Oral Health and Preventive Dentistry, 03/2004

This article reports a survey of the systems for the provision of oral healthcare in the 28 member and accession states of the EU/EEA in 2003. Descriptions of the systems were collected from the principal dental advisers to governments in the individual states. In many states these were the Chief Dental Officers (CDOs). In states without a CDO, descriptions were gathered from CDO equivalents or senior academics. A template (model description) was used to guide all respondents. Additional statistical information on oral healthcare costs and workforce was collected from the Council of European Chief Dental Officers, WHO and World Bank websites. The study showed that in broad terms there were six patterns (Beveridgian, Bismarkian, The Eastern European (in transition), Nordic, Southern European and Hybrid) for the administration and financing of oral healthcare in the expanding EU. The extent and nature of government involvement in planning and coordinating oral healthcare services and the numbers and pay of the oral healthcare workforce varied between the different models. The biggest recent changes in European oral healthcare were found to have occurred in Eastern Europe, where there has been wide scale privatization of the previously public dental services. However, most of the EU accession (Eastern European) states seemed to be slowly developing insurance systems to cover oral health treatment costs. In the existing EU/EEA, the public dental services such as those in the Nordic countries still have strong political support and some expansion has occurred. In Southern Europe public dental services seemed to have gained some acceptance for the treatment of children and special needs groups. In UK, which has a unique public dental service system, there are plans to make big changes in the delivery, commissioning and remuneration of dental services in the near future. Some EU member states which operate the Bismarkian system with health insurances offering wide population coverage, comprehensive treatment and benefits connected with frequent dental visits, were reported to be experiencing financial problems. The study also indicated that at present, with the exception of Portugal and Spain, where there is dynamic growth in the numbers of dentists, the overall size of the EU/EEA oral health workforce is expanding fairly slowly. Only a minority of member states appeared to collect data on uptake of services and care costs and there were great difficulties in assessing outcomes of care. The data on costs appeared to show wide variations from member state to member state in per capita spending on oral healthcare. In the majority of states, however, costs, especially those in the private sector, could only be estimated. Nevertheless, at a 'macro' level, the study indicated that, in 2000, the 28 member and accession states of the EU/EEA had a total population of 456 million and an oral health workforce of 900,000 (some 300,000 of whom were dentists) and that the cost of oral healthcare was about EUR 54,000,000,000. The study showed wide variations in oral healthcare provision systems between EU/EEA member and accession states and no evidence of harmonization in the past. Keywords: European Union, oral healthcare, systems, workforce, costs

The primary aim was to describe self-perceived oral health and function in a group of adults aged 75 to 84 years. The secondary aim was to study the agreement between self-reported oral function and clinical findings. A 5% sample (150 subjects) was selected at random from the total population (2,910) of 75 to 84-year-old residents in suburban Stockholm, Sweden. The inclusion criterion was that the individual lived independently, without any community assistance. A questionnaire covering self-perceived chewing ability, mouth dryness and bleeding gums was sent by mail. The total response rate was 86%. Of these 129 respondents, a 25.0% subsample was randomly selected for clinical examination by a dental hygienist. No radiographs were used. The average age of the individuals was 78.7 years (SD 2.71). Most were satisfied with their oral status and function: > 75.0% reported good chewing ability, correlating with the number of remaining teeth and dentures. Mouth dryness was reported by 41.5% of respondents to the questionnaire; one case was diagnosed in the subsample which underwent clinical examination. Bleeding gums were reported by 11.8% of respondents; clinical examination disclosed bleeding on probing in all participants. Mouth dryness and bleeding gums were not associated with chewing ability. Most subjects reported satisfactory chewing ability. Deterioration in oral function correlated with fewer remaining teeth and removable dentures. In relation to the clinical findings, mouth dryness was 'over-reported' and bleeding gums were 'under-reported'. Keywords: elderly, oral health, oral function, chewing ability, mouth dryness, self-reported health

To investigate caries-preventive measures (CPMs) applied by dentists in Mongolia to their own children in relation to the dentist-parents' professional and preventive care-related backgrounds and the children's dental health. A questionnaire distributed to Mongolian dentists in 2000 surveyed their professional and preventive care-related backgrounds. The dentists filled in a dental chart for their own children aged 3 to 13 years and indicated which of seven listed CPMs were applied to each child. Of the dentists surveyed, 245 replied (98%); with 146 having children (n = 208) of the target age. Statistical evaluation included chi-square test, one-way ANOVA, linear regression analysis, and odds ratios based on 2X2 tables. Of the seven CPMs, the following were applied on average per child: 3.7 (SD = 1.6) to 3- to 5-year-olds; 4.4 (SD = 1.3) to 6- to 11-year-olds; 4.3 (SD = 1.4) to 12- to 13-year-olds; with the youngest children receiving the fewest CPMs (p = 0.02). Demonstrating toothbrushing techniques and taking children for regular preventive check-ups were the most frequently reported measures applied to the children. Conversely, pit and fissure sealants and restriction of sugar were the least reported. The number of CPMs was unrelated to any factors connected with the dentist-parents' backgrounds among the youngest group; correlated negatively to dentist-parents' work experience (p = 0.002) among the middle group; and positively to dentist-parents' preventive knowledge (p = 0.04) and self-reported competency (p = 0.005) among the oldest group. Among the middle group, more CPMs were applied to those with greater DMFT/dmft scores. Caries-preventive measures applied to dentists' children should be improved, especially in regard to sugar consumption. Comprehensive efforts are called for, stressing modern CPMs. Keywords: caries preventive measures, dentists' children, Mongolia

To investigate the relationship between oral health-related quality of life and clinical dental measures in an elderly Greek population. A cross-sectional survey was carried out of adults aged 65 years or older living independently in Athens. Data were collected through clinical examination and interviews. Oral health-related quality of life was assessed through the Oral Impacts on Daily Performance (OIDP) indicator. The sample consisted of 681 participants. Data analysis used non-parametric tests (Mann-Whitney, Kruskal-Wallis and multiple logistic regressions). The response rate was 87.8%. Dentate participants with 1-10 teeth were 2.05 (1.25, 3.35) times and those with 11-20 teeth were 1.81 (1.11, 2.95) times more likely to report oral impacts than subjects with 21 or more teeth. Participants with anterior tooth spaces were 2.86 (1.70, 4.80) times more likely to report oral impacts than those without anterior spaces. Participants with 0-8 natural occluding pairs (NOPs) were 1.72 (1.14, 2.58) times and those with 0-3 posterior occluding pairs (POPs) were 1.57 (1.04, 2.36) times more likely to experience oral impacts than subjects with 9-16 NOPs and 4-10 POPs respectively. Decayed teeth were not significantly related to the presence of oral impacts. Edentulous participants with inadequate denture adaptation were 2.59 (1.46, 4.59) times, those with inadequate denture retention 2.41 (1.39, 4.17) times and those with denture overextension 2.51 (1.10, 5.74) times more likely to report oral impacts than subjects without the respective denture deficiencies. Clinical indicators of oral health status were significantly related to measures of oral health-related quality of life. Keywords: oral impacts, quality of life, elderly, dental status, teeth

The purpose of this study was to investigate the effect on enamel surface morphology of two commercially available bleaching products (AZ Whitestrips 6% hydrogen peroxide - Procter & Gamble; Platinum TWS 10% carbamide - Colgate Oral Pharmaceuticals) and their ability to prevent enamel demineralization in the presence of cariogenic solution, with or without saliva. Forty sound teeth were used to obtain 90 enamel fragments. Lactic acid (pH = 4.4) was used as a demineralizing cariogenic solution. The specimens were randomized into eight groups: Group A: product A + cariogenic solution; Group B: product B + cariogenic solution; Group C: cariogenic solution; Group D: (control group) stored in deionized water; Group E: product A + deionized water; Group F: product B + deionized water; Group G: product A + saliva; Group H: product B + saliva. Scanning electron microscope (SEM) analysis was performed to detect the type of lesions induced by the treatments. A score rating system was used to perform a non-parametric statistical analysis. Our study confirms that enamel alterations (i.e. removal of intraprismatic core and presence of deep porosities and pits) occur as a result of the application of a cariogenic solution (lactic acid). The enamel surface presented a honeycomb surface only in untreated samples previously stored in lactic acid solution. Conversely, both products were able to prevent enamel alterations caused by exposure to lactic acid. Saliva treatment reduced the degree of enamel lesions of both treated and untreated groups. Treatment with product A achieved better preservation of enamel integrity. Whitening treatment conducted with two 'home' bleaching agents had no adverse effects on enamel surface morphology. Several morphological aspects suggest that the tested products may even prevent demineralization of the enamel surface after exposure to lactic acid. Keywords: whitening, SEM, enamel, lactic acid

Biomedical prevention of diseases seems very difficult, but we believe that holistic medicine offers a simple and seemingly efficient solution that is useful for both physicians and dentists in their clinics, with a focus on improvement of quality of life as an important supplement to improving their patients' lifestyles. Quality of life is improved when the patient's personal philosophy of life is adjusted in accordance with life and its fundamental purpose. The relevant concept of personal growth can be introduced to the motivated patient in the clinic, during the conversation with the dentist. To prevent health problems in the future, personal development must focus on improving the quality of life of the patient by: 1) increasing self insight to obtain knowledge and understanding of the purpose of life; 2) recovery of character to be the good person the patient really is; and 3) full expression of talent in private and professional life in order to be optimally valuable to the patient and others. It is also important to work on the ethics of the patient to prevent the patient from destroying personal relationships and harm others, because such deeds will almost always also damage the patient. Parallel to clinical work, we believe that dentists can make an impact on their patients and inspire an improvement in their quality of life. The dentist, who sees the patient at shorter intervals, can coach his patient and often efficiently help him/her to improve intimacy and personal relationships, consciousness of responsibility, and quality of life which might be highly beneficial for the patient's health. Keywords: quality of life, QOL, philosophy, human development, holistic medicine, public health, holistic health, holistic process theory, life mission theory, preventive dentistry, Denmark

Over the past two decades an increasing body of research has been devoted to exploring the links between oral diseases and disorders and quality of life outcomes. As with similar studies in medicine, this work was stimulated by changing concepts of health, the development of theoretical models linking biological and psychosocial variables and the development and testing of measures that allowed those linkages to be investigated. This area of research is now referred to by the rather cumbersome term 'oral health-related quality of life'. This research addresses two important questions: 1) To what extent do oral disorders compromise aspects of daily living that individuals value? 2) What interventions mitigate their effects and restore the individual's quality of life? This presentation provides an overview of this field of research and a brief summary of some of the work that has been conducted to date along with the implications for clinical and public health practice of what that research has found. Keywords: oral disorders, oral health related quality of life, quality of life, outcomes, clinical trials

There has been, and still is a firm belief that regular use of dental services is beneficial for all. Thus governments in most European countries have shown some interest in training oral health care professionals, distributing the dental workforce and cost sharing. Constantly evolving treatment options and the introduction of new methods make dental clinicians feel uncertain as to which treatments are most useful, who would benefit from them, and which treatments will achieve cost-effective health gain. Although there is a considerable quantity of scientific literature showing that most available preventive measures are effective, and the number of sensible best-practice guidelines in prevention is growing, there are few studies on cost-efficiency of different methods and, secondly, the prevention and treatment guidelines are poorly known among general practitioners. In the eyes of the public, it is obvious that preventive methods practised by patients at home have been eclipsed by clinical procedures performed in dental clinics. Reliance on an increasingly individualistic approach to health care leads to the medicalisation of issues that are not originally health or medical problems. It is important to move general oral disease prevention back to the people who must integrate this in their daily routines. Prevention primarily based on healthy lifestyles, highlighted in the new public health strategy of the European Union (EU), is the key to future health policy. Keywords: dental prevention, health policy, oral healthcare systems, public health

Dental caries progression or reversal depends upon the balance between demineralization and remineralization. The 'Caries Balance' is determined by the relative weight of the sums of pathological factors and protective factors. Minimally invasive dentistry aims at the least possible removal of enamel or dentin, including reducing pathological factors and enhancing remineralization to avoid any removal of hard tissues. A structured caries risk assessment should be carried out based upon the concept of the caries balance. Following the risk assessment a treatment plan is devised which leads to the control of dental caries for the patient. The balance between pathological and preventive factors can be swung in the direction of caries intervention and prevention by the active role of the dentist and his/her auxiliary staff. Much is now understood about the mechanism of dental caries. We have known for a long time that demineralization of enamel, dentin or cementum is caused by organic acids that are generated by so-called acidogenic bacteria in the plaque when these bacteria feed upon fermentable carbohydrates (Silverstone, 1973; Featherstone, 2000; Loesche, 1986). The natural repair process is remineralization, which occurs when the pH rises again and calcium and phosphate from saliva together with fluoride enter the subsurface region of the lesion and form a new veneer on the existing crystal remnants in the lesion (Ten Cate and Featherstone, 1991). This veneer is less soluble than the original mineral and resists further acid attacks. The key to improved dental health for all is now for the dental profession to embrace this knowledge and put it into practice in the real world, to inhibit caries formation and progression, and to enhance the natural repair process. Keywords: caries, remineralization, oral bacteria

Clinical studies suggest that gingival inflammatory response to plaque accumulation may vary between individuals. Evidence seems to indicate that there is an association between susceptibility to gingivitis and susceptibility to periodontitis. Recently, among participants in a large scale experimental gingivitis trial, we were able to identify and characterize subjects that differ significantly in their gingival inflammatory response to plaque accumulation. Research efforts are being focused on the effect of genetic, anatomic and environmental host-related factors which may be implicated in the pathogenesis of the gingival inflammatory process, and whether susceptibility to periodontitis and susceptibility to gingivitis may partly share common risk factors. In this respect, it is possible that identification of factors related to increased susceptibility to gingivitis may help identify, at an early age, subjects at risk of periodontitis. Keywords: periodontal disease/diagnosis, gingivitis, risk factors, oral hygiene

Demographic developments indicate both an increasing proportion of the elderly in the population and an augmenting life expectancy. The elderly tend to retain their natural teeth for longer, and the first removable denture is inserted more often later in life. Oral health-related quality of life (OHRQoL) is influenced by functional parameters such as pain and discomfort, but also by psychological and social aspects. Dental care may restore oral function and alleviate pain and discomfort, e.g. caused by xerostomia. Dental treatment could further improve oral appearance of the elderly individual, which might provide self-esteem and thus contribute to the psychological well-being. Even social aspects like communication and social interactions could be positively influenced by dental care. Thus oral health and dental care have a significant impact on the quality of life (QoL) of elderly adults. Keywords: quality of life, elderly, gerodontology, OHRQoL, ageing

Most dental diseases are preventable. This indicates that the main concept of dentistry could be changed to a situation in which the dental hygienist becomes the principal oral care professional. The competencies of dental hygienists focus on disease prevention and oral health promotion; thus referral to a dentist would only become necessary in the event of a failure in the preventive program where disease cannot be controlled. Future oral health care personnel need to be better educated to encourage people to implement healthy lifestyles rather than to treat teeth. In addition, the connection between oral health, general health and health-related quality of life will necessitate a multidisciplinary approach to prevention and oral health promotion. To focus strictly on oral health would too narrowly define the role of the dental hygienist in comprehensive prevention and health promotion. There is no precise boundary between the oral cavity and the rest of the body. Dietary advice to prevent dental caries and smoking cessation counseling to prevent periodontal disease and oral cancer also promote general health. Consequently the focus on prevention and health promotion makes the dental hygienist a very important person in the dental team of the future. Keywords: dental hygienist, oral health prevention

Minimally Invasive Dentistry is the application of "a systematic respect for the original tissue." This implies that the dental profession recognizes that an artifact is of less biological value than the original healthy tissue. Minimally invasive dentistry is a concept that can embrace all aspects of the profession. The common delineator is tissue preservation, preferably by preventing disease from occurring and intercepting its progress, but also removing and replacing with as little tissue loss as possible. It does not suggest that we make small fillings to restore incipient lesions or surgically remove impacted third molars without symptoms as routine procedures. The introduction of predictable adhesive technologies has led to a giant leap in interest in minimally invasive dentistry. The concept bridges the traditional gap between prevention and surgical procedures, which is just what dentistry needs today. The evidence-base for survival of restorations clearly indicates that restoring teeth is a temporary palliative measure that is doomed to fail if the disease that caused the condition is not addressed properly. Today, the means, motives and opportunities for minimally invasive dentistry are at hand, but incentives are definitely lacking. Patients and third parties seem to be convinced that the only things that count are replacements. Namely, they are prepared to pay for a filling but not for a procedure that can help avoid having one. Keywords: caries, restoration failure, risk assessment, caries progression rate, introgenic effect, minimally invasive, lack of incentives

The management of a dental practice is most often focused on what clinicians do (production of items), and not so much on what is achieved in terms of oral health. The main reason for this is probably that it is easier to measure production and more difficult to measure health outcome. This paper presents a model based on individual risk assessment that aims to achieve a financially sound economy and good oral health. The close-to-the-clinic management tool, the HIDEP Model (Health Improvement in a DEntal Practice) was pioneered initially in Sweden at the end of 1980 s. The experience over a 15-year period with different elements of the model is presented, including: the basis of examination and risk assessment; motivation; task delegation and leadership issues; health-finance evaluations; and quality development within a dental clinic. DentiGroupXL, a software program designed to support the work based on the model, is also described. Keywords: dental risk assessment, dental risk management, dental software, DentiGroup, Hidep model, practice management, patient care planning, quality development, task delegation, treatment models

To review experimental and marketed techniques for the treatment of infected dentin as a potential substitute for conventional rotary excavation. A hand and systematic search of Medline (via DIMDI) was performed. Additionally, manufacturers' data about relevant clinical studies were checked. After classification of the identified techniques described, relevant studies are cited to allow an overview of the different treatment options. Excavation, disinfection and sealing techniques for the treatment of infected dentin can be differentiated. Besides several mechanical approaches, chemo-mechanical excavation, enzymatic digestion and photo ablation are discussed. Disinfection techniques can be undertaken with even less invasive approaches like gasiform ozone application, photodynamic therapy or local application of antibacterial materials. Additionally, or alternatively, the sealing of carious dentin is discussed using fluoride-releasing cements, dentin adhesives or antibacterial resin materials. Although some of the techniques are still experimental and much clinical research has to be done, many different approaches are so promising, or already established, that hopefully the days of radical excavation with rotary instruments are numbered. Keywords: excavation, disinfection, carious dentin, sealing

The concept of minimally invasive dentistry will provide favorable conditions for the use of composite resin. However, a number of factors must be considered when placing composite resins in conservatively prepared cavities, including: aspects on the adaptation of the composite resin to the cavity walls; the use of adhesives; and techniques for obtaining adequate proximal contacts. The clinician must also adopt an equally conservative approach when treating failed restorations. The quality of the composite resin restoration will not only be affected by the outline form of the preparation but also by the clinician's technique and understanding of the materials. Keywords: Composite Resins, Dentistry Operative, Dental Cavity Preparation, Dental Care

This report summarizes the clinical experiences and recommendations for use of the KaVo DIAGNOdent laser fluorescence device and of air abrasion (Kinetic cavity preparation). A major diagnostic problem facing clinicians today is the difficulty of achieving accurate occlusal caries diagnosis. Diagnostic accuracy is important because it determines the quality of the treatment decisions made, particularly with regard to the possibility of unnecessary operative intervention. The decrease in incidence of cavitated caries in Western countries, followed by the change in common presentation to non-cavitated caries, has made this accurate diagnosis more difficult. The deficiencies of using traditional methods of occlusal diagnosis are discussed and examined, along with the need for new, more accurate techniques. The use of the new technology of laser fluorescence is explained in detail with a discussion of the advantages and limitations of a commercial device: the KaVo DIAGNOdent. A minimal cavity outline philosophy is suggested for operative intervention, with particular emphasis on the advantages of using Kinetic cavity preparation (KCP) non-rotary method of tooth cutting. It should be noted that treatment options such as operative intervention should never precede adequate diagnosis and the use of preventive treatments such as sealants, should be utilized where indicated. Keywords: Minimal invasive dentistry, DIAGNOdent, air abrasion, kinetic cavity preparation

Erosive tooth wear is a multifactorial cumulative lifetime process, which may lead to tooth surface loss. Acids of intrinsic and extrinsic origin are the main etiological factors. This paper focuses on preventive measures and minimally invasive restorations. The application of high fluoride, time of toothbrushing as well as the intake of erosive foodstuffs or beverages should be optimized. Sealing of the tooth surfaces and small composite fillings are minimally invasive treatments for erosive lesions. Keywords: erosion, diagnosis, preparation, minimally invasive treatment