Chapter 1. Introduction to Primary Preventive Dentistry - Norman O.

Harris
Objectives

At the end of this chapter, it will be possible to

1. Define the following key terms: health, primary prevention, secondary prevention, and tertiary
prevention. Also, provide one specific example of each.

2. Name three convenient categories that aid in classifying dental disease and in planning oral-
disease prevention and treatment programs.

3. Name four strategies and two administrative means for reducing the prevalence of dental caries
and/or periodontal disease.

4. Cite two early actions that are essential for arresting the progression of the plaque diseases once
primary preventive measures have failed.

5. Explain why the planned application of preventive-dentistry concepts and practices, including use
of sealants and fluoride therapy, when coupled with early detection and immediate treatment of the
plaque diseases, can result in a zero or near-zero annual extraction rate.

Introduction

In the year 2000, in the Executive Summary of the Surgeon Generals Reporta on the "Oral Health in
America," some of the major challenges facing American dentistry were listed.1,2 It is appropriate to
abstract a number of these problem areas in order to better understand the role that prevention can
play in their solution.

1. Tobacco: This is a major societal health problem with very strong relationships to dentistry.
Smoking has a very devastating relationship to periodontal disease and oral and pharyngeal cancer,
while the use of chewing tobacco is associated with oral cancer as well as root decay (see Chapter
23).

2. The statistics of dental need:

Children

a. Dental caries is the most common chronic childhood disease.

b. Over 50% of 5- to 9-year-olds have at least one cavity or filling; by age 17, the percentage has
increased to 78%.

c. As a part of childhood, children have many injuries to the head, face, and neck.

d. Twenty-five % of the children have not seen a dentist before entering kindergarten.

e. More than 51 million school hours are lost each year to dental-related illness.

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Adults

a. Most adults show signs of periodontal or gingival diseases. Severe periodontal disease [measured
as 6 millimeters of periodontal attachment loss (pockets)] affects about 14% of adults aged 45 to 54.

b. Employed adults lose more than 164 million hours of work each year because of dental disease
and dental visits.

c. A little less than two-thirds of adults report having visited a dentist in the past 12 months.

Older adults

a. Twenty-three % of 65- to 74-year-olds have severe periodontal disease (characterized by 6

millimeters or more of periodontal attachment loss). At all ages, men are more likely than women to
have more severe disease.

b. About 30% of adults 65 years and older are edentulous, compared to 46% 20 years ago.

c. Oral and pharyngeal cancers are diagnosed in about 30,000 Americans annually. Nine thousand
die from these diseases each year. Prognosis is poor.

d. At any given time, 5% of Americans aged 65 and older (currently some 1.65 million people) are
living in long-term care facilities where dental care is problematic.
a
United States Public Health Service.

Throughout the entire Surgeon General's report, there is major emphasis on the great disparity
between those who get dental care and those that do not have access to a dental facility.3,4 These are
the people who are poor,5,6 are mentally handicapped,7 those that are disabled,8 children,9-12 the
aged,13 and those without dental insurance. There are others living in underserved geographical
areas,14 and still others who do not have access to dental care because of disease,15 culture, or race.16
To address these problems a national program and guidelines of dental care is needed that will
include these dentally neglected groups. The questions then become, "What kind of a national
program should it be? Is it possible to take care of so many people with so few dental health
professionals?"

It is the goal of the dental profession to help individuals achieve and maintain maximum oral health
throughout their lives. Success in attaining this objective is highlighted by the decline of caries
throughout the Western world,17 and the dramatic reduction of tooth loss among adults in the United
States. This progress has been mainly attributed to the use of water fluoridation and fluoride-
containing productstoothpastes and mouthrinsesand the growing acceptance and practice of
primary preventive care.18 Yet, dental caries remains a major public-health problem.

Untold millions of research hours and money have been invested in reaching our present capability
to control the ravages of the plaque diseases. Effective strategies that can markedly reduce the
number of carious teeth and better control of periodontal disease are now available. They only need
to be used.

All health professions emphasize that patients should seek entry into well-planned preventive

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programs. For dentistry, lack of prevention results in more restorations, periodontal treatment,
extractions, and dentures. The changeover in priority from treatment to prevention will require active
leadership and health promotion by the dental profession, consumer advocates, public health
educators, and health-policy planners. Public-health delivery systems, such as the military, national
and state public-health services, and industrial organizations that provide benefits to their personnel,
have usually been in the forefront of such change because of the economic advantages accruing to
the provider and health benefits to the recipients. For example, in 1989, a report by Malvitz and
Broderick19 recounted the results following the change of focus toward a maximum emphasis on
prevention for dental services by the Indian Health Service in the Oklahoma City area. The total
number of visits increased by 10%, yet the number of dental personnel remained constant. The
percentage of preventive services increased, along with a decrease of restorative procedures.

Benefits of Primary Preventive Dentistry to the Patient

For the patient who thinks in terms of economic benefits and enjoyment of life, prevention pays.
Many studies document the prevalence of dental disease, but behind these numbers there is little
mention of the adverse affects on humans caused by dental neglect. One study points out that 51% of
dentate patients have been affected in some way by their oral health, and in 8% of the cases, the
impact was sufficient to have reduced their quality of life.20 If preventive programs are started early
by the patient (or, preferably, by the parents of young children) long-range freedom from the plaque
diseases is possiblea sound cost-benefit investment. After all, the teeth are needed over a lifetime
for eating. Speech is greatly improved by the presence of teeth. A pleasant smile enhances
personality expression. Teeth also contribute to good nutrition for all ages. At rare times, teeth have
even provided a means of self-defense. On the other hand, the absence of teeth or presence of
broken-down teeth often results in a loss of self-esteem, minimizes employment possibilities and
often curtails social interaction.

Benefits to the Dentist

Possibly the first benefit of preventive dentistry is the fulfillment of the moral commitment to the
Hippocratic Oath that was taken by health professionals at graduation "to render help to those in
need, and to do no harm." Through ethics and training, the dentist should derive a deep sense of
satisfaction by helping people maintain their oral structures in a state of maximum function, comfort,
and aesthetics. A well-balanced practice that actively seeks to prevent disease but is also able to care
for those individuals where prevention has failed should prosper. Patients can be outstanding public
relations advocates if they are convinced that their dentist and staff are truly interested in preventing
disease.

If for no other reason, a dentist should consider prevention to avoid possible legal problems. A now
strongly supported law for medicine, but to a lesser extent for dentistry, requires that prior to
treatment, all optionspreventive as well as treatmentshould be explained to secure informed
patient consent. This discussion should include a comparison of health benefits and hazards, as well
as the economic and the oral-health benefits of prevention. Long-term patients, the lawyers and the
court system are taking a more unsympathetic attitude toward practitioners who have permitted a
disease to progress over many years without having taken some accepted primary preventive actions
to have slowed, or halted its progress. Patients no longer tolerate supervised professional neglect.21

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Primordial prevention

Prevention of risk factors themselves, beginning with change in social and environmental conditions
in which these factors are observed to develop, and continuing for high risk children, adolescents
and young adults. It is receiving special attention in the prevention of chronic diseases. For
example, many adult health problems (e.g. obesity, hypertension) have their early origins in
childhood, because this is the time when lifestyles are formed.

In addition to that, primordial prevention calls for changing the socio-economic status of society.
A better socio-economic status correlates inversely with lifestyle factors like smoking, abnormal
food patterns and exercise.

What is Primary Prevention?

When discussing primary prevention, we must first define a few key words. Health is what we want
to preserve, and it is defined as a state of complete physical, mental, and social well-being, and not
merely the absence of disease or infirmity. For instance, some individuals may actually be in
excellent health but believe, for some reason logical to them, that they have oral cancer. Such
individuals do not have an optimum mental well-being and will continue to worry until they are
somehow convinced otherwise that they are indeed healthy. Another person may be functionally
healthy, although facially disfigured, and as such be socially shunned throughout life.22 Thus, health
can at times be what the patient thinks and not the actual condition of the body. Even the
terminology "preventive dentistry" has different connotations to different people. As a result,
preventive dentistry can be arbitrarily classified into three different levels.

1. Primary prevention employs strategies and agents to forestall the onset of disease, to reverse the
progress of the disease, or to arrest the disease process before secondary preventive treatment
becomes necessary.

2. Secondary prevention employs routine treatment methods to terminate a disease process and/or to
restore tissues to as near normal as possible.

3. Tertiary prevention employs measures necessary to replace lost tissues and to rehabilitate patients
to the point that physical capabilities and/or mental attitudes are as near normal as possible after the
failure of secondary prevention (Figure 1-1).

In going from primary to tertiary prevention, the cost of health care increases exponentially, and
patient satisfaction decreases proportionately. An excellent example of the comparative cost of these
two levels of care was the treatment of an individual with poliomyelitis. It has only been a few years
ago that the cost of the polio vaccine was only a few dollars. The use of the polio vaccine to prevent
the onset of the disease was highly effective. But, for someone not adequately immunized, the cost of
treatment for poliomyelitis and subsequent rehabilitation approximated $50,000 or more for the first
7 weeks of hospitalization and outpatient care.23 Yet, the individual receiving the $50,000 worth of
tertiary preventive treatment and the attendant disability was certainly not as happy as the one who
benefited from only a few dollars' worth of primary preventive care. The payoff of the worldwide
drive to eliminate polio promises to have this disease follow smallpox into oblivion. Another
appropriate example is the fluoridation of drinking water. This costs approximately $0.50 per year
per individual, yet it reduces the incidence of dental caries in the community by 20 to 40%. If this
primary-preventive measure is not available, the necessary restorative dentistry (secondary

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prevention) can cost approximately 100 times more, or about $50.00 per restoration.18 Finally, if
restorative dentistry fails, as it often does, prosthetic devices must be constructed at an even greater
cost. This great disparity between the lower cost of prevention and the much higher cost of treatment
must be seriously considered if the United States is to develop an affordable national health program
in which dentistry is represented.

This text emphasizes primary prevention, and specifically focuses on primary prevention as it applies
to the control of dental caries and periodontal disease. On the other hand, it must be recognized that
primary prevention often fails for many reasons. When such failure occurs, two actions are essential
to contain the damage: (1) early identification of the disease (diagnosis) and (2) immediate treatment
of the disease.
Categories of Oral Disease

For planning purposes, dental diseases and abnormalities can be conveniently grouped into three
categories: (1) dental caries and periodontal disease, both of which are acquired conditions, (2)
acquired oral conditions other than dental caries and periodontal disease (opportunistic infections,
oral cancer, HIV/AIDS), and (3) craniofacial disorders which would include a wide variety of
conditions ranging from heredity to accidents.24,25 For instance, the ordinary seat belt and the air bags
in a car exemplify how a simple preventive measure can greatly reduce the facial injuries of car
accidents. Looming in the not-too-far distant future is the very real possibility that many acquired
health problems will be corrected or ameliorated for total populations by use of vaccines, genetic
engineering, or specifically targeted drugs ("magic bullets").

The treatment of caries and periodontal disease (and their sequelae) accounts for most of the
estimated $60 billion U.S. dental bill for the year 2000.26 Both caries and periodontal disease are
caused by the presence of a pathogenic dental plaque on the surfaces of the teeth and hence are
known as the plaque diseases. Any major reduction in the incidence of caries and periodontal disease
will release resources for the investigation and treatment of conditions included in the acquired and
craniofacial category.

The ideal, or long-range planning objectives for coping with both dental caries and periodontal
disease should be the development of a preventive delivery system and methods to eventually attain
a zero or near-zero disease incidence for the target population. However, a more realistic and
feasible shorter-term goal is the attainment of a zero or near-zero rate of tooth loss from these
diseases by integrated preventive and treatment procedures. Because of the varied etiology of the
second and third categories, that is, other acquired conditions and craniofacial malformations and
diseases, the planning for the control of each of these problem areas must be individually addressed
and placed within the priorities of any overall health plan.

Strategies to Prevent the Plaque Diseases

Before providing an overview of methods used to implement primary prevention programs, it is

important to point out that both dental caries and periodontal disease are transmissible diseases. If a
child is considered at high risk for caries, one of the parents27usually the mothercan usually be
identified as high risk; if a child has periodontal problems, usually one of the parents is also afflicted.
Any infectious (acquired) disease can only begin if the challenge organisms are in sufficient numbers
to overwhelm the combined manmade and body defenses and repair capabilities. For this reason, all
strategies to prevent, arrest, or reverse the ravages of the plaque diseases are based on (1) reducing
the number of challenging oral pathogens, (2) building up the tooth resistance and maintaining a

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healthy gingiva, and (3) enhancing the repair processes.

In general, periodontal disease is a disease that involves the soft tissue and bone surrounding the
affected teeth. Caries involves the demineralization and eventual cavitation of the enamel and often
of the root surface. If the incipient lesions (earliest visible sign of disease) of caries and periodontal
disease are recognized at the time of the initial/annual dental examination, they can often be reversed
with primary preventive strategies. For caries, the visible incipient lesion is a white spot, which
appears on the surface of the enamel as a result of subsurface acid-induced demineralization. For
periodontal disease, the visible incipient lesion is gingivitisan inflammation of the gingiva that is
in contact with the bacterial plaque. Not all "white spots" go on to become caries, nor do all cases of
gingivitis go on to become periodontal disease. In both cases, i.e., caries and periodontal disease, it
should be noted that if dental plaque did not exist, or if the adverse effects of its microbial
inhabitants could be negated, the decrease in the incidence of the plaque diseases would be very
dramatic. Based on these facts, it is understandable why plaque control is so important in any oral-
health program.

To control the plaque diseases with available methods and techniques, strong emphasis has been
directed to four general strategies to reduce caries and two administrative requirements:

General Strategies

1. Mechanical (toothbrush, dental floss, irrigator, or rinse)

2. Chemical plaque control. Use of fluorides to inhibit demineralization and to enhance

remineralization; use of antimicrobial agents to supress cariogenic bacteria.

3. Sugar discipline.

4. Use of pit and fissure sealants, when indicated, on posterior occlusal surfaces.

Administrative

5. Education and health promotion.

6. Establish access to dental facilities where diagnostic, restorative, and preventive services are
rendered, and where planned recalls based on risk are routine.

A brief summary of each of these primary preventive procedures will serve as an introduction for the
more detailed information presented in later chapters.

Plaque Control

Dental plaque is composed of salivary proteins that adhere to the teeth, plus bacteria and end-
products of bacterial metabolism. Both cariogenic and periodontopathogens accumulate in the plaque
located along the gingival margin, interproximally, and in the pits and fissures. Plaque collects more
profusely in these specific areas because none of these locations is optimally exposed to the normal
self-cleansing action of the saliva, the abrasive action of foods, nor the muscular action of the cheeks
and tongue. Plaque decreases in thickness as the incisal or occlusal surface is approached. Little
plaque is found on the occlusal surface except in the pits and fissures. As would be expected, plaque
forms more profusely on malposed teeth or on teeth with orthodontic appliances, where access for