oùnbe. of idenrifiablerlsk
t.ealmentplmdng; and âs such.are enrirelyprelentâble.IaÙo- faclors ùe thoùsht ro àfect the hos respônsero local iûiranrs.
inc.€æingthe severityof perlodontâldisase.The mostwell-.ecoA-
. roùsh snrfacesof rcsro.a.jonswhich âccumùlateplaque nize.tmd widelyprevalentrisk fa$orsa.e smokinsand diaberes.
morereâdilythan awell finishedorhighly pôlishedrestoE, Smo6ing
tior (Fig. 8.t); There is now unequivocal evjdenceto shôw thèt chronic periodôn-
. o v e r l d r - ' 1 {Ë d . 1 , . \, e ' e n r r l r d r ! , ' , o e { r " i o , . titis is No to five times more severeanongst snokers .ôdpûed ro
r ' \ , h d . ' - . - , ' i o " . . r e . f o r d ," n l p l " g u -d n d .i ' I . ' i . non smol<ers. Resolùtioûof inflMàtion and lông{erm stahility
ùlù, amerobi. perbdontalpalhoAeNi tu? alsomuch le$ fredictabl€following perio{tontâltrearnent in
l)2 0 Iheprevefri0n periodonlûldiseose
0d ronl.0l0l
snokers, aû.t rhere is a.lose (lependent risk ofdiseâse recuffelce
during the maintenânce phase. I.c.eascd in smokers, althoùgh,
oral hygiere lelels alone are no lo.gc. thoùEhr tu be àccouttable
for ihe increâsecLseverity ofth€ dhease.
Cônsi.terèble reseâr.h hds establishcd drat ni.otine m.y hale
side rangins ei?cts on thc hos.'s lmmne and iùllammâtorr
. vaso.onsÛictior ôf the periodontal ând gi.gival mi.rôvas
. rdr', ' nr . . p \ 1 , \ e n o a r . , ' . l f l . E o ) ,i
. a.edu.tn)d in the âbility ofrertrophils to ddhcrc to.apil-
. in a dose-dependent ûÈûoer, the production an.r rclease
of .yrokines such as interleùkins, TNFa and â.ùt€ phde
' a reductn,n of the concentntion of serum immunoglobtr-
lins, pa.ri.ù1d1y in n,bjects widr early o.ser pc.hdontitis.
Diabetes
Both ryp€ I a.,l typc 2 diaberes in.reâse rhe risk of seve.epcrts
odontlth by 2 I fold and this .orelaiion seens to be linkcd i(l
the sûtus of.tiabetjc control. thc p.esen.e of.ômplicàrioos afld
rhe duration olthe srdromc. Poor o. unrable glycæmlc co.tol
leads !o an incrcdc in advân.e.Lglr.ared end rroducts (AGES),
vhi.h a.e glùcose-derive.l compolnds thar tbrm when ihere is a
.htuni. elevàtion in blood Alùcose. ÀGEs link $ith re.eptos on
maùophàges to upreaùlate the mâc.ophagesn) relede biolognal
mcdiâû4 o{inflamûttiôû such d crtoklnes.
Thc.c is als,. hewever evidenceto sùggest lhat drc ar$.iatiot
betwccn diabetes and perlodontèl .tiseases a lvo var pro.es d
leriodonrâl iotè.rn)n in.reases the reslstaoce.o inulin. *hich
nrduces fuithe. hypcraly.aemia and thus further destâbilizesgll-
cacmi. .onrrn. This implies that trevention o. dcxhrent ol peri
odonral disersein diabelics mày. in rhc lonsre.m, help to stabilize
glycaemic conûolând drùs prevenr fnrther .oDphcaùons.
Riskfoctors
. Airo'ni.âl
anJ hirogeni. 6.roh my predisFosc to Flaque
. In srkes rnd d,rb{c. the hô$! infnmnratory resy,nsenay b!
'Ô, o, -É.'(.1_ ' i_ v
Periodontal
healtheducatiott
ûental hygielreadvice
The objeftile ofoùl hysiene cdu.2tbn is to produce a chan.qei.
behaviour, ûhich will result in a rcdu.thn ôf p1èqùeaccùnul2'
tiôn $fficient, ifposible, to prevcnr dre lnitiatiot atd trogtes
siôr ôf dertàl caries ând Fiodontal disease, ànd.o mâkc thc
patiert as indcpcndenr d posible ofprcfession.rl suppon. Asuc
.esful oltco.rc wiu depen.l tot only on masery ofPlùque oc
Ûol rechniqucs bùt also on â.hâ.ge ofbeha'iôur.nd coniiiiaia
\ïith the srsgesrcd plaqùe controL regimc. clearly, therelbre,tht
cliùiciân mur usc atr edu.atile aflroâch aim€d at ûanging
pàtienri attitude û periodontàl discaseand dentù1care,i
srcpsor prin.iples:
ratins the fô1lôwin.q
. beliefin surcftibility tô the.liseÀcl
. b€lieftltat lhc diseasÈ
is uùdesirablel
. beliefthar preventionis pô$ible;
. belieftharprevenrbn is de\irèble.
l'n,"rno- r'q'. 1'o :'ll"r b "-r.
p.oper ed!.dtional prin.lples su.h as step{ize advàtæ
selfpacing, rcpeared ièedbtck, an,l tcintaremett. !s verr
âctir parti.ip.tiôù by the trarient.
Denrà1heaLthe,lucat(,n and i$ttucnon in orâl btgieùe ùe
ditiotully cùrled our by dentai pesonû€l at rhc.hai*ide, bùt
and. $ùh reperition,is likelyto
f.ocessis lâbôuFintensivc
di€ mood ofthe iû$ructor and. ùereby, the eflèc of the i
r o 'l ' . r ' ) , . 1 o * a ' r ' l . ,l l r ' , I s ' r
!o be givcn at tht chèiside has bccn querione.l. Self:
comprisiûgsell examinatb. xnd inst rction
progrummcs,
âls, have bccn shown o be as efTecri\kas .hdside lnstrudion
dendl personnel iû changing orxl hrgiete habits.
lhe.lertal surgcry has lrightening ovenotcs tor dârf
who the! fi.d ir dltfi.ùlt tô corce.ùatc on adlne boiS 81
This làct alonc misht expl.rtr !l,e su..ess ôf selfed
manùds th€ fr€edomtu â$imilate nrlàrm,tion ln a Le$
crviroûûert .ompensaring for tLIela.k ofpefonal.ondt.
Regardles of ôe mcans employe.l, it is well Lf.{i rhû
hygiede irsÛactio. usuaul has no long rcrm Éffect uD
F.iodi.â.Uy reinfor.ed. Initial in.entives for behalioûâl
apper to fade atic. the target behaviour hxs been ac
Àccordirg to the Comdittee on Oral Health CaÉ Iôr
PLcvcnrbn dd Control .f Periodontat l)iseâsc(cônn
Probèbly lhe .rost inportùt ànd difficulr problen rhar
renains to be soh'cd before mu.h Progre$ cao be ûade r
' l ' a i f , - . ' l $ ' , o i d r
ihr indilnlLraL .o follow a presùibed ellèctivc ord hoLdl
caft pn,grâmme lhroughour his life.
:l'bis remains ûùe evet todày.
Inp.oved oral h-vgicûealon€ has little eftècr ôn singival
ditiôû, pocket,lcfdr, or subginaival flora ofdeep ped
..ô'. t,
1 . . ' . ' , \s i ' \ { , . o . o . o . ld ^ .
denrâl heâ1th e.hrca.jon mur be n,ppoiled by attention m
subAinsivdl etvûonm€nt.
Dietaryadvice
Plaqùefitrmdtiôn is not ,lcpcndenron the presenccof tud
, | -, '. r, r " i o' '1,- of '._ rr '' B,r' 01
 Peodonhiheohhedu(0lior

quanliryin man is aenerullyfa. lessfronounccd than codd be

antjcilatedfroû theoreticalcons;deûrions.There is areat indi-
vidualvariatioû in the amoun! of plaque fofmation, ând lts
respoDse !o differ€ntdietary resjmes.ALthouahdiet may lnflù-
enæthe quantilarn'epropo.liors offlaque micro o€a.hms. the
dinic.lsigrificanccofsùcb cbanaeswith respe.tb the initidtiôn
ûd lrogres ôf perio.toûtèl.tisedeis not knowr.
The rrèdirionalconceptof natùnl cleaosnrsby abGive food-
s not valid. Ths s oDeexmple ofadentaLh@lrh me$a8e,
stutfs
p o p - . l| d' f " D A ' . \ h , l h . l r " . o r o r d ' n " r o . L b p o t r ' r
CeNi.alroôrh regiônsare nôr subject to much physicalstre$
ûon foôdpaficles during ndri.âtiôni dd excesivechewinaoI
iâw vegerablesând fruit has â liôited etrect oû the qùantity of
plaquea..umularing at thesesites.Slmildly, gud .hewing does
nôr hâved efe.t ar redùcing plaqùe ât the gingival mùgir ot Smoklng

Figu.ê 8.6 Smôknrg c€ssation.1..1e.

ï\ l,' rr r , 1 , , ( ' r ' - ' , r ', r-r n-n'. nri'.
vôfthy of Ârither .onlideratbû md resear.h.Vitdins Â, C, èûd
| ,e ,, ., i/(. iF i{idi, .. q "h h'\. ,1 "1r,') 'ô.d\
engeùe very powe.tul, host damagj.g iiee .adicalsa.d oxySen Â.ri!e quitters ûose who are .eadt to make d Èttempt.
reÀctlv€specjes,which are producedLrythe waveof neuùophils Snôkers àre likely .o ûove from one .ategôry to the next at
rharinfiLtrarerh€ tjssuesdxrirs periodonraL
disede. anr rlme {Fis. 8.6) md it should be ùe dùty of dy healthcare
professio.a.ltô be in à positjoû to provide rhe nece$âry sùpport
Smokingcessâtl'onâdvice when ir might be needed. This sufpot should follow the 4 As

Iù rheUK, 70% of smoLeBhâvea desireto qiri! the h2bii. Every

. ASK abotrr smokins $arus ùd reco.d details ofihe sdok
)'of 30% atrempt to quit ahhouab only 2-17 are s c.essful.
TheFis.leaf eviden.e.hatadvl.e irom a Aenera.l medicâlprâcti
i u ' \ i , , , 1i - , S. i'Ëp,ii'' orop ' A D v l s l . ô ^ , ' r r ' J " o r q r i L , " . . ' . , a g o ,' h " l r k
snokiûs aûd will achiever quit rure of between3 ^nd 5 . In between smoking and periodontal disease,oi which dôst
Nortl Amerjcain partjcular,thereis a srowiûa acceprancc ofthe palie.ts a.c co.rpletely undwùe;
of d€ntal health careprofè$;onèh i. frovidina
respoûslbillties . ÀSSIST rhosewhô wish to qùit. B€ w;llina to.eËrpatieûts
ùlvicein smokins cesation, a role which has beencoiisolida.ed to the; general medi.al prâ.titlone6, or ro smoklng cesa-
by the a.ceptanceofthe relatiorshipbeNeen nnoki.s and led' r'o, ,o o Ji, .' r '.t ' 'e I i. '",i. Be
odortitis. hdeed. rhe dent2l ieâm is 'deally pla.ed ro deliver prepared ro help pètierts set'quit dates'i
snoking .essntionidrice to then patitn6; and it the UK, for
. ARRANGE tàllow-ùp appointmetts !o reinfô..e adlice
exmple,the potertial workforceto deliversrch adviceis co.sid'
ân.r ro monror Progre$.
ù!ble: 10000 dertistsi 40000 d€ntal rù6es; 4000 dcntal
This approach. in dàny wàys, is similar to thai âdopted by
The firr rep to adopting â $.cesful ream âpproachis .lenthts, dertal hyg;cnists, dental therÀpiss, an,.l deoûl hÉa1th
educètos when delivc.i.g oral hygiene èclvice!o improve plaque
. encoûaSeall rhe dentalteam ro urdersô ùaidna in smok cortrol. The den!âl tcam may, therefore, be bette. placed rhan
their medical coxn!€rparts ro deliver a veiy cost efièctlve. helth-
ing .e$ation counselling;
. elect! rd 1eâderwho needror nece$arilybe a dentlst,to
o o r l n ' r e w o r l ' ' , e o h p\ .e, J ' I . " "',.s'.:
. enforcea smoke-free envi.onmenrin rhe $orkpla.ei
. âlwaystakea fù11smôkirghisroryfrom pàtieûts;
lo potierts
Advi(e
. be p.epa.edrc a$essdre readiness
ofpatients to qurt.
r ' , , . b ." . , d É . d r n \ ' . ; l l i " . r ' ' " . o r ' .
? '.ônr_npl,'ô. i\' r,paô : 'ê r'd i'c i in!.
Cônremplators-whoare inrerered in quifting but not reè.lyto
r14 ond(0nr0l
t lïe prôvenrion ofperiodDnrûl
diseoie
|

Toothbrush
ing- typesand techniques
Designchaructefistics
Desianvariaiionsin tôôrhbrushes i.clude dimensiorsofthe heâd,
the le.ath, diameter,dd môdùlus ofeldr;ciry of rhe filanenrs
and rheir number,disffibutior, ând angùlâtion.Openii.g effi
cieûcy may further depend on noisture cortent, temperarûe of
the waterùsed,and bruhins technique.Thesevâriâblescônfound
comparisonof the mdy lnvesrisarionscùried oot to deterhine
optimû roorhbrushchamcteristi.s.Àfthôùgh.ùûent opiûior
fàvôursa sofGtextured,nylon, multi-tùfted brusb wirh a shorr
hedd,there is no cleaÊcùtevidencethat one paiticula( rype of
toôthbruh is supe.iorto othersçith respectto plâque removal
and pr€venrionof girglvitis. Freqùent ùse of a hard lexrur€d
brushhasbeenlinked io gingivèl rece$ion. Figure 8.7 PoweÉd too.hbtushes.

Toothbrushillgmethods
Toôthbtushinsnethods are càtegorizedaccordinsro rhe djrec
rioû oi the brushins stroke:(i) veftlcali (ii) ho.izontali(iii) rotl
rechDique;(iv) ribrating rechniques(Charrers,Stlllnàr, Bàss);
(v) circular techniqtre:(vi) pbys;oLosicaltechniqùe;(vii) sûub
brush method. Compdariv€ siudies of rhesedifferenrmerhôds
haveyielded conflictiôa resuhsand eachre.hniguehd irs own
p.otagonisB. The Bas technique is ore of rhe toorhbrùshinA
medrodsmost wi.lely recoûmend€dby dentistsand hygiedsts.
This irvôtvesplaci.g rhe b.is.lesofrhe brushar a45'angle ro the
l o n sd i , ô f ' " - n l , J n d \ b E r . n s ' n e b r L l i a " a " a , , , i , ' - p o *
terior diiection ro removerh€ plaque.In rhe gene:ral
bowevet researchshowsthn àbôùt ône in drreepeople us€no def
inite broshina stroke,ànd of rhosewho employ an identifiable
sÛoke,âlmosthatf ùsedthe rô1lmetbod.
Poueredtoothbrushes
There is eviderce to suggestthn pôwered toorhbrusbesw;ll
improve plâqùe .onùol in specificpatienr groups: rhosewùh
fixedorthodonticappliàncest childrer andadolesceûrs;
rhosevith
â physicalo! Learningdisâbiliry; and iûsriût;onalized parients
who dependupon cùe providersto brushrheir r€erh.Ir is dificùlr
to know whether rhe improvenenr in plaque conÛol is due to
increde.tefficiencyin brubins, o!rherher it is likely to be dôre
short te.m, ùd duÉto the novehyefecCofbrushirg lvith a new,
more erciting product.
Generalln the btush headsofpowere.t roothbrdhes tend ro be
mo.e comt'Lft thm thoseol convenrio.al, manualbtushes(Fig. 8.7).
The bmdles ofbr;des de ùnûged eitherin rowsor in a circula.
paftern hôûred ir a round head.The bristles de âlso a.mnsed a
more coûpæt single lufts, which feiliate inteiproxlmal cleaniDg
ând brub;rs in l€s æcesible æâs of the mourh. The rÉditional
dsiss ofbruh headopente wùh a .oûvenrlonal side ro side,ârcù
ate or bæk and forth motions; whereæ,rbe cirola! brush headshàve
oscillaring. rctatioûal, or.oûteFotatio.al Dovements.
A nunber of the lewer generation powered toorhbrùshes a1sô
havenoveldesiArfeatùreswhich are almedat funher improving
the eÊi.a.y ôf cleadinswnile .educirs rhe likeljhoodof girylvâl
Ûauma.SuchfeaturcsiDclude:
. an ac.ive brush tip to fècilitète plâqùe côftrot arôùnd
. an orthodooticbrush headfor clemins àrodd the codpo-
ûentsof orthodonricappliânces;
. rotatinAor spiralin8filmerts for improvedirterproximâl
. a clickinc mechaûisn to wâû wher d pre-deterdined
brushioafô.cehasbeenreached;
populatlon,
. rimers,which ùrÀ]ly indi.ate à brushingtime of2 min.
Toothpaste
It h6 1ory beeneshblishedthar buhi.a wirh a coNenrioDal
ride toorhpdte is â mo.e €Fe.rive mea.s of plâque co.!rc]
brushiûg with wùer àtone.This etre.r may be aitributed to
Aens, ab6iveq o. the ântioicrcblaL effû of flùoridê
mùy toorhF€3B ùe formlrlared witb more effûive anrmr
agents, whilh hake signifi.dt .ondibutio.s to plague emoval
'edl ,io, u ' . Al, 'or8l- rhe uegK of dbru,v _y tu)
I i.i\
inilrnce dre âDourt ofplaque renoval achieved,the àbmive
erty oi toothpare keepsdre pellicle l.yer thin atd pftverts rhe
mularion of sudæe stans. Tootlpæ.e with â high dentiûe
value my Guse destnctile lesioff ln the ceri.al rôôth region.
' l e o t n I n J e g r e Ê o i a b 6 , v . y . u \ i , I r l l r € , , . u J { *e p e
wlthout dmaAi.g r@rh srroctuÉ, ha rot bæn delermined.
toothpstes ùe now forndded with .ir'$âUizarion inbibitos suh
solùble pymphosphates,zinc .itÉte, ôr a pôlymer system
which have bær shown ro redùce sùphgingival cal@16 fortuatioi.
Cleaning
behveenthe teeth
It is well esrabllshedthat pe.iodortal coûditions ùe wors
lnterde.tai ar@swherestaûdardtoo.hbrushes de lessetre.tive
removing proximal sudâce plâque. Fufthermore,
 deming
Toolh ','
|

depslrs whi.h remain after btushing will prôûote the regrowth In parieûts withgingivilis, swollen papillâe mty itltially liûir
of lresh plague, and the establlshn€nt ôf â .ômplex and presun the choi.e of irterdentàl aid !o denral floss. Il however,ary !.ox
ablylarhôgeûi. flohon cleanedtoorh surfa.es day be àccelented lmal aûa.hnent lôss hd occurcd. the gingival receslot, which
vhen plaque remains on otber toorh rùà.rs. Tlt need fôr effec- will inevirabl)' occû with ireâtment, should, in due cou6e, aLlow
tie interdenrâl .leanlnA has led ùr the manùà.ture ôi various inrrdentâ.Ibruhes to be us€d inseâd.
devices.They shonld be recômnerded in âccordàrce with indi
vidual ddreriryând inrer.lentâl mâtoryr ll-rigâtiondevices
r .\ ! f o\:d d -"d\ ô b., r.',8 \' t-a o- $J' I F db, 'j
Woodpoints (toothpicks) tbrough a nozzle under presùre. Oral i.risâtors should not be
TheFoodpoint is effectiveonly vhere sufiicientinterdentalspâce useclc a sul:stiture for toothbrushing, anc{ are ttme-consumng
. . . \ , l ' L , F r o . o m m o C . - e ,I -r ." n s r l d \ o o . r p o r. ' . ' e . r | e r , , l i - . y . o r . eT l c l ' l ^ , , : q r I " p"ri"1ru.,g tr1. i i
riorto rourd or reclansllar ones,vhlch areireilèctiveor linsuâl devices may beLievethem to be môre effe.tive than prove.l. and
6peclsofproxinèl sùrfâces. Posterjorteeth normally havevider redûe their eIïorts ;r ma.uâl p1a9ùe coûÛol. N€verthcle$,
llryùal thèû bùccàtembns,,resàrdàlthoush âccesis mùch more supragirgn'al iffigatior hâs a smau adiun.tive effect on plâquc
restricted, woodpoirts canbe fixed in ahardle and insertedfiom removal and gi.giviris. particùlarly in dred ofthe dentition not
rcadily a..essed by .onveùioml mech2nical means. In special
.ases, ifigdior derices may hâve â role in d1edelivery ofchemi
Dentalfloss .al Ègentsto the onl cavny.
,A]ûoush flo$iûg requlres more disitâl skill èrd is much nor€
time-cônsùhingthan sing wôod points, rhereappeà.stô be no
alternatlvemethodofcleaningpioxlmal nùà.es when a normal,
hdlthypapllla fills rhe inrerdeûtalspee. \Xrhentoôthbrushingis
accompanied by fto$;ns, moreplaque tendsto be knoved frôn
dr pioxiÂul surtàcesdrân by tooth-bnÉhinA alone (Kiger
d / 1991). Fu(hermore, a 2-week superised .lini.âl ùirl of
pa!ie^$ wilh ginglvitis, show€dthn in.erdeûtaLbleedi.g s'âs
Éducd by about 67 per cer! by flo$ins ând hrosh;r8 compâ.ed
to a It per cen! reductio! achievedby toodrbrusbins akrne
(Gnves/ ,/. 1989).
There is little àppùert .tiffereû.ein the cleèdna ablhy of
{ùed àrd urwâxed flôs, nor ls there àry .tifferencebetw€en
dertà1tÀpeàûd wùed or unwaxeddentè] iloss wth resard to Tooth-cleaning-How oftenshould
theneffectivenesat redu.ing interdenralgingivâl bleedina. we and how often do we?
lnterspacebrush (single-tuftedtoolhbrush) Frequencyof tooth-cteaning
Th$.tevi.e was in;rodncedto improvedces tô tippe.l, rot.ted, Plaqre forms continuousll and toôth strâces cemot be mâi.-
or displè.edteeth èûd teerh àtre.tedby slrsiral recesslon.The tahed iû a plaque-fleestâreby .onventioûalmec|a.ical meâns.
'oûb,r d . ^ 5- .'F p. - b,u f "nd roodpor',.onp"n The objecroi plaquecont.ol in preventioûofperlodonraldisease
satesfor the lack of etrectivenessof wood poins â1ôneçithit ls, rherefore,rhe periodjcrenoral ofaccumulatedplaqueat nrter
lingul embrâsures. The inrerspâ.ebtushls of llmited vâlùeôn itsvalswLlichâresùfilcientlyliequert io prerentpâtholosicâleffects
o*n at cleaninsproxlmal sù{acesercpr ftr !ûà.es adja.entto dising from recùtrert plaque fbrmation. \a&ilÉ rhe optimum fre
quen.y ôf iôôth-.leàdrg is unknown,;t would appar thàt io.ll
'lhe !idù?.ls with hea.lthygingi!æ aod ro history ofpe.nrlontal diseâse
interdentalbrush [bottle brush] cd prevent girgivitis by vcry dro(ngh me.hàni.èl plaque
Openinterdeotèlspaces arecleanedûo$ drorouahlybydre irteF reDov2levery'1ii h. On the otherhàtd, ifthe ptevâillngstanda.d
dertalbrushs'hich is nanuracru.edin diffefcrr sùapcsand si,er. ofplaque contol is 1es thàn ideal or jt i.nâmmation is already
Tbe largertype h held bI ils vire handlevhile smallefrersions p.eseo.,colonlzarnn of the cleaûedtoorh su ace occùf! mu.h
are.ttachablero a metèl or pta$ic h.n Ue.Siùdiescomparinsthe soon€rand plaquegrows môre râpidly ând marùresldtet. This
interdeûtÈlbrushwith dentàlflos haveshowr ifto be superlorin nèt be attribùtable!o rhe presencè of beterial srowdr liætorsi.
cleâlinglârgeinterdentèlspaces èûd sugaestthar çhen the inter ginglvd flùid, which is scc.etedin largermoùtts by inllamed
dertâl brush is ùsedhèbltully, $pr.sinsival proximal surlaces gingival !iss!es.De.t2l plaqùe â..umtrlâtion mal' also iûcrease
.ân be kept free ôfp1agùe,and subgirgivèl plaqùeto â deFth of adjà.eûttô swollersinsival tissuesdue ro inpaired ùtùrèl cLeaN
2 2.5 llû belôw the gingivàl màrgin mày be removed. ing by tie tonAue.cheeks,and lips. Therefore,more frequent
r16 I Theprevenlion periodontoldileose
ondmnlrol0l
|
I
plaqùeremolal mày be necesarytô.orûol gioAn'iris.mrhcr rha.
preveûtlts omer.
hdlviduàl sus.eptibilirytô gingivitir dd periodonritismay bc
anotherimportûr fâ.tor ro considerin selecrinsa suilablef.e
quencyoftoôth .leâ ng. In their o.iSinaldpcrimenralA;.Aiitis
model,Lôeand co \rorkes (1965)showedthat, follovins the firsl
clinl.âl siSnsof iûflamm2tior. rhe inûodlction of thoroùghorè1
hygienemedùr€s. twice da;ly. ach;eved.esoLurionof girgiljrs
within a few days.Tbis wasrrueevenoflbe nore susceprible indj
viduals, who had developedgingjvitis at an earty st.ge of p1Àque
accumular;o.. Àccordjosly, to èchievesirsivÈl heâlth, rhe re.om-
mendedirte(albetweeD tooth cleming se$ionsshould,in theory
depend on the expecredthoroushness of cleming, ôn prevailing
gi.gival coûditiors aû.t or incLividuâlna.eptibiliry tu period{rntal
dis€ase.Iû pmctice, oost palients ùe condiriôned to believe in a
.leâdrg frequen.y of twi.e dâily aûd rherewould âpteâr to be no
good .edon to alter rhat perceptior. In the UK, rhee our of every
iour dentâreadultsquestionedctâimedro.1ed their teethâr leasr
twice a day with only,{% .leming lessthan onc€a day.The p.evâ-
lenceofvisible p1â9ue, denta.lca.lcùlu,andp.imâI'carious lesioos
ls greàterin thosesùbje.tswho bruh on o.e o. ieweroccaronsa
day cômpâredto twice daily brushers(Adult Denral Healrh
SNey-oia.l Health in dreUni.ed Kinsdon 1998).
Dentalhygiene behaviour-lech]]]iques
of
tooth-cleaning
Fifty tvo per cent of.lentàt€ adù1tsrepôft using denrâlhygiene
r r r o u r r . æ d r o r d, lo i ' ô o r l - b r - 1 d , d . " u' p . . - . r r l d r ' " 1
flossbeing the most f.equendy used method.Twenryeish! per
cenr.làin rô ùsedenralflossand 24% ro use a mourhwash.All
other merhôdsôl or aids to roorh cleaninsa.e usedby berw€en
only 1 dd 57, ofsubjects:vood pointsi smokers'loothpaste;dis
closingtableB;inrerspace brushrârd chewingAùm. :fhereùe no
dataregârdinainterdenta.lbrush€s.
Remârkâblv, overa thi.d ofthe populdtion.iônoÙecallhavins
beengivenâny advicercgafdingcareofthe'gums or havingb€et
shôwn how tô brusb thei. reeth,eiiher by a denrsr or a deDral
todi obout
loothdeoning
Chemicalsthat canhelpto reduce
plaqueformation
Plaque cont.ol by mechanlcaldebridement is highly labour-
int€nsive, whcther professionallyadmldsreied ôr prècti.e.l
pesonally.Satisfactory honre-cafefuthe. demardsa measu.e of
manuâldexterityand a high deAreeof motivar;on.vhich mmr
;.dn'iduls do .or po$c$. Nor su.pds;.gly, thcrctore.a larye
numb€. ofchemical aseDtshavebeeûlesredfo. thei. abil;ry$
.educeplaque âccumulaiion.Somechemicâh2ci by prerenti.g
colonlzatbû of the enmel or by remorins attachedorganlsd
bùt, or the whole,thesehàveshoùn 1e$promisethm ânrimido
bjalasens. Thissectionwill be limited to a consklemtiorof thor
chemicals which have been tested a prev€ntive asents for then
etrectsoû supiàgirgivâlplaque àccmnlÀtiôn.
chemi.al antiplaqueagentsare dsessedin severaldifferent
ways: ;' ",r/, sùdies may be edployed ro evalùateaÂtimicrôbirl
actiônishôrt-termrùdies ôfa few dnyscanasessthe ability ôftbe
.hemicalaAenrto lnhlbit plaquefomation;, /i/,; hoverer.rud-
iesôf2-3 weeksarene.essarrro r$ablish d inhibitory oi theft
peùtic eifecton gingivnisr and lonA tern studi€sofùnsuFedsed
usefo. severalmondr aft reqùlredto a$e$ tull). the adjùndive
valueofthe asentwhenusedin.onjun.tbn with toorhbruhidg.
I. sp;teofthe de .arge ofantim;crcbialsuhstances ofproven
effectiveness in rhe treatmeotof nany differert infectjoûs,th€
natùreofdentalplaqùeinfectionlimits the usefùloess ofcheol@l
asenrs.Of najor sisnjficanceareth€ apparertnoD speciûcna$e
of chronic sinsivitis and the proliferatjle capacjtyof oÈL bacleria.
Therefore,*hi1e variousàntisepticmoùthwashescd achieve a
temporâryreducrionnr rhe rumber ofbàcteriâ in plâque,o.t
ttroseagentsrhat remainaciivein themourh, tu exerta prclônged
effe.t èfterâdmidstràtior, ârecdpableofsigûificdr plaquelnhi
bition. Thùs, the cationicbisbiaeride, chlorhexldine,apped to
be anùch hor effectiveplaqùe-inhjbirôr;u ,i,, than ôrherânti-
septics with equal o. beûet nt aitra ^.ri\1ry. Indeed. it n ve
establlsh€d tiat tie ântlplaqùe effe.t of.hlûhexldine is unsù-
passed by all otber chemlcal âAents. Phenolic aAents (Lisdin4
2.d triclosan 2re moderately effeftive, wherco qurernaryanno
-,.,,
n i I n . , n p . , 1 a . .n , , , t . " , . . d . . . . , 1 6 . n , , , , . u r . s ,a .
ing agents, hexeti.lire, ùd eûymes are oflitde vâlue.
Chlorhexidine
Hou doeschlorhex*lineuorh ,
Chlorhexidiûe has a broad sp€clrùm of bactericidalacrivnr
àgalnst Grm positive m.l Gram negative orgarisms. It wd fl$t
markete.tbyICI (À{ècclesfield, EDsland)ir 19tl asas€æFldis-
infeftânt for skir ând mùcous membràûes.It is ùsed priûcilally
in the forn of chlorhexi.tine dislucomre.
Th€ positively chars€dchlo.hdldine birds to bacterirlell
walls and to 'ari{N om.l a,rÊ.es includin8 dre hydroxyapadteol
tôoth etuhel, the ôrganic pellic1ecovering the tôorh nûtua,
ôu.ôùs denbme, and saiivary prorein. Besidesafting iûmedi
atelyo. o.al hacter;a.;t is retainedon the tootb surfaceto exeûN
prolonsedbacteriddaletreff.andsubsequendy, d;ts concenrhûoi
fâlls. a bâcteriostaiic effect fàr several houa. It l.tem.ir
vith bacteria,dam2gingpe.meabilitybar;e6 ând precipitding
cytopLasn. :fhe pharmacodynmicsofchlo.hexidine,. the nouth
indicarcthat rhe lrcqueocyofapplicationshouldnot bc le$ ùt

Mi.e.tâilr: A 0.2 per cen.âqueoùs môùth rise in l0 Dl doses1û
1 min, rwicedèiln hasbeenshownb redu.ethe salivarybâcteria.l
.ôùnt by 8t 9t pe. centând. essentia.lly, to preven!plâquca..u-
mularlônând giraivjtis developmentin Nbiects whos€hâbitual
me.hani.al .1eâring is suspe.dcd.Sùppressionofthe salivârvilom.
howeler doesnot apped to play a maior pârt in denrdl plaque inhi-
bitio.. wbich t primarily a resultoi:the localanriba.teriâlà.tility
ofdnoùeidine rhÈt is bolrd to toodr surfee compônetts.
Hott, is chlorbexidine aclministered?
Chlorhexidine nay be a.lmlnist€r€das a moùth rinse,asà toodr
t6rc of gel, in d ôitl irrigâto! or âs â spny (Iig. 8.8). Iucowe
.ie.r localsideetre.tsnÀke it ùnsljlablefo.lonsrerm use.
The ântiplaque effecs ofchLorh€xidinea.c dose-.not cotcentra
tior{elared.thus, ôptimùû plâquc.onûol is dhieved by usi.g â
mouthw4h with â dividcd daily doseof 18-20mai t;r example,
l0mlof0.2 per.eni .hlôrhexidiûetwicedaily,of 1t nn of0.12 ter
cenrchlodreidine ôvi.e dàily. Significânt,althoughtuboptimdl,
e$ec$mar be obtddedwith redùceddosaseand Êeqùen.yôfùse,
lmely It ml o10.2pc.ceot.hlôrhexiditeoncedailyr10mlof 0.1
Fr cent chlorhex;dinetvlcc daily; ând It ml of 0.1 pef cent
.hlorhexidine once d2ily. In rheol', those si.le effects,such as tdte
disùLÀance, which ùe co.ce. tntioû-depentent, shoùld bc less
shen usingredùcedconceormtions ofthe.ln,g, therebylcadingto
bettercorplimce for lons-te.m usage.k shduldbc stftsed thàt
anrimi.robial agenB, chlorhexid'neiû.llrded, hâve little or no
plaquein doscslûtendedfôrinhibitjo. oi nev
efe.t on estâblishe.t
plagùe formàrior. Iurrhermorc. chlorhexicllnemonthwaslrcs,
th0t(0nhelp
chemi(ols ploque
l0 redu.e tormolion
Jthouah prcdùcing è làrae redù.riôn in slPraaingivâ.I Plèqùe
delelopment, hale â lessdramatic effÉctoû e$dLrlishedgingilitis
where subgingival plàqùe has ahcady fôrmed.
Tdte disru.ban.e càt be .educed by redùciDs .hc con.entrà
rior ofûlorhcxidine, and to achierc an effe.tive dose:an onl iûi
gator car be used to deliver a lafser volume, for example, i00ml
of 0.02% chlorhexidinc. Indetd,by imfrovinS thedistribulionoi
.hlorhexi.Lne to thc more inaccessibletu?asôf the .teût;rion. rhis
ule ofân oral jrrigat,r ûay achieve bemet plaque control thm a
0.2 per cent moxdrvash.
Nfanl toothpaste i.gredlens, notabLy a.ioni. detergents.
çill intera.r ùith, and ira.tlvate chlorhexidine. Às è resùlt,
artcmpts to formulate an actile chlorhexidinc-containins tooth
paste have, on rhe whole, met wlth little $rcce$. When âniodc
dercrs€nis are omrtted ffom toothpaste Ètmulations of 1%
''"rl rrd.,e 'od , r.r'o' ' f l J g ' _ " r , 1- . n g i \ i i r
be achicrcd. Staititg atd calcùlus, however, remain Problem
Aqucous gels .ontajDnrg I per cent chlorh*idine have been
cômmercialll available for many yeâ^. Clitical ùiah hâve
dero, -r.F" ,od.. Fd.. ,o, I tt qu- .r.,.9,\',..i {r
pafti.ipm$ vho brushed with the acl. However, the necessary
nbsence oi d€tersedts aûcLabrasjves ffon gel fornulat;ons ôf
.hlôrhexi.lnre reduces pariett acceptâoce, si'ce there is then
nodrirg in thc prodù.t ro co!nteract stuin formâtron.
AltbouAh .hlorherid ine Acl is oflittle èdjutcriveva.lue in itdi
vidùals with moderareorgood oral hygienc. it may have agreater
rherapeutic effect anoûg thôse with high plague levels a.d fiank
ginAivitn. Chlorhexid;ne Eel mày è]so be applied in trèys to the
teeth of seretly hmdicapped iÂdividuals, for vhom .ôovettioml
cleanlng methods are clltficult or utacceplable. The apPlicatlon
techniquecan beawkward,and this is likely to redu.e.ômplimce
Anorher optior for drose with À severe dis2billq. is a spmy
appli.ation ofchlorhqidine sôlution. This has been prolen ro bc
more Fopulaf than d1e moùthwash or gel, althoùgh srudles have
shovn rhat vhÉn à 1ôw dose (1.5-2.0û1of0.2 Pet cent sôlution)
ofchlofhexidine is àppljed in a sprây tô the !€erh of handicÀpPed
.hildren by dre;i parentsor carevorkers, it is le$ elÏectire than gel
applicatioD in tays. Hôùever, when applied nnder oPtimâl.ondi
rioûs by d€ntâl fofessiônals, there ;s a mdked i.nibiîory efe.t
.ômpârable !o the standdd mouthvash .eginen. Therefote, lf suf-
fi.iènt profe$io.al suppôt is provided. a spray àPPllca.ion oi
chlorheildnre would appeù to have some advantage over morc tra-
ditional mcdbds of chemical plâqùe .ottrol. Studics a.lsoshow
dra.. when teeth are târAeredto recen'echlodrexidine, mùcb lowe.
doses are re,tuired f-or plague control, thc prôpôrtion of dru8.
vhich becômesboùnd to rhe ôû.1mucosa,being dinimize.l.
ls cblorbexiclhe safe?
Ba.ieriôlogical studies.onducted afteL long-tern use of
chlorheidine mouîhwash have shown that, although rhe
rùmber ôf sèlivary âod plaque organrsms is redu.ed, thete is
 ond(onlrcl0f
I Theprsv6nri0n periodonlûldi!êose
no dete.rable shift in microbial I opùlatn,ns, no resrdùal effcc.t
on salivary or plaque bacrerid afief ccssatrcn ofriûsing atd litilc
cvidcn.e ôf bafterial m!lation or sclc.tbn ôf relstànt stmlns.
Thc rotal sâllvary bacrerial counts lcnd .o rebôûd to conlrol
lcrcls iithin.lSh ènd plàqùe fèrms agaln at ûôrmal ritcs
C h l o r h e a i d i n ci s L n o w n t ô h a v e L o w i n i r â r . y a n d i s m o s t
ùrlikely tu pndu.É sensirizètion. Àbsorfrion aftef oral ingestion
js lery low and l.,ngrerm ,& hù produced no.hndges in hàema
rologjcaL of biochcmi.al panmeteB. Prolonsed âppli.âriôn hès
fàlle.l ro show carcinosen;. o. ftratose c elle(s.
Wbat are tbe side elfects?
'r-he
of side e*ècts are o{ a local nètùre. r! hâs an
hÀjoriry
'.. irodù '.' I b", F i, r.F.., i'i{.
which mry lâr for several hours. Desquan,itivc lesn,ns of rhe
orâl nù.osâ ô..ur in à small numbcr ofindiridudls, pedrdps,luc
() precipiiàtiôû ofac ic mucirs and p.ôteiûs rhxi.ôv€. a.d
pforc.r mùcôus membrènes. This makcs dre epitheliùm vulne.a-
bl€ !o ùechani.al frâuda or to the cyloroxic effe.t ôf.hemicals,
inclùllnA chlofheaidine itself A few cases ot ùnilaieràl or
bllateral Farorid aland swèUitg hale been reponcd after use of
orl-\,J.'eaor '.''.'. lh_ lrra'e',ure ' "8"' r,'"
ôf nechânical obvruction of ihe parôti.l dùct. Thc unpleasânt
t.rt€ and mucosal effe.ts .an be .liminJshed by r€du.itg rhe
conccntmtbn (nnd using a ldrAer voLùme tu naiûtâit .Linic,l
Browr discolou.dtion of tee.h and fi11inss rs common, borh
virh môùthwash ând sel prefantio.s ôf chldhexidi!€, a s;de
eflecr which is shàred $ith odrer caibni. antiseptics. Brown
sraining ofrhe dôr$h of rhe toogue occu6virh the moùthqash.
bur .ot witb the rôodrpdtergel. The'e n aû lnrerâ.tiot between
locâlly adso.bcd chlo.hexidire aDd 1i{!o6 derived f.oû dier such
as rhc taûniÈllke brùces in red wirc, tea, .nd cotree. This
intera.rion is responsible fo. drc clrareteristi. stâin. Tbere is a1i)
d tendency fo. nrorc pratjingivai .alcù1ùs ro bc faflned, \rhich
couleracts ùe benefis ofchlorhexldire. Thc me.hanism forthis
eÈèc! nay involve the suppresion ofacidoscni. plaque bàcleria
"'. Ép,l'tue oo'r'.,f- L.n"Gr.'-,J:'8 ,êi r
tion ofcal.iun and thosfhate.
Stàin ènd caic!Lus fo..rât(,n are dôse .lepend€nt a.d.annot be
re.lu.ed signincandy virhout loss ofântiplaqxe efta.ls.
i{ben sbould cblorhexidire be ased?
Âlrhough rbe side eite.ts aft ninoi, theii existercc has Pla.ed
limirârions on ih€ appli.àtion ol' chlo.hcrldine to .lini.âl prâc
ticc. Ncvertheles, .hlôrhexidnre ha bccû shown to sefle ausetuL
1ù.ctio. i. tbe fôLlowirg circumstanccsl
. posr ope.arivc mâmgemeût ofperiodo.t2l woundli
. managcnrcntof desqmmÈtive forms ol airgirititsindi!idu
ah widr Finfùl gingi!âl lesionsnaybefla.ed o! a chlodrer
idlne mouihwash resimen insteèd of toodrbrushlnsl
. flaquc onûol dûing iûtermaxillâry urarnrn;
. lorg-t€rm plx,tu€ conûol ln hèn.licaPPed
individùalso
medi.ally .odpromised lrarlens
Untànmately, dre suc.essôf.h1orh*idi.c ln thse
situatlons is not equalled by ;6 tffect on eslaLrlished
diseâsc.A previously notcd, tht sàtdard moùthwash iegi
sill noÙemove existinA pragitgival pl29ùe, or Peteftare
rhe gingiv,l marsin to removesubEingirâlPlaque.Indæd,it
ètso altàrcrt that chLorhex,dincdoe\ ûot Peoetrarcthe
tè] spacesuffi.iently weLl !o hare xny sigûificant cffe.t on
deûtèL gingivitis. Fùithermore, if chlûhexi.litie mouthndh
$ed dùring lie iniiixl phaseolhysiene drerxpy,it will mask
effe.s of perso.âl mc.haûi.al piùqùe conûol ùpoû $hnh
fù1lôns term lreatmcntofperlodontaldi'easeis dePendcnr,
make proper evalu2rion of th€ palienfs effoits û
Chlôrtrexidine. drcrefore, should be rcsetred for Ptevenoon
plaque a..ùnulation only s'hcre me.hrnicdL flaqùe reûovlL
Phenoliccon]pounds
ùyûô1 .nd eùcalyptul,ûited çith mcnrholdd methyl
com
lare in r hydroalcoholi.vehicle,is a well-cstablishe.l
and long term.
moùth$.dr. Early stùdies, both sho(
moderaÉùtiplâque and antiginslljris effecrs,sith abnrer
s \'or
"' | ",ior"r'r""t r\ l prf l.l.l
.omparative sludics, siih chlorhexidinc as a postrle
hdve shown llsrerine to be somcwhat les effectivc Thûe ee
dâta on rhe strbstanliviry ofLlsterin€.
Tfi.ldd, ùodrer .on-n,nic phenoi, hd bæn a com,non
sriuenr of soàpsaod dcod.hnts for the lat 25 yÉau.Ii n a
specûum antimiùobià] aAe.r ofmoderète etivjtr and substâoa
It hasbecûfo.nulàre.t with a copol)"ner(Gaftrez)n, inPro\t
- t ( ,
. J lc ' , \ , \ , n 0 0 . , l o a n C n
àihievesnoderatt reductions;. flaqùe ùd giûaivirn oil
mrgnnude \i dnft sidee{Iectsvhcû useds à Pre bùsbitg
lle,.g .on-bnic, ùi.Losa. iS .omFrible *nb roothPde
cnG, and is ûoç àcommon con$tuen! oftoorhpdte in combi
ùith ôther chemlcal $bsd.es such ù Cflntftz, pyroPhosPhae,
zinc citrâte. Pyrophosphàte is a Ne2k aniidicrobial agent It
low substàûtivitrbur ac$ slnergisticallywidr ûiclosao!ogive
enhanced antimicrobial cffeû n] ùtto. Ziic, in cômnon e'
odrcf metâ.Iiôns, is a highl.r nLb$atti\e èn.jmi.mbial agenllr
formulated wrh crtratc to ftduce the metallic hse md.
.on,bincd sith ridosar, exhibitssrtergistlc actbn
,? ,r'" tu.ht tiiclosa.,byrofhorphate .ombi n,tion. Gdtrq,

salts,and pyrophosphâtesàre a1sô.ry-ralllzatbn lnhlbiûrs and,
bv jnterfering $ith the nineralizatbn of plaqùc, thcy rcducc
supûgiûgivâl cèlcu1ù formarbn. Data are arallable sblch
denonstrètethat the efaicacyof toothpdres co.td.ins crnrrez/
fticloer oi zin ciû.te/Ûiclosân hale moder effectsas inbibiro6
ofllaque and Ainglvnis, ând lidired evicLencewoùrd gger
ùd tne tdmer toothpdrc mây rlso inl,ibit the progre$ioo of
It appeas frod nmre.ôùs srùdics rhat ûiclosan in roodifdre
dæsnôr ftdù.e rbe bioarailabil;!y ofnùoride or dismpr the oar
ùralmi..obial ccoloAy ol lhe moùrh.
Professional
cleaning
and root plâning
Scaling
Scâlingâ.lone is sù*i.icrt ro completely remove plaqùe an.l
alcuhs from ermel leàvirg a shoôth .len sudace. Root suF
fices,however,whedrer sùpn or subgiûgivâl, day h.ve depôsirs
ofcalculus enbe.tded in cemeûtal iûegddiries (Fls.8.9a). ^
portioû of ceûentuh mùr. thercfo.e, be .cmoved to eliminare
thse .leposits (fig. 8.9b). Iurthcrmore. plaque dccùm!Ldtion
a$ B in.onramlnarlon ot ccmcntum b)' roxic subsrances,
noûbly Éndoûiins. Somc cvidence sùgg€ss tira! îbn cementùm
tur' be bnnoglcally unâcceftable ro adjacen! gingival tssùe ard
shouldbe Èmoved by i.ntrpla.ina, a p.ocedure which mâv resul!
i0 exponùe of.lertine. While this is ûor the ain ofùearment, ir
may bc unavoidabLe.There r little evi.ten.e thàr the cLegreeof
tuot smoorhina per se is of biologicàl imporrèrce although it
Iigurc 8.9 Root Nrfac6 aûl câI.ùt$ depôsits.
I rrc
ProlFsioMldmnns
I
giles dre best .linl.âl lndl.atbn thar.al.ul$ and altered cemen
tum havc bcen.omplerely rcnn)ved.
SùbAlnslval deb.idement shoùld .en t in â fiicientlr"
plaquc-frcc cnvironmcnt to allow rcnesal of jùn.riônal epithe-
Iium and drc cp;thcllal atta.hmeût. :rhe degr€e of subgingival
root qri.ce .leansing ne.esa.t' to a.hjeve this ù ljkeiy to vàry
froû patienr to Farie.r and ftom site ro site Akhouah it is {'cll
established d,àt non surgical ir$rumc.taihr often fails k)
achiere comflete re.roval of plaque and calculus, in.omplere
debr enent may still b€ compatibl€ wilh cLinicaLperiodooût
heè1th in many câses.ln other cÆes,failùre !o achieve complere
piùttre reno!Èl ùill alloù recolonlzation of the root surface to
Èke p1ee, ùd itflannation to peBlst or recùr
Fôllowing $bgingival iû$nmentÈtioû, good sùpmAirgival
pllqne cortrol is. prerequisite for pocker heèLirs. Àt sires oil,er
s'srent suprâg'nAival plâqùe âccùmdarion. pockd debrideme.t
hd no eife.t on singivitis; an initiâl, sûall reductior ir probing
depth is ieverse.t wnhiû 8 ùeeks dd rhe mèir periodorlal
pathôgens are re-establisheds nhin 4 8 weeks ir the propo ioûs
obsctred p.nr to deb.idement.
Polishing
PolishinA cnamcl mar result i. fto.ienrarion of su.fa.e .rysâls tô
c.care a snroodre. su.tæc. Hos'evcf, althoùgh early erperlmentâl
$ùdies hale shown drat p(nishin! tu â high gloss inhibits formr
rior ofpetlicle, plàque, àrd cdtclLu, there is no documenred evi
denceofperio,.lontal heal!h benefitsfiom drisfm(icc. Removalof
extr;nsic loorh stai.s tor cosmctic .easons,and rhe psy.hoiogi.a.l
t40 ond(onlr0lol
8 ThêFeveillon periodonlûldiseose
effec!ofhavins cled teeth èfter à dentâl àppointment my be the
princlpdlberefits of polishing, while removâlof ilùoride from
sùperficiàl 1àyersof the elldel côuld be a signiÊcdr drawbâck.
Cleùly, tooth polishing .annot be suppôrted on s.ientifi. grôdds
6 a routire procedure,bur hay be indicatedin specia.l inrù.es
whereplaquerenovâl is obvioudyirhibited by surh.e roughne$.
Tooth
surfoae
inshumentrliorl
periodontalcare
Supportive
sllren pedodo.t2l ûeatmen! is conplete, the lorg term stabjlity
of the pedodontaltissuesjs achievedwirh a prosranme oi sup
portiv€periodoDtalor mÀintenance càre.The oveiâ11àims ofsup
. pr€vent the recùÛencedd
progresion of periodoûrâl
. preventor reducetooth los;
, n . - i \ e r - " p . o b .D . , ) o . d , . e , o . , ; " , d , r , , , , e . , J
tlmely màrner otheroral diseases.
In ord€rro achievetheseàims,rheàttairmenrôfà high levelof
plaquecoûtrol ls esentiâl ànd selectivere-Ûatnent is â1sôoften
ne.esq' to rmore .e.urin8 deposirsofplaque an.l calcùlùs.
is ùatômary nr commen.esùpportivecareby âdoprinSa standa.d
apprôa.hû.il a deg.eeofstubility hasbeena$e$ed.Th€n, ea.h
sùppoitivecareprcAnmme should be t2ilorcd to meet dre iod;
vidua.l: p.e.ise needs.Th€ inrereûtion may in.lllde rciûfor.e-
nenr of orat hygiene insÛuctiôn with eirher Npragingivrl
rallnS. subainAivaldebridemeûror perhaps,a comb'.ation of
There âppearsro be no cleaf e derce ro i.dicate vhât fre-
quencyoi.ecaLl jnterval js likely to sjve the b€st loDs !e.m
rcsults,althousha I month recallintervalforpali€ntsseemsto be
lavou.edin nost cljnical triats and deûtalprætice.Ths in!eFa],
l - o q - \ e r .r p p p . r r o h r \ . - o l v  l j . r , ' , e r o i o , \ e , É n " r o
both clinlcims ân l pàrientsràrherthân beiûg bæedupôûspecific
clinicalard, or mjcrobloloslcaldatâ.Cieù]y, this is a! ar€awhe'e
Iùthe. res€arch is oeedcdto infô.m clùical practicc.
It must be emphdizedthat existingperiodonta.l disede mdr
first be treated àûd optimâl periodôûtâl health estàblished by à
sùsained courseof Ùedtnent before s.heduiing a re.a11prô-
;,dnn p, i..i r,l lei,iis l.'.hr.iL er n"ia,1 ,.
s.hedule comp.i;nA single-visit se$;o.s of scalina a.d oral
hygiene lnfu.rioû at widely spacedl.rervals is uûllkely ro
resto.eperiodontalbeahhor preven!proare$iveâllachmentlo$
wheûa slgnificantamout ofdiseaseis p.eserrât the outset.
programmes-the
Preventive classic
studies
'Ihe
.omponents ofd effective prev€ntjve lrosruoDe baed on
I d q , e ô , o l d , . d . 1 . 1 h e d l , l e . l u - r r . o n .o - I I ) B e ( ' " . r -
rion. and pofessiônâl tôorh .leadns. The relative inpo.lance of
ea.h cômponent hd beer àsesed in a nùmb€. ofclâ$ic studies
predominaûdy in the | 960s aod L97 (h. Thcse have meæûed vd-
ious panm€te$ of oml cleaniinessântperiodontal heakh, nmely,
plaque and calculus accumulâtion, girgival n lmmatlor, ging!
M.l bleeding, pocker depths, âttùhnert le!e]s, and bone resoe-
.;on. This wofk has bcen .aûled oùt bôrh in.hildreû àrd aduLts.
:Ihe discussior which follows coû.ehs non-sûgi.al ôethods of
p€rjodorral care. vhich have been standrdized for tesing oo
large groups of iûdividuals. :fhe paricipanrs were ôrdinùl
nembers ofthepulrlic rather thân pedodo. tal patients per se,dd
dre various Frocedures werc testd both fir rheir effecB on pe
existins periodonra.ldisede dd for their àbility to prerert ren'ù
recuûenr disease.Becauseofthe'trealmenl element. th€sepc
S i m n " d n n o _b e . o e y r e g " d e J r 1+ n " 1 1 ,..n i '.
Preventiveprogramnesin children
It n generallyasmed that gôo.l oral hygienepracticesarebest
equired in .hildhood ùher they mày be lDtesratedwilh othet
developlng health hâbits. Preveùive progrànnes in schools
prcvidecontinualôpporturniesfor peerinflùenceand the stimù-
ltting effectofdally peBonalnnerâctioo.
Evidence for the effe.tivenessof dental health edûcation prc
S.ammesin s.hôolsis equivocâI, Èlthoùghtheremay be sigriâcânt
imporements in Lnowledge and attitù.tes, chans€s;r behaviou,
æ meæuredby reducton in plague dd gitgivitis, ùe ùsualiy
. l - o r \ e o l l - , N i , u " N ' r , i l , l ' h . d u d ' , ô rp , o g ù m ' . ,
the UK was a l2.ge trial lnvolving 6700 1l-1,i-yeàr-ô1dswho
receiveda teacheFFcd;ated .lental halth edùcatiônprogmûne
comprisinglhree70 80 minutesessions. ârweeklyinretra.ls (Cnft
r98.i). The progmmnc employed adive learning principles dd
inclùded a slide presentation, experimertdt work, ùrd ùs€ of{o.k
sheets.lmprovemert nr phque and gnraivirisleveh,whlle statis-
tically sisûilicm!, wd small aûd fadedconsidcrablybetweenûe
5- àûd 28-ùeekobsenÀtjonperiGls.Nev€rtheless, the exposure to
srch a dental health prosrme misht conceivèbly improve the
uptake of sùbleguent practice-baed preventlve cùe.
SùpeNisedtôorhbnahirg in schoolsis an ahernàriveapp.oæh,
w|lch h6 beenevalùaredin severàlstudies.ror exampl€,in a
stud).of r2-1]-yearold s.hôô1.hi1dren, è I yeàr$,perviseddaily
 P'.vnnti,e I r'1r
P'oqroî",s
I

buhing reg;nren.educedgingivilis in t6 per cent ofall toodr thc cipedmentalan,LLpfe11frôm 6'i.r per ceût to 29.2 per ccnt,
d6 cxam;red(i. rhe last yeat, wh€reasa controlsrouF sho$'ed and thc frequenryof inllamrd gingivàl urlts from 4l.L pe. cent
À7t ler cent incrcde in Ainaivnis, typical ofdris stageofdrild to 18.8per.enr. Differen.esbetweertest andcorrroLg.oùpswerc
hood(Lindbe,l,/. i 966). highly sig.iiicant at rc-examinatiôn(Hdp.r"/. r978).
Âhhouah superyisedtoothbrushins may producea. overâlr Furthcrsùdies weft desisnedû as.ertèinthe sepùateeffectof
iûpovementin Aiûslral heal.h.a rùmber ofaddirionalobseFa- ea.h .omponenrôf dre prôphylà.ticregimen.
tionshavebeennà.te ir selerèl$udies: Poutsenrrrl. (1976)aiiemfred rc dctemine the beneinsthat
' rhe reductionof gnrgivitis is ofteû lneveoly dstribùted njght be oLrtainedhy profesional nxtrh-.leanitg alônein 78,
q , , , i ' r ' e d e ' t . t . o nq r h . f o r . r . n r l e . | , - J p p F r , f F û o r 7 y€arold children. Thus rhe eape.imental group received
thoroùgh mechâ cal cl€anlns erery 2 weeks wiile a.ontrol
rd of the mouth showinsgreÀterresohtiôn of itfl.mmà
tion thù the posterior,1esac.esible areas; groop were girer no profe$jonal tooth clca.ina. Both atuùps
' giûgilitis scorestend tô remdin somewhâthigher for proi re.eived foftrightly sùpetrisedflùorideri.sina. Tbroùahoutthe
sttrdr',home cùe stàD.tàrdswere no! ioten.io.ally ;nflùen.ed.
lnal sùrhces thù fôr bu.cal ând liqtual sufaces;
Âfter L year there ws a stàtisricàllysisnjficant,liffe.crce in
. this lype of preventile prôgrdme lacks âny prolonge.l
p " 1 r ' u n u l , r o rb F - ' e ' ! F - e - o r t " d . , ' p t . \ ' " " , : '
eile- aficr 't is s'ithdrawn.
AinAivnisin dre tcst gfoùp.:fhis s.ùd]''*as.ontinued for oûefur
Thef limitatlors of supervisedtôothbnshing hwe, ro some ther ]''ed dûing whi.h rhe inter!èl betweenprofe$ion2ltooih-
extelt,be€nolercone ir clùicàl trials in vhich denralpesonnel .leaningsesiors wâsincreùe.lro I skeks. Plaquea.d aingilitis
haveiûtrodùcedvùious otherprevertivesratesiesro childrenon s.o.esin.reasedin rhe eiperimentalaroup b!! r€mainedsigniii-
candylowcf dranin dre.onûôl grôup,wheretherewasno appre
In 197.1,Àxelsn,nand rindhe rcpored rhe effe.t ofa risoroùs ciâble chansc in oral .leanlinessor gingivâl he.lth (Agerbâek
preventivep.ogfmme in schooL.hildren aged inltially 7-14
]'fus. The ftst groups rece;vedprcfc$ional toorh cleaninA.oral Th€s€studiesdemons.arcthat rhe fregkncy of profesionaL
hygienelnsru.tion. and ropical lluoride afplicatioos crery 2 tootb cled.ing is ofmâjor imfoitan.e when it is the only p1èque
weeks. Pafentalinvolvementwasobtainedat.thebeginninsof dre conùol measurcùsed, alrhôùghn is difficult to sses thevÀlueof
studyândalier I year.The experimeitàlgrolp demoistrèred1ow toorh .leding per se becàùselbe involveme.t of drc .bildrcû
plaquescorcsa.d reAligible siansofAnrAivitis afier 2 yeas àrd itself may hav€nolivared ihem to pracricebeiter hone .ùe.
rhereweft no siA.lficant diffcLences betweenAinAivitisscoresof That the benefi6 of fortnishtly prcfessn)naL bôrh-cleâtitg
lroxinal and buccal/linsualared. Chiklrenin the coûtrolsroup, .àmot be àrÙibute.terrirely !o lhe reFeated.cmovalof 2-weÉk
o l h eo _ h ah d d . l . , l r r t h r g h e r p l . l u ' " r d gn 1 ' r ' ' " o e ' . old plaquehd àlsobeer demonstrated io a Late.study involvins
Thus,jt appearsihat cùeful fortnightly interproximèl.leânirg 13-1,i-year-old.hildren who receivedfo.rnishdy prorèssional
with flos or pollshing tips preveits glngllitls lû rhoseareasin rôoth-.leànins ir è split mouth desisn (ÀxeLsson and Li.dhe
children. Iurthermôre, the plÈque conrrol programme wÀs 198r). 'Ihe.hildren Nere divicLedinto two sroùps only one ol
equaLly effectivefor nolars èrd incisors. which receivedorèl hlgiene instruclion at 2 week intervals.
This study s'âs.conti.uedfo. $'o firither yeâ6. Durina rhc Th€re was an equâl reduciion ir plague and singlviiis in the
thir.l yeàr the iûrerval berweenprophylâ.ti. sesionswas pro unreated guadrans of both groups of.hildren sùggestn,gthai
longedto.iweeks iûthe youngeràgegronpsdd to 8 ùeeksin the dre subje.riveimpressionof tooth cleanLine$, d identilled;. dre
oldestase aroùp md dùrirg the foùfth year,è11clildren were .leded ja* gu.dràns of the aroup rot rec€ivinsoral hygiene
recàlledevery8 $eeks(Lindhed /. i975. Axellrôn and Lindhe ;n$ruct;on, was suffl.ient ù motivàte the children towardsa
1977).The ex.ellenr randard of oral hyAienewas mainrained s.ârdard of honrc .are thar was egual rô thèr achleredby lhe
during the thlrd and foufh ).eaa and rherewar no signlfl.dl Aroupvhich did rc.eile o.al hygieneinrn,.tiôû.
.hânge in giûAival .ondition. Sianlficantdifferences,boweref, The forn ighdy pfevent;veprcgmnme ôfA{elssôûàûd Lindh€
we.con.e agai. obscrcd besee. ter and conùol grcuts. This (1974)which F.oduceddrc mosr impresslrercdu.tiônsnot ôtly
inûôdu.torr 2-yedptuarmme of fi)rtnighdy prcfessnrtulix{h- of airAivitis bur alsoof carles,reqùire.labont L60 mi child per
deanlûgaid oral hysiere sessiors,followedby iecall àt lntervats j " . l , r r ii 1 " f 1 - , . n n , . l o Je"o,t."''tr',.
ol o.e or two monihs .lurinA the drird and tôurth yea6, p.act; in the trial, reqljred about 1,10min/chlld per yea.a'd .ô$ oler
.ally elimimred all signsofgingn'itis in schoolchildren. 'q,'Àmrh . r e f r e , . ' \ . 1 o ' " i n ' r . r ' a o , F .\ e
A trial with a slmilar desjsn assessed prlnarily the effectof trial pàrticlpÀntsèchjeled a much better sta.dard of dental
lr€vertjve measuresin à lârge grorp (1100) of schoolchil.trer hrahh-gingiviris wasnegligibleènd Fmcticallyno cariesderel-
b€tweentheâsesof7 m.t 17 yeùs. Specièl]ytralDeddentàlnurses oped.Aftenprs by othersro match theseresultshave,however,
adninntered oràl hysiene instructions ànd professioràltooth brer ùn$c.esfnt. Althoùsh other studieshaveachievedsimilar
cleanira,èrd èppliedtopiol fluôricLeeverythird week.Over the reductionsin plaqueand gingivitû, their effecton cariesha not
I year ûial period, the frequen.y ôfFlàque i ectedsurftcesir beenufficiendy largeto mèLesuchprosrmnes cos! eifectile.
la2 | I Theprev".nrion
ondonlro0fperiodonJol
dks0se
I

Preventiveprogrammesin adults Ànodicr. simihr I leâf sud-r inclu.lcd an idvestlgarion 0n

..iies !.crcment (Axelsso. ând Lindhe l')78) An exlerrncntil
irrom i pra.tnJ stâtdpoinl. it is nnnî imporû.t ro utcvcnt rhe
grolp of lll aduLrsre.eitd or hr'g,efe in*rudro$ ni,l tho!
proarcsshn of periodontilis, which n widesPre&l i. adult\, diat
ôtrgh scdlinS rnd rôot plàning rt rhe be.qinning of the srudr
to abolish glnslvitis. Ho$'ever. as ainaivitis elther frc.cdcs or
These Dcxsurer were releâtcd as ne.essâ$ ar 2-nonth rnreiarrs
,.companies derructlie t.Liodontal diseise n.d flaqùe i\ tLe
fo. thc lirs 2 yeàs,2nd at l-ûooth ,nrcnals durnrg dr thid
.onmon ætiologic2l aEcnr, those measuresshi.h effert a reduc
yea. A rotal oÊ 1s0 mat.hed conûols re.eiv&l onl)' ùditiooil
rio! ofti.An'itis in childret are l]ertincnt al$ for..hlls. On ùe
dûnL cnre ,t rcad! inten'als and. duritig rhis Pcfurd, deûon_
odrer band, in addrs, s!bgi..qn'al as $ell ès sùp!âE1rgrvrl
rrâred pe6istc.i girrgivilis a.d ptugre$ive loss of feriodoaùl
deposns of fla.tue and câlculLr are common so that prolissionaL
afta.hnenr. The cxperlneûtal grout showed neg!iaible sigN of
tooth cleaning ùa-v in.lude âû elemett ofsubainsi'r.l itBtr!mcn
rartun to trei! ea.h dcsùu.ii'e lesions. ainan'itis âùd ro lo$ ofperio.lontal sutfoit.
This nainteidncc schedule was dis.on.inued ùfler 6 feds.
The succes ol a prcvenrive regimen Jcfcnds la.gely o. drc
Tbc.. duriûg tlre following 9 fea.s, thc .tcâ1l Progr2mme!a
exredt to ùhich i! \'ill pftserve àttachnerc lcvcls. Ir .1iklren,
(lesi8rcd tu be nee.ls.clared Thus,6: pcr cent ofthe sublectt
ara.hûeù los occus infrequendy and thc onseqnen.es of
scrc recalled once fcr -rear.l0 ter cent ts'i.e per yeù..nd ) Pû
p1ùtue i..umùlarbn mùr b€ nreanrc,l frcdominrtt l b-v 16
.enr (those $'irh a rerett hnro.y of progre$,ve atta.hment !o$)
cfii.. on the gingj!æ. P.clcrrlre regideùs in âdù16, ho$ever,
werc rc.aued I 6 timcs pef ]edr, atd rhc lo$ itr.idence ofPdi
mar be .se$ed by co.rfxrlnE .l!âùg€s it attà(hmcnt lelel vilh
olonrxl dlsede and.x.ics $rs mèinui.cd (À{elsson 'r,/. 1t9l)
ùnÙeârd .ontrol ralucs.
'lhc This shos€d rh.t try tailofing ù,pPoiliv. mcarùres to in,lividud
fùndâûentàl imto'tân.c of ôiâ1 hygleile insû.tnû nr
reqliremcnrs, li is po$lble to redn.e greàily tbc over.lL profts
prevcnring pernrdottitrs was deinon{nied iû dre 1970s when it
siorèL i.pur () a ràtdadiz.d pfeveûti'e Proghmme \,lhùt
was sbosn rhat, wLet s.aln,g à.d polishn,g n ùns,fl,orcd br
deùnne.t ro dcntal or periodo.tal he!.lth. fufthc.nnE, tl]ls tir
oral hygicne iûrnLctiôt, thef gi.gifirls d.l piogre$ivc attâ.l,
oi$ndysetrcsa5anôdellorfetiodontal.ùe: jiitlll r immtb
mert lo$ occurs, reEardlessoINhed,c. thc pft,.e.lure is r€|citcd
a.hieve otlimum pefiodottàl co.dirnrns. followe,l by a sâidÀd
annualll, 6-mondny, ôr Lnond,ll (Sùomi /r/1. t97lr)
programmc of mainteldfcc .are during s'hi.h rtbiliry r
Thc needfors.èiing s'ill clcarLy .]e'peod to a large cxtcnt on dre
' ' a d , . ' , . - 1 . ' - \ , , i ,a
rate ofcalcrlrn fôLmarn,n and tlt prese.ce ofpathologicèl tock
In x 10 yeù' lonaitùdlnal stù\', ill SrvedÀhsbrtladwoikns
ets, *hici harbour subgingi!àl detosirs .f plaqut .û.1 cnlû,lus
rc.eived tràdi!ional dentdl.are and dren. {orat addirional4ieln
\xrhen pockeîs arc lcss tban ; mm deep, tbcftfore, ginglrLtis mal
tler s'ere enrolLed instead or t trearmcnt ProgramDe Nitha
bc rùbstdtially Éduce,l bI oftl hygieùe llsrrucùo. al{xre eve.
sro.A frevrnrive en,l,hxsis, \'hnh includcd s.â1,n9 rtd odl
s'hcn abrndant sùtragingival .xl.ulus s Prescnt Po.kcs of
j hy.qic.c in{ru.tion at 3'nn,ndtly tneN,ls (Sijderholm lri9).
I nm, ôt the othet hand. iill dot resPond ro oml hygi€De
The trcventive progra.rme rednced the tirclntrtion ol looth M
instù.tn)n ûril Nbginaivxl deb.idement hâs becn terfôrne.l
facescoâtcd ln p1âqùefiom 60 per .eDt !o âfPri)xiûâtelv 2{rFI
and, once pocket d€trhs excccd j mm, de(l!are non-ntgi.Jl
.enr,,nd rhe rête ofteriodontal bone Lo$ trcm abôut 0.1 mnpd
ûe.tment becon,esmu.lr les predictàLrle.
ycxr to zero: tl,e utc oftooth los s'âs hxl'ed. at 0. I tecth Fdirdi
Tbe elti.t d a prcphyhûi. regimcn, nor ôtly on gingilaL
virùal pcL 1ear. À co$ bcncfir xnallsls shoiad that ûa|nrml
hcalrh but alsô ôù rttachmcnr lerels, was rePte,l in â l_feèr
den!âl câre required 2 h of dentist tnne and 16 mit of dÊnsl
c l a s i . r t r d r ( S u o m ir r r l 1 9 i 1 , , r . S n ô r i . / r / . 1 9 7 : J r )i n w l i . h i
alriliary rime' per y€ù., shile die Preventilc Fturrâmnc neded
test gritrp was gire! dental hcalth edtrcatior, o.âl hllrene
5.1nin of dc.tist time an.l I h i4 ûnr oi ile.til auiliafl ine
inslr!ction, a.d ptufesionâl loo!1, clcanitrg at 2 4 Inonrh ,.ter
I r''rr.Àl r" \l ' l "'1 D'\" io
"àls. Con.d subje.ts, $ho fete not rccmitd to the prcrcnrive
the dertal .h2ir dûiig the f.Ncntl'e Progrdmmc. tltn d{mi
trogram.ic. had sub$attialLy gtcarcL plaque scores, ntoLc g,n- .ùe .o$ l0 20 per cent le$, bc.atrse the greatct ProPodonot
givitis, and thci. mte of aûè.hmeor lo$. at 0.1tm/"vea., {'as
dcnral cère w2s tc|f(,fded b! a dcrtal .urihùry: Iùrthùtut,
more dran lr! timcs g.exter thàn thei. cafcrlnentdl .o u i !e' l,ars
!-!rtb.i,nore, during the I reâr ùiâl pefiod, the exF.imentâl
gLoup drored almo* no radn)grlphic evnlef.c oi bone loss i. the i5betterthon(ure
Prevenlion
iegiôr stldie,l drc lower right posterio. scEment shereas thc ! Corùolled .lini.aL ûaLs hrE sb.wn rk( gi.givltis is.hildien ùnbr
.onfols exhibircd 0.19mn ôfûârsÛùl bonc desÛuction.'fwo r.auced br oiù hysi.ne ln*tu.tn,n ard Profesionâl t(ffb demins
a.d 2 hâlfyears niier the cxfcrlnrent h.d been .liscontinue.l rD.l . l. à.Iùks. ,ndLndùally{ailofed, nee.ler.Lùr.ll rrrevenrivr.rre tr
drc pfevertive regnre. disbanded, the iotme. cxPe.lmetul .onsnrent *nl loog rerm pÉnldottii rability
8flNp ()ntnn,ed to (l€mo.stfxtc .leâner teelh a.,l bcter peri . Tie ûtc oJ:.trâ.hmenr Lôssis rcnlced sisnii.rnttl N|o subjtrs
odo.tal hexlth than the formcr .onûo1gioùp. Ncvcrhele$, ùe are enroLlcJl.to l)r.gâdm.s ol itsûlâ. oraL|Igi.nc ln*roûion dxr
dlffcrcncc between groups sirh .cspect to oral hygic.c and llni lroflsio.âl morh{leanûr
giviti\ had diminnhel.
 I
I lar
R€hrentos
I

dût.gdre,ireds ofprelen.hn. rhe pafticipa.rs enJoreo â mu.n Pu-lda ,J \e,:t.S.P Rânfjor.t, D.A. Ker.. M.Nr. A\h).
ber( sddâd ofpe.iodolrat healrh and ar lmt.oved pcûodon_ pp. 4.1.1-1i1. ll.ilersirl ofÀIj.hiEar pres, An. Arbôr.
talliilsnosls (Bjôrn 1982)
Crafr,À{.Èl (1981). Dertal healrhedtrcârioûand fe.iodontal
dls.de: herldr |oli.i€r, diseaseùcr.ts, turger.qrotrpsand
Conclusions *raq3ies. ID: Pxl)li Htulrt A$,.tJ q pû'a.k"tdt Dîea! (ed.
sùsùptibility tu terbdonùt À l : , . I, P
, ' t.. ,,.O. .., .r,,,a..
bfcàL dos,n laries.oisiderabh
b"lbp- 'os't,, , , . , d . , ., , d - , q , , . L Crares,lt.c , Dilrey,J.A.. and sihnr, I w (r9s9) Coûparâ
must lt asessed professionatlv bctore selcctiû! a srirablc tire cftèctivencss ol ilossinAand brùst,ingjn t,lù.ûg inrcF
F!fluive srare8]'. Perhdontà.l hcat!h edu.ârior musr be .c1n proxiûralblecdug J. Pd, ù,tat., 60, 21a-24,-.
to(ed pc.iodi.ally wnir rhe esrabhshncn! of thorougb daitl, Ham|, S. E., rin(lhe,J., tonell, J..JohaNo.. L.Â., a Krls
irtûde.ral .leaning as a prin.ipal aoal tôr ttr! str\.efrDre son,r. (1918).nfer of a fie1dprosl1jfue haed on sisrerr
tùtienr.lxistinE lreriôdonrat dircâs€ shoùU be Ûexlco rld tcrl xùc pla.tùe.ontml on cariesand Ainsrritn in rhoot.hildre!
ononmlheelrhrc estâbl,stredbeibre ebbarking on a proAran,ne xtiet a fe ts.Ch"tnr. Deit. a|à/ r:!t/ùn,)t..6, t,- 23
oi sûptortivr pcrodo.tâl care. Ar this sràge. tt,e inrc.vat Hùsoson,A , No&lervd,O., Slotte,C. and Tnorsreùssen. H.
bc$een rc.ill visi6 hùsr àLsô bc .terermlned by in.tili.lùal
(19r8). l)isùit,ùtiof of pefio.lonrxtdiseùsein a Sqedjsh
neds 2nd su{cttiblllties. prcrerrjve srraresies. ûeâ.mcf1
of adùltpopùlanon197i. 198j and t99l.J Ctjn.pd.n)da,io!.,
!(iodorril disc2se. x.d strpporrjle.arc re-qimcs ûay all be 25.t12 118.
slpremmted in .ertain c;cnmscarce\ b), chemlcal mettrods oI
pl,,tuccorûol th.ùsh chenjcal ântidaqtre aseDs srrould rol JenJ.irs,\f.NI.Àr., Pâpafanou,pN. (2001). Eprdemidosy of
be(gùded as! c.nrcoierÙcfla.emr. reriodo.t2l disea\cir childrn lDd àdolcscents. psr:,/,,r,/-
! Ior thc more ùadirioral.
û{hùni.al n,eansof eliminariûg derr2l a t N2 0 0 0 , 2 6 , 1 6 a 2 .
Ftaqùc.
K i A e r ,R . D . .N y l u n d .K . , ù r d F c t t e rR
, . p ( r 9 9 1 ) .A c o m p è r i -
sor oi p.oarnal tlaqle rem.lal usinAflo$ âDdinre enûl
References btnst\e\.J.Clrt. Pe/iada,tù... 18. 681 6lt4
Âgûback. N, Pouken,S..Nletser,8., and Gtayjn.t,| (r9ts). I-nrdhc..1.,Ko.tr, c., aDd Àl,iûsô!, J (1966). The e*e.r of
l||e.r ofprôfess]onalùxrh .leansi.g everyltrûd s,eetion supervised ôral hygieneon rhe gnrsna ofchitdfc.._/. p!/t-
gifgivitisind denàl.arles i\ ch|dtet. ConnM Dlnt )tu/. alûna/. Ra., l,26:1 271
Epù"i1..6,4a4r Lio.lhe,J., A\el\son, P, and Tollstos. c. (19tj). B1te.t of
nxelsv,d, P, aûd Liûdhe,J (r97,.i).:rheeffccrof r p.erenrivc pr.,pcrorè1hr,Sicne o!linairns ânddertèt.xricsiû Swrdish
frogmmme on denûl plaluc. girlilitis, and ciries ln s.hoolchildien. Cor7rr,. D ûî AùL Elri.Janjot. , j, t iO L5t .
. l l . l , i r ' ' . /t . pttJ..at t.\.
,t, l-ôe,H., Theilade.E., aûd Jcnsen,S.B.(l961). ExfeimÉ.àl
Axels!,.,P, and Lirdhe,J (r9it).'fhe effcclofnplâqùe.or , . - tP . \ , . . 0 1 , 4 t ,
--
tA
.rol proAranmcon glnajritis a.,t denral c2ries,. rhoor } lccàul, L K , .leûkl.s. Wùf.M., à^d Kar. E.l. (2001). TIie
ùikhea.J. Dùn R'1, t6, t12 itll. re.sônsfor er.iction ollrerùanerr reerl in S.oltrnd: a It
A x e l s o nP
, , r n d L l n d h e .J ( r 9 8 1 ) l f f e . r o f o r a | L l s , e n c l e a f f t n l o \ !u p r u . l t . 6 r D . n . J . , l 9 O . 6 t B 6 6 2 .
insru.t'otr ând Frôfesslonalurh .leaning
O'Brie!, NI. (1991). Chil.tr€n' (lenral hcatîh in rhc Urited
grrgnrrisin s(hooichildren.Annli. Dtù AtuL Eikttfu,t..
K, do.l L o , d . ,t t F \ , i . r O , ,
9,2! 2i 5.
P o u 1 s eS . ,. ,A g e r b a e kN, . , M e l s e n , 8 . .K o . r s ,D . C . c i â v t n d ,
A x e l s $ .P. , L l n d h eJ, . , a n dr { r s ù ô ù , B . ( 1 9 9 r ) O n t h e p r c L., anl ltolla, c. (1976). The effc.r oa profcssioûèltoorh
\ e n r l o no f . ù i e s . n d l : e r j o d o n r ù. U
i s e d €R
. e ls ofa It .leansirg on gingiviris xn(l dertul cafiesin.hjt.lreù afrc. I
yea.lorgirùditul rudl, h a.l\ks. J. C/,t. pLrioda,tLt..1a, yeat.Ctunnti. Dd|t ard/. E!,1ù")/.,4,r91 1t..
1ll2 189
Sôderhn.,, G. (i979). ltre.r ôf. .tenratcareproarrn,meor
Bjôû, A.-1. (i982). E.ônomyùpe.6 of prelcnl se .tenri $ry. dentJlhealthcondlrio.s.A rudt ofemptoyees ofaSs.edjsh
In: t)ùtal Ll.lîh (.at in .t.às.Ji,a,id (eà. A Frrn,trcn). stri|),ard.'t-ncsis, Unlvcrity ôf Lund, Swedcn.
pp. 2l7 224. Quintc$er.e, Chi.àgo.
Suonri,J.D, crccre, J.c.. Verniltnn, J.it., Do),Ie,.1.,ctra.s,
clerhush, V. I-em.n, Il Â., âfd Nrorhiluù.. Fi V (1t90).
l J . , a r d L c a r h e r \ n o d[,. c . ( ] 9 7 1 à ) . , e € f f e . t o f c o n
iltai resul$ ofr lonAjtudiral rud], ofeùtt perjôdo.tirÀ ùolied oral hygienel,ro.e.lurs on the pfogresn,n ofperi
'. L4 r.r 19 leaFoll adol$cents.J. Cliu. pùatù"rt.. 17, odontâ.ldisc2se h adulls:resùltsdlterdrlfd mdfilxt ).ear.J.
702 708.
Ptialonr/.,12,ltz 160
LommrteeRepôrt(1966).O.at llea.lrhCareli,f rhepreranriod Srcn,i, J.D., west, T.D., Chxns. .jJ , ârd McclenJ.., B
a.d Cônù.I of PedodontutDnease.In: Wûtd \Vùrâta! ,l J.
(1971b) Ihc efe.r ol cof Ùolledor2 hyglcne
F.o.edu.csoù
I
I I lheprêveniion periodorr0ldisèose
ond.onlrol0l
I
rhc |rogresion oI Ferio.tontèl diseàsein adnhsr râdi
osmlrhicfitrdinss.J.?*,litol.,42, t62 t64
S r c n i , J . D . . S m i d r , l - . \ \ / ' , C h a n g ,J . J , r n d B â r b à û oJ, . P
(l97la). Stùdy of the effe.t ôf differenr propbyluls
t.cqucncieson the periodortium of young â.tu1tdales.
-J.PdùJ,"tt,l., 4/i. 4t)6410
S u o m i , j . D , I - e À h e r w o o . Ll ,c , c l b n s , J . J . ( 1 9 7 3 b ) .A
iôllow uf stùdy of former pàrii.ipdrs ir a.oûÙolied ora.l
hrsienest1 ],:J Ltjtulafltal.,14,662 66t4.
'toàtl,
J.E. tt9i t). alJil.lvt': lnrrl Àulrh n ù rtnirtd Kinzdrn
1971.Lordoû: The Starbnrry-Ofii.e.
Todd,J.8., and Lader D tr99l). Al,h Dûnal Hù/$
t1.J^at .L'r{.th-... {,r ol.
Todd.J.E..and no(ld, D. ( 19ai). .:hil.lftlr'rDuttrl Huhh j" Ibl
tl,jral Kntlllon t983.LotLlo.: The StâtioneryOllce.
\Xralker,4.,Cooler,l. (200A).Ott/Hulth n] th ri r;tLdKndùl
/998, Lotrdoo:The St.ùioreryofai.e.
A 0 0 l | o n aI r e a o r ng
Fairb.orhc.,K.J.. and Hcasman.PA. (2000) Ànti-.aln us
tsents.J. C/,?. Pd;odant,t.,27. 285 301.
Jcnkins,VaÀ{ M.,2nd PapaFnoù,PN. (2001).Epidenlologi
ofperioclonraldisease in .hild.eû dnd âdotescerts. Prrld,
t t l a g !2 0 0 0 , 2 6 , 1 6 3 2 .
Kinanc. D.li., and Chcsr.ùrr, LG. (2000). SmokinAand teri'
o . l o n l a l d i s e A ae /. t t R ' t ) f t L B i r l . t \ t d . , 1 1 . 3 5 6 1 6 t .
i.lensûràn,PÀ., ard Sernour, R.A. (199.i). Phâ.màcolosicâl
côrtrol of Ferio.tontaldsease.J.Der.,22,a2a 3)t.
1988. tLedsman,PÀ. (1998). Poçere.l loorbbrushcs.B'ir D.,rJ
l8.i , t68 169.
Sosl.olne, V/.4. (199u).E1)i,lcmi.loai.2lând.lini.al aspe6 ol
pefbdonta.ldise.sesin diaberts Atx. Poir./aûot.3, a 12.
 of dentaltrauma
Prevention
Richard
Welbury

ard iojulies as â direcr resulr of violelce (TableI.r). The majn

lntroduction
Dhûatic improvementshave been mâde over the lâst 2t-10
yeùsin ou. understandi'aofrvonn.l heallûaaod dre te.hniques dreû under 3 yeùs o|:age,whô are ùsuallyboth unsteadyon their
Àvailable ro Ûeàt tmùmatizedteerh.Dr JensAndreaseÀ summâ- legs ènd lackioa in a proper senseof.auriot, fùlLsâre rhe most
rizedsomeofrhese deveLopments in the followins vay.
T l . â . l . ! n r e ( l - iq ! ' " 1 d ô r p o , _ e F \ . r r . o E i r '
dedanded rethinkirs oo dre part of the professioûand this
h d ' ô ' h e , o n " p . o F\ e t ! o i ' e 1 d , : \ ep r e . ' . 'i v eF { o . -
dons, tumel preparalionsa.d ihe like to preservetoodr
stroctùre.Recentmd on aoitu rcsedchinto dentin bond-
ing agenn and pulpal responsesro a bacteriâtigh! seal
ùnder dentèl resto.ationsonce again force us to reihiûk
.treatment strategy in ôrder to savelooth stn.dte and
nairtàin pulp ritâlity. Recentadvânces in the nnde6tèûd
ins of vound heâlirg relatetlto dcntal thùm, tooth and
bonetransplantâtiondd implmration baveoFned uP new
treatm€ntave.ueswhich fôr the firs tjne nake it po$ibie
to fully !€sore eventhe nô$ severelymunratized denti-
tion. (Andreaser1994)
Developmeûtshave also ôccùrre.l in our approa.h to th€ reached.
pr*ention of dentaltraunà. This chaptef.onsidesthe ePidemi' (Tâble9.2).Aniatroge.ic caue ôf traùma,pariculady in youtAer
ôlôgyôf dertà1muoa ând s'âysin which it can be prevetted.
PniÀpninl nmi
Tiâuna to childreû! leedroccus quite frequendl.Previos sud-
iesintheUK (Toddand Dodd r 98t) sussestedthat the incldence
ôl thunÈ to teeth was io$easing.but nore receû!studieshàve
indi.atedà fÀll(O'Brjen 199'1).It is suggestedrhat th;s may be
dueto a nôre sedentaryLifèstylefor.hildret with ]e$ âciivepd-
ticipàtionin organizedsPor ând more recreationalreliability ot
computerAames. However,it is eviderr Èom the wôr1dlit€ruture Table 9.1 The .ausesofdental ûaumà in cbildreû
thar dental Ûâum. is a alobal entity. At the ase of t years lBritilh Deùdl Jutmdl 1989)
some3 r-,i0 per cent of boysa.d 16-10 per cett ofsjrls will have
sùffereddental Ùaûâ. By the ase of I2 yearsthe coûespondlûs
fisures are 12-33 per .ent of boys ard 'i-19 Per cent ol
sirls.TÈunaric injûies de twice d common in bôys in both the
pûmmert ard the priûry denûtions.The major.aùsesof these
lnjùriesvary considerably and inclù.teaccidenlsiÂaûddoûd the
hom€,falls during norhat pldy, injù.ies sutained duriûg sPon,
'peakpe.iods for dentd hiur)' aredes.ribedd beios betweetrthe
asesof r and l, and asaiobetveenthe àaesof7 â.,1 I0 Fôr.hiI
comnon caNe of injùry. ln scbool-agechildren,biq'cle, skâte
boùd, miffo-scoôters, md roadaccidentsârethe mostsignificàût
fa.tors, while in adôlesceDce there is another, alrhoush les
mârked, peak lùsely dùe to sports itjuries. Môst of.hese sPorts
injùries resxl! rrom pnrticipatioû jn conra.t sPorts such d
Ameri.àn footbaLl.rugby, soccer,boxina, wrestling, divina or
srick spôrts.However,othei sportslike sklinS, skèting,cycli.8.
dd ho6e riding. whi.h do not necesùily invôlve Playet conrad,
mèy aLsoplacethe pàrticipùr ât risk.
Th€ FédérâtionDerÈire Internarional (IDI) have recetlly
cla$ified ôrgànizedspori into two categories: (L) high risk sPors
lhar inclùde Àmericar foorbâ11,hockey, ice-hockey,lacro$e.
mùtiaL spo.ts.rusby, foolball,and skÀtin8;and (2) nedim rsk
.pon. rh, :r' ,c'o-kecL' L di\ing. '.lJÀh.8yrlr{: pd
chxtins. ând waterpoto (!DI r 990). In childhood a sma.llperceni
èseofinjuriesc?nbe àttributedto violence,bùt ooceadùlthoodis
violen e is tcommonercauseofdentaltnuma dransports
patiens where ùe anterior teeth are or y Partiàlly erBPted dd
root lenadr is not .ômplete, is 2wlsiôn rePortedlycausedby *ces
sile !.e$ure frôû è lùynAoscopedùring intubation.nâF+he$À
Broadly sp@king.àppr@ches.o uÂinrentioûai injury prevenùon
.d be divided irto edu@tion (prov;sion of informtion and Ûain-
ing), ervircmeotâl chdge {modincaiion of Producrs/€wi.onment,
ôr use of ddjrional safety devices). aûd enforcenent (usuâlly
rh.ough regulâtioû o. IeAislation).
in rhe UK
4)
It
t4
 7

I
1 4 3I t Preverlioi
ofdeitdlrdumo
I

'fable
9.2 The.atrsesofdenhl ûxumâ i. âlùlrs i. dre UK aboùtfùû and be ùssafed prx.ti..lly po$iblei how€ler.no ûèt
(Bt I { t D !/}tuI J rxn dI r9E9) ter hos sèfeûe equipmert or the plèr'grôunds làr'our,drereis
alvays ù rsk thar chil.treû ùill Ùip oi stunln€, nû lrto e..h
other ôr à pieceof equipmert, miss dÉir fôôrirg or Loôsedren
giip, or more seriousll,. frll frôm a heighr Ifx.lild falls iiôn aù
irem oftlar eqùlpJnent,dten he or sheht s sùbj€cfto the tor.es
of smrltr: This a..eleratnn droùAhour r 2.t m fâll s'iil resultiû
16 d fâll speedof 7 m^ or Li.7 nlrh at .he point of grcu .onta.t
The purposeof safersurfa.ing in a phr' ârer is o absorbthe
inrpa.t of sù.h a fall and to pfcvcnt a (hild suffcr;.a 2 hc.d
As the ærntogl oi dc.tal i.iurles is nùlrifè.roriât it is diffi- impacl,which couldbc lilc rhLcarc.inA'lhe abiliry ofâ sufâcero
, ' ' ir ' . f' ", -'l r "l rbsorban impact is measuredb-vits Critical Frll tsleight(Cl'H).
f-\e,',.. ,F.,
Âlthotrgh rhere is.or much dra! catr be.tore dbont â\phâlred B d t i s hS t 2 n d a .idl 8 8 ( 1 9 9 1 )a i \ r s d e r â i l st à . C F H l e s r i . gc r i t e
.iaâs wellas iestslôr a sull:c€sreslslar.eùod easeol ignnion. BS
Frimarr s.hool plalarounds, wooder gydnasiâ floors, or *eel
.1 l. 'a l.b"r.. ',1," 'r.'h. e rprl I 718i1ùscsdrc Scvc.'tylndca (SI) às, me2nsof.âlcularing CFH,
prc{.hool llir a.eÀ ard Fnbii. parks is oosrft.tcd ro estâb but x new Eutupeanrandard tor pl.Iground rùd..rn!i rs .ur-
lished sâfeit' Aùidclincs In d(ldition, it h$ been shown thar lndl- .e.tly being d rafte(I,which wi ll ùsel leadIûl! r) Criterià(HIC) À
viduals who take pâ,t in conra.t sports, ard those who hnve.n i 6 m e 2 . s o l c d l c ù l a t i . AC F l l . T h e ! e r , w h i c h d e t e r m i n eas
inùeased orc.jc! and nrddeqùate lip .ovrftaÈ hâve an i.c.cascd hlnans toleranceto an lnpact Sr, is basedon reseùc]into road
prcvâlcnce ol dental fàuna ând injllrles 2lso tcnd ro be nore velicle .tesign an.t the NÂSA mdûed spâ.e prôgr.ûme TIIa
scvcre.Iolerestnrgl! . re.eni rùdl stnrs'cdan increaed in.idûrce e$imàtedtlLesderiry ofablô\r ù, rhe headby mathenaticalinre-
of t.âuma in obese children .ompùcd to no.mal counlertârrs. gfutiôt ôfthe âream.Lera pl.tr ofLle.eleratbnveNN tlne fo. tlt
This was sàid to be due nr lesssell dcveloped prore.tive relleies eûrlre dûatbn of ùe impa.t eve.t (Watne Stâte ltnile$nl
while fallnrg. ft has al\o been slAae*cd rhât sponsso.,en may be CùFe). lhls .ùNe pndu.es a rheory ol slnn dùmtbn, high
'fhe
morc ssc,"!!ible thù meû tô injurr as lr has nor bccn tL2diiionâl a.celeràrior'rolerd.e. de.elefutiônnflered by a drild s heâd
iôr drem tu *eâr any form ofmoùth Frore.rior in spofts. âs it is broùghr ro â stot, ànd dre Frio{l ofrime overùhid, dr
As vitL ôther areasofmcdical diseâselirelention, ihe prelen, de.clcratio. â.ts mùst bc ..nsidcrcd. lo. bLaindamâAcnor ro
io, o,1" r 'i ,i ,.r h, o..ùf. ir ls summatcdrh2r drc.hildi hcadslnùld nor bc subjcd
Pridary p(\'cntion ls theprevention of.ir.nh$ân.es thxrlcad û) to â trolongd decel€.d.io,, ol morelhar t0g.
injuqr Se.ondarv rreveûiron is rhe prevenrn)n of ftdu.rnlr of lnpùcr ibsorbms sùrlacesare testedby .Lroppinsa headlom
itrju{' sr'rcrity i. inc erts \rhich do happen. leftiaq' p6'cnrion representation oIa chlld\ hea.tfrom ù seriesofheishs or to the
is the optima! lreatmenr aDd rehabilitxtiôn ofihe i.Jùrcd pc.son snrtâce.A.c!rnre ele.trom. de.eleràlionmeiNre,nen$ are raler
b minimize the imp..t of rhe injurr: dùrirs rhe period of iûpè.r n order to ôbtâin the SIs fôr these
falls, which àre rhen tiotted. A s,rli.€t C|lI represe^tsrhe
Troumo
to theprimory
denlifion g r c â t c rh c i s h t0 1 2h c a di N t l à l l Ê o mw h i . h a . h i l d . l à n d i . go n
a surfâ.e,.oul.t be erpe.ted ro xvoid surairilg a.rni.d lrad
. ...ùr..mmo.ly berwccn dre t.gesof 1 æd l injury. The heisht of the .u^e rt \hi.h the sI or HIC is 1000
t n..Ifuody.ânsed br' fills (luri.! nofural FliJ, represents the sùrfacetCriH.In ad.kior to ûe ùe.sùreneût ola
! tr t$r.ê is.omnDn in boys rhdglns ndâ.e CfH, BS 7188 dy, desciibestie mrxsûÉmenr oi ntu

| , t . . | , r , \ o r , , .
Primaryprevention 2. die sliI, Ésisaoceof the n,ù.erial:

Playgroi:ndsu-fàces ,l .i ... ,j.,,.,,,1\1.'ntJ .. )

Thc mo$ commoÀ.auseofroodr lûjurr-in.hildrcn is fâlli.g on 2
had rù|lacc.The British Std.târ.i fôi ne" pla), eqù4nnentn,f
pe.mxncntinstàllationoùt.toors,Bs 5696 (1t90). sÛo.sll re.-
omn,eûdsîhat aDy orgdizrtr,n responsiblcfur rhc furchaseof
play eq!ipmeût shôù1dedsui?dnra. i.rllacr âbsoôing sùrl'ace is
prov e.l ârôun.trhe itens f()m shi.h childrenâremos likel) to
fall. Sîudlesof Jccideftst. .hlldrcn i. pl2iAroùndshare show!
that the najôri.y of rhe more scriouscaseswere heid ûiùries
càuse(ldnough sriking hxrd s$ùnd. Pl2l€roundsshouldbe al
liom su$ainedlânding;and
.1. drc rcyonse ol the m,teriàl ro one tàrti.ùhf sourceot
TLe resllienior.ômpllânt elxromeri...mposlrbn of impa.F
ab*rblng rulàces is erpensive.À .heapcralre..âtilc is ùee bxrk
.hipplnss, bùr the\ehavethc disadlantagcot ncrdinSdailt .aking
o remorc.n,r erampLe. bLîkenglas xnd doa fae.es.In add;rbn r)
.o.sidcrario. of rhctla-raroù.dsuLfâcc.
all f lal'grou.l cquiirmo,r
sln d nrecr Bfirlsh StandafdSatctyCfircria (liE. t.l). Slidcs
 himrvp,evenrion
I
I

Table 9.3 Th€ percenrâscof.hlldren it the UK with

(.idental damaaeto pe.mâocrt inci(rs by sizeofoverteîa.,l
dse (Toddand Dodd l98t)

Àc" Chil.lren rvith Childr.r wjlh ChildÉn ùnh

(yeâs) overjel <t nn ore.jct >t mm ol€ijer rtun
lr
10 tt 11 ll
tzv zz
t+t> zz

Iisùre 9.1 Childrcni,plâyAroùnds

sboùldbc speclxllt'desisned
a€6 dnt cônformro acccptcd safctrsmd.rds.

sholLdûot be free stàn.liis, bùt shoùtd be built i.to ea,th

mourds.Clinbiog fruûes shoùld be no higher than 2.t m high
andbuil! over an acc€plablesurfac€(fis. 9.2). SuFNision of
snâll.hildrer àt play (pârenralor profesiôn.l) is veryimponant,
' '\FkiJofp,e\'
" ' d p o b , b l \1- n o " ",è!,o,\,' 4.

Inploygroundr
rhildren
rhould
' hrve eôui;ùeût dhr.onforns to Britis! S$ndûls
Bri'ishsu'dùds
: ::'":";.:,* tsisurc9.2 Impa.t abso.bingsùrû.6 nr phys.oùndsÀ essen.iâl
;:1,*'

Eâdy{mixedd€nlitiolr.}
treatnenl oi'
largeoverjels
In rhc llK. tirc ;.cidcncc of accidcntaldamagc m permanent
ircisorssjsDjticandyiocr€ases with ov€rj€s sreare. rhan 9mm
(Table9l, Fig.9.l). Èvenrhoughd,ep.ofoition ofchildrcnvirh
ar overjerof7 mm or more.neverex.ceds9 per.ert (lable 9 4),
this is still d sigrificàrt rumber of chitdren nt hish .sk from
! ! k r . I n , 4 . ' l o s " \ p r , l e - 1 . _ ' o ' \ i b " r s Ê q o .e ' . . / ,
À lhe coDcomitantrsk oftraùma r€nai$ ucl€,r. A recentsys
" d ,e.ri l, ,\o,r'\r' " .r', \\-r n r p o \ p .\ !
nificânÛiskfor.tenralÛâtrma,dd drereis sopportfôr in.luding
$(h a dedtrreûert in ân oithôdonricùeÈtmert in lex (Nyugen
?'/ 1999).Hôwever the rolesof sôme.oûfonn.ters(lip postùre,
spôrspdtl.ipxrn)n, tenden.yfo. a.cidenrt renains iô be e1trci
'Ihe
dded. saûeauthoB côûcludedtlut overjetmây àûu.]ly pLay Fisurc 9.3 Overjet ln.redes the tisr ol rrnùm^.
150 9 PrevenJion
ol denlûllrûlmo
'rable
9..i The percentàge ôfchildrer bl alteùirh an ovefjerof
7ùn or more in the UK ir r98l (Toddand Dodd 1t8t)
L oi r
L4 Li
les of â rô1eas a risk fen,r ln bor\, pobably bccâuscrhc nât!ùc
of then Ècrivùies oveûldes anr eifcci oforc.jcrl
It should be the aim ofan_v.adrA socicry totrevenr disiAure
ùefr frorn toss ofor danage tu a permanent in.ls)r and fof rhis
ftas)n a.lonccârly ùcâtme,n olhrse olerjets is justined.
Orhôdônti. rearmenr nr rhc cadv mixcd denririon is cla$i
.ally .àried ôtrr in un.hs ded afchcs uirg fun.rional affliâfces
or exûa onl ûac|ion. Bodr trealnents s'ork best dùring actile
arowth and ma_vb2ve a fdvolrable infllence on gioùth iû sôme
cascs.An e2rh sta( to trearmeût does not èlwàys meân âû earl)'
tinish. a.d ùe2lmens can be prolonged. Ho$ever, ifre.tnertjs
done in c.owded arches ther it is iûevirably l.,ngÉr ând involves
1n Primary.anine exûa.rn,n xnd ovcricr rcdu.tion.
' \,1É ol 01 ''g ' |"r.rn.
tôllowcd br ârch.edlignmenr \rlth fixe.t orthodôftic
Therefore, while it mav be feasible tu .oûe.t ln.i{tr orâl ftla-
liorshlF in the early mixed deûrition, â nùmberot prcbLemsmat
arise, and treatment shôn1d ûot be atempred ùnle\r rhere afe
sÛorg indlcâtioûs fôr doing sô, xnd .eralnly
p.ecise orthodontic diègnôsis êr.l Ûeûdenr plan (Rl.hardy)n
1trJ9).
overiets
. D d p. ,-4,,,t . backwârd displaceneot ollhe mandib!lar cofdyles agains
. .n I l', .; n 'h... 'l m' .d d.n. ' n rhe base oI the skull. Ufder $perin€.tal condiriors dÉr
. leJùcrio. ln ùnc,!ç{led archcsn with li,nrtioral applid.es dr eitn'
. ftdu.tiôn nr.rowded ù.hes itrvolves*ûÀ.ti.ns ln bodr dentiti.rs
P r n \ i \ i o nû l n r o l r t l rp r u t e ( t i a ri,r r \ p o f t ,
Dental irlùries âsô.iared Nirh sportr in Bfitish .lril.lrcn mdc.
Lt yeas oftge âc.otrût for ônlv rl pef cenr.fall injùrics. Thc
in.iderce in S$eden in d1e sme age Ahùp k 25 pcf .cnr duc t.
thepopllariry oficehôckey.In the maj{,fit,v of.ase' it s rhc fronr
teeth of the ùpper ja$ that arc affc.rcd. ând u$aUy n,orc rhân
ore toodi is ddèged. k is rare ihar a denral injury heâh
spon.aneonslr Fithoui .earmcnr and su.h injurics i. childt!
shoul(l be cofsrlered as serious, si.ce injlrics ro dic rccrh ùd
iaws rhat are not tulh dcvelof.d .an lcâ,] ro dici. bcins.dveft\
aliècted 1or life.:fhe ùse of noùth protecto4 has been m s
mandarory by rhe .onrroLling bodies ofsome spors i. diffiftû
.oùrrics.I. lr)62, iti.xs madc.ompùluy tàf Arnefi.an t!ûbdi
ptâyers, high s.hools, dd juùior.olleges, to weJr moùrh.q!ùft]s,
.n.l iû l97l mrÀd.rory for ùDilesry teams by the NùliomL
Collesirte Athlerics Àsso.iation (NCÀÀ). lû a.lditror n 1990
rhe NcÀA made ir dandâtorl fôr âll phlets to *eâr yÊllo!
moùrhgùaids r) .hat they ùere ea\il) visible b all plâyers,ofii
i l . . ," ,,. r.t ^ t a . | \ . J . . ,, , d . - . ,
.ent ofxll Âmefi.xn Lotballwound\ lnvolred idjùrles to thedo
tal or ta.iâl tissucr. Sadics ir odrcr sÈr$ halc dnrs. x dùmdi.
Fdtr.tn,n in ùe nùmber {,f dentxl lnjùies when a motrrhguùd
was Noni ard thej.àdlocâtion by dre dentâlFrofe$,or for ùlltEr
sons, csfc.ially .hildren and adoles.cnt\ involved ln onrMr
s]x,fts. is tustilled (lig. r./L).
In,])2.r to rbc m2rilla ând1o. m2ndiblc dufing sfoft is ùsùilli
Lry a direcl blow Èoo a Ês!, eLbos',or kfee. The if,urv
sùstànedhwe led to rhe .levelopmertof nouthslaft, tloriÈ
rive helrnets,and lacesuùds.Th€ (ltlèrer! fu.clions of m
1. lhey hol.l rhe $ft tissuesoftlLe lips and .hÉeks â\'â1,fron
tlie teedr, preve.rin.q lacerat,on or bruisin.q ofthe lifs and
chccks iAâinst rhc ha.d ard ir.Aùlaf tccth dùrlng lmper
2. IbeI .ùshnrn the teeth from dlrÉ.t fr.nta.l bl.,ws ând Édr
triburc drc forccs thar vould odrcNisc causc fL:crureot
dislocation oran!e.ior teerh.
l. Therprelenr offosina rccù iom.oming inr. vioknron-
tac., redùci.g the .isl. of rootb f.âfturc, o. da.,aEe rc
$'FportifS $^'ctùres.
1. They prcride the man.Lible snh resilient suppoit, shnh
aLrsorLxiùpàc$ thâr mi.qht ftàctùre tl,e unsumoiied xnSle
o . c o n d y l co f r h c . r â n d i b l c .
t. Thcr trcb prcvc.t neu&l(,si.al i.jùry br holdins rne jâ\s
apart, and act æ shock absorbeB ro frcvcnr utvard ànd
mal reduce intrac'aûlal press!re ard Lrone<lefoilnationdue
6 Ther f.ovide rrore.rio,r as2insr ncck injurics. ft hasbd
demonrrated on .ephâloameùi. tudnuraphs dut relosi
rioning of rhe nandibulàr cordyle, .ernal verrebne, xnd
other .eNi.àl àratomi. snrctùres takes i,lace wheo r
ûourhgndcl is iû plà.e.
'lhey
7. are pry.hologn xssersr.,..nta.r spofr ârL etes
8. Ther fill rLe spâ.e d.l suppoft adjà.ert teeth, so rhÀl
reûôvedble prôstheses .d be tàken ôtrr .luring .ontr.i
'Ihls
spofts. prerenrs possible fra.nte of the pf.sh*s dd
a..i.leûtâl ssê11ôwinsor iûhèling ôf rhe fiègner$.
 I t5l
Primwvr,wmrio,
I

Criteria. for rnaatbgtra'.1 co"sIr ction propefties olrhe materials r.r,v {'ith then .hemi.àl .otrpos. on.
The fDI hJs liste.l the following .riteriâ fo. coûrftt.tifs d. eft.c lhe properties .an be dift...nt s'ith ditre.ert biânds oi lhe sa.lc
t,!e moudrgùar.l lIDl 1990): mardiJl, ùrd diis n,ù! be,luc &, a Mriatnn, it the degreeol.o$
. The nourhsûrd linkidg beûveer polyFer chains, drc ptupoitiotr of pltsicizet
shoul.l be nùde of r resilieft n,arenaL
presenr, âùd rlie vol!'ne ofrhc iillcr paûl.le.
vhich can be easill,\1nshetl.cleù.ed, i..l readih,lisinfc.r.d.
. It shouid hale rdeqmte ietention to remain in pôsiti.n
durnig spôftnrg ûi!itr', .rd rllow 1or a norn,ùl occlùsal
reltrtionshipto gi!e mat,mùm frotection.
. ]t shodd àbsorb rûd dispense the erersl oi a shock b!:
o\' r. 'l - a \ , r Jd F 1 ' , . -\' rrr '1 r ". i '
ÉpftiLu.n,g the o..l$xl ftlâtntLship: âtlow nonû breàdr
nig:pnne.rilg ttÈ !,fr tissues.
TIÈ fDI âl$ re.ommerds drt nnfthgurds shoùld. prefer
ùll! be ûi'de by dentiss fro,n àù iùFresion ofthe.d, ete\ teeù.

Maatbgaatd design
Thcâ.cel,rrdlesign is bas.do. drât sugacstc,lbITùficr (1til).
r . , o , , l € . l " o n ). r ' ' , o . ' I r ' ' l l i '
Cldslll ùalocclusion.lt shoul.lbe.lose 1ntûg and slioul(l.over
the0..16â1surfr.esof the teerh, er.epr whereit is èntlclpared
tlùr die eJoliarnri ôf prlhary Èeth ôi fnither en,ption ofrefth Fieurc 9.,1 l{outhguâds ùe esse.tirl nr .ôtti.t spoftl
villô..û It sLôn1detftld xt leâstasfarbackdsthedstal surfa.e
'lhe
of rhe fi$t trefmanentmolar. nanles of rhe moutLrgnard
shouLd extendbeyondrl\e girgi!â.I âûâ.Lrûent,bur short oI d,e
mucobù.crl fol.l. Tbe nà.ge shollJ be no g.e,rc. rl,an zmm
thi.k olcr rhc labial mù.osan) avoid {d.hins the ll$. \rhl.h
'lhe
nnLldleadn, rhcnr splittins on impî.i. btr..al tAge of the
ilxng. slrould bc s.x,orh a.d rcu.dcd, and caLetrlLyrelieved
arùml lhe liena and mùscleatrachn,e.rs(FiS f.i) Tbc 1)alaral
À ] ' ( t o l r h e m o u r b g ! ù ( ls h o u k e
l { t e n . l a t f . o x i n , û c l rt . r m o n
to rhel)alùrean.l sholl.l be !àtflel .o a !nood,, d,in, tuundcd
&lgeîo avorl Lûterleren.e çnh speechand bredd,if.q,or stlmnlà
' o ' -o.€8"3 ?: f Fo " '
\hoûld n.r cx.ccd drc widrh .f rhc frccsay sfx.c, ând should
rdude ereoll ancl comfocâbll, with the optiosing di.h.
An ùllemarire des,gn adlo.ated bt Chalirnaf (l98tl dcr.ibcs
r bima{illùr} ùolthglai] thai cove^ both drchcs a.,l hold5
dre mùn.tilne rn r posnioù that .llows m.rirnùrn orùl a; l]ow
ilig 9 61. ft is daime.L rhar rl]]s design ôffe6 seveful rd!.nmges
br rlldvi!! .omplÉre p(re.rnn .f dre reetLr. rs selt trs tlie
intr! and rxûx{ral tlsnLes,fft,m iijqr k is dsô suggated drat
dri! mouth€ùard otfcrs i..fexscd nrandibulaf p(tetnxr b! giv
ing it rllld suppo(, redù.itrs rhe llkelil,ood of.ôn.ussiot LJypÉ
Enrirg rhe rJnsÙission offor.es dùo!gh dre temfro,na..libulif
i,,i.r to dr. bxsc of drc sLùli. Hos'cvcr, rhis rytc of m.ùtisùatu] ls
bulkl.nd ma_rnor bc ncU rolchrcd in \Pi,l1s that requii! a l{tr ot
rûniing and (oni.u.i.arion. furhcf sùdic5
h,lly elalùate rhe desi$ ol mo!!hg!ark.

Motûhgaard ,ndter;dls
Thc.,osr co.rmo.ly use.l .urc.i2l is l)ol}ninyLa($irc poll
.thylene copoltner (P\âc Pl). Polluretiâfe (Pll) vùs |ol,ùlâr, C.trenly crrcndcd ùppcr flouth!uâ.d rvlnr
'fhe
bur is .os' le$ fiequentlr !se,l thysical ànd .rc.hani.al tcth on drc o..tùal n,Éà.e
rs: I r,enenrion
ofdenrol
rroumo
I
Figure 9.6 â dd b Burllary ùoudrsùtud ielieved dntenorly.
T)tqes 0f motutbg aftls
Moùthsùafds.an be.ldssified lnto dr.ee ry|cs: (1) sn,.k,
(2) mourh fôrmed,àrd (l) cùslom madc.
StocA
Snr.k môurhgnar.ismùle of latex rubber or polryinyl .hlori.le,
and arailabLein snel], ne.lNo, and !â$c sizcss'erecodûonly
uscdin rhe boriûg ptufesion. They .an ooly be Left i. plâ.e b]
biring rhc rccdr rcgerhe..hare tu i Frent reterlive p.opcftier.
iûpe,le sFcch a.d bFathlng, dd are a daDgetto dre âinar,
esteciallywhcn co.s.bùsdessis impàired.There is to eddcnce
that rheyareeff€crilein rcdisùlbutln! forcesôfimpact, and soit
tssue injury mal rc lt thm tuùgh oi shàrF edges. sto.k
mourhgud ls .urenrly avàilàblefrom rn oithodonri. mùùltu
rrer fôr usewhlles'earinga ÊxcdappLiance. It is bulky and d,ete
is no ev encethat i! is ofanypLacticalbendt.
Ma rb-forrned
T'he
Mourh-fôrmed guùds are availdble i. No tipes. flrst is mède
withafnm white oure.shell of dplasticizcd vintl.hl.trideplâstic
in the form of è .tental ùch, which is fillcd s'ith r sô1i .heûo
or rhermosetting acrylic resin thar ls ddapred to rhc teedr. The
ourer she11is fitted ànd t'immed, ifneccsaLl, annd dre frenaL
arachmcntsprn,r o nlhig with soh lirinS and se.tilu ln th!
moulh Thc fc\in sets in rhe moulh âftcf 3-t ninùtes a0d
remains rcrilien. rt douth teûpe.âtufc. Unfortututely,Ih$
appljânceisc'remely bulky.nt it nakesnomralspÈe.hvnoa[r
lmpo$iblc. The mxrgin\ of the o!!er shcll nray xlso beshry
unles pr*ectecl by an adeqlaterhickûessol tht liûiûg mùtod
The se.ôùdmosr commoûly ured type ôf moùth lormedsuâd
( boil èrd Lrtre'tyF) i' consn,.te.l from atrefonncd therûople
tic shellofPVAc'PE .opolymeror PVC lhat is softened iù{dm
warer. àûd then 'rouldcd in tLreûonth by the athlct ùsir€
tonAueand finaes. Ev€nundc. pn)fessiôû.lsupedsiot it i!dil
il.ùlr ro nôùld this tlpe efaectivcly.f'he tnperètlue .ee$aryù
allon'adeqùte à.taptatjonfo. rhc teethis fâirly high anddtt i!
â risk of bùrning the moùth. In addi.bn. ifit is tot cenlted o!
rc.dy dûing moulding, ir will be rhinner in soûe irea, tht
redu.iùg is eftectn'cûcss.
Cù!tum-nâde moùthgùards ârc nrade br a heatitg vacuun û1
on dentaL casts pourecLfrom impre$io.s of tLreplàyer\ nouth.
Thjs is lhe most satisfâ.tôry ûoulhslar,l in r$ms.fd.eltabiliq
.n.tconrbr to rhc athlete. Àlsinate impressiors are takenofboth
âr.hes îoserbc.sith â wd jÈw resslrat;on. widr the m!ûdibleiÎ
dre physiological .cr po\itiôt. The mo!.hguard n .onstnûed
ùith af eve. o..lllsd imprint, which e.2bles dre atHete to bF(
dre murlcs of dre heJd ànd ieck d drc teeth.oûe into un,lom
'llis
.onta.r with the mouthAùard. iticreùes thc Épùâtoû
betweer dre .r2niâl bâseand the.on.lyle, and tedù.es ùe dskot
brdinconcù$ion. An optimal ihicknes of.i.t mm fo..he o.cLusrl
surfa.e ha been re.onmended. Poper errensiot ol dæ môùrh-
auard n verr important, but all traenm attdchmens mùsrbe
sufficlendy relieved. lt should bc extended ju$ shoft of the nùco'
bucc2lfold and distèlly !o covefuhc secondmoiàrs (ris.9.1).The
e,lges shoùld be smoôthe.l with â tollshiûg $ote, a.d Uamed
{'lrh an a.l.ohôl torch on rhc cast prlor roplàcem€n! ir the nôùrh.
HoIfûan er al. (1999) .tesùibe a heaq pd nstod mùdt
n,ourhgùârd thât hd a 0.8mn, hard plaçi. layer (coverinsthe
fæial Ain8lva, fi.ièl aspec!ofcron'ns and incisai edgesoftheant'
riof sia rcedr. wLlich n sdrdvichcd betveen No La]'ssol
'lhis
PVACPE co])olymer. type ofcrso,r madegmrd Pedoûed
Lresralter i, rrr, stùdie\ .omparing it widr i$o bôil dtd blte
gu&ls, and liAhr, nredtud, atd heâlTcusrom-made guârds.
Tln
snards rere rlaced or â speciallyconsÛucted .lcnùforn dDr
re.or.te.l:pro,ecrilcimpx.t at the incisalelaer rmje(ile im!æ!
àt the ùaLgiral sinsivai @n$ni$ion .f fore from dt ænr.d
in.ii)r tu rlre1.terJ1l..isoritof.c tmssmissiôùto the c.nines;iôrc
rdrmissiôn to lhe seco.dmolds. for.es of2i0, lto, andi00N
weÈ testedfile tines ib. cachgmrd. The boll and bite gutds
otÏercdrhe leastprote.tionconFcd rc the curom marlegu i
Care of maatbgaatds
rùdies hàve1edto îhe rccommendâûoùùat
tsacteriological nouth'
suùds shoùldr(a) be wdhed ùrth soaFand {'ater iûmediareh
ùlter ùse,(b) be drie.Lthoroushlyand srorcdin a perforated
box,
md (c) be rjûs€dir nouthwæh or mlld drtiseptic (e.s. 0.2 per tulcrum vhe. insertinA a ldyngôscôpe, retràctos or en ioscopes.
ceû!chlorhexidine)inme.tiately beforeùse àsain. PracticàIly, Moudlibrmcd ând cùs$m-made gùdds dd àdhevve ônl bm
mo$ deoriss would rdvise rhar the nouthsùard be rhoroùshly dâsc havc becn ùsed tu prevent dreseoral itrjuries.
inse{.]after
useân.tstoredin a sturdy idertifiâble côntârner Pre te.m jnfânts who need proft,nged oral intubdion mty
suffer Long+crm damage to rheir pa.lntes. Dmage mây rùge fiom
Life af mautbgaards indùcenent of.lefi pa.latesro dilderètion of primary incisorteeth.
A ûoudrgudd conrn.ted fôr a.ltld io drc mircd dcntition,and ApFliânces hdve Lreer descnbed which a'nr to protc.t rhe pâ.laral
ùp ùnti1abotrt1i yeds ôld, may needrc be renewedoncea year. tissre iû thissroup of wl.erable ncomtcs. Iurhermore, no$ very
Oncethe occlusion is estàblished,rhere is no rea$n why â f,exible nasal.ub€s are used. so dr;s rroblem sboùld not o.cùr.
polyliDylàcetàte-pô1)'erhylene môùrhsu.d. if well lookedâfter,
shouldnôr last fi,. berveenr{'o and thrccre2a.
)econoaryprevenI]
on
Mouthguordr Dentoalveolar
tÉuûa
Prômpr inreNeûtion follôwing accidentaldam€e !oreelh cm have
a secordary preventive effect by redùcin8 the .ompli.ations of
ùalna. The develôpmenr of bôth the acid etch techd.tùe, denlnre
bonding agents, dd ûore receûdy compomer techoolosy, where a
bonded resturâriôn .an be ùlieved withôùt wshjns ad dryjns,
meâns rhar drcrc is no ex.6e tu. leaving expôsed dentite for ùy
Special consideratiotts ir moutbgua*l design
length of time in coronal fracruies. The rc.oa.lrbn that nônieG
Parr;allydeDldte atl etes shoùl.t rot $eù remoràble prostheses
tirA calcium hydroxide is capabLcof allowing .ontinued roôt
1 l e p - 1 ( | ' ! , n g . , o o . . I o r i e r ' o p r F .e l
giowth md apeiicalion in non-vital immarure in.lso6 bd made
lior of iiàsnents if the appliànce weie rô frâûure. o..1ùsâ1
bolh treatnert and long rerm froanosis nrorc frcd;ctable for.hese
ins may be con$ruûed or a tlÉrmopldti. bde ro repla.e ûe
teedr. Recendy, hovcver, a nes piodu.t, Mineral Îiôxide
ÀsgÉgare (MTA), promises to replâ.e the time spent ehieling an
Àtl etes ùndergoins fixed oûhodonric teatment caû havc â
èpical bafier with ron s€ltina calciuû bydroxide bI crcatina a
moùûsuèrd const.uctecLptuvided that the brackers ard arch
barler lo ole apFonrtmen!. Ths would sâ\'eco.s;demblc patlen.
{ires ùe covered wirh wd priôr rô raking an ihpÈsion. cde
dd ôperètor tine. The awlse.l .ooth is nov a viable prcposirion.
shouldbe takÉn .o. ro place rhe l;ps or othd soft rissuesunde.
and if rôred .ôûectly àrcL replmtecL soon after injuJy nay be
tensnh by maklnA ùe mourhAE.d too thick. \Y/hile .he design
rehined d a fûftiôning ûember ôf the denrition wrh a heallhy
ofnoùrhguards and rhc mareriâls f.om which diey are oade reed
pe.bdônial ligdent for life. lven tlÉ èvulsed tooth with èr €x!'a
tuftht investlaat;on to produce more effectirc ard inexpeûsi\E
alleola. dry tlnr ofgitater rhan 60 min, which hæ hàd its ndrotic
suùds, rhcrc câ. he lirde doubt lhat evrlerce to date sugses$
pefbdontal ligmenr remôved, mèy grow è reù peiiodoftal llgr
thâi a.oûe..ly nMde moùdr8uârd rcduccs considcrably the sever
ûert with the help oflndogaiû Gel. Such advancesio .he l'leld of
de.tal trâumatoloSy arc €icnin€, dd enable the .lini.id rb retèit
teeth vhi.h woùld previoBly have beû extrâct€d. These advarces
hovision of morith protectionfbr special in ihe diagnosis, reitment, dd prôsnosis of dentâ] traùmatic
injuries hâlc bec. mos. sisnific?ni otr rLleldt 2i veârsànd cù
gïorips
.e.! koowledge is e$ential to ùeât appopfiately (\relbùy 2001).
Slirintiicted irjùries havebeenreportedin irdividùals who are
irteLlectually compronised as a resùlt of neùroloslcaldamase.
Thjsmaybe.tùeto brain èroxiaàt bith or côngenitâlsyrdrômes. Troumotized teethshould be
Therearea numberofmethodsfor the ûe.tmeût of self irduce.t
or,li.judes, and thesei.cludeproce$edhad acryllcsplints,wne
a âcryli. splints,and doubledri.knesssrft vinyl mouùAudds.
Mourhsnèrdshrve àlso been recômmendedfôr pariÉns with
PùkiNoû\ dseâsewhosein!ôlmràry môvementsmây ùâûà-
tizeôral soft dsùes. Conatosepatientsca. be p.orectcdirom
ï]e role of'the dentalpractitionerirl
i!ûa{ml injùi} by wiring a rcnAuesrenrrc dre mand;ble.These
ûatmentswill be discùssed morelully ir Chaprerll. child protection
Tne ùse ot larynAoscopes durinA inrubar;onânacsrhesi2have The incidenceof oroiàc;alinjurles in .hildÈn who have been
b€n a$ociarcdvith denlal injuries.Teelhmay be fracturedor physicaLlyabùs€dis ;. excessof 6t%. I. all typcsof abuse.dre
dnpLaced by using rhe ln.isal edgesof rhc anrcdor rccdr as â incidenceof orofacialinjùfies $hi.h are v;ible tu ihe dental
 I
154 | 9 P'elenlion
o{denrdlroumo
I
prâctitnner ls ofrhe orderoflt%. The dent pra.tl.nrnermay be
the first prcfessional
ro seeors8pect âbuse.Injùrlesmay rakedre
fôrm ôf .ontùsiors 2.d ecchymoses, Èbrasiônsand la.eiarbns.
bûns. bitesor denrallraumâ.
'Ihe
tollownrAelevenpoints shouldbe .onsideredby rhe den'
risi *herever douba or susticionsarearoùsed:
. Could the injury hâve hecn causedaccidertè11y
àrd if so
' Doesùe explânarionôr dre injury fir ùe âsean t the ctin-
. If the explanntrcnof câùseis consistenrwith rhe injury, is
ûis itselfwithin nomally acceprable iimits of behàvioùr7
. If ûere has beenany delayseeLiûsadrice,are there sôôd
redsons for rhis?
. Doesthe *o.y ofdre âccidenrvary?
. Th€ ùftre of the rehinrnshiphelveenparens an l child.
. Th€ child\ reùrio. ro orhefpeople.
. l ' t F t r r ' , , - r i , . o - , r n e J * o r " . , " t " \ " 1 r ,. , , 1.
. The senehl demea.ourofrh€ child.
. At1) commentsmadeby dre child and/orparentsrhÈt.âuse
coûcernabout dre childi upbrjnglng or life$yle.
. llisrory ofprelious lûjlùy.
Denral pm.tirioneB shoùld be âwde of lô.a.I prc.edùm.l guidc-
lines ser up by ÂJeaChlld ProreclioDComittees (ÂCPC!). In the
UK, eachæ. ûtr$ havean ACPC br taw d a resuh of rhe children
Aft (1989). which camejoto iorce iû 1991. IdeaLl)'eachACPC
shôuld havca denralmemberwho will prcrlde rhe locâl dent2l
expeftlse,and the best pàthwàysof refeûa.lfor dentistswill be
agrrtd. Thcre is puLrlisheddètâin the UniÉd Satesa.d rhc UK dr2r
shows clearly that dentÈl prd.ritbneF would yefèr ro speak ro a
dental .ollcâgue wùh expertisein the tôpi. betàie makln8 â rcièrnl
t o . . \ e , ô , : J . a . . ^ ' l e . e J , l t o f e . , . o ' . T h - e , ,. .r ,p, , -
he$,on !o .€fer be.auseof la.k of minnra. The de..al prcfeslon
needsto be involvediû intekgen y this;na in child I rctecrion
issues.\Xrithoùtsùchtraidng and an app.cciario.of lhe wo.l<of
o.he. agencies, we de likely to conrinue!o missopponùdriesro
helpchildrer in need.
Tertiaryprevention
Advancesin drnta.lmarerlâh science,esleclallylû the fielcLsof
implantoloAyand porcelainte.hnology,has meânt d,ar injuries
sdtained ln.h;ldhood and adolescence cù be expe.rùr be ûeated
it eârlyadtrlthoodvid, advarcedtechni.tuesthar ôftenmâk€rhe
ôriginal idjury;mp€rcepiablero the lâyûâns eye.In rhis Fay rhc
impact ofrh€ origirÀl injnry is signlficandt mioimize{r.
Conclusions
T'h€
p.elenrion of orà1 Ùâûâ and the mainte.arcc of a heâkhy
.omplete dcrtiiio. for life should be the aim of any carlng parent
an.l dentàl pràctitioûer.Pldygroundsànd play de6 shôù1dbe
..refully desisnedând consÙùcted. Yôung childrensplny shôu]d
be Npervised.Lârseoverjes shoù1dbe Ûeatedin the ûixed den-
tirior. Coftcdy fitting .stôd-made moùtbsùardrshôuLdbe
worn for cônractspoits.TraùmarizedÈerh shoùld be ùaÈd ro
lhe hi.qhestclinical star.iàrds.Lô.r1 prô.edurdl guidelinesfor
References
Bùî;rh De,tdlJa*sdl lt.)89). Pali€ot and practicenewslet!€r,
It Afnl.
BS 1696. Pld! eqe;ln@t ierentkdfû p*ùdnent in!îdlldtiln un
l'r{. Pârt l: methodsofrest, I986. Amendedt990r Part 2:
specificatn,nfor .orstrllctio. a.d pertbrmance.r986.
Amerded 1990j Pàr l:.ode ofpftûi.e tur iflrallation and
mâintenance,1979. An€nded 1990. tsritish Stèr.tards
I n s r i o t i o n ,L o n d o n .
BS 7188. British Stantùd methodsof test for impàct absorb-
ing Flaygroùr.l turfÈ.es, 1989. Amended 1991. Brirish
Stardardshstiturion, london.
Chapman,PJ. (r98t). The bimâxillârymôùthguard:in.Éase
protection agains orofacial and head injurles ln sport.
AÆltdlid"J. S.i. tlel. Span17:21 29.
IDI (Fédé.xrhnDenralreIntctltàtioli^lc)\'t.)t)o).aon,"rto" on
Dùîal Ptuàr.t. v/ôrki,aAPâiiy No. 7. LD.L Nro.ld De.tul
Hotrmann,J., Àlfter, G., Rùdobh. N.K., a.d Goz. G. (199t).
Experimentul.ompamrivcstudt ot vâLiousmouthAuârds.
E od.D.,t.Iià"ndtl.15: r5l r6a.
Nrùgen. Q.V, Bezeme..PD., Habe6,L.. and Prahl'A.de6en,
B. (r999). A svstenrâti.r.dcw of drc .elarionsh
it bet{'een
overjet si,e ând ÛaLmdi. dental injui€s. E 1 J. oûba1/.
2l: t0l ilt
oBrien, M. (i99,i). Childnn\ Dtrral Healrh i" îh U,bd
Kii!:.|atu 1993. HI4SO: Lônd.n.
Richa.dso.,A. (1t8r). a,tuteq;u Af$oda,trr (2n.1eAnJBDJ
Publications:Londo..
Trdd,J.E. and Dodd, T. (1985).CÀ;ldftn\Dùtdl Hu/rh iû the
Ilnitud Ki,ttdaù,/9Ej. HMSO: LondoD.
Ttrme..C.H. (1t77). Moudr protectos.Br Ddr""/. 1.13:8286.
Welbury, R.R. (2001) Tranmari. injùries ro the ieeth In:
Pdedià|rt Dert{tt! 12..1edn) (ed. 1{.R.N/€lb!ry)Oxford
U.n-c6ity P.e$r Oxfôrd.UK.
 of malocclusion
Prevention
Peter
Gordon
lntroduction
Malo..lusior of ûe teedr is oot really a diseasei. drc vay thtt
deûtèl caries ard periodoniiris âre, it is more a rcfle.riôn of the
nâûml variaiion thtt occu^ in aûl' bnnosical sy$em. Truc pft-
veftn,n ôf màlocclùsion js diriicult toÉnvisèse, asthere is a *rong
(Mi1ls
sederic component ir th€ make-tç of most nalocclusions
1978). Preventive meaures nay be efectlvè indeâlins wjth co\'!
ronnental factors, but ue ùnlikely to intlùen.e the outcome in
-e.qhere tr ", "' ô" ".rou,.l ' on.o-,l ro,e,roo1 ,'
The interception ând eady treètment ofdevcloping malocclu
slonshas comc rc be regdded âs bei.g âlmosr synônymous with
rhe prevenrion of malocclusio.. but int€r.eption is, of coùBe,
erly Ûenmert of malocclùsnrn rèther thao prevenùon. Tne Pre
veûtior is vnûally impossible, but eù]y reâtment may Prevent
' . | , l l e r p É . . . oonf J n " 'r-.,o.or nr) rc.-. i".r'r'n._
ncnr, or less Ûeàtnent. On dre oùer hancL,it some.imes re$ ts
in two.oûses ôforthodoDtic .rcâtmenÙather thâr ote. Tbede.F
sionas to whether tô rcat a malocclu\ion eârly ràlher thao late hd
ro be raken bering in nind the likely benefit to the subiect. bai-
arced aAainr the costs. I! dris reriew ofthe role ofintercePtivt
orhodontics the various sitùâtions will be cotsidercd in which
interceptive or carly Ùeatmett of a developing mtlô.clusion is
likely ro prove hetpful.
Normaldevelopment
The primùy hcisor teeth erupt ât âpproximatcly 6 mônths ofage
(Iôster ând Hamilton r969), followed by thcprlma4 first molars
at approxlmèt€ly l2 morths ofage These are followed by the pri
mdy cèdie teelh ât a.omd 16 donths a.d the piimary secot,l
molè6 at âround 2{ months. There a.e pârticùlar ôcc1L6à1
t€arurcs
rhar o..û .oûmo y in dre pdmdr dentition, as outlined by
Iriel (195.1) ant by Foste. and Hamilton (1969). These are the
I *r e ô ". hropo'd pd ad. -'\,d o r\" ut t P, aù.
cannreand distal to the lower prioary canine, the presenceof gen-
ûaLized spâ.ing inthe iûcisor.egion, and the ûo1èrteelh occlud-
ing so that tht distàl $rfaces of thc ùPper ând lower primtl
second molars are iû the sam€ verical plate. Vèriatlon 1n ihe
eruptio. sequenceôf the primary teeth is relatively ûncommoo,
thouAh thc.e is .ônsideràbLe vâtiâtion in the age at which the
reeth erùpt into rhe hoùth. Vada.ion in the occlusion of the Pri
mary teedr is.elarivelr comnon. Crcwdins ofPrima.y teeth is
not usually à t.obled, thoùsh âhsenceof sPacins betweeû the
prinâry iû.isor teeû is â reliable itdicatioû drar the Perma.enr
teerh in thât area s'ill be crowde,l in due.ourse (Bàume 19t0,
Leighton l97l). Variatiôt io dre occlùsiot ofthe molar teeth,
''., e .n r'É o ,,cro-pôrF - olr.c i nron
pl2ce, but is seldon tHied in the !.imary dentition, as ir dôes
not scem tu give rise to any functional P.ohlem
Thcpermanert !€erh stdt tô erùpt atâboùt ihe ègeofsixyeats
(Houston et â1. 1992). The fir$ tooth.o c.ùpt is senerally the
lower first permanent molâr, fû11ôwe.tby thc ùPper Iirst nolar
and dre lower ceotrul in.isor. The ùP|cf .enùâl itcisor. Lover
larera.lin isor, and upper làteraLincisofusuaily eruPr between the
èges of 7 ând 9 yeas. Tbe lowef canine and the foû fir$ Premo-
1èr te€lh crpt at àboù! the aae of 10 or ll. fàllowed by dre sc.-
ond premola$, tLle ùpper canine, ând rhe scco.d pernanenl
The distaLsufâ.es ôfthe secondprlmaq molar teerhadde the
erùpting firs pcfnanett mola6 inn) a .usP to cusP o.cluvon
with rheir oppos;ng teeth (i.e. l/2 unit Clds lI). The Perdàtent
upper incisoB ârc more proclined than their primary Prcde.eso6
and this allows sone forward .ePositioning of the mètdibLe,
which e..oumges dre lorm.tion of a Clâ$ I môld occLus'on(liiel
l9t4). The lowe. se.oûd primarv mold is larger dran rhe cotre
sponding tooth i. rhe upper ùch, and when these rcedr de she.l,
thc lower fist permanent molt moves mesially mther more than
the upper first mola'. :lhls a.lsoencouragcstht estèblishment ofa
Cla$ I molâr ôcclxslor.
:fhe above àccoùtt is very much simplified ând id€alized; in
reèLlife dre o..lûion is seldom so well o.sanizèd ù.t the.e are
severâlfacntrs, itheriled atd environmental. which cat itîuen.e
the devriopme.t of the oc.iNion.
Aetiologyof malocclusion
Sl<eletal
fâctors
The skeletalpttern (i.e. tbe .elarnrnshipofthe mandibleto the
mdillâ in .he anteroposte.ior,.radsverse, ù1d veitica.ldimen
siôs) is oneofthe mosrimpoila.t ia.to6 governlnarhe Presence
ôr èbseDce of a nalo..lusioD ofdre teeth,bel.g ioiimately relàted
t5a ofmolodusion
I 0 Prevenlio!
rô both incisor over,er and overbitc and û, rhe ô.clL6iôn of lhe
fteth in rhe bnccal sesmeDts.Tnere àrc twoaspe.B ofthe skel€tal
paftern which hève to be taken into account: one is rhe size of dre
mandible, reiàrile to the size ofthe maxilla; the ôther û the posj
tn,n of rhe ôardible, retative to die maxilla. Sin.e the 1àtter pat
ôf the nineteerth centùry cliûi.lans and researchworkers havc
madc detefmiûed effors rô iûflnerce the developirA skeleta.lptt
tem. A 'diÉty ôfmyo fnn.tlonal applianccs have b€en developed
and exÉr.isesproposed, wlth the nr!e.!io. ofmoditing the mus
cular environment of the develôpiûg bones, in lhe hope thereby of
influencina drci. final slze and pôsition. These derennined €trofs
have mer vidr some limited su.ces. lt does seem po$ible to
modify rhe position of the nàndible relalive .o the maxilla,
mainly by restrâinina.he dos'n$ards àûd fô^îàrds !.ànslation of
the maxilla duing Srowth, bnt this chànge in skelcrâl pattern
oc.us only to a minor exrent. Even Lcssarc ûe altdations pro
duced in dre size of dre maxlua or the màûdiblÈdrese chanAes
ar€ barely measurable.
Myo turclional o.rhodontic applidces cMunloùbtedLy inthÈ
ence rhe .tevelopns denlition. but they seem to produce dreir
effècs mainly by lndùcing d€nto alveolaf changes,rÈtlÉr than by
nodi&ins the un terlyins sk€leralpattero.
Slmi1r1y, the use of extm oraL rypliances ro npply relàtively
high fires ù rhe mdi11è, durhg growdr. car lnlluence dre posi
tiôn of the mdillà to à c€.!ai. exrent. but these forces âre s€ner
àLly apflie,l to thc tuaxillaria ihe teedr. The teeth ten.l to move,
under dre influeû.e ôf these forces, p.oducina dento-alveolèr
cha.Aes, Erhe. than dy r,bstmtial modiÊcat;or of dre ùnderly
The chdnses in occlusbn p.ôdù.ed by the use of myo-
functional appliances and head-aear dre àchieve,] only wirh a
major expenditufe oftime ând etroft. It is probably more appro-
priate to regad the use ofthcsc applian.es d àctive treatment o{
adevelopi.g malocclusion rather thân âsèty kn ofttcrcntiveor
,n.erccPnve nranue.
Soft tissueform and fuîctiorl
Skeletdl pàftern is onefacror thar can idfltrence rhe positjonofdre
rccdr, bui it is by nomedsûe ody fâc.oL.The dental ùches aDd,
indced, rbe skelerâl pâttern rself, develop within r soft tissùe
environment. Mus.ulâr {tiviry ir the l4x. cheeks, ân l totgue,
and in rhe muscles ôf màsriotion, hd a p.ofound effect on the
occlusior of rhe teedr, influetcitg, as it does. dre labiô-lingùal
in.llnainrn of rhe drerior teeth ând drc derelopmett of buccâl
segûeût ûo$ bites (\I/ilmott 198,1).
Suckinghabits
Digir+trcking hàbits cao causemâlo..lù!iôn, thoùgh they arc
ptubâblya 1es importaût causedran i5 per.eivedby the g€.erai
pùbllc. The dajorlty of your.q ch;ldfen havea sùckins hùit.
eitherdigit{uckina, orsucl<jnso.â dumnr (lôh$onaûd Larson
1993).The etre.r of this actlvity on rhc positbn ôf the teeth h
lery varialJle;in somecas€sâ vcry detrmined habit ûill haveno
notl.eable effec., in orhcf.ases the su.kins habir will producea
chadgÉin the position ofdre teeth. The elfècivill vary à.cordlûg
b s'hai it is rhat is bcioa s,.ked. Thunb su.king, if oûLy one
rhumb is beirg sùcked, vill tend to prodùce a ClassII divlslon I
rype of incisor relationslrip, with d dymneùic in.rede iû the
in.isor overjet, trodu.ed by proclination ofùe ùpDer itcisos a.d
retrodiration of the lowes (Melscn et â1.1979). The incsoroveF
birc Fill tn.t tô be incomplete, and there wiil be a tendenci
rowards a.rosbite ofthe hu..al segmett teeth. \Xrhile the .hild
is jndulsins in rhe hÀbit, there ;s a Loweriûg ofthe r.tra-orâr d
pr€sure âccompanied by a lowetcd rcngùe position (DaI aûd
Io$er 1971). These are the two f2crors. a$ô.iàted çith diSit_
strckjos, drat tend iô prô.tuce a Lru.calseEneût ùosbite. Sucking
both thxDbs (ât rhe sade tine) wlll !e.d rc produce ènore sym-
mericâl incrcasein itcisor overjet. li.geaù.kitg may haveles
crect on ihe ircisor overjer.
The cha.ges prodù.ed by the sucLina habit are dento aheold
chùAes, dre anAùlâinn ôf ûe teedr is changed with little or no
impècr oo the underlying skelet.l patte.n (Lârsson 1972). Vhen
' . " . 1 , 1 r\ d b ' . ' . . o l i r . d r o l " m ' \ e d l ' , : i ô . )
.'fl ' o p e r . ,i o | i L,Poro
d,\e,Fro otr!,.',l
clined ûd the lower teerh ret.ô.lite.t, then the lowe. liP my
sran to fun.rion behind the upper in.isos, mainrainiog the losi
, o , , t r ' . F ' d r ' - r p . . -' ^ " n f ' l u i. lh n't- r n i
not self-côûefting and wilt rcqtrne a.o!s€ ofonhodonri. ûe.!
menr to re erablish aclds I iicisor occlùshn. If d1ehablt isto_
ducinS ao obviôùs proclination ofihe upper inciso6, ir voùLd be
se.sible er discôurège the hâh;t before th€ establish;.8 oi a lip
trap. InteLceptire ùeatment of a sucking hablt *ill onlv be uselul
in C]àss I cascs-thùmb suckns is very often blmed for â.
iûûeâsed incisor olerjet thàt is really thc re$lt ofd tnderlling
Clâs lI sLelctal pattern.
Interceptive mcasu.es us611y involve rhc ptuvisiôn of some
sort olintra oml appliance, tôgedre. with the aPplicètion oiâbit
ofpsychological presrre. The applian.e dèy be an âcrylic b^s_
plate, retanred by Adâms.ldps, Fo$ibly with a bù:lge ofècrylic
iû the middle of rhe Palàte. Ths servcs as a rem,nder !o rhe
.hild ihat thel should srop sùcking dicif drùmb âû.1may redua
the sàtisfactjoo obtained by contiora.ion of the hablt
Psy.hôlogicèl pr€$ure. of en.ôùràgemet!, may bc brought to
bear br poirting ou! to the parent, it the presencc of dre child,
drat thùmb s(king js someihidg thÈt è11younachildrendo, ând
somcdrlng ihar rhet !e.d io stop doing d they g.ow older dd
lnterceptivemeasures
Derto à1veotù fèctors, rhe /,ùl .âuses of nâlocclusion, are the
oùrs thàt àre mos âmenable tô an inrerceprire çproâ.h.làrly
dûeùiôn ôf dr ùôûaly, fo11ôwrdby edly ûeardenr, cân sôme
times aroid the need for more complex treètmert àr a lèrer dè!e.
ThelafnNs fa.nE thât.an âdrcscly atli( drc dcvclopmeût ofaû
othe^vise normal o..lù\bn can be categorized according to the
derelopmentrl age ar whi.h a problem becomesevident.
Primaryderltition
ReLâtilelyllttle intereptive oithodonti. ûeatnrnr n .aûled oùt
iû the prinary dentition. before dre erupthn of anv pernanent
ieeth.The dental ar.hes are Acncrally scll aliA.cd. There may be
.ùinùeased incisoi oveijet, or aCltus III in.isor relationship, bùt
rheseocclusâl feâtùres âre seLdon so pro.olnce,l d,a! drey give
rire b .omment. CrcwdinA of thc pdmary dcntition is urùaul
expressedas an absenceof spa.lna dre primary reeth arc well
alig.ed and unspaced crovdinA s'ill become evidenr whc. rhc
pomanent teeth €rupt.
Ea'ly loss ofa prinùy first molar mar allov mesjal drjft of th€
js difÊcuk ro prevent wher lhe chlld is so
secoûdnola.:fhis
yoùû9.The rechiiqùes employe.l de the sde as those srageste.l
forlse iD rhe mixed dentidôn, but the sp{e maiûtanes have to b€
vom foran exiended pe.iod oftjme.lFthefrimàrysecond molaf is
ior prior ro the eruption of the permanent fiBr molar, thrn it is
veq, difiicult, though rôt âbsôlrtely impo$ible, ro prevent mesièi
no\rn€ût ofthe unerupte.t permàûent toôth (IieLts 1999).
Idy los ofa primary incisor shoùld hâve 1iftle etre.r ôn the
araogement of the permanent teeth. If rhe primait' in.L$a are
spa.ed,rhen one would not cxpc.. mlr.h nresial movemenr ot the
teûh dntal to the lost inciso. Some space closurc mal well take
pla.e ifthc trimary i.c;sors are not 9accd. but ir can be argucd
that, in this situtnrn. ùe permanent incÂo6 de alrea.ly shôrt ô1
spaceand the early 1os of the Frimùy tôorh hd merely served to
Io.alizedreprc-existiog crowdinA ofrhe pemranent reeth.
Mixeddentition
Ii is in drc mixcd dcnr;r;on rhar mostaftcmpts hâve been made t)
inteLccptrhc dcvelopmenr ofmàlocclusion, widr the aim of sim-
fliryins larcr o.thodooric rrcâtmcnt. or cvcn ofavoidnrÉt dre need
Ior offhodontic trealoent at a lat€r da!e.
Ear\ kss of primarl molar teeth
Theefect,ir themixed.tentnion, of eùly lô$ ofFrimarymolar
eethdepends on the anoùr! or crowdjrsnr d,e dentala.ches.
a.d o. vhich looth jr is lhat hasbeenlos (Richârdson196t). If
lhe dentition s crow.le.t,then the crowdins tends !o become
âlpdent either ir rhe ircisor regiôr, or elseir the region ofthe
pernarentmolarteeth.The cmulatile sizeôf the primarycanine
andmolar teeth exceedsthe cumùlùile size of the pernaneût
cmire ànd prenôlàr teerh (Hôustônet â1.1992), so that if the
prlmaryteethùe retaire.l until they àreshe.lln the ordimry way
as the perdanenr teeth erùpt, then rhere s'ill be sufiicient space
for rhe permanenr cânine ùd premolù teeth. Ii â primary molâ.
nxrh is 1or premÈrurely, throùgh ca.ies ând if the teeth ar€
ûowded. rh€ ftethrdja.ent to the tooth .hat is ext.acte,.lwillrc.d
ù) dfift inro the sPè.e thèt has become dvailable, rcdu.ing dre
d n , , , o . 1 . - \ . , b l p i ' 1 , u ^ . 1 ^| ô i . r ' " r , , l
Ifaprimary secondmolar is lôst aûd rhe teeth are crowded. the
fic pcrmanent molar sill môve for$ ârd irto the space,reducina
dr€ spæe availahle fof dre se.ond preûolâr. There mav be sone
shift ol lhe cer.re line. widr drc.rcwded incÂor teeth movits
ùound to the side ofrhe m;ssirg pfimary nnnaf, bùt dô* ôfthe
space lo$ occls by mesial movcment of the first permàûett
molar. Ifà primàry ti.s mol2r or caninc is losr and the teedl de
crowded, then dre tJcmaûeor in.l$r teeth will môve routd to
ùxr side, rcs ting in a more pronounced shlft oarhe centre linc
(van.ter Llnden 1990). There mav bc some n,rward movement of
thefi6tpermaneot nolar. but mo.c Io$ ol spa.e o..ûs asaren r
of driftins oIùe incjsor !€erh.
B.ilaùdng and comPentating efiractions
'Ihe
shifr h cente hre, which occùs when a toodr is lost on one
5ide. in a .rowded deûrition, is .Utficù]t to cotrec! orce estab'
hhed. A balan.ing extr{tior (exrmctmg a seco..l roorh, on drc
oppôsite sideofthe samedenralàrch) is somctimes .e.ommended,
'n crowdcd ârches, to p.eleni dre.enùe iite shift (Bal1 1991).
'. ', r,l \',r ' d 'ô L" "n e 'lr n.
ily dre samr toorh ôû rhe ôpposite si.l+the operulor is guided in
rhe fi.st insrâ.ce by rhe.ondiriôn ôf the teerh.
If dre occluion of ùc buccal segment teeth is Clàss I, *ith
Sood inrerdigirarion of rhe cùsps. then rhe los ôfa tooth ù oie
arch will allow nrcsial d.ift of the pôreriôr teeth in thèt ùch, on
rhât side,leddi.s ro,lisrurtion of rhe buccal segment occluion. A
compcnsatina exûa.tnrn, rhar is ùe dûetionofàtooth from th€
opposing uch, will a11owboth uFper lnd lower buccal segmcnt
teeth to drift fo'\'a.ds roAcdrc.. maiftalnlng dre Clds I occl$iot.
A compensâiirg cxùac|ion may a.l$ be cariecLôut it dÉ cde of
th€ eady Lossof a lowcf first pefmantnt ûold from à dentitlon
with à Clds I occluion, iû which cae the upper f]r$ molar dry
hale roopposiûs toothwilb which to occludca.dwill ove.-erùpt.
Bâld.ing ertnctioDs, to prsert centrclirc shihs ln o..lùsbns
with crôwded teeth, ùe comorly car;ed out. No matter what ùe
intekrch relf,dôship, centre llne discrepanciesâ.ediftlcult ro.oF
rect once estàblishedithe freveni'or ofa.enùe-line shlft may pre-
\€nr rhc rccd lor qùite .ompreheBive oithoclorti. ùeàtment a! d
later sage. CompensÈtingexûactioN are Le$ U_equendyindicaredi
drer are potentiàlly Neful mi.1y in Clùs t occllsions.
Serial extracr/.ons
Kjcllétren (1948). propôsedà rreâtmert for crow.led Class i
o..hsn,ns that illusÙares well rhe concept of balancing an,.l
compcnsaring €aûa.tn)ns.In the.ase ofà.ro$de.t Clas I occlù
sion.rhe o.clùsa.lptublemgeûera11ybecomes.ppùeût followi.g
160 lû Prevenrion
ol molodusiol
the eruptnrnofùe pcrmaner! lar€.alircjsors,whenit canbe seen
thât thereis i.$l1]cient spàcetodcconmodàrethe èûteriorteerh.
Kjellgren suEsesred drar the four primary caDiûeteethshonidbe
e.,r',J r (' N 't,o,nljÉ..po 1-hr o,n,,Flri,..
This wôutd a.Uowdrc fàur i.cisor !€eth nr eàch ârch to move dis
tallj iûto the space m.de alailablc bl' the exrrà.tions, rhereby
lmprovi.g d,e alignmeût ofthese teerh. Ir wodd be antl.lpard
thar the buccal segmert teelh voùld move ûesiâ11n rô sôme
exrenr. beb;.8 ro closeany resi.tual spâce.This mesial môvemenr
would occur jn both ùpper ànd 1ôwer af.hes. mai.tai.i.g rhc
ClassI buccal sesment ô..Iùsiôn.
Tbe intentlor is tô obtain good allgnment of thc teerh and
reliei ol ûowdirg by rhe elenrùal exûa.tbn ofâll four fi6. pre-
nol r.l.rl. losôf l - -.'l,qi iffo.. tr'r-\nLao!fo'
tunity iôr sportareoùs alignment ofthe permaner.."".,. ....,.
dd Kjellgren $gAe*cd drât dre four primùy fi6t molaB should
b€ eKracted rhentheirrôors were appro:imately halfresorbed, nl
order to ercoùrâge eù1y eruptnh of the fi6t prcmolâ6, so .bâ!
th€)', in tùrn, coù1d be eirra.ted ar thc eafLiesrpo$rbte momert.
The prôblem here is drar lhere is no gùdantee thèt the extrèc
tiôn ôfihe fi|sr primary molars will lead to eàrly eruptiôn ofthe
firsr premolars (Kcrr 1980). Iû addjtlor, n ls unlikely rhàt tlre
rôôs of rhe pdmary molars wilt all be resôrbirg àt rhe sâhe fute.
so the re.ommcndâtion that these teeth be extraûed ar just rh€
right domenr, when dreir roos are half resorb€d, is difficùtt to
impleûent. Arother difai.ulry lies lû dre fa.t drar rhc c.ufdon of
the lower premolù oc.ùB, or àlerage, ar qprolmarely the samc
tlme a the eruption ofthe permèrent cânine in thar ar.h. ]'hese
teeth are competing fôr rhe same space and rhc can,.e roorh s
oft€r.Usplâced làbialh ri, tbe erte.r drâr it unlikeLr !o alisn
sporraneoùsly fô11ôwingihe exùâ.rlo. ofrhe fiar premoLar
Seriâl exùactiôn, âs d1e r.hnique came ro be {own, s lor
practiceclnô\aadaysin ùe wav odci.ally describ€d by K,ellcrer.
In particùlar, the pridaJy firs molaB are nor cxtr2cred. since it
has bccr tôund thât tlese extrà.rions confer no ad.lirioml benefit.
Occasionally,ifthese teetharc;n poor condirion, theprimary fist
molâ6 mây be exùa.ted lnread of rhc p.imâry canine !€erh. The
alignmeft of rhe perûanent incisors proceedsnore slosty than jf
the primary .ân;.es hâd been removed, bùt the fiMl alisment
will be much rhe same. Extractior of primàry canire reerh to
allov a.llgnme.t oi the incisos is sometimes practicecL,espe.ially
il the maillafy laterul iocisoB ère lûrandirg, àrd ifexùâctiôns
a.e rcqù.cd in one arch, nr a CIàs I .de, then they arÉ generally
câûied ôur in bodr a.ches. Spnraneols aligment will re$ r in
ao lmprovemert in the porirbn of dre inciso6. bur sometimes
only ro â lirited exreni. If perfe.r âlignheni is rcguted. a fired
appl;a.ce will geD€râlly be recesât, ônce rhe pe.manent reth
Tlre tfearm.enr af .tnterior cmssbites
An mteriorùôssbireO.e o. mo.emaxillaryincisorsocclLrding
lingùa.lly n) the opposinA reed, oay become æpùert when the
incisor reeth rrupr. There may be dento âlveolar l"clors involved
in the .levelopmert of this àûôma\', ôr the .rôsbites nay bed
iûcLi.atioû of in ùnderlyirg skeletdl disùepÈûcy CroNdirg,
ien,ltirg in the linguÈldispleement ôfthe upper1èterèlircisûs
mây po$ibly be Ûearedwith a hodified seridlexÛdtion td
nique.Anàûterior cro$bite may reùlt from dre prolôngedEie,
tion oI a prlmary incisor(possiblya non vitÀLtooth tha! hasfriled
t, ùndefgoroor rcso.prbn)and thc bsequentlingùâl de|eûiot
of rhÉ permaneniûnh. In this casethe prômpr .emovalot rhe
offrnding prlhary rntrh may allow spontâneous ali8ndent ofrhe
c.upt;ng pe.manen t i.ciso.. providcd thar dre incisor ove.biteh?!
not produceda. occlusallock.
Earlytrealmer! ofinstandinaufper incisorteerhmaybeindi-
caredlor a varietyof reasons. :rhe n,evitabl€occlusaliûte.ferenæs
caoleadto ûandibular displacemeotr dre opposinglowertoorhù
tccdr arc liâble io move lâhially,froducing a màrkedSingiral
ftcesiônon thelabialaspecrofthesereeth.In addiriôn,thelabiÈl
surlaceofth€ instandns ùpperrncisorcanund€rgomùk&lat!i-
'chisel
rio., virh lhe producrionof a noriceabletace!or edse
incjsally. TreÀtment usually involves procliMrion of th€ lnstand-
ing roôth,prôbâblywùh . remôvableorthodorti. àppliànceIfrt
is ne.esâry rô .reare spa.e in the denta.la..h in ôrder ro dcon'
p l ,r r - ' r o ô ' r ô ' n e n . .r e r " i : r . . , J \ ' , . r, i o ' ê r l
nent will prôbablybe neededto providesutrlclentspace.
Ihere are a nuarber of pitfalls that nay prcreni dre $(e$fùl
execurior of dreseappareûtlysiûp1e roorh ûovements.Ifthe
reeih àre crowded,dren the u.eropred permâne.t câniæ tmrh
may impedelâb;al molcmcnt of the uppcr latcnl inclsorM{re
otten.lack ofincisor ovcrbireffay p.ere.r drc esrablishmeni ôfa
slabl€ Cla$ I iocisor relalionship.This is particularlylikelyil
lheres arunderlyins Cla$ III skeletalr€lalio.ship,iûwh;chw
int€rc€prile meàsuresare ùoLikelyto prove successtul an,l rhe
malocclusionr bestleit for deturik treatmeDtat a laterdate.
Tbe lreatment af posterior cmssbites
Co$bitcs invoivira posrcriofrccdra.c aencrauya$oci.td wnh
a discrepâncyiû widdl ôf the ùpper .ûd 1ôwerdenrà1drches. Itr
ûe caseof a bùccalcrosbite, the brccal cùspsof the lowû eeù
occlu.leoùtsrdethe bùccal cùspsof.he xpper te€dr, vith the
lower ârchbeirg dispropo(ionàtely$ide, or the trpperùrc* ln
rhe .de ofa linsul .rôssbire,the bnc.al .ùsp of the loser tooih
occludestirgùal tô the paiaral.nspofthe ôppôsinsuppû toorh,
with the ùpperd.h wide or the lowernâûôw.The dis.repân.yin
widrh may be dento-ah'colafin o.iAln. or lr ma).be â signot t
skeleta.ldis.reparcy.Buc.al segmeni.rosbires may be bilatenl
or lnilateràlard the tÙo rerd to be ûated differendy.
Inler(eplive
meorules
t .he dl -'m"n'ol,n-d'ûo lvov r"..."o', rl"-.
r o l r b n , , T ' h . l l c ' o r ( , r h r ' ,. o r u n h , r
. Unilâieml lotrÊriôr .rossbircsârÊiometl mes ûerted in order ro
pr!J- -r.p.,-ç -dî,"ro, --

A unilaterèl bu..al crosbire may be .$ôcia.ed vidr â
nandibllar displâcemeni. The discreFaûcy in xr.h siddr tro
docesa cusp to cusp transve6e .eldliorship between the dental
dch6 wh€n the teeth o..lude in .he retrûded conta.r posirion. lD
dder ro achiele à beùer oc.lusion, lhe ûmdible i\ po*ùrcd ro
oneridewhcn oornrg rothe inter.uspal l,osi!ion. This pro.lù.er â
nomal bn..al sesment occlusion on one side and a Ducca,cros
btre on ûe other. In sùch â case, if the mdillary' â.ch were
expardedin rhe transre$e dimensjon ûntil it was ftdc cnough îo
(commoddte rhe lower iD rhe retrtrded .onrâcr posjrjon, rher
bolh tle bù..al scsmenr crosbite dd dre mandibxlar displàce,
neût would be cotrecred.A naftôwnessof dre upper arch mdv also
be.sociàred with lack of spàce for the ;nciso. leeth, ard rhe
ex!ùsion of drc upp€r àrch ûay âlsr p.oride $rfficiert spa.e e)
cotrectthis prcblenr. Earh rreètmenr ôf milarerâl buccal segnenr
do$bire may be indi.ard ln dre early mixed denri.bn, aficr dre
trrçtiôn ot rhc i6r permdenr molâr, whcn ir becomesâppârenr
rhù there ls insufilcienr spacefor rh€ uppcf incisor leerh.
This lide of rreatmenr is àftn.tivc onll ifrhe skeletâ.Ipatern
is Cla$ I, so that there is no nccd .o corect rhe in.isor relarion
shit.nd ody ifthe expansnrnwilllrovide sufi.ienr rpa.e fo. rhe
uptcL incnor rceth. This .a. bc as€$ed br using dre sPa.c avail
ableibr rh€ lower incli,f rccrh as a sùi.le rô rhe spa.e available ior
d,c ùtler in.isô6. Ifrh€ ircisor relarlonship reqùlres.otrccron,
orùr rcerh are crowcLed,then an inrerceptive rpproa.h rô.orc.r
lhe bù.cal crxsbiie wiLL ùvolve iso corl.scsoftrea!ûent rèther
draDore. l_ôr rhe sâmc .eason ùe irterceprive approach is more
olten indi..re.l whe. drc Ûo$bite hàs a denrGaheolar basn
ndE than badng irs origjn in rhe skeleral pacrern In th€ làfter
.6e rher is likch ro be some ôthei ordrodon.ic ûearmert reeded
d " l,', di,' - 'J l, É,1' ,l b ne, or 'n ,, re,.-pr'\
Bllârerâl c.o$bites are seldom amen2ble
srh âge.Thcrc is usualLyè skeleral .oaponcn r in theèetiologyof
the coûdnioq there is oiter no asocided mandibùlar d'sfla.e
hent xrd, rherefore,les indl.arbn ièr ùeâ!ûenr. Iû a.lditbn,.he
ânoùnr ot cotreclion reqnired is .onside.,bly gr€arer thdr is rhÉ
caeNith au.ilateral crosbiteanda.y coffeclior is more likely t()
ÉlaFc. Ifa bilèreral ùôlrbirc is r.eared at è11,rhe coûe.ûon rs
ùsualll done as pait of r .omtreb€nsile cou6e of orthodonric
ûeatment, ràther th.n as an ;ntercettile meâsure. In rhe sanre
sar, a ljnsùèl crôssbire, if nor dùe to the defle.rn,n of a sinsie
tooth by r retained primary predecesq is gene.alll a$ociared
sirh 2 marked Clas II skeletal l,ârt€.n, ard is ror aftnxblc ro
tieâtmenr usina â. inter.eprive apprra.h.
Pernianenn
dcn1ition
Plannedlossaffirst permanentrnokr teeth
Haplrazafdlos oflirst permânenrmolai rccdr cao haveà deÛihen-
raltFe.r o. die dseloping o..lu!nn. :fhc vosr eilects âre n$dly
ken in rhc lowe. arch, sher ûesial rippin8 and mesiôlirgùl
tutarbn of the secôndmôlaf is ùsuallr elident, wirh a poof
.onta.ror no contaû berweenrhe se.ondmolar and th€ secônd
I
onnmûiiè( | l6l
Tûorh
I
premolar (Cr.bb àdd Rô.k r97r). In addirion, lhe upFer fisr
molù cm over-erùptinro rhe sFcc leii by lhe exlmftion of the
Los'ertooth In the.ase of eaflr lo$ ofan ulper Ê6t molar the
ùppersecoûdûôlafwill uually moven,esially,roratirg aboùtlrs
Falatelroôt,bnt * ùh relatirelvli ftlc titÏ)inA. I l]it is evidenrèr d
ca.ly age tl,ar the fi6t permanrntmolais havca t)oorlona term
prôgnosis,dren.arctulflânni.gofthe rimirg of the exû..tion of
theseteedl.an help mir;mize the delererloùs effects.
lfthe 1jBt molaf is los eârly,belbrelhe fornatioû ofrhe rôor
ôfthe uneluptcdsecondmoldr,then the seconddolafiiu sencr
allv move fona.ds beforeit en,pts, côûing rhroù8h tu .cplàce
ihe llrst mol2r(Tbilan.lefur,/ i 961).If the eaÛa.tn. ofthc t.y
nola. is del2yedunlil the secoûddolar ls eruprcd of is on
rhepoinr of eruptjor, therewi11belittle fôrwardnro(mcntoflbe
se.ond nnna., s'hich will then proceedto rip and forate ,n
dre ùrnrer des.ribedabore.
It iollows. then, ûàt the riming of dre exùac.ioûsshould be
\ ' r ' d r ' o r i ' I r o r h - & " r e . | , " n" , " f ,
If drere is ûo malocclusiôûând the first pe.mancn.molars are
beirg extrâcte.tsimply be.aùseofcaricso. hypopldia,then eârly
extrâctiorôfall foû reeth.s'hcn rhc bifu.calior oftheroorsôfrhe
lower secondûo1âr is j$r risiblc on a rudiosraFh(at ebourthe
'orç
d g - o ' , 1 - J , ' s i r ' . 1, \ ' r . 4 o \ " n e ,I o r ' . , ' e , 'p ' e d
secorclûolats, which nr dr;s câseis jlsr what is wàrted. If the
i.cisor olerjet is in-e$e.l, or rhe anrcrlofreedrare crowded,so
that rhc spâcccreâtedby the exÛâ.rion of the fi.st molaa 's
ûeededfor rhe allgrmcnr old,e r€erh,ûen the exÛa.rioûsshould
be del.yed.In dre .asc of the upp€r arch, in n,ch a !ruâûon, r
$ould be pruden. to delayùe extràftior ôfûe first nrolaa unril
afrerdre cruptionofthe secontmol.rs.Ir "ruld rhe. bc possibLe
b uc a. orthodonticappliânce,incorporatingthe secondmola6,
. . , ! \ ! . , , . e o r r t F . pe . , d - , r b l, t . \ i{
lorsof liÉt pemorent
nolqrtee
! !ùly los oanst pernânenr nolar reeth will âlLov ùesial dôvè
.rent of nÈ se.odd molar
. râre los of.[.I]N ùolar Rnl pr.udê sF.e aor the corte.tio^ ofa
Fâlocclusion, bur in the abse!.e oa.INding, rhÊ spâce.esulli.g
hom dre lâte lo$ oaù lovor 6^t dôlar drr be dlfr.nt rc dose
Tooth anomalies
5uprrnûmeral,,
tee[h
SupernùDc.ary teelh .an occur mywhere in the !uuu,. DuL arr
pdti.ularlv common in ùe mùil1ùy 1àbir1 legment. Thcy âre
us,ally cla$ifie.l by rheir shape, âs sllpplencn!a',.ou@, or
tuberculate (Taylor 1972). Sopplenrcnral tccth resemble lhose of
the normal seriesfonnd in that dea ofrhc mourh ir is often dif
icult to determire which is ùe rpcmume.ary .oodr. Corical
$pemùmerùy teedl have.onical c.ov.s and are usuall! fourd in
dre ma:illart lèbi.1 segheni; they aft som(imes inlei!€d ànd
r62 t 0 P r ù s r i oonl m o l o d B i o n
|
may rehain ùnerupte.l, more or le$ ind€Unirely. Supplemtntal
and .ôni.al teeth sel.{ôm irterfere with dre eroptio. ot the per-
manenr reerh of rhe rormal series. lf the suternumera.y teerh
€rùpr, rhe teerh are ùsuâ11ycrôwded and ext.aclio.s, wirh or
withoùi applian.e therapy, will be neede,]io allow âligûm€nt of
Tubercularc p€mùmeEry reerh, which occùr palatal to drc
l ! \ ' l o f 'i 1 , d l l . F i a ' .' ,J) 1" ênr" 'or'..n
pLtvenr dre eruption of the developing permareDt teeth. It;s rîry
imforran. rhar the prcsenceof rhele teedl is recognizedat an €arly
age. The uneropled tubcrcuLate supernuneraty teeth sholLd be
extracled, suraically. âs soor âs possibl€. It is not æcesàry ro
uDcover the u.erupted pc.mâ.ent ln.ists; the mncoperlo$eaL
flap shoù]d be repLaced and drc i.cisos left ro erupt sponta
neously. This is whar is aained br eady diagnosis if detec.e,l
drlr', the pronpr removal ofrhe t!bercùlfte supernumcrafy reeth
wllt alloç spontdreous eruFrio. of ùe permânent it.iso6. lf
.terecred late, then removal of dre supernumÉrâry teeth is le$
likely to resùli in sponlan€ous eruftio. of the .enùâi iûcisos.
Their subsequenr sùrgical erposure, fàllowed hy orthodônric
alianmenr, prô.luces a tess satisfactory result. Orthodonti.
exùùsion ofuûerùpted teeth terds to leave a long clinical.n,wn,
s'irh an ùnsari\ta.rôry gingivàl mùgin aD.l redlced pc.iodoûtal
Hypodontiâ
Hypodonria, when one or more ofthe teedr lails to delclop, is a
relarlrely commôn .ondiriori which is almos ceftainly hereditary
j' orlsin; as such, .herc is lirde s.ope fôr pr€lention. Il we djsre-
sard misslrs rhird mol2.s. thc prcralen.e ofwhich ls.Ufficxlt to
à$e$, lhen approximatctr 6 per cenr of people have one or nore
mssins teeth (Gruhnen l9t6). Eârly Ûeament is seldon indi
câted, but ifthe te€lh a.e crowded, thcn ùe absen.e of t perna
oûrt toorh vill innuc..e the decisbn s tô which teell, âre
scle.t€d ior erûa.tiôn
Ëctopicând ânomalousteeth
tuIalpositioneà maxilkrl ca.nine leetb
Malpôsitiore.i cùines ùe acoûsiderable nuisarce, fiom the poitt
ofview ofborh the pètient ard thepruc.;!ionc.. They a.e difficult
tu Ùear, the ùedtmert is lenathy ard demardina lû te.ms ofcô
operarbn ôn rhe pârt of the patlert and in te.ms of re.hni.al
expeitise ôn ùe pdt of the operator. :l'he malpositbned ùoth
.dbe1eIi âlôre, or r can be exràcte,li it can be aliAned by merns
of orthodorric ùearment, or it .an be aligned surgicâlly. Eaclr
of rhese remedies has irs own dlsàdvantaA€s. h it p$ible k)
inrercepÙhe devel.,ping problem and, by earLyinremennon, per-
sùad€ lhe malpositioned canine n) erupt itto the coûect positlon?
The commonest lirc oi i.rer.eptlv€ Ûeatment tlÉt has been
recomme!1de,l is exùâctôn o{ the primd!' canine tooth. This
approach is usually just;fied on empirical srounds ràther lhan
scientific clinicaLexperiencc;s citcdas theaùthority râtherthar
the resÈlts of ary prospc.tive mndomized .lidcal trièI. There
ha!e, howevc.. bccn reûôspective studies rhat hxve lett
'o l..l'n'o-,(.'1 r . r . o n , , J K u r o l r ' o r r. ), in
ûe trimary tooth has beet extrac!€d are compted to ccc
whi.h it hds .ot. and it is claimed thar the exrmctn,n ofthe
m.ry rooth hâs heen beneil.iâl. The trearment in rhese
live studics has never beet randomizcd and dre groups ln
rhe priûâry roorh has bccfl leit t, rt, always conlair.6s
$hi.h the reasof dre trinrâry too was left in place was thÀt
perm.nert toolhvas io a trLly hôpetes posiuon and rhefesd
i p, \hd oF'ero'. s" ,. i Th 1 ,lrer _\p d .-
ùc more likely it is thar the frima.y rôôth \aill hart
cxrm.red, on the srounds tha! thc d;pla.ehett oi the
canine may be dk in part îo somc tàilure ôf resoiption oi the
ofihe primary ùoth.
ll 1 ' " 1 , , 1 , r 'l ) i r ' . l r d r l L ) " i e " , L
aso.idted widr rhe prcser.e of â dimitutive ùfte.lateral i
or â missing late.al incisor. lt voul,l appear that the root of
latcral h.ivr mar p1èy some lat ir Aùidlng d1e en,ption oi
d€velopinscanine.The mdillùy canincreethshôul.LbePÀl
Ir the Labialsulcu from the âse of ten yeârsonwdds.If
teeth are rot labable at this âge, then .adiograpbs shotLld
tèLen, ro determine the position of the !.€.utred teth.It t
maûeûtcaniû€is lalaûlly displà.edto a r€la!;velymild
and there appea6 to bc a lack of root resorption of the !i
caniæ, dren crûa.tbn ôf the primary câninc woù]d bed
ablc line ofÛeatûeût, provided rhat it is intended eveniudly
align the permaoent roodr. This vill probèbly involvc tbe ùkoi
fixed orthodontic applian.e, pôsibly prec€dedby dre
exposùreofthe tooth, should it fâi1ù erupt spontaûeouly
exùaûion ofthe primary looth wiu seldom ren t tt
al;arment of the unerupt€d.disda.ed .anine, bùt may
some inprovemenr in rts tositior. The exûaftiot ofdÉ
roolh commits ûe opemtor to a p2fticulâr line ôf ûotment d
Iâterdate.Ifrhe rootollhefrimary entrh ha not stafte.rro
rhen the prlûary cânincmar hat à bettet long rerm pro!
dran â pe.manent.dine tha. hâs bccn rcpositiotedsùrgi
sirce ûansplanted.aùre te€rhtend tu undergoroot resorytion.
Helplulinterventions
Ttansqosirian of teetl)
Transposirio. ôf teeth occurs when two adia.ent teeth èftenp'
erupt ù then posirionsinterchanged. Ior sômereasotthe
thai are usuall-raffe.tedàre the permàncnt.anlne ândû6t
molâr in .he ùpper àrch and dre pcfmâneni .anine a'id

ir.isoi in dre lo*er ar.h. Or.e âgâiû there is little thèt.ar rre
donetufrevrnt rhe prcblemieârlyùedûert is sômetim€s.atried
otrtiù the lo*erar.h wherethe lateralir.isorû usualiyelrèfted,
lollô{ingits e.&,pi. erùpttuû.
D i Ltceratian af inci sars
Sq,ûnumer2ryreeth cr. trerent dre e.uprion of ùlipcr .cûûa]
inlisof tccth. ÀnothLJ ftas,û thcsc tce.h may fail t) enLpt is thât
rhedevelopina ùitrh is dih.eEred. Ihls developmental anômâl!
pfuduccsan anglc tr(wccn thc c1îwn of drc ûntrh a.d l$ rôor.
Th4.oull be câuse.l bv rrauma to the !.imary uu,cr r.c,!rs
aNiig d,eir inrpacrio.; dre triDùy teerh are,lrn'en ut irro lhc
l. - ,1" .1'i"l o\'o \. L\.
c'n"
iflrt jncisor, prodlcins an arsle between the croçn ofrhe toorh
arl its roor, which conrinles !o develop in i6 origj.al lDsirjo..
Thepemanent enth.hcû ialls to cfùpr. While thls ls a plaùslbl€
exllù.itlon for die riroduction of this anomalJ,,r has ro be sa,,l
thxt.lilacerated nrcison iieq!€ntly develop in sitùdlions vherc
therer absolLrtelyDo history oI traùmd !o the prjmary teeù !.,1
theæûology ofthe cordirion A qnite obs.ûe (SteNèft 1978).
Thûe is nôr n .h rhar .àn be dône to preve^t ûe dila.er.tiôn
ofincnor, brt etly diagnosis of dre rearon [r fai]ue ôferuptiôt
ofrhe pÉrmanent in.l!,rwiLl aL|x proper planning ofanr ubse
!ùent tfeatmcnr. Tlrc dlla.crarcd ûxrh i\ ù$ally exùa.ted,
thougnin $me .6e\ n mây be possible ro âlisn the toodr oitho-
loilcâlly. follo\ling i$ slrgi.al exposùre. This mr). hovever,
pndù.c a disâtipointina .cùlit. If drc.c is â markcd bcnd in the
ftnt oi the .crùal in.is)r it nray bc diffl.ult e, âllgn the ùxtrh
without i.tcfc.ing virh rhc positio. of its ncighbou.s.
Riskassessment
Sùeening
It hd sometrmes beenn,sgesed rhùt.hil.lren sfoul(l be sc.ee.e,l
ù drcprcscn.cofo..lusal aûomâLics, âr xbourrhc ascofteryears
(Churgard Ker 1987).Ttre ârgreûr It6 beendû this $ôu1.1
" p p d. \ - - û 1 .d
r ' ô f \ " . . d o n . J - . . 1 1 o , r , .' r . p e
'b ,\t r' '' P^otn'
nomenr.'Ihcqpc ols.fteninS prc.cssthat has$ùally beenadrô-
mÉd{ould invoh'ca.lini.al ortbodonti.asscssnrcnt aûd the rak-
iùE of a fan{ral mdn,Amph.Stùdicr of tLrcd}lcacy of uch a
soccringfro.c$ hâr indi.àrcddur rouri.c scrccninaoichlld.c.
fd o..lùsalan.mâlirss ould .or bc a cos.cfii.rivc .acr.ire (Hiles
'l'here
198i). arerwo reâs,nsi(tr rhis: the o..lùsal anoma.lles
tobe(letected h aly.de, whedieror not dre chjldrer arescreene,l
a,J ilin ànomàlyis.le.ectetlasà.en,lt ol dre r.ee.i.g trocc$.
drrc aÉ relacivelylèw casesiovblch dre child vould bcnciltfrom
eùll irter.eptile treèrnent (Popôlrch and TlionpsoD, 191t,
ÂclerûJnr and Proffit, 1980). Iù other words, rh€ sùeening
doesrôt èfect the ôut.omein the nèjofuy ôf.ùes.
Frocess
\Vhetheror ùot à sûeenùg prôgr.mùe $ould ren,lt nr th€
eùll, .lere.rioû of o..1usâ1probteds rhrt wôù1dôdrerwisego
ùn noticeddeperdsor rhe levelofpro!isioù and uptukeofdentâl
mr."*" ,e;
|
[orly lreolnell
. !ù]y û.ùDert ol a!{eloling malo(lusionftU $metimes etra:l
thr provisio, of tro.ou6És of ofthodolri. ûstnÉnt instmrl olo.e
scrvi.c\ (Àl Nlnti ând Ri.hèrdson, 2000). lfâ 1Dpùhrbn ol.hil
dftr À€xposed to a high lelelofproi\bn ol de!.âl serll.es, theû
thry àre likell to receive a dcnral LaanrinatnD in xnl, cde. The
\.ree ûg'for mèlocclLrsioothen bccomes pâit ô1 thât pioces,
and is rhe responsibility ofthe eklnnrins dcnrist. If rhe level of
provnnrn ofdental services,or ûe lptake olseniccs is lo$. thed
ùc rcsouces rhat could be sp€Dt or lhe frovision ot a s.reening
prosrammc for o..lusâ1 anomèlies wouLd p'obâblr bc bcrtd
di.c.tcd ar irnpn)ving the geûerè1dental condition of ùc chil-
dren, radrer rhdn ôn screenlûg ior râlocclùsioo.
Conclusions
. ft is difflcult ro pr€vent nalo..lùsôn raost of tbe etrort
rhar i\ expended ôr interceptive o{hodo.tics is dire.red
rcs'ards caflr ûentment nthei thù preven.lof
. Cxrelul riminc ôf dre exùa.tlon otpoor gualitl ilN I)€r
mancnt molas .an prelenr the delelopmen! of local
malo..lu\bns, as can piompr erùactlon ofretrincd primary
teerh dut ûe defle.tnrg the e.uption ot rhcir permanent
. Eafll rrcaùnenr of tuberculate sùpefirùmen.) tccdr $'ill
ccftainly c.couraEe \pôntuneous eruption ofthe permanc.t
lriso6, an.lgready simflilt their subseqneûtâ1igtnen1.
. There are some sirurhns ln whi.h eâr1voithodontrc treat
ment may be bcncficial, ftsuking ln a simpler treatmût
phù or nr a more rafid coursc of tfeârment, but .11 roô
often, eâlly treâtmcrr meaûs moÉ ûeâtment. eitet.Irng
orcr a longcr pernrd ot ride, or iû rhe prorn,on or t{'o con
se.urive cou6es of trea.menr.
. The lse ol myo-lù..tnnâl applian.es û .ôûeft dereloting
Clds II mâloc.lusions is probabl) better resèr.{e.ld a fùll
Lnowr .oùrse oforlhodon!;. ùcarmc.r thân a\ ân intercep
. T \ - d r r o rl . \ F q , , p , l ' , r ' 1 , ,dt,.1
'i 'a. 'ô'.' Cpr,lll"'-o-lo 'i I'\' "'-
menr aûd ôfprelentne ùeàtnreûr should bc to mlnlmrz€ the
totrl amoùnt oflretrrn,enr that !c.ds o be phvidecl
terd
References
Ackermrn, J.L., nnd Proffir, w'R. (1980). Pteventrveana
inrerceptileorthodorticsrd sro.g rhco.y tmvcs ùeak in
pra.ti.e A,!, olthal., 50,,at 1t,-.
Al Nimrl, K., Dd tnhai.hon, A (2000).Inre..eptiveôrtho
dônti.s ir the reùl world of.on,muniry dc.tistry.J P,ll
Drr.. 10,99 108
I6a I l0 Prevention
ol nrolodlsion
I
Ball, l.À. (r991). Bdld.ing rhe exûactio. ot p.ima.y reerh:a
t * . e e . l î t . J . P a t d .D m L , J , r l 9 r s t .
Baune, LJ. (19i0). Physiôlôsi.rôothmlarar;o. and its sisoifi
once for the develophent of acdusio.. J. DeûL Ra.,29, 123.
Chuns, C.K., and Kerr, $rJ.S. (r987). Inte..eptiveofrhodor-
ri.s: applicariofland outcom€in a demàrdpôpulation.Art.
D e n tJ. . , 1 6 2 , 7 ) 7 6 .
Cmbb.JJ., and Rock,v.P (1971).Tratmenr plânninsin rela
tjon to ihe first p€rnânenr m oI^t.Bt;1.Deû.J. , r3L, 39AaL
_D
D r ) . A J . \ \ . .r d l - ô . ' . l ' À n ' n r e . _ , B . f , o, nr o
the prevàlence of molar do$bire and som€asociàte.tèetio
loglcalconditiôns.D?ur P6eti. , 2\ , 1A21IO.
Erlcsor, S., ànd Kùrol. J. (1988).Early lrearmentofpèlàràlly
eroplirg mdillùy canlnesùared by extnclior ofth€ prl
n "n ,l n-\ P,"./ 0' roJ. to.2a1 .\.
Fields, H.\xr. (1999). Moderâte nonsl.eletalproblens. In:
Conlû,pafary 0$hoà0n1tt,]rdEd., Chapre.r I (\T/.R.Proffit
ecl.).Môsby:St.I!u;s.
Fôser, T.D.. a.d Hanilror, M.C. (1969). Oc.lusiôn in rhe
p.imary de.ririon. B/i, Deel.J.,726,7Ç79.
Friel, S. (1954). The developmentof ideàt o..lusnn! of rhe
sùm pads2n.l fhe te€û. AtM.J. orîbad.,40,196.
Gnhnen, H. (1956).Hrpodo.tiâ in the permarentdentirior.
AdaaLR4!,7 \SUt pL 3).
Hiles, A.M. (198t). k o.thodortlc screenirgof9-yFôld school
.hildren cosreffecrive?B/tt. De"l.J., r59,4114.
Housron,WJ.B., Stephens,C D, dd:rùlley. wJ. (i992). ,4
'rdtbaok
ofonha,la,tits,2nd Edd.,(Tablel, 1. p. 3 I and Table
3.2, p. l7), vrisht: Oxfôrd.
Johnson,E.D., anciLùsôn, B.E. (1993). Thumbauckins: lit
et^rwe re\ieq..l. Ddt. Chill. , 60, 38t-39r.
Kerr, NrJ.S. (r980). The ettèctoithe prerat!re 1os ofdecid
uoùscaninesàûd môlds on rhe e.ùprionofrhd. succe$o6.
EaNJ. At1bod.,2,t2) r2a.
K i ! ' 3 r e r B . I . o 4 8 l .( - r d l ,.{r(,iv p...,-
,.lnrein dentâl orthopaedi.r\etup'l A.td )drnî. S.asd.,8,
1713.
Larsson,E. (i972). Dummy md finserjùckins habits çrth
speciè]àrientionto their siAnificàûce for fècialgrowth aûd
occluslor. .1. Effect on fæièl sro\arh ard occlùsion.S,r,.
Tatu,//aÈ..
Ti^ Ar, 6t, 6at 614.
Leishton,B.C. (r969). The eùty sisrs ofnatoccluslor. Ûa,r
Exr Oibad. 5a...4t, 3t3 368.
!è! der Linder, r.PG.M. (1990). Prablen!a"l Prazd,r$
t" DdlafdcialAûope|u, pp. 27 18. Quiûtesence:Chicaso.
Melsen,S., Stensgaùd,K.. ùd Pe.tersen, J. (1979) Sùckiûg
h.birs and theirinîuence onswallowingpaÙernand prevâ-
1en.eof ma.lo..isiôn. E,: J. oût\d., r,21r-28a.
ÀIllls, J.R.E. (1978). The etrectof ofthôdônri. Ûeàtnent oû
'h-.|-i-lp J ' l l . l l . 8 ' .J a - L à . . . . , - 1
Popovich,r., ârd Thompson,G.\r (1971).Ivaluètior ofpre
vertive and '.tercept've otrhoJonr'c treârmeni berween
three dd eighteenyeaAof agÉ.châpt 26, J.:r. Cook (ed),
Tràrs..tions ôf rhe Third Inrernatiônal Ofthodôntn
Cong.ess, Sr. huis. C.V Mosby.
Ri.hardson, M.E. (r965). The relat;o.ship betveen the
relariveamourr oi spaccpresentin the deciduousdenr.r
archand the rate and deArecofspaceclosuresuhsequent to
the ext.action of a decidols molaL Deflt. Ptdtti., \6,
llt 118.
Sre$ârt,D.J. (1978). DilacerÀteuneiupted mdillâir, .enûl
l a . j s o r sB. t t l . D e s lJ . , 1 4 5 , 2 2 9 2 a ) .
Tallor, G.S.(1t72). Chanûerisricsoi sutcmumc.aryreethlû
die lrima.y and pe.manentdentltian. Dent. Ptd..i., 22,
201 208.
T h i l a n d e r , 8 . , J a k o b $ o n ,S . O . , a n d S k a s i u s ,S . ( 1 9 6 1 ) .
Orthodontic sequelaeof exiraclion of pernarent linr
nolats. S.dtd.Denî.J., 7 I, )Ba4r2.
Wilmott. D.R. (1984). Thumb sucki.g h2bit a.d a$aciated
dental differen.esin one of monozygousrwins, Art. J.
Aûbol.,II, 195 199.
Prevention
of oralmucosaldisease
Crispian
ScullyandAnneHegarty
lntroduction
Mostcooditiors that âffect oial mucosalhealth â.e acauired.
thrôùghenvironmentalôr lifesyle fa.rôB. albeir the genetic
conslitutiormay well iûfluencethe result of an onslausht by
some agentsuchas a miclo-o.8aûism.Variousbiological,physr
câl,andchem;calfacto.smay act sirstyor io coûcerttocauedis-
ease,someof which is preveniable. A ranse of infections caû affect
theorâlmucosa,brt few âre more devastâtlrsrhù HiV, which
car resù]t ir orâl ând other fùnsà1, rirâ], or other nù.osàl idec
Mùcosâllnregrity is cenÛâ1ro prôte.ting rhe môùth dgâinst
irfectio$, or lmù1ts from the environnent md lifesryte.Ade
quaie.utlitior and iû!ac! immuûe aûd other defencesare. in
tud, cerûal to mu.osal inteA.ity. This cbapterd@ls wlth the
nâjôrprelentableihrezrsro the ora.lmùcosain fôur seftlons.The
fisr É1aresto preventingoral infections,paiticula.ly in vulnem-
ble!at;eûts. The seconddealswith p.eventablerhreats iion
litesryle.
Therethen follow secrioûson iatrosenicdisease, pa.tic-
ulallypeventirs ard manaainsmucositis(aDùea ln which rhe.e
isneFevjdenceem€.si.s), and on nuirition. The latter is a larse
aodcomplex subject,but the role ofaood ûuffition iûprevertlrs
dùcosald;ede occu6 at manylevels.
(ûse:of orqlnuroroldi:eqres
lnfections
Thepreventiônof oral mucôsalinfeftions in an ihhùno.ômpe-
tent penon is a .elatively minor problen mosrly effectively
âchieledby avo;dins contact.Only ca.didldis is reauyopen to
prevedtlve
i.tewention, ard i. sone casesthis may be;odicared.
tor immunocompromised patieorsdrouAh,the impact of both
endogenousand exogenous idectlonscar becooside(able, a.d the
trse oforsanhns that car causeprobl€maticinfectjoûjs talse.
Id suchc6esstepsto preveÂtinfections,or ro Iion dren, may be
indicated. Tbe ûost .ôûmon ûùcosÈl i ectio$ are candidlass
Oral infectionsin the immunocompetentperson
Candidiasis
EqdoAenousmucosal infe.tions àre tot comon, except ior can-
dididis+specially chonic aÛophiccmdldlâsis(deûtulerelated
stomariiis).Cardidiasisjs predisposed to by xerostomia,the use
ôf ântibiotics, aûd the use of corticosterôids.Denture-related
stomatltispreseûtsaschronicmucosaleiyrhemâbeneathm ùpper
denture,mainly tulI deirures.Ir is most connon in the elderlx
especiè]lyfemales,ard parricularlyifdenrûes de wôm ài niaht.
The eartiestlesionsare pinpoint ared of hyperaemia,which
progressro diffuse uniform eryrhemaof the hard palar€. nôt
extending beyôndrhe linits of the deoture-b€arlnsa.ea.le{
padenrshavesôrenesùn]e$ thereÀ alsoaûgularcheilhis.Car-
àida albiuns may Ee impli.ateà ^rà Cak.lj'la spe.les colonize tbe
fittins surfaceofthedentur€.Remôvàlofthe deûtureplaqueuu-
ally teadsro .esolutionof rhe romatiris.
It n unclear why only some denûre weâres aet chronic
arrophiccaDdidiæissirce C. dlbi.dB is a coûnon otu]l.onme^-
sal.Facto6 rhai may be import.nt irclùde the locaLenvnonme't
beneathâ dentùre,die!, ûe spectrumor type ôf other ôrgadsms
in denture plaque, and the hor inmune àt.t othe. deferces.
Trauma may sometlmes .orùibùte ro a small extent, but
hypothesessuch as aLlelsy to dentùre nàterials have beet
Denrdre-relÀted slomaljtis usuaily resolves, or càû be
prevented;if rhe dentu.esare lefr out or rhe mourh ât nisht,
plaque is removedby brushios, and the d€qtufts disi ected.
Yea$lyti. enzymesàrd proteolyticerzymesârerbemo* effective
d t r , \ . g r . n \ ' ' . n d ' J . .D e i ' r - ^ o " k , E . o l , i ô a ô n i J n . n g
berzoic acl.l complet€ly eBdicates C. a#r|ad fron the dentu.e
. u r f , . e. , | ' " I Ê n ' p , n r o r n e! r y l . r e , n r i o e l n r " ' $ , 1
o r g i ,i . T ' n ' h - . ' e l d s r a . e o r . h e p r o t h e . . \ ( h l o r l i . i -
dire slucomte is ar elïectived,si ectant. solutionof at least
0.12% chlo.hexidioegluconarecad eliûinàte 6. a/rr.a,r ot the
acrylic resir surfaceof tbe dentuJe. and redù.e pdÀtâ1 inflanma'
iion. À p.oteaseconrairiîs denturesoàk (Âlcèlàseprotease)js
âlsoan effectiveway ofremovins dentureplaque,especiâllywhet
combinedwith broshios.
168 ll Prevenlion
olor0lnuo!01diseose
Chronicaùoph;ccardidiasr whichdôesnôt resolle(especially
lfthere is an anAulù cheilitis)mèy requireùeàtmentwirh topical
dritunaals such a ûystatin,mphotericin, or hi.ondole. Ilu-
co.azoleis aLsoeffec.ive,pàrticù1d1ywhen admjniste.edconcuF
rently with ân oral antisepticsùchæ chlôrhexidine.but should
nor be sed in parienrso. \(/ariarin.herapy.
Otber infectians
Apaft from hish stânddds ofpe.sonal hysieûe, rhe ù seof bariers,
and the âvôidance of contact with those wirh commnricàble
diseases and .he;f bodily nuids sùch as salivà, little cân be
done tu p.event exoAenousi ecrions wùh pâthoAenic agents thar
'"r.Ê m, uùl lesior. no._ of s5,.h r- L"rpF.\,,u\\ .
Orâl infectionsin the immunocompromised
peïson
TirereaG dramaticincredesir the nûber ôf immùnocompro'
nised personsboth d â.ônseguence of ùe elïecrsofinfectioo by
HIVar.t ôftreàrmenrôf orsanûa.sd2nr parierrswirh imnulo
sùppresive dgents.Both ar€ characierizedby a predominardy
T lymphocyteimmùne defecr.T celh a.e e$€nrial to prorection
àgèitrr infe.ttun vith fu.Ai. viruses.and somebacterià mâin1y
mycobacteria:imuno.ompromncd patierrs are drus ]lùle to
infectionbolh with fungàI,mycoba.teria.l, aÂdvlral parhoAens (if
'h-.,, n, | ,,oi,r' w'r\ rl-n\dd ù 'hoppôn'.'r i o Jdr-
isms,particù]ady,caûdidaând herpesviruses.
Infectioôsi. immunocompromised personstend to be recur-
rcnt or protracled,severe,md sometimesresisrantrc ùearmenr.
Occasioûallyrhey disseminàre.In genehl, the specÙum of
lÂiectionsis wider, aod their severitygrearer,the morc profou.d
oral fangal infections
SuperÂ.ia.l oral ftrAal infectio.s(mlcoset, esp€ciallycardi.tidis,
are extremelycommôn in immùno.ompromlsedpe6ors. Can
dididis accountsfor neù1y 80 per.ent of hospital-acqui.ed se.i
ous fuûs.] infe.tiôns. Mosr candidiasisis causedby C. alâianr but
other species a.e incedingly tound. Candjdiæispresertswlth or
withôut sôrere$, âs typ;cal whire or û€âm colouredlesiors of
thrush ôn ân erythemarousbacksrouDd(pseudonenbrareous
' , i d i d r ' n . o r . . e y r \ e m r r o u .d , . 1 . d . - , ,S. o r e p " ' e 1 , r ' .
developar8ùlaf .hcilitis.
Ordl " rdidi^i ' ',. | \ pr,\"r'-hle q '_l o-e.po' . -
to, sandâr.ltopicai aûtifunaè1s but relÀpses are in.reasin8lyse€n
and there is consequentlya tren t towdds rhe use of syremi.
imidazoles (ketoconæole)and bis-triàzoles(flùcônazoleand
iffacona,ole).lfântibiotics ôr .ôfti.osteroids(oralor;.haled) are
corlribù.irg caùses, redùcingthe doseorchanAinAdre rearoenr
may help. lnrermittert or prôlônSeduse of top;cal anlifurgaLs
nay be necessàrywhere the underlyins cause;s unavoidable or
ncurèble. Antifùnsal ptuphyldis may well be ;ndicared in
immu.ocompromisedpersos
Polyene
oniitunsoloseû
:lhe polyene agents. dedved f.om si.eptomyces species.inclùdc
l"irl) , ) { , 1 " d " n f l , o . ! , ! i 1 T l - e yi f t u l i , i , , l r
effec.ile topically, but have an unpleaant lasre. Ilucytosift
b€ ùsefirl as oml prcpbylaxis or rhempl i. a doseof t0
rg\;d"1. r dld-rd. . f u , , ' | . d d J .l o \ ii l . d . "
netabolic effectsoD bore narrow cells, naùseâ,vomitlrs,
hepaticdysluDctionhavedjscour€ed rs useasanrst ]iûe
Arols
ogenls
Azolesare syrthetic antifunsèlswhich are expeNile Tle
rently èvailàbleazolesùe ctoûinàzôle, mi.onùole, e.
ketoconùole,flucomzole,itra.oùzole, ârd voticordole. -Atl
azolesarefungistÀtic,nor fungicidâl.This is especially
.o or, d "h-. ' -d . 'h r,ôni "l J na ,,.,,pp , pd.
aslhosewirh AIDS. None ofthe èzolesareertirely benigr
totoxl.ity may be .ommon .o a.ll ol drem, aûd the potenrirl
eûdocrire toxicities exists,pdticuldly ar lligh dôses
às with any rew àgent, nôvel roxicùies may yet be discôvûed.
o ral berPesairus infect ians
Herp€s simplex virùs (HSV) infections de the môst
recosnizedoral liral iûfectiors:50 7t per cent of
pror,Fd pâ.É "' ô, 'fo e ôn LFiô'h1ipl de. lop od
Chronic, extensive,and painfut moùth ulcers
Lesions.
cïccially dre keratinized mucosa are the most common 1.
r or'. ard *' ',,p- l"b d nJJ b , r. \4" i
resuh frôm reàcti!ètior of 1àteft virùses(fôr example,ln
trigeninâl gàûglior) àûd the virusesde ofrenshedin sâliù
Thoù8h parientswirh Hsv-induced oral lcsio.s âre
maiûl). wirh suppoftive ùearmc.t. paiticularly ma,nte.ade
fluid inrake. antlpyretlcs and anâlgesics,and topicaLann
prerent bactedal supe.inrection,anti .als are indicated
lmmunocomp.omisedpâtients or ir othe6 where thûe
ireqùent seve.e re.uren.es or .ompli.ations. Ànriviral
ldis. therefore,mèy weLlLreindicatedin imm!
A.i.lovif is a potenr acyclic gunosine defivaiive ot very
toxicity. Adverseeffectsare rare aûd ex.renely mrnor
rashes,nausea,and other sastroinleslinal €ffects have
F p o ( . J | | . o m ep d . . . n - r e ê v , n Sr h e . l n I o r J l ) . , n l . i
blood ùrer and crearininelevelsmay b€ seeûaiter r
adninistnrion. Aciclovir ha sianificàntclinical benefit
HSv ard is far moreeffective.hm previoùsnucleoside
suchas idoxuridineor vidârabine.
Â.i.]ôvir hd been advô.ared for prophylaxis in i
promisedâduhsusing àn orâ1dôseof200ng rhreeto foLù
dài1yor à.i.lovir topicâlly.In esrâblished
lesionsviml
paln, and dù.ation of lesions a.e substanrially reduced
a.i.lovi.. eirher lnùavenously ât a dosc of250mA every8
or orally400m9 5 rimesa dây.Aciclovlr .esisrânce
6 now
in8 a clinical problem. particulafly in f,2t;ents wiih
airer ii$ue ând orsan r.ânsrlants,a.d vith HIV dise6e.
a.i.lovir{eslstant HSV isolates are fôtuunately, s€nyti
 ,.,e\i tr,'enr,rS
trtary; '^r'di*r." I r,,"
ordln
I

ioscamet(Ûivrdtun phopho^oibrmâtc hexa.hydràte).Valaciclo!ir,
lhefLo'drùg ir sômetimes !s€d.
Pr";tz;/. nÉlârively newsy.thcti. a.ydn gnè ne derivâtn'c
' |osessesihr sde èrtlv,ral sFcùùm as a.iclovir
. hd simlla. mechannm ofa.tion tô tha! ofâciclovir, in thât
i! ùndergoes pho\phorylation in rcspnre to HSv !iraL
d,J,midirc kinâse, is theû futhe. pbosphorrlÈted by host
(llcazlnres into â triphosphdle, vhich sele.tively inhlbits
HSV viral DNA rcpli.ation
. hd consider2bly more bioavàilàbiky uf to ll7
lhe 10 20% tar a.i.lovir
. hd i lonser inûa.ellùld effe.t than aciclorir
' n morc effective clinically than àciclorir
. is cheàler dran a.l.lo!i
. d â 1 pef.ent ùed applied evcry 2 houn for'1 days is
ellcctive in herpes labièLis
. Iamciclorir, the pro-drug, ls soûetimcs used.
New a.ti h$fes agents for herpes labialis in.lude i0 per c€nt
Otber ùral i'zlections
Vr ,r"{. .r \\./\/o lr' i{..,rFl oa' o \",
HSv i.Jections.vzv is latent in seûsoryroo! AanSliaand ftacti
lailor may causczo{er Ghinsles).The Lesio.saft ùl.erativeand
e{tremeLy painful. mal lead to scaûnrgand fost-herpeti. neûraL
gia,and occdionallyresultin disseminàtionofVZV Ac;.lovn is
rhem.st relièbletherapr.ând may redn.e the locidenccofpos-
hdpftic ûeuralgia,Lrut aciclovir{esistatt vZV ùe now being
identified.VàcclnesagajnstHSV ând vzv ùe low available.
Humd .]rcmesèlovirus(HCMV) ir one of the leadins.âuses
ofhorbidity and moraliry in immunocômptomised
islrrert 'r salivaryslùds, but only rece.tly hasbeenreco8nted
m causingoral lesioos:lhesc are ùsùal1y.hrônic Paintirl oral
ùl€rs.No èbsolùtelyreliablc.clTe.tiler(.ite n availableaaainr
HCMV bur rhe Towft vacclnc a 1lve.pasagedI'ICMY may
.onfer usetul protectiot in at tisk patients such ès traosPlâot
re.ipients.Passivtiûmu zètionusinAspecifi.ihmutoglobuli.
virh hiAh{irft, anri-HCMV antibody âltef e.idental exposuLc
ro the viros may ptuvide à.iegreeoftrctcctio. agâinn Prhary
iûfecion i. scroneEativtr,bj€cts at risk. Intcdebn hastot been
Iôurd ro be prote.tive.
L o w . l o s e so f â c i c l o v i r( 2 5 0 m 9 I t i m e s a d a y o r 5 m g / k g
2 timesaday hâvc.ot beenefe.tile i! teatnrcnt ofHCMV reac
tivâtlon nr bonc maûow Ûanspl.nt pdtients but ora.laclclovir
(200ms, 4 tim€s a day) siadifi.ândy reducesHCMV shtdditg
and.hish dôseaciclovir(4t0msr 1tiûes à dây).an prevenÙea.-
rivatiôû ôf 1èteot HCMV. Gà,.;.hr;,, à gùanoslneanalogù€, r
aftive Ègai$t .ylomeAàlovûÈ\.but is more toxic dran a.i.lovir,
.an ptudu.e reutropenia,,nay hale .d.iûôgenic dcriliry â.d. if
glren rvith zidorudnre,can pmdùc€profoutd myelosufpie$ion.
It is lsed for seriousHCùlV infe.tions nrch as retlnitis ànd
qral bacteria.l i r.fections
A wi.le .ange of bè.rerid câû. in imûutocomtrcmised Patlen$.
occasbnauy .olodze thc moudl md mây sometimes caùse orâl
inte.tions, or bc the portàl for scpri.aemia. Broad sPe.ùum
ùtimlcrobials .an aLsocàuse shif.s bùt such drugs are Primàrily
responsiblc fof dris. Bacteria thât are typically tôund dsewhere,
sn.h ès lowcr in the aastro;nresrlnal tt^.r lEvhoi.hid cor,
Pa'drîùrd! dtr|bntu, [.atenbaclet ,]adLn'. KbblE d lnex"tu"iat,
agàitst Sàln|/kld eùetit;d{) may cô1o ze lhc moùth, ètd selticaem6
invôlviûg !iridans srcpococci, coagulâse-negâûresaPhylo.o.cl,
capno.yrophaga and odrer mlcro orA2nisms ôrigimtiog in the
' ' i ' i , F | ' - F . ' ' ! ) - , , . ' I ' , ' q \ - 1 i
orLei imûu.o.omprom6€d paùen6.
In addiriôr to bacrcfial infections ot rhe oràl rùcosa,
ncuûopeûic pdti€nrs may develop petiodontrl iûfections and
oraanisms .ommonh riestd às palhosenic su.L1àsSralrll4.,..,rr
epi.LrnùJt, C dlùtdtr, S. dar&\, aùà P. a{rû"6d may be àete.teA
nr high cor.entnrions in subgingivâl pLaqùe.
Denral plaqùe .ônûo] may ùerefore be crilicât i. rhe idmuno
compromiscd.an.er patjert Conventionè] toothbrushing is tyPi
.àl1y coûû2indi.ate.L .lurlng le.iods of myelosùPPte$bn due to
tlie isk ofbleeding.nd itfèctionr but, sincefoâm brùsh nLbstitù!€s
are nor as effective in contdling p1ùtue and Sinsilitis, chemnxl
de.ontâmi.âtins resinens (such asaqueoùs.hlorherid i.c) are also
required. Odorbgeni. i.fections de pôtettiallr Lfe threatening iû
' 'e In | 'o -ftr'.io p,r"nt. - 'd bro"d PeL ùn F
reeded (such d t€nic;llinplus gentâmicir).
I e.rive agents of imponance in imn nô.omPromised
fxriens.It
. Hcrpe$di.eLlà zoster
. Hùman cytomegalovûus
. Pkrt/nnû?d dû"!1,?o!j
. Eù#abatiet dad.dL
. Kkbrtlld |".,n]o,idt
. \dllroret{tt e"td itidi!
Lifestyleissuesin preventingoral
mucosal disease
Lifestlle, or chadges in llfèstllc, can hàle â Daior imPact tn
prevenii.g dlseat in ma.y systems, in.ludinA dre oral mucosè,
170 I I PrevsDli0n
0f0r0lnu.or0l
dkeoss
bùr ir 6 in the areaof oral epirhelialdysptasiaû.1 .dcer rha.
llfestylefactorsarenosr significânriû prevenrirgoral disease.
Trâuma,Chenicals,or Burns
Traumè from appliàncesor prosheses may caùs€orat ùlceratnrn
and. very rarcry, neopldric charse. Orâ.1mutilàtion mây be seen
n sômepsychidricallydlstubed palierts or thosewith lerninA
disàbiliry Io sone Chireseànd Hiodu cùlrûes rhelips,.heeks.or
ronguea.e ceremôniaLly piercedby sped or orher objefts whjle
thepeson is inastare ofÛmce.In someEd! Africàng.oups,the
ùn1a is remôvedir children in rhe belief that healrh will be
Àdverse oral effefts ôf deftal amalsalll Inây iûclude attergt
llchenôi.l ra.rlors, eleciro,salvènnm. and amalgam tattoos.
ÂhalAâm 'tàttoos' âre the hôst coliûôn oml tartoos, bù. àre ror
.liscù$edh€re.In rhe dseloping world, è6ngeofdifferen. ryp€s
of raaooscao be seen,sone det;berâtetyiDdùced,othe.sacclden-
ta1. Acciclenral rarrôoing ca originate from use ôl rhe bùk of d
dùntJ"stdq esia (De n or Dendava) ùsed âs ar o.al hysiene
aid. ôre p2.riculdly obvious tàÙoo is lhat ofthe tabial and buccal
mûillary sirsivâ deared usins soor. tn Eriûea. femalesâ.e târ
tôoedôn rhe ânteriormdiliàrJ, siûs;và in cnildhood:mâlesare
tattooedor y in rhe canioeregions.In pdts ofNorth Africa. lhe
lip mày be tarroô€d a.d ir sod€ parrs of lresr Africà, the skjn âr
the coûh;ssùe is taùooed.In rhe d€velopedwo.ld, deliberare
tattoosûor û.oqmonly ûserribal or peisomlrmes epecially in
the lowe. labial mucosà.
Chemic.tly inducedlesionsofter presenrasmricosalburnsor
white lesions.They cû be causedby:
. DruCs
. aràlgesicrablets
. cocaine,snùtrôr smokeless
robaccodeiiberately.ubbed
irto dle I'nAi!æ or vesribùle
. pancrearin.arcauseulceratio.
. Orhers.especjailyalcoLolcortàin;.s washes
. Dertal prô.edu.es
. æids (chrcmic,ûichtoracetic,phosphoric)
. self-cùrlna.€siN, especiallyepôry .esiûs
. Tôbaccoprodù.B
. rhe hoûsepiar!Dieffenbachia
. lhe enzymebromellqir pineâFple
DiaAnosisis from rhe hisroryard clinical fearures.
Thermâlty i.duced lesionsolien pftsent ,s nucosâi h.ns or white
lesions,and cm be caued by hor foods ôr dri*s, not n*roments
(dental hadpiece ô. extrucrionfor.eps.for example),etecr.icat
bu.ns, cryosurge{',ô. mdiarion. Thôseseenes!€ciâlly on the palare
ôr bnsE, for exmple, pûza p.làte, preser! a whire lesions,blis
ters.o. ulces. Diagnosisis fron history and clinicâl featuæs.
I. soûe Aroùpsln developirgcôùnùiessùchâsin someAna
zonid ùlbes ard ir the Surila liibe ôfErhiopia, lùge plates,e
woro in the lower IiF. OtheB weaflip plugs.SomeAfricar ûibs
suchas ûe Tôposaof Sudm wea. a p;eceof wire, uu,e,ssuLr6
rhe Dogon ôf Mali wearrings, in their lower lip. In the wesrû!
counÛies,jewelle.yjs ùsM1lyappliedro the lips (lab.er)but rhe
pEftice of lingual pier.ira is a caùseof sone concen s,nce
oedemâcan be pronoùnced a.d may be hdddous ro the ÀiNatt
fllu<osal
domage
tonbeeoused
by
Epithelial dysplasiâ and cancer
o ral epi thetial .btspks ia
Studles i. \Vestern popùlatiors conJirm dre dsociètiôns of o.,1
€pithelialdysplaia (orD) th robaccoand alcoholse. Anatysis
of the effec$ of chewing or snoking tobacco, alconor coasunp-
tion, body nàss index, aD.t veserable.frùjt, and vltami i.on
inrake oD .he risk of e.ylhioplakia in Indim pôpularioasalso
showedihèr tob&cochewinsmd alcoboldrinlirg de sÛo.s rjsk
facors for erythroplakia.
The role of di€t ir prevertins oral epirheliètdysptaia is te$
, e " I a r . n d \ F r .' " b l e ' n û k " d e , u n . ' d e t Jr n p o " r ' r r r -
ablesir lôw€.i.g ûe risk ofoml cârcer,bùt this may not nece$
sarilyalwàysbe rhe cae wirh oral eplthelial.tysplasia. A srùdyol
1èmâletobacco/betel chewesir SourhIndjasùAgesÉdrharadjer
deficient in foods of animàl origi. wd â môie sisn;ncaûtrrk
tactorfor ôral premâliAnân.ydrar is a diet defi.i€.r in frùlts ùd
Oral tquamozs cell catcinoma: risk factors
\Vorkirg oùtdooGirûeâses.herÀkofllp cdcer: fan comrlexioû
fbbàc.ô.o.raiDs nicotineand orheralkâlôids.ÀLn1ûosm,nesare
\ - . , n p o L n d ., t - ^ , 8 r - ,r o b e l n e r , i o r ! . r I n o - e n , ,d 8 f , \ . n
tobæco.Vol.rite ûd orherdtrosàûlnesnay alsobecôntdburos.
The exce$ive ue or tobaccoFroducrs has been âssociared
with varioùs lesiôns in rhe oràl cavty. Tobac.o sboking can
havea range of adverseeffecs on oral healrh in.ltrdi.a predjspos
ina ro candida .ariase, caûdidiâsls.and ieukoplakia. Orher
 tiktye ssuer 0oru'rt*A oi'**
r. flevenn l rr r
I

tobacco-associared lesn,ns in.lùde tôôrh stains, âbrasions, Ahobol

snoker's melanosis, acùte necrtrizing ul.erntive gingivitis, àtd A studyof alcohôtôisusersfron soùrhLondorshoweda high
ôrherpernrdonral.onÀtlons, bùrnsand kehrotic pàt.hes,black ;.cidence of roôth weàr ânl traùma to the den.ition. and a small
hrirytongue,nicorlnicstomariris.p'latal erôsions, epnheliâldys minority had oral mucosa.l lesions, includlng rwo prevlously
plasiâ.
and sqùmôuv.ell.ar.inoma. ûeated .ai.inomas (Hatris ,t at i997). Àlcoholics have demon-
Tobaccois smôkedàs cigdettes, cigâ6, oi in à pipe and, in $nble .ytô1ogicd1abnormaliri es on oml smeds, thôugh whether
' ' y b e ' - e , e J ' n J r ' r p , yo l s i ) " t , ^ f ' , i ' th€se a.e due to a direct efe.t of alcôhol or m effect secon,lâryro
Àddirires.Àlcobol synefgizes with tohac.oasa risk â.tôr for all a$ociaied mâlnùÙitnrn is uncieâr (Tâble 11.r).
upperaeodiSestiveûact squamouscell ca.ciromd. The effe.t ôf
snokingfalls oIIsoonaftersmokingceæes.
AMlytical stùdjesstroDslysussestthat tobaccosmoking of 0rol (on(errisklodol5
ary type, bùt especiallypipe smokiog sjgnjficardy increâses rhe
dsl<oflip cancer.Detailsoftaryield ofcisarettes,and ty],eofcis-
âreiteusedfor the toDsestperiodcènbe ùsedd the basisofa cla!
sificatjorto exanine the effectsof djflerent types of cisareme.
CiSafttescan be .ldsified as low or medilm if the rar yield is
belor 22m9, m.l às high if ûr yield is above22ma. Compared
vith non sùokers,the risk oforal cmcerfor smokersusjns lov to
mediùmcisùetresis 8.t Md for hish tù clsâreûesis 16.4.
A regardsinûn-oral car.inôtu, the siresof tongæ, nouth,
oropharynx,and hypopharyn' âre sô ofren grcuped tôgether ir
ma\itl.al studies,or sroùpedin a variety of differenrcombrna Taba.cca PIus ahabol
tions.thar ir is dill]alt to discus rhesetumôuB individuâlly. The ep;demiologyof ônl carcer ald the vorry;ng in.reasesin
somepopulâtnrnshavebeer dis.ùssedelsewhere. The reasons
fôr
Smoheless tobacco anin reasingin.i.lerce oforâl cance.,paft;cularlyâmongyoùnger
Snokelestobâccocooiainsa numbe.ofcar.inoSensand its Be is peBonsis ùlclea. A suney of ).oungpe.sotuwith orâl càtcersug
tobedep.ee.ed.Thereis.]ed.ôn.ern aboùfthepôssible.ùclno sesr drat mosr a.e er?ôsrdto tràditioùl risk faclorsor robac.o
geni.ity and ôther advese etrefts ofthe snùfsôtd Ir small reabas smok;.g. d.inking a.lcohol,ù.t à 1ow consunptioo of fruit and
pouches. Thereis somelimited eviden.efor mâ$ociâtior between veserables.By 1988, bôrh tobà.co snokins and alcohôl con-
theue of such smokelesstobaccoand oral can.e.: there is no sùnption had beenacceptedas independeûtrisk facto.sfo. orul
doub!,however,thar smolele$ iohaccocan indu.e oral keratôsis câncer(orul squmou ccll car.lnoma).cônvincitg evidenceaLso
and gingival rece$;o.. The fict rhat rhis forn of snokeless now exisrsrhar rhe combined etre.t of â1côholand lobrcco is
tobaccojs h€ld nr the nouth 10. very lons periods, and is greàterthar ùe sum ofthe two etredsindependeûtl}Giveû th€
polulù wirh childrenând âdolescents is a cauL-tôr.on.ern. larseàttributalrlerisL fof rh€ two habnsôfsmokits and alcohol

Tâble11.1 Dietary componenrsrhàr mây either caùseor prole.r aga;nstrhe developmenrofcàtcer it hùnans+

ALcoholi.,lrlrks,mert, (r) cofeÊ()) ftuLri/r mill TrJ

VÈg<nbt<\.
Totâl energy, iâr (?), .ompler
cârbohydrÀtÊs (2), âl.ohoL(?)
Vitami. A,riBnin C 1?)riboflâvin (?),
iodine (2), non (2), selenn,n (r)

Nitntes and nnrites (2), sâ..harin (?).

Âtlàiôxins,N rnrôsô .ôùloùnds (?),

poly.y.li. rmmrti. hydrocârbotr(?)
The!au$ ol!!i.û
fsn Âimsrqq, B K , M.Mnhæ1,AJ , .od Md-effm, R (193r)
,{depteJ dif. In c"M E!ilaùilasJù1Pûnùs @. S.hùttÈùfrld,
îrJ J E
rNnen,, ds.) v. B. SNf,.les,r,hil&lebhq r 429
d, sF..urdyc, and LÊ${êll esùlishrl êfi{6 âre irdi.rEd br a,lus!io! oek (r)
172 I I Preveniion
ofor0lmuos0l
disoore
drirkins, dre dramatic rcducrion in risk (within t-10 veàs of
,lui!!ins) provides srear hoFe fof the prelentioû and .ontrôl of the
groving menace ot oral cancer
Betel aseand other babits
There is some.oni,sioo ôver the ùse ôfthe term betet. l'letel leâf
is deriled from rhe iret€l vlûe, while nurs fiom ihc bctcl pa.lm are
termed ùeca .uts. These two products may be used orally alone,
togedrer. or rogerhe. virh other material such as rcbacco, slaked
line, aod other a.lditives.In Papua Nev Guinca slaked line (bùt
not tobâcco) is è prominert compoD€nt of belel ; in odrer areas
tobeco mây be a marn comporent.
white ûere is clear elidence of carcinoseûic;ly r.om robacco.
rhe risk of ôràl càûcer is àlso increàsedin pesoN who chew betcl
with or without tobacco. Arecà nùt ùse clearly predisposcs to
orâl submucous Ubrosis. â recoarizcd premalisnanr .ondition,
.an .ause .ytôgeneti. .hanges whether tobècco is or is ror used.
ând cd result in the àppeMnce of r\ dtroso compounds in dre
sâ1iva includiûg N-niÛosoguvÀclne and niirosamio€s such as
l-(merhyl niÙosamino) prôpbniÛite a pôverfùl cèrcinosen
;n .ats. Afeca nuÈspeclfic N-nltro$ .ôdPounds càn also
câuse epnhelial chanaes , 2itm and can promote erperlmeûtà]
Resuhr
of useof belel
Molttblt.tsb tlse
In a study basedon .asesof ora.l.d.er in wômen àrd à cootrol
grorpb . o r l . g , e L ' r . n o lr s r d , l r'-rp' o, reÉ
coifirmed as jndependent.isk fâctors.but.o asso.iatnn wàs
foun.tfor moùthwashuse.Patjers wiù or2i cancerrcporteddôre
freqùenrlythaû did conrrolsrha! rhey used mouthwashtu dis-
suise the smell of tobàcco... (aod) ... alcohoL'and mouthwa\h
6e wd fourd to be strorgiy ùsoclatedwith smolirg and drlnk-
lng. Thus,usinAa moudrvâshappcafcdin rhcseinran.es to be â
proxyfor e+osure to robaccôoralcôhôl,themseives rsk determi
nans ôf ôFl câncer Hôwever â stù.ly from the USA repoited
rhàt,àfterâdjùsnenr for tobàc.ôand alocholxse,the risk ofohl
ca.cer amona usersof nouthwash rvas{ound tô be increased
by 40 pei ccnt in men and 60 per .ent in women.The increased
risk vas apparenronly wbenùsingmoudrwæhesofahighèlcohol
conrent (25 pef cert or hisher). Thùs, it àppeùs that th€
risk lrom âlcoholin mourhwashes is simild, at Leargualitatilely,
to rhât of al.ohol used for drinking, ahhough ir terms of
airdbutable fisk the conÙibùrion of Doudrvash ue tô ôrâ.1.àtcû
Otber liquicls
Pa.ri.ùld rypes ôf teâ (ma!é) co.sumed lû Latin Âmeri.a may be
asô.iàted ûlth oralcàncer. Sùdies frôm Brâziland Urogual'h,1t
demonsrrâtcd rhis asv,ciation.
M.tr;j ana ûse
ll ù\' l ee, .om- r.e rcf r,\ 'i . ,1 " r ' r m. t. tn,
smokers, btrt these have yet to be sufported by dâtà fron an
epidcmiological study.
Socioeconomic staltrs
The rclarionrhip beBveen socioeconomic stâtus and o.al .ancer
i ( ' - b - r . " 7 1 o : . 1 .T l - " a d , . r ' ' . i" ololi.r.t,
were considered (edù.àtion, o..upatiotal stàtus, an.l percc.tage
of porcrrlal {Drking life in employne..). Aftef adjustnent fol
esrabl;shedrisk fdrors, the third jndex (percenrase oi pôtential
$'orkins life in empl.,yment) only was foùnd ro have an indelen'
dent æsocjation vith onl cancer risk consistett virh dre hy!o-
thesls tha! behav;ours leading rô socià1 instability, or social
instablkv itself, arc linked to an inùeèsed risk of oral and
Occrqat;on
Limlredepidemiolôgi..l
evlde.cesuAgessin..eased ink for oûl
and phèryrsealcancerfor workersexposed to fornaldehrde,
workes çith acce$ to alcohol (sùch âs bàften.les and resiaunnt
wôrkert, elecffical and electto.ics s'ôrkers, te{ile and appa€l
$orkers, and mùnÈde mineraL fib.c vorkers. Most of th$ evi
den.e .omes frôm occupalioDal {liseâsesurelllance $udies and
r.om drospective côhort slldies in vhi.h rhe ntrnber ofcasesof
OTâlsqùâmous cell carcinoma: protectile factors
Diet
The mosrfavoûabledier fôr redùchg oral cance.risk is Alvenby
infrequentconsumpion of red ând proce$edmea!aod esEsand,
most of all, by freque.t resetableand fruit lntake. The rcle ot
specificfood groupsand diet varieryôn the risk oforal a.d tha-
rrngeèl cmcer hd beenconsldercdin a cde cottrol study in tbe
SwissCântôû of Vaud. Afrer allowaû.e fôr edncatioo,alcohol,
ù,ba..ô, èrd total €nergyintake.signifi.aflt ùends ofincreasing
risk *ith mo.e f.equcnrintake emergedfor eggs,.ed mcarand
pork. and pmcessed neat.Inversetrendsin risk wereobse*edfot
milk, fish, raw vegetables,cooLedvesetubles,ciÙus fruit, and
odrerfruirs. There8âs a r€ducrionoi âppro'imatelyt0 per cent
ln oral caocer.isk with rhe addrtionof ased.g per day ôffruit or
The !el2rion be$een selectedmicron!ûients a.d oral and
pharyngeal câncer risk wàs invesigated using data frôn a
casHont.ol s.udr in kalr and Switzerlètd(Nesri rt d1 2000).
l. general, dr€ more À hiùotutrient was corrclâtedio totâl
 Musitrs
II?3

vegetabLeand fruit intale, the sronger w2s its prôte.tire effect

latrogenicOralDisease
Preventing
Retinoids The rangeoforÈl lesionsnow rcognizecLâsiar.ogenic.ômplicè
tioos ls j.crcasins, àn{ undoubiedll will inûease;r the ftrùre,
The risk of oral .ancer has been irve$ely dsociated with .on
but mucosiris is symptomâti.auy rhe mosr Frofound Drug
sumption of fruir and vegetablesin sercral *udies an l with con
indùc€dlesioN èreâho important.
suûptior of lilamins. Rctiûoids N.h as 13 cis reti.oic a.id
(solretnroi.) a.d fenretinidÉ ând .arôteûoids such as cr-.ârôteûe
cansupp.es onl le*oplâkias. hoùetiooin may also prevent the Mucositis
developm€nt of carcinoma and can also prevent second prinuy
O.âl mu.osltis is a major dosellnited loxic elïect of inteosive
tûou6 in pàlients with onl squmoùs cùcinomas but does not
cancer rheràpy, and vadou aspecs have been reviewed oler th€
precnt recurrerces oflhe trimary neoplasm. Retinoids supprcss
pâst few yeà6 (Scully,l z/. 2001). Mùcosjt;s.somedmesterned
orâl premàlisnmt lesions a.d dedease the irci.lence of second
mucosalbârrier injury o. À{BI, is the term s;ven to the wicle
prihdy tumos ln head aDd neck cancef patietts. Ther€ is some
spreadoral erythema,ulcetation,and sôietess,vh ich is a.ômmot
eviden.e that ll cis.elinoic acid (isoÛetinoit) ethances cell
.ompli.atiôr of a numb€r of therèpeuticproceduresinvolviÀg
ùedrated immu.l.y aûd Lanserhds cel1saDd thât bda.arotene
chemo . radio-, or .hemoradlorherapy.used largely for cancer
indu.es a mononucle.r infiLtrate in the tùmoû n,gge$ing lhàt
rherapybû alsoin the conditioningprior to bonemairow ûds
idnunômodutatioû nay be a p.ote.tive mechdism against ihe
planatn)n-haemopoietic stem cell trètsplantation (HSCT).
rmoû. Retiûôids, however, also regulate gene expresion, vhich
Mucositisinvariablyfollows exte.nalbeân ràdjotherapylnvolv-
may be â fûher, ôr èlteûative, mechanism. k is thought tha!
iûg the orofacia.l ris$es, èrd may follo$ .hemotheFpy At least
rerino;dsrestoft nôrûal celt growth md djfrerentiation by meâûs
40 per cent ofch€môtherapypatientscan be affectedb1'mucosi-
of nùdeaf rctinoi. acid (R-{) receptors (RAR alphâ, betâ, ànd
tis, èûd there is ôften ùn.ter€stim2rionof severity o. undeF
samma) and rednoid x receptors(RXR alpha. beta. and gâmmâ). reportlng.In par;entsôn flùoroùracila.d .isplâtiû, 90 P€r cent
d " \ Fo p m u o . ' ' . " ' d ' . o p o , l e " ' J T ^ I ' J l r , . eo J l ! , -
ô"æii-{r"rorof1. tarly sereremu.ôsitis. Oral mucosltis ls seet it orer 7t% of
1 - r , " " . g e e - , . n . | ù r r . n r ' e Jo e
nerts, ârd 0.t pe. ceoi mixed reà (a.omposite ofvhole {'ater patlens dd is particuladl severe dter HSCT bccaùse of radiètiot
extrar ofgreen tea. tea polyphenols, ânt teapjsmens) âs the sole damàgeârd myeloablation. The cou6e tollows the Polymor
sourceofdrinking water for two weeks before inltiation of 7.12- phônuclearleukocyte.ôunt, whereconditionlngwirh total bo(ly
dlnethyl-benzlalànthracene (DMBA) .reatmert ând unt;l the imdiatiôn (TBl), aodmethoÛexàte for prophylaxisof graft ver$s
end ôf the experiment iD golden Sydan hâmres, slgnjlicandy hosi diseaseâs in allosraft patients, cèusesproiound myÉloNp
dù.ed rhe incldence of dysplasia ând oral cdcinoma (Li et a/. pre$ioû. and severemucositis. The litter is acoûmon seqùelae of
1999). Prôre.tion fron DNA damase and sùppression of cell hish-dosechenotherapyand upper màttle head a.d ne.k irrâdi
proliferÀtiôn côuld be lmponant mechannms to account for the ation,pdticùlarly with TBL
âûticàr.inosenlc effects of the tea prepârâtiots. EGCG I( )- Mùcôsirismày haveaslAnifi.anteffecton the qulity of iife, it
ep'€-o\i,i 'n- -À"11"'.. f m.ror oN' 'u'n,.l g-en '" Èrûs ofpainr âbihy to eat,swallow2.d talk. and thereis oftet.
afects.ell populdtiôns, inhibitirs srowth, vith a cLecreàse
;r eiri- lhererèrc,the nee.tto iûrerupt or cûai1 the themFy.rcducethe
.acy d.ells progresed from normal to.ancer. doseordelaytherapy.lnonc studysome30 i0% oftarieûts with
HSCT Èh thâr mrcosnisvas their môst sianiflcanttoxlcltl. md
Cancerchemaprelenrion:Bouman Birk inbibitor ws particula.lyaprôblem af!e. TBL
Bovmân-Birk iûhibiror is soybeèûderived proteaseinhibltor Mucosiriscanbe cànseddjrectLybr.rotôxic effecs and i.d;
tha!ha demonsÙablÉ .hemoprelenriveactidty ina nûberof i, recrly by susrâinedneutropeniaâfter .ytosatic theraPyw;th
,tr" and animalsystems.when the factorwasadminnteredto l2 chàûsesir mucosaliûmuûe reaulafio., colonizitg microlloE.
' b e . q , l , o r - , r L k , p l " L "o r n o r t hr e t r , a . o ' ' ' " and woùnd heâlioa.Mù.ôsitis cana.iseasa consequence oflhe
dinic2l rcsponsein lL per cent (Armstrongt,/. 2000) Pôsibly . Dired effectofthe inteaentive regiden on celi d'vision
via an effector rar oncogeneexpression (wan n al. 1999).
. Releaseof cytokines Guch ès loterleukin-l and tumoùr
reûosis factofalpha)
. Oral i.Jècrionsthat mdy ensùe
. ÂgsrÀvationby tm@â
Nor oûly doesMBI open the way to adbercn.em.l iwæion
by oral conme.sals.bur the flon chanscsseenin suchpdtients
leadsto the appea.ance or in.rede in poteniial paihogeff sùch
as à1phahaeoolyti. s.tptococci wbich cân lead to bàcterèem,â.
r7a ll Preveirion
olor0nruosoldiseoie
I
Stqh,oc,,t nits.an ca$c bacreraemia dd, especiallyrn îboseor
high doserytarabi.e, âdult .cspintury disÛes sytdrome. An-v
fall û reùtrophjl count clcarh asgrantes the situatlon. whilc
recô!er)-ofthe count is mi..orcd in iî{nution ât.t heèlins ol the
mucosiris,sothar healirg is .onrplerebr 2 I weeks.
Mucos'risappeaBfrom I tô 1t .Ltysàfter can.er r.câtment,
ea.lieralrer.hemôrherèpyrbanâtier ràdiodrerapr:lhe pah from
mn.osiris.ân be so intensea ro i.tcdircwirh eating,ànd slgnlt
i.aûtly affectthe qùalitr of ljfe riequcntlr leâdinstô the needfor
opbid analgesi.sarcLsometimesto jnt€rufrion of the pldned
cancertherapy.In âddition to caûsingpain, ulcc.anrc mu.ôiùs
car p.ovide a poital fôr diûôbial ertry, a.d can thus lead rô
locâlard lrmerimes sy$emici ectioDs,which may cvcn be life'
Murosilis-rharacterirlicr
' Ëry.hema,ulcention,soreres
. UD .o.io% oa.heno â mdioûenpr pabers dffeaed
. tt.,.-,
, , . , n. . , r t " i i i '.
' D
) i -
. Ld." r'u l]'4'otcn" ' brare cove.inA the ul.eB. SùrvjvinA kc.atinô.ytes resPon.l to
Prophylâxis
Thc has;c stmregies in ûâûàgement of mlcosiris aim at pain
reliel elfo.$ to hastcn healins, and prevention of inrectioùs
complications. Profhll2xis is howeaef, dre goal. Clinlcal trials
of agents aimed at frcrcn.inA or melioratiùg mucosilis havc
rôr, however, als'ays asscsscdthe .esults ôn strict critena, tew
ûu.ositis raling scâleshâvc becn.ered for vâlidity, ànd the mâny
mu.osiris s.alcs thai erir denl goô.1comparlsons of ptodù.$.
Spr.ial êttertioû should be direcred ro onl iniecrions in neu
'rol-,r 0.' lu'\t-" i,.nql { {. 'i,ooc"i '. 'r.
rhe leâding causeol bâctcmemia. Invasive furgè1 infectio. s of rhc
ônl .ality cm be .$ocialed s'ith systenri. tungâl lnfectioD and
de indi.àrions for the ùse ofliposon,âl amphoteri.ln B. Hosever,
antimi.tubial àpproacheshave net with conui.ting results,litde
effrci beiûg seeû wirh chlorhexjdine and slsteml. antimi.robials
in dre p.eventbn ôfmu.ositis in radiàtion patiens. In patietts
virh HSCI ând pâtiens with leùkaemia. .hlo.hcxidine may ûot
be effecti'e in treventing mucosiris. al.hoùgh the.e mày be
reduction in oml .olonizatnn by Cèt.lida. lfitiàl srudies of
tofical anrimi.tubials thû affe.t the Grdn negarivc oral nora
havc shown redù.tbns in dceràtive mucosjtis ,ludng radlariôn
ûerapy bur hare nor bccn assessed in lerkaeniatHSCT.
lliologic .€spo.se modifiers olïef the pôtertiâl for preve.tion
aûd for acc€lerationofhcalinA. Varhu!.ytokines ùlll et!€r cli.;
cal tridls in the near tutu.ci drcsc offer the poieûtiàl for reduction
of epitheliàl .ell sensitn'ity to thc roxic cftèctsofcancer therapy ot
lor stimulâtion of.cpaif ofdre damased tissue.
ol mutositis
Prophyluxis
. ùfonrdr ùlcrobal .oloniz"tlon
. Antivirùl Drothyldk
. ^ndaun!ÀL DtuDhrlab
. urroi _ . |'oD ,lr'.
. Brôlôli.al resDonse nodlÂeA
lladiationmucosilis
The àcute orâl mucosal fesponse rô Fdiotherâpl is a ren'lt ol
mltotic .leadr oI efithellal .e11s.The threshold ld mu.ositis
appem ro bc aboùi 20 Cy offractionâtcd .adntrherapy. The cell
.y.le time ofthe basdl kcratino.Fes i! êbout.i days and, as the
epitheliuûis aî leas 3 o..t.ells dticl<, radiation chanS€sbeAh to
appear .Lidcally ar ahout 12 daF .fter the st2rt of iûâdiàtiot.
Cli.i.alln theoral mucosamay initialLy tum whjtish, followed by
erytbcma, aûd ther àfter a few dâys is .ôvered by a patchy Ubri-
o- .d
nous cxudate.lfa higlt doseofradiarion is giveû over ashoff ùme,
ulcer2tion mal superven€€drl-von. with a ihick fibrinous mem_
.adiatbn dmage by divnliig morc mpid\', so dÉt sPontâncoùs
.ompleÈ hedliûg can be arri.lpated withiû I weeks ofthe end of
rÈdiation. The dcare€ of mucositls experierced ls deteimiûed by
the r€annenr dose, .adiâtior fieLd size, and lrdtioûation rhed
ules prescrib€d fo. indlridùâl pètients, and afpear! tô be no.lified
by saliva votLrme,toral cpidefnal gro{th faclo. (EGF) levei, .ûd
rhe .ôncerÛatlon of EGI in rhe oràl environmenr. Healing is
impaired by hlgh dose .adiotheiapy àtd by tobacco smoklng.
Oralmu.osr$ is afre,tue.t side effect ofcombined m).elôâbld-
ri'e .hemo èûd .adiorhe.apl pre.eding hâemopoieri. srem .eu
Ûdsplàntation (HSC:|). ùIu.ositis causespa'n, poor foôcLintake,
is à toft of etrÛr foi i.fecrion, and n typi.àlly seyerc atrd
frclonsrd with ûlceralion. Sùong opitte èm1g€siâis neededforà
median of6 dâys in ut to 50 per.eût ôfpatjenc. Mù.ositis tyPl
call-v begins ârôùnd i .lays post HSCT ân.l Pe6ists tôt a similâr
period. By ùorLn.t 9 r.i days I,oSGHSCT,bàs.lcell regeneratn,n
occu6 2rd rhe mu.ositls resolves
Prerentit)n
Porolidingimdiolion
ipof
Spadng at least ôre parorid Alând dùring irrèdialion ot parients
wirh head a.d ncck cancer will presene 1)a.otid fûctiot dnd
re.lùce xerostomia. Nlù.ositis can be .educed b-v protectitg rhe
mùcosa wirh .ridline nucosa sparlng blocks. or by modilyjog
rhe rddiâtlon trearmcnr. one rudy, ro a$e$ rhe benefit of
pantrid{pàring lradiarbn,.ompâre.l dre bodv weighrs of
parients nrè.liàr€d vith pa(tid-sparing techoiquc versus ihose
irradiated *ith bjlateml oppôsed photon beams, she.e both
parotid glands were nrcludcd in the raditiiot ll€lds Parien6
ùeated with parotid ryarins t€.hni!ùes ve.e bcter able tô

nainrainrhrir onl nuùirion and Lrodl weigh!, comparedwirh
pdiienBqlD had bodr pâroti.l glards jrradlar€d.
gl0nd
50liv0ry pro'edion
lundion ,/i m0di(01 0senrs
A a J " . 1 d ' . ' . . - ' - - . l o t ' F \. ' ( 0 6 r . - r ê , " r .
venôusly belorcmdiatio. rrearmenrâccùûularein high .oncen
ttæloûsiû the saliraq gla.ds ând sccm ro rcsult in a distin.t
tduction of sboft t,.rm .oxicity ôf rèdiodrerapyor .omôrned
hdnÈ.hcmother2py. Anifostine reduce.tâcuteânt chroûi. xeros
tomiabut nor mucosnjs. Antiiunoùr treèrment efficàcywâs
p€seNedrnaùseâ,vômitiûg, hypotensnn,and allè.8n reerôns
{ere the nost comnor àdverseetrè.is.
Counùin/Troxerurine (Venalôt Depor) ha'e shown fâvouEble
effecsn dre treatmentof radiogeri. sialadenirisa.d mucositis
in prospe.tive, randômized pla.ebo-.ontrolled doublc-blind
Arliinllommolory
ogenls
CLinlcal an.thistopâthologi.aldemon*mrion offtdu.tio. in orai
mucositlsvirh n,cràltaresqgess rhat sucnllà.e miahr hc rcc-
onûendedin rheprcrc.rio. orLadiârioni.duced mucosnis(Eriz
r/.2000). Proreolyticcrzymessuchas(ypsin,papair, md chy
norrypsin.ânbc benetici2L
\Grial etdt.2oor).
Benzydâmincwas evaluatedin Fatier$ wrh he&t ân.t neck
arcinoma tôr .r€rlmeût of ràdiatlor lnduced oral mn.ôsitis
(rp$ein d,/. 2001) when it.educed €rythena ant ulceràtio!by
about30 per.ent comparedwitb a placcbo;Arcat.f dra. l3 fcf
c,rt ofko,ydanlne srbjectsrenaiûecLnt.er free.onpared with
l8 })ercen! oi pLacebosubjects,and berzyddire significândl
delareddr€ useof systemicèrèlgesi.scôûpded "ith â pta.ebô.
leùydèmine wd nor effe.rlve, bosever, in rhosc receivlng
accelerâtedndiôtherapydoresofmorc than 22 cy,day.
Radiotherapy is âsôciatedwirh a mârkedin.rear in ôra.lG.am-
.e8.ti!e e.te.obactenaand pseudomona.ls, whi.h ôày rôt ônly
.onùibùte tu dre mucosirisbut releàseendolo:ins which câ.
caur adveBesyneûic effec6.If Gim-n€gative beilll do havea
de i. dre aetiolosyof irrèdiation mncosiris,then ir shôuld be
p$iLrl€ ro prev€ot,ûear, ôr delloràte mu.osiris by àbolishing
theGran-negàriveflôra.Indeed..llni.al ûla1sùsiûgpolymFin E
and robrdy.in applied .opicâll]' four tinrcs daily havc gircn
promiling rcsùlts.'flils reaimc. hasycr ro be fulll cvâlErcd to.
thenanagementofirradiat;onDucositis.and has.ot bcenshown
etre.tlrein thc mucositisa$ociatedvi!h che'nolherapllufth€.
.,i\ rf H.( r.) .n, .,bi^ .or.rds.
routinelyùsedir most.en(es, yer oral mu.ositisftmdtu asevere
a.d commonp.oblem Many instltlliors haveadopted.ornbina
dons such as ge.tàmicin, varconycin, and nystatiû d an oral
deconraniûarinsriose1àrprophyla.tic ùse,bùt furdier study is
- d e l o a r l , . r " ' h ,b " r a h . p o ' l o 1 o ' " .
Use of the low erergy heltum neôû lâsertherapy is .apableôf
re.lncingthe severnyand dùratbn of om1mù.ositis a\{r.iat€d
çith radlatlor therâpy.
174
Prevention
ol rodiolion-induced
muco:itis
. Paroril sFari.sBdlatioo
. Salikry clâr,i lote.ti.n wirh mÊdi.alagenis
. Ânti inndnarôry rgeùr
rrrcositis
Chemotherapy-inductci
The oral nucosal reaction!o.henrodrcrafr is dùe to a non-spe-
cilc lnhlbitory effectofrhe agento. dre mitosisofprollferatlnS
cells includnrg thoscir dre basalepltheltum..aùsins r redn.e.{
renewa.lràte ân l thus aùoFhy ând, ev€rû'âlly,ùlcemtion.Irrârk
oral ùl.erdion is, therefo.e,â pâ icula. p.oblcm iôr thoseon
chemotherapl Up to 20 per cent of Fticnrs on.hcmoùerapy
sdfer orèl ùlcerèriôn,especi.lly follovlûs admi.isrmtion of
.yrârabine, doxornbi.iû, bleomr-cln,etoposde, I lluorouucil,
.ardr \o r"'. rp'o-1 'r 'n *Fv"e
5-lluoroufuil devel,p mr.ositis. Mucositis cù caùsepaio and
mar be a poftal for infectr)nand lepti.aemià.The mtrcositistyp
i.ally persi$r symptumati.a.llyfo. up to L2 drys.
Prclention
kerhips
Ihere is $me eviden.erLlatice .hiFs usedfor l0 minutesLretore
5 fluorouracil(5ltl) ad.rinistmtlon ptvrnt ûùcositis. Thirty
€iAh! reportsofcheDorhc.afy trials s'erelnitiauy lndùded in a
receotCochranercriew; two qc.cdtrpll.âte repoitsand nine were
excludedas therewas .o ucablc i.fomxrlon. of ùe 2l nseable
stù.ljes,r,i hdd dala for mucosit;so. 945 rardomizcdpatients
ând It included darâ on oral .andidiasisf(r 1164 randomize.l
parientr. None of the propht'laftic .gers i,rclùded in lhe
coclirme reviewp.elenled mucositis,widr drc ex.eptn,not i.e
Anliifh.liveogenls
Chlorhexrdine is no nore eftecriverhaoçatc. at rcdù.1nsnru.ov-
ris. Sàlt m.t sodàmouthçash$ cheâpefùan ând a' €lTc.tiveas,
ihlorhexidineor a moudrwæhconraininglidocahe,Maaloxand
Benâdryl (Dodd et al. 2oaaJ. L daily pre\t.!i!e prorocol in
leukaemiÈ.ôûsisting ol (1) elimnatio. of bâcrerial flâqùei
(2) applicaiio^ of a mouthwashs'ith a nor-al.oholi. (nùtion
of chlorbciidine 0.12 pef .enr and (l) topicèl âppli.ètion oI
ndoporidone, fôllowed by swish and sça]]oq' çilh nystârin
100,000unirsren s in â significdr lmprovemen!iooral hyAiene
ând â sigrificânr dcdeaseid rhe inciden e of mucosirisèrd oÉl
ca.,lidiâsis(Le\y Polack'r,/. 1998). Ihere is evidene thàt pro
phylaclicue ofanrifurAalaaents,whl.h areabsôrbedôr pùtially
absorbedfrom thc gastrolntcsrlnâl ûa.t, redùced1e.1itic.1 siss
ol oral cardrlidsis,ard rbe parially ahvxbeddrugsmay be more
eftecrive(Clârkso.and \Xroftliûgton2000)
176 I I Prevêntion
ofor0lm!ros0]
diso0se

Drug-indLrced
lesions is itr.redÈd in proreir malûu.ritio!. Xerostomla ls a feature of

Ginaiv2l hyperplasia is a recognized comflication ot phenybin,

ciclosporin, .iledifine, and some odrer calcium'cha.nel blo.keB Fat antl fattl acitts
aûd hæ b€enrecosni,edibr yeas. SpaceprecLudes
tulldiscusion EpidemioloAl.al
eviden.e amnâ]
1i.ls a high nrul.eoi sarurated
but somearediscu$edbelowunderspeciiiclcsions. fats with oral d.l pharyrseal cmcer, ar least in males. Though
fètty àcids can be eseorial dierary .ompôtunts, there appearto be
no repo.rs on rhe elïecB ôf fatry à.id defrciencl o. tbe orâl
ol (hemothernpy-induaed
Prevention mu(osilii
Vitamim
Vitmins ùe e$ential o€ani. dieiâry fdtors iûcàpabteof beitg
syrthesjzedwithin drc body.vitaniB âreclàsifie.ta wateror tat
solùble(Table ll.2). They are reqùiredin otly small mounlsi
absercecan resùlr in â diseâsestare(Table1r.3) àrd somerines
vitamin exce$ ca. caùse d$ede.

Preventingmucosaldisease
through
nutrition
Nutritionâl deiiciencies can impair oml mucosâ bealth add or.l
inoune derènces,and compon€lts ofsone diets may be hamful
to the mucosa or, mdeed, carcinoseDic. CoNe6ely, or2l d;s@se
car interfere with feediûs ar.l ruffition as â cooseque.ce oi com-
promised masticàtion ànd s{rllôwing, pâin, or discomtort. Ior
€xmple, dally ftake ofnon starclt polysaccharides.protcin, cal-
.iùm. ûorhacm iror, nia.in. viramiû C, and lnùinsi. and mllk
$gâB de significânrly 1ôwerin edentareolder people, ard pldsna
âscorbÈtear.t retinol levels Ère sisnificàntly lower in ûe edentare
thd denràte persôûs(Sheihâm ar.t Sreele2001). The sane work
ers n,undplasma ascorbatelevels o be sisnifi.antly related to the
numberoftceth and postdnr .ontâ.ting pairs oftetth.
l lfccls on lhe oral mlrcosaof spccific
d efici en!'i es
Proreins
Proteir is rhe sôurceofdÉ 20 amino acidsjody eight (isoleucinc.
- o '
l e ' r r , , r É .i . h . o n , i e . p É , , 1 . 1 . n ,rrl - . ' e r 1 | - ùrdergoes
phar, èrd vâline)ùe esentiali thoùgh hisr iDeand argirLnea.e
alsoûe.esstuy fô.grôwing lnfan6. Prôtein-energy defi.lencymay,
in child.en. vary in iis effe.ts fron dild grôwth retàr.tètionto
mdamu (senemlmalnùÛitlôn) ard kwdhiorkor (proreû nal
nutritio.). Oral mucosâl lesions ln marasm8 have nôt been
.leafly rc.ordcd o. detined. Howeler, p.otein halnutritiot
de.redrs côllagrnsynrhesis in rô.ienrorâ1mu.osâan.toral lesio.s
havebeendesûilredn, kwashion.oiTbeseincludcocdemaofthe
VilominAtrclinol)
vrtamln A is iât solubleand ls found in anitul fâts, milk, and
liler. Vitûin A ca. alsobe derired froû precnrsors (cùotenesor
.dôrenoi.ts)foùnd jn pldrts, particula.lysrern leai' vegetâbles.
Viramin  is rored in the ljver: reseryescan lasr abotri L yed.
Natùrâ.Iderilativesofvir.minA, ard syûthetic2naloaues ofvita-
min A. knoçn âsretiroi.ls, car modxl e elithclial cell differÉn-
tiârio., po$ibly by regularinggere expresio!.
À
Hypervilominoii,
In hlpervitami nosisA rhcreh alopecia,peelingol the skin,coa6
enina of rhe halr, and bone pàin. Oral featùreshare only m.ely
beenre.ordedbur vitdiû A an.l someanaloaues suchas eûeù-
natemay causecbeilitis.
vitùin A deliciency;s urRlly dierary in ôiigit. In vitamin A
.leficlency,the eycsare first affe.redi night blin.lne$, xe.oph
rhèlmiâ, ànd conjuocrivalulcc.arbn appear.The skin becom$
dry and scâlr (rollicùiar hyperkeratôsis)èt.i the oral mùcos"
bccomcshyperkeratinized, with non kerutinizedmu.osa.hang-
irg irto keratinizedn,ucosâ. SalivâI.se.reb.y du.r;l epithetium
melapldi2 ard tbere is alsoa dire.r effecton the tdte
buds. llrpovitani.os;s A may be found in somepatiens wirh
Tabl€ 11.2 Clisificàtiôn ofvltami$
Mû.rif, 82 (Rlbotlârin)

to.gue and pafillâry aùophy.A.Aular stomatitn and hypôpig Vnamints6 (Pyridoinc)

mentarionci.cumonlly hâvc bcenrecoLded. Interestingly,toler-
anceof clenturesappearsto be increæedif the dretary prote,n Vinùin C (Isco.bi. à.id)
intâkeis improled ln edeltuloùspatieots.
Acinàr atrophl hàs beeorepoiled in dre submandibula.sâli-
vùI glm.ls olprotein deficientro.le^$ aod secretoryIgA may b€
decrede.t.This hâsbeenrelàtedto oral i.fections suchas nom2. Nicornric r lNienr)
Thereis alsoev encethat baclerialadb€.eoce to oral etithcllum
 Pr€venllng lhroush
mu(or0ldismse nùlli0n

nù.o.ùraneous candididis, àrd therapy wilh vitam in A nrâI pG côenzymesj. âmino a.id metâbolism. Vt2m;n B6 deficiency is
duce some imp.ôvehent. Hypovitdhosis À aLsoincrcascs dre pàfticùlùly Found io al.ohôlism, preaùncy. and the me ofsome
'us.elribiLity ôfrodenG ro i nfe.t;an \lith Ca",{ida d/lîn"r dru8s; e.g. iso.iâzid. Deficiency ofvilamin 86lea.ls to dermàtltis
Therc has been considerableinrerest in the role oivi.amin A ln dd perlpheûl neu.opâthy dd oràl mucosdl mânifeshrbns similar
o..ers. pâricùla.ly thôse of epitheliàl orlgin. Boih natural pre- to thôse ofrildmi. Bl2 defi.ien y wnh ânaular romatitis atd
.ursors(cârôteroi.is) ard syndretic analosues(rctinoids) nar hâve generolizedstonratitis d.l somerimes ulccratnrn.
someprotecrive ettÈ aAâinr.an.e.s.
Vilonin
B Pantôthenic acjd is necded àr the synûesis olcoe.zllt À, dec
Thoearescveral B tamins(Tabhsri.2 ùd r1.l):all arewatc.' essaryfôr severalnetabolic pathways. There is a tepoit oi glô$i
soluble. marhcd;er-related
Delicieûc;es ôr hâveôthercàùses:oral ris in posible pantothenic acid deticien.y.
ùlcerationand other conditions noted below, mny tollow. ljiofini.o.id(niocin:
nkolinûmidel
defi(isnq
Virûmin
8l2 delkienry whert, nuts, Deai, ând tish de rich so!rces ofnicotini. a.id. The
The ûost widely recoanizeddeficienciesare of vitamin 812. a.rive derivatile of.icorini. a.id, nicotimmide, is necessaryfor
Tlb vit:min is found mainly in l;Er. cags.meâi,and milk: liver the produ.tion ol NAD aûd NÂDP for oxidativc merabolism.
storesof dris ta$ up o 3 rars, and thus deÂcletcyis ra.ell of Defici€ncl of oi.otlni. a.id is seen màinly in the Wer in alco
dietaryorigin except nr vegans.Vitàmir B12 deiicien.y is holi.s. and .auses pellagri (dcmrattis atd ùeurological distùF
ryplcà11yseenir pernicjols anaemia,wheft rhere is deficietcy ban.et, ôrèl mucosal crythema, d.l pàpilla.y àùopby of the
of dre gdùlc inrrlnsjc faclor requircd for the absôrpriôt of n)ngùe. There may be â bumlng seNàtion in the tongue, and
byFfalivârn n ân.l èrgùlar stomatitls.
Glo$itis and soharitis mây resùlt from vitaûin B12 det - Vihnrin
Chs(orbi(oridl
ciencl The rongue tip reddensin the eù1y sas€s of deilc;cnq., V!âmin C is warer solùbleand found espe.iâllyiû fresh rrui$
and dr;s evenûally spreadswirh fisurirg the so called beet (mainly ir ciû$ fruits) ard vesetables:potaiôesare a .omnon
toûgu+and vidr papillail aùophy. Angulàr stomalitis, aph soùrce i. drc \Irest. Defi.iency js becauseof dietaty Lackol
dùc,anderosilelesionsmay alsobe seen.Somepatie.tsmay hare
BurningMouth syùdrome,even in the abscnceof rc.ognizable Vitdir C is inrolvcd n1ùe hydroxylationofproline in.olla
nucosal dsease. Orâl hype+igmentatbn hây Èlso be s€en. gens-vDthesis, ând defi.iencylea.lsto defectilc.ollaEenNith caP
ùIucosaL charaesrcspnd npidly b replacementthenpy. illary fraAility, a haeûoûhagic srate, anaemia.od follicular
Ur0nin 8l (lhi0nrine,
0neurineldefi(ienq hyperl<entosis and singivaL.hàtses. Vjramin C defi.ietcy cm
vitmir Bl is widely distributed i. foods.It is necessâqin the a1sôoccdionallypre,liToseù, ângu1àrstomalilisând o.al ùlcera
forn.tior of ûe coeozynedriaminc pyrcphosphare require.lfor tnrn. Thereis â tenuousa$ociationbe.veenvilamin C and a pro
oridàtile decàrboxylatiooof pyruvate and a-kercglutarate,and tectiveeffectagains.o.al.phdynge.l, ànd oesophâgcal .âo.eB.
utilizarion of pentoses.There is, tlrereforc,in 81 defi.ien.y, è Vilomin D
build ùp ôf lâctar€and pyruvate,;ntedèfing with .arbohy.lrùte Vn.nin D n dic aeneral nde for a groùt ot faÈsolùble steroLs.
netabolism.Deficien.y of vltmin Bi is .oûmon nr alcoholism vinmio D is found in fish, e.qgs. ànd milk producs,âtd uhnvio-
add l€adsto Beriberi, chàracterir€dby Folyncùltir, mùs.u1ar . ' l r h ô , . " ï . \ . . 1 , p ' ' u , - l F h ) J r c\ o l . ' r r " \ ' "
$eakness,càrdûc fallu'e, oen.àl drangcs and, in cLrildren, min D. Cholecdlcifcnnf(,m diet.ry soù.cesis .onvefted itto
grôwthretùdâtlon.A role tor vitami. B ;. Bùrning Mouth syt 25Jry.lroxycholecaldfedin the liver and dris is conlerteclit the
diome has bÉenprôpôsed,thoùsh thesefindinss havedot been kidnets tô the dtlve fàrm 1.25-dihydroxycholecalciie.ol. Vnmin
confirmedby others.Thidire deficlencynry also sluten the D affe.E .al.iû d.{ phosphatcmetabôlism. Oral mucosale$e.is
, u no r l o - i { . : n e i 1 \ p ' r n ' , d lo r ' 1 . " o . 1 . i hak nor been.tescribed burvitaminD dry'Jfect farotid tur.ù,n.
VihminB2(ribollovin)
defidenq Vilomin E
Riboflavinis foundin leô vegerâbles, meat,milk, an,ltÈh.It a.ts
Virâmi. E is the generÀL ,,]me for a Sroup ôf f.t solùble toco-
in the fùnation of t$ô coenzymes, favin adcninedinùcleotidephercls.Premàrùrelybonr, low birth $eight nrhnts âtc aenerally
and {1à!in mononucleotidc,involved in oridative met$oLtsm. cônsrlere,l to bc marginrlly 'itamin È'de!l.ient. However,
Detcietrcyofvitamln 82 i\.ommônlr dietary,is especiallyseen in
. l _ \ o ù L ' J D , i " l ô , L ' . o n ' r " . Ir ', n i ' I d r ' r r 1 r r ' " . r
alcoholics,and lcadsrc seb(rfhôei.dermtitis, cornealvarulâriza-
in plasnraâ.d bu..âl mucosalc€llsin healthy,Premaùre infants
tioû, and aDaemla,and o.al mucosathanifestàtlôts similar !o ir the lirst 6 veeks of life, the other cellsshowedno su.h deli
rhoseof vitmin Br2 deÊcienqrAnaular $omatitis, glôsitis md .ier.y during dre stùdl ând rhe âùthos concludedthat tlÉse
oralnlceratioohavebe€nreco.dcd;. ritamlû 82 deficieûcv infàùts.to not needroùtinevirâmin I srpllemcnturnrn(Kaempf
Vihmin
86{pydoxine)
dêliderry dd Lin.terkan! I998).
Viramio86 ir fùnd in ûeàt ànd legeûblesand is invohrcdin ihe No ôral mùcosal,liso.dersappeàrtô have beenre.o.dèd rn
formationof pyridoral phosphared.d fyridoxamhe phosphÀte, vitdmir I deficienc]:Howeret there may be a rclatbnship to
r78 1l Prcvmrion
Dlonlmuosol
drse0se
|

- : ! P - a
È ;.4ë; E t ! j
3
6,i i Èg ; q 2 z f

F ! 9 2 d;
€ €
i i À
-! f r

t! :!

e,ff
ô F : ; ;

E , E
se
* j g !"; I E h !
F *
! 3 8
E E J ; 6 ] i E E È
3 Ë B È - ! a= 9 E
6 E,d à
.â
.8 : r€ Ë : &
ë
b -! Ei t
ÈC,E
Ë i : e ; ,iiaE i É é
-!

: È 3 .
E E 2
.É ,r ià Ë
E ; é i
a  .c
i
E -
P -
4
- a
g
3 1
È; â*
j: j j q-i
. 1 a È
;=-i:€
ts ;l {:. ifÉ
! Ë È HÈ x E
b
*
:i; E s # Ë- : 5! r P !.: > Ê ;{ É
:
.9? E
3 i - Ê
è Ë
É É s E €
E 2 4
 Prevenlins
mu(o$l
dise0$
lhrouqh
nulli0n 179

E
E
a
!.!

=
t r

3 1
!
e É--= ! a 2
q 3 : !
{-I - ; t s *

E
a
â q t
E
: !

È È ; ; ! : I T ;
! ;
1 a à Ën
t -

: à
; T
à Z â Ë E

j
Ê Ê

I
{
q

l3 ï."

! È
Ëé
{,
-q
y1 .a jj t u! E
Ê3Ê
= 5
! ':t
E 2 Ê !
I30 | ll Prevenrion
olor0l
mu(osol
dseore
I

car.inôgenesis, since viramin E, like ct .ùotene, is arlioxidant
and appeds tô inhibir experihertâl ôràl .ârcinogenesis and, in
hùmans, highÉr serum vùdin E levels appeù asociat€d wirh a
decreasedrlsk of oral cancer
Vitoninl{
Vitamin K is a fat so1ùbLenaFhthâ{tuinone dcrivarive tound in
Arecn veSctâbles.Malâbsorytion, pareniera.lnuÙitiôû, àtd mtico
aguLana causedeficiency.
The oral mucosâl manlfestâtlons ofviradin K deficiercy caD
inclxde siûsival bleedins and pos-qtLacion haemôfhage.
folko(id
Folic acld (pteroyislutamic acid) is biolosically ina.tlve: fôlates
are rhe active water solùble forms. Diera.y lolare. p.esent in
gr€€n veg€tabl€s,liv€r and yeast, is conveited to dre a.tive teùa-
hydrofolatc, which is involved in synihesis ôf purine dd pyriml
dine bèses, àfter absorptior i! the sûalL inlestioc. Folate
d " 1 É ' y r _ ) p , . a l l )b " . r ' e o f . J , e t J e f ' e n , q 8 r ! ' \ r g . d -
b1es,md can ùise wrhin a relatile]y shor! period ot time, sid.e
body stores lâst less thàr 3 monrhs. Alcoholism aod son€ cy.o-
toxic dtugs a.d phedytoin de ôther relâtivetl côrlûor causes of
defi.ien.y offolat€ at tbe celh ar level.
Iolâre deficiency leads ro impaired synrhesis è!.1 repair of
DNAw;rh meAalohlâsricchaûge lû haemopoletic dd ôthercells.
Buc.â.I epirheiial .ells show changes sidilâr tô those in vltamin
BL2 deÂciency.
Some patients vith chroûic hypetnaric cândidlasis may be
folare,.lelic;ert. lola.e deficient i.dividuals may alsô s!ttrer from
chronic arropiric candidiasis but the restomrion ofserun folate to
nornàl levels rârely hâs âny bereficiè]effect indlcatins that folate
deficiencr in nselfmày nôt be an âetlologLal faclor.
The orâl màûlfestatioûs of vitml! .leflciercies are sum ma.ized
i n T a b l e L1 . 1 .
l)letary iro. is foùod mainly in meât. hoo isvnai ro oxysen ûùe
poft and inùa.elllrlar respirariôn, being inherent nr soûe
enzyhes. NIos irôn is presenr in hæmoglobini some is stored 'n
ma.ropLlâgesin the liver and spleen d ferrriû ànd haemosiderin.
Iroo is tra.spoûed d ..a$fe..in.
Defi.ien.y.an àrisefrom dieraryoLahsoTtivecàùses, bùt usu
ally is a consequenceof chronicblood los-typically because of
merorrhasln(Tab1e1 r.4). Iror deficiencyaffe.s râpi.lly dividing
cells such as bone dàrrow èDd oral mucosa. hyPôchromic
microcytic âûaemiaresults.The serum iroo and seruô feffitin
Orà1mucosâlmanitèsrations of iroû d€ficiencya.e .ommon
and iDcludealo$iris, angulàr stonatjtis. and Bù.ning Mouth
syndrome.Atophl. glôsitis is foùnd in up to,10pe. centof iron
deficientpatienrsand anaularstômâtitisin It pe. cenr.Àboùt
one third ofpâtients haveâ sorercngue.Mmifeslatio.s respond
within Èfes weeksto.eflâccment drerapy.Aphthaemay be seeû.
Iron deficiercy may play 2 ole in ihe orâl cârriâseof Candida
sp€.iesmd dèy be ooe reùon why onl .andidâlcàdaae is moe
prevàlentir feûalesthân males.
Thereis apo$ible roiefôr irot deflcie.cyin carcinos€nesis it
riew ofthe premdlignartpote. r;al ol dre Pludmer Vinsonsyn-
drcme. This syn lrome, consisringof i.on defi.iency,dysphagia
a.d posGcri.ôid ôesophâg€al st.ictu.e may be àccompaoiedby
glo$itis a.d angular srômètitjs, atd may be â$o.iaied, it ùf
to tt per ccnr, with .ar.itomâs of !h€ posÈcricoidphaJytx,
oesophagus.stoma.h, and occasionallymouth. However,dy
sig ficanr.oLefor iron deficiencyit oral carcinogenesis basyû
to be eslabijshedand. ln animâ.Imodels,iron deficiet.y hashad
-:
o'l)eqL''^..| . , \ ' n r l o r l . ' r i o g _ n i- . .
Titt
Ziûc is irvolved in severalenzrmereàftions.Deficiencyofzin.is
6ùè11ydjetary,o. due .o the inherited .tisorderacrodermâtiiis
edretupathicà. lt cèn havemany seneraletrects(Table1r.t) but,
âs rar as the orÈt mùcosais conce..ed,zin. deficiencydoes,or
caùseâùôphy-t leastin animâls.
Table 11.4 Main causes
ôfiron deficiency
I Poor intaLe P.Yeq,
2.
Ilacmolhage fton genirourindryôr gânroln-

Table ll.5 Ge.era.leffectsô{zinc deûcjer.y

utrition0l (ousing
defeds 0rolfilu<osol
Diseose

Bulloù!F!rulàr dÊrnâtitis
 Prevenrinq ondob,,aisoAersror
immun0losi(ally'medi0hd
I

olhor
melols such a nofttrnal btù$n ôr tôngue lhrostirg âtd neuroPa-
'') -,..a o,loso r'de'o le orJdnnpdi,Fle
ls sùûmdize.lin Table1l 6.Thereis some
of drese
Therel€vance
elidencethat seleniùm deficietcy may pred;pose rô orâl cètcer.
Ghssitis
Aùophic tongùe (Alo$itis) is commor in elderly PeoPleand a
Commonoral mûcosâlmânifestationsol'
mtukerfôr malnuùirion.
nutritionâldefects
A g lar srqmatit;s
Th€reis evidencethat malDutritio. doespftdisposero occd,onal
Angular stomatilisis predisposed
by
oral iifectiôns inclùding candidiasis,tô sepsispost operatively
. dentûe weùiDc anddisordersihat p.edisPôse tocandidiasis
and ro rbe spreâd ôf acùre necrotizing gingivitis to pro<luce
canùumoris o. nôna d well d to non speclfi. rômâtrtls, ând
hr8ùaLpapillary atrophy.
OnL oucosalsymprons âreespeciallycommonin deliciencles .
defl.ien.y $ates suchd irot deticiency,bypo-vrtmtnoscs
of folic rci,.l and vitamin 812: inchdiDa bu.niûa houth (cspe.ia11r82, 86, malabsorPtionsrâtes (es. Crohnt
syndrome. alo$itis. ânsdtu $omètiris, and ulcc6
B"rning Mo tb slrrdro'ne . .lefecB in imûùnity sù.h as in Down sytd.ome, HIV
Bumjng Mouth tyndiome (BMS) is the te.m usedvhen symp inË.tiôn, diabetes.can.er
tons describedusully asn bûûing sensâtjotexistiû the absence . disôrderswhere dre lips àre enlarsed,sù.h às orofacial
ofldentifiâb]eorsanicaeriologi.alfætors:it is often 2 medicatlv àûd Down syndrôme
sr2nuionâtosis,Crohn'sdisease
ùnexplainedsymprom.
. No precipitatitg caùsefor BMS cânbe i.lenrifie.lin ove.50
per.eût of the patienls
0101
ilutflionold€li(ien.y: nonileiiotiont
. A psychose c câlsesùchâsanriery,dePre$ionor cance.o_
phobiècar b€ identiilcd in about20 per cent.
' t. .he others,BMS appeàsto follos' cnher a dettal iûter
ventionôrar upperrespi.atorytfact i.fectioû.
. D f i n n l , n r l o n J ' . o r n r . b ' e r ' . / ' d . , ' e t h e ). J l
also present wùh bùrning. Oraanic problems with Do
derectâble.linical lesiors that car cuse syoptôms similù to
BMS;.cilde a hæûtolôgical deficiency state(deflciencies ln
r r o' l o Q i d . n r \ r " n , ' B . I n . b o ' t { 0 p r ' r ' . F L i r e I
tongue stEce from poor denture coû$roctiot. paftfû.tion

m.t deficiencvreatu.esof Ùàcenetdls

Table 11.6 Relevance
IncorpoBred if, glutâthione
leroxld6es, rhioredoxin
redù.tae and thvroid hornon.
ln.oryotuEd ni tctùlloenztfl
g immunologically-mediated
Preventin
and otherdisorders
Recûfientaphthoûsstomatitis
The aeriôlog! ofrecuûeni aphthous stomâtltls (RAS) is in mo{
casesuncler, but lhere may be a seneric basis àûd Po$ibly an
es Iâl[ùe ro ùn'e nr babies infective agent, d yet unidentlfied, ând other â.iors mèy be at

ph.sphorytiiloq srDtltss ol . inc;dents .an provoke ul.ers in

.ro$Jint sÊ oa.olhsen and
Iû.orponted ù detdlo.nztmes
ihv.Lved DcvclopnertaL
Môlybdenum Cofa.rof nr en7-ymes
nr metabolismofturi.es âdd âbnôrmallries
!l'rimidines
Skeletil ând neurôLdgic.L
)Atdlâ
?Cro$rh Èturd.hon
Ttdtnd: mlaar ttanûrtlc
people wirh RÂS.
. .tr/aff: eûotioùl d;surbance or stres can prcvoke ePisodes
ofRAS.
. Nûahal fût|$t ithæbeen susaered thèt ltAS; caùsedby
reactivârion ofa làtett herpes simpl* !irùs, but although
virusessuch a HSV, vùicella zostr, âdeûo virusesbâve beet
inpljcated. no vinses have bee. di.ecdy isolèted fiom RdS
lesionsoffi n.L usiûg cytoloSy oi electrôn mic.oscoPy
i82 TI PreueJrrion
ôf0r0lmu.osûl
dise0ie

Bæterià, màinly rhe L-tbrm srreprococcalbacteria, Srrapr,

tu M ld"gtt anà Strep.nbs, couLdhavea possible liûk bùt
Shap rdgrtr is ùlik€ly to be rhe aeliologicâl aserr of RÀS.
Hlicoba.î* b|û; \4 been.onsidered a â posslble cèusefôr
R-{S, but rhis posibility h2s no! Lreensùpportedby ânti
body studles.R-{Srarelyrespondto ant;microbiars.
lrrr*:Certain tbodsare.in somepatientswith RÀS,relared
to ulcehtioni theseare chocolare,coffee,peamts, cereds,
almonds,sÛawbeûles.cheese,romaroes,aûd wheât floùr
(.ontainins sluren). Th€ maiû àllersenic substan.esâ.e
beÂ,oicacid ard/or cjnnmonaldehyde.
Lichenplanùsând lichenoidreâctions
Dng reddio": Non sreroidal mti inflMàtory drùgs ând
TLF'Ê'i.C) il.l'.r1lrr. in.ii.ob.-T I To. .^e
other .lruas suchd nicorddil mày pioduceaphthouilike
ul.e6. Sodium lauryl sulphàrein dentifri.esmar piîcipl- Hos'ever, a wide m.ge of druas hâve bee. implicated. most
cômmoûlr the non-re.oidal anri-inflmmatory aAen6, antlb)'-
pertensive €erts, antidiabetic druss, àrd drtimâ1drials (Tâb1e
Innxm d,fe.n Aphtbots Iike ulce6 are foùnd in 60 p€. cenr
1r.7). Oral licheû planus may also appe2. i. close .elatjorshi! to
o f 1 , r - H l v i i i , e d p . r . e ,, . $ . ' r , i t r ' r o d e ' , i - n , i - , .
dental ftstoradre matedals. especlalli amalgam. Receoi studies,
mild neutrcpen;a,myelo.lysplèsticsyndrômesand other
hoveve.. have found little reliable evideoce of hyperseffi!ùity
formsofneutropenia.
" ' u , \ e J p p e r r .n e o f . . . h - n o , r r e a r . o r f o o m F . o r p o . F
Hatandr iûbdld"ce:A possibleàssocintbn berweenthc .estoralions shoul.t danpen .he enthNiâsm for the vhôlesale
nc"rr" I t-.nd r\Fo,r. of Ms"'d," r r'À' i, .eplacenert of analsans.
RAS during the 7 dày post-ovtrlationperiod p.ecedi.g
onsethavebeensuggesredbùt epidemiologicsudies have orofacialgranulomatosis
shown no dsociation between R-{S and dre menrrMl .ycle.
The sroup ordisordes variouslydescrlbedd oral CrohD'sdreae
However there are patientswhoseRAS remits with oral
or oroia.ial granùlomanrsis(OFG), and rhe relatedMelke$son-
estrogenconÛd.eptiveso. durina preanaûcyaod some
Roserthrl syndromedd Miescher'scheiliris (cheilitis gianulô-
undergocompleteôrpdrial remissiondud.g prea@ûcy.
matosa)mèy sometimesbe precipitÀtedby identifiableagents.
SnaÀ;nsÀdln^: P^tients Niû R AS a.e usuaLlyron smokers There i! no doùbt tbat classicCrchns disede can be compli-
(Ttzùn ,r ,/. 2000) dd rhere is a ouch iower pr{alence and
.ared by oral lesions especiallyonl ulcerâtionard this may aho
severity of RâS in hea1')). compâred !o noderate smokers. be seen$hen adùointest;nal symptomsarcabse.t.Hoverer. rhe
Some pâtierts repoit an onser or RAS parall€l !o snoklns constellationof manifestarionsthar may he seen;n any comb'na-
. F - . ' ô r . s h i , o , l - r . r c p o r , o ' r o l o f R A S o , . I n , ,d ô r
tio., i.cludinA oroiacialsveuing. mucosalrags,giogivaLhyler
of smohins.The se of smokele$tobacco(cbewjrs tobæco plasin. mù.osal cobblesoninS,ulceA, ând angular sromadris,
aod sûufols alsoâsocined witha sisÂifi.andylowerpreva- may ako be seerinthe totèt.bserceof.tereftâblesaslrôintestinàl
len e ôi RAS. Siûcerhe mucosalk€rurinizariorin smôkeles disease.ând the alter.at;ve term ofofâciâlA!ânulomâlosishrs,
tobaccô6ers is genemllylimiredlocally,jr is sxggested tlur
nicotine itself, or other syslenically absorbedsubsrances, Table lI.7 Druss most comonly implicètediû the aetiology
hay piovide sone addjtioDal protective role.
of lichenoid reaûions
Htuîint àcfi.ie"c!: Deflciency of virmiD B 1, B 2, or 86 hd
beenfôund in around28pe.ceDtofRAS compâredto 8 per
cenr in healthy irdividuats. Deficiencyof Virâmin 812, Betâ-^d.e.ergic blocke6
idic acid, or iron was foun.t i. 17-7 per .enr of R^S
p.tients .ompaæd ro 8.t per cenr in controk. Complete
lemissiorof ulcerètiônwd â.hiev€din 6t pef cert ofthose
p â , ,r " \ h o s e F o n f o " . " n F n , 5 e , " 1r\r d . r r ' r , i r - NSAIDs
ins 15 pe. cenrexperieûce.t someimprovement.
Ga 'ou.c taat '/t ea{: ThF \rol , n"Lb' }, oa . o'i-
ated with coeliæ diseàseàrd glùten-sensnireentercpathy
(GSE),car leâdto deÂ.iencyofB vitmins and folare,vhich
mayplay a role in rhe ædô1ogyof RdS in somepâùents.
Infldnndttry botel 'rte^, (IBD): Crobnt disease and
ùl.erâtivecolitis, may be èc.ompûied by R-{S.
 iùmuf0iosiiolly
Prevenlirs mediûhd disorde', l 8 l
ondorher

rherefoLc.bccn ùlssc$cd. This ma-v be he$ful o avoid tLre Table ll.8 Somc factor fft.lpitating errtliema nuhifôrmc
s t i g . , âo f t h c r c . m C r o h n s d i s c â s c .
In somc drcrc nray bc an allcfEi. bâsis n, OFG and pdiens
mry .espnd to dierary mânitularion and avoida..c oi pùtarive
!rccùiranrs rrh as lafioùs tlaroùrinss aûd orhcf addiriles. In
$neparients thereapped ro be spe.ifi. tuod inûlerat.es, su.h âs
!o "'..r''J - . o'e1t-r'o'-
yellow, or n,onosodium glutdmarer micro orgânkms sù.h as
l t,ohttùnn !ûdrtbt,Lbtr may tlay â.olc

ÀllergicIeactions
Piovdr aUergi. reè.tioùs in rtu mouth de exûemely rùe, bu! n is
lileLy dr.r some mùifesàtioùs h.ve been overlôoke.l aDd llllt lood
1o- " ril. I l ' u.b F , ô ; 1 i . eôr b ô r e r . I o r
tarcetlùr hitheno suFposed.There hâ!e, fo' eiâmpl€, been cleù
mnflcs ofrations ro mfioùs dcntifii.cs aûd orher materElr.

Erythema
inultiforme
The âetnnogy of er,v.hemanùltiiafnre (EùI) ls ù.lexi irr
r:"4.-.
mosti.ricnts,burâppcasrobcânim.runol.Aical hype$ensiùvrq
rcætior with rhe attear2.ce of cytotoxic cffccrof.ells,
C D 8 - T l _ v m p b o c ) r ei sn, e p i t i r e l i ù m ,i n d u c i n ga p o p ( x i s o i
keralinocytesar.l leddirs ro sdtelltreceil .ec.osis Thc
scùtiere.l
((!ion is triAgere.lby:
rCt. { l,.B(u, , f,.,' Baa,. o,.
Oxi.am n n $eioidrL.m rù:laùûidory Jrùls
graft vs. host.tiseæe,inflammarorybowel ,.lis
sdrcoidosis,
polyaiteririsnodosâor sy$eû].lÙpus ery!hematosus r'.t;.iLL*
edse,
, f1atlddliti!6 û chû"i.dh such as benzoates,njtrobeû,eiie,
pel{umes,rerperes
' l,srstr.hdn phôùdi.tes (e.g co Ùimôxazole), cephaLos
poriûs,âminopeni.illins,quhôlores, ihlormezànone,bir
bitùrâres,oxi.âm non{reroidal ânri-inflammdtry .lrugs,
dùi.oû!ulsJnts, prote$e nûibnos, atlopurirol or even
coii(osteroils, and màny othe4 mal nigaer scvcrcElf ol
toi. epidermâlne.rolrsisln pafti.ùlxr (lâble 11.8).
Re.uûen.esofdrug irdnce.l erytheûè mùltiforme are rùr+
unlesthe drus is re.dnin^rered

cell gingivitis
Plasmn
GinEivallesn)nrthat hâk beente.medali€rEi. ginsivorohatitis
or tl.$a ccll Aing;riris halc bccn Lccogn;zeJ fu many reas.
Âllergi. fcx.rlo.s pr.dù.inE .hcilitls and alnsival .hanseshave Nlcrnruallt relarel homonal (Frt,Âese.ônc).hdgcr
been.Les.fib€d\rirh râftâr.onùol ard rôme orhei dertifri.es.
TdrasodiùmanJlor letrupotàssnrn,ftrofhosfhâre (Pti) is rhc
rnti.alculusconrponc.tof.rost tanâr conûol dc.titriccs. \rhlle
trrofhosphâtcs alonc arc nor rcspnsiblc lor hnrcfcnsirivitl 01pyropi,oslhatcs.Third. in.rexse.L.ot.€Dtrations of dctcraenrs,
rer.tions,severJ modlti.atlons,which nay ]e&l to adverseoml câpableofprodùcirs hyprsc.sitivitt Éâ.tlôns, .re nece$ary!o
nanifestationsmar occùr wlier FJrophosphères are àddedto a dlow dre pl,ropirosphates .o bccomcsolublÉiû the dentltiice
dûùfrice.Iir$, reùasodnimplrophosFliatein a dentrfricefoins foùith, â pre exisrinsco. d ition ol .cdncedsxliv.ryflow m.\ aù.q
a slshth alkalinesolùtron ùpor orèl ûse,which co!l.lrrrltate oral nent hypeBensnivily !o !aft2. contrn tôothpÀstes.Vlile
r"rldr.:- | . : ,r . - d r r , r o , o l tln)phosphaÉs Lble been approve,lâs additivesin dettifrices.
kno{n.o beseDsitizes,arenee.ledto masl.be stro.s bitter taste these cômpour.ls, along Fidr thc in.feased.oûcetÛârions of
 I
1 8 4I ll P'evenlion
oforûlmu(orol
diseoq
I
flèvorinss dd deterserts ànd rheir hisher iûtrèorâl alkàlini.y, ùe
$ronglr implicàted âs the .âsàtive fà.tor in ceftàiû hypeBensi
Contâctstomâtitis
CoDtècr stomatltis may reslit from anliblotics such as $repto
mycin. n€omycin. and bâciùacln. oils ofcdia and.l{rves. mer.ûr,
gold. el.anlt, ilavouring âAentssù.h as.itummon in tôoihpare,
epory resl.s, acryli.. eugerol, polyeùer impresslon material, and
k2rayâ gum. Nickel co.taining and s.aj.le${teel .c can give
.ise to contac! allersies. Contact cheilitjs hæ occurcd with thc
tluo.escein statrs jû somelipsicks, carmine, oLeylalcohoL,methyl
h€ptine carbmate, p€ppermint, câroD€, spearmint, pineapple,
mangoes, asparagùs,and cinnamon oil.
Angioedemâ
Ansioedema can result from . ranse of asents,for example,
aûsio€demaiD respoûse to rùbber dam m.l to ethylereimjDe(iû
'Scùtm
) hd beer repofted.
Hypersensitivityto local anaeslhetics
Hypersensitiviryto local anaestheri.s ls un.ommon. Â11ergies
Iignocainearc rarc.The parabersprcservarives
vnutions accounted fir somealler8i. responses,
iioû ofpreservàtnefreepreparètionshàsminimized the hazùd.
Hypersensitivityto methyllnethacrylate
M e L h ) . m e r hr. ) . . L e . q ' , i \ . t ) i r F 0 8 , . i r e oo u t r u c
!l
Conclusions
. The preventlor of onl caûcer s best achleved by reducins
risk factois kDo$'r to cause cancer in lhe moulh and eLse
{ \ e r e I n , f F b o d J .T ô b e o . F . . e * \ " J . o h o . o t r m p ' , o n .
betel use, and prôlônged exposûe tô sùnlisht, .re foû of
rhe hosr idpoftant risk fdrots impli.ated in rhe ætiology
. The sde risk fa.tôrs a.e alsô implicated
ment of potentiàlly màligmrt lesiors.
. In addition,improvingthediet by ircftasing nrtakeof fro;t
and vesetâbles,r.eâtiûgpôssiblei.fections, sùchascard;'
dosisor syphilis.and improvirg orÈl hygien€,may reduce
the p.ev2lence of prc-lM.ligndr lesions.
. Derture-iûdù.€dsomatitis cànbe preveûreditde.ûres arc
not woin at night, pldqueis removedby brusbin8.aÂd th€
denturesdisi.recred.
. Apart frcm biah stuûdddsofhygiene,and the avoidmceof
corlactwith drosc dr commùni.abledisedes,ortheir ris
Nes, llttle can be dooeto frevent pdmary inte.tiônswith
virdes that cm causemlcosal lesions.
. OrÈ1iifectio$ nr rhe immunocompilmisedpeBon mèy be
preventedby prophylætic lherapy.paft;cularlysith anri
fungàl anclèrtiliral agers.
. Chlo.hexidiûesll,.onateaqùeousmouth rlnsesntry havear
eilectin the mamgementofRAS, po$ibly bI redtr.ingseG
. Prôven.llersic reactionsin the mouth can be preventedby
identi4'ingâncLàvoidinsùe caus€.
ro References
oflocal adâesthetic
and the intioduc- Arm*rons, W.8., Kenne.ly, l..R., Wan, X.S.. Ariba. J.,
M.Lùen, C.n., anl Meyskers,F.L..Jr. (2000).Single-dose
o B ^ q n ' r- B ' r l i r r ' b i ô , o n n t d t e' ,
patients n'ith oral leu-koplakir. Cat.4 Elidantat. Biowrkn
Ptd. , 9(.r),43-1 .
Clarkson,J.E., Wo.thinston. H.Y, ând Edet, O.B. (2000).
Preventionof o.al nrucoslrisor oral cûdidiæn for patieÀts
with caûcerreceivioschenothehpy (excludins headand
ne.k.û.et). Cûhu", Ddlàtav S!t1. Rt .,l2), CDoao978.
Dodd, MJ.. Dibblc, S.L., Miaskowski, c., MàcPhail, L.,
Grcenspan, D., Paul,S.M.,Shibè,G., aûd krson. P.(2000).
Rdndomizedclinical trial oi tbc effe.tivenes of 3 côn
mody used mourhwashes nr û€ar chemôtheEpyinduced
mucositis. 0/,/.t/s. Aràl lt'd. ordl Pdthù|.Otdt Rddial.
E"lod., 9O(I), a91t .
lpstein,J.B., SilvemaD,S.Jr, P2as;afino,D.^., Cro.kett, S.,
s.hnbert, ùLM., Seûze.,N.N., bckhart, PB., Ga.llagher,
MJ., Peterson,D.8., and leveque. LG. (2001). Bet,y-
damine HcI for prophylùjs of radiâtion-indu.ed ôral
mucôsitis:resrlts from a multiccntc.,randonized,doùb1e
blird, flacebo-coûfuolledclini.al ûial. CdMi, 9214).
875-85.
Eriz, D., Erkà1,H.S.,Serir, -NL,Kucuk, B., Hcparl, A..I]han,
4.H., Tulumy, ô., and CàLmàl<,A. (2000). Cliûical a.d
histopatholoalca.lemlllarion of sucrâlfateir preventionof
orulmucosirislndu.ed by radiarioûrherèpyirpafleDtsv,th
heâdand neckma.lisnd.ies.jtdl Ottrol. , 36lr), 116 20.
in the develôp Gljral, NI.S.,Pai.aik, PM.. Kaù1,R., Pârikh,H.K., Conradt,
C.. Tamhanlr.. C.P, dd Daftèiy,G.v (2001). EfÊcacyof
 I
RefereftA
lr85
I

hydrolytic enzymes nr preventi.a radiattun therÈpl
indoce.tsideeffecrsio pati€ntswidr hcadand û€.k.an es.
rta..d al 4- sit \ s \-F.
Haûis,C., w.rnakù]sùrlya, K.4., Gelbier,S., and Jôhnsot,
N.Yr.,Peters,TJ. (r997). Oràlard dentalhealthin èlcohol
misusi.gpaiicnts.ir,r,1 Clin. Ex!. R4.,21(.9),17O7L)
Kâeûpl D.E., aûdLinderkamp,O. (1998).Dobeâlthr''preûà
ùre inârts fed breastmilk reed lihmiû E supplementa
rioni â1phà- ând gâmma tocothetol lercls in blôod
componentsand buccalnucosal cells.Prlktl: R'J.,14(1),
t.l 9.
lerT-Pola.k. M.P, sebe11i,P, and Polack, N.L. (1998).
lncidcnccofonl compli.ationsaûd àpplicatlonof a prever-
tive pror{,colin .hildren with È.ute leùk€mia..lF. C,r
D!,trjr, 18(t), r89 91.
N e g r i .E . , I r a . c e s . h i , S . , B ô s e r t i ,C . , L e ! i , F . , C o n t i , E . ,
Parpinel,À{.. and la Ve.chià,C. (2000).Selectedmicronu-
tri."nrsa.d oral ând pharynse.àl cûceL Itt.J. Cawer,8611).
122 7.
Scuuy,C. (2002).Orel ulcerarion,a new aûd ùnùslaLcomd!
. r1an.Br D1n.J., L92L), ))9 4a.
Scully,C., Epseir, J.8., aDdSarls,S. (2001).Oral Mucosnis.
Had dnd Nth, (iù ptessJ.
Sheihan,À., ùd Steele.J. (2001).Doesth€ conditionofthe
môuth and tecrh affe.t the abllily to cat certain foods,
nuùicrr ând dietâry intak€ a.d ruûiriônal $àtùs do.gsr
otlct pe.plel P'bti. HedllbN/rrl.,4(3), 797 801.
Tuzun, 8., Wolf. R., Ttzun, Y, and Serddogh, S. (2000)
Recù(e.! aphdnru!stômttitjs aod smok;.s. 1,rJ D4,/d
i . r 1 . , 3 9 ( t )l t,8 6 0 .
\va!, X.S.,Nfeyskens. EL.,Jr Armstrong,\x/.8.,Taylor,T.tl.,
èrd Kennedy.A.R. (1999). Relationsh;fbetweenprotease
acliviry ând d/ oncogeteeiFre$ion ;û pati€n6 with oral
teùkoplàkia tredred with the Bowmèn Birk Inhibirof.
Cd,.ù E!ldor;a/.B;atu*o! P/.,,8(7),601 8.
Prevention
in the ageingdentition
J â m eSst e e laen dA n g u W
s alls

rhe rsk of deûlal dis@seaûd limitatioN on the ability to receive

lntroduction:
What is old ageand care às à reNlr of medical. social, ôr economic constmitts.
whatarethe oralhealthissues? PreventioD ofdisease1nevery.aseis rarelyd appropriatephilo!
Dental diseaseand tooû Lo$ âre .ot a. nrevitable .ons€quen.e ol ophy, ând the .on.epr ôf priorltiziûg differe.t items ôf .are
ioùeâsinaaAe.but both are almost ùniversalàtd both àre irre becomes in.reàsingly impoff2nt witb indesing âge.
versible-Ev€ûiùally, if a persôn lives lons enoqh, dlsability o r ' u n l e r p o , n r. l o r . b . m . d e J i ' - ' h e r e. . n o " r c J
lh.oush rhe fuûcrionalimpai.medÛesulrirgfrôm tôôth losswill whi.h someone becomes officially elderl)', âny chanse in the
!âkeirs toll, to a greate.or lesserdegree.As age in.redes, the empbasis ofdenrâl.are is ûot sùdden,occuring dt somepred€
emphdis of.teûtat cùe ofren moves away from preventing dd termined stage of 1ife, but is sEdual a.d dictatedby individul
namging everydheded toorh,towardsa wider strâteayaimedat coosidetarlons. One definition of eldedy is anyonewho ù ten
yeùs older thad yoù are yonrself (this is a defi.lrion palticulàrly
rhepreventlonofÀ nore senerâlcoûdilioû:iuûctjonall;nitârion
ând dentdl disàbilitx which usùally .esult from iooth loss. prevalent amorsst denral studeûts aûd srardparents).old ège
Preverrive deûtist.y ior older people. whether aimed âr the cân lasr a loûA time. Normàl retiremeût aae; in the eadysirties
irdividul or the vhole population, Â gererèlly best viewed and in mo$ $re$em counties, lif€ expe.tdcy foi {om€n 6 over
frôm this peispective.Preventinaôr minimizina this disabiliry 80 yeùs, whiLe ma.y irdividuals $ûvive for coNidenbly longer.
invôlves primàry prevention (pieventins disease,to.example by As ase incredes, so does life expectatcy. Prevention of dental
fluorlde use or oral hygiene), se.ôndâry prevertion (preventing disàbiliry is required fo. rhe rcst ofà pesont life. Out objectjve
diseasep.osression,for exampleby early detection)or teftiary shoù1dbe tô exrend the oral hea.lth span to mÀtch th€ lifè span
prevention(preveniinAthe impairmeflt dd disàbiliry re$rlting of ôur pàriens. Table 12.1 showsliË expectmcyfor adults âr
yea6 of
from disede, for example by ûeatmenr plàming stEtesies âûd ditrerert àgesin the UK a.d illusÛates that the average
llfe remaining,evenfor 70 yea.-olds(i2 yearsfor men, r, years
The proporio' ofth€ popularionwho de elderlyis ircreasing {or woden), is ofter considcrably longer thd the mediâ.
glôbal]y.Âs we wi11see, the proportionofthis increæ'.a.umbef survivalofa conveûioûalreronrion. Funhermo.e.the pote'ùal
ofelderly peopLe who ùe de.tate is alsorising. at leastin môn of for discrepancybetweenbiologi.al a.d ch.onolo8icalageis welt
lhe developedwodd. In the medium term, this rvi1l acld up to a knôwn and àpplies to oÈl heakh d mu.h d tô my other Àpect ol
lor ofdenral carefor a lot of olderpeople.
Some.tiseæesmd maDagemerrprcblemssuchas dry doudl
ând root cârles,ùe fairly specificto oLderadulrs,so tLrereûeedrô How doesthe oralenvironment
be specificprerertive approaches tailoredto su;t these.However,
ndy of the differercesbetweenthe eld€rly aûd rhe rest oi rhc changewith age?
populatiônare simply ofdegree,so the broadstruleaiesavailâble Àgeins is æsociàtedwith somepathologi.al àtd physiolosical
for the preventionof sùchdiseases aresimil2r to rhoseusedfd any , r d ! . . h . ! ' , . , 1 ï e , h o r l - " r " r e " l , h , r e " n d 1 . . e a e r d , - t r . .
2dult ât risk. \X/har is very diffe.ent for the elderly is rhe contex! These21Ieciborh hdd dd soft tissles.
i ' q h , | ' É p , É \ e r i ô r ' " 1 e , o " F . D . . e ù e p r e v e nor , ' i l
essentia.l sep by which ôral disability can be prevented,but it is Table r2.1 Lire erpectân.yat differentàsesin the U.lted
not the only consideratior.Difficult qùestionsoften hâveto be Kirgdon lr 1999
æked about the most efficieût use of resôurces,becâ6e the com
plexiry (andso dre cosoof.a.e hâsthe pôtentialro risewhile the t0 yeùs 60 yeds 70 years 80 yers
bereÊrsmay diminish. A nunber ôf ôther peripheràlissùesmy Mer 21.J 19.2 6.9
deternjne $'hat preveotivesÛatealesare môr appropriàtemd 22.4 149
whetherlhey are elTecrive. Thesein.lude individul vàriàtiotslt
r90 l2 Prevedion
infie0geins
d!rlirion
Chùges ù rhe dcnrâl hard tissueso..ùr rbrolghourlife. fïere
is a.onriù,ed nûà.c n,an,rario! ofc.âmcl afd of expose.lden-
tine, with in.rea\ed c.ysralgiowdr, alrercd..ie.rarion, Jûd in.oF
torarion oforhef minerals rnn, ûe ro.rh surtùe. These .hxnEcs
i r r ' , I { , , , , , r , , lI . . , , , 9 , o - i . , ,
dc.ri.erilizrtiôn. Dentinc !ndergôes an ln.fcâsc if peritubular
l . . " , , o , , , t F ' . . , L a " , , . . D , . i' , . . " 9
nore highh nr incnl ized tisue. I ne vxsculnriry èûd rhe vollurc of
rhe pdp is ieduccd wirh an in.rease in f!lpal ilbrou\ ûstre, arcas
ot ectôpl. .alciucitlon, ând a rduced nunber of odontoblasts.
The ûet efièct ofthese chânscs xfc leeth thJra.emorc mine.ùlized
àrd s'lrh smâller ard les vasculir tùlps in oldefpcol)le.
Therc a.. a oùmber of orbc. age c1iùrge\ rhar affcct .he soft
ri\{es ot rhe oril .avlry. bur rhat have no beari.S upof tlF der
tnion. Thcy comprise:
. Thifnirg ot the o.rl et,rhelnm wldr fclucel (lensnv and
deprh ot dre retepelr xppa.anr, lnprnnrg eplrhcli2lirlacli
ment ro rhe sùb mu.osa.
. Rcd!.tion ir rhe quairi!) oi conne.rivc
i.c.easedcollâsendcnsirl' ùrd r reduccd.dre
. Rcdùcrior in dre clasrlcit) of elNln
liiving
Thcse drarges aft usù2lll oI lnnit€.l .lini.âl
rerds ot miiniâifing ôral heahb.
It is ir dre \alivary glands thar v,nc olrhe most.llnicaut, riE
nifi.aût charges hkctla.e. There ak markcd changesiû rlre$ftG
lxre of $e sxlivâry glands, wirh x ..dùced ûûmber oi secrcrory
trûits, ând an increde in ilbnnr and t:rty tisn,e ùlrhl. rhe gland
rhar ak potcnriaLly ofmore ditucr relevaDcerc oral h.-alrb.Studies
or d1e al.crùrioo ofsèlivûy flow widr age ùe.ômpli.arcd by dte
involrcmcn! ol ihe slllvary Al2nds in sysremi. discâse,and rhe
irilùen.c ofr snle vdiety ot'mcdications upon sxlirary fun.rion.
llowevef, if ricsc variables âre .onùollcd for. it is low x..îrcd
thaÙhcre is little a.ltemtio,rin srli!àq- flos U1,nrrhc majorglùds
wrLr r..rcâ!.9 age, eirher in rcms olrimulared or .cstifg llov
i.tes. I hc.c is, however,$nrc diminltlon ir floç fo jilro. stur
vary.qlaûds, which may hàre jmponart imtlic,rioos in terms of
rnucosaLrmmmlq: T2ble 12.2 sho** rhc findifgs lir a rargr of
sûd,es on the relatbnship berNeen sâlivary Rov ard age
The profôund srrucNraL chanuestharcx. he obsene.lwith aAe
lo not àpped b tit with rht âpparcnt lâcl( ol Iunftiôna.l impa.r.
O.e erplèùàtionls drcsuggesior thxt drcfc is isgnifi..nr "tirtr.-
toml rserle' within rhc sal'viry gLxrds, and rhc .cd!.rior nr
seùetory .âpa.ity with ège is lnrùfficjcfr ro nnerfere wirh ro.niâl
firn.tiônâl Ilos. Howeler, shoùld ant li,(her.ha11enge ù rl,c
rcÉrion occu., lhen a re.tu..nrn in ûow ls nore likeh in older
itdlrlduals tharinrhe loùns (Fig. 12 1)(Baùm,r,/. 1992) Ths
hyporhcsis is $rpporte.L bI rhc lûdnrg rhât oldef fcotle exlieri
er.ea m..etrolound ftdù.tion in salilarv n.*, {,idr i giveo aÙi
.hotincLgic challenge rha. the yoùng (FlE. 12.2). Thjs rs àr
imponx.r .oDsi.lerâtn)n in i. age gionp whcrc drugs with rhe
.àpa.iry tu.edlce sJlndr dos'a.e fieqùerrlr Fes.ribcd.
Ther nre .lso some dlterarb.s i. sâln'ary composirior *ith
in..easiûg age, *ùL ftdtr.ed fftci. and LgÂ, alreratnû in the
parrefl, of sali!èrr, mrins. and rcduccd so(lnrm coùrelr Ther
chaoseswlll have $me lnllucncc o. d,e tiùrftionâ] chdrâ.terlsi.s
ol this lûtortànr otul fluid, aldrouah d,e natlre ofthese etfe.6
has rct ro be .lere.mine.l.
There d! alv, ag. x$ocirred medic.tl .hânges thar .xr irfu
elce the prevenrtun oi discas.. These indude:
. rmreased useofprescriptio. medidres to .ouùetud dlsexsrl
. Redu.ed virùal acuity ftom presblopie ând .riara.6l
. Redù.ed mus.lc hulk leadins to fètigk duinA onl hvclcne:
Âlthougb rhesc .ray seem ro tre rJthef deta.bed fton ortrl
heàllh, ûeI c.n have a plrnàùnd dlècr on rhe ora.lrnvironmcnr,
relxred ro ditfi.![\' clerniûg, theporenrial t;rdierir] d,àû.qe,r
(ir the.ar ol medi.ario.s) salim$ effe.s
Li ndmâr!, thcrc are relarlvely few ùue âge-.hanEcs rhar
.llrectly affecr rhc de.!i!ion, rlthôugh $me (such âs rhe chdngs
tu .hc dcnt2l pùlp) cèn hake dental tLcahcnr nore complex.
Hos'c!a.. becanseofthe in.Èâsln8 fisk.fsysenl. dsede ând i$
ûeatmcnr with'ige, rhere.an be quitc i suLrsranrialilrerùior in
bod, rhe risk èrd the impli.arb.s oforal disease.
Agerelcted
chonges
. Àae relâreJ arlrlcs iû rooth rru.n& ,n.l e iirrded nrn.rdisa-
ti.o â.J re uccd pulpal vas.ùhrq
. Sûu.ruml dBng6 n, rhc sùLnarvglânds Fdù.Ê! thel. tir..lorùr
. S.LiLaryI1!" hres re rlrtnrly lnaltè.r.d b' srtr.ruml.hÀnses lo
rh.$sd.e oaaddiû,nÀl drâllenaei ro sùlivtra d.rv
. Age related.hàrSÉs ln lci.ni hcrlrh.ln ilso âtre.r onl herldl
Populationtrendsin the oralhealth
o To r O epr e o p r et n: en s eo t t n e
dentateolderadult
Thc or2l health ofè popdârn,n is nor srâti.: .ondrtrôùs .ode and
so, ard discasesan(l.on.litiôns affe.t rârnN d cmographi. grôups
ai different sars ar difïirefr riùes i! history Denral .xrics is ân
caceLlentexrmple; se.dar ùcrds i. denral .aries are.les.rlbed in
Chai)(r 16, with râte\ ofdiscasc rcducing marke.Uy ovr. re.enr
decadesnr dÉ irdù$ializcd narions. Àrore subde .hanges aho
o ' .; L '' JlFol r
diseJseofthe wcalthy. i. lbe trentierLr .enrw ir bccxme d.lis
eàseofeverybodl, s'hilc fos', llie perdnlum hâs rcndcd ro swn,g
just a liiile drc orhcr wây, wirh rhe highr{ lercls ot ca.ies asoci
ited *irh rclativc defnlarior in irdù$lallzcd .ou.tries. Sù.lr
!rerds are impoftart if l,reventi!€ philoroph,es âfc ro Lrc
 Popul0rion
trendr
Intheordlheollh
0fal,, **f, t9l
I

I
È
z

_!
ë
_l E

5
à

3
-9
E E E a E
,t .',
!

E
-
a É
c

:
È 2
E

a
E a,
E
p

E :
E z . t
È
z 7, 22 E. )
lea I 12 Preveirion
inlhe00ein0
denririof
t - "
TIe legù.! ofèllofthis is Jû importânt drd irtÉresirg oie, if
ve hope to prelenr .râl .tisabilirr in ôldef people. Nor beidg
e(lenrùlors r rot enough to erntre â fur.tiôrâl deûitlôr. ù{dry
ol.ter ùdults ha"e erûe rerdr. btrr âr€ dependent on pfurhetic
replacerens of diosc thar have been lost jn ofder tuf rLrem ro
firnction Eren rmon.q dios€ \,ith somerhilg èppioJ.hnrg i full
set o1 nanual teerh. Fisùrc 12..:ishoii thât dr.sc a.c I'kch to bc
prsent by virme ofre*oLarn)n, a.d repcâtcd rc{orâtn,.. A ttpi-
cal .tettate adult aged 70 re6 of age ln the UK w)uld bâve
anrund 18 reeth, $irh abour hâlfofrhcm fillcd. wouU hâv. abour
a 10 pef .cnt .han(c of bavi.g dn a(iti.ial lùll coveragecrowf,
bùt it drcr had,.roFn n'oukl h2ve drou.d 2 or I of average.
Reroratn,nr such as lâ|€c UllinAs a..l cronns are rarely permâ
.crr, x.d usu,lly need servicing and retla.emûrt fron thre to
rinr lt rhc ûntrh undcncâdr is ro sun'ile. Prelefrive srràtegies
fôr the el.lerlr L,ave to be seen in.hls onrert, and dcslsflcd
a(ùnd .iaximizin.q the lu.nionàl lo$rlllities rhèr this reN
tound gcncml imirrovemenr in oral beùllh ailows.
Trends
in orolheolth
ol olderpeople
. The npid in.reasenr thÊ f,unber.f.l.lef Fotlevlù naturâlr.erh
\rnl conrinue tu !ÉrÉrÀlde.rdÊs in mant inJù{riili,ed.ounùles
. OLl.r F$Fl. sho l!rv! rtuftl denùtion: will Énd tû hxre x hish
I ' i , i
t Pr.!c.!ir. $rd.s'.s fùr ir el,lenr need rô be seen,nttu.offexr
What couldbe achieved
with older
adults'oralhealth?
Cohc. (Cohef a.d llendeBon l99l) h.s .les.ribe.l rhe .on.epts
of irerfèct bealth' ard oFrimum healrh', dd rhe dinin.tiôn
betscc. drc tso is uscrirl nhen ùring ro ûlefril soâls Ior dre
elclerly. From a biolori.al perpe.tive, lcdi.r hcalth' las bccn
fi ..,. " . , , " , r r . . , . . - r J. \ r{,.
caF.iry anl in lertè.l. hlrnory wrli ea.h ôrher .ell (Tsùldle
l9l4). AD ofie! lluote.l 19tE V/orld He.lth Orgâni:aùri deiini
tiot of heâtth tukes â dtr.h videL. less bnnogl.al apprca.! and
desûibes heâ1th d a state of ()mplete ph_rsl.alaûd mcrtal well
beirg' (\\rHO 19t8). \{/hlle ùese dellnitnnN .orer hcalt! ln irs
*idest sense,thev could tur as Êarilr trc atflicd to rhc naros'cf
âreâ oforâl hedth. Perfe.t oral hcahh' is nor ditIi.dt ro ùndcl
stnf(1, Lr!t ir itself. r is not â parti.darll useful concept.
^..ofdlna to rhc sûi(lv biological definiriof, ir $o!l(l rell!ire
l2 yrund teerh ln â m.ùdr rhat ha,ùous nodise,sc 2nd where rbc
ô.dùsn)n ls ideal. ft sct rhis as an objcctiv. tor olde' d.hlrs woùld
bc mca.inAlc$. It is umchielable by all bùt ù tlrv rninoiitt, ènd
cvcn should i. be lio$lble, the.ost ofù.hielnrg ùrd ûriûtàinnrg
it wouu ln,trllr be lirohilritne. The .oû.ept of optjmum oril
hcâlrb' is lsetul .ho!sh. Optrnù,n heJth liâs beer defired d
'd,âr
sùrewhere the.ostof.ny iûlrôv emert o trôveighs d,e !â1tre
xra.hcd to die in,froven,enr' (Cohen rn.t Hen.ieisor 199r). The
rerûs .ost aû.1 !èlùe mar be inrerycre,l purcl,v in tcLms of
e.ônoûi.s, bur côul.t tust as rend,ll be atflied ro quxliry.flifeor
nnf ôrhei nèjôr panneter bl whic h heahh ; i$c$c,l . Ottimùn
oral Lleal ,'.ar app\ ro Jnv àgearoùr, b!! cha.res occu.,n botrr
dre.os. dd.t dre vJlue of.ûe \irh ifcrasi.g àae, so rhc b.hn.c
terds ro slilft. This is à tâ,tiorLa.l,v usctirl .on.ctt s'hcû elxLLûr
ing drc dcrral nccdr ol older adult\
O$timûû.Jlal heêlth: whâl is a "l'Lrnctional
dentition"?
Ar rhc beAlnnin! ofrhe ôvenrr' Â6t.emrr', ûere.d be almost
no elded! popdarn)n û]*l,ere û the woild where 12. or lor ùat
nrafte. c!e. 28 nannl reth i rhe nôrû Strbstunûâllossol lndi
ridùxl tccdr sirh ln.rcaslnA ale is a.lmos unileAal, èù.1 in rlr
U ted Kingdom, rLe me.ù nurrber of teeth an,ofg denrâe
peotle àgeJ It rnJ ov.. in l99il sas 1t.1. Oldcr pcople do not
âpfcar m bc unilefsaur afte.td b-r t]1eif lnpairmett, ânclcleùli
mo{ pcoplc rù*if no iu effects lron paft 1 nn,rh los. Oû the
o d , e . s i d e o fd r c . o i n , . o m f l c t c l 6 s o f t c c d r . a n b e a $ o . i a r É d w n h
1 ù r l c l i o r a la f ( l n u û i l i o n à l d e l i c i c n . i c s( S h c i h a m, r , / . 2 0 0 1 1 I. t
No!l.l be collenienl lÊsomewherein bets'c.r. r m1.1mun dcnù-
tlor .o!l.l be.letiredr a t,oinr aLroveFhi.h s'c .ould bc ûrfident
ôfgoôd fm.rior.Ior bodr rhe ûliri.hral an(l là.populatiolrs d,is
tirnclio.al limirarion
coul.l r.t ù r nrnnù,'n ùrgerr !6'e...8
ând dentil disrbilitr s.ùld bc builr xflrurd maintainifls a denti-
tn,n abov€ rhis lerel bI prcveùtiig dental disede àù.1rootb ro$.
Some yed l!gô, rhe \lHO arteûrtted to detine sùcr, â n,ir,
ûtrû dertition, coûsisteDt ùrth seneral heaLlh ud furccior
ûXrHOit82) r'hetun.rtunaldenrirnr wâsserâr 20 teerh,this
bci.8 rhc rumbef shl.h ias seenas being able to po"ide *ffi
.icnrfur.tn). s'lthout the ûeedfofùj removable prorhas The
lgùrc sa5 usc.lo. rbe limited evidenceavrlhbLe at dre time.
If such a co..cft is n) bc lalid, lr i\ irnFortatrt tu be .Lexrâb.ut
what tin.tional misht a.ttraur. meaû Teeth have r ilrge ôfroles,
but nr biological terms, rhe nost iùI)o(nnt is .clârc.l to m.sri.a-
tio. a.d c,rina. Â glan.c ar.omparxrne dental amtumr illùûer
thc .l.rc rchtnrnship beNeer ùe dentnbn, dler, ùrd evùLftion
Clasi. sudi$ as lona âgo as the 19j0s dn)LLEhsholved thât.hdr
ûg is ro! erûell.ecesdry for,liE.stio. ofmost àods, at lcx{ in
healthy"vo!nsâdùlts. Thjs,loes nor nran d,ât tbcï a.c,trcLcurt ù)
good n!ùition as rhe abse..e ot re.th mâr 2kc. too,lschoi.c of rhe
elhcreû.y wrth {hi.h nùtrierls .an be €rtracle(I, bùt comllcrc
digestior ôf mùi foods .an occùr withoùr li6r beina.hewed.
hlâtur"l lreth ond nùlriliorl
Thcrc is no gùc{bn drar nartâl teedl ùe ne.hani.xllr ûu.h
'l
inorc cfilcic.Ùhar .omplete denrtes. h€ft is al$ eriden.e thdt
dre nùmb€r of teerh dftècrs rhc 2bilitr ti, birc a.d (hcs sfc.ifil
Ioodsand llur dris.an rlte. dier and nuririon. Thc cridc.cÉ
cones lior (lu,te a lar.qenùn,ber ot r€lrti!cl,v sn,ill s.alc studics
(1or exanple, Claurcey rt r/. l9E.i, Citlson l9lJ.1. Nlotnihxn
199t, Joshrpura 1996, Krall t ,/. 1998) an.l some .icional
s!rleys co.dùcred more recerr\. Bodr dic BLitish Nxrional Dict
 beebievod
Wh0rould w h 0ldù0dulB'
0r0lhè0lth? 195

dd Nùûitior Sùrrey (Steele,r a/. 1998) aûd lhe third Natonâ.I
HedLthând Notrition Sùrveyln rhe USÀ shoved that pcople
wirhoutteeth h.d.Ufficrlty eatins a ranaeof foodsof could not
edrhenàt â11. This relàrionshipheld evenattercorreclinsfor rhe
etre.6ofase and seûder.The problen foodsincludedâ o@bcf
ofconno.ly eatenfreshfroit ard vegetables, pafticularlyin their
nw sratc.lufthefmorc, rhe probâbilityofbeing àbleto eat tbese
loorlsinûeasedasthe nunberôfteerh irûeâsed.Almost everyore
with 20 or môre reethhad cômpletedietàryfree.tom.
Jut becaEe rhere is dietalt' freedoû. it doesnor àrtomaticè1ly
follo{ lhat dre diet is entirely satisàctoryand nùtiition is soo.l.
Ho{evea data iiom borh UK âûd US $udies sùagÉr that there ls a
stms ffeûd in dris direc.ion.Intakesof key dietdy .ômpoûents
âtd Ntrjents sùcha dietary Êbre ând \'âr;ousvitâmlns aûd miner-
alswûe much hiShe.in thc dcntaterhaûin dre edefltu1ôus, while
for fibre md viramin c there was also à measurùbleincrede ir
inaleswith ar locreasinsnumbe.ofteeih.Peoplewirh20or more
tæthhad the hishest inrakesofau key nuùients and, senernlly,the
halest blood valùesfor dresea well (Sheilramrt "/. 2001). Table
12I shô${ the vâ1ùesfrom the Brltish sutrey, and iLlusrratesrhe
rlatio.ihip betweendentâ1stÈte àûd ndtrhion aftercorectirg ior
the.1,nft,ùndingetre.ts ofase, geûder,md sociè]class.
Generally,nutririon is be$ wherethereare more teedr.Giren
thâr hèving more lhan 20 teedri! dsoclâtedwith being able to
earever the most challengingfoôds,sucha apples,nuts,and raw
câûôs, àr.t thar thjs is suppofted by additiooal material on
inrakesârd blood valuesof key nuûiens, the distins diet and
ûurritioû da|awould broadlysùpportthe 20 toorh concept.
Natural teeth ând other conceptsof health
The function ofteeih extends to nôre thèû just earins. The ble
of naturàl teeth inclxdes communicaiiôn md sociâl fùnctionins.
The appedance ôf a pe6oûi .eedr is inportant for social func
rionins. and the number ofteelh câr he ân impôrtant vâriable in
rheif appedance. Concepts of a minimum dentitioû required iôr
sàrisfacto.y appedd.e ùe Do! ieally valid though, âs the posi
tiofl,.oloùr, ùd shàpeof the teeih are âlso importdt Iàctors. The
sde ârgùment miabi apply ro spee.h. However, there $ clca.
evidence drat the.e is a shèrp reducriot in ù€ proPoition of
people who wed dentures where there are more than âboùt 20
!ee.h (see li8. r2.t). BroàcLlyspeakins, havi.8 20 or ûore teeth
is dsocjated s'ith being able tô fùnctlon, at all levels, wiihoùt
dentùres. Elen where the.e are missitg teeth ant€rio.ly, the more
teeth that ùe present and in gôod heàlth, the more divefe the

Table 12.3 Dierary lDûke values ând flâsma values f.r sele.ted key ntrtritlonal compooents in older adults, by tùmber of.ecth.
aftercorrectior for the innucn.c of ase, sender, social .1ds, àrd pùtial denturc stâtus (trom Sheihlm 'l rl. 2001)

Incakeoff,on *ârch PolysacchàridÊs

t) 1i
Inhl<eoainûinsi.rmllksùs* (.ft,n
nÀtùmlsour.er r.h ^ rrun) G) 1i
I."k .r r"-- c' (-g)
3:5
llasnâ as.orbâte (mmol/l) iu ta
fl"*ei.,(;À.1/l) 2.1 2.1

70

60

50

20

10

0
13 9 14 15 20 21 24 25 2A 29-32
NLmberol naluralteelh

Fisure t2.t The prcpo(ioDolthe lolulation Fith de.tùres â..ordrns to the nùmbe. of teeth thÊr bavc (!rom Kelly d,, 2000)
 I
196 12 Pr€ùenrion
inthe0geing
dentitior
|
I
resto.ariveoprions foi filli.g the spaceswith somerhingodrer
rbânder!ùres.Somework suasesrsrhar the benefitsexrends'ell
beyo.d eatiDgfùrctiôn, asrete.rion of20 or more teerhhasbeer
shovn !o be ssociâtedwlrh reducedmentàl ând physi.alimpair
me.i nr old àse,ùd erenlover morrality(Shimdaki,r,/. 2001).
Mode.. conceps of oral hea.ldrhave errended beyond disase
and furctiôn. Lo.kcrr ,nodelofordl healrhftcoanizesdÈr whlle
impai.ment ànd tuÂ.tio.al limilarions âre imporant, disâbiliry
and handicÀp càn o.ctr.. perhaps €ven where physl.al tu.ctional
limitarioû doesnot. Meaùrins ont healrhbasedon rhe person\
oral heâ.lthrelatedquaLjryof life n,gges6rnar rherunberofteeth
js atsorelatedro dris, a welt d simply to tuncrion.The eviderce
that thereis any sorr ofrhresholdar 20 reedris le$ ctearthoùgh,
âûd qùa1iryof life issùeslrclude dre presenceof discomfortdd
pain, satÂfa.tionwith rhe.lenritiôn aDdalsothe eip€clariorrhèt
a pe6on hs of their own deûtnioû. The evidenceis limiteJ, but
st,L.liesfrom seve.alcoùrÛies, in.lud;ng rhe UK, Creece,and
Ausfuâlia suggesrrhar rhere is sode .uhuml variation ùlrhin this
and thar mo.e reerh senerdllymea.s berrer orâ1heâlrh relâted
qù,.llqroflfe, ùp to ànd indeedbe)'ondlhe 20 toorh thresnold.
The numberofteeth may corclate with dierârypon-nriâlard
nùtritional outcome,bur ir is a crudemedùre and doesnor iake
rnto accoùDtthe way drar rhe reerhmeet,ôr fôr rhât mârre.rheir
condition.lb sômeerrcoi rhe way rhàt reethâre lost or rhe pa!
tern ofretained teerh would appea.ro be simple .han.e; depen
denr ôn the locâtior of disease.Howcver. rreatmert planning
sffategies have beeo sugg€sredthèt a.ltef rh€ way d,a! diseae is
mamged,md rherefore,overa perio.tof rime, rhe.lisrriburionof
teeth rhàt emerses.Ioremost mong theseis rhe conceptof rhe
'shortened 'Ibis
dcnraLarch' (SDA). ;s a simple philosophnfiri
developedb)' Kâyser(1981) thât .âo be applie.lto èûy denritbn
so long asrhc.e a.e sùffi.ient reth. As resourcesàre à1mostalways
lidlted vhen dealirg with olde. peopl€(whetherthey be fiûa.-
cial, iime, speciaListskills, or the abiliry ro receivecare)then
treatmeûtwill ofien needro be prioritlzed. SDA theory woùl.l
araucdrai the arterior reethtake the highesrprioritn 6 rheya.c
à.aiheticallyand mechùicalty importa.r, bùt è1sobe.aùsrrhey
àrea.ce$ibleior cleâdrg and fo. denralcare Ir shôit, they area
sood bet. Premolùteetharealsor sood bet, beingac.essible,
a.ealsogenenllysingleof doublerootedând thereforea.eeasyro
ùeât, m.l àlsoedy b accesard clean;pdicuiady imporrânrin
dre elderly.Mô1ds though ar€ les accesible,navervo o. lhree
rootswirh fûcatloos berveenihem ard complcxcâ.al sysems.
v i " r eu n - diff.,I
and expcosive. Although thesemay oftenbe rredted,rheyslnNld
take â low prioriry. oûly re.eiving.de whcn the prjority teerh
furûer forward havereceivedthe .de ihey nced !o secxrerheû
fùrure. If resou.cesare exhàustedadd rhese reelh nee.t conplex
treahent. dreycan be *Ûa.ted of evenletitùnfeared.
SDA is an attr.ctile con.epr and verv appropriÈtefor older
pârier6. bur in maoy câsesmay not be aPpropriatebecausethe
disÙibutior ofteeth precludesir. Nevertheless, the p.in.lple of
p.nririzarior ofkey teedr is an imlortmr ore èûd in.reæesrhe
erÊciercyoftheteeththat de there.carefùlpldnlDs ândpriorii-
zar;oDmay help to preveût ôra1disabilitl', evenvhen rhe 20 rtrrh
ihresholdjs approâche.t. Where môie Èeù are16r, the.€is srillr
placefor strâtegicplàûning âs a nens of prerenting disabiliry
Ta.g€lirA resources ro key rerh for mdimum prosrhcticbenelit
and manaAi.glhe proces of becomingedentulous.d bothnake
à ùseiùlconûibùtlon|owardsprcventingoral disabiliry.
h $mmâiy, the rargetof20 .atu.al teerhin;rialLysuggesred
by ihe \?HO, is prôbâblyn reasonable wo.king rule, and woùld
seen tô be âso.iated th the poleûriaLfor conionâble dd efl
cient èarin8.a.d for dieraryand nurritioml freedom The pEcÀe
r r r b , ' r ^ . r . ' . ' l l ' É l l e q q " l l . l . S n . 1- e ' f f u J o , . - , o !
" ) b T r. r, . 'or"l Lh'n l2 l..f iJ.l 'o û*F po . o o--
tâ.t. bur a rhresholdvalueofaroùrd 20 teerhis M1id.At a publi.
healih level.prevmri.A oral disability ir mo$ of rhe populadon
coùld be ùhieve.t by ntunrainlna 20 or more healthyaûd tunc
tnrnal natunl tee.h. At an in lividuà1level rherewill alwaysbe
peoplewho ca.not iùnction wlth 10$ ofreeth and othea whooi
eat a challenAinAmeal with rothirg bur rwo l1l fitting pieces ol
ac'ylic ro help. However,evenwhen deâlins vi.h nrdividuÀls,
' _ r r ' e q i ' , n e 1 ,p " a r i n S" , r n d \ ' ! r I I r \ . m r . . n r m , m
help to ensured levelof Â,n.rb. co.sisrentwirh heallhaûdheLp
io prevert severeorâl disablliry
bu!
v v n a lw l m t l I n e a 0 1 [ I yI o
achievea functionalnatural
dentitionfor life?
Missedtargets
It is àll very well. havi.A a târgerro dnn ar for the populâtioror
for yôur pdienr, but lr bas |o be sonertring thàt is àchievâble.
Despitetie indease;. the reteotior of naùrd1teethin the oLdel
populatio. tha! has been described,we de rlll somew.y ofi
20 naûnl teedr b€ing a ùdvesal posibility. O..e aaa'n,rhe
most rece.r dâta coDesfrom the UK, wherein 1998 just orer
onc-fifdr ofÀLl adùlls âsed 6t yeàn and ôveracûally had 2l or
morc râtuml teeth.The remrin ler havr al.ead).m;sed rheiârger
192 12 Prevmlion
inlheogeing
d".nfilion
Figqre 12.1 The fun.rional cap..ity ôfthÊ sâlivdryglànds
: 6 0
0 t0 20 30 40 50 60 75 90 105 120 150 130240 300 360
Tme
-c Young Subject +
Figure I 2.2 The eitèct of anricholiturgjc drùgs on sâlira.y nov
doeloped for differert groùps.The oral healthofolderpeoplehas
uDdersonetrènsfomàtiôn ir receÂtdecadesand rhe chans€swe
hrle seenùe prôbrbly morc dramaricrhan for my orherpopùlà
tioû grôup. What ls morc. charaeswill conrinùe.The preventive
reeds for the elderly now afc quile diiferert from those of foity
yeds âgo, and ln ânodrerlorry yearswe ùe likety rô be fa.ed
with anew setotproblemsagajû.Thjs secrion.tesùibeswhar has
\ . p ô " , e , r . u h " r \ i h , p p " - . . 1 d \ o s r \ , . J r - . ' , p r e .e n , , , "
denrisrrylor dre oLderpe6oû.
Trendsin orâl health in the last fiI\ years
R(enr decadeshaveseensomeremùkàble chânges.Iifty yers ago
d1e.on.ept ofprevenrioûir the eLterlywôtrld hnvebeedseens
gùiteabsurdir manycountries, not ledt in the UKwhere,ln r968,
ôvÉr80% ofpeopleof pensionable ase weieedentul{,uscray d,l
1970. Many of the remaiûder were so tu down dre oad 6$'ards
total txtrh lo$ drâr preveD.ionfor this populatn,nwoùld have
OderSubjècl
s€em€dlike r completewasteof resources. Hov times chanse.
Figùre 12.1 showsthe npid redùctionofthe proponlonofpsple
edertulôs benveen1968and 1998in the United Kingdoû (Kelly
.r ?/. 2000). In rhis regard, the UK ma). be liÛle differeni fmû
lÈy similar .!ûÛies, but becaue there ha been â .ômpùble
sùftycondu.ted sery decadesince1968,the tFnds ln oEl heâ1th
have beeneasyto ûa.k. There is evidencerbât i. other counùies,
the saning poinr wasprôbably befter with 1ôwerlelels ofedentù-
louness(V/HO 1986),but the tre.d hd bær s'mih nr mostoa
drosecourtries whe.e nar;onal suryeyshavebeen conducted,wùh
thc excepr;orofthosevhe.e ratesofedertuLismwereal.@dylov.
Kûowina how a popùlaiion has behave.tover à period of tlme
is nrvdluàble,d it allowsùs to ûÈke predi.tionsofhow it my
coDtinueto chmge in tutùre yem. l-igùre 12.1 è1soshowsthe
predicied trends for totâl tooth loss ôver the nert three de.âdesio
the UK. Tôtâ1tôoth loss is prediùed rô reduce tô very low levels
indeedby 2028, ever dong peopleàged7i or more.However,
 Populorion
rrmos ololdepe00h
i rhe0,ûDr0hh 193
I

theredu.tiônin p.evalenceofroral toorh tos is pà(ly tô dô wirh
older,laigely edentulous gen€rationsdyirg ôùt and bein8
laleed with cohortsof ageing adùks who hâvererainedrheir
ieetn.The.eis evidencethar evendônsn thesegroupstberels a
sLignrredu.tbn in rhe incidence of e.tenrulôusness (i.e. rhe
nùmberof new .des), but rhis reduclloD is smalt àrd lôoks
ulikely to disappearcomplerely.Iirhat is more, thc inc'de.ce is
nigher in dre l2te middl€ agedmd elderly.In ôrherwords.drere
will alwaysbe a few peoplewho, for whitever reôon, lose their
ûdunl teelh a! somestège.As tôoth lossis cumularive,nosr of
rheedentulous de likely ro be ô1d.Tbis w2sp.obablynor always
rhecde. A. one time therewasa rclarlvclyhiAh incidercein the
you.s and niddle aged,bùt lessso in dre old. The darafrom the
UK in 1998 sùsgestthai rhe decenniâlincideDcewâs aboùt 2 -4
perce.t per decèdefor peoplengedbetween'1t ând 74.:fhe inci
den.eis qùire diificult to calcuiùtefor peopk agedover7t y€a6,
but may be â little higher.FacinS2 denturefor ûe fisr time is
notedywhenyoude old, dd.heoml disabiLiryrhatcar resùltis
b o e r p . ' e r ' d o 1 . " , ù t l " , ' , 8 . n J , r 8 F f e . l p É . e, ,o , .
Th€ reasonfor sùcha dranatic chanseir ôrè1healrhfortoûes,
particulùly anons mlddle tged àrd older âdulrshæ 1itt1eto dô
with the reducrionlr ràtesof.lent.l cùies observe.lir younser
seoerations. The e,pldâtion fôr nuch ôfrhe chàngecànbe found
ln liaùre 12.4.This showsthe ûumberofrenored teethper 100
peoplein the Fopulationfor eachage group ir eachyearùat a
turional surey was .lrnducrd. The effe.r is of a wave of resrora-
tlons movins à.rôs rhe pasefrod left tô righr, with the peak (rhe
larsestcoûceûtrÈtiôn of fillings) beingdong rhôseborn beMeen
1914 ard 1963. This was a tlme when cades.ateswe.e hish,
beforewidesprcadfluotidatio. of too.hpasteso. va.er supllies
and vhen .esrorativedentâl cârewd becomingcomtoftableand
wideit acce$iblc,.ot leas lhrou8h an irc.easeiû the rumber of
de.tists 2nd theirwilLnrAre$to unde.ldkeresrorativ€ procedures.
In the UK this.ame aboutwirh thc availabilityofrelâr;velyinex
peûsiveNatioùl Heâlth Servi.edentisûy,bur in orhercoùnù,es
alternativesystemswe.e avaiLablewhich made dentÀûy more
r . . . i b l ^ .W l e , J l . e Jq , l . o r ' l ! ' g F . ! \ . ,s e _oré(.ve
carebecomirs moredesirable.

-@- 25-34

iÈ 65 74
-&- 75+

2003 2014 2024

Iigure l2.l The p€rccnragcofrhe UK dentàreb)' ase,1968 1998,wnh proj€.rionsto 2028, bæed or data f.om thc UK Adùlt Dcnrâl
HealthSùreys (Kelly ardl 2000).

16 24 25 34 35-44 45-54 55-64 65+

ligure 12.4 'rhe . uûber ôf .esoredtæth by ageftom 1978to 1998.bâsedon dâÈ fioû the UK Âdulr Dertal HeahhSuneys
(Ke1ly'',t 2000).
lea I 12 Preveirion
inlhe00ein0
denririof
t - "
TIe legù.! ofèllofthis is Jû importânt drd irtÉresirg oie, if
ve hope to prelenr .râl .tisabilirr in ôldef people. Nor beidg
e(lenrùlors r rot enough to erntre â fur.tiôrâl deûitlôr. ù{dry
ol.ter ùdults ha"e erûe rerdr. btrr âr€ dependent on pfurhetic
replacerens of diosc thar have been lost jn ofder tuf rLrem ro
firnction Eren rmon.q dios€ \,ith somerhilg èppioJ.hnrg i full
set o1 nanual teerh. Fisùrc 12..:ishoii thât dr.sc a.c I'kch to bc
prsent by virme ofre*oLarn)n, a.d repcâtcd rc{orâtn,.. A ttpi-
cal .tettate adult aged 70 re6 of age ln the UK w)uld bâve
anrund 18 reeth, $irh abour hâlfofrhcm fillcd. wouU hâv. abour
a 10 pef .cnt .han(c of bavi.g dn a(iti.ial lùll coveragecrowf,
bùt it drcr had,.roFn n'oukl h2ve drou.d 2 or I of average.
Reroratn,nr such as lâ|€c UllinAs a..l cronns are rarely permâ
.crr, x.d usu,lly need servicing and retla.emûrt fron thre to
rinr lt rhc ûntrh undcncâdr is ro sun'ile. Prelefrive srràtegies
fôr the el.lerlr L,ave to be seen in.hls onrert, and dcslsflcd
a(ùnd .iaximizin.q the lu.nionàl lo$rlllities rhèr this reN
tound gcncml imirrovemenr in oral beùllh ailows.
Trends
in orolheolth
ol olderpeople
. The npid in.reasenr thÊ f,unber.f.l.lef Fotlevlù naturâlr.erh
\rnl conrinue tu !ÉrÉrÀlde.rdÊs in mant inJù{riili,ed.ounùles
. OLl.r F$Fl. sho l!rv! rtuftl denùtion: will Énd tû hxre x hish
I ' i , i
t Pr.!c.!ir. $rd.s'.s fùr ir el,lenr need rô be seen,nttu.offexr
What couldbe achieved
with older
adults'oralhealth?
Cohc. (Cohef a.d llendeBon l99l) h.s .les.ribe.l rhe .on.epts
of irerfèct bealth' ard oFrimum healrh', dd rhe dinin.tiôn
betscc. drc tso is uscrirl nhen ùring ro ûlefril soâls Ior dre
elclerly. From a biolori.al perpe.tive, lcdi.r hcalth' las bccn
fi ..,. " . , , " , r r . . , . . - r J. \ r{,.
caF.iry anl in lertè.l. hlrnory wrli ea.h ôrher .ell (Tsùldle
l9l4). AD ofie! lluote.l 19tE V/orld He.lth Orgâni:aùri deiini
tiot of heâtth tukes â dtr.h videL. less bnnogl.al apprca.! and
desûibes heâ1th d a state of ()mplete ph_rsl.alaûd mcrtal well
beirg' (\\rHO 19t8). \{/hlle ùese dellnitnnN .orer hcalt! ln irs
*idest sense,thev could tur as Êarilr trc atflicd to rhc naros'cf
âreâ oforâl hedth. Perfe.t oral hcahh' is nor ditIi.dt ro ùndcl
stnf(1, Lr!t ir itself. r is not â parti.darll useful concept.
^..ofdlna to rhc sûi(lv biological definiriof, ir $o!l(l rell!ire
l2 yrund teerh ln â m.ùdr rhat ha,ùous nodise,sc 2nd where rbc
ô.dùsn)n ls ideal. ft sct rhis as an objcctiv. tor olde' d.hlrs woùld
bc mca.inAlc$. It is umchielable by all bùt ù tlrv rninoiitt, ènd
cvcn should i. be lio$lble, the.ost ofù.hielnrg ùrd ûriûtàinnrg
it wouu ln,trllr be lirohilritne. The .oû.ept of optjmum oril
hcâlrb' is lsetul .ho!sh. Optrnù,n heJth liâs beer defired d
'd,âr
sùrewhere the.ostof.ny iûlrôv emert o trôveighs d,e !â1tre
xra.hcd to die in,froven,enr' (Cohen rn.t Hen.ieisor 199r). The
rerûs .ost aû.1 !èlùe mar be inrerycre,l purcl,v in tcLms of
e.ônoûi.s, bur côul.t tust as rend,ll be atflied ro quxliry.flifeor
nnf ôrhei nèjôr panneter bl whic h heahh ; i$c$c,l . Ottimùn
oral Lleal ,'.ar app\ ro Jnv àgearoùr, b!! cha.res occu.,n botrr
dre.os. dd.t dre vJlue of.ûe \irh ifcrasi.g àae, so rhc b.hn.c
terds ro slilft. This is à tâ,tiorLa.l,v usctirl .on.ctt s'hcû elxLLûr
ing drc dcrral nccdr ol older adult\
O$timûû.Jlal heêlth: whâl is a "l'Lrnctional
dentition"?
Ar rhc beAlnnin! ofrhe ôvenrr' Â6t.emrr', ûere.d be almost
no elded! popdarn)n û]*l,ere û the woild where 12. or lor ùat
nrafte. c!e. 28 nannl reth i rhe nôrû Strbstunûâllossol lndi
ridùxl tccdr sirh ln.rcaslnA ale is a.lmos unileAal, èù.1 in rlr
U ted Kingdom, rLe me.ù nurrber of teeth an,ofg denrâe
peotle àgeJ It rnJ ov.. in l99il sas 1t.1. Oldcr pcople do not
âpfcar m bc unilefsaur afte.td b-r t]1eif lnpairmett, ânclcleùli
mo{ pcoplc rù*if no iu effects lron paft 1 nn,rh los. Oû the
o d , e . s i d e o fd r c . o i n , . o m f l c t c l 6 s o f t c c d r . a n b e a $ o . i a r É d w n h
1 ù r l c l i o r a la f ( l n u û i l i o n à l d e l i c i c n . i c s( S h c i h a m, r , / . 2 0 0 1 1 I. t
No!l.l be collenienl lÊsomewherein bets'c.r. r m1.1mun dcnù-
tlor .o!l.l be.letiredr a t,oinr aLroveFhi.h s'c .ould bc ûrfident
ôfgoôd fm.rior.Ior bodr rhe ûliri.hral an(l là.populatiolrs d,is
tirnclio.al limirarion
coul.l r.t ù r nrnnù,'n ùrgerr !6'e...8
ând dentil disrbilitr s.ùld bc builr xflrurd maintainifls a denti-
tn,n abov€ rhis lerel bI prcveùtiig dental disede àù.1rootb ro$.
Some yed l!gô, rhe \lHO arteûrtted to detine sùcr, â n,ir,
ûtrû dertition, coûsisteDt ùrth seneral heaLlh ud furccior
ûXrHOit82) r'hetun.rtunaldenrirnr wâsserâr 20 teerh,this
bci.8 rhc rumbef shl.h ias seenas being able to po"ide *ffi
.icnrfur.tn). s'lthout the ûeedfofùj removable prorhas The
lgùrc sa5 usc.lo. rbe limited evidenceavrlhbLe at dre time.
If such a co..cft is n) bc lalid, lr i\ irnFortatrt tu be .Lexrâb.ut
what tin.tional misht a.ttraur. meaû Teeth have r ilrge ôfroles,
but nr biological terms, rhe nost iùI)o(nnt is .clârc.l to m.sri.a-
tio. a.d c,rina. Â glan.c ar.omparxrne dental amtumr illùûer
thc .l.rc rchtnrnship beNeer ùe dentnbn, dler, ùrd evùLftion
Clasi. sudi$ as lona âgo as the 19j0s dn)LLEhsholved thât.hdr
ûg is ro! erûell.ecesdry for,liE.stio. ofmost àods, at lcx{ in
healthy"vo!nsâdùlts. Thjs,loes nor nran d,ât tbcï a.c,trcLcurt ù)
good n!ùition as rhe abse..e ot re.th mâr 2kc. too,lschoi.c of rhe
elhcreû.y wrth {hi.h nùtrierls .an be €rtracle(I, bùt comllcrc
digestior ôf mùi foods .an occùr withoùr li6r beina.hewed.
hlâtur"l lreth ond nùlriliorl
Thcrc is no gùc{bn drar nartâl teedl ùe ne.hani.xllr ûu.h
'l
inorc cfilcic.Ùhar .omplete denrtes. h€ft is al$ eriden.e thdt
dre nùmb€r of teerh dftècrs rhc 2bilitr ti, birc a.d (hcs sfc.ifil
Ioodsand llur dris.an rlte. dier and nuririon. Thc cridc.cÉ
cones lior (lu,te a lar.qenùn,ber ot r€lrti!cl,v sn,ill s.alc studics
(1or exanple, Claurcey rt r/. l9E.i, Citlson l9lJ.1. Nlotnihxn
199t, Joshrpura 1996, Krall t ,/. 1998) an.l some .icional
s!rleys co.dùcred more recerr\. Bodr dic BLitish Nxrional Dict
 beebievod
Wh0rould w h 0ldù0dulB'
0r0lhè0lth? 195

dd Nùûitior Sùrrey (Steele,r a/. 1998) aûd lhe third Natonâ.I
HedLthând Notrition Sùrveyln rhe USÀ shoved that pcople
wirhoutteeth h.d.Ufficrlty eatins a ranaeof foodsof could not
edrhenàt â11. This relàrionshipheld evenattercorreclinsfor rhe
etre.6ofase and seûder.The problen foodsincludedâ o@bcf
ofconno.ly eatenfreshfroit ard vegetables, pafticularlyin their
nw sratc.lufthefmorc, rhe probâbilityofbeing àbleto eat tbese
loorlsinûeasedasthe nunberôfteerh irûeâsed.Almost everyore
with 20 or môre reethhad cômpletedietàryfree.tom.
Jut becaEe rhere is dietalt' freedoû. it doesnor àrtomaticè1ly
follo{ lhat dre diet is entirely satisàctoryand nùtiition is soo.l.
Ho{evea data iiom borh UK âûd US $udies sùagÉr that there ls a
stms ffeûd in dris direc.ion.Intakesof key dietdy .ômpoûents
âtd Ntrjents sùcha dietary Êbre ând \'âr;ousvitâmlns aûd miner-
alswûe much hiShe.in thc dcntaterhaûin dre edefltu1ôus, while
for fibre md viramin c there was also à measurùbleincrede ir
inaleswith ar locreasinsnumbe.ofteeih.Peoplewirh20or more
tæthhad the hishest inrakesofau key nuùients and, senernlly,the
halest blood valùesfor dresea well (Sheilramrt "/. 2001). Table
12I shô${ the vâ1ùesfrom the Brltish sutrey, and iLlusrratesrhe
rlatio.ihip betweendentâ1stÈte àûd ndtrhion aftercorectirg ior
the.1,nft,ùndingetre.ts ofase, geûder,md sociè]class.
Generally,nutririon is be$ wherethereare more teedr.Giren
thâr hèving more lhan 20 teedri! dsoclâtedwith being able to
earever the most challengingfoôds,sucha apples,nuts,and raw
câûôs, àr.t thar thjs is suppofted by additiooal material on
inrakesârd blood valuesof key nuûiens, the distins diet and
ûurritioû da|awould broadlysùpportthe 20 toorh concept.
Natural teeth ând other conceptsof health
The function ofteeih extends to nôre thèû just earins. The ble
of naturàl teeth inclxdes communicaiiôn md sociâl fùnctionins.
The appedance ôf a pe6oûi .eedr is inportant for social func
rionins. and the number ofteelh câr he ân impôrtant vâriable in
rheif appedance. Concepts of a minimum dentitioû required iôr
sàrisfacto.y appedd.e ùe Do! ieally valid though, âs the posi
tiofl,.oloùr, ùd shàpeof the teeih are âlso importdt Iàctors. The
sde ârgùment miabi apply ro spee.h. However, there $ clca.
evidence drat the.e is a shèrp reducriot in ù€ proPoition of
people who wed dentures where there are more than âboùt 20
!ee.h (see li8. r2.t). BroàcLlyspeakins, havi.8 20 or ûore teeth
is dsocjated s'ith being able tô fùnctlon, at all levels, wiihoùt
dentùres. Elen where the.e are missitg teeth ant€rio.ly, the more
teeth that ùe present and in gôod heàlth, the more divefe the

Table 12.3 Dierary lDûke values ând flâsma values f.r sele.ted key ntrtritlonal compooents in older adults, by tùmber of.ecth.
aftercorrectior for the innucn.c of ase, sender, social .1ds, àrd pùtial denturc stâtus (trom Sheihlm 'l rl. 2001)

Incakeoff,on *ârch PolysacchàridÊs

t) 1i
Inhl<eoainûinsi.rmllksùs* (.ft,n
nÀtùmlsour.er r.h ^ rrun) G) 1i
I."k .r r"-- c' (-g)
3:5
llasnâ as.orbâte (mmol/l) iu ta
fl"*ei.,(;À.1/l) 2.1 2.1

70

60

50

20

10

0
13 9 14 15 20 21 24 25 2A 29-32
NLmberol naluralteelh

Fisure t2.t The prcpo(ioDolthe lolulation Fith de.tùres â..ordrns to the nùmbe. of teeth thÊr bavc (!rom Kelly d,, 2000)
 I
196 12 Pr€ùenrion
inthe0geing
dentitior
|
I
resto.ariveoprions foi filli.g the spaceswith somerhingodrer
rbânder!ùres.Somework suasesrsrhar the benefitsexrends'ell
beyo.d eatiDgfùrctiôn, asrete.rion of20 or more teerhhasbeer
shovn !o be ssociâtedwlrh reducedmentàl ând physi.alimpair
me.i nr old àse,ùd erenlover morrality(Shimdaki,r,/. 2001).
Mode.. conceps of oral hea.ldrhave errended beyond disase
and furctiôn. Lo.kcrr ,nodelofordl healrhftcoanizesdÈr whlle
impai.ment ànd tuÂ.tio.al limilarions âre imporant, disâbiliry
and handicÀp càn o.ctr.. perhaps €ven where physl.al tu.ctional
limitarioû doesnot. Meaùrins ont healrhbasedon rhe person\
oral heâ.lthrelatedquaLjryof life n,gges6rnar rherunberofteeth
js atsorelatedro dris, a welt d simply to tuncrion.The eviderce
that thereis any sorr ofrhresholdar 20 reedris le$ ctearthoùgh,
âûd qùa1iryof life issùeslrclude dre presenceof discomfortdd
pain, satÂfa.tionwith rhe.lenritiôn aDdalsothe eip€clariorrhèt
a pe6on hs of their own deûtnioû. The evidenceis limiteJ, but
st,L.liesfrom seve.alcoùrÛies, in.lud;ng rhe UK, Creece,and
Ausfuâlia suggesrrhar rhere is sode .uhuml variation ùlrhin this
and thar mo.e reerh senerdllymea.s berrer orâ1heâlrh relâted
qù,.llqroflfe, ùp to ànd indeedbe)'ondlhe 20 toorh thresnold.
The numberofteeth may corclate with dierârypon-nriâlard
nùtritional outcome,bur ir is a crudemedùre and doesnor iake
rnto accoùDtthe way drar rhe reerhmeet,ôr fôr rhât mârre.rheir
condition.lb sômeerrcoi rhe way rhàt reethâre lost or rhe pa!
tern ofretained teerh would appea.ro be simple .han.e; depen
denr ôn the locâtior of disease.Howcver. rreatmert planning
sffategies have beeo sugg€sredthèt a.ltef rh€ way d,a! diseae is
mamged,md rherefore,overa perio.tof rime, rhe.lisrriburionof
teeth rhàt emerses.Ioremost mong theseis rhe conceptof rhe
'shortened 'Ibis
dcnraLarch' (SDA). ;s a simple philosophnfiri
developedb)' Kâyser(1981) thât .âo be applie.lto èûy denritbn
so long asrhc.e a.e sùffi.ient reth. As resourcesàre à1mostalways
lidlted vhen dealirg with olde. peopl€(whetherthey be fiûa.-
cial, iime, speciaListskills, or the abiliry ro receivecare)then
treatmeûtwill ofien needro be prioritlzed. SDA theory woùl.l
araucdrai the arterior reethtake the highesrprioritn 6 rheya.c
à.aiheticallyand mechùicalty importa.r, bùt è1sobe.aùsrrhey
àrea.ce$ibleior cleâdrg and fo. denralcare Ir shôit, they area
sood bet. Premolùteetharealsor sood bet, beingac.essible,
a.ealsogenenllysingleof doublerootedând thereforea.eeasyro
ùeât, m.l àlsoedy b accesard clean;pdicuiady imporrânrin
dre elderly.Mô1ds though ar€ les accesible,navervo o. lhree
rootswirh fûcatloos berveenihem ard complcxcâ.al sysems.
v i " r eu n - diff.,I
and expcosive. Although thesemay oftenbe rredted,rheyslnNld
take â low prioriry. oûly re.eiving.de whcn the prjority teerh
furûer forward havereceivedthe .de ihey nced !o secxrerheû
fùrure. If resou.cesare exhàustedadd rhese reelh nee.t conplex
treahent. dreycan be *Ûa.ted of evenletitùnfeared.
SDA is an attr.ctile con.epr and verv appropriÈtefor older
pârier6. bur in maoy câsesmay not be aPpropriatebecausethe
disÙibutior ofteeth precludesir. Nevertheless, the p.in.lple of
p.nririzarior ofkey teedr is an imlortmr ore èûd in.reæesrhe
erÊciercyoftheteeththat de there.carefùlpldnlDs ândpriorii-
zar;oDmay help to preveût ôra1disabilitl', evenvhen rhe 20 rtrrh
ihresholdjs approâche.t. Where môie Èeù are16r, the.€is srillr
placefor strâtegicplàûning âs a nens of prerenting disabiliry
Ta.g€lirA resources ro key rerh for mdimum prosrhcticbenelit
and manaAi.glhe proces of becomingedentulous.d bothnake
à ùseiùlconûibùtlon|owardsprcventingoral disabiliry.
h $mmâiy, the rargetof20 .atu.al teerhin;rialLysuggesred
by ihe \?HO, is prôbâblyn reasonable wo.king rule, and woùld
seen tô be âso.iated th the poleûriaLfor conionâble dd efl
cient èarin8.a.d for dieraryand nurritioml freedom The pEcÀe
r r r b , ' r ^ . r . ' . ' l l ' É l l e q q " l l . l . S n . 1- e ' f f u J o , . - , o !
" ) b T r. r, . 'or"l Lh'n l2 l..f iJ.l 'o û*F po . o o--
tâ.t. bur a rhresholdvalueofaroùrd 20 teerhis M1id.At a publi.
healih level.prevmri.A oral disability ir mo$ of rhe populadon
coùld be ùhieve.t by ntunrainlna 20 or more healthyaûd tunc
tnrnal natunl tee.h. At an in lividuà1level rherewill alwaysbe
peoplewho ca.not iùnction wlth 10$ ofreeth and othea whooi
eat a challenAinAmeal with rothirg bur rwo l1l fitting pieces ol
ac'ylic ro help. However,evenwhen deâlins vi.h nrdividuÀls,
' _ r r ' e q i ' , n e 1 ,p " a r i n S" , r n d \ ' ! r I I r \ . m r . . n r m , m
help to ensured levelof Â,n.rb. co.sisrentwirh heallhaûdheLp
io prevert severeorâl disablliry
bu!
v v n a lw l m t l I n e a 0 1 [ I yI o
achievea functionalnatural
dentitionfor life?
Missedtargets
It is àll very well. havi.A a târgerro dnn ar for the populâtioror
for yôur pdienr, but lr bas |o be sonertring thàt is àchievâble.
Despitetie indease;. the reteotior of naùrd1teethin the oLdel
populatio. tha! has been described,we de rlll somew.y ofi
20 naûnl teedr b€ing a ùdvesal posibility. O..e aaa'n,rhe
most rece.r dâta coDesfrom the UK, wherein 1998 just orer
onc-fifdr ofÀLl adùlls âsed 6t yeàn and ôveracûally had 2l or
morc râtuml teeth.The remrin ler havr al.ead).m;sed rheiârger
 W h o l u i i l l m i l0l hbel . vo d h Ê w0 l u n d ' o nmi r r t r d P r l i o n rI0hr) | 191
I

md !rcvc.tlna disability for theû vill b€ defcndcnt on careful ÀuDber of ftth betreet attc.ders ancl non dtlenders bde.l on
phnninga.d manaaemenr ofwhât is leli. Howevcr,sen 20% is .lata f.om the 1998 UK Adult Dental Heâlth Survey.Although
age,r deal beter than the situâtlot 20 yea6 aAowhe.ea fun lhese data are .rôss-seciionalthe implicatiot is that dental Àtten
tionaldenrit;on in older adults was t serlujD€ruriry Ifwe lôôk .tance does .esù1t it tooth rerent;on. This ls suppo.ted by dàtà
ùtd,eliture senerat$nsofolderè.tults,fo. exampleat the'1t-54 showing mù.h higherlelels ofurteated diseâsein non-attendes
red oldsof1998, the potential!o maintàioa fùn.tloning mrural ln thc UK, ârôurd 60 per cent of cLentatepeople aAed 7t yeâ6
derrltior is considerable;o\et uo% hal,21, or more leeth. l0% J F dô l d . r J ' l e ) s , r , d r"q Jer. L ,L, .F^ cene: io1'
norethan l0 yca6 pftvnùsly. Th geûerètioncoùldbc stnregi- (5t 74) the prcportion is eveo hiahc. ar 68 Per cetr, md seÂer-
caLLymanased,could havediseâse prevettedor slowedand a high dI_.efroto; ^ o d 1 , J F- e o . , r , r i' S f o r L . e 1 _ , i '
propoftioncoxld continueinto o1dage with the poterlial tor â slowly iûcreasins. Nerefthetess, ùound 20-10 per cert or olde.
.oûpletediet md good nuùition. Theseùen.ls cd be modelled people oûly àttend when they nffer pain o. problems. If strategic
to seeNherewe ùe likely to be in rhe funte, thoûgh mùch le$ pldning is to have any chance ôfpreleûling onl disability, dren
' 0 p F r ' e , ' e l . _ , o n .J ' | ' l r | ê . . o r i1
âc.uratelythân for total loodr loss.NÉvÉtheles, ùsits crude |, 0 o /D'
nodellingte.hniques,by 2018 6l % of65-7,1year ol.ts {.11 t.i younaer generÈtlors will .eed tô be broùsh. into sôme kint of
yeâroldsir 1998)a.epredicredro bare 2r or more ùtrtral teerh deûta.l cde. Iurthei,norc, those chârged with prcriding the care
Thûe doessccmh be dre reâ.Ipotntial to preve.t dre disâbillty will need to be weu briefed in the.oncep6 of $rtegic F lântins,
ftsùhingfrom toôrh 10$ io older aae for dre maJorirrofpeople. and wlll need to be workinA in an environnent whe.e this is
Tô dô rhis thorsh we needto a,ldrc$ the baûieB to à.hievins
rhis.Theseiûclude soclal,ecoûomic.and attltudinal bùners, ds The Èasônswhypeopledo not dteûd ihe de.tista.eûàty md
vell4 p.erentlng denrâldiseâse an.t the co.sequences ofdenràl !ùie,.l, bur in.lude feù, ànxietn and .ôst. Iû okl€r adults. there
âre also drta to suggest that a fèel;.g that there n nô need 1ôr
treàtment is also d idportan! coosideEtion, PerhaPsrefleding
chânged p.io.it;cs $itL1incredina aae. Re.ent data sragesr that
Fâctorslirniting the abilily to rcceivecare
the proportion of people for whom Fearand anxiety is a baticL is
Dental non-attendance redÙcins. Ncvertheles, feàr does apped to be â major ta.t{,. in
Notererybodlaocs to rhe dentir for.heck ùps. This is notapr! noû-aftendan.e amongst older adulrs, bùt cost may be a more
lo..i',-l-"r .'" n, ".\d +rll o'e. , ùrl i.F,ôd' impotunt varjable ir dererdiniûg vhether Ûeatmett $ àclually
body reading it, bor cLentâlatter ance mry be one oi the major
limirios facrors in the ability ro retèin r€edr. Despite tle unnec- Ir is impossibleand unwise ro mèke bold stateftens àbout rhe
esùytoolh !i$uc removal thar has undôubtedly bee. undcraken imfortân.e ôf côst as a barrier t) re.eiving ca.e in older people,
iD lhe nane ofgood dcntisÛy ôatr rhe yeds, the inpac! ot dcntal just âs ir ls in+proprjate to make bô1d stètemenrs abour the rol€
alterdance does sccm. on balance, to be asociated $'irh bette. ofweaith. The willitgûes io re.eive .are .lePendsi.large pàn on
orâl health in rhe form of morc reth ôver à lifetine thm non- the valuc pla.Éd by the ind;vidual on ônl health as weu d their
artendance This is not fu say thnt it is the èttenda.ce ihar has âbiliry b pay for lt. Imbalances are .ommon. The .ole of the
nccc$arily re$lied in more reeth being retâined, but theft is d denr..Lprâctitloner is k, keep in sisht the ultimaie obiective of
.lear $ôciùion. Figure 12.6 shoss .l€ar!'' rhe differetce nr drc care, i.e.. n dre long ierm prerertion of disàbility, dis.omtoit,

o
^l I é,'" r.'* éd ""^'
Fieuc 12.6 Toorh .e(ntion of dentàl âterdcs compx.€d{irh nôi lttendes ât drffe.€Dtases(Kelly t ,1 2000)
198 12 Prevenlion
inlhê0geing
def,i,ion
ùd dissatisfact;o.. Ir is rhen the job of dre prcre$ioral !o Iird a
prôg.amme of p.eventioû èûd fuearmeût rh2r can be maDased
virhi. both dre tlnaocièl, physiolo8ical, and psycholoAical limi
tations thar prevail, bùt thàt sri11 neer rhe key objective.
Manaaeme.t concepts such as the shofie.ed denral arch (see
àbôve) .d en.ompa$ prevenrile prin.iples and rakc accounr of
eco.omic limitàriotu as well as ihe limitarlons iûposed by fear
Lim;tatio s relate.J Ia disabilitlt and illness
\vb€ûpldning ôralca.e;. olde.people, rhedentÂtharto dmw
on d nMber ôf resouJces. Àt the top of the list of resourccsare
linancialresoù.es,in odrervords rhe àbility for the.os6 or cafe
!o be met. Sôderimes.rha! n met by the state,somerimesby
insuFrce ôr sohetlmcs d;recdy by the patienr.Howevcr, rhere
are orher resourcesthÀt may limit the àbiliry of the elderly tu
re.eivecare.:fhcdentisthasto hàvethe skills, drc equiprent, ènd
the time ro deal wth someof rhe .omplex problemshe or she
faces.The parieût also lras !o hÀvethe rime, ùd i. rhe caseof
the e1der1y.the abiliry ro receive.de. The abiLiry!o set to rhe
surEeryto sit for lons enoughin a cha;rso rhar lreatment.an be
provided, aûd the dexterity $ ma;nrâin a cleân and healrhy
nouth are all key resôurces thâr can l;mir rhe abiiity ro prevent
Despirelhe co1ùmnin.hes lû dc.ral ,ournalsdevotedto the
provisionof dcnml careto old peopleurable ro leavehomeor ro
tolerateiûteûention, mosr older dults (over the a€€ of .erire-
menr 6t, for the sakeofarsumcft) arenobiie àrd rel.tively self-
r e r n - 1 4 . l d d , - b l i l i l o n n o n I o . , e r " d u l r . . bb, u ' l ' l , e
fre.tùencyôfdlsability ard its selerity rend b lncreasewirh ag€,
parti.û]tu]y over rhe ageof 80 years.ThÉ rangeofdisâbiliriesjs
wide, bor ditricuhieswirh locomotiônand pefon2r careare rh€
ûo$ .ômmon fo.msi md both might havesomebearinaon the
èbility b mâintainâ reasonèble standardofonl heârn
Or.l heâlthproblemsmâybe comp|cètedbecaùse ofan i.abil
ity roobtâ'n careÀ âren rofdlsability, for exàmple,whereêNb-
ject is hôùs€bound aod unabletô redh a dentist.Seleredisabillry,
ro â ievelrhat lim;ts peoplero rheirown home is,,or uJ'corùlor,
thôqh ir affectsa miûority of ô1defpeople,erer of over7t yeù
olds. Ir ;s .easooèble to âssùmerhat â larse majority of âdù1ts
beyood.elirementasewoùld be ahiero visir rhe denrists sùrgèry.
However.while the $bje.t may be able !o reæha.tenrisr,rreat-
mert mjght still be comprom;sed in otherwaysby genera.l healtb.
Fof exâûple, ûe .lentir may havedifficulty provicLinggood-
qùa.lity.arc because ofrhe involùn.ârymovementsofPàrkinsor's
disease, ôr whercrhepatienrcamor be Ùearedsuplnedùe ro mus
culoskeletalôr card$lascularp.oblems.The scaleof sùchprob,
lems lD the commùniry âs a whole r ùnknosn bur all hecome
morelikely witb inc.edins age,Md dây be a s;gniûcanrimped
imeût to mainrainingoral heèlth.
In ôd1er.lrcumsrances, ir may be possiblefo. the prcFe$ioMl
to provide,and the parieDrto receivequlity ùearmenr,but this
may be .ompronised by the pÀtienr'snrâb;liry ro maintâir rhe
dertition in Sood condnior be.Èuseof difti.ult;es virh oral
hygiere.A wide nnse ofspecilc condirio$ nay be resporsible,
for exmple. sev€.e.hrc.ic anhri.js, any ûeurolosicèldisûù-
barcesôfmôtor fùndioû (e.g.strokeandneuronusculardiseases),
dnd perhapsalso pa;nful oral mucosal conditions. HoNever,
dong evenrhe most severelydisabledadùI.s,epideniolôgiol
datasuggestthar Àmâjorlty arc ablero wâshrhejr handsmd hce
and could lerhaps be dpected to perform th€ mo* basicohl
pfev€ntive measures.such as fiùorlde mouth rinsing, evenif
btushina is ror po$jble. A raDgeof alternâtivesto.onvenriônal
rcorhbrushesùe avâilablethàt mày help tô offset tne h)'siene
probtemsthat resllt fron disabiliryand illne$. The provisiorof
domiciliarycùe from à hygienilr may alsobe a cosi effecrive val
of provjdins this. rd(âtiôn ôf carersls defin;telya priorjly for
Medicalcorditiôns and rheir resùltantdisabilitiescân leadto
an impaircd âbility ro achieveoral hedlth in one odrer vay. WheF
me.ticèl prôblens are sever€,or 2 chroric debilirètlns i1lûss
exists,theremây be â tÈnden.l.for oral heal.h!o se€mrrjvial md
'not
worth the effort . I! ma.y c;rcumsrances rhis is urder$and,
able.On tbe orhe.hand,jfsubiectsreachthis stÀgewrhàredon-
able de.tidon, the effort requiredro mèinràinat leâs ôneâ5pû
of rhelf ow. well beiog in good con.lition ûay nor be giear.
where olde. adllts canbe enpôwered(by properinsÛuctlonaod
educar;on)to take cdreof rheû owr orai heahh, rhe beûeÊrsi.
terns of self-csteemând gereral well being, may exrnd vell
beyon.lthe reethdremselves.
Tbe effectsof.lenral .I^ease antl of dental carc
Older p€oplearear sreaterrisk ôfspe.ii. diseases, nolablycaries
of rhe expôsedrôor surà.es,wbich ca. be very dûasiûs aûda
risk to the sùrvivalof the roorh.Trearoenrfor clinical condirions
ûat arecommonin yoùn8erlife ;salsomoredimcul!, alreringoùr
abiiiry tô ûanagedentald;seaseThis parricutù]yappliesro pLrlp
ànd periodôntal dÀeases.SpeciUcprele.rlve merhodsfor the
cordltionsofmost relevance io olderpeoplearcdiscu$edi. derail
Preventingdenraldisease;.olde.peoplejs ar esertiâl stepin
preveûtingûe disabllity rhât ca. .esuh f.om uncontrolledrooth
lôs, sô orâl disease;s certainlya threat to our àblliry tô p.event
oral disabili.y;but rhe treatm€ntofth"t disedeis eqùa11y xprob-
lem. Dental trealmentcanconÛibùtero â.celerare denraldisabll-
Ity, thfouAh iat.oaenjc tooth tissue desùtrùion ôr th.ough
inappropriate plmning.
ÎâdirionaL.estorativesolùriorsfor the manaAement of denral
dise6e,paitl.dady deûrâl câ.ies,havethe potenriâlto be very
dmaging to the $uctûe of rhe toodr. Mode.n rechniques tus'
allow lhe remo!èl of the ûiddû ofheâldry rissuein o.<l{ ro
acc€sscaries,but càrele$ ôr thoùEhrlessuse of a bur can still
reù1t in extensivelossofvaluable loorh rissue,and shoite! rhe
life of the nx,rh. ThouShrle$ pLannings probably more of d
probleh. Fùll covemaecrcw.s, of!e! usedto inprove the àppeù-
àn.eofntooth, genenlly reguireexte$ive removalofsonndtoorh
tissuelnevitublyveakenina ùe structureof the toorh and poren-
tir1ly rhreateninsthe pùlp. Most derlisrs wiu be Iànllid wirh
 Prevenlr.q m'" n.l,elærlyI
oentold r99
I

tlædownwardstihlofatooth dra. hasacrovnplacedto imprcve
[s appearance, a.d theû Loses vitaiity. The rooth dren rcquires
endodon.ictreàrment fôlloçed by post placementand a new
crownonly ro then erd up with a root fractnre,emracuo,',a,'!
rhenprepa.ationoflhe leeth either side as brid8e abutments,as
, l . s l - , r . ) . l f , d , . I . i 1 . r \ , { " b , n . " l F r \ . , , . , J , is , n -
eraLlyeaècerbàred ir peoplewith extensivelyrestôre.tmoùths as
all .estorationshavemùsirs that âre sùb,ec!!o breakdownand
s ll h. L'ourpl. que.r r I S . d 'o l'orJ, eÀFpro8rp,,.on.
Techûolosyhâs provided sômesolutions to rheseproblems
sirh tureriâls ând techniques rhaÙedu.e the needfôr removâl ôf
lùge ahôun$ of ti,ôrh tissÙe,bur bad plaming will alwaysbe a
bâfr€rto good .reatmenr.
hnus
Preventinodentaldisease
in the
elderly:
root cafies
Iù most cdes, the preventionof speclficdental diseases i. .his
8roù!co ôrmstô the sde bàsicrù1esasfor yoùnseradùlts.:fhe
chdsesir the orà1environnert may alter the enphasn a litde.
bùr the stràregiesùe sinilù. This sectioû.teè]swlth the condi
tionswhererherearespecifica.tditiorèl issuesre1ùedto ag€.The
mo$importanrof theseis roor caries,a fo.m ofdental cafiesthar
is rdr in the pôpùlètionùnde. t0 ye26 ofâge. bur prôbùly ûe
blgger threâttô rhe viabillry oFnaluraltcedriû old age.Becaùse
ofthe.udùlarive e{Iectsof damageoler a llfetine two otherdis
casesicodditiônsàre Nôfthy of discussionir rhe codiext of rhe
elderly:pe.iodonfuldiseasemd toodr wea. Borh a.e .ôveredrn
detailelsewhere û thr book,sorhesevill bedis.ssed o!1y it the
contextot 1rcrcaùn8a8e.
lloot câries:prevaknce,
incidenceand
distribùtiûnof Ies!o1rs
There is wide \ariitioû in the reported lrcmlence ôf rôôr cdies,
fom d lôw d 7.1 per cer. in a iluoridatedcomnmity to 100 per
cenr in p2rienrs arterding à gerontotosy clinic. Th; anse repre-
seits na.ùmLvùa.ior in prcnlenè and di{eren esû.1Ê,{îagnos
ti..rireria ande&dinatiôn ûethodsùsedby the reseùchwork€s.
one significmt sourceol vârlation is the wèr that dæaol icstot€d
root sùfees arehandled.Itis not posible to decjdewhl anyarven
resorètlonhasbeenplâced,$ .esôritioûsplacedbecause ot.eri-
'fi]ted'
cal wear ini'làte the conpo.ent ofa rôôt snrtuceDMI sco.e.
l o ! \ " i 1 1 . d , " r r o n , h ê | N . r g 8 ( J ' 1 " ' ô , \ r o ' r e n ro r
resiomtionsplacedon root surfacesare to nranage.?ries. This prob
lem has beeûdiscussedir detdl by de P2ola,t /. (1989). One
fufther confoundinEprôblemis that restoratio.spla.ed tô restore
cervicâl$ef .an $bse.tuentlyundergomrginal breakdownand
dnelop reurent decal I! ispo$ible suchrôot surf{es would hâve
develop€ddecay had rhey tutr beet restored to manâgc the wedi
alt€rnatn'ely, ir is alsopossiblethat the ody reson theydseloPed
decaywæ because o{the presene ofàrestotarioDDarsln.
One thirs that is cl€aris thar the pÈvalenceof root cariesin a
popùi.tiôn increaeswith incrcâsinaage.Tâb1e12.4 showsthe
variârionir the numberorlesionspef persônèffected,depe.ding
upoû ihe àge and mtùre ofthe populationsrudied,àtd d€non-
sûares much higher levels of root caries in an institutlo.âl
.ompùed to a free livioa population.Thesefigùresareusetul.but

TableI 2-4 Meân numhcrof vulnerabteroots,.oot lesiôns,dd Rcl it r UK olderaduk populatbn, br âgefor free Livinsadults
ândfor rhoseolder a.tùksliviûs in ar innirutjon (fion Steele,t,/. 1998).

8t+ freeliwing Àll free-tivirg Insritution

ll.7 12.8 9.6 1l.i 9.)

0l
t.l 1.7
4.2 02 0.1
L ]
254 26
I2q. 21%
Irevxlen e ol unsound rooh
Mcr'nnunber of unsornnroô6 it

!ôpoiiô! or d d6 dùt e! r\FôseJ û dre monrh tlr]r ve e Eo.ded 6 hei's d(at(d, û !È$ôftn, or r6rcRl aid ,l(rred
RCI {), the rcor.Èries rdei aoi n{ NodeJ s batrs decved, o! re*orcd ard dt.a!ê,i
 Prevenlr.q m'" n.l,elærlyI
oentold r99
I

tlædownwardstihlofatooth dra. hasacrovnplacedto imprcve
[s appearance, a.d theû Loses vitaiity. The rooth dren rcquires
endodon.ictreàrment fôlloçed by post placementand a new
crownonly ro then erd up with a root fractnre,emracuo,',a,'!
rhenprepa.ationoflhe leeth either side as brid8e abutments,as
, l . s l - , r . ) . l f , d , . I . i 1 . r \ , { " b , n . " l F r \ . , , . , J , is , n -
eraLlyeaècerbàred ir peoplewith extensivelyrestôre.tmoùths as
all .estorationshavemùsirs that âre sùb,ec!!o breakdownand
s ll h. L'ourpl. que.r r I S . d 'o l'orJ, eÀFpro8rp,,.on.
Techûolosyhâs provided sômesolutions to rheseproblems
sirh tureriâls ând techniques rhaÙedu.e the needfôr removâl ôf
lùge ahôun$ of ti,ôrh tissÙe,bur bad plaming will alwaysbe a
bâfr€rto good .reatmenr.
hnus
Preventinodentaldisease
in the
elderly:
root cafies
Iù most cdes, the preventionof speclficdental diseases i. .his
8roù!co ôrmstô the sde bàsicrù1esasfor yoùnseradùlts.:fhe
chdsesir the orà1environnert may alter the enphasn a litde.
bùr the stràregiesùe sinilù. This sectioû.teè]swlth the condi
tionswhererherearespecifica.tditiorèl issuesre1ùedto ag€.The
mo$importanrof theseis roor caries,a fo.m ofdental cafiesthar
is rdr in the pôpùlètionùnde. t0 ye26 ofâge. bur prôbùly ûe
blgger threâttô rhe viabillry oFnaluraltcedriû old age.Becaùse
ofthe.udùlarive e{Iectsof damageoler a llfetine two otherdis
casesicodditiônsàre Nôfthy of discussionir rhe codiext of rhe
elderly:pe.iodonfuldiseasemd toodr wea. Borh a.e .ôveredrn
detailelsewhere û thr book,sorhesevill bedis.ssed o!1y it the
contextot 1rcrcaùn8a8e.
lloot câries:prevaknce,
incidenceand
distribùtiûnof Ies!o1rs
There is wide \ariitioû in the reported lrcmlence ôf rôôr cdies,
fom d lôw d 7.1 per cer. in a iluoridatedcomnmity to 100 per
cenr in p2rienrs arterding à gerontotosy clinic. Th; anse repre-
seits na.ùmLvùa.ior in prcnlenè and di{eren esû.1Ê,{îagnos
ti..rireria ande&dinatiôn ûethodsùsedby the reseùchwork€s.
one significmt sourceol vârlation is the wèr that dæaol icstot€d
root sùfees arehandled.Itis not posible to decjdewhl anyarven
resorètlonhasbeenplâced,$ .esôritioûsplacedbecause ot.eri-
'fi]ted'
cal wear ini'làte the conpo.ent ofa rôôt snrtuceDMI sco.e.
l o ! \ " i 1 1 . d , " r r o n , h ê | N . r g 8 ( J ' 1 " ' ô , \ r o ' r e n ro r
resiomtionsplacedon root surfacesare to nranage.?ries. This prob
lem has beeûdiscussedir detdl by de P2ola,t /. (1989). One
fufther confoundinEprôblemis that restoratio.spla.ed tô restore
cervicâl$ef .an $bse.tuentlyundergomrginal breakdownand
dnelop reurent decal I! ispo$ible suchrôot surf{es would hâve
develop€ddecay had rhey tutr beet restored to manâgc the wedi
alt€rnatn'ely, ir is alsopossiblethat the ody reson theydseloPed
decaywæ because o{the presene ofàrestotarioDDarsln.
One thirs that is cl€aris thar the pÈvalenceof root cariesin a
popùi.tiôn increaeswith incrcâsinaage.Tâb1e12.4 showsthe
variârionir the numberorlesionspef persônèffected,depe.ding
upoû ihe àge and mtùre ofthe populationsrudied,àtd d€non-
sûares much higher levels of root caries in an institutlo.âl
.ompùed to a free livioa population.Thesefigùresareusetul.but

TableI 2-4 Meân numhcrof vulnerabteroots,.oot lesiôns,dd Rcl it r UK olderaduk populatbn, br âgefor free Livinsadults
ândfor rhoseolder a.tùksliviûs in ar innirutjon (fion Steele,t,/. 1998).

8t+ freeliwing Àll free-tivirg Insritution

ll.7 12.8 9.6 1l.i 9.)

0l
t.l 1.7
4.2 02 0.1
L ]
254 26
I2q. 21%
Irevxlen e ol unsound rooh
Mcr'nnunber of unsornnroô6 it

!ôpoiiô! or d d6 dùt e! r\FôseJ û dre monrh tlr]r ve e Eo.ded 6 hei's d(at(d, û !È$ôftn, or r6rcRl aid ,l(rred
RCI {), the rcor.Èries rdei aoi n{ NodeJ s batrs decved, o! re*orcd ard dt.a!ê,i
 I
200 | 12 Prcvenrion
inrhêodein0
dÊnririôn
t - '

they do ror give any jdea of ihe likelihood drar any Aire. i.d;- Therc i5 now a lafge numberof stùdiesinve$ig.ting risk fæ
vldual rvili developroot carles.Ifcaries is to occufo. rnc roo., 'r tors for root carles,and it can be diÊiculr ro disentanglethe €âL
is fi6t ûece$âry rhat rhe irxtr su.faceis exposedln rhc orâl caritl rlsk fadors fiom iheir .o-vdiables. chronologicàl àge is probably
by 1ôssôf pernrdonûlattachmenr.Widrout râk1nAinro âccount ofliiile sig.ificancclr.r in dere.mlnlnA.oot .dies activitn bùt
thedôunr ofrôôrerposùet is impo$ible to â$c$ drc LcallNcl increased bloloAi.alage,$ith as$.iated medi.al/physi.aldeeri
ofrisk. The root cdies in.tex(RCI) givesan atta.+ .ar', relarins orarion and disability may be ôf mu.h greaterimportarce.Ior
to drc number ol surfrcesar .isk (Katz 198'i). RCI is given nr exaûple, hiah Levelsol root carieshâve bee. reportcd in the
Table 12..1.O.ce a8a;n.dreren a r.e.d fbr ar iDc.ease in RCI chronicallyill. insrirutiooalizedolderadults,drog addi.ts,andin
with ase. up ro 38 per cenrby the ase ofst yea.s.ID the cde of iodividuaLswith altercdsalivaryrunctiond a ftsult of disedeor
dre datapreseûted, resto.atjonsarecounredwlthin the RCI score its ffeatneûr. Thereis alsoa stronsr€laliooshipbetweerpastroor
sothe valuesindicatedisesehistorynther rhàûàctive.tisede.Ân cariesexperienceèn.t the developmentof n€w lesions,and a
alte.rative calcùlation for decayonly is siven, RCI(d) which wedkerâsociatioû bet{een coroùl decayexp€rjenc€and oor
showsa sinilù lreDd.Fùrthermore,there is àn nneveûdisÙibu- càries.Higher pre!èlercerètesare seenin men comparedwith
tion of root carles/restorâtiônssnhin ûe popùlatiônsù.h thar 80 woden dd ûere âre a number of sociè1àftitùdiùl vèriableslhat
per cenrofnew lesionsoccurh about20% of the pôpulàtior,àrd àreàsociàtedin both àposiriveaûd è n€Aativena.ner widr root
only aboùt 5{l per cenr of rhc Ëcc-livioA older topulâtion hâve car'es.The nùmbe$ ofrcmaininA teethmd activeso.ia.lpûti.i-
root cariesat à11,èlthôughùp to 80 per.ent showcdioa lesions patiôn are borh negitive predi.torsfor root cùies. Negalivelile
or a pattern of re$or.tiors that strggesà histôrr ôf cdies on the events, los educâtioûàl àttèirmenr, 1ow ircome, recurent
root surfaces. This côncentritiônoccursdespiterhÉ âldosr ûi- chrôni. illness.infreqùentôràl hygiene,irresnlârèttedance,ad
versâlpresence of rôôr sùû.e exposurein older irdividuals. smokinSareall positivep.edi.r,.s of the levelôfdiseâseâ.tivity.
The limited daraavallableoo annualincidencein â varieryof CâriesthouAbneedssuaâr,plaque,and asulrableenvi.odûent
popùlatiônssugAessabourtwo nev carioussu âcesFe. hundred if it is rc devclop,and rcot ca.iesi\ no different. Rea.listicalLy,
ùrfa.es ar .isk pcr year.The exceprionro this is darafor chroni thesearelhe a.eas2t vhich aprevent;vestrateaycanbe ta.getd.
callyill subje.rs,anong whom câriesrâresaremuch hiAher.O.ce Epidemiologicalstudiesh2veshowr drat rcot .ales rs $roflgLy
àgdn, hor studiesfoùnd that thesenew lesionsoccured in a rclakd to rhc fregùen.yofsù8arsintake.Dentinehd a higherpH
m'no!ûy of the popùlation. for deminerâlizâtiôn thar enamel,so redùftio.s i. prl rhât ocor
Tberc is a characteristicdistribution for root carieslesions wrh sùgarsiotake will be mai.tained belov ihe dcm;nenlizing
wlthin rhe onl caviq',with an irc.@sedprevalenc€ in mandibular lhreshold1à.Lonse.on 2 dentire su|fâce(Fis 12.8).Poo.or lnfie-
nola. teeth, iotlowedby mdillùy arteriôr teeth, dd mùiildy qùent hygieûeis àlsoasociatedwnh aDjDcreased rlsk of dise6e,
posterios.Mandibûlù dteriors seemro be ûe leastssceptible whiie à ûdber of stu.tieshale showr that weùins a partjaLde.-
!o root cùies. In èdditior, rhe bu.cal ând inrerproxiûal sùrta.es rre mÀy.1sôbe importânt,perhàpsûore rhar doubliÀgtbe risk
aremore sùsceptibleto Èttà.k thù the pa1àràlor lingùl âspefts of rôot decÈybeingpresert.
of v ûerdbleteerh. This pnùern ôf.aries sùr.eptibiliry har a
marked similarity ro the pdtten of ôrè1sùgâr .learâr.e repôrte.t Rootcaries:miûobiologyênd histology
byDawesard Macphe6on(1991).vhe.e susa.cLeèÈnc€ is slow
Decay is a process of microbiâl oriain. SùePkûû6 nxtdîi s DT
est, .àries rites are raised.However this perceivedparern of pfime impoitan.e in initiatinA corona.l .aries, âlthongh othû
attackmày be.listôited by rhe .hartuteristicpafter. of tôoth lossspeciesmay be of greater signiÂ.ance in exre$ion ôfthe carious
anoûg$ the elderh ùd àlsoby rhe inclmiôn ôf re$ored.eNical lesion intodert;ne. Theit remains howerer sôûe debàre.ofterr
wearlesions.OnceaAaiolt is very.lifficult .o pick apan.
ins the slecies of bâcteria drar are respons;ble &,r rcot lesiôns.
As a conse,tlenceofthe elevâted cdt;cal pH fof demineralizatiôn
Root caries:risk factors of,.le.line, bacreria of lesser ac;doac.ic;ty could .onûibùte to
Ther€ have been a lùse number of variables dsociated with the deminenlization of root lesions. The orgaoisms most commonly
developûentot root cariesfrom both prevâlencean.t ]rcidence cùltured from plaqu€ ovedying root caries lesio.s or rrom the
*udies. Beck st zl. (1987) proposeda mulrifâctor model rhat dentine itself are Arù"an!û' spe.les (rituMt, "d6/""à;;, ^nà
illustrètes the inÛicare web of ætiological vdiables thâr may be tedi;;), Sîltutut,! xnta/j!, Ia.tôb.cilli aûd cm.lida specles.
asociâtedwith eitherthe selerity or rhe progre$ioûof the disease The detection ofs. ,,ralr aDd LactobaciLlj iD pla,tue samples,
(Iis. 12.7).As woùl.t be expecred,subjectswith periodortâldis eveû àt very ]o\q levels, has beeo related to the developmen! ol
eàsehdve àn inùeâsed level of root cries becausethey hare more rôor .diÉs sirhin thar individùâl. This pÀttem holds trùe for the
exposedrôôr, but the artack rare is greater fo. rhose vith mouth asawhole, but dete.tion in p1âqùeât à specific sire did ûo!
ùnÙered pernrdônrâldisease.ompa.edwirh subjectsafier per! ne.e$arlly mean that.âries was a1sôpresent ât rhÀt site. Beighton
odontalcare.This perhapsrefle.tsbeterbysiene in thesesubjects and Lyn.h (1993) 8Éd n nôvel sdpling te.hdque to remove
(ôlder indiriduals who demonsirate2 sood stâodârd of oral small quarriiics of caùùs deûtine fn)m tut lesions wnh vdying
hygienehavefew roôr .dier lesionr. degr€es of.linical âctivity. Mi.rôbiological .ulture of these
 PrevenJing
de0101dkeole y. ro0l(ories
intheelde

Sociodsmogrâphic
Faclors Psycholoqioal,
Edu€ton, Agê Sqaiôôùlt'lÉland
ooàirniveFactors

BêhâviorâlFâclors

Physicâl/ Medicâl OtherP@venlive Sell-Adminisieredorâl

Us€ol P.€v€lnivsSstulæs 8ru6hing
Smoldng Fl6sing
Alohd nuo'1d6Tdhpa$ô
F@d F@q!ênry Hom Fl@rdê Frmê
Oral RlskFaclors

Environmentâl

Oral Dkease

t
Useof Prolessionel
Resloralive Services

I
OralStalus

Figu.e 12.7 $aeboffa-os affectitrgùe o..ùûence oftooth cùies (from Be.k 1987)

5.9

5.4

Figure 12.8 pH tlneshotdfo. de.ayin dentine

dentire smples hasdemonsr.ateda strcûg pôlitive relàtionshjp
betveer .ùies âftivjty (assessed on clini.al diterià) ètcl the
freqùencyof isolatlor of toth S. nrtanr and candidàspecies.
J. ,rtad were isolated more freque.dy fron sôft lesiots, 1ùg€r
lesions,dd rhoseclosestto the gingivâl margin. The candida
species,whlle isolated more frequenrly at similar sites, were
presertiû Lownunbers.Their pres€ûce was thoùght to be ]iûked
to their suilabili.y fo. rhe eûvironmentruiher thd rheir aci.lo
genicity,alrhoughcddida do producecollagenase enzymesthat
mây facilirarerhe spreadof cùies in dentine.
The macroscopic and miùoscopic appea.a.ce of root sudace
lesioûswill dependùpon the stàgeofprogrc$b! of the disede.
202 12Prwmlion
inlhe0geing
derrillon
A root sùrfacethat is exposedir lhe noulh will takeur m;neral
Iron oral fluids fomirs à hyp€rmjûe.alized su.facel2yerthât is
notpresenton roo surfaces that havenot Lreenexposedi. the onl
caliry.The eàdy roor cùies lesionis chæcterjzedby demi.e.al'
iz.tior bereath this hypermineralizedsurface.Dissoluiion of
apalire crystalsand splitlirg of the collagen bundles withln
the dentine maûix a..ômpany deminerâlizèrion.Cllnlcally
derectâblesoftenirg ôf the rôor sùrIà.e o.cùrs at a relatively ea.ly
sûge of the lesion,with surïàcebreaktovn ar a Dunber ofdis
.rÉtÉ.iô.alizedsirs. Ba.rerialpeneÙâtiônirto rhe .temirerèlized
sudaceo.curs quite qui.kly after rhe ônser of decay,btrt the râte
ofpoare$ion ofthe lesioncaûbe slow..esùltingln a clinicâlpic
turc ofeiÉnsive, but shallow.cariouslesiôn!on the roôt sulfàce.
Obviously,such lesionscâ. proarc$ towards the pulp ôf the
tooth, and will l€ad €venrull). to plrlpal exposure.
The .liàgûosisof câriesâ.rivùy in .lertiæ is dependenton detec.
inA the iextureofa lesionnther.ha. irs colou. Howeler pùshinga
sharpprobci.toashâllow lcJo. thathd tbepotenriâItu redineml'
izenay p.oducea surface defectlhat ca.not beclÉnsedresùltingin
locèlizedcdriesprosre$ior. The tdtùre of th€ lesior should be
dsese.l ùirg à srÀping âftiôn with ether a probe or ar excavator
nther thd by pùshing the pmbe tip into the dentlne su.face.
Root ca e5: Frevention
Stfutegiesto preventor corûol roor .ârlescàn be rarAete{lât rhe
ary ofthe key facroGin its development:drc rcot suda.eand its
envi.onmeoi(lo. exampleuiis nuoridcsof siâloaoauet,plaqùe
o n r o . . d r e ' o n û o l oorm b i r e .oL r r e s cq l e r c . l r o r ' É ' e J , e
Tbe root saface and tbe oral em,ironment
Lifelong expoNre io water cootaining optjmum l€vels(l fpm
or pro ràra for the clinàric coodlrions)of fluoride reduccsdre
prevalence of root caries.The maannudeofùe redu.ùon,r nôt as
greard thar {or.orônal lesions.The effectù doserelated. The
âttacknte for â popùlâtlonvith l.t mg/L fho.ide in their wârer
was sianificantly]e$ thao that for subjeclsexposedto 0.7 ms/I-
(Bùrt n "1 1986). Fl6ride alsohas à beneficjalefiect in duLts
whô drink fluôridatedwarer bur did nôt do so when their t€eth
were developing,with reduûiôn both in càriesprevàlencemd
inciden.e.(whelron ddl. 1993iBrusthàr 1996).These.tàtaùe
independentofùe acknowledged preventlvebenefitsfrom ùsiûg
a nùoridecontainlûadentifri.e Oensen1988).Topicalàpplication
offluoride either d ir r dertifrlce, or a à rlnseor gel a$i{s in
preventinAdecây.However.there is Iittle infomation available
i h o l o a n . l J ! r c 1 1 r , r ' f o l - ^ r iI s ' . , t:16rôp
venr roor caries.:fhelariat;o. in crir;câl pH fo. dentine,when
compâredto eDmel, and ihe relatjvelysreate'uptakeofnuodde
by dertine, when compâre.l to eoamel, must affect rhe
dosekesponse sradient for flùoride and !h€ method of fluoride
delivery(neutral/èci.tùlated,solutio.,/sel/1om).N€w toothpasres
with hish fluoride corcertràtiors offlùoride ôrp to t000ppm)
drenow avallable.o facilitatethis proces.
 vdiety of reajmes have been des.rlbed for rhe preveûrion
and reminerâlization oi roo! caries iû lndiridùals wlth redùced
salivary no$. All iûclude lhe usc of t{Dl.al fluorides, eiihû dÀ
moùrh rinse, or in gel forn, widr or wlthour cûstom filled
polyvinyl guâr.ls. In addilion, a supeFatù.ated câlcnû phd-
phàte moùthwash can be used to enhan.e reminerâltalion. All ôl
rheseûcâtment modaliiies de ofbenefit in the xe.osromi. paiknr
A;vinA a .edtrcriôû in .Àries pr€vale.ce. They have also beer
shownro be benefi.iàlir subj€crswitha hish ca.iesincidence
norn- "lirrr) q . l t 1 J n .o , 1 " . ( . , ( n e , r . . . b.
the S. nrtar! .olanlz tlaa ôf rhe roôt surface as we! a! e
Preventjoo jn people sith {erôsomitshoùld also incru,le
fômof srimuluslàrsuhstitùt for sâlivr(Fig. 12.9).Saliva.I
can be enhâncedusiûs tasie(althôushcareneedsto be râken
pariens with reeth not tô ùse acidic or sugâr-containlng
phèrmacologlcal,or mccbânicalsimùli. The drugs used
e.harce saljvaryuov must be choiinergictgotists, and
hÀvethe porerliai for causinssystemicside-effects.
Nele
rhere are repôns of sood sbo't .erm successin enhdcing
wernesswith orâ1pilocèrpin€hydrochlorideand
6ed ir low dôses.Recendy it ha been csdhhh€d that
susar-freegùm stimulàressdlivarynov and enhan.esihe ate
increse in pH of plaque a{ter à cario.qenicch2llenge, dd
beoeflt xeroùomic sùbjects. Chewing gunx are availablevli
cortàin tluoride to mâximize the preventive effect and
dine !o dsist io ba.terla.l conÙol.
Thereare a nmber ofconmercially wailable salivary
nres for use whe.e the patient hàs à dry nolth. In
.àses these will have liûle ;mpa.t ôû rôot .âries, but those
ràidng flùorde have beeo shown tu be effe.tire reminera]izl
mediâ for enanel ;" ,itu. Same artificial salivasarlenpt
in.rease sàln'dy flo$' by i.co.po.ating an a.id tdte st'n
These srbstances can caue demineralizdtiôû of tooth tissue
their ovn riSht ând may be connterprodùctive in tb€
P laclae and mitohialogical control
It has been demoûstr.ted rhat the derelophent of neç
lesions can be prevente.t, dxrjns lhe ma;.tenan.e phde of
odontal ùeathent, by vigorous md regular individulaDd
sional tooth .lemiûg, brt sùch vjgorous o.âl byglene mây
iatrosenicproblemsôfits ôwt. Neverth€le$.elïectilt hysl
offundamental importànce in prevetrli ng .oot caûes.
chlorhexi.lineglùcoûateis â bis'biguaûideantiseptlc
ôd
be ùs€d to reducc oral colônizÀtion with S. t rtd'ù, and
a$is! jr reducina .arles aftivity. k hd been used to some
eitherasa sa.d-alonerlnle ôrgel, or in asociationwnh
in preventinAdecay.Longetstermule is dsociâte.lqilh
of the dertition md changes;n tâste. but the gel prelaôri
les likely to be asociatedsith theseproblems.
.an alsô be æplied to the .oot surfa.e in â vârnlsh
remains active for between I an,l 6 months. k has âlsoben
d a .omponent of chewinaaum. Resular ùse ot ths gun
 P i e v e n ù, innrg0d i i m si e
nl h e e d r , . " . , * , ,0,
|

%' %'
,.1

tw w ,@
chewing

Sall

NaHC03

IigDfe 12.9 Sâlivâsùbsitlres

beenshownto recLu.e plàqueàrd càriesleveisar.t incredesalivary
flow in debiliraredôlderpeopie,dd this nèy proveto be a lery
uetul adjunct.o orhef methodsof.afie! prore.tiôn.
Dietar! cantrol
The relatioDship betweeûsusa6 in die d;et and cades,des.ribed
elsewhere in this book, is well estabtishedand extendsrc root
Prevenrionby mân2gi.g diet rhouahreguiftsa brantiâ.I
càries.
behavioua.l.hmAe and ln the .ontexr of the older pttiert, alterinA
dietary hâbits developedover à lifetime ls not eay. ft is dre fie-
queffy of$rgaB irtake that is criricaL.Dâtaiiom lhe UK National
Da"1dNJrÛor',^n o'ron rrr"'lrh:rrl"r. <oioot . ic.
beinspresentwd apprôimâtely dôubledwherethe freqùercyof
sugar intake exceedednine episôdesper day. h pn ricà1terms,
highfrequen.les ofsugârsintakeareolien the resultôfsugù ir teà
rndcoûie.bisculteating,or lonetlmes sù.king sseets,perhàpsto
rlleviaterhe effe.s ofadry moùth, rhe lâûer s.endio.m be quite
devdtaringtô the dentitior. Pdtiens will often be preparedto
ei'lace sugù widr saccharireir hoi ddnks, ând ro alier their
ditary babirsvhen the st.ate8l.impoitân.eis fully explèited.
The dieraryprcblem is pdti.ù1d1y acùtein rhe in$itùtlonal
setlinswherefoodis masp.oduced,ânddredlet oftentdlôred to
lhe low€stlevel ofmastjcato.ytuncrion.resultinain â hlgh.âr
bohydraledie!, often with frequent susaf intakes. Probablr
lûsely because of!his, ratesofroot ca.;esio insritutionsa.emù.ll
hisherthàn in free llvins ol.terpeople.Alt€rins dieta.yp.acice
ir suchcncum$ancesis €:ceptionallydifl'lculi.
lloot câries:mârlaginglesiolrsto prevent
diseaseprogressiolr
Rootcùies cm be a djfiicùlt treatmentproblem,especiallyifthe
decèyextendssùb girgivally, iûterproximaLly,
or inro rheturcâtlon
iesionofperio.lortally iNolved molar reeth.The.earerhreepo!
slbletreètmentstrategles.
1. Chemotheràpeùti.treàtûent leadina to rem;Éralization.
of shallowcariousroot suriâcelcsions]S
RemineraLizalion
practiel, bur the .eminerâlized tissuetakesoû.he apFtuan.e
ofm arresredcarious lesion.The surfâces da,r D.ow" u'
blàck with a leathery rexture lnitially, âtcLwitl eveDtually
hârdeûto siv€ a rolished hishlr mineralized sùrIàce.Some
pâtiens may Do! be prepârcdto derate this discoloùÈtioD
of rhe root sùrfæe.Suchrenioeralizedsuifa.esùe reported
to be moreresistàrtto fu'ther cadou aÛa.k than àdiècent,
otherwisesound,,.lentire.
' :, f- , { -., n". Th lrL er 'orn ol ^p , i\_ Tr, '
agemenr simpiy comprises remov2l of the sôftene.t $ûfèce
deniire with a discor larsebur, rollowedby re.otrtoùrinsof
rhe ioot d.hitectûe to gile a smooth,cle2.sablesùifa.e
.hat is rhen namged chemotherapextjcally. This âpprcdh
is only appLicable fot shallowlesions,whe.eexcellcntresults
havebeenrepofted.
L Restoration of the defect. Once frank cavrnoon nas
o..ùûed ôr$here àccesforcleaningis simpll not prafticd
ever èfterrecontourina,cariousdentitu shouldbe removed
and the defectresrdred.onventionallt À plethoraoftuotF
colouredmarerlalsarenow availableand atethcusualmat-
rials of cboice, ranging from Blâssiononet cementsrc
compositeresins. th a raneeôf prodùctscombining tbe
compoD€nts ofborh.
V/here resoration is reqùired,the restorârivemateriâlltseli
cd potenri.lly have a pteventive rôle. Both Glass Ionomer
Cemert (GlC) and compomersreleàseflùoride, ahhoush at
l f f e . e ' r J c . . l , , d f i . i " , .L l . ' h . v er h e ' " p -' t , oIr\i
tluofide sporge tèLing up nuofide bns when the locèl ionic
côn.enûâtionis hish (e.s. vhen e+osed rô â ftùoride coûtaining
dentifrice or rinse), and subsequenilyreleàsiûgir. Ther€ s
extenslreevidencefrom both ,,n/a and ;, rnr studiesthtt this
l l r o i c . r - - , p , e \ F 1 ' \ d " m . n F ( 1 , - . r-''od, ' l , " e . F a : . F
âlizationânrnd ierorètiors. However,this doesnor extendto
bei.s âb1eto ôbsere à long r€rm aûli carieseffectat thereis to
cli.ical evidenceof .a.iesiniibitiot from curendy availâbleûiâls
dâh (Rddal and $rikon 1999).The re4o.s for ihls disptuityde
 I
204 | l 2 h s m t i o fi n , h ê o g edi ne qi i o n
I

urcl€ar,but couldbe.elatedto rherebeinsinsufficientfluorideto

showa clioically sjsnilicaûrbenefit,or it may simply rflect the
_ y p eo. i l . . o ' . u . e J I r r " . r ' J , ' l u t u ,o n
.9 o6
Root carieslesionscm be ioacce$ibl€.o convendonalinstrÈ
menration.ln suchcircuûstânces. dre chemo{ncchani.a.l rcmovâl È 0 5
-q
-l>od
ofcariousdcniinc usinAa hypo.hldit aEenrtu dit'upt cLâmàged
-[- Youns
côllagenfibres ûdy be è vidble àlternètlve ro cld$ical câvity
'6
prepârètiortechnntûesùsing b!6. This À virrualLypain ticc aûd
d , b F ' F ) ' - l r . p . - r r . l y . r . , J o m | l - 1 . e ' rr .

rool(oriei
Prevenlilg o 2 4 7 9 1 4 2 12 4 7
1me(dâYs)
Figlre 12.10 Sùgl.al vesus non surgicalteatmcnt ofpedodon
at diiTetei.rges(RÊprôdù.cd
ra.l.liseas€s ftôûr Holm-Pede6en
d /1 (l9rt) \anh pcmnsior ftom the edûororJ. clin. Pcrio.)

k is ofter necesary !o help older patienn adapt thelr oral

hyaienere.hÂntres,and !o irtroduce aids sù.h a! wood points
ând botrle b.ùshesto feilltate interproximalclcanlng.Careneeds
ro bc raken rô ensurethèi dris €ducâtior prc.ess ls self pàced
radrerthanfored. and thar the senxnr€problemsof ùndertaking
a task ùat is far froo staiahtforward are fully a.k.owledsed.
Preventing dentaldiseasein the R d- dnin.,J.lF^en ) . p o o r e r \i ^' , i , J ' J n ! , - o r i o r i t i p
me.n that therev'll oiten .ome a time whet an ol.lerpe6on cat
elderly:periodontaldr'sease no lonAercopcs'lth their ownoralhygiere.Vhen thh o..uts the
lo$ oipefiodontalata.bmènt is rirtually ûiveBal èûd increaes \ e p o - i . d i.,*.'".b . F . h , n ga ' J e ' ' l ' 6 | o d , F r
with ase,bur lhe relationshipberwecnageand anachmentlds is the skills requi.edto b.ush vdebody elsei teedr is otlen mot
a resùlrof lons tern €xposu.eto plaqueradrerthan to any age- difficùlt thdD heLpins a patlent derelop their own sk;lh
charseswithio the periodootiun. The rateofprogrcsion ofperl- Irtro.lùcing an electrictoodrbtushand/or chemicaLplaquecon-
odoDtaldiseæeis idxenced by rhe bodys immune response that Ùot cù help in rhesed ifficult .lr.ùmstdces, bùt minimizins dï
tes rith ageresuhirg in nodlfied patternsofdisede. Shâllow ongoing 1os of atrachme.t throuah goôd hygiene.lependson
pocke$ are at reducedrisk of froare$;on ir older populntlons excelleûtcooDunicarionand a largehelpingofempathy.
vhen comparedto deeppo.kers.Periodonta.l disede mày be ùe
p r , , p J - a o ' l o r ' o o ll o * r n l e o p l e . p e J , b o . e ' . br 't
Dot for olde$ adults.Thls may be a reflectionofan rnnateresrs- Prevenling periodonlcl diseose
tanceto periodoûtal.lestructionamonss olderadultswbo rctain
sômeteerh, ôr simply thât the teeth most likely !o be Lostas a
cônseguenceof periôdontàl derrùcrio! have already been
exrm.tedin rhe ô1dercohorts.In orherùôrds, the teeth l€f! with
shallowpo.kets âre the sùrvirôrs,thôseàt lower risk fron p€ri

combired with profesioràl scâtins èûd root plani.s (oldef

individualsrespondjustâswellas dre younaro non{ùrs1.almd-
aSemcntrecbniques,seeIiA. 12.10). ohl hygieneremèiN the
mainstal for prerentrcn of fùther 1ds of Ètrà.hmert, ènd an
e$e.f ial pre{equisitc of succe$fulmanagemÈnt. UnfôrtuûÀtely,
orul hygienein olderp ie.rs is complicatedby dre alte.arionsin
giûgival archjtectureth .esult tiom diseascand is mademore
difÊcult by the exposureof root su.ræcs,and the iNohemtnt ôf
root fùrcations.This doesrot prev€nteflectiveo.al hyaiede,bùt
cannake it nuch nor€ d'fficul! ror the patienÙo achleve.
Preventing in the
dentaldisease
elderly:tooth wear
V/earoccu'sasa n2turâLpilenoneûonon all teethwidr use,sois
rech cally rot a disedeat âu. As it i! nreveBible,the severityot
weù slll increasewidr aae though, so, fôr certain iDdividuls,
weàr ir exce$ of dris physioloai.al norm sill occlr, a.d may
ô..asioraily becomeùracceptable.wâtdtitg interventlon !o
preyenrfurther danâge.Too.h wed ls ùnireBèl in older people

with eiFo re ofbodr p.imâï.,nd sc.o.dary dentine beitg com
monplace. wnh incredsi.g agc. it bccomcs difficult to define the
lûe be!çeen accertaLrlca.d una..cptâble ievtl\ of wexr, ùd i.
r - e , 1 , ' . . o f t " ' , q- o , l . . i . f . l , , ' ô { '
Jsesoent. Toorh s'eâr is,lcsc.ibcd in detail in Ch.çter L This
rction dcals sirh rhc issuesspeciflc o older adults.
PrÊvâlen{r
D'ra on rhc t.clalcn.e of n)orh wexr in ôlder .dults are tairly sr'à.sc.
There are some .lara co.ccffi.g the prevâl€n.e ôf cerlical \tedr
\veù ùolnd the necksofthc rccrh is almor ùniversâlly present it
oLderpopulations and d,e tre!âlc.cc incrascs s'lth agt Premolùs
àre the nost liequendl inrckd tcffh, followed by in.iso$ in aLl
âgegrotrps.Dèa from national sutreys rhât hara attempted io meà
sure wear $,gges rhàr vhilc.rild tu moderate weâr is u vesà1,
scrcrc.orcnal wea in the €l.lerlr', at a lelel tlut mlghr rcquirc
irtervenrion, is Frobably qùire uncommon. Pcople who de âr risk
froû rhe nost selere tàrns of$'eàr vill ofreû have had this ûe.ted
ben,rerhe! reâchol.t àge.Thejr Deedsmay bc morc Lelat€dtô ûain
renan.e of resoradôns ràther tlun treameot ol s'e-,
Aetioiosly
Toôth $eù o.cùrs throushou! a liferimc as â rc l. ofnôrûal fnnc
tio! dd is à prodùû of al I rh ree mecha.isms ot q'ed. rhese de:
. Èrosion Ghc pn)sressire loss of hard tooth sùbsince bI
cheni.al dissoLutiôr, not iDvolvin.q bàcrc.ial â.tbn).
. Àrtffior (the proa.e$ivc lo$ of hard iooth snbstitce
ia6ed by direcr cootact betwcc. occluding and prôximâ]
{rfa.es of the teeth).
. Àbralion Ghe progresn'e los oÊ hard roorh \ubrrance
.aùsed by mechanical flcto^ otl,er tha. masr.xùon or
iooù tu toorh cônr{ts).
ÀtÛitior àûd abrÀion nill occur. ro â ]nnired ertedt, ùith
soùid rooth r'ssuc. Thcsc rso me.hani.d effe.ts wiLl be potenri
ared b1 tbe damage.àùsed by erosion. as thc soiicned surface
ptudu.ed âfrer à.id àùa.k will be mo.c .cadily renove.l by
me.hârical trànma. ltcesive wear is nofln2lly dre pbdtr.t ofân
cxaccrbatn,nofone ofthe meihè sms responsibLero.l)hysnnos-
ical scal. This tendr tu re\nlt ir apÈttemoftood, ti$uc lo$ rha.
m2y bc ofù5e in helping o.Letermlre the calse ofweir in 2 paf-
rlcula. clinical situâtn)n. Wed is commody a product ot morc
!ha. one aerioloAical rafiable. For ekmple, .upping ofthe rooth
sùdà.c is rhoùght b resuh from è combinat,on ofacid soitcnlna
ofdle dentire dd then freferenrial s'car dùrinA paratun.tion or
Prevcntolt arrd ffanaEe!11ent
The neânncrr ofan older padenr presentiûg with awon, derrition
drar requiLcs oi)cm.ile iniervenrior .ù be very comFlea indccd
,r i ) i. r' I ' 1 , . L" D ' r h o ç f l ' r t \ . ' o r
pprol , ,l !{ \. ç 'l
used Thcrc a.c a ûLnber ofrep\ thar.d be oken, o.ce diâgnosis
205
of cxccssire wet hrs been midc. t) prevett the coûditio. t.onr
.qetting xny su\e Theseprocedurcsare a.ll design€.lto negàlc rhc
âcriotogi.a.lfi.tôr dÉr has becomc dominânt in the wearftoccs.
k is ohvhlr thâi remoel of lhe dccalci6ing àgenrs in e.osilc
wea.will help tu âûest itsprosre$.It dnùld be relàtivel-veâsr to
perform dietary- counsellinE ror a strbject shose erosion s'as of
dietrry oriAin. This shoùld arest the rafid frogftss ot tlte tiss,e
los, if rhe dicia$ advi.e is followe,l. A nùmber of nedicat,ons
vith los'fH have a.l$ beeû reported astrcdu.ing erôsiv€damate
(àbnormal use ol asfi.in. .hewible VrtaDnr C. ifor n,nl.'), atd in
rhe el.terll, ths mâ-vbc.frelevat.e. Às wilb di€t, modillina the
habitual pâttern ofusc. or.hanging the fonn of mcorcanon m.ry
Eft,sn r d J renrlî ofA6ùi. regùrgitatiôt ma) trescrr a mo.t
.oûplex problen,. Âûy preventatire measùresshoùld bcsln with
Ê " '''1 . u i . o . 1. ' . ll '.bl .R- -'" io'
re$ . of ir.ompetef ce ol thc .ârdia. sphin.ter nt ! he bàsc ol ùe
o€$p1hg6 car cùuse sclcrc e()snt,. âùd becaùsereflur ls more
.onrnoû when rlie palie.t is sùpine. atd salivary secretbn (and
hcnccpe.e.thn) is it iis low€s! ar night. medi.àltùrglcal a{lvicc
should bc s)ù€ht. ÀsymFloùaric aasùo{,esophageal reflur
.liscâschas been implicèred l! pâric.ts s'lrh edne pèttern ve,t
in whom no orel1 retiôlôsy coùl.l be idc.tified There are also a
nlmbe. of drugr whl.h mèy .â!se n2uscaof vomiting a a snle
efii.r. on.e agair, rhe Farie.cs phi'si.ix! .onld be coùsùrred to
see if J! ahe.nàtive rhcrapeù.i. âgett is rvaiLrblc. Ii rhere is an
oblloùs timc dùfirg vhi.h reflur or r€Au.Sitarnrn o..uts, theD it
nay lt possibLca, protect the denti.ion usinE a $ft srnmt. This
shoul.l exleDd wcll onto dre p atal nrcosal in dre ùpper àrch,
ând it may be ofbenefir rc fla.e r fluori.te gel or anracid pftpara
tlon nside the splint bcforc ùse.
There is some evidcnce rhat ùpicâl fluonde drcrâf-v n of bet
efir in the .ontrol ol erosivc nrrh iisme loss. À mânâEcmeni
regime simllar to rhar for patiens withxeroslon,ia m.I be ofbtd
efi! du.in8 rhc .are ofpatiets in whom aû aetnnogi.èl fèctor
cannot be eliniruted. This n paitl.ulady imtoftanr 'f salivary
.hange is côrtribuling ro the ptubleû iù the t.s llacc.
ùfe.hèmcal vear as a rcsùlt of tormal mali.âtorr' lùn.iiôn
cannot be elimiûère.l .ompletcly and ir pdt ôf normaL âgcing.
Thc mo{ diffi.ult problen whc. ia.ed çitl âttrition an.l 2brâ-
sion is decidlng rvhen dre p€(eilcd wcaf ls in ex.es oldre fhye
;ological nom ât.l th6 re!ùires ûcatment.
Aii.irion n nnbt likely ro ocûr ir drc presen.e ôf bnrxism,
ând rhe mânasemelt ofbrùxnm n a.onpld ùbjeù. Seco.dart
p.eventile regin,es m'aht lnchde, occLraalsflint thcnpt Gârd
or sof!), occlusl adjùrhett, psychotrofic mcdicatn,n, dû.isome
rines fs-vcholoal.xl .ouûellina. Of an cmpid.al bâsis,the provl
sron ofsone form ofocchs. splint shorld âct a! a mechàûical
bnffei, preventl.g rood!ûF&xtrh .ôntàct ùd ensutina thatdmage
is ro dÉ spLir! and not drc te€th; but there s to ev,dcn.e tu suP
pôn rhe efficacyofiny ol these ùedtmetts.
A problem worthy of Tc.ifi. mention nr relalion to old€r
people is the totential fof damase frôm Forcelain .cstomrn,ns.
 I
206 I i: Prwflridi in 'hereiid deitilion
t " -

Por.cla;n ;s a v€ry hard mareriâl and .a. havc àn abraslïe surf!.e llDctionâl impâirmentis an esentiâl {ep bI wbi.h rhis could bc
lfit ;s poo.ly glazed or ifir har bee. adjusted afd not re glazed. r.hlev€.t.nd is reievantrc everrone,bùr sù.cc$ dcfcnds on â
Regùlar co.racr \1irh ôpposing nârùal rooth rissre will resû]r iû re.ognitioùthèt in reding agep.esentsùniqùepoblcmsrcauidng
'eq..atid w€ar ofthe nâtuml entrh producing av€ry complicàte.l imàgiûÈtiveend,often individual.solur;o.s.
ma.aAcment problem Eren ln rhc abscnce of i brùxisr habir,
nnglazed po.cclâin can cèuse $Lrranrlal damagc ft is aLways
desirableto produ.e bodr ro atrificial ûoùû.onra.ts on ametul-
References
' i \ ' , i r d " , o . - ' 1 . , . o , . . ', "
i B a u D . B J . , S h i p ,J . 4 . , i n d w ù , Â J . ( 1 9 9 2 ) S à l i v â r gy l a r d
hlghll Alazed porcelâin sù.face. Aw2rene$ ofthe potertial for tu.ction a.d aaeinA:amodelfor stù.lyingthe irterà.riorof
<lanuge.d prevent a morc se.ious problem froû develôpi.g. aglng md systemicdisease. aitlal Rdie\ ii AMI B t!!!
Generall,, çear in drc older popùlètiôr ûâr not be dre prob .".t NeJïi"e,4,ta ta4.
'rhc
l€m ir seems. mosr p.obleûràri. ùeà. ô.drs $hen rhc lo$ of t l e c l <J, . D . , K o h o u t , L J . , H u n t , R J . , a n d H e . k c ( . D . À .
îoorh tisn,e is rapld. a.d .àpnlweù usù11y presen$ as aprcblcm (r987). rLoôtCaries:phl,sicâI,ûedi.aland ps_rchosociâl cor
eârtier in life a.d dris otler needs.onplex ùcatmcnr. In older
reLàres ir ar elderlypôpulari0n.Gtil|"tît, a,242 21.1.
ad!lts a iêd1er .onsen2rive ùeamert dppioa.h bùih arù.d trc
Bcignron.D.. ànd Ly.ch, EJ.R. (1981).Reldtiorship\berween
vcntinA e{cesile weâr is ùsuxll_rapfrcpriàr.
Ieê$s and primarr ur.xries lesions <;ùndo,lrlog, tO-
L0t 108.
Preventing
toofhweol Bnrlmdr, B.Â. (r986).Impâft ofexposûetu nùôride-adequarc
sâteron roor$rfr.e.xfie\ inelde"ty.Gralontu.2,2A3 20,-.
. n,orh weâ. ^ a norùalpL)siolûgi.:l pro.e$, but l er.6ibl., so rhe
teeth ot oldÈr a,lùlt becode prôgresiaelj' {off s ith as. B u f t , B . À . ,I s n a i l ,A . L , a n dE k l u n d .S . A .( 1 9 8 6 ) R
. o o !c a r i e s
. Conplete prevention ol $ear is nlpôsibLe, btrt sinlLÊ *Êrs r. i,. , pi 1 , l r : J , , . d J \ g \ r t , o 1 . t -o n r , . )
ù.ldre$ ûdeiyins diseÀseFroccs.s or ù prDlde dire.rpore.rior Jendl0fDatdl Raqdt,65, I ltflli8.
ol dr. ieetÀ fron dmâSe này be àlpropnak f.r.lder teolle virb Cdtson,G.E.(1984).TheelTe.tofisc.thc lo$ olteed,andprcs
rqrldrt lrrcarcs'ru \yeù
thedcrehèbilitador.1,terlrJ,"a/ DntdlJrodl, a,i,93 9t-.
Chaun.ey.H.H.. Nlucnch,lvl.E., Kapùr. K.K., àrd Wèyler,
À.H. (1981). Thc effccl of rhe loss oa îeedr on dret and
nttni.r. Iitulndtn tdl Dentd/JatnéL 34,9u ro|.
Conclusions
Cohen.D.R., àn.l Henderson,J.B. lI99r). H r'. PreLentrtt
The ûend r)sards the Éîeotronoftuturxl reerhi.rc old,ge olfèrs ".O'lô
a 4 dr l . r ' - r . . rP r . . . ù r b d .
rhe .trtunt prcDccr ofa tlnftiorÈl ratufal denrirbn to. everyore
(1991).Th€ disÛiburiôn
for 1ife.:lheporcnrialbenefirsofthis ln termsofnuûirioii, health, Dases, C.. and MâcPhrsof, L.M.D.
andgrnerâlwcll beingfor ol.lerpeopledî .onsidcrâble.I lowever oi sâln'a a.d srcrose aroùnd the moùtLr dnrin8 dre ù\e
this is orlr a pn*pc.r ând is srlll somewâyfrom re-',). of.hes'ina gum and the imtlicdliors for rhe sne specifi.ùr,
Achievinga fun.rional ûarùraldcnririo. deperdson dre abll- of .aries an.l.â].ùlùs depo\ir;.t1.J,nt"àt rJ Dr'nat luedth,
ity ro prevenr rhe fi,nûional lidltarnrns of Llnconi,olledroorh 7 2 . 8 t 2 8 i 8 .
1ô$,and rhc lrotentialdisàbiliryând handi.apdrxr mighr.e lt. D e P a o l a ,ù L S . , S o F r k 2 . , P N l . â n d K e D r , R . L . ( 1 9 8 9 )
lmpaiftd onl fun(ion canoccurât ânr shSc i. lifc, bur is gerer ùferhodohAicalksues relati!rc!o rhe qùèrtlficationofrôor
a.Uygrcarefvhere more teethhâre bcc. Ios!,so it is dre olde$ nr sntlà.eattes. GetudûûologJ, a,I a.
the .ommu ty *ho sufferrhe Aftarcsrlimirariols. Thonghtiul G.a!, PG., 'lodd,
J.E., Slack,C.L. .nd Bnlman,J S. (1t70).
tearmenr flùDnnrgèroundrh€ .o..cpr ofa n,inlmùm frû.riodal /\dLll Dù?tdl ltedhh 1fl Eidd"l atl w.le! ii 1968. LoÛdot
de.titioo might help tô pfevenrrbis, bur nr tùrn ùill dependon IIMSO.
frcvention of sFe.ificdiseas.sinduling periodonrâldisebe md M. (1988).The effe.rof. flùorid.te.tdenûlrr.eon.oot
,,i..t,'" r. - rôo |.lr . Ê l r - \ . r , o . Jcrscn.
and.oional .aficsln ân ol,l{ a<lùttpapr\tntion. Jarrul ùItt.
and e deUreryol wcllFhn.ed ard exe.ùte.tireâtncnt ûccl ro Aninû Dert.l Aly.jaùn, 117,iJ29-S12.
he provnled iû d oral envi.o.men! ûàr presensirs own p$b-
lcms.The impàci ôfaae.hânges,Ênanclalan.t.ttltudlnal barr! Joshi!ùra, K.J., \Villert, wr. àrd Dôu€la\s, c.\i/. (1996).
The impâ.t ofederttllôùsnes on nld and nurdcnr i.rake
e6, rDclan a..umulating bur.lenofsl,srehi. lllnessca. comb,ne
to ûake theproce$ much more.tiffi.ùlt rha. it is là. m!c| ofthe Jorftidl tf theAîkriûn Dutdl A!tucidtin, r27,119167.
rest of the pofùlation Kâtz, R.V (198i). Dev€lopmentfor ân ird$ iàr lhe preva
Theretentlo.ofa ftrocrloDal ârd mtural dentir;onfo.life is now lenceof roù ùries.J,/m?l tfDotdl Radt,l),63,814 8)8.
à Èallsi. Aoal fàr nost iûdividmls cùrrc.rly in mnldle age ând KâyserÀ.F. (1981).Shol1r.cddcnùlarcbesand oral lunftlon.
eveDfo. manvtc.ple in oldei ègegrotrps.Ptu!îrrina lisear ard .la"tnal o ùl R.hal,jlitdtr,n, 8, \51 162.

KeLlr',
À{., Steele,J., Ntrttau. N., Brâdnocl..G., Morrs, J.,
Num, J., Pire, C., Pifts, N.. Trcasure,E , and V/hre, D.
|.2OAO). A.lrh Dental Hcdhh Sx'ary:Otul Hedllh iû the Uiiled
Kt,{.Io,} i" 1998. Lt'nà<in. \SO.
Krall, !., Hdyes,c, ùd Gar.ia, R. (1998). How d€ntirioo
{arus 2od masticàroryfun.tion affe.t nùùi€nr ,niakc.
Jù-tdl 0fth! Aùdtd" Dûrl A!ûiatto,,I29, 1267 1269.
Iock€r,D. (1988).Measùrin8oml lrcâldI a concepllal frame
Notk.Cùtu"|""it!DLntdlHulth.5, t ra.
I{oyûihan,PJ. (1t95). The.elatjonship betweendiet, ûurii
don and denrâlhcalth:ân overviewù.t trpdarefôr ihe 90s.
Nkbni," R6ûr.b Raieat,8,l9i 221.
1.,d. . R.. I J \fil'o' \.r lô ' (,..-,ô rr -
resorarnes:a sr$ematic Lcviei'ol a secondar!cùrestreèt
ncnr. J utndl a[ Dù"dl R&dr.À, 1 a, 62a 6) ]-.
sheihm, À., Sreele,J.G.,Ma.cenes,w., Bates,CJ., Prenri.e,
,{., lo*e, C., Finch, S.,2n.l $:/dlls,A.\X/.G.(2001). The
relationshfubcNeen denlal statùsèrd hàeûarinosi.alâdd
bioclrcmicalmeùxres of ruÛitiônal ratùs amo.E oldeL
Fotle. À rdîional nney of ô1derpeoplein crcat B.itain
Jatndl aJDe"î.l ll6edt.t, 80t.2), 108-41) .
Shinâzaki,Y, Soh, L, Sàlto, T, Yâmâ\hira,Y, KoAa, T.,
Mlrazak;, H., and Tàkehùa, T. (2001). Iûfluen.e of
247
I
dertition statùsor physi.al disâbility,meitèL impèirment
èrd mortèllty in iNtltutiorèhed el.terlypeople.J,,/,,/ ,/
DestalI<Nk.t$,AO,ai1 alt.
Steele,J.G , Sheihaû,Â., v. 1s,A.N..c., ard Md.efts, Ii..
(.1998). The Naliotdl Dkt atl Nrttilta, Stuaey AJrl^ dtql
6t )èdf d"d ord. ALI HebL.trhg. Londor, TSO.
Twâd.lle,A.c. (1974). The côûceprof heâ1thrâtes. J,. Jù
Mù1.,8,29 83.
\(hefton, H.P, HôLland.TJ., and o Mtrllâne,D.M. (1993)
lhe pftvalen.e of ûtr sufa.e .aries among Ifisi adùlts.
C L f l d u t u h g ! , l O .t - 2 1 5 .
wHo (worid Health orsani,arnrn) (19t8). Coûrlrution of
ùe \rofld Healdr Organlzaibn. Lnncx l. tÀ. F;û |tn
\. .' . t \ . / t H . . l t A " " . .r , . . , . \ H O . L . r . . .
wHO (L9lJ2).A ReLTea af Cttrè"t Reùîùnudatio"tfol t6e
aruà"izàth" à"à Aàni'?;nrdlbn tf ardl Hubh 'entu ;n
Nuthern ann V^ttrn Eltup'. \\rHO reanrnal offi.e fir
Europc.CopcnhaAcn.
WIJO (1986).Caxntr! PûJ;/e'on Aùl Hù*h in E tule 1986.
\(rHO regiooaLofficerbr Ëu.ope,Copenhagen.
lmpairment-preventing
a disability
JuneNunn
lntroduction
Thelastfive yeùs hale seensignifl.anrchargcsin rhewholeisa,e
ofdisability;dre rcasorsfor ûls willbe dis.ùsed ln rhis chaprer
ft is 'n,poftaot thèt ve.lefine s'lrar is meaû!by impàirmert, dis-
abiliq. ând handicnpbeforepn).eedinAfurrher.
In rhe earlynnretiesrhe term handicâppedwæ stjll in useiû
ùaûr coùntriesând indeed..eraitr so to.layln p1à..alikeJapan
and Hoùg Kông. Pre$ure irom dre wi.ler disâbiliry moremenr,
andfrom àdvo.âtesofpeoplewirh disabilitiespeinnded rhosc;o
liealrhàrd sô.la.lcarc.asvelt as a wi.ter àudien.È.that this tcrm
stigûatizedpcoplewho were.tifferent.Therc ha bcc. a grâdual
mole èwayfrôm th; med;calùodel desùibins peopleas hand,
icapped' to the so.ial model wbcfe d,e emphasisis more ôn th€
envi.onmentimposnrgdisàbility on a perso. widr impairment
(Hutchivrn 1995).
Medkol
ondSociol
Models
of Disobility
The trend doq' 6 awar fron èttàching a label ro a pe.soo and
by implicarion,vhar they cdnot do. tos ardsân enablingcultûre
ô1hos rhc societywe live in can empowe.people,anybodv,by
removlngsomeof dre barrieB i., self-tutillmenrjn nrose\tho ùe
seenasditli.en! (V/atson2000).
As an exûple of this $an.e, drink aboùt yoùrselfjyon mav
well be shor sighled,so yôu haveaû nnpâirmenr.whether it
dnâbles yôtr dependsôn a ombe! of rh;oss: rcxt mav be roo small
o read or you canrot gct closc enouah to seethirgsi yo! prevent
it becoming a disability by subsrirurlnA wirh aûificiâl ienses.l.
other words, yoû do ûot àl1ow the impairmenr tu diqble you.
\Irhile sr.iety is oofc âwâ.e ofirs role ia this, there is still inèp
propriate discdmirarionr Foplc wilh disâbilnies do not hèveeqùity
of a..îss to 8c.c.al hcatdr care, let alone denrat care. Theft is still
contusion ove. terninolosy iûd ù otrt otuffe àpproach io being
inclusive: wi.ness the ctdsic'disabled tôilets, freqently ac.ompa-
.;ed by a wheelcluir loso. N.har à ûenral pi.rûe thls .onjlù?s upi
So, while mo$ people withiûpdrûrnts have tocoexistâlong-
side some degree of.tisâblemenr, rhe erienr b vhi.lr rhis occu6
will depend on their impèirment(s), dd the so.ietl.s response.
V.e mhrakenly talk aboùr lpecial needs' wher âll it meàN ù
ordindry ûee.ls not ofdlnariiy beinS mct. Special Care is pe.haps
more èpposire sin.e it implies that ir is drc approach dra! is st€
.ial or dlfferent ând not thc i.d;vidùr]. Ard iD essencethÀt r
what sbould scparateou. the cd.e and servicesfor peopie whô have
lmpairmc!t since, in most instarces, ùe orai dd/ôr dental needi
d? i!ùtine, bur n is lhe approach which is required thàrdeûand!
qreciat 2tt€ntionl; for example, è yoùng peisor wL1ôhas seizùresof
uûknowr o.igin, a quesliorable hsrory ofa heàft mûmùt and
moderare ietuning dlsabilitn bùt .ecds to have a loorb exrrofte.l.
lmpairment-general
and dental
'fwo
broadar€asàreemersinshere.Thereis the disab;litr conse'
qùent or notj upôn r generalizedimpairnent llkc. for exaDpLe,
.erebrèl palsy,and tLlr disnbiliry sùffer€das a consequence
of
To .ônsider .he latre! t.sr, drc mosr receûrnalional denral
surver ofUK adùlts lmked ar.hc w2y i! s'hich people'sactLrat
and perc€iveddertdl statusidpa.ted upon ùeif qùaliry of life.
Por rhc irsr ti.re 'n 1998, d,e UK ûatlonaloràl he th surey
inguiftd lûto pcoples'pe(eptions ofthe way in which rheir oral
starLsatre..edaspcftsordaily livins. This wasbasedon the 6e ôf
dre O.al Health Impact Piofile (OHIP), 6 devÉlopedbr Sladc
ând Slercer. The ]àtter authors dapred rhe \\.orld Hcakh
Oiaânjratjoû'scltssificaiioùof impâirment,dlsabllity.and lrandi
capiûto sevendomàinsthar impaft on or.l râtûs ofan indjviduâl:
tun.tionèl limitètiors, pht'si.a] pâln. psycholog;cât
discomfàr,
physicaldisability,psycirolôgiù1.lisabilny,yr.ial d;abiliry, a.d
 l3 lmpoirnrmlprNerling
0 disobilily
I
Fisurc I L I Th. s.!en donrifs of the Oral Health Inla.t
(Àftef Sla,lcÙd sFr.e,
- are ro* to befound ir sn.r11.ôûmunnies liling ir dured hoù6
L r ' l i l l ' r . i . l l r ' .
over hâlfofrhe adù|6 rulied (,=t281) hùl experie!.ed prob
iems jû one or morc oi rhcs.,lomâi.s in the J,eàrprjor ro rhe
survey.lo.7 per.e.t oi drc adùks, lhese trobLeùs o.cured lerv
olten. Pmblcms that were mor commorly reponed related a,
ph)'si.âl ])âin if .10 Fer.ent of rhe ftspordenrs, ,nd teeL,nArensc
a.d scll co.sciols in 2l per.ert. Ni,rereetr pef.enr o! pcotlc
tuforcd dur they o.cdior.J\' ô. ofro f(rûd it diffi.ulr tu rclar
.r w.re en,bàrd$ed by then ord iarc. Thc .ha.x.rcrsri.s ot
peoplc sho fc|orted troblems were dhr rl,ey \rere nore ortetr
froû unskilled nanual ba.karoùrds r.l trtten.l&l ù .leftisr o.Ly
s'hcn dief h troblems. Den.xll!, rhc\e pcoflc wcrc .dia.t o. a
mix ol nârurul teetli ârd denrûe\, hxd morc x.rircly dc.alcd
rccrh and 1èwersonûd reeih (Nùftxu rr,/. 20{)0).
T h e f o r n e r s c e n a r r , ,. f d i s a b i l i r y c o n s e q ! e n i io . a g e D e r a l
inpairûenr, llke .crcbrâl fahr, is mo.e tin,i ,ar. The rs,es that
suroûd rlis will bc c9l.rcd in rhe n,.ce&lirS prragrùphs.
(ize nf rhc n"^hl.*
P!ûn.q àû exa.r figure on rhc runrbcf ol 1fôI)lc wirh imfrif
rnents in rhc UK is d!|fi.ùlt LJe.a6e ir depends on rhe deti.itn)n
$ed. A iiAu.e olrroùnd 10 pei.ert of rhe popùldtn)n mar not be
u. rcalistlc. \vhrt s ûôie .eftair are rhât rhc gr)ùf ot tcotlc wh.
will .ome wirhi! rhe remir of sPc.i2l .ârc dcnrisny nill nnlef
(wil.lmaD.r ,/. r999).
The survivâ1 of loiv bifrh wci8ht bibi$ s'irh inil,â,nnc.6
imprôves all dre rime. Hoscrc.. diis s!ryn'al is no! wirhouii.or
se!!ûrce. The very x.t ot kccfj.8 Nh hiEh risk bibies aln'e caf
r
I
in irself 1,ro,lu.e in,l,ai'n,.nr. N.oniàl .r.. in .iânr .c.trcs is
now so sophisti.ate,l drat brbies bo.n b2rel)' wld,in rhc dci.ition
oÊvirbiliry $Niv., but rr a cosr.
'fo
oÊtlcr ùis tiorcnrial inctuasc
{
ir runbers ol .lrabled ch,ldren born an.ually is d,e l,osibillrt
nllo(led by Aefelicscrfl,ini.q ù.d resLin.q,olnle.hfuing high risk
i
I
frcgnùncics sith rbc ir.sibiliiv of rcfl.i.xtion oi sc'cfcll
affe.td taetuses(E.lsdds 2001).
The erlis ofdisâbilitl de erroti!e, toitùous àr.l ûis is roftlr
foruù to àii these. screeriûs èlloùs for dre.lete.tioû 01 loeol
âbnormxlùl bùr theqùerlon is:ur orLrer Legitlnately decide the
II
fa.e o{ an indiridùal? I. an idcal vorld ie vould ùlsh f(tr no
i m p â i . . r c n t r d i n i s . o t a r c a l l r l x . d t h c b c r s c . x n h o p et o r , \
t h a r S o . i c r y d o c sn o r s i r i n t ù d a c m c . . o n n ' l n ù 1 i v e s . b ù r n e i e l l
|rovidcs lor dior nho loj rbc ma.l. ofr.r civilizcd so.iûy mN
bc hos'wcll it.ars Èr dbscs'ln.arnot l{nrk xiicf rhcrnsclves.So.
wlile mnlr .hildren xith imprifmetrts who. teD or ilftee! yers
r8o, wonl.l not hrve suan'e.l fos lo so i..l i.ro âlolcsccncc ânl
bc,von.l Th. bu€co.ifa E.out ofrhosc in mi,ldlc lifc sho, ior
exaDple, halt iiitellect!ùl imprirmens, b!! çho hâ!î oùrg.oFf I
i
ùr.l even oùttile.l the .rre àrd ùttenrion ofrheir p.renrs are those
wLrô find theoseLles !r .omûutrit! .âre. \Yhile ûany of rller
t,rotile dr lenged rdults *ould, l! dc.âdes par, Ihve beer â..omrno
dared in L,ng-strr lnrirtrtiùb. these hxve .losrd rhen doots
ùnder the normalizarnrn Foll.r of the 1980s. M.trr {L.h rdults
w i r h . à r e 6 , 2 . 1h o ! 6 o { r h e d a ! : \ x / h i l e t h i s i s , l . s i r â b L ct ô r r l l
+ , fr . . . , , t , t ^ , r i , , . ! , t ,.1.,b.
ti.ùlârhvhcrc dcrrâ1.aft is.on.cmcd.
A recent &lveftisemenr tiom a d^r.q comtany, wid,2 ficturc ot
n Drnber ol olderpeople dar.lng, raf ù hen(lli.e lhat an.oùrced:
'by
2008 dr€ nlnber 01 hea!! drug ùse6 will doùble. Okl age
o ". , , o ..,.or F. I,.F , ]-,n F
rhef âse. Jnd in trr, rhe mâjority of.ll disàbLe.1people ire
e k l e r y . l . d , e U K t h e . e a r e 6 . t J n i l L i o n. l i s d r l e . ll , e o f L e ,t h ' i s ,
o.. in cight .f drc lroliùlâti.lr ol shom an) pcr .cnt .fc srcarer
dùù 6i )eâÀ. Iû.reisirglr'. these ôlder xdùlts wiLI hJve more nrt
ùrèl teeth rDd will expect theirdenrisr to go on tro!nltig cnre lbr
rlie,n ûto lâte ol.l àge. So, rnore ol.ler lreople. wirli iùral.ùens
ârd nnE of them $ith teeth À .lnllelle Lf tl,e ptufessnû in
en$ing ih,t not onl-v do .llni.ians of the tuture hare the leq
varled skills nc.essa$ n) trcvide rhe .orrinui.s .ùe tnd rLrese
adùhs $ill dcma.d, bùt als. rhc nexlbilirl n) pr)rlde.ùe in a
scrri.E rt)|rofriâtc f.r rhit individml, $hi.h m2I n.f bc in a
Irôm rhe foiegoin.q. we.rjr Nlme drù rliere is liLelr to be ni
. l t . r r . , ô r l , . . l r o , . , ' , r . 1 . .
rio. ofdr p|ulario. {'irh so.r. forn, ofin,t,iifl.c.t diar.uI.l
ùar nor tùstit\' spe.ial denril.are
Dentalstatus
W. acknos'lc.lAcrhar rhc numb.. ofli.otlc $'ith i.r1)2if.icnrs nixr
çcll i.cr.isc, â.1 rbâr n,o.c ot drcm s'ill hila hiAhcr.itc.rxrios

oldcntal servl.e\ rhd might .ùtrenrll bc rh€ .ae Y/hat ol their
Jcnrâlsture?ùfor reports on people Fidr impanDetts will show
onc dcpresslngfa.t. \\rhile ornl heâlù may àr the mo$ taft bc
liûh diffcfent berùeen thôse wtrh impairrrents ard so called
oomxl pcc$, the *ry in which that de.t2l di\cxse is ûânilge(l is
diffdenr. Histori.rlly, peoFLes'idr impairnenB hâve ten.led û)
hNe nore leeth cxûr.tcd and fewer teeth re$orel. Dcrtal.are is
oiler .qe.cL2tcdas âtr emergeùi- (Pesson tr d1. 2000). Wlth fe$'
etæltions, tiL-ventlv€ .âre h.s not beetr emfhasizcd in the wa! rt
lû pùt, this is â rcnccthn ofawarenes: the nvrrencss ot the
dertul profesron, awa.encsson dre part ofpàtients ùn.l of carc$.
The oûer àspec! ls of b2..ic.s. Thest tale nàny forn,s bur the
obvnN ones ùe attllldes which ârc riAmâtizing, aspecs ot dlc
erviroùrent tl,n! t.e\rnt cxsc ofmov€dert, rùd lack ofknos'l-
eJge.b.ùr ,l ' sabill ty that prevens heahl,.ire $.fkcr ptuvi.ling
'v,hy
is denral .are so imtoftant? Fof mady people wid, dis
abiliries,the preserce ol orùl/dent2l disca\€ or ihe n€ed lor den!âl
ùrc. cân bc life rlt'eareniûgi fôr erample, â ])cso. iith ûuscular
lt'st.ofby a.d cxten\ive dental needs, and fo. nhonr d geneiil
anaeshericalmos .eitainlt meèN a penod ofFccks 1n m rtet
Many prtients hârc n) .ope $th the stle eÈicls of their
i,rtrirmcntor is ûeatmett:the petso. virb I)inx bitidn wllô h.s
a larexa.ueigl as àcônse!ue.ce ofdrc t-vpcof shmt diey 1ia{e hà,ll
tlt org.n fiDsplanr fàricnr wbose .ompliatc€ with dici. dtl-
ieiectionmed icalio. is poor be.aùe ôf their dnrg relaredE inSi'a.l
.vÈrgrôwrh. Renèl trmsplènt ])atic.ts ai{) hâ'e a dental int2il
mcnt, bearing as ther- do the hdllma.ks of lonljtàùding re.al
d;cxsc $irh dis.oloured ànd hypotlâsric reeth. Althôtrg1i dilfi
.uk n) qlLanrifl, mdr! peofle with lermi.g disâbilities. unable ro
ùrl.ularc rheir prin, dor only eàr and sleef bcttcf xnd, a r.onse
q , i f i , ' i ' \ F , - l " , h ' r . l ' , , . i T p{ o ' '
rhey lùve recene,l dent2l càrc.
lssues ing opLimal
surround oral
healthfor peoplewith disabilities
In rhc l9j0s .heft was â mo'ernen!, sancd in S\aeden,to nor
in izc' dic liles of people with lùpaiflnc.ts. paitl.ulafly iitel
lectual impairmenB. Id the UK this re$rltcd in dre s.alitg .low!
ofmafl lo.g srâr inrnutions ând the settin.q ut ot $alL grôup
homcs in s.aftered comûÙriries, in orde. to mofe doseh nite
gLae people rvith disab,llties nrro so.ierr \\rhat were the co.sc
lueûcs of rhis. o. drc whole, desir.ble move? ln niany ot rhe
ffadilionallong srâl bospifuls, sâlârie.lpeBonneI wo.kl nE on{te
o ' 1 " " , . 1 . n . . 1 1. d d J r . l , r . 1 h ,r ' . ' , t , . j n " t
an envialJleseru.e, becalse ir mcân. thdt residetts go! comti.c'
hensire cde iû d eûvironmcnr thar was irûilid and secu.c a
borus h terms ol'achieving a su..essful ôtrtcome iot $mc
.hâllenging pàtients 1or whom carc in tl,e commùniry bâs
onptumized thir dertal care (Tiucfur,/. 2001).
kJues optim0l
s!û0undins 0r0lheolth y/ilhdisobililies 2 t l
I0' peoph
\VLile rlie changcr n) tlte Conûuniry DentàL SeNice in the
UK enâble.t oral cârc n) be prôvded fà.pâtient\ with disdbiliries,
the rerriction on rc$ur.es, indùding rhc la.k oftr.inin.q oPPoF
tunitles for stèl1 halc nrilltried Ègrinst a. oprimal service bcina
alailable The Jnove towxrds a det,very of care bèsed on rhc
Peisônrl DenlilScni.e\ Dodel lâs rhcpotenti.,.l todetrd( tillthef
froûr thc .onpfehetsile frelantire md .ufutn'e dcnt.l .are that
lssues of coreto people
thedelivery
surrounding with
impoinnentr
lâ.L oa lLrldi1u aorrtài.iry in the Coûmuti$ Denril Sèrv,..
Thc develofmert !f Pedot.L Dcntâl Senl.es
aion olst..iàlisr sÊni.es and t..iln,.s
IJMill,ngnes ofsonr. geneml dentiL FùctlrloneN ro lro"de dcùml
seni.er to soûrcgroutrs i' the.odmùniiy
Compoùn.Lilg rlis are rhc aftltudes of the catcs and ad!o.ètes
ofpeorlc wlrh dis.blliti€s. Carers ôftet lèel d],t dren.liets
shoùlllbe rrcatcd nôrmallt, which meâns notlorci.s dre is{e of
mourh .leaning. I! Dos cascsrheir.hrrges are unâbl€ to ùn.Ler
raLe mouth cere adcqnarel-ror then ovn.
Thn isd. i$ùc xls, for ecotom icsi ùndertaking comf.chenslve
cère !n(le.gcncral ùaeshesia is cxpcnsile, the.ostlna dcPenditg
or rhe ùnlt liom s'hi.h ù,ch ùeâtment is prôvided, u! to !1000
pd pariert treate.l If there is ûot r. agArc\sive prôgrammc ot
prcveûtiôù to ùccomt anl sùch pro.ed!res foscoPeràtrleLyi nrcn
'. ' " , , b :| r " q t ' ' t u ' - (-'
mcnrùddergerernlanâcsthesla, fôr retrir of rcpairândin mosr
inran.€s, more e{ûrcin,rs. Geternl a.2erhc\ia is not Nrthour
'lhe
a\o.irted mo.biditv ând elen nroftrliry: dettul Profcssn)n
ne.Js tu de.ide. oD tbe bâsis ofcrld€r.e. Nhat lNcl and soPhisti
' 'i r', lo off J' f'r', 1 ' r '' 1r
ulârll ifâfterc.re is ùn.cliable.
Asidc tfom eononics, thc wish on the part ofcarcrs and echo
.',e ,b i | 'o -"1
thùr rhelact no.are.t è11,sù.b is dre reluùance of many general
dûrtal !.a.rirn,ne^ to oflèr tlt dcnrxl.are re!ùir€d. The .eâsons
fôr this are nu.rcroùs L'ut ceûtre a.où.d lx.k of expericncc and
tràining ind rhe per.eption thàr,lcntÀtry fôrP€oPle s'irh inpâir
mcr6 is bodt tiûe .onùLnina and re(lùires ïrc.lal fê.ilnies
Suvns shor', hoscvcr, that the 1ùtter is o.l!' ûue for n mi...ity
.fpeopLe. The lâckofan! additionalfecs in thegeneral rlent:lser
!i.es, as exsts for .bildren with nnfai.nicnts. meaN thrt adul$
cons€rt ard restraifr ,.c felâied is$es in ,lcliverlnlt oral md
dcntal.xre for peotle Fidr disâbilnies. Thete is, not ùntuturall-!,
. " . , " r ç r t . , o r ' . , p i . . . . .
fbr $medrlng like rooth b.ùdring. It be.ones a bigAd i$ue ior
 I
211 I 13 lmp0irmenlprevenrinq
0 disobilj'y
I

the sàfe deliverl of care lor adult pâtienrs wlth lnrcltc.rùil

lnpairmenrs wl& do nor have the capd.irr tu conserr b {:a.c 2n.l
for whom no odrcf aduh nat legèlly consenr
rheir bel,all Curcnr gunhn.e rn hglând Muld suAEcst rhar
.lenrâ] ftt sboùll troceed. provi.led rhe dental .i.. cnrisâgRl
hùs rhe êgreemenr 01 F.cnts or g!èrdiJns, and i! in rhc bcst
inrcrcsr ofthepàtiert. cood pm.ti.c di.rares thar, sherefeasiLJle.
agree,nc.t on .he lreùmenr plan br a rc.ond. .x|erlerced .hri
.ixn n adrisâble. The tegAlarion ln S(trla.d golering this
.! r, ..t r .\',ô , ,,- -f ,. ,J ,i ! ,,
is more resrictile in that lr .cqui..s â dentrsr to obfuin a.eftif]-
c2re ofincapàcirr, ftum rhc fâticnt! generrl me.li.a.l prx.tltn)nd
tor each coûse ofÛearmenr (Dcl,arrment oIHe.lrh 2001, Lro.s
2001).

lisufe li.2 ^ .arîoon deli.ting d.hitc.ûurL b.rnùs b..ùmu

Prevenling
oraldisease.opLimizing
principles
câTe-generaj
Thcrc are genernl wàys ro pn)nrorc dre oral heaith oapeople \,lth Rc.cnr l.gislarion will prote.t people wirh impaiime.s s'hc.
disùbihties bef{,re.onsldc.arion oÊspecih. techii.lurs and modal- ir cornesto ù.cesinu servi.es; dre Disabilit! Dir.imi.arion A.r
oI199t .n.t the Humm Righs À.t of 199,! i. di. tlK borh hr\t
Care needs n, bc a..cssible afd to rlut en.t, peode $irh dn faFre..hin-q impli.ârn)ns f(r a..css rc and ofi)onnitis fôr, orùl
èbilitie\ rhemsclvcs oughr ro b€ involved in th€ planning ofser .nd dentâl .afe. Gen€rxl dcnral f.a.ririo.er, as owtrer ol sn l
'1be buside$es, mur makc fcasonablcakcrriofs ro rheir prJ.ùces to
vi.es rnor basi. s'ày ro trornore thi\ is, of.oùfsc, to hâla a.
âdvo.àre someone k) cnsu.e rhâ1 the in.lilidual .otr.e$cd emble Feople }nh impdirmenr\ nr à..css dicir l,.cmisrs lr rs
re.civcs dr càre drer, ûeed if drer ârc not in r psirio. to deûùd illcsal to .cfirse ro o||er.âre to d pdieùr on rhe lnrnds ofdrir
ir theDrch'cs (Goo(lley 1998). This ielies or .arc6 b.j.g ùware o1
porenrial nccds. rhe nee.l for ieuular .he.k-ùfs a.d the aLrsolùre ft is hvidnùs b ralk xbout t'eve.rifS o.al àûd denr.l dtrease
nc.csity of .liill, ùourL!.Leanintj qrines. in dic.ontcx. 01leotle with d&bilnres as a gruup apan becau*
Simple thnigs like phrsi.al a(.c$ ro bnlldings àrd adequâre cxch one is dn t!li! url wirh irdivi.lual needs.I. rhc samc s'x,!
.r fùking are inresral issfts (IiA I1.2). Ensuring dur fiÂân.lxl as odier.hârile$ ha! e applie.t .ùûcnr xndeven n.!el rfin.4ncs r.)
haûiers to .lenral .are aft fcmorc.l is viral d.l rhis ir.lde\ dre a1,ccs ol rhe promot,on of orà1 Lreâltl Lr individuals, dic sân.
hiddeû.ors of hrvina b t.alel lnrecesèri\' long.Llsm.es iar apflies to people who have an impaihe.t onlv m..c so. ifw.
so c2Lledspe.ial.rre, a\ s'ell âs râki.8 rin,e olfwork ârd dl,ool 2.c ro frevfl,r dertisû1,, or the lâ.k ô{ir, dlsablins rhcm.
SeNi.cs thcn,seh'esnee.l ro be otreftd ncxlb\', t;r c{r,nfle, with Tlrcfc afc rhoùgh, Irc.iric rsJiefis of or.1 herlrL .âre nnd
dori.ilia.y care rnorc Acncrally alailable. t.e\ eùtion of dise.se lor people wirn imFimrc.ts diû..cd to be
The British So.ietr- io. Disibilir) and Oial Hedrh nas .o.srde.ed differeùtly, ând rl,esr \.]ll be dealr widr i! drc Èllos
Gùi.lehies on the sra.dards for oral .are for peôple with pb}si.al
i l . ' , . , J , l l ' . , 1 . ' . i : ' t ' a i - 1
Preven
LingoraI di5ease-praclical
BSDHGuidelines
onstondords
ol orolcoreforpeople
with
phyri(ol
inpoirmerts Behit..,lour ânâqenieflt
Ord a$e$menr.riteir r. i.le.rili risk fiftotr for orat he ù IJcotlc srth liùiraliofs of ùoleûent rs a .onseqnen.eof rbeil
impairnrenrnced \pc.ial .onsidc.ûions for 1be sJte.lelNervof
Ddelot.rÈff ol lniili.lua] oral.rre pLa.s
, . 1 , - , . " ' , ' b . . 1 , . o .{ , \ , 1 o l " | ' o i
Ap!tupriarÉ orâl hy8ieoe ùciliri.s and ùrds
dedrisn, drc lcasri.rxsn'c, in .eÛs ofoFrimi2iig .are.nd niû
Cufom dÉ!s.Êd lreve..lvc and paLlrr.r! me res i n i z i r a d r e f e e d f o r r e s t r a i ûst h o u l . b
t e u r i L i z e d . ' l h i \w i l l l n
Ii.nriû.r.or of need n,f, ard â..e$ .o, fcnrrl .riê ' r b""'.
Dertil iiJrui.o rulti-prcÊsional rÊrms riqucs i.voh'i.g safèa.d eIfeftiveposiriôdng { nMr extend )
Su$.rt ard co.dnùlng ..lu!:rion fDr heaLrh.xrÉ tle6ônn.l ânll cat.f
drc lse ol conscioùsse.tàrionor eren grneral anac{hcsa xj xn
.J| ,o 'r
 , g' 0o, i l eeû t o , , i o , o ' P u u I,
P,efnrio ,',
i

'looth other rofi.âl nùofide agens, is oo! liàl There is â n€w, hlgh
tissûe flùoride roodrpastc (2800ppm r) alailable on the ndket. \Vhjle
it ûaI havc a pla.e ln the propliylaxis aaain! mdpatt cènes 'n,
fôr eiample, radiodicrapy patietts, its ùse in Fticntr whô iantot
The orcmll frevâlcncc of dcnral .2dc\ in pcople $irh prôfomd
disabilitics rcnds io bc simild () that found in people withoùt is
expeclorate rc be .aùtloned .Sèinst.
impâirmenB. Mrere ir diflè6 is iû the componen$ oidie cârics Corlc.rnrnal dentâ1treaûnenr m2y nor be çprôpriate fôr all
patlents. Ior soûe, d,e onlt means to deliver sr.cesstul trcarnent
exFrience lnderr peopl€ widi l'oor .ootc.,tbn o. .halleqjing
behavio!. as well as limired âcce$ ro dcnrâl scri.es fd $hâtver \àfely is with .be aid ofgeneftl ânaesthesia.Tbis implies rd.li.al
reaso!, ofieo tend to have more ùnreated dccay, nrorc misn,g reàtment planni.g, since the ôpportunily ro provide aftercère
teeth, an.t fewer restorations (Iig. 11..1) sill be leverely limited. Accompanying this approach nru* be
Ho* evef. wbere prevenrire ând tredrmert servicesaie ld.getcd lcry intenslve preveûrive care, if costlr rev,urces âre not to be
âr pdticulâr gtuups, dre evi.tenceis thèr orè1heàlth can be main wâsrcd. For orher parierts, d.omfrcmlse mry fted tô be reichcd
ral.ed at a high level. and rccoursenade to the use ofan altctnative approach to manas'
T(ryl.xl fluofide xppli.artuns are indi.ated ln this liatient llg ca.ious lcsn,ns,f{r example, usins Ca.isolv!! id cômbination
grûùp who hay bÉ dt higher dsk for the delelopment of carious wirh glass n,nomer restoralive mâtcfiaLs or a srmple àtraumaû.
lesions. Alminisr.ârion of sù.h agcûs .an be diffi.ùlt it à resrornti'e technique (ÀRr).
scvctuly inrclle.rualll nnpan€d peN,n, althôrgh Dnrèpharo vat
tlrotegiet
Riskfo<lor:ondmonogemenl orie5
fordenlol
iish is quick rc appll and is very n,leraût of môisûte so tha!
enslrjns a dry ûeld fo' a f.o!2crcd pc.iod. âs is regùirecLùith ' Di.t.rycon$iruels Ànd form
. tiqùiJ oral medi.ines

' Pôd orÀl .lelmLeisragû.rior

. Resistù.e ro nrourh.leâninc

. ùorhpr*è alternativôtslrluo, iie mourhwÀl]

. Higi .los. ropi.àl nùorides

. Rrd,.d tcarnen! Dlànninr

. cliLorhexjdcne set, 'arnnLr

' ' 1 . , ô ' s ' , '

otlres ùe eitloring rhc ùsc of ozone for the condol ot.xrious

Iigu.e l3.3 lieltùe.t
cushi.ns in ùse {ilh a dnibLcd paùent
lesiôùs nr this groul) of patlens for whon conrcnrnrnal .lental
.aft is not prulioltrle. Thc ùse ofozone rendeB drc carn,ùslesion
ina.rive wirhout tlie need fo. dcntal dri11s or the use ot lo.âl
anacrdresla. Neither is there an abvntrtt ne.esity !o flâcc x
.csrorâtn,n in the c.!itJ,, itldiient manaEehett is ditïcult. Ior
paricnn in whod ûpre.li.table
vbere rhc arcntbn spât is sliort, lhis is â LlsetùldetLro.l of.e.
dcdtrg x rntrh free ofùtiv€.2ries in a sho( spâceoftim€. Cli.i.al
ûiâls Jre row beina .ordù.ted ot this nerhod of rreâtnent.

D " , . ' t o ^ i1 , " . l o r - o l ' ç , ' i a p . i , 1 ' . I l

I g u r e I t r . 4i l ) r l { J r t r ô f e ] r . n r q
need to be dilïerefl!. Ior peopLr *irh v€ry rrolôund impairmens,
nDd is ofter liqLrrljze,l o. fcd id semi solid stare aficr nashing
Food rhus needs to be i. x fom drat câû be broLen dow. easily
and this tends to be tbods high in NI{IS. Relate.l to dri\ is the
move torvards itcrersed in,lepcndetr.É fôllo*ing oû .o.malizx-
rtrhJ.nrnphilil rn,n. f{tr people with ûil,lc. inklle.tul impàirme.ts. Clicnr\ in
 I
216 I l3Inpdimeir prevenliiq
0 disobiily
I

âdult ùainin8 .enûes afc encouragedro budget ùsing their Soft tissues
pocket money and buyio.qràodsNftlr,uslally colfectiolerr', to
CingitiTis
âid thls. In addirbn, somc \cry disabledchildren ard adults
needrc takehiah câlorieslpplemeDs ir orderto maintèin their Thr ginglvalsâtû in mdnypeôplewith impairmens,m.l the
nuÛitbnal ratùs. liq d oral medicinestaken on à regulâr pernrdonta.l heahhof$me, de going tô be affe.re.lby the rela
bdis .ân be devasatirs ft. ùe denririonand ;. chronicuse6. âs tively poor levelsôf orrl hygieneûèt prevaiLin this populâtion.
'Ihe That nots'ithstan.lirA.drcrca.c tcw dâtaon dre â.tua]perhdon-
with thoseon long term nutiitioràl supplehenB. deniâ.I
rcam .eed ro work closelywirh the prescribirg physi.iâû dd tal sta.B ot pcople with lmpâirments.Re.ent rùdies indnaÉ
.lieticiânsro ensurethat rheieastdertè]]vharnful drtrg resiûe is drâr Feriodontaldlseâseir ùbiqùirou\ bur rhen, thât is the câr
alsoin dre g€neralptulation. This ;$uc nccdsro be kept in peF
For patientsùho hàvepôrentiaur damaAlns.llers,carc6 a.d spectlverwhile sever€gingivi!is mayp.oare$ ro tJeriodontitis2nd
othersirlolved ree.t|Ôbe hade awarcofrhis addirlo.al .isk, ard thls roo.h loss,snall moùn$ of plaqu€ a.e no! i.compâtiblc
' o s " - \ Fr | , t . f - r " t , F , a . . , , , d , , j 3 ê , ! . . , . f r . ! , , \ ! wirh life, md so rher€js ltrd€ poinr ir nounrirs cos.lyinlervcn-
cère.This will in.lude re$ùlar moudr clcârinA using nuoride tior progr.mmesbde.l on profesional.ère ifthere is mt a good
toolhpa$ewherepôssible.Ifrhe parientwlll not nrleEre the ùsc chancethât theseeffortscn! be maintaineda! home.This is not a
ol t{ntrhpa*c.drc. a tood,lïush dipped iû fllori,:le nouth$âsh cosr cilcctlvcâl)pro..h.
(0.2% sodiuû fluorlde) as par of drc moudr cleâning.ourine. l_orceftaiûsubgroups,like peôple$ùh Dowr syrdrome,pû,
will deliler d eqùivalentmoùnt offluoridc but in âlehide d,ar odontèl diseèseand early rooth los has beer noled to be more
the pàtient ûây find mo.e âcccptable prevâlent,perlkps .lue ro a combination of poorly conrrolled
plagre levelsand an alÛatbn in thr phago.ri. â.tivitiesof fttr
Taotb tt'ear ùopnih. Vfth .his in mi.d. carrs and otheLrneedo be vigilant
A si8.ificarr .umbe. of people wlth nenrolôgicàlimpâirûent i. hcblng to malntain realll good oral hygienein individuâis
car$ our habillaL.oo!h cienchinAor grinding. Thû form ôfârfui- w;dr Do\'. sy.dromc.
tion cânbe devastatingto the dentitiôû,pdti.ularlr ln.omblna- Mourh cleaninais â difficult a.cafor cârc6rthc dmtal by8ien-
rion s'ith crcsion lor a sig.ificèot proFortion of people $ùh nt or dentl* needrrc wo.k dùoùsh a .ùrom-made prosrndde
.erebrdlpa.lsnsdùoeovrphaAealrcllù discase(GORD) mây be for peoplewho cùûor maintaiùtheirown oràLhygiene.Thispro
an issùe.Ths cènsesconsiderablepain and is reen lo those rocolmuy be i.corporâtedintodrct)ârients'C2rePla.s sodratrU
palientswho ùe oralty fed âswell âsin peôp1efed viâ a per.ura- staff involvedin rhcir cârc oL rclativcs.knos strat necdsto be
ûeoùsendoscopic gàstrôromy(PEG)andcadfesuh i. gagA;.8as
well æ frank vonlting. Ifrhis bcconrcs chronicrhen!he poren.ial Thereareè runber of *ays ir which toothbrùshes car be nod
for àspirntlônof ga{fi. .onrcnts bccomesâ re2liryand respiaro.} ified to nèLe them ediei to mânipùlùe. for patiens who have
i.fecrionsô..û moreftcquendy. difficultl, srâspiûg r corventional, slim handied brlsh, as tor
Toodrwearot rhis .2ture is linked wirh €rosjoÀ,especjallyor exdple, the persônwhô h6 ùthriris or ûus.n1ù dy$rophy,.
the palata.Lsurfres of mulllary rccth,and dre occlùsàlândbuccal larser hèrd1e.ân mèLe mouth cleâmis a feasilrleFroFosirion.
surfèces ofloùer moldr.eeth. It may be rhar rhe denrâlram arc NIànysuchmodiU.aiiorsresemble2 biclcle arit ând àremadcin
rheti$Ùo roticc ânysuch{liso&lerardhale beenirsrumentèt iù mbber or pla*ic to fit overih€ toodrbrùshhandle
such r parient beinA invcsrigaredtor GORD. Ln a ldrieDr who Fôr pàtiertsùlD ùe resistùt tô mouth .teadng, .ârersû€edto
càûnottolerateextensive..ehabilitarive denralcarelhen ir may be câtryôutthis tsk. Tlis may be tu.lltare.t by the ùseofepowered
necessafy to .emovebadlywon aod seûsitiveteeth.lor a moreco brushaltLroughsone severelrinrelle.tully idpaired patientsde
operativepatient who cm copevith procedures undersectâtronor raitled by dre noiseand vlbi?tbn. and rcsir attemptsat inûo-
one who is sllilcjendy fit for è seftrà1 àræ$heti., fn1l .ôverage dùcing â brus]r;.ro rheif moudrs.A Sùpe.bturh has merit ln
ofaffectednolarte€th wlth pre formedmeràlùowN, day âllevi- rhat the drc sersotopfoslnA brlsrlesallow.leanlna ot dfte nt-
ar€ symFtoms and prevent fùfther rôoth tissùe l{,ss (Shrw ,t ,/. faces buccal. occlusal ând linAual widr orc brush stLokc.
r998). \Xrhcûa.cc$ is limitcd of briei dris brushis repoted e, be efû-
Prof€sbnâl raff ir hosfnak. nr particùhr thoselookins âfter .ienr at removins pl.€ur. Likewisefo. pâtien$ who havea sore
bedri.tderpàrieûts,needb be madeawârcofrhc porerrialtbf drc nouth but io whoû exc€llertpLaquecortrol is vilal, lhe parient
corstitùens ôf proprietary mourh .leaninS xlds ro bc erosile. vith mucosnis induce(l br chemo.herapyor radiolheràpyfo.
Vhile thesecommer.iaLlyavailableswabsor moudr sponscsa.e exûple, ther a soli bristled brùsh is helplirl: ooe sùchbrushjs
ôfrenusedon hosplûl wa.ds,a roolhb.usbin conbinarion s'rrh the UlÙâsmve, which is èvailàblefrom rhe US ancL limited oùt
roôthpareor flùoridc mourhwâsh,d {.lescriltr€d
abole,isperfecrly lets in rhe UK dd sùeder (Anlborg2000).
Pàrieûtswho àreeithertôo ill oreitremely châlleûgirgir their
Âbrasi.). is alsoseeni. peoplewho practicebizùre oral habits behrvnû needâ dilTerentçproâch ror rhoseumble tô sùâllow,
and it is in thcscpâtienc rhat the crownsof teethmày be 8ôrn to rhe parien.in ITU o. thosewith lifelimiring illness,mourh.aÊ
n,.h an exrnr thar exùa.rnrnis drc orly alternative. ree.tstô be cùried our for the prtienr in bed br a ruse or otlier

.arer, .nled with àù aspirating toothb.ùsh lnstru.rions on lbc
nriûe to folldv nrst bc kept with each Paricnt so tbat
drâûseovea in raffdo not leâd to a lack oford bl'sicne dàinlc-
nan.e. The nu.se or .ùer m2I need to usc a motrth P.oP to gar.
a..e$. Toodrpa{e or the bùsh diPFd intu fluoridc moùthwâsh
s describcd abole mâr be 8ed âround a.u toodr sùrftues laain-
giv.l h€âlth is toof. .hlôrhexidcûc gel.an bc swabhed âroùnd the
ù.ùih either on a brush or usinE sôte gel $neâred onb a gàuze
wnFped filser. It is imporant ù renember that thc f(rding
àgens ld toôdrpaste lnactila.e cblorhexnlenc $ rhxr the iwo
shoùld .ot be used àt the sâme rimc. câres .eed also to be as âre
of the porentièl iniera.rion bets'ecn antifùûaals ând .hlorhcxi-
dene a.d $ âvokl lheir.on.urren! use
Àltenrarirely, chlorhcxideûe can hc inserted inb the gi.givâl
nrlcus area it a va..nh form, d,ùs leavitg à.escNon in dris aft.
Eviden.e, .urcndy rvailâblc, gsests drat dre è.rimi.robièl
fôr uP to sû monlhs
benefit fionr dris is sust2ined
paticnt who eirhcf .aûnot o. vill to! alkrs'
The challenging
xflybo.ty to clean thejr mouths Prese.ts more ol r tfoblemi somc
' L'\ oo' 'i\' " sirh impairme!6, the.c hâve b€e. three broâd apProachcsto the
iu ' a'. ore.\r
.orfrort. Sonre.âre6 h2vcaPhllo
rhiûg ihàt car€6 wili ofteD .ot
sopli.âl view ihat they should nôt Lre rest.ainlng .liens rn ôRter
ddly ljvina. like rô.dr bnsh
!o acconplsh routin€s of lormal
ina. This reeds ro be.lisc,r$ed and a relevant analogy made; for
elsewhere io dle bodyivoùld.are6
cxample, wi ih .a.e of èn ulccf
not clean ând cLresà lcA ùl.er? In e$ence, Periodontal .lisedc cm
be likcned to the sàme proce$ a.d cûers heb cûlisted in moùth
cl€aninE d pàft oftheirdutv of câ.e
Somepariens may.csi.t cleaning by adopting .litïerenr bchav-
iouûl strarcgies, lik€ .etching or gagaing when . nnrhb.$h is
inùodùced or elen $'hcn dleû nourhs are touchcd. A .onrcn-
tioûèl apptuach to this problem,.clying N it do€s ô! d high
degreeofcognitive functionlng to brinét abont ècdinràtizètio.. 's
rot suirable. Altern2rives, ntilizing a .ombin2tbn aPProâch of
beharioùr Foditi.ation and tcùrodeleloPmental theory hâve
a.hieved su..e$ in deseosirizttion suffi.ient to àc.omPllsh oraL
hygiene, and deûtàl cà.c withoùt recoùBe to Aencrâl aûàes!hcla
(Reidrr r/. 2000).
Self-in{licted]'rauna
lnfection ôf gingival tissues is an almôst inûa.table Problem it
some irdiridutls wirh severe learning disabilities Howerc., â
'orpr'."rnlr'D a lô.i 'i i b. r' f
n self mulilarn,n invotring oEl tissùes Iû PeoPle widl specitc
syrdromcs. like fôr exâmple, tesch Nyhaû syndront, self muti-
1ètion is an inteAral tari ofthe cooditiôù For oùeB, a trlgAer
rhàt caû bc soûethins l;ke.eedinl8 is sùfficiert !o set ôffàljcious
.ir.le, when ioadvertent biting ofliPs or tongue cd. Poduce Fd'n
and swelling rhat perpetuâtc\ rhe .ycle of ûadù Thi5 .an resùlt
in cLehydr ion nece$ilatirg hospitalization as the individ!al!
mouth becomcs ùô sore to cat or driûL. Prevettlon lics ln minl
mizing ûe woN effects eidrd bI extEciing the o[lèndins tôoth
or teerh, if they ère i. ùe primary dcntitioni or more ùsùalll'.
6psds
of0l dismsê-pr0dkol
Piweflling 217
fittnrg srfi PVAC-PE sPlints to prelent Âûther sott ùsue tnuma
and dllo$ the are2 ù heâ1.O..asiooalll the trauma s a conse-
quencc of malocclusiôù aid ofthô.lonii. ûeàtnent .at P'ercnt
re.ùrrences, provldcd sufficjent cooP€rarion cd bc a.hieled tû
rheàdjusnenr olàL.hwir€s. often utder ons.ioùs scdation. Band
an,l bracket placcment, any ofthodonti. extracrions,d.l debond
ing will usualLyneed ro nke Placc mder gencml daathcra
5aliva
HJtPersali!.rtion
cânal\obe ùscfù1inanotherproblcm
Theuscof ôrèLapplian.es
foùod in peopl€ viih imtainnen$, drat of erce$ive droolirS
l-his is secn inûose s'lih Poor ncùromùscular .ontrol. âs foùnd in
.er€br2l pa.lsyor in drôse who have hdd a .erebro va\.nlù aco-
denr. This cà. be d ùnflcasdt hâbn àr all concetned. In the
young, rols be.one covered widr sa.liva,drc.hild oftcn requires
lieqùeni changes of bibs or oihcf .lothes dùritg dle dnr', ànd 1n
wirter lbc.ir.nmoml $ft tissuesbecom€ cx.ôrièted. In.hildren
prcvention of such a probLem: su€i.â1, pliarmacological o' with
ùe Pros ând 'Ôns
lalaial ùaininaâids. Edch has its advo.ates,d.d
l
ar€ lisred in T2ble l.l.
Cuûently, rhc evi.LencesùpPortinfi etuh is anccdotal and fùr
thcf researchis .eqùired ù) âscertaiûshether ùe betefis ol the
les irvisive âpFtoà.h ùsitg thc palatal trainlng Platcs rs as cor
ef€ciive d, Io. cxamPle, thc ùse of hlor.ite td(hes The later
self adhesive dcfmal Patches con!àin hvosclnc hr-drobromide,
*hnh is grâduÀLll relesed over â 72 hour Peno'1, âcûng d ân
antègonist ù parasympathominretic âctivities, in dris.de drool-
ing. Howcler, the drug is costly and prevc.iiôn requires regulâr'
su$ained ùse. Slrgery ot the other hatd, iNolving âs t dÔestlrc
re-routeins of sè]iva.y sldd rlucts md on occæions gLand abla
rion, is immedialei althoùgh, ihe.e is eridcn.e oI â Par.doxicàL
rerrn of furction post suLgery in some cases However' as iû
paiieûs fo. whom radiothenPy has removed mos ifnot a.ll sdi
lary gla.d fùnctiot. rhe resuitânt .ise in râ'npânt cd.ics, rn preli-
ously carienresistant teeth tikc l(nver !tinn, is dramati. whât
is lrss clear obiectilel)'. is ho$'su..essfui the palalal ùaiûins
iô their ùse ère
tlat€s dre and whedrer the beûefiB nûribùicd
:rhere is 2 link belwccn GORD ând hyPe6âllvation. Parients
n, vhod hypesali*tlon is a observed.rhôuld bc investlgarcd tÔr
rhc distre$inA .on.lition ofGORD The.lenral ted mal be the
firsr to notl.e the dentâl erosivese,tuelàeol.hronic regusitation
(Nu.n r999).
Xerostomia
Tbis is an impairment thât ls more deva$atj.A thd excessile
salilatn)n for à laryer tumber of PeoPIe Both rhc aualilv and
qùartiry ôf salila .hange wlth age, but added to this are the
effeffs on saLivaofdisease and its treatme.t
Aacins Lrriias with it imtairmett and.hrônic co.dirions' likc
for cxdple, Sjogrens.Useâsc,which isa..oûPanicd bv svnfroms
 I
218 l3 lmp0irJiênt-preventing
0 dis0bility
|
I
Tabk r 3. I Prosand Consof differenrâpprôa.hesro rhe preverrior of droolins
Bcbarioû nodit.âdor and
O&t .lal rcgulaionrhenpy Po$,bnityol nsrânreJbenelii\ele.
Usudlly hÀ r prc.onnd etle.t Choi.E
.f techniqùetswùh varyûg .ui.omes
of2 dry moùth. It is esr;mared rhai by rhe end of rhis decade,the
.umber of el.tertypeopleor medicètiônvill double.One ofthe
sideeffectsofmany of lhesemedi.inesis that dreyprGlucea diy
mouth.This e\?ôsesolderpeople,far nore ofwhom now hèvenàt
ufrl €erh, to dertal caficsând Êorthosewho âreedenrate,rhe dif
nc,Jtiesôf mânâgiogdenrnreswithour âdeqlatereserves of sa.liva.
l-or à p$ponior of people,ùeatmenr for malignânt disease
vith radiothe.apyioducesch.ngesin salivalyglan.t tissùesu.h
that the secretioûof saliva n dnsricalty Àltered.Whb ca.eful
plannina,someofrhe deletcdouseftèctsof tnis approa.hcâo be
ûinim;zed, ifnot prevented.hy carefulco$Ûrtiôn ôfste.ts to
shield.he salivâryg1ândtissuefrom the rà.ti.tiôn beam.
It;s essenriâl ihar àdenr;s!b€ apù ôf the on.ologplâ.n;ng
ttah, sorhatpariertswhô arcscheduled to hâveiû&liarion ro rhc
heJdànd leck rcgion ùe prorided wnh rhe .ece$arypre opera-
tn'cdenrâlcùetô Noid cxtraclioos,md dlus minimizc the.isl. of
osteor2diorecrosis pos-oper2lively.Peri,ôperaiirely,a p.osrho
dondsrshoùtdbe ava;lablefor ihe consÛu.tionofstcrrs ro shield
dertal tisNes in dre line ofthe bed. In add;tion,atrosthodon-
list wili be neededro consrru.robrùrâto.sfo. slch pèrierts rô
prevert thè vorst of rhe dertal dilabiliry diâ. car acctuefrom
radi.â.I,æcoNrrucrile nùgery
Pof{per2iively, these denrarepârients are àt high risk of
' l - \ " l o o , ; d e ' , JJ r e . ' , . 1 n ' . . b - T d , . i ' c . o - " . 9 s . " . . r . -
prcventive progrâmme s'ith high dose flùori.le appllcatiors.
Cllni.al r;als hale indicàredrhat sodiumflùorideroôdlpasiear a
.on.e.ttation of5000 ppm vas ablero remlnerali,erôor suface
Iesionsand to redù.e pla.tue scoresslsnifi.ântly bI comparjsor
q,l ' o..-, i, b |0!,tDnluorf-'oô,lpr{,
Most oncologlproaraomeswill emplôyâ p.otocolrha! incor
poûtes.lailv useofchlorhexideoemôurhwâlhof sel ro laciLirare
moùth .ledinA and provi.le respirefrôm o.âl ulcerarior. lr is
importdt thai .arc sraff2doinisrernystatinasânrlfuDA2ldrerapy
rahour inrc$ile; Need f.r equipmenq PariÊ.t has ro 6e
xr leâr 3 'a(, no.llric.ljoùlr sunrbLe.or modenre
Vâriàble dosc rcqlircd iô pro.iL.e gland ûophvi Re.orery
pôsibLe: ResidùÀlsalna qùâliry ar.nges uolavoùrùtrhi
PosiLril,tr of sr.onas, oieoradiontrr.sh â.J.rriÊs
'limÊ!o'AUmlLa.aonLruuusmrnkntrn.e
BeneUGlrirble dd mt rNained
E{trÊnsnrj S e ellacsi ToLeiNe
IntÉnsik ând d.rÊ.oasù'nlig fbr .ùrc6i
Nû obre.rive {idÊn.e of henetns
Po$rbilnt, oa ftLrtse; Peforation ând los ol t6.ej
Xer.$omiâ ànd.ariesi Âltenû,.ns in qualit)'ofs ivi
Paiien6 need ro be hospirâlized,ûeàreJ unJerAc.ertrl
ar ètine distânt,prcËnbly onehou!,iron chlorheidenero àvoid
inacti!Ètiônof the turme. S;mil2rly.nuor e toothp.sreshodd
notbeuled in conjunctionwith chlorhexidene for the smereasôn.
There de a Aioup of par'enrsfor whom practicèihelp wirh
salivarepla.eûert is reqùlred.For somc.stimular'onofresidùal
gland tunctionwnh, for exmple, pilôcarpine.anbe helpfù].Io.
others. subsritutesar€ i.dicated and the plethôrâ of s,lùrn,ns
ôfferÉdls indicativeofthe r€lativeron strccesôfmâny ôfùese.
lisf ol solivo
substitutes
PatjeD6who ùe dertèteshoL,ldbe wtunedaboutdrc dargeroa
usinSco.lèctiorery!h.t is both cariogeni.and enalve.Simila.l).,
thepH oiâ numberof salivasùbstirùtes,forexdple, clandosâne.
nay be low enoûghtô pronôte denralercsio. Crablell.2).
For somep.tiens, the.omponenrsofrcplâcemer!salivamay
be cùhùrè11yurà.ceprablea\ fi,. e{âmplc with Saiila Orrhana,
which contàirs por.ine ga$i. muci.s. Orhes. to. exmple,
Bioteûe,cânnôtbÉùsed{'ith dete.geûsor orher$ch teûsioùtive
ègens like ûe fôming.onritucn6 in toodrpâstes lhar ina.ti\'âre

Tabl€ 11.2 The pH of {rm€ salila $britues
PH
t i
t l
] 1
A.1
dre enz_vmes_vstemi.tcaL2l to drc prcdù.t: rhcsc agenB âfe noF
mallr Ddketed as a sprar',moùth*ash, .hewing guû. at.l toôth
p6te às rcomplete system lortariens hon,euse A nun,bcr ofdrc
subsrirurescome widr addcd fluoridc, ior cxanrdc. Lllbonnt rnd
SalivdOithâna. Thc cxâct.onrcn6 slntrlld bc.hc.kcd agxinr dre
11 DF,, J r-r. .o,l | , I rot{ ',.
for the irdn i.lu.l p.tienCs ûeeds (Dèriels .?001).
Conclusiors
fôr rhose.Lenriss aûd hygierits nr!ôlved h pàlliàrile care, drere
will be dre responsibility for a grouF ol tarief$, somc ofFhom
vill b. bcd.'ddcn ard ùn.ons.nns, odrers of whomsiU have life
linri.hg illncss. \Xrhile this ma1 be a temporary stqe for some,
ùe conblned etrecrs of llfe suppoit with ûasal oxygeû, ù open
Doudr pstu.e.l)a.e.terâl fccding. and occasio.al sù.tx,n ofthe
anwal will add to lhe sensàrionofà dry moudr. V/hilc oml .om-
fàr nay seem .o be a relariveh mi.o. considcnûo
patien!, i. can detrac. markedly Êom dic fxiicnfs qualiry oflife.
lÀ conclûsion, nrtelligen! an(l pro2crive jrrevcnrivc dcnàl .arc
cân do much toI).c!crr thcunv,nrcd scAuclaeof dcûtaLdrsea€ rs
sell d enhan.ins the qù.tllty ofllle tur peôple whô ûr) .ot be
dble ro d€nànd rhat care lhe,nselves,but in whom r scnscofpos
r i v e o . a l w € l l b e i f . qi s , u s . â s i m 1 D n à n r .T h i s m u s t b c d r c i m p e r
atlle of arr' .lertal tedû.
References
Àhlbors, B. (2000). Practic.l prelertion. tn: D^dùl4 dd
Ozl c./'" Nùnd, J, ed.) fDI world DeDtàLPr€s. lsuN:o
9t3926r O 9
Ditul)j/it! à"à atul .dft.(2000) (NMn, J H. eA.).fe.teràtion
DenrâireInrernâriôndleISBN 0 9t19261 0 9. À!ùilable
from rhe prifte^: Te1:01502 580881
Baysan,^., Whilel, R.. and LIn.h, E. (2000). Ânrinicrôbial
ctlèctsofa norcLozonegeneratlnEdevi.e on mi.ro orgàù
. , N " . . , . . d ' i l b \ ' , , , : , ' l i , l
a,t{ Rdr,ln.l98 jor.
r,t,*** | :rs
I
Britisb Socicryftf Dlsabilitr âtd Or.l llerlû Guidclincs.
On:wFw.bsdh.o$.ùk
DcFltmcnr ofHealth (2001).SeeLnrgco.sent:\qkirg $irl1
teofle with lcami.g dlsablllties.Depaitmen. of Hcâldr
wFs.doh.Aovùkr.on\ert.
Dâniels, T.n. (2001) Evàluât'on,diffcfential diâgnôsisrnd
t r e ù m c n ro f . d o { o n r n . J . R l e u m d o l .S u f p l . 6 l , a r 1 0 .
Elvrrds. S.D.(2001).Prevettiot of disability on Aroùndsot
nrfferi.s./ nld ErhJ,27.180 182.
Goodley,D. (199u) Suftofti.g peoplewith leâmiûs dllucul
riesin selÈ,lro.iq annLpsard nodels ôfdrabihtr l/,,/t
So..CàE Co,,nniit!, 6, 138-446.
Hut.liison, T (199:). Thc .lassifiotxtr of Disrbility. A,l.
D t r .( . b l t d . 7 3 , 9 r , 9 .
Klingberg, G. (2000) Bchù'ioû nrâflxsemenr .hil.lren àn(l
adolescenrs. In: Dn r;/ù tul oral Hulth lNvn, J. e,l).
F D I W o d d D c n r a lP r c s s . I S B N :90j l 9 2 6 l 0 9
LyoDs,D. (2001).Adul6 widr l..apa.ity (Scôtlàùd) Act 2000.
Hùt tt B!!/, 5t), 116 1+t).
Nuùr, J.ll (1999). Droolinét.À review of die liter.ture and
proposalslor rmnagemcnt.1.aù|. Rthdl,27. t-at t-11.
Nuii.ll, N.À1.,Sleele,J(1., Pinc, C.NI , N.hite, D.. aù.lPit$,
N.B (2001).Thc impâ.r oforâ1heâ1û.àreon peofle in dic
U K i n 1 9 9 8 .6 r D . r i . / . , 1 9 0 ,L 2| 1 2 6 .
Person, B.il., Stiefel,D.l . Gritith, r\LV, lruelole,1.L., an.l
I{àftir, M.D. (2000). Charâ.tefisi.s ôf dental em€rgeû.)
.linn patients wûh àD.l will,out disabilities .lrci: aal.
DtiL,20,ll.l l2O.
n .11 x
Re , J.À., Kiis, PL., and Kibàùi.k. N.ÀL (2000).
De\enrizâiiôùof dre gag rellex in an adult wiù cettbraL
palyl':a.Ar report.Vr.t / Cdft l)ert.,2tt.t6 6tt.
Shàw,I-., weâdic.ill. S..atrd Smith, À. (1998).Tooth "ear in
.hildren: an lNe*isarioû ofetioloAicâltiffos ir .hildren
with .erebrJlpè1syan(l gâsùocoR)ph2acal rellu.-/. D'rr.
CLt/n,69,181!!-t]6.
Slxdc,G.D.(1991) Deri!ètron afd lalidarion.f i shortrôrm
oml healtnimpa.r prôiile. ColnntntryDûL ALI Elià,t,)/..
2i.1a.),29t).
.n|illcr. \\.ils)n, K.L, and Gallisher,
S.. J.E. (2001).oml healtlr
srxiusard dentalservi.eùseoladùlts sirh lcrminA disablt-
iries living iû resideftiaL,nsirurions ard ifl dre .ommu
tit\.Conùr"i, De"t. Hùlîb, 18,167 1r1.
\IraldmxnH f .L ( 1 9 9 r ) .
, . 8 . , P e r l m â t , 5 . P , à D . lS w e f u l l o fN
Childrcawidr dlsxbilities:morethan jusr ûnnbc.s../. D-r
cbtt , 65, 48 ,- 491.
Watson,N. (2000).Batiers, dis.ridlration and pre,ùdicc.I.:
D{r[ili4 d"d Ardl Ctrt. (Nuù, J ed.) IDI v/orl.l t)cnral
P r e $ .l S B N r 09 t l 9 2 6 l 0 ,
Thepreventionof socialinequalities
in oral
health
N i g eN
l uttall
lntroduction
Evi.lencefôr rhe existenccof social inequaliri€sin heahh hrs
existedthrorLghouthisrory.In fifteeûthcenùry Fernrc, xuuF
ity rateshave bee. shown to be relàtedto rhe size of womer's
dowrieson maûiageiwomen wirh h;gherdowrieswerefound ro
beles likèly to die s'idr;n anyAiveûy€arlbanwomeowjrh low€r
dov.ies.In odrercs€s îhe evidenceis stilt lisible inoûàrchite.
tuel he.itage.It wasfdhionablemong the weâithyin W.rôrid
Figurc t.f.t The Ne.Lopol's of Gl6gov CJrllLJrJl
clàsgôw tô hdve m obelisk as a memorial, s'hjch has created 2n
impressive dhy in The Glâsgow Necropolis, è Victorian ceme
rery (Fig. 14.1). Dâvey Smùh ând colleàgles hav€ shov. that
these vary in height âccord'ng io aa. at dcath. ThÀ hd been
interyrered as indi.aring rhar wedthier peôple (ùho woutd be
môre lilely ro afford a aller obelisk) terd to live lonser. As çelL
as sho$ing rhÉ irisrôri.al dpect of !ùiètiôns in mortality dsoci
aled wirh laryins deaites of weâlth, dresÉfindings âlso nise two
turthe. sisûjfican! points. Thc first is thar ln boih exdFles rhe
22a I 14The0reveflrion ii oruiheûllh
0lso(nln€ouoli'ies
I
social smtitlcatio. ofdre people invôlved is quite è naûow band
of rhe ppulation d a vhole. V.omen with .{ôwries h the Ëf
rccnth cc.rury s'erc the nost pfivileged ôf their time, as ve.e
those intered i. the Glasgow Neciopolis. Yet mortâ.lity seems!o
have bcen uncrcnly distribùted on ihe basis ôf fiûm.ial weallh
sen withln rhls naûow band of the privileged. The secon,lpo;nt
i.tertified by Carrotl, Daley Smith,2n,l Be.rctt ls thai rhesehÂ
torical Êndioss aLsoseem ro dcmonstnre tbat explandtiots for
jn€qùaljtjes based on co.temporary concerns nây nôt be sùffi
ciert to explÀin hlstorical ineqxalitles as many of dre unheâlrhy
àctivities we recôgnlse todÈy were the preseNe of the afi'luent
.la$es in rhe pà$.
The issue ofsocial ineqùÀlitles ir health wa beainnina to be
specifically discused in the mid nlnereenth c€rlury. In the
UnitecL Kiûgdom in 18'i2, Châdwick reporred drar drc avera8e
a.qeat deâth lor genùy ân.l protè$iooal pesons war 3 5 ; for tràdes
men, 22 years and for laboùers and servànts, It yea6. Deaihs
1,nJl .-. "TôaSm."o\r-rr.1 i f e r .g, o ' r p . . i o r. r r "
repofted d paft of rhe 1851 Cen$a; md ir 1887, . proposal wa
nade fo.a srstem to classil'people hy vrial c1æs specificalty to
look at lhe issu€ ofdiÈère.ces in dre aac o{ death berween poor
md rich peopl€, although this vâs not actually done ùnril 1911.
So, before the ctoseofdr€ nio€teenth .enlury, drere was âlrea.l!' a
wi.lespreè.i ècceptarce that class difl'ere.ces ir liic expectan.y
€:isted. tlovever, d,e causesof thcse diffeten.es were dispute.l
and€.hoes d this dirpureare$ill nûbling on ir the twenty U6t
The dispute cân be cônsnlered as ano.he. facet o{ the
nature/nufture lsslle thar has permeàted so ûâny debat€s(e.s. the
nalure ofhuman intclligence). I! the caseofsoclal ine.txalitjes it
J.iJ(d | ' o ,l( i_$ '\ | p,,' n o'i :o. i, 'o i'_) s"
de.ived th.ouAb bioloSi.âlly dèterûine.i inherited lâctors
(narur€) versus the view drat social.ondiriôns, eûviroment, aod
utbrinsing (nùrtùre) {'eiÊ ihe dererdinans. At ore extreme ol
rheseposniôns lay dre propôsitiôr rhàt rpe4on: social.las was
a resùl! ofthe proce$ ofnâtural selccihn as propôsed by Dàrçin.
'lowel
This froces .ot o.ly determlned membership of rhe
sociai classesbuf also crpla;.ed their disadvàttèse.t posjtjoû j.
tems ôftheir health and physi{tue (nàture). At ihè other ex(ene
there ùd dôther dannins vieq exemdified by rhe quore belo$,
thÈt sô.iàl irequèlities between deads in inians were lârgely.lue
ro their upbrirging (nurtùre):
The tetriblc hcâry deadr rate among yourg children n, our
tmn is of couse due to a certain extent to the fclative
unheàlthness ofolr sutroundinas. bùr thai ls by nô meèts
lhe chiefcalse. The facto. drat is ofprimdy impônàtce h
mternal misnanasenent ... Erery visitor in the homes of
the workiûg class kûows orLy loo well the hopeles igno-
rdce ofthe mèjofty ofthe mothe^ in resard tu ereryihins
, ' l ' ' r r , B o r ' 'e l t ' y o - - p i r I .
(DL Ha.old Kerr, Asisrant MedicalOlncer,
New.asile ùpon Tr"ne,t910.)
Tbe fa.t thât sôciâLirequalirics iû health hÈle be€û,]iscu$ed
in dre Unired Kirg.tom lbr ar leâst r50 yea^ is è fèirly $rong clue
âboùt the la.k of ary cl€dr cut âgrced apprôach tô how lhey oughr
ro bc rackled. There vas a nxrry ofcont.oversy durins th€ r980s
oo ihc pùbli.âtiôû ôfthe }ilack Rcpor and the ldter publication
of The Heàlû Divide. Thc .onûoveBy is detâlled in rhe Itûo-
ductio. !o drc colle.tn,n ôfbôth iepofts lhât sas later issuedit
paperback, largely to male ùp for dre.litticulty in obtâinitg orig
' , " . o t ! . s l , iI r r e p r o J r e ' b )' l r U K C { F ' û " ' . n r
.teliberutelr limitcd prlnÈrû. The probl€ms stcmmed fron the
proximlry ol dre i$ues involved it soclaL inequalities ând the
pô1iticè1phllosoph ies of rhe maior pôlitical pùtjes in rhe Unred
Kirgdom. Ooe side of rhis was fânonsly ilhs!ûred in Margdet
'Ihat.her's
pronouncement that the.e is nô sùch ihjng a society
(â "iew which is noi likcll to be entirely sympathetic to conslder
ations of lo.ial ineqùalnies ). The isue was ldsely bùrie.l 6 a
Governdenr coûcern rhroughoùr rhe i980s èrd 90s with whât
Macintlre has desc'ibe,l âs only aû o..asionâl considerâtio. ol
'ra.iariôns
iû health'.
However, it is difficult to stiile a I r0-yeâ.{nd debàte for lons.
dnd in 1998 dre subje.t ùd revisited by a conrmittee .hàired bv
S; Donald À.bei)n. It ûored that lhat wh;lc averagehôusehold
incooe ha,.lg.own by4oZ in reèl terms during the previoustwo
.lecades,i! ha,l arown mù.h tdter amotg the richest in dre popù
la.jon. Fof dre poorest tenû, av€rage income indedecL by ooly
l0 per .rnr (befor€ bousi.g costt o. fell by 8 per cent (âiier
them). fùrthermore, the ineqùaliti€s in heaLth between sô.iâl
c1ùses in ihe 1990s hâd .istn from those oi the rccent pa$; the
ditrereûce in lif€ expeclancy between so.ièl cld$ I ard V .ose to
9.t years for mer and 6.,i years fo. women.I ùt morlalirl vd
foùnd to be tùice as hish i. Sâlrord. on€ of the wors hedth aLeas,
Èn r 'ô' \(Jlol\,o'eol'h be{lrJ'l deô
Thc A.heson Report recommended rhai heâ1th inequaliries
shoùld be tâckled oD a b.oalL iioflr recqnizitg that drey â.c rhe
ôutcôme oi'caual chains thnt run itto âtd irom drc basi. rftr
tu.e of vr.iety. l-he repoft uses dre tcLm ùprred for pol'cies
rhar would hâve ûeû nrflue.ce dùoùAh lo.ietèl chaoge such d
1ô1 dôrn.-red ol
or' ddre r. r r:.lr-re. r ii, {
wirlr a narros'er rdge ôf benefits such as iree nicotite replaæ
men! dierâpy. :rhe À.hesôn Repoft was also quite clear thèt die
key to beg:.ning the redu.tion in health inequl,ûes wds to cot
centrare on rhe needs ôf present aod luture mothts ât.l their
childrer to Frovid c cnbân.ed ôpportunities lb.heâlth for rhe next
:fhe ll.erature on soclal inequlities iû health is rlddled with
.ortrèdictory evi,.lenceradding haty ofthe underlyi.a issùes
A greèt deal ol the eviden.e is based on the jote.pretation ol pat-
terns.nd trends h oortalitydâta. This ôpens up thepo$ibilides
ofa ldk ôf completene$ in datasers,.hdees iû definitjons ortr
t;me (f the medùre ùse(l to classify people or of the circum-
stan.e! of rheir death) aûd in somc.ases, perhêps, the ùse ofvrlue
judsements and the iùplicalion ofâ de8.ee ôf certdinty thar may
not be eûtirely jnstified by lhe dàt2 qùalitir However, ote matt{

is ùfchalleng&lr in Y/estern So.ierr !,.lally disadlarraAcd fcotilc
lie )oùnger and âre ûu.1, more likelv tu hivc batricsIho dic ir
comparison {irh people fn,m tuE prirlleged ba.kg(n.ds. This
.hâFter.onsidets the .ompamrirely lc$ sianiii(a.t i$ùe ol how
then sociàl .ir.uûrân.es aff€.r drelr oml hcaldr.
What aresocialinequalities
in
health?
SocidliDe.lLrllries i! healrh âre rhe differe..cs i. cxpcricn.cofill
r$s, or derth, bet$eer grorps ofpcoplc shcn clasi|c.l on d,e
basisof some sô.ial illli.aror. Often dris is rhc RcAisnâr General!
cLa$llication of n,.id .1ass(làble 11. I ) Th. .l iftàref.e io healrh
nofter refered tu rs a gradicnf dr.ivc,l iom d,e generalpaft€n
ir graths oIJ liie decreasnrgor in.ftxsing trcm rhc.iorc iÈluc.t
of advanrascd i. sociery ro dr no$ iùFoverished or .li\a.lvan
ege.l. Thepxûem is inrariabll drcsamerslofi.g lioù good indi
.atiôrs of health ann,ng rhc soci2lly advdnraged trolesronaL
grôrLpt) poo. indi.xrions ol l,eàlth dnong ûe so.ial\ disà.tv.r
râged unskillc.l worLiog groùp. furthermore, the hagnùnde of
rk diftire.ces can be liuger fôr iûstar.e. womrn,n rLre most
disâdvantaae.lgroups ofsocretv hàre been fourd tu be nead_r20
rimes more liLel! tô .tie froh .x8e\ ftlâted to p.cs.a.cv and
d,ildbinh tha. \omer in the $o high€s y).ial.lases
Thc tc..r'Jcfrn'âtion' is rred.l!ire.ommôùl) in rhe.onrext
oiiûequalitie\ Deprivatn). si.glcs oùt rhc mosr ,l isâJvrntâged in
so.let! anl cd ùke several forms xl.hoùEh. in rhc lnsr, ir h,s
been more commô y measured onh i. rc.nrs of a lack of tlrc
tuterixl dspe.ts c.jorcd by sociery a d whole. Material deprila
rnn.on.ernss'hcdrcrFolnc hàveste.illcgoodsorresouic€sthrr
aÈ ommon rlthin a socicry. Orher tornr 01 depri'ùion .re
io.ial deFfiratô. {'lridr desc.ibes dre roles aûd relrtionslxps,
membcrsh;f and so.irl conrdcts in socretyàùd multiple depriva
rior' whi.h des.ribes rhc crr.ic.cc of selefuL fôrms ofdetrila
rion.on.urendy, su.h as los ln.ome, poor bouslns, a.d
ùnenrdoymc.t. Soci2l dclusio. is also J tenn used in some cor
rexts. Ihls des.ribcs {'hàr ca. hâi,pe. çhen teople or ared suffer
fronr a combi.2tio. of liilk€d problems su.h Js unerplôyneùt,
foor si.ills,low in.omes, poor housing, bad hralth, frmily break-
lovn, d.d high .rlne environmens. The r€rms depfivarn)n and
soci2l$clusior ùe, therefoie, similâr bnt, perhap\,.ân be dlsi.-
gùjshe.l rs.llftèrnrg iù rheir.overare. So.ial cx.lùsn)n ispmb2bly
:fable 1,1.1So.iàl clâ$ i. the trnired Kirrgdôm deilne.l br rl,e
R . , . ' , r' ' , - . | ' , , o . i i , o . ' t o '
ProatnionJ (e! L:wyer,denrnt, x..omtant)
I',rrmiJiJ? 1È.'r kJ!.r r riÈ mrn.gÈr)
Sklll.(l ioirnn0url (..!. rrFtrr. sl,ùÈ Ntrtarr)
sk leJ mânuâl (e ! brt Ji(r,.ool)
P rt) \l ?d .d b . ndu.m l, n \irl,et
Un\Lnld minùil (e.s .lexner, hbouEr)
I
û J h (! o ( . e i s p ( ! l r e q . i û r te0s rh | )2c
I
.rorc corc.dyatflicd b dic mo*d+.ircd ol thcdeffiledr those
ofrcr dcl,.ivcl ofà l,omcr ofx. cducùrionj ofhcxkh .ak a.d/d of
Peofle if de|ik.l dreasa.e liLely ro bNc â highcr cxposurc rc
ncaàrn'. inlluorcs on hcâlth. â.d ro lâck.csour.cs ro aFnd $mc or
thcrn or theif effe.ts, thân people livlns in less deprived.ir.un
stùces. Theie.ùe other foûns oiea.lûion ù well: teople wirh (lis
nbilities, ard thoseol sone elh.ic or agegrolts. may ako eal,cric.cc
vnrying exlorre !o dresei.lliæncs on healthi dnd in ccicain cil
ùrùs.!.es J pesôn\ sd m.r. ûfluen.e heèlth opporiùrities (ùnre
hed o ti,ose mmralh æo.iâie.t wirL sender .tiferencet.
Whaleffecldoe:deprivation
have?
The Bladr Rel)ort of 1980 frcscntc,l a .omfrchc.snt r.\'ics'of
ine.lùali.ies in hea.lthxnd ln a..es to health.a.e beôvern o..upr
tion.l.la$es. The c€ntràlfiùdins Nù thlt ùortalit\' afd morbid
ity ùâs greùter aDong t,eotle lioF unskilled afd paftly sl.illed
worklrs bà.kgroun.ls The report also Dored thar people wnhin
these gn,ups r1*, ued health servl.es less freqtreftly tha oûer
' ' 1" , t ' t ' : d r . r . . . . 1' " , " l _
.onsidered as preventlve. lhe repor.on.ltrded thal
Ths p.nteû ôf urqkl use is dpli.dble not h terns of a
nor radoùl responseto siclme$ Lr-vworlring cL6speotle bù1
.t a rrional wciAhtinA ofrhc fc..cn'cd (x6.nd bcrcil6 rc
them of artendance and .onpliatce wid, the p.es.ribed
regide. These .osts dr.t bereÂs diftèr bet$eer the so.ièl
.1âses bôth on âc.onnt of ditrereftes iû wàv ôf 1ile, ior
rmints a.d rsù.cr. a..1ol the à.r that (xts n) rheworkins
.lass arc actuuy in.rasL-d bI thc li)s'ef le1Él\ and Frhaps
f.orc.qùxlitl ot ftrNisn)n to s'hi.h nra.y hark a..ess.
Sociol
inequolities
-
. Clù$ JlttÈfn.es i. litè È{re.tânc!
. HerLth inequiinies shonLdbe ti.kled on r btuxd florr
' ùtofuLitr xnd dô.bidiry a greaier adông F!.Fle ltud unsLilled ind
lariLr sln1ed br.kstumd\
. P.oplc wnnni n,.s. sroùrs 16. h.afth seni.cs lc$ r...10.r{ } rhrn
.drer o..ulnrl.otrl Aroù|s
vvnaLc a u s eSs o c r ar ln e q u a l l l l e
r ns
health?
The m..hari$ ol the rclxrn,nshb berneen deprlvatbû md ill
hcalrh is a mattc. of i.tcnsc intcrcst ând i5 srill àn issue being
The Blacl. Repoft .o.si(le.e.l ùur possible erpldnà.ions là.
o b s e { & l s o c i a lr f q u a l i l i e s i . h e a l t h :
. Th€ Artelæt Ëiplanatiof $sgests thrr perio.lic chd.ges ro
the Registrù Ge.efuLi so.iàl cl,$ sysem hale âltitl.iill_t
z:e r +, r,wenrron
ofsor0
nEuol
esinù0
heorh
I
nrllated dre lncAmlirics if hcrldr beNeer occupàtional
-qrôtrps.À...fdi.E n rhis .xi,lanà.io., lhe hi1!re ro redu.e
nÈ!kiiries beNÉn o..trf,rioml .L,Esescan be aftrilrured
n, a re-asi8n.rcnr to i more 2ltlùeù cl.ss of sôûe of the
pookf Denr bcr .t so.ictr sho.irher i.e in befter heLldr, or
\Lhose herltl, rhetr inphres. Icrrins â rn,rlLer blr srill
disadrar tâg.d .qrouf. Thrs wrs hrgelv Aisnissed rs a pr).es\
a\ ir vxs tclr diar d,cre wrs little eudence of dis upsxrd
moveme.t. ft ixs ,lso È1. rhar !he conrr.ftroû oftLre size{f
poorr o.olûrioùl gro!ps wr ùnsuppoited,,hhoùgh
larch rhere hùs been c1eù evidenG oi the contLartnn of
v{ial.lis V. |!ûliermore, irÈ,toalitles in hulth.àn trc sccn
ùsing,vifier! o1alrerltrle melNres of detfivarnnr. whi(b.
ifrnrLhing, n,ggen rlhfthe Re!israr Gc.cril's !o.irl .lâ$
da$iti.rrio. n,rv urdeierinute dltrerencestrtFccn gnlx
ofpeople ta\cd or dr.'r l.vcl ôfJ.fri\riiof.
. Th. Ni.!tuIârd So.ial Seleùnr, Explaûarnn sLgacrs rhÎ
hcalù irseLtn,ù\ sonrhow deternir vrnre.oromi.
t.si
tion. People ni poôr Lleahh v)ùld b! r'irrrc of dici. lr.il.ll
drù.1vrùtJgÉ more d.ftr' rhc yr(itrl .là$es whlle the
he.lthy wonld hîlc an adra.tagc rhât wo!Ltl help dren ger
good jobs an.1 so n,vc rLI) rlx, y{iàl Lr.l.ler. Ilriden.e lor
diis rr'Pe off(n:.s\ hàs .oin. tion, r\ro se6 ol irn.hngs rhar
ta11er*onen rcnd m n,or'ui) rh. ocû,!âr,ofàl .lases ar
n,n(lrge. this ls al\o aû explaûation rhrt {ôul,l i|t)l! ro
fcoflci.h.is.hil(lreùha(l nujorhealthproblemstharmry
hxve rx.llLdcd dr.n, tion, rhe srrne ed!.arion.l di.l o..upa
tbnâl opforuniti.s âs rbeif tee6. There is noù generaL
i(..lira.ce tl,ù1 this processd.es make x linited.o.tribù-
tion ro ife(lùùl,tres û Lrerlù ând Leahl,.ak. btrr rhir ir is
lir tiom beifs r.omplete erphdartun
. scc,.cd lcssiii.r.d bI ti.ro6 aso(iâre,l Fi.l, .ulru.al b.llcÊs rhrn
Th. C!lrural/ lleh.vioûfuI Lpldarnx$ n,gler rhar hrdrb-
rcla(.] behaviols, LiLe cigarere smoklng. p.or d,(i lru
Ia.k ol cycr.is.. lcr.l 'o ,he oLrserle.l nrequdiries. h.his
view iûe!ùaliriesln heihh.fisr b..iusc i,c.tl. iom a.
ù.sl.ill(l o.clpnioDâl LrJ.k-qioûd ùe more lllelr, r{, adopt
''l '.a,e,. L.o rr. . l
frore.riDg tlierr herhh dÙD d!^e fft)m skilled ...LLprnnul
. The llarerirl !f sûuLrolist Eatlînatnns con.cn rhc folc
of elleûral ..û.titnr,s: l,azxrds ltlatins tu f.or housin8,
cenah dangenrs o..upatn,rs. follLrrio.. ùn.mf loyrnef r,
ù.d ps\.hôso.irl rfess hâve aU bccn xsn).iar.d s irh lÛôrc'
lhcrc hilc b.or .halLenges1o !herft. tlie Lafter.vo expldl
rn)ns.an, in ta(t. b. rgâi.lRl as !lin,n.r froD er.h orLrer,6
bchari,\r' .âf.o. be separaredliom rs so.irl cortexr. Ànexxmple
ol rhls is eviderce on.hil.lhood x..ide!s ft is known rlrat ttrcrc
is i g.e,Ér llkellhoo.l of .Liildrer iiom m\killcd o..Luarionxl
ba.tEfou..ls being !r!olved nr d.iden6, ir ronrpù]r)n ù).bi]-
'l
.lr. riom sli,lle.l o.. up.tiôùrl bx.kgfuù.ds. hr .ùhùralrhcbir
ioù.il liew ùrr exphin rlis $ belnr dùe tu skarcr rc.klcssncss
or risk ùknrg behJriour ilxtlor i h.l, oa farentàl sùteNis,on.
\Vhered the mrteri.li$Àfl,.nL.1ist erplanàrioD ùrr see tln is
Lenrg due to -qieùer erposuie to risl,\ envroDrnents (la.l( ol pliy
spâ.e leâdnrr nr playnig {in roxds) lûd difJr.ulty !r superusng
.lil.lrer ]tr higli rise l!ôùsilg es&s.
The iss,e ol ,he roLetliye.l br ihse erfLrn,hons is i kq' r.
dre ù.dcrs.rndins of {).ial in.qmliries in bealth xnd ho$ dr!
miglrt be taclLed IL€ belùrntuair.ultual exphmtidr woùld
i!.ll.arr thxr prevertnn, oflidlvidual belnvntus G.s smokiûg)
miEhr hcb rcdu.c hcxlrh inqùilitir\. On thc otbcf hând.rlre
i.xrcri,lisrkm(R,âlisr crtlin,tion sluld lookb rh. t,n'ision oi
a bctt.r sociàl drJ l,htsi.rl ..vi.on.icrr fi. rbos. r'.ôm lcl)rird
I 1 " , ' l . ' ' " o l ' _ ' r l r r
The ulâ.k ltepo( in ihe I 9E0s an(l ù, br,l!en, .e!isr ofrhe li.
cri rc bI Mâ,Air.r Vhirch.rJ i. Th. H.rlrh Dilid. in 1992
seemed tû {bs.ribe to dre vie* that the marerlxlisusft alist
crtltrnrriof Frs the domi.rn'. if nor excLun'e, exthnirion lor
incqlaliris if h.ilrh Se(tul sr!.lies werc qlor.d ro shon rhât
n,oraliry fion hearr dise.ie $'as erflùred ùore b) so.'al ineqùùl
rties drèù by srroknrg behâviour Othereliden.e wd.ned to s|où
dÙr the r.lôpriôù of heaLthy LJÉhavntus.ôttld help diife.enriae
Lrûweeû the hedlth ôfpeoplÉ ir. favonrâblc $.ia.l erlituùlenuL,
bnt !!r beNeÉ! peopLelivnrg ir deprired areds.()rnef \!ork.ited
.oû.erned dre.ùltùrxl xspe.t of dre erplam.nn that has l(Dked û
tbe role ofthe c!lt!re ofpoverir', whi.hproposes diar people ftoù
lioorc. ba.kAroùnds harc .iorc n.Aâtivc .on..ts ot hcrkh, inJ â
lx.k ofofientatn)n d r çoùld lcad drcm rc dkc an irrctu{ r. Fr-
venrive Led.h behxvn)r ASdn, rhe eriden.e .ird did nor srLttort
thr idd dDr rotlc lom foorJ cnrircn.r.fts â.tLrally hold su.h
vi.$r. For .xin,lnc, in r sù|y oi disilunà.q.,] morh.6 rn,l
dau.qhrcs in S.orhn.l, hcald, seNic. use i. rhe Io! nser Ae..r.o.
bt i lâdr olsLlL nr deâlins wrlh û€ heahh.ùe sl-slem.
Ila.inrtr., hos.\'c.. has.lâin,cJ rhar rh. BLr.k Rc|ôr hN
bre! wi.tely rnisnrc+rered xs enrirelr supporlns rhc mtcriâl-
isrlst^,.ilulin \iew. rn he. view peopleh.ve pLr.ed roo n,!.h
' ' l : , , r ' , 1 \ ,
on,.rcndrrn,.s rhar ral.c â sof.ci life br reco.qriziog rhe.ee,l Êor
a.rion to ad.lress issuess!.h is disrbrlry ètrd rnLreùlth\ treluv
lo!s nr oder to re.lu.e soci.l rne!urliies nr Liedlrh.
worh !n.e dre Bhck Report hrs !treâitlÈd ùôie dtres âbour
hoù soci.l ile!ùâhties .dr âfe.r PeoPlcs'LieahLr.These tend rô
suFpoit die .onûibtrtnn of x vâriety of pnr.esse\ n, health
ine!ur iries. !vi.len.e susgesrs rhar rdoles.enrs frôù depri"ed
bid.Sfoùn,ls n,ry bc lcs dnadranrâ8cd br rhc,r soùâr.i(ù.1
sxnLes tl,ar ]oùn!.hildftn and adults. It ha dr) been tuùnd
dixt people ùho wefe .hnn,ilxllI ill i! .hildhood tefld () br
sevekLl disadv,nù8ed bt cadr middlc igc ia rhc_r..mc t.on a
dcfrn'c,l Lra{:l.gr\rid. bur iot ifth.r can,. t.om ân rÈ]u..! ba.[
Airùnd. This bis bccn sc.n bl !n.c ro l]rolidc .\'il..ce làf nrr
ùralsclc.ri.D: rcsùlri.E t.om afro{:.$ nhcrcbl h.âlrh_r r..ragos
rf. s.l..r.l là' crlù.rrio.rl àf1l oc.uplional ofto{ùfiries rioûr
n h i c h l . $ h . à k l , _ vt c c . a g c s i o m . l e t , f i v . . l b â . k g f o ù n . l s â r .

excluded. The Biâck Report noted.har ineqùalitles ln healtb pÉr
sGt elen vher maûr brhxvbural ard biolôgi.aL fa.nrs arc
controll€d for. Sùbse.ltrefi wo.k has confifûed this, bùr also
sho*s thàt differen.es in bchâvbural facbrs bctwecn social
sroùps, such d shokins, .an still a..ôùni fof aroùnd 3J-507 of
diltèrencesin then eiFeri€û.e ôf Lreàrtdiseâse.
\I.ilkinvn has ar€ùcd thât ir is poverty relalive !o othes ii
. pârti.ular $.ie$ thar has a ALcarcr;nilue.ce on morraliry rhan
âbsolL,tepovefrr al(,ne. Hc c;res rhrcc ficces ofevnlence: fi'srlr',
moitalit)';s.clâted mor€ closely to relatile income sithin
.ounùics rhrlr to dil}èr€oces n absolùe jn ome berveer them;
. o , r y . ' o , . 1' 0 1 . 1 , . i . . , ' a ' d ' o L p ô { . . r , ' . ô ' , É .
rhât have smaller income differentiâls .nd; thirdly, ûôst ôf rhe
lo.ger lerû inûease iû life expectancy appea* o be unrelared t,
long-rcrm econon,ic grorrh.ares. \\ri&inson extended this argu
nenr to ldentily wb.t he .onsidcrcd n'rs an underlying.aue of
health ine,l!èllties. The gradiens rhar are observed ln heal.h
vhen eaùnioe.t by sô.iàl .las refle.r both r,.ia.l positn,n (where
people stèrd ilr relttiôr tô orhers ln $.ierr) and nrâtc.ial c;(um'
sàr.rs (e.s. ability to afford housiûs, healins) Il nare'ial slar
dârds s'eÈ drc maln causeofineqlalir;es, rheditfererces in health
would is.rcaseofdcc.case dire.ily as nate.ial stàndardsincreased
.rd,,
.i uoqe\-r.,1",r LnsLl. -1. r.-po'-rr ro.
i.flùc.rlâl th,r absolu!e tovertt sûgge$€d drat it was àspe.s of
so.i.l positbn rhar hâd thc Arcarcr effèct on heahh inequùLir,es.
\vitkûsot believed the iûdire.t etlè.6 of ùese psr.hoso.la.l .if-
nrcl&le hûease.l e+osure ù behaviotrrâl risks
.csultina riom lsychosoclal stress ûcludins $res relÈte.t dri*
ing, smoking, ând rhe direft etre.a ofrhe pbysbloAi.al effe{s ôf
chrodc menral and emotional sù?rr.
Hôwever, rLrebasisfor Wllkiny,n s .laimr bas bccn challcngcd.
Judge hd .lained thar dâh ùûderhina rhc clain\ lackcd (om-
plereness,while lrn.b a.d .ollcàgucs have suAgeste,i rh2! !l,e
pro.es èdvêrced Lry \XTilkin$n is rnprobablc. Lyn.h hâs
âdv,rced dre .eo nràterirl inrerFretutior a .r dlternarne erFla
darion. Pa.ed dôwn, this vi.w *arcs drât n is drc direct eftèfts of
poreity àrd its.onseqùen.es rhar a*è.t hcâlrh.Iû modcnr socict).
(inùeasiûglr perhapt mone) is rhc kcl tu a vidc rxnge of
resoùr.est nor jùst ro bri\.are resourcessuch as hoùsins, prl!àre
ûansP.rt. tood. 2.d heâti.a, b!! also ftlirectly to resour.es
slrhi. rhc buhlic donrâin such as librarles md e.lùcation and
hcalth. h.di sùDnra'i,ed the dillerences betweer hs rnd
\YilLinson's vie$s usnrg the metàphor ofrir trèvel.
Differer.es h neo-material .onditn)ns bcm.ccn Urst ard
econom-vcla$ may produce heâ1th ire.tmlities after a lona
fligbt. Iirst .]ds pasenge^ get, amorg ôrher advantages,
berier foôd àrd ser"i.e, ûore \pa.e rdd â \'ider, nore com-
fortâble seàt rhar re.lhes lne, a bed. Firsr .la$ pâ$cnAc6
r , \ " I r , . h - d . a d , . . 1 .\ l ' l i
f e - , - . 1 ' , . l . l d a F ,
,l .- \-J 'l '.q, ,r ". J,
engerdered by perceprn,ns offtlatna disadvantaac. Llûder
I lr0|spsdive 2 2 1
T|]einternotionfl
d neo material i.ter1)tetâtion, pcoplc in ccononl harc
sorse ireallh becùusethey sat in à oâ,.l)cd slûc and a.
lncoDfor.ùble seat, ând rl,cl Fe.c not able ro slccf. Thc
fn.t that ther car see.he bisser seas as ther e'dll< oÊflbe
plane is not dre cdùse ollheir loore. heakh. ll.lcr a fsr
.hosociâl inrc.pLctar;o.. rheschcalth incqùalitics woùld be
redtr.e.l by abolishing fi6t cl.$s, or perLràpsby ma$ Fs)
chorLreràpytô dlter perceptlons ôf relatile .tradvânrage.
lrôm rhe neô mârerièl viewpoint, he rh nieqùèlliles can
be rcduced bv upgrading condlrnrns in e.onoml da$.
A ùseful tjekrâl fradewôrk fôr Ùyiûg to û.ter$ard â11the fac
er\ thar ûiglrt con eivabl"- âff€it people\ herhh hd beer pro
posed byDablEren & \Xrhitehead(Pi!. 1.1.2).Thisrmphasizes rLlrt
ar the (re of dre ptuces ls ûe irdividùd whô hd pâfticuld f.c
rors thdt caù àffect his or he' healrh $rch as aenelics. dae-dnd r:.
Thcsc âre sccr as nmllentiâI. bû larael_!ùnclrâûgeable.Sùround-
inA this. like aû oûnrn. are lâye.s ofoùer lnI1ùen.esiln which re
.t. \u _ n , , I s , l r ' , ' .l l r ' - ' r , l -_'"r'
clllural, a.d €lrlrofme.tal condirionsvill aiïcct thc living an.l
\lorklog conditionslrirhnr which a le6on hasro ois!. Thesein
tun mày iÀflùerceth€ Locdlcomnrùniîyefvironmenrand,l.àlh,
rhe lifestylefactorsofr! lrdivi.lLràl.The beneiî oflhe Dodel is in
its €mphâsisthèt fàctorsfonn t to be sisrifi.aût a. one lnyer will Lre
i!fl!e!.ed by the layersabove.Fore{an,ple,.egisrâtionofi.fânts
tôfAcncmldcntal.atuis knowû b belowcrmoûg rhe$ciauy dis-
advantaged. TLrismây reflectdiflicùlriesnr acce$nr termsor tiDe
and .o$ oftr|el (layer1). TLreposirioûof ûese iûfaits ûay àlso
be worsenedbr thÉ Lô.arbnôf dertrl sûgeriesâû.y from pôoier
a.casand by rhc lcrcl of paticr. drârAeslevied on NHS dental
ûcarmcnr and .cgularionsfor cxcmpt$n from palncnt, that
nriAht i.nucncc rhci.pxrcnts attc.dah.e(laref 3). Àll ofrhcr are
innuence.lby seneEl Golemmc. t I olicr 02rc.l)
perspective
Theinternational
Thc Bl,ck Rei)o,t ,ho co.sidcrcd intc..at;onal c!r.rc..c aboùt
!.lal ;rcqùalirics in hcalrh. Tbey nored thar dre tipc of i).ial
stmtificâtio. uscd in drc UK wâs not commo. nr orher.ountfies.
In the Unired Srares,socialsrolFs are oalendelinea!e,.]onrhebdsis
oI'ethnlcjty or we th, whereds in European da!a, s€osruphical
region is often rheLrasislor strnlilicaro.. \'everlheless, lheand,ors
o \'ltepo. r' 1." n..r- .F'rpF Fn'oi
so.iâl ire,lualities relàted to h& th were a univeBrl phenomenon.
Ar aralysis oamortalir) rales in Dermirl., ljirland, ljrànce.'fhe
Ncthcflxnds. NoNay. Svcdcn, and Cemany indi.ated rhxr
inequaliriesdsô.iârd wirh wealth did â1soexir ir ôther counÙies.
h finldnd, Irance, cermùy, dn.t TLre NerherLdds rLredifererces
; , i . . . | . b e , . t . i , ' 1 1, 1 b s , . i '
scc.,cd s;milar ro dic dilïcrc.ccs àund nr dre Uritcd Kinadon.
Hovclcr, a va.ictl ofsudics hârc slnwr rhâr Dcnmâfk. Norzy.
and Swcdcn h,vc lc$ markcd $cial incqualitics. Olcnll, i..cffr-
lional conla.iso.s have suggesed rhat low iriânr deàdr r2te is
a$ociâted viù per .itira GDP wirh s..rc 2lJirional cridcnc. tô.
 V

,rul l4 Theprevefrion
0l soci0l ilierjnor0lfreo
insqu0 rh

Figure I .t.2 The ma]tr dckmnurs of h.â[h. (soun:É:Drl, ]s.e. ù,{l \vl' irel'e:Ln,I 99 I )

dL anr.iarn). {'irh a more egalitàrir! iû.ode disiilruriôniln odler nr rheif o\rn o..ùpdn,n, $hefexs nnùie.L womo xre .l$ified
wôrd\. with kxhlr ù.,1 i6 dj$nbùrion. o ô j ' l"r L { ll r. I ô\
neasure for mrterirl deprilrtidr as e!ûùilts rend to .le.reâr
'doFn'
di. !r.ial.lars liddcr. Thr mcdx,d.ontinu6 !, be trsrd. bur
Mqindeterminonts
ol heolth h,s bccn crirn:izcJ on rhc bâsir dnt ir nill nor als'âr's r..ùreely
. Àge, sÊx,xoJ .ofyiùionùl
.l,ssih màrdcd $rmcn ù.d rhat .hx.gcs t. drc dcilnirn)ns hxve
l,,.roE
bccn acQsd of carsing prcblcms i. i$.$i.g rrends.ft di1{c6 f...1
. lndlridnxl life{yle ù.r.s
rll rhc od,cr mc,sùrcs in Tâblc l.:1.2br bci.g brs.ll o. rnomraùor
. S..il âr{l.oûxnrrny k.vorl* re!ùdins an individùxl ftther thafl r leouftphi.al trer.
! l-,en! r'.d {orkinc .ondnnrr Iro$ ol rhe re.ent work o,, cl:asi|i,.g.lelirivùna hd beef in
. Ce.lral s..1. e...omic.!lLUral ùnd .nr mrùdri'l ..ldnidrs dr. ,l.vdol,n,cn r of ircà brs.d m.Àsurcs.I. I 9l I , dic D.Pârmdt
. , , t . . . ç . l . . r , , . . . 1
(lenrilv areasFtrh r,oof social in(l enlirofn,or.al .ondl.iofs. Tl,.
beneln 01 ùea base.l ù&alres is rlrùr there tùe iegùlar lle.eni,ùl
How is deprivation
measured? up.lùes of rhe bùseDformùûoû .lufurg r|e Naûor.i Censls (dre l,sl
'fh..e
are à vaûety ofmeâ$,remenr is esinrhcilcldofincqùilirics. bein-qundertrlien ni 2001). Tliese meùlres enàbleù!ûson's depri
'fhe
lirs is s Liether$.iâl lncquxlirir5 x.c bcù mcd!rc.l in rcms of !âriô! s.ore rô be detednre.l rvnLnut ary ree.l ro gadrer pe6onJl
socia dt$ ofd irdiri.Lnâl or nr rcrms ofrhc.hùrx.rcrisri(s.idrc nfonrrion, ôdiei rhrn dieir rddress or postcode. Sofu oI rher
!m in $hi.h rhe ir(livnlùtrI live\. SoDe of ùe main nhsùes dral ùea bded n,e,Nres ll)oE àn.lJrnni.l hi\t bee. ..iti.i2ed or rln
hwe beer phposcd r.d ùscd irc showf if TabLe L;... !(ùnd\ ofnrlr\n)n ofxspe.s, $li.h ln themsetvs ùe notmatre$
'l'Lis
IDe!uaLniesln healrh nr rf.r ofmoft,liry r,res àn,o.g occuta ofdeprivatnxr le.s. ethni.itr ). hs l.ûsell renmed fn,m tl,en
tloml gû,ps have bee. nrcâs cd br drc Regisrof G€reril! del1n intended *e Jrrmrn, [t in{xn.e. $as .m.en,ed \ri.l, $txb]isl,nu
lrion of!).ial dis in the Llrned Kmg.lom d plùt of ûe.le.eùiàl dr. imtJict ot d(j'i!xrio. o. tJrimxry cârc sorkloxds ind, dicrcto.L.
repots ot dic R.girri6 Genernl oflûglrnd dd \Vâles xnd ofS.ôt indu,lcd an_rà.os d r miAbt.cqùirc ùldirio.il r.rc ro mMxgc
lxnd sin.c l9l I The cutrent red! re brse.l or il! e .xrrpries (vrh (c.8. sizc olrhc rftircd tiotulrrion i. in arcâ).Thc DoE dctrnatior
dre rhird Tnit is based on dre slren delel.,ped fôi the 1921 indcx indudcs 12.to6 $r(h as rhc .un,b.. ol drillrcn undcr ll.
Cc.rs dur clasills people.r tlie blsis ôithelr o..updn)n (llble vhich is.or rn issle rhnr is.lirecdl,sociâled wirh letrn'âriof bùr
rt.1). Tndirionalh: nie. rna sii.qle Noùeû .ùe .Làssiie.l.!...rdiry onc rhar mrv bc uschrl :s r mcrsm.i rhc.ccd ù. tu\ rA.

'lable 1,1.2
Componenrsof ihr mrjôr me$uresol nalerial dcpfivxrn,n$ed ir ûe Unircd Kingdon (Àdaptedtionr ca*tâirs àn.l
Mofis 1991)
H o u l e h o l d \v i i h . u r . l r
r, F."i;.
Clriklr under t yean old
Nnhlnv Rrtio
Sran,lar,lized
Pop!lâtion.ha.gÊ/mobilnr
1921 r98l
The Cas.aj6 & N{onis and lbs'dsend sysems on the othet
hnnd hâve more fa.e !èlxli!y' lû what rhcr mcâsùe, in tLrat drey
.ircuûrârces tha. dpfear d;rc.tly relrted to
deprivdiôn. Hôweler th€seroo nal hdrel)roblcms. Borh in.lu.le
the level of câr oùneBhip ir aD ârea.Tlre impa.r oi c2f o\anership,
ho$evef.ls likrly to differ be6veen mninlv .ù ral and mxnnr ùrbxn
areasiin â rurà1nreaa ca. mây be rbsolùtcly csentld tof pesonal
trdspotutior, whcrcas in ân nrban arer it may be letgely a dLain
on people with limited resour.es. À turther foinr is that bôdl
nraues are ldgely concened vilh material dcprn'atbn ând tâke
no account of other types of .ieprl!ètion sxch a soci2l,lcprivâtbn.
A.eâ hascd nrcasùre\ on dre whô1e dlso hàle the proLrlcm that
many Fotlc wbo arc not deprlvtd mây live in a deprived a.câ.
a.d mânl roplc s'lù are deptived may lile ltr.on det.ircd
ùeas. I! Brglan,l ând \Xralcr,fi)r eaample, it hâs been e$iùr.e,l
d,at as mrny as tt fcr.cnr of tlre mos deprived ildn'ldrals Iivc
où6idc rhc 20 per.en. ofared thJt ùe ûo$ detlive,l. This {trt
ôf problem màkes tàrgeli.g ànri Jcfrilatùn s.hem€s exûetely
, , r , l l l - a o . ,e " ' ! .\. , r , - b . . d l ' p r ' . a ' o '' ' . '
sùres .omes iiom Slogsett ând Joshi who l(Dke.t at the mortalitl
âdông 100,000 adùlts over 9 y€a6. Th.y ioùnd rhe ùsùl grâ.li
enr in dôitaLity è.ros ared categorized on dic basls ofd€priva
rrcn, bur dsô looked at snnilar i.di.2106 of individnal
deprivarior; for eieple, where the a.rà mcasll.c l(r,ked rt 1eve1
of.âf oùner$ip in âù ùeè, the iûdn'idual mcâsurc lmked ât
whether rLe pe6on hù(l access!o 2 car. Thcy (,ndude.l tlut
nmsred?I 22e
H0{irdoprivrlrion
I
lndir!\ uf,LFri. rtion
Jùnm
L9rl lrss
depri\'2tiinr wa\ \hollr.f' ùr individuat lssû rarher that an cnv!
rônmertal or geog.apli.xl ône; èreasdlffctcd be.âùse ôfthe Pto
pôrtion ol def.ivcd indiriduals tfty hâd living iû then.
Iftlivi.lùak ln'ina ir depriled deas wno s'ctc nor Persôndlly dis
advartèged did nor cxpdience eice$ risl<.
The ùeenrremen r of dcprivarioû is develofinaall rhe tiûe dûd
neN rneaurcs miaht be expectedvhe. drc 2001 ceûns fin,linas
bc.omc alallâble. l!fthermorc. ùere a.e tôw ùeasurcs ùat âre
nor relièrt oD Censusdata. one ù,.hmeasùÉ is thc Index ô1MlL
riple Deprn'ation dcvelop€d by the DeFftmcrt ofEnvirotment,
'ltursport.ful
th€ R.aions in 2000. The IÀID uscs i3 indicàrors
, . ! , , \ d o , , ' F ' , . ' e a , ' ' o i ' o r ' \ .o , ' ' " .
cnflo.vment, herlth deprivatbn ând disàbility, educrthn skills
and training, houslns, dnd ac.css rc serlices. The systcn *i11
opcrarcson a geographicaLrâdr. dixn lndiridudl bavs an.l. tlrde-
forc. mav be prone to the san,eproble!ù idettified 1ôr eâdicf area
mcasures th.t ray n,irlâsi]-ï nany deprlle.l in.lividùal\ wl,ô
lile in fon dcffiled xre.ù.
\\rhilc arcâ mexsureshale their frcblems ofmis.la$lUcarion.
they ,lo harc rhe advàntèse of thc abilitr tô be luked !o p'.
.odes, thereby frovidlng a simple and non-i.ûtLsive method ol
.lasifr'ing ftliliduâls on the b.sis of thei. likcl,v experietce oi
depri!ùtron. Howcvcf, United Kitgdoo post codcs kke the sen
er.l forn ÀAl 2BB s'hi.h idertifies t fàirh snall area ôfhôuses.
bùt deprivatlon measurcs rù.h 6 tir.t oI Ca4râi.t xnd Nloûis,
ùhi.h hàve i post.ode breakdown àvâihblc. ùsc olly the Po$
230 I 14lheprevmrion
0ls0(i0l
ineq
uolilies
in0r0lhêûhh
I

codesector(e.s. AAI 2) whic! ofrer coversm ar€aconraining
severalrhoùsàrd people. An arduous, but uirinârely nore ùeftrl,
meaure might be one whi.h ùsesdre eûrire lDsr codeând may be
rhe wây in which Ârtuie measu.esulrimarely so, âtrhôùgh rhls
misht be stymied by issùesofpdvacy thar oushr to be àfforded to
ind;ddualswho may be identifiableby ue ofa tu1lposrcode.
Deprivatio'n
and oralhealth
It hæ beenshovn in rermsofmonàtity thàt the healtbofinfan$
and childrer ;s afecred by sociàl ineqùalities fron birdr orwards.
D " ( p i , e, l , e : c r r h . ! d F n , n lf " d l r l - | . , . d r n . i n p o \ n 8 . e r l
dencepresenredro rhe AchesonCommitee sbowedrhar rhe dif
fercnr;albeweer cariesin the primary denririoo of t yeù old
childreû tiom p@. backgroûds and thos€ from ,fiueût back
sroùndswiden€denormouslybelweenr98l and 1993. This hd
a.1sobeen trùe in geogmphical termsj t-yed-old childreû in rhe
Nofth West of Ensland (with exrensiveâ.easof deprivation) had
almost60 per cenrnore experierceofcades,md 12 yeù olds 75
per cenr more experiencecompared wirh similarly ased childien
ir the Soùrh(with .omparar;velyfewerùeasofdeprivatiôn).
By rhe age ôf five a soc;alclæssradient in or.l heâ1rhis â1redr
wetl estâblished, âs shown ir fiûdinss from the dnml Scottish
Heâlth Bôards Dental Epidemiologicàl Progmme seriesofhien-
dal sùrveys6r the p.imâJyderririon of t yâ-olds (lis. 14.3).
Oûly 20 per cent of children tivinA i. dep.ived æd of Scodd.l
had no experieûceof dentâl cdies compded with almosr 60 per
cent ofchildren who lived in the most aflluenr ar€a!. Flauie 14.3
al.toshowsthat approximtely the sde level ofdiedmnlase cû be
seenin thepehaûent denririonar aae12 yea6.Unired Kiûadom
findinss lbr the meao nuober ofactively decayedteeth in 12 aûd
r5-yed-oldi *on two of dre @tional childrert dentat hslth sù
veys urdefaker in 1981 ard r99l ùe shown in Fisùre 14.4.
Th€se also sbow drâ!, despire a fau iD caries experierce berwee!
r98l ând 1993 moûa bodr aae aoups. â soc;alclds s€dier!
contirues to be preseût ir the Êndings for 12- md r t-yed-olds.
Deprivotion
ondorolheolth
The I 998 Adulr Dental H@lth $Fey is à rbve ôf material for
ex2mi.irs socialinequalitiesin adùlt oral heâlth.The surey datâ
ircludesmeasxres ofsocialclæs,borh individùa1âûdthe moretE-
ditional heâdofhoùsehold', æ well æ oral infornarion relared ro
the Jdmàn index of depii%tion for En8la.d, od Ca.srairs ard
Motis indexofdepriwtion fôr Scodand.FiAùes r,i.t l,i.l0show
the relÀtiôrohip ôf thrÉe nesures of dep.ivarion ro oral health iû
the U red KinAdom. The fiAurcs sbow rhe relarioDshipberweer
vùioù orâl hedith mea$res wirh deprivârion. The Jarman system
ued for England ls basedon quintiles which is a divisiôn of
rhe s.oresinto 5 aroups of app.oximatelyequal size (i.e. each
grôrp.ônsistsof approximately20% of popularion)Assisrmenrs
ro cateaodesin the Carstairsand Morris sysremùe basedoû

5
6 4 0
E Câriêsi€ê (dmft=o)in 5 yr o ds 1997/A
I Caieslree{D[4FT-0)in l2 yl olds1996t
5 o o
6

10

l(Leasr 2 3 4 5

_ Depivaton(Câlstâils& lvoris)
Figûe 14.3Cdiesfreetro d€cây,missingor filled reedt mol1g t md 12 yeâ?otd chitdr€nby deprivâlion(Scoddd, 199611998).
 :

6 3
+ Aclivedecây n 12 yr ôlds 1s33
+ Actved€cay n 12ylolds 1993
6I oe -&- A c t v êd 6 c a yn 1 5 y r o d s 1 9 3 3
-* Act ve decav in 15vro ds 1993

t.9
:

E 0 2

Fjsùre r1.,1 Â.rive decry rmons t2 aDd I t yeâr ôl.l .hildÈf by so.ial.l6s ofhexd of hourho]Ll (Unlted Knrgdom, I9s: & l99J)

.9
Ë tu
e
6 +Donrur€s wlh nâluraleelh

P 4 0

5 (Lêasid€pived) 4 3

(Jarmârquinles)
DePrivation
Fi$rre f.i.5 Onl satùs br deprivation(Englând,r9t8).

pre.terernloedsco.cs.In the 1998 Adult Dmta.l HeÈlth sdmllc
apprôximetely 8% of the Scôtt$h de,1t2repoPuhtion wctc
included in dre mos! dcp.ived grôtrp. Dir€ct comPdrisonot
rhc rcsùlisbet$eencounûicsir not heàùrgful a thc\emeartes
of dcp.i'ariôr hale ditllLcnr .omponeûts ând clasriflcàtlon
Therc $â\ â ràtistically signifi.ant but small A.âdlent fôr
fcople rvhohà.ino ritural tccdrsronpedæcor,linero rh€Jarnùn
scoreofwberethey lived in Englètd (Iiaùft 1l.t)r I0 Pc..ent oi
thoseIiving iû die rost aÉllLentareaswc.e ibut.l to hâveno nat
ùràl teedrrc.ralniûg .omparcdwlth r6perccnt of tlioselh'ing in
rhe most defLiveddeas.Tbe depri*tioû ocastLreusedit S.oÈ
land shoç€dâ moÈ mârk€ddiffereûceb{s'ccn deprivition atrd
otul sràrus.A quarterolp€ollc living nr the ù){ dePrivedârea\
ofS.orL.rd ha,l no tetth in I998, .onpâred with L4 Per c€.t in
rhe oos âtltùenr arem (Fignrc 14.6). Thcrc was also a vcr]
,,, u n, r,**'* ot',iotinequ0tines
inorotheoih
I

.s
E 6 0

e." ..:|

3 l o D€niurês
wilhnaluralêêth
ô
Ë-
E

r (Leasr
depdved)

Deprvârior(Carstairc
& Moiiis)
Figure 1.1.6OraLsarus by deprivadoniû Scodâd nr 1998.

! 3 0

I Prciessional
ll N,laôagemenl
lllNMSki ed I M Skil6d lV Partyskiêd VUnskilêd

Soc alc ass ol head ol household

Figure 14.7 Oral satrN by sociâl.1a$ of head of househôld(Unired Kingdom, 1998).

markedgûdieût betweerpeoplelirin8 in th€ Unncd Ki.Sdom
cldsified ac.ordlûAto sociâlcla$ ofheùd ofhousehold;odly 1.8
per cent ofpeople frôm protèssionalhouseholdbacksroùndshèd
nore of their own teeth lefr comparedwirh over l0 per cenr of
thosefrom an unskilledhouseholdbacksroùnd(Iig. 14.7).
There was litle diifererc€ ir rhe meân ruûber ôf mlsing
teethând rhe meânnunber of decaye.t teethâmônspeopielivins
in different areasof dep.jvarion in nnghrd clasified by the
Jdman meaure (!is. 1.i.8).However the depivd,oû neæurc
usedin Scotlâ did irdicate rhàt peoplein cLeprived are6 had
sjgnlficandymore missinaand decaye.lteeth thd peopleliving
ln aÊluentdeas iû S.odaûd (Fia. r'1.9). Soc'alcl2$ or heâdor
hosehôld a.lsorevealed a aradient in dre expe.ienc€ of missing
dd de.ayedteerh a.rô$ peôp1efrom professlo.atand u.skilled
worklng backgtounds;n the Uaited Kiûsdom as a whole (Iis.
14.10). Peoplefrom socialclassV (unskill€d)had t0 per c€r!
mo.e mi$inA reedrand lvice as maoy d€cayedte€th on av€mge
thanpeoplein socialcla$ I (p.otesional).
Thereis evrlencetiom srùdiesin seneralnedicine thât peopl€
tiom sociallydisâdvântâged backgrourdsa.e Less likeLyto atterd
 Dspvotionondorolheolth ,J

e 3

E 6
ô
E

*æ*

5 (LeasldêFrved) 4 3 2 (Mostdepdved)1

Deprvalo. (Jarmanquinties)
Figùre 1.1.8Meanflumberofni$inE md dc.âye.lte*h by detr'varion(Engldd, l99s).

I
_----//
/--.t

1 (LeasLdeprived)

Depfivârôn (carslairs & f/loifis)

Fisure 14.9 Meai nunLJerôfmnsins and de.ated teeth by dcFrratlor (S(tlând, 1998)

ràr pi?venrive consultations ànd lcrr likely to folLow healdr mee
sags. Figures 11.11 r,1.rl examnrc some lsues iû dentjstry by
!sing social clas5ofhead ofhousehol,l as ar ifldi.aùr ofmaterial
There ('crc siEnifi.anr .tifferences in a vafi€tr of or.l hedllh
behaliou$ $hich pcople were àsked aLrout in rhe 1998 Âdûlt
DenûlHeâkh n er. More people from a profcssn,nalbtkgror nJ
thar froû d. unrkilled workins backÉtrrnd sèid th€y rcndedtu
do rhe sort of.hinss that dentistssayatc sood for dentalhealth:
aûcnd dentè1checLups, brsh teeth at leâsttwi.e a.lây, and ùse
ân addiriôn.l methodibr .leaniûs teeth(Fia. l.i. 1 L).The is$r€ot
unegualuseofhealthscLrice\s onewhich hâsalsobeet ideÀliied
in gcûcralde.ticineand rcrmeddre inve6ecarclaw which sales
diar thosewith leastnccd of htaLthcareuse drc health servic€s
234 I 4 Theprêveiiion
0fi0d0linequ0lifies
inm0lheûJh

*'---æ'-

lP@lessionalllÀlanâqêmênl & trtNMSkitednon. tlNl SkltÉd tV pany ski ed

Iechn câl
Socialclass ôf head ol househotd
Figure 1.1.10ùlean ounbe. ofmissinA and declyed reedr br sociâld2$ of head of household(Unitcd Kingdoû, I998).

\-l
\

. - - . - - - - . - - . - - . - - Y - . -
6
àoo

+ Cb ms to Sô fôf rcgùrêrcrreckups
+ Crâ ms to brlsh leelh al teasttwæ dâiy
'r- clâims lo usedenla lloss
+ C aims lo use moulhwash

-*-' '--"-.
**-;::::*"

rProfessona tNMSki ed tMski êd tv pa.ry v unsk ted

Managementnôn-mânuâ manuat sktt€d

Socia ctâss ôf head ol househotd

Figure 1,i.11 Self rcpited o.al health bcl.liour by sô.ial dâ$ ofhc..l ôfhôùsehotd (Udred KinAdom, 1998)

dore, â..1 more effectlvely. draa do those with sratcsr need. Tlie
'inve6c
c2re law'àlso applics !opreverrne inten'cnrions ùsçellâs
ùeatmcnrs. Heahh promotion bded ôn prôvidi.g ;niô.marton to
tbe ppùlatior âs a whole has had the gfercr lntac! on Feople
who are socièlly dd e.o.omically advantaged.
Peopleftum unskillcd ço,Liiig backsronndswerealso foùnd
to be lesslikely .o rakc rime otÏ work ro go tô a denùst rhan
peoplefrod â prof€ssnlrâlbàcl.sround(!ig. 14 12).Fudrermore,
whenâskedabouttheir ldsrdentalvûit peoplefn)m vr.iâl clâ$ V
(uûskilltd) weft foù times ùore likely tô lhve had n)me reedr
 theprevenrion
ol50{ûlreqLrn
irie\F oid heolrh ,r5
|

----r--;_-..- + usua y hastme ofi wo ro!o rod€nrist

-..-

ll rllNMSkiled lll,I Skll€d V Padly V Unskled

Mànâ!êmentnon-nanua manuaL ski ed

Soca cass ôl head ol holsehold

Figure 14.12 De.tèl Ûeatme.t during l6t visn to .lenri$ br \o.ial.las ofhead ofhouÉhold luiird Kiùgdod, I998).

.9

s
+ FndsNHSdenracare€xpensive
.+. Doêsnolwânlfâncylrcalmenl
* No oôinl1ôvsl un ess lhere s a need

I Pblésslonâ | lllNMSki êd lM Ski êd lV Fadly V Unskled

Mânagemenl
nonmanuâ mânua ski ed

Socialclass of Head oi HoLsehold

!'i$ùe l1-ll vicvs.boùt dcrtâl r'sirs by s.ciâl cLas ôf he.d .f boùsehôld(U.ircd Knrgdom, 199s).

exÛacted as rhose from so.iàl clds I (professiônâ1).However there
wès no sociâl clas grâdient i! the experien.e of havirA teeth
filled, dtd oû1y a slight, but râiisri.ally slgnlti.ant dlffefe!.e in
rhe erperierce of hâving a s.ale ând pollsh.
Iigure 14.13 .onsiders {rmc is cs rhat harc bcc. idcnriiicd âs
hùoB thàtput peôpleoffsoing tu a deorir fir .he.k{ps. People
ftom so.ial.lass I were thÈ lexs likell tô sây they fin.l dert.l ûeat
mcntcxpc.snc. Thegrâdientf(tr thls only exrendsn, $.ia1.1N Iv
rhcn .cduccs nr so.ixl dass V lhis ls iikely ù refle.r ihe effe.t of
cxcmption fLom trcatment co*s mong many in wial classV, but
may also resuk from ottinA ib.lc$ cxfc.sive ûeatmens nL.h a
roorh cxùa.rnrns.:fhcrc mxl also be a gereml la.k of tûili.rity
z:o ll rlerrevenri,,
* mriolineq!0li
osinor0lheohh
I

6 2 5

4 2 0

Fisùe i4.l.i Total rooth tôs by socialclds ofheâd ofhoùÉhold (Àdùlts ifl Ensland & vrâles I968 1998).

,9
! 5 0

* 4 0
Ë
+ Shownhow lo cleanre€th

3 2 0

l PDf€ssonâl Management Nl\,|Skli€d tttMSkted V Partyskited V Unskiêd

&Têchn
ôâ nonmanual
Soca cass ôt hêad ot holsehotd
Figure 14.15 Deniâl advi.e re.eired fron dertist b soclaldas ofbe.d of household(Unired Knudom, 1998).

wlth the currenr level of dertèl .harges amons rhose who rdely
aftend. On the whole, people from soclal cLds V are à1mor twice
as likely than peopLein socià1classI rc say lhat they dô nôt want
'r.n
r cÉa'.t b-i..-,h"r lher I rôp,ir ir
atterding a denrh! ùnless rhey have â specinc need ro do so. One
factor that mayperhaps be tesspftdlct2ble is rhat ofasradlent for
dentaLanxiety.Dertat ànxiery is a major batrier to aftendlrg a
d€ntlstand piesentsa .onsldembleba..ierro rheprôvisionof.lln-
icat care.The surey ftsults presenredh€resùggesrit ùô has a
socialclassgntienr and drar pcopleio socialclds V ùe twi.e as
likely s thosein !ô.lal classI ro sayrheyfeelaùiôu! abouraoing

fromo profesrionql
People b!(kground
ore:
. Môrelikely to rftcnd loi d.nrùl .hecLq)s,6rùsh tÊÊdrt$l.e r dar',
usc.ùddnional nerho<ltbr cleâri.s tÊÊdr
, -. .-],. h"!" -e, -\ ., .d
! -". rhou lo'rAo's o .- e :
Theprevenlion of socialinequalities
in oralhealth
Ii seens thet wherever there is socio econom;c st.atificatiôn of
so.iety, health ineqnalities \rlll app€a.. Social disadvartaae ls
lugely ùherlted nr th€ senseth ir is besiowcd on people from
bûrh ârd its cfti.6 oû ùe newborn are imnecLiate, as show. by
greâter infanr mortâllty among those living in deprircd.ftùm-
$an.es. Gererally speakirg, polici€s !o re.luce social inequalitits
tLlenselvesreed tô be directed speciÉcaLlya! the eleoc.ts oflife
that differentiate berween rhe àfiluert and dre poor, such 2s
x'aacs. housinÉt.health, and edùcarion Tà.kling these is d pollti
cal issue.â.d vill depend on the philôsophy ofthe Goleinment
in powe. ând rhc âpprcacb ùey take. Àbsolute redisùibùtioD ol
weahh need nor bc rhc issùeas Caû-Hill has pôinte.l out; there is
.redlstrlbùtloÀ
â differen.e between pôti.ies âined èt to brirg
èbour equâlity àrd welfare poLiciesàimed at raising dre iandards
ofthe poor to a so.ially acccfrable minimùn.
Pediafs the most obscrvable Government pôlicy in th€
Unite.t Kinsdom to redrce ioe,tualities (althouEh undertàkeû in
d àse $hen the tern wd oot in vosue) is the Nâtional Health
service itsell Despre the dlfficultjes .he system finds itreif in
from time to time, r has undolbledlr presidcd over a aenÙa.l
healrh ihpiovenert. Ir dentat health the inprolemenr $ .Lear
ir rhe quite dramatic reduc.lon oithe ]]e.certaae ol edentuloùs
L,( "r\eI ruJ',^,ll'.1,.f" 'u 'p||' o The Bla.k Committee teh rhar the preventive wèy o atldck
per.ent betwren 1968 to 1998 ir Instènd aûd Vâles. Hovever,
d Fignre 14.14 shows, the dental heaLlh srâd;enr betseen dif-
fereft sôcialclasseshs remajned more or le$ unchâ.sed over the
1 " r ' d \ " r - | 1 F ,' . d . h o s l ' l . r e r . , n i m o o . e ' .
amona people in ea.h $.ial .làs groùp, rhe relative denial
heahh differen.e beNeen .ldses hàs inûeùed over the l0 year
pe.iod. I. 1968, 27 per.enr ôf rhose from sôciat cla$es I, II, &
IIINNIveie edc. tulous .onpared vith almô$ twice asmaty (46
per.eor) amons ùose from ùnskilled workins bàcksrounds. By
48.'fi .1r." e'pl,o 'rhre"loJJ'.re. p- r."l
soclaLcLæsI. II, or IIINM were edentulous, whereas 22 per cent
we.e edeniulous âmons those from ùnskilled worklns back
srounds. This is a sood example of the p.oblems confroûtins
those who wànr to reduce health jnequalities; vhere â univesal
iftervertion is ùnleitaken, lt can olte. be ihe most aflùeût in
society who gèi! most. Similar findings permeate Eederal health
where Caff Hl]] hès sumnarized the posilion resafdins early
.teûh ràtes (those before the ase of 6t) as one ir which the
Thepfeventiof in0rûlheohh
ofsocioliiequoliue5 2)7
ntrnbei of.teaths has ,lec.casedduring the Natiooal Heahh Ser
'i.r erâ but a sredter p.ofoltion of them sti1l occlr amona the
mor sociè11ydetrive,l
:fhÈre is d importaû! le$on for redùcing social irequaljries;.
healih.hat.d be leai,red tiom dris. \rhere the sod n !o.edù.e
he.lth ineqùalilies trcvefl.ive nethods shoùld be tirscted il e.o-
Ma.intyrÉ and ôthe6 hak examined th€ qùa1ity ofeviderce of
manr of rhe submissions (incLudina rheif own) to ùe Àcheson
Committee i. i998 thàt were pro!os€,1ro c.able health ine.tùaLi
ties !o be reduced.They nôted thèt whiLe many had evidenceofthe
efecrs of so.i2l ineqlullries ôn !ârioùs health issucs,most la.ked
ev ence about the effe.tiveûes of interentio.s to redu.e vùià
tiôrs ir health. lurtbermore. ûis ùd partjculatly dre case for
mècro level intcNentbns at the sôcietallevel(e.4. rdarnnpoli.ies
to.ombxr smoking), tha! mlcro l{cl nrctretrtiotu at the indn'id
uâl level {smokina cc$arbn by nicotite replaceoe.t strategiet.
Nelerrhele$, À{acirtyre has alsô ca11edfor ;rten'e.tions plaûtud
nnder the nridatile SavinE lives: ôur healthier narior' to conslder
'ùpsrem'
issùes slch as what is pu\hing peôple nrto dre !n'e.?
(so.ial circùnstarces) as well âs downsifd issuesthat dr€ con
cerned wirh pnllins people out of the riler' (medi.àl cùe).
Table r4.l corsiders son€ plausible lnterventions ùa! may
redu.e denftl health irequaLitjes. The e\'lden.e base for mos of
these d a meèN of re,lucirg beâltl1 ine,lulities .loes not erst
to ary.qreâr extcûi, er.ept in the cde ofwater fluoddatlon when
a systcnatlc revierv of the evidence ro dâte has b€en undertaket
by the NHS Centre for lteliews ard Diseminâtion. These
int€Feotions shouid, tLrerefore,be resarded as susgestions for
cons eration .ather thad evidence basedsùideLj.es.
Preventionof early developmentof oral
heâlthinequalities
inequalities i. health lies in.hil.lhôod dd, r. rheliAht ofmassive
research,thc fi6t reds ôflife. Dentlsty is perhàpslorùnate tô have
one extremely effe.tili method for lhe prelention of deniaL .dies
ùat hd irs effecr duri.s rhe develôpment of lhe d€rlition: wâre.
fluôridÈtion. It is Lnown rhât popùlatiot meæùres such a hcalth
promotlon ofteD increacs bdlth ineqùalhies; so è conce.n 2bour
$ârer fluoriddrloD misht bc thar lr, d dorher forn ofpopular;on
inteflentior, might also inc.easc, miher thâû r€.tùce, heaLth
inequèlities. tslos'eve., drc rcaso. why ûaûy heallh lromotio.
ln.ervenrio.s in.rease gndients it heallh is drat thc .Iïlùent de
moi? likely ro respord to rhese !}'I,es ofnretrention, but there is no
behaviôùral .hârge compoûenr requiftd tà. water fluoridatiot to
bave an etre.t. lûthemore, there is .urc.rlt' more deûtàl cùies
developinA incbildren living in depived condilionsr ifnuoriàdôn
hâs an equlclTect on âll teeth then thebeneût to detrived children
should in rheory be sreater thd for ûose f'on mo.c âfiuent ba.k-
arou s. :fhe Acheson côhûittee sæmed qùite cotrenr vith tht
elidence f.esertcd to it fu say health in€qualitl€s in childrcn weÉ
z:e I tl teprwention
ofsoriol
inequ0liti$
inorulhe0hh
I

Tàbl. 14.1 The p'€ventionoforâi healrhi.equlirires their otherwisebull or monororousd2ily Life The consumption
of swee6mông .nlldre. living in depriv€dùcùmstm.es may
?.cv.niôr ôf etlt derel.lmenr Preventionofoml hexhb
âlsofulfi] ân inportunr role in .elievins someof the burdenof
ot oràl hahh inequLlnes in.!ùàLiries,ù adulthood
theû liring .onditions. It aho seemsplaxsibletlut $vee6 rhâr
las longer, .h as tle bo;led sugar!ùiery, may be bouaht in
so.irt Poli.ies târcurtig so.iÀl p.lictes fâvo!rtna'
ih. so.,allr dNdlmrxsed tb e rurallr dlsidvân nseJ
prefererce to heâlthieritems t.om a dcntal stândpon!, slch as
swcers;n d,e lorm of bars,rhich côuld dùa.lly be earer all at
IlL'ônda.on oa wârer sùI,pli.s Ixte i.n oi .overàÂeof
ô!.e, drerebyfcducingslgâr exposxrefrequercy.
free dentâl. e tu dÊprire.] srolps thefe are pc.hapsseveralplaùsible vèys to tàke action ôn
Aùioù on hidden sùÂâ6 sugar borh ar a midsrream èûd dôwnsÛeâm level. In mid-
nûgeries in hÊÀlthcenùes . ' ? . a . ! e b . o . l , rb - , o , , d r - d . , ,z n d r ' i i l c ' , \ c o n
R.$ri.ù.n ôl les beahhy læturersto limit strgârin prôcessed frxds and ddnls. or ar leas!
to mak€ rt cleèr hoù mù.h is presenr.Sliahdy rurlhe. down
Attendao../RegisRrn,n oa
strem thereis àû à.knowledAed role for sclroolsin p.omoringand
Dental Pm.ririorer (exic..ll providing heahhy foôds, whi.h would be directcdat Aenûalâs
well asdeûtalbcâlth. Downstreamar rhe level ofrhr individùal,
. , - t o , l d b Fr d t ' I p r , , c r . - f f ' ' \ ' r e " l \ t ' r o m o r , o n n . p
rial tùsere.tàt thosefrôm deprlvedbacksfoundsro emphdizedre
role of frequerc) ôf sùgari.take. Any such inrerv€nt1onvoùld
!ô$ùe serl'n. n,r.hlldren ifae.rive.ommùnlcârlo. probablyrequire an urde.srandjnsof the curreût role ôf sveet
tioù depnved bi.ksroùods
eatingmonA thc sociauydisadvârage.t.
Prùghl]Des to promore smoklry
the piomotion ofequ;ldbLeac.e$ to services wd identlfiedas
â need;n thc Yrbite Paper'TheHealth ofrhe Natiôn. This con-
Progi:'lùer b pronoE rl.ohol
ridereddre .ee.l fbr .esoùrceallocètioûto fô1lôrv.elârive.eed,rbe
P.{,giâmnres ro .onsider dcnt.L àvailéility ofprovcn clinicâl câ.e,md the renôval of bâÛiersto
anxicty.nông$ dre i,.iâllt care,particulàrly fôr rhosewith poorcr hcakh rârus, and rûe
rcduciionofvarlatlonsir the ourcohe of.are a.rGs tbe counry
In dre GeneraL DertaLServicestepstô try tô prôvidean eguirable
denialservicehÀveinclùdedtheprovisio. ofincenrivesro.egnte!
re.tu.edbr flrc.id2tior and perr on tu rc.ommendnùormationof i.fants from deprivedba.kg.oundsfo. denlalcared well d sone
vater supplies. Hoverer, the Systemati. Rslew of Water Flùori localizedcdpaigns tô lncreaseinfa.r.cAisrrarionrû areaswh{e
dation $bseguendycaûied our by the NHS Cc.lre for Relieçs it hasbeenshowr tu be 1ôw.
aûd Dissemi.âriotrwæ slighttr more 8ùardedaboù!the eli.terce The interventbns discu$cd so far ar€ p.edomiûèntly nid
they obtained bû co.clud€d rhèfthe reviev {ascsrs streù irtervertiôns invôlvln8 comnru.iiicsa.d Aroups.Thereis
also â role for ioterventiôrs èt dre individua.llevel ln helping
à bereilr in redùci.g dre ditrerencs ln sererny of rooth
tô re.lu.e hea.ldlineqùallrlcs.ft hâs âl.eadybeer said ûàt rhe
,lecay(a meâsred by dmr! o. DÀ{IT) berween.la$es
problem rvith many effedire prcverrive inretreûrions,sucha
among five and 12 yeaf-old chlldr€n. No effe.t ôn the
someforns ôf healû pronotio., is rh2t drer ofrenincreaseholrh
overallmeàsùreof ttreprcporrionof.âries f.ee.hildren was
ditreren.esbetwcen rhe â*luert and the poor. Howeler, sone
detected.Hovevc.. rhe quality ôfeviden.eis lowand based
clini.ally appliedprerentive meùxres can be tùgeted, srh a
or â sha.ll nùmber of siùdies. The ar$ciation belveen
sômeformsofindividuaLnuor e b6e.t treàmenr ùd the p.ovi
rÈter flùôridat;on, cari€sàrd sociâl .la$ .ecds lir.lher
liôn of tl$urc sealaors.Both of thesewill fâceàn inirial bariel
rcsuliins fion chjldren from deprived ba.karoùndsbelûs le$
SuAarmây be alother ficrr drar is li.ked ro sociàlinequâliries likely ro attcrd dentalcliûics.A further prôblen will br tô cld-
in ôrèl healrh.Thcre is eviden.erhar dre dicr of the les advan sify . deprived'indilidml r€llably.
tuaed consists of more processedtoods dd less fresh nrods dran
rhc moreafflùentin so.ietir This is especià11y rhe câseamongrhc
Prevefllioo n f ô r a l h c â l t l ti n ( q u a l i t i c \i n
nost imporerishedfamilieswho may live in sinsle roomsvhere
thereis noopportuniryro prepùe fôod,and d aconseqùenc€ may adulthood
haveto rely entirely oû packègedand take-awavfoods.Certatn ID the Urite.l Kingdôû. thr prev€nrio.of soci2li.equahriesin
types of sweei may âlso be dn inexpensireway of paciô'ios or heaLthir .rtults is côBideredle$ of a priodry ihân in child'en.
e w d r d i a\sI I e ' s h o r F \ , 1 9 ' , , J d . Ii { , L l r . , rI n r , . . . I{oveveri rhey âÉ nôt enrirelysepamble. The use of prereniirc
The heraiurc oo smokiûg àmong nntrhe6 ;n dep.ivedgioups heà]thservices mong âdllts sù.hasaiteodinsrordentalcheckurs
. r g 8 ê , , , , h d. n , . ( r . ! c , F ( , . n r ô \ i d . ,- n . . n , , r J . y
8J! , ' mây oftèr an opportùnitv for children tu attend for deotal cârcalso.

h addiriôr ro opportu t!, drere n the stue oI transnission of
he. rh behaviôursbesveeû tûi1y ûembes; a pareDt s'ho b^shes
their reeth every ght is probèbly môre likel! to eocoùûge tl,eir
.hlldrcn rô dô likesi\e rhân a pdenr who brushesirresùlùly.
fhe rô1eôf pâtienr .ha.ges iû NHS deûrisry xs a bùû,er to the
1e$ Neàlthy does nd aFpeù ro hnve been exdmined 'n âny grcat
d$âil. !'indinSs liom ùc Adùlr Dcntal Hexlth surey (figure
11.r3) bale sùEgesed rhat rhefe is a v,.ia.l.la$ gradient lû find
inE dental .are eapeûsive,but rhls reveBes adôrg sociâ1clas V
This might rcflcct rhc rolc ofncc dcntal ca.c drat ir provided fôr
drose or incooe suflort, o. od,e. indicaroE ol low in.ome. whô
will teûd to be cLÀsitie.l d soci2l dâ$ \a Âccc$ ro dcn.al .dt
amons îhe most sociaLlydeprived may aho bc affcctcd b,v li,.xrnn
of deftaL slrserles. The use oI tiee trarstorla.ion in t]oo. rùxl
âreashâsshown thâtâtendânce râtes at ar tcmtal and .iild hea.lth
dinl.s.xn be nnptuved by redù.ing the difti.ulties thxt would be
invohed ir the jolrûer ro dr cliiic by orher n,eâns. lo.âtina
drop jr derlal sùrseries h merlical clinics may aho bc a way ol
encouiaging people who are not regjstered elsewhere!o affcnd tol
dentâ1.de ând hay, in pàfticuld, help lnfàrts to be brolsht inlo
' dr ' | " , r . '..1 r"erd .. T-f i ,i,. ô rel ,,.
À .onmon experien.e mons people $her .leàling snh lhe
Narhnal Healih SeNi.e n a feeLingofnôt knôwirg whàt is going
or a.d hos rhis dnùld be dealt with. lhere is a rieN that people
from profeslonâl groups snch d l.wye6 and accounlants ire
better equipped to negotiàte dreir {'ay dr.oùAh drc hcalth.d€
sysiem rhus c.cari.a an aduntagc' ovcr drose unable to do so.
D . o . r d ' " b . " \ ' l ' l i p r . o
8
dentiss ùe p.obrbly more coùforrable talkins to fcllow p..fes-
sionalstha! anyone eise,ard this may be a lâcror i. somc idequal-
Ities iû .lentàl care. There s elid€rce sulpoftlng this as a
po$lbilit]- fiom mednd stùdies. lt lras been tou.{l drarpcople in
. 1" I dl "d\"r 'i- d rÀ "l"t t. o,.1 t
tr- " . 'tr'
rxther thar me.lical practilione6. The.e is âlso cridcn.c drar
s@iâUI Ji sadmnra8cd pcoplc arc lcss likclr () be inv€$igtte.l at.1
off€red surgery ôû.e heùt diseàsehù developed and thât rhosc
who are ôffere.t cardÈc rgery ùe le$ likely ro be clâ$ificd ar
nrsert ùd hâve to wèit longer than people froD aftlucnt back-
gmunds. It seeûs ùniikely thar this ls a .orscioùs poli.y or the
pafr ofthe medi.âl professnn, âdd ûân therefore, be e reflection
of factors such as communi.rtlon âlthough it m.y àLsonr tart
Lcflc( attendance br parlents ai .lini.s ôr benrg ex.]ùde.l by
heâldr hchavloùB $.h as smoklns. Daia ftom the 1998 Adnlt
Denral Health $vey (Figûe 1.1.1,1)suggess there is a social
.l.s gràdleût nr being give. !.elenrive dentàl ca.c àd!i.c b-r a
den.is. There is a gfcatcf rhan 50 pef.en..han.e thâi a person
tiom sociâl cla$ I vlil hare.e.eived v,me advl.e about tooth
bmshiûs or suo ca.e f|om a dcntist than someo.c ftom sô.iàl
clds Y Agaln dris ma-vbe inlluence,l by dreir denral ancrdancc
behàlloùa but the'e is also lil.ely !o be a commu.ic2tbn fa.û,f
iû'ôlved d well. People fron, sociilly {lel,rivcd bac|grcu.ds also
seen ûore likely to say drey leeL anxioùs abo!! àtrendins a
.teûtist, which mav tre a aurther reflection of a Êeelingof lack of
.ontrol if â clinical scttirg. Thcrc G cridcn.c ln nredi.âl seûlngs
l h e s ' Ê ^ r h o or r. "d * q 0 i l i ei ù ù r u ' h | 'rq
I
rhât rh€ .hoi.e of Jgent delive.ing dre intenentiôt mèy be an
impoitânr .ontributiûS fà.tor to a succcsnLl outcome. stùdies
rhat haveemploled people rodeliverar inrerventioû drèwneither
t-ro,r ùc same locality or àge group or cthnlc backgroûcl have
shown drat oùtcode cd be enhance.l by such meaures. Good
.ommûi.atioù rÀd aitertivc.cs b avoiditg uninlentiotàl
favouritisn is somcdriûg rhat 16 to be a.hieled xr the level ô1
n n'iduâl hcâlth pE.titiotes .n l nal be onc ol ùe mâit .o!
tributions dixr rhel .d màLe to the t.ovisior of an equiùb1e
Smokins md dlcohol intake are âlso fè.tors thar harc â $.rar
.las gradiert. Bolb afiè.ro.xl healih ând.a! hève an even s.carcr
effe.t or general healdr. Thc Â.he&rn Coûmitlee reporcd in
1 9 9 8 r L r a t . l t h o u g h s m o l i n g h a d d e . r e a s e . tô l e r à l l i r h 2 d
remàiûed stùble amona pcoplc who were the ûost disa,lrantâ8ed
in socicry The.onmitt€e reviewed elidencc aboùr the efte.6 of
iaxins ûbdcco.E ù de!€trenr ând .on.ludeclthat iÀcreÀin.q tâxa
rn n ô y seem€d to fufthcr red(e the disposÈbl€income of drc
least weàlthv. ûaryofs'hom secmcd to find rLreirsevereha'<hhilr
irsclfx dereftnt tô gillng ùp smoking. lof dris .tâson the con
mincc Lccommended dre provisio. of nicotine replacement
Fâtchcsoûpres.fipin,n, whiihvoùld âr !câst.enFe dre.ost b.r
rier to drc .rosr disadvaûtàsed, who can obài. NHS presùiP
lions free of.harae. This re.ômmetdalio. vâs put inù pm.tice
in dre UDited King.lom in 2002.
h âdditio! to lftu(i.g thc orxl nu.osâ, drhki.g àlcohol is a
Fncrorû n,dny âssaulrsand tu.idetts that ofien lea,l t. tccdr beins
dmdsed. Dc2dr from xl.ohôl rehted d,seses a.c moft ihan ioû
times higher mong unskiued workiûg m€! than amona nen
ftum profe$ioùL grolps. Thcft is al$ a stLggesioÀ lhâr ftoblcm
d.inking mong rhe morc afiluent in \ociety is les harmtul to
their ueûeral health tha. ro thar of the p{Ér, d they are protcctcd
from $de ôfthe deleterjo!s erïcctsofal.ohol by their betterdie.,
housng,healthcare,andorhcrta.ùtrs.Despiteevûetce!osugacsr
thar trying ro tri.c toba..o otrt ôf reeh ot l)eotle càn ftdu.e dre
bùd€ets of poor tdilies ratber dra. affe( then \moking, the only
'up$eam'
meanûe profosed b). A.he*r! committee vds to tec
onneûd rhât fis.al Dedurcs shoùld be ue.l to keep the pice of
alcohol at dre sdûe level year on re2i Dow.s.emr frôm ûn the
froblcm ofpoofpeôple with aLcoholtroblcms was see! d à tùget
' o ' ' r n r
i r a ' ' , p ' p o l : e , - ?' o , . l l J , ' F 1 ê
.har a'c available tu the uen€riL popùlù.ion
What !,!e l( ow, and u,hat cârr be rlo e to
prev(rri olxl health ineq1lâlities
Gener2llyspcakinA.thereis al{koftriaLs rbar haveld)ked at the
effectir€ressofpa.ticular denrâlintertentionsotr sociâlinequal]-
ties in ôral heaith.tlndc.standably,mov work h:u concenaatcd
or the conmon iife rhrcatcninanedi.d problemsid€ntified bI
the Depùtmenr of Heâldr in 1r9ii .ôrotury heart (lisedc and
$roke, câncers,nental iune$, HIV/ÀIDs, ât.l accrd€nts. How-
e'er rese.lo t€ll !s à lor âbout what mây or dày tot work às
measuresto reducc incqùalities h dentn(y. On drc whote,
2a0 J 14Theprsertiof
ofs.idliflequslilies
inmo heoth
J
str..esstulindividual irreivenrn)nsarc rhosethat è..uràrelr rarEet
rhe poorând râkesomere.ôsnitnnrofrheir reeds.UrdetstundlnA
hôw a bebâviours!.h àsshoking fits inro dre liles ôfpeôp1emar
L - , i T o r , , - t . r, . ,d,. ,,€.
ftdu.e or climinateit. The invoh'cmenrofpeople frôm dre sme
backgioùndxs thosereceiling dre inteffcûr'o. mat aso be à ker,
b success. ldertlfylns fcotle of dre Lrasis
ôfrheir $.ixl .'(unl
ran.cs tor inrervertiônâlsorcquiresgoodinfordâtbn. ù{os ncn
dtprn'arion ûean,resâre bascdo. inlbrmarlon.bour Aeognphi-
.âl areÀratherdun i.dividlals âvonLngdre needto asksc.sirive
infô.matior ftum teofle. lloùever, applt'i.a dicsc measures
eltèc!lvely reqùifcs accu.ate geographi.al i.io.marion iboùr
vhere peoplelive, qùitc ofier in the form ofposr codes.caùer
ing suchinlormâtionin lhe heè1thservi.ex.curârelyn, lherefore,
c.uciùl ro impleme.ri.A somehealth imprcvemcnrschemesai(l
.an bc âidedbl heà1thprofesionals'.o oFmtion il ennrlnA drât
addres dehlls ot'ptients ùe gâthered.onrlncrcll 'f|ere is.lso.
nee.lfôr properlr condlcred rriâ1sof .he âbiliry or oral heèlr1i
ff€rlentiods to rcduc€socialinegmllriesin oral healdi.
The.eispe.bapsro bettef wal b conchdediis.hàprer rhann)
gùore dic mdi! re.ômmendarionsol dre Achesoûengdry lnû)
lnequliries iû healrh.
Arheson
enquiry
recomnendotions
. rharalLloli.iês lih.lr to hnlt m lmpi...n beâkb shorld h!.ralu
r àiid in rerins olthsir imF.r.n h.nlrh inequalities
h o ,c ' , . !, ". ii-.e
. fùither rep\ st$ùl.l he takcn ù rèdu.e in.ome inequllrles an(l
'P -- tr tnè
Conclusions
. Vlieieler some fom ofsocial strrtifi.âtloo i\ fàund rhcrc
a.c coûelate.l heâ.lthlnegù,lirics
. The ir.iden.e ofccrâ,,, heù1th behayxnrs dlffcrs bctFee.
s o c l a lg r o u F ( e . A .s n o k i n g , h e i l r ' d r n * n r ! , r A U r u , , ' c
erercise). Howevef. c!r. whetr drese fâcr
for (e.s. l@kins ar oon snokers onlr) drc ditfc.ence in
moiali$ nrcs â'e srill eppèrenr (bùÙeduccd) be.ween diI-
ferent An,ù|s.
. The etre.rs ofdef.irarion appeâr tu be a ])c.ual Edrer lhan
a .omrnù.irl .lis&liîntage. Indlvidùâls s'bo ,.e fo! disad
vartaged do not have i hrghei risl ôa d)lng if rhcy lnr in i
dc|rived areà,ùor .lo disadmnt.ge,l l,eolle whô live in &tvân-
rageda.c.s gàio ary berefit fn)m thci. aco.qophicâl lo.ùioù
. [ffe.tnî hcalrh inrerleDrions do .ot alsavs re,hce health
incqualiries benveen $.lal Erouts d.d so,re ùJ! acruatlv
incr.ae them Thi\ seenrsrc bc behavioù i i! ôrigin: ihe
$ci,lly advarûged mxy bc in a be(er positior tô imple-
mcnt he rh)'Nlifestlle behaviouE lhdn the poor be.x$e
rhey ùe more likelv r, gcr heàldr iÀfôrmùrion ftum healrh
proli$ionà sr mrl hrve tèncr .omFring life cor.erns; aod
sill bc in a be..er poltlon to iûplenert behavn us rhat
h.vc a .ost tlioension (e.s healrhl diet).
. Ihc only i.tcrvenlion lor which s)sremàti. reviews nn)s'
rhcre is limited ev en.e of effeftivenÉs itr ftdù.1nE e.ial
iûcqnxlirics in ohl heakh (û cliitdren) is uorl.latbn of
\rare.$pplics (NHS Ccrùc fôr RevieFsànd l)isseûluùon,
Re|oft l8). Howeve., the qùa.llq ot evidcr.c ins,lcr.ibed
as low d.d basedon r snâll nmber ofstudies.
Acknowledgements
This research\aasfuûded br tl,e Chief S.ienrisr Of|cc of lhe
Defarrmer! oltslealthôfthe S.ôttishExe.utft Fho do nor nec
e$ariLt shùredF vie$ expres\€d. l'ha.ks rc Mâ,.qrrer\v hirehead
1.r sutfhing lJigùre 1.1.2br, Dâl gren, G. & Whltchcad. M.
( 1 9 9 1 ) . F l ! ù r e1s1 . s .r 1 . l L 1 1 . l l s ' e r ed e r i v e d
. l i r e . r l yi i o n d !
l99E Adùlt Dertdl He,tlth sur.et'dataand do .o! atpear in the
ong,rù sur!ev report.
References
A.heson, D. (1998) lnd4'tnd.rr Enq';ry intt li.tltd!1rj ir
Hrlrr. Lôûdonrlhe Srâtn8Jy Offtice.
ArLrdter L., h.vistle, V. lanrbcr, Nl.. lo6tea M., Shel.loû,
T., a.f wâtt, L(199j). ndje,4 th RlvûJt e nE Efinit
f H . t ' . r ( " . . \ . . . .
âùlt . Y{rk: NHS Ccnûc lor Reviewsand Drssenntu.,o!.
Benzeval,-NL,Judse, K., a.d whirchcdd, M. (199t). h'*ltl/s
Ik4nalnitt in H'nblr. A" Agenlalùt Atliùn. L.ùdotlKinr\
Cdr Hill. R. (1t8l).Thc inequàliliesnr heùlrh.lebar: a.nù-
.al rcric{' oi rbc i$ùes./. So..L,arit, 16,1a9 142.
Cûoll, D., Darer Smlrh. G., a.,l Ben.etr, P (1996). Sone
obseffàrio$ on heè1thâûd so.nre.oûorni.st.trs.,/ Éa,1t
Prth.,I,2a 39.
Depârtmert ofHedrh. (1t9aJ. Vdtldtirnth tlk//h. \Ytn1.n,
âre .onùnlcd tht D.tùrtt,ot 0JHldhh dnl rr' ^rHS ,r1 Loûdon: Depait
J o n e s ,c . M . . T a r l o . , G O . , V h r t t l e , J . a i , E v a û s ,D . , â n d
liott€r, D.P (1997). \X/drerUùoful.tion, toôdr dÉ.ayin
5 rcar olds.and socidld."prilationûeasùed br iheJafman
s.otu:arùlisisollàra fiom llrirish dentulsuNeys. n,: i{lJ,
3 1 t , 5L l 5 r 7 .
Mâ.iûrvrc. S (1991) The Bl..k Repofr rnd beyond$hrr ak
drc is$cs?Jr. .1.i.,'1U,.14.l2l i.,ii.
ùtacintlfc, S. (2000). Pr€lention àûd redùûn)n of hc.ldr
i n e q u ù k i e sa. , : , u . . 1 J . ,1 2 0 ,l l 1 9 - 1 1 i ) 0 .
Townscnd,P (1981).Depri\iùon J. 50..P|li.!,16.121 )16.
n,s.scnd. P, afd Dali.lson, N. 11992)IiqxdlitLt ,t Heùh.
rh Bhtb ue!ùtl nxl Th HultÈ Dirià (û:\iscd cl.) Hal
m o r d s n o û h rP e . g ù i ù .
Oralhealthpromotionandpolicy
A u b r eSyh e l h aamn dR i c h a rW
d att
lntroduction
Ohl dirases arc important pùbll. hexl.h ptublems. TIIel are very
pBaleût ar.l their iûpâ.r on borh so.iery end the indivnl!àl rre
signiUc.nt. Pain. disâb'litr. âûd hândi.ap hon onl disears .re
onurcn. xnd the .ors ofûeatment are a mrjot burden to herlth
oÈ s,lsûns (rable 1 5. i ). Ibe causesof dental diseasesere knoÙn
2'd rhe corditions arc largclv f.$cnrâblc. On drc basls of ûose
.rireria, oral and dertal diseasesare â lublic hcalù prcblcnr.
lrrthermor€, inequalitLesLn orâl henlth âre a lroblemi disâdrân-
taged èÀd socldlly ercLùded populattoû groups slffer highcr.atcs
of diseâse rLran their môre àffluent contenporaries. Th€ 'no!€
toNards ar elxlen.e based àpFroâ.h ro tredlmenr à.1 pre\rcntior
h,s hiAhlighted dre limitario.s of cônvcntional dctrdl health edu-
.a.btr. Ihose limirarn n\ an.Lthe expdsion ofcôrcepts oû heakh
prodôtion h$ 1e&1ro a wider recôgnitio! dut there is a need !o
âdopr a dore progre$i!e approeh to prelertlon.
In rhis chafrcr, orâl hcalth pLonun,n nlll be deflntd anctan
oudinc givcn ot drc ph;losophl undcflyin8 ihe domindt
atif.oachcs i. hcalrh f.omoinrn, Hcalth lofAll, and the inteBe.
toral acrjor. Tbc cfidcmiological bâsis 10. smteEl is explùed
âni d,e âlflicàtion of an inrcArarcd âfproa.h ù .hn,ni. dlsea€
tunt1rn, the.ommon fnk/health apptuâ.h exmined. Casesndies
usirg food .n t periôdoÀtal heùlth policis w, l l i l lustate rhe .erc
vance ofdiese afl,.oaches to o.al hcalrh.
Limitationsof conventional
dental
healtheducation
Dcntal bcâlth cducarbn aims ro prcmote oml health drotrgh
&lùcational n,eans, frinciFlly rbe troris;on of infirmarn)n ù)
'Iâblc
1t.1 Criteria for a public health piobleû
. Prevrlên.eô1the .ôndniôn is high. or il lronmor, drc.on.li-
rbr sh.dd br s.riôùs.
. hpa.t of.ôndniôn ôn indiriduals qutrLityôillli (!ain, dn.on-
1nit, tun.tiôml linnnriôn, sô.irl nôl.tiôn)
. Inpd, on v cr so.i.q (consôl tcaamr. rlN ofI shooL ol
p , J , : , . . , , r . . t l
lmprcle ôrÈl heèlth knosledgc ând a$aren€ss Through the
acquisitn,n ofkno*ledge, a cirdnge in bchavbùr i\ then.ôNid
ered likelr ro ô..ur. This ralher simlrlisri. and oùrdat€d âpproJch
hrs .loûrn,a!e,l denràl hciltb cdù.arbn prx.tice tor Jnany yea6
but làils a, acknorvledge the .oFple{iries of bùmar behaviouf
a.d rh€ lmportânce of the broader sociâI. ccoromi., and enliron
menral fa.rûs dererminiÀg behdljour cbangc. How €ffe.tile is
.\-"lL , o, lil li ,'p noÛ'rotJ\',,1
Seleraleffccrilcrcss ftllews hâve be€r undertakef .o a$c$ dre
' , ' ' , - J c l l . l r " ' o '
)
(Browû, 1994r S.hou ând Locker, 199,1t Kay and t"ocl.er, 1996,
1998i Strod,/,/., 1996). In broad terms, â11the reliews hàve
âdopted a similaL mcdnrd: a syremâtic search ol'lhe tublishcd
and unpublished lireraruie to dete.mine rhc orc.all impa.t oi
interrenriors or a range ol outcomcs. Th€ .omdôù findirgs ol
'râblÊ
drse revie{s are shown in 15.2.
TLreeffe.rilene$ revjess also idcnritied rhd ûdnl inrerlertiors
wdc poorly desigred, inèdeqùately evaluarcdard la.ked a tLleôret
icâl basn. k is âpparent that è difèrenr +rroach ls reqùikd to
pronr oral health and reduce ineqùâliries âcrosrrhepopùlâtiôn.
Theneedfor an'upstream
approach'
The presenr dom'ranr âppma.h tô preventio! is re.ognizablc nl
rhc followina alleg.4: A màn was standing by thc side ol a fiver
'fable
I 5 .2 common fiûdirss of ellèctiveoessof d c. tal htaltLl
. lntr.viùg nr,lividùals'knodedge oaorâLhÈahhGo & r.!iev.d
lif \hôft !eri.ds. but cffc.G oû behayio!rarevery linned.
t tr,.,.o. o o- ol ,t ,, -. b, \i ,,
. intorv.nri.ns ar ar n irdlaL lereLâ'Èefaedneat red(itg
lliqùc lN.Ls orly in rhe slntt tÊ.m.
. coo.hbn,shifs.rnpiiAns ann.d ar lmlrovrng oml
S.bool Lrase.l
htgicûc.re lârgeL!neffe.ri'e
. IIss media.mtaigns âre ,.elledivè at prôûotnu cnher
llovledge or behâvn,ùr.hanAè.
. Vci! riw $u.lleshâveâsÊsedthe eaae.is
ofdr.tJ he.Lth
..ù.r',on on sùaâs.o'sù'n!Ù.n.
,"0
|
pnmoriof
rs 0,. heohh ond potiq I
UP9TRENN I L L NE S s
FA.TOP,IE9
{ANUTACII/RfRS
?F ltùNÈs5

T ûTEDD
a t r D O ûu a
\, \
\.'.
\ ' ) '

TOUN9TRÊ.11H
!igur€ li.l Lllsi..iù Downsrexm approâ.h.s

âfd heùd à .rr of a droinln}r pcro. (F !u.e l:. L).lle Juùped Ius betr dot. Irbtea.l of expendin! $ nnL.h efàr on doft!
ln n) rcs.uc hin,, tùlle.l him ro die bank, and applicd à,tifi.irl sû.im rnl mi(hreaû aû'vit'es. nore efforts sho!1.] be dire.re.l
, ' ti i . J , , \ F . - ar maki.g th. rivrf shrlloçer, so rhùr feofle do not hrre to leànr
ùft .rics iiom otlrer drosning people. In jllmpco lrc .cs.!er ro iFim mikins heilthier .liorces tlie ersier .Lror.es (ùrr1É
b.oùght some brk and resucitatcd drcn, 'fhc .escne..o!i.l 19861'iD.l coDÙo11lrS rLredtiviriÉs of rln^e |ushing peotle
no. core on his o$n $ he so. nrnc hch.6 inll ûachnes. Shll iûto the wàÉr a dneù ârta.L û! tLe determinlnrs ofbealth
he .oùld not .ope. So ther iîfkcd f,src. in tedms 1o!r har.led
atrd six handÉd-$irh mo.c con,lt$ e.tùipmeDt. Th€ ûumbers
oldro$ning people bc.a.rc so numerors thnt sorDe.ouL.t !ût be
u e l l n r l r o l r so r n e ar l n p l o m o o n
rescùea before permanenr damagc o..ùr'.d. llow coùla he Thc modc.. hcilù i).ôm.rio. mov.n,cnrhâi.ùerged oùr oirhe
*op rhcm Èom d.osîing: S\idûirg lesons serc dre srrtrro.. ted for a funchnerta.l chaflre in sftElr () adllcve ind rnxnûin
T t. . . . i . d , 3 . ' \ 1 ' , , . 1 t ' healt|. ft ,s tràse.l or ù pùLr]i. Lre.lrh philosôpl,v rl,û nnruld
èr rô riûedidles.t n .o.sl.ler why people Nho.ould lor swlm etr.ornFa$ the prevûmon of.lseàse âr â priûârr' lcveL.and sel
were in dic rn'er. \Vho Nrs puninu tl,em in ut5..an1 otdlv, the piômotnù oihe th(Nliln) 1988). lhcsc tw) rc...ttr,
(NI.Kinlâr
I9r.il. \.he! rpplled n) devel)pins cn!;()n.rcnÉ n'hi.h fm.hu h.âldl
Thc dc.tlst\ con.enùrtior or downstream' !i.tij. LrlâminA lef Lhone\ ntr people in.o!irg siù rb.ir lir.s,.ccl ro
di5tm.rs ,ttenrion fiom rlie uFÛeam' î.rn,itics of dic .onf.. be xdopted in â mî.ne. rhÎ cn..ùfaEcs rh.sc (hoi.cs ro b. dr.
tio.cr,v, ÊoodiDd dink.ômpânies iln) arc insbi.s l,eorle inro ca\irr.hoi..s (Milio I9ua) Hcrlrl, |roi.orio. ci. be.onsiJere(l
thc $rtci. I lerLth Norkers ,Lnkllr lnrentûc onlr xtrc. d,c ran,rE. 'rs
rhe.onrbnratlon of cdù.atn,ril rnJ c.vi.or.icrrrl $l,|ors
 Gmmlprin.iples
01orch,.0hh I z+s
p'o'norion
I

for a.rbns ând corditlons ôf llrins co..lucire ro heâ1th (c.€en
ât.l Kreurcr 1990). Strâtegles ro ch2nse the iènge of opir,.s
avâilâblee) pcofle ard to make hcalth lromoring choi.es easlel
.nd/or rc dimlûish heâ1th damagi.g oprions by making thcm
ûoÉ ditll.ùk to chôose (Ifilh 1986). Ârother definûrcn js
nerlth promorb. is d,e pro.es ôfenâblinA indivnlùàLs ù.l.om,
mùnlries !o in.re6e .onrr{n orer rbe deterdinan8 of hcàld, i.d
theftbl improle then heahh. Heàllh promoriôn feprcscnrs a
hediati.g sceteg! betseen peotle ard their envnomlflr. (oJ'r
biiin.q peBonàl chol.e and social respônsibillty for heallh to
cLcarea liealrhier hrù.c (YrIlO 1984). Ir is di.ecced to the
ui,lerlviûg.leftrmlna.ts âs \rell às the lmmcdj2te caùses ôf
hc,lrh. The càusesofrhc calses.
Heolth
promotion
involves:
Table I5.3 Th€ Ottav. Chùter (wHo 1986)
'I
\" n, . ' rd \, ir. a .{ \. J[5 frur.r,o,, d, t'o. -
Proûôring hêrhh thn,qh pub|. IÛli.!: ht' fo.using r emon
or thc iûlrft on h.trhh .f!trbli. Foln iesltum âll se.ron, and
n.! j!$.l]e berlrlr rcor
Crearnrg. mlFôftive èrvironmenr:by â$essinsrhe im!r.r oD
heahhot dre cnvironmcntnnd.ldjiviog orFortunrties.o nrke
.hanges.ondn.ive rô hcalrh
l)eyeLopinglresonalslills: by nô!inA ber,.ndnre tmnsmtryot
ofinfoD.tior, ro lrônôte !.der{andins, rnd .o srp|oû rhÉ
develo!,rerr ofF.rsoml, sô.id nnd !.lni.al skrllsFhi.h e.âb e
indnlduals ro nlie a.tlon rô lrôùôte herhh
SrrenArheflng.oùùuritl rcrlôn: br suppofting.on.retÊând
etle.rive.ommùniry â.!ior ir dÉturingFrlôriti.s, n\Jiins de.i
siors, Flùrnitg sntregier rnd,mrlemen.na thenr ro !.hier

. Prevemng disase âr âfrnniry level

R.ôrienrnis heahhservr.es:by fefo.ùsnrgâ(enrioû r{r! frôrn
' Màkin! lre.lth promorioÀ choi.es o$ier ùc r.s!ô.sibilny n) f,rovide.!rarive ard.lnric.l s.rvi.cs
. Conrbnrnrgpe^on .hoi.e ànn so.iùLiliF.nrbnnv aor heâlrh rôward\rhÈg.aLof reâlrhgan.

eipli.it.on.em lof hcalù aod equitl ir â]i ùed ofpô1i.r â!d br

Thedominantphilosophy,
primary a.courtdbilirr for healtnnnpact.ln hetrhhcare,eq!iry n basedon
healthcareand healthpromotion AristorLetdictum thar thereis no Arearc.lnjlst'ce thi. ro rrear
unequl .ascscauâlly. Eguity requnesrhât peoplewho arealike in
The De.la.arion01Almà Ara (WHO I9rE), àùd ,e srLbseque.t
relevanr ftspe.rs bc ùeâredin like I:shion, àrd prople who are
developme.tol d,e \vHO sÛateElfor 'H ealthfor All by dreYeâl
unlike ln releva.t.cspecsbe ûeatedèppropiiàtelyin unlike fash-
2000 cffectiv€lyset rhe ascndafor lhe neù pùbli. hcalrh' ard
lon. This co(estords ro hôrizodtalegùlrt'-like trcar.rcnroflil.e
hcalrbfroûotior movemc.ts.The prir.iples in drc Declaration
i.dividuals, nDdv€rti.al equity-rhe ùnlikc ûca.nent ofunlike
, , { ' C ' "r r L , r r . r . e t t . ' . r r i _ .
i r d i v i d u i l s( C ù 1 \ ' e1r9 9 1 )
. Equilable DsÛilruin)n. coveûmeDrs mur endravou.ro
The Éin ineqdty .. referstu difièrcnccsahich areunneces
cquildblydistiibùte rhoscva.iables$tri.h inUùcn.chealth sa.r rfd avoldàb1e bùr, in addirn,û,arcalsoconsidered !ntiir ând
.., ",,) P" , 1 , . ' r , . 1 . " ' .. , n ' , . . ùnlu{'. (\X/hireheâd1991). Redu.ing ine,tuxllrlesir hcâlth is
sho!l.l pâitl.lparc in âll .lecisiôrswhi.h x*icr thei. herirh. esrblishedasone ofthc pLimctaks oth€aldr piomôtiôn (\rHO
. Fo.ùson Prevenrioûl he focusof healthplrnnersand fund 1984). Fqùny n â! ed,i.xl prin.4ne and ir is ùn$?rising thar
inA must shift ftom hedi.al/dcnrdl careto p.eventn)nand drc ctirical triiciples urderlyitrA nealtb promorion corlàrm to
ircâlrl,promôrioû. dre Declaratioû ofHelsinkia.d i.cludc rcsp€c.fbrpersoûs,benef
. Àltrolriate Tedrnololjl Emphùis shôuld be o. rbe mos iceûce, rôn-malefl .en.c x.d jusric€
The Oftâv. Charcr i.clùded rhe .on.ept ôf heâhhy pùbll.
al,f.opriarete.hnoloAya.d pesonneltu dealwirh frobLem.
poli.y (Tdbler5.l). This gocsbeyondthe healthcde sl,reD. ft ls
. A NIùlli sectôiâlÀpproadr. Sol!ùionsù) lll-hc2hh canrot
.ôn.erdedsidr ihc heaLthnnpL.èriors ôfal1poli.les ln.lùdina
" . o \ . , r ô , 1 . b . .1, . , - , o . \ ; . , . . ^ . o . ,. . r
e.onomi., employment. agricùltùre, hoùsiôg, Ùaû\porr, and
.ùlture, ed!cètiôn se.ûrs n,usr .o ordnrarepoli.ics rhâr ervlroûmert poll.les rc.ognizi.g rhrr imFrovemeûsiû heahh
.orncs tion, i nlki sectorâlrâther thxn a pùfcll heâlth secror
Esdblishinghealrhytùbli. Folicy is ore ofdrc five ùeds for app()â.n. NIilio (1981)d€finedhe.lthr publl. poll.y âs t.ologi
achielingthe goâl ofHcxl!h for All by dre Yca.2000 The others .xl in fcFfcclive, mùlti sectorâllû s.ope and fafticifâro$ in
are.reàûrs sluportiv€ €Dviro!ûenr\, srcngrhedng comdmitr str2tesy. llealthy pnblic poll.y sûescs dre need!o analys€àrd
aûior, develop;ngpesonal skills, and .corienrùg heelrhse.yl.cs r J " r " l l , " j b l i . " ' c . ' l , o " . o i r u , , \ -
(\(Ho 1986). The Oftawà chaiier âlso ifclùded rhree p.o.css well as thoseof the professn,.alswho âcr ds advocares, .n.l rhe
ûrethods-mcdiarion. enâblemenr. and ad!oc..y ihtuuAh tuiicrloûingof 1ô.alând.€nùal aovcmmer!. Un.le6tèûdirs re
whi.h ptutlc could begir ro tâke more corùol ôver theif hcakh exnting poli.r envirc.mcnt is ce.!ral ro rhe delelôpmenr ol
(\\rHO 1986). HeildrJ, Fnlrli. poli.t, is chdrafterizedbv aû hcakhr p!bli. polic!:
 promotion
l5 0rolheolth ondpolity

Generalprinciples
of oral An integrated
commonriskiheâlth
nearrn promolron f-^r^-
,orLU,
--^-^- ^1"
o PP 'uor, I
Oral bcalth f.omorio. hd emerged in hn€ ùith .levelopments ir
The solùtlo.s to rhe chronic disedse|roblens are soruûo.s sr,àre,r
general health prcmorion. Oral heal!h Iromotion srratesies
{'ith orhcr hcakh s'orkc6, cdùcaror, ând rhc.ommùnity. Thc
should be based ùpon rhe tirllos'ins Auiding l)fi.cidcs:
$aregies to mirigde dre heâlth prolrlenù arc in.oryorared in dÉ
. B" 'o' Io' o'1 e - " rlr O r " " " r r . , r l r L D ô r o ' o , . I \ ' . r : ô i n , ' r
bodr normarivc a.l lây measuresof leed ècrioD and support, environmenral charge, Legislation,rmprovina
. Dcrclot a rânAe ofcLearly stated and ch..Llenuirg gôd1s persônâlskiLls,and edpoweiing peôp1en, be.ôme stakehôldersir
. P.cvcntn'e rdther lhâr curètive apprôâ.hes prômote $.ietj, xnd colle.iively work b .hanEe the sùu.(t€s {ùl.ll
public heakh reaslres to thepublic.ûd pubft.".'"'-*', deiennioe dreif hcalth. Sl8.ifi.ant 6ntnn ofdentaL drseâses.aû
c.g. tluo.ide in waler. malnl) be a.hleved ln terms of {).ixl poli.!: Ihe rask of oral
r ' , , 1$ i 1 i o . . . \ i , . . . o\ a . k r " . t . . . I
. Bc bâse,l upon contemporâry theôries of indiridual and
take dre spe.lli. ().lai meantes shl.h xre rcgulred k, {rlve
orsâdzarional chânAe
generrl ard ordl healrhFrobleûs, rûd ro pafti.ipdte jn rhe iûF1e
. A re orientàt,o. from pies.riPtiôn to *,pporlve heahh
mc.tati.. of rhcs. pol'c'cs.
prcmorion meihods redr€ss the b.lance of irfltren.e
and makc he2ldrier choices easier Promôre self-esteeû 'The ()f chronicdisuâ5es
determilrant5
,fd facjlnare .lecisiôr meking skills ratler tban bc
llealîh ed!caîlor poliq ùod interverlions hale lbclsed or heaLtir
behalroùrs ànd hare beeD relatrlely inattenrile to so.ial contex
. Contrat the influence ôfrhose interc$s whi.h froducc and tùnl fèctors thât are related to heaLth behavloùrs iû sereral.
profit fron ill heaftL1.This iûvolles .o.ûols o. i.dustry Lrfestyles are coûnodv .orsidered ès rmportènr èetiologicèl
sFoNored edn.arnrnal materials in schook. adveiiising. a..l .auses ofmorbidùy àrd ûortàfty. othes ilrerpret liferyLe ds à
campalgN to reclu.e bdûiers tu sood oEl heahh. coùFo!teey!,re$ionoftheso.,al and cuhùral circunruncesd,trr
. Ptrbli. health rarhcr than 'ndivi{luâlly l:o.!$ed lrogrâmmes. .onditbn aûd oûsûaiû beharnù, in addnbn ù rhe per$ûal
. l o . . o , \ F o , . . . , i ' " ' 1. r "' l , r ' 1. , . ' " .le.isions the in.lividual mây mâke (Green ând Krenter 1990).
blùùg âpprôà.h a.knowl€d8iû:j rhelimircd rcâl choiccs But dÉ àppàrert simple àcts are erneshed in nôre coûplex life
âvailable tu any individuâI. time habits and $.ial .ir.ùmran.es as$.irtcd $ltLr Life*y1t
(G.aham 19t0). rivi.tj .orditb.s providc .hc .o.rcxt ln $hi.h
. Àddress dre ùnderly;ng dcrei,ninan!s oforal hedrth.
Iiicstylcs arc sùsrai.cd.
. Tackle .auser thar arc commo. ro a .umber of cb.onic
Social dctc.mi.ar$ hâve dghtly taken â moftpuni.ent fosi-
rio. in recenr toli.) discu$io.s (ùIâflnor ând Wilkinson 1999).
. \ ' o p o , ' \ ê , r '| l' l - , , , r, i Tle prln.ipal detcrnhânrs of heahh and dlseaseare sr.ial and
)l
. À c.mmitmert ro disrribute succes eqùitably e.ôûomi. .ôndniôN, .uiture, ard ôrher erlnonmertàL {a.tos
. (Mârmor 2nd \x/i lki.so. I 999). Soci2l st.uctufc 's drc tLuc acr'.-
lNure à.rions are €liden.e ba\ed.
IoEicâl aacnr i. mosr .hrcni. discascs. Nlosr bchavbu.s are
. Commu ty pdri.ipâtiôr rarhÈr ihan pn)fessbnaut donri-
sociâlly pâffcrned a.d oltcn clustcf {'irh orc anorhc. This l)ar
lerled behaviorral resFoûsehas led Link and Pheldo (199t) to
. W-r\a iap,r'|.rIt.\ 'l i, .J,8"r.É.
Bror .ons er sitùatlons that plice irdivi.hals d! rrk ofrisks. lùleed
'soclal
Seleciing a rrateSt' ls iûIlue..cd hI rhesc c.ire.ia à.d philo some eFidemrôlogists fromot€ the rorior ol the prodùc
$phn , p()fe$io.al, a.d political pesfecrives. The etnlemio rior'ofdrsede (Krieser 199.1).Thesocial environmenr has,there
loAi.al bâsisfir rrarcgy scle.rion 1àr oral bedllh tronolion is the fore, be.ome more sigrificdt foi heâ1th(Sheihd 2000).
Common Risk Fa.ûtr Àppioâ.h and thc \Vhole Populatior Health promotior is directe.t ât dre !nd€rl-ving determinâns,
Srrâtesv (Rose 1992). rhc caùscsof thc .aùscs. as scll xs rhc imnrcdiarc .auses ot' lll
hea.lth. r'he immediare .ausrs of dre Dajof denral dreases,.aries
plomolion and prfbdontal diseâseaÈ diet, dirt (plaque), ând sûokins. orâl
Heohh itrotegy
mucosal lesions. oral cancer, tmporomandlbular joint dysfùnc-
. Ânxlvse â ùndetsrÀ.d the broâd beliefs oldre.oomlniry Àss.ll rio. a.d !âin a.c rclare,l ro robacco. alcohol.
:6 ih.se ôa rhe lnf{lonxls who â.r àç Àdm.âres rmuma ro tecrh 2nd Êws ro accidcns (Fis lt.2). As rhcsc câucs
. De\dop a roge ôa clearlr $ated rd.hrLlengins soals arc common to â .umbcr ot orhcr ch.onic discascssuch as hcaft
. E$ùre (rlo.s ârc.viilenc. b6e.1 d6ede, cancer,strol<es,acci.lents, i! is otiondl ro ùse â common
risl. fâcro. âttroâcb (Sheihim a.l \traii 2000).

Figure tt.2 Common risL fa.ror.pprôâch
À conrmonrisk/hrâlth +'irctorapilroactt-an
integfâ1Êd
âpproach
The key con.ept trnde.hinA die i.legrited common rnk
âpproeh is thâ. pn)motina general heâlth by.onÙothig à snall
nuûbei ôf rlsk fa.ûr$. mày have a màJor impàù on a lârge
Duûber ôf direasesar a Iover cosr, arearr efficieniy, ard effe.,
tiren€ss than discase sFcific approaches.Sdvnrgs uay Dc xradr
by .oôidinâtins dre $ofk do.e by varioùs specialisr groups êûd
or8ânizariors. De.ision-mikeB and individurls will Lre more
readih influcnccd by measùres dire.re.i ar p.eventinA heart
diseaser,obes;ti, sûoke, cancers,diaberes,âs well a\ dental.aries
tha. ii dcntal diseasespeclfic reconûendxtn)ns are nrade alone.
Tbefe are baslcalll, two approa.hes for an cqujtv orien.ed
hcalrh policy: focusing ôr ûnrn\ or o. rpcciii..isL fælors ro
rcducc specitic diseasesaû.i publi. poli.ics aimcd ar im!.oving
heal!h cotrdnloff. iû geûera.L,and among those ar parricular rsl<.
The neq Flblic heâhh poll.y is no lon8c. o.ienred ro s,ngle
ani,resmhd.ommon
sk/hedrh
rrr,',m'.,h
|.z+r
diserses.The Coômon Risk/Hedlrhfaftor Appro..h (CRHIA)
disriÀgùishes Lretreeûactlonsained at red!ciûg rsk facrorsànd
aclionspromotnrs healthtâctori. The stratesyinclLrdes€fiorsto
iûprôve heâhh by reducirg.isks, promôring heâhh. àûd
sfengrhenins posslbilltirs tu .op€ *ith given risk fa.tors
.reating suppo(ile €nvironments,reduclngrhe negativeetre.ts
of.ertaln .isk fa.tofs add fa.illtarinE behavnur .hanges.Ore
of dre p.ln.4nes of lreâltb prcmorion ;s to tocuson rhe wbole
popùlatlon.atherthan on .llseae-rpe.ifl..Èrlsk groups.À major
beûefitof die comnoù RrLHealth lectorÂpprorch is the focùs
or imf.orina hcâkh conditionsi. gc.c.al tb. drc wholc popula-
tion ard fo. ao\r ar hiah .isk. Ir thcrcby rcduccs sociâl
Corceps of.omnon rsk factôrsmust inform pùHic health
(ork and e.lùcatior.A nlmber ofchronic diseas€s s!.h as heèrt
disease,carcer, strokes,àcciderts, àrd oral diseasesha!€ r$k
factorsln.ommondd nùy risk fùtos ùe rele!èùtto morethar
ore .hronic diseèse.Pielertive $rdtesies bèsednpôr CRH|À
 I ï
2a3I -l 0r0lheolth
F o m o l oonn dp o l k y
I
$ill cxct a faonrable el1e.r,nor ôn1yon r slngle diseâsebnt
simultan€oùslyon seleral.ondiriors.
'l
h;: t 1 ;ilr,:r':rilrlrrqii:i;l'rall:.
for ilFl iJ'À
The majof risk à.rofs ià..bronic diseâsesare smolnng; diets high
nr etLrate.L tà.s Md sugus, and los' in ilbr, f.uir i.,l rcSerablesj
il.oho L:2.cnle.6r à sedertùr' ljfe$l,le, $Ès; and lo* .onrnn dd
cnvjrcnmcnrâl lollùrio. (Sheiharn aû.1 \Vâû 2000) Nuûeions
expcft conmirrees have .onclftle.l that F:utr.ulù diers, nJnely
lhose lrigh ir satùrrted fèfty acids, nor-mi1k erÙinsic srLgrs and
los û toll,unsatû.tes, fibre ald vitmins A, C, and E a1î ass).i-
aled !lth.oronary heaft disexse,$n,ke. diabctcs, .ar.ds, obcsiq,
and d€ntâI .ùres. lûcredlrg scienrifl. eviden.c tfonr Lpidcmid.A-
i.al, chlicâl. dd ôthrr relerart rescar.h trxs bccn 2ccu,.u,arcd ro
show ihùr non milk erùinsn mgârs are a.aùse ofa mnsc ofdis
Êases,cspc.iâllr dcntal .iries. Sheihrûr..hims diat Drrrlùta n F.,llul;r1
d itsat ùj'.t.lox "rJ..tr^ diultr, x.ondusio. surr)orcJ br most
conternpôrùf s.ienrifl. eviden.e (RLLgg-Gùnr ànd Nunn 1999).
A reduction ir don-nllk exûj.si. $A26 inàk. is.lesirâble in
riew of rheir .afioÉjcaicitl, rs n'ell as odrer hirmlll effects on
EeneL?lhealrh. Thc \Irond Healdr Orgaûizarioû èû.1COMÂ rec
onme.dcd rcductions in iof mllk exùiÀsic n,g.s (NùIIS) tô .
nraximun ol I 0 irer cer ! of energy nnèke.
Smoki.E hâs bee. :ûtlnite.l rn è hrge nunber ofdiseâses.It
i\ erlmared rhat smokina.xuses âboùr l0 l,er .eft ofnll Q..er
drseùes ànd deèths.'lhey âi$ hâre morc pcfndoDtal dncasc xnd
odrf d;eases oi d,e ora1mu.os..
HiSh âlcohol cofsùmttlon in.r&tsesthe iisk ôfâ wide vdiery of
coodirionssu.h 6 rùsed blôôd presûe, livef .irfhosn, .al'dn,va5.u-
lù .lsde, dd .ân.ers. In !ddi.n)n, nra.r so.ial froblcna sudr is
lm,lv v,olence,ùime, and lnjùdes xk Ii.kL{ $idr bcxlT âlcohol
!se. Tr.uûi to the headolien ln.lùes t]â.ù?s of dr. jxws xnd rcûh.
Dift .â$es ln ammarn,n of drc sl.in ân.l mlcosâ. Denial
F 4ue (dift) n dre mâin.aùse ofsinsilal nrilammarion ân,l lJcLi
od..titis Sim,lan\', biolilms ofbafterjâ or dre skin, ifnot wâshed
rvay.lexd ù, plmples ard morc scrious sl.i. .ondiiiofs.
hjuries arÉ re\ponslble fd ma.r dcirhs in both dclclo|ina
aD.l de!e1ôped.ômÛie\ A..idcntal intury is rhc most imfoitanr
.au\€ ol dearh and hospital à.lmi$iof aoong chlldreû ànd loùng
!_igure 15.1 H,gh rnl aFFrôr.h
peôpLe ni die UK. [û)pe, aûd L]S The pfev.leûce of deùtâl
trum anong rLrildten ard yomg ptuple is xbont 15 per .ent.
lhisl cfifriJoa rlsii iiirtoili
Soûe ofthe rsk h.tors cluster ù srours ofpeolle. Chàns,fs ofe
of dre tdcto6 n,ir in|uen.c dic odr.6 Pcol,lc {'ho s,..r.c irc
noft likelr tu ext r dlet hish ln tâts xn.l gârs and ldv in llbre,
polyunsaturated fany acids,fnùt, aid nurienÙich foods.onrairi
ing ViradnN A, C, dr.l [, rrke les eÉr.ise âùd .tink ûore al.o
hol rhan non+mokef\ (Sheibxm and \Xraft 2000) r'he.Lrrering
offisk fa.ûn in i.dividùals ard grcufs, faûi.ula.ll dn)sc xr drc
los'cr nr.ialAroufs sùa:t.srs draiffcvc.tivc âfpma.hcs slnruld br
dirc.t.d ar dùsc$ of.nk faaors orm,n o a numbcr ofdi*asts
arJ rhc sociâlsrructu.cs whid, i.fluence inliriJurls h.alrh risks.
i.rir irr ri i li!ih-rl1,li!tïilt. Iin5
lhe e.otutni. L?.nrnalefor pftvenrlye mexsufts depetrdson rlÉ
preralence of dre diseav: *hen rLe pfevaletr.e is verr los, ard the
disearesnot \efbus. rhe retùrns (nien do nt jùrlfr tlle intervdts
rion. lo. caâmftc rbc (Nr fc. .xrics lcsion sarcd rn.rcasc\ as û.
lerel of.l..ây in a l,otulario. ,l.crcars. Ar rbc lonr. lclch of
d c n t â I . â r i c s .r o a | r c l a i l i n i g i . m o s r i n d u s r . i r l i z c dc o u n û i c s .d r c
r.adirional lrevefrive merho(ls $rch as lùo.i.le rinsing, ffofcs
sionàl\' rttlied fllornles,âf.l i.tensn'e.hiisnle Je.t2l hedrh
cdù.xrion ncc,l ftr bc Jusr,ilcd bccansc rhc cosr cfic.rivcncss ls
r o "
l ô r . - " . r . o
r - o l l . . ' ,
perio(lonlaldirase rers of rhe a$ùmtrion rha. thosefre,l is|osc,l
to develop ûâny càvnles .nd pocles ùe distiûgurshabLelion
d!^ear ldv risk.II\âr idplies sômeûe!!s ôfi.lenrifying rhose in
spe.ial need. the high .i!k $âtegy aids tô ideltifi people Nho
mây devel.,p dlseae ir the ftrture br' die nse eirher ôfa prediùne
naLkerorofan eaL11leanrÊ of dre disease$hi.h pre.edes its.ln,
i.al mdLiferarnû so drat rfioiis .a! LJe fô.ussed or theù
( F i r . l t . l ) . S . r e e n i . g i s ù s e dt o . l e r e . r r l r i e i . . l n ' i d ù â l sr t h , g h
fisk tof.l.*c nn)nitorlng âd spe.ial prev€ntlve ûeatment.
O - ., rt lr-l r L .'r."-. 'l o ) | \1 r.
intervertnn, \,hnh is nndertaken is âPptupriàte rô the nl.lilidù.I
.onccncd, who has x hia]r prcbâbilitl of liùufe discase (Rose

1992) A coroua{ is thdî those a! rsk, once meitiiled d.d .old,
rre lilely to Lreberter motl\'àred topàrticipate io ùe care o*èred.
This â$umes d,a! dre in.ervent,on is sersilive to the behaliourâl
- 1 " 1 " ) o r _ \ p p F r . o r .' ,. I É r o . . J . . r
A fù,ther àdvdfhge is drat tliose nor dt rlsl do not hale ro
ùndcrso fG'crrilc trcarmcn. linâl\'. drc high risk *râtcAl.on-
senes vêluâble resôur.es by dne.tins servi.es where rhr need d.l
potertial benefits.re likely to be greatest. How€ler this does rot
ne.e$arlly lmply thar the overJll r.riô of benefirs to coss rs
To LreNeful in pftdi.tive .ase-finding. â tc* mùr dete.r rhe
mâjority ofhish risk.hlldren ând at ùc same rinr identify dn)se
at low risk. To b€ more pre.ise. they mù{ halc liah scnsitivitl,
orh€Nire lranr with fot..rial .a.ics wiU not bc idcntiticd, as
well as d high spe.ifi.ity to prevent ex.errile dilûn)n ofthe hilh
risk groùp \aith n,bj€ùs *ho rre, i! frct, .t .omprrùti'ely low
' i \ . \ p ' r ' . f l i' i . , - | l ' [ ' \ " , , ' t
tess is ù coûsider s€ûsitn,itl â.d sFciti.iry in tcms ol r.ftcned
patirnrs shole rcst rcsulr is \rong. A .cvicw ofdrc lirc.anrc on
rhc âvailable ll(dicro6 ofcaries lbùûd !ha! none dre oi suflci$!
sensiriviry ùnd sfeciilclt_v Uohnson l99lr Sheiliàn ùn.l Jolle
l99l). The best indicalor oI fùnrre caries rn nrll! ur1s is Fa$
.aries exF€rience,bùt prior.Lseàse $ not à reliable predictor of
rùturedseÀe. Althoush the future.ourse of.tise6e is dificulr io
prdi.r ùccurâtcly in Ftri.uhr n ivrduaLs,efi.lemiological drrà
allow us to seervhrt the furùft patterns of. ies iû srrpr of.hll-
dren.o!l.l be, ifrheir cùies sarus ùlÈr rherare yourg isknoùn
This allows prediftior not only of$hdr the DMf fôr L0 yeJÈôlds
will be rer dtey are 18. bùt ofwhl.h teeth will be.ome .arnN
add shl.h sudà.es s'iu be ata.krd (McDorald and Shrilrâm
'l'hese
1992). prdl.rons allov planninA of drc numbcrs and
types ofdenral perx,nncL rqùi.cd ;n dic futurc. but not idcnriç
inE s'lri.b.bild vill .ccd rheraty.
In additn,n n, rellâbiiitl. and lalidiq. rhc.c,rc sclcnl tà.nrs
to be coûsidere.t LJeforeuddeiiâklng or advisins rhe ù\e ot a
s.kcnira tcsr. Thc rccomn,ende,l inren'enlion .eeds ro be suc
.essfùl is ftdù.ins rhc i..idcncc ùnd/oL sevc.iry or dre discâsc.
V/hen theainr is drc dctcction ofonc o. n,ore oa.l.cs râdrer rhân
Level
figurc 15.,1 \Virok pôpdâtion rpproâdl
rjsk/heorh
Aninhs,ored,omm0n I0.rùtppr00th
lr4e
discasc i6cli, o.e mùsr en{re thât the olerall €fect qill hare
more bcncfia drxr dlsadlanrâgÈsfrom rhe poinr of liew of the
child bcinA s.rccncd. the ter ùself mur be rcceptùle to the
sub1ectin teiins of nrcon'c.ien.€, dls.omfort, û.1 risks of side
eftècts.Furhcrmore, it mur be \iûpleatd cçableofrrpnl atpli
catnn fu large numbers ofsubjects (E!( ân.l llwood 198t).
To summarize, the high risk statcgl fbf preventin! .a.i€\ and
Feriodontal diseasesbas scvc.al d.asba.ks, and if relied upon
exclusjvely it canno. bc cxpcfted to make â major impa.t o! the
disease.The cùrûrt preoccutr.jof virh markcLs ofctiseasepre-
di.rtun is misdirected aid is lnlikely to t.oduce informario. of
use to .ônrrol deût.J disedes.
Wholepopulâtionstrategy
Ioitùnatelv .norher $rJtegr' lhich coûplemens d,e usc of rhe
hi8h risk st.âtegy is rhc s'holc popuhrnrn nEtegy (fig. it..1).
Thc.oû.cp$ of the $hole populario! nrategy hève beer adop!e(]
bv rhe \i/orld H€alth Orgânizadon (NiHO 198.i) d.1 nrcorporated
as Pinctncs of Hcalth Promotn,n:
. Iocus or whole fopulâtion ndrcr rhan on disebÈ'spe.ific
. Aclion should be addLcsscdtowafds the many fâ.tôs infltr
en.lrgnealtn in o.der roensu.c ihar ihc (ml envronment,
whi.h is bcyond drc.oûùol ofindlvidùa.ls, is.oddn.ive to
ln nar) ,n(lùs.ialized coLmtrics roda-v.ompMed s'lrh iwenty
yea6 aAo, denral lreùllh in child.c. and younE adùlts ls mafkedl-v
befter This improlement hd .om€ abo!! as a result ofchâûscd
noms ofbeharioùin the popuhtlonÀ awhoLe, toaedrerwidr 2n
afte.arbn in ûanda.tûiDs prâ.tices aû.1the ad.lrtioD ofthoride
b &ntrhpxre. rhe.odturseùse view, ûèt modeû denlis!ry car
taLc mù.h ofdr.ftdit bl, |iving identified dre.ànses ù.1merh
ods ofpreventbn, is odly a smd1lpèrt of the pictlre (N&lâ.o!sky
dd Sheihrm 199.,i). The imtroveme.t ol heakh âs a rcsùrr or
widcr so.ial fa.us is not .ontlned to.âries. Co.cerning the
nraj(,r cpidcni. dlsea\eswhi.h hâve decline.l drdatically dù.ins
rhc past hmdred Ieâ^, ùt.Keo$ û exdired è nunber of l".tors,

zro ts amlreorh
promorion
mdruJiv
I
in.luding medl.al t.ogre$, phi.h mighr have ().tfibùrcd û)
then re.lu.rbn (II.Kcown 1979). The .onûlbùin)n of rhc mc,l
,.à1prôfessbn, ercn immuni2arioù, ùJs quite limir€d.
The lmpll.ation ofrhese frn.tiûgs ^ thâr mâjof 1mf.olamcn6
!r dre preren.nrn olJisede rend ù follo" mxjor $.lal .hânscs.
s'hether these afe altenrions i. so.irl norms (dierary pâtterns.
oral .lcanl' nc$, .ortràception), in dre xrailabilirl oi l.el resources
(fluôri.lâred tuorhl,isle, qu.ljty, ând qùanriry of ièod) o. is a
resuLtofe.sincc.ins (l:llor arion ofwarer sùprlics. clca. wàrer,
effe.tilc waste dsposrl). There ls no rcâson why a slmilèr
xpProachshonld rot provÈ egùalll sùc($slil if 1he 1ùtrre.
Just,s the high risk \Ùa.e$ rcqùircs â scieflilic basis,boù nr
t.hnicâl mattes ùd evaluâtn,n, rhc sâme ls lrùe 01 rhe whôle
po|ulalioo $raregy. ft depe.d\ ufon elnlemiologi.nl, sô.tulogi-
.al, ând orher res€archto ldentlfy mpo.ra.t lelerminân$ ofdre
dne.ùe in quesrion. ind â.rii.q to.h.nge rheir prcralc... i. rhc
al,p.ofriate .lne.tion. In rhc casc of cùries, rhe dere.minânts
which are open to inteFenrbn arc su.qa4 consù,nptiôr âùd rl,e
froteftive inflnen.É ôftlùo.idc: rl,e disrributior ofcâries (DùIr)
deperds on rhe di{.iburions ol rhese expoùres. Altefi.tj sholc
eipon,re distributions may be the nosr rtre.rile sal.frcducing
rheFevalen.e otc,rics, bodr ni rhe pôpulartun asa $holcand iiso
spe.iil.âllt' 2niong rhose vho are ar hlgner risk. Such a snaregy
doe\ nor cx.lude the ùse ofa high risk rrarcAy as wcll, in âfFro
pri.te .ir.ùm{an.cs. The sciûrific b6is for the wholc pofùlation
*rareAy has beeû oudined bv Rosc (1992). I Ie dfuws the disrii,.
tn). bcncen .wo knids of âernn{€i.al qusrionsr rhe li6t seeks
the causcsofcases: Why do &,ne t,1, Ect ca.ics û d,is !ime?',
and die secondseeksthe .allre' of incideoce Y/h! do sone pal/
lrtar hùve mù.h.a.ies whilc in orl,e$ ir is uûcommon7 .
The whole popùlatn). !.xrcgy (VPS) àfteûps to.oûrol the
.lererûinrûs, removing rhc und..lyiûg .a!rs. Therefore, ir hâs
grert benefits ro all sccrions ofrhe popr .tiôn. Thi\ \ïas illr$
ù ed b! the Ar.line of.a.ics The \vPS atfror.h is Lrrhdv
nùrâllv afprolriate. The aim ls ù) ahcr vrial .o.ms: çhen rhai
norm is a..epred ând i.stitulionil ch.n-qeshaye o.cùûed, rhcn
reinforceûeûr of ihe bcharioùr is ùnne.e$.ry. Ikhples of {.h
ftritutlonal .hxnaes xrc rhe arlapralioD oftheir ptudn.ts on the
paft of indù!.y (ihoridate.l roothpare, IN \ùsaf sna.kt, a.d
governnrcnt a.rion su.h as ù foôd ând healrh poli(t including
iedu.tb. in sugi6. The more effe.tlve rhe basi. t.c1'cnrio. rà.
theg(rlu). rbc smalLer\rill bedÉ $bgnrp rhar s'ill rcAuire i.tli
vidu2lizcd preveDtior ârd ûearmenr
'lhe
$h.lc l,ojr!latron kiLtegv .an be Ned tlealbh. For.xânl
tle, it.ar be dne.tcd at a dcsiAnaredliaft oi tlr torrl popdârn,n
Nh ,s a school, .lisÛi.t or px( ofa dis.ict a dircted popllè
tion str2regt. Thn rehanN.llfefenr r'.om rl,e hith risk srùtegj, !r
thrt lt does not uses.feenins ofindivnh,al s!bje.ts 1or risk fâctôrs
(Slieihèû ând Joffe l99l).
The sllne popul2tion straregy, relies hervilr' ôn inre^e.nnl
llaû ûg involvi.A on drc macro le!e], MiiisÛÈs ôf Envlron-
meûr, Iood and Runl AÛàirs, fdu.atiôr, [dplôrmeni, Foreian
Affâirs as well xs drc HeàLlh Mirisr!, en.l o! a ni.r) level,
V
inreilliscipl;nary plaDnnrg: getûng te.ches, priûdy heahh \rôrk-
rh.i. eÛàrrs.'fhis iptiroi.h se6 the.gerdâdd eùablishes Dorns
For erimple, the ldeà thàr ex.esile ronsumprn,n of ugar is
Jenime.tal to heâhh n à w ell acceptedbellef and many foocl
ard d.ink mânuà.rure6 tère.e fo susar rdned' o! theii hbels.s
x pôsitive \ellin! teature. On.e dre nofm has bccn csrrblishcl.
eforts shout.t be nâde to in$nutn)nâlize drenr by a !edù.ùo. in
s{bsrhes to produce ând Prodtre the ptudrr, 6nûols on advcF
tnirg and on impofts, bI en.oùrâÉjintjdrc tro,lucrion oflov aftl
no-$,gârr xhernarive\. a.d b,v(hinAi.g edùcirion malenars.
A rommon
ftk/heclthlo(foropproo(h
. Rnk tâ.r.is lndùl. ai.r, sr.s, hfJ,dt, saokn,g, d.ohot, erer.ne,
. I..ns or {hole t)ol)ùlrri..s ,drl'lao on ilscÀ. sp(ili...nsl
. Develot a !i ordlnxred a.d llâf,f,en âU,fôàal
)ellrngs ror orat neatIn
-"^ '- ^ri ^- -^+i^-
P ' u , , , u L , u ,I d L L , u , l
1fâdlrn,nallr dental heahh cdù.ârion $is ùndcrrâk.n s'irhir
schootstùSeriûg s.hôol.Lrildrer. \{l,r rva this rhe.as€ xnd wh.r
are d,e limitatioDs ofthis àpproàchr Iû liûe wlth devel{rpmentsiD
he.lrli promotiôù pôli.y, r1rôsrrvofkinE in orxl healdr frcmorion
have in.reasingly adopted a nmrc holisric apt.oach $'hi.h
irvolyes â.rivirr ln a mngc ofditlircnt scrincs widr â vx.icry of
pdtners.Iisufe 15.5 p.e\ens a mnEc otscrings ân.l comlnci.cr
rùr r.tn)ns rcldxnt &) rhc pmmorio. of o.il herld,. Workin.q in
dris $,ar prorlde\ an orrporuniry fra.ti.àllI r. i.rcSrirc oL.l
heaLth afti!ir) iùo ôthei ûens of poli.r' and pn.rlce. Ir rtsr
enablcsoml hcildr p.o.iorcn ro rârger innùef1,rl de.ision
mxkers tu enrùe drat oml h.xhh nsks a.. âddLc$cd ar â scnior
Lerel wlthin ofgmizartuns and âgen.ic5.
Intcrr'i:{rtot?l in pnrinersl]ipi
lcti.Jn--1'oi-fi:ncl
Thc ccnnâl focls of rhe \VI lO I lealth for All 2000 aFproèch is
an inrc6eclo.ùl app'oæh (\vILO l98l). Tliis àpproach recosnizes
rhât econoFic, en!iroûmentèl. ùd soci.l.hdDges drouLd ùûderLlc
individul bchâviour .hânEe. P.omoring health r(l!ires dr
involvemenr not only ofhexhh prcfessn)nals,bùr ofall sc.ron of
societ!, ii boû public and prn.te sttiers.
A wnle rùge ofpàrûeB hrve Jn iûpôfta.t pâft tô plxy itr rlle
prornotioû ôf oril LreaLdr(Talrie 1i.1). Th€.nallensc fx.i.s ont
hexhh pft,nntre.s is hiEhlightinE rhc sigriil.a.cc and rclcvin.e oa
oral hexhh n) orhef pr)fesn).ats. x8cn.ics, ind sccror The
Conmon Risk/Heâhh Fa.ktr Appmâ.h prcvldcs a rhco.cti.il
bNir f(tr thn. xr docs rccotjnirio. of rbc in,ti2cr ofonl heal.b or

Settings
Malr x for the tnlegralo. oi potenl a sertings,targel gro! ps and acl vilies for ora heallh promolôn (Modiled irom Leeds Heallh
PrômotionSeru ce 1995).
Fisure lt.t Setiigs ,ttrôich ro ôm.lh€âlth p.ononot
Table lt..! Pot€.tial pâiinc6 i. oral herlrh promotioû
Health frtnirsiônnls,lirr er^nplc do.tor, heaLrhvlliron, thrr
!.h.arioo se,Tl.es,nr exrmFletea.he., s.hoôl gorenor,
Localaudrorirt lalï, for eramflÊ Lare*, plùning .lclarmenrs,
socialvorke6,.arerns raft wnhni.âr.houcs,lo.aLpo!,ti.im\
Volunrart'se.to! lor enmDle Ase Côn.ern,Prca.hool l€ar.ing
Àlli.r.e, T€rren.eHisg 's Îun. À1ûd
Commer.eand indu$a,ti,r exanple foô.lrctailes, food rmdù.
es, &laeftisingi.dù$ry, Nrter it.lùstj'
covenment, kr.al, rrtn,.ll, rnd intcm.rlônal
stagesi plalrilirlEan oral heâlth
Prornotrorl sll?tegy
'ro
tromotc o.al health àrd re.lùce inequalitles rcauires r.ô.rdi
Da!€d and tlanned appnra.h. À.1hoc intertettio.s are u.likely tu
b€ eliècti\r and arc theren,.e a çâste of p trblic resontces.Àr a lo.a.l
disricr o! na.ioml level the planûing cycle ou!lines staacs in rhe
plaDnlng proce$ (r'isure ij.6). Erch ràge i! the troce$ shoùld
lirk lo.qelhervirh drc next rc.Èate a côhesile plan ola(ion.
promolion
for0r0heohh
Serlinss 0di0n 251
Târget
Group
tlre nee^ of tbepopûlatior
Stage1: Assess
It; €$enti2l rhat xty rtuesy should addres the needs ot rhe
poFùldtion it is aiming to dsist. tn dic IIK a great .{eèLofvâlu_
able infomarbn is w.ilable on rhc oral health teeds ol dlc PoPu-
lat]on. Brnish A$ociarion for dre Stu.ly of Commùnnl' Dentisûy
(BASCD) sun-cy results ofdettàl healù in 5, 12, atd L'l yed. old
child,e. in a dirfi.t pro! e somc usefùl indicètro.s of oral
heèlth reeds in the.hild pôpulation. Vcry limùed epidemiologi-
.r1 dàta are availablc. howevet for dre adult populatiot èt dr€
lo.a1level. Nâtional o.al hea.lthrtv€ys ofdrildrcn dd âdn1tsin
theUKhàle been co.dù.ted over the last l0 ycar. whi.h Protnle
ùrefù1data on dre changing ûÉnds in oral heallb 2crcssihe PôPù
Iaitun. Normative :sscssments of oral heakh, âlrhoùgh lery
impoftànt, providc only a.lini.àl pesfecrivc on dre needsofd,e
|ofulâtioû. Odrer itdiQtors of.ccd are a.lsoreq'rired to cnsll.e
rhat a btuad !ie{ n taken b determite the prio.ities ol dte
])opùhrbn (Tàble Lt.i).
SîaEe 2t set go.1lsflr cbanse
goalsàreprerequisires
Clearmeâsunble f(trPô1icylfyou do not
koov whcrc yoù want to be, you will not know ùheD you harc
èfived tb€.eo. b dre bestroùte.A.bicvableor desirèbleLevels
of
heà1thproridc plâùsibleûeN,res iôr aoal seting.
252 promorion
I5 omlh".ohh 0ndpoli.y
|
STAGE1
ASSESS
NEEDS
STAGE4
II\4PLEI\4ENT
Fjgure 15.6 Pta..ing.y.le
Tablc 15.5 Iniormâtiôn ftqulrcd for ao onl hea.lthpromorion
. Cl1ùcalovei\'iewolparûrs ofhcâlth md disede
. so.io-dcmôgr:FhicDo!ùlatiôr prolile
. Key daraon orâl he"hh determinds nr popùlarlon€.g. NMÈS
consuDpùon,smôkrngnres
. Eaistinarelciant !ôLiL_y
iririar'ves and servi.etrovison
. Resôù.esâvâilable,cg. !e6ônnel, tnâ.ces
! ?ubli. .oDccns .nd denâf,.]s
Ar ôverallofal heaLthgoalis tô a.hisc
a natrral, aunctiôna.l,accep.abl€deftition, which enabl€san
i.dividùal to eât, spak, â.d sociàti,ewiihoû disconfort,
paio,or enbdrassmenrfor a lifetime,and which corûlDùtes
ro gener well beinA.In factie terhs that k, drerer€nrior
ihroùghoutlife ofà fû.rional, âesheric,narû.I dentirioo
of rôt lessrha. 20 leeth ènd not rcquûi.g recousero a
prosthesis (wHO 1982)
Goals tor acceprâblelerels of oral heâlth s'eit pLoposedby a
sroup of Chief Dental Officers frôm Northe.û Europeàn
Counlries(Tâble ij.6). In addltlon, d a..eptablelevel of ônl
healdrwoùld inclùde:
. Salisfàctoryprosrhericreplacemenrofany missnA deniàl
unit which obvbBly derructsfrom ae$hetics.
Tâble I t.6 Suggesiorsfor dceptablelevclsof denralhealthby
ase (WHO 1982)
ÂC" Meân no. of DMF
missi.g r€eth
0 reedrvldr lockcs >lmm
rt Lr r.'h $ rlL p! k{s >lron
0 Éerh vldr po.k.s >l mm
)144 t2 Iewer than 7 Éedr 0 teerh wi.h
I2
. FreedomÈo'n pan,.
. No ura.ceptabledeposirs.
. No urdceptable in!.;nslcanomalies.
. Ân ô..Iùsion. which is functionâ]ly and cosmericauy
Gôd! for oml heahh can be eipressedln terms or healrh,
disease,
bealdrpromorion,and trèining:
. Orâ1heâlrhcoah. ror cxâorle, cariesfreelevels.
. Diseascgoalssuchasorâl cd.errares.
. Heâlth promorionAo2k like developmenrof heâ.lthypublic
pollciesin nuûirion.
. Thinina aoah,rô. exûple, skillsdevèl{,pDentofwo.l<fo.c€
Stage 3: Detekp an action an.J mal ation plan
B.sed upon dre goalsalreadyset,ar àctionand evalu2t;onplan is
requi.ed $ oudine th€ scopeèrd derail of dre sr.aregy.Based
upon the prin.iples oudine.l above,it is e$entia.lthar a broad
ranaeof complemertaryerbns a.e ircluded in any orâ1healù
,ôr.ii.'.,tu,!g) Rd'.1,F olellolh 'l -.JL r,o' ",e^-n
tions is unlikely to produceany strràined lôngrerm lmprore
ments in oral healrlr. The approachesoùtlined in lhe Ortawè
Chatcrprovide excitùg àûd innôvatlrewaysro racklerhe ùûder
l).1o8 determinann of orà1diseasesin sociely.Ar imporrânr
elementin lhe action plàrning n the idcniiÊcalioDof potentiâl
parrrersard èlliesfor change.
:fhe evalùationôforal healrhpromorionhasbeenà æglected
.rea ot pnciice ior mary yeàs. ÀssesinAdrc cÈectsoainrerven
rionsèrd proridin8 feedhackro Fructlrionesand the population
shoutdbe coNideredascoreelemenrsin any oral heàlû $mresy.
Qualrty evèlnàtionreqùi.es adequareresourcesànd peBornel
with the nÉ.essary skills and experience(wHO 1998). Heahh
prôûotn)n erâlErion cao higlJight changesln a mnge of out
comesreleva.r to the acrionsimplenenred (Nùrbeam 1998) In
oràl hea.ltbpilmorion evaluatiorè vârieryôfourcome measlres
can be uscdto assess chansesâchievedar dilïerenrpoinrs ir the
process ofinrplcmenrâtior(Vatt er/. 2001).

St.'ge1: im|lement Plan
Only ùhen the first stageshavebeencompletd shoul.l imple
nentation commerce.Iailure to tully plan où. the interlentiot
invariablyresultsir è disèptojDtingou(onc.
Stage 5: eMhnte and re,ielL'prasres'
Evâ.luarirgar.l relie\ring rhe olrcomesofdrc sùatesyidtntifies
su.cesses
ànd faiLÙres, both of s'hich ârc impoftant tô .onsnler
ruDIc neattnapproacnes Locafles
and periodontaldiseaseprevention
Food an.l rutiti{rn poliL} r.J reducenon-nrilk
ertrirlsicsçgarslevcls
The nèin etemens of lood and nuûirio. poli.y are:
. to ensure rhe adequacy ol dic natbnal die. in ierns ofits
qnmtity, qùâlity and variety a! affordablc pd.er;
. to ensure ènthoritàtive experr advice to Govefnnenr,
food pro.tu.ers dd mènufàctrùes, the publ;c, hospitals,
nùseries, s.hôols ùd i
.
e, cive ppôrt ro heàlth and other proièslonals;
. to provnle idormation àbout i.dividùa.l foods in.ludiig
. to hôûnor Ûends ii disease, health, nuùitional raûa
. ù, unde(ake reseârchto estàblish asound scienriilc basisfor
The prln ipal objective is to implemeDt locally deviscd lood and
^ concerredser ofactiors basedon s.ientific prin.iples ànd
inrcndcd ù ensûe the safety ard the nùûnionàl quâl'ry of
rhe fôo.t slprly ard dre âcce$'biliry of sood, affôrdâble,
aDdprop€rly labeled fàod for all popùlatbn groups, as vell
as to ercoùras€ and ràcilitarc rhc bealthy use offood. Such
pôlicies de more likely to srccee,l vhc.c thel ftIle.t à
.onsenn6 betweer àl1the parties concernedwith.he inteF
er ôfrhe popnlètior nr the forearolrd.2nd whcrc.hei! is
sovrrnment iûvohemert and sùpport (\flHO l9t0).
There are a rânge oi possibLc rcles for sovernmett to promore
hcaldr rhroùgh sponvEd nuùitior policies and progmmmcs:
. development and use of.ôst efficient mâ$ stmtcgies in
nuùition edu.Ètiôr;
. .
advo.a.v for resulârion ôffoo.t $a!.tards, nut.ient labcllns,
. .
fdma.nrn of inieBe.torâl mechànisns beN€en sovemmcnt
depaftmens, NGOS, and the prlvâte seclo. to promot€
nurr;.bnal .on.erns in policy mâking, to coo.dinâtc
etrdrs/avoid dupti.atior ard to coorlinate desire,l chargcs;
Publir
heolth
opproothes periodonr0l
totoriesord prevmrion
dheose
1253
. bsidiesrà. pfmârr fôod itdùstries to cn.oùrasePro.luct
' F \ - . o p n' ,p! i \ ' ' . I k , r \ ' . e _ ' r r . - t i l , . .
. develofmcntofpoli.y andaùidelincsfà.dletûy Pr.cticein
governmenri.stnutnns serlins foo,l (schools.Llosptals,
prisons.olti.c.xntetns, ù.nr);
. honer brokerÈge' of i nfôrtuatn,n:opposiùgmisrnbrmarn,n;
. .telelopoenr ofand paiticiPàtlon in a tational reseèrcli
$ra.egy in nùûitbn; at.t
. traininc of hcalth persoùnelin oinimum standards01'
ûutrltional knowlcdseând ski11.
. dlscoxrase imporatnrn àt.l mùufaclurc of susâr èn.t
sugèÈconlai.inapodù.B, pa(icularLyco.fc.tbnery, Lris
cuits, bâbyfoods,ând soli dnnks:
. , l - l o rJ ' . e r . . r r . ; u r r o l r ' o . ! e " . $ i ' * - d
a sa m a t o rc a s n . f o P ;
. removeâll Nl{E gâtsfron iniao! and babyfôods,paedi
Ètricmedicines,fLuit jùi.es, ùd vitaml. prcparâùons;
. rednceûe levelsof NùtE $gas in coûmo.ly usedfoôds
aûd màkeavdilablcmore ga.free foodsl
. ie.tucethe NNIE susa6 .onient ôf conf€ct;ons
ând drinks,
ard màkeavailablcsùsaFfreefoodsând sràcksand drinksl
. devclopa.aterinc pôlicy n schools,.olleges,largein.lus
ùirs,institutions.Thcpoii.yshôuldensùredrepro'isnrnoi
foodslow in NME sùgarsl
. irtroduceao edu.a.b. pô1icysresing lhar NÀ{E sùgd àre
drenntrient.lensiryof foodsl
ntrùitiôtuily Foorand,lccrease
. .onÛô1àdv€rtisincâ.d mkleading1Èbels
onproducts.
Policies to i pr,lve peri.]do1i1âllerltli
h â recenr reviev ofme.hani.al ôràl hygiene pfa.ti.es, liaùdsen
(r9E6).me ro some impoiiant.or.lBbns which liave imPli.a-
Inrns fi)r public heà]th aspcctsof periô.Lontaldiseæe.Thc tun.lù
. Thcft is nô scientific ev;dence thar one specific toolhbrush
rypc and desigr is more slperior at removiûg plaq!€.
. The nnl rechûique oftoo.bbrusbiûg is the le.st effecrilc in
removing p1a9re; no single method wa r,perior to odrer
. lhe optimal riequcn.l. and rariiûg age lor scalins and
|olishing har noi been determ i ne,l. Thc 6-nonth itterval is
unsubstx.tiated aûd is too Senenl a re.omdendètioo.
R€aula. ins.fùmettàtion dnd poLishi.g sln,ùld tôt be caried
oùt at diseasc-ireerit€!.
Th€ role of.oot planing is qùestionablc.
. Scalins. folishlng, roôt planitg, and surEl.al ùeâtment ol
shallo$' periodontal po.kes resù]ts in pcrmanent los of

254 pronroliof
i5 0rolheohh ondpolky
Slr;rtegiesl'or û!ntrilll ing pLrriodoirtal
disrâsrs
Alrl,ough seve.e Feriodonta.l di\€xse is .ot s'idcs]'c2J, d,e tær
drar rl,c cors ol ùeatirg tire.lisense xre hitjh bccâuscofrbc orga
nizario. ol.leûtulare, does qùalift' it 2s a dcnrâll,!blic problem.
In addirio.. d,e srmptoms oiperndonral dlsca\cs sù.h âs blccd
nrg, halirosls, r:rinsi\'il rece$,on, md tôoù Losshare an impa.r
on n,any Feople Inithermorc, ic h,r sutlicien! i.lomatron to
conn ol rhe common foims of rhe discasc(Shcihân, 199 l ).
lonr straregiescd be.onsidercd:
. popllèrion srâreg!' fir alrcrina behdrionn and ii particu
lar ôral .leanlnE etfe.rilcncss ro .edu.e the dertàl p1èque
leret ofthe .ommLnitr.
. se.on.lary pr€'efuion srLaregy ro dere.t aDd trert people
with destn,.rive perbdontâl discâsc.
. hlsh{isk *ratcAy lor b.i.girg preveitive and drerapeori.
cire to ilcuvi.lna.ls a. sfe.ial risk.
. combnre.l popdâttun, se.ondary prcvc.tion an.l high risk
The high rlsk rnrcïI reens people to i.lenrify those ùirh
una.ceptubly hiAlr flaquc scores.E flè.tile periodôDrâl .afe iôr rLe
ligh risk ln)rps n diill(uh ro dchiele and mdnraiû drd.osdr nr
tide and fc(rùccs. A lopù]àrlon srèregr aids o redrce the
plêque level ot rhc wholc t)of!làrion; ùoviig rhe .lisûiburio!
curve to rhe 1eft. Sùch a srratcAy sâvcs morc reed, rhà. ) high
fisk onc. bccâuse,altholgh high risk people l(se ùE tcerh pcf
pe.$n. the.c a.c more lo\a thar high risk people. A whole popu-
hrn)n s.arcgr, bl iowenn-q rhe oleràll phqùe s.ore. redù.es rhc
nùmbfl of high risk people. A se.ondary fG'cn rion str2teAy âi ms
to neat all tlesons wùL slgns of eafll ])c.hd.. t2l I ise,sessuch as
ginAn'iris ànd sh.llo$ pern onral fo.kc$. Cutrcnr concct6 of
Frio.lotrtal .tisedes ànd thelr rlîxrmcnr .ctitred ro earlier, cas
serio!s dout\s ôn the jusrifi.arnrn ftr e.h â s.arcsr
Thcpfulàrion strareAyismo$ likely ù, benetit drepcrn)dorhl
hedlrh ofdre majù1ff ofpcoplc becaur r rnal reduftion olerJll of
tlà,lueterl,eJrwill.edù.e these.cml lc(l.fF.iodo.ràl disede.
This sboùl.l lead to drÉ exÛx.ibn of fescr rc$b rhan if rhc bulk of
resoùr.esn cod.enùated on â sinall nlmber ofhish rsk peolle or
oû ûeâriru a.ll rln)scsirh ci.h signs ofperiodonol diserses
'l
Figùre 1i.7 ùe lood health poll.I Draùix-x fm.$'ork for idc.rirt'nrg trjornies lôr tr.môi iô. .f he,hhie. eiting (Sr.de6od I 98i)
t
(osestudies-heolth
oolities
. Iood ind nnûnion !o1,.r b redù.e n.n mliL exûim. Ne l{els
r Pùrdati.n srarèsr' ù ftdu.e rLr denhl plaqtu leveL of tl,e
' Se.ondâryprevention rrategt to dete.t ind tæxr peolle slth
J.srudnr Fe.iodorLd d jscÀ\e
P r a c t i cea\l a m p l eosi o r a lh e a l t h
promotionusingthe CRHFA and
OttawaCharter
Fooalin nuaseries
Rarhcr rhân fôcusing of ly uton caries preleftion, a. ùlÉûrtlle
appmâ.h is dic dcvcloli.rcnr ofa holistic .u.irio. |.og.àm,ne,
whicb âims io imf.o\a dic orcrall .ucririo.al starLr oftr€rhool
chil(lren. Such an approach will not onlr re.l!,ce nor nilk exrrni
s. srsà6 cors,ûprioD èrd hen.e irpiole ôràl heâtth, bur sill
àlso lmprove the overrll ,lrr.lit! of pres.hool .hildren s diet, and
thereby promote then gro$th aû.ifurûe developûenr
TIie range of pôtrntlâl paftners lnvolved in. pfts.hool healtn
promotion nutririôD prognmme is outlired ir Iigure 1i.1,
t.acdrcr wiù drc \.ar'ôus nffions thàr n,rv be àdotre.l. A {iie
rânge of\e.(trs aft lnvolved i! the food.hâin all ofahom h.r a
poteùridl rô1e.Rdrhe. rlhr only foor anentn,n on the consumers
of foô.i, tL$ approx.h re.{r€nizes the imp.ftan.e of i.nùen.idtj
key groùps frcn ibod produccr. ro manuià*urcr ro gorcmnrcnt
deFrnrcnrs (sandcrson 1984) Hcxkb cdu.ario. là.N only onc
.onrFrnc.t part.i rhc ok.all pmAr2m.rc. and can bc ta.gcrcll ar
i .angc of i.lluc.riâl fânnc6 ând frofe$ionals, nor only dr
fùbli.. Odrc. .omflcmcn râry icriô.s.an id,lrc$ cosr 2nd rccc$
issuesln relârn,n i, nDd
lf Bra,il food tolicies i. stÀe nù&ries hrve not onl! n,bstan
tiâllt' rcdùccd ùaâs consumption 2nd i.itrorc,l dic nuùitionâl
qùali$ of dre dicr, hùt su..c$full_v rcducrd ca.ics i.c.cmcn6 orcl
2 onc ye2' fe.iod (R od.iaues rt ,/. I 999). The cate'ùs siaff we.e
allocaled le$ sùsar lôr cooklrs and bakirg ard narùral Irlr

nLgary.{rinks.SimilarfoodpoLicyguidelinesh:vc
d.inks replâ.ecL
bccn irtrcducecL for nursenes,childtc. i. .are an.l res enliâl
homcsfor oldrf peoplenr Bntain (C2dhe \X/âlkerTrust l99ti
Ca.olincValker Trust 1998).
l kâlt} prornotingscirools
\, F,.8,,1 . '" t,,b F.'1. robe' ',
traùmâ to tcûh and jaws, shich is bolh exF.sirc tu ùeat àt,] has
'Ihe
d considcmblc impa.t o. indi',duals' quality ofli{e. causesof
.tenùLly reld!€d ûau,na i. .hildreû is acc ens ât school in reLè
rior to lighting, bullyilr:i. and spofts. The indivnlùalizcd xpprcâ.h
to pre'enrion oÊn âu.ra b front teeth is tô treât chi1,l.c. with pft)
Ûudirg teeth blofthodo.ti.s or€n.oûage the !se otaum Eùards
lhis âpproèch has hà,] â minor cftè.. on preventhg taumâ.
The WHO Hcalth Prn{tritg Schôols programme offeÀ at
alrcrflative approa.h to tâ.klinA drc ffl,blem ot dettàr ûnuma
âhôngst adoles.ents (NIoFcs .t rl. 2002). Such ân appma.h
focusesùpon the iniluc..c ofrhe vrial ând phtsicar env'rc.nent
on beahh. The corcept of rbc Hcâlth Promôtitg Sdrool tlâ.€s
cmpha\is ùpor developnrg a rang. of.omplemÉntary policies ând
actions t,promote the heelth aDdwellbcinÉi of\trLdens, statl, anll
rhc widcf .ommuûity inlol\erl ii rft schoo\. A Htdlth PtuoarntS
Sùaal ûn h.hàfa.tuizd A . !.hù/ ùrnàn4 nft"{thoti,! ! ,aldc
x1 at a l:ubLt ttiu fu lrnry, /umt"g. n"d uûLinr. In rclûj.n ra
a.idenû d.l the preve.tion of dcnral tftùha, . wûe û.8c ot
àctions an,l Flicics are po$ible (l,ble lt.7). AU drese depeûd
lton collâboratire workitg bet$eeo vâtf. stùdents, parents,
ducarion autlntrliies, 1.,.â1golernùent and hcâhh ptufesionals.
'lhe
role ol'derfistsin ryal heallhpron]otiolr
ùIost dental public bcalth otli.er ln!ôlvemett will bc as hea.lth
advocâtes.Health advocaq is ùe tutbns ôfhealrh f.otc$n)nals
Table 15.7 Prevcorion oforal injuries dùough Hcalth
. PesoreLând y,.ial edûrtiù rincd âr derelopinslifÉ skills
fo.ùs ùlon.onfli.t rÊnntrtiôIi,dealingenh reLa.onshitf,rôblens
. ' o . lo o l , d d . C
. SchooLpoli.y on bullrinlr rnd vlôi.n.e berseen$udÊntstô.r..tc
a Nploûive $.irl Ênvirônm.ntwlthnr s.hool
. Phlr.al envrn,nmÊnt phy ùrcrs,slors teLdsall m.nn.re,l lor
. S.troolhealih troll.y reR,ùr.e\lnd t.nring fot s3Éin fint aid
. Àl.rnd loli.l-re*i.rion on âl..hol ..nsumltiot sithii s.ho.l
' Pn,vi\n,ùôfmoùth guards-..e$ible rnd:ùTôrd.blcspotrspro
. lnrks \elrh healù se\1.es Fn,Leddestor cmergeD.trrftrment
.' l' .--n,:! J" ' ,l . .n I
I
[ o n ( u i o n sl 2 t 5
I
ard odrc6 with pei.eive(l auihofit-t it heallh, to inntren.e die
de.isions ând tutiôts of i.dividùxls, .ômm!ni.i€s, and golern
me.rs'hi.h influet.e heal!h. Hcd.h xd!ôcà.y inrolvcs edu.xting
senior aovenrment ancl conmunity leâdeis aod iout.alis^
de.ision mâkc6 in genetal, âboùt sPe.iii. issues. ard seû,tg
iheagcûda tu olrtuin tolirical de.isioûs thnt,mfrok heâlth ofthe
population. To incrcaseefte.tivene$. 2dro.xtes *ork within thc
domiùn1 pbilo$phr jt pubhc he2lth, nxneh, Lruilding tiarneF
ships wilh dic conduûity, odrer prote$bûâl groùls. a.d oiher
se.n^. They tlacc rheir skills at the disy,sal ofthe communitl:
Bcing.n ràp rot o. tot.
Dentists must be.omc ream membe6 in adrî.n.y ancl ed!c2
rhn ùôrkirg \aith orhcf ofgxûizatioos, govcffment sectos, and
virh .omnurity orgarizarbns. TlIe role ofin,lividul prdtitron
cs in prerentio., is limired. PnbLic herlth dcrtlrs shoul(1won.
as heàjtl, rd\'..ùtcs and.o oi.lin2tc lo.xl healrhFromoùo. i.tr.-
ti\îs by tiN esablishinA â lo.al OraL tsleùkh Pmùtrnx, CroùIl
(OHPG) ro deleLop an 2ctn,n p1d, lsing goals and riâtegies as
guidcllnes. The) aDd orhcr healt[ promoters shou]d "ôik Nrth
indlstry b imptule key pro,lucs (str.h as lo\t s!gâ6 and sr8lt
"e. l' 'r lJr,,t C,'l.r, ^., i{,.1,i-!o' al
.ction. mosr notably dereloplnA poli.i€s o! sugàr Fto{lu.ùotr ând
prômolion, saic! envirônmen.s to cnhan.e socrèLcohcsion and
re.lu.e violencc md a..i.lens.
proctitioners
Denlol :hould;
. n!.rinria use ôaarÀilxblenaaf, lfcludins denhl tl,e0tiss .ràl
heâlrh troinorer, and hygienist atd orher Lo.ÀLresour..s, i.cludif,s
. dareeô. lo.J ,nniaiives, !med, tor emmpLe,:t ihosc Î Pir,.ùLrr
risk ol.hron,. dn.é.s or rhorÊr'ho mry Pro!. Farri.ùlàrlt rtr.ePti-
blÊ to behrviôùr drdige (e,B adol4rens)
. agiee.n d 'nclrs lor rsesing, É.o inÂ, ânJ nodtoring di.t in tlre
wholÈ !ra.d.e topùûon,
. dèvclo! nrns for rhe,lelnlry oa.llÈ.drÊ.omsetLiq{ rolF'.ôte
. agreèot rù4tes wbi.h sill ali.rv th.s.ln ti.e based,ntrr'.v.s ro
\Irirhiû dre health se^'icc o.al hexlthpronole6 slnùld be â.tlve
nr th€ tiâininA of other trimary health càre won.cN (indtrding
deûûl) ând .are $trkers oùtsilc rhc h€alth ser!i.$. Sul)toft {û,1.1
be Aivcn to .xre6 in the loùrh cd(atiôn and welàr \eft , 6 Thn
shoulclinclLtle thc prcmotion of oral hcalth of individual won.cr,
as thel ù.e unlikclr tô ac.ept tesl,onsibility to proùore aood orxl
heahh habits in rheir.lieDts unlss drey âre supPotte,l ir tbeir
efftrts to a.hiek sood ohl heâ.Lthfor thcnisclves.
Conclusions
The ûri. .câ{,ns fôr the drà.r2ri. de.line in d€.!âr carles,n
n,dustfialized .ouû(ies ire .clared môre to beâkh PromotLoû
 -

I
2 5 6| ) O r c l h o opl rho m o im
ondp o k y
I

rhin ro (lental services {Nadanovskv and Shcihim I 99.1) A ll pre
\'€frive ùeùnires requift e.onoml., $cial, in,l lDlirical sûaÉgies
ro cns!r their a.ceprâlce, inptenrcnrarion, a.l etlècrive.e$. À
tùblic orà1h€alth sÛâterl dlrc.tcd ar..ducing dre.ons,mprior
of n,Aa6, and prôdotinr sarcf ilù.ril2rion rnd nùoridared
nxthFsc will red!.e the prev,.len.e of denhl .a.i$ t. . lcrcl
where i. *ill be an irsiAniti.ànr frobleû. The poli.ies and ronÈ
mlrity heâlth ptumorn). prcscfrcd here hile Lreen Ùideh
accetæd b) inrerûarbnal. râtionâI,2n.l locùl groùps ù NeLl .s
publi. â!d.onrnùnirr hcalrl, tracririones. tsy âdoprn,g â h€âftll
prôhoin)n, ()m.ron .isk/heùhh fictor âppioâ.h ând lnteErâtina
orâl hed.h i.irh Acncrâl heakli policies, poli.ie\ ù) pn)motc orâl
hea.lthshoùld bc(o,.. mo.e ef]èrire ud efficient. What is nrc,
oral trcalrh sill cease!o be mùgiùâlize.L. Denris6 nùsr bc.onic
read membc$ in advoca.y ân(l edu.Jrio! wirh orh€r orAâ zx-
' i o , ! ô . ' , ' , . . . ' J " l o ' , ' . . o r €/ ." .ô
References
Bros'n, L (r99.:t)./idfut, it ùûal liùlrb dt.dt,n n"d tuht
lflnatrr)efttuu al n lhtuhrt Huhli Edt.dio, Qxdietlt,
2 r ,8 l r 0 2 .
Buff, M.I-. and llwood, Pc. (1t8j). Rcsca..hand (levelop
ment of health Fromorn,nservi.cs s..ccni.8. l. Od,f./
'[t\tbrak
rJ Pttli; 1|ùltlj, Vol III (ed \Xr.W H.llârd. R.
Detelsân.l G. Knox). ft. 'l 84. Oxfoi(l LlliveAùy Press,
Carolne Vèlker Trtrsr (199i). EÙi.E $'cll tbr older peoFle
Prafti.xl ddd .uùitio.al gùnlelnreslor foo.t iû residenriâl
{rd nuÀi.A ho.rcs ,id tô, communitymeâ1s. Repoft ofxn
exper wrklna Arout,.Caroline\7.lker Tiu$, London.
Càrôlnre Walkef ïusr (1998) N!ùitloral gûideljres fôf
û.ler 5 s in .bild .àrc: Reforr oaanexFertsôrknrg grotrp.
'liùr,
CarohreNà.lker londor.
culyer. ^.J. 1t993). Eqtb a,l Hdtt Catu P',lnt. A
Di\.b'n t Pdrtr. Rcsc..ch à.d Pol,.y Group, Preûief\
Coulcil on Hexl.h. Wcll being and So.iJl Jdri.e,
O n r a r i o (. ù { i m . o ) .
f.ândse.. ^. (l9ilO Nlechani.rl or.l hygiene ptu..lses. In
Dt"tdl Pll.ttè ù"tol ''tkt! url Atul Hyt;t"t Ptd.ti.u.
( H . L o c ,a n . lD V K l e r x n a ne d s . )p p . 9 3 - 1 1 6 .I R r P r c s s .
Crxhâm,H. (lr)9{)).Behavi.g\rell: womer\ hea.lthBehavnNr
in .o.fexr. Iû Votdt'r HLdhli alr,,n (fl t{oberts ed.).
Rourledge,l.ondoD.
GrÊcn,L.\(rmind Kreùter -N{.(1990) Heahh p()mo.ion xs a
fùLrlic liealthsrrareslfof the r99ttr. !\rrwl Rù'Et oJPtth,
llùlth.II. )79 71
Joh.son, N. (199r). Ri'h t6 li aht Dttdp'. Dùtdl
Cûk! tltr^1.ûi ùl Hi::h nnl Lù'RiiÈ GMF drl hJ,,ltdlt.
CaûbridgeUnnersny Prcss,CâmLrridge.
Kau L. ènd Locker,D (1996).Is dertrl hedlthrdu.ârn,nefe.-
ti!e7 A sr$emâri. relieù ôf .trce1r e\iàen e. LuùtnnitJ
Dnirrj arl 0tu1Lljie"ritlog,2l, 2)l ]ii.
Kay, I dd Lô.ker. D. (1998) â sJttuùt.t RojL! rl tht
EIIdik*\ aI Iltaltt P,ùt|tiat AnMl at Pruhnjut od
H"7r, l le2lth Edùcâton Aurhority,I-o.do..
Kiieger, N. (199.i). Epi.lemnnotrrxn.l dre rreb 01 .rùsatn)n:
lràsrnr,oneseeùdre spidert Sù;.1S.jùrJ a"d ]Itdib|, a9,
88t 90t.
Link. B.(1. a.d Phelan,J. (lr)9j). So.iâl .ondirionsâs tun,l.
menkl .arLscs of d iscasc../.H hh, ù Bûàrjor, lL\tn Iss[e),
80 r"1.
Nfafmot,ùL and \Yilkin{i.. R. (t999). Sa.i,l DûMrrtdr^ aJ
Adlir. Oxtud UniverslryPrcs. Oxfod.
I l . D ô n a U , S . P â n d S h e i h r û rA, . ( 1 9 9 2 ) T
. h e d i s r i b u r i o ûo f
.afie\ o. diflerenr ûDrh surià.cs ar ra.ri.A lcvcls ol
.xfies r .ompilarn,. of datx fon 18 t.cri.us studics.
Cùtnt,4 DtùiIHqhlt,9, :9 aa
À{.Kcos.. T. l1.r-9). tLe Rah aJ tl,ltt,r. B6il Bla.kqell,
} l.Kinlay.J.B. (1911) A casctô. retoc.!$ins upstreaF dre
toliricâl ecofomt' of illnes. Pro.eedtrgsoI dre Americèn
Hea,t Às$.iarh.. C..lèrcncc .. 2fthing behalioràls.:
e ! . e s t o . a i . U o v â s . u l arfl \ k , p p . i - l r , A n r c r i . i r H c a r r
A$o.iùtlon, Seiftle.
Milio. N. (r986). Ptunorng lterlth Thtor[b l'tll1t l].rt].
CanadianP!bli. rreilth Àsoci.tioû, Oft.wa.
Mrlio, N. (r987) Hù]llt) PtùL, Pùli,J: l!rù,' r,l Sft,trir.
(-,'lo , ',H.1 1 1 ,. \ , 1 1 , , ,
I l,
Nlilio, N. 119881.À{rklng heèlthy ptrbli. poli.y Hrlr,
P t a n . t i ù n , 2 , 2 6 1j 4 .
ùt.,ysés.S.T.. Nlo).sis,S..J.,Waft, R.G. r.d Sheihàn,, A
(iû prest. lhe impa.t ot healthpronntbn s.hoolspoli.i.a
on oral healthoI12 lear olds.Hùllt Pû|btio, L]tdniiontl
Nâdâ.o\5lo:,P ind Sheiham, A (1991).The 'elalile .onûit\r rlon
01.leût.l seNrcesto rhe chaises ùd geôsrapLri.âlwûiârbrs
nr .ùies stJrusoi t aùd L2 veaÈôld.lildfenin Eiglxlll dd
\V.lesi! dr 1980s.Crr.r,zr;4 Dûtu|HtuLb,ll,2lt 221
\, 1.1.D. r^c. lr..r ' . I' r,I i a p. , ..
problÈmsând nntrtbions. HaTbLPtutunit)"lûa,àù,nal,l),
Rodfisues,C.S.,\\raft. R.G.. and Shc,hâm.A. (1999).Etlc.ts
of dletor gu elineson ular ifltukt and dentaL.arc\ rn
I reâr ôlclsâtendln! nûsetie\ inBt^z\1. HtrbL Pù, ùr?
Intutnntr,tdt. 14, )19 at.
Rosc. G. (rr92). I bt Sî.k{ rJ PE'ot"t ^4'rlrr. O:foi.l
UnnarirI P.c$, Ortord.
Rùsa-Gùnn,A. and Nunn. J. (.1999).NLttitjo", Dit d"l Ot?!
Hs,rr. oxford Ilnircni{ Prc$. oxfàrl
Sàndersor,À1.[. (r98,1)SÙategies for implementiig NACNI
reco,nmerdations. kr.?, 10, t3i2 6.
Sheihan, A. (r991). Public heàlth:Bpecs ofperiodontal.lf
eisesnr,ûape.Jorthl afal,]ùl PetioJù,hlùs.Ia,162 9.
Shciham,A. (21)00).lmfroving onl heàlthfôrall: fôcu$i.8 on
dererninanB .nd .ondirbns HuhL Edxtàùi Joenà|,59
tt1 61.
Sheihdm,A. dod.Joftè,l!r. (1991).Pùblic deûralhearrhstrâle
gies 1or dentilying ant conûollirg denral iànes in hrgh
drd iow risk popùlatiôrs.Iî Ri\k a*d\ lb Oul Di\t\t.
D.iîtl Crti6: f,Ia&d\ 0J H;rh nid L\L Ritk Gnx!\ .xJ
L/trâlr Vol. 1. (ed N.\\r.Jôhnson)pp 1.1t 8. cdbrldge
UniversityPÈss,Camb.idge.
Sheiham,A. àrd Vàtt, R.G. (2000).The.ômôoû risk factôr
ap|roach: 2 ritio.al ilfroâch lor troùoti.A oril herhh
Cùî"nx,j4 Dtnrin! anà Otul Elidun,h$,2a, a9t-706.
s.hotr, l. ùd Lo.ker, D t.r994). OMl tulth: A Rtriù ùf tt.
L[e.ûw]ù 0[Hùhlr [.drLaùn did HuhÀ Prûbti,t.Du.h
Cenûe iù Hcalth Pft,motio. and Hcaldr Edùcation.
Sprcd.À.. Â.deKrn, R., a.d Itcasntc. E. \r1)t6). E|I.ù,t udl
hhhh ln ?olio".t,htdhîe Rai'!, Healrb Pron,otion \Iràlcs.
Cafdifu
vaft, R.C., Iuller, S S., Haineû, R., 'lreanre, E.T., âûd
S t i l l m r nr o v e , C . ( 2 0 0 1 ) .O r a l h e d l ! ht r o n , o l i o f e l a l u à
rion rinrc iàr dcvclol,mcit Co,ùrt,i4 Dùûi1r! àrd Atut
Epi./e"ralas,29, t 6t 6.
V/hiteheàd,M. (1991).The.onceptsànd pnnciplesoIe.l!it)
û,1 heakh.Hedltht'tonarDt,6. 2 t7 2a.
Won.l Heâlù O.ga.izatbn (1t]8). Aimâ Àt. 1978: PtiFdry
lleùhh Carc. Rcpor of the Idternâtionâl Coûferenceon
PrimaryHcakh Carc.Àima-Àtq USSR,Septeûrh. l97il.
\\/orld l ledl!h O.ga.izath.. Generâ.
v/o.U Hcaldr Olaaûlzâtn) n lr98l). GloùdlSîates fat ttùltb
l;1 All hJIli. tuî 20A0,\YHCI, Healtl, fo. All ScricsNo. :J.
N/orld Healtl, Orcânizario..GcnNa.
\x/orl,i Hcâlrlr O$anizârn)n (1982). A R*i.tt ùl Cthrul
l?{aûne,,ldî;a"! fol ir Aryd";zdtun .xl Al,ti,i!tt./iùl
of Cannt"t4 Atul Herhh S,t,tur i, Nutbu" a,d w7\tùn
[.ktufu. kepotr of t wllo Wo.kshop. \r.'.r]d He tll
orgâ zètior Reglonil Ofuce for Eu.ofc, copenhâgen
wôfld Health OigànizàtloD (1984). Hedbl) Pnnùtnt. A
Dj!.k!!iùj Do,rnta/ rn îte a:t,elt did Pùn.;lilL\. V.|IC,
IIell1h O.aa.izari.n Rc€nral Oftl.e for [ùrope,
Y/ôrld Health Orsànizatioil (1t)8().'rtu oîàuu Cbûîî Jrr
Hdltt Ptùrttjafl. Iledlth Pûrtu|io" 7, pt. iii !. N.orld
Hexhh Ofgùizartun, Cenevù
Wodd Heâlth Orgxnizarbnll99\). Faal d"d Ntîtlra" Palt!
,/ rzl,1!. Report of â' \IIHO conference,Bldalesr 1990.
l
f | l q r o \ r | . \ r , ' H . l . , o - , . . , o ,
RcaionxlOffi.e fof Eûope. Copeûh€eù.
Wôrld HedlrlrOrgarrzàtion11.)L)t)Dit ,xtùiri. did n fr,
rttlio" ,J .bran1.d;vdvt. Te.hni.al Report. Series797,
\flodd Hc2hb Organlzatbn,Genew
\Trorld Hcalù Organizlriôr t.l99a). Hedlth Pt|ùrtiaa
Erdhdran: laleûn"Enddtirit k P,Lq lt.tkor. Côpenhàgen:
vorld I lerkh Organizition.Gcneva.
 the conceptof prevention-
Developing
eviden
ce*baseddentistrv
Johnlvlurray

Dâtà fion the Nctherlandswds impoftÀnt.be.aùseit showed

lntroduction
Eviderce thùt the o.al hcalth ot'a.onmunit) is improvina can be
show! by floFfly coordinated epl.lemlolo8jcal studies. Eviden e
rhar a parti.ular trearmenr is a. lmprcredent ôt preliously
ac.epred treatùeots o. protocoLs i! bes show! by systemari.
reviews,prospectiveclinicalsûdies, ideally by rd.tod,€d contln
rhar dre de.1iûein cariesbad ô..ùtred ;r both primdy èûd 1)cr
r , r d . r , Ù o ,. . t r f , 4 . . . . d r / p .r , , t , , h - n o - n . . -
ràrt diàgom iuùilating dF doçnward ùen.l \tas comPlledfroô
tbc \X/HO Global Oral Daû Bdk (fig. 16.l). gjving DMIT
!âlues in l2-yeaFold childr€n ùsing dre le.iod 1967 81, liom
.inc westerdzed'or delelopÈd.oùnÙies.This Je.line in.aries in
permanert reerh i! .hikl.e! ârd adôlescentsshould leàd to I
gre.ter relc.tbn o{teeth in adult life.

Seculardeclinein cariesin children

The suggestiorthdt rhe derrâl ca.iesratesin English chjldreo
were declioins s'6.autbusly pùt forwârd by Palmcr io 1980.
The tbem€ofa de.line in denul cè.is took on ân lntdndrioDl
flavour when a co er€lce wù held io Boron ir 1982. Speake$
fron Dermark, lrelànd,the NcrherLands, New Zeà]and,Non'ay,
ScotLand,Sweden.m.t the Uoited Statcsall .ônfirmed that a
dos.Fafd trend indent.l cârlesin chiLdreûàn,l yoùdgadùttsh&l
occuiredln rhc 1970s(Glà$ 1982,Tâbl€ I6.l ).
Trendsin edentulousness
The $ardèrd ofdennl heaithin È cou.rry dependsin Paft oû the
dttirùdeol ihe popnlationto denralcare,aû.I the resou.esavà
ablefo. dentaLûeètnett. Thcre is alsôè hisloricalPesPectn'ein
rhacùcarûent è!èilaltrleto a FoplLlàtionin rhc pxr oftet nakcs
itselfÈLt jn thÈ stàtisticsofthc present.Ior €xamflc. the nèû-
asemeûtof pcfodont.dcUsease durinE ùe 1910s!o 1950s in ûe
UK, by rhe exrracrionôfteeth an,l rhe provisiot ofdenrùes, hd

Tâble 16.1 De.llûinc dentalcariesin Mùùs.olnùies (refer€nces

in Glass1982)

Aee ofsubjéch (yêùt

19'2

r2-rl 1?tA .,
L2-11 193?

rt

).6
19,-I r.1 1.t
6 1 1 191910
1911-r-,
usÀ Çrr 19r9-ri0
zo: tOOoeolinttheomep
0lorevention-ev
denrÈboçd
denfi$y
I

d12

Fisùre 16.1:freûdsnr denralcaies 1967$l DIII'I as 12 yea6.

(Source:\vho GlobaLOrnLDataBank ltensor e! al. 1986.)

Tàble 16.2 PftMlùce ofedentulosnes in varioùsEùrôped

Il
1970 1975 .ounÛiesNrHO 1986).

Fienre 16.1 dmls vâlus i;r 6 reaGold.hlldren from dre

Nedr€rlards. (K.lsbe€k 1982.)

30
Caresin the Neberands tt.0 65
GDlL

rzô -2

1.0

ll.0 79

ren ted iû âhigh prevàLeûce of edertulousress. The findirs ir tlE

ai6t.alional surveyinEnglandand walescaûed out in I968 thar
37 per.€nt ofadù16ovefthe ageof16 !a6 had no mnùxl teeth,
cerainlr fo.sèd arentlôn on rhedenrâlnee& ofadults(cray r/,
1970).Elen ifrhe parternofdenrâl Ûentûenr chânsedilrùedi-
a€ly, hom exù2cr;onrcwardsrcsto.atio. and prevc.rion. drose
alreadyre..le.ededentllou willtèaiure in rhe râristicsu.til drcy
d e A . Li n ' r ) o l e d e ',r l o r ! c . " \ ' r i o r ' r t o r . - , o r " ' .
(WHO l9il6) shows.he UK almostar lhe bottom of lhe lisr in
Figure 16.2DMIT valuesfo. 12 yearold childrenfrom the lerms oredenlllousne$ lwo agesrouls (:fdLrle16.2).Ëde.ru
Netherlands.(Ka.lsbeek
r982.) lousnc$ hâscondnucdto dcclinc;r drc UK. Thc fopoltion of

Tàble 16.3 Predi..iofs ofûtal ùrtrh 1os i! the United
Kingdom (Kelly r/ r, 2002)
Predicledfuturc lev€lsi'ôr
in l99S 2008 2018 2028
u;; o:
1''-l 2 lmparted wi5dillli lfttil
)a
ta 26
tt
ddults2Acd16 andoverin rlis otegory lcll io 29 per centin L9lil,
2 l p e Lc c n ri n 1 9 8 8 .â n d L l p e r . e r ! i n 1 9 9 8 .
The 1998 tiK Adult Denixl Heè1thSùs'eI gxrc x predi.tioD
ô , . L e l a " . o o ' " ' l ^ ' I ô - 0 - 8' l - ' " "
uirg mèrkeddeclinc ir cdcniulùsnes eleû ovet
l,eârs (Tàble 16.l). HowcvcL.for verr eLderly people(itt and over)
it is obviousthat conflete dcrtùres will still be nee.le,li81 per
.eûr ofdrù agearoùp wcfe edentulôusnr t998r ths frcpoitron,
,r cùrrcnrprcje.tons, is dùe to lalLro I I pcr .ent b} 2028.
Trendsin the dentateadult
ThÉ r998 À.hrl! Denral Hcaith Snrvey provided in,tora.t iûfôr
dârior oD the stalus of dcntate adults. Tlie overall tiicùfe for
dentare adtrlts oIàll ages conccâlslarge differencesn, thc disexse
ârd ûeaune.r extc.icn.c of ea.l, age .olion. Am.ng youûg
teoplc rhc lcrcl ofdise.$e eiterlefce is lo$'. shile ln the ûiùlLe
ase gtuups there is a greâtcr Lcliaû.e on rerôiùive rcâù.c.t. In
rhe ô1destage groùF Ghosc âgcd j5 of more) ù$i.g rccth n)fm a
lârfe pârt of dre overàll toorh <)nditlôû âùd make a siEnili.ant
i mpa.t on rhe ôlerdLl mo! rh status (Kcll-r d al 2000) (Iri8. I 6.4).
Tùc .hallenEe fof the future, n, lefl.s oi prevtnùôù. s to nd,.
tair ùc number ofsourd uDtredred rccrh in the L6 2.1 yeù old
col,or, dùoùgh tu age it yearsaûd beyond.
Trends
in orrl health
De.line in .in!s ,ù ch,ldr.0 obsere.l from nrÉ lxte 1910s
BeneÂÉ obsered in trodr nenrltlons
ldentulôNnes in Brnùin{i6lrlgh in rhe 1970s bnt tr mprovinÂ
l0 pd.cùr ol 'hose.ver 3i rÊar sill need.ôùplû. d.rtures, fl?n
Dis.enràf,le in!rcrÊmrn. in rhe p.tt.rn ol it$oBtion and toûtl,
lo$ i. rhe dÉ.rare lopda.on
l"-ipûd
0fùvid".n.e
b05ed 0ndirirrlpodi(ê
d0nririiy 261
|
dentistry
lmpactof evidence-based
^- ^l i-i ^^l ---^ri^-
u|| L|lI|'\dt P,drL,rr
a, 'o, . , n4. _\! ii ôr' , '''. ! i-l, o
l, | l
ventn'c appnnh can aJsobc foùnd it the eftoits made to i.lentiry
bcsr practi.e,.void unne.essarr' tredtmcrt, Prov'.le rlre most
0
approFriàte cârc. md re.luce the nccd ftr iittlÉr i.te.enùon
TLreprophylactic .emorâl of lmpactcd wisdom teed,, hat been the
subject ofcoDsi,le.xble debÈterecenily. rirm views {ôrand xsainr
t5 the pràÙice of.cmoring impdcled slsdom teeth hivc b€en
c'presed; a sFtemari. review câme ro dre folloùnrg conclu\bns:
p .
r\rl\ ' F "r..o F\ , s .-l fr''"- '. r'r la
. Thnd n,ol,r nùgery rates !â.y sidell a.ros the LIK
. Âtuuûd lt% oldrifd molas removcd tàf prophyla.tic fùF
pôs€sare diseâsef.€e.
. Surgical re,,or2l ofthir.l mola6 ca. only be iùsilicd s'hen
.lear long tern bcncfit iô the patlen! is expe.ted.
"l . It ls nôr poslble to predi.i reliably wh$hef iûPècied d,itd
rhc age ol 8t molas $i11 delelop pathôLoglcâl change il they are nor
. There de ûo rândomiszed control studies tô.omPare dre
lôrg rerm oùtomt of eady rcmoval with rere.rn,n oi
Frholoar-free third molar.
. In rhe âbsen.e ofaood evidence to support ProPhyLacù.
rcmoval. there appcars o be ltd€ jurifi.atn,n fôr the tou-
tine rcmoval ofpàtholoat''ffte idPdcted driLd n'n,f
. To e.sùe xpproprinle r.câtment refetrah, saiiing lists ior
.he su'Ai.al removal ol drifd mô1ùs should be monitored
dnough a ptu.es ofaudit
In d fc.ent sudy to i,lcntift tl,e 1ea$ cosdï. nor effecrilc 2rd
rnor .ost effe.tnî m.nagement *rarcgy for r synptomaric dis
ease fiec mxndibular third molxf, n wd cot.luded ùxt ierentio.
of lbcsc teeth is te$ cosll rc the NllS, moft etreftn'e 1ôr rhc
parlent. and more cos effcffive to both ])2ries nDn rFm.Ml.
How.'er, sbould the likeli|ood ofdeveLoPlng rete2t episo.tesof
peri.oronitis, fdbdoûtàl disersc. xnd .âries incrcâse sob$.o
(Edwàr.ts
,/,/. l r9r).
l'he Key Nle$2ac in tLe compe.diùm Cliûi.al Evidcn.e wd
'\re fôùnd limircd eviden.esuagcring that dre ha.m offtdôv
ing àsymptomaticinpâctcd wlsdod teftb outs'eighthe Lrenefi6
(CIi .âl E!idence2001).
Dhârival, Goodciland Shepherd(2002)pro\i.le.1somclmPor
ranr Jatain rheir reliew ofûends rn Oral Sutaer,v itr rûsland ând
Wales l99L-2000. The treqùetr.lesoforal su.El.al Prôc&lutcs
was de.ilcd i;oh the Denàl Pra.ti.e Boat.l DiEer ofStatistics.
The .unrber ofinpa.te,l rhird mohr extractionsitr the Gene.xl
Den! ScNi.e in.reasedsead;l), ùntil 1991, aticr whi.h th€re
w a s a l 2 p c r . e n t d e . r e d e i o 2 0 0 0 ( I i g1
. 6.t)coin.idlngwithdre
 !
I

,""!-t :,_ iri!,"i.. :, I ri.

Ë60
5

Lôrê,iâw
adults agett 55 âhd ôvêl

i:r;ii:*f i::]fil:51"..,",
Ii:g:l* â***
Figure 16..,iDisùibùrion of tooù .ond itiois arouod the dourh in.leflrar rralûrs rn thc UK 1998. (Kcltr r,l 2000.)
 '-prr'o'wioenrt d'r'"1 on, ritolI atr,'e uo '
ro'eo
I

d well d bàcrerial cndotôxj$ ùd whjch is, therefôre, bioiosi

.ally .ompnrible Fith rhe fitrmèrion ofâ lona jlln.tiôtâ.I ePirhe
inLm. Perhals âbeftcr descriptiôû an{la mo.c ontedporar! term
for this pro.es is 'oot surfacedebtidenent.
One ôf the fnditional disadvaûtagespith sùb8lngivxl ilsrù
nenrètio. his Lrccnthe .e$i.ted .cce$ to dcep p..kes, f! rcàtions.
rnd othcr anatumicilly complex sitcs.To some eiten!, tbis Prcb1em
has been overcone bl rhe inuduction of new genetaaon tn*nt
mcn$. borLrdânunl and lowtrdriven, which iave intpn,ved the
ellicienc,vof root inrunenra!ioo. lulthèrmôre, resi.bal Pthosens
ûèr nighr .cnrain fôllôsrng root tlânning. for *anple in rhc
91 92 92 93 93 94 94-95 95-96 96-S7 97-9a 9& 9S99 2000 pocl{ efirhcliud or the rdjacenr conic.rive tisn,es, .an be tâF
Figu.e 16.5 lrcqùenc-vand.or ofimtâ.cd llird molâs dùxG gete,l ûore spccifi.ally uslng locaLj-v,lelivc(d,sloFrelease a.timÊ
tnlE in (iDS 1991-r999. (Dha.ival, Godel an.trShefherd 2002.) .rôbi.ls thar have bed lnrrodoced dùrinE thc 19t0s Th$ mea.s
that the aims ofroot snrfa.edebri lehc.t.an noe bedhieved mo.c
.ffe.rirelt ùd .orsistertly rhm has hltherto bee. pssiblc xnd tht
ded for perio,lo.tal !urse\- has bem redùced.onsiderablr'.
shift in eûiFhasis!o a mo.c co.srFatne apprôâ.h to the manâgc-
dert ofimpà.ted wjsdom leeth. vs.
Endodontics-Retreat1nent
roo[-eno sufgery
Protectingthe lingualnewe during lower Rooî .anal tfc2tment ùsuJlly f!,ls becâuseo{persistent rool caû,I
third rnolar removal infe.tior. Th;.ad bt nàûèged no. su.Ei.ally by cle.ning atd re-
seàllnA rhe fulp ryà.e, or surgi.ally ro rcmove tLre rôot end
RobiNon ànd Sm,rh (1996) rerJoitcdrhat tugerl with hnsuil
(èpicecroml) ard pe.iapicàlles'on beforc tilling the rooi enfa.cc
flàp re!.dctionresultcdir linAnxl senrorydisturbâncein 6.9 l)cf
ccnr ot' cases,wheft$ surgery withour linguil llap reûa.riot
}]ldl $ùdres bâve claiùâted surgical and .on-sùral.xl reûeat
resulrrd ir linsuJ sensory,lisurbâncc ir 0.8 per .ert of càs€s.
Dert ind,vnluill-!. s'irh hlgltlr' tJnùble ând .onul.titg iesùks
Ther côùclûdedthat. for rhe matoLityot .asesinvôlving Loser
, r . . " - t o . . t r " q n - rr , 8 . . ' ê \ r . r " J \.. p"ef.'1
thifd hôlù removàI,lingûaLrerrâctlonshould he avoided.This
cilând nôn sûgicâl o!tcomcs, bùt neither the retroslc(ive $trdy
conclusnrnn'asupponed bl GèrgalloÀlbiol errl. (200(l).
ofAllen (1989), nor tbe prospe.tive. .atdoûized in\tstiÉiitn)d of
Kvist md Reir ( 1999) showed ân-vs! $emrtic dillèrencc DLtisiôn'
Periodorltal sùrgeryvs. non-surgicâl âpproach m,kins is. rherelore, based oo individual case relarcd lactor\,
h periodontis,drerehrs beenco.sidcmbleexpânsono"erlhe rast vhi.h ù âlly fâlour the less i.vasive not surgicaL âPttua.Ll
20 )eà6 olrhe evidcn.cbasetàr noninrgicÈl mrnagementas thc (EM,peân So.i€ty of End.doit.n%y 199ri).
priû.lpal lnteNertiôn for rhe treÀne.t ol lcdodofl.al diseases. Daû nôm ùc Denhl Pra.ti.e Bôâfd Disest ôf Stàtrvics
The initial eliderceemergedtiom fivohl .llnlcâ.Iru.ties repoiled (DhâLisal, Goodey, and Shephc.d 2002) shô$ that ûe ârnùaL
iù the 1980s.lor exâmplc,non{rrEl.al Ûeêtôetr, scèlnrg,and numbcr ofâpi.ectomies fèll by 56 per.ent between l99l 92 and
rôôt plmûing, \us f@nd !o be conifanble, *ith respectto lorg- 1999?000(IiE.166).
ierm .linl..1 ôur.ômes,to threedlllèren.surgicalpm.edut! nsing uece.r a.d rapid rechlologicalddva.cc! ln nôn'sûgicaLanl
" , ' l , - ,H l l , d \ A ' | . . ùrgicàL€.lodo.iics ({,peratiûgmicroscofcs.Nili rôtàrr'nrtru
ofrcportsb_rBadeBtenigroup conlirmeddie lorÉirerd effeftive ,l ,. h".. ' , . { e t .r ' . o '
nes of scalingand root plaùing, ànd demonsralcdclexfly that nN retrôfrlling o2tc'i,ls) mây rei or.e or .b2rge rhis vieù, bnt
rhis ûcarnrenrn effe.rivr,everin "ery dee! Fod.ets(s-12nrn) Iôi eviden.eor dieir clhi.âl effeLti!en€$is tot rcr rlailable.
vhl.h periodoûtà]sùrgeryçoùL.lprcvioùsl-rhale beenthoughtto
be bodr e$e.tiil a.d i.cvitàble (Badersend?/. i981).
Tbe biologi.al tasir for perndontal heal,ngfoLlowinStLcar
ne.! is âlso nos beûef ùndersoôd.It is {rdely acc.ptcd rhar l{otoble chonges in dinitolpro<tice,novinglowords0
peûodontallt' atfecredr]$ucs, i..lùdlns tlle ulcerdte.lpocl<e. nore(oniervoliYe opprooto
epithelirm, retair rh€ r.he.ent cxpxcity ntr regenerùion.The
in.licâtionsfor some surai.âl fro.cdùrcr su.h âs soft tr$ue or renoÈI of i,rf,.ted sisdùn t!frl
pocke! cùreràge,pocker elimi.arion. xnd boneresectrôû.re ro ree.l tb. periodonul suq.ry
lonsef àppàrenr.Tlie obiectiveofsc,lina ând ut plantins is tô roNurgi.al end.ddti. û.ârDef, t
d.hieveà root sulice rhât is ticc of plaqrc md .!.l.ulus deposts.
266 I6 Deve
oping o{prevenii0f
lhetotuepl evidflre
b0sed
deftirlry
92 S3 93 94 94 95 95 96 96 97 97 93 S3-9S99 2000
Nurnbef x cos6 of.prc.tônx.s nr dr. (;DS nr
lreatlnrnt ol' aplltl!oxsulcers
thc aims ot rreatmer! ofaphthoùs ùlcers (seeChàpter 11) ùe ro
.cduce laio as vell as th€ frequency and durarhn of ceratn,n.
with mimùal adle6e effects.Suggere.L rearmenrs ln.hd€ e)pl-
càl corîicosterods, cl oihexidire, ard hexldine. Nlne sm l rad-
.lomized conÛô1 Ûir1s found no ()nsiscnt cffcct of rcfical
coilico$eronls or dre in.i.len.e ôf nes' d.ers, .ompared wlth
.onroltre|ârario.s. They lou^.1 seàk eviden.e dht ropi.al.or
ri.oreroi.ls mar redu.e dtrr,tion olulcc6 ând hàsten 1râir reliel
wirhôut .âusing notable lo.al or syic.ri. âdvcrsc ciicc6. Râr-
domized .ônÛôl r.ials (RC\) halc found rh2t .b lo.hcxid ine .qlu
.onxre mourh rinses n,àr rdùce ùe.lùratlon an.l severjtf ot each
episodc ol ulccmrion, b!! (lo ror a[e.t ûe û.idenc€ ofrecurreût
ùl.cnrh.. Thcrc is no evi(lenceofbenent ftom heri.ùie moùth
wash o' hon, a trotrierâry .rtisepric mouûsdh .ompâre.l with
.onr.ol n,ourhwashes(Clini.Jl lviden.e 2001).
Ûral nlûco5itr'5i pntielrts retei',,j g
che othei?py
Oral nù.ositis is a weLL-knowncomplicarn). o{ .hemothempl
(seeChrpter r1). Cla.kso.. \Xrothingro. an,l Ede. (2001)evalu
xted rhe effc.rivcncssof o.âl â.d tofical frophyla.tic agenrsfor
o m l m u . o s i r i sa n d o r a l c â n d i d i a s i lsn ! â r i e n r sç i r h . ù f . e r
(ex.ludi.tj hcad ànd necl. càrce,)conpared with fLa.eboor ro
.ontlol. Onh ràndoûrzedand,tuasirardorized controlle.ltrirts
wereeu8iblc to. inclusionin rheir.er,ew. o.ly ice chiFsshowe.l
àtr bûrefit ii preventing mù.osirn. Nonc of rhc odrcf sevetr
2ao,!s exannred (cl orhexidile, prosâgla!.lin, slutdnre,
sucr2lfa!e,molsrimostrm, .ènomite, àn.t àlluptrrinol noudl
wash)showe.tàry beùefir.
lriiè(tiveendocardi[is,
der]tistry,
anrlântilliotic
prophylaxis
In a rcccntaride Seyûrour,lr/. (2000)sùgg€$edthàr r wÀ time
f o r a r c - r h l n ko . â n t ' m i . r o b i a lf r o t h y l à x i s i n d e n ! , s r y .T h e
au.ho$ poinr our tlut dental pro.edures. espe.i!l\'lhor
that re{h in a ba.teL?enla, are frequently b1dd iir inlè(nt
endo.xrdiris (IE), hen.e dre need for xntibiotic Frophylù{,s
to..rc.5ù.h fn,.edu.e in ar risk patieûs. This has beûr tlie
.llnl.xl do.ùhe and teâ.hing fôf the pdr t0 yeèrs. Recent
evidence from rhe USA ùd the Netherlan{ls ch2llenges rhc
frtrctice oÊ frcsc.ibi.A 2.tibnri.s bcfofc dcnral pro.€dùres to
frcvc.t c.do{:a.diris.Ir additbn.heft ls in.renslns .on.ert over
'l
thc unncccssaryusc ofantibnti.s. heI sùmmÙized the situatiot
roû re.enr rudies ôf endocai.tirr p.tients eûher fail
tu show a dedtâ1.ônneùio! ùith ini!.rive endo.èeliris, or
.ad odly sh.ç x small ode, dthough rhe stu.ly designs are
low ln dre hiera(hr' ofvaliditl ddd .â! Lreciiticised. Other
.ôùrilJutors to the debrte add tbar tbe dansers olchemo
tr.jrh_vlàxis oùr$'cigh drc daûse$ of endo..fdltls and thnt
.hemop()phllâxir i\ poôrll idertiiled even wheù it risk
parie.ts are idenrifled. Indeed tlÈre is eviden.e to s,ggest
diâr sl,ontancous ba(tcracmia (mther than dedtal Ûeât
m€nd are most lilell ro b. thc causc .f IE i. aÈri\k
iùli! ùâls. l1 drn is d,e cise, dicn drc usc .i a.tibntri.
prophylaxis needs to be reco.sid.r.d rnd 2 g.câtcr cmphâ-
r ' p . d o r r r p o ' r . o . l " . 1'
AÛtihiotr'ccover fbr pâiieris $';th joinl
pro5thc5es
Aolibiotic prophylaxis for ])2ricnrs s'ith f(trrheil. joints siLl
remâins a.ontentious is$re, despite repoffs dnd Euidclincs
ftum drr British So.iery for Afuin,Ûotrial Chemodier2fy. rhc
Âmerl.ar Dertâ1 Aso.iàtion, $e Àmeri.âr Aca,lflny ofOftho-
paedi. Surgeons, the tsritish Orthopaedi. A$o.ia!ion, i.,l tl,c
Bfitish Dentâl Â\$.ixtioû. Seymour d /. (2002) comnen! rlur
lerl fe$ orthopde.lic surgeons reqùest dentrl rdvicc bcfofc toint
repLacen,e.r. bur m.rt insisr on xntibnti..ovef befotu dertaL
ûeatment. Ihey believe drt patierts wou1d be t]etter s.alel rll
round, and her.e rtalesser r6kofjoû ûIeûion. il rheyàttc.dcd
() drelf oral hedlth befde surgerr rs opposed ro relyiûS ùpof lhc
dubious ti.xcti.c of anribn)ti. pn)phllâxls'.
0rganizationof services-clinical
governance
Virtual\, elery brd..h of,le.dsùy can pnrr tu .hanser elther in
dini.al pm.ti.e, ir ofder tu lrerert ndtô$.rA nr.nletts, to delel
opnetrs l' .linl.xl gnidelines, âimed .t focllrg actlo! o. lhor
nm Likely o benefit, or t, improliry the orgaûizrûorot Éffces.
A! 2.o'for2tc lcrcl âll ofganizxrn)ns,\4rether.leûtal pràùices,
denlal s.hooh o. hosfitxls mtr* cnrbra.e .lini.al sovernxû.e
'a
ianewo,l< rh.ough whi.h organnarn,ns are accountable for
cortinùolsll imtroling rhc qùâlit-r of theif serri.ts xnd sâfe
gradins high stafdards of c2rc b-v c.cûi.8 a.
whi.h *.elic.cc iû ctini.al .xrc sill I]oùfisli. Fl!ùre r6.7 sltoNs
 I
kh,sas | 267
I

for chiltlren born n'ilh cleft liË/palâte

Ser.vices
StudiesbI the Royxl College of Sùgeons Àudit CoFniiree and the
clidcal Stan.lùds Àdvisory G.ouP s!nr$!.i dDt the results from
nost cenùes it Btitain comFred ùntàrcùrÈblv sith lonErerm
re!,16 Èom the b6r ùnits ln Eùtup€. Ovcr 70 nr rgcons lvee rNoL!&1
irom tl .eûûes in the United Ki.Sdon Às theÉ àre 'boùt 1000
bâbiesLEm witl th,s.ondition cvery ]eù, mo$ $tgcons were low_
.14 rclûe o1!mùr6 . Thc CSÀG rcPort' ac.elrcd bv the c''"emnrcnr lû
1998, sussc*e.t that 'erlices sh[Ld be concentrutcdinto a snalL
number ol e+ert ce...cs (betqfcn 8-Li ccniÉs 1;r ùe $liole of
the IIK), IùllI *affed ard equipped with aPPrôPriatcfa'ilitics'
Tbc.oncent2tbn ôf seni.es does .ot in itselfgurà.tec improlcd
o!!.omes, bùr,loes èlloF â snalle..ùnber ofsûseo.s rc be'omc
'high-voluûe
opefttos' The oùtcomes fiom câ.h 'enrc must be
2udite.l rigoflNlr! boih s'itli. rlrcUK..d @mP.rF l$nh rhe bst
!_ig!.e 16,7 i' revÉntlor, etide..e b.sed ûeâtù.nt, nn.l djni..l nr lùropc, to enaùc m itirtoreme.r ir {xddàrds Thùs, not onlv
does the exFitisc ofd,e i.dividùal ïreciàlists invô]led (sÛgeons.
o(hodontiss, paedi.ûic dentnts, sFe.h anl langunge thei'P$ts
etc.) .ccd tô.lelclop. blt thc orgàtizârnû ofseNi.es Provided bI
€a.h cenrre,nn6t @ntinùâlll imProle
in diegrdm mrtic fonn how Preten tion, evdencc-bde.l treatment,
and c]l.ical Soveflra.cc.ân work toaether to imFhvÉ ôràlheakh (honges
in dinkolprodire
indude
T}e six n]onthly |ecall erarnination . Nkd aor ârrimL.robhl prollyb{is
'lhe . Nei gurd.li.es on $ nr.nrhty etrânûànon
l)e]rânment of Hcalth asked rhc \\re$ Nlidlxnds Te.hoolÔg].
A$cssment Group to.àrI our n bP Slr€dàti. rcvie$ ofthc
Clini. nllecrivenes ùnd Co{ lffe.tivcne!\ ol Routine Dent
Chccks. Iroû a poô1 oi orcr 2100 cit2tn)ns .td ab$.cs, the Conclusions
resù16 of29 $udics were considded in deraii Forthe inve$iaa
The is$res nised in the previous tùo sectnrnsreUc.t mv te$onal
rioD of rhe relètionship betlvee. dentrt chc.k{p frequcd.v .nd
vlews concdditg dlc.hatging fft.rice oi dettis!ry snrcedrc htst
meanrcs ofcùres, thcft sd afrcpon.tera.cc ofstu.lies reportrg
cditionof thisboolrwaspublishedsventvleàsago'lLeIs isbv
aù incrcasei càries and â de.reasc in die fumber ôIrecdr, dd a
no means comprehensive: the .eader nrây {ell 1)o1nt to odrer
decredsein fillitgs with de.reâsina dentJl check{p frequcn.ies nl
aspe.s ûhi.h ûigbt have been inchde,l
A .nft refleffive ôi elidm.e bascd aPProa.h tu den!âl disede
CoNiderias perioJontal disease. s'itb the cx.ePrion of one
ànd its ùa.âgement cân now be,li\.enied !ù.tLer dNeloPmens,
single stùdr reporlinÉi a signilic,tt in.ieùe in âita.hmcût letei
bodr inairidùâl and .orporatc. are r€quiltd li'drc Pi'r{i'c of
r r \ , , , . r ' r . ô ' d e r t
dcntistry, ind tLreor2lh€a1thof tb€ poPùl2tbn, is golng ro conùnùe
teniv io the detectio. of the elïecl of diflèrent dental chcck fre
ro imprôre. At the lndividml Profcssiôù lelcl. âpFnonal.Ômmit-
qu€ncieson ihepermnnent dentirion ând ble&lin8, problDg dcPih,
rent ù) côntinùlng ProfcssbûaL,lcvcl.rPmenti\ re'l!ncd, âtd vill
fresenie ol flaque or calcullLs, giûSilirir, ând lerbdoûtàl hcalth
'lwo be.cEùlated i. rheLrKby rhe tl€ncml Denlal Codci L At a cÔrPo-
stùdics itvolvi.g otul .à.cer demoDstratcd a signih'ant
rule lcleL âll oBanizÈtionsmNt co.iinùoNLv i.r]tove rhcir ser'lces
incrca\e it t!.ioùr size and advancemenr of the sâÉic at.llagnons
Iinâlly, dtd of Ereètes importan.e, the tubii. àt l'rge dÙst
wirh a decrc,se in de.râl .hecL !f ffe.luency 1d .hecks at
ipt.c.l.te d,c rit. role ùq halc tu PhI in mêin!àin1ng rhe!'
l2-ûonrh lnrervâLs.
own oraLhcaLth.It is hoped rhât thls book helF to srinulàte 'td
Thc rùdy cotdùded thdt ùere is Littlc existnrA clldetce ro
gnide chxnges ,n âll se.tots.fdte or2l health .omnunLrv, sr tlFt
s!|por or returc the pracricc of ercouraalng 6 morthly dental
fu(ber improtemcûB it oral heiLth 2rc r.hielcd
checks ln ùlults and child.en (Tavlor l,cKrnàl communi.âtion)
j-
| É ' ". "-o' 11; 'i\ 1F \' ' to
rnk g.oùps, ind rhcrefôre, considerànon shruld be Siven to References
whether a popllario. É-.è11Poli.y or r te.all Policl bar.l of
rsk would be nore ,cceptâble.
'fhde
is àtecd f(trfu(hcrPrimary ÀlLer,R.K., Ne{to.. C.\I/.. and Brown, C E (r989). À statls-
i ,.,"). r'i,lrr'r,J .do { r_'rP
research,.ldre$ins thc tule ofthe dent.rl check and rs etlectire
i i, 26r t
re$ in dlilerent ot2l diseâses. nent.a*s. Jaft "d l 4f I xloJûùt,
 I
268 reon(e olprevs-
l6 0evêlopins on.ev
derre-bo$d
denir-y
I
I
Bède6ten,,t., Nilveùs. R.. and Esclbc|a.J. (1984).Effecrof
ûônsûgi.al periodontalrhcnpy. II. Severely advancedperi
.àottitrs. Jrkr"dl 0f Clintà l Pùodanrola8!, 1r, 63 t-6.
c l a r k s o nJ, . E . ,w o r t h i n s t o n ,H . V , â n d E d e n ,O . B . ( 2 0 0 1 ) .
Interventionsfor prelenring o.d mùcosiriso. onl can{lidi
as,s for patients wirh .ân.ei re.eivina .hemotherapt
(ex.ludirs lrad 2nd neck ca..er). UFdareSôftwèreLtd,
't
he co.hraû. Libm5. 3.
Clini.âl Evldence(2001).A comleodium oflhe besralailable
evidcnccfo. ei]èc.ivehealth care.BMJ PùblishinsGrotrp,
Dhafiwal.D.K.. Goodey,R., ard Sh€pherd,J.P(-2002). Trends
;n onl su.geryin Englanl aod Wahs 1991 2AOO.Bx Dekt.
J , r92,639]'!.1
Edçâds, M.J., Rrickler. ùLR., Gooder R.D., and Shepherd,
J.P Tbe cost.cfrective.ess ard costefe.tileûessof remo'èl
and .ete.riofl oi aslmf.on,atic, diseNe free thûd nolars.
B j :D e n t . J . , 1 8 7 _ 3 1 t .
Eu.ofeanSocjetyof Endo.tonrology(1994). Consens$repôrt
ofrh€ EuroFeanSô.ietyof Endodontulogyon guallryguide-
linesfor endodontictreatn eùt.Iûndi|'tul Edrà|nt;t Jùrt-
i d l , 2 7 , 1 7 52 1 .
Fficdman. S. (1998). Treatment ôurcoûe and p.osnosi\ of
endodonri.rhcrapl Chàfrer lt ln: l)., O6tàvik T.R., Pitr
'L'rùtunt ,'1
FaÀ leds) Lrintidl L"ùà0"t,/0$: Ptudn,D d"d
Apitdl P#iolarrti!. Oxfôrà,B]â.ksell S.ieû.e:l6l-101.
Garsallo Albiol, J., BùÈnechea,R., a.d Gar-Escoda. C.
(2000).Lingml nÉil e porection duri.A surAicalremovalol
lower third dolar. A proTcct;ve rândonisedsrudl 1rr"/.
qrdl. Ma,;Iofd.. Sxrs.. 29, 268-1 |
G1ds, R.L (ed) (1982). :fhc 116rinrernalionalconieretrce o.
the de.linins p.era.len.eofdeûtal.aries./. Dd,r. R'r., 61.
(SfeciaLIss!e),1101 81.
G i à y ,P G . , ï d d , J . 8 . , S l a . k ,G . L . a n d B u l m a nJ, . S ( 1 9 7 0 ) .
Ahb Dtrtal Hulth in Englandanà \Yalu ;n ?96ii. HùISO.
Hill. R.\(r..RaamftoLd,S.P.,Nlodson.8.C.. Applebeûy.E.4..
Cafiesse. R.G, Kerr)'.GJ.. and Nisslc. R.R. (198r). lour
tIFs of per;odonral ùearment comparedo!r. 2 !eaA.
Jtundl ofP,odoatolosJ,52. 6tt 62.
Kâlsbeck,H. (1982). Evidenceof decrcaseiû prevalen.eoi
denralc.rièsin th€ Netherlaids:û eyâlùarionofepi.teni
ologicalcari€ssùrley on .1 6 ù.d 1l It yearold chil,lren
betweeo196t and 1980./. l)at R'J.,6l (Speci21 Issue),
ra2l 6.
Kel]v. M., Steele,J.G., Nùttàl], N., Bmdnock,G., À{orris,J.,
Nunn, J.H., Piûe, C., Pitts, N., Tredure, E., ar.] White,
D., Qoao). Adù Deùal He'llh Shtq. Otul Healtb is the
Urîed Kiki.Jatu199E, Government Stètisricàl Seô'ice,
HMSO.
Kvisr, T., ând Reit. C. (1999). Resuls of c.dodonric
,. d-r,qed ,lir,."l . ' dj oÊp,r ,s
sargi.àl èûd no6ursicè1 pro.eàrûes.Jùrri'l al Endalontid,
12,al4 7.
I-he manasemrnr of pa.iÈnB with idpà.ted third no1àr
(sisdom) teeth.NHS Cenùe nt Reriewsand Dlssemina-
trcns(1998).
Palmcf.J.D.(1980).Dcntul healtbin.hildrcn€n imp.ôvrng
pi.tte? Br D!"t. J., r19,48-10.
Robinson,PP, andSûith, K.G. {1996).Lnsual neryedâoise
dufinA lo{'.r tbird molar rcmovxl: a .omparson or ts1)
* ;i rt ,,. ,li9x. B! D. .J .Iao. :a
Srymouf.R.4.. Lowry R., \(hlùofth,J.M., and Nlartin,NLY
(2000).Infectilee.doca.dj.is,dentistryandânr;bioticpc
rhyldjs;; time fôr a rethinkTBt Dt"t.J.,189,610 6.
Sclmour. R.À., \{rhitwofrh, J.NL, and Marln, NL (2002).
AûîiLrioticcoverlor patieûs vitb joint f.osdreses Still a
J,r a, - lô I P r.., 1.,,1 ,, , ", , ,.
V\(ôrl.l Heè]rh Orgrùizàtiôù t.l9a6). Coktt,) Plarlet û Otdl
Hdht i" Eûate t986. WHO,Gene\^.
 I
268 reon(e olprevs-
l6 0evêlopins on.ev
derre-bo$d
denir-y
I
I
Bède6ten,,t., Nilveùs. R.. and Esclbc|a.J. (1984).Effecrof
ûônsûgi.al periodontalrhcnpy. II. Severely advancedperi
.àottitrs. Jrkr"dl 0f Clintà l Pùodanrola8!, 1r, 63 t-6.
c l a r k s o nJ, . E . ,w o r t h i n s t o n ,H . V , â n d E d e n ,O . B . ( 2 0 0 1 ) .
Interventionsfor prelenring o.d mùcosiriso. onl can{lidi
as,s for patients wirh .ân.ei re.eivina .hemotherapt
(ex.ludirs lrad 2nd neck ca..er). UFdareSôftwèreLtd,
't
he co.hraû. Libm5. 3.
Clini.âl Evldence(2001).A comleodium oflhe besralailable
evidcnccfo. ei]èc.ivehealth care.BMJ PùblishinsGrotrp,
Dhafiwal.D.K.. Goodey,R., ard Sh€pherd,J.P(-2002). Trends
;n onl su.geryin Englanl aod Wahs 1991 2AOO.Bx Dekt.
J , r92,639]'!.1
Edçâds, M.J., Rrickler. ùLR., Gooder R.D., and Shepherd,
J.P Tbe cost.cfrective.ess ard costefe.tileûessof remo'èl
and .ete.riofl oi aslmf.on,atic, diseNe free thûd nolars.
B j :D e n t . J . , 1 8 7 _ 3 1 t .
Eu.ofeanSocjetyof Endo.tonrology(1994). Consens$repôrt
ofrh€ EuroFeanSô.ietyof Endodontulogyon guallryguide-
linesfor endodontictreatn eùt.Iûndi|'tul Edrà|nt;t Jùrt-
i d l , 2 7 , 1 7 52 1 .
Fficdman. S. (1998). Treatment ôurcoûe and p.osnosi\ of
endodonri.rhcrapl Chàfrer lt ln: l)., O6tàvik T.R., Pitr
'L'rùtunt ,'1
FaÀ leds) Lrintidl L"ùà0"t,/0$: Ptudn,D d"d
Apitdl P#iolarrti!. Oxfôrà,B]â.ksell S.ieû.e:l6l-101.
Garsallo Albiol, J., BùÈnechea,R., a.d Gar-Escoda. C.
(2000).Lingml nÉil e porection duri.A surAicalremovalol
lower third dolar. A proTcct;ve rândonisedsrudl 1rr"/.
qrdl. Ma,;Iofd.. Sxrs.. 29, 268-1 |
G1ds, R.L (ed) (1982). :fhc 116rinrernalionalconieretrce o.
the de.linins p.era.len.eofdeûtal.aries./. Dd,r. R'r., 61.
(SfeciaLIss!e),1101 81.
G i à y ,P G . , ï d d , J . 8 . , S l a . k ,G . L . a n d B u l m a nJ, . S ( 1 9 7 0 ) .
Ahb Dtrtal Hulth in Englandanà \Yalu ;n ?96ii. HùISO.
Hill. R.\(r..RaamftoLd,S.P.,Nlodson.8.C.. Applebeûy.E.4..
Cafiesse. R.G, Kerr)'.GJ.. and Nisslc. R.R. (198r). lour
tIFs of per;odonral ùearment comparedo!r. 2 !eaA.
Jtundl ofP,odoatolosJ,52. 6tt 62.
Kâlsbeck,H. (1982). Evidenceof decrcaseiû prevalen.eoi
denralc.rièsin th€ Netherlaids:û eyâlùarionofepi.teni
ologicalcari€ssùrley on .1 6 ù.d 1l It yearold chil,lren
betweeo196t and 1980./. l)at R'J.,6l (Speci21 Issue),
ra2l 6.
Kel]v. M., Steele,J.G., Nùttàl], N., Bmdnock,G., À{orris,J.,
Nunn, J.H., Piûe, C., Pitts, N., Tredure, E., ar.] White,
D., Qoao). Adù Deùal He'llh Shtq. Otul Healtb is the
Urîed Kiki.Jatu199E, Government Stètisricàl Seô'ice,
HMSO.
Kvisr, T., ând Reit. C. (1999). Resuls of c.dodonric
,. d-r,qed ,lir,."l . ' dj oÊp,r ,s
sargi.àl èûd no6ursicè1 pro.eàrûes.Jùrri'l al Endalontid,
12,al4 7.
I-he manasemrnr of pa.iÈnB with idpà.ted third no1àr
(sisdom) teeth.NHS Cenùe nt Reriewsand Dlssemina-
trcns(1998).
Palmcf.J.D.(1980).Dcntul healtbin.hildrcn€n imp.ôvrng
pi.tte? Br D!"t. J., r19,48-10.
Robinson,PP, andSûith, K.G. {1996).Lnsual neryedâoise
dufinA lo{'.r tbird molar rcmovxl: a .omparson or ts1)
* ;i rt ,,. ,li9x. B! D. .J .Iao. :a
Srymouf.R.4.. Lowry R., \(hlùofth,J.M., and Nlartin,NLY
(2000).Infectilee.doca.dj.is,dentistryandânr;bioticpc
rhyldjs;; time fôr a rethinkTBt Dt"t.J.,189,610 6.
Sclmour. R.À., \{rhitwofrh, J.NL, and Marln, NL (2002).
AûîiLrioticcoverlor patieûs vitb joint f.osdreses Still a
J,r a, - lô I P r.., 1.,,1 ,, , ", , ,.
V\(ôrl.l Heè]rh Orgrùizàtiôù t.l9a6). Coktt,) Plarlet û Otdl
Hdht i" Eûate t986. WHO,Gene\^.
lndex
æesultàoel)otssiln 29
sù.rose dep.ndêd 63 9
âdvar.ed glrùted etd prod!.s (AGES) I .12
igeing dentinoù 139-201
ordl environmert 189 90
periodonlal diseàse 20,1
leriodôntal diseôe 204
rising popùlation of 190
adtibiori. F ophyldis 266
âpicÀlp.rio,lontitis ræFerlodontnn
Areà Child ProtÊ.ti.n Colùitiees
acoibic æid Jævitàmin c
âttrition 111,117-13,120
l\â.i|tu ûidrlhjl'r aiûtulrtn 61
beer,erosionpôtential I 19
behaviô u. m.naA.me.i 214 rt
BN.GMA '3
Bovman Bnkinhibnôi lll
Britnh Sô.ietyofPædiaùlcl)e.ùùy
burdig mouth synd.ome181
ând leriodontal dte6. lJl) l
.hemi.â]ly indu.ed LcsioN 170
periodontdl discde 126 7
pÉvenri'c FrcAammes ir 110 t
se.ulâr,ledine in. ies 261
chlorhexidine i2. ll, ll6-a
inrllcationstor ùse 113
clinicâl gofumd.e 4 t,266-l
.ob minP vnanin 8,,
.ola drinks, eosio. porential 119
Criii.ùllall Heiglrt 113
I t.l
Ddn, H Trtndley 13 -10
in de.iduou teeth 10 11
indnabkd people 21t 16
m.l edy nu.rnion 10-11
enàmelslâb experimens 13
eFidemiologi.al $ùdies 11-12
ând areqùen.yôf ro.qd.ônsùoDtlon 20 1
hlnm inreNenùon slaies lt 16
in $atiôn exp.riûe.ts 20
.1t ft'ùgencn. ot 79 9t
miûobioloaical âsFrts ot prevendôn
di.mbiologial lFdi.riôn of 14
i. pc.ma.ert teÊth l0 LL
lroLe.tnf tâ.ror 27 9
-,i
tubti. healtlr anpro'h 2tl
s..ulàr JÊdine ln 43 -.1
rc zÂ, enÀnel .tious lesions
{len.âldiseâsen older pâriens 193 9
dèntuL bcallI, e,lu.àtion t
p.riodontâl diseâse 112-l
JæzÀ, ohl healdr pronrotion
dentn injùries æ denml tùma
denr?l non riienda.cc lr7 ,
primàry prerention 148 t1
se.ônd.ry preventlon 1il 1
teftiry prore.rion 1t4
r* ,1, perioao.titisr pùlp
,leprivÀtionxnd ôraLhealth 2lÈ7
diâf,eresnellm, aùd pcriodo.ùr
rnd derol càriesris* 9 1,1.31,90
epid.ûiologi.âl sud,es l l-12, 1j
longiridiùl sudier 1.4
in.l orÀl .a..er rnk 172-l
ind pêriôdo..al,llseâre 112 l
por-eruprive Êtrtrt 10, 1l
protc.ive tâ.ton 2i 9
sùgÀr .onr umptioû ,,11 20
.ligitau.kif,g in m o..Luùo. Ita
270 lndex
behavioui manaAemenr 2 L4
pFÊntlor.l oful disêàsÊ21,1 19
self i.lli.ted thrûa 217
rùûitlonâl inllr.n..s on
pfotÊ.rn É ftrd.tion of 102
reâ. ons dunng erùption 82
ulrrxrru.tufuL ch.oÂes relâred o
ft ,r, e.mel càrioùslÊsioN
ènrnel caious lesions 79 95
approxnnal rl.f.aes 8l
.ln,icâl Jere.tior 37 3
frcc s.rooth nut .es 36
hislopatholôsi.,l leatures 82-j
managenre.t of 33 95
ô..lud sudr.es sG 7
emnel hypopls,a l, 10
eId.lslâb expÊrimen. la
endldoril.ri.rotlon 100
erosior I lt, LL3,l20 l
erythemr nùltiforme l8l
Êriien.e bâsêddentistry ,1 t, 261 3
.lini.al governâ.ce 266 7
inla.t or.lini.âl pn.ti.e 261 6
se.nLrrdccllne in.xries in .Ndtcn 261
ne.Js in dentd adult Fopulàrior 261
trerds in erl.nLulôùsnes 26I l
FédérâtionDêntuirc lniermti.nd
(FDr) 1.!r
nsurese'1.ùt 81,r1 t
efii.ien.y ând etre.tivenc$
râons agrin$ ùsÊ.1 9l
flloridâtion oarvater suftlies 13 40
iemperatedd rro!i..].lim.tcs
a!,!Lnd.lon bv dentir t2-J
ùa bonÈlrâ.trûê in.den.Ê t6
aod denhL !:triesexFerien.e 19,,10, 11
ând dentaL.riies rnk !1,90
Êfe.t .a.e$âiion ôfflnorid.don 't4
sc.ulâr.hanses in.rries
lùoride suFpl.mertâti.n 4t-6
llùùride roorhpâres ,13 tl, ,0
deLivcry,d hpeffing ,stùcrio.s
develotmÉn. ,ù 48-,
efe.r oa addtrivcs tl 2
effe.r o. roor .aries tl
low Joserl.s .on.enûùi i oa 19
iml llùorlde l! drinkinr r'âter 13, l9
ùd lluoiide toothpir.s 49 t0
ûuro.ligosæcbârides 2.l t
atun jùlces, Êrov.t potc.iiàl
tir.ctioml deûtitio. 19l t
fâaos L,ntitg 196 9
Aâsrc oesôph4erl retlux 113
i. dlsnbled F.ople 216 17
ro ,ljr FrndontaL dnede
glas iof,omer .edens ,J
glucân binding proleins 63
s\a.slltra.steràses 63 9
Gnûrl RaFlds Muskegôn
Heâlrh Pronrotlng s.hools
ol 9l
heredft4 Éu.tôsc intolenn.e 12
heryÊs inu infe.tions 163-9
hvperensitivty Ertions 134
40
hrogènic oEl disexse 171
mpdt.d wisdon têeth 261,26t
,mpalrmenr ç? dnabiliry
in.ubiti.nexpèriûcn( 20
4l ,i
nrfectiveendo.rrdnis 266
ftÊrdental b$h (bottle bruslt llt
nrrerdental.iea.i.a 11,1 t
àld
isonâlrooligosr.cbdrl,les 24 5
KLùn d l,!'rûik 169
119
lcsal âsle.is ofnuori.làdon .il t
Ldnnrtut NtbttCn 69
lldren.id !êa.tions 182 l
mu.osùl {liseâse t69 7l
lirslal llâ! reth.tio. 26i
lo.aL rtuc$heti.s 10,1 t
hl'Fesensitiritv to 184
M.K.y, Dr lrederi.k la

anrerior.tusbnès 160
LraLin.inrdrd.onF..sariigerrtâcrio.s
nilù.entlon ot io.iso6 l6l
eànr lo$ oaf.imâ.y mol Éedr Li9
e.roti.hnomdous teeth 162
nnerÊprnr meirfts lt9 lil
dJposirionel mdilldry cail.e reerb 162
mileJ Jeniiiion ltt 60
Ffmâ.ert dÊntnion 161
tlâr.ed lo$ oflint permânentmolar
Fo$einn.rusbite\ 160
senal e*r&dons lt9-60
sùfr.$ue lorn ma tu.Ûion in ltti
sulfrunÊrary teeth 161 2
rtà.sposition ot teeth 1ar2 l
mÊrls. and pllqk pH 19
ùûll.rl fico6 i. câriesrist 30 1
MellÀnby, lâ.ly Mat, L0
merllyLrerba.4ldic hyl.e6e.siriviry 134
I4ineei Tnoxde Àggregdte 103, ltl
ûorled .nrmcL .{z lluorosi
.on*nL.tlon.rneriâ Lt1
lili of 1il
spe.lâl grcuPs 151
llfeslb n cs 16t-rl
Drc!e.rio. ihrouÂh nutrition 174È31
.hÊmothenpy indu.ed 17t 6,266
ridir.où{ùdu.cd ll1-t
r'r'*
|,"
Nâtlonâl DiÊt Ànd NùÛniôn Snrver 14 sù$oi.ve.6e l/r0
ûends ,ù 128-,
ll9 ni.oùnmidè * ûcornric æid pèiôdon.J surÂÊry 26t
F.riodortitis 99 lLz
aeii.log.r 99 100
ron nrilk exùinsi. sùgrs 22 endodonn. n,.r.flon 100
rùserier. aood,n 2t4-t epidcmioloÂt 101 2
nâtruxl detetu$ agaitr 102 4
and.ùei Ns.eptibihy l0 ll preseNrtion oflnjùred !ùb 107 9
rnd eùnel .lclcloFme. r 910
.!ûitionùl.leu.lencv 1r6 31 .fter roor.anaL ûeatment 110-l I
r!(irion trrnsiti.n 9, 12 trrÊrÊf,tn,noaruL!,ùiuty r01 7
..cuf!tio., rnd cân.er rGk 172
.lderpxtlenB 139 90. l9r 6 6.106 mod,f!,.9 iôfl âm.r.t.o reslony
oiL lprhelidl dJ,sFlasiàlrr) io okler tJàtiÊ.c 202 3
orâLheÀlth Fromorio. 241 17 rn.l Friodontrl diseasè 110, lll
.LLsrcrnrr of rÀk aâ.or 2.i3
Às risk fx.û tor denr:I.ùics 8l
dererminÀnEaf .hrori. diseises 2,16
dominant Énosophr 2,11
epidêniôLdsic.Lbdsn 248
generil Frin.itles 246
lnte8mred âtproÀ.h 21lJ3
,nteEe.tuirl â.tion 2tl) 1
!ûpulaùon dd high{isli $rareÂies 2.43 9
lubln lealdr approàdr 2t],1 pl6oà.ell ginglvitn 13l t
utsrreiû aFFroæh 241 4 playgrourd sùrtâ.es in tÉth
ùholepopuladon rràregr 219 t0
ôrofù.iùl gnnulomâ@th 132 l
Ortàvâ Châ.ter 2.it,2t.i t
orerjÊ., eârLj'(nixrd dentniôn)
trofesiooal roodr.leânina 90
Psklùa4.L'rùne ra9
Pdteua loùs 6l d...al 'nârefiâl\ drmiging 10t t
ÀgÊ'ng/ ngeng Prnen6
as drntal .dies rnk 3r-r0 prevennoù oa injLrr' I01 r
invôLvemeft ln denràl .arles mânâsenent sepwne eicalario. 107 8
ty'lJornre s itimin Br
periodonbLdtrede l2t-/1
.hildren.nd ddolcsce.G 124 I
dertal hrsie.e ndice 112
É.ùûeft aphrhoùs$omârirh 131 2
rem,nenliTario. ot .ari.ns lesions 79
trÊ\alen.e ând serÊritv 129
lrÊrÊrtlon 129, 140 l
ribollÀvine r# vnamiû Br
,1
!ùb1,. health trFFroù.h 2t1
den$l.fics 9 iri,31,90
 I
272| l èr
I
t 1skte tats- kt " Ii " t uJ)
periodontaldnease111 2
root .dâl ùearmenr,lrvention ot
Fenoao.lnn 110-11
distribution 199-200
effe.t of fluoride toorhpdtes t 1
,..lden.ê 199 200
nanagement 201 4
mlc.obiology.ndhnùLogy 200 2
in olaerFàtiens 199 20.i
rrvâlence 199-200
prewnrio! 202 :
saln? composiriônand dentll .des risk 81
ând denral mries rn! 90, 91
in d:sabledpcople 217 19
t.tjd:,bùtLtu 2Q3,218
Sâlmonellaêlreridi ri s 169
selt lntlicred trâumi 217
slelêtal 6.tos iD mâltr.lulon 117-a
socidlaebs iD.dies ris! A0
so.ial itu!ùrlities 221 -.10
eaae.. ol detriutio. 22t
i.Érnadondl petspe.rive 227 3
m$uemenr of 221 l0
sft,cconomi.râtùs 172,221
!, ,r, sô.iâl iftqùÀlkiÊs
spods, mouth proie.rion if, c? moùtha@ds
squnoùs ccll .ir.inômr 170 2
aù,ed experimenB 21 4
emnel s]âb erpcriûenE 2.i
it.ubation experimers 24
inrÊnrniioû sùdies 2l
obsemriomi sùlies 2l
F.utrent aththous 131-2
â$o.iâtlon çitb caries 6i-6 .lini.âLimpllcarions121-2
ir disâbledpeople216
e r ô s i o n1 1 t , 1 1 3 , 1 2 0I
st?9 uûoL|ûNîdlàtrt ét
in olderpâtien6 204 t
Strt|,t(etur ,ibtuli$ 6t
StdlldatÆ nn^ 6,,66, 6-t, Ia2
Stnltotui"t n,1d"t 11,21,2>, é4, 6t,66,6a, pievenriôn120 1,20t {
69.200 tôôth weri iddd lt6, r17
strtliotEû ûzlI 65, 66, 6J tdspNitioù of teeth 162 l
sh4tM$ pdfdid\,n 6t
Trisiândâ Cùnhâ 12,1:l
StdP@tttJ Jal'nri"J 65, 66 TùIkr .hewinggun $udt 3l
StnùMlr lt"pn 65,67, ll0, 1a2 Tùku sugarrlldie 1t 16
StftFtùûa arb n^ 65
sù.rce -dependentadhesod 63 9
vrcin.rioù, fôr dental.ùies 72 -1
!d Leeùùenhæk,Ântoûie 61
.ro${ectiomlsùdies 1l-r4 v&i.elln-zGter litus 169
nerûer ro redu.e 2tl
sugd, .aiôgen,.ty of 21 2 hylerihmirosls A 176
gar suDsrutes w s*eeteneÀ
n'pernumehry ieerh 161 2
rôLei ù .des prevennod ll
v k m i . D 1 0 ,1 7 7 ,1 7 9
w i m n i nE 1 t 7 , 1 7 9 ,1 8 0
rnd peri.dôntâl dÀffe 111 2, tll
rôcopberols r* vnrmin !
\X/.rer(Iluorid.rion)Bill (r93t) 44
vâter lplies, flùori.latlon l3-!0
rootbbrushes,elecÛi. 134
lcnpc$re a.d ûopi.al .limres 40
Jd,l, nuride od nuori{lation
whiÉ spotleslons83 4,86
soodpoin6 Goorhli.kt 1lt
woild Hêahh Orsanizatiôn (\YHO)
flùoriderepons tt, t3
ra,À, toothb shingi ùorlpdter
rooth mortaliry 129
lero$ôm,a 202, 211-19
lluoride rd flùoride to.thr,âres
rbrulon llt, I it, 120
nttntion llt, 117 13, 120